WtVEftSfTY OF CALIFORNIA 
 ">UWIA COUEGE OF MEDICO 
 
 I W?ARY 
 
 AUG 1 5 1972 
 'RVINE, CAUFORNIA 9266*
 
 /
 
 THE DISEASES OF THE EAR
 
 PRACTICAL TREATISE 
 
 DISEASES OF THE EAR 
 
 INCLUDING 
 
 A SKETCH OF AURAL ANATOMY AND 
 PHYSIOLOGY 
 
 D. B. ST. JOHN ROOSA, M.D., LL.D. 
 
 Professor of Diseases of the Eye and Ear in the New York Post-Graduate Medical School 
 and President of the Faculty ; Surgeon to the Manhattan Eye and Ear Hospital ; 
 Consulting Surgeon to the Brooklyn Eye and Ear Hospital ; formerly Pro- 
 fessor of Ophthalmology in the University of the City of New York^ 
 and of Diseases of the Eye and Ear in the University of Ver- 
 mont ; formerly President of the Medical Society 
 of the State of New York, etc., etc. 
 
 SEVENTH REVISED EDITION 
 
 NEW YORK 
 WILLIAM WOOD & COMPANY 
 
 1891
 
 COPTRIGHT, 1891, BY 
 
 WILLIAM WOOD & COMPANY. 
 
 TROW DIHICTORY 
 
 i AND BOOKBINDING ( 
 
 N1W YORK
 
 TO MY FEIEND 
 
 Ualbot Els, fl&.B. 
 
 IN REMEMBRANCE OF OUR YEARS OP INTIMATE PROFESSIONAL AND SOCIAL 
 
 RELATIONS, THIS BOOK IS AFFECTIONATELY 
 
 DEDICATED
 
 PREFATORY NOTE TO THE SEVENTH EDITION. 
 
 IN this edition, certain changes and additions have been 
 made, which it is hoped will increase the value of the book. 
 Such additions will be especially observed, in the discussion of 
 the relation of diseases of the nose and throat to the ear, the 
 value of operations upon the drum-head and ossicles, as well as 
 in the history and practice of operations upon the mastoid. 
 Minor changes have also been made in many parts of the book, 
 and a new and more complete index has been made by Dr. Frank 
 N. Lewis. The last edition was translated into German by Dr. 
 Ludwig Weiss, and published in Berlin by August Hirschwald. 
 The author sincerely hopes that his book may continue to find 
 readers, not only among students of medicine, but among practi- 
 tioners as well, for, although otology has made great strides in 
 the last decade, it still lags behind many departments of our 
 science and art, in the estimation and knowledge of the pro- 
 fession at large. Even among specialists, who are devoted to 
 otology and fields not remote from it, a wider knowledge of 
 what has been done for diseases of the ear, would sometimes be 
 of service in lessening the quantity of literature upon well dis- 
 cussed themes. I therefore hope that this book may not be 
 anywhere considered as an elementary work, suitable only for 
 undergraduates in medicine. In many parts it consists rather 
 of a series of monographs intended for specialists as well as for 
 general practitioners. 
 
 NEW YORK, August 22, 1891.
 
 PREFACE TO THE SIXTH EDITION. 
 
 IT is now eleven years since the first edition of this work was 
 published. The manner in which it has been received by the 
 profession of this country and of Great Britain and Ireland, has 
 been a source of great gratification to me. I offer my hearty 
 thanks to my brethren for having given my labors in otology 
 such a kind appreciation. In revising this book, while perhaps 
 no page has escaped alteration, and many pages have been 
 added, pains have been taken to preserve the original plan. 
 It was written for three classes of readers. First, it is intended 
 to be a means by which advanced medical students may acquire 
 a knowledge of the diseases and anatomy of the ear. . Second, it 
 is designed for general practitioners, to whom it may be a guide 
 for the diagnosis and treatment of cases actually in hand. Third, 
 I also hope, that professional men who interest themselves 
 largely or exclusively in otology, may in the future as in the 
 past, find in it something of interest and profit to them. 
 
 The larger part of the work is essentially a digest of my own 
 experience in the treatment of diseases of the ear, now ex- 
 tending over more than twelve thousand cases for which I have 
 had the personal responsibility. The nomenclature of this 
 book has been accepted quite generally in the profession, and 
 some of the views which were set forth for the first time in the 
 first edition, have been recognized as true, and have taken their 
 place in the great structure of human knowledge. 
 
 In this edition, it will be found that I have endeavored to
 
 PREFACE TO THE SIXTH EDITION. 
 
 make deductions from my clinical experience in certain novel 
 directions. Time will eventually establish the truth, or expose 
 the incorrectness of the conclusions which I have drawn from 
 my cases. If any of them are wrong, the facts at least will re- 
 main, I trust, a substantial contribution to a department of 
 medicine to which I have given some of the best years of my life. 
 
 I wish to express my thanks to my valued friend, Dr. 
 Charles E. Hackley, for his aid and advice in correcting the 
 proofs, also to Dr. J. B. Emerson for the preparation of the in- 
 dex, and much other assistance. 
 
 Many of the anatomical illustrations were prepared expressly 
 for this edition, and most of these are from the museum of my 
 distinguished colleague, Professor William Darling. While en- 
 gaged upon this work, Dr. John L. Yandervoort has extended 
 to me great courtesy in his official position as Librarian of the 
 New York Hospital. Many of the engravings of instruments 
 were furnished me by Messrs. John Reynders & Co. 
 
 NEW YORK, November 1, 1884.
 
 PREFACE TO THE FIRST EDITION. 
 
 THIS work is intended to be a guide to those who wish to treat 
 the diseases of the ear. The portion that is devoted to a de- 
 scription of these diseases, and the means for their relief and 
 cure, is founded upon my own experience in the observation and 
 treatment of more than thirty-eight hundred cases, in public 
 and private practice. I have, however, taken pains to give the ex- 
 perience of other practitioners, both at home and abroad. I have 
 endeavored not only to give a comprehensive digest of the most 
 recent European researches, but also to present, with entire im- 
 partiality, the views and experiences of American practitioners 
 and writers, so far as the plan of a practical treatise like this 
 would allow. To give a complete account of all that has been 
 written on otology has not, however, been my aim. 
 
 Considerable space has been given to illustrative cases, with a 
 view of showing the actual symptoms of aural diseases and the 
 results of treatment. I have also added historical sketches upon 
 all points of practice that are new or still under discussion, in 
 order that the successive steps by which our present position has 
 been reached might be distinctly traced, believing that thereby 
 the practitioner will often be saved needless labor in re-investi- 
 gating and re-experimenting. The nomenclature contained in 
 this treatise is that which I have found, after some years of ex- 
 perience in lecturing upon diseases of the ear, most readily 
 grasped by the student, and is, I believe, founded upon the 
 real nature of the diseases. 
 
 The anatomical portion of the volume has been compiled from 
 the most recent authorities. The text-book of Professor J. 
 Henle, of Gottingen, a work which has not been translated into
 
 X PREFACE TO THE FIRST EDITION. 
 
 English, has been made the general basis of the descriptions of the 
 various parts of the ear, and of the arrangement of the subject. 
 
 In the preface to a translation of " Von Troltsch on the Ear," 
 published a little more than nine years since, the translator had 
 so little faith in a general professional interest in the diagnosis 
 and treatment of diseases of the ear, that he quoted a proverb 
 to indicate that an ordinary human life would not suffice to see 
 the fruit of the tree then being planted, in presenting to the 
 English-speaking profession a work which has done much for 
 the progress of otology. 1 
 
 In view, however, of the active and permanent interest in this 
 subject, which has shown itself in the formation of societies, the 
 establishment of journals, improvements in methods of practice, 
 and a general appreciation of diseases of the ear, the author can 
 but felicitate himself that even in a short life he has seen some 
 fruit of a tree, which, although he did not plant, he at least as- 
 sisted in cultivating. 
 
 The practice of otology in this country was, a few years 
 since, almost exclusively confined to charlatans ; but it is now 
 cultivated by a class of men who are the equals of any in the 
 profession. Ten years ago, in most parts of the country, those 
 who wished advice upon a disease of the ear were forced to seek 
 aid outside of the profession. At the present time, there can 
 be found those in the large cities who are constantly and suc- 
 cessfully treating aural diseases ; and all over the land the old 
 and familiar advice, "Not to meddle with the ear," is growing 
 far less frequent. The day will soon arrive if indeed it be not 
 already upon us when otology will take equal rank with 
 ophthalmology, to which department it has so long been a 
 mere appendage, and when some knowledge of the diseases and 
 treatment of the ear will be required of every practitioner. 
 
 I have been assisted in various ways, in the preparation of 
 this work, by many who may rest assured that I have not been 
 unmindful of their labors because their names are not here 
 mentioned ; but to Dr. Charles E. Rider, of Rochester, for assist- 
 ance in compiling the anatomy of the middle ear, and to Dr. 
 George M. Beard, for critical suggestions in the literary execu- 
 tion of the work, of a very valuable character, I am much in- 
 
 1 " Arbores seret diligens agricola quarum adspiciet baccam ipse nunquam."
 
 PREFACE TO THE FIEST EDITION". xi 
 
 debted, and to both of these gentlemen I desire to present my 
 cordial acknowledgments. 
 
 It is believed that in the foot-notes, the various authorities 
 whom I have consulted have been given proper credit, and they 
 are given in full at the close of the sketch of the progress of 
 otology, and at the end of each anatomical section, in order 
 that an aural bibliography of works actually consulted by the 
 author, and accessible in this country, may be furnished to 
 any who may desire to pursue any special subjects further than 
 would be fitting the limits of a text-book. 
 
 Most of the engravings were made by Messrs. J. A. Cough- 
 Ian & Co. Those of instruments were furnished by Messrs. 
 Shepard & Dudley, Otto & Reynders, and George Tiemann & 
 Co., of this city. 
 
 The chromo-lithographs were drawn by Dr. H. P. Quincy, 
 of Boston, from cases loaned me by Drs. Clarence J. Blake and 
 Henry L. Shaw, Surgeons to the Massachusetts Charitable Eye 
 and Ear Infirmary. Without the assistance of these gentlemen, 
 I should have found it very difficult to procure satisfactory 
 representations of the morbid membrana tympani. Dr. John 
 L. Vandervoort, Librarian of the New York Hospital, has ex- 
 tended me many courtesies in giving me free access to the 
 valuable library of that institution. 
 
 NEW YORK, May 29, 1873.
 
 CONTENTS. 
 
 CHAPTER I. 
 
 A SKETCH OF THE PROGEESS OP OTOLOGY WITH A BIBLI- 
 OGRAPHY. 
 
 PAGE 
 
 Vastness of Otological Literature. Apathy in regard to Diseases of the Ear. Wilde 
 the Reformer of the Science. Carl Gustav Lincke and his Handbook. Papy- 
 rus Ebers. Hippocrates and his Knowledge of the Ear. Alcmaeon the Dis- 
 coverer of the Eustachian Tube. Rufus of Ephesus. Aristotle. Discoveries 
 in the Time of the Ptolemys. Galen and the Want of Progress in his Time. 
 Achillini and Berengario describe the Ossicles. Vesalius the most accurate 
 Anatomist of his Day. Ingrassia, Columbo, and Eustachius each claims Dis- 
 covery of Stapes. Fallopius and his Career. Anatomical Writings of Eusta- 
 chius. First Monograph on Anatomy of the Ear. Constant Varolius. Fab- 
 ricius of Aquapendente. Valsalva. Casserius, a Pupil and Rival of Fabricius. 
 Stenon describes Ceruminous Glands. Discovery of Helicotrema. Du Ver- 
 ney and his Plates. Cotugno and the Aqueducts. Meckel. Rivinian Fora- 
 men. Hyrtl and Bochdalek upon its Existence. Ruysch. Brendel and 
 Zinn. Scarpa upon the Internal Ear. Saunders, Todd, and others. Monro's 
 Claim to have first traced the Nerves into the Cochlea, Vestibule, and Semi- 
 circular Canals. Everard Home's Account of the Membrana Tympani. 
 Soemmering. Shrapnell. Thomas Buchanan on the Importance of Cerumen. 
 Wharton Jones. Discoveries of Toynbee. Troltsch, Politzer, Lucse, and 
 others. The Organ of Corti and its Discoverer. Pathological Anatomy of the 
 Ear. Progress in Treatment of Aural Disease. Herodotus on Specialists. 
 The Remedies suggested by Hippocrates. Celsus. Archigenes on Venesection 
 and Foreign Bodies. Galen on Noise. Peculiar Method of removing Foreign 
 Body from Ear. Paulus ^Sgineta, his Classification and Operation. Arabians, 
 their Knowledge of Otology. Paracelsus burning Books of his Predecessors. 
 Capivacci on Differential Diagnosis. Ambroise Pare first uses a Syringe for 
 the Ear. The Education of Deaf Mutes. Old Method of detecting Inspis- 
 sated Cerumen. Lusitanus on cutting off Ears of Thieves. Fabricius of Hil- 
 den. Thomas Willis, his Observations on Hearing in a Noise. The Thera- 
 peutical Work of Valsalva. Petit on Caries of the Mastoid. The Discovery 
 of the Eustachian Catheter. Guyot, Cleland. Perforation of the Membrana 
 Tympani. Trephining the Mastoid. Sir Astley Cooper. Saunders on Perfo- 
 ration of the Membrana Tympani. First Infirmary for Diseases of the Ear. 
 Saissy, Itard, Beck. Sketch of Kramer's Career. Discovery of Artificial 
 Membrana Tympani. Yearsley. Wilde and his great Work in Otology. 
 The Text-books of Toynbee, Troltsch, Erhard. Modern Text-books and Jour- 
 nals. Bibliography, 1
 
 XIV CONTENTS. 
 
 CHAPTER II. 
 THE EXAMINATION OF AURAL PATIENTS. 
 
 PAGE 
 
 History. Power of Hearing Conversation. Test Sentences. Tick of a Watch. 
 Tuning-fork. Aerial and Bone Conduction. Malingering. Angular Forceps. 
 Specula. Troltsch's Otoscope. Examination of Pharynx. Rhinoscopy. 
 Use of Eustachian Catheter. Politzer's Method and its so-called Modifica- 
 tions. Bougies. Valsalva's Method, 44 
 
 CHAPTER III. 
 
 ANATOMY AND PHYSIOLOGY OF THE AURICLE AND THE 
 EXTERNAL AUDITORY CANAL. 
 
 Auricle. Etymology. Anatomy of Muscles, Intrinsic and External. Physiology. 
 Blood-vessels. Nerves. External Auditory Canal. Anatomy of Curva- 
 ture. Ceruminous Glands. Hairs in Canal. Auditory Canal of Dog and Cat. 
 Relations of Canal to Parotid Gland, Inferior Maxilla, Mastoid Process, and 
 Dura Mater. Blood-vessels and Nerves, 81 
 
 CHAPTER IV. 
 THE MALFORMATIONS AND DISEASES OF THE AURICLE. 
 
 A Finely Formed Auricle an Indication of Character. Malformations. Super- 
 fluous Auricles. Ely's operation for Prominent Auricles. Tumors. Angio- 
 mata. Othaematomata. Perichondritis. Malignant Growths. Syphilitic 
 Affections. Erysipelas. Effects of Gout 97 
 
 CHAPTER V. 
 
 DIFFUSE AND CIRCUMSCRIBED INFLAMMATION OF THE EXTER- 
 NAL AUDITORY CANAL. 
 
 Comparative Frequency of these Affections. Diffuse Inflammation. Leeches. 
 Incisions. Warm Douche. Fountain Syringe. Fayette Taylor's Douche. 
 Method of Syringing. Syringes. Anodynes. Desquamative Inflammation. 
 Furuncles. Local and Constitutional Treatment. Calcium Sulphide. 
 Lowenburg's Views, 123 
 
 CHAPTER VI. 
 
 PARASITIC INFLAMMATION OF THE EXTERNAL AUDITORY CANAL 
 SYPHILITIC ULCERS AND CONDYLOMATA CONTRACTIONS- 
 DIPHTHERIA SARCOMA CARIES. 
 
 History of the Discovery of the Growth of Aspergillus in the External Auditory 
 Canal. Varieties of Vegetable Fungi found in the Ear. Cases. Syphilitic 
 Ulcers and Condylomata. Narrowing and Closure of the Canal. Diphtheritic 
 Inflammation. Sarcoma. Caries of the Canal, 143
 
 CONTENTS. XV 
 
 CHAPTER VII. 
 INSPISSATED CERUMEN. 
 
 PAOB 
 
 Merely a Symptom of Aural Inflammation. Frequency of the Affection. Symp- 
 toms. Reported Cases of Damage to the Ear from the Presence of Wax, prob- 
 ably not based on Correct Observation. Causes. Treatment. Cases, . . 158 
 
 CHAPTER VIII. 
 FOREIGN BODIES. 
 
 Exaggeration of the Importance of this Subject. Statistics. Insects. Living Lar- 
 vae. Fish. Inanimate Foreign Bodies. Treatment. Delusions as to Foreign 
 Bodies in the Ear. Foreign Bodies in the Eustachian Tube. Ear Cough, . 179 
 
 CHAPTER IX. 
 ANATOMY AND PHYSIOLOGY OF THE MIDDLE EAR. 
 
 Statistics of Diseases of the Middle Ear. Membrana Tympani. ShrapnelFs Mem- 
 brane. Rivinian Foramen. Light Spot. Layers. Blood-vessels. Nerves. 
 Lymphatics. Cavity of the Tympanum. Scheme for Studying Boundaries 
 of this Cavity. Ossicula Auditus. Blood-vessels. Nerves. Mastoid Pro- 
 cess. Eustachian Tube, Historical Account of. Physiology of the Middle 
 Ear, 213 
 
 CHAPTER X. 
 INJURIES OF THE MEMBRANA TYMPANI. 
 
 Diseases of the Memhrana Tympani not Independent Affections. Vascular, Nerv- 
 ous, and Lymphatic Supply, a Part of that of the Canal and Middle Ear. 
 Drum-head Subject to Injury by Explosions, Blows, and so forth. Effects of 
 Condensed Air. Serious Injuries of the Head. Fracture of the Handle of 
 the Malleus, 2r,9 
 
 CHAPTER XI. 
 
 ACUTE CATARRHAL INFLAMMATION OF THE MIDDLE EAR. 
 
 Nomenclature. Statistics. Symptoms. Treatment. Leeches. Paracentesis. 
 Subacute Catarrh. Hemorrhagic Inflammation of the Middle Ear. -Aural 
 Hemorrhage in Bright's Disease. Vascular Tumors of the Drum-head, . . 1!78 
 
 CHAPTER XII. 
 
 ACUTE SUPPURATION OF THE MIDDLE EAR. 
 
 A Consequence of Acute Catarrh. Symptoms. Causes. Course. Cases of Men- 
 ingitis Consecutive to Acute Catarrh and Suppuration. Criticisms upon the 
 Modern Antiphlogistic Treatment. Neurotic Cases. Treatment and Cases. 
 Acute Serous Inflammation of the Middle Ear, 30?
 
 XVi CONTENTS. 
 
 CHAPTER XIII. 
 
 CHBONIC NON-SUPPUBATIVE INFLAMMATION OF THE MID- 
 DLE EAE. 
 
 PAGE 
 
 Frequency of this Disease. Nomenclature. Catarrh. Proliferous Inflammation. 
 Subjective Symptoms. Vertigo. Tinnitus Aurium. Insanity. Subjec- 
 tive Symptoms of Proliferous Inflammation. Objective Symptoms. Impair- 
 ment of Hearing. Changes in the Membrana Tympani. Eustachian Tube. 
 Naso-pharyngeal Inflammation. Adenoid Growths. Pathology. Causes, . 339 
 
 CHAPTER XIV. 
 
 CHBONIC NON-SUPPUBATIVE INFLAMMATION OF THE MIDDLE 
 
 EAB (Continued). 
 
 Treatment of the Catarrhal and Proliferous Forms. Constitutional and Hygienic 
 Applications to the Naso-pharyngeal Space. Nasal Douche. Cases of Acute 
 Aural Disease caused by its Use. Gruber's Method of Cleansing Nares. Pol- 
 itzer's Method. Anatomy of Nasal Cavities. Nebulizers. Faucial Catheters. 
 Removal of the Tonsils. Treatment through the Eustachian Tube. Air. 
 Steam. Vapors. Fluids. Bougies. Electricity. Death from Improper 
 Use of Catheter. Duration of Treatment. Prognosis, 380 
 
 CHAPTER XV. 
 
 THE TBEATMENT OF CHBONIC NON-SUPPUBATIVE INFLAM- 
 MATION ( Concluded) . 
 
 Operations upon and through the Membrana Tympani. History from 1650 until 
 our own Day. Sir Astley Cooper's Cases. Schwartze's Statistics. Politzer's 
 Eyelet. Tenotomy of Tensor-tympani. Galvano-cautery. Division of Pos- 
 terior Fold. Front's Operation. Hinton's Removal of Accumulations of Mu- 
 cus. Abandonment of Operations by American Otologists. Condensed Air. 
 Exhaustion of Air. Weber-Liel and Woakes on Paretic Deafness. Results 
 of Treatment, ............. 415 
 
 CHAPTER XVI. 
 CHRONIC SUPPUBATION OF THE MIDDLE EAB. 
 
 Consequence of Acute Suppuration. Otorrhcea an Improper Term. Often con- 
 founded with Chronic Inflammation of the Canal. Relative Frequency of the 
 two Affections. Symptoms. Perforations of Membrana Tympani. Treat- 
 ment. Syringing. Astringents. Fluids. Powders. Electricity. Artificial 
 Membrana Tympani. Cases. Prognosis, 443 
 
 CHAPTER XVII. 
 
 THE CONSEQUENCES OF CHBONIC SUPPUBATION OF THE 
 MIDDLE EAB. 
 
 Chronic Suppuration and its Results Inevitably Dangerous to the Health and Life 
 of the Patient. Refusal of Life Insurance Companies to take Risks of such 
 Cases. Cicatrices and Adhesions in the Tympanum. Polypi. Exostoses. 
 Mathewson's Operation for their Removal. Cases, 473
 
 CONTENTS. XVli 
 
 CHAPTER XVIII. 
 
 THE CONSEQUENCES OF CHEONIC SUPPURATION OF THE 
 MIDDLE EAE (Continued). 
 
 Diseases of the Mastoid Process. Periostitis. Caries and Suppuration. Trephin- 
 ing or Opening the Mastoid. Cases. Statistics. Historical Account of the 
 Operation, ............. 496 
 
 CHAPTER XIX. 
 
 THE CONSEQUENCES OF CHEONIC SUPPURATION OF THE MIDDLE 
 EAE (Concluded). NEUEALGIA OF THE MIDDLE EAE. 
 
 Caries and Necrosis of the Temporal Bone. Cases. Treatment by Operation and 
 Internal Medication. Fatal Hemorrhage. Cerebral Abscess. Pyaemia. 
 Paralysis. The Ophthalmoscope in detecting Cerebral Disease of Aural 
 Origin. Neuralgia of the Middle Ear, . 545 
 
 CHAPTER XX. 
 ANATOMY AND PHYSIOLOGY OF THE INTERNAL EAE. 
 
 The Vestibule, Semi-circular Canals, Cochlea, and Auditory Nerve. Physiology 
 of the Internal Ear, 591 
 
 CHAPTER XXL 
 DISEASES OF THE INTEENAL EAR. 
 
 Difficulty in Diagnosis. Clinical and Pathological Advances. Differentiation be- 
 tween Diseases of Middle and Internal Ear. Nervousness and Nervous Deaf- 
 ness. Symptoms of Primary Disease of the Cochlea. Acoustic Neuritis. 
 Atrophy of the Acoustic Nerve. Cases. The Tuning-fork in Diagnosis. 
 Deafness to Certain Tones. Double Hearing. Electricity. Syphilitic Dis- 
 ease of the Cochlea. Cochlitis. Cases, ........ 612 
 
 CHAPTER XXII. 
 DISEASES OF THE INTERNAL EAR (Concluded). 
 
 The Effects of Quinine. Cerebro-spinal Meningitis. Meningitis. Disease of the 
 Spinal Cord. Parotitis. Acute Inflammation of Membranous Labyrinth mis- 
 taken for Cerebro-spinal Meningitis. Hemorrhages and Effusions. Injuries. 
 Concussions. Aneurism and Tumors. Disease of Semi-circular Canals. 
 Pathology. Treatment, . 641 
 
 CHAPTER XXIII. 
 DEAF-MUTEISM MECHANICAL ASSISTANCE TO THE HEARING. 
 
 Acquired and Congenital Cases. At what Age are Children Conscious of Sounds ? 
 Causes. Tables of Examination of 147 Cases. Hearing-trumpets. Audi- 
 phone, .............. 685 
 
 INDEX OF AUTHOES, 725 
 
 GENEEAL INDEX, 731 
 
 DESCEIPTION OF THE CHEOMO-LITHOGEAPHS, . 743
 
 LIST OF WOOD-CUTS. 
 
 1. Tuning-fork, 54 
 
 2. Blake's Tuning-fork, 57 
 
 3. Angular Forceps, ............ 59 
 
 4. Gruber's Speculum, 60 
 
 5. Method of holding the Speculum in Position, ...... 61 
 
 6. Method of Examining the Auditory Canal and Membrana Tympani, . . 62 
 
 7. Collin's Lamp, 63 
 
 8. Forehead Band, 63 
 
 8&. Electric Lamp for Illuminating Ear, ........ 64 
 
 9. Blake's Operating Otoscope, 65 
 
 10. Hinge Speculum, ............ 66 
 
 11. Turck's Speculum, 66 
 
 12. Anterior Nares Speculum, .......... 68 
 
 13. Goodwillie's Nasal Speculum, ......... 68 
 
 13a. Elsberg's Nasal Speculum, ... i ...... 69 
 
 14. Eustachian Catheters, actual size, ......... 70 
 
 15. Introduction of Eustachian Catheter, 71 
 
 16. The Eustachian Catheter in Position, ........ 72 
 
 17. Air-bag, 73 
 
 18. Diagnostic Tube, ............ 73 
 
 19. Method of Using Politzer's Apparatus (with box for containing iodine or other 
 
 evaporating substance), ........... 75 
 
 20. Dr. Allen's Xose-pads for Politzer's Apparatus, ...... 76 
 
 21. The Auricle, 81 
 
 22. Profile View of the Skull with the Skeleton or Cartilage of the Auricle, as 
 
 well as that of the External Auditory Canal, ....... 82 
 
 23. Muscles of the External Ear, 85 
 
 24. View of the Cartilage and Muscles on the Posterior Surface of the Auricle, 86 
 
 25. The Muscles of the Head, 90 
 
 26. Section through the External Meatus and the Ear at the Point of Junction of 
 
 the Cartilage of the Auricle with that of the Auditory Canal, . . .91 
 
 27. Horizontal Section of the Head through the External Auditory Canal, . . 92 
 
 28. Annulus Tympanicus, 92 
 
 29. Cast of Auditory Canal and Adjacent Parts, ....... 93 
 
 30. Section of Left Temporal Bone, 93 
 
 31. External Surface Left Temporal Bone, 95 
 
 32. Case of Prominence of Auricles (front view), ....... 98 
 
 33. Case of Prominence of Auricles (posterior view), ...... 99 
 
 34. 35. Deformity of Auricles, 101 
 
 36. Othaematoma. From a photograph taken from a plaster cast when the tume- 
 
 faction was greatest, ........... 108 
 
 37. The same Ear after Rupture and Contraction had taken place, . . . 108
 
 XX LIST OF WOOD-CUTS. 
 
 *'<* PAGE 
 
 38. Showing Amount of Contraction after Rupture of Cyst, 100 
 
 39. Shows Separation of Perichondrium from Cartilage, 109 
 
 40. Auricle Deformed by Inflammation, 113 
 
 41. Tumor of the Anterior Part of Auricle and Auditory Canal, . . . .117 
 
 42. Improved Fountain Syringe, 128 
 
 43. Fayette Douche, 129 
 
 44. Syringe for the Ear, - 133 
 
 45. Reservoir Syringe, 133 
 
 46. Method of Syringing the Ear, . 134 
 
 47. Aspergillus Nigricaus, . 147 
 
 48. Aspergillus Flavescens, ; . .148 
 
 49. Specimen of the Spores and fully developed Growth of the Aspergillus Fla- 
 
 vescens, . . 149 
 
 50. Penicillium 150 
 
 51. Otomyces Purpureus, 150 
 
 52. The Right Temporal Bone, without the Petrous Portion in connection with 
 
 Ossicula Auditus of a Newly-born Child, seen from within, . . . 214 
 
 53. Left Temporal Bone of the same Subjecl as preceding figure, . . . 214 
 
 54. Section through Tympanic Cavity, Left Side, 215 
 
 55. 56. View of Membrana Tympani, showing Handle of Malleus and Trian- 
 
 gular spot of Light, ........... 219 
 
 57. Vertical Section of Fibrous Layer of the Membrana Tympani, . . .221 
 
 58. The Membrana Tympani, in connection with the Ossicula Auditus of the 
 
 Right Temporal Bone, . 225 
 
 59. Temporal Bone of Left Side (inner view), 226 
 
 60. The Right Temporal Bone, with the Membrana Tympani and Ossicula Au- 
 
 ditus of an Adult, 229 
 
 61. Section of Right Temporal Bone, 230 
 
 62. Section through Tympanic Cavity, Left Temporal Bone 231 
 
 63. Tympanic Cavity with Ossicles in situ, 232 
 
 64. Anterior Surface of Malleus and Incus Articulated, 232 
 
 65. Ossicles of the Tympanum, 233 
 
 66. Posterior Surface of the Malleus, Incus, and Stapes Articulated, . . . 233 
 
 67. Vertical Section through the Right Temporal Bone, 239 
 
 68. External Surface of Left Mastoid Bone, 240 
 
 69. Vertical Section through Right Temporal Bone, ...... 240 
 
 70. Vertical Section of Left Temporal Bone, 241 
 
 71. Section of the Head, showing the Divisions of the Ear and Naso-pharyngeal 
 
 Cavity, 244 
 
 72. Transverse Section of Upper Part of the Eustachian Tube, .... 245 
 
 73. Transverse Section through Lower End of the Eustachian Tube, . . . 246 
 
 74. Same as last, 246 
 
 75. Vertical Section, showing the Mouth of Eustachian Tube and Rosenm filler's 
 
 Fossa, 247 
 
 76. Transverse Section of Eustachian Tube and Surrounding Parts, . . . 248 
 
 77. Section of the Upper Third of the Eustachian Tube, 249 
 
 78. Section of the Middle Third of the Eustachian Tube, 250 
 
 79. Fracture of Handle of Malleus, displaced, 277 
 
 80. Fracture of Handle of Malleus, reduced, ....... 277 
 
 81. Paracentesis Needle, ........... 289 
 
 82. Diseases of Bone in Case of Meningitis following Acute Suppuration of Mid- 
 
 dle Ear, .315
 
 LIST OF WOOD-CUTS. XXI 
 
 83. Siegle's "Otoscope" with Ely's Attachment of a Syringe, . . . .368 
 
 84. Pharyngitis Granulosa, ........... 370 
 
 85. Posterior Nares Syringe, .......... 383 
 
 86. Davidson's Syringe with a Nozzle to go below the Soft Palate, . . . 384 
 
 87. Vertical Section of Bones of Face (posterior half), ...... 388 
 
 88. Vertical Section of Bones of Face (anterior half), 390 
 
 89. Nebulizer for Nostrils and Pharynx, 391 
 
 90. Tonsil Knife, 395 
 
 91. Tonsil Forceps, 395 
 
 92. Apparatus for Steaming the Middle Ear, 399 
 
 93. Bottle for the Generation of Vapor of Iodine. An ordinary air-bag is used 
 
 for forcing the vapor into the catheter, ....... 400 
 
 94. Hackley's Eustachian Nebulizer, ......... 404 
 
 95. Proat's Knife 433 
 
 95. Delstanche's Masseur, 439 
 
 96. Vessel Used in Syringing the Ear, ......... 454 
 
 97. Buck's Pipette, 455 
 
 98. Knapp's Powder-blower, .......... 457 
 
 99. Toynbee's Artificial Membrana Tympani, ....... 465 
 
 100. Method of Inserting Artificial Membrana Tympani (Toynbee), . . . 406 
 
 101. Section of Aural Polypus, 476 
 
 102. Section of Aural Polypus, 477 
 
 103. Section of Aural Polypus, 478 
 
 104. Blake's Modification of Wilde's Snare with Paracentesis Needle, . . . 481 
 
 105. Scissors for the Removal of Aural Polypi, ....... 481 
 
 106. Buck's Curettes for Clearing Auditory Canal and Tympanum, . . . 482 
 
 107. Schwartze's Chisels for Opening the Mastoid, ...... 507 
 
 107a. Wilson's Trephine, 543 
 
 1075. Petrous Portion of the Temporal Bone Removed, ..... 550 
 107c. Mastoid Fistula following Necrosis, ........ 551 
 
 108. Left Temporal Bone, Exterior View (Necrosis), ...... 553 
 
 109. Left Temporal Bone, Inner Surface, ........ 553 
 
 110. Left Temporal Bone, Sawed through External Meatus, Middle Ear, and 
 
 Cochlea, ............. 554 
 
 111. Right Temporal Bone, from Case V. , showing the Cranial Surface of the 
 
 Bone, .............. 554 
 
 112. Caries of Squamous and Mastoid Portion of Temporal Bone, .... 555 
 
 113. Caries of Petrous Portion of Right Temporal Bone, ..... 557 
 
 114. Caries of Lateral Sinus of Right Temporal Bone, ...... 558 
 
 115. Caries of Squamous Portion of Temporal Bone, ...... 558 
 
 116. A Diagram designed to show the Relations of the Tympanic Cavity to the Mas- 
 
 toid Cells, the Jugular Fossa and the Cavity of the Cranium, . . . 560 
 
 117. The Left Vestibule, with the Semi-circular Canals, from an Adult, seen from. 
 
 within, .............. 592 
 
 118. The Vestibule, 592 
 
 119. Section of Temporal Bone of Right Side through the Cochlea, . . . 594 
 
 120. Osseous Cochlea and Semi-circular Canals with Stapes Bone, Left Ear of 
 
 Adult, 594 
 
 121. Right Osseous Vestibule, Semi-circular Canals, Cochlea, and Ossicula Auditus 
 
 of Newly Born, ............ 594 
 
 122. The Right Osseous Labyrinth <i a Newly Born Subject, opened on its Poste- 
 
 rior Surface, ............ 595
 
 XX11 LIST OF WOOD-CUTS. 
 
 no. PAGE 
 
 123. Section of Right Temporal Bone, showing the Osseous Semi-circular Canals, . . 595 
 
 124. Osseous Cochlea (Right) of the Newly Born, opened from the Outer Surface, . 596 
 
 125. Section through Cochlea and Vestibule, ........ 597 
 
 126. Periosteum of Labyrinth, 598 
 
 127. Periosteum of the Outer Wall of the Cochlea, 598 
 
 128. Utricle and Membranous Semi-circular Canals of the Left Side, . . . 599 
 
 129. A Piece of the Wall of the Utricle, with the Otoliths, 599 
 
 130. Transverse Section of a Cochlear Spiral, ........ 601 
 
 131. From the Terminal Auditory Apparatus of a Cat, ...... 603 
 
 132. Profile View of Outer and Inner Rods, . 604 
 
 133. Membrana Basilaris, with the Terminal Nerve-Fibres, 604 
 
 134. Expansion of the Right Cochlear Nerve, seen from the Base of the Cochlea, . 605 
 
 135. A Diagram designed to Illustrate the Physiology of the Labyrinth, . . 608 
 
 136. Hearing-trumpets, . . . * 719 
 
 137. Auricles, 719 
 
 138. The Audiphone in its Natural Position ; used as a Fan, .... 720 
 
 139. The Audiphone in Tension ; the Proper Position for Hearing, . . . 720 
 
 140. Method of Using the Audiphone, 720
 
 A TEEATISE ON 
 
 THE DISEASES OF THE EAR. 
 
 CHAPTER I. 
 
 A SKETCH OF THE PEOGEESS OF OTOLOGY WITH A BIBLI- 
 
 OGEAPHY. 
 
 fastness of Otological Literature. Apathy in regard to Diseases of the Ear. Wilde 
 the Reformer of the Science. Carl Gustav Lincke and his Handbook. Papyrus 
 Ebers. Hippocrates and his Knowledge of the Ear. Alcmaeori the Discoverer of 
 the Eustachian Tube. Rufus of Ephesus. Aristotle. Discoveries in the Time of 
 the Ptolemys. Galen and the Want of Progress in his Time. Achillini and Beren- 
 gario describe the Ossicles. Vesalius the most accurate Anatomist of his Day. In- 
 grassia, Columbo, and Eustachius each claim Discovery of Stapes. Fallopius and 
 his Career. Anatomical Writings of Eustachius. First Monograph pn Anatomy of 
 the Ear. Constant Varolius. Fabricius of Aquapendente. Valsalva. Casserius, 
 a Pupil and Rival of Fabricius. Stenon describes Ceruminous Glands. Discovery 
 of Helicotrema. Du Verney and his Plates. Cotugno and the Aqueducts. 
 Meckel. Rivinian Foramen. Hyrtl and Bochdalek upon its Existence. Ruysch. 
 Brendel and Zinn. Scarpa upon the Internal Ear. Saunders, Todd, and others. 
 Monro's Claim to have first traced the Nerves into the Cochlea, Vestibule, and 
 Semicircular Canals. Everard Home's Account of the Membrana Tympani. 
 Soemmering. Shrapnell. Thomas Buchanan on the Importance of Cerumen. 
 Wharton Jones. Discoveries of Toynbee. Troltsch, Politzer, Lucse, and others. 
 The Organ of Corti and its Discoverer. Pathological Anatomy of the Ear. Prog- 
 ress in Treatment of Aural Disease. Herodotus on Specialists. The Remedies 
 suggested by Hippocrates. Celsus. Archigenes on Venesection and Foreign 
 Bodies. Galen on Noise. Peculiar Method of removing Foreign Body from Ear. 
 Paulus ^Egineta,his Classification and Operation. Arabians, their Knowledge of 
 Otology. Paracelsus burning Books of his Predecessors. Capivacci on Differential 
 Diagnosis. Ambroise Pare first uses a Syringe for the Ear. The Education of 
 Deaf Mutes. Old Method of detecting Inspissated Cerumen. Lusitanus on cut- 
 ting off Ears of Thieves. Fabricius of Hilden. Thomas Willis, his Observations 
 on Hearing in a Noise. The Therapeutical Work of Valsalva. Petit on Caries of 
 the Mastoid. The Discovery of the Eustachian Catheter. Guyot, Cleland. Per- 
 foration of the Membrana Tympani. Trephining the Mastoid. Sir Astley Cooper. 
 Saunders on Perforation of the Membrana Tympani. First Infirmary for Dis- 
 1
 
 eases of the Ear. Saissy, Itard, Beck. Sketch of Kramer's Career. Discovery of 
 Artificial Membrana Tympani. Yearsley. Wilde and his great Work in Otology. 
 The Text-books of Toynbee, Troltsch, Erhard. Modern Text-books and Jour- 
 n als. Bibliography . 
 
 THERE is perhaps no department of the art and science of medi- 
 cine, in which there has been so much literature, with so little 
 exact, or as we say, scientific knowledge, as that which w T as 
 formerly known as aural medicine and surgery, but which is 
 better designated by the term Otology. 
 
 Hundreds and perhaps thousands of volumes have been 
 written on the anatomy, physiology, and diseases of the ear, 
 and yet until the age of Valsalva, the seventeenth century, the 
 treatment of the affections of the organ of hearing was purely 
 empirical, while the knowledge of its anatomy and physiology 
 was generally incorrect and superficial. Even after the inves- 
 tigations of the famous Italian, investigations which occupied 
 sixteen years of his life, and the subsequent anatomical dis- 
 coveries of the eighteenth century, it was reserved for our own 
 day and generation to place the science of otology, or the knowl- 
 edge of the anatomy, physiology, and diseases of the ear, on a 
 level with that of other fields of labor in medicine. 
 
 A singular apathy in regard to the maladies of one of the 
 most important organs of the body, an inexplicable ignorance 
 as to their results, a most irrational and empirical manner of 
 treatment, have been our heritage from the fathers. Probably 
 to-day, in the closing years of the nineteenth century, aural 
 medicine and surgery is more generally regarded from the 
 standpoint of the errorists of the dark ages, than is any other 
 department of our science and art. It is to be feared, that even 
 now, many wise and skilful practitioners do not know, that to 
 drop stimulating or even anodyne applications upon a membrane 
 which they have never examined, to probe an ear for wax that 
 they cannot see, are purely empirical practices which every con- 
 scientious physician should hold in abhorrence. 
 
 The great reformer of this science, Wilde, 1 wrote, as late 
 as 1853, that "the affections of the ear, whether functional or 
 organic, are spoken of, lectured on, written of, and described 
 (even in great part to the present day), not according to the laws 
 of pathology which regulate other diseases, but by a single symp- 
 tom, that of deafness" 
 
 It is with no desire to recount the details of the long and 
 painful story of the gropings in the dark, which have charac- 
 terized the teachings on otology from the days of the philoso- 
 
 1 Aural Surgery, English edition, p. 7.
 
 PROGRESS OF OTOLOGY. 
 
 pher of Cos, until the seventeenth century, that I attempt an 
 historical sketch of our progress up to our present position. I 
 have neither the time nor the facilities for such a task ; but an 
 endeavor will be made to sketch the history of otology, from the 
 sources to which I have access, in such a manner as to show 
 the obstacles which, until twenty years ago, have prevented 
 the satisfactory progress of the science. 
 
 I must first of all, make especial acknowledgment of my in- 
 debtedness for a large part of my material, to that valuable com- 
 pendium, "Lincke's Handbuch der Ohrenheilkunde." ' I have, 
 however, consulted the original authorities as far as the best 
 medical library of New York that of the New York Hospital 
 and my own would permit. Where no other authority is given in 
 a foot-note, Lincke is the one from which I quote, and often by an 
 exact translation. The discoveries and teachings in the anatomy 
 of the ear will be first reviewed, after which the progress in the 
 examination and treatment of its diseases will be noted. 
 
 For the convenience of the reader, I have given the titles of 
 the works consulted, both at the foot of the page, and in the for- 
 mal bibliography. 
 
 In the Astor Library in the city of New York, is a fac-simile 
 copy of one of the oldest medical treatises that is known to ex- 
 ist. The original is a papyrus book in the Royal Saxon Library 
 of Leipsic. It is called the " Papyrus Ebers," it having been ob- 
 tained by the celebrated Egyptologist, George Ebers, while in 
 Thebes, from a certain native, who is said to have taken it. about 
 the year 1861, from among the bones of an Egyptian who had 
 been buried more than thirty-four hundred years. This book is 
 entitled " The Hermetic Book of the Medicines of the Ancient 
 Egyptians." 2 It is written upon papyrus, three-fourths of a 
 meter wide and twenty meters long. It is one of the six medical 
 works named by Clement of Alexandria. 
 
 Among other subjects treated of in this large volume, is a 
 monograph upon " medicines for ears hard of hearing," and " for 
 ears from which there is a putrid discharge." Inasmuch as the 
 translation of the hieroglyphic language of the manuscript only 
 extends, as yet, to the table of contents, we cannot know whether 
 the Egyptian priests had a better knowledge of the proper treat- 
 ment of the ear, than was possessed by their Greek and Roman 
 successors many centuries later. 
 
 1 Carl Gustav Lincke was a teacher of otology in the University of Leipsic from 
 Easter, 1837, to Easter, 1840. His name appears in the catalogue of that University in_ 
 the sessions of 1845-46 for the last time. 
 
 9 Papyrus Ebers. Das Hermetische Buch iiber die Arzneimittel der alten Aegypten. 
 Leipzig, 1875.
 
 4 A SKETCH OF THE 
 
 A papyrus of later date is in the Berlin Museum. This has 
 been translated by Dr. G. Brugsh,' and there are also similar 
 manuscripts in the museums in Leyden, London, and Turin. 
 
 PROGRESS IN THE ANATOMY OF THE EAR. 
 
 Hippocrates probably knew very little of the anatomy of the 
 ear, although one passage is found in his works which indicates 
 that the membrana tympani was not unknown to him. 2 
 
 Alcmseon, a disciple of Pythagoras (570-504 B.C.), is said to 
 have had a knowledge of the art of dissecting the human body, 
 to have known the construction of the ear, and to have antici- 
 pated Eustachius in the discovery of the passage leading from 
 the tympanic cavity to the pharynx. Lincke thinks that this 
 much cannot be conceded to Alcmseon, since it rests only upon 
 his assertion, brought forth and denied by Aristotle, that goats 
 breathed through their ears. This statement of Alcmseon is said 
 to have rested upon other grounds than the existence of what 
 we call the Eustachian tube. Plutarch says, however, that 
 Empedocles discovered a snail-shaped cartilage in the ear 
 (KoxAioiSqs xovSpos), which he considered the real organ of hearing, 
 and that the vibrations of the air caused it to give forth a tone 
 which was then perceived by the soul. 
 
 The knowledge of Aristotle (384-322 B.C.) as to the anatomy 
 of the ear did not go beyond the membrana tympani. But Aris- 
 totle made numerous dissections of animals and many impor- 
 tant discoveries in anatomy. There are indications that he had 
 an indefinite idea of the Eustachian tube. 
 
 In the time of the Ptolemys in Egypt, when dissections of 
 the human body were instituted, Erasistratus made the discovery 
 that the nerves originate in the brain, and he traced them so 
 exactly to their origin that we find the acoustic nerve properly 
 indicated in his representations. 
 
 Rufus of Ephesus (A.D. 98-117), who was the first medical 
 lexicographer, and who lived in the age of Pliny, 3 used the names 
 helix, lobe, tragus, and anti-tragus, which are still employed to 
 describe the different parts of the auricle. He probably obtained 
 them from Herophilus, a contemporary of Erasisr^atus. 
 
 Marinus, the preceptor of Galen, and whom Galen named 
 
 1 Hartmann : Lehrbuch, Einleitung. 
 ' Tb Sfftua rb irpj? rrj OLKOT/J 
 
 irpbs rSi vffrtdi ru ir/cATjpw \tvrbf 
 
 Iffnv &<ritfp apaxviov, ripora -rov 
 
 TOV a\\ou Sepjuaroy. 
 3 History of Medicine (Dunglison), p. 169
 
 PROGRESS OF OTOLOGY. 5 
 
 the restorer of anatomy, called the acoustic and facial nerves 
 one, under the name of the fifth pair. 
 
 Galen (A.D. 130-200) does not seem to have made any great 
 advance in anatomical studies, and they were greatly neglected 
 down to the fifteenth century. The darkness of the blind lead- 
 ing the blind is scarcely broken for thirteen hundred years. 
 What Galen wrote, was authority, and naught else. One valiant 
 and polemic skeptic in medicine, would have effected more good 
 during these centuries than all the ponderous tomes that were 
 written by philosophers who reasoned upon premises that had 
 never been thoroughly established. As late as 1559, one Doctor 
 Geynes was called before the College of Physicians in London 
 for impugning the fallibility of Galen. On his acknowledgment 
 of his error, however, he was again received into the college. 1 
 The strong arm of the church, in the dark ages, prevented ana- 
 tomical investigations on the human cadaver, and for hundreds 
 of years anatomical knowledge remained at a standstill. 
 
 Galen, however, corrected the error of his preceptor in think- 
 ing that the facial and acoustic nerves were one, and showed 
 that the latter entered the meatus auditorius interims, a passage 
 which his predecessors had regarded as impermeable. He gives 
 no account of the anatomy of the internal ear, although he com- 
 pares it to a labyrinth, a name which Fallopius, fourteen hun- 
 dred years later, fastened on it forever. He believed that the 
 external auditory canal extended to the dura mater and touched 
 the auditory nerve. 
 
 There is no record of the ossicula auditus until the fifteenth 
 century. An Italian anatomist, Alexander Achillini, generally 
 has the credit of discovering the little bones, but it is probable 
 that he and Jacob Berengario first described them, although 
 they did not discover them. This is the opinion of the great 
 anatomist, Bartholomeo Eustachio. The discovery of the ossi- 
 cula auditus did not at first include the third and last of the 
 chain. 
 
 Berengario also first described the membrana tympani " with 
 exactness." The exactness of his knowledge, may be shown by 
 the fact, that he was doubtful whether the origin of the mem- 
 brane was in the acoustic nerve or the meninges of the brain. 
 
 Andreas Vesalius (1514-1564), who is said to have been the 
 most accurate anatomist of his day, 2 described the long process 
 of the malleus, the Eustachian tube, the vestibule, and the semi- 
 circular canals. He was a reformer in anatomical learning, he 
 
 1 Chambers's Encyclopaedia, American edition. Article, Galenus or Galen, 
 8 Dunglison : History of Medicine.
 
 6 A SKETCH OF THE 
 
 boldly attacked the views of Galen, showing the errors in his 
 teachings. His anatomical plates were made from drawings by 
 the best masters. They were published in a folio edition at 
 Basle in 1542. 
 
 The honor of the discovery of the stapes bone is claimed by 
 no less than three anatomists, viz. : Ingrassia, Columbo, and 
 the renowned Bartholomeus Eustachius (1604). The first named 
 wrote commentaries upon Galen's works, that were published 
 long after his death. He claims to have shown the bone to his 
 scholars in 1546, at Naples. Fallopio, or Fallopius, at one time 
 claimed to have had a part in the discovery of the ossicle, but 
 in view of his own greater discoveries he finally relinquished his 
 claim in favor of Ingrassia, after one of the latters pupils had 
 assured him, that Ingrassia had actually discovered and named 
 the bone. The weight of evidence, in spite of the opinion of 
 Eustachius, seems to lean toward the side of Ingrassia as having 
 the honor of the discovery. Anatomical and geographical sci- 
 ence were about this time in an embarrassed position from the 
 claims of priority of their discoverers. Fallopius did good ser- 
 vice, in the study of the anatomy of the ear, in describing the 
 tympanic cavity more accurately, the two fenestrse, and their 
 communication with the vestibule and the cochlea respectively. 
 
 The anatomical writings of Eustachius were published in 1563, 
 before his death, but the Tabulae, Anatomicce did not appear un- 
 til 1714, a century and a half afterward. He was probably unable 
 to publish these on account of his poverty. Of posthumous fame 
 he has had a large share. His anatomical plates were repro- 
 duced with Dutch and German commentaries in the latter 
 language as late as 1800. The Venetian edition of his works is a 
 beautiful specimen of printing. The part referring to the ear 
 occupies only seventeen pages yet his fame now rests chiefly 
 upon his description of the Eustachian tube. 1 
 
 Gabriel Fallopius (1523-1562), of Modena, died in the bloom 
 of youth, at thirty-nine years of age, 2 but he lived long enough 
 to accomplish much for anatomical science. He showed, among 
 other valuable points in the anatomy of the ear, that the mastoid 
 cells communicated with the cavity of the tympanum. He de- 
 scribed the fenestrse rotunda and ovalis, and gave his name to 
 the canal in which the facial nerve runs in its passage through 
 the cavity of the tympanum acquceductus Fallopii.* 
 
 The great Cuvier regarded Vesalius, Eustachius, and Fallo- 
 
 1 Bartholomaei Eustachii : Opuscula Anatomica Anatomica, MDLXHI. 
 
 2 Chambers's Encyclopaedia, p. 233. 
 
 3 Gabrielis Falloppii : Opera Omnia, Francfurti, MDC.
 
 PKOGKESS OF OTOLOGY. 7 
 
 plus as the three anatomists of the sixteenth century, to whom 
 belongs the honor of having restored this science. 
 
 Bartholomeo Eustachio (1500-1574) described the tensor tym- 
 pani as well as the stapedius muscle. He also gave a more ex- 
 act account of the tube leading from the pharynx to the middle 
 ear, which is called the Eustachian tube, although it was dis- 
 covered by Yesalius. He described the modiolus of the cochlea, 
 and gave a good representation of the membranous zone. He 
 also recognized the three portions of the facial nerve. 
 
 The first monograph on the anatomy of the ear was from the 
 pen of Volcher Koiter (1587), a student of Fallopius. It con- 
 tained no original observations, however. 
 
 Constant Varolius (1543-1573), ' so well known from his de- 
 scriptions of the brain, made the singular mistake of supposing 
 that the muscles of the cavity of the tympanum were nerves 
 which were torn by the sawing through of the bone. Subse- 
 quently he admitted this error ; but he went so far to the other 
 side, as to say that the tensor and laxator tympani muscles could 
 be moved at will. 
 
 Lincke does not think that the famous Fabricius of Aquapen- 
 dente (1537-1619) contributed very much to our knowledge of 
 the anatomy of the ear, while he led many away into error as 
 to some points. For example, he thought that the chorda tym- 
 pani nerve was a peculiar body, and not a nerve. At any rate, 
 Fabricius did good service by his labors as a comparative anato- 
 mist, and it should be remembered that he was the instructor of 
 the discoverer of the circulation of the blood. 
 
 The folio edition of his works, published in 1600, 3 contains a 
 very systematic and clear account of the anatomy of the ear as 
 then understood. He gives the name myrinx, as well as my- 
 ringa whence our myringitis to the membrana tympani. Fa- 
 bricius ascribes the discovery of the Eustachian tube to an 
 earlier date than that which assigns it to Eustachius. Accord- 
 ing to him Aristotle knew of it. 
 
 Julius Casserius (1593-1609), who was a professor in Venice 
 in 1609, a pupil and subsequently a rival of Fabricius, described 
 the fissures that make the cartilaginous portion of the canal so 
 flexible. He and Fabricius described the laxator tympani minor 
 in the same year, and both claim to have discovered it first. 
 Casserius also gave a better description than had hitherto been 
 done of the membrana tympani, the ossicula auditus, and the 
 labyrinth. He was the first to describe the two and a half 
 turns of the cochlea and the membranous zone. 
 
 1 Biographie Medicale. Paris. 
 
 y Heronymi Fabricii ab Aquapendente. De Visione, Voce, Auditu. Venetiis, 1600.
 
 8 A SKETCH OF THE 
 
 The function and physiological action of the ceruminor." 
 glands were first described by Nicolaus Stenon (1665). Lincke 
 speaks of him as Stenson ; but this must be a mistake in tran- 
 scribing the name of the great Danish anatomist. 
 
 Lincke ascribes to Du Verney the greatest reputation of any 
 of the anatomists of the seventeenth century who devoted any 
 attention to the ear. He threw new light upon many dark sub- 
 jects. He was the first to give good representations of the ceru- 
 minous glands, the Eustachian tubes, and the semicircular 
 canals with their five openings in the vestibule. 1 His plates are 
 particularly clear. 
 
 Passing on to the eighteenth century, we find Antonine Marie 
 Valsalva rising up a head-and-shoulders above the anatomists of 
 his age, and far exceeding his predecessors in the amount and 
 exactness of his knowledge. He devoted more than sixteen 
 years of his. life to the study of the anatomy of the ear, and for 
 the purpose of its study dissected more than a thousand heads. 
 His master-work was a treatise on the ear. 1 This work passed 
 through five editions in a short time. He described the attach- 
 ment of the tensor tympani to the Eustachian tube. He made 
 the mistake, however, of supposing that the ossicula auditus 
 had no periosteum, and that the cavity of the tympanum was 
 connected by many openings to the cavity of the cranium. He 
 discovered the muscle that opens the Eustachian tube and moves 
 the uvula. He also showed that the fenestra ovalis was covered 
 by membrane. His anatomical plates show a good knowledge 
 of the cochlea and semi-circular canals. 
 
 Morgagni (1682-1771), himself an original investigator, the 
 founder of pathological anatomy, a student and friend of Val- 
 salva, edited his master's work and made some additions. 
 
 Of Valsalva's contributions to the treatment of the ear, 
 which were quite as important as his anatomical investigations, 
 we shall have occasion to speak in the second part of this sketch. 
 Valsalva had a rival, whose name the lapse of time has well 
 nigh effaced, Raymond Vieussens (1714), who also wrote a work 
 on the ear. He gave new names to various parts of the organ ; 
 but his descriptions are said by Lincke, to be so mysterious that 
 his contemporaries could not understand them. 
 
 Rivinus (1717), professor in Leipsic, observed an opening in 
 the membrana tympani, which he believed to be a constant ana- 
 tomical condition. This supposed discovery excited the warm- 
 
 1 Tractatus de Organo Auditus. par Dr. du Verney. Nbrembergse, 1684. 
 * Tractatus de Aure Humana. Lugdunum Batavorum, 1742. Also, the same. 
 Trajecti ad Rhenum, 1717.
 
 PROGRESS OF OTOLOGY. 9 
 
 est discussion among such anatomists as Walther, Ruysch, 
 Morgagni, Cassebohm, and Valsalva. Hyrtl, until recently the 
 distinguished anatomical teacher of Vienna, thought that it was 
 a rent in a macerated membrane ; but his predecessor, Berres, 
 believed in its existence and described it minutely. 1 
 
 Professor Bochdalek, of Prague, has revived the question, 3 
 and has described the foramen of Rivinus as a constant opening 
 in the membrana tympani ; this author says that there are some- 
 times two. It is, however, according to Bochdalek, so small as 
 not to be seen without the aid of a magnifying glass. 
 
 In a discussion in one of the medical societies of Vienna, 3 
 Professors von Patruban, Gruber, and Politzer unite in affirm- 
 ing its existence, thus confirming Bochdalek's statement. 
 
 The famous Ruysch (1718) (Frederick), professor in Amster- 
 dam, contributed to our knowledge of the distribution of the 
 vessels of the cavity of the tympanum, and corrected Valsalva's 
 statement that the ossicula were not covered by periosteum. 
 
 Cassebohm (1730) (Joan. Frid.) published a monograph upon 
 the ear, in six parts, which Lincke calls " a monument to Ger- 
 man industry and German spirit of inquiry." " Ein Denkmal 
 deutschen Fleisses und deutschen Beobachtungsgeistes." He 
 disproved Valsalva's idea of the close connection between the 
 cavity of the tympanum and the cerebrum ; he described the 
 cochlea and the development of the auditory apparatus in 
 the foetus. 
 
 Brendel and Zinn (1747-1753), two Gottingen anatomists, the 
 latter of whom is well known as the describer of the suspensory 
 ligament of the lens, known as the zonula of Zinn, made further 
 investigations as to the structure of the cochlea. 
 
 Brendel discovered the opening uniting the two scalse, the 
 helicotrema of Breschet. Zinn describes the opening through 
 which the auditory nerve enters the cochlea. 
 
 It is claimed, in an inaugural thesis published in Erlangen in 
 1754, that Casimir Christopher Schmiedel, discovered the so- 
 called Jacobson's nerve. 
 
 Dominic Cotugno (1761), the discoverer of the fluid of the lab- 
 yrinth, won such a reputation by his work upon the internal 
 ear that he was called to the anatomical chair at Naples. He 
 was the first clearly to show that the labyrinth was filled with 
 fluid, and that this was one of the necessities for the perception 
 of sound. He described two canals, one opening in the vesti- 
 
 1 Prager Viertel. Jahrschrift, 1806, I. 
 
 s Troltsch on the Ear, 2d American edition, p. 26. 
 
 3 Monatsschrif t fur Ohrenheilkuude, Jalirgang III. , No. I.
 
 10 A SKETCH OF THE 
 
 bule, the other in the cochlea, and both communicating with the 
 cerebral cavity. They were named in his honor. 
 
 Phil Friederich Meckel confirmed and corrected the observa- 
 tions of Cotugno by injections of quicksilver. 
 
 Antonio Scarpa (1747-1832), nearly thirty years after the pub- 
 lication of Cotugno's writings, issued a work on the structure 
 of the ear, which brought the knowledge of its inner arrange- 
 ment to such a height, that it seemed to his contemporaries that 
 there was little more to be done. The investigations of our 
 own day have shown how premature was this expression. 
 Scarpa wrote upon the fenestra rotunda, which connects the 
 tympanic cavity with the lamina spiralis of the cochlea. He 
 described the osseous labyrinth with exactness, the membra- 
 nous labyrinth, arid the expansion of the acoustic nerve. 
 
 Scarpa was secretary to the octogenarian Morgagni, when 
 the latter had lost his sight, and he wrote letters of advice in 
 Latin at the dictation of his blind preceptor. His beautiful cop- 
 per-plate representations of the ossicles in situ, are somewhat 
 diagrammatic, but they are almost as instructive as the accu- 
 rate photographs of Rudinger of our own day. Those of the 
 semi-circular canals remain in some respects unsurpassed. 
 
 Saunders, Van der Hoeven, Alex. Fischer, Teole, and David 
 Todd (1806), also contributed essentially to complete our knowl- 
 edge of the anatomy of the ear. 
 
 Alexander Monro 1 (1797), "Professor of Anatomy, Medicine, 
 and Surgery " in the University of Edinburgh, was the author 
 of a monograph on the organ of hearing in man and other ani- 
 mals. It is a fine specimen of typography. In his preface he 
 states that Dr. Camper called in question his description' of the 
 semi-circular canal in whales, and that Scarpa said that some of 
 his teachings in regard to the human ear were erroneous. Pro- 
 fessor Monro, claims to have been the first anatomist to trace the 
 auditory nerve within the cochlea, vestibule, and semi-circular 
 canals. He quotes from Valsalva, Winslow, Cassebohm, Haller, 
 Cotunnius, Meckel, and others, to show that none of these anat- 
 omists had traced nerves into the cochlea. Dr. Monro seems to 
 make out a good case for himself as against Scarpa, as far as I 
 have been able to determine, and to be entitled to the credit of 
 having traced the nerves into the cochlea, before and with greater 
 minuteness than Scarpa, and he appears to have been correct in 
 his comparative anatomy. 
 
 Sir Everard Home (1800) wrote an excellent, and, for its time, 
 exact account of the membrana tympani in a paper for the Royal 
 
 'Three treatises on the Brain, the Eye, and the Ear. Edinburgh and London, 1797.
 
 PROGRESS OF OTOLOGY. 11 
 
 Society. 1 The measurements are accurately given, but Mr. 
 Home supposed that the fibrous layer was muscular. He seems 
 to have been a comparative anatomist of great ability. 
 
 Samuel Thomas Soemmering (1806), a great name in anatom- 
 ical science, contributed to otology by a series of plates of the 
 anatomy of the ear, 2 which are almost as well worth study to- 
 day as they were seventy years ago. 
 
 Henry Jones Shrapnell (1832) contributed a series of papers 
 to the London Medical Gazette.* He described the membrana 
 flaccida of the drum-head, its nerves, with clearness and accu- 
 racy. His description of the former is available for the student 
 of the present time, and ShrapnelFs membrane is probably firmly 
 fixed in the nomenclature of the anatomy of the ear. 
 
 Thomas Buchanan (1832), of Hull, brought out a monograph 
 illustrative of the anatomy and diseases of the ear. His ideas 
 as to the importance of the cerumen produced many errors in 
 treatment, from which the profession has not yet fully recov- 
 ered. He published four works ; the title of the last one illus- 
 trates what has just been said : " Physiological Illustrations of 
 the Organ of Hearing, more particularly of the Secretion of 
 Cerumen, and its Effects in rendering Auditory Perception Acute 
 and Accurate." 4 
 
 The distinguished English surgeon, T. Wharton Jones, Esq. 
 (1836-39), contributed to a great cyclopaedia an article on the 
 organ of hearing, which comprised all that was known up to 
 that time, and which is a very valuable monograph for refer- 
 ence. 5 
 
 We are now, in our review of the investigations of the anat- 
 omy of the ear, down nearly to our own time ; and we come to 
 the familiar names of Huschke, Arnold, Schlemn, Johannes 
 Miiller, Breschet, Boiinafont, and Toynbee (1824-51). 
 
 Huschke, and especially Breschet, examined the labyrinth 
 more thoroughly. Breschet called attention to much that was 
 incorrect in anatomical nomenclature. Bock, Jacobson, Arnold, 
 Schlemn, and Miiller greatly increased our knowledge of the 
 different nerve-tracts. The anatomical and physiological text- 
 books of Breschet, J. F. Meckel, Weber, Cloquet, and others, 
 added much to the common stock of anatomical knowledge. 
 
 1 Philosophical Transactions, 1800. The Croonian Lecture. 
 
 . - Samuelis Thomae Soemmering : Icones Organi Auditus Humani. Francof urti ad 
 Mcenum, 1806. 
 
 3 Vol. x., 1832. 
 
 4 Mr. Wilde on the early history of Aural Surgery. Dublin Medical Journal, 1844, 
 p. 441. 
 
 6 Cyclopaedia of Anatomy and Physiology. Edited by Robert B. Todd.
 
 12 A SKETCH OF THE 
 
 These authors grouped and assimilated facts that the centuries 
 had produced, and added not a few, as the result of their own 
 labors. 1 
 
 Toynbee " (1851) investigated anew the membrana tympani. 
 He especially added to our knowledge in regard to the fibrous 
 layer, and described, for the first time, the dermoid layer. This 
 paper was published in the "Philosophical Transactions." It 
 was preceded by papers in the " Medico-Chirurgical Transac- 
 tions," on the pathological anatomy of the ear, papers which 
 have given Toynbee lasting fame, because they did very much 
 to place otology upon as sound a basis in pathology, as that it 
 had obtained in anatomy, by the labors we have enumerated. 
 
 Toynbee's statements, that the Eustachian tube was usually 
 a closed canal, that muscular action was required to open it, and 
 that swallowing was a simple way of effecting this, led to Polit- 
 zer's method of inflating the ear, of the value of which procedure, 
 more will be said in our review of the progress in therapeutics. 
 
 Von Troltsch (1856) began a series of anatomical investiga- 
 tions which, we may hope, have not yet ended. His contribu- 
 tions relate to the structure of the membrana tympani, the 
 muscles of the Eustachian tube, and the pathological anat- 
 omy of the middle ear. He described two peculiar constant 
 formations on the inner side of the membrana tympani, (pockets) 
 which had only been mentioned by Arnold, as folds of mucous 
 membrane. In the course of some investigations of the cavity 
 of the tympanum of the foetus, he also found that it was filled 
 with a proliferation of the mucous membrane of the labyrinth 
 wall, which forms a mucous cushion that rapidly lessens in size 
 after birth. This anatomical fact, explained the frequency of 
 inflammations of the middle ear in young children. 
 
 Gerlach s (1858) followed Toynbee in the investigation of the 
 fibrous layer of the membrana tympani, and showed that in the 
 extreme periphery the circular fibres were wanting. 
 
 Magnus (1860) investigated anew the articulations of the os- 
 sicula, and asserted that there was no real joint between the 
 malleus and incus. He also denied the voluntary or involuntary 
 contraction of the tensor tympani muscle. 
 
 Politzer and Lucse (1862) published the results of experi- 
 ments, which were supplementary to those of Miiller, showing 
 that the origin of a certain crackling sound in the ear was not 
 in the tendon of the tensor tympani, but in the Eustachian tube. 
 Politzer also made valuable experiments upon intra-auricular 
 pressure, proving that in the Valsalvian method of inflating 
 
 1 Lincke : Band I., p. 27. * Diseases of the Ear. English edition. 
 
 3 Schwartze, Archiv fur Ohreuheilkunde. Bd. L
 
 PROGRESS OF OTOLOGY. 13 
 
 the ear, not only were the tympanic cavity and the membranes 
 of the fenestrse of the labyrinth with the membrana tympani, 
 placed under an abnormal pressure, but also the contents of the 
 labyrinth the labyrinthine fluid, the membranous labyrinth, 
 and the termination of the acoustic nerve. 
 
 Lucse ' showed that a vibrating tuning-fork placed on the 
 mastoid process set the membrana tympani and ossicula auditus 
 in vibrations which could be represented. 
 
 Corti J (1851), an Italian anatomist, reviewed the work of his 
 countrymen who studied the cochlea in preceding centuries, 
 and divided the lamina spiralis membranacea into two different 
 broad zones an inner one, Zona denticulata ; and an outer, 
 Zona pectinata. He described a regular arrangement of pillars 
 or rods like the strings of a miniature harp, parts now known as 
 Corti's pillars, and for some time supposed to contain the termi- 
 nation of the acoustic nerve. 
 
 Kolliker, Claudius, Bottcher, and Deiters, followed Corti in 
 investigations of this part, which will be fully noticed in discuss- 
 ing the anatomy of the internal ear. 
 
 Hyrtl (1858), an anatomist of great industry and reputation, 
 made an important discovery of the frequency of a thin and por- 
 ous bony covering to the cavity of the tympanum, and thus 
 explained how readily, in certain cases, an otitis may become a 
 meningitis. 
 
 The pathological anatomy of the ear, which may be said to 
 have been first accurately studied by Toynbee, has received large 
 additions since his time at the hands of German, English, and 
 American writers, among whom are Hinton, Meniere, Voltolini, 
 Troltsch and Schwartze. Many contributions upon pathological 
 subjects have been made of late to the various otological jour- 
 nals. Moos and Steinbrugge, especially have begun to furnish 
 accounts of the pathology of the cochlea, which are steps toward 
 the clearing up of a dark chapter in aural pathology. 
 
 The chief advances in aural patholgy, since the above was 
 written are in the investigation of mastoid abscesses and their 
 relation to diseases of the brain. The connection between sup- 
 purations of the tympanum and of the mastoid, is beginning to 
 be more clearly understood. The surgeon has become more 
 anxious to secure free drainage from the tympanum, in order to 
 prevent transferrence of the suppuration to the cerebrum, with 
 its inevitably fatal results. Besides, he does not even hesitate 
 to attack the brain substance itself when he has good reason to 
 believe that pus has formed in it. 
 
 1 Virchow's Archiv. Bd. XXV., Hefte 3 nnd 4. 
 
 ! A Manual of Histology. Strieker, p. 1054 (Translation).
 
 14 A SKETCH OF THE 
 
 PROGRESS IN AURAL THERAPEUTICS. TEXT-BOOKS, DISPENSARIES, AND 
 
 HOSPITALS. 
 
 In the earlier ages, the progress in the treatment of the ear 
 by no means kept pace with the advance in the knowledge of its 
 anatomy. While the structure of the organ was sufficiently well 
 understood to cause the investigation of its diseases to be both 
 interesting and profitable, the treatment was crude and illogical, 
 unworthy of the knowledge which should have been its basis. 
 
 Herodotus 1 says that there were specialists in Egypt, a par- 
 ticular physician for each disease, but no mention is made of 
 aurists. " The art of medicine is thus divided amongst them ; 
 each physician applies himself to one disease only, and not 
 more. All places abound in physicians ; some physicians are 
 for the eyes, others for the head, others for the teeth, others for 
 the parts about the belly, and others for internal diseases." 
 
 Although Hippocrates knew very little about the anatomy of 
 the ear, he speaks at some length of the causes of aural disease. 
 For many of these, he must have drawn upon his imagination. 
 They were very comprehensive, and may properly be said to ex- 
 plain almost anything. They are such as heat, cold, dryness, 
 moisture, the blood, mucus, and the yellow and black bile. 
 
 Hippocrates considered internal inflammation of the ear as 
 essentially an inflammation of the head. He described pains in 
 the ear connected with high fever as a very dangerous disease, 
 and he states that if neither pus escaped from the ear, nor blood 
 from the nose, the death of the patient usually occurred from the 
 ninth to the eleventh day. This was probably the disease that we 
 now name acute catarrh of the middle ear, and the great medical 
 philosopher was certainly right in calling it a serious one. 
 
 Among all the improper remedies which Hippocrates recom- 
 mends to be dropped into the ear, there is one good one, although 
 it is a very simple application, which is often thought to be a sug- 
 gestion of our own day ; that is, the instillation of warm water. 
 The great physician advises the water to be poured in by means 
 of a sponge. If this simple, but often efficacious treatment were 
 universally practised in cases of acute inflammations of the outer 
 and middle ear, it would alleviate a great deal of suffering. 
 
 Hippocrates seems to have had an eye to the effect upon the 
 patient's mind, to use no harsher language, if we may believe 
 that the following passage was not, as Lincke insinuates, interpo- 
 lated : a "If any person has a pain in his ear, the physician should 
 roll a bit of wool about his finger, and then pour some warm oil 
 into the ear, and then taking the wool in the hollow of his hand, 
 
 1 Herodotus, translated by Gary. Euterpe, p. 125. 
 1 Lincke's Handbuch, Bd. II., p. 5.
 
 PROGRESS OF OTOLOGY. 15 
 
 and hold it before the ear, in order to make the patient believe 
 it has come out of it. In order that the deception may be com- 
 plete, the wool should be at once thrown into the fire." 
 
 Hippocrates laid considerable stress upon certain aural symp- 
 toms in constitutional disease. For example, he considered the 
 presence of sweet ear-wax as a bad symptom, while that of the 
 bitter was not. He noted that acute aural disease, sometimes led 
 to a fatal result on the third 'day after its occurrence. This indi- 
 cates his perfect appreciation of the serious character of such a 
 form of disease. He says that deafness following a fever is 
 sometimes cured by nasal hemorrhage or diarrhoea, and so forth. 
 
 Heraclides of Tarent, advises caustics made of verdigris, 
 copper filings, and honey, for the removal of granulations aris- 
 ing from abscesses in the ear, and for hemorrhages from the 
 ear, the juice of white horehound, quince, and gall-nuts mixed 
 with vinegar. Galen quotes much from Apollonius in regard to 
 remedies for various affections of the ear. A famous remedy 
 for earache was burned opium and castoreum. Apollonius rec- 
 ommended the oil of bitter almonds for fleas and maggots in 
 the ear. He removed foreign bodies by means of ear-spoons, 
 little hooks, and probes, which were wound about with wool and 
 dipped in turpentine. Hardened cerumen he softened with a 
 solution of saltpetre in vinegar, and then cleaned the ear with 
 lukewarm water or oil. 
 
 Asclepiades, a friend of Cicero, recommended instillations 
 for the ear, of oil in which three or four cockroaches or an 
 African snail were cooked, while a piece of henbane in oil of 
 roses, or woman's milk, is to be afterward added. 
 
 Aulus Cornelius Celsus (B.C 44-A.D. 19) also used a compo- 
 site remedy which was said to be of service in all kinds of dis- 
 eases of the ear. It was made of cinnamon, cassia, blossoms of 
 bulrushes, castoreum, white pepper, ammonia, myrrh, and saf- 
 fron, as well as of various other agents. These substances were 
 all rubbed up with vinegar, and diluted with the same agent 
 when used. Celsus, in his treatise " De Medicina," spoke in 
 some detail of aural disease. He was perhaps the first to recom- 
 mend vigorous injections of water in order to remove foreign 
 bodies from the ear, although this proper recommendation car- 
 ries less weight than it would have done had it not been mingled 
 with a great deal of bad advice, which shows that a disposition 
 to use the simplest means for a desired end, is not always con- 
 nected with great learning. Celsus recommends in obstinate 
 cases of a foreign body in the ear, that the patient should be 
 laid upon a table, and upon the side of the affected ear, when 
 the surgeon should strike with a hammer upon the table, in
 
 16 A SKETCH OF THE 
 
 order to dislodge the foreign body by the concussion. Celsus also 
 recommends plastic operations for the restoration of lost or dis- 
 figured auricles, unless the subjects be unhealthy and cachectic. 
 
 Among the mass of writers mentioned by Lincke, as being 
 before 1 Galen's time, Archigenes seems to have had some cor- 
 rect notions. He practised venesection for severe pain in the 
 ear, and employed purgative enemas, warm baths to the ear, 
 especially by means of a sponge dipped in hot water. He warns 
 against the use of cold water. He also has his method of re- 
 moving a foreign body from the ear, and recommends a vigorous 
 shaking of the affected head. A child is to be seized by the 
 feet and well shaken, while adults are to be held very much as 
 Celsus proposed ; that is, they are to be laid on a table, while 
 the leaf of it nearest the head is to be repeatedly opened and 
 shut with a slam. Archigenes, like other ancient authorities, 
 however, thinks very much of instillations of various kinds for 
 the relief of the different forms of deafness. He recommends 
 speaking-tubes to the deaf. 
 
 Galen (A.D. 130-201) recognized the importance of the ear, in- 
 asmuch as it lies so close to the head. Although his classifi- 
 cations of disease are very minute, we do not learn much from 
 his writings, except the value of agents that will excite the 
 secretions of the nose and mouth, which he recommends in aural 
 disease. He complains of the empirical practices of his pre- 
 decessors, in ordering now cold and now warm remedies, now 
 sweet and now sour ones. 
 
 He also tells of a poor patient of some less learned or less 
 practical man than himself, who, in accordance with advice, 
 used black pepper as a local means of treatment for an inflamed 
 ear, and whose sufferings were so much augmented, that he 
 came near hanging himself. Galen objects to the too common 
 use of opium, which seems to have been employed very much 
 in relieving the pain of aural disease. Tinnitus aurium, accord- 
 ing to Galen, was due in some cases to exhalations from the 
 stomach, and in others to increased sensitiveness of the ears. 
 Both of these causes, certainly leave much to be wished for in 
 the way of exact knowledge as to the nature of this distressing 
 symptom. It would be tedious in the extreme to follow Galen, 
 through his classification of diseases of the ear and remedies 
 for them. Like his predecessors and contemporaries, he was 
 not willing to admit that there were some diseases for which 
 remedies were useless, so far as their knowledge went. The 
 aural prescriptions of the ancients were usually extremely com- 
 posite and correspondingly dangerous. 
 
 Galen makes some very sensible remarks about the various
 
 PROGRESS OF OTOLOGY. 17 
 
 kinds of sounds that are pleasant or otherwise to the ear. The 
 soft and slow tones of the human voice, in his opinion, are much 
 the pleasantest to the human ear. A rough and quick voice 
 is distressing. Fine ears tolerate only a weak, soft voice, 
 diseased ears, only a very geiltle and weak tone, sometimes 
 even absolute silence. If Galen had lived in the nineteenth 
 century, and in New York with its uneven pavements, boiler 
 shops, locomotive whistles, elevated railways, and Wagner 
 music, he might have added largely to his category of sounds 
 unpleasant to tired and morbid ears. Galen's classification was 
 a subjective one ; for example : 1, Otalgia ; 2, hardness of hear- 
 ing ; 3, cophosis ; 4, paracusis ; 5, paracousmata, or hallucina- 
 tions of hearing ; but it was not without value. 
 
 For earache from a cold, he recommends the warming method 
 by means of wolf's milk or pepper mixed with old oil. For 
 "inflammatory earache" fatty or oily substances are recom- 
 mended, the fat of geese and hens ; and if the pain be very 
 severe, a mixture of opium, musk, and the white of an egg, with 
 or without the addition of castoreum, or a solution of opium in 
 thickly cooked juice of fruit. All these substances were poured 
 while warm into the ear. 
 
 Dioscorides and Plinius, recommend a host of remedies for 
 aural disease. Among others, the latter advises the excrement 
 of pigeons and the ashes of horses' dung. 
 
 Cselius Aurelianus, a successor of Galen, stands out promi- 
 nently from the absurd theorizers of his time, in his clear de- 
 lineations of pain in the ear and his sensible remedies for it 
 leeches, cups, poultices, mustard-plasters, and so on. 
 
 About this time we read of the materia medica of Marcellus, 
 who gives us a glimpse of the popular remedies of the day. 
 Frog's fat is recommended for pain in the ear ; the urine of 
 pigs, of children and men, and the blood of young chickens for 
 an ulcer in the ear ; for worms in the organ, the saliva of a 
 hungry man, and so forth. We see a great deal in the ancient 
 literature, concerning worms in the ear ; so that we must con- 
 clude that they were much more commonly found in the olden 
 time than with us. This was probably due to the fact that cases 
 of neglected suppuration were very frequent, and that living 
 larvse were thus often developed. 
 
 The famous surgeon and obstetrician, Paulus ^Egineta (GOO 
 A.D.), who flourished in the seventh century, should be remem- 
 bered as a contributor to the surgery of otology. He expended 
 much energy on the subject of foreign bodies in the ear, a field 
 which has unfortunately always suffered from surgeons over- 
 anxious for operations. 
 2
 
 18 A SKETCH OF THE 
 
 Paulus ^Egineta made a good classification of cases of closure 
 of the external auditory canal : 1, congenital ; 2, from ulcera- 
 tion ; 3, superficial or deep. He gives sound advice as to the 
 removal of aural polypi, divides deafness into congenital and ac- 
 quired, and seems altogether to'have been a man in advance of 
 his time. His surgical writings are said to abound in novel and 
 ingenious views. He suggested the operation of detachment of 
 the auricle for the removal of foreign bodies situated in the 
 tympanic cavity or deep in the external auditory canal. This 
 operation was again advised by Troltsch and was performed 
 (1871) by the author of this volume, and by Orne Green (1881), 
 and Buck (1882), and in spite of theoretical objections urged 
 against it, has proved itself a practical operation in certain cases. 
 Hippocrates, also, is said to have recommended this procedure. 
 
 Guido Guidi (1595) about this time, in his recapitulation of the 
 works of Hippocrates, Celsus, Galen, Paul of JE>gina, and others, 
 gives the sensible advice to keep the ear uncovered, and the 
 meatus unstopped, in order, as he says, that sound may enter it 
 properly and the ear-wax run out freely. For congestion of the 
 ear, he advises leeches placed in the nostrils. 
 
 According to Lincke, the Arabians got their knowledge of 
 otology, whatever it was, from the Greeks, of whom Galen was 
 the chief authority ; so that we can only add a few more absurd 
 remedies as their contribution to knowledge : for deafness, the 
 brain of a lion mixed with oil (the brain, not the lion) is advised 
 by Rhazes. Serapion advises instillation of woman's milk, for 
 the cure of earache in children, and he gives the important 
 caution, that the milk must be that of a woman who is nursing 
 a female infant, if it be a boy, who is affected. 
 
 As we have seen in noticing the progress in our knowledge 
 of the anatomy of the ear, the centuries from Galen to Valsalva 
 were dark ages for our science. Lincke says: "Otology re- 
 mained at the same point at which the Grecian, Roman, and 
 Arabian physicians had left it." In Lincke's own list of the 
 progress of these centuries we find traces of ignorance and em- 
 piricism only. One author named Gadesden recommends that, 
 in cases of inflammation of the ear, one of the lower classes be 
 hired to suck out all the morbid material of the ear, by means 
 of a tube placed in the meatus externus ; and this is said to be 
 a cure for all kinds of deafness, not even excepting that from 
 a purulent affection of the organ. Lincke believes that Peter de 
 la Cerlata was the first to use a speculum for widening the audi- 
 tory canal for purposes of inspection. ' 
 
 "The passage quoted to sustain this view is "per inspectionem ad solem traJtendo 
 aurem et ampliando cum speculo aut olio instruments.^
 
 PROGRESS OF OTOLOGY. 19 
 
 Johannes Arcularius (1560) gave some sensible rules for the 
 management of aural disease. He declaimed, for instance, 
 against the indiscriminate practice of stuffing the ear with cot- 
 ton ; but he advised an extremely peculiar means of extracting 
 a foreign body from the ear. ' The head of a lizard is to be 
 cut off, placed in the affected ear, and allowed to remain there 
 for three hours. The animal is then to be removed, when the 
 foreign body will be found in its mouth. 
 
 Alexander Benedetti (1560) recommends, as a remedy for 
 pain in the ear, the semen of a boar, which is to be carefully 
 taken from the vagina of a sow before she has dropped it upon 
 the ground. This, however, is the suggestion of a writer on 
 general medicine, and not on otology. 
 
 Gabriel Fallopius (1523-1562), professor of anatomy, surgery, 
 and botany in Ferrara and Padua in this century, seems to be 
 entitled to the honor of having first taught that a discharge of 
 pus from the ear of a child should not be meddled with ; for 
 as Fallopius gravely taught, and as was gravely repeated by 
 some of his legitimate successors for more than three hundred 
 years, this discharge of pus is an effort of nature to throw 
 morbid material out of the head through the ear. The otorrhosa 
 of adults, according to Fallopius, is also a discharge from the 
 brain, and should not be treated by astringents, but with mild, 
 cleansing remedies. He used an aural speculum, and employed 
 sulphuric acid to remove polypi. 
 
 The great revolutionist in medicine, Paracelsus (1490-1544), 
 who began his lectures at Basle, by burning the books of his 
 predecessors, and who afterward boasted of having read no 
 books for ten years, seems to have paid very little attention to 
 the treatment of diseases of the ear. Deafness he considered to 
 be incurable, "for what nature had once taken away a physi- 
 cian could by no means restore." He had, however, like all the 
 ancients, his remedy for worms in the ear, and one for each kind 
 of worm. 
 
 In the latter half of the sixteenth century, a certain Capivacci 
 seems to have deviated a little from the errors of his predeces- 
 sors. He speaks with more precision of aural disease. He de- 
 scribes thickening, ulcers, and cicatrices of the membrana tym- 
 pani, and says that deafness which arises from an affection of 
 the nerve or labyrinth is incurable a declaration which his 
 successors, three hundred years after him, find true of a large 
 proportion of cases. Capivacci also describes a method of mak- 
 ing a differential diagnosis between the diseases of the per- 
 ipheric, and of the central parts of the organ of hearing. One 
 end of an iron rod, an ell in length, is put between the teeth of
 
 20 A SKETCH OF THE 
 
 the patient, while the other is placed upon a keyed musical in- 
 strument, such as a zither. If he could distinguish the tones 
 produced by the vibrations of the keys of the instrument, his 
 deafness depended upon some lesion of the membrana tympani ; 
 if not, it was an affection of the nerve. Here we see glimpses 
 of deduction from the anatomical knowledge of the time. 
 
 In the seventeenth century, we hear of De Vigo (1600), body- 
 surgeon to Pope Julius II., curing his Holiness of a very obsti- 
 nate abscess of the right ear by means of a mixture, or lini- 
 ment, of 3 ij- of oil of eggs with 3 iij. of oil of roses. What kind 
 of an abscess this was, or where it was situated, Lincke does 
 not tell us. De Vigo was opposed to the removal of foreign 
 bodies by means of the detachment of the auricle, because this 
 part was too sensitive for an operation, and quiet natura sagax 
 raro vel nunquam deficit in orsis bonis operationibus. 
 
 Peter Forest, who may have been an Englishman, judging 
 from his name, but who practised in Rome in this century, to 
 whose works Lincke gives no definite reference, collected fifteen 
 cases of aural disease that seem to have been carefully observed. 
 One is a case of disease of the ear, ending in an affection of the 
 brain and death. He speaks of pain in the ear caused by the 
 rays of the sun, and he tells a wonderful story of a female deaf 
 for seven years so deaf that she could not hear a clock strike 
 who, being advised by that character so common in medical 
 scenes, an old woman, to put some musk in her ear, did so, and 
 was cured. He also tells how his teacher, Gisbert Horst, the di- 
 rector of a hospital in Rome, used to cure deafness with water 
 that had been distilled over a young mouse having no hair. 
 
 We trace one of the delusions that still lingers among us 
 namely, that the hearing is completely destroyed when the 
 membrana tympani is broken to a writer named Hercules Sas- 
 sonia, who lived in this century. He also had the peculiar no- 
 tion that patients always spoke in a low tone when the disease 
 of the ear was seated in the auditory nerve, because the nerve 
 supplying the tongue, a branch of the fifth, was at the same time 
 affected. In deafness arising from venereal disease, blisters 
 behind the ear and a mixture of oil of guaiacum and hydro- 
 chloric acid as a local application, of which the patient drank a 
 little, were highly spoken of. 
 
 The great Frenchman, the father of modern surgery, Am- 
 broise Pare (1510-1590), figures in otological history as the first 
 one to employ a syringe for cleansing the ear. He also recom- 
 mended artificial auricles of papier mache or leather. 
 
 It was in the latter half of the sixteenth century, that zeal 
 for the education of deaf mutes first began to exhibit itself. It
 
 PROGRESS OF OTOLOGY. 21 
 
 is probable that the Greeks and Romans made no efforts in this 
 direction, for they had decided that nothing reached the intel- 
 lect except through the hearing, that there could be no intel- 
 lectual process without hearing, and they had given over deaf 
 mutes as they did idiots and insane people. Although isolated 
 instances had been noted of instruction for the deaf mute in- 
 stances like that of the dumb youth taught by one of the early 
 English bishops, St. John of Beverley they were generally con- 
 sidered as supernatural occurrences. Rodolphus Agricola, of 
 Groningen, born in 1442, stated that he knew of a deaf mute 
 who had been taught to write and note down his thoughts. 
 Fifty years afterward this was denied, on the ground that no one 
 could be instructed who could not be taught through the ear. 
 
 Jerome Cardan, who was born in Pavia in 1501, is said to be 
 the man who showed that written characters and ideas may be 
 connected together without the use of sounds. This fact, now 
 universally accepted and assumed, was a new idea in the six- 
 teenth century. Benedictine monks in Spain, first put Cardan's 
 principles into practice, and from that country they gradually 
 spread throughout the civilized world, until now in every nation 
 the deaf mute, like his more fortunate fellows, has an oppor- 
 tunity for education. The reader has seen what a great debt the 
 scientific world owes to Italy, and nowhere is this more apparent 
 that in what was promulgated by Cardan. ' 
 
 Caspar Tagliacottzi (1597), of Bologna, who did so much for 
 plastic surgery, did not neglect the ear, but attempted to restore 
 the auricle by taking integument from the adjacent skin. He 
 relates one case, that of a Benedictine monk, for which he had 
 done this with success. 
 
 Although the aural speculum had been used a hundred years 
 before, we find a certain Johami Hartman (1(390), a disciple of 
 Paracelsus, very unwilling to use it ; for he advised the detec- 
 tion of inspissated cerumen by the following simple method. 
 He placed a curved silver tube into the ear and blew through it. 
 If the patient felt the breath to be cold, the deafness did not 
 proceed from impaction of wax. In our day the detail of this 
 method is sometimes simplified without altering the principle ; 
 that is to say, a probe is used to see if wax is in the ear. Through 
 all this century, the seventeenth, there are numerous volumes 
 on the treatment of the ear, but they all tread through the bar- 
 ren waste of drops and decoctions, theories, nomenclatures, and 
 rank empiricism. 
 
 Lusitanus gives an amusing explanation of the practice of 
 
 1 Encyclopaedia Britannica, Vol. VII. Article, Deaf and Dumb.
 
 22 A SKETCH OF THE 
 
 cutting off the ears of thieves. He said that such treatment 
 rendered them incapable of propagating their kind, and hence no 
 more thieves could be born of them. He founded this opinion 
 on the statement of Hippocrates that the division of the veins 
 behind the ear, rendered a man sterile, because the semen, which 
 was generated in the head, could no longer pass down to the 
 genitals. 
 
 Johann Baptista van Helmont, evidently a Belgian, casts 
 away the theory that had so long prevailed, of deafness being 
 caused by ascending exhalations, and clears up the whole matter 
 by ascribing it to the work of the devil, or other evil spirits. 
 
 Marcus Banze (1640) gives us the first idea of an artificial 
 membrana tympani, by proposing to place a tube of ivory, the 
 end of which is covered by a bit of pig's bladder, in the auditory 
 canal, as a protection to the exposed ear, when the membrana 
 tympani was lost by ulceration. He did not, however, propose 
 this as an improvement to the hearing power. 
 
 The renowned surgeon, Fabricius of Hilden (1646), or Fabri- 
 cius Hildanus, so called to distinguish him from Fabricius of 
 Acquapendente, contributed somewhat to the surgery of the ear. 
 He invented an instrument for extracting foreign bodies from 
 the ear, as, indeed, every surgeon of eminence seems to have 
 thought it his duty to do. This instrument consisted of a large 
 tube which was introduced into the auditory canal down to the 
 foreign body ; of a smaller tube with a toothed extremity placed 
 inside of this, and in this again a trephine, which was turned 
 in an opposite direction from the second tube containing the 
 teeth. He also wrote of the removal of aural polypi. 
 
 In the latter half of the seventeenth century, Thomas Willis ' 
 attempted to prove, by experiments on animals, that total deaf- 
 ness does not ensue when the membrana tympani is destroyed. 
 He also made some interesting observations on deaf persons 
 who only heard in the midst of a noise. The most interesting 
 one is that of a woman who could only hear her husband when 
 a servant was beating a drum. The conversations in that 
 family were probably not very protracted. This kind of im- 
 pairment of hearing, which was called paracusis Willisiana, 
 was referred by its describer to a relaxation of the membrana 
 tympani, the normal tension being restored by the noise, or 
 vibrations of the atmosphere. These observations will be found 
 in full in the latter part of this book. 
 
 Du Verney (1683), known by his labors in the anatomy of the 
 
 1 Opera Omnia Amstersedamia apud Henricum Wetsteinum. Pars physiologica. 
 Cap. xiv. , p. 67.
 
 PROGRESS OF OTOLOGY. 23 
 
 ear, and his work on its diseases, contributed very little to sound 
 knowledge, although he made an attempt to arrange the dis- 
 eases in accordance with the anatomy. He however, disputed 
 the generally accepted opinion that a discharge of pus from the 
 ear came from the brain, and showed that the meatus audi- 
 torius internus was closed by the auditory nerve, a*nd that the 
 pus must pass through the cochlea and the f enestra ovalis and 
 fenestra rotunda, before it could get into the external auditory 
 canal. 
 
 Du Verney modified the suggestion of Hippocrates to get at a 
 foreign body not otherwise easily removed, by making an open- 
 ing behind the ear, and recommended that the incision be made 
 upon the upper side, because the vessels are smaller in this po- 
 sition. He thus anticipates Von Troltsch, who made the same 
 modification of the original suggestion nearly two hundred 
 years later. 1 
 
 In the works upon the ear that appear in this century, we still 
 continue to hear much of the presence of worms, or living lar- 
 vae a state of things, however common among the ancients, 
 that is now very rare, because suppurating ears are usually 
 cleansed. The disgusting and magical ear-drops of the early 
 and dark ages are still used in this latter part of the seventeenth 
 century. Thus one writer records, that a Capuchin monk mixed 
 the urine of a female donkey, that had brought forth but once, 
 with that of a male hare, of a wolf, or in case of the absence 
 of the latter, of an entirely white goat, warmed it, and adding a 
 little oil of caraway, used it as drops for the ear. Urine of the 
 various animals figures largely among the ear-drops of the pe- 
 riod. Paullini, one of the writers of the day, is in doubt, how- 
 ever, whether it is proper that women should use the renal 
 secretion of dogs as a remedy for deafness. 
 
 We begin to hear more in the latter part of the seventeenth 
 century of the education of the deaf and dumb, but it is mingled 
 with much that is absurd in attempts at treatment. The great 
 error was then made, as it often is now, of supposing that the 
 diseases of the ear which produced deaf-muteism, were of a dif- 
 ferent nature from those which in the adult cause deafness only. 
 
 John Wallis, an Englishman, was perhaps the first to in- 
 struct a deaf-mute to speak and he instructed him so that he 
 spoke very well. The case was one of acquired deaf-muteism, 
 the patient having lost his hearing at eight years of age ; but 
 he became able to read the Bible aloud, and to converse with 
 some fluency. 
 
 Diseases of the Ear. English translation, p. 488.
 
 24 A SKETCH OF THE 
 
 Lincke begins his account of the progress of otology in the 
 eighteenth century, with the lament that it did not keep pace 
 with the anatomical investigations of the ear, which had been 
 brought to such a high point by the labors of Valsalva, Casse- 
 bohm, Cotugno, and Scarpa, and he says that otology would 
 have advaifced very much faster, had Antoine Marie Valsalva 
 devoted himself more to its prosecution. But Valsalva did 
 much to give us correct notions in regard to the diseases of the 
 ear. He proved that there were cases where the membrana 
 tympani had been restored. He showed that the hearing power 
 is merely impaired, not lost, by a perforation of the membrana 
 tympani. He recognized anchylosis of the base of the stapes as 
 a cause of deafness. He gave us the Valsalvian experiment 
 the mode of forcing air through the Eustachian tube by a forced 
 expiration, with the mouth and nostrils closed and he advises it 
 as the best means of cleansing the middle ear from pus. He 
 proved that the cavity of the tympanum is connected to the cells 
 of the mastoid process, by a case in which he injected the former 
 through a fistulous opening in the latter. 1 He also showed that 
 closure of the Eustachian tube is often a cause of impairment 
 of hearing. This is certainly a refreshing catalogue after we 
 have been wading through the disgusting empiricism of the 
 centuries before. 
 
 He reports the case of a man who suffered from a nasal poly- 
 pus, which gradually by its growth closed the pharyngeal orifice 
 of the Eustachian tube, and caused deafness. He also relates 
 the case of a man, who suddenly lost his hearing while suffering 
 from a pharyngeal ulcer in the neighborhood of the tube, when 
 a tent was placed in the ulcer, but who immediately regained it 
 when the tent was removed. Valsalva's century is, however, 
 also cursed with theoretic treatises on aural disease, such as 
 that of one Frederich Hoffmann, who goes on, in the good old 
 way, with instillations of wonderfully compounded ear-drops. 
 Lincke mentions numerous inaugural dissertations of this time, 
 but they relate chiefly to cases that were not properly understood 
 by the reporters of them ; and these authors, as well as their 
 theses, are deservedly forgotten. 
 
 J. L. Petit (1774), in a work upon surgical diseases, reports 
 many interesting cases of caries of the temporal bone. In one 
 case of suppuration in the ear, with caries of the mastoid, he ad- 
 vised that this part should be cut down upon and trepanned. 
 
 1 As I have elsewhere shown, this case was for a long time supposed to be one of 
 perforation of the mastoid by a surgical operation. See chapter on the diseases of the 
 mastoid.
 
 PROGRESS OF OTOLOGY. 25 
 
 His advice was not followed, and the patient died. He also re- 
 lates cases where this operation was successfully performed, 
 and he must therefore be considered as the originator of this 
 valuable means of treatment. ' 
 
 We then come to the famous postmaster of Versailles, Guyot 
 (1724), who first injected the Eustachian tube. His own hearing 
 was impaired, and in order to relieve it he introduced an angu- 
 lar tube of tin through the mouth, opposite (gegen), not into, the 
 Eustachian tube. The distal extremity of this instrument was 
 attached to a leathern tube. This was connected to the reser- 
 voir of two small pumps, which were moved by two cranks and 
 a wheel fastened in machinery, by means of which he forced 
 fluid through a curved pewter tube, placed behind the uvula, 
 into, or about, the mouth of his Eustachian tube, and relieved 
 the impairment of hearing. 
 
 Beck 2 (1735), who quotes from the "Hist, de 1'Acad. des 
 Sciences," thinks that Guyot washed out the mouth of the Eusta- 
 chian tube. We now know, thaf even this is a very valuable 
 means of treatment. I regret very much that I cannot find 
 Guyot's original report to the French Academy, in any of our 
 New York libraries. 
 
 Archibald Cleland (1741), an English army surgeon, advised 
 injections of the Eustachian tube with warm water, by means of 
 a syringe joined to a flexible silver tube introduced through the 
 nose into the oval opening of the duct, at the posterior opening of 
 the nares, toward the arch of the palate. A sheep's ureter was 
 fastened to the silver tube, to the other end of which the syringe 
 was fastened. His contemporaries seem to have paid little 
 attention to his suggestions, for Van Swieten recommends 
 catheterization of the tubes through the mouth as a possible 
 operation. Wilde attempts to claim the use of the catheter as a 
 British discovery. He makes Guyot a mere suggester of the 
 operation of catheterization, but I think the evidence is in favor 
 of the French postmaster. Cleland also used probes of the same 
 size of the catheter to explore the tube. He does not allude to 
 Guyot's suggestions to the French Academy, but, unfortunately 
 for poor human nature, this is by no means proof that he did not 
 know of them. Certain it is, however, as Wilde states, that the 
 English surgeon was the first one to introduce the catheter 
 through the nose, the only proper way of performing the opera- 
 tion ; and he says that Guyot never practised the operation 
 
 1 For a full account of the operations on the mastoid, see the appropriate chapter 
 in this work. 
 
 2 Die Krankheiten des Gehoerorganes, 1827, p. 21.
 
 26 A SKETCH OF THE 
 
 which he recommended, and that it was on this ground rejected 
 by the French Academy, as "he wanted the recommendation of 
 facts to support and enforce it." 
 
 Archibald Cleland still farther advanced the science of otol- 
 ogy by introducing a three-inch convex lens, with a handle, as 
 a means of examining the ear. The ear was illuminated by a 
 waxlight attached to the lens. 
 
 Julian Busson (1748) proposed, in rather an undecided way, 
 to perforate the membrana tympani, in order to remove collec- 
 tions of pus from behind it ; but, as this was a very dangerous 
 operation, he advised the inhalation of vapors through the 
 mouth and nose, and then that they be forced into the Eusta- 
 chian tube by means of Valsalva's method, as he thought that 
 the pus might thus be driven out of the middle ear. 
 
 Jonathan Wathan (1755), an English author, reported cases 
 of restoration of hearing by means of catheterization of the 
 tube through the nose. His papier is in the " Philosophical Trans- 
 actions of the Royal Society."* He seems not to have known of 
 Cleland's labors in the same direction. 
 
 The surgeons, after the seemingly complete failure of phy- 
 sicians to successfully treat diseases of the ear, animated by the 
 invention of the Eustachian catheter and Petit's operation for 
 perforation of the mastoid, seem to have been exceedingly ac- 
 tive in otology during the latter half of the eighteenth century. 
 Antoine Petit, as well as Cleland, recommended the use of an 
 instrument through the nose instead of through the mouth, as 
 proposed by Guyot, and injections through the tube are every- 
 where recommended in their writings. 
 
 The successful cases which were reported about this time 
 were usually among young persons. It is probable that the use 
 of the Eustachian catheter fell into disrepute, because it was 
 used in chronic cases in which the prognosis should have been 
 pronounced bad or hopeless from the beginning. The want of 
 success in such cases must have been disheartening. It con- 
 tributed much to the opprobrium attached to the practice of 
 aural surgery, which exists in our own day. The necessity for 
 greater exactness in the diagnosis and course of disease, exists 
 now as then. If we achieve it, otology will be on as sure a foun- 
 dation as any part of our science and art. 
 
 One very careful soul, who seems to have been in great horror 
 of the operation, proposed that patients upon whom the catheter 
 was to be used, should have the hairs of the nostrils removed, 
 and that lukewarm milk, or a linseed-meal mixture, or the like, 
 should be drawn into the nostrils a day before the instrument 
 was introduced, so as to make the parts more pliable.
 
 PROGRESS OF OTOLOGY. 27 
 
 The operation of perforation or trephining the mastoid process 
 also fell into great disrepute, because a Danish surgeon, Berger 
 (1792), caused it to be performed upon himself, and very im- 
 properly, for " deafness which had been years in occurring, and 
 which was accompanied by vertigo, headache, and noise in both 
 ears." Meningitis resulted, and the patient died in a few days. 
 This put a stop to the performance of this very useful and neces- 
 sary operation, until it was lately revived, chiefly through the 
 efforts of German and American surgeons. 
 
 Everard Home ' (1800), by his writings, suggested to Sir Ast- 
 ley Cooper the operation of perforation of the membrana tym- 
 pani, which the great English surgeon performed successfully 
 in four cases. The history of the rise and fall and revival, of 
 this operation will be found in the chapter on chronic non-sup- 
 puration of the middle ear. 
 
 John Cunningham Saunders Q wrote a work on the ear, its 
 anatomy and diseases, which went through several editions in 
 England and one in America. It is a brief but scientific trea- 
 tise, and far beyond its predecessors in value. It is character- 
 ized by simplicity, and is without the absurdities of the older 
 text-books. It is deficient in descriptions of the methods of 
 examining the drum-head, and teaches the erroneous doctrine 
 that it is proper to probe a membrana tympani to see if it be in- 
 tact. It should be remembered that Saunders advised paracen- 
 tesis of the membrana tympani in cases of acute suppuration of 
 the tympanum an operation that was revived by Schwartze a 
 few years ago. 
 
 He says 3 : "But let it be admitted that the tympanum has 
 suppurated, ought the membrana tympani to be abandoned to a 
 casual ulceration, or is it better to open it by art ? I am inclined 
 to prefer the latter, and if I can be assured, by any symptom, 
 that suppuration has taken^place, I should not hesitate to make 
 a small perforation of the membrana tympani, and to repeat it, 
 if necessary, taking, at the same time, every precaution to sup- 
 press the fresh collection of matter.'' 
 
 Saunders speaks wisely against the objections made to check- 
 ing a purulent discharge from the ears, and shows that disease 
 of the brain is very apt to follow a neglected chronic suppura- 
 tion, and he gives some interesting illustrative cases. The book 
 is very deficient in its treatment of the Eustachian tube and 
 middle ear. Thus early do we find, in spite of Cleland's and 
 
 1 Philosophical Transactions, 1800. 
 
 2 The Anatomy of the Human Ear, etc. Edited by Wm. Price, M.D., Philadel- 
 phia, 1827. 
 
 3 Loc. cit., p. 59.
 
 28 A SKETCH OF THE 
 
 Wathan's teachings, the English prejudice against the use of 
 the catheter, a prejudice which has only lately been overcome. 
 
 Saunders was the first to establish an infirmary for the treat- 
 ment of diseases of the ear. It was also an eye infirmary, and 
 was opened in March, 1805. At a later date it was limited to 
 the treatment of the diseases of the eye. In 1816 John Harrison 
 Curtis established the " Royal Dispensary for Diseases of the 
 Ear," in London. The work of Curtis ' adds nothing to our 
 knowledge, being a feeble imitation of the book by Saunders. 
 
 J. A. Saissy (1819), of Lyons, devoted the last twelve years 
 of his life to the study of aural disease. He published a work 
 on the ear, which attained the honor of a place in the " Diction- 
 naire des Sciences Medicales." This work was translated into 
 English by Nathan R. Smith, the celebrated American surgeon. 2 
 
 I. M. G. Itard (1821), Physician to the Royal Deaf and Dumb 
 Institution in Paris, also publishes a treatise, which was trans- 
 lated into German, 3 and which did much in the pioneer work of 
 clearing up the undergrowth of centuries of neglect. 
 
 Then followed Deleau, on the diseases of the middle ear and 
 on perforation of the membrana tympani, an operation for which 
 he claimed more than it deserved. 
 
 Thomas Buchanan (1823), of Hull, published a work on the 
 ear, which is highly spoken of by Sir William Wilde, especially 
 as to his remarks upon catheterization of the Eustachian tube 
 and puncturing the membrana tympani. He had, however, fal- 
 lacious views with regard to the physiology and diseases of the 
 external auditory canal. 
 
 Karl Joseph Beck (1827), of Freiburg, published a "Handbook 
 of the Diseases of the Ear." 4 It is a succinct and carefully writ- 
 ten compendium of what was then known in this department of 
 science, and has a very good bibliography, with the exception 
 that the names of English authors ar^e very often misspelled. 
 
 Wilhelm Kramer (1833), of Berlin, an author who died in 1874 
 at a ripe old age, brought out a work which was animated by the 
 true scientific spirit, and which greatly simplified the practice 
 of otology. After this he published a number of volumes. He 
 introduced a valvular-handled speculum, that was an improve- 
 ment upon the very clumsy ones hitherto in use. He also gave 
 us the air-press, by which air or vapors could be introduced 
 through the Eustachian tube into the middle ear. 
 
 1 A Treatise on the Physiology and Diseases of the Ear, by John Harrison Curtis, 
 Esq. Third edition. London, 1823. 
 
 5 An Essay on the Diseases of the Internal Ear. Baltimore, 1829. 
 
 3 Die Krankheiten des Ohres und des Gehors. 
 
 4 Die Krankheiten des Gehoerorganes. Heidelberg und Leipzig, 1827.
 
 PROGRESS OF OTOLOGY. 29 
 
 In discussing the practices of his predecessors, the intoler- 
 ance of Kramer's spirit is seen an intolerance which is pain- 
 fully manifest in his later works. 1 In 1860 he speaks of the 
 writings of Hinton of London a writer whom, I am sure, all 
 my readers will learn to respect " as in every respect unimpor- 
 tant," while Toynbee's pathological investigations, to which 
 science is so much indebted, are actually treated with sneers. 
 In 1865, Kramer published a monograph, 3 which was essentially 
 a review in a very unfriendly spirit of the labors of Toynbee, 
 Wilde, Troltsch, Erhard, Voltolini, and others, of whose writ- 
 ings I shall soon speak. What good work Dr. Kramer actually 
 did for otology in his younger days, was overshadowed by his 
 subsequent writings. In spite of what I am almost inclined to 
 call common sense, he persisted in rejecting the modern method 
 of investigation, as well as the results of examinations of ears 
 removed from persons who have been deaf. He still continued 
 to use the handled bi-valved speculum, with sunlight as the 
 only source of illumination, and on cloudy days sent away 
 patients without examination up to his last days of practice; 
 and because Toynbee made post-mortem examinations of many 
 ears of persons whom he had not seen during life, Kramer re- 
 jected all pathological investigations, except experiments con- 
 ducted upon a dead body or a glass model. He described Politzer's 
 method of inflating the middle .ear " as a miserable resort in 
 cases of necessity, the employment of which, all pompous com- 
 mendations to the contrary notwithstanding, stamps him who 
 uses it with want of skill in the introduction of the catheter." 
 Again he called Toynbee, in his work published in 1867, 3 and this 
 after Toynbee had lost his life in experiments as to the effect of 
 chloroform and hydrocyanic acid, *'a wretched aural surgeon." 
 "Ein miserabler Ohren-arzt." These are fair specimens of Dr. 
 Kramer's style in dealing with an opponent, with any one who 
 claims to have accomplished anything for aural pathology and 
 therapeutics in any other way than by the employment of his 
 catheters, his bougies, and his valvular-handled speculum. 
 
 Yet Kramer did much for the advance of otological science. 
 If he had possessed an unprejudiced and receptive spirit, he 
 would have accomplished much more. The author well remem- 
 bers him in his pleasant consulting room in Berlin, in 1863, dis- 
 dainfully declining to use the simple method of examination just 
 recommended by Troltsch, but sending away his patients who 
 
 1 Ohrenheilkunde der Gegenwart, 1860. Berlin, 1861. 
 
 Ohrenkrankheiten und Ohrenartze in England and Deutschland. 
 
 3 Handbuch der Ohrenheilkunde, p. 44. Berlin, 1867.
 
 30 A SKETCH OF THE 
 
 needed examinations on dark days, to wait until the sun should 
 shine. He frequently visited England, and had quite a large 
 consultation practice there. He unwittingly did much to deepen 
 the general distrust of the treatment of aural disease. 
 
 In this review of what has been done to bring otology up to 
 its present position, I have been compelled to notice the difficul- 
 ties with which the advance of the science has been obliged to 
 contend in the way of improper and unjust criticism, from one 
 who, in this country and England, acquired the reputation of 
 a safe guide and leader in this part of the field of medicine. 
 
 Joseph Williams ' (1839) obtained a gold medal from the Uni- 
 versity of Edinburgh for a monograph upon the anatomy, phys- 
 iology, and pathology of the ear. It is an excellent compilation 
 of the knowledge of his time, written in a pleasant style, ap- 
 parently by a writer with very little or no experience of his 
 own. 
 
 George Pilcher (1841) wrote an essay on the ear, which re- 
 ceived the Fothergillian gold medal from the Medical Society of 
 London. It is a valuable compilation. The section on foreign 
 bodies in the auditory canal is full of warning interest. There 
 is, however, very little of the author's own experience in the 
 volume. 2 
 
 The text-book of Wilhelm Rau 3 is written in an attractive style 
 and scientific spirit, but unfortunately for its permanent hold 
 upon the profession, it does not anticipate the real advance so 
 soon to be made by Trdltsch in giving us a simple method of ex- 
 amining the drum-head, the stand-point for modern otology, 
 just as much as Sims's speculum is for gynaecology, and it has a 
 place among books written from the knowledge of the ancients. 
 
 The work of James Yearsley, 4 although having some unscien- 
 tific characteristics, as its title would indicate, is a valuable 
 book, especially for its sound doctrine with regard to the origin 
 of most cases of impaired hearing in the mucous membrane 
 lining the throat, nose, and ear, and for its account of the dis- 
 covery of the artificial membrana tympani. 
 
 The profession has of late become more alive to the value 
 of Yearsley's artificial drum-head, which, as is well known, is 
 formed of cotton, by the papers of American, German, and Eng- 
 lish otologists, but nothing essentially new has been added to 
 the original statements of its inventor. The history of the man- 
 
 1 Treatise on the Ear. London: Churchill, 1840. 
 
 2 Treatise on the Structure, Economy, and Diseases of the Ear. American edition, 
 1343. 
 
 3 Lehrbuch der Ohrenheilkunde. Berlin, 1856. 
 
 4 Deafness, Practically Illustrated. Sixth edition. London, 1863.
 
 PROGRESS OF OTOLOGY. 31 
 
 ner in which the value of an artificial membrana tympani was 
 suggested to Yearsley is interesting. 
 
 In 1841 a gentleman from New York consulted Dr. Years- 
 ley, in London, in regard to his deafness, who informed Dr. 
 Y. that he was enabled to improve his hearing power so 
 that he could produce in his left ear a degree of hearing quite 
 sufficient for all ordinary purposes. This was done by the in- 
 troduction " of a spill of paper previously moistened with cotton 
 to the bottom of the passage upon the remains of the membrana 
 tympani." l 
 
 This was the real discovery of the artificial membrana tym- 
 pani, although Dr. Martel Frank, in his cyclopaedic text-book, 
 refers to a means of. preventing injury to the ear, but not of im- 
 proving the hearing when the membrana tympani is lost, by 
 the use of a silver, gold, or lead tube, the inner end of which 
 is covered by a membrane. The fact that such a means of pro- 
 tecting the ear was used in 1640 has been already alluded to. 
 It cannot be said, however, to be an artificial membrana tym- 
 pani in the sense of Yearsley's cotton- wool, which he soon sub- 
 stituted for the paper of the New York patient, or'of Toynbee's 
 disk of rubber attached to a wire. The artificial membrana 
 tympani has proved itself a very valuable means of treatment, 
 and is in constant use by many of those who treat suppurations 
 of the middle ear.* Of late years, the use of the artificial drum- 
 head has assumed great importance in the minds of the laity, by 
 its recommendation for all diseases of the ear, by interested ad- 
 vertisers, who describe it as a new invention, and sell it for a 
 very large price. 
 
 The work of Dr. Frank, 3 already alluded to, will be found a 
 valuable work of reference, although it lacks individuality. 
 Hoffman's mode of examining the auditory canal and mem- 
 brana tympani is fully described by Frank on page 49 of his 
 book ; but he attached no importance to it, not foreseeing 
 that it was to supersede all other methods, as it has done, as im- 
 proved and brought into general use by Von Troltsch. 
 
 The work of William R. Wilde 4 (1843), surgeon to St. Mark's 
 Hospital, which was republished in this country, where it has 
 had a large circulation, and which was translated into German, 
 probably did more to place our science upon a sound basis, than 
 anything that has been done in otology since the days of Val- 
 
 1 Loc. cit, p. 221. 
 8 Frank, p. 293. 
 
 3 Practische Anleitung zur Erkenntniss und Behandlung der Ohrenkraukheiten. 
 Erlanger, 1845. 
 
 4 Practical Observations on Aural Surgery. London, 1853.
 
 32 A SKETCH OF THE 
 
 salva. This work was founded on the observations of a careful 
 observer, who had acquired fine habits of study as a skilful 
 ophthalmologist. It was not, as the works of Lincke and Frank, 
 a cyclopaedia of what had been written on otology, nor did it 
 contain absurd theories like that of Kramer, but it consisted 
 in the application of thorough anatomical, physiological, and 
 therapeutical knowledge to the study of an organ that had 
 been hitherto treated as if it were something different from 
 any other part of the body, and not subject to the same ac- 
 cidents and diseases, and consequences of those diseases, as 
 other parts made up, in like manner, of integument, of carti- 
 lage, mucous membrane, periosteum, and bone. In fact, Wilde 
 afterward Sir William Wilde, in consequence of the well- 
 earned recognition of his Queen brought otology, or aural sur- 
 gery as he called this department, down from the terra incog- 
 nita of the ancients to a point where it could be investigated by 
 the average practitioner, and where it was respected by all. He 
 gave us the conical specula, reviving a suggestion of Dr. New- 
 burg, of Brussels, and Ignaz Gruber, of Vienna, and drove the 
 unhandy ones of Fabricius and Kramer out of use. More than 
 all, he taught us that the true nature of aural disease was in- 
 flammatory in a large proportion of cases. With this as a stand- 
 point, he inaugurated a successful system of antiphlogistic 
 treatment by means of incisions in tense tissue, local blood-let- 
 ting, blisters, the administration of mercury, and so forth. This 
 system, although modified and enlarged, still obtains with our 
 wisest practitioners, and is an everlasting monument to the 
 genius of its promulgator. He displaced the fanciful and theo- 
 retical notions of Kramer, which were having wide credence, to 
 the great detriment of the scientific knowledge of the nature 
 and treatment of diseases of the ear. He was the first author 
 to place aural surgery upon a rational basis. Wilde deserves 
 the title of the Father of Modern Otology. 
 
 Then came Toynbee's book ' (1860), which is mainly valuable 
 for its anatomical and pathological investigations. It can never 
 take rank with Wilde's book as a useful treatise for the practi- 
 tioner, indispensable as were Toynbee's labors as an anatomist 
 and pathologist. Mr. James Hinton's supplement, however, 
 materially improved Toynbee's treatise. 
 
 Dr. Anton von Troltsch (1861 ), of Wiirzburg, published a mono- 
 graph 2 upon the anatomy of the ear, in 1861, which he entitled 
 
 1 The Diseases of the Ear : their Nature, Diagnosis, and Treatment. Reprint. 
 Philadelphia, 1860. The same, with a supplement, by James Ilinton, F.R.S. Lon- 
 don, 1868. 
 
 * Die Anatomie des Ohres. Wiirzburg, 1861.
 
 PROGEESS OF OTOLOGY. 33 
 
 a contribution to the scientific establishment of otology. It was 
 certainly all that and something more. While it gave a very 
 simple and complete account of the anatomy, except that of the 
 internal ear, there were many wise suggestions in the text 
 with regard to the treatment of aural disease. Troltsch showed 
 himself to be a disciple of Wilde and Toynbee. He built upon 
 the foundations which the clinical skill of the Irish, and the 
 pathological labors of the English observer had made, and 
 brought otology in Germany into a position which made it an 
 inviting department of labor. His work upon the anatomy con- 
 tains the results of many original investigations, which will be 
 found in the anatomical descriptions of this volume. 
 
 This work on the anatomy of the ear was soon followed by a 
 text-book upon its diseases, 1 which had the same scientific char- 
 acteristics with the monograph upon the anatomy. It has been 
 translated into the English, French, and Italian languages. In 
 this country it met with great favor, having passed through two 
 editions, and it has given tone to all the otological literature and 
 investigations of its day. Troltsch improved and brought into 
 general use the method of examination of the canal and drum- 
 head first proposed by Dr. Hoffman, of Westphalia which had 
 been entirely forgotten by the profession and thus at one step 
 advanced the science very materially. 
 
 In 1862, the same year that Von Troltsch issued his text-book, 
 Dr. Adam Politzer, of Vienna, promulgated his method of inject- 
 ing air into the middle ear, the so-called inflation. It is hard 
 to overestimate the value of this simple procedure, and the 
 benefit to our science and art that its invention caused. The 
 writer can but quote the opinion of an eminent practitioner of 
 this city, of large experience in aural disease, who, in speaking 
 of Politzer's method, once said to him : "If a man were to take 
 this air-bag and travel through the country, advertising himself 
 as an aurist, and blow up all the ears indiscriminately that were 
 brought to him, he would be a very successful quack.'' Indeed, 
 the effects of this means of treatment, especially in the case of 
 children, or even adults, who have suffered but a short time 
 from impairment of the hearing, from disease of the middle ear, 
 are often wonderful. 
 
 Toynbee just missed making the discovery of this method of 
 inflating the ear, in his physiological investigations as to the po- 
 tency of the Eustachian tube, and especially when he proved 
 that it was opened by the act of swallowing. Politzer evidently 
 followed Toynbee's investigations very carefully, and with rare 
 
 1 Die Krankheiten des Ohres,
 
 34 A SKETCH OF THE 
 
 wisdom availed himself of them to make an invaluable addition 
 to our means of treating the ear. 
 
 The late Dr. Julius Erhard (1863) published a work upon the 
 diseases of the ear, 1 which is a peculiar mixture of truth with 
 error. Most of its theories are based upon imperfect observa- 
 tions and are misleading in the extreme. It has little or no 
 practical value. 
 
 In 1864 Dr. von Troltsch, Dr. Politzer, and Dr. Herman 
 Schwartze, of Halle, issued the first number of the Archiv. filr 
 Ohrenheilkuride, a work which has been regularly continued 
 under their management, and which has formed a true guide to 
 the otological student and practitioner. 
 
 In 1865 Dr., now Professor, Politzer published a monograph 
 upon the membrana tympani, which was translated into English 
 and published in the United States by my friends and colleagues 
 Drs. Arthur Mathewson and Homer P. Newton, of Brooklyn. 
 This monograph was the first serious study of the drum-head, 
 and holds a high place in otological literature. 
 
 In October, 1867, the first number of the Monatsschrift filr 
 Ohrenheilkunde was issued, under the direction of Dr. Voltolini, 
 of Breslau ; Dr. Josef Gruber, of Vienna ; Dr. F. E. Weber, of 
 Berlin ; and Dr. N. Riidinger, of Munich. This journal is still 
 continued, with the addition of a department devoted to diseases 
 of the throat. All of these editors have contributed very much 
 to the scientific advance of otology ; while Dr. Riidinger has 
 probably done more than any anatomist of his day to elucidate 
 the anatomy of the Eustachian tube. His photographic atlas of 
 the ear is a work of permanent value, and one of which the 
 author has made frequent use in illustrating some of the chap- 
 ters of this work. 
 
 Dr. S. Moos, 4 of Heidelberg, issued a practical treatise on aural 
 disease in 1866, and Dr. Gruber, 3 of Vienna, one in 1870. Both of 
 these volumes show much original research, and are worthy of 
 an English translation, which would bring them before a much 
 larger circle of readers. 
 
 The American Otological Society was established in 1868, and 
 has held annual meetings since, and has published thirteen vol- 
 umes of " Transactions." To these papers the author has had fre- 
 quent occasion to refer in the preparation of the following chap- 
 ters, and it is believed that they furnish evidence of the high 
 character of the work that has been done by American otologists. 
 
 1 Klinische Otiatrie. Berlin. 
 * Klinik der Ohrenkrankheiten. 
 3 Lehrbucli der Ohrenheilkunde.
 
 PROGRESS OF OTOLOGY. 35 
 
 No outline of what has been done in the last twenty years 
 for otology would be complete without a reference to the writ- 
 ings of the late Professor Edward H. Clarke, of Harvard Uni- 
 versity. Dr. Clarke published a paper on perforations of the 
 membrana tympani, ' its causes and treatment, which was prob- 
 ably the best that had been written on this subject. It received 
 a full recognition among foreign authorities. This article con- 
 tains a very important sentence, quoted by Troltsch in his text- 
 book, a passage full of meaning and warning : " So necessary is 
 a careful attention to the ear, during the course of an acute ex- 
 anthema, that every physician who treats such a case without 
 careful attention to the organ of hearing, must be denominated 
 an unscrupulous practitioner." Dr. Clarke also published a 
 monograph upon polypus of the ear, which contains very much 
 of value as to the nature and treatment of these products of in- 
 flammation. 
 
 In 1869, Drs. H. Knapp, of New York, and S. Moos, of Heidel- 
 berg, began the publication of the Archives of Ophthalmology 
 and Otology, which are issued simultaneously in English and 
 German, and which have added much to the scientific interest 
 in otology. The union of the two branches of science in so 
 valuable a journal has certainly assisted to gain the respect of 
 the profession for the department of otology. In 1879 these pub- 
 lications were separated, and the author of the present work 
 became associated with Drs, Knapp and Moos in the publication 
 of the journal devoted to otology. 
 
 In 1872, Dr. Laurence Turnbull issued a "Clinical Manual of 
 the Diseases of the Ear." In 1873, the first edition of the present 
 treatise on the ear was published. In the same year Mr. W. B. 
 Dalby, of London, published a volume of lectures upon the ear, 
 which is of permanent value. The work of Dr. A. D. Williams, 
 of St. Louis, was also published in this year, and contains many 
 original observations. 
 
 Dr. Weber Liel's * (1873) work upon the nature and curability 
 of progressive impairment of hearing, is a monograph which has 
 been subjected to close analysis and criticism on the one hand, 
 and from which much has been borrowed on the other. It is an 
 ingenious and interesting work, but, in the opinion of the au- 
 thor of this work, its theories have not been substantiated. 
 
 In Italian, the work of Dr. De Rossi 3 (1871) is written in the 
 
 1 American Journal of the Medical Sciences, January, 1858. 
 
 * Ueber das Wesen und die Heilbarkeit der haufigsten form progressiver Schweho- 
 rigkeit. 
 
 3 Le Mallattie dell' Orecchio.
 
 36 A SKETCH OF THE 
 
 spirit of the modern German school, and forms a reliable guide 
 to those reading that language. 
 
 One of the most valuable works that has ever been published 
 upon diseases of the ear is the one entitled " The Questions of 
 Aural Surgery," by the late James Hinton (1874). It is written 
 in a purely scientific spirit, and is full of valuable facts and 
 wise observations, while it suggests much for more thorough 
 investigation. It was accompanied by an atlas of the mem- 
 brana tympani, consisting of one hundred and fifty pictures 
 of the drum-head in water-color. Literature must be searched 
 very carefully to find a scientific work upon any subject so 
 essentially honest and impartial as the volume entitled " Ques- 
 tions in Aural Surgery." 
 
 The lectures on aural catarrh, by the late Dr. Peter Allen 
 (1870), are valuable in many points. The second edition passed 
 through the press in 1874, during the author's last illness. The 
 death of Dr. Allen was a loss to our profession of a hard- 
 working and ingenious student in otology. 
 
 Mr. George P. Field (1876), the successor of Toynbee as Aural 
 Surgeon to St. Mary's Hospital, published a small octavo upon 
 the ear, which has some unique features, especially in the illus- 
 trations of the various forms of diseases of the membrana tym- 
 pani, as seen through the speculum. The book contains many 
 valuable cases, and is altogether a positive contribution to aural 
 medicine and surgery, and has passed into the second edition. 
 
 Among the most valuable of the text-books on the ear of the 
 present day is that of Dr. Charles H. Burnett (1877). The part 
 upon anatomy and physiology is particularly well presented. 
 
 The monograph upon " Deafness, Giddiness, and Noises in 
 the Head," by Dr. Edward Woakes (1879), of London, hardly 
 assumes to be a text-book. Its peculiar views are chiefly those 
 of Weber Liel of Berlin, and will be alluded to in certain discus- 
 sions in this volume. The author is enthusiastic in the promul- 
 gation of his views of the causes of aural affections. His work 
 has passed to a second edition, and he has adherents in this 
 country. 
 
 The work of Dr. H. Macnaughton Jones (1881), of Cork, also 
 lays great stress upon Weber Liel's views as to paretic deafness, 
 and operations upon the tensor .tympani, without, however, any 
 claim like that made by Woakes, to, have been coeval with the 
 latter author in his views upon these subjects. 
 
 The work on the ear by Dr. Albert H. Buck (1880), of New 
 York, contains a vast amount of valuable research in otology. 
 The author's experience has been lafge, and every one interested 
 in otology will find its pages very interesting and instructive.
 
 PROGRESS OF OTOLOGY. 37 
 
 Especially to be mentioned are the sketch of the physiology of 
 the ear, the chapter upon the mastoid process, and the one upon 
 fractures of the temporal bone. 
 
 Of text-books upon the ear in the French language there is 
 very little to be said. Modern otology finds very little comfort 
 in such works as those of Miot and Bonnafont, although the 
 latter-named author has laid the profession under obligations by 
 his contributions to the subject of exostosis. 
 
 Among the recent works in the German language are those 
 of Urbantschitsch, of Vienna, Hartmann, of Berlin, and Politzer. 
 The work of the first-named author is an elaborate cyclopaedia, 
 with scarcely a trace of personal coloring, dreary in the ex- 
 treme, but valuable as a work of reference. Politzer's work 
 upon the ear is worthy of the expectations raised by the renown 
 of its author. It has been translated into excellent English by 
 Dr. Patterson Cassells, of Edinburgh, and is accessible through 
 an American publisher. 
 
 In 1879, The American Journal of Otology, a quarterly, was 
 founded by Dr. Clarence J. Blake in conjunction with a number 
 of eminent aural surgeons and physicists. The journal was es- 
 tablished in order "to afford a medium for the publication of 
 original communications on subjects coming within the scope of 
 the two departments to which it was devoted," acoustics and 
 aural surgery. This journal was ably conducted, but the publi- 
 cation ceased with the fourth volume in 1882. 
 
 There is also a French journal 1 devoted to diseases of the ear, 
 in conjunction with those of the larynx, which furnishes many 
 original articles as well as a fair digest of foreign literature. 
 
 The latest work on the ear that has appeared up to the time 
 of the writing of this chapter, is that by Dr. Oren D. Pomeroy, 
 long and favorably known to the profession as an original and 
 industrious worker in otology. His volume contains the result of 
 the author's large experience, with a compendium of that of 
 others, written in a judicial spirit. 
 
 Lincke, writing in 1840, regrets that in Germany no clinique 
 for the treatment of aural patients had as yet been organized. 
 Dr. Reiner, he says, had attempted to do so in Munich, but had 
 failed, as had Dr. Lincke in Leipsic ; and we know that Saun- 
 ders and Cooper had failed in establishing one in London ; for 
 in 1804, Saunders had an eye and ear infirmary in London, under 
 the name of the " New London Dispensary for Curing Diseases 
 of the Eye and Ear." But the aural part was so unsuccessful, 
 that it became necessary to close it to the aural practice. John 
 
 1 Annales des Maladies de POreille et du Larynx.
 
 38 A SKETCH OF THE 
 
 Harrison Curtis, in 1816, was more successful, and when Lincke 
 wrote his dispensary was still carried on. In 1828, the New 
 York Eye and Ear Infirmary, which had been in existence 
 eight years, treated 91 cases of diseases of the ear to 925 of 
 diseases of the eye. That institution, according to its last pub- 
 lished report, treated more than 2,800 aural cases. In the Man- 
 hattan Eye and Ear Hospital, New York, 1,809 aural cases were 
 examined in the last year ; in the Ophthalmic and Aural Insti- 
 tute, 1,579 ; and in the Brooklyn Eye and Ear Hospital, 1,731. 
 These facts indicate that due scientific attention is being at last 
 given to the ear. 
 
 In New York City, there are five special hospitals for the 
 treatment of aural diseases, in conjunction with diseases of the 
 eye a' union which seems to find favor chiefly in the United 
 States, Ireland, and Canada. 
 
 The marked distrust with which the profession at large re- 
 garded the theories of the nature and treatment of aural disease, 
 did not begin to give way until the views of Wilde became gen- 
 erally known and accepted. It was not, however, until a simple 
 and practical means of examining the auditory canal and mem- 
 brana tympani had been suggested and accepted, that otology 
 became an inviting field of professional labor. 
 
 The next step was to recognize the pharynx as the starting- 
 point of the diseases of the middle ear, and to separate these 
 from the less frequently occurring cases of diseases of the ex- 
 ternal ear. With this came a simple means of opening and 
 treating the Eustachian tube and the tympanic cavity. If now, 
 we can succeed as I believe we are about to succeed, in separat- 
 ing affections of the nerve from those of the middle ear, that is 
 to say, diseases of the perceptive apparatus from those of the 
 parts devoted to the conduction of sound, otology will take rank 
 with ophthalmology for exactness in diagnosis and prognosis. 
 
 If any cause remain for looking askance at the claims of 
 otology, it is to be found in the attitude of those otologists who, 
 in a spirit quite out of keeping with true medical philosophy, 
 devote too much of their energy to the explication of the causes 
 and treatment of incurable aural diseases, and who lay too little 
 stress upon recent affections and the hygienic knowledge which 
 may prevent insidious and incurable diseases of the ear, and who 
 reject all attempts at an exact diagnosis of affections of the 
 labyrinth, declaring themselves agnostics, at a time when faith 
 and works may bring to us a knowledge of what they declare to 
 be beyond human ken. 
 
 In concluding this introductory chapter, I beg that the reader 
 will bear in mind that I have not attempted to make it more than
 
 PROGRESS OF OTOLOGY. 39 
 
 an outline of what has been done in otology from the earliest 
 times until our own day. I have endeavored to sketch only that 
 which has left its traces upon the science, and which has con- 
 tributed materially to its progress. I have merely desired to 
 give such a historical account of the work of the fathers, as 
 would render any frequent references to them unnecessary in 
 the body of this work, and one which may be a guide and en- 
 couragement for those who are interested in this department of 
 medicine. 
 
 AUTHOBITIES CONSULTED IN PREPARING THE PRECEDING HIS- 
 TORICAL SKETCH. 
 
 For the convenience of the reader who may desire to consult the original authorities which the author 
 has examined in preparing the preceding sketch, their complete titles are here given. The bibliography 
 will, however, be seen to refer only to the works actually examined, and not to those mentioned as quoted 
 by the authorities themselves. 
 
 Archiv fur Ohrenheilkunde. Herausgegeben von A. Von Troltsch, A. Politzer, 
 und H. Schwartze. Wiirzburg. I.-VL, Neue folge I.-XIX. 
 
 Archives of Ophthalmology and Otology. Edited and published simultaneously 
 in English and German, by Professor H. Knapp, in New York, and Profes- 
 sor S. Moos, in Heidelberg. New York : William Wood & Co. Carlsruhe : 
 Chr. F. R. Miillersche Hof-Buchhandlung, 1869-72. 
 
 Archives of Otology, Edited in English and German by Dr. H. Knapp, Dr. S. 
 Moos, and Dr. D. B. St. John Roosa. 
 
 ALLEN, PETEB. Lectures on Aural Catarrh. London : J. & A. Churchill, 1871. 
 
 The Same. Second edition. 1874. 
 
 American Journal of Otology. Edited by S. Clarence J. Blake, in conjunction 
 with Professor A. M. Mayer, of Hoboken ; Alexander Graham Bell, Dr. El- 
 liott Coues, U.S.A., Professor A. Dolbear, Dr. Albert H. Buck, Dr. Samuel 
 Sexton, Dr. J. Orne Green, Dr. H. N. Spencer. New York, 1879-1883. 
 
 Annales des Maladies de 1'Oreille et du Larynx. Fondees et Publiees par MM. 
 Ladreit de Lacharriere, Isambert, D. Kreishaber. Paris : G. Masson, Edi- 
 teur. 
 
 BAKR, THOMAS. Manual of Diseases of the Ear. Glasgow : 1884. 
 
 BECK, KARL JOSEPH. Die Krankheiten des Gehoerorganes. Heidelberg und 
 Leipzig, 1827. 
 
 BURNETT, CHARLES H. The Ear : Its Anatomy, Physiology, and Diseases. 
 Philadelphia : Henry C. Lea, 1877. 
 
 BUCK, ALBERT H. A Manual of Diseases of the Ear. Second edition. New 
 York : William Wood & Co., 1889. 
 
 BONNAFONT, DR. I. P. Traite theorique et pratique des Maladies de 1'Oreille et 
 des Organes de 1'audition. Deuxieme edition revue et augmentee. Paris : 
 J. B. Balliere et Fils, 1873. 
 
 Biographie Medicale. Tom. I.-YII. Paris : C. L. F. Panckoucke. 
 
 BRESCHET, GILBERT. Recherches anatomiques et physiologiques sur 1'Organe de 
 1'ouie et sur 1'audition, dans 1'homme et les animaux vertebres. Deuxieme 
 Edition. Paris : J. B. Balliere, 1836.
 
 40 A SKETCH OF THE 
 
 
 
 CLARKE, EDWARD H. American Journal of the Medical Sciences, January, 1858. 
 CLARKE, EDWARD H. Observations on the Nature and Treatment of Polypus of 
 
 the Ear. Boston, 1867. 
 CoTUNNn, DOMINICK, PH.D. ET M.D. De aquseductibus auris humane internae. 
 
 Anatomica Dissertatio. Viennse : apud Rudolphum Graeffe, 1774. 
 CUBTIS, JOHN HABRISON. A Treatise on the Physiology and Diseases of the Ear. 
 
 Third edition. London and Edinburgh, 1823. 
 Cyclopaedia of Anatomy and Physiology. London : Longman, Brown, Green & 
 
 Longmans, 1839. Article, "The Organ of Hearing." 
 
 DUNGLISON, ROBLEY. History of Medicine, from the earliest ages to the com- 
 mencement of the nineteenth century. Philadelphia : Lindsay & Blakis- 
 
 ton, 1872. 
 Du VEBNEY. Tractatus de organo auditus, continens structuram usum et mor- 
 
 bus omnium auris partium. Norimbegse, 1684. 
 DALBY, W. B., F.R.C.S., M.B. Cantab. Lectures on Diseases and Injuries of 
 
 the Ear. London : James A. Churchill, 1885. 
 
 Encyclopaedia, Chambers's. Philadelphia : J. B. Lippincott & Co., 1872. 
 Encyclopaedia Britannica. Ninth edition. New York : Charles Scribner's Sons. 
 EUSTACHII BARTHOLOALEI. Sanctose vermatis medici ac philosophi opuscula 
 
 anatomica. Venetiis, 1563. 
 ELY, EDWARD T. Ophthalmic and Otic Memoranda. By D. B. St. John Eoosa 
 
 and Edward T. Ely. Revised edition. New York : "William Wood & Co., 
 
 1880. 
 
 ERHARD, JULIUS. Klinische Otiatrie. Berlin : A. Hirschwald, 1863. 
 FIELD, GEORGE P., M.R.C.S. Diseases of the Ear. Second edition. London : 
 
 Henry Renshaw, 356 Strand', 1879. 
 FABRICIUS de Acquapendente. Opera Omnia Anatomica et Physiologica. Lug- 
 
 duni Batavorum, 1738. 
 FRANK, MARTELL. Practische Einleitung der Erkentniss und Behandlung der 
 
 Ohrenkrankheiten. Erlangen, 1845. 
 
 GRUBER, JOSEF. Lehrbuch der Ohrenheilkunde. Wein, 1870. 
 HARTMANN, DR. ARTHUR. Die Krankheiten des Ohres. Kassel : Theodor 
 
 Fischer, 1881. 
 HELMHOLTZ, H. Die Lehre von den Tonempfindungen als Physiologische 
 
 Grundlage fiir die Theorie der Musik. Vierte umgearbeitet ausgabe. 
 
 Braunschweig, 1877. 
 
 HARTMANN, ARTHUR. Deaf Muteism and the Education of Deaf Mutes by Lip- 
 reading and Articulation. Translated and enlarged by James Patterson Cas- 
 
 sells, M.D.. London: Balliere, Tindale & Cox, King William Street, 
 
 Strand, 1881. 
 
 HKNLE, J. Handbuch der Menschen. Bd. II. Braunschweig, 1866. 
 HERODOTUS. A new and literal version from the text of Baehr. By Henry 
 
 Cary, M.A. London : Henry G. Bohn, 1854. 
 HINTON, JAMES. Atlas of the Membrana Tympani, with descriptive text. Being 
 
 illustrations of diseases of the ear. London: Henry S. King & Co., 65 
 
 Cornhill and 12 Paternoster Row, 1874. 
 HINTON, JAMES. The Question of Aural Surgery. London : Henry S. King <fe 
 
 Co., 1874. 
 ITARD, J. M. G. Die Krankheiten des Ohres und des Gehors. Aus dem Fran- 
 
 sosichen. Weimar, 1822.
 
 PROGRESS OF OTOLOGY. 41 
 
 JONES, T. WHARTON. The Organ of Hearing, in Cyclopaedia of Anatomy and 
 
 Physiology. Vol. II. London, 1839. 
 JONES, H. MACNATTGHTON, M.D., M.A., F.K.C.S. I. and Edin. A Treatise on 
 
 Aural Surgery. Second edition, revised and enlarged. Philadelphia : 
 
 Presley Blakiston, 1882. 
 LINCKE, GAEL GUSTAV. Handbuch der Theoretischen und Praktischen Ohren- 
 
 heilkunde. Bd. I., II. Leipzig, 1837-1840. 
 
 KRAMER, W. Die Ohrenheilkunde der Gegenwart (1860). Berlin, 1861. 
 KRAMER, W. The Aural Surgery of the Present Day. Translated by Henry 
 
 Power. London : New Sydenham Society, 1863. 
 KBAMEB, W. Handbuch der Ohrenheilkunde. Berlin, 1867. 
 KKAMER, W. Ohrenkrankheiten und Ohrenaerzte in Deutschland und England. 
 
 Ein Nachtrag zur Ohrenheilkunde der Gegenwart. Berlin, 1865. 
 'KBAMER, W. Die "exakten" deutschen Ohrenarzte. Berlin, 1871. 
 MIOT, DR. C. Traite Pratique des Maladies de 1'Oreille, ou lefons cliniques sur 
 
 les affections de cet orgaue. Paris : F. Savy, Libraire-Editeur, 24 Kue 
 
 Hautefeuille, 1871. 
 Monatsschrift fur Ohrenheilkunde. Herausgegeben von Dr. Voltolini, Dr. Josef 
 
 Gruber, Dr. U. Eiidinger, und Dr. F. E. Weber. 
 
 MONRO, ALEXANDER. Three Treatises on the Brain, the Eye, and the Ear. Edin- 
 burgh, 1797. 
 
 Moos, S. Klinik der Ohrenkrankheiten. Wien : W. Braumuller, 1866. 
 NOTTINGHAM, JOHN. Diseases of the Ear. Illustrated by clinical observations. 
 
 London : John Churchill, 1857. 
 PILCHER, GEORGE. Treatise on the Structure, Economy, and Diseases of the 
 
 Ear. By George Pilcher. First American from the second London edition. 
 
 Philadelphia : Ed. Barrington and Geo. D. Haswell, 1843. 
 POLTTZER, ADAM. Die Beleuchtungsbilder des Tromnielfells in Gesunden und 
 
 Kranken Zustande. Wien : Wilhelm Braumuller, 1865. 
 POLITZER, ADAM. The Membrana Tympani in Health and Disease, etc. With 
 
 Supplement. Translated by A. Matthewson, M.D., and H. G. Newton, M.D. 
 
 New York : William Wood & Co., 1869. 
 POLITZER, ADAM. Lehrbuch der Ohrenheilkunde f iir Practische Arzte und Studi- 
 
 ende. Bande I. und II. Stuttgart, 1882. 
 POLITZER, ADAM. A Text-Book of the Diseases of the Ear and Adjacent Organs. 
 
 Translated and edited by James Patterson Cassells, M.D., M.E.C.S., Eng. 
 
 Philadelphia : Henry C. Lea's Son & Co., 1883. 
 POMEBOT, OBEN D. The Diagnosis and Treatment of Diseases of the Ear. New 
 
 York : Bermingham & Co., 1883. 
 PRITCHARD, URBAN. Handbook of the Diseases of the Ear. London : H. K. 
 
 Lewis, 1886. 
 
 Eossi, DE. Le Malattie dell' Orecchio. Trattato Teorico, Pratico. Genova, 1871. 
 EATJ, DR. WILHELM. Lehrbuch der Ohrenheilkunde. Berlin : Veiiag von H. 
 
 Peters, 1856. 
 SAISST, J. A. An Essay on the Diseases of the Internal Ear. Translated from 
 
 the French by Nathan E. Smith, M.D. With a Supplement on Diseases of 
 
 the External Ear by the Translator. Baltimore, 1829. 
 SAUNDERS, JOHN CUNNINGHAM. The Anatomy of the Human Ear. Illustrated 
 
 by a series of engravings of the natural size, with a treatise on the diseases 
 
 of that organ, the causes of deafness and their proper treatment. First
 
 42 A SKETCH OF THE 
 
 American, from the second London edition. With notes and additions by 
 Wm. Price, M.D. Philadelphia : Benjamin Warner, 1821. 
 
 SCHWARTZE, H. Die Wissenschaftliche Entwicklung der Ohrenheilkunde, Ar- 
 chiv fur Ohrenheilkunde, Bd. I. 
 
 SCHWAETZB, PBOFESSOB H. Pathologische Anatomie des Ohres. Kleb's Hand- 
 buch der pathologischen Anatomie. Berlin, 1878. 
 
 SCHWABTZE, H. Translation of the above, by J. OBNE GBEEN, A.M., M.D. Bos- 
 ton : Houghton, Osgood & Co., 1878. 
 
 SEXTON, SAMUEL. The Ear and its Diseases. New York : Wm. Wood & Co., 
 1888. 
 
 SHBAPNELL, HENBY JONES. On the Form and Structure of the Membrana Tym- 
 pani, p. 120 ; on the Function of the Membrana Tympani, p. 282 ; on the 
 Nerves of the Ear, p. 505 ; the London Medical Gazette, vol. x. , April 7, 
 1832, to September 29, 1832. London, 1832. 
 
 SOEMMERING, SAM. TnoM. Icones organi-auditus-humani. Frankfort a. M., 1806. 
 
 STBICKEB, S. Handbuch der Lehre den Geweben, des Menschen und des 
 Thieres. Leipzig, 1869-1871. 
 
 STBICKEB, S. A Manual of Histology. Translated by Henry Power and others. 
 American translation. Edited by Albert H. Buck. New York, 1872. 
 
 Transactions, Philosophical, of the Royal Society of London. For the years 
 1800, 1801. 
 
 Transactions of the American Otological Society. Vols. I. -III. 
 
 TOYNBEE, JOSEPH. A Descriptive Catalogue of Preparations Illustrative of the 
 Diseases of the Ear, in the Museum of Joseph Toynbee, F.R.S. London, 
 1857. 
 
 TOYNBEE, JOSEPH. The Diseases of the Ear, their Nature, Diagnosis, and Treat- 
 ment. (Reprint.) Philadelphia, 1860. 
 
 TOYNBEE, JOSEPH. The Same, with a Supplement by James Hinton. London, 
 1871. 
 
 TBOLTSCH, VON ANTON. Die Anatomie des Ohres, in ihrer Anwendung auf dem 
 Praxis. Wurzburg, 1861. 
 
 TBOLTSCH, VON ANTON. Die Krankheiten des Ohres. Ihre Erkentniss und Be- 
 handlung. Wurzburg, 1862. 
 The Same, 4 Aufgabe. 
 
 TBOLTSCH, VON ANTON. The Diseases of the Ear, their Diagnosis and Treatment. 
 Translated into English by D. B. St. John Roosa. New York : William 
 Wood & Co., 1864. 
 
 TBOLTSCH, VON ANTON. Treatise on the Diseases of the Ear, including the 
 Anatomy of the Organ. Second edition, from the fourth German. Trans- 
 lated and edited by D. B. St. John Roosa. New York : William Wood & 
 Co., 1869. 
 
 TBOLTSCH, VON ANTON. Gesammelte Beitrage zur Pathologischen Anatomie des 
 Ohres. Leipzig, 1883. 
 
 TUBNBULL, LAWBENCE. A Clinical Manual of the Diseases of the Ear. Philadel- 
 phia : J. B. Lippincott & Co., 1872. 
 
 UBBANTSCHITSCH, DR. VICTOB. Lehrbuch der Ohrenheilkunde. Wien und Leip- 
 zig : Urban & Schwarzenberg, 1880. 
 
 Valsalvse Opera. Viri celeberinni Antonii Marise. Tractatus de Aure Humana. 
 . . . . Omnia recensuit et auctoris vitam addivit Joannes Baptista 
 Morgagnus. Lugduni : Batavorum apud Johannem Hasebroek, 1742.
 
 PROGRESS OF OTOLOGY. 43 
 
 WILDE, WILLIAM B. Some Observations on the Early History of Aural Surgery, 
 
 and the Nosological Arrangement of Diseases of the Ear, by W. B. Wilde, 
 
 M.E.I.A. The Dublin Journal of Medical Science, Vol. XXV. Dublin, 1844. 
 WILDE, WILLIAM B. Practical Observations on Aural Surgery, and the Nature 
 
 and Treatment of Diseases of the Ear, by William B. Wilde. London : John 
 
 Churchill, 1853. 
 WEBER LIEL, DR. FR. E. Ueber das Wesen und die Heilbarkeit der haufigsten 
 
 form progressiver Schwerhorigkeit-Untersuchungen und Beobachtungen. 
 
 Berlin : August Hirschwald, 1873. 
 WILLIAMS, JOSEPH. Treatise on the Ear, including its Anatomy, Physiology, 
 
 and Pathology. London : John Churchill, 1840. 
 WILLIAMS, A. D. Diseases of the Ear. Including the necessary anatomy of the 
 
 organ. Cincinnati : Bobert Clarke & Co., 1873. 
 WILLIS, THOMAS. Opera Omnia. Amsterdamna apud Henricum Wetstenium. 
 
 Pars Physiologica, Cap. XTV., p. 69. 
 WOAKES, EDWARD, Lond. On Deafness, Giddiness, and Noises in the Head. 
 
 Second edition, enlarged and revised. London : H. K. Lewis. 136 Gower 
 
 Street, W. C. 
 YEARSLEY, JAMES. Deafness Practically Illustrated. Being an Exposition of 
 
 the Nature, Causes, and Treatment of Diseases of the Ear. Sixth edition. 
 
 London : John Churchill & Sons, 1863.
 
 CHAPTER II. 
 
 THE EXAMINATION OF AUEAL PATIENTS. 
 
 History. Power of Hearing Conversation. Test Sentences. Tick of a Watch. Tun- 
 ing-fork. Aerial and Bone Conduction. Malingering. Angular Forceps. 
 Specula. Troltsch's Otoscope. Examination of Pharynx. Rhinoscopy. Use of 
 Eustachian Catheter. Politzer's Method and its so-called Modifications. Bou- 
 gies. Valsalva's Method. 
 
 IT is a self-evident proposition, that in order to intelligently 
 treat any disease we must carefully and thoroughly examine 
 the parts involved. This is certainly as true of the affections of 
 the ear as it is of those of any other organ. In making such an 
 examination a definite plan should be followed, even in the 
 seemingly simple cases, until at last a large experience enables 
 the practitioner to omit or hurry over some of the details which 
 were necessary in the beginning of his practice. 
 
 In the examination of an aural patient, the following method 
 is the one that I have found very useful : I usually keep a 
 record of the cases ; a plan which the young, and consequently 
 not very busy practitioner will find extremely valuable. The 
 name, age, and occupation of the patient are noted. The history 
 should then be given. This history should include a pretty full 
 statement of the general condition, the diseases from which the 
 patient has suffered, the number of times he has had what is 
 called " earache," the medication to which he has been sub- 
 jected, and so on, from his earliest recollections until the date 
 of his coming under observation as an aural patient. 
 
 By no other means than by eliciting such a history, can the 
 practitioner get the essential knowledge for a thorough under- 
 standing of the subjective manifestations of the affection of the 
 ear. It is very important to ascertain when the troublesome 
 symptoms were first observed. Sometimes several minutes will 
 be consumed in obtaining an answer to this question. The first 
 reply will be, perhaps, "A few months ago," or, "A year or 
 two." If this response be followed by the inquiry, " Before that 
 time were your ears perfectly well ? " in many instances the pa- 
 tient will state, " Well, no. I have had a little dulness of hear-
 
 THE EXAMINATION OF AURAL PATIENTS. 45 
 
 ing on one side for ten or twelve years, or for a good while " 
 (which proves to be a number of years) ; or perhaps he says, 
 "There has been a little discharge from that ear, 'which didn't 
 amount to much,' ever since I had the scarlet fever or the 
 measles." As illustrative of this point, I may mention a case 
 which lately came to my clinic. The patient, an old man, gave 
 the following history : While sitting quietly by the fire, blood 
 began to run from his ears, until he had lost quite an amount ; he 
 stated positively that this was the first time in all his long life, 
 that he had ever had any kind of an affection of the ear, and 
 that he could imagine no cause for it. On close examination in 
 the manner of questioning above indicated, he admitted that he 
 had suffered from a " slight running from the ears, which didn't 
 signify, ever since he was a child." An inspection of the or- 
 gans showed that both membranae tympani were removed by 
 ulceration, and that large granulations existed. These condi- 
 tions of course accounted for the seemingly mysterious hemor- 
 rhage, to which the patient could assign no cause. 
 
 It is well in obtaining the history to allow the patient to tell 
 his own story, occasionally interrupting him, as may be neces- 
 sary, in order to keep him to the matter in hand. After having 
 thus obtained as accurate an account as possible, the next step 
 is to test the power of hearing. 
 
 The tests of the hearing power usually employed are : 
 
 1. Ordinary conversation. 
 
 2. The tick of a watch. 
 
 3. The tuning-fork. 
 
 'Many attempts have been made to produce an instrument 
 that will so accurately test the hearing power as to supersede 
 the imperfect tests that even all these three constitute. As yet 
 success has not been attained. Politzer, 1 after admitting that 
 the instruments as yet invented are useless for the precise esti- 
 mation of the degree of impairment of hearing, describes his 
 own acoumeter. In this instrument the tone is produced by the 
 striking of a hammer upon a steel cylinder, which is connected 
 by a screw with a perpendicular vulcanite column. I have 
 tested it thoroughly, but I see no advantage in it over a watch, 
 if the latter be carefully tested, so that the average distance at 
 which it can be heard by persons with good hearing power is 
 known. 
 
 The power of hearing conversation, perhaps tells the most 
 about a person's practical hearing power, and yet it is difficult 
 to test it. About the best test of the hearing power that we 
 
 1 Text-book. English translation, p. 163.
 
 46 TEST SENTENCES. 
 
 have, is the one which shows the patient's capability for hearing 
 what is said in social intercourse, at the table, in the drawing- 
 room, and so on. Inasmuch, however, as practitioners, espe- 
 cially those who live in large cities and towns, have not always, 
 or even usually, the opportunity of making such a test of their 
 patient's hearing capabilities, and since the amount of this 
 power, although it may be appreciated by the observer himself, 
 cannot be made clear to one who simply reads the case, we are 
 obliged, in recording the histories of patients, to be content with 
 noting at what distance words can be understood when they are 
 directed to the person observed, with his face so placed that he 
 cannot see the mouth of the speaker. This latter precaution is 
 an essential one, since all persons with impaired hearing soon 
 learn to watch the lips of the speaker, in order to compensate 
 for their loss of hearing power. 
 
 Dr. A. H. Buck : has made an attempt to furnish test sentences 
 so that all the members of any one group or class should be as 
 nearly as possible equal in value in penetrating power. Ex- 
 amples of such equivalent test sentences are given by Dr. Buck, 
 as follows : 
 
 1. Pour oil on the waters of Lake Erie. 
 
 2. All hail ! thou hero of fourteen wars. 
 
 Each of these sentences contains eight long vowel sounds 
 and are equally free from non-resonant, consonant, or short 
 vowel sounds. 
 
 Dr. Buck a has found, however, that the objections to these 
 test sentences are practically insurmountable, and he does not 
 think they can be made available to any extent ; yet in a rude 
 way, I think we may make them of use. I come more and 
 more to the use of this test of words spoken as near as may 
 be in an ordinary tone, as being the one that conveys the best 
 idea of the hearing power. On the other hand, I am more and 
 more distrustful of the watch as a means of testing the hearing. 
 This remark applies also to the acoumeter. I shall long re- 
 member the critical remark of a boy once under my care for 
 impaired hearing, who after submitting for some time with pa- 
 tience to a test of his power of hearing a watch tick, finally ex- 
 claimed : " I don't care to hear the watch ; what I want to hear 
 is what people say to me." Since this incident, I have endeav- 
 ored to learn the capability of the patient to hear conversation 
 under ordinary circumstances by a test of the hearing power, 
 and when I wish to demonstrate an improvement, I induce a 
 
 1 Report of the First International Otological Society. New York : Appleton, 1877. 
 * Treatise on the Ear, p. 18.
 
 TESTING HEAKING BY A WATCH. 47 
 
 friend of the patient to converse with him, under conditions the 
 same as those that existed before the improvement took place. 
 
 In testing the hearing by means of the watch, it should be 
 first placed at a distance at which its ticking cannot be heard 
 by the patient, and then gradually approached to a situation 
 where the ticks can be accurately counted. The latter may 
 fairly be considered as the farthest point of distinct hearing. 
 The hearing power is sometimes tested by placing the watch 
 where it can be certainly heard and then withdrawing it to the 
 furthest limit at which its sound can be perceived. This is a 
 fallacious test, for the sound once perceived, it is eas} r for a de- 
 fective ear to follow it until it reaches a distance far beyond its 
 normal range of hearing. The ear which is not being tested 
 should be closed by the hand during the examination. It is not 
 possible to state the distance at which a watch should be heard 
 by a healthy ear, for the simple reason that different watches 
 may be heard at different distances, so varying is the distinct- 
 ness of the tick. It may be approximately stated, however, that 
 an ordinary ticking watch should be heard, by a person with 
 average hearing power, at least four feet. To this rule there 
 are, however, many exceptions. For instance. I know a medical 
 gentleman in this city, who, as tested by the ordinary transac- 
 tions of professional and social life, is not at all hard of hearing, 
 who cannot hear a watch of common tone more than six inches. 
 
 The discrepancy in the power of hearing the watch and or- 
 dinary conversation, as was shown by the author in a paper 
 published in the American Journal of the Medical Sciences, is 
 so marked as to render the tick of a watch almost useless for 
 determining the hearer's power in many cases. Such cases as 
 these, I have since learned, are invariably due to disease of the 
 internal ear, in some of its parts, and not to an affection of the 
 middle ear. This discrepancy is one of the means of differential 
 diagnosis between affections of the middle and internal ear. 
 
 In testing the hearing power by means of a watch it is well 
 to remember, as Von Troltsch suggests, that all watches are 
 heard better immediately after they are wound, and also that 
 the intensity of their sound is increased by holding them so 
 that the surgeon's hand covers the back, or when they are held 
 by the patient's own hand. In the two latter instances the cause 
 of the increased clearness of the tick is, in the one case, the re- 
 tardation of the reflection of sonorous waves from the watch, 
 and in the other, the conducting power of the patient's own arm 
 as it is stretched out. The use of a tape or other measurer, to 
 note the number of inches at which the watch is heard, is indis- 
 pensable for an accurate record of a case. The measure should
 
 48 REGISTER OF HEARING POWER. 
 
 not be used, however, until the distance has been ascertained 
 without it. When the patient cannot hear the watch at any dis- 
 tance from the ear, it should be laid or pressed upon the auricle, 
 mastoid process, or forehead. Before using a watch for the pur- 
 pose of testing the hearing power of diseased ears, we should 
 carefully ascertain how far it may be heard by persons whose 
 hearing is unimpaired. 
 
 Dr. J. S. Prout, Surgeon to the Brooklyn Eye and Ear Hos- 
 pital, has greatly facilitated our means of recording the hearing 
 power, by a simple method, which is somewhat analogous to that 
 used in estimating the acuteness of vision ; but, as Dr. Prout 
 says : ' " The accuracy with which we measure the visual power 
 by Snellen's test types, and record the resulfs obtained, cannot 
 be arrived at by means of any of the usual sound-makers (sono- 
 factors) ; nor will it be until an instrument can be made which 
 shall always produce uniform tones." Dr. Prout recommends a 
 formula for registering the hearing power, which he describes 
 as follows : "For nearly three years I have recorded the hearing 
 power as a fraction, the numerator of which is the distance at 
 which the particular sound is heard, the denominator the dis- 
 tance at which it should be heard by an ear of good average 
 hearing power. This denominator must vary according to the 
 sonofactor used, and should generally be expressed in inches. 
 
 "For still further simplification, and that the method may be 
 adapted to international use, I suggest the following abbrevia- 
 tions : A. D. , auris dextra, instead of right ear, or R. E. ; A. S. , auris 
 sinistra; P. A., P. aud., potentia auditus, hearing power; V., vox, 
 the spoken voice ; V. S., vox susurrata, whispered voice or 
 simply S., susurrus, a whisper; H., horologium, the watch. 
 
 " If the system should become general, then the formula 
 P A, A D, H, = J$, would to all otologists represent the fact that 
 a watch that should be heard at 36 inches was heard by the 
 right ear of the patient at a distance of 12 inches ; the formula 
 P A, A S, V S, = &, would mean that the whispered voice was 
 heard by the left ear at 6 inches that should have been heard at 
 36 inches." 
 
 Dr. Prout's method is now universally employed. If a watch 
 can be heard by a person with good hearing power at least 48 
 inches, and we wish to express the hearing power of a person 
 who hears that watch one inch, we use the fraction -fa, and so 
 on. If the patient only hears the watch when brought in contact 
 with the ear, we may employ the formula % ; if only on pressure, 
 $ ; if not at all, -fe ; if on the mastoid, j\. 
 
 The objects to be gained by testing the hearing power are, of 
 
 1 Boston Medical and Surgical Journal, February 29, 1872.
 
 TEST BY WATCH AND CONVERSATION. 
 
 49 
 
 course, to learn when a patient is first seen how much his hear- 
 ing power is impaired, and as he continues under treatment 
 whether or not any improvement has taken place. If the watch 
 alone be used for this purpose, there are many opportunities for 
 error in opinion. For example, some patients, especially chil- 
 dren, readily imagine they hear the ticking of a watch when 
 they do not. Adults who are very much troubled by tinnitus 
 aurium also fall into this kind of error. In testing one ear with 
 the watch we should be careful to exclude the other, for sound 
 readily passes through the bones of the head, or the air, or both, 
 to the other ear. Especially is this the case when one ear is so 
 much affected that it is only heard when pressed upon the mastoid 
 process ( ^), or not at all ($). I think it is true that patients 
 affected with certain forms of disease of the acoustic nerve, 
 hear a watch relatively much worse than they do conversation. 
 
 Table showing the Disproportion between the Power of Hearing 
 the Tick of a Watch and the Human Voice. 1 
 
 No. 
 
 Sex and age. 
 
 Hearing distance for the watch. 
 
 Hearing distance for conversation, the pa- 
 tient being with the back to the speaker. 
 
 1 
 
 Female, 17. 
 
 Elaid T 
 TIT' " TO"' 
 
 Words spoken loudly at 10 feet 
 
 
 
 
 with difficulty. 
 
 
 
 RJL T, 
 To> ** 0"' 
 
 Loud conversation at 20 feet. 
 
 2 
 
 Male, 45. 
 
 B. A L A- 
 
 Voice at 30 feet ; cannot tell the 
 
 
 
 
 direction from which sound 
 
 
 
 
 comes. 
 
 3 
 
 Female, 28. 
 
 B. A> L- A 
 
 Conversation at 20 feet. 
 
 4 
 
 Male,- 56. 
 
 R laid, L. laid. 
 
 Conversation at 20 feet. 
 
 5 
 
 Male, 62. R pressed, L. pressed. 
 
 Loud conversation at 20 feet. 
 
 6 
 
 Female, 23. 
 
 B- A* -"-*. A- 
 
 Loud conversation at 6 feet. 
 
 7 
 
 Male, 9. 
 
 B. A L. A- 
 
 Loud conversation at 30 feet 
 
 8 
 
 Male, 16. 
 
 Elaid T. laid 
 To> ** To"' 
 
 Conversation at 20 feet. 
 
 9 
 
 Male, 18. 
 
 "R 40 T, 34 
 " 40' "'-' 40* 
 
 Conversation at 12 feet. 
 
 
 
 E4.0 T. 40 
 XTfj ^' A Q * 
 
 Conversation at 30 feet. 
 
 10 
 
 Female, 15. 
 
 B. A' '-' A' 
 
 Conversation at 20 feet. 
 
 11 
 
 Male, 19. 
 
 K. A, L. H- 
 
 Conversation at 20 feet. 
 
 12 
 
 Female, 29. 
 
 Rlaid T laid 
 To"' TO" 
 
 Conversation at 20 feet. 
 
 13 
 
 Male, 40. 
 
 H. D. R A, L- {ft 
 
 Ordinary conversation with great 
 
 
 
 
 ease at 30 feet. 
 
 14 
 
 Female, 25. 
 
 B. if, L. A 
 
 Ordinary conversation with diffi- 
 
 
 
 
 culty at 20 feet. 
 
 15 
 
 Male, 32. 
 
 R A, L. i# . 
 
 Conversation at 16 feet. 
 
 16 
 
 Male, 15. 
 
 R. A> ^- niastoid. 
 
 Conversation at 20 feet. 
 
 17 
 
 Male, 41. 
 
 B. A' L- A- 
 
 Conversation with ease at 40 feet 
 
 1 American Journal of the Medical Sciences, Vol. Ixxiii. , p. 50. 
 4
 
 50 
 
 TICK OF A WATCH. 
 
 Table showing the Disproportion between the Power of Hearing 
 the Tick of a Watch and the Human Voice. (Continued.) 
 
 No. 
 
 Sex and age. 
 
 Hearing distance for the watch. 
 
 Hearing distance for conversation, the pa- 
 tient being with the back to the speaker. 
 
 18 
 
 Male, 45. 
 
 R ^, L. ^ys. 
 
 Conversation at 40 feet. 
 
 19 
 
 Male, 54. 
 
 R ri,, L. n*. 
 
 Loud conversation at 45 feet. 
 
 20 
 
 Male, 70. 
 
 R i--- L. Jft 
 
 Conversation at 30 feet. 
 
 21 
 
 Female, 16. 
 
 R. 4 3 o> L. & 
 
 Voice with difficulty at 10 feet. 
 
 22 
 
 Male, 80. 
 
 B. A, L- jfr 
 
 Conversation at 40 feet. 
 
 23 
 
 Male, 32. 
 
 R. A* L A- 
 
 Conversation at 30 feet. 
 
 24 
 
 Male, 36. 
 
 R contact T mastoid 
 
 J* -iir> ** ~ * o~- 
 
 Ordinary conversation at 18 feet. 
 
 25 
 
 Female, 24. 
 
 R. A. L - A- 
 
 Conversation at 10 feet. 
 
 26 
 
 Male, 74. 
 
 R ^ L- A- 
 
 Conversation at 50 feet. 
 
 27 
 
 Female, 15. 
 
 R. 4 2 , L- A- 
 
 Ordinary conversation at 40 feet. 
 
 28 
 
 Male, 71. 
 
 R tf, L. 1^. 
 
 Conversation at 20 feet. 
 
 29 
 
 Male, 44. 
 
 R. *fc L. #. 
 
 Conversation at 30 feet. 
 
 30 
 
 Female, 22. 
 
 R. tf, L. A 
 
 Conversation at 26 feet. 
 
 
 
 After removal of ceru- 
 
 
 
 
 men and inflation. 
 
 Conversation at 30 feet. 
 
 31 
 
 Male, 38. 
 
 R , L. pressed. 
 
 Conversation at 20 feet. 
 
 32 
 
 Male, 13. 
 
 "R 5.5 ] J_ 
 ** 3 o> 1J ' o- 
 
 Conversation at 30 feet. 
 
 33 
 
 Male, 21. 
 
 Rl T pressed 
 10' " TO"' 
 
 Loud conversation at 8 feet. 
 
 34 
 
 Male, 33. 
 
 R. SS, L. ? v 
 
 Conversation at 50 feet ; general 
 
 
 
 
 conversation with ease ; does 
 
 
 
 
 not hear high notes well. 
 
 35 
 
 Female, 17. 
 
 K. A. L. A- 
 
 Conversation with some difficulty 
 
 
 
 
 at 30 feet. 
 
 36 
 
 Female, 34. 
 
 R 1^, L. 5 
 
 Loud conversation at 6 feet. 
 
 37 
 
 Female, 37. 
 
 B. A, L. j#. 
 
 Distinct voice at 2 feet. 
 
 38 
 
 Female, 36. K. *, L. $. 
 
 Voice at 34 feet after use of arti- 
 
 
 
 After use of artificial 
 
 ficial membranse tympanorum. 
 
 
 
 membranes, R T \, L. ^. 
 
 
 The tick of a watch is produced by the striking of a little 
 hammer upon the apex or side of the tooth of a ratchet-wheel. 
 It is therefore a simple unvarying tone, modified as to quality 
 in different watches. Now the sounds produced by the vocal 
 cords, reinforced by the resonating cavities of the nose and 
 mouth, may pass through a range of musical notes, which, as in 
 the case of the late Madame Parepa Rosa, may compass three 
 full octaves. A mere regular sound, such as that of the watch, 
 is certainly in no sense to be compared to the musical tones of 
 that wonderful instrument the human larynx. If, however, the 
 power of hearing the watch tick stood in any definite and fixed 
 relation to the ability to hear ordinary conversation, it would 
 serve very well as a test for registration. If, for example, we
 
 VON CONTA'S METHOD. 51 
 
 were able to say that a person who has a hearing distance by 
 the watch of f$, has a degree of hearing sufficient for the duties 
 of life, that it is as adequate as f -g- as tested by Snellen's test- 
 types is for seeing, the statement would give us a definite idea 
 of just how much the hearing power is impaired. But a refer- 
 ence to the table shows that the power of hearing the tick of a 
 watch stands in no exact proportion to the power of hearing con- 
 versation. On the othef hand, the test by the voice is also in- 
 adequate. When a person is waiting to hear a voice in a quiet 
 room, his ability to hear this, when compared with what is de- 
 manded of an ear, is utterly inadequate as a test. As is well 
 known, a healthy ear can appreciate from seven to eleven oc- 
 taves. Probably the life we lead in large cities and towns re- 
 quires such a power if we are to hear all that is demanded of us. 
 How then can the tones of the larynx, capable at its greatest of 
 reaching three octaves, form a sufficient test ? 
 
 Again, as will be shown in a subsequent chapter, a whole 
 class of persons suffering from disease of the ears hear better in 
 a noise, while another class hear best in quiet places. All these 
 things must be taken into consideration in testing the hearing 
 power or erroneous conclusions will often be reached. Unre- 
 liable as are the statements of patients as regards the history of 
 their cases, their testimony as to their improvement or non- 
 improvement is always of value in determining the true state of 
 the hearing power, and better still are the statements of their 
 relatives or friends, who, no matter how great their affection, 
 are always annoyed by being obliged to make an effort to make 
 them hear. They, at least, will gladly hail and note any greater 
 ability to hear on the part of a person with whom they have 
 been in the habit of conversing. 
 
 THE TUNING-FORK. 
 
 The value of the tuning-fork in testing the hearing power is 
 chiefly in the way of determining whether a given disease be in 
 the middle or internal ear. Von Conta, 1 of Weimar, recom- 
 mended it some years since, however, as a means of testing the 
 hearing power. In his method, the vibrations from the tuning- 
 fork are conducted to the ear through an elastic tube. The num- 
 ber of seconds during which the gradually decreasing vibrations 
 are heard becomes the measure of the hearing power. This 
 method never found any great favor, and so far as I know is not 
 often employed. 
 
 1 Archiv. fur Ohrenlieilkunde, Bd. L, p. 108.
 
 52 THE TUNING-FORK. 
 
 Since then, however, the tuning-fork has been and continues 
 to be widely employed in various ways for the purpose of differ- 
 ential diagnosis. I believe we now have in it, by a very simple 
 method, a valuable aid to a knowledge of the situation of a 
 given lesion. I shall, however, before describing the method 
 I now employ to the exclusion of all others in the test with the 
 tuning-fork, first give an account of the history of its use in 
 aural diagnosis, with a statement of the. methods in which it is 
 generally used. 
 
 As is well known, if we close our ears, and speak, the sound 
 of the voice seems to be confined to the head, as it were ; its re- 
 flection being to a certain extent prevented by the closure of the 
 external auditory canal. If now the auditory nerve be sound, 
 and there be impacted wax in one auditory canal, or a thicken- 
 ing of the mucous membrane lining the cavity of the tympanum, 
 the state of things will be similar to that when the external 
 meatus of a healthy ear is closed by the finger, or by some simi- 
 lar means, and the vibration of a- tuning-fork placed upon the 
 bones of the head will be heard more distinctly by an ear thus 
 affected than by the sound one. If the ears are equally affected, 
 it will be, of course, more difficult to come to a conclusion. If 
 the nerve be seriously impaired, from a primary lesion, or secon- 
 darily, by disease which has extended from the middle ear, no 
 such marked difference will be noticed when the external meatus 
 is closed. 
 
 Again, when the tick of a watch cannot be heard at all, if 
 the auditory nerve be not seriously impaired, the vibrations of 
 the tuning-fork, when its handle is placed on the teeth, fore- 
 head, or mastoid process, will be distinctly heard ; while if the 
 nerve be the seat of serious lesion, so that absolute deafness 
 exists, these vibrations will not be at all perceived in the head. 
 Some deaf-mutes, who were born deaf, and perhaps with a dis- 
 ease of the central apparatus, have assured me that they always 
 felt the sound of the tuning-fork passing to the region of the 
 diaphragm or stomach, and they would involuntarily place their 
 hand there when the vibration began. The large tuning-forks 
 of the note C are to be preferred to the smaller ones. 
 
 There is one source of error in the use of the tuning-fork in 
 this manner that cannot be fully avoided. Patients who do not 
 possess fair habits of observation will say that they hear the tun- 
 ing-fork better from the better ear, because they think that 
 they ought to do so. A little care in urging such persons to 
 notice the sound carefully will usually cause a correct answer 
 to be given. Its chief value is, however, among persons who 
 can be taught to observe what they actually hear, and who
 
 THE TUNING-FORK. 53 
 
 will allow their theoretical notions to remain in abeyance for a 
 time. 
 
 The following case illustrates the old method of using the 
 tuning-fork as a means of diagnosis, and also the inadequacy 
 of the watch as a test of hearing : 
 
 Dr. W , aged thirty-three, consulted me in regard to an 
 
 uncomfortable, "stuffy" sensation in the right ear, attended by 
 a slight impairment of hearing. His history was that he had 
 had nasal catarrh for some months ; for two days he has ob- 
 served the aural trouble. On testing the hearing power by the 
 watch it was found to be normal, or |, on both sides ; but the 
 tuning-fork was heard better on the affected side, and the pa- 
 tient, a busy physician and an exact observer, was sure that 
 his hearing power was somewhat impaired upon the right side, 
 although the watch did not detect it. The membrana tympani 
 was slightly injected along the handle of the malleus. 
 
 I diagnosticated the affection as sub-acute inflammation of 
 the middle ear of the right side, and treated it by the use of the 
 Eustachian catheter, Politzer's method, and a gargle, as well as 
 by the application of a leech to the tragus. After the first use 
 of the catheter and Politzer's method, the tuning-fork was heard 
 with equal distinctness on both sides, thus confirming the diag- 
 nosis and illustrating the value of the test. The patient re- 
 covered perfectly in a few days ; but at each visit before the ear 
 was inflated until his ear was fully restored to the normal con- 
 dition, the tuning-fork was heard more distinctly on the affected 
 side. 
 
 As has been previously intimated, I no longer employ the 
 tuning-fork in this manner for the purpose of making a diag- 
 nosis, but I rely upon the statements of the patient as to whether 
 the tuning-fork is heard more distinctly and for a longer time 
 when its vibrations are conducted through the air or through the 
 bones of the head. It is much easier for any person to determine 
 whether he hears a tuning-fork when held in front of the ear 
 better or worse than he does when it is placed on the mastoid 
 process, than it is for him to say on which side of the head he 
 hears it better. It is consequently a step toward an objective 
 test, if not one itself, if the distinction which we ask the patient 
 to make is one so easily made that even an ignorant person can 
 make it. It is, I believe, perfectly easy for even a stupid per- 
 son to determine which of two sounds is the louder if there be 
 any appreciable difference between them. This is the whole 
 problem to be solved in determining the difference between 
 conduction by air and by bone. This subject will be more 
 fully discussed in the chapter devoted to diseases of the in-
 
 54 AERIAL AND BONE CONDUCTION. 
 
 ternal ear. Here it will be sufficient to indicate the method of 
 testing. 
 
 A tuning-fork " C 2 " (according to Helmholtz C 2 = 528 vibra- 
 tions) is heard better by persons with normal hearing when held 
 while vibrating in front of the entrance to the external auditory 
 canal that is, it is heard louder. It is also heard longer. This 
 is also true of other forks, but for the sake of clearness the re- 
 marks here made are confined to the C 2 tuning-fork. At my 
 request, Dr. J. B. Emerson, Surgeon to the Manhattan Eye and 
 Ear Hospital, undertook some experiments, which show these 
 statements to be correct. ' 
 
 Starting from such observations upon healthy ear, we find 
 that in disease of the external or middle ear the intensity with 
 which the tuning-fork is heard through the bones is increased. 
 In other words, the natural relations between conduction through 
 the air and through the bones is disturbed. The bone conduction 
 is better than the aerial. It has also been ascertained by many 
 
 FIG. 1. Tuning-fork. 
 
 examinations that the diagnosis of disease of the middle or ex- 
 ternal ear may always be made when the bone conduction is 
 increased in intensity and relatively in duration. On the other 
 hand, in a case of impaired hearing with a loss of bone conduc- 
 tion, while the conduction through the air aerial conduction- 
 remains, we know that we are dealing with an affection of the 
 labyrinth or acoustic nerve. We may formulate the propositions 
 as follows : 
 
 I. If the hearing be impaired, and we find the aerial conduc- 
 tion better than that through bone, we are dealing with disease 
 of some part of the acoustic nerve, which may be either pri- 
 mary or secondary to disease of the middle ear. 
 
 II. If the conduction through the bone be intensified and last 
 longer in time than the aerial conduction, our case is one of dis- 
 ease of the middle or external ear. Of course, if the case be one 
 of impacted cerumen or other disease of the external ear, it is at 
 once diagnosticated by an examination, and the test by the tun- 
 ing-fork is practically useless, but it becomes very valuable in 
 cases where we are in doubt as to whether disease of the middle 
 
 1 Archives of Otology, vol. xv. , No. 1.
 
 AERIAL AND BONE CONDUCTION. 5.5 
 
 or internal ear exists, if, as I believe, after much experience, it 
 be one that can be depended upon. The method of making the 
 test is extremely simple. The tuning-fork is placed in vibration 
 by being struck on the knee of the examiner. It is then held in 
 front of the meatus to test the vibrations through the air, and 
 is again set in vibration and its handle placed on the mastoid 
 process about in its centre to test the conduction by bone. 
 
 In testing the duration of the conduction by air (aerial con- 
 duction) or by bone, a stop-watch is essential for accuracy. 'The 
 patient indicates the moment he ceases to hear the vibrations 
 by lifting the hand. I am well aware of the criticisms made 
 against this method of examination, that it is entirely subjec- 
 tive, that it leaves too much to the patient's intelligence and 
 truthfulness, and so forth. To these and similar objections I 
 can only answer that those who give this method of using the 
 tuning-fork a fair trial will, I am sure, find that it is an ex- 
 tremely valuable test. In my opinion the test by aerial and 
 bone conduction will, if tried, supersede all the methods of ex- 
 amination by the tuning-fork as yet known. 
 
 The tuning-fork is heard better through the bone in disease 
 of the middle ear because of the increased resonating capacity 
 of these parts when diseased by increase of tissue. When, on 
 the other hand, there is disease of the acoustic nerve, the sound 
 is heard most distinctly and longer when it passes through the 
 best channel that is, through the external auditory canal, the 
 tympanic cavity, and the fenestra ovalis. 
 
 When an affection of the middle ear exists which cannot be 
 detected by the watch or by conversation, although said to exist 
 by the patient, it will be found that the tuning-fork will con- 
 firm the patient's statements that one ear " is not right ;" that 
 is, the bone conduction will be longer and more intense than 
 the aerial ; and a thorough inflation will often restore the nor- 
 mal relations. The objections that have been made as to the 
 value of the tuning-fork as a means of assisting in a differential 
 diagnosis, are chiefly against the old method of determining on 
 which side the tuning-fork is heard better. Yet even when used 
 in this way it is valuable, although as I trust, it is soon to be 
 superseded by the simple tests of the intensity and duration of 
 aerial and bone conduction. 
 
 According to Politzer, 1 E. H. Weber was the first to show 
 the facts that have been stated with regard to the increase in 
 intensity of the sound of a tuning-fork on the side of the meatus 
 that is closed by the finger. Mach, quoted by Politzer, ex- 
 plained this fact by the theory that the reflections of the waves 
 
 1 Reprint from Wiener Medizinischen Wochenschrift.
 
 56 THEORY OF TEST BY TUNING-FORK. 
 
 of sound from the ear was prevented by this closure of the 
 auditory canal. Politzer concludes, as the result of experi- 
 ments, which may be found in detail in the first volume of the 
 " Archiv fur OhrenheiLkunde," that the increased perception of 
 sound that is felt in one ear depends upon two causes : 
 
 1. The waves of sound that have been carried from the bones 
 of the skull to the air of the external auditory canal are reflected 
 back on the membrana tympani and ossicula auditus. 
 
 2. In accordance with Mach's theory, the passing out of the 
 waves of sound which have reached the labyrinth and cavity of 
 the tympanum, through the bones of the head, 1 is prevented by 
 the obstacle they meet in the closed ear. 
 
 It will thus be seen that Mach and Politzer explain the phe- 
 nomenon of increased perception of sounds conveyed through 
 the skull, in an ear whose peripheric portions are obstructed by 
 disease, or by some mechanical cause, entirely by the theories 
 that the loss of sound is prevented by the obstruction to its re- 
 flection from the auditory canal, and that the force of the waves 
 is also intensified by their being thrown back upon the nerve. 
 
 Even if we do not now employ the tuning-fork by determin- 
 ing on which side of the head it is heard better, the explanations 
 as to the interesting phenomena revealed by such a test are not 
 without value, and they are accordingly given. If, in a decided 
 case of catarrh of the middle ear, the tuning-fork is heard better 
 on the normal side, we must conclude that there is some lesion 
 of the labyrinth perhaps as Politzer a and Schwartze suggest, 
 " a fluxion toward the labyrinth with serous exudation in the 
 nerve structure." In cases of this kind, as the pressure upon 
 the labyrinth is removed by a decrease of the catarrh of the 
 middle ear, the tuning-fork will be heard better on the affected 
 side. 
 
 Politzer ' explains the fact that in some cases of perforation 
 of the membrana tympani, the tuning-fork is heard better on 
 the affected side by two reasons : 
 
 1. The mobility of the ossicula auditus, by which the passage 
 outward of the waves of sound that have once reached the laby- 
 rinth is retarded, is lessened. 
 
 2. By the perforation of the drum-head, the cavity of the 
 tympanum and auditory canal are converted into one space, 
 and a greater resonance from the larger air-chamber is pro- 
 duced, which acts upon the fenestrce ovalis and rotunda, and 
 increases the intensity of the perceptive power of the labyrinth. 
 
 1 Archiv fur Ohrenheilkunde, B. I., p. 321, 1868. Politzer, loc. cit. 
 * Loc. cit., p. 5. 3 Loc. cit., p. 12.
 
 BLAKE'S TUNING-FORK. 
 
 57 
 
 The tuning-fork used by Politzer in his experiments and in 
 his practice corresponds to the second C in the base, vibrating 
 512 times in the second. On striking it, we notice particularly 
 two distinct tones one the ground tone .or dominant, the other 
 the upper tone or musical fifth ; either one or the other pre- 
 dominates, according to the density of the substance against 
 which the tuning-fork is struck. In employing it for diagnosis, 
 the predominance of the upper tone is often very confusing to 
 the patient, and the cause of error. 
 
 In order to get the pure dominant, it is only necessary to 
 affix a pair of metal clamps to the ends of the branches ; this is 
 done by means of small screws. If the tuning-fork is now 
 struck even with a hard substance, only the dominant is percep- 
 tible. Dr. Schaar, 1 of Vienna, diminishes the intensity of the 
 upper tone by gentle pressure upon the lower por- 
 tion of the branches. The value of the tuning-fork 
 in testing the perception of different musical tones 
 has been much increased by the discovery that, 
 by fixing the clamps at different points upon the 
 branches, it is possible to obtain all the tones and 
 semitones up to an octave above the musical 
 fourth of the dominant tone of the tuning-fork. 
 
 {POLITZER.) 
 
 Dr. Blake/ who has written a good digest of 
 this subject, says that " Itard used a bell which 
 was struck by a pendulum, the force of the blow 
 being determined by the space through which the 
 pendulum passed before striking ; in this way the 
 difficulty as to control of the intensity of the sound 
 was overcome, but the tone remained the same." 
 Following this idea, Dr. B. caused to be constructed 
 the tuning-fork as represented in the accompany- 
 ing woodcut (one-third size), that is, the common 
 instrument with the clamps as used by Dr. Polit- 
 zer, but with the addition of a hammer, the head 
 of steel, one face being covered with soft rubber. 
 " Lucae proposed the use of a hammer faced with 
 some elastic material for striking the tuning-fork. 
 The handle of the hammer is a steel spring,' sliding in a bar af- 
 fixed to the stem of the fork, and fastened in place by a small set 
 screw. By using either the steel or rubber face of the hammer, 
 either the upper or lower tone will be rendered most prominent. 
 
 Fia. 2. Blake's 
 Tuning-fork. 
 
 'Blake : Reprint from Boston Medical and Surgical Journal, p. 3. 
 s Blake, loc. cit.
 
 58 ENTOTIC USE OF SPEAKING-TUBE. 
 
 By affixing the clamps as Politzer directs, we obtain the variety 
 of tone, and by the distance to which the hammer is sprung can 
 regulate their intensity. The adjustment is simple, and obviates 
 the necessity of employing any other musical instrument." 
 
 In cases of disease of the auditory nerve, it is often of in- 
 terest to test the capacity of the patient for hearing high or low 
 tones. For this purpose I use a piano, connecting the ear of the 
 patient to the keys by means of a flexible stethoscope. Politzer ' 
 uses an harmonium, in the casing of which is an opening, for 
 the insertion of the auscultation tube. 
 
 Dr. Bing makes what he terms an entotic application of the 
 hearing-trumpet as a means of diagnosis. In practising Bing's 
 method, words are spoken into the mouth of a hearing-trumpet, 
 the other end of which is- directly connected with the cavity of 
 the tympanum by being inserted into the nozzle of a Eusta- 
 chian catheter, whose extremity lies in the Eustachian tube. 
 The waves of sound pass through the hearing-trumpet and 
 catheter directly to the base of the stapes bone, and are thus 
 transmitted to the terminal filaments of the acoustic nerve. In 
 a case in which speech cannot be at all understood through a 
 hearing-trumpet, but is heard by its application to the interior 
 of the tympanum, we may conclude that the hindrance to the 
 conduction of sound is in the malleus or incus, while the mobility 
 of the base of the stapes is not impaired. 4 
 
 For a full account of Lucre's interference otoscope or apparatus see previous edi- 
 tions of this work. I have omitted it in this edition, since it seems to me that all the 
 tests by the tuning-fork except the simple one have become unnecessary. 
 
 MALINGERING. 
 
 In countries where liability to military service is universal, 
 there are many malingerers, who claim to be dull of hearing in 
 one or both ears. Next in frequency, it is claimed that there is 
 absolute deafness of one ear only. It is so difficult to maintain 
 for any length of time a false assertion of absolute deafness of 
 both ears, that it is seldom attempted. The only malingerers that 
 I have seen in our country since the close of the civil war, have 
 been found among the applicants for the pensions that our Gov- 
 ernment gives with such liberality to those who were in any 
 way disabled while in the national service. Dr. David Coggin's 3 
 method of testing a patient who states that he is deaf of one 
 
 1 Text-book, p. 167. 
 
 8 Politzer : Lehrbuch, S. 215. Translation, p. 186. 
 
 'Archives of Otology, Vol. viii., p. 177.
 
 COGGIN'S TEST. 59 
 
 ear is simple and valuable. He uses a Camman's bin-aural 
 stethoscope. He plugs the right metal socket with a wooden 
 stopper if the patient claims to be deaf of the left ear. On using 
 the stethoscope in this manner for hearing speech, a person with 
 good hearing power will find that he cannot distinguish it with 
 the right ear. The person who claimed to be deaf of the left 
 ear, was first tested while the tube of the right arm was plugged, 
 and it was found that he could hear a whisper in the thoracic 
 cup, which served as a mouth-piece.. The tube containing the 
 plug was then removed, and the tragus was firmly pressed 
 against the meatus, so as to completely close it. Then the tube 
 was applied to the left ear, as before ; the patient positively de- 
 nied that he could hear what Dr. Coggin said to him. He knew 
 that the tube through which he supposed he heard before was 
 no longer in the right ear. As has been said, simulation of im- 
 pairment of hearing on both sides is very difficult to detect. 
 Such a person should be kept under observation for some few 
 days, and repeated examinations made as the ingenuity of the 
 surgeon may suggest them. 
 
 EXAMINATION OF AUDITORY CANAL AND MEMBRANA TYMPANI. 
 
 The next step after noting the hearing power in the examina- 
 tion of our imaginary patient, is the exploration of the auditory 
 canal and the membranse tympani. 
 
 FIG. o. Angular forceps. 
 
 It is, of course, implied in this that an affection of the auricle 
 needs no special assistance for examination. 
 
 For the purpose of examining the external auditory canal 
 three instruments may be necessary : a pair of angular forceps, 
 an aural speculum, and a concave mirror or reflector. The first 
 is of use to remove any temporary obstructions which may pre- 
 vent a view ; the second dilates the canal ; and the third throws 
 the light into it.
 
 60 SPECULA. 
 
 According to Wilde, 1 Dr. Newbourg, in a memoir published 
 at Brussels in 1827, recommended an instrument which is the 
 origin of all the tubular ear specula now in use. It was a slender 
 horn tube, four inches long, with a bell-shaped outer orifice. 
 Subsequently this instrument, which was much too long, was 
 improved by shortening it, by Dr. Ignaz Gruber, of Vienna, and 
 generally introduced to the profession by Sir William Wilde in 
 1844. After a fair trial of the bi-valvular instrument of Kramer, 
 and the funnel-shaped one of Toynbee, I now use the conical 
 speculum, either that of Wilde, Troltsch, or Gruber. I do not 
 think that any one of these has any great advantage over the 
 others. The practitioner will do very well with any one of them. 
 Too much stress is sometimes laid on a little change in shape. 
 I prefer that the interior surface of the speculum be brilliant, 
 and not black, as those of Gruber are sometimes made. 
 
 Those who consider that there is an advantage in a funnel- 
 shaped instrument will find the one here figured preferable to 
 
 FIG. 4. Gruber's Speculum. 
 
 Toynbee's, because the transition from the wide orifice, which 
 dilates the cartilaginous part of the canal to its fullest extent, 
 to the narrower, which exposes the osseous portion, is gradual, 
 and thus prevents the reflection of many rays at this point. 
 
 The speculum for ordinary use should be made of coin silver 
 or it should be nickel-plated. For the purpose of applying acids 
 or caustics, one of hard rubber, porcelain, or glass is to be pre- 
 ferred. The instrument is warmed by the hand before being 
 used, and then inserted gently and slowly into the meatus with 
 the right hand, the auricle being lifted up with the left, and 
 the speculum held in position by the thumb and index finger 
 of the same hand. It will thus be kept under complete control, 
 and the examiner will be able to turn it so as to successively 
 view the different parts of the whole surface of the membrana 
 tympani, and at the same time to thoroughly straighten the 
 canal by pushing up its upper wall. 
 
 It is very important that the speculum be held properly, for 
 I have seen many a student, for the want of knowledge of this 
 
 1 Treatise on Diseases of the Ear. English edition, p. 60.
 
 METHOD OF USING SPECULUM. 
 
 61 
 
 simple manipulation, labor for a long time without getting any 
 view of the membrane, while the instrument was resting on 
 some portion of the projecting wall of the canal. A very con-, 
 siderable amount of pain may be caused by the rude introduc-- 
 tion of the speculum. I would advise each practitioner to allow 
 one to be introduced into his own auditory canal, before he be- 
 gins to use the instrument upon his patients. 
 
 Having thus dilated the canal, the light may be thrown into 
 it by means of the otoscope or reflector of Troltsch, which is a 
 concave mirror of about three inches in diameter, having a focal 
 
 FIG. 5. Method of Holding the Speculum in Position. 
 
 distance of about six inches. Ordinary daylight is the best 
 source of illumination for this mirror, although sunlight, lamp- 
 light, gaslight, electric light, that of a candle, or the reflection 
 from a light-colored wall, may each be made available in this 
 method of examining the outer parts of the ear. This is a very 
 simple process, although many make a difficult one of it. If we 
 but use the skill we acquired in our juvenile days, in throwing 
 a dazzling light upon a desired object by means of a bit of 
 broken mirror, it will serve us in good stead here. The mirror 
 is held very lightly in the hand, and the light is condensed upon 
 any desired part by a very slight movement.
 
 62 METHOD OF EXAMINING MEMBRANA TYMPANI. 
 
 It is now almost universally conceded by the profession that 
 this method is altogether the best that has yet been suggested 
 for the examination of the membrana tympani. It was first 
 introduced to the profession at large by Professor Anton Von 
 Troltsch, in 1855, without previous knowledge that it had been 
 suggested by others, although Dr. Hoffman, of Westphalia, had 
 previously, in 1841, used an ordinary shaving mirror with a cen- 
 tral opening for the examination of the ear. Professor Edward 
 Jaeger, in his work 011 "Cataract and Cataract Operations/' 
 published in 1853, suggests that his ophthalmoscope may be 
 used with the concave mirror of four inches focal distance, for 
 the examination of the external auditory canal. I have also 
 been informed by numerous practitioners that they have often 
 used the ophthalmoscopic mirror for examining the ear ; but in 
 
 FIG. 6. Method of Examining the Auditory Canal and Membrana Tympani. (A handle 
 to the otoscope other than that formed by the head-band is not necessary. It will be found 
 much more convenient to make the head-band serve a double purpose.) 
 
 spite of all these statements and the fact that Frank, 1 in his 
 work on the ear, gives a sketch of Hoffman's otoscope, the 
 credit of the introduction into general use of the concave mirror 
 for the examination of the ear as certainly belongs to Troltsch, 
 as the invention of the ophthalmoscope to Heinrich Helmholtz. 
 It is somewhat surprising, however, that after the description 
 which Frank gives in his text-book of Hoffman's method, and 
 the drawing which he furnishes of the mirror, no attention was 
 paid to the subject until Troltsch revived it without knowing 
 of Hoffman's apparatus. 
 
 I introduced the use of the aural mirror, or otoscope as it 
 should be called, into the practice of the New York Eye and 
 Ear Infirmary, in 1863, where it soon superseded all other 
 
 1 Practische Anleitung zur Erkentuiss der Ohrenlieilkunde, p. 49.
 
 TKOLTSCH S OTOSCOPE. 
 
 63 
 
 methods, and whence it has been very generally adopted in the 
 
 United States. 
 
 It may be safely said that the adoption of this simple method 
 
 of examination has done more for the scientific and practical 
 study of aural disease than any previous sugges- 
 tion in this department. It has placed within the 
 hands of every practitioner a method by which he 
 may, in a 
 few minutes, 
 learn to ex- 
 a m i n e a 
 membrane 
 which not a 
 few physi- 
 cians have 
 never seen 
 011 the living 
 subject. 
 
 FIG. ?. Coiin's Since the use of the electric light as a means 
 of general illumination, excellent apparatus are 
 
 constructed for examining the nose, pharynx, and auditory 
 
 canal. 
 
 FIG. 8. Author's Forehead Band. 
 
 FIG. 8a. Pomeroy's Forehead Mirror. 
 
 I deem it unnecessary, to describe the numerous methods 
 which preceded that of Troltsch, since they are fast becoming
 
 64 
 
 BINOCULAR OTOSCOPY. 
 
 obsolete, and their description belongs rather to the history of 
 otology than to a practical treatise. Even the method of ex- 
 amination by means of the direct rays of the sun, which held 
 out so long in the hands of some practitioners, has at last given 
 way to the use of the mirror and ordinary daylight. 
 
 It is sometimes convenient for the examiner and the patient to 
 sit during the examination of the membrana tympani, and some- 
 times both may stand, or, 
 as I usually examine, the 
 patient may sit in a re- 
 volving chair, while the 
 surgeon stands. The po- 
 sition of the patient will 
 not be an important mat- 
 ter, so long as a good il- 
 lumination is thrown into 
 the canal. A forehead 
 band is essential in mak- 
 ing applications to tjie ear, 
 and it is often convenient 
 at other times. I cannot 
 see any advantage in the 
 various complicated and 
 expensive bands with ball- 
 and-socket joints, but I 
 use a simple screw attach- 
 ment by which the mirror 
 is fastened to the head-band. I prefer a head-band of elastic 
 material, such as india-rubber webbed cloth. 
 
 I never look through the opening in the mirror, but rather 
 over the rim of it. The presbyope and hypermetrope will need 
 his reading glasses in order to make an examination of minute 
 points. A clip containing the appropriate convex lens may be 
 made for those who look through the hole in the mirror. Those 
 who do not, will be obliged to employ their glasses used for read- 
 ing, in order to get an accurate view of some of the details of the 
 drum-head, ossicles, or the tympanic cavity. A lens may be in- 
 serted in the speculum, as suggested by Dr. Loring. 1 
 
 Mr. Edward S. Ritchie, of Boston, at the suggestion of Dr. 
 Clarence J. Blake, 2 has made an instrument which is designed to 
 overcome the disadvantages attending the exclusion of one eye 
 from the visual act in operating upon the membrana tympani : 
 
 FIG. 8b. Electric Lamp for Illuminating Ear. 
 
 1 Verbal Communication, N. Y. Opbihalmological Society. 
 * Late Contributions to Aural Surgery. Boston, 1870.
 
 OPERATING OTOSCOPE. 65 
 
 " It consists of a hard rubber speculum (Politzer's) of the 
 largest size, fitted with a metallic rim, to which is attached a 
 revolving prism and an arm, bearing at its outer end a lens of 
 about an inch focus ; this arm is movable, but sufficiently firm 
 to remain fixed at any angle at which it 
 is placed. The prism is just within the 
 focal distance of the lens, and its inci- 
 dent face is armed with a small metal 
 shield, having an opening in the centre 
 corresponding in its short diameter to 
 the diameter of the pencil of light falling 
 upon it from the lens. 
 
 "The advantage of a prism over a 
 mirror or other reflecting surface is, 
 that we have almost total reflection ; 
 and but little of the light concentrated 
 upon the prism by the lens is lost. 
 
 "In operating, an assistant is re- s'cope!* 1 
 
 quired to draw the auricle upward and 
 
 backward, and keep the speculum in position, with the pencil 
 of light upon the opening in the shield of the prism. It is not 
 claimed for this instrument that it at all supersedes the head 
 mirror of Troltsch, but it is certainly of great advantage in the 
 more complicated operations, where a steady and uniform illu- 
 mination is indispensable. The instrument, as a whole, weighs 
 only about one hundred and fifty grains, and can be made much 
 lighter ; so that when once firmly inserted in the meatus, it re- 
 mains in position, and there is no necessity for holding it nor 
 fear of its slipping out of place during the operation." 
 
 The practitioner will often be obliged to examine the ear and 
 pharynx of a patient who is too ill to get up from the bed. The 
 light from a candle or of Colin's lamp then becomes a very con- 
 venient and ample means of illumination. The finest changes 
 on a membrana tympani and in the auditory canal may be ob- 
 served by the aid of the otoscope and such a light. 
 
 
 
 EXAMINATION OF THE PHARYNX AND EUSTACHIAN TUBES. 
 
 After having heard the patient's history, and having ascer- 
 tained the amount of hearing, we may proceed to the examina- 
 tion of the pharynx and nares, and mouths of the Eustachian 
 tubes. Although the profession has been a long time in coming 
 to an appreciation of the fact, it is now generally conceded that 
 the starting-point of a large percentage of aural cases is in these 
 parts. 
 
 5
 
 66 
 
 PHAKYXX AND EUSTACHIAN TUBES. 
 
 The pharynx is best examined by turning the patient's face 
 to an open window, and holding the tongue by means of Turck's, 
 
 or a simple hinge speculum. Turck's 
 instrument is to be preferred to others, 
 because the hand of the examiner does 
 not obscure the view in its use. I 
 often, however, use a reflector and ordi- 
 nary daylight for an inspection of the 
 pharynx, and it has some advantages 
 over a direct illumination. 
 FIG. 10. Hinge Speculum. Some surgeons prefer to use artificial 
 
 light in examining the pharynx as well as other parts of the 
 body, but I much prefer ordinary daylight for all examinations, 
 when it is possible to use it, to that from any artificial source, 
 or to the direct rays of the sun, since it seems to me that the 
 natural hues are thus best observed. In the evening, of course, 
 
 Q 
 
 Pro. 11. Turck's Speculum. 
 
 artificial light must be used. A reflector should then be em- 
 ployed. It is well to have the reflector attached to a forehead 
 band, as in the practice of rhinoscopy or pharyngoscopy, which 
 will bS immediately described ; but I may defer any description 
 of what to observe on examining the fauces and pharynx until 
 we come to speak of pharyngeal disease. 
 
 RHIXOSCOPY. 
 
 Rhinoscopy, as a practical method of examining the posterior 
 nares, was suggested by Sir William Wilde in his treatise on 
 "Aural Surgery," having previously been spoken of by Bozzini,
 
 EHINOSCOPY. 67 
 
 as a possible method of examining the parts behind the hanging 
 palate, in a book published in Weimar in 1807. l 
 
 Professor Czermak, of Prague, following up Turck's investi- 
 gations on the larynx, was the first to actually introduce rhino- 
 scopy into anything like general use ; while Dr. Semeleder, 
 Surgeon to the Gumpendorf Hospital in Vienna, and afterward 
 Surgeon to the Archduke Maximilian, while in Mexico, gave us 
 the first full account of what was to be observed by this means, 
 with some interesting cases. Voltolini, of Breslau, has also 
 added much to our knowledge of the value of this means of 
 diagnosis. 
 
 It is by no means necessary that every aural patient should 
 be examined with the rhinoscope, nor will the most accom- 
 plished manipulator be able to see the mouth of the Eustachian 
 tubes in every case ; but every one who attempts to treat the 
 disease of the organ of hearing will find his diagnosis very often 
 facilitated by an inspection of these parts ; for example, when 
 any unusual difficulty is experienced in entering the mouth of 
 the Eustachian tube. 
 
 For the practice of rhinoscopy we need a lamp, or other 
 source of artificial illumination, a small mirror, a tongue spat- 
 ula, and a concave mirror that may be attached to a forehead 
 band or placed on Semeleder's spectacle frame. Any brightly 
 burning lamp, or a good Argand gas-burner, will answer as a 
 source of illumination. 
 
 Various kinds of costly apparatus for the purpose of con- 
 densing the light have been suggested and employed. If the 
 surgeon be not satisfied with an ordinary lamp, perhaps the ap- 
 paratus of Tobold will be found the best. In some instances, 
 although not always, an instrument for holding back the uvula 
 is required. Various appliances have been suggested for this 
 purpose nooses, hooks, spatulas, and so on for any of which 
 a surgeon of ordinary tact will find a substitute when wanted,, 
 
 It is above all things requisite, that the patient should be 
 tractable, and this tractability is perhaps more common than 
 many surgeons imagine. Those who precede all their manipu- 
 lations by an appeal to their patients to be very quiet, to be sure 
 not to stir, not to mind a little pain, etc., and who at the same 
 time make a great show of instruments, will generally have in- 
 tractable and timid patients ; but he who goes quietly to work, 
 will find few patients that will not submit with more or less 
 patience to all. such manipulations as are required in rhinoscopy, 
 the use of the Eustachian catheter, and the like. 
 
 1 Laryngoscopy and Khinoscopy. By F. Semeleder. Translated by Dr. E. T. Cas- 
 well, 1866.
 
 68 RHINOSCOPY. 
 
 The patient being seated in front of the examiner, with a 
 good light at one side, the mouth is well opened, and the tongue 
 held by means of the depressor mentioned above. The surgeon 
 should be careful in placing the tongue-depressor, so that he 
 may not cause undue pressure, which will produce gagging, and 
 prevent all further manipulations. The light is then turned 
 upon the pharynx by the head mirror, so that it is accurately 
 focused, when the parts will be illuminated. 
 
 Having secured a good view of the pharynx, uvula, and ton- 
 sils, the throat mirror is to be introduced. This instrument is first 
 warmed by holding it for an instant over the flame of the lamp ; 
 its heat is then tested by placing it on the back of the hand, after 
 which it is gently and quickly introduced, with its reflecting face 
 
 FIG. 12. Anterior Nares Speculum. FIG. 13. Goodwillie's Nasal Speculum. 
 
 upward, into the space between the soft palate and cavity of the 
 posterior pharyngeal wall. There are some patients, however, 
 in whom it will be impossible to make a rhinoscopic examina- 
 tion, on account of the small space between the uvula and pos- 
 terior wall of the pharynx. A very few, also, have such irritable 
 throats as also to render such an examination impracticable. 
 
 The examination of the nostrils anteriorly anterior rhino- 
 scopy, as it is called by Cohen ' is often an important part of 
 the examination of a case of aural disease. 
 
 It is very often sufficient to place the patient in front of a 
 good light, and open the nares by pressing upon the tip of the 
 nose. A thorough examination of the anterior nares may be 
 made with any of the specula of which cuts are here given. 
 
 Zaufal, of Prague, has of late years laid great stress upon 
 anterior rhinoscopy. He has devised a set of nasal specula for 
 this method of examination, and he has contributed largely to 
 our knowledge of the morbid appearances of the nasal cavities. 
 A little experience must be had with these specula, before the 
 surgeon will be willing to trust himself to deductions from what 
 he may see. 
 
 1 Diseases of the Throat, p. 75.
 
 ZAUFAL'S SPECULA. 69 
 
 ZaufaFs specula are long tubes of various sizes adapted to 
 the inferior meatus of the nose, with a funnel-like extremity 
 through which the light 
 is thrown. When Dr. 
 Weir, of this city, was 
 an aural surgeon to one 
 of our infirmaries, he 
 used the tube of the en- 
 doscope for the same 
 
 / -i j. FIG. 13a. Elsberg's Nasal Speculum. 
 
 purpose of obtaining an 
 anterior view of the mouth of the Eustachian tubes, but Zaufal 
 has made much greater publicity of the results of his examina- 
 tions by this method and probably never knew of Weir's work 
 in the same direction. 
 
 EXAMINATION OF THE EUSTACHIAN TUBE. 
 
 We may now turn, as the next step in our examination of a 
 case of supposed aural disease, to the investigation of the con- 
 dition of the Eustachian tube and cavity of the tympanum. 
 The means of this examination may be classified as follows : 
 I. The Eustachian catheter. 
 II. Politzer's method. 
 
 III. Valsalva's method. 
 
 IV. Eustachian bougies. 
 
 From the date of the promulgation of the use of the Eus- 
 tachian catheter by the postmaster of Versailles, Guyot, until 
 Toynbee's time, the views of the profession as regards the use 
 of this instrument have varied exceedingly. At one time it was 
 almost utterly rejected by the greater number of respectable 
 practitioners, and at another time has been considered by them 
 as a panacea in the treatment of aural disease. The text-books 
 of Wilde and Toynbee, which attached very little importance to 
 the use of the Eustachian catheter, and Avhich bear intrinsic 
 evidence that the authors did not choose to be very familiar 
 with the details of the proper employment of the instrument, 
 probably did more than anything else to cause the profession in 
 our own country to settle down, until a few years since, into the 
 belief that the Eustachian catheter was always a useless and 
 sometimes a dangerous instrument. I well remember the dis- 
 couraging response of a prominent American practitioner, who 
 had then had large experience in aural disease, to my state- 
 ment, at the beginning of my active professional life, that I pro- 
 posed to use the Eustachian catheter in the treatment of diseases
 
 70 
 
 EUSTACHIAN CATHETER. 
 
 of the ear, that he was glad to say that he never had used the 
 instrument, and this was the common sentiment among our re- 
 spectable practitioners until the publication of an English trans- 
 lation of Troltsch's work on the ear. In respect 
 tf f to the change in sentiment in this regard, I only 
 ff // need to say, that nearly every American surgeon 
 I! /y who now treats aural disease, attaches much 
 
 importance to the use of this instrument. 
 
 We have now to speak of the Eustachian 
 catheter as a means of diagnosis. The material 
 of which the instrument should be made may be 
 either hard rubber or alloyed silver. For the 
 injection of warm vapors the hard rubber in- 
 strument is the only one to be used, because the 
 heat will very soon nlake it impossible for a pa- 
 tient to bear the metal instrument in the nostril. 
 For myself, I use the hard rubber instrument for 
 all purposes. 
 
 In the method of introduction, we proceed as 
 did Archibald Cleland, an English surgeon, who, 
 after Guyot, did the most to demonstrate the 
 utility of entering the mouth of the Eustachian 
 tube with an instrument, and we pass the cathe- 
 ter through the nostril. It is very difficult to 
 imagine how the Versailles layman succeeded in 
 introducing an instrument into the tube, through 
 the mouth. He certainly did not use a catheter 
 such as we now employ, and which is represented 
 on this page. This instrument is a delicate 
 tube of about six inches in length, with a slight 
 curve at its extremity. A long and flexible 
 catheter might, it is true, be passed behind the 
 soft palate into or opposite the mouth of the 
 tube, and this is the operation which Guyot 
 demonstrated to the Paris Academicians, and 
 which, by removing mucus from about the trum- 
 pet-shaped pharyngeal extremity of the canal, 
 relieved his impairment of hearing. 1 
 
 The various steps in the operation of intro- 
 ducing the Eustachian catheter are as follows : 
 
 ] . Let the patient be seated on a chair, with 
 a little higher back than usual, so that the head may be sup- 
 ported. If the patient be a child or a very timid subject, it may 
 
 FIG. 14. Eusta- 
 chian Catheters (ac- 
 tual size). 
 
 For a fuller account of Guyot's operation, see Introductory Chapter.
 
 EUSTACHIAN CATHETER. 71 
 
 rest its head against a table or wall, or what is better, be sup- 
 ported by an adult. 
 
 I seldom use the Eustachian catheter in young children ; for them I almost 
 exclusively use Politzer's method of inflating the middle ear. 
 
 2. Let the patient blow his nose, so as to moisten the passage 
 and remove any collections of mucus, while the surgeon takes 
 the catheter, thoroughly cleansed and warmed, and forces air 
 through it in order to be sure that it is permeable. 
 
 3. The operator, standing a little to on6 side, draws down the 
 upper lip with the left hand, and with the thumb and finger of 
 
 FIG. 15. Introduction of Eustachian Catheter. 
 
 his right hand lightly holds the catheter close to the funnel- 
 shaped end, nearly in a vertical position, so that the guide or 
 projection at the side of the funnel-shaped extremity looks 
 directly downward, until the catheter has entered the meatus, 
 when it is quickly turned to an approach to the horizontal 
 position, when the beak will rest on the floor of the nasal 
 meatus, close to the septum, with its convexity upward. 
 
 4. The catheter is then to be slid or insinuated backward with 
 a gentle motion, keeping it as close as possible to the floor of the 
 meatus, gradually elevating the handle until the instrument be- 
 comes perfectly horizontal and the beak rests upon the posterior 
 wall of the pharynx.
 
 72 EUSTACHIAN CATHETER. 
 
 5. At this point the funnel-shaped end of the catheter in the 
 hand of the operator is to be raised a little above the horizontal 
 line and at the same time withdrawn a little. 
 
 6. Turn the catheter about a quarter on its axis, from within 
 outward. This motion lifts the beak of the instrument into the 
 mouth of the Eustachian tube. This latter movement is aided 
 somewhat by the contraction of the soft palate, which performs 
 a swallowing movement, raises itself, and lifts the beak of the 
 instrument into the tube. Once in position the catheter should 
 
 FIG. 16. The Eustachian Catheter in Position. 
 
 not cause the patient any inconvenience in speaking or swal- 
 lowing, and the guide will lie at about an angle of twenty-five 
 degrees with the tragus. 
 
 The difficulties that are found in introducing the catheter, 
 simple manipulation as it is, arise from two causes : 
 
 First, the surgeon does not always hold the instrument in a 
 vertical position (see Fig. 15) until he has got the beak well in 
 the meatus. A failure to do this will often cause the instrument 
 to pass between the inferior and middle turbinated bones, in- 
 stead of along the floor of the meatus, which must be hugged in 
 order that the instrument may get to the mouth of the tube. 
 
 Second, the patient is apt to shut his eyes spasmodically and 
 contract his facial muscles, and thus prevent the relaxation of 
 the parts that is necessary during the manipulation. This diffi- 
 culty is only to be overcome by persuading the patient to open 
 his eyes and look about the room, which can be done if the sur-
 
 DIAGNOSTIC TUBE. 
 
 73 
 
 geon have a quiet, assuring manner. This difficulty usually 
 passes away with the second or third use of the instrument, and 
 sometimes it does not arise. 
 
 Having introduced the catheter we may force air through it 
 into the cavity of the tympanum, by means of an air-bag whose 
 nozzle should fit accurately in the funnel-shaped 
 extremity of the nasal instrument. Air may also 
 be blown in from the lungs of the examiner through 
 a slender bit of rubber tubing, the tips of which are 
 placed in the opening of the catheter and the mouth 
 of the examiner respectively. The use of the rub- 
 ber-bag or syringe is to be preferred to the latter 
 method, on the ground that it is not likely to offend 
 the natural feelings of the patient, against the in- 
 troduction of air from the lungs of the examiner. 
 
 After air has been forced into the middle ear in 
 this manner, the membrana tympani should again 
 be examined by the surgeon, to determine if it has 
 become injected, or if it has undergone any change 
 in position ; that is to say, he should see whether the current 
 has actually reached the cavity of the tympanum or not. 
 
 I have caused an exact representation to be made of the size 
 and curve of the Eustachian catheters used by me, for I was for 
 
 FlG. 18. Diagnostic Tube. 
 
 a long time greatly annoyed by the difficulty which I often 
 found in introducing instruments of a larger calibre and curve. 
 I am constrained to believe that the catheter would be much 
 more widely employed, were instruments of small calibre and 
 curve generally figured in the text-books and sold in the shops. 
 
 Most authorities recommend the use of an instrument like 
 .the stethoscope, which is placed in the ear of the patient while
 
 74 POLITZEE'S METHOD OF INFLATION-. 
 
 the air is being driven through the tube, and they claim to be 
 generally able to decide as to whether the air enters, by the 
 sound communicated through the tube. I believe it will be 
 found very difficult to distinguish sounds proceeding from 
 the pharyngeal mouth of the tube from those produced in the 
 cavity of the tympanum, and I do not, therefore, attach that 
 importance to the use of the stethoscope in this manner, that 
 has been usually ascribed to it ; but I rely more upon the ap- 
 pearances of the membrane of the tympanum after the air has 
 been forced in, with some attention also to the sensations of 
 the patient, as to where the air is felt, than upon the use of the 
 diagnostic tube. 
 
 I very rarely make use of the instrument. It was formerly 
 called the otoscope, a manifestly improper name, as Kramer 
 said. The mirror for examining the canal and membrana tym- 
 pani is the only otoscope. 
 
 POLITZER'S METHOD OF INFLATING THE EAR. 
 
 The next means of examining the condition of the Eusta- 
 chian tube and cavity of the tympanum is named, from the 
 physician who suggested it, Politzer's method. It is a means of 
 diagnosis and treatment of very great value, and we owe very 
 much to Professor Adam Politzer, of Vienna, for this method of 
 sending air into the middle ear. 
 
 As is very well known, in the action of swallowing, the 
 uvula rests upon the pharyngeal wall so as to shut off the upper 
 from the lower pharyngeal space ; so that persons affected with 
 cleft palate, who cannot thus separate these spaces, are greatly 
 inconvenienced by the passage of solids and fluids upward to 
 the posterior nares. It was long ago shown by Toynbee, that the 
 pharyngeal orifice of the Eustachian tube opened during the 
 swallowing process. Politzer's method takes advantage of these 
 physiological facts in the following way : the person to be ex- 
 amined takes a little water in the mouth, while the surgeon 
 places the nozzle of an air-bag into one of the/ nostrils, closes the 
 other with his finger, and causes the patient to swallow the 
 water at a given signal previously agreed upon, when he forces 
 in the air by compressing the india-rubber bag. I usually say 
 " now ; " upon which the patient swallows. 
 
 In examining children, I use, as suggested by Mr. Hinton, 
 a piece of rubber tubing, and force the air from my own lungs, 
 on giving a signal by raising the hand. 
 
 The effect of the air thus forced in upon the membrana tym- 
 pani is often wonderful. A person who has become deaf to
 
 POLITZEE'S METHOD. 
 
 75 
 
 ordinary conversation, sometimes in an instant again hears 
 the familiar tones of human conversation, and feels himself in 
 a new world. In such a case, mucus has obstructed the calibre 
 of the tube, or the mobility of the ossicles has been interfered 
 with. In the former case it is driven away by the current of 
 air, which must of necessity go against the mouths of the tube, 
 and will usually pass on into the middle ear. The patient's own 
 testimony will usually, although not always, be conclusive as 
 to whether the air entered the ear. The exceptional cases are 
 those in which the Eustachian tube and the cavity of the tym- 
 panum have become so nar- 
 rowed by a hypertrophy and 
 sclerosis of the lining mucous 
 membrane that only a very 
 narrow, feeble current can en- 
 ter, or perhaps where atrophy 
 of tissue has rendered it less 
 sensitive than normal. We 
 shall have need to dwell upon 
 the uses of Politzer's method 
 when we are discussing the af- 
 fections of the middle ear, and 
 I therefore content myself with 
 this description of it, while we 
 pass on to Valsalva's method of 
 inflating the ear. 
 
 A great many modifications 
 of Politzer's methods of proced- 
 ure, chiefly, however, as regards 
 swallowing as a signal for the 
 operator to compress the air- 
 bag, have been made by various 
 persons. Some of these bear 
 
 r's A PP a- 
 
 iodine or other 
 
 FlG m _ Method of Using 
 
 ratus (with box for containin 
 
 evidence of the tendency of the evaporating substance). 
 human mind to seek change, if only for the sake of change. 
 Gruber causes his patients to say hie, hoc, instead of swallow- 
 ing upon the signal. He enters into a laborious argument 
 to prove that his method is better than that of swallowing. One 
 of his objections to Politzer's method is, that patients object 
 to drinking from the glasses which he has near at hand. Dr. 
 J. Oscroft Tansley, 1 of New York, proposed that patients, instead 
 of swallowing, shall blow as if about to blow out a lighted 
 candle. Both of these modifications of one minor part of Polit- 
 
 1 Medical Record, March 1C, 1878.
 
 76 TANSLEY'S MODIFICATION. 
 
 zer's great invention, especially Tansley's, are of value in cer- 
 tain cases. They are not more important as modifications of the 
 method, than Hinton's use, in the case of children, of an india- 
 rubber tube, through which air is forced from the lungs instead 
 of from an air-bag. The late Dr. Peter Allen ' substituted a nasal 
 pad, which is pressed against the opening into the nostrils, in- 
 stead of into one of them. Two air-pads are mounted on a piece 
 of covered copper wire. These can be brought close together 
 or separated so as to stop up the openings into the nostrils. 
 
 The pads are held in place by the metal which serves as a 
 handle. There is a hole through each pad, and these holes com- 
 municate with two short bits of rubber tubing joining into a 
 single tube. The pipe of the air-bag used for inflating is inserted 
 in this latter, and the apparatus appears as in the engraving. 
 
 This instrument contains a very useful modification of Po- 
 litzers apparatus, and it is much preferred to the original by 
 
 PIG. 20. Dr. Allen's Nose Pads for Politzer's Apparatus. 
 
 some surgeons. There is no advantage in the double bag such 
 as is employed in the nebulizers, and which has also been pro- 
 posed for Politzer's method. 
 
 Tansley's method of blowing instead of swallowing was sug- 
 gested to him, as he states, after practising Holt's method. Dr. 
 E. E. Holt found that the air readily entered the tympana by 
 closing the lips tightly and distending the mouth and cheeks 
 easily with air, and then discharging the air-bag as in Politzer's 
 method. He consequently caused the patients to undertake 
 this manoeuvre instead of swallowing. I find the methods of 
 Gruber and Tansley very useful in many cases, but in by far 
 the most instances, I prefer to cause my patients to swallow on 
 a given signal. 
 
 I am told on reliable authority, that in one of the continental 
 cities, rival teachers of otology lay great stress upon the impor- 
 
 1 Treatise on the Ear, p. 97.
 
 VALSALVA'S METHOD. 77 
 
 tant point as to whether the air-bag is pressed upon on its side 
 or its distal end, when used for inflation. One teacher causes his 
 pupils always to compress the bag on one side, while the other 
 as strenuously insists that it can only be properly employed by 
 compressing it from the distal end. 
 
 VALSALVA'S METHOD. 
 
 The distinguished anatomist Valsalva, who is well known to 
 the profession by his treatise on the ear, suggested a means of 
 inflating the membrana tympani, which has become so popular 
 as to be used by nearly two-thirds of all the patients who come 
 to physicians on account of their ears. It has been recom- 
 mended by generations of medical men as a means of curing 
 affections of the ear, or of determining if the Eustachian tube 
 be open, or the drum-head broken. Universal as is its use, I re- 
 gard it as almost a useless and not an entirely safe method. It 
 consists essentially in forcing air into the ear, after a vigorous 
 inspiration, the mouth and nostrils being closed, It will be ob- 
 served that when the ear is inflated by this method, a very great 
 use of the muscles of the chest is made ; and just in this lies the 
 danger to the ear. This vigorous expansion of the chest causes 
 a congestion of the ear which is sometimes more or less perma- 
 nent, and materially harms the part by increasing the flow of 
 blood to it. There is another objection to the frequent employ- 
 ment of the Valsalvian method, or experiment, as it is some- 
 times styled. It soon ceases to have its momentary effect of 
 increasing the hearing distance, which it does by rendering the 
 membrane of the drum tenser, and then the membrane becomes 
 relaxed and flaccid, so that I have sometimes seen the mem- 
 brana tympani of patients who have been in the daily and per- 
 haps hourly habit of forcing air into the ears, flap to and fro 
 like a valve, on the slightest movements of the nostrils. 
 
 This latter objection, of course, applies to Politzers method 
 if it be very frequently practised ; but as it must be done by 
 means of an apparatus, patients are not so apt to take it into 
 their own hands. I do not now advise the use of the Valsalvian 
 method in the treatment of aural disease, and as a means of 
 diagnosis it is, in most cases, vastly inferior to the use of the 
 catheter or Politzer's method. 
 
 BOUGIES. 
 
 I may add a word about the last-named means of examining 
 the Eustachian tube, namely, bougies. Filiform catgut bougies 
 may sometimes be employed with advantage in determining if
 
 78 BOUGIES. 
 
 the non-entrance of air by the catheter or Politzer's method, be 
 due to a stricture ; but the need for their employment occurs 
 only in a very limited number of cases, and when they are used 
 great care and judgment are necessary. This subject will be 
 fully discussed in the chapter on " Chronic Xon-suppurative In- 
 flammation of the Middle Ear." The examination of the condi- 
 tion of the drum-head and ossicles by Siegle's otoscope will also 
 be discussed in the same place. 
 
 It will be understood by the reader that very many cases of 
 aural disease for example, those of the external auditory canal 
 will not require the exhaustive examination that has just been 
 detailed, yet many cases will require a systematic and complete 
 observation, such as I have attempted to delineate, in order that 
 an exact and consequently valuable diagnosis may be made. 
 The time thus consumed is sometimes considerable, but it is not 
 as great as those who simply read these descriptions will per- 
 haps imagine. The details occupy more in description than in 
 execution ; and their strict performance will of themselves in 
 time make those who carry them out, good observers of the 
 phenomena of disease.
 
 THE EXTERNAL EAR.
 
 CHAPTER III. 
 
 ANATOMY OF THE AUEICLE AND THE EXTEBNAL AUDITOBY 
 
 CANAL. 
 
 Auricle. Etymology. Anatomy of Muscles, Intrinsic and External. Physiology. 
 Blood-vessels. Nerves. External Auditory Canal. Anatomy of Curvature. 
 Ceruminous Glands. Hairs in CanaL Auditory Canal of Dog and Cat. Relations 
 of Canal to Parotid Gland, Inferior Maxilla, Mastoid Process, and Dura Mater. 
 Blood-vessels and Nerves. 
 
 THE auricle (auricula, external ear) is perhaps little more than 
 
 an appendage to the human organ of hearing, although it is 
 
 such an important part of the ear of certain animals. Its gen- 
 
 eral shape is that of a funnel. Its frame-work, or basis, is made 
 
 up of flexible flbro-cartilage, and it is 
 
 from one to two millimetres in thick- 
 
 ness. The cartilage is of the variety 
 
 known as reticular, and it is covered by 
 
 perichondrium which contains many 
 
 elastic fibres. These fibres pass into the 
 
 substance of the cartilage, and form a 
 
 network in the meshes of which small 
 
 cartilage cells are embedded. From the 
 
 time of Rufus of Ephesus the different 
 
 parts of the auricle, which give it its 
 
 beautiful and useful shape, have been 
 
 named as follows : 
 
 The edge that forms the outer border 
 of the auricle is called the helix, from 
 a Greek word, eXif, anything twisted, 
 cAio-o-o), to turn around. This ridge varies 
 in breadth, and is more or less distinct 
 
 in different individuals, according to 
 
 the care that has been taken to preserve 
 the shape of the ear. It begins at a 
 
 point on the concave surface of the cartilage, called the spine or 
 crest of the helix, spina seu crista helicis. By following down 
 the posterior border with the finger, it will be seen that its tissue 
 6 
 
 FIG. 21. The Auricle, i, He- 
 
 Kx ; 2, anti-helix; 8, Iowa hdicia; 
 
 " "
 
 82 
 
 ANATOMY OF THE AURICLE. 
 
 does not pass into the lobe of the ear, but that the latter is 
 formed by the integument alone. 
 
 Just beneath the helix is a fossa fossa navicularis, or boat- 
 like fossa separating it from a second ridge-like border, the 
 anti-helix. Just in front of the opening into the auditory canal 
 the cartilage becomes thickened, and forms a projection or edge 
 called the tragus (Latin for goat), because hairs usually grow 
 upon this part, which were supposed by the ancients to give it a 
 certain kind of resemblance to the beard of that animal. Just 
 
 F.c. 
 
 FIG. 22. Profile View of the Skull, with the Skeleton or Cartilage of the Auricle, as well 
 as that of the External Auditory Canal. The latter is exposed and drawn downward, c.m. 
 (after Henle). 1, Meatus auditorius externus ; 2, tuberculum articulare of the temporal 
 bone ; 3, mastoid process ; t, transverse section of the zygomatic process ; H, helix ; A. A., 
 anti- helix ; F.t., fossa triangularis ; S, scapha, or fossa navicularis; F.C., concha; C. h., 
 cauda helicis ; A.t., anti-tragus ; T, tragus; ** *, fissures in the cartilage of the external 
 auditory canal. 
 
 opposite to this, across the mouth, or meatus, of the auditory 
 canal, is a similar projection, called the anti-tragus. The great- 
 est concavity of the auricle is called the concha, from a Greek 
 word meaning concave shell. This concavity passes into the 
 meatus auditorius externus, or outer opening of the ear. Above 
 the concha, and separated from it by a projection, is a depres 
 sion of a triangular shape, fossa triangularis. 
 
 Elastic fibrous bands, springing from the malar bone and
 
 MUSCLES OF THE AURICLE. 83 
 
 mastoid process, fasten the auricle in its position, and allow it 
 a certain mobility. The auricle is completely covered by the 
 common integument of the body. This integument is more 
 firmly adherent to the anterior surface of the cartilage than to 
 the posterior, and from it, at the extremity of the ear, a projec- 
 tion or tip, called the lobe, is formed. The lobe or lobule con- 
 tains no cartilage, only fat and tough connective tissue. It is 
 also poorly supplied with blood and nerves, and is consequently 
 not very sensitive. It is very distensible, and when over-bur- 
 dened by heavy ear-rings may become very much elongated, and 
 thus its beauty be greatly marred. 
 
 In rare cases serious inflammatory reaction follows the 
 usually harmless operation of piercing the ears for the wearing 
 of ear-rings. Gruber ' observed that the lobe contained cartilag- 
 inous structure in one case of this kind that he observed in his 
 practice. He thinks that the inflammation was due to a wound- 
 ing of the perichondrium. 
 
 MUSCLES OF THE AURICLE. 
 
 There are three muscles which move the auricle, and which 
 are attached to the surrounding parts. They .are 
 I. Levator or Attollens auriculam. 
 II. Attrahens auriculam. 
 III. Retrahens auriculam. 
 
 They are placed immediately beneath the skin. In man they 
 are usually rudimentary ; but they are the analogues to certain 
 large and important muscles in some of the mammalia. 
 
 Some persons, and especially those whose hearing has be- 
 come impaired from chronic aural disease, acquire considerable 
 power in employing these muscles, as well as the intrinsic ones. 
 I have often observed their action^when patients were listening 
 for the ticking of a watch, which was being gradually ap- 
 proached to the ear, and it may be observed when such persons 
 are attempting to hear distant sounds. 
 
 The levator is the largest of the three muscles. It is thin and 
 fan-shaped. It arises from the aponeurosis of the occipito-fron- 
 talis, and its fibres converge to be inserted into the upper part 
 of the auricle. 
 
 The attrahens auriculam is the smallest of the three. It 
 arises from the lateral edge of the aponeurosis of the occipito- 
 frontalis muscle. Its fibres converge and are inserted in front 
 
 1 Lehrbuch, p. 61.
 
 84 MUSCLES OF THE AURICLE. 
 
 of the helix. This muscle is separated by the temporal fascia 
 from the temporal artery and vein. 
 
 The retrahens auriculam consists of two or three bundles of 
 fibres, which arise from the mastoid process. They are inserted 
 into the lower part of the cranial surface of the concha. 
 
 The names of these muscles indicate their action : the levator 
 slightly lifts the auricle, the attrahens draws^t forward and up- 
 ward, and the retrahens draws it backward. 
 
 Hyrtl states that no brute has a lobe as a part of the auricle, 
 and that none of the mammals living in water have an auricle. ' 
 
 INTRINSIC MUSCLES. 
 
 The auricle has also a set of muscles which are contained 
 within its structure ; intrinsic muscles, as they are called by 
 several authors. With a single exception these muscles run be- 
 tween different parts of the cartilage of the auricle and of the 
 auditory canal. 
 
 They are all muscles of animal life, but they are very slightly 
 developed, and are therefore pale, and thin, and flat. They lie 
 closely upon the cartilage, and are inserted into its fibrous cov- 
 ering by means of short tendinous fibres. They are sometimes 
 absent. It is possible, although not certain, that they always 
 exist at birth, but that they subsequently atrophy from want of 
 use. Two of these intrinsic muscles of the auricle belong to the 
 cartilage of the auditory canal, the remainder to the auricle. 
 The former occasionally run over into the latter. 
 
 1. TRAGICUS. This muscle lies on the anterior surface of the 
 anterior wall of the cartilage of the auditory canal, near the 
 upper and the lateral border. It is quadrangular in shape, and 
 nearly as long as it is broad. It is composed of parallel fibres 
 running nearly in a vertical direction. (See Fig. 23, 4.) 
 
 2. ANTI-TRAGICUS. This muscle lies on the posterior sur- 
 face of the posterior wall of the cartilage of the meatus. (See 
 Fig. 23, 5.) 
 
 3. HELICIS MINOR. Henle says that this is the most con- 
 stant of the muscles of the auricle, and that it is often the 
 strongest of the intrinsic muscles. It is a fan-shaped muscle, 
 and is found on the lateral surface of the helix between its root 
 and spine. (Fig. 23, 3.) 
 
 4. HELICIS MAJOR. This muscle runs over the anterior mar- 
 gin of the helix, and is only loosely connected with it, and passes 
 
 1 Lehrbucli der Anatomic des Menschen, Bd. II., p. 517.
 
 MUSCLES OF THE AURICLE. 
 
 85 
 
 over by a kind of tendinous termination into the levator of the 
 auricle. (Fig. 23, 2.) 
 
 5. TRANSVERSUS AURICULA. Transverse Muscle of the Au- 
 ricle. This muscle consists of fibres which are not very thickly 
 combined with loose connective tissue fibres, that run on the 
 posterior surface of the auricle from the scaphoid fossa to the 
 concha over the deep furrow corresponding to the anti-helix. 
 <Fig. 24.) 
 
 6. OBLIQUE MUSCLE OF THE AURICLE. Obliquus Auriculae. 
 
 FIG. 23. Muscles of the External Ear (after Henle). J/J meatus auditorius externus ; If", 
 spine of the helix ; 1, attollens, or levator auriculam ; 2, helicis major ; 3, ht-licis minor ; 4, 
 tragicus ; 5, anti-tragicus. 
 
 This muscle bridges over the furrow on the posterior surface of 
 the auricle, which corresponds to the prominence on the surface 
 of the cartilage that forms the lower, sharp root of the anti- 
 helix. (See Fig. 24, O.m.) 
 
 7. DILATOR OF THE CONCHA. Musculus incisurce majoris au- 
 riculce Santorini. Sometimes the above-named muscle is found 
 on the tragus. Hyrtl 1 has found it arising from the anterior 
 
 1 Hyrtl, loc. cit., p. 518.
 
 86 BLOOD-VESSELS OF THE AURICLE. 
 
 circumference of the external meatus, whence it runs downward 
 and outward to the lower border of the tragus, which it draws 
 forward, and thus enlarges the space of the concha. The same 
 author says that he knows of no instance of the voluntary 
 change in form of the auricle by the action of this muscle. 
 
 "The power of moving the auricle as a whole, is, however, 
 by no means very rare. Haller speaks of many such cases, and 
 B. S. Albin, the greatest anatomist of the eighteenth century, 
 used to take off his wig at his lectures, to show his students how 
 easily he could move the muscles of the auricle." 
 
 Duchenne and Ziemssen, 1 .by means of faradization, found 
 
 E.s. 
 
 T.a. 
 
 C.m. 
 
 C.c. C.fi. 
 
 FIG. 24. View of the Cartilage and Muscles on the Posterior Surface of the Auricle (after 
 Henle). E.s., elevation made by scaphoid fossa ; U.c., elevation formed by concha; O.m., 
 oblique muscle; E.f.t., eminence made by fossae triangularis ; T. a., transversus auriculae; 
 (7.m., cartilage of the external auditory canal ; *, attachment to the edge of the osseous 
 canal; (?.c., cartilage of the auricle ; C.h., cauda helicis. 
 
 that the muscles of the cartilage of the meatus narrowed the 
 incisura auris, and thus the canal leading into the ear, prevent- 
 ing a portion of the sound undulations from reaching the mem- 
 brana tympani, while, according to Duchenne, the helicis major 
 and minor lift up the helix, and thus favor the access of the 
 sound waves. 
 
 BLOOD-VESSELS OF THE AURICLE. 
 
 Arteries : 
 
 1. Posterior auricular, from the external carotid. 
 
 2. Anterior auricular, from the temporal. 
 
 1 Henle, loc. cit., p. 729.
 
 NERVES AND PHYSIOLOGY OF THE AURICLE. 87 
 
 (The temporal is the smaller of the two terminal branches of 
 the carotid.) 
 
 3. An auricular branch of the occipital. 
 
 It will thus be seen that the blood-supply of the auricle is 
 entirely from the external carotid artery. 
 
 The veins of the external ear empty in part into the temporal 
 vein, as well as into the external jugular, or into the posterior 
 facial vein. 
 
 NERVES OF THE AURICLE. 
 
 The nerves are the 
 
 1. Auricularis magnus, from the cervical plexus. The cer- 
 vical plexus is formed by the anterior branches of the four upper 
 cervical nerves. 
 
 2. Posterior auricular, from the facial. 
 
 3. An auricular branch of the pneumogastric. 
 
 4. An auriculo- temporal branch of the inferior maxillary 
 nerve. 
 
 The branches of the cervical plexus are on the posterior side 
 of the auricle. 
 
 PHYSIOLOGY. 
 
 The exact functions of the auricle still remain in doubt. We 
 do not yet know to what extent, if any, the perception of the 
 point of origin of sound, or the conduction of sound to the 
 membrana tympani are assisted by the muscles of this part. Ac- 
 cording to Hensen, 1 the results of experiments as yet made are 
 contradictory. Those that indicate much importance to the 
 functions of the auricle are of doubtful significance, while those- 
 that indicate tljat the auricle is what we may call a rudimentary 
 part are more positive. In 1832 Esser 2 showed that the reflec- 
 tion of sound-waves from the individual parts of the auricle do- 
 not assist much to their entrance into the auditory canal. It 
 was also observed by Harless, 2 that the perception of sound was 
 not weakened when a long glass tube was placed tightly in the 
 passage, even when the body causing the sound lay far out- 
 side of the direction of the axis of the canal. Mach's 3 experi- 
 ments also showed that the different parts of the drum-head 
 were not differently affected according to the direction of the 
 sound. Schneider's experiments are even more positive against 
 
 1 Handbuch der Physiologic, von L. Hermann. Geho'r von V. Hensen, p. 23, 
 Leipzig, 1880. 
 
 2 Hensen, loc. cit. 
 
 3 Archiv fur Ohrenheilkunde, S. 72. 1874.
 
 88 PHYSIOLOGY OF THE AUEICLE. 
 
 the influence of the auricle. He filled the depressions of the 
 auricle within and without with wax, only leaving the canal 
 free. The canal then being directed toward the source of sound, 
 tones were rather intensified than weakened. Henseii concludes 
 from Schneider's observations, that the direction of the auricle 
 toward the source of sound, has less influence upon the distinct- 
 ness of perception than does the opening of the canal with a 
 good round meatus. Sounds, according to the same author, are 
 most distinctly perceived, when they fall upon the ear sideways. 
 It remains an open question if vibrations of more than one 
 thousand times a second can be concentrated on the auricle by 
 reflection. On the other hand, Rhine, experimented upon an 
 auricle filled with dough, and he found the tick of a watch was 
 heard further when the auricle was uncovered. Politzer ' thinks 
 that the concha is the important part of the auricle in assisting 
 the hearing. He found, on examination of persons hard of hear- 
 ing, that the limit of audition was nearer the head as tested 
 with the metronome, when the concha was covered by a stiff 
 piece of paper, while no alteration in the hearing distance was 
 observed if the other depressions of the auricle were covered. 
 Politzer also regards the tragus as of great importance for the 
 reflection of waves of sound that strike the auricle. Kiipper 2 
 denies that the auricle has any influence upon the ear in the 
 way of reflecting the waves of sound, or as an elastic body 
 vibrating with the waves and conducting them directly to the 
 deeper parts. He insists that Boerhaave's notion that the un- 
 dulations, after long wandering, are united in the auditory canal 
 by the depressions of the auricle is incorrect, and he believes 
 that the auricle cannot perform any such office, but that a mem- 
 brane like the membrana tympani is necessary for this. He 
 reminds his readers that birds whose hearing power in every 
 respect exceeds that of man, have no auricle. Kiipper adopts 
 the theory of Darwin and Haeckel, and classes the auricle 
 among the organs that evolution has rendered useless in man 
 except as appendages, in this case as an ornamental one. Mach 3 
 confirms Kiipper's views, but he considers that the auricle is 
 a resonator for high tones, such as the rustling of the grass, 
 the leaves, sounds important to animals, but even this function 
 he believes only exists to a slight degree in man. Burnett 4 
 claims to have anticipated Mach's views in regard to the reson- 
 
 1 Text-book, p. 61. Translation. 
 
 J Archiv fur Ohrenheilkunde, Vol. IX., p. 76. Neue folge, Vol. III. 
 
 3 Loc. cit. 
 
 4 Text-book, p. 34.
 
 PHYSIOLOGY OF THE AURICLE. 89 
 
 Bating capacity of the auricle, but the experiments of Burnett 
 include the external auditory canal. In the opinion of the latter- 
 named author, the absence of an auricle in birds does not argue 
 against its utility as a resonator in man, for the wave lengths 
 of the high notes used by birds are so short that they resound 
 well in their shallow auditory canal. Dr. Sexton, 1 as the result 
 of some experiments upon the living subject, concludes that the 
 range of hearing for the tuning-fork is increased in some per- 
 ,sons, when the occipito-f rontalis muscle is contracted. He thinks 
 that this muscle acts as an auxiliary to the attollens auriculam 
 .and attrahens auriculam. As the result of one dissection of the 
 human subject, he found that traction of the deep temporal fascia 
 moved the auricle freely. He also found that when alternate 
 tension and relaxation were practised on the same fascia, the 
 drum-head also became tense or relaxed, the motion being visi- 
 ble. The anatomists describe the occipito-frontalis as a muscle 
 which occasionally has muscular slips extending to the pos- 
 terior auricular muscle. It is possible that in exceptional cases 
 the action of the former muscle would affect the auricle as well. 
 The action of the deep temporal fascia upon the drum-head, as 
 described by Dr. Sexton, is with difficulty conceived of, when we 
 remember that the drum-head is nearly surrounded by bone, and 
 only connected through the handle of the malleus with soft 
 parts the tensor tympani muscle. How the action of this mus- 
 cle can be influenced by traction of the deep temporal fascia, I 
 cannot conceive. 
 
 The relations of the muscles of the auricle to the occipito- 
 frontalis, are well shown in the cut from Sappey on the next 
 page. In the exceptional cases in which the power of moving 
 the occipital and frontal muscles, as the occipito-frontalis is 
 called by the French anatomists, it is readily seen that the auri- 
 cle may also be moved. 
 
 A careful study of all that has been written upon the physi- 
 ology of the auricle, as well as observations upon the living sub- 
 ject, render it tolerably clear to my mind, that the auricle is 
 really, as Darwin and Hackel claim, only a rudimentary .organ, 
 and not of value in hearing, except under exceptional circum- 
 stances. Even if the tick of a watch be heard further, as Rinne 
 and others show, when the concha be uncovered, this by no 
 means proves that conversation is heard further by its aid, since 
 the test by the tick of a watch is a fallacious one as compared 
 with that by human speech or the notes of music. It is probable, 
 however, that the rudimentary capacity of the auricle as a res- 
 
 Medical Record, November 17, 1883.
 
 90 
 
 MUSCLES OF THE AUKICLE. 
 
 onator is greatly increased by placing the hand behind it, and 
 that those whose hearing is impaired, may sometimes increase 
 their hearing power in this way. If this were not the case, the 
 human race would have long ago abandoned the habit. 
 
 FIG. 25. The Muscles of the Head (from Sappey). 1, Posterior auricular muscle, having" 
 two sets of attachments, a superior very short, an inferior much longer ; 2, superior auricular 
 muscle ; 3, anterior auricular muscle ; 4, occipital muscle ; 5, section of the aponeurosis which 
 extends from the occipital muscle to the superior auricular ; 6, aponeurosis, extending from the 
 occipital and running under the inferior surface of the auricular superior ; 7, superior fibres 
 of the superficial temporal muscle, situated at the termination of the two parts coming from 
 the occipital muscle ; 8, lower fibres of the superficial temporal, united to the anterior auricu- 
 lar by a fibrous band which forms a part of the epicranial aponeurosis. 
 
 EXTERNAL AUDITORY CANAL. 
 
 The canal leading from the auricle to the membrana tym- 
 pani consists of two portions, an outer part, which is formed of 
 cartilage, and an inner, which is of bone. 
 
 Its external opening, which is formed by the cartilaginous 
 portion, corresponds anteriorly and below with the margin of 
 the external ear. Behind, it is demarcated by the ridge which 
 connects the anterior border of the auricle with the margin of
 
 EXTERNAL AUDITORY CANAL. 
 
 91 
 
 the osseous meatus ; above, it is bounded by the root of the 
 helix. 
 
 Inasmuch as the membrana tympani is not on a plane per- 
 pendicular to the walls or sides of the canal, these do not ex- 
 tend equally far inward. The anterior and inferior wall is the 
 longest. It thus becomes impossible to give an exact measure- 
 ment of the canal which can be applied to all ears. The canal is 
 also curved, and its cartilaginous portion is very elastic. 
 
 CM 
 
 cc 
 
 CM 
 
 FlG. 26. Section through the External Meatus and the Ear at the Point of Junction of 
 the Cartilage of the Auricle, CC, with that of the Auditory Canal (after Henle). A small 
 portion of the upper wall of the latter remains as a narrow band, CM' ; CM", lower wall of 
 the cartilage of the external meatus ; H", spine of the helix ; L, lobe of the ear ; *, fibrous 
 lip of the border of the osseous meatus ; 1, epicranius temporalis muscle ; 2, levator anricu- 
 laris ; 3, temporal muscle ; 4, upper wall of the osseous canal ; 5, cavity of the tympanum ; 
 6, membrana tympani ; 7, stapes bone ; 8, vestibule ; 9, meatus auclitorius internus and acous- 
 tic nerve ; 10, lower wall of the osseous meatus ; 11, parotid gland. 
 
 The first curvature is described by Henle as zigzag in shape, 
 and is well shown in the two cuts from his work on anatomy. 
 This curvature is constant. These curvatures may be overcome, 
 and the outer portion of the canal rendered nearly if not quite 
 straight, by drawing the auricle upward and backward. The 
 cartilaginous portion of the canal is interrupted, especially on its 
 inferior wall, by gaps and fissures the so-called Incisurce San- 
 torini. These gaps are filled up by fibrous tissue. The osseous
 
 '92 
 
 EXTERNAL AUDITORY CANAL. 
 
 portion is an integral portion of the temporal bone, and has a 
 groove for the insertion of the membrana tympani. (Sulcus pro 
 membrana tympani. Hyrtl.) 
 
 The length of the canal, according to Hyrtl, varies from 9 
 
 FIG. 27. Horizontal Section of the Head, through the External Auditory Canal (after 
 Henle). 1, Cartilage of the external auditory canal ; *, fissure in the cartilage ; 2, cartilage of 
 the auricle ; 3, tuberculum articulare of the lower jaw ; 4, fossa mandibularis ; 5, membrana 
 tympani ; 6, cavity of the tympanum ; 7, vestibule ; 8, transverse sinus ; 9, mastoid cells. 
 
 lines to one inch. The average length of the canal, according 
 to Troltsch, 1 is about 24 millimetres. The cartilaginous portion 
 forms about one-third of this, or 8 mm., and the osseous canal 
 the remaining two-thirds, or 16 mm. 
 
 The angle which the upper wall of the canal 
 forms with the membrana tympani, is an obtuse 
 one ; but that between the lower wall and the 
 drum-head is acute ; it is one of about 45. 
 
 The width of the canal varies as well as the 
 length. It is widest at the junction of the osseous 
 with the cartilaginous canal, and next to the mem- 
 brana tympani. 
 The casts made by Dr. F. M. Wilson, as here delineated, con- 
 firm Hyrtl's and Sappey's moulds of wax, and show that the 
 canal is a spiral turning anteriorly inward and downward. 
 
 FIG. 28. Annu- 
 1 u s Tympanicus 
 (actual size, from 
 Professor D a r- 
 
 1 ing's museum). 
 
 1 Treatise on the Ear, second American edition, p. 18.
 
 EXTERNAL AUDITORY CANAL. 
 
 The auditory canal is lined by integument, and not by mu- 
 cous membrane. Hence it is not correct to speak of a catarrh, 
 of the external auditory canal. This integument is merely a 
 continuation of that of the general 
 surface of the body. The nearer it 
 approaches the membrana tympani, 
 the thinner it becomes, and finally it 
 covers the drum-head as a very thin 
 layer. 
 
 " The integument of the cartilag- 
 inous portion of the canal is 1 mm. 
 thick, and contains soft hairs, with 
 their sebaceous glands, the cerumi- * nd Ad J acent Parts (actual size )- 
 
 -. , , ,.,,, ~ , . ., , External auditory canal; 2, mastoid 
 
 nous glands, and a little fat in its sub- cells . 3> tvmpani c cavity . \ Eusta . 
 
 CUtaneOUS tissue. In the OSSeOUS part chian tube ; 5, fenestra ovalis ; 6, 
 
 Of the Canal, the integument is Only P sition f membrana tympani; 7, 
 ,1 . -i , i /., i posterior opening of mastoid. 
 
 0.1 mm. in thickness, the soft hairs 
 
 become very few, and the ceruminous glands are found only on 
 the posterior upper wall, where they are generally seen, even 
 close to the membrana tympani. Small papillae are found 
 
 FIG. 29. Cast of Auditory Canal 
 
 FIG. 30. Section of Left Temporal Bone (actual size, from Professor Darling's museum). 
 1, Styloid process ; 2, carotid canal ; 3, promontory ; 4, floor of tympanic cavity over carotid 
 canal ; 5, mastoid cells ; 6, external auditory canal. 
 
 arranged in rows under the cuticle, and also a corium with 
 .abundant elastic fibres, of which the lower layers pass into the 
 periosteum." 1 
 
 The ceruminous glands are like the sudoriparous or sweat 
 
 1 The Organ of Hearing. J. Kessel, Strieker's Manual, p. 951. Translated by J. 
 Orne Green.
 
 94 EXTERNAL AUDITORY CANAL. 
 
 glands in their development and secretion. The only difference 
 between the secretion of the two kinds of glands, is that the 
 ceruminous glands contain some coloring matter. (Cerumen is 
 probably derived from cera aurium. Hyrtl.) 
 
 The substance of the ceruniinous glands is a yellowish-white, 
 rather fluid material, which consists essentially of fat-globules, 
 coloring matter and cells in which single globules of fat and 
 coloring matter are embedded ; there are also hairs and scales 
 of epidermis from lining of the meatus (Kessel). When the 
 cerumen has remained in the canal for a long time, its watery 
 contents are lost by evaporation, and it becomes a hard mass. 
 
 Sometimes the hairs of the canal grow to such a length as 
 to obscure the view of the meatus and the drum-head. In such 
 cases I have been obliged to remove them with a pair of curved 
 scissors. By rubbing upon the surface of the membrana tym- 
 pani, they may cause a tickling sensation in the ear and become 
 a source of annoyance. Dr. R. F. Weir relates such a case. 1 
 
 According to Buchanan, an author who laid too much stress 
 upon the part which the cerumen plays in the economy, there 
 are from one thousand to two thousand ceruminous glands. 
 
 The child at birth, and for some time after, has no osseous 
 meatus. The cartilaginous portion is at first attached to a mem- 
 branous part, just as it is afterward to the osseous portion. 
 
 Gruber 2 thinks that there is a very narrow rim of osseous canal in the last 
 months of embryonal life. 
 
 In the newly born this membranous portion constitutes about 
 one-half of the canal .; but it gradually becomes shorter as the 
 bone grows outwardly. 3 
 
 This ossification proceeds irregularly, and often leaves a for- 
 amen, which, according to Troltsch, has been mistaken for a 
 pathological condition, the result of caries. An inflammation 
 of the meatus in a young child, as shown by the same author, 
 might readily pass through this foramen to the maxillary articu- 
 lation or parotid gland. 
 
 The auditory canal of the dog and cat are closed at birth, as 
 are their eyelids. There is, perhaps, as Troltsch suggests, an an- 
 alogous condition in the closure of the meatus of young children 
 with vernix caseosa, and the approximation of the walls of the 
 meatus, near the membrana tympani. 
 
 Some birds have the power of stopping their ears by a kind of 
 
 1 Transactions American Otological Society, third year. 
 * Monatsschrift fur Ohrenheilkunde, Bd. II., p. 67. 
 4 Tx6ltsch, loc. cit., p. 6.
 
 RELATIONS OF THE AUDITORY CANAL. 
 
 95 
 
 valve. The turkey has a kind of erectile tissue projecting into 
 the meatus. so that it can close the ears more or less perfectly 
 when angry (Troltsch). 
 
 RELATIONS OF THE AUDITORY CANAL. 
 
 The cartilaginous portion is bounded anteriorly and inf eriorly 
 by the parotid gland. Cases have been observed where abscesses 
 of the parotid have discharged into the auditory canal, through 
 the fissures of Santorini. This occurred during the fatal illness 
 of the late President Garfield, while he was suffering from sup- 
 purative parotitis. Enlargements of the parotid or lymphatic 
 glands may contract the calibre of the canal by pressure. 
 
 The anterior wall is also in relation with the posterior wall of 
 the articular fossa of the inferior maxillary bone. Hence a blow 
 
 FIG. 31. External Surf ace Left Temporal Bone (two-thirds size). 2, Mastoid process ; 3, 
 zygomatic process ; 4, styloid process ; 5, external auditory canal ; 6, glenoid fossa ; 7, tym- 
 panic process ; 8, vaginal process ; 9, mastoid foramen. 
 
 upon the chin may produce a fracture of this plate, and cause a 
 hemorrhage from the ear. The thick articular cartilage protects 
 the auditory canal and temporal bone from the full force of such 
 a blow. 
 
 The posterior wall is made up by the mastoid process in such 
 a way, that the canal is only separated from the transverse sinus 
 by two thin plates of osseous tissue and the air-cells lying be- 
 tween them. The superior wall is covered on its upper surface 
 by the dura mater, and forms a portion of the floor of the mid- 
 dle fossa of the skull (Troltsch). 
 
 The wall between the integument of the canal and the dura 
 mater, may be exceedingly thin, and inflammations of the mea- 
 tus may produce disease of the brain.
 
 96 EXTERNAL AUDITORY CANAL. 
 
 The auditory canal is bounded above and behind by portions 
 of the mastoid cells, that are included in the "middle ear," so 
 that, strictly speaking, a portion of the mastoid part of the 
 middle ear is situated beyond the membrana tympani. Inflam- 
 mations of the mastoid, in not unfrequent cases, occur with no 
 perforation of the membrana tympani, and the pus evacuates 
 itself in the auditory canal. The importance of these relations 
 was first fully pointed out by Troltsch. 
 
 BLOOD-VESSELS OF THE AUDITORY CANAL. 
 
 1. Posterior auricular artery, which also supplies the auricle. 
 
 2. Deep auricular, from the internal maxillary. It enters at 
 the articulation of the lower jaw, supplies the tragus, and then, 
 gives off branches to the canal. 
 
 NERVES. 
 
 1. From the third branch of the tri-facial or fifth nerve. 
 These enter through the anterior wall, between the cartilaginous 
 and osseous portions. 
 
 2. An auricular branch from the pneumogastric, which en- 
 ters the anterior wall of the bony canal. 
 
 This auricular branch was first described by Arnold in 1828. 
 
 The effect of irritation of this branch is often seen by the 
 cough produced when the aural speculum is pressed upon it, or 
 when the part is touched by a probe. 
 
 PHYSIOLOGY. 
 
 The length and curvature of the auditory canal prevent the 
 membrana tympani and auditory canal, under ordinary circum- 
 stances, from being injured by wind, changes of temperature, 
 and the like. The cerumen probably also guards against the 
 frequent entrance of insects. The auditory canal increases the 
 power of tones by acting as a resonator. ' 
 
 1 Hensen, loc. cit.
 
 CHAPTER IV. 
 
 THE MALFORMATIONS AND DISEASES OF THE AURICLE. 
 
 A Finely Formed Auricle an Indication of Character. Malformations. Superfluous 
 Auricles. Ely's operation for Prominent Auricles. Tumors. Angiomata. 
 Othsematomata. Perichondritis. Malignant Growths. Syphilitic Affections. 
 Erysipelas. Effects of Gout. 
 
 A FINELY formed auricle is justly esteemed one of the marks of 
 personal beauty. The celebrated physiognomist, Lavater, also 
 attached considerable importance to this part as a means of de- 
 termining character. A humorous German critic, quoted by 
 Voltolini, in speaking of Lavater's ideas of physiognomy, says : 
 " It would be very queer of Dame Nature, if she had hung every 
 one's character on the nose, so that any one who was a master 
 in physiognomy could read it. Perhaps fearing this, some 
 people shut their eyes and are ashamed to look one in the face." 
 A French author, Dr. Amedee Joux, quoted by Troltsch, goes 
 much farther than Lavater in his estimation of the signification 
 of the auricle. Besides the part which it plays in indicating hu- 
 man character, he claims that, more than any other organ of the 
 body, it descends with its particular form from father to child, 
 and that by the shape of the auricle we may be assisted in deter- 
 mining the legitimacy of children, and the conjugal fidelity of a 
 mother. He says, " Montre-moi ton oreille,je te diraiqui, iu es, 
 d'ou tu viens, et ou tu vas," or, as we should say in English, " Let 
 me see your ear, and I will tell you who you are, where you came 
 from, and where you are going." 
 
 I am inclined to think that this view of the importance of the 
 auricle is somewhat fanciful. Whatever may be the significance 
 of the auricle, as regards character or legitimacy, its perfect 
 shape has very little to do with the power of hearing. Whether 
 it lies properly fitted to the head, and has all its parts of helix, 
 fossa helicis, beautifully shaped, or whether it laps over like that 
 of an inferior animal, or be a shapeless appendage, makes very 
 little difference in the power of hearing music or the human 
 voice. As we have seen in the discussion in the preceding chap- 
 7
 
 98 MALFORMATIONS OF THE AURICLE. 
 
 ter, the functions of the auricle are like its muscles unimpor- 
 tant and rudimentary. 
 
 We may conveniently classify the prominent affections of 
 the auricle as follows : 
 
 1. Malformations. 
 
 2. Tumors, benign and malignant. 
 
 3. Syphilitic diseases. 
 
 4. Othfematomata. 
 
 5. Perichondritis. 
 
 6. Eczema. 
 
 7. Effects of Gout. 
 
 8. Erysipelas. 
 
 I. MALFORMATIONS. 
 
 Many of the so-called malformations are the natural results 
 of ill-treatment of the auricle. Many women, especially those 
 of the lower class, cover their ears so tightly with their hair, cap 
 
 FIG. 32. Case of Prominence of Auricles. 
 
 and hood, that they finally, by the excessive pressure, flatten out 
 and fill up the natural elevations and depressions which go to 
 make a finely shaped auricle. Children's auricles are sometimes
 
 PROMINENCE OF AURICLES. 99 
 
 injured in their passage from the womb to the world. Boys often 
 get into the bad habit of pressing their caps down upon their 
 ears. They thus cause them to lap over and give them the un- 
 sightly appearance known as " dog ears." A boy, twelve years 
 of age, presented himself in 1881 at the clinic in the Manhattan 
 Eye and Ear Hospital held by myself and Dr. Ely, complaining 
 that he was ridiculed by his companions on account of the 
 prominence of his ears. He desired, if possible, that an opera- 
 tion be performed which should relieve him from this annoy- 
 ance. The accompanying cuts give a good idea of the degree of 
 the deformity of one side. It was equally deformed upon the 
 other side until relieved by Dr. Ely's operation. The second cut 
 
 FIG. 33. Case of Prominence of Auricles. 
 
 gives a good idea of the back view of the auricles before and 
 after the operation. 
 
 Dr. Ely describes his operation as follows: 1 The right ear 
 was first operated upon. An incision was made through the 
 skin, along the entire length of the furrow formed by the junc- 
 tion of the auricle with the side of the head posteriorly. This 
 was joined at each end by a curved incision carried over the 
 posterior surface of the auricle, and the skin and subcutaneous 
 tissue included by tnese incisions were dissected off. Two in- 
 cisions, nearly parallel to the former ones, were then carried 
 through the cartilage, and an elliptical piece of the latter, meas- 
 
 1 Archives of Otology, Vol. X. , No. 2, p. 97.
 
 100 PROMINENCE OF AURICLES. 
 
 uring 1 inch by inch, was removed. The pieces of excised 
 skin were considerably larger than this. The edges of the; 
 wound were then united by ten sutures, of which seven only 
 included the skin, while three passed through both skin and car- 
 tilage. Owing to the natural folds of the cartilage, it was im- 
 possible to secure perfect coaptation on the anterior surface of 
 the auricle, and a small space was here left to heal by granula- 
 tion. The dressing consisted of absorbent cotton and a bandage. 
 Healing ensued with very little pain or swelling the posterior 
 incision united by first intention and the anterior wound by 
 granulation. The sutures were removed on the fourth day. 
 
 Dr. Ely varied the operation upon the left ear somewhat, by 
 transfixing it with a scalpel and excising a piece of cartilage 
 of the desired size and shape, together with its overlying skin. 
 Additional skin was then removed from the posterior surface. 
 Three sutures were used through the cartilage on its anterior 
 surface and one on the posterior. The dressing was absorbent 
 cotton and a bandage. Complete union by first intention was 
 not obtained, but the result was as satisfactory as in the first 
 ear. Ether was used as an anaesthetic for both operations. The 
 posterior cicatrices were hidden by their position, and those on 
 the anterior surface are hardly noticeable. The hearing was 
 normal before and after the operation. The boy expressed him- 
 self as entirely satisfied with the result, and came of his own 
 free will for the operation on the second ear, some weeks after 
 the first had been operated upon. 
 
 I have since performed the operation in one case, in the man- 
 ner which Dr. Ely performed his first operation, and I append 
 the note of the father of the child, a physician, as to the result. 
 Dr. S writes : 
 
 DEAK DOCTOR : 
 
 Before the operation the auricle projected at the extreme point li inch ; 
 the left ear 1 inch. Since healing the projection is |. There is a red cicatricial 
 spot on the auricle that shows, but would not ordinarily be observed. He is so 
 much improved that people would not now notice anything unusual about the 
 ears ; but before, both being prominent, and one much more so than the other, 
 it was observed by every one. 
 
 The detachment of the auricle is by no means a formidable 
 operation, and I can cordially commend Ely's method as an ex- 
 cellent means of removing the deformity Qf prominent auricles. 
 
 ARRESTED DEVELOPMENT MICROTIA. 
 
 There is a class of malformations of the auricle which has 
 the same pathological interest with other forms of arrested de-
 
 MIOEOTIA. 
 
 101 
 
 velopment, such as spina bifida, coloboma iridis, etc. , but unfor- 
 tunately they are also cases for which our art can do nothing. 
 I refer to those cases in which the auricle is congenitally ab- 
 sent, or where it exists only in a rudimentary form. In such 
 instances the cartilaginous and osseous auditory canals are 
 usually also wanting, but the middle and internal ear may be 
 well developed. 
 
 There are cases, however, in which the whole ear is undevel- 
 oped. The deformity usually affects but one ear, but both ears 
 are sometimes similarly affected. Attempts have been made by 
 surgeons ' to make a passage to the drum-head and middle ear, 
 
 FIGS. 34, 35. Deformity of Auricles. 
 
 but as yet they have failed. It is probable that the middle ear 
 is not in a normal condition, for the impairment of hearing is 
 usually, if not always, greater than could be explained by the 
 mere absence of a canal leading to the membraiia tympani. 
 
 The illustrations seen above, and the account of one case, give 
 a fair idea of these deformities, for which art has as yet done 
 very little. I have never seen any artificial ears that served any 
 good purpose in masking the deformity. In females, the hair 
 can be made to do very well in this respect. Fortunately, but 
 one ear is usually deformed. 
 
 Superfluous auricles sometimes occur, just as do supernu- 
 merary toes and fingers. They are objects of anatomical curi-
 
 102 DEFORMITY OF THE AUKICLES. 
 
 osity rather than of therapeutical interest. Beck 1 details a 
 number of cases in which, by freaks of Nature, the auricle was 
 placed on the back, the shoulder, and near the angle of the 
 mouth. 
 
 The case of which an illustration is given on the preceding 
 page, consulted me in 1881, with reference to a relief of the de- 
 formity. He was thirty years of age, and was born with a rudi- 
 mentary and deformed auricle on each side. There was also bony 
 closure of the canal on each side. He understood loud conversa- 
 tion some four or five feet away. He heard musical sounds well. 
 In this case it is evident that the deformity is confined tothe outer 
 and middle ear. The patient, as is seen by the cut, is a well-de- 
 veloped man. He has learned a trade and succeeds well in it. 
 Dr. David Hunt 8 reports three cases from the practice of Dr. 
 Blake, in which the deformity of the auricle and the absence of 
 the auditory canal constituted the disease of the ear. Hunt be- 
 lieves that these malformations originate in the auricle. He 
 regards "the association of the malformation of the auricle as 
 due to the interruption of a natural order of events, according to 
 which a certain stage of development of the auricle precede? 
 the formation of the meatus (auditory canal). 
 
 I am indebted to Dr. "William Hunt, of Philadelphia, for an account of de' 
 formities of the auricle occurring in five children of one family. The first child, 
 instead of an auricle, had a little pedunculated growth in front of the tragus. 
 The second had the same defect, and two similar growths in front of the tragus. 
 In a third, the upper part of the auricle was turned over forward. A fourth had 
 one auricle half an inch longer than the other. A fifth child, whom Dr. Hunt 
 saw when it was two or three weeks old, is described by him as having " no ear 
 at all. There were mere nodulated small masses of cartilage and skin, with a 
 little point which seemed to be an opening, but was a mere cul-de-sac not more 
 than an eighth of an inch deep." Dr. Hunt saw the child again in a few months, 
 but the auricles had not developed. It was difficult to tell whether the child 
 heard or not. The monthly nurse was positive in her opinion that babies with 
 good ears hear at once, and this coincides with the opinion of most nurses, as 
 Dr. Hunt and I agree, but as I shall discuss this question in speaking of deaf 
 muteism, I merely allude to it here. There was but one child in this family of 
 six in whom there was a perfect auricle, although the children were perfect in 
 other respects. 
 
 FISTULA OF AURICLE. 
 
 I have seen two, if not more cases of fistulous openings in the 
 auricle, which were said to be congenital and from which pus es- 
 caped at certain times. In one case these fistulse were associated 
 
 1 Krankheiten des Gehororgans, p. 108. 
 
 1 American Journal of Otology, Vol. III. , No. 1 .
 
 TUMORS OP THE AURICLE. 103 
 
 with one just above the thyroid body. I advised incision of the 
 fistulse and the application of tincture of iodine or bichloride of 
 mercury to the open canals thus made, but in neither instance 
 was my advice followed. Indeed, I only saw the cases inciden- 
 tally, the patients having consulted me for another form of aural 
 disease, apparently not connected with the fistulous ulcers. The 
 patients seemed to fear that a stoppage of the periodical dis- 
 charge from these ulcers might do them harm. I should be in- 
 clined to regard these fistulse as marks of arrested development 
 of the auricle, since they were congenital and not connected with 
 any other form of disease of this part. 
 
 They did not communicate with the auditory canal or middle 
 ear. Schwartze ' also reports such cases. 
 
 TUMORS. 
 
 The tumors found in the auricle may be divided into the 
 following classes : 
 
 I. Fibro-cartilaginous. 
 II. Sebaceous. 
 
 III. Vascular. 
 
 IV. Malignant. 
 
 FIBRO-CARTILAGINOUS TUMORS. 
 
 The first-named form is a simple hypertrophy of the normal 
 structure of the auricle. 
 
 According to Billroth, 2 these tumors consist chiefly of fusi- 
 form cells and connective tissue, and are nothing more than 
 hypertrophy of a cicatrix such as occurs on other parts of the 
 body after injuries. They seem to occur much more frequently 
 among the African than the Caucasian race. I have removed 
 several of these growths from the auricles of negro women, 
 while I have but rarely seen them among whites. It is not 
 true, however, that they never occur in the white race. I re- 
 moved one during the past year from the auricle of a German 
 woman. I am also informed that they occur very frequently 
 among the Africans of the East and West Indies, where they 
 grow to an enormous size. 
 
 The etiology of these growths is very simple, if my own ex- 
 perience may be trusted on this point. They occur as the result 
 of the irritation of the lobes produced by the truly barbarous 
 
 1 Pathological Anatomy of the Ear. Translated by Orne Green, p. 23. 
 * General Surgical Pathology and Therapeutics, p. 551. Translated by C. E 
 Haekley, M.D.
 
 104 FIBRO-CARTILAGINOUS TUMORS. 
 
 custom of piercing the ears in order that ear-rings may be worn. 
 They are much more apt to be found in the lower classes, who 
 use brass ear-rings, although the growths may occur even if gold 
 ear-rings % are worn. They sometimes reach an enormous size, 
 and become a very serious deformity. If these ornaments are 
 considered indispensable, as no doubt they are, ladies should 
 wear them by causing them to be clasped around the auricle by 
 means of a suitable contrivance now sold by the jewellers and 
 very much used. 
 
 One of the older .authors, Frank, gives illustrations of the 
 proper instruments with which to pierce the ears, with a de- 
 tailed account of the operation ; but the efforts of the medical 
 adviser should be toward the prevention of the custom rather 
 than increasing the facilities for retaining it. 
 
 Dr. Agnew ' reports a case of what finally came to be a myxo- 
 fibroma of the auricle, which arose from a scratch from a toilet- 
 pin. It occurred in a boy ten years of age. At the end of 
 eighteen months a tumor occurred at the site of the injury, of 
 the size of a buck-shot. It returned almost immediately, and at 
 the end of two years it was again removed, and was found to be 
 about three times the size of the original growth. Two years 
 after, the tumor having returned, it was again removed. Dr. 
 Agnew saw the boy when he had reached the age of eleven, and 
 removed a tumor from the place from which these tumors had 
 been removed. Six months after there was a small nodule in 
 the lower end of the scar near the lobule. Removal of this was 
 advised, but no subsequent history of the case is given. 
 
 In some cases it is impossible to heal the edges of the open- 
 ing made for the ear-rings, so that there are a few females who 
 are never able to wear them, on account of the impossibility 
 of securing a sound cicatricial border. I once operated for the 
 closure of a gap in the auricle, made by the dragging of the ear- 
 ring. After paring the edges and uniting them by suture, a 
 good result was secured. Wounds in this region heal readily, 
 and with a remarkable absence of deformity. Sutures are well 
 borne, and the pain in healing is generally very little. 
 
 Fibro-cartilaginous tumors should be removed if they attain 
 such a size as to be at all troublesome. The removal is readily ef- 
 fected by a V-shaped incision made with strong scissors. The 
 edges of the wound are then brought together by sutures. The 
 resulting deformity is usually very slight, and is much less than 
 that from the tumor. 
 
 Sebaceous tumors should be removed by enucleation. 
 
 1 Transactions American Otological Society, 1876.
 
 ANGIOMATA OF THE AUKICLE. 105 
 
 ANGIOMATA. 
 
 . 
 
 Angioma of the auricle is not a common disease. Cases have 
 been reported by Mussey, 1 Kipp," Chimani, 3 Politzer, 4 and others. 
 Chimani, however, entitles his case a cirsoid aneurism of the 
 auricle and meatus. Repeated injections of chloride of iron 
 seemed to cure the case, which was thus treated when the pa- 
 tient, a boy, was five years of age. In four years the disease 
 had returned so as to be troublesome. The tumor was again in- 
 jected with chloride of iron ; three injections at intervals of 
 some days were made, when the tumor of the auricle had near- 
 ly disappeared. That of the canal was removed by the knife. 
 Kipp's case was the result of a frost-bite. After an injection of 
 chloride of iron in the hands of another surgeon, the tumor in- 
 creased in size. The tumor was situated on the outer side of the 
 left lobule. It was of the size of a hazel-nut. The tumor was 
 situated beneath the skin, which was movable over it, and trav- 
 ersed by numerous large veins. Dr. Kipp removed the tumor 
 with the knife. The wound healed by first intention. It was 
 found to be covered by a fibrous capsule. The tumor itself was 
 composed of spongy tissue, similar to the corpus cavernosum of 
 the penis. By the microscope the growth was seen to consist 
 of a network of connective tissue trabeculse. The walls of the 
 spaces were lined with a layer of endothelial cells. Politzer s 
 treated his case by cauterizing the part of the tumor lying be- 
 
 hind the ear with Pacquelin's cautery (thermo-puncture). He 
 first tried subcutaneously the largely dilated posterior auricular 
 artery. The patient was dismissed cured in ten weeks. The 
 auricle had decreased in size by two-thirds and no longer pul- 
 sated. 
 
 When an angioma can be readily separated from the sur- 
 rounding tissue, enucleation is to be preferred to any other means 
 
 of removal. 
 
 Dr. F. Eve " reported a case of aneurism by anastomosis occur- 
 ring in the auricle, which probably started from a congenital use- 
 void growth. The whole pinna above and behind the meatus was 
 enlarged, soft, of a dull red color and pulsating moderately. A 
 humming bruit could be heard on auscultation. The right com- 
 
 1 American Journal of the Medical Sciences, 1853. 
 
 5 Transactions of the American Otological Society, 1875, p. 79. 
 
 3 Transactions American Otological Society, Blake's report, 1874. 
 
 4 Text-book, p. 634. Translation. 
 
 6 Loc. cit. 
 
 6 London Medical Times and Gazette, May 8, 1880.
 
 SYPHILIS OF THE AURICLE. 
 
 mon carotid and the temporal and posterior auricular arteries 
 were enlarged. Hemorrhage had occurred. The whole auricle 
 was removed by Dr. Thomas Smith. There were changes in the 
 tissue such as increase in the number of arterioles and capillaries, 
 hypertrophy of the Malpighian layer of the cuticle, and enlarge- 
 ment of the sebaceous glands, which were attributed to the in- 
 creased blood-supply. This case is probably essentially of the 
 same nature with those described under the head of " Angioma." 
 Mussey's case of " aneurismal tumors upon the ear," is a re- 
 markable one. There were three tumors. They apparently had 
 their origin on a so-called ncevus maternus. An alarming hem- 
 orrhage occurred from one of these about a month before Pro- 
 fessor Mussey was consulted. They were compressible almost 
 to obliteration, and communicated with each other. The com- 
 mon carotid on the side of the tumor was first tied ; in four 
 weeks, as the tumors were not markedly diminished, the caro- 
 tid of the other side was tied. A cure was then obtained. 1 
 
 SYPHILIS OF THE AURICLE. 
 
 Bumstead and Taylor a state that only one case of chancre of 
 the auricle has been reported. This was by Alb. Hulot, in the 
 Ann. de Derm, et Syph., t. x., p. 47. Paris, 1879. The secondary 
 manifestations of syphilis are, however, occasionally seen upon 
 the auricle. The various syphilitic eruptions may occur here as 
 upon the other parts of the common integument. Ulcerative 
 processes from syphilis may take place in the auricle. Gummy 
 tumors may also occur in this part. It is hardly necessary to 
 say anything more with reference to these evidences of con- 
 stitutional syphilis, than that they should be subjected to the 
 appropriate constitutional treatment by means of mercury and 
 iodide of potassium, while soothing local applications are made. 
 
 HORNY GROWTHS. 
 
 Buck, 3 Burnett, 4 and Pomeroy 5 report horny growths of the 
 auricle. Their removal is, of course, easily accomplished. If 
 not thoroughly done, the tumors will probably recur. 
 
 1 American Journal of the Medical Sciences, 1853, vol. xxvi., p. 333. 
 
 8 The Pathology and Treatment of Venereal Diseases. Fifth edition, p. 789. 
 
 8 Transactions American Otological Society, 1870. 
 
 4 Treatise on the Ear, p. 231. 
 
 8 Treatise on the Ear, p. 50.
 
 OTHJEMATOMATA. 107 
 
 OTH^MATOMATA, OR VASCULAR TUMOR OF THE EAR. 
 
 The peculiar effusion of blood which quite often occurs in the 
 auricle, and especially among the insane, and which is known 
 as othsematoma, hsematoma auris, or vascular tumor of the au- 
 ricle, has caused quite an amount of discussion among scientific 
 observers. Virchow ' and E. R. Hun, 3 of Albany, N. Y., are the 
 authors who seem to me to have given us the clearest and best 
 accounts of this interesting affection, and, in what I am about 
 to say, I shall avail myself of their labors, together with some 
 experience of my own on this subject. 
 
 The so-called othsematomata may be divided into those of 
 idiopathic and traumatic origin. The idiopathic form occurs 
 chiefly, though not exclusively, among the insane. I have seen 
 two cases occurring in people of sound mind, which corre- 
 sponded very well with the descriptions of those occurring in 
 the insane as given by Dr. Hun, whose observations seem to 
 have been confined to this class. Dr. E. G. Loring has also 
 seen one idiopathic case in a sane person. The symptoms of 
 the idiopathic form of the affection are as follows : Before the 
 tumor appears we find the ear or ears, as the case may be, red 
 and swollen, and the face and eyes give evidence of a strong 
 determination of blood ; occasionally, however, there is no red- 
 ness of the skin, and there is merely some oedema of the auri- 
 cle ; among the insane there is no manifestation of general 
 ill-health. In a few hours, or it may be days, an effusion of 
 blood takes place. The tumor occupies the concha in the main, 
 but it extends over the auricle so as to obliterate its ridges and 
 cause the usually beautiful part to appear like a roundish red- 
 dened tumor, varying in size from a bean to a hen's egg. This 
 tumor is evidently of an inflammatory nature, being hot and 
 painful. The swelling is usually quite firm, but a careful ex- 
 amination will detect fluctuation. 
 
 The vascular tumor of the auricle, judging from Dr. Hun's 
 statistics, is much more common among men than women. He 
 reports twenty-four cases, of which twenty-three occurred in 
 males. The form of insanity was general paresis in eight cases. 
 melancholia in six, acute mania in four, chronic mania in four, 
 and dementia in two. These statements accord with the views 
 of other authors, so that we may conclude that hsematoma 
 auris, when occurring in the insane, is a symptom which is 
 
 1 Die krankhaften Geschwulsten, Bd. I., p. 135. 
 * American Journal of Insanity, July, 1870.
 
 108 
 
 OTH^EMATOMATA. 
 
 highly unfavorable, and which points to an incurable form of 
 disease of the brain. 
 
 The tumor either ruptures spontaneously, sometimes with 
 such violence as to spurt the blood to a distance of several feet, 
 or, unless interfered with, is gradually absorbed. Spontaneous 
 rupture is more common than absorption. 
 
 Dr. Hun's observations show that the traumatic and idio- 
 pathic othaematomata are not alike ; for in one case which he 
 details, an insane person, already suffering from hsematoma of 
 one auricle, received a blow from a broom-handle on the other, 
 which produced swelling and ecchymosis, but no hcematoma. We 
 
 FIG. 36. Othaematoma. Prom a photo- 
 graph taken from a plaster cast, when the 
 tumefaction was greatest (after Hun). 
 
 Fia. 37. The same Ear after Rup- 
 ture and Contraction had taken place 
 (after Hun). 
 
 must, therefore, I think, strictly distinguish the idiopathic from 
 the traumatic form. 
 
 The etiology of haematoma is deemed by Hun to be two-fold, 
 viz., cerebral congestion and centripetal irritation of the system 
 by the emotions ; and he considers either of these causes suffi- 
 cient to produce the effusion. In general paresis there is, ac- 
 cording to all authors, a tendency to repeated congestions of the 
 head, and it is supposed that the blood-vessels of the ears be- 
 come so dilated as to favor the effusion. The second factor in 
 producing hasmatoma auris, centripetal irritation of the sympa- 
 thetic from strong emotions, is especially active among the 
 insane, because their emotions are not under the control of the 
 will.
 
 OTH^EMATOMATA. 
 
 109 
 
 Virchow has made the pathology of othaematomata very 
 plain, both by his descriptions and the excellent illustrations 
 which he furnishes in his great treatise on tumors. He says 
 that ''the older authors described the affection as erysipelas of 
 the auricle occurring in the insane. It was supposed that in the. 
 hypersemia and general change in the system a hemorrhage 
 occurred, which caused a separation of the perichondrium from 
 the cartilage ; but in true othsematomata, pieces of the cartilage 
 become attached to the perichondrium." 
 
 CASE I. J. A. C , set. 34. General paresis. Admitted January, 1857. 
 
 Insanity hereditary in his family. Discharged June, 1858. Readmitted May, 
 1859. July 24th, a simple sanguineous cyst was observed in each ear. Effusion 
 rapidly took place until the outlines of the auricle were obliterated. Septem- 
 ber 30th, the tumors have gradually subsided. Patient died May 10, 1860. 
 
 FIG. 38. Showing Amount of Con- 
 traction after Rupture of Cyst (after 
 Hun). 
 
 FIG. 39. Shows Separation of Perichon- 
 drium from the Cartilage (after Hun). 
 
 According to the Berlin pathologist, the morbid process 
 seems to be primarily a softening or deliquescing one. induced 
 by general disturbances of nutrition, or possibly although this 
 class of cases seems to belong to itself by local injuries of the 
 cartilage. The tumor disappears either by gradual absorption, 
 spontaneous rupture, or by the puncture of the surgeon. Coag- 
 ula often form, which make a delicate coating over the sepa- 
 rated portions, and these afterward serve as means of adhesion. 
 When suppuration does not take place, great deformity is apt 
 to occur from the thickening and retraction of the soft parts, 
 especially of the perichondrium.
 
 110 OTH^EAIATOMATA. 
 
 CASE JI. D. M , sei. . Melancholia. Second attack. Haem'atoma began 
 
 May 18, 1869. On July 3d had haematoma on both ears. August 1st the left 
 auricle burst at upper portion of concha, and the contents, consisting of fluid 
 and clotted blood, were thrown to the ceiling, a distance of twelve feet. Died 
 September 9, 1869. A section of the auricles showed that the perichondrium was 
 much thickened, and separated from the auricular cartilage on its outer aspect, 
 so as to leave a large, smooth cavity, lined with a smooth, shining membrane, 
 and containing a few drops of serous fluid. 
 
 Vascular tumors caused by violence should not be confound- 
 ed with those occurring idiopathically. Gudden, a German 
 writer and physician for the insane, quoted by Virchow, has 
 shown that the auricles of ancient statues are very frequently 
 ornamented by tumors resembling the vascular effusions seen 
 among the insane. In the gallery at Munich the head of Hercu- 
 les has such ears. These misshapen auricles are the typical 
 marks of the ancient boxers or pugilists. Such fighters wrapped 
 their hands in leather, and, thus armed, struck the ears of their 
 antagonists ; consequently in the figures of Hercules, Pollux, 
 and other classical fighters, a deformed auricle is a regular ap- 
 pearance. Other historical personages the Trojan Hector, for 
 example are represented as having othaematomata. 
 
 To conclude from these observations that the othaematomata 
 are ahuays the result of traumatic influences, that they are more 
 frequent among the insane because they are very apt to injure 
 themselves or be injured by their attendants, seems to me to be 
 manifestly incorrect, judging both from Dr. Hun's observations 
 and from the fact that these tumors are very uncommon. Even 
 the English writers, living in the land pre-eminent for pugilists, 
 scarcely mention them. Wilde ' describes and gives an illustra- 
 tion of one case, however, which seems to have been a haema- 
 toma, but was not recognized as such by the author. It was 
 idiopathic in origin. It occurred in a male aged twenty-four, 
 and was about the size of a small pear. It occupied the upper 
 portion of the left auricle, between the helix and the concha. 
 It was treated by incisions, and considerable deformity resulted. 
 
 Toynbee " describes these cases under the head of cysts, and 
 seems inclined to ascribe a traumatic origin to them, and he 
 states that it is the opinion of Dr. Thurnam, physician to one of 
 the county insane asylums of England, that they are less fre- 
 quent than formerly, on account of the fact that violence is not 
 so much employed in the management of the insane. Dr. Thur- 
 nam evacuated the contents of the tumors, and used setons, and 
 
 1 Aural Surgery, English edition, p. 164. 
 
 4 Diseases of the Ear, American edition, p. 53.
 
 OTH^EMATOMATA. HI 
 
 thus claims to have prevented the deformity to some extent. 
 Toynbee mentions but one case, that of a boxer, that he has him- 
 self seen ; but his description is not detailed enough to allow us 
 to judge whether it was identical with those observed in the in- 
 sane. 
 
 Dr. Hun was so strongly of the opinion that the idiopathic 
 othsematoma are symptoms of insanity, that he considered any 
 person having such tumor upon the auricle, even if sane, as 
 a person to be carefully observed as to cerebral symptoms. 
 This is an opinion of Dr. Hun's which I obtained in a conversa- 
 tion with him upon this subject. 
 
 While Professor Brown-Sequard was a resident of New York, 
 I had an interesting and instructive interview with him on the 
 subject of vascular tumors of the auricle. Dr. Sequa"rd has 
 found that sections of the restiform bodies, or largest column 
 of the medulla oblongata, in animals (Guinea-pigs) will produce 
 a hemorrhage beneath the skin of the auricle in from twelve to 
 twenty-four hours. This hemorrhage is soon followed by gan- 
 grene of the part. I had, through Dr. Sequard's courtesy, the 
 opportunity of examining such ears, and of verifying the fact of 
 the subsequent gangrene. The hemorrhage usually occurs in 
 the fossa navicularis of the auricle. This hemorrhage usually 
 takes place on the same side with that of the section. 
 
 Dr. Sequard also stated that sections of the sciatic nerve, by 
 reflex action upon the medulla, would produce the same result, 
 and that he had produced in his own person flushing of the auri- 
 cle by pinching the sciatic nerve. Dr. Sequard believes that dis- 
 ease of the base of the brain, which is, however, not always 
 attended by insanity, is the cause of hsematoma auris. In the 
 human animal, gangrene is not apt to result from the hemor- 
 rhage ; probably because the thicker tissue of the human auricle 
 has a greater resisting power. 
 
 It will thus be seen that Dr. Sequard's views confirm those of 
 Dr. Hun, while they shed a new light upon the clinical observa- 
 tions of the latter. 
 
 Meyer ' and Blake 2 report cases of othsematomata in which 
 pressure and massage were employed in treatment with good re- 
 sults. Both of Blake's cases were males, with no trace of other 
 physical disease, of sound minds, and with " no antecedent or 
 individual history of insanity or intemperance." The first case, 
 however, occurred in a pedestrian, being the " champion short- 
 distance walker." As Dr. Blake suggests, this occupation, from 
 
 1 Archiv fur Ohrenheilkunde, vol. xvii., p. 2. 
 
 2 American Journal of Otology, vol. iii., p. 193.
 
 112 OTH^EMATOMATA. 
 
 its severe strain upon the muscles and the circulation, may have 
 had some bearing upon the etiology. This patient flushed easily 
 under any physical exertion or slight mental excitement. The 
 tumor was opened, two drachms or more of bloody serum and a. 
 little dark blood withdrawn, the cavity was then well probed, 
 and sponge pads were adjusted to the anterior and posterior 
 surfaces of the auricle and kept in place by an elastic flannel 
 bandage. This treatment was continued for a week, and then 
 massage was employed four times at the interval of several 
 days for about fifteen minutes at each visit by an expert, Dr. 
 Graham, of Boston. "The tissues were gently and firmly rolled 
 between the thumb and finger with gradually increasing force 
 until the last five minutes, when the pressure was gradually dk 
 minished." Under this treatment the ear resumed its normal 
 appearance in about two months. 
 
 In the second case, that of a teamster, the hemorrhage oc- 
 curred the day after the patient had exerted himself very much 
 in loading heavy bales of goods. He was a temperate man, but 
 undersized, and was occasionally subject to very severe exertion 
 in his business. He was seen by Dr. Blake on the very day the 
 hemorrhage occurred. The same treatment was applied as in the 
 previous case, and on the fifth day the auricle had nearly re- 
 sumed its normal appearance, and the patient was discharged. 
 Meyer's cases did not do quite as well as these. Blake thinks it 
 possible that the stuffing of the cavity with picked lint and too 
 frequent massage four times daily, as practised by Meyer may 
 have prevented the best results. 
 
 The result in three of Meyer's cases was very satisfactory ;. 
 in two of them resorption took place within a few weeks, and 
 there was finally no deformity of the auricle. It is interesting 
 to note that one parent in each of Meyer's cases had been insane. 
 In view of this, Meyer calls attention to Hun's observation, that 
 the appearance of othsematoma in sane persons usually precedes, 
 a later mental disturbance, and agrees with my own opinion, 
 that while all those suffering from this vascular tumor of the 
 auricle may not be insane, yet they probably have some kind of 
 disease of the brain. These observations seem to be borne out 
 by Brown-Sequard's experiments, and by an analysis of the cases, 
 of Blake and Meyer. Othsematomata do not seem to occur in 
 persons entirely free from cerebral disease. 
 
 From all that has been written of vascular tumors of the 
 ear, and from my own experience, I think we may safely af- 
 firm 
 
 First.-t-That there are two distinct varieties of othsemat^-. 
 mata : Traumatic and Idiopathic.
 
 PERICHONDRITIS OF THE AURICLE. 
 
 113 
 
 Second. That the idiopathic is much more common among 
 the insane than among others, but that identically or nearly the 
 same affection does occur among the sane. It is probable, how- 
 ever, from Brown-Sequard's experiments, that the affection is 
 caused by some lesion of the base of the brain, so that although 
 persons suffering from vascular tumor of the ear may not always 
 be insane, they generally have brain disease, or they may be- 
 long to the large class of neurotic or neurasthenic people. 
 
 Third. The traumatic form differs from the idiopathic in be- 
 ing a simple extravasation of blood from vessels ruptured by 
 violence. In such cases the deformity resulting from the spon- 
 taneous effusions does not occur, unless among professional 
 pugilists, where the violence is frequently repeated, and the auri- 
 cle, from repeated hemorrhages, 
 assumes a shape like that result- 
 ing from a true othsematoma. 
 
 Fourth. The treatment by 
 pressure after evacuation of the 
 contents, followed by moderate 
 massage, seems to give very good 
 results and may be confidently 
 practised. 
 
 PERICHONDRITIS AND CHONDRITIS. 
 
 Any inflammation of the in- 
 tegument, connective tissue, and 
 cartilage of the auricle, leading to 
 effusion of serum, blood, or the 
 formation of pus, will be apt to 
 cause a deformity of the part ; but 
 such a case should be distinguished 
 from an othaematoma. 
 
 The sketch from a photograph, 
 which is here given, shows the 
 result of what was at first an in- 
 flammation of the cartilaginous 
 
 portion of the auditory canal. A polypus formed from the pro- 
 longed use of poultices for the relief of what was supposed to 
 be a furuncle, the inflammation extended to the tissue of the 
 auricle, and after a long period of suffering, during which small 
 abscesses were formed, which were evacuated after pursuing a 
 sinuous course in the integument, the auricle attained the shape 
 which is here shown. The hearing power is unimpaired when 
 the very small meatus is kept open. 
 
 Several cases of inflammation of the tissues of the auricle 
 
 FIG. 40. Auricle Deformed by Inflam- 
 mation (chondritis).
 
 114 PERICHONDEITIS OF THE AURICLE. 
 
 have been published since my case was reported in 1873, ' and 
 some of the reporters have fallen into the natural error of stating 
 that similar cases have not been before noticed. All these cases, 
 although differing in minor respects, agree in being essentially 
 inflammations of the perichondrium, and in leaving some de- 
 formity behind them as a rule. I did not name my case perichon- 
 dritis, when it was first reported, but a comparison of the account 
 of the case with those of later writers will show, I believe, that 
 the various reporters are speaking of the same form of disease. 
 Chimani was one of the first, if not the first, to report a case of 
 perichondritis a of the auricle. His was that of a soldier in the 
 Austrian army, who was suddenly seized with a sensation of 
 heat and pain in the left auricle, with swelling of its concave sur- 
 face. Four days after the attack, when he entered the hospital, 
 the whole auricle was a shapeless mass of inflammation. Poul- 
 tices were applied, and in three days fluctuation appeared. An in- 
 cision was made ; quite a quantity of synovial-like fluid mingled 
 with pus was evacuated. It was afterward treated as an abscess 
 and dressed with picked lint and a bandage. In two weeks after 
 the patient came under Chimani's care, the auricle had recovered 
 its normal form and elasticity. Chimani considers this case as a 
 primary one of the perichondrium " an inflammation with the 
 formation of exudation." The absence of a bluish-red coloring 
 and the character of the contents distinguish it from a vascular 
 tumor. Dr. Pomeroy's ' case of abscess of the auricle was one in 
 which the disease extended from the tympanic cavity to the 
 canal and thus to the auricle. The patient was a man forty-two 
 years of age. The auricle did not become involved for some 
 weeks after the primary inflammation. The patient was not 
 under constant observation, and recovery took place after free 
 evacuation of the pus, with great deformity. This case is to be 
 classed with those of secondary inflammation of the auricle, such 
 as that reported by myself. It may be said here, that it is not 
 unusual to see very considerable swelling of the cartilaginous 
 part of the canal following an inflammation of the tympanic cav- 
 ity. This usually subsides under the use of the warm douche, 
 and generally without extending to the auricle. Knapp * re- 
 ports three cases. The first began as an inflammation of the 
 canal, and after some weeks recovered also with deformity. 
 The second case was seen but once, and no details are given 
 except that there was fluctuation in the concha. Tie third case 
 
 1 Transactions of American Otological Society. 
 'Archiv fur Ohrenheilkunde, Vol. II., p. 171. 
 
 3 Transactions of the American Otological Society. Vol. II., p. 83. 
 
 4 Archives of Otology, Vol. IX., p. 196.
 
 PERICIIONDEITIS OF THE AUEICLE. 115 
 
 was one shown Dr. Knapp by his colleague, Dr. Brandeis. Dr. 
 Brandeis' patient had a "mild chronic aural catarrh." There 
 was a reddish diffuse swelling of the cartilage of the meatus and 
 the adjacent parts of the concha. After an incision watery pus 
 escaped, and the swelling disappeared in a few weeks. 
 
 Pooley's case ' occurred in a woman of twenty-one. When 
 she came under Dr. Pooley's care, there was the history of a boil 
 in the ear ; the swelling extended from the canal to the concha, 
 and finally to the entire anterior surface of the concha. It was 
 treated by incisions, injections of a weak solution of carbolic acid 
 and iodine. Pressure was also employed by means of a bandage. 
 The pressure seemed to alleviate the pain. Considerable deform- 
 ity of the concha remained. The acute inflammatory symptoms 
 lasted for about two months, and, as in all these cases, the long- 
 continued suffering, the discharge undermined the general 
 health. Pooley does not regard frequent incisions as assisting 
 very much, but as perhaps aggravating the case. 
 
 The lobule may be affected in perichondritis and may not. 
 The cases reported do not differ in character, but simply in in- 
 tensity and course. Dr. Knapp's case, like mine, arose from a 
 f uruncular inflammation, and after this suppuration of the drum- 
 head occurred. This is an unusual order of things. Whether or 
 not the lobule is affected certainly depends upon other causes 
 than the existence of a perichondritis. In my case there was 
 perichondritis and also a slight affection of the lobule. 
 
 These cases, except that of Chimani, are essentially the same 
 with that reported by me in full in 1873. 2 As I then said, the 
 extension of the inflammation of the auditory canal to the car- 
 tilage and perichondrium of the auricle is unusual. I believe 
 with Pooley, that incisions may be too frequently made, and 
 that they are rather to be avoided than employed, although not 
 entirely given up. 
 
 Kipp 3 also reports, under the head of "Spurious Othsema- 
 toma of Both Ears the Result of a Burn," a case of perichon- 
 dritis of the auricle. In his case there was scarcely any de- 
 formity, simply a wrinkled condition of the fossa of the helix. 
 After incision Kipp employed tincture of iodine to the outer and 
 inner surface of the swellings. 
 
 It will be seen that Chimani's case is the only one of those 
 here reported, that bears any close resemblance, in its origin or 
 course, to the othaematomata. The others are clearly like the 
 
 1 Medical Record, 1881. 
 
 2 Transactions American Otological Society. Boston, 1873. 
 
 3 Ibid., 1873.
 
 116 MALIGNANT DISEASE OF THE AURICLE. 
 
 cases of Dr. Pomeroy and myself, and belong to those of second- 
 ary inflammations. While this form of disease, as has been said, 
 is rare, the primary form is much rarer. 
 
 Chondritis and perichondritis of the auricle may result by 
 simple extension of an inflammation of the cartilage of the 
 canal. It is probable that prolonged poulticing may favor such 
 an extension. The deformity from such an inflammation will 
 be considerable, under the most favorable circumstances, if the 
 inflammation once set in. When fluctuation occurs, it is better 
 to make a thorough opening, and to connect sinuses by cutting 
 so as to convert them into open wounds. Gruening recommends 
 cutting through the entire auricle, from before backward ; while 
 it is of the utmost importance to secure thorough drainage, I 
 do not think incisions entirely through the tissues necessary 
 for this. lodoform gauze forms a good dressing after incisions. 
 Vaseline is a good application for the swelled tissue when sup- 
 puration does not occur. Over this, cotton wool and a bandage 
 generally form a comfortable dressing, and perhaps aid in les- 
 sening the inevitable deformity. I have seen several of these 
 tedious and trying cases since the last edition of this book was 
 issued, and see no reason to doubt my original opinion that they 
 usually -originate in the cartilage of the canal, and that any case 
 of furuncle under unfavorable conditions, or perhaps injudicious 
 treatment, may result in chondritis or perichondritis of the 
 auricle. Perichondritis and chondritis may be readily distin- 
 guished from othsematoma, if the disease be seen early in its 
 course, but when the canal, if once diseased, has recovered, and 
 the auricle alone remains affected, there may be a possibility of 
 error. 
 
 MALIGNANT DISEASE. 
 
 Epithelioma. The auricle is sometimes, although not fre- 
 quently, the seat of malignant disease. I have observed one 
 case of epithelioma of this part, in which the whole auricle was 
 destroyed, and the disease had invaded the auditory canal. I 
 lost sight of the patient after some weeks, and I can give no ac- 
 count of the subsequent course of the disease, which was un- 
 checked by the treatment adopted the application of fuming 
 nitric acid. Dr. J. Orne Green, of Boston, ' also reports a case, 
 and quotes one from Velpeau. 
 
 Epithelioma of the auricle usually begins as a small papule, 
 which finally develops into an open ulcer. This spreads very 
 
 Transactions American Otological Society, third year.
 
 ECZEMA OF THE AUEICLE. 117 
 
 rapidly, involving finally the auditory canal, and, unless ar- 
 rested, the deeper parts. Excision or amputation of the parts is 
 the only proper treatment. When the auricle alone is involved, 
 this is very easily accomplished. In the healing process care 
 should be taken, as suggested by Dr. Green, to prevent the 
 closure of the meatus by the cicatrix, a result which followed in 
 the case reported by him, in consequence of the refusal of the 
 patient to remain under observation until the wound was healed. 
 
 Sarcoma. Sarcomatous tumors may occur on the auricle as 
 well as in the auditory canal, where they arise from the carti- 
 laginous portion. They grow very slowly, but they may extend 
 to the auditory canal, to the middle ear, and even to the laby- 
 rinth and meninges of the brain. Early removal is the only 
 safe means of treatment, and even then the growth may return. 
 
 The accompanying engraving is a representation of a tumor 
 
 FlG. 41. Tumor of the Anterior Part of Auricle and Auditory Canal. 
 
 of the auricle, apparently beginning in the parotid gland, which 
 was seen at my clinic in 1883. The patient was a woman of 
 about forty-five years of age, otherwise healthy. 
 
 ECZEMA. 
 
 Eczema of the auricle is not one of the most frequent affec- 
 tions of the ear, as shown by the statistics of eye and ear hospi- 
 tals and writers on otology ; but a large number of cases never 
 come under the attention of special observers, and are. conse- 
 quently, not found in their statistics. Inasmuch as eczema of
 
 118 ECZEMA OF THE AURICLE. 
 
 the auricle is usually attended by the same disease in the audi- 
 tory canal, it will be more convenient to speak of them both at 
 this time. 
 
 Eczema of the ear, seems to occur more frequently among 
 females than males, but it is found in both sexes. The symp- 
 toms are the same as those of eczema in other parts of the body, 
 with some symptoms peculiar to the ear. The symptoms pecu- 
 liar to the ear are redness, swelling, and the formation of ves- 
 icles which become pustular, and which finally cover the whole 
 region with unsightly crusts, from which a discharge occurs. 
 The auricle becomes a misshapen mass, while the swelling and 
 incrustation of the integument lining the auditory passage and 
 membrana tympani impair the hearing to a serious extent. 
 Fulness and noise in the ears are then added to the patient's 
 other symptoms, and the condition is unpleasant in the highest 
 degree. The disease, when left to itself, is apt to have a very 
 chronic course, and yet it is very amenable to proper treatment. 
 The causes of eczema are not very clear. I have usually ob- 
 served it in persons of weak constitutions, and not among the 
 strong and vigorous. It rarely occurs upon the auricle alone; but 
 it is usually found in conjunction with the same disease on other 
 parts of the body, most frequently in conjunction with eczema 
 of the face and head, although it sometimes occurs on the auri- 
 cle and in the meatus alone. 
 
 According to Ausspitz, 1 formerly an assistant to Hebra, ecze- 
 ma of the ear differs from the same disease as it appears in 
 other parts of the body, in occurring with a greater amount of 
 swelling and secretion of more serous fluid than is usual, together 
 with the more frequent appearance of fissures in the tissue. 
 
 Treatment. The results of treatment of acute eczema are 
 usually soon seen. The advice of Ausspitz, to do as little as 
 possible in the acute form, is excellent. The auricle should be 
 kept from the air. This may be accomplished by the use of oils, 
 powders, or even by a plaster-of -Paris bandage. A good appli- 
 cation is the formula of Ausspitz : 
 
 B . Flor. Zinci 3 ij. 
 
 Pulv. Alum,- 
 
 Amyli Pulv aa j. 
 
 M. Ft. pulv. 
 
 This powder is dusted over the affected portion with a camel's- 
 hair brush. If the auricle be excoriated and sensitive, astringent 
 
 1 Archir. fur Ohrenheilkunde, Bd. I., p. 124.
 
 ECZEMA OF THE AURICLE. 119 
 
 solutions of sulphate of zinc may be used. I usually employ 
 vaseline or cold cream in the early stages of eczema of the auri- 
 cle. Cod-liver oil is also a good application. I endeavor to keep 
 the parts constantly covered with such a non-stimulating oint- 
 ment as one of those just named. 
 
 At the same time with this local treatment, the physician 
 should carefully consider the general state of the patient, since 
 in this a cause for the eczema may often be found, which being 
 removed by appropriate management, will prevent a relapse of 
 the affection. 
 
 Eczema of the auricle and auditory canal is not often brought 
 to the notice of the surgeon until it has become chronic. Its 
 treatment then may require the greatest patience and care. The 
 treatment which I have found usually successful is the following : 
 The auricle is carefully, but liberally, anointed with a one per 
 cent, solution of carbolized oil. The auricle is then covered with 
 an impermeable sheeting of rubber tissue-paper or oiled silk, in 
 order to keep the parts soft and pliable, and bandaged accord- 
 ingly. An improvement will soon be noticeable, inasmuch as the 
 crusts will become detached. The inflamed corium which is now 
 exposed will soon yield to a soothing salve. 
 
 The diachylon ointment of Hebra, spread thickly on lint and 
 applied to the surface will act very well. After the eczema has 
 ceased to exude, we may conveniently add the oil of tur ol. fagi, 
 or ol. cadini one drachm to the ounce, either to Hebra's oint- 
 ment or to the officinal zinc salve, to which a little oil of sweet 
 almonds may be mixed. An addition of salicylic acid in non- 
 irritating doses, i.e., three grams to the ounce of salve, will pro- 
 mote the formation of healthy epidermis. 
 
 The local treatment of the auditory canal is often unsuccess- 
 ful from the want of the personal attention of the physician. No 
 one who is unable to examine the external opening of the ear 
 down to the membrana tympani, can tell when it is or is not 
 clean. Without a thorough removal of the material thrown off 
 in an eczema there can be no cure. An eczematous auricle may 
 perhaps recover spontaneously, an eczematous auditory canal 
 will, probably, never thus return to a normal condition. The 
 material thrown off from the inflamed integument collects in 
 the narrow passage, and by mechanical irritation increases the 
 swelling, and produces the most troublesome symptom of the 
 disease impairment of hearing. The auditory canal should be 
 therefore carefully cleansed every day with the syringe and 
 angular forceps or cotton-holder, under a good illumination with 
 the otoscope, and then an appropriate liquid application be 
 made. A liquid preparation is to be preferred to an unctuous
 
 120 ERYSIPELAS OF THE AURICLE. 
 
 one, for the simple reason that an ointment will again block up 
 the passage, and thus prevent the patient from securing the full 
 benefit to his hearing power which the removal of the epidermis, 
 crusts, and pus has produced. We may fail to cure many a 
 case of disease of the integument lining this part, if we do not 
 carry out our own advice ; we should never give over the treat- 
 ment into the hands of the parents or attendants of the patient, 
 for they will be incompetent assistants. 
 
 The warm douche is very valuable in the treatment of chronic 
 eczema of the canal. It allays itching sensations, and is usually 
 very grateful to the patient. The use of the douche may be en- 
 trusted to the patient himself. It is well to use it very often in 
 the early periods of treatment, say once an hour. The warm 
 water is a direct antiphlogistic : I have seen obstinate cases of 
 inflammation of the canal, that have existed for years, cured by 
 its use alone. 
 
 The application of nitrate of silver in solutions of from ten to 
 forty grains to the ounce, is, I believe, on the whole, the best 
 that can. be made in the treatment of eczema of the canal. The 
 disease may be often complicated with aspergillus, or a vege- 
 table fungous growth in the canal. Diachylon ointment on a 
 little cotton, forms a good application to keep apart the walls of 
 the canal at the meatus. 
 
 Bichloride of mercury in solutions of from one-twelfth to one- 
 fourth of a grain to the ounce, applied with a dropper or by 
 means of the cotton-holder, has proved an efficient remedy in 
 my hands in chronic eczema of the canal. 
 
 The only specific remedy for internal use in chronic eczema 
 of the auricle, as well as that of the same disease in other parts 
 of the body, is arsenic. In chronic cases I usually give Fowler's 
 solution in connection with the local treatment, and it is gener- 
 ally of great avail. 
 
 There are various arsenical waters that are of service in the 
 treatment of chronic eczema in the ear, as well as that affecting 
 other parts of the body. One that I have used with apparent 
 benefit is from the Virginia Springs. 
 
 ERYSIPELAS. 
 
 Facial erysipelas often begins at the auricle, and sometimes 
 it is limited to this part. It sometimes also occurs in the course 
 of chronic eczema. Indeed, erysipelas occasionally has its ori- 
 gin in a small eczematous patch or spot near the auricle. It is 
 probable, however, that this never occurs if the subject be in 
 good general condition. The local treatment that I have em- 
 ployed with satisfaction, is an application of a solution of acetate
 
 EFFECTS OF GOUT INJURIES. 121 
 
 of lead, in tincture of opium and water, the famous lead-and- 
 opium wash. It is important, especially in delicate subjects, 
 that eczematous spots behind the ear be promptly treated, lest 
 they become the starting-point of erysipelas. Oxide of zinc oint- 
 ment is a good application for small eczematous ulcers. 
 
 THE EFFECTS OF GOUT. 
 
 Calcareous formations are often found in the auricle, in per- 
 sons of a gouty habit, as in other parts of the body. These 
 symptoms of gout are often accompanied by a great deal of local 
 pain, which is sometimes relieved by an unctuous application to 
 the hardened and tender parts. Dr. Garrod, 1 of London, first 
 called attention to these formations, which he found to be urate 
 of soda. They were most frequently found by Garrod on the 
 upper border of the helix, and were supposed not to exist on the 
 lower part of the auricle ; but I saw what seemed to be such a 
 formation, in the concha of a gentleman who suffered from 
 gout. Unlike those cases reported by Dr. Garrod, this spot was 
 very painful. 
 
 Where the gouty diathesis exists, it is not uncommon to find 
 heat and pain in the cartilage of the auricle. The practitioner 
 should be on the lookout for such cases of apparently simple 
 dermatitis, for they may indicate the constitutional trouble, 
 which will only be relieved by treatment of the general system. 
 
 INJURIES OF THE AURICLE. 
 
 Wounds of the auricle may sometimes be followed by an ery- 
 sipelatous inflammation, but this is not apt to be the case. 
 
 They usually heal promptly, without suppuration, although 
 inflammation of the cartilage or the perichondrium may result. 
 Injuries of the auricle from direct violence, such as pugilists in- 
 flict upon each other, generally produce great deformity. The 
 treatment of such injuries requires no especial notice in a work 
 of this kind. 
 
 ANGIOMA. 
 
 At the February meeting (1884) of the New York Ophthalmo- 
 logical Society, Dr. E. Gruening reported an interesting case of 
 angioma, of which he has been kind enough to furnish me an 
 account for these pages. 
 
 In October, 1883, a man, aged twenty-three, consulted Dr. Omening on account 
 of a circumscribed swelling in his right ear. He stated that he had first noticed 
 
 1 Troltsch : Diseases of the Ear, p. 56.
 
 122 ERYSIPELAS OF THE AUHICLE. 
 
 a little growth two years before. He had never suffered from any injury of the 
 ear. No congenital anomaly had been observed. He consulted Dr. Gruening 
 about the tumor because its pulsating sounds had become very annoying, espe- 
 cially in the stillness of the night. There was found a semi-globular, bluish, 
 soft, and strongly pulsating tumor occupying the right concha and encroaching 
 somewhat upon the lower wall of the external auditory canal. The tumor had a 
 diameter of fifteen millimetres at its base, and an elevation of nine millimetres 
 above the surrounding skin. Pressure with the fingers easily emptied the tumor, 
 but the pulsation was not diminished by pressure upon the arteries of the head 
 and neck. The whole mass was excised on October 25th. The incision was 
 carried through sound skin and the underlying cartilage was removed with it. 
 The copious hemorrhage, venous from the centre and arterial from the edges, 
 was arrested by pressure. The wound healed slowly by succulent granulations. 
 Four weeks later a soft pulsating cicatrix had formed. 
 
 Dr. Gruening's case is an essential contribution to our knowl- 
 edge of this rare affection. If the pulsating cicatrix enlarges or 
 is troublesome to the patient, it will be proper to excise it.
 
 CHAPTER V. 
 
 DIFFUSE AND CIBCUMSCBIBED INFLAMMATION OF THE EXTER- 
 NAL AUDITOEY CANAL. 
 
 Comparative Frequency of these Affections. Diffuse Inflammation. Leeches. In- 
 cisions. Warm Douche. Fountain Syringe. Fayette Taylor's Douche. Method 
 of Syringing. Syringes. Anodynes. Desquamati ve Inflammation. Furuncles. 
 Local and Constitutional Treatment. Calcium Sulphide. Lowenburg's Views. 
 
 THE affections of the external auditory canal may be conven- 
 iently arranged as follows : 
 
 I. Diffuse inflammation. 
 II. Circumscribed inflammation. 
 
 III. Vegetable fungous growths. 
 
 IV. Inspissated cerumen. 
 V. Eczema. 
 
 VI. Foreign bodies. 
 VII. Polypi. 
 
 VIII. Exostoses and hyperostoses. 
 IX. Narrowing and closure of the canal. 
 
 X. Syphilitic condylomata and ulcers. 
 
 To avoid any misconception, I would remark that while 
 bony growths (exostoses and hyperostoses) are classed under 
 the affections of the external auditory canal, they are generally 
 consequences of inflammations of the middle ear. It will there- 
 fore be more appropriate to consider this rather important sub- 
 ject under the head of diseases of that part. An account of 
 their pathology and treatment will be found in the chapter de- 
 voted to the " Consequences of Chronic Suppuration of the 
 Middle Ear." The subject of "Aural Polypi" will also be de- 
 ferred until a subsequent chapter, for they are also much more 
 frequently the result of inflammation of the middle ear, than of 
 disease of the external auditory canal. Otitis externa is the 
 generic term for all the various forms of inflammation of the 
 external auditory passage, but it is not specific enough for any 
 exact study of these affections. 
 
 Inflammations of the external auditory canal are much more 
 rare than those of the middle ear ; of 6,800 cases of the different
 
 124 STATISTICS OF INFLAMMATION OF CANAL. 
 
 varieties of aural disease observed by myself in private prac- 
 tice, but 387 were cases of inflammation of the auditory canal. 
 This proportion varies somewhat from the statistics of other 
 authors and those of public institutions. 
 
 In the Manhattan Eye and Ear Hospital, during the past nine- 
 teen years, there were examined 20,103 cases of aural disease. 
 Of these 1,060 were cases of inflammation of the external audi- 
 tory canal. This does not include cases of impacted cerumen or 
 foreign bodies, or inflammations which had their origin in the 
 parts beyond and extended to the canal. Including inspissated 
 cerumen and foreign bodies, there were 3,538 cases of affections 
 of the external canal, or about one-sixth of the whole number. 
 
 Dr. Biickner, of Gottingen, has compiled a table of reports 
 from various authorities. 1 In a total number of 58,645 cases of 
 diseases of the ear thus reported, there were 14,905, or 25.5 per 
 cent., of affections of the external ear. 
 
 The highest percentage of diseases of the external ear in 
 Biickner's tables is 39.5 (Ocker), the lowest 13.3 (Roosa). In 
 Wilde's tables, 2 also quoted by Biickner, the percentage of ex- 
 ternal affections is very high, 55.8. Since the time of Wilde it is 
 undoubtedly true that our means of diagnosis are better, and we 
 are enabled to transfer many cases from the column of the ex- 
 ternal auditory canal, to that of the middle ear. 
 
 Some writers speak of the inflammations of the external 
 auditory passage as being catarrhal in their nature-; but as 
 Troltsch strongly insists, and as has already been said in the 
 description of the anatomy of the auditory canal, there cannot be 
 a catarrhal inflammation where there is no mucous membrane. 
 The lining of this passage is integument, and in no proper sense 
 can we speak of a catarrh of the integument. 
 
 An account of diffuse or general inflammation of the exter- 
 nal auditory canal will first be given. 
 
 DIFFUSE INFLAMMATION. 
 
 Symptoms. The subjective symptoms of diffuse inflamma- 
 tion of the external auditory canal are itching sensations in the 
 canal, pain, and a sense of fulness and heat. 
 
 I speak of these symptoms in the order in which, on careful 
 examination of the history of the cases, I have found they usu- 
 ally appear. It is true that patients often give a period later 
 than that in which the itching sensations occurred, as the one 
 
 1 Archiv fur Ohrenheilkunde, 1883. 
 1 Text-book, English edition, p. 114.
 
 DIFFUSE INFLAMMATION. 125 
 
 in which their ears first troubled them, but ears in a normal 
 state have, so to speak, no sensations ; that is to say, they are 
 not thought of, and need no especial care. When an ear be- 
 gins to require something to relieve itching sensations, it is 
 already diseased. 
 
 The objective symptoms are impairment of hearing, redness 
 of the canal and perhaps of the membrana tympani, swelling, 
 and, at a subsequent period, suppuration of the epidermis and 
 integument. In the lower part of the canal, where we have the 
 density and tenseness of periosteum, the pain may be as severe 
 as that from inflammation of the lining of the tympanic cavity, 
 or as that occurring in paronychia. 
 
 Prolonged suppuration of the integument, or even suppura- 
 tive action that has been of short duration, but violent, may 
 produce polypi, or, as I prefer to call them, granulations, in the 
 external auditory canal. I have seen several such cases. One, 
 that of a lady, was complicated by a precedent inflammation of 
 the cavity of the tympanum ; but the inflammation of the ex- 
 ternal auditory canal was an independent one. Very large gran- 
 ulations, or polypi, sprang up in a few days after a poultice had 
 been applied. This poultice was ordered by the attending physi- 
 cian to relieve the initial pain of an inflammation of the canal, 
 such as sometimes occurs from the continued instillation of 
 astringents. It was applied for some days through a misunder- 
 standing of the damage that might ensue, and very large gran- 
 ulations formed. 
 
 Another case occurred in an Irish laborer, whom I saw while 
 I held a clinic in the University Medical College. I removed a 
 large polypus from the canal, which the patient stated posi- 
 tively had occurred in a few days, and that he had never pre- 
 viously suffered from disease of the ear. After the treatment 
 had progressed for some time, I found that the inflammation 
 was confined to the canal and the outer layer of the drum-head, 
 and that his statement as to the existence of previous disease 
 was probably correct. I could find no cause for the rapid course 
 of the inflammation. 
 
 A third case I saw at the Brooklyn Eye and Ear Hospital. 
 The trouble in the ear had lasted seven days, and here also there 
 was a large polypus. The fourth case was that of a lady whom 
 I saw in private practice. She suffered from what she supposes 
 to have been an abscess or furuncle of the external meatus. It 
 was lanced, and then poultices were applied. I saw her six days 
 after. She had used the poultices nearly the whole of the six 
 days. I found the canal blocked up by a polypus as large as a 
 filbert, growing from the anterior wall of the canal. The final
 
 126 DIFFUSE INFLAMMATION. 
 
 result of this case in deformity of the auricle, is seen in the en- 
 graving on page 113. 
 
 The practitioner need give himself no uneasiness about the 
 occurrence of these granulations. As a rule, they subside spon- 
 taneously. If not, when well pedunculated they are easily re- 
 moved with a curette with sharp edges. 
 
 The microscopic appearances of the growths are identical 
 with those of polypi springing from the mucous membrane of 
 the cavity of the tympanum, which will be fully discussed in a 
 subsequent chapter. 
 
 Although it is anticipating somewhat of what should be said 
 under the head of treatment, I will here state that the undoubted 
 cause of these growths, in two of the cases just given, was the 
 prolonged use of the poultices. Troltsch called attention to the 
 fact that poultices produced tedious suppuration ; but I believe 
 this is the first intimation that they cause the sprouting up of 
 exuberant granulations in the canal. 
 
 Causes, The causes of the diffuse form of inflammation are 
 various. Irritation of the ear by means of ear-picks, by hair- 
 pins, favorite instruments with women ; the instillation of such 
 agents as Haarlem oil, Cologne water, camphorated oil, and so 
 on, are frequent causes of an inflammation of this part. 
 
 Surf-bathing sometimes is a cause of inflammation of the 
 auditory canal and outer layer of the membrana tympani, either 
 with or without an inflammation of the middle ear. This is not 
 apt to occur among careful, intelligent persons. In surf -bathing 
 the bather should take a little pains that the shock of the waves 
 does not come upon the side of the head, but in front. When 
 the ears are .filled with water, they should be carefully dried. 
 Prolonged and repeated diving should be avoided, especially by 
 those who have sensitive or diseased ears. Caps of oiled silk 
 and plugs of oiled cotton are also useful in bathing to those 
 whose ears are sensitive to the entrance of salt water. In seri- 
 ous cases of aural disease, sea-bathing must be prohibited. This 
 subject will be again alluded to in the discussion of diseases of 
 the middle ear. 
 
 There is probably some antecedent inflammation of the in- 
 tegument which causes a resort to those agents, to relieve the 
 troublesome itching sensations. Cold draughts of air are often 
 spoken of as causes of inflammation of the outer canal ; but such 
 influences are more apt to produce an inflammation of the naso- 
 pharyngeal space, and through that of the middle ear. In fact, 
 the causes of external otitis diffusa seem to be chiefly local, if I 
 may so speak ; that is, the disease is caused by mechanical causes
 
 DIFFUSE INFLAMMATION. 127 
 
 acting locally. There may, however, be an antecedent eczema- 
 tous inflammation before the diffuse, non-eruptive form begins. 
 
 A diffuse inflammation of the external auditory canal, quite 
 often occurs during the latter part of the course of an acute sup- 
 puration of the middle ear, but it usually subsides without spe- 
 cial treatment. 
 
 Of late an apparatus, consisting of a very small sponge, at- 
 tached to an appropriate handle, and called an aurilave, has been 
 devised, and is sold largely by apothecaries as an instrument 
 for cleansing the ear. It does a great deal of harm. By its use 
 the secretions are packed in the ear, and inflammation of the 
 integument or inspissation of the cerumen is very often caused. 
 
 Physicians are often asked if the outer ear should be pro- 
 tected from the cold air by a plug of cotton, ear-muffs, or simi- 
 lar means. The beginning of aural inflammation is rarely from 
 the auditory canal, although the auricle is sometimes frozen 
 from exposure to cold. If, however, a person sit -in a railway 
 carriage which is going very fast, with the ear next to an open 
 window, or if the auditory -canal and membrana tympani be 
 exposed in any similar manner to a draught of air, an inflam- 
 mation of the canal and of the tympanic cavity may ensue. But 
 when there is no such draught upon the ear, as, for instance, 
 when a person is walking or driving in the open air, there is no 
 need, unless there is danger that the auricle will be frost-bitten, 
 or there is a strong wind blowing, of using a covering to the 
 meatus auditorius any more than to the nostrils. The natural 
 curvatures of the canal will prevent a current of air from reach- 
 ing the drum-head. This is, however, only true as respects 
 healthy ears. In cases of chronic aural catarrh, and in the 
 other kinds of troubles of the middle ear, the canals sometimes 
 become very sensitive to the cold, and require protection when 
 healthy ears do not. When no inconvenience is felt from allow- 
 ing the ears to remain uncovered, it is better to leave them 
 without protection. The habit of plugging the auditory canals 
 with cotton on every slight pretext is a bad one, because it is 
 apt to irritate the integument and to cause the ears to be over- 
 sensitive, and it may produce dermatitis. As I have said, we 
 do not usually get an inflammation of the ear from an exposure 
 of the auditory canal, but from such causes as wet feet, an ex- 
 posure of the whole surface of the body, and so on. 
 
 Cousins, of London, 1 recommends a little conical cap of vul- 
 canite, made of flesh-colored material, as a protector to the audi- 
 tory canal from cold and noise, and from water in bathing. This 
 
 British Medical Journal, December 31, 1881.
 
 128 
 
 DIFFUSE INFLAMMATION. 
 
 protector seems to me to be an excellent contrivance for use in 
 the cases where protection of this kind is needed. 
 
 There is altogether too much solicitude on the part of moth- 
 ers and other persons as to the cleanliness of their children's or 
 their own ears. The auricle and the edges of the opening into 
 the canal, which are about all that the little finger will reach, 
 are the only parts of the organ that require cleansing when the 
 ears are in a state of health. Any further manipulations with 
 towels, ear-spoons, and so on, are meddlesome, and may become 
 dangerous to the health of the canal. 
 
 Treatment. An attack of diffuse inflammation of the exter- 
 nal auditory canal (otitis externa diffusd) in an adult may often 
 
 FIG. 43. 
 
 be cut short by the use of leeches. They should be applied as 
 Wilde long ago pointed out, not on the mastoid process, but on 
 the tragus, for the reason which Troltsch gives, that in this 
 place the vessels which supply the canal and outer layer of 
 membrana tympani are most conveniently and surely reached. 
 Leeches in this form of disease are not as certain to afford relief, 
 however, as when used for an inflammation of the middle ear ; 
 when, as we shall see, they exert an almost magical influence, 
 so rapid is their effect. In the early stages of the disease, when 
 the pain is severe, and suppuration has not yet occurred, but the 
 canal is red, swelled, and sensitive, great benefit will be pro- 
 duced by scarifications of the cartilaginous wall. This scarifi- 
 cation is made with a tenotomy knife. The incisions should be 
 from three-fourths to an inch long on the walls of the canal, as 
 recommended by Gruber, of Vienna. Warm water should also 
 be allowed to run into the ear, by means of the fountain syr- 
 inge, the Fayette Taylor douche, Clark's douche, or any similar
 
 AURAL DOUCHE. 
 
 129 
 
 means. When patients are told to apply warm water to the 
 ear, unless they are particularly instructed, they will almost in- 
 variably use the syringe, thinking that is the way in which the 
 water is to be applied ; but what is required is the steady flow 
 of warm water upon the part, and this is best attained by means 
 of the douche. Patients should be instructed in its use, and es- 
 pecially should they be told that, unless the auricle is kept on 
 the stretch, so that the walls of the canal are apart, the water 
 will not enter the ear. I am thus particular in my advice, be- 
 cause, even to this day, I find that many physicians advise that 
 
 warm water be applied to the ear by 
 means of the piston syringe instead of 
 by a douche. As has been seen in the 
 first chapter, Hippocrates advised the 
 use of warm water to the ear for the 
 relief of pain, but it fell into unde- 
 served disuse until the value of its ap- 
 plication was reinforced in the minds 
 of a profession filled with the idea of 
 the virtues of composite "ear-drops." 
 The fountain syringe and Taylor's 
 douche are more convenient than the 
 solid cup making up Clarke's douche, 
 and they have pretty generally super- 
 seded the latter. 
 
 The Fayette aural douche l consists of two 
 siphons, so arranged that the flow starts at the 
 same moment in each ; and while one siphon 
 conveys the water into the ear the other lifts 
 it gently out, without friction or pressure upon 
 the inflamed tissiies. 
 
 In the figure, B C represents the ear-piece, which is made of suitable size and 
 shape. Two holes are bored through it, one lying above the other when it is in 
 its proper position. On each of the two projections at the larger end, a piece 
 of flexible rubber tubing (such as is used for nursing-bottles), about four feet 
 long, is fitted. At the small end of the ear-piece the division between the holes 
 is cut back about one-eighth of an inch, so that placing the finger over this end 
 leaves one continuous passage from the top, A, to the bottom, T). With the 
 finger over the small end of the ear-piece, as just described, when water is 
 poured into the funnel A, it will flow directly through both tubes, and come out 
 at the lower end, D, in the drip-vessel. When all the air has thus been ex- 
 cluded and a current established, the funnel A is dropped into the basin or 
 pitcher which serves as a reservoir, and a single siphon is formed. The rubber 
 tubes are now compressed by the thumb and finger at E, so as to arrest the 
 
 FIG. 43. Fayette Douche. 
 
 1 Archives of Otology, Vol. VIII., p. 355.
 
 130 AURAL DOUCHE. 
 
 flow, the finger is removed from the end BC, and the ear-piece is inserted into 
 the auditory canal ; then letting go the tubes at E, a double siphon is instantly 
 established, AB conveying the water into the ear, and CD carrying it out by 
 atmospheric pressure. Thus the resistance and pressure, often painful, of the 
 in-coming and out-going currents is avoided, and a small amount of constantly 
 changing water, of any desired temperature, is kept in contact with the auditory 
 canal and drum-head. Any amount of water desired can be used in one con- 
 tinuous bath, without the trouble of refilling the reservoir several times, as is 
 so often required in using the fountain syringe. 
 
 Dr. Taylor invented this douche while under my care, and 
 he found it, as have many of my patients since, a pleasanter 
 method of using a warm douche to the ear than the fountain 
 syringe. 
 
 Objections are made by some writers to the continuous use 
 of warm water in inflammations of the canal, but my faith re- 
 mains unshaken in the great value of the warm . or even hot 
 douche in the vast majority of cases of acute inflammation of 
 the canal and tympanum, and I recommend it to the profes- 
 sion in great confidence that only in exceptional cases will 
 they be disappointed with its effects. There are a few patients 
 who never find it pleasant, and some who can bear it only 
 for a time, but most patients, even young children, who at 
 first object to its use, soon find in the warm douche a source of 
 relief from pain in acute inflammation of the canal or middle 
 ear. 
 
 In the absence of the cup, a bit of rubber tubing and an ordi- 
 nary bowl, by the application of the principle of the siphon, will 
 make an efficient and simple 'douche. 
 
 The value of the aural douche is by no means limited to 
 cases of inflammation of the outer portions of the ear. In acute 
 inflammations and chronic suppurations of the middle ear, it 
 becomes a very valuable means of alleviating pain and of 
 cleansing the ear. For the latter purpose it is especially valu- 
 able among children. 
 
 If the use of the leeches, the employment of scarification, 
 and the warm douche do not wholly subdue the pain which 
 is quite unlikely a small flax-seed poultice may be applied in 
 the meatus, over the mastoid, and in front of the auricle ; but 
 the ear should not be covered by a large poultice, as is often 
 done, for reasons that have been already fully given. A poul- 
 tice should never be applied to or on the ear for more than a 
 few hours. They are almost as dangerous a remedy in aural 
 as in ophthalmic practice, where they have caused the loss of 
 many eyes. 
 
 At night the ear should be kept warm by wrapping it in cot-
 
 DIFFUSE INFLAMMATION. 131 
 
 ton, and the patient should lie on a pillow that is warmed from 
 beneath, by means of a rubber bag filled with hot water, or some 
 similar contrivance. A plug of cotton saturated in glycerine or 
 smeared with diachylon ointment, is also of value in subacute 
 cases. By attention to these details much suffering will be 
 spared the patient, and the course of the affection will be short- 
 ened. In addition to the local treatment, it will sometimes be 
 necessary, although not often, to give one of the preparations 
 of morphine, or a dose of chloral internally. I -have not found 
 much advantage from the addition of narcotics to the warm 
 water instillations, although there may be some benefit from 
 their use. 
 
 In severe cases of inflammation of the external ear occur- 
 ring in adults, I have lately, at the suggestion of Dr. W. S. Ely, 
 of Rochester, used at bed-time, to be repeated every two hours, 
 if necessary, a formula, embracing sulphate of morphia, hydrate 
 of chloral, and bromide of sodium in each dose, with the effect of 
 securing sound sleep in cases where other means for the relief of 
 pain did not enable the patient to get but snatches of repose. The 
 wit of the medical attendant will sometimes be taxed to its ut- 
 most in order to secure rest for his patient suffering from acute 
 inflammation of the auditory canal. Indeed, I find it generally 
 easier to secure prompt relief from a pain in the ear, arising 
 from an inflammation of the tympanic cavity arjd mastoid cells 
 than from a diffuse or furuncular inflammation of the canal. 
 Yet, in all the anxiety to relieve pain, the physician may derive 
 much consolation from the knowledge that the patient will ulti- 
 mately recover with perfect hearing, if the auditory canal and 
 drum-head be the only parts seriously involved. 
 
 The popular remedies for ear-ache, dependent upon whatever 
 cause, are usually sweet-oil and laudanum, molasses, Haarlem 
 oil, glycerine, and a roasted onion. The oil, laudanum, and 
 molasses are tolerably efficient ; but although they are useful in 
 their property of stilling pain, they are far inferior to the leeches, 
 scarification, and warm water. I have seen children, who had 
 been suffering from severe pain in the ear, drop off to sleep in a 
 few moments after a tablespoonful of warm water was poured 
 into the ear ; and yet I am very sorry to say that there are some 
 rare cases where warm water seems to aggravate the pain ; the 
 leeches sometimes also fail us in the disease now under discussion. 
 
 The onion acts just as the conical flax-seed poultice, and may 
 be resorted to if the warm water fails, and leeches are not to be 
 had. Haarlem oil, and all similar stimulating applications, do 
 nothing but harm, and increase the sufferings of the distressed 
 patient. The laity resort to such applications, and submit for
 
 132 DIFFUSE INFLAMMATION. 
 
 days to pain in the ear, without going to a physician, because 
 they have been taught by sad experience that doctors pay very 
 little attention to an ear-ache and yet what pain is worse ? 
 Warm vapor of any kind, the vapor of chloroform, the smoke 
 from a cigar, for example, is very grateful to an inflamed audi- 
 tory canal or membrana tympani; and a steam nebulizer be- 
 comes at some times a very useful adjuvant in treatment of 
 acute aural inflammations. Sometimes children, who awake at 
 night with ear-ache, may be quieted by breathing slowly into 
 the auditory canal. 
 
 Some practitioners are in the habit of indiscriminately advis- 
 ing blisters behind the ear in all forms of aural disease, whether 
 acute or chronic. I formerly supposed that they were not of 
 much value except in chronic cases, but I am convinced that 
 harsh as is the remedy apparently, it is sometimes very efficient. 
 The following case is one almost in point, and I do not now 
 hesitate to advise blisters in severe inflammations of the canal 
 as well as those of the middle ear. 
 
 I lately saw a case in consultation with Dr. S. Beach Jones, 
 of acute catarrh of the middle ear, occurring in the course of 
 measles, in a young boy, for which the mother had applied a, 
 blister over each mastoid, and apparently with good effect. In 
 these days of pleasant remedies this seems harsh treatment, but 
 the mother and ^the boy seemed satisfied with what Dr. Jones 
 and I would have hesitated to recommend. I only object to blis- 
 ters because I think better results may be attained with milder 
 means. Their efficacy can hardly be doubted in many cases. 
 Speedy relief from the severe pain of otitis is as imperative as in 
 peritonitis or iritis, and I have dwelt on the various remedies at 
 some length, in order that the practitioner may be at no loss 
 for some agent that will cut short the inflammatory action. I 
 will tabulate the remedies in the order that I consider them 
 valuable: 1. Leeches; 2. Warm douche; 3. Blisters ; 4. Scarifica- 
 tion ; 5. Conical poultice in the canal ; 6. Steam or warm vapor ; 
 7. Narcotics. 
 
 Dr. A. D. Williams recommends the use of a solution of a 
 sulphate of atropia, two to four grains to the ounce, which is 
 dropped into the auditory canal as a remedy for the relief of the 
 pain from aural inflammation. I have found this an uncertain 
 remedy, but in some cases it quiets pain. I think, however, 
 that it is more apt to be of use in the rare cases of neuralgia of 
 the ear cases where there is pain without the usual signs of in- 
 flammation than in external otitis. Knapp ' reports a case of 
 
 1 Archives of Otology, Vol. XI., p. 33.
 
 SYRINGING THE EAR. 
 
 133 
 
 transient poisoning from the instillation of a few drops of atropia 
 in the auditory canal. The patient was a woman of twenty-five, 
 in good health. Four hours and a half after dropping in a half 
 per cent, solution of sulphate of atropia the hands of the patient 
 began to swell and become stiff, the face became scarlet, her 
 throat dry and so forth. The symptoms abated in about five 
 hours. The pain in the ear was relieved and a subsequent in- 
 stillation of a weaker solution had no evil effect. The auditory 
 
 FIG. 44. Syringe for the Ear. 
 
 canal and membrana tympani were free from excoriation and 
 ulcer. We sometimes see this extreme susceptibility to atropia, 
 but it is so rare, that I do not think it is to be regarded if it 
 becomes necessary to use it for the relief of pain. I wish I 
 could say, that it had often proved an efficient agent in my hands 
 for the relief of the pain of otitis. 
 
 Most adult patients go about while suffering from external 
 diffuse otitis. During the more acute stages it would be better 
 
 FIG. 45. Reservoir Syringe. 
 
 to keep them in-doors and in bed. If this can be accomplished, 
 the use of diaphoretics will aid the local treatment. 
 
 If, in spite of our efforts, suppuration is once fairly estab- 
 lished, or if the disease has advanced to this point when first 
 seen by the practitioner, we must endeavor to limit the suppu- 
 ration. To this end thorough cleansing of the ears is necessary. 
 This is best accomplished by syringing a simple procedure, but 
 one which many physicians are unable to carry out efficiently
 
 134 SYRINGING THE EAR. 
 
 and with neatness. The appliances necessary for a thorough 
 syringing of the ear are, first, a good syringe. I think the small 
 piston syringe is the best, and I do not advise the common soft 
 rubber enema syringe called " Davidson's " in this country. 
 The glass syringes are of no use whatever. 
 
 Where patients are likely to need an aural syringe for a 
 long time, it is better to advise them to get one made of brass or 
 German silver. The hard-rubber syringes are carelessly made 
 as a rule. Indeed, the practitioner will find it difficult to secure 
 a good syringe without taking some pains, for even the metal 
 
 FIG. 46. Method of Syringing the Ear. 
 
 ones sold by the instrument manufacturers of New York are often 
 very carelessly made. Luer, of Paris, sells a reservoir syringe, 
 represented in Fig. 45, which is exceedingly useful, especially 
 in hospital practice, where much use of a syringe is required. 
 
 Then we need a bowl a small one, not a large wash-bowl, 
 but one such as is used as a finger-bowl being thin and easily 
 held and a receptacle for the warm water which is to be used 
 in the syringing process. No towels or napkins are needed 
 about the neck, to prevent injury from the water ; no assistant 
 beside the patient is required, if he be an adult, and if the proce-
 
 SYRINGING THE EAR. 135 
 
 dure be carried out as will be described. The patient being 
 seated, holds the bowl well under the auricle, in the hollow just 
 under the lobe, keeping the head perfectly straight, and using 
 both hands to steady the vessel. The surgeon should thoroughly 
 straighten the auditory canal with the left hand, and placing the 
 nozzle of the syringe well into the meatus, direct the stream, 
 with the right, down to the membrana tympani. It is well to 
 prepare the patient for the shock of the water, by allowing a 
 part of the first syringeful to pass into the concha, and not into 
 the canal. 
 
 It will be seen that no patient is capable of thoroughly 
 syringing his own ear, and that no person who has not been 
 taught the simple process will be able to accomplish the object 
 for which syringing is undertaken, that is, the cleansing of the 
 auditory canal and the outer surface of the membrana tympani, 
 and, if it be perforated, the tympanic cavity. Notwithstanding 
 these facts, patients suffering from an ulcerative process in the 
 ear, and who require the daily removal of the pus as* an essen- 
 tial to recovery, are often sent away without other instruction 
 than the advice to syringe the ear. It is almost as difficult for a 
 person to properly syringe his own ear as to cauterize his own 
 palpebral conjunctiva. We certainly should never think of 
 leaving the latter manipulation to any but a person who had 
 been taught to manage it properly. 
 
 The ear affected with chronic external otitis should be 
 syringed from one to three times daily while the secretion is at 
 its height. It should afterward be carefully dried by means of 
 absorbent cotton, upon a cotton-holder. The cotton-holder may 
 be made of wood or metal. If the end be roughened, the cotton 
 may be more easily kept upon it. Neither syringing nor cleans- 
 ing with a cotton-holder need be at all a painful process ; it must 
 be done gently, and this direction applies to all the manipulations 
 upon the ear. A wise patient will prefer to leave his case to 
 nature and to his own care, than to trust his ear to a physician 
 who handles it roughly. As I have before said, in discussing 
 another subject, one of the best means of becoming a gentle and 
 successful aural surgeon is to submit one's self to the use of the 
 Eustachian catheter, the speculum, syringe, and cotton-holder 
 before beginning to practise upon patients. 
 
 The agents which may be used in checking ulceration in the 
 canal are numerous. I perfer solutions of nitrate of silver, of 
 alum, and of the sulphates of zinc and copper, to the others. The 
 nitrate of silver I use in strong solutions, from 20 to 40 grains to 
 the ounce, pencilled over the parts ; the sulphates and the alum 
 in solutions of from 1 to 4 grains to the ounce, instilled into the
 
 136 CHRONIC SUPPURATION OF CANAL. 
 
 ear. The choice of the astringent is, however, much less im- 
 portant than the thorough removal of the pus, which should be 
 done at least three times a week, and, if possible, daily, by the 
 physician himself. The patient or his attendants should use 
 the syringe from once to four times a day, according to circum- 
 stances. 
 
 What may be done for a neglected suppuration of the audi- 
 tory canal, by the mere daily removal of the pus and the appli- 
 cation of a caustic or astringent, however many alteratives 
 and other constitutional remedies may have been taken in vain, 
 is sometimes marvellous. Astringent or absorbent powders are 
 more applicable to diseases of the middle ear than to those of the 
 canal. 
 
 Indeed, careful and thorough cleansing, without the subse- 
 quent use of astringents, will often effect a cure. It is now my 
 habit to delay the use of astringents until I am sure that no prog- 
 ress in a case is being made without them. In some cases I am 
 never compelled to resort to any other treatment. This is some- 
 times overlooked by those who attach much importance to the 
 use of constitutional remedies or internal medication in the 
 treatment of localized suppurations of the ear. A suppuration of 
 the external auditory canal, like the same disease in the middle 
 ear, has a natural course, which often needs mere guidance to 
 lead it to a successful termination. To study this course is more 
 important for the young practitioner than to learn what drugs 
 are said to be of service in certain diseases. 
 
 If the pain be severe and the tension evidently marked, the 
 proper treatment is incision. A narrow knife is a very good 
 one for the operation. The incision should be deep and free. In 
 very delicate and sensitive patients it may be well to put the 
 patient under the primary anaesthetic effect of sulphuric ether 
 before making the cut. This is done by causing the patient 
 to inhale the fumes of the ether in the usual way, holding up 
 the arm while inhaling. When the arm drops, usually in 
 twenty seconds, the incision may be made without causing pain, 
 while not enough ether will have been taken to cause nausea 
 or vomiting or other serious inconvenience. In place of the 
 ether patients may take a dose of brandy or whiskey before sub- 
 mitting to this painful operation. I dare not recommend any 
 other anaesthetic than sulphuric ether, even after hearing all 
 that is said for chloroform, bromide of ethyl, and the rest. 
 
 In the writings of Dr. Buck ' and others, some stress is laid 
 upon what is termed " desquamative inflammation" of the ex- 
 
 1 Diseases of the Ear, p. 86 ; also Medical Record, December 15, 1877.
 
 DESQUAMATIVE INFLAMMATION. 137 
 
 iernal auditory canal. A separate form of diffuse inflammation 
 is made by this method of naming diseases, but I continue to 
 regard the desquamative variety as merely one of the very com- 
 mon stages of diffuse inflammation. A certain amount of des- 
 quamation must occur in any severe inflammation of the integu- 
 ment of the canal. The kind of desquamation described by Buck, 
 I have often observed in cases of aspergillus of the canal, and 
 also after eczema and impacted cerumen. I think bichloride of 
 mercury, gr. ^ to gr. ad aq. f j., and nitrate of silver and pure al- 
 cohol, particularly well adapted for the treatment of these cases. 
 The practitioner should always be on his guard, lest he mis- 
 take a chronic suppuration in the middle ear for one of the 
 auditory canal, with an intact membrana tympani. It will be 
 .seen by the statistics in the chapter on the former disease, that 
 & long-continued suppuration in the ear usually has its origin, 
 not in the canal or outer layer of the drum-head, but in the 
 cavity of the tympanum, whence it advances and perforates the 
 membrana tympani. Chronic suppuration in the external audi- 
 tory canal, contrary to what has often been written, and con- 
 trary to the opinion of most practitioners with whom I have 
 conversed on this subject, is, judging from my experience, a rare 
 disease. When it does exist, it is almost always curable, if prop- 
 erly treated, by the free use of the warm douche, astringents, and 
 leeches, if need be. 
 
 CIRCUMSCRIBED INFLAMMATION, OR FURUNCLES OF THE EXTERNAL 
 
 AUDITORY CANAL. 
 
 By circumscribed inflammation occurring in this part we 
 .simply mean furuncles. They generally arise in connection 
 with the existence of furuncles in other parts of the body, and 
 ^.re, like them, very painful. They also produce impairment of 
 the hearing by mechanically closing the auditory canal. Tinni- 
 tus aurium noise in the ears a symptom which is apt to be very 
 troublesome in almost all other aural affections, is not generally 
 present when furuncular inflammation exists. It may be, how- 
 ever, after the pus from the boil has been evacuated, and some 
 of it, perhaps, remains in the canal and presses upon the mem- 
 brana tympani, and through it upon the ossicula audit us and 
 auditory nerve. The tinnitus is absent in the early stages, be- 
 cause there is no pressure exerted upon the drum-head by a cir- 
 cumscribed swelling of the canal. 
 
 There will be no difficulty in the diagnosis if the ear be ex- 
 amined by means of the otoscope. One or niore circumscribed 
 swellings are found in the calibre of the canal. Their usual
 
 138 FURUNCLES. 
 
 situation is a point near the tragus, on the anterior wall, and 
 we may have two or more at a time. 
 
 The proper treatment is to make an incision at as early a 
 period as possible, and then to continuously apply warm water, 
 giving the ear an uninterrupted warm bath, as it were. It 
 makes no difference whether pus or blood be evacuated by the 
 incision. The relief following is generally immediate in either 
 case. If the pus be deeply situated it will be better to make 
 the incision with a scalpel, cutting downward. If it be near the 
 surface a bistoury may be used, and the cut made from below 
 upward. The ear should be syringed with warm water after the 
 hemorrhage has ceased, and carefully dried with the cotton- 
 holder, or the impairment of hearing and sensations of fulness 
 will be greater than before the opening was made. 
 
 After the furuncle is opened, and the pain caused by it ha& 
 disappeared, it is well to smear the passage with ointment, in 
 order to hasten the softening of the indurated tissue surround- 
 ing the furuncle, but as long as pain continues the use of warm 
 water should be persisted in by means of the aural douche. The 
 thorough cleansing will usually relieve the impairment of hear- 
 ing caused by the swelling and closure of the canal, while the 
 incision and douche will cut short the pain. Each new furuncle 
 is of course to be treated in the same way. Sometimes steam, 
 conducted into the canal from any suitable vessel, is of great 
 comfort to the inflamed part. 
 
 Leeches are not usually of much service in furuncular in- 
 flammations of the canal. Warm water is not always well borne, 
 but in the majority of cases it is of the greatest value in palliat- 
 ing this troublesome affection. In this respect I cannot agree 
 with Politzer, 1 who thinks the warm douche gives rise to fresh 
 eruptions. After all my experience in this painful, although 
 not dangerous affection, I still hold to the knife, warm water, 
 small poultices in the meatus and in front and behind the 
 auricle, and the internal administration of narcotics, as being, 
 on the whole, the best means of treatment. 
 
 Dr. Buck * thinks that we cannot expect the same relief from 
 an incision into the auditory canal as that made in paronychia, 
 because " a comparatively unyielding cylinder of cartilage sur- 
 rounds the inflamed tissues and renders relaxation of the parts 
 almost an impossibility." I think there will be no difficulty in 
 relaxing the tense point, if the incision be made through it. In 
 order to secure this, the surgeon should feel about very care- 
 fully with a probe for the most sensitive part before operating. 
 
 1 Text-book, Cassel's translation, p. 600. z Text-book, p. 71.
 
 FURUNCLES SULPHIDE OF CALCIUM. 139 
 
 If needful, he should make two incisions at different points and 
 be sure to make them deep enough. If the inflammation be not 
 plainly circumscribed, the disease will have passed over the 
 narrow boundary line between this and diffuse inflammation. 
 If incisions are then useful, several must of necessity be made. 
 A plug of glycerine, or diachylon ointment, or a small, finger- 
 shaped, flax-seed poultice is of much service after the incision. 
 
 Buck and Politzer have seen furuncles of the ear occurring 
 in persons otherwise in good health, but, as I have already said, 
 I consider auditory f urunculosis to be an indication of a low state 
 of the system, and I do not think I have ever seen a primary 
 affection of this kind in a thoroughly well person. When such 
 cases come to me, I invariably find a necessity for constitutional 
 treatment. It is not unusual to observe a circumscribed inflam- 
 mation of the canal after a tedious or severe suppuration of the 
 middle ear, or rather while it is in progress, but this I consider 
 an entirely distinct affection from that which is now being dis- 
 cussed. 
 
 Ringer, 1 in an article upon the sulphides, in his work on 
 therapeutics, says that the sulphides appear to him to have the 
 property of preventing and arresting suppuration. He thinks 
 that in an "inflammation threatening to end in suppuration 
 they reduce the inflammation and avert the formation of pus." 
 Based upon Ringer's statements many cases of suppuration of 
 the various parts of the ear have beent reated by Sexton, Bacon," 
 Rupp, 3 and others, and reports of the results made in special 
 and general journals. These writers are loud in their praise of 
 the value of the drug when used to prevent or limit suppuration 
 in the ear. The Therapeutical Society of New York reported 
 on the whole favorably upon the results of the drug in suppura- 
 tions. I have given the sulphide of calcium a fair trial, and I 
 have never seen any benefit whatever from its use. I have also 
 carefully studied the reports of the cases furnished by the vari- 
 ous authorities just quoted, and I fail to find any evidence in 
 them that the favorable results are any different from those oc- 
 curring in similar cases when no drug was used internally. It is 
 the habit of those who use the sulphide of calcium, as will be 
 seen by a study of their cases, to employ all the local means that 
 are used by surgeons in treating suppurations. It is claimed that 
 the use of the knife is avoided by the abortive power of the drug. 
 
 1 A Hand-book of Therapeutics, p. 137. Tenth edition. New York, 1883. 
 * Archives of Otology, Vol. XV., p. 122. 
 
 3 American Journal of Otology, Vol. IV., p. 194. Transactions of the American 
 Otological Society, Vol. III., Part II., p. 181.
 
 140 FURUNCLES CAUSES. 
 
 But all of us see many cases subside without incisions and when 
 no internal medication is employed. Sexton ' says, " In some in- 
 stances I rely entirely on this remedy (calcium sulphide) in the 
 treatment of inflammation in the ear ; but free incisions are in 
 some instances of course not to be omitted." 
 
 The question of the value of internal medication is one noto- 
 riously hard to solve ; but certain it is, however, that calcium 
 sulphide has not yet obtained a firm hold upon the profession as 
 a means of aborting or checking suppuration. I have not been 
 able to satisfy myself that we as yet have any specific for aural 
 inflammations of a suppurative character. 
 
 We shall probably not be done with the case when one fur- 
 uncle has been evacuated, and has healed ; for here, just as in 
 other parts of the body, one boil is apt to follow another in rapid 
 succession. ^ 
 
 I have recently used a menthol solution, as advised by Ger- 
 man writers, but I have not found this to be an abortive, 
 although it is on the whole a good application. If there be, 
 as there perhaps is, a specific bacillus to be found in furun- 
 cles, an agent to kill this would be in order. Yet, I think, 
 there is a soil prepared for it before the germ becomes nox- 
 ious, here as elsewhere. But we should be on the alert for any 
 means of cutting short this obstinately recurring affection. It 
 is well to remember that the old English adage, an ounce of 
 prevention is worth a pound of cure, holds good in medicine as 
 well as in other arts. 
 
 Causes. This brings us to consider the cause of this affec- 
 tion. I do not think I ever saw a furuncular inflammation of 
 the external auditory canal in a patient who was in other respects 
 in a good physiological condition. It seems to be the evidence 
 of a wrong state of the system of some kind. 
 
 Furuncles are very apt to occur in anaemic persons. I have 
 seen several cases where they were troublesome after parturi- 
 tion, during which the system had been much exhausted, and 
 perhaps the patient had not been under the most judicious man- 
 agement as regards the diet. When iron was administered, 
 and nourishing diet substituted for slops, the boils ceased to 
 recur. 
 
 Dr. Lowenburg," of Paris, examined furuncles of the auditory 
 canal, prior to their opening, before the pus formed in them 
 had come into contact with the atmosphere. The pus freshly 
 
 1 American Journal of Otology, Vol. I. 
 
 2 Archives of Otology, Vol. X., p. 220.
 
 LOWENBURG ON FURUNCLES. 141 
 
 obtained was cultivated in beef soup or diluted extract of beef. 
 The coccus of furuncle was abundantly produced by these ex- 
 periments. Lowenburg regards these micro-organisms as the 
 cause of furuncular inflammation. Micrococci suspended in air 
 and water get into the canal, and passing into the glandular 
 structure set up inflammation. 
 
 His exact language is, "I think that every furuncle is an in- 
 vasion of a particular species of microbes, which exist in the air 
 and in water, and which are multiplied under the influence of 
 the decomposition of certain substances. In consequence of some 
 circumstances still unknown, these microzotes (microzoaires) 
 enter a pilo-sebaceous follicle ; they then fructify and excite the 
 characteristic furuncular inflammation." Lowenburg then goes 
 on to show that once having entered the follicle, the micrococci 
 propagate themselves by what he styles "auto-infection." The 
 parasitic origin of furuncles is further substantiated, in Lowen- 
 burg's opinion, by the fact that they chiefly occur in parts ex- 
 posed to the air, the face, the hands, the neck. "The first aural 
 furuncle," he continues, "is found at the entrance of the canal, 
 the succeeding ones affect the deeper parts, and the predilection 
 of furuncle for those who handle rags." 
 
 The contagiousness of furuncle is also insisted upon by this 
 writer, and he records a case where a strong and healthy man 
 suffered from one in the ear after his wife had been affected by 
 one. ' The furuncle in the man was in the left ear, in a corre- 
 sponding situation to one in the right ear of the wife. Lowen- 
 'burg treats furuncle by an incision, under local anaesthesia by 
 the cold spray. The part is then kept moist with solutions of 
 thymic or boric acid. Weber-Liel injects their tissue with a 
 solution of phenic acid. Lowenburg considers that poultices 
 favor the formation of micrococci, and that they should not 
 therefore be used in the treatment of furuncles in the ear. 
 These views of the parasitic origin of furuncles are entitled to 
 great respect in the present condition of the mind of the pro- 
 fession, in regard to the parasitic origin of disease, yet I cannot 
 regard it as yet settled that micrococci are not consequences 
 rather than causes of the diseases thought to be produced by 
 them. Certain it is, that 'there must be in the general system 
 some preparation for the invasion of these dangerous micro- 
 organisms, or in the frequency of furuncle, contagion would be 
 much more common. If furuncles be contagious, common ex- 
 perience shows that they are only so to a limited degree. I have 
 never observed that they passed through families. Lowenburg's 
 one case seems to me slender evidence upon which to base such 
 a theory. Then as regards the value of thymic and boric acid
 
 142 LOWENBURG ON FURUNCLES. 
 
 as antiseptics, I am, from experience in their use, and from the 
 results of recent experiments, extremely skeptical. I believe 
 that water is quite as efficacious as many of the so-called anti- 
 septics. When a question such as the great one of the septic 
 origin of disease is being discussed, I believe that the great 
 truth that must be somewhere in this subject will be the sooner 
 brought out the more frank and critical are the analyses of the 
 theories and experiments that are being constantly -set forth. 1 
 
 1 Congres Periodique international d'otologie. 2 e Session. Milan, 1880 ; Trieste, 
 Imprimerie G. Caprin, 1882.
 
 CHAPTER VI. 
 
 PAEASITIC INFLAMMATION OF THE EXTERNAL AUDITORY CANAL 
 SYPHILITIC ULCERS AND CONDYLOMATA CONTRACTIONS- 
 DIPHTHERIA SARCOMA CARIES. 
 
 History of the Discovery of the Growth of Aspergillus in the External Auditory Canal. 
 Varieties of Vegetable Fungi found in the Ear. Cases. Syphilitic Ulcers and 
 Condylomata. Narrowing and Closure of the Canal. Diphtheritic Inflamma- 
 tion. Sarcoma. Caries of the Canal. 
 
 IT is more than twenty years since the profession became generally 
 aware of the fact that vegetable fungi were germinated m the 
 auditory canal, and that they caused or aggravated inflamma- 
 tions of this part and of the surface of the membrana tympani. 
 By the publications of Professor Schwartze, of Halle, Dr. Wre- 
 den, of St. Petersburg, and many others whose names will be 
 quoted in this chapter, this fact has now become well known, 
 and has enabled us to more clearly understand and more suc- 
 cessfully treat certain cases of otitis externa. 
 
 The history of the growth of the aspergillus fungus, as well 
 as that of the other vegetable parasites that have been found in 
 the ear, is interesting and important, and a full account of it 
 will, I am sure, be welcomed by the reader. 
 
 In 1867, Schwartze 1 reported a case of inflammation of the 
 auditory canal, in which the aspergillus fungus was found. 
 Professor J. Vogel made the microscopic examination that set- 
 tled the fact, and he called Schwartze's attention to two cases 
 which had been previously reported ; one by Mayer, in Muller's 
 Archiv, p. 401, 1844, and one by Pacini, quoted by Kuchen- 
 meister, in his work on " Parasites," published in Leipzig in 
 1855. In both these cases the fungus was a species of asper- 
 gillus. 
 
 Mayer's case was peculiar. The fungus occurred in the ear 
 of a child, having what he called scrofulous otorrhoea, and the 
 parasite was contained in round and oval cysts, of the size of a 
 cherry-pit. The walls of the cysts were fibrous, filamentous. 
 
 1 Archiv fur Ohrenheilkunde, Bd. II., p. 7.
 
 144 PARASITIC ' INFLAMMATION. 
 
 white in color externally, while within they were hollow, green- 
 ish, and granular. 
 
 Pacini's case was like those that have since been observed : 
 
 A boy of fourteen years came from a sea-bath, and complained that water 
 remained in his ear. Itching and painful sensations ensued, and at last nearly 
 complete deafness. In the auditory canal small transparent vesicles were seen. 
 Two weeks after a whitish membrane was found on the walls. It was removed 
 by syringing with warm water ; but it soon returned. The microscopic exami- 
 nation revealed the presence of a fungus. The parasite was removed by the 
 injection of a solution of acetate of lead, of the strength of two grains to the 
 ounce of water. 
 
 Dr. Robert Wreden ' reported six cases of the growth of the 
 aspergillus fungus the year after Schwartze's case was pub- 
 lished. He gave the name of myringomykosis to the disease 
 caused by the fungus. He subsequently added eight to these, 
 and published the whole, with a very complete account of the 
 appearance of the fungus, in a monograph. 3 
 
 Soon after the publication of Schwartze's and Wreden's cases 
 others were reported by Orne Green,* of Boston, 0. J. Blake, 
 Knapp, and by myself 4 and others. Indeed, the occurrence of 
 such a fungus in an inflamed ear is now a well-recognized fact, 
 for which we are indebted to Schwartze. 
 
 The literature of vegetable fungus in the human ear has be- 
 come very large since the publication of the cases of Schwartze, 
 Wreden, and of the observers immediately after them, but in 
 very few directions has it increased the knowledge given us by 
 Wreden's first brochure. 
 
 Wreden 8 and Swan M. Burnett, 8 however, have lately reported cases which 
 furnish pretty strong evidence that the fungus known as otomyces purpureus 
 may be found in the auditory canal without being a part of the aspergillus nigri- 
 cans, or, as Wreden had thought, the highest form (most developed) of the spe- 
 cific aural fungus. In other words, a distinct variety of vegetable fungus has 
 been found in the ear. In Burnett's case a mixture of tincture of opium, sweet 
 oil, and glycerine had been poured into the auditory canal to relieve the symp- 
 toms of what was called psoriasis. The ear became painful after this, and on 
 examination Dr. Burnett found a plug of dark-red, quite consistent material. 
 An examination with the microscope showed this to be a fungoid growth. In 
 Wreden's case evidences that the growth was one of the highest forms of devel- 
 
 1 Archiv fur Ohrenheilknnde, Bd. III., p. 1. 
 
 1 Die Myringomykosis aspergillina. St. Petersburg. 
 
 3 Transactions of the American Otological Society, 1869. 
 
 4 American Journal of the Medical Sciences, January, 1870. 
 
 6 Wreden: Archives of Ophthalmology and Otology, Vol. IV., No. 1. 
 Archives of Otology, Vol. X., p. 319.
 
 CAUSES OF PAEASITIC INFLAMMATION. 145 
 
 opment of aspergillus nigricans were found, but not so in Burnett's. He found 
 in his specimens at no stage of their growth nothing but otomyces purpureus. 
 Professor Faiiow, of Harvard University, thought the specimen was probably 
 not a variety of aspergillus, as Wreden supposed, in regard to his case. 
 
 Causes. In order that we may correctly understand the na- 
 ture of parasitic otitis, it should be remembered that it is not a 
 primary disease, but a consequence of a diffuse otitis, which 
 may have been of such a mild character as scarcely to have at- 
 tracted the attention of a patient, especially if it occur in one 
 who is taught to believe, as most patients are, that an aural dis- 
 ease will "wear away" of itself, or, at any rate, that medical 
 assistance will be of no avail for it. 
 
 The disease, that is the formation and development of a vege- 
 table fungous growth, may result from an eczema, or, as in Bur- 
 nett's case, just quoted, from a psoriasis, or probably from any 
 form of inflammation of the canal, especially if oils have been 
 dropped into it. I have not yet seen a case of otitis parasitica 
 in which I thought there was any evidence to show that the ear 
 was sound just before the growth occurred. The soil must first 
 be prepared by a loosening of the epidermis before the fungus 
 will grow. 
 
 The origin of the disease may generally be traced back to an 
 inflammatory affection of the canal, one that has softened the 
 tissues. Added to this, oils, generally the common sweet oil, 
 have been used to combat the inflammation. Given these two 
 factors, the inflammatory basis and the oils, and the propagation 
 of the aspergillus fungus may be pretty accurately predicted. 
 One of the best reasons against the use of oils in the canal is 
 their liability to cause the growth of a fungus. 
 
 The fungus is actually a mould, such as clings to damp walls 
 and adheres to bread that is not kept thoroughly dry. As we 
 should expect, the habits of the Russians, living as they are 
 almost compelled to, in badly ventilated rooms during the long 
 winter, are very favorable to the production of aspergillus. 
 
 There is hardly a doubt that these cases of vegetable fungous 
 growths in the ear were formerly mistaken for impacted ceru- 
 men or eczema, and otitis externa diff usa. Since my attention 
 has been called to the subject, I recall two cases of very obstinate 
 inflammation of the auditory canal, which I now believe were 
 cases of the growth of vegetable parasites in the part. It is an 
 interesting fact, that they both recovered from the affection 
 without any use of the specific parasiticides. 
 
 The wax is thought by C. H. Burnett to be a protection against 
 aspergillus, but I regard it rather as an incident in the formation 
 
 10
 
 146 PARASITIC INFLAMMATION. 
 
 of the fungus, for I think it is pretty well established that ceru- 
 men never becomes hardened or impacted in a healthy auditory 
 canal. 
 
 It is not very uncommon to find a growth of aspergillus at 
 the bottom and on the sides of an auditory canal that was 
 packed with cerumen. The disease is apparently much more 
 rare in England than in this country, for an aural surgeon in 
 large practice in London had not even seen a specimen of asper- 
 gillus that had been found in an ear until I sent him a slide 
 containing one, taken from one of my cases. 
 
 Symptoms. The subjective symptoms of the growth of a 
 vegetable fungus in the ear are very similar to those from in- 
 spissated cerumen. There is a sensation of fulness in the ear, 
 with tinnitus aurium, vertigo, impairment of hearing, and pain. 
 
 As is well known, pain is not a common symptom of inspis- 
 sated cerumen, although it does occur. Pain is, however, usu- 
 ally one of the symptoms of otitis parasitica. It is not usually, 
 however, the severe pain of a furuncle, or of acute catarrh of 
 the middle ear, but it is a dull, heavy sensation in the ear. 
 
 The objective symptoms consist in the adherence to the walls 
 of the canal and to the outer surface of the membrana tympani 
 of whitish, or blackish, or even reddish flakes, that may be read- 
 ily mistaken for simple epidermis or hard wax. Sometimes these 
 flakes or casts block up the whole passage. They cannot be re- 
 moved by a syringe ; but the angular forceps, which should only 
 be used under a good illumination by means of the otoscope, are 
 required to detach them. When the casts are removed the tissue 
 beneath is found to be reddened and tender, and in a very few 
 hours the growth will be found to be reproduced. 
 
 The microscope must be called in to make the diagnosis cer- 
 tain. The appearance of the growth, as seen by the aid of this 
 instrument, will soon be detailed. The practitioner who has once 
 carefully observed the objective and macroscopic evidences of a 
 vegetable fungus, will, however, not be apt to fail to recognize 
 it in a subsequent case without a microscope. 
 
 The varieties of vegetable parasites that may be found in the 
 ear, and which there cause or increase inflammation, are 
 
 C flavus, III. Graphium pencilloides. 
 
 I. Aspergillus < glaucus, IV. Trichothecium roseum. 
 
 ( nigricans. V. Otomyces purpureus. 
 II. Penicillium glaucum. 
 
 The aspergillus fungus, which, in one of its varieties, is the 
 parasite most commonly found in the ear, seems to have a pecu-
 
 ASPEKGILLTJS. 147 
 
 liar affinity for a diseased auditory canal and membrana tym- 
 pani, and to be found almost exclusively on this part of the body. 
 Dr. William H. Draper, of this city, has, however, observed one 
 case of the growth of the aspergillus fungus on the inner side of 
 the thigh, and it afterward appeared in the auditory canal. 
 Wreden was not able to find any penicillium fungus in his cases, 
 but Blake ' reports a case in which, on the second attack of otitis 
 parasitica, specimens of bastard penicillium were found. 
 
 Dr. Hassenstein, 3 of Gotha, has observed one case in which a 
 patient suffering from the usual symptoms of aural catarrh was 
 found to have a yellowish-green secretion upon the membrana 
 tympani. This secretion continued for some ten days, in spite 
 of treatment, and there was considerable redness, swelling, and 
 pain in the auditory canal and drum-head. 
 
 FIG. 47. Aspergillus Nigricans (220 diameters), a, Mycelium fibre ; 6, fruit-bearing 
 fibre ; c, naked sporangium ; d, sporangium covered with basidia only ; e, more mature spo- 
 rangium ; i, spores in a state of germination. 
 
 This secretion was found to contain three varieties of vege- 
 table fungi, as an examination by Professor Hallier, of Jena, 
 showed : 1. Aspergillus glaucus. 2. Stemphylium, which was 
 very like stemphylium polomorphum belonging to the asper- 
 gillus. 3. Graphium pencilloides. Dr. Hallier was unable to say 
 whether the second variety sprang directly from the aspergillus 
 or not. The graphium pencilloides, of which an accurate botan- 
 ical description is given in the article from which I am quoting, 
 occurs in nature on wood, especially on elder-wood. 
 
 1 Transactions of the American Otological Society, fourth year, 1871. 
 
 2 Archiv fur Ohrenheilkunde, Bd. IV., p. 164.
 
 148 PARASITIC INFLAMMATION. 
 
 Dr. F. Steudener, 1 of Halle, describes another form of fungus 
 which occurs in the ear, Trichothecium roseum. The evidence 
 on this point is not quite conclusive, however, for Professor de 
 Barry, to whom Dr. S. showed the specimen, said it resembled 
 this fungus, although it could not be thoroughly examined, the 
 specimen having been injured. Dr. Steudener then cultivated 
 the actual trichothecium fungus upon some epidermis, and in- 
 asmuch as the spores and mycelium resembled those in the 
 fungus removed from the ear, he thought himself justified in 
 assuming that the latter were actually those of the trichothecium 
 roseum. The evidence is therefore not quite positive as to the 
 nature of the fungus. 
 
 The different varieties of the aspergillus fungus are by far the 
 most common kinds of vegetable parasites that have been found 
 in the ear, although, now that attention has been turned to this 
 subject, others have been found. ^ 
 
 FIG. 48. Aspergillus Flavescens (220 diameters), a, Mycelium fibre; &, fruit-bearing fibre; 
 c, sporangium-bearing spores upon the basidia ; g, basidia, showing constriction preparatory 
 to the separation of spores ; k, epithelium. 
 
 The first two of the accompanying drawings of the aspergillus 
 were made by my friend, the late Dr. William B. Lewis,* for an 
 article by myself upon the subject, from specimens of cases 
 occurring in my practice. The third engraving (Fig. 48) repre- 
 sents another specimen from the same source, which was drawn 
 by Dr. Charles S. Bull. Dr. Lewis describes the fungus as of 
 three essential parts : 
 
 First, the mycelium, a dense network or pseudo-membrane of 
 delicate fibres, which form the groundwork or roots, as it were, 
 from which the second part, or fructifying portion (fertile 
 hyphen), arises perpendicularly ; and third, the free spores, which 
 lie thickly strewn upon and in the mycelium. 
 
 1 Archiv fur Ohrenheilkunde, Bd. V., p. 163. 
 
 2 American Journal of the Medical Sciences, Vol. LIX., 1870, p. 105.
 
 ASPERGILLTJS. 
 
 149 
 
 The physiological relation of the fruitful fibres to the mycelium is not shown 
 in the accompanying cuts, but may be at once made clear by examining a portion 
 of common mould with low power. 
 
 The fibres of the pseudo-membrane are unfruitful, branched, straight, or 
 curved, and frequently somewhat swollen at the joints. In the broader fibres 
 transverse cell-walls are distinguished, and all, broad and narrow, contain faintly 
 granular plasma. The breadth of the mycelium fibres was from 0.00015 to 0.0002 
 of an inch (0.0038 to 0.005 of a millimetre). 
 
 PIG. 49. Specimefc of the Spores and fully developed Growth of the Aspergillus Flavescens. 
 
 (Case III.) 
 
 In the fruit-bearing portion are found the changes in form which establish 
 the varieties. It consists of a filament, which, especially in the aspergillus 
 nigricans, is stouter than those of the mycelium, bearing upon its summit an 
 enlargement, the receptacle or sporangium. 
 
 Those who are interested in a fuller botanical description of the fungus will 
 find it in the journal from which I have quoted, as given by Dr. Lewis, in an 
 article furnished by Dr. L. and myself, and in Wreden's monograph.
 
 150 
 
 PENICILLIUM OTOMYCES PURPUREUS. 
 
 FIG. 50. Penicillium (after 
 Blake). 
 
 In Dr. Blake's case, which has been alluded to, a portion of 
 the specimen was planted upon lemon-peel, placed in a closed 
 glass vessel, at a constant temperature of 80 F., when it gave, 
 at the end of the third day, a well-developed growth of the Lep- 
 tothrix form of Penicillium. 
 
 The specimen represented in the accompanying wood-cut 
 exhibited a mycelium and fully devel- 
 oped sporangia (a). The spores, of 
 which a collection is represented at 6, 
 were of a brown color and oval outline, 
 of about the same size as the spores of 
 Aspergillus nigricans. Under a mag- 
 nifying power of 300, some of these 
 spores showed a double outline. Min- 
 gled with this growth there was a close network of very fine 
 mycelium. 
 
 Treatment. The treatment of otitis parasitica is exceed- 
 ingly simple, but it is often very tedious, and the practitioner 
 must not expect that all the 
 aural "symptoms will be re- 
 lieved when the vegetable fun- 
 gus has ceased to appear. We 
 may only expect to relieve the 
 most troublesome symptoms, 
 pain, vertigo, and impairment 
 of hearing, by the destruction 
 of the parasite. The inflam- 
 mation will continue, in some 
 cases, long after the micro- 
 scope has failed to find any 
 traces of aspergillus in the 
 auditory canal. 
 
 But the loosened epidermis 
 and the flakes of mould should 
 be carefully removed every 
 day by means of the forceps 
 and syringe, the ear being well illuminated while the former is 
 used, and the canal frequently douched with warm water by 
 means of the fountain syringe or the Fayette douche. I am in 
 the habit of pencilling the canal with nitrate of silver in strong 
 solutions, after the cleansing process is over, for the purpose 
 of destroying the fungus, and subduing the inflammation of the 
 integument. At the same time, I treat any affection of the 
 middle ear, that may co-exist with that of the canal, by the ap- 
 propriate means. 
 
 PIG. 51. Otomyces Purpureus (S. M. Bur- 
 nett), a, a, a, a, Younger asci ; b, b, b, mature 
 asci ; c, free spores ; d, mycelium.
 
 PARASITIC INFLAMMATION. 151 
 
 Dr. Wreden gives a long list of agents which he believes to 
 be useful as parasiticides. He mentions, among others, alcohol, 
 bichloride of mercury, acetate of lead, tincture of iodine, and 
 carbolic acid. He prefers the hypochlorate of lime, which he 
 recommends to be used in the strength of one to two grains to 
 the ounce of water. The salt must be freshly dissolved in water 
 at each application. Fowler's solution ranks next to the lime 
 as a parasiticide, according to Wreden. Solutions of tannic 
 acid, gr. x. ad. j., are used by some authorities. 
 
 Drs. Orne Green, of Boston, and Knapp, of this city, concur 
 with me in believing that a thorough use of warm water is -the 
 only parasiticide generally necessary. 
 
 The bichloride of mercury in solution, gr. j. ad. f j., and pure 
 alcohol are certainly efficient in the destruction of the fungus. 
 Either may be dropped into the ear ; alcohol causes some burn- 
 ing, but the pain is not usually severe, nor does it last long. 
 
 According to Siebenmann, 1 Kramer described a specimen of 
 aspergillus niger with great accuracy in 1859. He does not give 
 the reference to Kramer's writings, and I have not been able to 
 find it. Kramer found the fungus in the form of a white mem- 
 brane upon the membrana tympani. Its inner surface was cov- 
 ered by black specks supported by pedicles. The membrane was 
 the mycelium, the black points the condiophores. Kramer cured 
 his case after many relapses by the use of acetate of lead. 
 
 In the treatment of parasitic otitis it is wise to observe all the 
 antiseptic precautions suggested by Lowenburg : 1. Do not use 
 oils or fats. 2. Use alcoholic solutions, or solutions containing 
 as little alcohol as possible. 3. Dilute these solutions with boil- 
 ing water before using them. 4. Heat all instruments that is, 
 wash them in boiling water used in treating aspergillus. a 
 
 The following cases will furnish a commentary on what has 
 been said, and perhaps illustrate the nature of the affection 
 better than any more extended remarks. The. first two have 
 already been published, 3 but the third has never before been 
 printed. 
 
 CASES OF ASPERGILLUS. 
 
 CASE I. I was consulted, June 30, 1869, by J. F. B , a gentleman set. 24, 
 
 in regard to pain and impairment of hearing in the left ear. He stated that 
 about a year before he had experienced a sense of fulness in the ear, as if it 
 were " stopped up," and that, at the same time, there was considerable tinnitus 
 aurium. He consulted a physician, who diagnosticated inspissated cerumen, 
 
 1 Archives of Otology, Vol. XV., p. 189. 
 
 *Loc. cit., p. 196. 
 
 3 American Journal of the Medical Sciences, loc. cit.
 
 152 ASPERGILLUS CASES. 
 
 and removed a large quantity of what seemed to be ear-wax from the canal. 
 The relief afforded was of short duration, for the ear soon filled up. From that 
 time to the present the patient has been in the habit of syringing the ear, and 
 at times masses of some foreign substance were removed by this process. Of 
 late he has noticed black particles strewn in the substance removed, which he 
 thinks are due to the entrance of dust from the smoke-pipe of a steamer during 
 a recent voyage from Europe. The patient now experiences very considerable 
 pain in the ear, and it is the occurrence of this new symptom which has led him 
 to consult me. The other symptoms the sensation of fulness, tinnitus aurium, 
 and impaired hearing, continue. Patient's general health is good, though he is 
 very subject to naso-pharyngeal catarrh. 
 
 On examination, a watch which is usually heard at least thirty inches from 
 the auricle is only heard one and a half inch, and the auditory canal is filled 
 with a lardaceous mass, punctated by minute black spots. This mass was very 
 adherent to the walls of the canal, and could not be thoroughly removed by 
 syringing, but required the use of the angular forceps, under a good illumination 
 by means of Troltsch's otoscope and ordinary daylight. The surface beneath 
 this mass, which peeled off from the canal, was red and very sensitive. After 
 the removal of the foreign substance, a minute perforation of the membrana 
 tympani was found situated in the anterior and inferior quadrant. There was no 
 true suppuration, but mucus alone bubbled out from the opening during the in- 
 flation of the Eustachian tube. The Eustachian tube was shown to be perme- 
 able by Politzer's method, but there was very little sensation experienced in the 
 ear when the air was forced in. 
 
 On the removal of the collection, the patient experienced immediate relief 
 from the pain and tinnitus aurium, but the hearing was not very much improved. 
 The diagnosis catarrh of the middle ear was made, while an exact definition of the 
 state of things in the canal was delayed. Portions of the lardaceous, flaky sub- 
 stance removed from the canal were placed in glycerine. 
 
 He was ordered to'use injections of wai*m water, by means of Clark's aural 
 douche, several times daily, and to drop in a solution of zinc, sulph., gr. ij. ad. 
 aqua 5j-> twice a day. The Eustachian catheter was used, and air injected 
 through it into the cavity of the tympanum. 
 
 It was some days before the entire collection was fully removed, and in spots 
 where it had been separated and taken out it was renewed very rapidly, and 
 each time reproduced- the symptoms of pain and fulness. A weak solution of 
 carbolic acid was then used ; but it caused very great irritation, and inflamma- 
 tion was set up, which lasted many days. This was treated by the use of warm 
 water, through the douche. "When it had subsided, the. lardaceous masses were 
 removed by the forceps, and in some instances casts of the membrana tympani 
 came away, although the walls of the canal showed the most disposition to a re- 
 production of the growth. 
 
 July 27th, the opening in the membrana tympani had healed, and the hearing 
 so much improved that the watch was heard six inches, and the symptoms com- 
 pletely relieved. There was still a slight tendency to the growth of the fungus, 
 as it proved to be, on the posterior wall of the canal. The membrana tympani 
 was lustreless and rigid, the handle of the malleus distinct, but there was no 
 light spot. From the 1st of August I did not again see my patient until October 
 18th. Meanwhile he had used the aural douche daily, and the growth had not 
 returned ; but the catarrhal inflammation of the middle ear had not been materi-
 
 ASPERGILLUS CASES. 153 
 
 ally benefited, as shown by the rigidity of the membrana tympani and the inv 
 pairment of hearing. The membrane is now (November 19th) somewhat translu- 
 cent, and the patient is being treated, with benefit, by means of the injection of 
 air, the use of a gargle, etc., for the middle-ear affection. 
 
 The flakes, preserved in glycerine, were examined by my friend Dr. 0. E. 
 Hackley and myself under the microscope, and Dr. Hackley believed them to 
 exhibit specimens of Aspergillus nigricans. At a later date Dr. Wm. B. Lewis 
 very kindly made a thorough examination, and confirmed Dr. Hackley's opinion. 
 In this case it is clearly evident that the growth of the fungus was secondary 
 to the inflammation of the middle ear, for the patient never fully recovered his 
 hearing power. 
 
 CASE II. September 28, 1869, I was consulted by Mr. S , set. 51, on ac- 
 count of impaired hearing, vertigo, pain in the ears, and tinnitus aurium. Ver- 
 tigo was the symptom upon which the patient laid the most stress, and of which 
 he was most anxious to be relieved. He said that he was so dizzy whenever he 
 attempted to walk about, as to be unable to attend to his ordinary business. 
 His condition in other respects was excellent. The patient also stated he had 
 heard perfectly well until two months since, when he was attacked with the 
 aural symptoms narrated above, which had been aggravated since their incep- 
 tion. He had been treated by the instillation of oils, and so on. He could hear 
 my watch about one inch on the right side, and not at all on the other. Both 
 auditory canals were found filled with a tenacious material, which could only 
 be removed by the forceps. It was several days before I could completely re- 
 move the firmly adherent coating of the canal and membrana tympani. 
 
 The morbid product was immediately examined by Dr. Lewis, and found to 
 be a specimen of the Aspergillus flavescens. Its removal gave the patient great 
 relief ; but on the reappearance of the growth, which was in two or three days 
 after its thorough removal, the vertigo and tinnitus returned. The membrana 
 tympani was intact, but lustreless and rigid. The Eustachian tubes opened 
 sluggishly, and there was all the evidence of aural catarrh, besides the affection 
 of the canal and of the outer layer of the membrane of the tympanum. The 
 free use of warm water, with an astringent, finally subdued the morbid process 
 in the canal, so that the patient was able to make a journey to the South. When 
 he left my care, October 18th, the auditory canals were entirely free from ab- 
 normal secretion, the hearing was improved, so that the watch was heard from 
 five to six inches on the right side, and from one to two on the left. The dizzi- 
 ness was entirely gone, and the tinnitus ceased to be annoying. The catarrh of 
 the middle ear, as shown by rigidity of the membrana tympani, sluggish action 
 of the tubes, and impairment of hearing, still continued. I saw this patient 
 about a year afterward, and he was entirely well, his ears having returned to a 
 normal condition. 
 
 CASE III. Lt. L . fet. 30, U. S. N. December 2, 1872. Since a child, 
 
 has been more or less deaf in right ear, owing to a series of abscesses. This 
 impairment of hearing was increased by his service near the frequent explosion 
 of cannon. About a year ago he had an abscess in left ear (probably in audi- 
 tory canal), with considerable purulent discharge having an offensive odor. For 
 about two weeks he has had a series of abscesses in the left ear, with consider- 
 able discharge of black material.
 
 154 ASPERGILLUS SYPHILITIC ULCERS. 
 
 Hearing distance, B. -&-, L. &. 
 
 The tuning-fork was heard more distinctly in the right ear when the handle 
 was placed on the forehead or teeth. The pharynx is granular. 
 
 The right membrana tympani is very much sunken and is opaque. 
 
 The auditory canal of that side contains numerous scales of epidermis strewn 
 with black spots. 
 
 The left canal is full of pus, and the membrana tympani is perforated. 
 
 The microscopic examination showed the presence of the aspergillus nigri- 
 cans in both auditory canals. 
 
 The patient's general condition was excellent, except, as is the case with 
 most aural patients, he was somewhat despondent on account of the loss of 
 hearing. 
 
 The diagnosis of chronic suppurative inflammation of the middle ear, with 
 aspergillus growth, was made as regards the left ear. In the right, there was 
 chronic non-suppurative inflammation with the same fungus growth in the audi- 
 tory canal. 
 
 The patient was seen nearly every day until December 24th, and treated by 
 the use of leeches, the syringe and warm water, with the subsequent applica- 
 tion of nitrate of silver, gr. xl. ad. j., brushed over the canal and drum-head. 
 The patient also caused his ears to be syringed at home, and instilled a solution 
 of sulphate of zinc, two grains to the ounce, inio the ears. The Eustachian 
 catheter and Politzer's method were used to force air into the middle ears, and 
 the patient used a gargle of chlorate of potash. 
 
 The aspergillus fungus disappeared in a few days, but the affection of the 
 middle ear and canal lasted much longer. 
 
 On the 24th of December, however, just twenty-two days after he came un- 
 der treatment, Lt. L was discharged, with hearing distance for wateh, 
 
 Q I -I O 
 
 B. jjjT, Ij'-jTv At sixteen feet distant he could hear and carry on a conversa- 
 
 ^O 4O , 
 
 tion in the ordinary tone, with his face away from the speaker. The left canal 
 still continued to swell, and the epidermis to scale off. The patient had eczema 
 of the scalp and auricle. Some weeks after he was said to be still improving. 
 
 Cases of the formation of vegetable fungi in inflamed audi- 
 tory canals are now matters of such every-day occurrence, 
 among those that see much of aural disease, that they are not 
 cases of great interest. Nevertheless they are of considerable 
 importance. Their origin should be understood and their occur- 
 rence not overlooked. 
 
 SYPHILITIC ULCERS. CONDYLOMATA. 
 
 In the course of secondary syphilis ulcers and condylomata 
 may occur in the auditory canal, just as syphilitic eruptions may 
 occur on the auricle and on other parts of the general integu- 
 ment. They are, however, somewhat rare. The manifestations 
 of syphilis in other parts of the body, with the characteristic ap- 
 pearance, and the absence of itching sensations, will usually
 
 NARROWING OF CANAL DIPHTHERITIC INFLAMMATION. 155 
 
 make the diagnosis quite clear. While it is true, as Schwartze 
 intimates, 1 that it is sometimes difficult to decide whether a given 
 case of granulations in the auditory canal depends upon a syphi- 
 litic dyscrasia or not, since the anatomical constitution of the 
 tumors are the same whether syphilitic or not, yet this is not 
 usually the case. There is no more difficulty in making a diag- 
 nosis here, than in determining whether a case of iritis is or is 
 not caused by the poison of syphilis. Of course it is important to 
 decide as to the existence of syphilis in a person suffering from 
 ulcers or granulations of the auditory canal, for if syphilis be 
 not present, local treatment will often be all that is required. If, 
 however, the ulcers be the manifestations of the venereal poison, 
 or be modified by it, the use of mercury and iodide of potassium 
 will be essential. 
 
 NARROWING AND CLOSURE OF THE CANAL. 
 
 Of congenital closure of the auditory canal in connection 
 with absence or deformity of the auricle, I have already spoken. 
 There remains to be mentioned, -however, a narrowing, or even 
 closure of this passage, which sometimes occurs as a result of a 
 neglected inflammation usually if not always of an ulcerative 
 character. It will perhaps be better to discuss the whole subject 
 of contractions of the canal under the head of bony growths, 
 exostosis and hyperostosis, these being usually the result of in- 
 flammatory action. I will therefore refer the reader to the 
 chapter upon the results of chronic suppuration for a considera- 
 tion of the subject of closure of the canal as a result of inflam- 
 mation. 
 
 DIPHTHERITIC INFLAMMATION. 
 
 That diphtheria of the middle ear may and does occur, has 
 been shown by numerous observers. I have seen it in one case 
 where no antecedent inflammation of the middle ear existed. A 
 suppurative inflammation of this part may readily take on a 
 diphtheritic form in case the patient be attacked with the consti- 
 tutional disease. I have never seen diphtheria of the canal, but, 
 as we should imagine, it is sometimes developed on the excori- 
 ated parts of an auditory canal already suffering from simple 
 inflammation during an epidemic of diphtheria. 
 
 1 Archiv far Ohrenheilkunde, B. IV., p. 263.
 
 156 SARCOMA CAEIES. 
 
 SARCOMA OF THE CANAL. 
 
 I have seen one case of tumor in the canal, which was said 
 TJV a competent microscopist, Dr. Welch, to be a round-celled 
 sarcoma. The case is elsewhere reported in full by Dr. Buck, 1 
 who sent it to me for consultation. The patient was a girl of 
 fourteen. The first intimation that she had of trouble was a ful- 
 ness and pain in the part. The canal was found to be filled up 
 near the meatus by a firm fleshy mass. It sprung by a broad 
 base from the upper and posterior wall of the bony part of the 
 canal. The child was healthy in all other respects. Besides the 
 marks of sarcoma Dr. Welch found osseous tissue in the centre 
 ''with wide medullary spaces in which the tissue is rich in cells 
 and fibrillated." Dr. Welch pronounced the tumor to be osteo- 
 sarcoma, taking its origin most probably from the periosteum. 
 Dr. Delafield confirmed Dr. Welch's opinion, and he added if the 
 bone be not involved and the tumor can be completely removed, 
 the prognosis is not very bad. Dr. Buck, Dr. Weir, and myself 
 agreed that the tumor should be completely removed, which was 
 done by Dr. Buck, under ether, by means of knives and a sharp- 
 dged steel scoop. A zone of skin, apparently healthy, surround- 
 ing the entire base was also removed. The growth sprung from 
 the periosteum. The exposed bone was scraped and a solution 
 of chloride of zinc, forty grains to the ounce of water was 
 painted over the exposed surface. The patient, who was of 
 strong and healthy parents, did perfectly well, and remains well 
 four years after the operation. Dr. Buck, in closing his account 
 of this remarkable case, states that the maternal grandmother 
 died of some uterine disease which may have been cancerous in 
 its nature, and that a grand-aunt and two second cousins suf- 
 fered from cancer. 
 
 CARIES OF THE AUDITORY CANAL. 
 
 Death of the bony wall of the auditory canal with no disease 
 of the tympanic cavity, is not a common affection, but it may oc- 
 cur. I have under my care, while writing this, a gentleman of 
 more than eighty years of age, who, while not suffering from 
 any other form of aur"al disease, has an affection of this kind. 
 Just at the junction of the osseous with the cartilaginous canal, 
 anteriorly, the bone is diseased, and my associate, Dr. Emerson, 
 has removed a small piece of dead bone from it. The disease be- 
 
 1 Diseases of the Ear, p. 121.
 
 CAEIES OF CANAL. 157 
 
 gan as a severe local inflammation of the canal furuncle, for 
 which the patient was treated by his physician in Newport, Dr. 
 Rankin. The symptoms, which wrere severe, abated, and when 
 Dr. Rankin referred him to me, at the end of the summer, there 
 was some tenderness at the junction of the auricle with the 
 bone, and an offensive discharge of pus, but no serious general 
 symptoms or disease of other parts of the ear. In a few days 
 loose bone was detected and removed. The bone does not heal. 
 It is some four months since the occurrence of the original in- 
 flammation, but the surrounding parts are now free from ten- 
 derness and pain. The indications of treatment are, of course, 
 to keep the opening free from granulations and pus, and to favor 
 the throwing off of the bone. At the advanced age of my pa- 
 tient, I feel obliged to content myself with mild measures. I 
 occasionally scrape the granulations and also the surface of the 
 bone with a curette. The patient lived some four years after the 
 above was written, and his ear gave him very little trouble, al- 
 though I do not know that it completely healed. 
 
 I have seen one case of nearly complete absence of the audi- 
 tory canal, to which I am puzzled to assign a place, or rather 
 I am uncertain whether it belongs among the cases of bony 
 growth from inflammation in infancy, or in intra-uterine life, or 
 with those of arrested development. It may perhaps be properly 
 inserted at the close of this chapter. 
 
 Dr. W. J. Welch sent to me, for advice, a very interesting case of closure of 
 the auditory canal. The patient was twenty years of age, said to be " deaf 
 since he was five years of age." His ears were never treated, and he had not 
 grown worse. He has always been well in other respects. He is intelligent. 
 His ancestors were healthy people. He never had a discharge from his ears, and 
 very rarely has he had an earache. His hearing distance is : right ear, -|^ ; 
 left, the same. The voice is heard behind him three feet. The bone conduc- 
 tion seems to him louder than aerial. The duration is about the same as 
 aerial. The auditory canals are each less than half an inch deep, and funnel- 
 shaped. Air enters the tympanic cavity by Politzer's method of inflation. No 
 change in the hearing distance is observed after inflation. 
 
 I considered the condition as congenital, and no treatment 
 was urged upon the patient, although an explorative opening of 
 the canal by a dentist's drill was suggested. Whether this bony 
 closure of the canal was the result of intra-uterine inflammation 
 or merely of arrested development of the canal, remains an un- 
 solved problem to me. If the former be true, then the case is 
 one of hyperostosis of the canal. It is possible that an inflam- 
 mation occurred in early infancy, which led to closure of the 
 canal. In the chapter upon the " Consequences of Chronic 
 Suppuration," this subject will again be discussed.
 
 CHAPTER VII. 
 
 INSPISSATED CERUMEN. 
 
 Merely a Symptom of Aural Inflammation. Frequency of the Affection. Symp- 
 toms. Reported Cases of Damage to the Ear from the Presence of Wax, probably 
 not based on Correct Observation. Causes. Treatment. Cases. 
 
 ALTHOUGH I am convinced that the hardening of cerumen is 
 merely one of the symptoms of aural inflammation, I do not 
 feel as yet justified in discussing its nature and treatment in 
 an incidental manner. As a symptom, inspissated cerumen is so 
 prominent or annoying, that it has been classified as a separate 
 disease for a long time, if not always, although it is merely, in 
 my opinion, a consequence of an inflammation. 
 
 The writers on otology of the future, will, I am sure, treat of 
 hardened cerumen in connection with their accounts of the dis- 
 eases of the external and middle ear, and will not award it a 
 place by itself, although the writers of the present day do not as 
 yet feel justified in this manner of discussing it. 
 
 Among the laity, and even in the profession, hardening of 
 the ear-wax is generally regarded as a very harmless affection. 
 It is also considered by many as the most common of all the 
 diseases of the ear. The first treatment that many aural pa- 
 tients receive at the hands of their medical advisers, is a vigor- 
 ous syringing, or worse still, probing, in order to see if the wax 
 be not hardened. 
 
 Now the facts are, that inspissation of cerumen is, compara- 
 tively, not one of the common affections of the ear, and that 
 when it does actually occur, it is by no means the simple and 
 harmless disease that it is often supposed to be. Of 6,800 aural 
 cases observed by myself in private practice, only 497 were what 
 might fairly be said to be cases of inspissated cerumen ; that is 
 to say, cases in which the impaction of ear-wax was the chief 
 of the aural symptoms. 
 
 In the Manhattan Eye and Ear Hospital, of the 20,103 aural 
 cases recorded in twenty-one years, 2,228 are classified as cases 
 of inspissated cerumen. Yet, in a large proportion of these, it is
 
 INSPISSATED CEKUMEN. 159 
 
 admitted by the attending surgeons, that the hardened wax was 
 but a symptom of what may have been more serious disease. I 
 have found that it is the habit in certain circles, to speak of 
 the hardening of cerumen, as if it were a trivial affection which 
 almost any one is competent to manage, and one that needed no 
 considerable attention. 
 
 In the first place, no one is competent to remove hardened 
 cerumen without careful instruction, and in the second, it is a 
 significant symptom, the careful study of which will in many 
 cases be of great value in preserving the hearing of the person 
 affected with it. Hardening of the cerumen often occurs in the 
 course of suppurative processes in the middle ear, as well as in 
 cases of chronic non-suppurative disease. It also occurs in dis- 
 ease of the internal ear the nerve or labyrinth. In such cases 
 removal of the wax may slightly or even considerably improve 
 the hearing. If it be improved, a superficial examiner may be led 
 to believe that impaction of the wax was the only disease, but an 
 exact test of the hearing power will often convince him that the 
 patient still has defective hearing, even though it be greatly 
 benefited by the removal of a large plug of cerumen. The cases 
 of inspissated cerumen, in which the hearing becomes perfect 
 after its removal were in the beginning, I believe, cases ofin- 
 flammation of the canal or of the tympanic cavity, which have 
 run their course, leaving behind them the wax made hard by the 
 evaporation produced by the abnormal heat, when the canal or 
 tympanum or both were inflamed. 
 
 Cases are sometimes presented to me, where the patient can 
 state positively that there was, some time anterior to the impair- 
 ment of hearing from the blocking up of the ear, a period, 
 although a brief one, of decided pain. In many cases also, it is 
 easy to see the evidences of inflammation in the epidermis of the 
 canal, after the wax has been removed. In some, I grant that 
 it is not, but I feel confident that close examination will show in 
 every case, a probability at least, that an inflammation in some 
 part of the ear, a morbid condition, preceded the period when 
 the wax was not removed by the motions of the jaw, but when 
 it remained as a nucleus about which the whole secretion of 
 the canal collected, until it finally became an obstruction to 
 hearing. In my opinion, the proper way to classify inspissated 
 cerumen would be to say, for example, inflammation of the canal 
 with inspissated cerumen. Suppurative inflammation of the 
 middle ear with inspissated cerumen, and so forth. I speak thus 
 in detail, upon this point that inspissated cerumen is but a symp- 
 tom, because I believe that many curable cases are dismissed 
 with but partial relief, because it is thought when its removal is
 
 160 INSPISSATED CERUMEN SYMPTOMS. 
 
 secured and the hearing is much improved, that impaction of the 
 wax is the only disease. In many of these cases, unless the ear 
 be subjected to appropriate treatment, not only may the wax 
 soon become again inspissated, but the fundamental disease 
 which caused the impaction of the wax remains uncured, and it 
 may become permanent. From careful observation, I believe I 
 may state, that the activity of the ceruminous glands is usually 
 increased, and the canal becomes exceedingly hot and moist 
 during a subacute or acute catarrh of the tympanic cavity. It 
 is in this increased action of the glands that the beginning of 
 impacted cerumen is to be sought. 
 
 Symptoms. The prominent symptoms of true cases of inspis- 
 sated cerumen are: 1. Sudden impairment of hearing. 2. Tin- 
 nitus aurium. 3. Vertigo. 4. Pain in the ear. 
 
 The practitioner will not need to spend much time in deter- 
 mining the cause of such symptoms. If they be produced by 
 impaction of the cerumen, a glance at the auditory canal by 
 means of the speculum and otoscope will determine the matter, 
 or at least it will give us positive evidence as to the presence of 
 the inspissated substance. It need hardly be said, that the prac- 
 tice of probing the ear to determine if the wax be hardened, is 
 an.extremely unphilosophical procedure, while it is not without 
 danger to the membrana tympani. I am obliged to say, how- 
 ever, that I have seen several cases in which this probing has 
 been undertaken without ocular examination ; and -where in- 
 flammation of the lining of the canal, of the drum-head, and in 
 one case even perforation of the 'membrane, had resulted from 
 the manipulations in the dark. 
 
 The appearance of inspissated cerumen is very character- 
 istic. Wax which presses upon the walls of the canal and upon 
 the membrana tympani, in adults, is of a dark brown or black 
 color, and usually fills the canal. In children, however, in 
 whom the disease also occurs, the wax is usually of a yellow 
 color, and is more apt to be in layers. The presence of even 
 quite an amount of soft yellow cerumen, which still leaves an 
 opening, however narrow, down to the drum-head, can hardly 
 cause any unpleasant symptoms. 
 
 The diagnosis of inspissated cerumen is sometimes obscured, 
 by the useless habit indulged in by so many of the laity and of 
 the profession also, of pouring olive or other oils into the audi- 
 tory canal on the appearance of any aural symptoms. A lady 
 once came from St. Louis to consult a New York physician in 
 regard to a loss of hearing. She had been seen by no less than 
 six medical men, all of whom had prescribed applications to be 
 dropped into the ear, and none of whom had made an examina-
 
 INSPISSATED CERUMEN SYMPTOMS. 161 
 
 tion. She had suffered for six years from the great impairment 
 of hearing, and came to New York as a last resort. Having 
 arrived here, she was sent to me. I found the ears filled with 
 oils, but beneath all this, hardened cerumen, which was easily 
 removed ; and, although her hearing had been impaired for so 
 long a time, the removal of the wax restored it to the normal 
 power, so that she heard ordinary conversation with ease, and a 
 watch several feet. In this case, I did not imagine, until the 
 ears were cleansed by the syringe, that impacted cerumen was 
 the cause of the loss of hearing. I could scarcely believe, that 
 oils would be persistently dropped in an ear by so many different 
 advisers, before the membrana tympani had been examined. 
 
 The tuning-fork will be of use, if the inspissated cerumen be 
 confined to one side in determining the prognosis ; but practi- 
 cally the better plan is to defer any statement as to the prog- 
 nosis until the cerumen is removed. 
 
 In cases of disease of the acoustic nerve with impacted wax, 
 the tuning-fork will sometimes be heard better by bone than by 
 aerial conduction, but when the wax is removed, the hearing re- 
 mains impaired, but the tuning-fork is heard better through the 
 air than through the bones. Of course, if the hearing be nearly 
 or absolutely gone from disease of the nerve, the presence of 
 wax will make no difference in the ability to hear the tuning- 
 fork, so that, if the tuning-fork be not heard better through the 
 bones with impacted wax, the prognosis as to improvement of 
 the hearing is very poor. 
 
 The loss of hearing from hardening of the cerumen, as has 
 been intimated, is apt to occur very suddenly. I have seen sev- 
 eral cases where patients could tell the very instant when the 
 ear "closed up," as they often say. The jolting of a ride in a 
 rumbling vehicle often displaces the hardened material, and 
 presses it into the canal, causing troublesome symptoms in an 
 instant ; and, as I have said, these symptoms do not occur, no 
 matter how much cerumen may be in the ear, until the impac- 
 tion takes place, when the loss of hearing, the tinnitus aurium, 
 and the increased resonance of the patient's own voice, calls his 
 attention to the ear. 
 
 Pain of the most distressing nature sometimes occurs from 
 the impaction of cerumen. I remember one case where ano- 
 dynes had been used for ten days to relieve a pain in the ear, 
 which an examination showed was the result of the affection 
 now under consideration. In another case, that of a young 
 lady, suppuration of the drum-head resulted from the long-con- 
 tinued impaction of cerumen. This suppuration was preceded 
 by very severe pain, from which no relief was experienced until 
 11
 
 162 MENTAL DEPRESSION FROM HARDENED WAX. 
 
 the mass of cerumen was evacuated spontaneously, like a cork 
 from a bottle of champagne, and, as the patient stated, with a 
 report like that of a pistol. The removal of a plug of cerumen 
 from the auditory canal of the other side, a plug that was very 
 tightly wedged in, saved the patient from a similar experience 
 on that side. 
 
 These rare cases of suppuration caused by wax, should not 
 be confounded with those frequent ones of chronic suppuration 
 where the wax hardens over the opening of the membrana 
 tympani. 
 
 It is probable that some of the cases reported by the earlier 
 authors as instances of great damage to the ear from inspis- 
 sated cerumen, were cases of this kind. Toynbee's ' cases of 
 absorption of the bone, imbedding of wax in the mastoid cells, 
 are possibly only cases where hardened wax supervened upon 
 chronic suppuration of the middle ear. 
 
 Among the cases that are appended to this chapter, will be 
 found another where excruciating pain was one of the promi- 
 nent symptoms of a case of inspissated cerumen. Yet neither 
 pain nor vertigo are the ordinary symptoms of this disease ; im- 
 pairment of hearing and tinnitus are the usual ones. 
 
 Great depression of spirits, almost becoming melancholia, 
 was observed in a case reported by Dr. Edward T. Ely and 
 myself. 2 
 
 MENTAL DEPRESSION FROM IMPACTED WAX. 
 
 Mr. T , set. 18, has been seen at intervals for several years on account of 
 
 a chronic suppuration in the right middle ear. The left ear was normal. On 
 May 15, 1879, the right ear was in very good condition ; the hearing was $, and 
 there was no discharge. Patient came again on September 24th, complaining 
 that since June he had suffered from "a feeling of heaviness in his head." 
 Was " unable to concentrate his mind on anything for more than a few min- 
 utes." Felt as if he must give up his studies (in which he was very much inter- 
 ested), and wished to know whether he must leave college. Thought his deaf- 
 ness had increased, but had no pain, tinnitus or discharge. The patient was 
 sullen and very despondent. Otherwise his health seemed to be excellent. He 
 was very reticent by nature. 
 
 H. D., E. -f^. External auditory canal filled with hard wax. After remov- 
 ing the wax, the hearing became \%, and the tympanic cavity looked as it had at 
 former visits ; there was no discharge. 
 
 The patient obtained speedy relief, and in a few days reported the discom- 
 fort about his head gone. He was then as cheerful as usual. 
 
 This case was interesting, as illustrating the disturbing influence of impacted 
 wax, even with an entire absence of tinnitus. 
 
 1 Text-book, English edition, p. 51. 
 * Archives of Otology, Vol. IX. , p. 16,
 
 INSPISSATED CERUMEN CAUSES. 163 
 
 CAUSES. 
 
 The causes of hardening of the wax in the auditory canal are 
 not as well settled as we could wish. As I have already observed, 
 I no longer believe that it is an independent affection, or a dis- 
 ease only of the ceruminous glands. There are cases, however, 
 in which at the time of the removal of the inspissated cerumen, 
 its presence is the only bar to a perfect recovery of the hearing 
 power. In such cases the disease which caused the wax to 
 harden has passed away, and it only remains as a foreign body. 
 Yet in by far the majority of cases the hearing is not fully re- 
 stored by the removal of the wax. I will tabulate the diseases 
 in which hardening of the wax may occur. 
 
 I. Chronic Suppuration of the Middle Ear. 
 
 Hardening of cerumen in such cases is not always injurious. 
 A layer of hard wax sometimes serves as a good artificial drum- 
 head, and improves the hearing. When the mass has become 
 thick enough to cause pressure, pain, tinnitus and vertigo may 
 result, and it should be removed. It is important, therefore, in 
 extremely chronic cases of suppuration of the middle ear, to 
 remember that a layer of black wax may be sometimes more 
 profitably left than removed, since it sometimes acts as an arti- 
 ficial membrana tympani. It is to be understood, however, that 
 this is not the rule when there is a hope of healing the mem- 
 brana tympani by local treatment. 
 
 II. Chronic Non-Suppurative Inflammation of the Middle Ear. 
 
 The symptoms of patients suffering from this form of disease 
 are often aggravated by impaction of the cerumen. So unob- 
 servant are many as to a loss of hearing, that until a plug of 
 wax has closed the canal and rendered hearing of ordinary 
 conversation carried on near them, very difficult, do they admit 
 that their hearing is at all defective. In such cases the rule is 
 without exception to remove all the hardened material. 
 
 III. Diffuse Inflammation of the Auditory Canal. 
 
 I have seen hardening of the wax, especially in children, in 
 the course of this disease. As has been before intimated, the 
 black color that usually indicates hard wax in adults is not 
 found, when it is impacted in the ears of children. The mixture 
 of layers of epidermis with the wax is more marked in these cases 
 than in others.
 
 164 INSPISSATED CERUMEN CAUSES. 
 
 IV. Foreign Bodies. 
 
 The cerumen may become impacted in the ear in cases where 
 foreign bodies have been placed in, or have entered the auditory 
 canal, and have not been removed. I have on several occasions 
 removed hardened wax that contained insects that had entered 
 the ear. In one case, that of a little boy, the parents remembered, 
 on questioning, that he had once, about a year before, complained 
 of pain in his ear for a few hours, and that he had said some- 
 thing was in his ear. The pain was stilled and the occurrence 
 was forgotten until new symptoms appeared, such as impairment 
 of hearing and tinnitus. An examination revealed impacted 
 cerumen, in the centre of which was found an insect. 
 
 V. Exostosis and Hyperostosis of the Canal. 
 
 Impacted cerumen occurring in a case where the canal is 
 narrowed by a bony growth, is difficult to manage, for it is 
 particularly difficult to remove the wax when it lies behind the 
 contraction of the osseous canal. I have one such case in my 
 mind as I write, that of a physician from the South, who in his 
 annual visits to the North, is obliged to devote as much time to 
 getting the hardened wax from his auditory canal, as is usually 
 devoted to the care of the teeth. The presence of the wax great- 
 ly diminishes his already impaired hearing. Even a thin layer 
 lying on a part of the drum-head is sufficient for this. In his 
 case, the connection of the hardening and massing of the ceru- 
 men, with an inflammatory condition of the canal is very plain. 
 
 VI. Parasitic Inflammation. 
 
 Impaction of cerumen is not at all unlikely to occur in con- 
 junction with parasitic inflammation of the canal. As was inci- 
 dentally mentioned in the preceding chapter, wax may harden 
 upon a growth of aspergillus in the canal and upon the drum- 
 head. 
 
 While these pages are passing through the press I have un- 
 der my care a boy of eight years of age, who came to me some 
 four weeks ago on account of defective hearing. Both his audi- 
 tory canals were found to be filled with impacted cerumen, which, 
 as is apt to be the case in children, was removed slowly and 
 with difficulty. Dr. Emerson, my associate, has spent many 
 hours upon the case, using the syringe, curette, probe, and for- 
 ceps at each sitting. Wlnen several layers of wax had been re- 
 moved, we found aspergillus of luxuriant growth underneath, 
 clinging closely to the canal and membrana tympani.
 
 INSPISSATED CERUMEN CAUSES. 165 
 
 Sometimes the patients with inspissated cerumen say that 
 they perspire excessively ; and again, they are not at all aware 
 of any such peculiarity. Often, indeed, they state positively that 
 they do not perspire any more than is natural. I think, there- 
 fore, we must reject this from among the causes of this disease, 
 although it is given by some authors. 
 
 I have no doubt that the bad habit of cleansing the audi- 
 tory canal with the end of a towel, or with an aurilave a bit of 
 sponge fastened on a handle or the like, has a tendency to pack 
 the cerumen in the canal ; but after all, a cause must, I think, 
 be sought for behind this, and this is to be found in an inflam- 
 mation of the middle ear, which has extended to the auditory 
 canal, or in an inflammation of the canal itself. 
 
 I have observed that almost all patients suffering from inspis- 
 sated cerumen ascribe the attack to "cold" which they have 
 taken. In many of these cases no evidence is found to sub- 
 stantiate the theory, for, as all my readers know, patients are 
 very apt to ascribe all kinds of diseases to cold, even when they 
 cannot positively remember that they have suffered from a cold 
 in the head, throat, or chest. Yet many cases have come to me, 
 in which there was a naso-pharyngeal catarrh coincident with 
 the impaction of cerumen, or with the aural symptoms. 
 
 I suppose a very slight swelling of the auditory canal would 
 prevent the free removal of the cerumen, which naturally takes 
 place from the motion of the lower jaw, as it presses upon the 
 lower part of the wall of the meatus. When the wax has once 
 collected, partial evaporation of its watery contents occurs, and 
 we get the characteristic black color, and the mass becomes, on 
 its surface at least, as hard as soft wood, and in rare cases as 
 hard as some kinds of stone. 
 
 Cases enough have been seen to show, that inflammation of 
 the canal does favor inspissation of the cerumen ; the only ques- 
 tion upon which any doubt may be thrown is, whether impaction 
 of cerumen does ever occur without an antecedent inflammation, 
 and from purely mechanical causes, such as packing of the secre- 
 tion by improper attempts to cleanse the canal, or from a peculiar 
 tendency to excessive action of these numerous glands. Certain 
 it is, that some cases require only local treatment, and that what- 
 ever inflammation preceded the evaporation of the fluid of the 
 cerumen, was fully removed when the patients came under treat- 
 ment. 
 
 Many patients suffering from chronic non-suppurative inflam- 
 mation, complain that their ears secrete no wax. This state of 
 things is due to two facts : One is, that such patients are very 
 apt to syringe their ears very frequently, and thus remove all
 
 166 GLYCERINE AS A REMEDY FOR DEAFNESS. 
 
 the cerumen as fast as it forms. The other is, that the chronic 
 catarrhal, or proliferating process, probably extends to the audi- 
 tory canal, and interferes with the functions of the ceruminous 
 glands. 
 
 Under the guidance of Mr. T. Wakely, who published an 
 account of the wonderful virtues of glycerine in the London 
 Lancet, 1 the profession were at one time very much in the habit 
 of recommending the use of this agent to re-establish the secre- 
 tion of cerumen. Mr. Wakely even published a work entitled 
 "Clinical Reports on the Use of Glycerine in the Treatment of 
 Certain Forms of Deafness." Mr. Wilde showed that the reporter 
 of these cases was not "conversant with either the normal or 
 pathological appearances of the ear," and glycerine, after a fair 
 trial, which is still kept up by some physicians, proved to be of 
 no avail in relieving impairment of hearing. Its only value is 
 as an emollient to soothe an irritated or dry canal. It should be 
 diluted with water when used in this way. 
 
 Its use for the restoration of the secretion of cerumen was 
 about as rational as the other instillations, of which an account 
 has been given in the introductory chapter. Yet in our own 
 century, a surgeon to a London hospital gravely recommended, 
 as a portion of a new cure for deafness, "the finest curled wool 
 on the sheep's head, carefully cut with scissors, and washed in 
 hot water," and added "that the best wool is that procured from 
 a small German sheep ;" z while in the same city, Wakely's book 
 was gravely noticed as a contribution to clinical medicine. 
 
 From present appearances another quarter of a century will 
 pass away, before many physicians will cease to advise the use 
 of glycerine and sweet oil, for a disease of the ear, of the exact 
 nature of which they know nothing. Were it. not that valuable 
 time is often lost in the treatment of inflammation of the ear, 
 in many cases where this advice is given, there would not be 
 much to regret, since in many instances the glycerine or oil 
 softens the hardened wax, so that its position is changed at 
 least. Sometimes it even effects a removal of it without the 
 use of a syringe, but for one case where inspissated cerumen 
 actually exists, when this advice is given without an examina- 
 tion, there are a score where there is no hard wax to soften, 
 and where the advice is positively harmful. Glycerine, as usu- 
 ally prescribed for the ear, has very few antiphlogistic virtues. 
 It usually perpetuates rather than cures an inflammatory process. 
 
 Treatment. The treatment of inspissated cerumen is exceed- 
 ingly simple. The hardened material should be removed by the 
 
 1 Wilde's Aural Surgery, p. 38. * Wilde, loc. cit., p. 4&
 
 INSPISSATED CERUMEN TREATMENT. 167 
 
 use of the syringe and warm water. The syringing should be 
 performed in the manner that has been depicted on page 133. 
 In the majority of cases but a few minutes are necessary to re- 
 move the mass. In some cases, however, we are compelled to 
 use a solvent for a few hours prior to the syringing process. I 
 usually use a saturated solution of the bicarbonate of soda for 
 this purpose. The cerumen is sometimes so hard, and so tightly 
 wedged into the auditory canal, that a daily sitting for a week 
 or more is necessary to its removal. I have notes of several 
 such cases. In one of them, I finally softened the mass by the 
 use of fuming nitric acid, after having completely failed to 
 make any impression upon it by alkaline solutions or oils. 
 
 Professor S. D. Gross recommended a pick and curette for 
 the removal of inspissated cerumen. He says : "Ear-wax, how- 
 ever hard, or however firmly impacted, is more readily removed 
 with such an instrument than with any other contrivance of 
 which I have any knowledge." ' I am constrained to say, that 
 I consider such advice from so eminent a source as the late Pro- 
 fessor in the Jefferson Medical College, calculated to give a 
 dangerous and false impression as to the proper method of re- 
 moving ear-wax. The syringe and warm water will be found 
 to be the only means that are necessary in ninety cases out of a 
 hundred. The use of the "pick and curette," or of any pointed 
 instrument, is a dangerous means of removing inspissated ceru- 
 men, except in the hands of men of very large surgical experi- 
 ence, who have learned to treat ears as if they were soap-bubbles. 
 It is only in the rare cases in which the syringe fails that the 
 use of an instrument, employed under a good illumination by 
 means of the mirror and forehead band, should be resorted to. 
 
 In some cases it will be necessary to lift the first layer of 
 hard wax with a delicate probe before the syringe will make any 
 impression upon it. In others, this will be necessary even down 
 to the last layer. In such cases the curettes of Buck and Politzer, 
 used under good illumination are of great assistance. Too great 
 stress, however, cannot be laid upon the necessity for care in the 
 use of instruments upon the auditory canal, especially near the 
 drum-head. In the hands of the average practitioner, the syringe 
 is the best instrument for the removal of impacted cerumen, 
 because it is usually efficient and always safe. Dr. Pomeroy* 
 recommends a syringe "with a flange and a long narrow tip" for 
 the removal of hardened wax. The stream of water from the in- 
 strument is no doubt efficient, but I think this syringe in unprac- 
 
 1 American Journal of the Medical Sciences, October, 1864 
 9 Text-book, p. 85.
 
 168 INSPISSATED CERUMEN TREATMENT. 
 
 tised hands is more dangerous than a probe, and I still use a 
 short nozzle as seen on page 132. When it becomes necessary to 
 make an opening in wax upon which the stream of water may 
 act, nitric acid may be used, or a saturated solution of caustic pot- 
 ash (Blake), a small hole being burned in the centre of the mass. 
 
 The auditory canal may contain a surprisingly large quantity 
 of hardened cerumen, and it is necessary to examine the ear 
 quite often during the syringing process, in order to see how 
 much remains, lest we continue the injections after the wax is 
 removed, and thus injure the drum-head. All the wax should 
 be removed. The thinnest scale or flake left upon the drum- 
 head, is sometimes sufficient to keep up the disturbing symptoms. 
 I have seen several cases where the diagnosis was correctly 
 made, and the syringing undertaken, and yet the symptoms 
 were not relieved, because a small flake of wax was left upon 
 the drum-head. 
 
 The membrana tympani is usually found very much reddened 
 after the removal of the wax ; but this is probably due to the in- 
 jections of warm water. It is also sometimes pressed inward. 
 This may be due to the mechanical pressure which has been ex- 
 erted upon it by the cerumen, or to the catarrh of the tympanic 
 cavity which so often accompanies or causes this disease. 
 
 If the hearing is very much improved after the removal of 
 the wax, the ear should be protected from the shock of sounds 
 by a little pledget of cotton placed lightly in the meatus. If the 
 drum-head be sunken inward, Politzer's method of inflating the 
 middle ear, or the Eustachian catheter, should be employed to 
 restore it to a normal position. Since some persons are disposed' 
 to frequent attacks of inspissated cerumen, it is well to advise 
 them to have the ear syringed with warm water once in two or 
 three months. It is probable that it requires a longer time than 
 this, for cerumen to become so hard or so tightly packed in the 
 canal, that it cannot be readily removed by the patient or a non- 
 medical friend. 
 
 It is always well to examine both ears, even when only one is 
 complained of. I have often found the ear in which the hearing 
 was still unimpaired, quite as full of wax as the other, although 
 it iiad not yet become pressed upon the drum-head, and thus had 
 given no trouble. 
 
 I append a few cases, which illustrate what has been said, 
 and which will, perhaps, contribute to a knowledge of the eti- 
 ology of the disease. 
 
 CASE I. Buzzing Noise for Two Days, then Pain Inspissated Cerumen. 
 
 March 5, 1873, Mr. De S , set. 28, consulted me about a pain in his ear. 
 
 Two days since he experienced a "buzzing noise" in the ear, and last night he
 
 INSPISSATED CERUMEN CASES. 169 
 
 had severe pain in it, which was relieved by some liquid application. The buzz- 
 ing noise still continues, and he cannot hear well from the left side. 
 
 The hearing distance is : Eight ear, normal ; Left ear, ^ gj or the watch is 
 heard when pressed upon the auricle. 
 
 Tuning-fork is heard much better on the left side. 
 
 Diagnosis : Inspissated cerumen in left ear. 
 
 The mass was removed by syringing, and the hearing distance became 51 in 
 a few moments. 
 
 CASE II. Head Symptoms for some Months, ascribed to Sunstroke Treated 
 for Cerebral Disease, without Examination of the Ears Inspissated Cerumen Re- 
 movalCure. A. B , coachman, at New York Eye and Ear Infirmary, in 
 
 1864. The patient complained of head symptoms for some months. He ascribes 
 them to a sunstroke. On cross-examination it was found that he had never act- 
 ually suffered from sunstroke ; but that since his head symptoms chiefly 
 buzzing in the ear and deafness had begun, he imagined that they were caused 
 by a fancied sunstroke. 
 
 He stated that he had been treated in a New York hospital for some weeks, 
 but without benefit. His ears had never been examined, and he had concluded 
 to have their condition investigated, as many of the symptoms which made him 
 ' ' bad in the head " were referred to his ears. 
 
 An examination showed inspissated cerumen in both ears. I have mislaid 
 the record which gave an account of his hearing power ; but all the trouble- 
 some symptoms were at once relieved by the removal of the mass, which was 
 done by the use of the syringe. 
 
 This case is almost as striking as that related by Troltsch. 
 in which a poor fellow was blistered and cupped to the verge of 
 severe depression for a supposed concussion of the brain, which 
 proved to be caused by inspissated cerumen. 
 
 CASE III. Abscesses near the External Meatus Impaction of Cerumen Res- 
 toration of Hearing after Removal of the Cerumen. The following case shows, I 
 think, that a swelling of the canal may prevent the normal exit of the cerumen, 
 and thus favor its impaction : 
 
 Miss J , set. 29, consulted me March 23, 1873, on account of her ears, 
 
 and gave the following history : For fourteen or fifteen years she had suffered 
 at intervals from abscesses in both ears. The hearing has been seriously im- 
 paired on the right side from an ulcer resulting from scarlet fever, since she 
 was five years old. For the past two or three mouths the hearing has been 
 impaired in the left ear, and she has siiffered from abscesses near the external 
 meatus, which have caused great swelling and tenderness of the parts. The 
 impairment of hearing was most marked in the morning. For the last four 
 weeks she has been constantly deaf, although for a few moments a few days ago . 
 she heard very well ; she then felt as if something had broken in the ear. 
 
 Hearing distance, tested by the watch : Eight ear, -.,>; ; Left ear, - 4 Q 8 -. 
 
 Diagnosis. Eight ear, chronic suppuration in tympanic cavity. Left ear, 
 inspissated cerumen. A small furuncle was found in the outer part of the 
 canal, which was a very narrow one.
 
 170 CASE OF RECURRENT LN'SPISSATION OF CERUMEN. 
 
 The mass of cerumen was removed in about twenty minutes by syringing, 
 when the hearing distance became -/. 
 
 Politzer's method of inflating the ear was then employed. 
 
 March 6th : H. D., if. 
 
 After the use of Politzer's method, the hearing distance became f f. 
 
 The above case illustrates the theory of the preceding chap- 
 ter, that inspissated cerumen is in reality but one of the symp- 
 toms of certain forms of inflammatory affection. In this case 
 the inflammation had not fully run its course, for the canal was 
 red and swelled. Perhaps, indeed, this was an habitual condi- 
 tion of the part. 
 
 CASE IV. Recurrent Attacks of Inspissated Cerumen for Twenty Years Ul- 
 ceration of Membrana Tympani during Two Attacks Recovery, but Inspissation 
 of Cerumen continues to recur. I have under observation and care a gentleman 
 of about thirty-eight years of age, who has suffered from attacks of inspissation 
 of cerumen for more than twenty years. He has been under my care for four- 
 teen years. At first the wax hardened at intervals of months, but now, espe- 
 cially in the summer, the intervals are so short, that the patient is obliged to 
 present himself once a month for examination, and generally for the removal of 
 the plug that has formed in one or both ears. 
 
 Five years ago, the hardening of the wax was followed by ulceration of the 
 outer layer of the membrana tympani. This healed under the use of nitrate of 
 silver. A few months after, a granulation was found at the bottom of the canal, 
 and an attack of pain occurred. The canal became red and swollen at the junc- 
 tion of the auricle and the mastoid. The canal and drum-head were again 
 treated by the warm douche, and in a few months the wax again accumulated 
 and hardened. A year after the patient again had an abscess in the right ear. 
 Although the wax hardens in each ear, inflammation has as yet only occurred 
 in the right one. This probably perforated the drum-head, but it healed 
 again. 
 
 The inflammation extended from the canal inward, and hence it was not so 
 easy to decide as to whether it had passed through the layers of the drum-head 
 or not. The last inflammation that as yet affected the ear, in conjunction with 
 the impaction of the cerumen, occurred a year and a half ago. This did not 
 perforate the drum-head, and healed under the use of iodoform. The patient 
 now comes for examination every few weeks, in summer especially, and by re- 
 moving the wax before the plug has formed, we hope to prevent the recurrence 
 of inflammation. After a careful study of this case, I have not been able to 
 satisfy myself as to what causes the wax to harden. 
 
 That the inflammation follows, rather than causes the inspissation, seems to 
 be true here. The patient is a gentleman of excellent, even vigorous general 
 health, whose habits are correct, and whose position in life enables him to take 
 the best of care of himself in every respect. I have tried in vain, to prevent the 
 accumulation of the wax by pencilling the canal with nitrate of silver. 
 
 It ought finally to be stated, that although the hearing has often been much 
 impaired for some time, it as yet remains practically normal, except when the 
 patient is suffering from a recurrence of impaction of cerumen.
 
 EFFECTS OF QUININE UPON THE EAR. 171 
 
 The following case, which may be considered a remarkable 
 one, illustrates not only the etiology of inspissated cerumen, but 
 also the effect of quinine upon the ear ; and I insert it as much 
 to show the influence of this agent upon the auditory apparatus, 
 as for its bearing upon the subject now under discussion. 
 
 It has already been published, 1 but I think it worthy a wider 
 circulation than it has hitherto obtained. 
 
 CASE V. Inflammation of the Auditory Canal, caused by Quinine Impaction of 
 Cei'umen Use of Nitric Acid to effect Removal. On the 3d of May, 1870, I was 
 
 consulted by Dr. N , set. 34, on account of his throat and ears. He stated 
 
 that he had had acute pharyngeal and laryngeal disease some ten years before. 
 He also informed me that neither he nor his parents have any recollection of any 
 serious difficulty with his ears prior to the date of the attack, from whose con- 
 sequences he is now suffering. The laryngeal inflammation was followed by 
 chronic naso-pharyngeal catarrh, and in 1863 he was obliged to take five-grain 
 doses of quinine for some weeks on account of nervous prostration from malarial 
 fever contracted in the Southern States. These doses were increased to ten 
 grains, and cinchonism was produced. The symptoms of cinchonism were, ring- 
 ing in the ears and dizziness. In 1864, the doctor again took quinine until the 
 constitutional effects were produced, the dose finally reached being twenty to 
 twenty-five grains, which was taken every other day. While employing the 
 quinine in this manner a severe attack of otitis occurred. The patient states 
 in a written history taken from his diary that he recovered from the otitis under 
 antiphlogistic treatment. 
 
 After recovery from the aural disease, Dr. N was obliged to resort to the 
 
 use of the quinine on account of the constitutional disease a severe malarial 
 neuralgia. He took one dose of fifteen grains, which was followed by pain in 
 the ears. Several efforts were made to return to the use of the quinine, but pain 
 in the ear supervened on each dose. "From this period, February, 1865," to 
 quote the exact words of the patient, "my ears began to give me constant trouble. 
 I was incessantly annoyed by unnatural noises, which would frequently reach 
 such a pitch, for a few moments, as to exclude all other sounds." The naso- 
 pharyngeal disease also increased, and in March, 1865, he was seen, on account 
 of the state of his ears, by a distinguished practitioner. The throat was consid- 
 ered the origin of the aural affection, and it was accordingly treated, and was 
 improved ; but the ears remained in the same condition, that is, they were sensi- 
 tive and affected by tinnitus, and there was some impairment of hearing. 
 
 After the pharynx had been treated, until July of this year (1865), and while 
 undergoing treatment, another attack of otitis media occurred, which was pre- 
 ceded by five weeks of facial neuralgia. The use of quinine for the relief of 
 these attacks had been avoided ; but at last, the patient, worn out by pain, took 
 a fifteen-grain dose of the sulphate, upon which the ear disease immediately 
 supervened. The quinine was taken on July 30th, and the attack of otitis media 
 occurred on the next day. The otitis was of so severe a character as to place the 
 doctor in a very depressed condition, and when he recovered from this and the 
 neuralgia, which he did simultaneously, to use the patient's own language, he 
 was "a perfect wreck." 
 
 1 Transactions of the American Otological Society, 1873.
 
 172 EFFECTS OF QUININE. 
 
 He then sailed for Europe, and in the Scotch Highlands recovered from the 
 malarial disease, never having suffered from it since up to the present time. The 
 ears, however, became very sensitive to the air, and cotton plugs were resorted 
 
 to, and Dr. N lias never from this time been able to leave the meat us open, 
 
 even while in-doors, until the past week. The hearing power was also greatly 
 impaired while in Scotland ; the patient therefore went to the south of France, 
 where his ears were still troublesome. The aural symptoms were tinnitus, a 
 sense of pressure in the auditory canal, and frequent attacks of neuralgia oi the 
 fifth pair. The intellect also became somewhat obscured. After a year's stay 
 
 abroad, Dr. N returned home, when the naso-pharyngeal catarrh returned. 
 
 He then, under the advice of a physician, began the use of the nasal douche for 
 its relief, taking all the precautions that are enjoined, using a warm solution of 
 common salt in water. It was observed, however, that in an hour or two after 
 using the douche, there was an uncomfortable sensation in the ears which became 
 more prominent after each application. The physician then advised "less press- 
 ure " in the use of the douche ; but the next application was followed by severe 
 pain, and this method of treatment was abandoned. The patient was then suffer- 
 ing from what was called an inflammation of the auditory canal ; all treatment 
 was given up until September of this year, when another attack of otitis media 
 and of facial neuralgia occurred. The next two years were spent in Italy. 
 
 The general health of the patient was then excellent, but the healing did not 
 improve, and the patient was obliged to use the cotton plugs. Returning to 
 America in the spring, the naso-pharyngeal catarrh, which had not appeared 
 while in Italy, returned, and in April, pain occurred in both ears, for which he 
 was treated by leeches, diaphoretics, and hot fomentations ; after this attack the 
 patient describes himself as totally deaf unable to distinguish the loudest 
 sounds. " There was a feeling of spasmodic constriction, and fulness invading 
 the cavity of the tympanum, and a sensation of pressure upon the drum-head." 
 On the third day the patient became able to hear what was said to him, if the 
 words were spoken very loudly and with the mouth applied close to the ear ; as 
 time passed he became still more improved, so that he could hear conversation 
 addressed specially to him at a short distance, and a watch usually heard at four 
 feet, at a distance of two inches on each side, H. = -&. 
 
 This was his condition when he first came under my observation, on May 3, 
 
 1870. I found that the general nervous system of Dr. N , from his years 
 
 of suffering, was in a highly sensitive condition. His pharynx was highly con- 
 gested, the uvula very long, and both auditory canals were extremely sensitive 
 and plugged with hard wax. For two weeks the patient was under my care, 
 during which time I cut off the uvula, and made many attempts to remove the 
 impacted wax by syringing, and the use of the forceps ; but in all these attempts 
 I failed, in consequence of the hardness of the cerumen and the tightness with 
 which it was held by the auditory canal, and also because the ear was extremely 
 tender to the slightest touch. 
 
 At the end of this time, the patient was suddenly called to Minnesota, and I 
 did not see him again until June 26, 1872, when he presented himself and gave 
 the following history of the time that had elapsed. The very small quantity of 
 wax removed, and the cutting off of the uvula, had relieved the pharynx and ears 
 to some slight extent, and, the climate being adapted to his condition, he did 
 very well, except that the hearing was impaired. 
 
 On June 18, 1871, another attack of otitis occurred, which caused some con-
 
 INSPISSATED CERUMEN. 173 
 
 siderable discomfort, although it was a less severe attack than those which had 
 preceded it. The otitis again occurring, the patient came to me, on the date 
 above mentioned; more than two years from the first visit. I found him suffering 
 severe pain, for which he was taking anodynes ; the ears were about in the same 
 state as when I last saw him. The hearing distance was about - 4 %, the canals were 
 plugged with hardened wax ; the patient appeared in fair physical condition, but 
 mentally he was excited and slightly irritable and depressed. 
 
 I proceeded to remove the impacted wax, and that from the right ear came 
 away on the second day. It was so tightly wedged in that the removal, which 
 was effected by the syringe and forceps, caused severe pain, although the walls 
 of the canal were not touched. On the fifth day, after the use of vaiious agents 
 to soften the mass of cerumen in the left ear, I burned it with nitric acid, and 
 then succeeded in removing it. This removal also caused great pain. The 
 meinbranse tympani were suppurating, that is, the outer layers, and they were 
 somewhat sunken, especially along the handle of the malleus. The use of a 
 solution, nitrate of silver 40 gr. ad ]'., and inflation by Politzer's method, soon 
 restored them to a normal appearance, except that the curvature remained al- 
 tered. The sensitiveness of the ears was removed, so that they could be touched, 
 applications made to the drum-head, and so on, without producing any unpleas- 
 ant sensations. The hearing distance became - 4 a g- on the right side, and was im- 
 proved on the left, but to what extent I do not know, not having seen the patient 
 for some time. He became able to sleep without an anodyne. The cotton plugs 
 which had been worn for years were now removed, and he became altogether a 
 different person, as regards his mental condition. 
 
 I think we must regard the otitis in this case, although to a 
 certain extent dependent upon the naso-pharyngeal catarrh, as 
 chiefly caused by the use of quinine. By looking at the history, 
 and observing how promptly and invariably the pain in the ears 
 occurred in several instances after the use of the agent, we are 
 forced to the conclusion that quinine was the exciting cause of 
 the aural inflammation. At what date the impaction of wax 
 occurred, we cannot positively determine. I am disposed to be- 
 lieve that it was at the time the patient awoke profoundly deaf. 
 in April, 1870, or more than two years before it was removed. 
 The wax was certainly there one month after, in May, 1870, when 
 I first saw him. 
 
 The condition of the patient's mind is illustrated by the fact 
 that he allowed two years to pass away with no attempt to 
 remove a foreign body, from whose partial removal he had ob- 
 tained some relief, and which he believed to be one of the causes 
 of his impaired hearing. I can only partially account for this 
 delay, by supposing that my efforts at softening and removing 
 the mass had so far succeeded as to lift the cerumen from the 
 drum-head, and thus gave partial relief. Indeed, the plug, which 
 I took out on the second day, was on its way out, and would, I 
 think, have soon escaped spontaneously, with one of the loud
 
 174 INSPISSATED CERUMEN CASES. 
 
 reports with which hardened wax sometimes shoots from the 
 auditory canal. The structure of the plugs was that usually 
 found, that is, cerumen in layers ; but there was some epidermis 
 exfoliated, and also some pus between the mass of wax and the 
 canal. 
 
 The case seems to me to be one of those which have been 
 reported, where inflammation of the integument lining the canal 
 was one of the causes of impaction of wax, and it may be a con- 
 tribution to the etiology of that disease. The earlier history also 
 illustrates the effect of quinine upon the ear, which I believe is 
 sometimes an inflammation of the conducting portions, as well 
 as of the acoustic nerve or labyrinth. We have long suspected 
 the latter effect, but the former has not been often observed. 
 
 The following case occurred in my clinic at the Brooklyn Eye 
 and Ear Hospital, and was reported by Dr. David Webster, ' who 
 was then House Surgeon. 
 
 It illustrates the serious inflammatory trouble that may be 
 ,caused by inspissated cerumen, a fact which has been already 
 alluded to in this chapter, for there is no doubt in my mind, that 
 while the impaction of cerumen is sometimes caused by inflam- 
 mation, that it in turn may produce ulceration by mechanical 
 pressure. 
 
 CASE VI. Pain Tinnitus Deafness Inspissated Cerumen Suppuration of 
 
 the Canal Incisions Recovery. D. H , aged 28, laborer, presented himself 
 
 at Dr. Roosa's clinic, at this hospital, November 1, 1870. Five days previously 
 his right ear was attacked with pain, tinnitus, and deafness, which symptoms 
 had gradually increased up to date. He had slept but little for the last two 
 nights, in consequence of the severity of the pain. He could hear the ticking of 
 an ordinary watch at the distance of only one inch. 
 
 Upon examination we observed a little pufflness of mastoid process, and some 
 swelling back of the angle of the lower jaw and of the walls of the meatus. 
 There was also some pharyngitis. Through the aural speculum the external 
 meatus was seen to be plugged with hard wax. This was removed by carefully 
 syringing the ear with warm water. Some pus was found in the canal, and at 
 first the membrana tympani was thought to be perforated, but upon more care- 
 ful examination it was found to be intact, though a complete examination of it 
 was rendered impossible by the narrowing of the meatus consequent upon the 
 swelling. 
 
 Politzer's method for inflating the middle ear was practised, and the patient 
 was directed to fill his ear frequently with warm water. 
 
 November 2d. He said that the pain was so relieved that he rested well 
 last night, and complained more of a sensation of soreness than of pain. The 
 tinnitus and swelling were undiminished, but the hearing distance had risen to 
 ten inches. On using Politzer's method, the patient felt the air enter neither 
 
 1 Medical Record, vol. v., p. 536.
 
 INSPISSATED CERUMEN CASES. 175 
 
 ear, and when this was done again, with the addition of the vapor of chloro- 
 form, the air was felt only in the left. He was directed to continue the use of 
 warm water. 
 
 November 3d. The swollen walls of the meatus had become more sensitive 
 to the touch, and the pain had returned. He was treated by means of the warm 
 aural douche, Politzer's method again used, and the entrance to the meatus 
 stuffed with cotton in order to exclude the cold air. 
 
 November 5th. The swelling had increased. Dr. Prout, who saw the pa- 
 tient for Dr. Koosa, made two incisions in the walls of the meatus one back- 
 ward, the other upward. Pus followed the knife in the latter. The pain caused 
 by the incisions was immediately relieved by the warm douche (Clarke's aural 
 douche). 
 
 Dr. F. M. Pierce, 1 of Manchester, England, reported a case 
 where the symptoms, arising apparently from inspissated ceru- 
 men, were more severe than any I have ever seen in my prac- 
 tice, yet from the severity of cases which I have seen, I can 
 well imagine Dr. Pierce's case. 
 
 Four days before Dr. Pierce saw the patient a chemist, age not stated he 
 had a severe earache after taking a cold bath, which soon became a diffused in- 
 cessant pain over the whole head and neck, with nausea, vomiting, and fever. 
 His case was regarded as one of cerebral inflammation until the fifth day of his 
 illness, when Dr. Pierce saw him and examined the ears. The watch was not 
 heard on that side, while a tuning-fork placed on the head was heard only on 
 that side. The walls of the canal were swollen and congested, and there was 
 impacted wax. This was removed piecemeal by the forceps, syringe, and a warm 
 lotion was dropped into the ear. The next day the patient was free from pain, 
 fever, and nausea, and he could hear the watch two inches. After syringing the 
 ear (clearing out the remains of the wax ?), the watch was heard thirty-six inches, 
 and the patient fully recovered. 
 
 Dr. Pierce suggests, and I suppose the reader will agree with 
 him, that the cold water in the canal set up a diffuse inflamma- 
 tion, which was favored by the presence of a hard foreign body, 
 which was probably not fully impacted when the water got into 
 the ear, but which became so, and increased the inflammatory 
 symptoms. 
 
 In many cases it will be necessary to treat the auditory canal, 
 after the removal of the wax, for a diffuse inflammation. I 
 then use a solution of nitrate of silver of say twenty grains to 
 the ounce, pencilling it upon the canal, especially at the junc- 
 tion of the cartilaginous with the osseous portion, every other 
 day, until the normal condition is restored. 
 
 Medical Times and Gazette, March 30, 1878.
 
 176 INSPISSATED CERUMEN. 
 
 STATISTICS. 
 
 Two hundred and thirty-one of the 497 cases mentioned on 
 page 158 as treated by me in private practice, were plainly also 
 affected with other diseases of the ear, as follows : 
 
 Chronic catarrh of the middle ear 120 
 
 Subacute catarrh of the middle ear 20 
 
 Chronic proliferous inflammation of the middle ear 24 
 
 Chronic suppuration of the middle ear 19 
 
 Inflammation of the external auditory canal 16 
 
 Eczema 9 
 
 Foreign body 1 
 
 Parasitic inflammation of the external ear 1 
 
 Acute catarrhal inflammation of the middle ear 5 
 
 Disease of acoustic nerve 9 
 
 Other complications 7 
 
 231 
 
 It will be seen that about one-third of the cases seen in my 
 private practice were plainly accompanied, if not caused, by 
 aural inflammation. I am bound to say, that this proportion 
 would have been largely, increased, had I earlier in my practice 
 given as much attention to the study of inspissated cerumen as 
 I now do. It was easy, especially when the patients who were 
 relieved by the removal of a large plug of cerumen said they 
 heard perfectly, "had no more trouble," were "in a new world," 
 and so forth, to conclude that their delight at their recovery 
 from the fulness, pain, and impairment of hearing was founded 
 upon a complete cure of the aural lesion. A little more thorough 
 examination often shows, however, that the wax is but the most 
 striking symptom of an insidious process that will finally, unless 
 checked, destroy all useful hearing power. 
 
 The case of recurrent attacks of inspissated cerumen related on page 170 is 
 by no means a very uncommon one, although not in as aggravated a condition 
 as the one there described. A patient once having inspissated cerumen, is very 
 apt to have a recurrence of the affection. 
 
 COMPOSITION AND FUNCTIONS OF CERUMEN. 
 
 According to J. E. Petrequin, 1 cerumen is of a smeary con- 
 sistency, on account of the soapy material made by the potash 
 
 1 Archiv fiir Ohrenheilkunde, Bd. V., p. 230, from Comptes Rend, de 1'Acad. des 
 Sciences, xvi., pp. 940, 941. 1869.
 
 COMPOSITION OF CERUMEN. 177 
 
 which it contains. A part of it is soluble in water, another in 
 water and alcohol. It also contains, according to the same au- 
 thority, about one-tenth per cent, of water, a mixture of oil and 
 stearine, and a dry material not soluble in water, alcohol, and 
 ether, in which potash, and traces of chalk and soda are found. 
 A s age advances, the parts of the cerumen that are soluble in 
 water and soluble substances increase, but those soluble in cilco- 
 hol diminish ; so that in older persons the cerumen becomes dry 
 and brittle. 
 
 Kessel's account of the cerumen is as follows ' : The contents 
 of the ceruminous glands only differ from those of the sw^eat 
 glands in the fact that the former contain masses of very fine 
 coloring matter. The substance secreted by the ceruminous and 
 sebaceous glands together, is a yellowish -white, rather fluid 
 material, which consists essentially of small and large fat glob- 
 ules, corpuscles of coloring matter in masses, and cells in which 
 single globules of fat and coloring matter are embedded ; hairs 
 and scales of epidermis from the lining of the canal are also 
 found in the canal. 
 
 Those who are curious in regard to the opinions of the last 
 century and the early part of the present one, on the subject of 
 the functions of the cerumen and the affections of the ear caused 
 by the suppression of the secretion, will find the book of Thomas 
 Buchanan, 2 of Hull, interesting reading. Mr. Buchanan ascribed 
 most of the diseases of the ear to impactioii of cerumen or stop- 
 page of its secretion. He believed that it had a very important 
 function in relieving the harshness of the waves of sound. If it 
 were not for the lining of cerumen which is in the meatus, the 
 waves of sound would fall irregularly upon the drum membrane 
 and cause it to vibrate unevenly. Mr. Buchanan also explained 
 Mr. Everard Home's case of double hearing by his theory of defi- 
 cient secretion of the cerumen. It w r as that of a music teacher, 
 who found that after a cold the pitch of one ear was half a note 
 deeper than the other, and that a simple tone was not recognized 
 as one by both ears. This is a specimen of the author's fanciful 
 notions about the important functions of this lubricating and 
 protecting secretion. 
 
 1 Strieker's Manual : The External Ear, by Kessel, translated by J. Orne Green, 
 p. 951. 
 
 2 Physiological Illustrations of the Organ of Hearing, more particularly of the Secre- 
 tion of Cerumen, and its effects in rendering auditory perception accurate and acute, 
 with further remarks on the treatment of diminution of hearing, arising from im- 
 perfect secretion, etc. Being a sequel to the Guide and to the Illustrations of Acoustic 
 Surgery. London, 1828. 
 
 12
 
 178 INSPISSATED CERUMEN 
 
 He makes a disease Tubulus Hirsutus of the growth of 
 hairs in the canal, saying that no one with acute hearing has 
 hairs growing over the surface of the membrana tympani. He 
 also tells a singular story of a man who became very deaf, in his 
 opinion from years of loud talking to a deaf wife. He imagined 
 that the continued screaming at last lessened the sensibility of 
 theportio mollis. 1 
 
 The function of the ceruminous glands, is probably that of the 
 sudoriparous glands. They keep the parts in which they secrete 
 pliable, and also prevent the ready admission of insects. There 
 is no evidence that the cerumen has anything to do with the reg- 
 ulations of the intensity with which the waves of sound reach 
 the ear. 
 
 Hallucinations have been in rare instances relieved by the 
 removal of inspissated cerumen. Professor Mayer, formerly 
 director of the Insane Asylum at Hamburg, is the authority for 
 this statement." 
 
 I once saw a lady who, though not regarded as a person of 
 unsound mind, seemed to be such, and who complained greatly 
 of tinnitus aurium in all its varieties. I found the ears full of 
 impacted cerumen ; but she utterly refused to allow me to remove 
 it, and I never saw her but once. It would have been very inter- 
 esting to know the effect of the relief of the tinnitus upon the 
 hallucinations of which she seemed to be a victim. Epilepsy is 
 said to have been cured by the removal of hard wax from the 
 ear. (See page 205.) Certainly it has been from the removal of a 
 foreign body. It will be seen, by reference to the following 
 chapter, that it may cause ear cough and ear sneezing. 
 
 1 A good synopsis of Buchanan's book will be found in Lincke's Sammluug aus- 
 erlesener Abhandlungen und Beobachtungen aus dem Gebiete der Ohrenheilkunde, 
 Bd. IIL Leipzig, 1836. 
 
 2 Troltsch on the Ear, second edition, translation, p. 531.
 
 CHAPTER VIII. 
 
 FOEEIGN BODIES. 
 
 Exaggeration of the Importance of this Subject. Statistics. Insects. Living Lar- 
 vae. Fish. Inanimate Foreign Bodies. Treatment. Delusions as to Foreign 
 Bodies in the Ear. Foreign Bodies in the Eustachian Tube. Ear Cough. 
 
 IN entering upon the discussion of the subject of foreign bodies 
 in the ear, I desire to express the conviction that its impor- 
 tance has been often exaggerated. The reader of medical jour- 
 nals, who has not given any special attention to diseases of the 
 ear, must be surprised to find this subject figuring so largely in 
 literature, when he knows that the general practitioner of large 
 experience sees but very few of such cases, even if he lives 
 remote from specialists and surgical experts. The reports of 
 hospitals and infirmaries for diseases of the eye and ear also 
 show that the entrance of a foreign body into the auditory canal 
 is brought to the attention of the attending surgeons with com- 
 parative infrequency. 
 
 The following table shows this : 
 
 Total number Number of cases 
 
 of aural of foreign 
 
 cases. bod} - . 
 
 Manhattan (New York) Eye and Ear Hospital, 20 years, 20,103 130 
 
 New York Eye and Ear Infirmary, 1889 3, 738 49 
 
 New York Ophthalmic and Aural Institute, 1889 983 10 
 
 Brooklyn Eye and Ear Hospital, 21 years 23,729 309 
 
 Massachusetts Eye and Ear Infirmary, 1889 3,952 19 
 
 Salem Hospital, 15 years 1,276 21 
 
 St. Michael's Hospital (Newark, N. J.), 1888 615 
 
 Newark Eye and Ear Infirmary, 1889 1,296 13 
 
 Illinois Eye and Ear Infirmary, 1885-1886 1,971 
 
 Buffalo Eye and Ear Infirmary, 1889 171 
 
 57,834 562 
 
 i 
 
 In the Manhattan Eye and Ear Hospital, for twenty years. 
 130 cases of foreign bodies in the ear have been presented for
 
 180 FOREIGN BODIES. 
 
 treatment, and 2 of supposed foreign body. In my private prac- 
 tice in 4800 cases there were 2G of foreign bodies, and 4 in which 
 the patient or friends supposed there was one, and yet none was 
 found. 1 These statistics show that foreign bodies in the ear, are 
 not as frequently seen by the surgeon, as the inexperienced prac- 
 titioner might be led to suppose. 
 
 But my opinion that the importance of the subject has been 
 exaggerated, by the great mass that has been written upon it, 
 is not founded altogether upon the relative infrequency of the 
 cases. If cases, that are comparatively uncommon, are still very 
 dangerous, in nearly every instance when they do occur, the 
 medical teachers have a right to call attention to them as being 
 very important and to dwell upon them, even at the risk of 
 wearying their listeners and readers. But foreign bodies in the 
 auditory canal as a rule, are not dangerous. In this respect they 
 have none of the importance of foreign bodies within the eyeball. 
 Foreign bodies in the tympanic cavity, are necessarily dangerous 
 and destructive to the functions of the ear, but in the vast major- 
 ity of cases of foreign bodies in the ear, the foreign body is this 
 side of the drum-head. 
 
 This much is said by way of introduction, with the hope 
 that it will enable the practitioner who may consult these 
 pages, to enter upon the management of a case of foreign 
 body in the ear, when it comes to him, with coolness and with- 
 out fear that he has one which will brook no delay, and which 
 will tolerate no mere palliative means, without danger to the 
 hearing or the life. 
 
 ' The usual point of entrance of foreign bodies into the ear, 
 is through the external auditory canal. They sometimes pass 
 beyond this part and become lodged in the cavity of the tym- 
 panum, or Eustachian tube, while in some rare instances a for- 
 eign body has entered the ear through the Eustachian tube. I 
 have therefore entitled this chapter "Foreign Bodies," so that 
 I might properly include all such cases in the descriptions that 
 are about to be given. 
 
 The foreign bodies that are found in the auditory canal, are 
 very naturally placed under three heads : insects, or the like, 
 which creep into the passage ; their larvae, which are generated 
 there ; and various articles, such as beads, buttons, peas, beans, 
 and so on, which are pushed into the ear by children or silly 
 adults, or which may be thrown into the ear. 
 
 1 Buckner's statistics, made up from various authorities, show that of a total of 
 43,730 cases, 670 were cases of foreign bodies. Archiv fiir Ohrenheilkunde, 1883.
 
 INSECTS. 
 
 INSECTS. 
 
 When a live insect gets into an ear, the pain produced is 
 usually intense and agonizing. Insects are more apt to get into 
 the ears of sportsmen while hunting in thicket and underbrush, 
 and of farmers laboring in the field, than of dwellers in cities 
 and towns. Yet, on the hot days of summer, when insect life 
 is very active, the city practitioner will sometimes be called to 
 remove a bug from the ear, if the agony induced by the foreign 
 body do not stimulate some of the family to a successful at- 
 tempt at its removal. 
 
 There is an insect, which lives on the leaves of fruits and 
 flowers, and which, like others, sometimes flies into the ear, 
 which is called an ear- wig, and there was an ancient supersti- 
 tion that it crept into the brain through the ear. The forficula 
 auricularis, or so-called ear-wig, has probably no more propen- 
 sity to fly into the ear than any other insect ; any of the ordi- 
 nary flies may do so. 
 
 I have seen a few cases of cockroaches in the ear, as well as 
 croton bugs. I have never had any difficulty in removing them. 
 In some instances they die in the ear, and then they become the 
 nucleus for the collection of cerumen about them. 
 
 The most efficient and the speediest means of removing an 
 insect from the ear is the use of a syringe and warm water. As 
 little animals usually get into the ear when the patient is in the 
 fields or forests, where physicians are not always at hand, lay- 
 men should be taught, in the case of the occurrence of such an 
 accident, to immediately pour water or any bland fluid in the 
 meatus. This will disturb the animal and either drown it or 
 cause it to run out. 
 
 Some writers advise the use of an oil dropped into the ear 
 before the water is used, but Wilde and Troltsch agree that this 
 is an unnecessary waste of time. In all the cases I have treated, 
 the insect was promptly dislodged by the use of the syringe, and 
 I have no doubt that the simple filling of the auditory canal 
 with water, will cause insects to come out at once. 
 
 LIVING LARVAE IN THE EAR. 
 
 Insects sometimes deposit their eggs upon the pus of a sup- 
 purating ear. According to Wood, who is quoted by Blake, 1 
 insects have a very acute sense of smell. "No flock of vul- 
 
 1 Living Larvae in the Human Ear. Archives of Ophthalmology and Otology, VoL 
 II., No. 2.
 
 182 LIVING LARVAE. 
 
 tures can be directed more unerringly to their revolting prey by 
 scenting its odors from afar." 
 
 The odor of an otitis media purulenta, thus brings the insect 
 to deposit its eggs in the auditory canal and cavity of the tym- 
 panum, where they soon become grubs or larvae. 
 
 These larvee always excite considerable, and sometimes very 
 severe pain, but in the cases which I have seen, the patients 
 complain much more of the wriggling movements of the grubs 
 in the ear, than of the pain. 
 
 The ancient works on aural diseases speak very much of 
 worms in the ear and of the proper means of removing them. 
 It is probable, that these so-called worms, were the larvae of 
 insects wfyich germinated from eggs deposited in the pus of a 
 chronic suppurative process. Certain it is, that the practitioner 
 of the present time, sees very little of worms in the ears, since 
 the habit of cleansing an ear from pus, has become a well- 
 recognized duty. The pain from the presence of these grubs, 
 which actually fasten themselves, when hatched, into the tissue 
 of the canal, and bite upon it, as it were, is apt to occur sud- 
 denly. An Austrian physician, Dr. Scheibenzuber, 1 reports a 
 case of a peasant ploughing in the field, who was seized in an 
 instant, with a severe pain in the ear, which he ascribed to the 
 flying in of a bug, but the surgeon found the ear full of well- 
 developed larvae. 
 
 I have several times observed dead insects, in the pus that 
 was washed out from an external auditory canal, and it is un- 
 doubtedly true, as I have already suggested, that we should, 
 equally with the ancients, have many cases of living larvae in 
 the ear, were it not that suppurating ears are usually now- 
 a-days regularly cleansed. 
 
 The larvae that have thus -far been found in the ear are those 
 of the muscida sarcophaga (Blake, Gruber), and of the muscida 
 lucilia (Blake). Dr. Blake * has made a study of the nature and 
 habits of these grubs, by taking them from the ear at a very 
 early period of development ; as near as could be ascertained 
 within twelve hours of the time of their deposit. He placed a 
 specimen on the bottom of a thin glass vessel, and covered it 
 with a piece of raw beef, soaked in warm water, in such a man- 
 ner that by inverting the glass the movements of the larvae 
 could be easily studied under the microscope. Dr. Blake found 
 that the apparatus by which the larva attaches itself, and which 
 pierces and tears the tissue, is made up of a strong but delicate 
 
 1 Monatsschrift fur Ohrenheilkunde, Jahrgang III., Xo. 3. 
 * Archives of Ophthalmology and Otology, loc. cit.
 
 LIVING LARV.E. 183 
 
 framework of horny consistency and of two hooks also of a 
 stout horny structure, articulating with this framework. The 
 larva burrows its way into the tissue on which it feeds by re- 
 peated extension and contraction of the hooks, alternately pierc- 
 ing and tearing. These movements explain the agonizing pain 
 which patients experience when the larvae appear from the 
 eggs. These hooks are very large in proportion to the size of 
 the body of the larvae. 
 
 Dr. Blake says that the instincts of the animal lead it to bury 
 itself beneath the surface, and to seek warmth and moisture 
 and a soft, yielding tissue for its work. Hence they are always 
 found at the end of the canal, or in the cavity of the tympanum. 
 As yet, they have always been found in connection with sup- 
 puration of the middle ear, with its consequent perforation of 
 the membrana tympani. 
 
 The examination of the auditory canal infested by living 
 larvae, shows small white worm-like animals moving rapidly 
 about, very much as a mass of common earth-worms. As I 
 write, I have before me a number of specimens of the dead 
 grubs. They are about half an inch in length, and of the 
 diameter of a large knitting-needle. 
 
 Dr. Gruening reported at a meeting of the New York Oph- 
 thalmological Society, in 1882, a case of living larvae in the 
 auditory canal when the tissues were sound, but his case is as 
 yet unique in literature, I believe. 
 
 Very small fish, have been known to enter the auditory canal 
 while the victim was bathing. One of my patients, a lady, gave 
 me a minute account of such an occurrence to herself. The 
 little intruder caused great pain for some hours, and finally 
 came out spontaneously. In the Reading (Pa.) Eagle of July 9, 
 1880, there is a circumstantial account of a case of the entrance 
 of a fish two inches long, into the ear of a boy of fourteen, while 
 he was bathing. According to this account, he suffered for 
 two weeks from intermittent and severe pain. As his parents 
 thought it was "only an earache," no physician was called. 
 Laudanum, rabbits' fat, and molasses were among the remedies 
 used for the two weeks that the boy was suffering intolerable 
 pain, which greatly reduced his strength. The mother of the 
 boy, finally, in one of his fits of pain, wound a handkerchief 
 around the head of a pin and probed the ear. " She saw some- 
 thing protrude," and got hold of it and pulled it out, when it 
 proved to be a living fish of the length above stated. The lady 
 who, while she was under my care for aural affection of another 
 kind, told me of her sufferings from the entrance of a. small fish 
 into the auditory canal, also said that the pain was so decidedly
 
 184 LIVING LAEVzE. 
 
 intermittent in character, she being for some hours at a time 
 without pain, that she could not believe anything animate in 
 her ear was causing the trouble. 
 
 Treatment. I have found it impossible to remove living larva? 
 by means of the syringe. The more they are syringed the more 
 lively they become. Before the syringing is attempted, some 
 agent should be instilled into the ear which will kill them, when 
 the syringe will usually remove them. Sometimes, however, 
 even after death, their hooks penetrate so deeply into the tissue 
 that they can only be removed with the forceps. The forceps 
 should not be needlessly used, however, for even with the most 
 careful manipulation, and with tractable patients, they often 
 abrade the integument of the canal, and thus cause pain. I 
 have used Labarraque's solution of chlorinated soda, to kill these 
 grubs, but simply because it was at hand when I saw the cases. 
 
 The larvse have also been killed by forcing the vapor of 
 chloroform into the cavity of the tympanum through the Eusta- 
 chian tube. I believe, however, that it will be sufficient to force 
 the vapor into the external ear, or to instill some such fluid as I 
 have mentioned into the canal. 
 
 It need hardly be said, that the disease which allowed of the 
 deposition of the eggs, and the hatching of the grubs, should be 
 treated after they have been removed. Even those who are 
 advocates of allowing a discharge from the ear to remain un- 
 checked, will hardly defend such a neglect when the ear has 
 become a disgusting receptacle in which larvse are formed. 
 
 INANIMATE FOREIGN BODIES. 
 
 The foreign bodies that are placed in the ears of children by 
 themselves or their playmates, have, from the time of the first 
 writers on otology, formed a fertile field for the labors of sur- 
 geons. From some source or other, the laity have got the im- 
 pression that a foreign body in the ear, like a wild beast acciden- 
 tally let loose upon a civilized community, is to be hunted down 
 at all hazards. The presence of a foreign body in the canal is, 
 after all, however, not a very serious matter. Children do not 
 usually push them in far enough to do any harm. It is the 
 meddlesome interference of nurses and friends, and sometimes 
 of unwise practitioners, that forces them into dangerous posi- 
 tions. There was a notion prevalent in England, in Shakspeare's 
 times, 1 that poison poured into the ears was as dangerous as if 
 
 1 Hamlet, Act III., Scene 2.
 
 INANIMATE FOREIGN BODIES. 185 
 
 taken into the stomach ; and from this, in some manner or other, 
 has come the idea that a foreign body in the ear becomes at once 
 a very dangerous thing. 
 
 It would be well, if this fear of foreign bodies in the ear, 
 were transferred to cases where they have entered the eyeball, 
 where the most serious results do occur from the neglect to 
 promptly remove a foreign substance. Unskilful or indiscreet 
 attempts to remove a foreign body from the ear, are often more 
 dangerous than the foreign body itself. In the case of a foreign 
 body in the eye, it is the loss of sight that is threatened, and it is 
 usually the worst that can happen ; but it is not a very rare ex- 
 perience, that improper attempts to remove a foreign body from 
 the ear, have cost the life of the patient. 
 
 When, therefore, a child is brought to the practitioner, in 
 whose ear there is, or there is supposed to be, a foreign body, let 
 him first, by ocular examination, be sure that the diagnosis is 
 correct, and then let him attempt to remove it by a safe means. 
 
 "First catch your hare," is the quaint and familiar beginning 
 of the old receipt for cooking this animal ; and in imitation of 
 this sage advice, the writer, taught by experience that the diag- 
 nosis of mothers and nurses is not always to be trusted, would 
 urge upon his readers the wisdom of not attempting to remove 
 a foreign body which he cannot see. There is nothing more 
 deceptive than the tactile examination. Again and again, have 
 I seen physicians click with a probe, what they supposed to be 
 a foreign body, when they were simply striking the bony wall 
 of the canal. The surgeon should not take the testimony of 
 the most intelligent nurse in the world, as to the presence of a 
 foreign body in the ear, unless he sees it himself. Such testi- 
 mony is only valuable to prove that a foreign body was once in 
 the ear. Any attempt to remove a foreign body that is not seen, 
 but which is supposed to be in the ear, will usually lead to a dan- 
 gerous and mortifying failure. Even when it is seen, a forcible 
 or violent attempt is always a dangerous procedure. 
 
 Voltolini, 1 in writing on this subject, says, "that even the 
 point of a dagger, if allowed to quietly remain in the ear, will 
 not do as much harm as forcible attempts to remove it." 
 
 The danger to be apprehended from attempts to remove a 
 foreign body by the use of force is, that it will be pushed down- 
 ward in the ear, and through the membrana tympani into the 
 cavity of the tympanum, and even into the labyrinth. Unfor- - 
 tunately for the fair fame of surgical science, such cases are on 
 record. 
 
 1 Monatsschrif t f iir Olirenheilkunde, Jalirgang II. , Xo. xi.
 
 186 INANIMATE FOKEIGN BODIES. 
 
 Treatment. If the physician see a case in which a foreign 
 body has really got into the auditory canal a fact which he 
 should determine by the use of the speculum and the otoscope 
 before it has been meddled with, he will almost always be able 
 to remove it by the process of syringing the ear with warm 
 water. Children, however young, will readily submit to this 
 operation, and it is almost always successful, if, as I have said, 
 there have been no previous manipulations with instruments. 
 Unfortunately, however, the cases are not usually seen by a 
 physician until the friends of the little patient, having found by 
 the child's own statement that a bead, or a pea, or a shoe-button, 
 or the like, is in the canal, and having been able to see it, have 
 pushed it well in, in their misguided zeal to remove that which 
 in itself is not dangerous to the ear or its functions. 
 
 Many cases are on record where foreign bodies, which had 
 not occluded the auditory passage, have remained in it for years 
 without doing harm. Thus Wreden 1 reports a case in which he 
 removed a button from the outer ear, which had remained at the 
 junction of the osseous and cartilaginous canal of a boy of seven- 
 teen, for twelve years, and without doing any harm. If, how- 
 ever, the foreign body has become impacted by the attempts to 
 remove it, and if serious inflammatory symptoms have arisen, it 
 is better to wait until the latter have subsided before any further 
 attempts at removal are made. 
 
 Then, if instruments are to be used, the child should be placed 
 under the influence of ether, and by means of a small bent probe 
 or hook (a wire loop will often do good service), or the instrument 
 used for dividing the capsule of the lens in the operation of ex- 
 traction, it should, if possible, be dislodged from its wedged 
 position, and then removed by the syringe. No manipulation of 
 this kind should be attempted, however, unless the foreign body 
 is well illuminated, so that the surgeon can see exactly what he 
 is doing during the whole of his manipulations. 
 
 In cases where injections made while the patient is in an up- 
 right position, do not remove the foreign body, Voltolini has 
 adopted the following method with success : 
 
 The child is laid upon a table, so that its head may hang a 
 little over the end of it. The membrana tympani then forms a 
 plane with the upper wall of the auditory canal, that runs ob- 
 liquely downward. The syringing is then performed as usual. 
 In two cases Voltolini has succeeded in removing the foreign 
 body by this manoeuvre, when the ordinary method did not 
 succeed. 
 
 1 Monatssclirift fiir Ohrenlieilkunde, Jahrgang III., No. 12.
 
 INANIMATE FOEEIGN BODIES. 187 
 
 Voltolini has also used the galvano-caustic in breaking up 
 the so-called Johannis brod, or carob bean. The bean having 
 become so firmly wedged into the ear that it was impossible to 
 move it one way or the other, he inserted the needle "with 
 lightning-like rapidity " into the body, and when it cooled, the 
 bean broke with a snap audible to the patient and to those about. 
 When sufficiently broken up, it was removed by syringing. 
 
 Foreign bodies, such as peas, beans, and the like, are harder 
 to remove after they have been in the ear for some time, than 
 metallic bodies, because they swell and thus become wedged 
 firmly in the canal, and if they have been pushed into the cavity 
 of the tympanum they excite still more trouble and become still 
 more unmanageable. 
 
 I have notes of forty -four cases of foreign bodies in the ear 
 that have occurred in my practice, and I have never but in one 
 case failed to remove the offender, and then I saw the patient 
 but once for a few moments. The syringing did not succeed, 
 and I asked the mother to bring the patient to my clinic at the 
 hospital, where she might be placed under the influence of an 
 ansesthetic, but she was not brought. 
 
 In one case, when the child first came under my observation, 
 a button was lodged in the cavity of the tympanum by efforts 
 to remove it. I syringed it in vain on several occasions. I then 
 proceeded carefully with instruments, the patient being anaes- 
 thetized. This attempt also failed. I then ordered the mother 
 to syringe the ear three times a day, which was necessary on 
 account of the purulent otitis media which had been set up by 
 the presence of the button in the cavity of the tympanum, and 
 I also advised the careful use of poultices. To my delight, in 
 about four weeks I had the satisfaction of removing the button 
 from the canal, where it had been brought by the syringing and 
 the use of the poultices. 
 
 For years, I had under my care, a little child of four years 
 of age, who, according to her own statement to her nurse, put 
 an ordinary shoe-button, made of papier-mache, in her ear. As 
 soon as the nurse's attention was called to the case, she re- 
 ported it to the family, who sent for a physician, who saw the 
 button, and attempted to remove it, under chloroform, using for 
 this purpose a small elevator. It is stated that half the button 
 was removed in this way ; but the other half could not be dis- 
 lodged. 
 
 In a few days, the child having become very weak from the 
 operation and the anaesthetic, I was called in consultation. A 
 careful examination was made. The membrana tympani was 
 found to be gone, there was considerable swelling of the canal,
 
 188 FOREIGN BODIES. 
 
 but the button was not to be seen either by the physician or 
 myself, although he thought he detected it with the probe. 
 
 Another surgeon was called in, and he was not able to find a 
 foreign body, and the child was under treatment for years for 
 a chronic suppuration of the middle ear, the membrana tympani 
 and the ossicula being gone, and the hearing irretrievably in- 
 jured. 
 
 I recite such cases, in order to show what harmful conse- 
 quences may result, from the most conscientious attempts to 
 remove a foreign body with instruments. 
 
 No engravings are given in this volume of the numerous 
 hooks, forceps, perforators, drills, picks, et id genus omne, that 
 have been devised by surgeons, with more ingenuity than wis- 
 dom, for the removal of foreign bodies from the ear, because I 
 firmly believe that the vast majority of such instruments are 
 very dangerous weapons ; while they are usually greatly in- 
 ferior in efficiency to the use of the warm water and syringe. 
 Cases will occur, however, in which syringing will not be suf- 
 ficient ; but I should not hasten unduly, unless the body had 
 become impacted in the tympanic cavity, or was causing un- 
 pleasant or serious symptoms. In such cases the ordinary arma- 
 mentarium of the surgeon will generally contain instruments 
 adapted for the individual cases as they occur. Let him remem- 
 ber, however, that once beyond the membrana tympani, he is 
 dealing with parts whose injury becomes dangerous not only to 
 hearing but to life. 
 
 Dr. Elsberg ' thinks very highly of a delicate double screw 
 hook, with two little prongs pointing in different directions. It 
 can be introduced into the canal and laid against a sensitive 
 part, according to Elsberg, without causing pain or injury. By 
 twirling it around from left to right, the prongs will endeavor 
 to bury themselves into the substance they rest against ; on re- 
 versing the motion it unscrews, taking no hold, or letting go if 
 previously fastened. Dr. Elsberg, also uses this instrument for 
 foreign bodies in the nose. He only advises its use in the ear in 
 exceptional cases, that is, those in which syringing fails. For 
 the removal of impacted cotton, such as one case reported by 
 Elsberg, 2 I have no difficulty when I use the ordinary angular 
 forceps, with delicate teeth. I have never been in the habit of 
 classifying all the cases where wads of cotton are pushed down 
 to the bottom of the canal, in cases of aural disease, among for- 
 eign bodies. They are very common accidents in the treatment 
 
 1 Medical Record. February 1, 1870. 
 
 2 Detroit Lancet, September, 1882.
 
 INSTRUMENTS FOR FOREIGN BODIES. 189 
 
 of aural disease by the patient himself, and hardly seem to me 
 worthy of more than an allusion. 
 
 Patients who use Toynbee's artificial drum-head, occasionally 
 lose the disk of rubber in the ear, and come to a surgeon for its 
 removal. This is usually easily accomplished by the syringe. 
 If not, a bent probe may be used to lift up the disk to a situation 
 where it can be readily grasped with the forceps. Such patients 
 from their experience in this direction, are very tractable and 
 tolerant of manipulations in the canal. Consequently the re- 
 moval of foreign bodies from their ears is a very simple matter, 
 as a rule, certainly as compared with a similar operation upon 
 children. Some years after Dr. Elsberg had published his ac- 
 count of his instrument, he found that other surgeons, some 
 forty years before him, had invented similar instruments. It 
 will be found on study of the old text-books, especially those of 
 Lincke and Frank, that most, if not all, of the modern inventors 
 of instruments for extracting foreign bodies from the ear, have 
 been anticipated, and that there remains not much to discover 
 in this field. 
 
 For example, Dr. Kinne l recommends a hook made of a pin. 
 Dr. Gross' instrument is essentially this instrument, as is the 
 cystotome used in cataract operations and often used by aural 
 surgeons. It is passed behind or to the side of the foreign body, 
 when it is easily fastened upon, and a dislodgement occurs. 
 One of my staff at the Manhattan Eye and Ear Hospital, Dr. F. 
 M. Wilson, lately removed .a bead from the auditory canal of a 
 child by "stringing" it upon a Bowman's lachrymal probe. Dr. 
 Wilson intended to use the probe to dislodge the bead, but find- 
 ing he could easily pass it into the eye of the bead, he did so. 
 Dr. Knapp " lays some stress upon the use, in difficult cases, of a 
 flexible silver hook, the concave side of which is roughened and 
 hollowed out. Such a hook, it is claimed, is less likely to slip off 
 the foreign body. Dr. Knapp adds his testimony to the nearly 
 unanimous general statement of experienced surgeons upon this 
 subject, that he does not remember a single case in which he 
 failed to remove a foreign body by syringing or by the hook. 
 The recommendation by Politzer 3 to use alcohol in the ear to 
 avoid swelling of the canal from the prolonged use of water, is 
 a good one, and, as Knapp says, it may be enlarged so as to in- 
 clude its use for swelling of the canal from the swelling of the 
 foreign body itself, since alcohol is such an excellent remedy for 
 the shrinkage of proliferating tissue. 
 
 1 Detroit Lancet, June, 1882. " Medical Record, January, 1883, p. 25. 
 
 3 Text-book, translation, p. 628.
 
 190 DETACHMENT OF THE AURICLE. 
 
 The ancient suggestion of Hippocrates, Paul of ^Egina, 'and 
 Du Verney, which was revived and re-suggested by Troltsch in 
 1802, to detach the auricle from the ear, will be found worthy of 
 consideration, when it is found impossible to remove a foreign 
 body through the canal. It is not a dangerous operation, and it 
 is much to be preferred to any risk of serious injury to the cavity 
 of the tympanum or the labyrinth. 
 
 Following the suggestion of Troltsch, I performed the opera- 
 tion of detachment of the auricle for the removal of a foreign 
 body in April, 1874. In 1881 Dr. J. Orne Green ' performed the 
 same operation, and, in 1882, Dr. A. H. Buck. 2 
 
 According to Politzer, 3 it has also been performed by Lan- 
 genbeck (Berliner Med. Wochenschrift, 1870), who removed a 
 button from the tympanic cavity after partial separation of the 
 posterior attachment of the auricle. Moldenhauer, 4 in 1881, also 
 removed a stone from the auditory canal of a boy of three and a 
 half years of age, after completely detaching the auricle posteri- 
 orly. Schwartze adds a note to Moldenhauers article, the latter 
 writer having quoted him from Troltsch's text-book, to state 
 that he has separated the auricle in three cases for the removal 
 of foreign bodies from the ear. Schwartze gives no more exact 
 date to his operations than to say, " In the beginning of the last 
 ten years," (Aus dem Anfange des vorigen Decenniums). This 
 probably means in the years 1872, 1873, or 1874. From all this 
 it appears, that either Schwartze or myself, was the first to per- 
 form this operation, after it was suggested by Paul von JEgina 
 (see introductory chapter), and re-suggested by Troltsch in the 
 first edition of his text-book. 
 
 Schwartze 5 urgently advises against the cutting out of pieces 
 of the cartilaginous canal or a partial chiselling out of the pos- 
 terior wall of the osseous canal, in order to get a larger field of 
 operation in removing a foreign body from the ear. 
 
 The case in which I performed this operation, was that of a 
 gentleman, who when about sixteen years of age, was accident- 
 ally shot by himself, the shot entering the ramus of the upper jaw. 
 The zygoma and the outer wall of the orbit were fractured. The 
 auricle was detached and the lower jaw was broken. Twenty-two 
 shot were removed from various parts of the face. The auditory 
 canal became nearly closed, but there was a constant discharge 
 of pus from it. It was evident that the bony canal or tympanic 
 
 1 Transactions American Otological Society, Vol. II., p. 471. 
 
 s New York Medical Record, December, 1882, p. 676. 
 
 'Text-book, translation, p. 631. 
 
 * Archiv fur Ohrenheilkunde, Bd. XVHI. , p. 59. B Loc. cit.
 
 DETACHMENT OF THE AURICLE. 191 
 
 cavity, or both were fractured, for pieces of dead bone came 
 away. Granulations sprouted up in the canal, and severe head- 
 aches constantly recurred, so that the patient was prevented 
 from engaging in business or study. Lead probes were used to 
 keep the canal dilated. In 1874 one was lost in the canal or 
 tympanic cavity, and all attempts to remove it had failed. 
 Then Mr. W- - came under my care. I used the usual means 
 to find and remove the style ISTelaton's probe, sponge tents, and 
 so forth but I was unsuccessful. I was never certain that I had 
 found it. The canal was narrow and inflamed, the drum-head 
 was gone, and manipulation was difficult. I then determined 
 to detach the auricle. The patient was placed under ether, and 
 with the assistance of Dr. F. H. Rankin, now of Newport, R. I., 
 and Dr. Sturgis, of this city, I separated the auricle from the 
 bone posteriorly, and searched for the style. Similarly with 
 the experience of Buck and Moldenhauer, I did not find that the 
 operation enlarged the field of operation or exposed the tympanic 
 cavity, as freely as I had been led to hope. Yet the detachment 
 was of very great and essential assistance. The style ivas not 
 found, but a shot was removed from the tympanic cavity. The 
 wound was united by suture and healed by first intention, the 
 facial neuralgia passed away after the removal of the shot, and 
 in 1879 the leaden style came away spontaneously, the patient 
 all the time taking good care of the purulent affection of the 
 middle ear and canal by syringing, and so forth. The shot 
 must have made the pressure that caused the neuralgia, since it 
 ceased when this was removed. 
 
 The operation of detachment of the auricle, has certainly now 
 a sufficient foothold in the experience of surgeons, to relieve it 
 from the stigma cast upon it by a distinguished professor, who 
 once said that "the idea of separating the auditory canal from 
 the squamous process of the temporal bone, with a view of ob- 
 taining access to the extraneous substance, as suggested by Von 
 Troltsch, is so absurd that it ought to be ranked among the ex- 
 ploded notions of the barbarous ages." Another writer, in the 
 American Journal of Otology, January, 1881, alluded to the 
 operation only to speak of its " utter futility," but in spite of this, 
 it is now a sound surgical procedure, based on an experience that 
 fully justifies its performance, whenever it may be indicated by 
 an inability to get at a foreign body through the canal. 
 
 Dr. Orne Green performed the operation on May 11, 1881, upon a man who, 
 with suicidal intent, placed the muzzle of a small revolver directly in the right au- 
 ditory meatus, and fired two shots in that passage. Three days after, the patient 
 was brought to the City Hospital of Boston, complaining only of headache, sore-
 
 192 DETACHMENT OF THE AURICLE. 
 
 ness of the ear and face on the side of the injured ear. The meatus was found 
 filled with half-burnt powder, and with a probe loose foreign bodies were detected. 
 Three days after admission a semi-circular incision was made above and behind 
 the auricle, through the periosteum, and the periosteum with the auricle and 
 cartilaginous rneatus earned forward until the edge of the osseous meatus was 
 reached. Dr. Green then readily seized a loose foreign body, an irregular bit of 
 lead. After syringing and digging out masses of powder, the anterior osseous wall 
 of the meatus was found to be loose and was removed. A porcelain-tipped probe 
 detected a second mass of lead firmly wedged in. This was loosened and removed. 
 A third mass of lead, also detected by the probe, was gradually loosened and re- 
 moved. The auricle was replaced, the incision united by sutures, and a carbolic 
 dressing applied. The patient did well for four days, he then refused to eat, 
 became delirious, and died six days after the operation. The post-mortem ex- 
 amination showed serum beneath the pia mater and congestion. The dura mater, 
 pia mater, and brain-substance just over the roof of the tympanum were firmly 
 adherent and could not be separated from the bone. Just above, passing into the 
 brain for half an inch, was a small sinus, evidently the track of a piece of one 
 bullet. There were small bits of bone embedded in the dura mater at this point. 
 On examination of the right temporal bone the whole anterior wall of the osseous 
 meatus was found to be wanting, the tissues in front of the ear around the glen- 
 oid fossa were gangrenous. The roof of the tympanum was perforated by an 
 opening 8 mm. long and 4 mm. broad. The bone within the tympanic cavity was 
 entirely bare. The ossicles were gone, and the lower edge of the fenestra ovalis 
 was broken away. No lead was found in the bone. The lead removed weighed 
 in all 48J grains. Two bullets of the size used would weigh 60 grains, leaving 
 llf grains, which in all probability entered the brain. When Dr. Green first ex- 
 amined this case, he found that the meatus was unusually small, and this fact, 
 with the certainty that if the bullets were found they would be flattened, caused 
 him to undertake the operation of detaching the auricle. 
 
 Dr. Green goes on to state, that if one portion of the bullet 
 had not glanced upward, and passed through the roof of the 
 tympanum into the brain, a condition impossible to diagnosticate 
 beforehand, there were no reasons why recovery should not have 
 occurred. Langenbeck, by the aid of this operation, removed a 
 small button which had entered the left tympanic cavity, and 
 caused a very extensive reflex-neurotic pain in the arms, upper 
 jaw, with hyperalgesia of the skin of the affected parts, and 
 finally contraction of the left hand. The wound healed by first 
 intention, except a slight fistula under the parotid. The patient 
 recovered in three days from the reflex symptoms. ' 
 
 Dr. Buck's case should also be given, for I am sure a careful 
 consideration of this subject, will establish this operation in full 
 favor, especially in cases where the foreign body has entered 
 the tympanic cavity, and where in addition to this the meatus 
 externus and canal are abnormally small. It goes without say- 
 
 1 Troltsch, Lehrbuch, Sechste Auflage, p. 510. Leipzig, 1877. Berlin. Klin. Wochen- 
 schrift, 1876, No. 15.
 
 DETACHMENT OF THE AURICLE. 193 
 
 ing, as Troltsch said when he advised a revival of the operation, 
 that it is to be reserved for urgent cases. Yet no surgeon need 
 be deterred from it, by the idea that it is a formidable surgical 
 procedure. It is far from this, and I have no reason for with- 
 drawing my recommendation of it, which I gave in the first 
 edition of this book, published in 1873. 
 
 The case in which Dr. Buck detached the auricle, is in brief 
 as follows : 
 
 The patient was a boy of nine years, in whose right auditory canal a playmate 
 had thrown or pushed a bean. An effort was made to remove it by a physician, 
 but it failed. The boy was then brought to Dr. Francis Delafield, of New York, 
 who, with Dr. Buck the little patient being under the influence of sulphuric 
 ether tried to dislodge the bean, which was seen between the anterior and pos- 
 terior walls of the canal near the membrana tympani. These attempts were 
 made with steel hooks. The bean was what is known as a locust bean, very hard, 
 "the surface is essentially as hard as ivory" (Buck). A locust bean measures 
 10 mm. in length, 7 mm. in breadth, and 5 mm. in thickness. After waiting for 
 some days and making experiments with a dental drill, and by soaking the beans 
 in hot water and nitric acid, and finding the results unsatisfactory, Dr. Buak 
 determined to detach the auricle, which he did. The bleeding was profuse. 
 The bean was seen lying transversely across the long axis of the canal, but it was 
 so firmly impacted that there was great difficulty in removing it with the steel 
 hook, although this was finally accomplished. The case finally did well, although 
 the auricle healed slowly, and granulations formed in the auditory canal. A per- 
 foration of the membrana tympani was found after the operation. This Dr. Buck 
 is inclined to think was caused by the attempts at removal. A note from the 
 physician who first saw the case just narrated, to Dr. Buck, 1 states that he never 
 saw the foreign body at all, but that attempts were made to remove it by "a 
 nurse or one of the lady guests at the house," who used a hair-pin, and then by 
 " a gentleman guest," who used a crochet-needle. 
 
 Thus the old story is repeated. Nowhere do "fools step in 
 where angels fear to tread," more promptly, than when a foreign 
 body has entered the auditory canal of some luckless child. This 
 locust bean was probably firmly lodged by the hair-pin and 
 crochet-needle of the "lady and gentleman guests" who took 
 part in the hunt after a bean, which would have been easily re- 
 moved by the syringe, if it had been left where it first lodged. 
 This case caused Dr. Buck, who formerly looked somewhat 
 askance at the syringe as the first means to be tried for remov- 
 ing a foreign body from the ear, to state that " it is a fair infer- 
 ence to draw from this case, that it is decidedly better for the 
 general practitioner, when called upon to remove a foreign body 
 from the ear, to restrict his efforts to the employment of the 
 syringe with tepid water." 
 
 1 Medical Record, January, 1883. 
 13
 
 194 FOREIGN BODIES. 
 
 Dr. Lowenberg 1 reports an ingenious method by which he 
 removed a small ivory ball, from the tip of a quill pen-holder, 
 which had been forced into the ear of a boy nine years of age. 
 Various attempts at removal, by other hands, wounded the 
 canal, perforated the membrana tympani, and excited severe in- 
 flammation. After the inflammation had subsided. Dr. Lowen- 
 berg attempted to remove the body by syringing, by Valsalva's 
 and Politzer's methods of inflating the ears ; but he failed. He 
 then extracted the ball by bringing the point of a small brush, 
 dipped in joiners' glue, in contact with its outer surface, allow- 
 ing the glue to harden, and then extracting brush and ball to- 
 gether. 
 
 Dr. E. H. Clarke, who is quoted by Blake in the same report 
 from which I have taken the description of Dr. Lovreiiberg's 
 method, once adopted a similar procedure with success. The 
 foreign body was a hard, smooth ball, and it was extracted by 
 passing a thread through a small square of adhesive plaster, 
 and bringing the latter, by means of a fine tube, into contact 
 with the surface of the ball, when sunlight was concentrated 
 upon it by means of a lens, until it softened and adhered, when 
 it was easily extracted. These two methods are certainly to be 
 commended as both ingenious and safe. 
 
 Of the cases of foreign body in the ear, that I have seen in 
 private practice, very few are worthy of more especial notice 
 than I have already given them. 
 
 In two of the cases, both male adults, the foreign bodies were 
 thrown in the ear. In one case the patient was passing along 
 the street when a bean was thrown into his ear. The bean was 
 dislodged by means of a small hook, and then removed with an 
 angular forceps. In the other case some young men were en- 
 gaged in " flipping" beans, and one entered the auditory canal. 
 It was displaced by a probe, and then removed by a syringe. In 
 another case, an okra seed had been pushed through the mem- 
 brana tympani in the efforts to remove it. Suppuration of the 
 middle ear existed when I saw the child, and the okra seed 
 could not be seen. In the course of a year it came out during 
 the syringing, which was advised as a means of treating the 
 ulceration. There was one case, in which a cockroach entered 
 the ear of a man of thirty-six. He came to the office, stating 
 that he had pain in the ear during the night, but without know- 
 ing the cause. The insect was easily removed by the syringe. 
 In another case, that of a lady, quite a large quantity of sand 
 
 1 Report on the Progress of Otology, by C. J. Blake, Transactions American Oto- 
 logical Society, 1872.
 
 MARION SIMS ON FOREIGN BODIES. 195 
 
 was removed from the canal and from the surface of the drum- 
 head. Of the Manhattan Hospital cases, a very large proportion 
 were removed without an anaesthetic, and whether with another 
 instrument than the syringe or not, at least without difficulty. 
 Ten were removed under the use of sulphuric ether, and chloro- 
 form was used in one case. Failure to remove the foreign body 
 did not occur in any case. Two of the cases are said to have 
 been injured by instruments before they came to the hospital. 
 If the notes had been fully kept, a greater number of cases of in- 
 jury from attempts at removal would, I think, have been shown. 
 
 In one of the cases the foreign body had been pushed into 
 the tympanic cavity. It was removed, five days after the first 
 visit to the hospital, by Dr. Parclee, he having dislodged it at the 
 first visit. 
 
 There were two cases in which no foreign body was in the 
 ear, although one was supposed to be. In one case, a piece of 
 the point of a lead-pencil broke off in the ear while the patient 
 was carrying it in her hand. She ran against some obstruction 
 and broke the pencil in her ear. It was easily removed with the 
 syringe. 
 
 My distinguished countryman, the late Dr. J. Marion Sims, 
 published an article, illustrated by three cases, in the American 
 Journal for Medical Sciences, 1 that ver} r warmly and ably advo- 
 cated the use of the syringe for the removal of foreign bodies 
 from the ear, but which did not receive the attention it deserved. 
 
 This was -the first important article Dr. Sims ever published. 
 So impressed was the literature of the period of Dr. Sims' writ- 
 ing, with the idea that forceps, and so forth, must first be used 
 before any other means are tried, that it was only by accident 
 as it were, when washing away the blood caused by fruitless 
 attempts to remove a foreign body by such instruments, that he 
 found the syringe and warm water the very best means of re- 
 moving such offenders. Dr. Sims gives Mr. Carpenter, of Castle 
 Comer, Ireland, the credit for being the first to call the attention 
 of the profession to the universal applicability of the syringe for 
 the removal of foreign trodies from the ear. He also narrates 
 the experience of no less a person than Sir Benjamin Brodie, 
 who'with characteristic British honesty, tells us how lie failed to 
 get a foreign body, a pea, from the ear, after using all sorts of 
 methods, and finally left it to rot and come out of itself, or " to 
 be washed out by a syringe." 
 
 Dr. Sims maintained his interest in this subject long after he 
 had won great fame as a gynaecologist. He read a paper upon 
 
 'Vol. ix., 1845, p. 336.
 
 196 FOREIGN BODIES CASES. 
 
 " The Extraction of Foreign Bodies from the Ear" before the 
 British Medical Association in 1878,' in which he repeated his 
 views as to the value of the syringe. He criticised the ear syr- 
 inges made in London as being clumsy, as having a large 
 nozzle, so that they throw a large stream of water. Dr. Sims 
 recommends for occasional use, in removing foreign bodies for 
 example, the ear syringe so commonly sold in the United States. 
 It is of hard rubber, and holds about an ounce. It is very light 
 and is easily managed with one hand. Useful as this syringe 
 is for occasional use, it is usually so carelessly made, and is so 
 small, that the practitioner who has much use for an aural syr- 
 inge will prefer one of metal, a size or two larger, but having 
 the same, nozzle, and made on the same general plan as the 
 "American hard rubber ear syringe." Even patients who are 
 obliged to use a syringe for a long time, will find a metal syr- 
 inge the cheapest. 
 
 Dr. E. D. Speir," of Boston, recommends pressure with the 
 fingers "upon the skin, close to and in front of the tragus, car- 
 ried upward and around the meatus, upon the auricle, and back 
 again to their starting-point, when the manoeuvre is repeated 
 several times, ".for the removal of a foreign body found in the 
 cartilaginous portion of the canal, and lying upon the wall. 
 
 The same movements of the canal, are advised to effect a 
 change in position of a foreign body lying beyond the centre of 
 the cartilaginous canal, or even one that has been pressed partly 
 into the osseous portion. Dr. Speir gives several instances in 
 which the position of foreign bodies in this canal has been 
 changed by this procedure. It is especially recommended for 
 foreign bodies that have not been tampered with by improper 
 means. It is just these, that may be easily removed by a syr- 
 inge. 
 
 A Pea in the Ear for Thirty Years Unpleasant and Painful Symptoms Final 
 Removal by the Patient Himself. 
 
 My friend, Professor William Darling, having told me of a 
 well authenticated case of a foreign body remaining in the ear 
 for thirty years, at my request, he procured the history for me. 
 I regard it as of sufficient value to warrant its insertion in the 
 patient's own words. 
 
 When a boy in Scotland, nine or ten years old, I put a pea into my right 
 ear, under the impression it would come out at my mouth. I was immedi- 
 
 J British Medical Journal, December, 1878, p. 868. 
 s American Journal of Otology, Vol. III. , p. 197.
 
 FOREIGN BODIES CASES. 197 
 
 ately seized with excruciating pains, and the doctor was sent for. Of course, 
 I told my father and mother where the great pain was located, but I neither 
 told them nor the doctor the cause. I can remember them holding me in bed, 
 while the doctor was dropping some liquid into my ear to try and relieve the pain. 
 The doctor who attended me was the uncle of Professor William Darling, of 
 New York, and I remember many expedients were tried to relieve my agony. 
 Suppuration ensued, and after a time I got b'etter, but the ear was a continual 
 trouble ; if I got wet or cold it went to that sore ear. After coming to Montreal, 
 
 I requested the lata Dr. W. P. S to try and remove the pea, but he would 
 
 not believe there was any foreign body in the ear, and it was only after urgent 
 solicitations that he at last extracted what appeared to me to be the half of the 
 outer skin .of the pea, but which the doctor said was only "hardened wax." 
 After any violent exertion I felt as if the pea was displaced, until I got a night's 
 sleep. 
 
 Before. the opening of the Atlantic, now the Montreal and Portland railway, 
 and before the road was ballasted, I rode from Sherbrooke to Montreal (100 
 miles), with only an engine and tender, and the jolting on the rough road so 
 displaced the pea, that at night it was impossible for me to sleep. I knew the 
 pea was the trouble, so with as long a pin and as small a head as I could find,. I 
 determined to try and remove the pea which' had now been in my ear over thirty 
 years. After cautiously introducing the pin into the ear, a grating sound was 
 felt, and with some trouble the pin head was got over the pea, and by slowly 
 working the pin back and forward, gradually the pea was brought to the open- 
 ing, when unfortunately the pin then slipped out. At this point, the narrator 
 states, he awoke his wife, who in attempting to remove a " black thing " which 
 she saw at the meatus, pushed it back. The patient, however, soon, by careful 
 manipulation with the pin, removed the pea from the ear. 
 
 The writer then continues : Half of the skin still adheres to the pea, but 
 the division and germinating points are as plainly marked to-day as they were 
 upward of fifty years ago. I am now sixty-one years of age. Previous to getting 
 the pea out, I could never sleep on my right side, I was continually bothered by 
 a most annoying singing when the pea was in. The hearing is unimpaired. 
 
 Dr. Ludwig Mayer 1 has collected the cases of foreign bodies 
 in the ear that he has been able to find in the literature of the 
 fifty years preceding 1870. The whole number is 77. Of these 
 persons 
 
 16 were between 1 and 10 years of age. 
 10 " " 10 " 20 " 
 10 " " 20 " 50 " 
 
 1 was over 50 
 
 The age of the remainder is unstated. 
 
 In 66 cases the foreign body was in the auditory canal. 8 were 
 in the cavity of the tympanum, and 3 in the Eustachian tube 
 Of the three cases in the Eustachian tube, two were at the pha- 
 
 1 Monatsschrift fur Ohrenheilkunde, Jahrgang IV. , No. 1.
 
 198 FOREIGN BODIES CASES. 
 
 ryngeal orifice. In the third case, a barley-corn projected from 
 the pharyngeal orifice, and at the post-mortem section it is not 
 stated of what disease the patient died the foreign body was 
 found to reach into the osseous tube. 
 
 In two of the cases the foreign body was in the ear but twelve 
 hours before seen by the^ surgeon who reported them. In only 
 12 of the cases was the foreign body in but a short time, vary- 
 ing from days to weeks. In the remainder they were in for 
 years. Four were in for four years, two for twenty years, one 
 for forty-five, and one for more than sixty years. 
 
 The substances found were a needle, carob beans (6), beans 
 (3), cherry pits (6), living larvae (4), peas (1), a wisdom tooth of 
 the upper jaw, a grain of coffee, a snail, pearls (2), point of a 
 glass syringe, a glass ball, wads of cotton (C5), a carious tooth, a 
 piece of hard coal, a wad of paper, a gun cap, a piece of bone, 
 a piece of bread, a bit of lead, laminaria bougies in the tube (2), 
 a millet seed, a piece of coral, a barley-corn in the tube, and an 
 agate stone. 
 
 Dr. Mayer finds, on an analysis of these cases, that the at- 
 tempts to remove the foreign bodies had usually caused much 
 more trouble in the ear than their presence. 
 
 In 48 of the 77. cases, functional and pathological changes are 
 said to have occurred as a result of the presence of the foreign 
 bodies. In 11 of the cases it is reported that the attempt at re- 
 moval caused these disturbances. 
 
 Pain in the ear was generally the disturbing symptom in 
 those cases in which the foreign body caused any trouble. This 
 was chiefly due to the irritation of the lining membrane of the 
 canal, which is so closely allied to periosteum in its nature as to 
 be subject to intense pain. Besides, as shown by F. E. Weber, 
 the pain in the cartilaginous portion of the canal is severe on 
 account of the fact, that the fibrous tissue of the cartilaginous 
 canal is fastened to the squamous portion of the temporal bone, 
 above and behind, by tense fibres. As has been shown, the 
 canal is very richly supplied with nerves, and this serves to ex- 
 plain the severe pain experienced when a rough body is in the 
 ear, or when the canal is abraded by attempts at the removal 
 of a smooth and harmless one. 
 
 Polypi arose five times in consequence of the inflammation 
 of the ear. Severe hemorrhage occurred five times, and always 
 in consequence of attempts to remove the foreign bodies. 
 
 In one case there was delirium, and in three cases suppura- 
 tive meningitis, and once a cerebral abscess, with, of course, a 
 fatal result. 
 
 The membrana tympani was perforated, and the cavity of
 
 FOREIGN BODIES CASES. 199 
 
 the tympanum inflamed, from the efforts at extraction in the 
 three cases in which meningitis resulted. 
 
 In one case the patient, a child, attempted to push the for- 
 eign body a piece of flint-stone^cmf through the other ear. 
 Suppurative meningitis occurred, and death resulted in a few 
 days. The stone was so firmly fixed in the mastoid cells that 
 trouble was experienced in 'removing it, even at the post-mortem 
 examination. 
 
 In one case on the section, a wad of paper was found in a 
 cerebral abscess which communicated with a collection of pus 
 in the tympanic cavity. It had probably been forced there by 
 the attempts to remove it. 
 
 The disturbances of the nervous system were considerable in 
 some cases, and they throw light upon the influence of chronic 
 aural suppuration upon this part of the organism. In three 
 cases there were general convulsions ; there was paralysis of 
 one side of the face in five cases, atrophy of the arm in two 
 cases, twice there was anaesthesia of the whole of one side of 
 the body. There were two cases of epilepsy. The facial paraly- 
 sis was caused by a continuation of the inflammation to the 
 Fallopian canal and the facial nerve. 
 
 The convulsions and the epilepsy were probably caused by 
 reflex action through the medulla oblongata, due to peripheric 
 irritation of the fifth pair of nerves. 
 
 The cases of atrophy of the arm and anaesthesia of the body 
 are so imperfectly reported, that Mayer does not attempt any 
 explanation of them. 
 
 Our limits do not allow of a complete transcription of the 
 cases which Dr. Mayer has collected with such care ; only a few 
 of the more curious or important ones can receive a further 
 allusion. 
 
 In one case, a horse coughed some oats into the ear of a man 
 as he was going by the animal. 
 
 Deleau, Junior, removed a foreign body from the cavity of 
 the tympanum, an agate stone, by an injection of water through 
 the Eustachian tube. The reader will find this case fully re- 
 ported in Lincke's collection of " Monographs on the Ear." 
 
 The case of atrophy of one arm, epilepsy, anaesthesia of 
 one-half of the body, is the famous one of Fabricius Hildamis, 
 quoted by Von Troltsch. 2 The patient, a young woman of eigh- 
 teen years, is said to have been cured of all these symptoms by 
 the removal of the foreign body, a glass ball, eight years after it 
 
 1 Lincke's Sammlung, Bd. I., p. 154. 
 
 2 Text-book, American translation, p. 490.
 
 200 FOREIGN BODIES CASES. 
 
 was inserted. (See latter part of this chapter for a full account 
 of this case.) 
 
 Handfield Jones ' saw a case in which hemiplegia with con- 
 vulsions arose from the presence of insects in the ear. 
 
 Wederstrandt a reports a case in which molten lead was 
 poured into the right ear of a drunken man. The pain was not 
 severe ; the hearing power was gone. The patient was able to 
 leave the hospital in eight days. The lead was not removed, 
 and severe suppuration occurred. Seventeen months after he 
 was in the same condition, with paralysis of the right orbicu- 
 laris palpebrarum muscle ; a polypus had grown over the lead. 
 
 In three of the cases death occurred, and in all of them it 
 may properly be said to have been caused by attempts to re- 
 move foreign bodies, which, whatever disturbances of the sys- 
 tem they might have produced, would not probably have led to 
 
 death. 
 
 
 
 Mr. Pilcher, in his work on the ear, " reports a very instructive 
 case from the Lancet, in which surgeons of a London hospital 
 attempted to remove from the ear of a child of seven years of 
 age, the head of a nail, which they never saw, but which they 
 felt with a probe. 
 
 The first surgeon to whom the child was brought said he saw 
 the head of the nail, but he did not attempt to remove it because 
 four men could not hold the boy's head still. A director, dress- 
 ing forceps, which were both bent in the forcible efforts, forceps 
 with hooks were used, and they were also bent straight, but the 
 nail could not be removed. An incision was then made behind 
 the auricle, and the meatus was exposed. A search was then 
 made for the nail, with forceps and an elevator. Tooth forceps 
 were then used; three pieces of metal, which appeared to be 
 pieces of the nail, were removed by these delicate instruments. 
 The malleus bone was then removed by the forceps. 
 
 The patient was now so exhausted that "his pulse could 
 scarcely be felt, and his skin was bedewed with cold perspira- 
 tion." 
 
 The operator then stated that he had used "more force than 
 was warrantable." He thought, however, there was now a large 
 opening (sic) through which pus might escape, and yet he feared 
 that a portion of the petrous bone might exfoliate, and that 
 meningitis and abscess of the brain might occur. He stated 
 
 1 Sydenham Society Year-book, 1861. 
 9 American Journal of the Medical Sciences, Vol. IX. 
 
 3 Treatise on the Ear, American edition, by George Pilcher. Philadelphia, 1843- 
 Reprint, p. 219.
 
 FOREIGN BOPIKS CASKS. 201 
 
 that he had seen three or four cases which had terminated in 
 this manner. Of course the little victim died, and that too on 
 the third day after these operative attempts. 
 
 The post-mortem examination revealed softening of the base 
 of the brain, and of the anterior part of the hemispheres. Not a 
 vestige of the bony part of the external auditory canal remained, 
 it having been removed during the operation, and the floor of the 
 tympanum was also wanting. There was considerable pus in 
 the tympanic cavity. 
 
 "The nail not being in the tympanum, sections were made 
 through the cochlea, vestibule, semicircular canals, and mastoid 
 cells; but there was no nail to be found" 
 
 The following case, also belongs in this sad category of great 
 damage done by unwise attempts to extract a foreign body. ' 
 
 Extraction of a Foreign Body from the Tympanum, with Resection of the Tym- 
 panic Ring. The following case is related in the Norsk Magazin for Laeger- 
 idenskaben, vol. xii., No. 11. A little girl, aged four, while playing on the sea- 
 shore had a stone pushed into her ear by her sister. A few days later, upon the 
 sister's confessing her trick, the mother attempted to dislodge the stone by 
 means of a hair-pin, but not succeeding, she took the child to several physicians, 
 one after the other, all of whom made repeated unsuccessful attempts to extract 
 the foreign body. It was then, two and a half weeks after the accident, that the 
 <jhild was sent to the Eigshospital in the service of Dr. J. Nicolaysen. Examina- 
 tion showed numerous erosions in the external auditory canal, the outer two- 
 thirds of which was swollen and ecchymotic, the inner third entirely denuded of 
 skin and periosteum. The drum-head was gone, the tympanic ring bare, and the 
 cavity of the tympanum filled up by the foreign body. The stone seemed to be 
 wedged tightly in the anterior part of the cavity. There was some purulent 
 secretion from the tympanum and meatus. The first efforts at extraction were 
 unsuccessful, and the operation was put off till the following day to give time 
 for the manufacture of some strong hooks. When these were procured they 
 were slipped past the stone, but were broken off and their points left in the 
 cavity of the ear. As the child had several times stopped breathing the chloro- 
 form was withheld and the operation again interrupted. The third attempt was 
 successful. A very fine saw was introduced and two notches made in the tym- 
 panic ring, one directly forward and the other downward. Then the intervening 
 section of bone, about one-fourth of an inch in length, was knocked off with a 
 chisel. The stone was now readily extracted and with it the broken hooks and 
 ossicles. The stone measured 8.75 mm. in length, 5.5 mm. in width, and 4.75 
 mm. in thickness. The well-meant efforts at extraction had siicceeded only in 
 wedging it in the tympanic orifice by its largest diameter, thereby destroying 
 the drum-head and the ossicles. 
 
 The fact has already been alluded to in this chapter, that 
 persons sometimes suppose there is a foreign body in the ear, 
 
 1 Medical Record, vol. xxv. , p. 208.
 
 202 FOREIGN BODIES DELUSIONS. 
 
 when there is actually none in it, and when there probably 
 never has been one there. At times delusions occur on this 
 subject. I have seen several cases of the kind which are quite 
 remarkable. 
 
 Two cases I saw at the New York Eye and Ear Infirm- 
 ary, where the patients, who were women of the lower class 
 of life, supposed that pins were in the auditory canaL No 
 amount of reasoning, nor the subterfuge of pretending to re- 
 move a pin from the ear, by syringing, could satisfy these 
 females. 
 
 In another case a woman brought her son to my clinic in the 
 University of New York, and stated that he was passing pieces 
 of anthracite coal from the external meatus. She had quite a 
 quantity of coal in a handkerchief, which she said had been 
 passed from the ear. Some of these pieces of coal were larger 
 than the auricle. The boy agreed with his mother in her insane 
 statements. I am sorry that they passed from my observation 
 before I could fully investigate the cause or motive for the de- 
 lusion. 
 
 In another part of this work ' allusion will be again made to 
 the cases, not uncommon, in which patients with chronic disease 
 of the middle ear, and persons who perhaps were of sound mind, 
 firmly believed, in spite of the negative result of my examina- 
 tions, that there was inspissated cerumen in the auditory canal. 
 Indeed, the sensation of fulness of the canal in chronic cases of 
 disease of the middle ear, is often so decided as to render such a 
 belief pardonable, in a person who has not full confidence in the 
 surgeon who examines the ear. 
 
 It has been mentioned, in the second chapter, that the hairs 
 of the auditory canal sometimes lie on the drum-head, and thus 
 become irritating foreign bodies. 
 
 We see from all this, that it is by gentle manipulations, made 
 with delicate instruments, under the guidance of personal skill 
 and ingenuity, that these cases are to be managed. An eminent 
 artist was once very earnestly inquired of by an amateur, as to 
 what he mixed his colors with. His answer was, " With brains, 
 sir !" Perhaps nowhere in surgery, does this old anecdote better 
 illustrate the necessity of using instruments with brains, than in 
 the removal of foreign bodies from the ear. 
 
 The conclusions to which I have come, as to the mode of a 
 procedure in cases of suspected foreign bodies in the ear, may 
 be formulated as follows : 
 
 Chapter on Chronic Non-suppurative Inflammation.
 
 FOREIGN BODIES. 203 
 
 1. Assure one's self by ocular examination of the presence of 
 the foreign body. 
 
 2. Try syringing with a large syringe with a small nozzle, the 
 patient being placed in various positions, according to the situa- 
 tion of the body. 
 
 3. If this fail, use a Daviels' spoon, a wire loop, a bent probe, 
 a cystotome used by oculists, or the like, and attempt to 
 change the position of the foreign body, so that the stream 
 of water can get behind it and force it out. This displacement 
 should generally be done under ether, especially in the case 
 of children who have been frightened by previous attempts 
 at removal. 
 
 4. If the foreign body be so wedged in that this method fails, 
 Lowenburg's gluing procedure, Elsberg's instrument, or some 
 one of the numerous aural forceps, are worthy of use. 
 
 5. If no urgent symptoms occur, and these attempts at removal 
 have caused excoriation and inflammation of the auditory canal, 
 wait until they have subsided, meanwhile syringing the ear with 
 warm water several times a day. 
 
 6. If all ordinary and safe procedures through the meatus 
 have failed, separate the auricle and get at the foreign body 
 from behind. 
 
 7. In a case where there are no symptoms of injurious effects 
 from the presence of a foreign body, do not act hastily ! but re- 
 assure the patient's family, that no clanger will result from delay, 
 and wait until proper means can be taken to safely remove the 
 offending substance. It is very seldom, indeed, that there is any 
 urgency in the case, except in the minds of the friends of the 
 generally infantile patient. 
 
 FOREIGN BODIES IX THE EUSTACHIAX TUBE. 
 
 Among the cases whose statistics are reported by Dr. Mayer, 
 two will be noticed where laminaria bougies were broken off in 
 the Eustachian tube. Dr. Hecksher, of Hamburg, relates an 
 interesting case that belongs to this class. The patient was a 
 principal of a college, who had been accustomed to treat his 
 own ears which were affected with chronic catarrh by the 
 use of the Eustachian catheter. 
 
 Dr. Hecksher received a telegram one day from the pa- 
 tient, for whom he had occasionally prescribed, stating that 
 he had got a foreign body in one of his Eustachian tubes. 
 When Dr. Hecksher reached the patient, he gave the following 
 history : 
 
 He had introduced through a metallic catheter a whalebone
 
 204 FOREIGN BODIES EAR-COUGH. 
 
 probe into the tube. On the end of this probe was fastened with 
 a silk thread a raven's feather, which he used for the purpose 
 of washing away mucus from the tube. 
 
 One evening as he was using the apparatus, he drew back 
 the probe without the feather, and he found that he had left it 
 in the tube. It caused so much pain that he could not sleep. 
 Attempts were made by a physician to remove the foreign body, 
 bu' they failed. Dr. Hecksher then attempted to remove the 
 bo^y, but the parts were so swollen that he could not practise 
 rhinoscopy, and see the feather, and he failed with various 
 kinds of forceps to remove it. 
 
 So much inflammation ensued that he was obliged to de- 
 sist, and use antiphlogistic treatment ; but the patient finally 
 removed the feather himself by the aid of the catheter in- 
 troduced in the usual way, and his finger passed behind the 
 uvula. 
 
 Politzer ' also relates two cases, quoted from Urbantschitsch 
 and Schalle, where foreign bodies have reached the cavity of 
 the tympanum from the pharynx. The first was an oat husk, 
 which had stuck in the throat in chewing an ear of grain.. It 
 entered the Eustachian tube and the tympanic cavity, and came 
 through the external meatus. 
 
 In Schalle's case a piece of hard rubber syringe, employed in 
 douching the nose, broke off, and entered the tube and tym- 
 panum. In the drum cavity it caused acute suppuration, and 
 was removed by incision of the membrane. 
 
 EAR-COUGH. 
 
 Every practitioner who has been at all in the habit of ex- 
 amining ears, must have observed a cough which occurs in 
 many patients, whenever a certain part of the auditory canal 
 is touched by a cotton -holder, a probe, or the like. There is- 
 the greatest variation in the sensitiveness of patients in this 
 regard. Some of them scarcely tolerate any contact with the 
 osseous canal without responding by a cough, while others, 
 and by far the greater number, during a long course of treat- 
 ment never exhibit any disposition to cough when the canal is 
 touched. 
 
 Certain other reflex symptoms from irritation of the walls 
 of the canal have been observed for centuries. Such are sneez- 
 ing and vomiting, and even epileptic seizures. For example, 
 Troltsch" quotes from Pechlin, who, writing in 1691, says he 
 
 1 Text-book, English translation, p. 631. 
 9 Lehrbuch, Sechste Auflage, p. 522.
 
 EAR-COUGH. 205 
 
 knew a man in whom contact with the external auditory canal 
 always caused vomiting. Arnold, 1 also quoted by Troltsch, tells 
 a story of a now famous girl, who suffered for a long time from 
 a severe cough and expectoration, who besides often vomited 
 and gradually became very thin, and who was finally relieved 
 from all her symptoms by the removal of a bean from each ear. 
 Arnold relates another case where a " disease of the chest " was 
 cured by the removal of a foreign body from the ear. Toynbee * 
 also records the case of a patient, who suffered from a cough 
 which no treatment subdued, until a portion of dead bone was 
 removed from the auditory canal. The most important of all 
 the cases of reflex symptoms from irritation of the external 
 canal of the ear yet reported, is that of Fabricius, of Hilden, 
 whose case Troltsch also quotes. A girl of ten years of age. put 
 a small glass ball in her ear. Many attempts were made to re- 
 move it, but they were unsuccessful. Finally she was seized 
 with hemicrania, anaesthesia of the entire left side of the body, 
 alternating with severe pain, until at last epileptic attacks oc- 
 curred, with atrophy of the left arm. At eighteen years of age 
 she came under the care of Fabricius, who drew out the story 
 of the glass bead, which had been well-nigh overlooked, since 
 she never complained of earache. He removed the foreign body 
 and cured the patient of all her troubles, as he writes to his 
 friend Bauhinus, " Restituum est quoque brachium." 
 
 Schwartze and Koeppe 3 also speak of reflex phenomena from 
 foreign bodies in the canal. Koeppe, 4 in an article upon "Re- 
 .flex Psychosis from Aural Diseases," relates two cases where 
 treatment of the hose, throat, and ears restored the patients to 
 sound mental condition. In the first case there was ozaena and 
 catarrh of the ears ; in the second hardened blood was removed 
 from the auditory canal, where it had remained for years, as 
 the result of a hemorrhage from a fall, or several falls, upon the 
 head. These cases are exceedingly interesting. 
 
 Dr. Kupper 6 reports a case of epilepsy from a foreign body 
 in the auditory canal, and also a case of cerebral irritation from 
 inspissated cerumen. 
 
 A young woman of eighteen was admitted to the hospital with the following 
 history : She had had severe pain in the right ear, and suppuration had finally 
 occurred. Toothache also set in later, when she put a piece of a root in the 
 
 1 Loc. cit. 
 
 2 Treatise on the Ear, English edition, p 39. 
 
 3 Archiv filr Ohrenheilkunde, Bd. V., S. 283. 
 
 4 Ibid., Bd. IX., p. 220. 
 
 6 Ibid., Bd. XX., p. 167.
 
 206 EPILEPSY FROM FOREIGN BODY. 
 
 suppurating ear to relieve the pain. She was not able to remove it, and since 
 that time she had suffered from epileptic seizures. They often occurred daily 
 and sometimes several times a day. An examination showed the young woman 
 to be well except as to the right ear. The tuning-fork was heard better on that 
 side, the watch was only heard when laid upon the ear. The auditory canal was 
 sensitive on pressure, and full of pus. Careful syringing caused vomiting and 
 vertigo. The canal was filled with polypi that were very sensitive. The pa- 
 tient was put under the influence of chloroform, and the polypi were removed. 
 On the next day the foreign body was removed with a blunt hook and syring- 
 ing, the patient being again under the influence of chloroform. The piece of 
 wood was 1 cm. long and f cm. thick. Only two attacks of epilepsy occurred 
 after the operations, one within a few hours of the last operation, the other two 
 days after. The patient also recovered full hearing power. 
 
 The second patient was a woman of seventy-six, who suddenly began to have 
 cerebral symptoms, headache, vertigo, vomiting, severe spasm of the muscles of 
 the face and of the extremities. She especially complained of pain in the right 
 ear, and it was found to be sensitive on contact. The organs of the old lady 
 were found to be in good condition, except the right auditory canal, which was 
 completely stopped by wax. The mass was removed with great difficulty in 
 about two days, after softening it. The necessaiy manipulations caused serious 
 symptoms, but as soon as the wax was loosened they disappeared. The mem- 
 brana tynipani was found to be the seat of old disease, and was adherent to 
 the promontory. There was no hearing-power on that side. In six weeks the 
 patient, who was much run down by her symptoms, had fully recovered and was 
 able to go out. 
 
 Wilde 1 also, quotes from Dr. Maclagan "a case of epilepsy 
 and deafness, dependent on the presence of a foreign body in 
 the ear." After the seed of a sycamore, which had been in the 
 ear ten years, was removed, the epileptic attacks ceased, and 
 the deafness declined. Sir William seems to have been some- 
 what skeptical about this case, and he says: "I must confess 
 that I am inclined to bring in the Scotch verdict of 'non 
 proven,' as far as the seed is concerned. The state of the ear, 
 either before or after the removal of the foreign body, has not 
 been recorded ; nor whether the seed ruptured the membrana 
 tympani, or caused any disorganization of the parts." Wilde 
 goes on to , say, that if the introduction of a foreign body into 
 the canal causes epilepsy, it must be by pressing upon the sen- 
 sitive part which he had met in some persons, in syringing the 
 ear. He was not able to explain the phenomenon, but later on 
 in his book he quotes another writer, 2 who explains it by hyper- 
 sesthesia of the auricular branch of the pneumogastric. Strange 
 to say, there remains a doubt, from the varying statements of 
 anatomists, as to whether the auditory canal is or is not sup- 
 
 1 Aural Surgery, p. 189. 
 2 Loc. cit., p. 326.
 
 BRANCH OF PNEUMOGASTRIC IN EAR. 207 
 
 plied by the pneumogastric. Quain ' only speaks of the auricu- 
 lar branch of the pneumogastric as supplying "the integument 
 of the back of the ear." 
 
 Sappey 2 describes it as supplying the canal, as do other au- 
 thors, for example, Gruber, 3 who says : " The auricular branch 
 of the vagus extends not only to the posterior surface of the 
 auricle, but also to the cartilaginous part of the auditory canal. 
 
 Troltsch 4 also describes an auricular branch of the vagus 
 which, as he says, enters the posterior part of the osseous canal. 
 This acceptance of Arnold's discovery of the auditory branch of 
 the pneumogastric is usually accepted, although the most com- 
 plete article on ear-cough of which I know, that by Cornelius 
 B. Fox, 6 agrees with Quain, that the auricular branch of the 
 pneumogastric only supplies the posterior part of the pinna (au- 
 ricle). In about twenty per cent, of the persons examined by Dr. 
 Fox there was found a hypersesthetic state of the nerve supply- 
 ing the auditory canal, that is, they were persons in whom any 
 slight titillation of the nerve produced a sense of tickling in the 
 throat. These are the persons alluded to in the opening sen- 
 tences on this subject in this book. Dr. Fox also believes, that 
 when this condition exists, it is a congenital peculiarity, and that 
 the connection between the nerves involved takes place in the 
 brain. The cases of ear-cough cited by Fox are similar, and in 
 some instances identical, with those I have enumerated. There 
 is no attempt made to trace cough to evanescent or temporary 
 influences, such as cold upon the face and auditory canal. In 
 the two cases of his own cited by Fox, in the one instance the 
 cough was caused by wax and an ulcer of the canal ; in the 
 other, by an inflammation of the canal produced by the use of a 
 spirituous irritant. Lockart Clarke 6 supports Fox's view as to 
 the origin of ear-cough, "in the fibres of the fifth cerebral nerve 
 distributed to the auditory canal." Mr. John Wood, 7 an examiner 
 in anatomy of the University of London, states positively that he 
 has traced a branch of the vagus into the auditory canal, "pass- 
 ing through a minute foramen between the jugular fossa and 
 the glenoid." 
 
 1 Elements of Anatomy, eighth edition, p. 560. 
 
 Traite d' Anatomic, Tome III., p. 842. 1877. "La peau du conduit externe est 
 extrtmement sensible. . . . soit enfin au rameau auriculaire de pneumogastrique, 
 qui vient se perdre dans la pean de la portion osseuse du conduit." 
 
 3 Lehrbuch, p. 144. 
 
 4 Ibid., VI. Aufgabe, p. 29. 
 
 5 British Medical Journal, December 18, 1869, p. 650. 
 
 6 Ibid., 1870, p. 51. 
 7 Loc. cit., p 328.
 
 WOAKES ON EAR-COUGH. 
 
 From the facts so well established since the time 'of Fabricius, 
 theoretical writers have made the most possible. Woakes 1 seems 
 hardly to consider them exceptional, and argues with ingenuity, 
 but I cannot think soundly, that there may be quite a large class 
 of cases of affections of the larynx, that are due to auditory irri- 
 tation. He suggests spasmodic croup as occasionally owing its 
 origin to a draught of cold air falling upon the ear. He also 
 attempts to explain "derangement in the in nervation of the 
 laryngeal muscles " as possibly due to reflex influence from the 
 auditory branch of the vagus. He instances the coachman ex- 
 posed to east wind and rain, and who finds his voice " husky, 
 shrill, or faltering" in the evening, and he argues that the excit- 
 ing causes are draughts of cold air and wet upon the surface 
 "the impression of which, is conveyed by the afferent vaso-motor 
 nerves associated with the cerebro-spinal nerves of the surface 
 receiving the chill, to the sympathetic ganglion with which they 
 communicate : in this instance, the superior cervical ganglion." 
 Dr. Woakes traces the irritation, 1, from the vaso-motor fibres 
 associated with the auricular branch of the pneumogastric ; 2, to 
 the secondary vaso-motor centre, the ganglion of the pneumogas- 
 tric, whence he says it is deflected through a sympathetic fasci- 
 culus to the first cervical ganglion ; 3, thence by the nervi molles 
 to the vessels distributed to the mucous membrane of the larynx. 
 He rejects the simple idea that the morbid impression is con- 
 ducted along the sensitive fibres, from one region to another. 
 
 Orne Green 8 suggests in a review of Dr. Woakes' book quoted 
 by Woakes himself, that the mechanical commotion of the larynx 
 caused by the cough, is the cause of the local inflammatory mis- 
 chief in this organ. The subject is an interesting one, but the 
 cases of reflex phenomena from irritation of the canal are too 
 infrequent, in my opinion, to justify the deductions of Woakes in 
 regard to laryngeal paresis, and subsequent inflammation. Dr. 
 Woakes quotes an amusing story, from Miss Edgeworth's tales, 
 which will bear repetition : This author relates that a choking 
 Norwegian clergyman at a feast, was relieved by a blast of air 
 from a bellows, which a friendly companion blew into his ear. 
 " The effect was magical : the expulsive action of the laryngeal 
 muscles, called into play by this novel method, speedily got rid 
 of the food which the gluttonous haste of the pastor, had caused 
 to go the wrong way." 
 
 Woakes 3 points out that sneezing caused by irritation of the 
 
 1 Deafness, Giddiness, and Noises in the Head, p. 74 et seq. 
 * Boston Medical and Surgical Journal, 1879, p. 911. 
 a Loc. cit., p. 93.
 
 EAR-COUGH. 209 
 
 auditory canal, cannot be due to or explained by referring it to 
 "an irritation of the third branch of the fifth nerve exciting the 
 motor laryngeal branches of the vagus, through communications 
 existing between the roots of these nerves," as claimed by Fox, 
 Clarke, and Russell, because with the act of sneezing, the vagus, 
 as a motor nerve, can have nothing to do. 
 
 These cases are, I believe, rare and exceptional, and I am 
 not ready to accept Dr. Woakes' theories of laryngeal paresis 
 and cough, or to believe that we have any but very infrequent 
 occasion, to refer to the auditory canal for the explanation of 
 coughs. When this theory was first promulgated in this coun- 
 try, I was called to see a child of six. months of age, who suf- 
 fered from persistent cough. I was asked to examine the ear 
 to explain the trouble. But while the history showed that the 
 child had recently had pleuro-pneumonia, the ears revealed 
 nothing abnormal. The cough in this case may easily have been 
 due to pleural adhesions. I only mention the case, to show how 
 ready we all are to give up obvious and simple explanations, to 
 search for those that are recondite. 
 
 Ear-cough is a very uncommon disease ; when it does occur, 
 we may usually find an obvious local cause for it in the audi- 
 tory canal, as in the classical cases, such as a foreign body 
 or inspissated cerumen. To trace any considerable number of 
 laryngeal affections to transient impressions on the auditory 
 canal, to impressions that act more directly upon other parts 
 of the surface of the body, is to go beyond the bounds of what 
 seems to me logical reasoning. To produce ear-cough, we must 
 have a continuously acting irritant. I do not deny that a blast 
 of air upon an auditory canal, in cases such as make up the 
 twenty per cent, contingent of Dr. Fox's tables, may produce 
 ear-cough, but withdraw the draught, and the cough will cease, 
 just as it does when the bean, or wax, or probe is removed from 
 the ear. It seems to me, very unlikely that a permanent lesion 
 is produced by such a temporary influence. 
 
 14
 
 THE MIDDLE EAR.
 
 CHAPTER IX. 
 
 ANATOMY OF THE MIDDLE EAB. 
 
 Statistics of Diseases of the Middle Ear. Membrana Tympani. Shrapnell's Mem- 
 brane. Bivinian Foramen. Light Spot. Layers. Blood- Vessels. Nerves. 
 Lymphatics. Cavity of the Tympanum. Scheme for Studying Boundaries of this 
 Cavity. Ossicula Auditus. Blood-Vessels. Nerves. Mastoid Process. Eusta- 
 hian Tube, Historical Account of. Physiology of the Middle Ear. 
 
 BY far the greater number of aural diseases affect what is 
 known as the middle ear. Of 4800 cases, occurring in my pri- 
 vate practice, 3673 were diseases that involved these parts 
 chiefly. 
 
 Biirkner, in his statistical tables, already quoted, in a total 
 number of 58,645 cases, places 39,238 in the category of diseases 
 of the middle ear. This makes a percentage of nearly 70. My 
 own statistics exhibit a percentage of more than 70. Those of 
 the Manhattan Eye and Ear Hospital for thirteen years, more 
 than 76 in a hundred. Of a total of 10,335 cases, 7957 were af- 
 fections of the middle ear. It is probable that a more exact 
 knowledge. will in the future diminish this proportion somewhat. 
 I believe that it will yet be found, that diseases of the labyrinth 
 and of the trunk of the acoustic nerve, are more frequent than 
 is now supposed. However this may be, the diseases of the 
 middle ear, will probably always far exceed in number those 
 of the other parts of the organ. The anatomy of this region, 
 therefore, demands a careful and exact study. 
 
 By the term middle ear, we mean the membrana tympani, 
 the cavity of the tympanum, the mastoid cells, and the Eusta- 
 chian tube. 
 
 THE MEMBRANA TYMPANI. 
 
 The membrana tympani, or drum-head, forms the boundary 
 between the external and middle ear. It partakes of the char- 
 acteristics of these two parts, in being composed of integument 
 and mucous membrane, while it has one structure the middle 
 or fibrous layer that is peculiar to itself.
 
 214 MEMBRANA TYMPANT. 
 
 The upper border of this membrane lies 7 mm. nearer to the 
 entrance of the external auditory canal than the lower. The 
 posterior border is about 5 mm. nearer this entrance, or mea- 
 tus, than the anterior. The angle that the membrana tympani 
 
 FIG. 52. The Right Temporal Bone, without the Petrous Portion, in connection with 
 the Ossicula Auditus of a Newly-born Child, seen from within (after Rudinger). 1 4, Is above 
 the incus, whose short process is directed nearly horizontally backward ; 5, the long arm of 
 the incus, which extends freely into the cavity of the tympanum ; 6, the malleus, in articu- 
 lation with the incus ; 7, long process of the malleus, which runs under the crista tympanica, 
 in a furrow, to the fissura petroso-tympanica ; 8, the stapes, in articulation with the incus. 
 
 makes with the axis of the auditory canal, is one of about 55. 
 The inclination of the two membranes to an angle opening up- 
 ward is one varying from 130 to 135. In the newly born it was 
 formerly supposed, that the membrana tympani lies more hori- 
 
 PIG. 53. Left Temporal Bone of the same Subject as preceding Figure. 
 
 zontally than in the adult, and that it is almost in the same line 
 with the upper wall of the external auditory canal. 
 
 According to Pollak, quoted by Politzer,' this is incorrect. 
 
 1 Atlas des Menschlicheii Gehororganes. Munchen, 1867. 
 Text-book, translation, p. 20.
 
 MEMBRANA TYMPANI. 
 
 215 
 
 Pollak has made numerous measurements, and he states that 
 there is no perceptible difference between the inclination of the 
 membrane of the newly born and that of the adult. 
 
 The peculiar manner in which the membrana tympani is 
 placed in the canal, causes it to form an acute angle with the 
 lower and anterior wall of the auditory canal, but an obtuse one 
 with the upper and posterior wall. 
 
 The general shape of the membrane 'is elliptical ; but the 
 
 FIG. 54. Section through Tympanic Cavity, Left Side (actual size, anterior half). 1, 
 Squamous portion of temporal bone ; 2, mastoid cells ; 3, membrana tympani ; A, A, 
 chorda tympani ; 5, aqueductus Fallopii ; 6, incus (body) ; 7, malleus (handle) ; 8, Eusta- 
 chian tube ; 9, fossae (middle cerebral) ; 10, groove for meningeal artery. 
 
 regularity of the ellipse is broken in upon by the incomplete- 
 ness of the bony ring surrounding the membrane. In the upper 
 part of this bony ring an oval section is wanting ; this space is 
 known as the segment of Rivini. 
 
 The long axis of this ellipsoid runs downward and forward, 
 the shorter backward and downward. If the diameters of the 
 membrane are measured in the direction of the axis of the ellip- 
 soid, that of the long axis is 9.5-10 mm., and the horizontal is
 
 216 SHRAPNELL'S MEMBRANE. 
 
 8 mm. Measured in the usual manner, the horizontal diameter 
 is 8-8.5 mm., and the vertical 8.5-9 mm. 
 
 The Rivinian segment is filled by the tissue of the cutis and 
 the mucous membrane of the tympanic -cavity. The greater 
 part of the fibres of the tendinous ring of the membrana tym- 
 pani bend from their former course, and at this point turn 
 toward the short process of the malleus, which lies more deeply 
 where it is inserted. The remainder of the tendinous fibres of 
 the ring pass upward, and are lost in the connective tissue of 
 the periosteum. 
 
 This causes an irregular triangular space to be formed, 
 bounded above by the Rivinian segment, and on each side by 
 two bands, which attach the apex of the small process of the 
 malleus, to the anterior and posterior corners of the osseous 
 groove. 
 
 This space, and the tissue filling it, was first described by 
 Mr. Henry Jones Shrapnell, 1 and named by him the membrana 
 flaccida. It is often called Shrapnell's membrane. Mr. Shrap- 
 nell considered that the function of this flaccid membrane was 
 to protect the more tense fibres during the effects of sudden and 
 loud sounds, or the actions of coughing and sneezing, when by 
 yielding it saves the tense fibres from being ruptured. In the 
 hare and the sheep, that would be otherwise defenceless animals, 
 were it not for the great power of their ears to warn them of 
 approaching dangers, this structure is remarkably developed. 
 
 The tissue composing Shrapnell's membrane is less tense than 
 the remainder of the membrana tympani, and sometimes falls in 
 like a pouch toward the tympanic cavity. It consists of a very 
 thin layer of cutis and of mucous membrane. The mucous 
 membrane extends to the osseous edge of the Rivinian segment, 
 and from here passes over to the projecting neck of the malleus 
 bone, which lies opposite. 
 
 The existence of a minute opening in the membrane the so- 
 called Rivinian foramen has been warmly disputed from the 
 time of its discovery, 1717, by Rivinus," a professor in Leipsic, 
 until the present day. Professor Patruban, 3 of Vienna, found 
 such an opening in 300 membranes, part of which were healthy, 
 part diseased. He allowed a fine stream of quicksilver to pass 
 
 1 London Medical Gazette, vol. 10, p. 120. Several German authors speak of Shrap- 
 nell as Odo Shrapnell ; but his name, as it appears in the original of his articles, is as 
 here given. 
 
 8 According to Von Troltsch, the so-called foramen of Rivinus was first discovered 
 by Glaser, in 1680, who was then professor in Basle. Bochdalek, however, claims the 
 discovery for Colle. 
 
 3 Monatsschrift fur Ohrenheilkunde, Jahrgang III., No. 1.
 
 RIVINIAN FORAMEN. 217 
 
 into the so-called canal, and it always appeared on the other side 
 of the membrana flaccida. 
 
 Professor Joseph Gruber 1 has also found the foramen in many 
 specimens. Inasmuch as he oftener found it in pathological 
 specimens, he thinks that its size is at least increased by disease. 
 Gruber does not believe that it is an opening always to be found ; 
 but that it is one frequently observed, and that it would be an 
 interesting inquiry as to how far it is the result of disease. 
 
 Politzer 2 thinks that the Rivinian foramen is a constant ap- 
 pearance, not an anomaly or result of disease. 
 
 Hyrtl 8 denies the existence of the foramen, and says that 
 he has never found it, either on the adult or infantile cadaver. 
 The ability to blow tobacco-smoke from the ears is the result, he 
 thinks, of a want of development in the upper part of the mem- 
 brane. 
 
 Professor Bochdalek, of Prague, rediscovered the opening at 
 the upper margin of the membrana tympani, one-third to three- 
 fourths of a line from the edge, and reopened the discussion 
 which Hyrtl seemed to have closed. 
 
 If the Rivinian foramen, or canal, does exist in the membrana 
 flaccida, it is so small that only a fine bristle, or hair, will pass 
 in it, and the anatomist must sometimes persevere for hours with 
 a magnify ing-glass, in order to find it. Bochdalek 4 describes his 
 discovery of the opening as follows : "To my great astonishment 
 ,1 saw, by means of a magnifying-glass, on the posterior portion 
 of a small depression on the membrana tympani, and a little be- 
 hind the malleus, a very small canal, in which was perceived, 
 although very indistinctly, a punctiform opening. By means of 
 a very fine bristle I succeeded in entering a narrow groove, not 
 more than one-third of a line long, which ran in an oblique 
 direction from above downward, and somewhat anteriorly, into 
 the cavity of the tympanum, so that the bristle passed immedi- 
 ately beneath the handle of the malleus, and just as closely 
 beneath the chorda tympani. On pushing the bristle still farther, 
 it passed under the tendon of the inner muscle of the malleus, 
 and struck on the inner wall of the cavity of the tympanum." 
 
 Dr. Bochdalek also found the foramen in the opposite mem- 
 brane of the same subject, as well as in sixty -three other prep- 
 arations of the membrana tympani. Forty of them were from 
 fresh subjects, the remainder had been preserved in alcohol. In 
 two cases only the opening was not found. In both these cases 
 morbid changes (thickening ?) had occurred in the drum-head. 
 
 ' Loc. cit. * Loc. cit. 
 
 3 Anatomic des Menschen, p. 520. . * Prag Viertel. Jahrschrift, January, 1866.
 
 218 RIVINIAN FORAMEN. 
 
 Kessel 1 believes that the foramen is the result of inflamma- 
 tion. He says that he has convinced himself of the correctness 
 of this view, by dissections and by examination of the living 
 subject at Gruber's clinic. 
 
 I believe in the existence of the foramen of Rivinus, from the 
 clinical fact that I have heard a whistling sound, seemingly 
 through the membrana tympani, in several cases, when the Val- 
 salvian experiment was made, when neither myself nor other ob- 
 servers could detect the slightest opening with the eye. I have 
 also been startled, in one or two instances, on blowing my nostrils 
 violently, by hearing the air whistle through the drum-head, as 
 it seemed. On one occasion, I immediately consulted a friend 
 who has large experience in examining the membrana tympani, 
 and he decided that it was not perforate, as did several others 
 who soon examined the ear. Indeed, I have never suffered from 
 any disease of the ear, that led me to suppose the drum-head could 
 be perforate. 
 
 I cannot escape the subjective conviction, therefore, that the 
 foramen of Rivinus exists, and that air may be occasionally 
 heard to whistle through it, although the opening itself cannot 
 be seen. 
 
 Mr. Wharton Jones 2 described the circular and radiating fibres 
 of the membrana tympani in his article on the organ of hearing. 
 
 Sir Everard Home 3 supposed that these fibres were muscular, and he thought 
 that by this muscle ' ' accurate perceptions of sounds were conveyed to the inter- 
 nal organ." Mr. Home admitted that the muscles of the malleus stretched and 
 relaxed the membrana tympani, but only in order to bring the radiated muscle 
 into a state capable of acting. 
 
 Mr. Home reports a case of double hearing, and he explains it by a defective 
 action of the radiated muscle, which was not exerted with the same quickness 
 and force in one ear as in the other, so that the sound was half a note too low, 
 as well as later in being impressed upon the organ. It is interesting to note that 
 nearly all the cases of double hearing are observed as occurring in musicians. 
 
 The patient, judging from the history, evidently had a catarrh of the tym- 
 panic cavity, and the double hearing probably arose from unequal pressure on 
 the labyrinths. 
 
 The objects in the membrana tympani, which first strike the 
 attention of the observer, are the handle, or long process of the 
 malleus bone, and the triangular spot of light. I am now speak- 
 ing of the membrane, when viewed through the auditory canal. 
 When this is detached, the reflection called the light spot, is not 
 
 1 Strieker's Hand-book of Histology, p. 953. 
 
 * Cyclopaedia of Anatomy and Physiology, vol. ii. 
 
 3 Philosophical Transactions of the Royal Society of London, 1800. Part I.
 
 LIGHT SPOT. 219 
 
 seen, because one of the conditions for its formation is removed, 
 as is also true, to a certain extent, of a membrane seen after 
 death, when the tissues are macerated. 
 
 The long process of the malleus, also called the handle or 
 manubrium of the malleus, divides the membrane into two parts. 
 The anterior part is smaller than the posterior. The attachment 
 of the malleus between the layers of the drum-head will be 
 described in the description of these parts. 
 
 At the extremity of the handle of the malleus is situated the 
 apex of the light spot. This point is also the place of greatest 
 concavity of the outer surface of the drum-head, and is called 
 the umbo (boss of a shield), or navel of the membrane. 
 
 The light spot, as will be seen in the chapter on chronic non- 
 suppurative disease of the middle ear, is one of the important 
 standpoints for the diagnosis of certain affections of the middle 
 ear. The study of the conditions necessary to its formation is 
 therefore of importance. 
 
 FIGS. 55, 56. View of Membrana Tyrapani, showing Handle of Malleus and Triangular Spot 
 
 of Light. 
 
 An account of the normal color of the membrana tympani 
 will be found in the chapter on chronic non-suppurative in- 
 flammation. Until the investigations of Troltsch and Politzer, 
 this was described as seen in the dead subject ; but the post- 
 mortem appearances of this membrane, are no guide to its ap- 
 pearance in the living subject. The ordinary breadth of the 
 light spot, at its base, is from one and a half to two millimetres. 
 (Politzer.) It is sometimes interrupted in its continuity. 
 
 The chief causes of the existence of the light spot, according 
 to Politzer, 1 are the inclination of the membrane to the. axis of 
 the external auditory canal, and the concavity produced by the 
 traction of the handle of the malleus. 
 
 If light be thrown upon a dried preparation of the human ear, 
 as in the examination of the living subject, through the auditory 
 canal, the light spot will be found in the same position as it is 
 seen in life. It is also displaced very little by moving the eye in 
 
 1 The Membrana Tympani, p. 26. Mathewsou and Newton's translation.
 
 220 LIGHT SPOT. 
 
 different directions, because the axis of vision corresponds so 
 nearly to the axis of the meatus, that the light spot can change 
 very little with respect to the inclination to the membrana tym- 
 pani. 
 
 No light would be reflected to the eye, if the membrane were a 
 plane surface ; for, with its inclination to the auditory canal, all 
 rays thrown upon it would be reflected against the anterior and 
 lower wall of the canal. In consequence, however, of the inward 
 curvature from the traction of the handle of the malleus, its parts 
 undergo such a change of inclination that the anterior portion 
 stands directly at right angles to the axis of vision of the ob- 
 server, and the light thrown upon it is reflected back to the eye. 
 
 Politzer proved the correctness of this opinion by stretching 
 an animal membrane over a large ring, and giving it the inclina- 
 tion of the membrana tympani. No reflection will be perceived 
 until the central portion is pressed inward, or made concave by 
 traction from behind it. 
 
 Helmholtz ' also states that the triangular spot of light is due 
 to reflection. Voltolini a claims that the light spot may be seen 
 when no auditory canal is present ; indeed, even when the mem- 
 brane is completely removed. This seems to me to be a mistake ; 
 for while there is a reflex from any generally convex brilliant 
 membrane, such as the drum-head, although it has a central con- 
 cavity, there is no such triangular and fixed one, as when the 
 auditory canal is present, and this is the whole point of the theory 
 of Politzer. 
 
 Voltolini is Correct, however, in calling attention to other 
 modifications of the light spot, than its inclination in the audi- 
 tory canal. If this part of the membrane become thickened, in- 
 flamed, or infiltrated ; in other words, if from mechanical or 
 chemical causes it cease to be a brilliant membrane, and it does 
 not reflect light as well as formerly, the light spot will no longer 
 be triangular in shape, and perhaps not exist at all ; but neither 
 the concavity nor polish of the membrane have all to do with the 
 existence of the light spot, as Voltolini asserts. Any person can 
 prove this for himself by a few simple experiments, with a mem- 
 brane stretched over the end of a tube. 
 
 The -light spot depends upon three factors, viz. : 
 I. The inclination of the membrana tympani to the audi- 
 tory canal. 
 
 II. The traction of the malleus, which renders it concave at 
 the centre. 
 
 III. Its polish or brilliancy. 
 
 1 Monatsschrift fur Olirenheilkunde, Jahrgang VI., No. 8. 2 Loc. cit.
 
 LAYEKS OF MEMBRANA TYMPANI. 
 
 221 
 
 THE LAYERS OF THE MEMBRANA TYMPANI. 
 
 The membrana tympani is not quite 0.1 mm. in thickness 
 (Henle) about as thick as very fine letter-paper or gold-beaters' 
 skin. This thickness varies within small limits. 
 
 There are three layers in the structure of the membrana tym- 
 pani. 
 
 1. A thin layer of integument. 
 
 2. A fibrous layer. This layer forms the principal thickness 
 of the membrane. 
 
 3. A mucous layer continuous with that of the tympanic 
 cavity. 
 
 The integumentary layer may be easily separated from the 
 fibrous layer, but the mucous membrane is so 
 closely connected to it that it is impossible to 
 separate them. (Politzer.) 
 
 It is made up of many layers of pavement 
 epithelium with a Malpighian mucous layer. It 
 has, however, a very thin layer of connective 
 tissue, which is arranged differently from the 
 fibre of the lamina propria, and in which a con- 
 stant relation to the vessels and nerves of the 
 outer layer is observed. (Politzer.) 
 
 The first or integumentary layer of the mem- 
 brana tympani has none of the hairs or glands 
 of the lining of the canal, of which it is a direct 
 continuation. The papillae are found as far as 
 the short process of the malleus. 
 
 The epidermal cells, the cuticle, and corium 
 diminish gradually in thickness from the per- Section 
 iphery toward the handle of the malleus; they 
 then increase and are thickest on the outer edge Henle). i x soo. 
 of this bone. 
 
 The fibrous layer consists of lamellae, each one of which forms 
 a mesh-work of smooth fibres with narrow, almost fissure-shaped 
 apertures. The fibres have an average breadth of 0.01 mm. 
 
 The majority of the fibres run to the malleus in a radiating or 
 circular direction. A small number of them, however, run in 
 different directions between these two sets of fibres. The radiat- 
 ing fibres are external, beneath the cutis, the circular next to the 
 mucous membrane. 
 
 The fibres of the membrana tympani are sharply outlined 
 and opaque, flattened on the sides, swelling out in the middle. 
 They are from 0.0036 mm. to 0.0108 mm. in thickness. Some- 
 
 FIG. 57. Vertical 
 of Fibrous
 
 222 LAYERS OF MEMBRANA TYMPANI. 
 
 times they appear to be homogeneous, but they are actually 
 fibrillated. Chromic acid, chloride of gold, and osmic acid 
 bring out the fibrillated structure. (Kessel.) 
 
 The fibrous layer might be well described, according to Kes- 
 sel, "as a deep layer of the corium changed and adapted for 
 physiological purposes.'' The slits or apertures which have 
 been spoken of are usually empty and appear to glisten, or on 
 their edges they are covered by a finely granular mass. 
 
 Cells are sometimes found which fill them exactly. Troltsch 
 called these cells the corpuscles of the membrana tympani, and 
 they are named Troltsch's cells. The larger spaces contain en- 
 capsulated nuclei, and are frequently filled with amaeboid cells. 
 
 On the periphery the thin layers of the membrana tympani 
 interweave, leaving large and small spaces between the fibres 
 for the passage of vessels, and form, by union with the outer 
 and internal layers, the "tendinous ring," which is attached by 
 means of a thin periosteum to the osseous ring, or annulus tyni- 
 panicus. 
 
 All the layers of the fibrous portion are united to the osseous 
 ring. Kessel confirms Grubers observation that the circular 
 fibres may be followed into the tendinous ring ; but he adds, 
 "these fibres singly, and at some distance from each other, 
 pass off again from the ring at very acute angles, collect to- 
 gether, and reach nearly as great thickness as that which results 
 from the union of the fibres, coming from the epidermis, cutis. 
 and mucous membrane.'' The tension of these fibres causes a 
 convexity of the radii of its surface toward the meatus externus, 
 giving the membrane a general convexity. The circular fibres 
 do not exist on the lower third of the handle of the malleus and 
 the adjacent parts. 
 
 The organic muscular fibres described by Sir Everard Home 
 have been rediscovered by Prussak, as spindle-shaped fibres in 
 the membrane. 
 
 The handle of the malleus is attached to the fibrous layer be- 
 tween the radiating and circular fibres. According to Gruber, 
 there is a cartilaginous formation, which begins over the short 
 process of the malleus, and extends mm. below the handle. 
 This is firmly united below ; but above, at the short process, 
 there is a kind of a joint, the cavity of which is filled with syno- 
 vial fluid. 
 
 Prussak, Moos, and Kessel ' say that while this cartilage ex- 
 ists that is to say, that a third of the short process is of car- 
 tilage it passes into the osseous portion without interruption. 
 
 1 Strieker's Hand-book, p. 955.
 
 LAYERS OF MEMBRANA TYMPANI. 223 
 
 There is also, according to Prussak and Moos, a thin layer of 
 cartilage cells under the periosteum of the handle of the malleus 
 not only in infants, but also in adults. 
 
 Kessel found on sections of the ossicles in embryos from 
 three to nine months, that the malleus is surrounded by an in- 
 dependent periosteum distinct from the elements of the fibrous 
 layer, and only united with the mucous layer by a duplicature 
 of the mucous membrane. In place of the short process there 
 are a great number of glistening nucleated cells under the peri- 
 osteum and in the duplicature of tissue. These elements remain 
 through life as cartilage cells, and form a solid mass with the 
 osseous portion of the small process. 
 
 At birth, the malleus is only closely united to the membrana 
 tympani at two points at the short process, and at the lower 
 third of the handle. The fibrous layer is united with the perios- 
 teum of the upper portion of the handle of the malleus only by 
 loose connective tissue, so that a slight motion of the bone is 
 possible at this point, without an articulation. 
 
 The mucous layer consists of an epithelium and a fibrous 
 framework beneath it. On the inner side of the membrane, at 
 the upper part of its posterior half, is found an irregularly tri- 
 angular fold, 3 mm. to 4 mm. high and 4 mm. broad, which 
 arises close behind the annulus tympanicus, and extends to the 
 handle of the malleus. A cavity is thus formed which opens 
 below, which is called by Troltsch, 1 who described it, "the pos- 
 terior pouch " of the membrana tympani. 
 
 The best view of this duplicature is seen by viewing the 
 membrana tympani from the inside, while it is still in position, 
 after the roof of the tympanic cavity has been removed, and 
 the incus detached from the malleus ; but it may even be seen 
 from the outer surface, by a good illumination, in the living 
 subject. The tissue of the pocket is the same as that of the 
 fibrous layer. (Troltsch.) 
 
 A similar space is found in front of the malleus, but this is 
 not formed by a duplicature of the fibrous layer, but by a small 
 long process turned toward the neck of the malleus, by the mu- 
 cous membrane that lines the tympanic cavity, and by all the 
 parts that enter and leave the Glaserian fissure, that is to say 
 by the long process of the malleus, by its anterior ligament, the 
 chorda tympani nerve, and the inferior tympanic artery. 
 
 Villous processes are found on the edge of the mucous mem- 
 brane, especially in children. These processes are also found 
 
 1 Von Troltsch : Lehrbnch der Ohrenlieilkunde, Vierte Aufgabe, p. 38. 1868.
 
 224 BLOOD- VESSELS OF MEMBRANA TYMPANI. 
 
 on the pouch of Troltsch and on the malleus. They are covered 
 by flattened epithelium, and are composed of connective tissue 
 in which there are capillary loops. 
 
 BLOOD-VESSELS. 
 
 According to the investigations of Kessel, there are blood- 
 vessels, nerves, and lymphatics in all the layers of the meni- 
 brana tympaiii. It had been previously taught by nearly all 
 the writers, that there were no blood-vessels or nerves in the 
 fibrous layer of the drum-head, although, according to Gerlach, 
 there was a capillary anastomosis between the mucous mem- 
 brane and the cutis on the periphery of the middle or fibrous 
 layer. Kessel ' also claims to have first described the lymph- 
 vessels. 
 
 According to Kessel, there is a direct passage of blood-vessels 
 from the outer layer of the membrana tympani to the cavity of 
 the tympanum ; a complete capillary network in the fibrous 
 layer communicates with the cutis and the mucous membrane. 
 
 The blood-vessels that pass from the auditory canal down 
 upon the membrana tympani, come from the deep auricular 
 artery, which is a branch of the internal maxillary. 
 
 Those on the mucous membrane arise from the vessels of the 
 tympanic cavity. 
 
 The blood-supply of the outer layer of the membrane may be 
 very readily traced in many cases of inflammation, or after in- 
 jecting the canal with warm water. The whole circumference 
 of the membrane is usually found injected in connection with 
 redness of the lower part of the canal. Larger vessels run im- 
 mediately behind the handle of the malleus to the uinbo, where 
 they pass off in radii to the edge. 
 
 NERVES OF THE MEMBRANA TYMPANI. 
 
 Nerves are found in each layer of the membrana tympani. 
 The larger nerve-trunks accompany the chief vessels. They 
 divide as these do, and frequently unite together like the capil- 
 laries. They form thick networks under the epithelium of the 
 cutis, and also under that of the mucous membrane. A funda- 
 mental plexus, a capillary plexus near the vessels, and a sub- 
 epithelial plexus may be distinguished. 
 
 The chief nerve-trunk consists of medullated fibres, which is 
 provided with a sheath of Schwann, and lies on the boundary 
 
 1 Loc. cit., p. 958.
 
 NERVES OF MEMBRANA TYMPANI. 
 
 225 
 
 between the cutis and the fibrous layer. It passes on to the 
 membrane at the upper part of the posterior segment. Besides 
 this chief trunk, several small branches enter the membrane at 
 different parts of the periphery. 
 
 In addition to the openings in the fibrous layers, with their 
 contents, Kessel found a large number of nucleated swellings, 
 provided with two or more processes, that unite with the nerve- 
 fibres, and which lie above and between the single fibrous layers. 
 
 FIG. 58. The Membrana Tympani, in connection with the Ossicula Auditus of the Right 
 Temporal Bone (from a photograph Riidinger). 1, Transverse section of the fossa sig- 
 moidea, in which is the transverse sinus ; 2, lower section of the transverse sinus ; 3, inner 
 side of the transverse wall thrown back, which causes, 4, the emissarius mastoideus to be 
 opened ; 5, carotid canal ; 6, the membrana tympani connected to the mucous membrane of 
 the cavity of the tympanum ; 7, the malleus on the anterior and upper portion of the handle 
 (the pockets of the membrana tympani are seen) ; 8, the divided tendon of the tensor tympani 
 muscle ; 9, the incus ; 10, stapes lying by the stapedius muscle, on the pyramid, which is 
 opened ; 11, stapedius muscle ; 12, section of facial nerve ; 13, chorda tympani nerve. 
 
 The greater part of the cell elements found between the 
 fibres of the fibrous layer, must be considered, according to 
 Kessel, as belonging to the blood- and lymph-vessels, and to the 
 nervous system. 1 
 
 15 
 
 Kessel, in Strieker's Hand-book, p. 962.
 
 NERVES OF MEMBRANA TYMPANI. 
 
 The nerves of the mucous membrane of the membrana tym- 
 pani are also more numerous, according to the author from 
 whom I have just quoted, than has been hitherto supposed. 
 There is a plexus near the vessels, and a sub,-epithelial plexus. 
 The former accompanies the lymph- rather than the blood-vessels. 
 Its receives its fibres, in part, from threads of the tympanic 
 plexus, which pass on to the membrane, with the mucous mem- 
 brane, from different parts of the periphery, and partly from the 
 nerves of the cutis, passing through the fibrous layer. The sub- 
 epithelial plexus is a fine network directly under the epithelium, 
 which it supplies with threads. 1 
 
 The outer nerve-supply of the membrana tympani is from the 
 
 Pio. 59. Left Temporal Bone (two-thirds of the normal size). 1, Squamous portion of 
 temporal bone ; 2, petrous portion of temporal bone ; 3, mastoid portion of temporal bone ; 
 4, internal auditory canal ; 5, depression from dura mater ? 6, sup. petrosal sinus ? 7, eminence 
 from semicircular canal ; 8, carotid foramen ; 9, zygomatic process ; 10, groove for meningeal 
 artery ; 11, mastoid foramen ; 12, lateral sinus. 
 
 fifth pair. The main trunk is a branch of the superficial tem- 
 poral nerve, from the third branch of the trifacial or fifth nerve. 
 The chorda tympani nerve runs along the inner surface of the 
 membrana tympani, but gives no branches to it. 
 
 LYMPH-VESSELS. 
 
 They are arranged in three layers, like those of the blood- 
 vessels. The first layer belongs to the cutis, the second to the 
 fibrous layer, and the third to the mucous membrane. In the 
 cutis they form a very fine network, immediately under the rete 
 Malpighii. This network passes over the capillaries at many 
 points. They gradually pass into large capillaries, which often 
 
 1 Kessel, p. 963.
 
 THE TYMPANUM. 
 
 227 
 
 interlace with the blood capillaries, and finally unite in indepen- 
 dent and larger trunks. These run either posteriorly and above, 
 or, exactly like the blood-vessels, pass at various points to the 
 periphery and to the auditory canal. 
 
 In the mucous membrane, also, there is, although not in large 
 number, a sub-epithelial network, lying near the tendinous ring. 
 These vessels are distinguished from the blood capillaries of the 
 same width by their manifold dilatations. 1 
 
 THE CAVITY OF THE TYMPANUM. 
 
 The tympanum (drum), cavity of the tympanum, or drum of 
 the ear, is the irregular, air-containing space lying beyond the 
 membrana.tympani. The mastoid cells, also containing air, and 
 lying in the mastoid portion of the temporal bone, are connected 
 with the tympanum at its upper and posterior part; while the 
 Eustachian tube permits the entrance of air into the cavity 
 through the upper part of its anterior wall. 
 
 The points to be noted in the description of the tympanic 
 cavity are indicated in the following scheme : 
 
 THE 
 
 TYMPANUM 
 
 presents for ex- " 
 animation its 
 
 1. DIMENSIONS. 
 
 2. WALLS. 
 
 3. OSSICLES. 
 
 4. LIGAMENTS. 
 
 5. MUSCLES. 
 
 the Anterior, 
 the Posterior, 
 the Outer, 
 the Inner, 
 the Upper, 
 the Lower. 
 
 Malleus. 
 
 Incus. 
 
 Stapes. 
 
 Ligaments of mov- 
 able joints. 
 
 Ligaments of im- 
 movable joints. 
 
 Tensor Tympani. 
 Stapedius. 
 
 Malleus Incus. 
 Incus Tympanum. 
 Incus Stapes. 
 
 Obturator Stapedis. 
 Mallei Superior. 
 Mallei Anterior. 
 Incudis Superior, 
 
 6. Mucous MEMBRANE. 
 
 7. VESSELS. 
 
 8. NEBVES. 
 
 1 Kessel: Handbuch der Lehre von den Geweben, p. 851.
 
 228 DIMENSIONS OF THE TYMPANUM. 
 
 1. The dimensions of the tympanum, like those of the exter- 
 nal auditory meatus, vary much in different individuals. The 
 following table shows about the average diameters as given by 
 Troltsch : ' 
 
 Antero -posterior diameter, 13 mm. 
 
 Vertical " . .at anterior part, . . 5 to 8 mm. 
 
 " " . at posterior " . .15 mm. 
 
 Transverse " . .at anterior " . . 3 to 4.5 mm. 
 
 " " . opposite the drum-head, 2 mm. 
 
 2. The anterior ivall presents, at its upper part, an opening of 
 considerable size the tympanic orifice of the Eustachian tube. 
 Below this is a strong bony plate. 
 
 The measurements of a cast of the tympanic cavity repre- 
 sented on page 93, are as follows : 
 
 Distance from attachment of upper part of the membrana 
 tympani to the superior margin of the opening of the Eustachian 
 tube, 1 line ; from opening of mastoid cells above to the supe- 
 rior margin of the opening of Eustachian tube, 3 lines ; from 
 opening of mastoid cells below to the inferior margin of the 
 opening of the Eustachian tube, 6 lines ; vertical diameter of 
 the tympanic cavity, 6 lines ; distance from the membrana tym- 
 pani to upper inner wall, 2 lines ; to lower inner wall, 1 line ; 
 opening of Eustachian tube, vertical diameter, 1 line ; horizon- 
 tal diameter, 1 line. A plaster of Paris cast contracts somewhat, 
 so that these measurements are actually too small. 
 
 The posterior wall separates the cavity of the tympanum 
 from the mastoid cells. The opening into the cells is at its 
 upper part, close under the roof, and considerably higher than 
 the orifice of the Eustachian tube. 
 
 The outer wall of the tympanic cavity is composed, for the 
 most part, of the membrana tympani ; but it extends much 
 further backward than the membrane, and contains three small 
 openings : the aperture of the iter chordae posterius, the Glaser- 
 ian fissure, and the aperture of the iter chordae anterius. 
 
 The opening of the iter chordce posterius is on a level with 
 the centre of the membrana tympani and close to its margin, 
 and gives entrance to the chorda tympani nerve. The nerve 
 then runs upward under the long process of the incus, on the 
 free margin of the posterior pocket of the membrane, then for- 
 ward across the neck of the malleus, and finally enters the iter 
 chordce anterius. or canal of Huguier. The Glaserian fissure 
 
 1 Text-book, translation, p. 171.
 
 FENESTRA OVALIS AND FENESTRA ROTUNDA. 229 
 
 opens above, and in front of, the membrana tympani ; while 
 just above it is seen the aperture of the Her chordae anterius. 
 
 The inner wall of the tympanum is the outer boundary of 
 the labyrinth, and consists of bone. It has two small apertures 
 closed by membranes. The upper and larger opening is called 
 the fenestra ovalis, or oval window, and leads into the vesti- 
 bule ; while the lower and smaller one is called the fenestra 
 
 FIG. 60. The Right Temporal Bone, with the Membrana Tympani and Ossicula Auditus of 
 an Adult. 1, Squamous portion under figure 1 the sulcus of the transverse sinus runs down- 
 ward ; 2, a bristle passes through the mastoid foramen ; 3, mastoid cells ; 4, antrum of the 
 mastoid, communicating both with the mastoid cells and with the tympanic cavity ; 5, styloid 
 process ; 6, membrana tympani a point of mucous membrane of the tympanic cavity is seen 
 under the number 6 ; 7, the malleus under the chorda tympani we see the divided tendon of 
 the tensor tympani muscle; 8, the incus; 9, the short process ; 10, the chorda tympani nerve; 
 11, the stapes ; 12, stapedius muscle ; 13, facial nerve ; 14, stapedius nerve, branch of facial. 
 The relations of the mastoid cells to the cavity of the tympanum and the relations of the 
 former to the transverse sinus are well shown. (After Rildinger.) 
 
 rotunda, or round window, and communicates with the cochlea. 
 The former is closed by the periosteum of the vestibule, to which 
 the base of the stapes is attached. The fenestra rotunda lies 
 below the fenestra ovalis, and is closed by the membrana tym- 
 pani secundaria. Both these openings may perhaps more prop- 
 erly be called canals, since they have considerable depth, the 
 membranes which close them lying at their inner extremities.
 
 230 ANATOMY OF TYMPANUM. 
 
 In front of the fenestrse, and partly between them, lies the 
 promontory, a projection of the first whorl of the cochlea. 
 Upon it may be seen three shallow grooves for branches of the 
 tympanic plexus. In front of the promontory the inner wall of 
 the tympanum consists of a very thin plate of bone separating 
 this cavity from the carotid artery. This plate is pierced by 
 many minute openings for vessels and nerves, and has, besides, 
 many irregularities on its tympanic surface. 
 
 Just above and behind the f enestra ovalis, is a slight rounded 
 ridge, corresponding to the aquceductus Fallopii, which gives 
 passage to the facial nerve. This canal is covered by an ex- 
 tremely thin plate of bone. Behind and below the f enestra 
 ovalis is the pyramid, a hollow, bony projection containing the 
 stapedius muscle. The bottom of this cavity of the pyramid is 
 in communication with the aquseductus Fallopii, by means of a 
 
 FIG. 61. Section of Right Temporal Bone (actual size. From Professor Darling's mu- 
 seum). 1, Cochlea ; 2, external auditory canal ; 3, attachment of membrana tympani to bony 
 ring ; 4, head of malleus ; 5, tympanic cavity ; 6, mastoid cells. 
 
 minute canal. Just behind the ridge of the Fallopian canal, and 
 about on a level with the fenestra ovalis, is seen a hard, smooth, 
 bony surface, which corresponds to the external or horizontal 
 semicircular canal of the labyrinth. 
 
 The upper wall, or roof of the tympanum, is the partition be- 
 tween this cavity and that of the cranium. Its thickness and 
 density vary considerably in different subjects. It is sometimes 
 very thin and porous, or entirely wanting, so that the tym- 
 panum forms a part of the cranial cavity. 
 
 The lower wall, or floor of the tympanum, separates this 
 cavity from the jugular vein. Like the roof, it varies greatly 
 in thickness, being sometimes wholly membranous. It is very 
 irregular on its upper or tympanic surface ; and lying much be- 
 low some points in the floor of the external auditory meatus, 
 and below the orifices of the Eustachian tube and mastoid cells >
 
 PATHOLOGICAL CONDITIONS OF TYMPANUM. 231 
 
 it is usually covered, in cases of purulent affections' of the 
 middle ear, by a large quantity of pus. It is perforated by the 
 glosso-pharyngeal nerve and a minute vessel. 
 
 Studied with an eye to pathological conditions, some of these 
 walls present very important relations. Thus the roof of the 
 tympanum lies in contact with the meninges of the brain, so 
 that in caries of this wall the patient may die of purulent men- 
 ingitis or cerebritis. Again, caries of the lower wall may be 
 followed by phlebitis of the jugular vein ; while caries of the 
 
 PIG. 62. Section through Tympanic Cavity, Left Temporal Bone (posterior half, actual 
 aize. From Professor Darling's museum). 1, Squamous portion of temporal bone ; 2, mastoid 
 cells ; 3, jugular fossa ; 4, canal for Jacobson's nerve ; 5, carotid foramen ; 6, aquasductus 
 Fallopii ; 7, fenestra ovalis ; 8, fenestra rotunda ; 9, promontory ; 10, Eustachian tube. 
 
 inner wall has sometimes caused destruction of the coats of the 
 carotid artery and fatal hemorrhage, also a suppurative inflam- 
 mation of the labyrinth, with extension into the cavity of the 
 skull. It is easy to see, too, how even a non-suppurative in- 
 flammation of the tympanum may affect the facial nerve, since, 
 during a part of its course, the nerve is separated from the mu- 
 cous membrane only by a thin plate of bone, which may even 
 be deficient in many places. Indeed, swelling of this nerve, 
 causing temporal facial paralysis, or destruction of it, producing 
 permanent paralysis, is not uncommon in connection with a 
 suppuration in the middle ear.
 
 232 OSSICULA AUDITTTS. 
 
 OSSICTJLA AUDITUS. 
 
 3. The three small bones of the ear, the ossicula auditus, 
 which serve for the conduction of the sonorous undulations 
 through the tympanum to the labyrinth, are the malleus, or 
 hammer ; the incus, or anvil ; and the stapes, or stirrup. 
 
 The ossicles are articulated to each other, and extend, al- 
 though not in a straight line, from the membrana tympani to 
 the fenestra ovalis. 
 
 The malleus may be described as consisting of the head, 
 neck, short process, manubrium or handle, and the long process 
 or processus gracilis. ' The head is the larger, upper extremity 
 of the bone. Posteriorly it has an elliptical depression, twice or 
 thrice as long as it is broad, and of considerable depth for artic- 
 ulation . with the incus. Below the head is a constricted por- 
 tion called the neck, and just below this, and on the upper end 
 
 PIG. 63. Tympanic Cavity, with Ossi- FIG. 64. Anterior Surface of Malleus 
 
 cles in situ (actual size. Prom Professor and Incus. Articulated (twice size. From 
 
 Darling's museum). 1, Fenestra rotunda ; Professor Darling's museum). 1, Short 
 
 2, promontory ; 3, annulus tympanicus ; 4, process of malleus ; 2, head of malleus ; 3, 
 
 incus ; 5, handle of malleus ; 6, stapes ; 7, handle of malleus ; 4, broken processus 
 
 head of malleus. gracilis ; 5, long process of incus ; 6, short 
 
 process of incus ; 7, body of incus. 
 
 of the manubrium, is a prominence to which the processes are 
 attached. The manubrium extends downward and inward, be- 
 ing inserted into the drum-membrane between the circular and 
 radiating fibres of the middle layer. The processus gracilis 
 passes from the eminence below the neck forward and outward 
 to the Glaserian fissure. The short process lies at the base of 
 the manubrium opposite where it gives attachment to the ten- 
 sor tympani. 
 
 The incus lies just back of the malleus, and may be described 
 as having a body and two processes. On the anterior and inner 
 surface of the head is seen the surface for articulation with the 
 malleus. The short process projects backward and articulates 
 with the posterior wall of the tympanum. The long process, 
 
 1 Some writers call the handle of the malleus the long process.
 
 OSSICULA AUDITUS. 238 
 
 much more slender than the other, descends at a right angle 
 with the short process, and parallel with and behind the manu- 
 brium, to end in the processus lenticularis, which articulates 
 with the head of the stapes. This articulation lies a little higher 
 than the tip of the manubrium. 
 
 The stapes consists of the head, neck, crura, and base, and 
 is the innermost and smallest of the bones of the ear, and in- 
 
 Fio. 65. Ossicles of the Tympanum (actual size and twice the size. From Professor Dar- 
 ling's museum). A, Malleus. 1, Short process, processus brevis ; 2, head ; 3, processus gra- 
 cilis ; 4, handle, manubrium. B, Incus. 1, Body ; 2, short process, processus brevis ; 3, long 
 process, processus longus. C, Stapes. 1, Head ; 2, base. 
 
 deed of the body. The head presents on its outer part a surface 
 for articulation with the lenticular process of the long process 
 of the incus. Just internally to the head is the constricted por- 
 tion called the neck, into which is inserted the stapedius muscle. 
 From the neck the crura diverge horizontally, the one forward 
 and inward, the other backward and inward, to 
 be inserted into a thin plate constituting the 
 base, which lies upon the membrane of the fen- 
 estra ovalis. On the outer side of the base is a 
 delicate ridge running from the extremities of 
 the crura and into which is inserted the obtura- 
 
 ,. Fio. 66. Poste- 
 
 tor StapedlS. rior Surface of the 
 
 The dimensions of the ossicles are : length of Malleus, incus, and 
 malleus from summit of head to short process, Sta P es - Articulated 
 
 , r (twice the natural 
 
 about 4 mm. ; from short process to the end of size) 
 the handle, 4 to 5 mm. Long process or handle, 
 about 2 mm. Length of the incus from summit of head to the 
 end of the long process, about 6J to 7 mm. ; to the end of the 
 short process, about 5 mm. Length of the stapes, about 3 mm. 
 Greatest distance between the crura, about 2 mm. Length of 
 the base, about 3 mm. ; width, about 1 mm. The long process, 
 or processus gracilis, is sometimes called the processus Folianus 
 (Coelius Folius, Venice, 1645), and also the process of Rau, after 
 Professor Jacob Rau, of Leyden. 
 
 4. Of the ligaments of the ossicles we have two classes : the
 
 234 LIGAMENTS OF OSSICULA AUDITUS. 
 
 ligaments of the movable joints and those of the immovable 
 joints. 
 
 The malleo-incus joint may be classed with the gynglimus 
 articulations on account of the character of the articulating sur* 
 faces. These surfaces are covered by cartilage about 0.04 mm- 
 in thickness. The capsule is tense. This joint is provided with 
 synovial membrane. 
 
 .The articulation between the short process of the incus and 
 the posterior tympanic wall is an amphiarthrosis, and is sur- 
 rounded by a tolerably thick and tense capsule. The motion is 
 quite restricted. 
 
 The joint between the processus lenticularis of the incus and 
 the head of the stapes is an arthrosis, the processus lenticularis 
 corresponding to the ball and the head of the stapes to the socket. 
 Both surfaces are covered with cartilage. The cartilage is much 
 more delicate than those of the other joints, and is characterized 
 by being rich in elastic fibres. 
 
 The ligamentum obturatorium stapedis is a thin membrane 
 inserted into the ridge on the outer side of the base of the stapes 
 and into the inner edges of the crura, closing the opening formed 
 by these parts. 
 
 The head of the malleus sometimes lies in contact with the 
 roof of the tympanic cavity. More frequently it is connected 
 with the roof by the cylindrical lig. mallei superius (Soemmering). 
 The neck of the malleus is held in place by the cartilage which 
 sometimes takes the place of the long process, and by the lig. 
 mallei anterius (Arnold), which goes from the spina angularis 
 of the sphenoid parallel with the fissura petro-tympanica, to be 
 inserted upon the head of the malleus. 
 
 The incus, when not in immediate contact with the roof of 
 the tympanum, is attached to the roof by means of the lig. in- 
 cudis superius (Arnold), and is inserted into the posterior border 
 of the body of the bone. 
 
 The posterior surface of the head of the malleus is oblong, 
 and it extends in spiral form from above downward and inward 
 to the boundary of the neck. It consists of two surfaces, which 
 meet in an almost vertical edge. The incus has an articular sur- 
 face corresponding to this. These surfaces are covered by a thin 
 layer of hyaline cartilage. The capsular ligament connecting 
 the bones allows of considerable motion. A fold, described by 
 Pappenheim (1840) and Riidinger, projects into the cavity of the 
 joint. 
 
 The mechanism of the joint between the malleus and incus is 
 compared by Helmholtz to the cog contained in certain watch- 
 keys, where the handle cannot be turned in one direction without
 
 ARTICULATIONS OF OSSICLES. 235 
 
 carrying the steel shell with it, while in the opposite direction it 
 meets with only slight resistance. When the handle of the 
 malleus moves inward, the inferior cog of the malleus catches 
 the inferior cog of the incus, and causes the long process of the 
 incus to follow the motion of the handle of the malleus inward. 
 When the handle of the malleus moves outward, a strong move- 
 ment of the articular surfaces follows, the inferior cog of the 
 malleus recedes from that of the incus, and the incus will con- 
 sequently only follow the motion of the malleus outward to a 
 slight extent. ' 
 
 The articulation of the incus and stapes does not admit of 
 much separation of the bones, but they can move sideways to a 
 greater extent. 
 
 The articulation between the stapes and the margin of the 
 fenestra ovalis has been the subject of much microscopical 
 study by Eisell, Buck, and Brunner. The tissue connecting the 
 margin of the fenestra ovalis with the margin of the foot-plate 
 of the stapes consists of elastic, fibres, which run in a radiat- 
 ing direction, converging toward the margin of the foot-plate. 
 These margins are covered with a thin layer of cartilaginous 
 tissue. Voltolini denies that there is cartilage in this articu- 
 lation. 
 
 The stapedius muscle arises from the bottom of the pyramid, 
 or eminentia stapedii, the hollow of which it fills. At the ori- 
 fice of the canal it becomes tendinous, and thence runs, at an 
 obtuse angle with the rest of the muscle, to the neck of the sta- 
 pes. This is the smallest distinct muscle of the human body. 
 
 Although it has been a matter of discussion as to whether 
 the lining membrane of the tympanic cavity is a mucous or 
 serous membrane, Politzer, from his own investigations, has no 
 doubt but that it is a mucous membrane. He thus agrees with 
 Krause, Troltsch, and Wendt, who found mucous glands in the 
 tympanic cavity. According to Politzer, vascular folds of mu- 
 cous membrane extend from the walls of the tympanic cavity 
 to the ossicles. These folds are the means of connecting the 
 vessels in the coverings of the ossicles and those of the walls of 
 the cavity. Besides these folds, Politzer found a number of in- 
 constant prolongations of connective tissue, which were for- 
 merly supposed to be pathological products, but which, as he 
 was the first to prove, are the remains of the gelatinous connec- 
 tive tissue which fills the middle ear of the foetus. 
 
 Sometimes the anterior portion of the tensor tympani is con- 
 nected with the tensor veli palati. According to Politzer, in 
 
 1 Lehre von den Tonempfindungen, p. 217.
 
 236 MUCOUS MEMBRANE OF TYMPANUM. 
 
 the new-born infant there is an immediate communication be- 
 tween the lower portion of the muscular cavity and the facial 
 canal. In adults, there are one or more oblong fissures be- 
 tween the eminentia stapedii and the facial canal. In these 
 fissures the fibrous coverings of the connective tissue of the 
 muscle and the nerve come in contact and amalgamate. 1 
 
 5. The tensor tympani muscle arises in front of the anterior 
 opening of the canalis musculo-tubarius from the pyramid of the 
 temporal bone, from the upper wall of the tubal cartilage, and 
 from the neighboring border of the sphenoid. It passes over the 
 septum tubae into and through the canal of the tensor tympani. 
 Just before leaving the canal it becomes tendinous. The tendon 
 is inserted on the inner margin of the handle of the malleus, at 
 the anterior edge of the rhomboidal surface, obliquely to the 
 longitudinal axis of the malleus. 
 
 6. The mucous membrane of the tympanum is a continuation 
 of that of the Eustachian tube and naso-pharyngeal space. It 
 is extremely delicate and consists chiefly of an epithelium and 
 a layer of connective tissue underneath. On the lower, the an- 
 terior portion of the inner, and the posterior walls, the epithe- 
 lium consists mainly of columnar cells ; while on the promon- 
 tory, roof, membrana tympani^ and ossicles, pavement cells 
 predominate. The thinness of the connective tissue is such 
 that Von Troltsch asserts that the mucous membrane cannot be 
 separated from the periosteum, and that every catarrh is a peri- 
 ostitis. But, according to Kessel, the connective tissue of the 
 mucous membrane in some places forms a fibrous framework 
 which separates it from the periosteum, and passes from one pro- 
 jection of bone to another through the free space of the cavity. 
 One such bridge has frequently been observed to pass from the 
 eminentia pyramidalis to the processus cochleariformis, while 
 many are seen on the floor of the tympanum. 
 
 BLOOD-VESSELS. 
 
 The anterior and middle parts of the tympanic cavity are 
 supplied 
 
 1 . By the branches of the ascending pharyngeal artery, from 
 the external carotid. 
 
 2. By branches of the middle meningeal, which pass through 
 the hiatus canalis Fallopii and the petroso-squamosal fissure 
 into the tympanic cavity. 
 
 3. By the internal carotid, which sends a few small branches 
 from the carotid canal into the tympanic cavity. 
 
 1 Diseases of the Ear, translation, p. 43.
 
 BLOOD-VESSELS AND NERVES OF TYMPANUN. 237 
 
 Politzer ' has shown that there is a vascular communication 
 between the middle ear and the labyrinth, through the osseous- 
 wall separating them. He says that the blood-vessels of the 
 middle ear can be seen proceeding from the deeper layers of the 
 lining membrane, accompanied by numerous prolongations of 
 connective tissue and penetrating almost perpendicularly into 
 the bony substance. The blood-vessels of the bony wall thua 
 connect the blood-vessels of the mucous membrane of the middle 
 ear with the vessels of the labyrinth. 
 
 This vascular connection readily explains the easy trans- 
 ferrence of disease of the middle ear to the internal ear, a fre- 
 quent clinical experience. Yet the communication is not so easy 
 as to make it certain to occur in every case. 
 
 NERVES. 
 
 The tensor tympani muscle is supplied by a branch from the 
 otic ganglion, and from the internal pterygoid, a branch of the 
 third division of the trifacial. 
 
 The stapedius is supplied by a filament from the facial nerve. 
 
 The nerves of the mucous membrane are derived from the 
 tympanic plexus, consisting of a combination of the great sym- 
 pathetic, the trifacial, and the glosso-pharyngeal. 
 
 The nerves that make up the tympanic plexus, according to 
 Von Troltsch," are 
 
 1. Several carotico - tympanic nerves, branches from the 
 plexus of the sympathetic in the carotid canal, which enter the 
 cavity of the tympanum through special foramina. 
 
 2. A twig of the superficial petrosal nerve, entering the 
 cavity from above. It is regarded by some as a connection be- 
 tween the otic ganglion and bend of the facial. Others consider 
 it a continuation of the tympanic nerve (Jacobson's) to the otic 
 ganglion. 
 
 3. The ramifications of the tympanic nerve, arising from the 
 glosso-pharyngeus. 
 
 The otic ganglion is situated near the foramen ovale of the 
 greater wing of the sphenoid bone, in front of the middle men- 
 ingeal artery, on the outer side of the cartilage of the Eusta- 
 chian tube, and the point of origin of the tensor palati muscle. 
 
 It is made up of motor fibres from the third division of the 
 fifth nerve, of sensory fibres from the glosso-pharyngeal, and of 
 fibres from the great sympathetic. 
 
 1 Archiv fur Ohrenheilkunde, vol. xi. 
 1 Treatise on the Ear, translation, p. 97.
 
 288 MASTOID PROCESS. 
 
 Its branches of distribution are to the tensor tympani and 
 the tensor palati muscles. It sends a twig to the external 
 pterygoid branch of the fifth nerve, and several communicating 
 branches to the auricular nerve of the third branch of the fifth 
 nerve. 
 
 By this ganglion the soft palate, the drum-head and tensor 
 tympani, and the integument of the external ear are put in re- 
 lation with each other and with the general nervous system. 
 (Troltsch.) 
 
 The chorda tympani nerve seems to pass through the tym- 
 panic cavity without being in any physiological relation to it. 
 Division of this nerve in operations upon the tensor tympani 
 muscle usually has no effect upon the functions of the ear. ' 
 
 Prussak's experiments on dogs show that irritation of the 
 cervical sympathetic by the galvanic current causes contraction 
 of the blood-vessels. When the irritation ceased considerable 
 expansion occurred. 
 
 THE MASTOID PROCESS. 
 
 The mastoid portion of the temporal bone (/*a<rro's, a nipple or 
 leat) is situated at the posterior part of the temporal bone. Its 
 external surface is rough, and perforated by numerous fora- 
 mina. One of these, of large size, situated at the posterior bor- 
 der of the bone, is called the mastoid foramen. Through it 
 a vein passes to the transverse sinus and a small artery. 
 
 This roughened appearance of the mastoid is sometimes so 
 marked that it resembles the inner cellular structure of the bone. 
 In some rare cases there is even complete absence of the outer 
 layer of bone, so that the air cavities open externally, as well 
 as into the cavity of the tympanum and the external auditory 
 canal. 
 
 Gruber 8 has seen emphysema of the neck and of the occipi- 
 tal region result from the inflation of the cavity of the tym- 
 panum in cases where such external openings existed under the 
 skin. 
 
 This foramen does not always exist in the mastoid process, 
 but is sometimes found in the occipital bone, or in the suture 
 between the temporal and the occipital. 
 
 The mastoid portion is continued below into a conical pro- 
 jection, which is the true mastoid process. To this process are 
 
 ' See Chapter X. for an account of the functions of the chorda tympani. 
 3 Lehrbuch, p. 32.
 
 MASTOID PROCESS. 
 
 239 
 
 attached the sterno-mastoid, the splenius capitis, and trachelo- 
 mastoid muscles. 
 
 On the inner side of the mastoid process is a deep groove, 
 called the fossa sigmoidea. In this groove is a part of the lat- 
 eral sinus, and the mastoid foramen opens into it. The mastoid 
 
 PIG. 67. Vertical Section through Right Temporal Bone (anterior surface of posterior 
 half, two-thirds size. From Professor Darling's museum). 1, External auditory canal ; 2, 
 internal auditory canal ; 3, tympanic process ; 4, sup. semicircular canal ; 5, vestibule ; 6, 
 styloid process ; 7, mastoid cells ; 8, tympanic cavity. 
 
 process is hollowed out into a number of spaces of various size, 
 which are called the mastoid cells. 
 
 THE MASTOID CELLS. 
 
 The upper or horizontal part of the process, called also the 
 antrum mastoideum, is in communication with the tympanum 
 by means of one or more openings in the posterior tympanic 
 wall ; and since it exists even in the infant, before the develop- 
 ment of the mastoid process, it has been suggested that the 
 name of "upper cavity of the tympanum" would be more ap- 
 propriate. The second part of these cells, lying in the mastoid
 
 240 MASTOID CELLS. 
 
 process of the temporal bone, are below the horizontal part- 
 The whole consist of a great number of irregular spaces of vary- 
 ing sizes sizes that also vary much in different individuals. 
 The whole are enclosed by a dense cortical layer of bone, sepa- 
 rating them from the cavity of the skull, and limiting them ex- 
 ternally. This cortical layer also is of different thicknesses in 
 different individuals, a fact of some practical importance in 
 cases of suppurative inflammation of the middle ear, implicating 
 these cells. . Several small foramina are seen in the mastoid por- 
 tion of the temporal bone openings for branches of the middle 
 meningeal artery and the vasa emissaria Santorini. 
 
 The cells are lined by a mucous membrane similar to that of 
 the membrana tympani, but it is more delicate. 
 
 The epithelium consists of smooth cells of the same consis- 
 tency and arrangement as those of the membrana tympani. 
 Under this we find two layers of connective 
 tissue, corresponding to the periosteum. 
 The latter layer contains numerous nerves, 
 and blood- and lymph-vessels. The upper 
 layer very frequently separates itself at the 
 free edge of the cells, like a membrane, and 
 becomes attached to more closely lying tips 
 or projections of bone. By this means the 
 cavities of two cells lying next each other 
 become separated. In the larger cells these 
 PIG 68 External Sur- membranes are stretched horizontally, like 
 face of Left Mastoid Bone curtains, by means of processes which arise 
 
 (from Professor Darling's f rOHl them. (KeSSel. 1 ) 
 
 S^^; tSJS ^ birth the mastoid process is but the 
 emissary vein ; 3, mastoid rudiment of what it is afterward to be. It 
 process ; 4, external auditory j s a sma ll tuberosity, and contains but one 
 cdl of any considerable size, which after- 
 ward becomes the mastoid antrum. 
 Dr. E. Zuckerkandl J was induced, by finding what seemed to 
 him a remarkable specimen, taken from a man who died in 
 middle life, to reinvestigate the anatomy of the mastoid pro- 
 cess. In the first specimen that attracted his attention he found 
 the cells even into the antrum filled with diploetic tissue, and 
 the adjacent ones to this latter part also containing fat. The 
 fat and diploe were just the same in appearance with that of 
 other fresh bones. The other parts of the ear were sound. There 
 was no trace of a pathological cause. His subsequent exami- 
 
 1 Handbuch der Lehre von den Geweben. Vierte Lieferung, p. 864. 
 8 Monatsschrift f iir Ohrenheilkunde, vol. xiii. , No. 4, 1879.
 
 VARIETIES IN MASTOID. 
 
 241 
 
 nations showed him that in many cases the mastoid process was 
 entirely diploetic in structure or fully plugged with fat, and that 
 these tissues appeared together and in connection with air-cells. 
 Zuckerkandl examined 250 ears. He found that the external 
 appearance gave no positive indication of the internal structure. 
 
 FIG. 69. Vertical Section through Right Temporal Bone (posterior half, actual size. From 
 Professor Darling's museum). 1, Squamous portion of temporal bone ; 2, mastoid process ; 
 3, external auditory canal ; 4, internal auditory canal ; 5, carotid canal ; 6, eminence of sup. 
 semicircular canal ; A, A, aquaeductus Fallopii ; B, B, sup. semicircular canal ; C, C, hori- 
 zontal semicircular canal ; 7, mastoid cells. 
 
 He found the following varieties in the examination of 250 tem- 
 poral bones : 
 
 1. The whole process filled with air-cells. The air-spaces 
 more or less of the same size. The surface thin, in spots trans- 
 parent. 
 
 2. The process containing air-cells, but the cavities small. 
 
 3. The cells of unequal size. Generally those of the pars 
 squamosa were larger. 
 
 4. The process entirely an air-chamber (in toto lufthaltig). 
 
 16
 
 242 
 
 VAEIETIES 
 
 MASTOID. 
 
 The cells are large and extend to a line drawn from the lower 
 wall of the auditory canal through the mastoid process. 
 
 5. The cells of the pars squamosa were large, while the pars 
 petrosa of the apophysis contained one large cavity. 
 
 6. There were in the whole process only three or four tubular 
 cavities, whose termini made up the antrum. 
 
 7. The process involved only one cavity, on whose walls were 
 ridge-like partitions. 
 
 The varieties in diploetic and fatty contents were equally 
 great. Of 100 temporal bones belonging to 50 subjects, the mas- 
 toid process was completely pneumatic in but 40 cases. In 22 
 cases, the process up to the antrum contained red or yellow 
 
 PIG. 70. Vertical Section of Left Temporal Bone (actual size. From Professor Darling's 
 museum). 1, Cochlea with lamina spiralis ; 2, external auditory canal ; 3, opening of mastoid 
 cells ; 4, plate of bone separating the tympanic cavity from carotid canal ; 5, squamous por- 
 tion of temporal bone ; 6, mastoid process ; 7, tympanic cavity ; 8, aquaeductus Fallopii. 
 
 adipose tissue. Nine times the lower half of the process was 
 diploetic or contained fat, while the upper part was pneumatic, 
 and in the remaining 29 cases only the apex, of from 3 to 5 
 mm. was narrow-celled, diploetic ; otherwise it contained air- 
 cells. In 8 of the 100 cases the mastoid processes of the same 
 person were different in structure. In 150 macerated temporal 
 bones the results were as follows : Fifty-two times the process 
 was completely filled with pneumatic spaces. Twenty times 
 only the lower half contained diploetic spaces, while the upper 
 was pneumatic. Thirty-eight times the apex only of the process 
 was diploetic from 3 to 5 mm. Seven times the diploetic structure
 
 VARIETIES IN MASTOID. 243 
 
 extended only to the pars petrosa of the process. In summing 
 up, there are found to be entirely pneumatic processes in 36.8 
 per cent. Completely diploetic, 20 per cent. In 42.8 per cent, 
 diploetic and pneumatic cavities existed together in the same 
 bone. These investigations make it probable that many, if not 
 all, of the reported cases of hyperostosis or sclerosis of the mas- 
 toid were really only normal conditions. 
 
 Dr. Giovanni Zoja, : of Pavia, examined sixty-eight fresh 
 preparations, and one hundred dry ones, in order to get the 
 average size of the mastoid process and its cavities. The result 
 of his investigations is that the breadth of the mastoid is 19 mm., 
 its thickness 13 mm., and its length 12 mm. About one milli- 
 metre should be deducted from these measurements in the bone 
 of the female subject. Zoja does not confirm Velpeau's view, 
 that the mastoid process is more developed in advanced life. 
 The cortical layer, according to these examinations, has an aver- 
 age thickness of from one to two millimetres. 
 
 In two of the sixty-eight specimens belonging to one subject 
 the cells were united into one large cavity, so that they formed, 
 as it were, a mastoid cavity. This was also found in another 
 case on one side only. The cells in the centre of the process are 
 usually the larger, and communicate with one another, if they 
 are not separated by the membrane that has been described. In 
 several cases there were cells only in the base of the process. 
 Occasionally these cells extended to the side of the skull, or even 
 to the middle of the petrous part of the temporal bone. 
 
 Dr. Zoja thinks that the development of the cellular structure 
 goes on in a kind of system. They become gradually larger, 
 and are lined with a peculiar membrane ; in the spaces a gela- 
 tinous mass is found, which becomes gradually serous, and is 
 either taken up by the vessels of the cavities or passes into the 
 cavity of the tympanum, where it is absorbed. 
 
 In five of the sixty-eight specimens the antrum was found to 
 be separated from the other cellular spaces by a membranous 
 partition. 2 
 
 BLOOD-VESSELS OF THE MASTOID PROCESS. 
 
 The blood-supply of the mastoid cells is furnished by the 
 stylo-mastoid branch of the posterior auricular artery, while 
 their nerves come from the tympanic plexus. 
 
 1 Gruber's Lehrbuch, p. 33. 
 1 Henle : Lehrbuch, p. 751*
 
 244 
 
 EUSTACHIAN TUBE. 
 
 THE EUSTACHIAN TUBE. 
 
 The Eustachian tube, like the external auditory meatus, con- 
 sists of an osseous and a cartilaginous part. The former meas- 
 
 FIG. 71. Section of the Head, showing the Divisions of the Ear and the Naso-pharyngeaL 
 Cavity (after a photograph Riidinger). 1, Cartilage of external auditory canal ; 2, osseous 
 auditory canal ; 3, 4, membranae tympanorum ; 5, cavity of the tympanum ; 6, dilator muscle 
 of the Eustachian tube ; 7, levator palati muscle ; 8, mucous membrane of the pharyngeal 
 orifice of the tube ; 9, left membrana tympani ; 10, handle of the malleus and short process ; 
 11, tensor tympani muscle ; 12, mucous membrane of the membranous portion of the tube, 
 perforated by a needle ; 13, levator veli palati muscle ; 14, mucous membrane of the posterior 
 surface of the pharynx ; 1 5, mucous membrane of the pharynx, attached to the lower surface 
 of the body of the sphenoid bone ; 16, sphenoidal sinus ; 17, hypophysis cerebri and its rela- 
 tions to the cerebral arteries and the cavernous sinus. 
 
 ures 11 mm., the latter 24 mm., so that the whole length of the 
 tube, from its opening into the tympanic cavity to its pharyngeal 
 orifice, measures 35 sam. The tube, from its tympanic end,.
 
 EUSTACHIAN TUBE. 
 
 245 
 
 runs forward, inward, and downward. Its axis makes an angle 
 of 135 with the axis of the external auditory canal, and an angle 
 of 40 with the horizontal plane. 
 
 The diameter of the osseous portion of the tube is about 
 2 mm. The walls are smooth, and covered by a mucous mem- 
 brane, which, like that of the tympanum, is closely adherent to 
 the periosteum. The lateral wall belongs to the pars tympanica ; 
 the median wall separates the tube from the carotid canal ; the 
 upper wall is formed by the septum tubae, the floor of the canal 
 for the tensor tympani muscle. 
 
 The shape of the anterior extremity of the osseous tube is 
 very irregular, the inner wall extending forward much further 
 than the lateral wall. This part, ''the 
 isthmus," is the narrowest portion of 
 the tube. Here the tube gradually 
 widens, and ends anteriorly in a trum- 
 pet-shaped orifice 9 mm. high and 5 
 mm. broad, which projects slightly 
 into the post-nasal space, and ]jes a 
 little above the level of the floor of the 
 nostril. 
 
 The cartilage of the tube is made 
 up of two plates a median and a 
 lateral. The median plate, which is 
 much the larger, is triangular, and 
 into its upper and outer part is inserted 
 the hook-shaped and smaller lateral 
 cartilage. But most of the lateral 
 wall and all of the lower is formed of 
 membrane instead of cartilage, the 
 membrane forming nearly a half of 
 the circumference of the tube. 
 
 ,, -.. .., f ,t ,-i spheno-staphylinus muscle. 
 
 The median wall of the cartilage 
 
 of the tube is below 1 mm. in thickness on its posterior extrem- 
 ity, but increases in size gradually to 2 to 3 mm., and on its 
 free anterior border may even reach 7 mm. The tissue of the 
 cartilage is chiefly hyaline, but it has a fibrous base substance 
 at various spots ; sometimes on the surface, sometimes on the 
 interior, and especially near the edges. 
 
 The mucous membrane which fills up the concavity of the 
 cartilage, and which changes the calibre up to the vicinity of 
 the pharyngeal orifice to a plane surface, is 0.6 mm. thick at its 
 densest portion. It is connected to the perichondrium by loose 
 connective tissue. It is made smooth by numerous acinose 
 glands of about 0-6 mm. in diameter and 0.15 mm. in thickness. 
 
 FIG. 72. Transverse Section of 
 Upper Part of the Eustachian Tube 
 (after Henle). *, Fibres of the
 
 246 
 
 EUSTACHIAN TUBE. 
 
 These glands form a continuous layer backward from the phar- 
 yngeal orifice for some distance. Toward the cavity of the tym- 
 panum they are less numerous, yet, according to Von Troltsch, 
 they are found on the tympanic orifice. Toward the pharyngeal 
 orifice large mucous glands appear lying on the outer side of the 
 cartilage. 
 
 The lateral wall of the tube, which, with its upper border, 
 bounds the convex surface of the enveloping ridge of the car- 
 tilage, has about the same thickness as the median wall, and the 
 same covering of mucous membrane. The tissue in the upper 
 half is quite firm, in the lower more relaxed and spongy. Fat is 
 its chief structure. 
 
 A portion of the tendinous origin of the spheno-staphylinus 
 muscle unites with the firmer portion of the wall, and for some 
 
 FIG. 73. Transverse Section through the 
 Lower End of the Eustachian Tube (after 
 Henle). *, Mucous glands ; **, fibres of petro- 
 staphylinus muscle. 
 
 FIG. 74. Transverse Section through 
 the Lower End of the Eustachian Tube (af- 
 ter Henle). *, Mucous glands ; **, trans- 
 verse section of the petro-staphylinus 
 muscle. 
 
 distance this origin runs in a thin layer between the upper bor- 
 der of the soft wall of the tube, and unites with the convex sur- 
 face of the latter. 
 
 The spheno-staphylinus muscle being thus attached to the 
 tube has the power of rolling over the upper inverted border of 
 the cartilage, and of enlarging the angle which the lateral wall 
 forms with the median. The opening or gaping of the tube de- 
 pends upon this action, which occurs with the act of swallowing. 
 
 At the point where the lateral wall of the nasal cavity passes 
 into the pharynx, at the same height with the posterior point of 
 the inferior turbinated bone, lies the pharyngeal orifice of the 
 tube (Fig. 75). 
 
 Since the inner wall of this canal projects into the calibre of 
 the naso-pharyngeal space, the mouth of the tube lies more in a
 
 EUSTACHIAN TUBE. 247 
 
 frontal than sagittal plane. It has a puffy median border, while 
 the lateral wall passes without any distinct line of separation 
 into the nasal cavity. The width of the mouth of the tube 
 varies in different persons, and has the general shape of a 
 funnel. 
 
 According to Riidinger/ the minute differences in form of 
 the Eustachian tube in animals are so characteristic, that from a 
 section of the Eustachian tube the animal from which it has 
 been taken can be designated. 
 
 The known functions are to conduct away the secretions of 
 the cavity of the tympanum, and to act as a ventilator of this 
 part. What part it has to do with the conduction of sound to 
 
 FIG. 75. Vertical Section showing the Mouth of Eustachian Tube and Rosenmuller's Fossa^ 
 
 the ear, or what connection it has with the voice, has not as yet 
 been determined. Riidinger has observed fatty degeneration of 
 the tubal cartilage of man, and it may be conceived that fatty 
 degeneration of its muscles may occur in some subjects and be- 
 come a serious impediment to the performance of its functions. 
 
 The mucous membrane of the tube is at its lower part quite 
 thick, like that of the pharynx, of which it is an immediate con- 
 tinuation. Its epithelium is ciliated, the motion being in the 
 direction of the pharynx. This anatomical fact explains the 
 intolerance which this membrane displays toward the injection 
 of fluids from the pliaryngeal orifice. The tube of the infant 
 differs much from that of the adult. It is shorter, wider, and 
 more nearly horizontal. 
 
 2 Strieker's Hand-book, p. 973. '
 
 248 
 
 EUSTACHIAIs TUBE. 
 
 Riidinger divides the fissure of the tube into two portions. 
 There is a semi-cylindrical space under the hook of the carti- 
 lage which he calls the safety tube, and the fissure connecting 
 with it the accessory fissure. 
 
 Both divisions are produced by the shape of the cartilage, 
 and are separated from each other by projections of mucous 
 membrane. The mucous membrane is firmly attached to the 
 tissues about it on the concavity of the hook ; but at that point 
 where the accessory fissures begin, fold-like projections are pro- 
 duced between this fissure and the safety tube. The projection 
 
 FIG. 76. Transverse Section of Eustachian Tube and Surrounding Parts (after Rudinger). 
 1, Median cartilaginous plate ; 2, lateral cartilaginous hook ; 3, dilator of the tube ; 4, lava, 
 tor of the soft palate ; 5, basilar fibre-cartilage : 6, 7, acinous glands ; 8, fat in the lateral 
 wall ; 9, safety tube ; 10, accessory fissure ; 11, fold of mucous membrane ; 12, adjacent tissues. 
 
 of these folds prevents the safety tube from being closed. The 
 closure is first possible at the point where the bend of the carti- 
 lage becomes narrower, and the mucous membrane is not closely 
 united with it. This point is at about the middle of the tube, 
 where the mucous membrane has. a slightly undulating surface, 
 as seen in Fig. 78. 
 
 The question whether the tube is normally open that is, 
 when the muscles of deglutition are at rest is one which has 
 been much debated. Throughout the narrowest part of the tube
 
 EUSTACHIAN TUBE. 249 
 
 the larger part of the outer and inner walls are in contact, but 
 at the upper part is a small chink, which, as some authors 
 claim, remains patent, while others deny this. However, any 
 observer with normal tubes will be able to notice that the tube 
 opens, or at least widens, at every act of swallowing. If the 
 nostrils are tightly held, air will be pumped out of the tym- 
 panum by the act of swallowing, and this air will be restored 
 again to the ear-drum by swallowing with the nostrils free. 
 
 MUSCLES OF THE TUBE. 
 
 The muscular apparatus of the Eustachian tube also belongs 
 to the pharynx. Indeed, these parts are so closely connected in 
 
 PIG. 77. Section of the Upper Third of the Eustachiau Tube (after Riidinger). 1, Me- 
 dian cartilage ; 2, lateral cartilage hook ; 3, perichondrium ; 4, submucosa ; 5, insertion of 
 the dilator of the tube ; 6. safety tube ; 7, lateral projection of the mucous membrane ; 8, 
 median projection of the mucous membrane ; 9, accessory fissure. 
 
 all their structures, that an affection of one part independent of 
 the other can hardly be said to occur. 
 The muscles of the tube are 
 
 1. THE ABDUCTOR OR DILATOR OF THE TUBE. This muscle 
 is also known as the spheno-salpingo staphylinus muscle, the
 
 250 
 
 MUSCLES OF EUSTACHIAN TUBE. 
 
 circumflexus palati, or tensor palati mollis. It is probably the 
 most important muscle of the tube. 
 
 This muscle arises from the sphenoid bone and the cartilage 
 of the tube. It is inserted on the blunt edge of the cartilaginous 
 plate along the whole length of the canal. It passes forward, 
 inward, and downward, and its fibres spread out along the edge 
 of the soft palate, and 011 the side of the pharynx. It enlarges 
 the calibre of the tube by drawing the hook of the cartilage for- 
 ward and a little downward. 
 
 FIG. 78. Section of the Middle Third of the Eustachian Tube (after Rudinger). 1, 2, 
 Cartilage ; 3, dilator of the tube ; 4, folds of mucous membrane under the cartilage hook ; 5, 
 folds of mucous membrane in the accessory fissure ; 6, submucosa. 
 
 Riidinger confirms the view expressed by Von Troltsch and 
 Mayer that the dilator of the tube passes directly into the tensor 
 tympani muscle This is true not only of the tendons, but also 
 of the muscular fibres. 
 
 Rudinger compares the rolling of the muscle about the ham- 
 ular process of the pterygoid plate of the sphenoid, to the pulley 
 arrangement of ^ie superior oblique muscle of the eye. This 
 attachment is certainly a point of fixation in the movements of 
 the muscle.
 
 MUSCLES OF EUSTACHIAN TUBE. 251 
 
 2. THE LEVATOR VELI PALATI. This muscle is not very in- 
 timately connected with the tube, and yet it plays an important 
 part in its mechanism. It arises with a cylindrical tendon on 
 the lower surface of the temporal bone, on the anterior border 
 of the entrance to the carotid canal, and by a few fibres from 
 the cartilaginous portion of the tube. 
 
 In the soft palate the muscles of the two sides are closely 
 connected. From this point they separate, and each one runs 
 upward, and is firmly attached, in the vicinity of the osseous 
 tube, not only on the bone, but also to the cartilage and the 
 mucous membrane of the tube. 
 
 When this muscle contracts, by its becoming thicker, the 
 membranous floor of the tube is pressed forward, and thus the 
 long diameter of the tube is shortened, and the transverse di- 
 ameter is enlarged, that is to say, it is made to gape *ery 
 widely. 1 The salpingo-pharyngeus muscle also assists in this 
 action. 
 
 3. THE SALPINGO-PHARYNGEUS (RUDINGER). This is a thin 
 muscular layer, that passes from the lower end of the tube ob- 
 liquely downward and backward, and is connected to the lower 
 end of the median cartilaginous plate, and to the mucous mem- 
 brane. It is inserted in the posterior wall of the pharynx. Rii- 
 dinger considers this thin muscle to be a fixator of the median 
 cartilaginous plate, in its various positions caused by the con- 
 traction of the constrictor of the pharynx and the levator palati. 
 
 The opening of the Eustachian tube is the result of a combi- 
 nation of muscular action. If the three muscles are innervated 
 simultaneously, and their contractions occur at the same time, 
 the hook-shaped cartilage is fixed by the dilator of the tube and 
 drawn outward, the concave portion of the tube becomes a little 
 less curved, and the semi-cylindrical gutter is widened. If the 
 levator of the velum contract, the space of the tube at the pha- 
 ryngeal orifice is enlarged more than three lines. 
 
 If the muscles cease to act, the elasticity of the cartilage 
 comes into play, the canal becomes narrower, without being 
 at its lower section completely closed, however. 2 Respiratory 
 movements of the membrana tympani have been often observed, 
 and these occur through this gap in the tube, which cannot be 
 said to be ever firmly closed. Any one who has often climbed 
 high mountains and has become "out of breath" from exertion 
 in reaching the top, must have observed in his own ears this 
 
 1 Riidinger : Beitrage zur vergleichenden Anatomie und Histologie der Ohrtrom- 
 pete. * Riidinger, loc. cit. , p. 7.
 
 252 DISCOVERY OF EUSTACHIAN TUBE. 
 
 continuation of respiration through the tube. This fact throws 
 light upon the etiology of cases of diseases of the middle ear, 
 arising from inflammations of the respiratory organs, such as 
 pneumonia and bronchitis. 
 
 BLOOD-VESSELS. 
 
 1. The ascending pharyngeal artery, from the external 
 carotid. 
 
 2. The internal maxillary, the larger of the two terminal 
 branches of the external carotid, also supplies the Eustachian 
 tube by its middle meningeal branch. 
 
 3. Branches of the internal carotid artery. 
 
 NERVES. 
 
 1. The internal pterygoid, a branch of the third division of 
 the fifth nerve, sends a supply to the dilator of the tube. 
 
 2. The superior pharyngeal, a branch of the second division 
 of the fifth nerve, sends branches to the pharyngeal orifice. 
 
 3. The glosso-pharyngeal supplies the mucous membrane. 
 
 4. The pneumogastric supplies the levator veli palati muscle. 
 
 Historical. The history of the successive steps by which the 
 Eustachian tube, has taken its true and important position with 
 relation to the study and treatment of aural disease, is a very 
 interesting one, and has been very succinctly given by Dr. 
 Ludwig Mayer, 1 from whose writings I have already quoted in 
 the chapter on "Foreign Bodies." 
 
 As has been said on page 4, Alcmeon and Aristotle knew of 
 the Eustachian tube, but Eustachius was the first writer who 
 gave an exact description of it. This is found in the edition of 
 his anatomical works published in Venice in 1564. a 
 
 The passage in reference to the tube, as quoted by Mayer, is 
 as follows : 
 
 Ergo a caverna ossis lapidei, in quam meatus auditorius, conchion appellatus 
 finitur, via in narium cavitatem perforata est : ab ilia enim meatus alter oritur 
 rotundo canaliculo similis, et instar tenuioris calami aniplus, qui oblique ad 
 interius interiusque basis capitis latus procedens, in medio quatuor foraminum, 
 totum istud os penetrat atque perfodit. na posteriori ipsius sede arteria soporaria 
 calvaria ingreditur : anteriori quartum nervorum cerebri jugum extra ipsam 
 emergit : externurn latus arterise in dura cerebri membrana distributee adituin 
 
 1 Studien iiber die Anatomie des Canalis Eustachii. Miinchen, 1866. 
 1 Bartholomaei Eustachii Opuscula Anatomica.
 
 EUSTACHIAN TUBE. 253 
 
 patefacit : internum denique fissura quaadam circumscribit, quaa a cuneum 
 referentis ac lapidei ossis extremis partibus, oblique infra et anteductis, fit. 
 Caeteruin hunc meatum, de quo sermo est, arbitrabitur fortasse quispiam eo loco 
 desinere ; res autem non ita se habet, sed alterius generis substantia auctum, 
 inter duos faucium seu guise musculos, & paucis hucusque bene cognitos secun- 
 dum, paulo ante me moratse fissurse ductum ulterius procedit ; et juxta radicem 
 intemaa partis apophysis ossis alis vespertilionum similis in alteram narium 
 cavitatem terminatur ; et in crassam palati tunicam prope radicem gargareonis 
 inseritur. Substantia sane ejus, qua extrema fissurse ossi temporum et cuneo 
 simili communis tangit, cartilaginea est ac admodum crassa ; huic vero appositae 
 partis substantia exacta cartilage non est, sed membranosum nescio quid habet, 
 et tenuior evadit a hujus meatus intena extremitas narium cavitatis medium 
 respicies robusta est cartilage, quaa plurimum extuberat, mucosaque ; narium 
 tunica obducitur, ac fini ejusdem meatus quasi canitor prseferta esse videtur, 
 figura teres non est, sed aliquantum depressa duos efficit angulos : latitude 
 cavitatis calamum, quo scribimus, fere adsequat, sed in fine duplo latior est, 
 quam in principio, quae similiter mucosa sed tenui induitur tunica. Hoc calli- 
 dissimum naturae artificium a me inventum contemni (ut opinor) non debet : 
 siquidem turn philosopbis, turn niedicis non parum utilitatis afferre potest. nam 
 antiquiores philosophi, quorum numero, ut Aristoteles refert primo de natura 
 animalium undecimo fuit Alcmeon, capras non modo ore ac naribus, verum etiam 
 auribus quoque spirare, forte ob earn causam arbitrati sunt, quod meatum quam 
 descripsi non ignorarent atque adeo saepius experti fuissent spiritum, ubi ipsum 
 quis cohibet, ad aurium cavitatem vi quadam impulsum recurrere, et instar 
 fluctus, auditus organa percutere. Erit etiam niedicis hujus meatus cognitio, 
 ad rectum medicamentorum usum maxime utilis, quod scient post hac ab auribus, 
 non augustis foraminibus, sed amplissima via posse materias etiam crassas, vel a 
 natura expelli, vel medicamentonim ope, quse masticatoria appellantur, com- 
 mode expurgari. 
 
 The last paragraph of this quotation shows, that Eustachius 
 anticipated an earlier use of his discovery, than was made by the 
 profession. 
 
 The writers who followed Eustachius up to Valsalva's time, 
 based their labors on what Eustachius had done. Mayer, in 
 order to express his estimate as to their value, quotes Goethe, 
 who says : " Denn eben wo Begriffe fehlen, da stellt ein Wort 
 zur rechten Zeit sich ein." Where an idea is wanting, a word 
 can be put in its place. 
 
 Valsalva, however, described the muscles of the Eustachian 
 tube very exactly, but a hundred and twenty-five years after 
 Eustachius. He supposed that the function of the muscles was 
 to keep the tube constantly open. It was not until 1850 that the 
 anatomical descriptions began to be accurate. Then F. Arnold, 
 in his "Handbuch der Anatomic des Menschen," published at 
 Freiburg in Bresgau, in 1851, gave a careful description of the 
 tube. Merkel ("Anatomic und Physiologic der menschlichen 
 Stimme und des Sprech-Organs ") and Tortual ("Neuen Unter-
 
 254 PHYSIOLOGY OF MIDDLE EAR. 
 
 suchungen iiber den Bau des menschlichen Schlundes und Kehi- 
 kopfes "), 1861, afterward described the canal. Von Troltsch, 1 in 
 an article published in his " Archives," elaborated the subject 
 much farther. The labors of Mayer and Rudinger have brought 
 our knowledge of the anatomical structure to the present stage. 
 It should never be forgotten that Joseph Toynbee, was the 
 first writer, in a paper presented to the Royal Society in 1851, to 
 show that the faucial orifice was controlled by the muscles of 
 the palate, and that the act of swallowing affected the calibre of 
 the tube. Toynbee thought that the tube was completely closed 
 in a state of repose, and although not strictly correct in this, his 
 labors can hardly be overestimated. 
 
 PHYSIOLOGY OF THE MIDDLE EAR. 
 
 The waves of sound may reach the endolymph of the laby- 
 rinth, through the bones of the skull. It is with difficulty, how- 
 ever, that sonorous vibrations are transmitted from the air to 
 solids and liquids. A special apparatus to secure their trans- 
 mission is found in the middle ear, for, as we have seen, the 
 external ear has a very small share in this function. 
 
 Functions of the Membrana Tympani. 
 
 The presence of the membrana tympani, in whole or in part, 
 is not essential to fair hearing power. This was first clearly 
 proven by Sir Astley Cooper, 8 in a case of which more will be 
 found in the discussion upon paracentesis of the drum-head, in 
 a subsequent chapter ; but, that it is very important to good 
 hearing in some cases, is shown by the numerous instances in 
 which an artificial membrana tympani raises the hearing power 
 from a very low degree to a high one. The membrana tympani 
 is perhaps more properly considered as the outer expansion of 
 the ossicula auditus, for it is so intimately connected with the 
 malleus, as to be essentially a part of the chain of bones that 
 conducts sound to the endolymph of the labyrinth. Very great 
 thickening of the drum-head, that is to say, of its fibrous and 
 mucous layers, must of necessity involve the insertion of the 
 malleus which is in its layers, so that we can hardly speak of 
 the functions of the membrana tympani without including those 
 of the ossicles. Yet there are a few points in its physiology 
 that may be mentioned by themselves. Wollaston 3 snowed that 
 
 1 Archiv fiir Ohrenheilkunde, Bd. I., Heft i., p. 15. 
 * Philosophical Transactions, p. 155. 1800. 
 Ibid., p. 306. 1820.
 
 PHYSIOLOGY OF MIDDLE EAK. 255 
 
 if the membrana tympani be rendered very tense, the ear is 
 rendered insensible to low sounds, but those of a high pitch are 
 made more intense. Blake ' also found that in two cases of 
 voluntary contraction of the tensor tympani muscle, the percep- 
 tion increased from 3000 to 5000 vibrations during the contrac- 
 tion of the muscle. Blake also showed that in a membrane 
 slightly opaque and not very concave, but with a number of 
 small calcareous deposits on a line with the lower end of the 
 process of the malleus, the perception of high tones was greatly 
 increased by an opening made in the drum-head. 
 
 The peculiar formation of the membrana tympani, it being 
 of the shape of a funnel with a depressed centre, surrounded by 
 sides somewhat convex, make it, according to the physicists, 
 peculiarly susceptible to sonorous vibrations, and it is easily 
 thrown into corresponding movements when waves of sound 
 enter the auditory canal and strike upon it. The membrana 
 tympani probably has no fundamental tone of its own, or that 
 tone has not been exactly determined. It is not thrown into 
 vibrations by waves of a particular length more readily than by 
 others. 1 Had the membrane its peculiar fundamental note, we 
 should be distracted by its prominence in the ordinary sounds 
 of life. Hensen s says, and has proven by experiment, that the 
 membrana tympani is toned to a relatively deep note as the re- 
 sult of its funnel-like shape. Hensen also states that perhaps 
 the peculiar note of the drum-head, may be produced by blowing 
 air into the auditory canal. This tone, he says, cannot be ex- 
 actly determined, but it is certainly not higher than 700 vibra- 
 tions. But, he adds, it is doubtful if a precise tone can be 
 assigned to such an un symmetrical membrane. 
 
 Seebeck and Mach, quoted by Hensen, 4 say that the regu- 
 larity of our perception of tones is due to the deadening of 
 sounds produced by the ossicles and the fluid of the labyrinth. 
 It is probable that the membrana tympani can only be properly 
 considered as a sound conductor in connection with the ossicles. 
 It has one function entirely its own, however, which is of the 
 highest importance. It is the protecting membrane of tlu3 tym- 
 panic cavity, although its complete destruction or great thicken- 
 ing of its layers, may not destroy the power of hearing. Even if 
 a fair hearing of speech and music remain when it \s removed, 
 the tympanum is deprived of a covering which is essential to its 
 continuation in health. As is seen in the study of chronic sup- 
 
 1 Transactions of the American Otological Society, p. 77. 1872. 
 
 s M. Foster's Physiology, p. 575. J Hermann's Handbuch, p. 42. 
 
 4 Loc. cit., p. 43.
 
 256 FUNCTIONS OF OSSICULA AUDITUS. 
 
 purations of the middle ear, when the membrana tympani is 
 destroyed or even partially removed, the tympanum is exposed 
 to a series of dangers, any one of which may be destructive not 
 only of the hearing but of the life. To preserve and quickly re- 
 store an ulcerated membrana tympani, becomes therefore a very 
 important duty. 
 
 Ossicula Auditus. 
 
 Many observations have been made upon the vibrations of 
 the ossicula auditus by Politzer, Blake, Buck, Mach, Kessel, 
 Hensen, Burnett, Helmholtz, and others. 1 
 
 The action of the malleus and incus has excited considerable 
 attention. Helmholtz 3 has shown, as has been already noticed, 
 that when the malleus is carried inward, the incus also moves 
 inward, and when the malleus returns to its position, the incus 
 returns with it. Its saddle-shaped joint with cog-teeth permits 
 this movement, while it prevents the stapes from being pulled 
 back when the membrana tympani and the malleus are pushed 
 out more than usual. The joint then separates, so that the mal- 
 leus may be moved alone. The ligaments also serve to keep 
 the malleus in place. The bones conduct vibrations as a single 
 solid lever, the fulcrum of which is situated at the attachment 
 by ligament of the short process of the incus to the posterior 
 wall of the tympanum. 
 
 Every movement of the membrana tympani is transferred 
 through the ossicles to the membrane of the fenestra ovalis, and 
 to the perilymph of the labyrinth. The vibrations are increased 
 in intensity, but diminished in amplitude when they reach the 
 perilymph. It is generally conceded that the ossicles have no 
 independent vibrations that can be perceived, but that they act 
 as a single solid body in conveying vibrations to the labyrinth. 
 
 Tensor Tympani Muscle. 
 
 Even when the tensor tympani muscle is not in action it is 
 of use in preventing the drum-head from being pushed out too 
 far. Wher\ it contracts the membrane becomes more tense. It 
 has been supposed 3 to act either as a damper, lessening the vi- 
 bration of the drum-head in the case of two powerful sounds, or 
 as having an accommodative power in attuning the membrane 
 to sounds which fall upon it. According to Hensen, 4 this action 
 
 1 For a good digest of these see Hensen's article in Hermann, loc. cit. , p. 47 et seq. 
 
 2 Die Tonenpfindungen, loc. cit. * Foster, loc. cit. 4 Loc. cit., p. 65.
 
 FUNCTIONS OF STAPEDIUS. 257 
 
 is excited in a reflex way by the vibrations of the drum-head. 
 The contraction of the tensor tympani is produced at will by 
 some persons, and is accompanied by a crackling sound. 
 
 Stapedius Muscle. 
 
 The stapedius muscle is supposed to regulate the movements 
 of the stapes, by preventing its foot-plate from being forced in 
 upon the fenestra ovalis, during great or sudden movements of 
 the drum-head. 
 
 Lucae, quoted by Hensen, 1 found this contracted when the 
 orbicularis palpebrarum muscle was strongly excited. He found 
 with this a weakening of the power of hearing all musical notes, 
 but an increase in the capacity of hearing those of 10,000 and 
 more vibrations. 
 
 Hensen, in one experiment carried a needle through the ten- 
 don of the stapedius muscle. The point of the needle was in the 
 facial nerve. As long as the tensor tympani was intact, the 
 stapedius contracted energetically upon the reception of all 
 tones, as Hensen believes in consequence of a mechanical move- 
 ment of the ossicle produced by the tensor. When the tendon 
 of the tensor was divided, the needle in the stapedius moved 
 only upon the production of higher tones, from about 7000 vi- 
 brations and upward. In lower tones, the movements were in- 
 distinct, and the tones of the great and contra octaves did not 
 produce any effect at all. 
 
 Budge, quoted by Hensen, has attempted to show that the 
 stapedius muscle is of importance in maintaining the equilib- 
 rium of the body. 
 
 Eustachian Tube. 
 
 This passage serves to maintain an equilibrium of pressure 
 between the external air and the tympanum, and as a means of 
 exit of the secretions of that cavity. The physiology of the 
 Eustachian tube has been most accurately studied by Toyiibee 
 and Politzer. It is to their studies and experiments, that we are 
 indebted for that most valuable means of treatment, Politzer's 
 method of inflating the middle ear. Politzer 2 concludes that 
 
 1. The tube is not constantly open. Its permeability varies 
 in different persons. In some cases, even in quiet respiration, 
 an interchange of air from the pharynx toward the tympanum 
 
 1 Loc. cit., p. 65. s Lehrbuch, original, p. 77. 
 
 17
 
 258 FUNCTIONS OF EUSTACIIIAN TUBE. 
 
 takes place ; 'in others the act of swallowing or a powerful ex- 
 piration becomes necessary. 
 
 2. The tube is especially opened by the action of the muscles, 
 during the action of swallowing, as shown by Toynbee and 
 Politzer. 
 
 3. A difference in the pressure of the air, is more easily 
 equalized from the tympanum to the pharynx, than from the 
 pharynx to the tympanum.
 
 CHAPTER X. 
 
 INJURIES OF THE MEMBRANA TYMPANI. 
 
 Diseases of the Membrana Tympani not Independent Affections. Vascular, Nervous, 
 and Lymphatic Supply, a Part of that of the Canal and Middle Ear. Drum -head 
 Subject to Injury by Explosions, Blows, and so forth. Effects of Condensed Air. 
 Serious Injuries of the Head. Fracture of the Handle of the Malleus. 
 
 THE diseases of the membrana tympani occur either as a result 
 of an inflammation of the external auditory canal, or of the 
 middle ear. I have not seen any cases of independent or primary 
 myringitis, or inflammation of the drum membrane, such as are 
 delineated with theoretical minuteness by some writers on otol- 
 ogy. The anatomical structure of a membrane that has but one 
 layer of tissue peculiar to itself, and that in its centre, but which 
 is a direct uninterrupted continuation of the adjacent parts, pre- 
 cludes the idea of an inflammation that occurs primarily in this 
 part. There is probably no independent disease called myrin- 
 gitis, in the sense that we speak of a keratitis or a retinitis. 
 
 Dr. A. H. Buck ' has reported a case of interlamellar cyst of the membrana 
 tympani, which might be supposed to be an independent disease of this part ; 
 but the history shows that the patient was suffering, at the time of the formation 
 of the cyst, from chronic eczema of the auditory canal, which renders it probable 
 that the case was one of extension of disease of the canal to the drum-head. 
 
 The vascular, nervous, and lymphatic supplies of the parti- 
 tion wall between the auditory canal and the middle ear, belong 
 also to those parts which it separates. Neither the integument- 
 ary nor the mucous layer of the membrana tympani can be 
 fully separated from it. These facts show that the drum-head 
 has no independent existence. In the vast majority of instances 
 the diseases of the membrana tympani are of a secondary char- 
 acter. It is possible, however, that there may be a primary in- 
 flammation of the membrana tympani in exceptional instances, 
 for example, from a draught of air blowing upon the membrane. 
 Yet, even in these cases, the inflammation, even if it begins in 
 the drum-head, advances so rapidly to the contiguous tissue, that. 
 
 1 Medical Record, vol. vii. , p. 572.
 
 260 INJURIES OF MEMBRANA TYMPANI. 
 
 the inflammation becomes one of the middle ear almost in an 
 instant. For these reasons, the term myringitis was discarded 
 in the earlier editions of this work, and this example has been 
 followed by most of the recent writers on aural medicine and 
 surgery. Sir William Wilde, when using the term myringitis, 
 did not mean an inflammation of the membrana tympani alone, 
 but he used it to describe an inflammation of the middle ear, as 
 careful reading of his work will show. 
 
 Politzer, in his work upon the ear, so recently translated into 
 English, describes a primary myringitis, occurring "after the 
 action of a cold wind upon the ear, after a cold bath, after sea- 
 bathing, or in the course of acute naso-pharyngeal catarrhs." 
 He also describes the formation of one or more blisters of the 
 size of a hemp-seed, and filled with serous fluid, as well as, 
 minute abscesses. He thinks, however, that the abscesses of 
 the membrane described by Boeck, were secondary formations, 
 occurring in the course of acute or chronic affections of the 
 middle ear. After a careful consideration of the views of Po- 
 litzer, and my own experience, I am still unconvinced that pri- 
 mary myringitis is anything more than an extremely rare affec- 
 tion. If indeed it occurs at all, I am doubtful. 
 
 The membrana tympani is, however, subject to injury from 
 explosions, or sudden and violent movements of the atmosphere, 
 which cause the undulations to be condensed and forced inward 
 upon the drum-head. It may also be ruptured by the force of 
 condensed air, as, for example, that which is found in passing 
 through the lock of a caisson used in excavating for the foun- 
 dations of bridges, or the making of tunnels under rivers. The 
 membrana tympani may also be ruptured by blows or falls upon 
 the side of the head or upon the ear, or from direct injury by 
 the striking of a sharp instrument directly upon the membrane, 
 by violent sneezing or coughing, by the use of appliances for 
 washing out the nostrils, and so forth. 
 
 The explosion of artillery is not apt to cause rupture of the 
 drum-head. When we consider the number of persons who 
 have been thus exposed to injury, it is somewhat surprising that 
 no more have suffered from this cause. After diligent inquiry 
 among army surgeons, I have heard of but very few cases of 
 rupture of the membrana tympani occurring from this cause ; 
 and although I have seen many patients who became partially 
 deaf from the exposures incident to campaigning, during our 
 late civil war, I have as yet seen but one case, where a rupture 
 of the drum membrane occurred from the explosion of artillery. 
 The long-continued exposure to heavy firing often, and perhaps 
 always, causes a temporary ringing in the ears, probably from
 
 RUPTURE OF MEMBRANA TYMPANI. 261 
 
 concussion of the labyrinth, and sometimes hemorrhage from 
 the vessels of the membrana tympani, but very rarely is a rup- 
 ture produced. The effects of the concussion do not always pass 
 away, and some soldiers acquire a chronic inflammation of the 
 internal and middle ears from this cause, just as do boiler- 
 makers, who work amid deafening noises. Ruptures from con- 
 cussion do occur, however. I once saw a woman at the New 
 York Eye and Ear Infirmary, who had suffered such an acci- 
 dent from the firing of a pistol near her ear ; and Dr. Hackley 
 observed a similar result in an actor who was obliged to fire a 
 pistol over his shoulder during a play. The power of the mus- 
 cles of the Eustachian tube, which act very quickly, and force, 
 as it were, a current of air in upon the drum membrane from 
 the inner side, is probably that which counterbalances the effect 
 of a sudden condensation of air upon the outer side. The little 
 chink, which normally exists in the calibre of the tube, is also a 
 source of protection. Besides this, the structure of Shrapnell's 
 membrane, made up as it is of fibres, much more loosely woven 
 together than those of the remainder of the drum-head, assists 
 it to yield to great shocks of sound. Those persons who suffer 
 a rupture of the drum-head from external concussions, prob- 
 ably have some catarrhal affection which prevents the air from 
 freely circulating in the tubes and the cavity of the tympanum ; 
 for we can scarcely believe that so few would suffer this acci- 
 dent, were all drum membranes equally liable to it. During the 
 heavy fighting of our civil war, infantry soldiers in the trenches 
 were in the habit of lying down, while the artillery behind fired 
 over their heads ; and yet, as I have found by inquiry, rupture 
 of the membrana tympani was scarcely heard of. 
 
 Gruber's experiments on the cadaver show that the resisting 
 power of the membrane is very great. Dr. Schmidekam as- 
 sisted Professor Gruber 1 in these experiments, which proved, 
 according to the former author, that the resisting power of the 
 membrane was greater in man than in the other animals. It 
 required a column of quicksilver of 143 ctm. high to rupture the 
 membrana tympani of an ear that had lain in alcohol for a few 
 weeks. The stapes and incus had been removed. The rupture 
 was straight and parallel to the lower three-fourths of the ante- 
 rior line of attachment of the malleus. In another case a drum- 
 head, which exhibited the remains of a former inflammatory 
 process, in the form of a false membrane, was not ruptured 
 until a column of quicksilver, 168 ctm. high, was used. Here 
 again the rupture occurred on the anterior segment. 
 
 1 Lehrbuch, p. 332.
 
 262 RUPTURE OF MEMBRANA TYMPANI. 
 
 Gruber also examined the resisting power of the drum-head 
 by the following experiment : He introduced a catheter with a 
 bulbous extremity into the Eustachian tube of a fresh subject, 
 having a healthy membrana tympani, and fastened the catheter 
 in the tube by means of a stout thread stuck through it. He 
 then allowed a stream of air from a compression pump air that 
 had been condensed four or five fold to pass suddenly into the 
 tube, or after closing the tube by tying a cord about it, he 
 stopped the external auditory canal by means of a gutta-percha 
 plug, with a small tube in it, through which he allowed the 
 compressed air to pass. Gruber was never able to break the 
 membrane in this experiment. The gutta-percha plug with 
 the tube was driven out of the canal, but the membrane was 
 never ruptured. 
 
 Professor Gruber saw a great many patients who were en- 
 gaged in the battles of Schleswig-Holstein and Bohemia in 1864 
 and 1866, and although he examined nearly all the aural patients 
 of the Garrison Hospital in Vienna, he saw but one where the 
 explosion of projectiles had caused a rupture of the drum-head. 
 In this case the soldier was knocked senseless by the explosion 
 of a grenade, which killed two near him. When he recovered 
 his senses he was suffering from tinnitus aurium in the left ear, 
 and was deaf on this side. Pain occurred, and in three weeks 
 after, when he was seen by Dr. Gruber, he was found to have a 
 roundish opening about one and a half line in diameter, in the 
 anterior and inferior segment of the drum-head. The tubes were 
 pervious, and there was no evidence that he had previously suf- 
 fered from aural disease. This, however, was the only case 
 among hundreds of soldiers that fought at Konigsgratz, who had 
 suffered the injury which has been detailed. 
 
 Dr. Andrew H. Smith, one of my colleagues at the Man- 
 hattan Eye and Ear Hospital, was the medical officer in charge 
 of the men engaged in laying the foundations for the bridge 
 from New York to Brooklyn over the East River, and had many 
 opportunities of observing the effects of compressed air upon the 
 membrana tympani. Through Dr. Smith's courtesy, I saw some 
 cases that illustrate this subject ; and I here give from Dr. Smith's 
 notes, one of rupture of the membrana tympani which occurred 
 while the patient was passing through "the lock." 
 
 Dr. Smith describes the case of rupture of the membrane as 
 follows : 
 
 John H , on May 17th, the pressure being about 35 pounds to the square 
 
 inch above the normal ; the patient was attacked while in the lock going down 
 for the first time, by a severe pain in the right ear, followed by a slight discharge 
 from the meatus. No sensation was felt as of anything giving way in the ear.
 
 EFFECTS OF CONDENSED AIR. 263 
 
 He completed bis watch, and then reported to me. On examination, the drum- 
 head was found to be ruptured at its upper edge. The opening was nearly cir- 
 cular and rather less than a line in diameter. The patient preferred not to go- 
 on with the work, and he was not seen by me again. 
 
 Dr. Smith believes that most of the men who suffered from 
 aural trouble after having been in the caisson, had previously 
 some impairment of the permeability of the Eustachian tubes. 
 The men under his care were "most strenuously" instructed not 
 to enter the caisson unless they were able, when holding the nose 
 and blowing forcibly, to feel the air enter both ears. Neverthe- 
 less, cases occurred in which this precaution was neglected, and 
 the individual was, in consequence, caught in the lock unable to 
 " change his ears." ' 
 
 Dr. Smith says that the structures within the tympanic cavity 
 not being acted upon by the increased pressure, "are placed 
 relatively in the same position as the skin under a cupping-glass," 
 by the continued exposure to the effect of compressed air, when 
 the Eustachian does not open, or rather, as we should say, when 
 it does not act well, from swelling or thickening of its tissue. 
 Then the intense congestion occurs, which may be followed by 
 inflammation, finally resulting in perforation of the membrane, 
 as happened in one case reported by Dr. Smith in his paper. 
 
 Politzer's method of inflating the ears was found very useful 
 in treating these cases of simple congestion, which, if they had 
 not been treated, would have resulted in tympanic inflammation 
 and perforation of the drum-head. As an effect of the use of 
 this method of treatment, many of Dr. Smith's men were en- 
 abled to continue at their work who could not have otherwise 
 done so without danger. The treatment became very popular 
 among the men, so that as many as four or five of them would 
 come at Dr. Smith's visit to have their " ears blown out." 
 
 I saw three or four of these cases of congestion of the tym- 
 panic cavity, they having been sent to me by Dr. Smith, and 
 was enabled to see the great advantage of skilled medical advice 
 to these men. Many ears would certainly have been perma- 
 nently injured had not Politzer's method been employed at an 
 early stage of the trouble. 2 
 
 1 This is the term used by the men to signify the operation of holding the nose and 
 blowing until the air is felt to enter the middle ear. This operation has to be con- 
 stantly repeated while the air pressure is increasing in the lock, in order to relieve the 
 pain resulting from the pressure upon the membrana tympani. In some persons the 
 act of swallowing answers equally well. ' 
 
 2 Dr. Smith's paper on "The Effects of High Atmospheric Pressure, including the 
 Caisson Disease," received the prize of the Alumni Association of the College of Physi- 
 cians and Surgeons for 1873. My extracts were taken from the manuscript loaned to. 
 me by the author.
 
 264 EFFECTS OF CONDENSED AIR. 
 
 A gentleman who once consulted me in reference to what I 
 deemed to be an incurable chronic catarrh of the middle ear, 
 which had resulted in thickening and sinking of the drum-head, 
 afterward came to me with a perforation of the membrane of 
 one side and discharge of pus from the tympanum, which he 
 stated was caused by a visit to the caisson. The perforation 
 soon healed, and the hearing was rather worse than before the 
 accident. 
 
 Dr. John Green, 1 of St. Louis, had previously to Dr. Smith 
 made some observations upon "the physiology of the Eustachian 
 tube, during a short exposure to an atmospheric pressure of sixty 
 pounds to the square inch." Dr. Green's observations were made 
 while bridge-piers were being sunk to the rock underlying the 
 bed of the Mississippi River at St. Louis in 1869-70. 
 
 The entrance to the chamber of condensed air was "through 
 an air-lock, or small chamber into which the condensed air 
 could be admitted gradually, occupying, for the higher degrees 
 of pressure, from four to ten minutes." The exit occupied about 
 the same time. 
 
 The accidents to the ears occurred, as in Dr. Smith's cases, 
 while passing through this lock. Sudden chilling of the body 
 from changes in temperature in the chamber were, according to 
 Dr. Green, causes of catarrhs. This theory is rather more suffi- 
 cient to explain the cases of tympanic congestion when the tube 
 was not completely pervious, than the one of mechanical press- 
 ure, although undoubtedly both causes acted together in pro- 
 ducing aural affections. 
 
 Dr. Green notices an interesting phenomenon observed in 
 coming out of the lock, which Dr. Smith also observed. There 
 was a spontaneous escape of air through the Eustachian tubes 
 in a succession of puffs, succeeding each other at intervals of 
 fifteen or twenty seconds, independently of respiration, and ab- 
 solutely without the concurrence of an} r muscular action. The 
 phenomenon suggested to Dr. Green "the action of a lightly 
 resisting valve, necessitating a slight but perceptive increase of 
 pressure within the tympanic cavity, to open the passage to the 
 pharynx." Dr. Green observed several cases of rupture of the 
 drum-head and acute catarrh occurring as a result of the unequal 
 pressure, and of the exposure to an uneven temperature. 
 
 Dr. A. Magnus," of Konigsberg, investigated very carefully 
 the behavior of the ear in condensed air, in 1863, while a rail- 
 way bridge was building in his city. He proved that the injury 
 
 1 Transactions of the American Otological Society, 1870. 
 s Archiv fur Ohrenheilkunde, Bd. I., p. 270.
 
 EFFECTS OF CONDENSED AIR. 265 
 
 to the ear was caused by pressure upon the membrana tympani, 
 because when he plugged the auditory canal hermetically, no 
 unpleasant sensations were felt, but when he removed the stop- 
 per the air streamed with a powerful current into the canal, and 
 pain occurred very soon. The ear that was stopped remained 
 without pain, and the Valsalvian experiment soon relieved the 
 pain in the uncovered one. Magnus also proved by an exam- 
 ination of ears when the pressure was being exerted, that the 
 membrana tympani was actually pressed inward. The triangu- 
 lar spot was obliterated when the pressure was greatest and the 
 pain severe. A patient without any membrana tympani, who 
 was subjected to the condensed air, had no pain. Indeed, there 
 was not a trace of an unpleasant sensation. 
 
 The membrana tympani undoubtedly owes much of its re- 
 sisting power, as Mr. Shrapnell pointed out, to the existence of 
 a triangular membrane at its upper portion that is less tense 
 and thick than the remainder of its structure, the so-called mem- 
 brana flaccida, or ShrapnelKs membrane, which yields when 
 undue pressure is brought upon it. The membrane has, per- 
 haps, some additional defence in its oblique position in the 
 canal, which causes a portion of it to be covered by the walls in 
 such a way as not to receive the whole force of the column of 
 compressed air. ' 
 
 The membrana tympani is perhaps more frequently injured 
 by mechanical violence to the head or to the membrane itself. 
 Professor Robert F. Weir, 2 formerly surgeon to the New York 
 Eye and Ear Infirmary, has seen four such cases. In one the 
 drum-head was ruptured by a blow upon the head with the hand. 
 In another, fragments of rock from a blast struck the head and 
 ruptured the membrane. In the third case the injury was caused 
 by a snow-ball striking the ear ; and in the fourth a hair-pin was 
 accidentally forced through the part. In the first three of Dr. 
 Weir's cases the rupture was slit-shaped, parallel and posterior 
 to the handle of the malleus. 
 
 I have now under my observation a gentleman of about fifty 
 years of age, whose membrana tympani is said to have been 
 ruptured when he was a small boy, by blows upon the side of 
 his head, given by one of his teachers. The membrane is nearly 
 entirely gone, and there is at times a purulent discharge from 
 the tympanic cavity. Teachers and parents who have the bad 
 habit of striking children unexpectedly to their little charges, 
 
 1 The effects of compressed air upon the hearing power will be again alluded to iii 
 the chapter on "Chronic Non-suppurative Inflammation." 
 * Verbal communication.
 
 266 INJURIES OF MEMBRANA TYMPANI. 
 
 should be warned of the danger of a box on the ear to the in- 
 tegrity of the organ. 
 
 The membrana tympani is sometimes ruptured in attempts 
 to remove foreign bodies, such as inspissated cerumen, and so- 
 on, by means of a probe, as has been seen in one of the preced- 
 ing chapters. The text-books of Toynbee and Von Troltsch 
 record several interesting cases of injury to the drum-head by 
 mechanical violence. The latter author relates one in which a 
 young man, while going up a ladder, accidentally struck his ear 
 against a blade of straw, which passed through the membrane 
 and caused the severest pain, so that he nearly fainted. In one 
 of Toynbee's ' cases the rupture was caused by an unexpected 
 blow upon the ear of a boy by a tutor. In another case the ear 
 was hit by a bolster while the boys were engaged in a playful 
 contest. In both of these cases the rent was found to be on the 
 lower part of the membrane. 
 
 Toynbee also relates a case which is of interest on account 
 of the nervous symptoms produced by it. A young man of 
 seventeen, while shooting, in endeavoring to force his way 
 through a hedge, got a twig into the right auditory canal. It 
 produced sudden and severe pain, followed by bleeding. Mr. 
 Toynbee saw the patient a week afterward. The pain speedily 
 subsided ; but for days after the accident there was "a feeling 
 on the same side of the tongue as if something cold had been 
 rubbed over it ; the taste on that side also was impaired." The 
 sensibility of the tongue to touch was, however, unimpaired. 
 
 The chorda tympani nerve was probably injured in this case ; 
 for the same sensations are sometimes caused when a bit of 
 cotton-wool is brought in contact with the cavity of the tympa- 
 num and with the nerve. 
 
 I lately saw a man of thirty-eight years of age, who stated 
 that at sixteen, he ruptured the right drum-head in the following 
 manner : While in the woods engaged in securing sap for mak- 
 ing maple sugar, he bent down over some underbrush, so that 
 a twig entered the auditory canal. Immediately "he felt as 
 if half his tongue were paralyzed." He does not remember 
 whether the ear bled or not, whether there was any pain or 
 suppuration from it, but he does remember the loss of sensation 
 in half his tongue. He has never heard with the ear since the 
 accident. He has chronic inflammation of the left ear. There 
 is no aerial conduction whatever on the right side. There is a 
 distinct opacity in front of the handle of the malleus. 
 
 This patient is a highly educated man. While there are sev- 
 
 1 Text-book, p. 28.
 
 RUPTURE OF MEMBRANA TYMPANI. 267 
 
 eral negative points in. the history, since he cannot remember 
 whether he had pain, or bleeding, or suppuration from the ear, 
 there is enough that is positive in the history and in the appear- 
 ances to enable us to believe that this is a case of rupture of the 
 membrane, followed by proliferous inflammation of the tym- 
 panum. Since the patient has a chronic inflammation of the 
 middle ear of the uninjured side, we may believe that we can- 
 not ascribe all the morbid changes in the tympanum to the in- 
 jury of the drum-head, unless we suppose that there may be a 
 sympathetic inflammation of the middle ear, just as there is a 
 sympathetic inflammation of the uveal tract of the eye. This 
 supposition is not wholly groundless, although as yet appar- 
 ently having only an analogical foundation. Sympathetic in- 
 flammation of the eye usually, if not always, has its origin in 
 the uveal tract, and involves the muscle of accommodation ; 
 why may not a traumatic inflammation of one ear, especially 
 an injury of the ossicles and middle ear, produce a sympathetic, 
 plastic inflammation of its fellow ? 
 
 The case is inserted here, chiefly to show the effect of an in- 
 jury to the chorda tympani nerve. In thinking it over, how- 
 ever, the possibility of a sympathetic otitis has occurred to me. 
 Reasoning from analogy, it is possible to suppose such a condi- 
 tion of things. 
 
 The function of the chorda tympani is probably chiefly in connection with 
 that of taste, and not of hearing. 
 
 Professor Flint ' relates a case which sustains this view. A soldier received 
 a gunshot wound, the ball passing through the head, entering just above the ala 
 of the nose, on the left side, and emerging behind the mastoid process of the 
 right temporal bone. The wound healed, with the iisual symptoms of complete 
 facial paralysis on the right side. The buccinator and orbicularis oculi were 
 completely paralyzed. The hearing was perfect. The sense of taste was entirely 
 abolished in the anterior portion of the tongue on the right side. These facts 
 were verified by Professor Dalton, of this city. 
 
 Experiments upon dogs and cats, and other animals, also show, according to 
 Flint, that the chorda tympani influences taste ; for sections of the root of the 
 fifth pair, or of the chorda tympani, is followed by loss of taste in the anterior 
 portion of the tongue. 
 
 The chorda tympani is given off from the facial, as it passes vertically down- 
 ward at the back of the tympanum, about a quarter of an inch before its exit 
 from the stylo-mastoid foramen. It ascends* from below upward in a distinct 
 canal, parallel with the aquseduct of Fallopius, and enters the cavity of the tym- 
 panum through an opening between the base of the pyramid and the attachment 
 of the membrana tympani. It becomes covered by mucous membrane, and 
 passes forward through the tympanic cavity between the handle of the malleus 
 and the vertical cms of the incus (see Fig. 44, on p. 194), and then passes out 
 
 1 The Physiology of Man, The Nervous System, p. 157.
 
 268 RUPTURE OF MEMBRANA TYMPANI. 
 
 of the cavity, through the canal of Hugier, at the inner side of the Glaserian 
 fissure. It then passes downward, between the two pterygoid muscles, and 
 meets the gustatory nerve at an acute angle, and communicating with this it 
 passes to the submaxillary gland ; after joining the sub maxillary ganglion it ter- 
 minates in the lingualis muscle. 
 
 Its anatomy seems to indicate that it has very little to do with the function 
 of hearing. It merely passes through the tympanum, without supplying any of 
 its tissues, as has already been described in the chapter on the anatomy of the 
 middle ear. 
 
 Claude Bernard also performed experiments upon the chorda tympani of cats 
 and Albino rats, by cutting out the facial nerve at its exit from the stylo-mastoid 
 foramen. In from six to ten days the terminal twigs of the lingualis nerve, and 
 the nerve-fibres coming from the chorda tympani were found to have undergone 
 fatty degeneration. Degenerated nerve-fibres were also found in the tip of the 
 tongue, but not in the papillae. There were also degenerated nerve-fibres in the 
 submucous tissue. 1 
 
 Severe vomiting sometimes causes a rupture of the drum- 
 head, as does strangulation by hanging. The cases of rupture 
 that occur during whooping-cough, and sneezing or blowing the 
 nose, are not properly to be considered in the present chapter ; 
 for when the membrana tympani is ruptured in such cases, 
 there is usually, if not always, some pre-existing catarrh of the 
 Eustachian tube and tympanic cavity. I have seen several such 
 cases, but in all of them I have been able to trace disease of the 
 middle ear as having preceded the breaking of the drum-head. 
 The great accumulation of mucus caused by the catarrhal in- 
 flammation will be very apt to cause a rupture by mechanical 
 pressure from within upon a distended mucous membrane and 
 fibrous layer, unless the cavity be emptied by means of the 
 catheter or Politzers method. 
 
 In countries where punishment is meted out in exact pro- 
 portion to the amount of personal injury done to the person 
 assaulted, blows upon the side of the head which result in rup- 
 ture of the membrana tympani are made the subject of careful 
 medico-legal examination. 4 
 
 In order to determine the cause of a rupture of the membrana 
 tympani, it must be seen within a few hours of the injury ; for 
 suppuration may occur soon after it has occurred, when it will 
 be impossible to decide whether it had a traumatic or spontane- 
 ous origin. 
 
 1 Monatsschrift f iir Ohrenheilkunde, No. 1, 1873, from Comptes Rendus, Hebdom. 
 dea Seances de 1'Academie des Sciences, T. Ixxv., No. 27. Paris, 1872. 
 
 s According to the Austrian criminal code, an injury is defined to be a severe one, 
 when the person suffering it is deprived of his usual health, or kept from his occupa- 
 tion for a period of not less than twenty days. Politzer, Wiener Med. Wochenschrift, 
 Nos. 35, 36, 1872.
 
 KUPTURE OF MEMBKANA TYMPANI. 269 
 
 A traumatic rupture of the membrana tympani, especially 
 one arising from the perforation of the membrane by a sharp 
 instrument, is much more apt to cicatrize promptly, without 
 suppuration, than one that has been perforated in the course of 
 inflammation of the middle ear. 
 
 The force of large waves upon the side of the head in sea- 
 bathing, is an occasional cause of rupture of the membrana 
 tympani. I have seen such cases, and one where both mem- 
 branes were ruptured. A wave is sometimes allowed to strike 
 upon the membrane with great violence, and if it do not break 
 it, it will at least excite an inflammatory action. Physicians 
 who practice at the sea-side, should warn their patients of this 
 danger from surf -bathing. Long Branch and Newport, furnish 
 every year a certain contingent of aural patients from this cause. 
 
 A little care so that the waves do not strike the side of the 
 head in full force, and plugging the meatus lightly with cot- 
 ton, will be found to be a sufficient protection from the sever- 
 ity of the waves. If water be allowed to stay in. the auditory 
 canal for some time, it becomes a source of congestion ; but 
 such causes of diseases of the middle ear are more appropriately 
 considered in a subsequent chapter. 
 
 Dr. C. H. Burnett, 1 of Philadelphia, has reported a case of 
 evulsion of the membrana tympani, from the splashing of mud 
 into the ear by a horse while the patient was crossing the street. 
 The patient was thirty-nine years old, and consulted Dr. Burnett 
 three days after the accident. He stated that his ear was sound 
 until the mud came into it. Upon returning to his shop he was 
 a machinist he was examined by some of his comrades, who 
 said they saw foreign objects in the meatus, which they pro- 
 ceeded to extract with chips and mechanics' small tools. Several 
 "little white pebbles" were taken out, which were probably the 
 ossicles. Great impairment of the hearing of the ear followed. 
 The patient was very pale, anxious and bathed in cold perspira- 
 tion when he visited Dr. Burnett. A watch that should have 
 been heard 40 feet was only heard 5 ctm. The tuiiing-f ork placed 
 on the vortex was heard very distinctly in the injured ear. 
 
 On examination, Dr. Burnett found the meatus uninjured. A 
 small piece of mud was adherent to the antero-superior quadrant 
 of the periphery of the membrana tympani. The membrane was 
 entirely destroyed, except a very narrow border. There were no 
 ossicles visible. The inner wall of the tympanum was fully ex- 
 posed to view. The mucous membrane was healthy, but slightly 
 abraded on the promontory. Twenty days after, without treat- 
 
 1 Transactions of the American Otological Society, 1872.
 
 270 RUPTURE OF MEMBRANA TYMPANI. 
 
 ment, patient was free from pain and "ruddy and cheerful." 
 The border of the membrana tympani had become adherent to 
 the promontory. Of course the hearing power was not improved, 
 thanks to the care of his surgical comrade, who so carefully 
 removed the " white pebbles " from his ear. 
 
 Dr. J. Orne Green ' reports a case where the explosion of a 
 bag of gas near the ear caused a rupture of the membrana 
 tympani. The patient, who was preparing for an exhibition in 
 which an oxy -hydrogen light was to be used, was standing a 
 few feet from the bag, and with his left side toward it at the 
 time of the explosion. The immediate effect was some slight 
 confusion of intellect, which soon passed off ; but the next day 
 the left ear began to be painful, and on blowing the nose, air 
 whistled through it. 
 
 Dr. Green saw the patient twelve days after the accident, 
 and found the membrana tympani red and swollen, and on the 
 posterior segment just behind the umbo, a rupture 1 line long, 
 nearly perpendicular, through which purulent matter could be 
 forced by Valsalva's method of inflation. H. D., ^. 
 
 Dr. Green states that this patient had previously suffered 
 from impaired hearing and mucous rales in his ears. Most of 
 the cases of rupture of the drum-head on record, if the ante- 
 cedents had been inquired into, would undoubtedly exhibit the 
 same condition of things. 
 
 The assistant of the patient whose case has just been quoted, 
 suffered at the same time from the explosion of a bag of gas, 
 and also received rupture of the membrane, which resulted in a 
 purulent inflammation of the tympanic cavity. He was treated 
 by Dr. Henry L. Shaw, of Boston. In both of these cases the 
 rupture healed perfectly, and the hearing power was partially 
 restored. In Dr. Green's case it became ff- 
 
 Dr. Green saw two other cases in which the patients suffered 
 from the concussion of the same accident. It caused a loud 
 buzzing in the ear and confusion in the head. The patients 
 consulted Dr. Green on account of the tinnitus which was caused 
 in one case, but aggravated in the other, for the latter patient 
 had previously suffered from disease of the middle ear. 2 
 
 If a person be a sufferer from catarrh of the middle ears, the 
 drum-head, as has been already intimated, is much more likely 
 to be ruptured by blows, falls, exposure to the surf in bathing, 
 
 1 Transactions of the American Otological Society, 1872. 
 
 8 Dr. Green records several other cases of injury of the side of the head which pro- 
 duced a rupture of the membrana tympani, but as they do not differ from others that 
 are noticed in this chapter, I beg to refer my readers who may wish to carry this sub- 
 ject farther, to his interesting paper.
 
 RUPTURE OF MEMBRANA TYMPANI. 271 
 
 or the like. In fact, I am inclined to doubt if persons with well 
 ventilated tympanic cavities, and normally acting drum-heads 
 ever suffer a rupture of the membrana tympani, except from 
 very great direct violence. 
 
 In 1875 I saw a little boy who was thrown from his pony a 
 few hours before he consulted me. He struck upon his right 
 side, and he had a free discharge from his right ear immediately 
 afterward. His hearing distance was V when examined, and 
 he heard the tuning-fork better on the injured side. Blood was 
 found on the walls of the auditory canal, and the membrana 
 tympani was ruptured in the centre. The ear was let alone very 
 carefully, and the drum-head soon healed. There remained, 
 however, a depression in the centre at the site of the rupture. 
 This little fellow had nasal and pharyngeal catarrh at the time 
 he received the fall, or I suppose it is not likely that the mem- 
 brana tympani would have ruptured from what was a slight 
 injury, for he fell upon the lawn of a country place, and from 
 a very small pony. At any rate, in spite of the best of care from 
 his family and from a distinguished expert in aural disease, with 
 whom I have occasionally seen him professionally, he has gone 
 on with a catarrhal or proliferous inflammation in the middle 
 ears, until now, as he is growing into manhood, his hearing is 
 very much impaired. 
 
 I once saw a case of hemorrhage from the auditory canal in 
 a boy of three and a half years, who fell from a rocking-horse. 
 He had had a discharge from the same ear a year before which 
 had ceased. Some hard wax and a large blood-clot were re- 
 moved from the auditory canal, but the membrana tympani was 
 uninjured and looked natural. 
 
 In 1881 a young gentleman of nineteen consulted me in re- 
 gard to an injury to his left ear, of which he gave the following 
 account : Two days before it was hit by the flat surface of a 
 boxing-glove in the hands of his antagonist. He became dizzy 
 and felt a sense of pressure upon the ear. He did nothing to 
 relieve these symptoms and they passed away. But on consult- 
 ing me, he states that he has now a feeling of tightness and 
 pain in the ear, and noise causes discomfort. He once had a 
 discharge from the ear after scarlet fever. His hearing dis- 
 tance is 5 8 -g- on the injured side, f-f on the other. The tuning-fork 
 is heard better in the affected ear. There is a red line through 
 the anterior segment of the membrane, beginning at the end of 
 the malleus. The ear was inflated by Politzers method, and 
 this was repeated every few days. The patient was also ad- 
 vised to wear cotton in the meatus of that side. The ear grad- 
 ually recovered its normal sensations.
 
 272 RUPTURE OF MEMBRANA TYMPAXI. 
 
 Here, again, we had to do with an ear that was probably riot 
 entirely sound when the accident occurred. It is probable, from 
 the history, that the drum-head was at one time injured by 
 ulceration, and that it was a cicatricial membrane when the 
 canal was struck. 
 
 In the following case the drum-head was so badly injured by 
 direct violence, that it will never be a perfect membrane : 
 
 F. N , aged forty-one years. Five days ago his infant child, while he was 
 
 playing with it, pushed a button-hook into the right auditory canal. A momen- 
 tary pain occurred, attended by bleeding. The patient's wife washed out the 
 ear, and great pain followed. Since then the pain has diminished, and he has a 
 purulent discharge from the ear. He never had a disease of the ear before, as 
 far as he knows. The hearing distance is R. E., - 4 3 ; L. E., $. The tuning-fork 
 placed, on the vertex is heard better in the right ear. The bone conduction is 
 better than the aSrial on the right side. The upper wall of the osseous canal is 
 red and swelled. Pus lies upon the right drum-head. It is red in the periphery 
 and along the handle of the malleus. It is perforate in the inferior and the pos- 
 terior quadrant. The left membrana tympani is opaque and neoplastic. The patient 
 was treated for two months. The suppuration nearly ceased. He had no pain, 
 and slight tinnitus, when I last saw him, but the perforation in the drum-head 
 remained. 
 
 * 
 
 Although this patient had no recollection of ever having had 
 a disease of his ears, I am sure, he must have one day had some 
 affection of his uninjured ear. The impairment of hearing (f), 
 and the neoplastic drum membrane cause me to believe this. 
 He may also have suffered in his right ear, so that it may have 
 been more susceptible to injury than a normal drum-head. Yet 
 it must be admitted, that a thrust with a button-hook is capable 
 . of rupturing a drum-head whose tissue has never been injured 
 by ulceration. 
 
 At a recent meeting of the New York Ophthalmological So- 
 ciety, Dr. Loring reported a case of rupture of the drum-head on 
 each side, with bleeding, from a fall upon the forehead upon the 
 fender. The patient was a child, and the strictest inquiry, ac- 
 cording to Dr. Loring, failed to elicit the history of catarrh of 
 the nares or middle ears. 
 
 In this case the rupture occurred, as Dr. Loring thinks, from 
 contre-coup, the ears not being directly affected by the. fall, but 
 the full force came upon the region of the frontal sinus. The 
 child, according to the statement of Loring, has since suffered 
 at times from aural catarrh. 
 
 Very severe injuries of the head, such as those suffered by 
 laborers falling from scaffoldings used in building, or by being 
 hit by "falling planks" (Buck), falls, gun-shot wounds in the
 
 FRACTURE OF TEMPORAL BONE. 273 
 
 auditory canal, serious beatings or pummellings upon the head, 
 especially over the temporal bone, may produce fractures of the 
 temporal bone, as well as other bones of the skull. Bleeding 
 from the ear, or a serous discharge from the ear, are among the 
 prominent symptoms of such an injury. These cases are usu- 
 ally seen by general surgeons, who do not give the ear a critical 
 examination in determining the nature and extent of the in- 
 juries. It was formerly supposed 1 that a severe and long-con- 
 tinued bleeding from the ear was positive proof of a lesion of one 
 of the sinuses. But as Buck 2 has shown, a bleeding from the 
 tympanic artery may cause this, without necessarily involving 
 the sinuses. When an injury to the head is followed by bleed- 
 ing from the ear, even if it be trivial, we may, as stated by Buck, 
 diagnosticate a fracture of the temporal bone in the vicinity of 
 ShraprielPs membrane, and probably in the line of the Glaserian 
 fissure, but we cannot state that a deeper and a more extensive 
 injury has occurred. A fracture of the temporal bone may occur, 
 however, without hemorrhage from the ear. Buck quotes a case 
 from Dr. Geo. L. Peabody, which proves this. A man fell twenty 
 feet from a scaffolding, striking his head upon the pavement. 
 He died two days after the injury. There was no evidence of 
 fracture of the bones of the skull. " There was a thin watery 
 discharge from the nose, but there were no aural signs except 
 deafness." There were several fractures of the skull. There 
 was one on the right side extending from the foramen lacerum 
 posterium through the middle of the petrous portion of the tem- 
 poral bone, and terminating in the roof of the tympanic cavity. 
 The ossicles were found imbedded in a clot of blood. There was 
 no blood in the mastoid cells. On the other side, there was a 
 more extensive fracture of the same parts with a clot around the 
 ossicles and also in the mastoid cells. The fracture extended 
 into the semi-circular canals of both sides, and the right cochlea 
 contained a clot. 
 
 It is certain also, that patients recover from fractures of the 
 tympanic portion of the temporal bone. A prominent physician 
 of a neighboring city was attacked by ruffians one night, a few 
 years since, and severely beaten over the head, so that he was 
 unconscious for a short time. A large hemorrhage occurred 
 from one ear, but he recovered perfectly, except that his hearing 
 power was nearly destroyed upon that side. The membrana 
 tympani a few months after the injury was without a cicatrix 
 or other evidence of a rupture, as I found on examination. 3 
 
 1 Prescott Hewitt in Holmes' Surgery, vol. ii., p. 128. Edition of 1861. 
 
 2 Diseases of the Ear, p. 278 et seq. 3 Loc. cit , p. 29. 
 
 18
 
 274 HEMORRHAGE FROM TYMPANUM. 
 
 This gentleman having died some year or so after the injury, 
 it was supposed by some that his death resulted from it. But I 
 have very good authority for stating that he died from chronic 
 renal disease. 
 
 Dr. J. D. Rushmore, surgeon to the Brooklyn Eye and Ear Hos- 
 pital, also reports ' with great care a case bearing on this subject. 
 A man of sixty-eight years, after a peculiar and uncomfortable 
 feeling in his head for a few minutes, fell backward and toward 
 the left side, and lost in a few minutes, by the estimate of a physi- 
 cian, about sixteen ounces of venous blood from his left auditory 
 canal. He became unconscious for a few hours, and complained 
 of headache and vertigo. The man had been a busy but well 
 man. There was no renal disease. Dr. Rushmore saw the patient 
 four days after the injury. There was then tenderness around 
 the left auricle and dulness of hearing on that side. There was 
 slight oedema of the mastoid and a narrow ecchymotic spot ex- 
 tending toward the styloid process. The auricle was hyper- 
 semic. A soft clot filled the canal, and this was swollen and 
 tender after the clot was removed. There was no hemorrhage 
 and no serous discharge. Hearing distance for the watch, 0; 
 tuning-fork better through the bones, and it was heard better 
 on the sound side. The drum-head could not be seen. The 
 ear was treated by cleansing, leeches to the mastoid, oleate of 
 morphia in front and behind the auricle. Sleeplessness was re- 
 lieved by opium, bromide of potash, and alcohol. The result 
 was that the patient finally heard the watch in contact with the 
 ear, and the voice fifteen feet. The bone conduction remains bet- 
 ter than aerial. In all res-pects, except the dulness of hearing, 
 the patient, ten months after the injury, was as well as before he 
 received it. When the membrana tympani was first seen, fully 
 six weeks after the injury, there was a red irregular line, broad 
 on the periphery, and narrowing toward the centre of the mem- 
 brane, extending from the apex of the light spot to the end of 
 the handle of the malleus. Five days after, the red line had 
 nearly disappeared, and the light spot began to be mapped out. 
 There was a purulent discharge from the ear for sixteen days 
 after the injury. 
 
 Dr. Rushmore concludes, that there was a fracture beginning 
 in the external auditory canal, and extending, down ward and 
 forward. The origin of the bleeding he is at a loss to explain. 
 I think there is no reasonable doubt, however, that it was from 
 the vessels of the tympanic cavity. 
 
 The tuning-fork located the situation of the hemorrhage. 
 
 1 Archives of Otology, vol. ix
 
 HEMORRHAGE FROM TYMPANUM. 275 
 
 Had there been a hemorrhage into the labyrinth, the bone 
 conduction would not have been better than the aerial. A 
 careful examination of an osseous specimen will convince any 
 one of the possibility of rupturing the tympanic vessels only, 
 by such a fall. The healing of the membrana tympani with 
 scarcely a trace of the rupture, explains those cases of re- 
 ported bleeding from the ear, when the drum-head shows no 
 cicatrix in a few weeks after. That such a perfect healing may 
 occur, I have been able to demonstrate on several cases. 
 
 A profuse watery discharge from the ear, occurring immedi- 
 ately after the injury, is good evidence of a fracture of the pe- 
 trous portion of the temporal bone, but a watery discharge may 
 set in a short time after the accident, and be merely inflamma- 
 tory in character and by no means be the cerebro-spinal fluid, 
 even though it be excessive. The facial canal and the motor 
 filaments of the fifth nerve may be injured in fracture of the 
 temporal bone, and paralysis occur. 
 
 Our knowledge of these cases would be greatly increased, if 
 a careful examination of the membrana tympani were made in 
 each case of supposed fracture of the base of the skull. 
 
 Prognosis. The prognosis of a fracture of the temporal bone 
 with rupture of the membrana tympani is by no means unfavor- 
 able, except as regards an impairment of the hearing, as is seen 
 by the illustrative cases. But each case must be considered by 
 itself. No general prognosis can be made. 
 
 The prognosis in a case of rupture of the membrana tympani 
 depends very much upon the nature of the injury that caused it. 
 An accident of this kind, when produced by the concussion of a 
 heavy explosion or of a severe blow upon the side of the head, 
 is much more serious in its nature than an injury to a drum- 
 head from the forcing through it of any sharp body, such as a 
 knitting-needle, pen-holder, twig of a tree, a blade of straw, or 
 the like. The former class of injuries are apt to produce a frac- 
 ture of the temporal bone, a concussion of the labyrinth, or a 
 fracture or dislocation of the ossicula, as well as a rupture of 
 the drum-head. Such a result, at once takes the affection away 
 from the category of simple injuries, and renders it a very seri- 
 ous one, not only with reference to the hearing power, but also 
 as regards life. The tuning-fork becomes a valuable assistant 
 to diagnosis in cases of rupture. Its vibrations will be heard 
 more distinctly in the injured ear than the other, and the bone 
 conduction will be better than the aerial, if the labyrinth be not 
 injured. A simple rupture usually heals in a few days without 
 great injury to the hearing. A suppurative process may result,
 
 276 RUPTURE OF MEMBRANA TYMPANI. 
 
 however, and become chronic, when the treatment should be 
 the same as that of any other similar affection arising spon- 
 taneously. 
 
 Treatment. We can do very little indeed in the way of 
 treatment, if no inflammatory symptoms, such as pain or swell- 
 ing, occur. Above all, we should not disturb the ear imme- 
 diately after the occurrence of the injury, as is sometimes 
 mistakenly done, by syringing it. There is a very prevalent 
 disposition in the profession, to syringe the ear in every case of 
 aural disease that presents itself ; but no ear should be syringed 
 without a good and sufficient reason. 
 
 A large clot in the canal should be removed with gentleness 
 and care, but syringing the ear immediately after a minute 
 hemorrhage from a superficial injury is bad practice. Union 
 by first intention, is favored by letting the drum-head absolutely 
 alone. It is meddlesome surgery to do very much to such cases. 
 
 When inflammatory symptoms occur, they should be met by 
 leeches, the warm douche, and by the other means that will be 
 detailed in the chapters on "Acute Inflammation of the Middle 
 Ear." Meanwhile the ear should be protected from the cold air 
 by a bit of cotton placed in the meatus, and the patient should 
 be kept under careful but not meddlesome observation. 
 
 Fracture of the Handle of the Malleus. 
 
 This rare accident has been described by Meniere, Von 
 Troltsch, and Weir. 1 The history of the case of the second- 
 named author is as follows : A man accidentally thrust a pen- 
 handle which he held in his hand into his ear, in consequence 
 of knocking his elbow against a door. The severe pain caused 
 him to faint. After he recovered, he found that he heard badly 
 from the injured ear, and he suffered from tinnitus of that side. 
 Von Troltsch saw the case a year after, and from the peculiar 
 slanting position of the handle of the malleus, and from the fact 
 that it was uncommonly thick under the short process, he diag- 
 nosticated a united fracture of the manubrium. 
 
 Hyrtl, is quoted by Von Troltsch, as having described such an 
 united fracture in the malleus of a prairie dog. This fracture 
 was also situated just under the neck of the malleus. The mem- 
 brana tympani of this animal is, according to Hyrtl, very super- 
 ficially situated. 
 
 1 Von Troltsch on the Ear, second American edition, p. 151.
 
 FKACTUKE OF HANDLE OF MALLEUS. 277 
 
 Dr. Weir's case is one of. ununited fracture. ' A man, aged 
 thirty-two, came to Dr. Weir's clinic, at the New York Eye 
 and Ear Infirmary, on May 11, 1867, and gave the following 
 history : Four months previously he fell into an open area-way, 
 a distance of about fifteen feet. He became unconscious, and 
 remained so for nearly sixteen hours. He had been informed 
 that his right ear bled for about an hour. Upon returning to 
 consciousness he felt a severe pain from the right ear, across 
 the forehead to the other ear. The pain lasted for nearly a 
 month, and gradually diminished ; but the great tinnitus, which 
 dated from the time of the injury, continued unabated. There 
 was no history of any foreign body having entered the ear. The 
 watch was heard upon the affected side when pressed firmly 
 upon the ear. 
 
 The drum membrane was normal in color ; but there was an 
 irregularity in the handle of the malleus. The bone was found 
 
 FIG. 79. FIG. 80. 
 
 to be fractured a short distance below the short process, pre- 
 senting the appearance shown in the engraving. The broken 
 ends of the bone were completely and transversely displaced. 
 
 When Dr. Weir caused the patient to perform the Valsal- 
 vian experiment, the fragments came into apposition, and the 
 line of the bone became regular ; but the posterior portion of 
 the membrana tympani projected unduly forward from want 
 of support. In a few moments the displacement recurred, with 
 corresponding sinking of the posterior of the drum membrane. 
 Dr. Weir's colleagues Drs. Hackley and Simrock thought that 
 a faint whitish line, posterior to the malleus, might be a cicatrix 
 from a laceration of the drum-head. The patient did not return 
 to the infirmary. 
 
 1 Transactions American Otological Society, 1870.
 
 CHAPTER XI. 
 
 ACUTE CATAKKHAL INFLAMMATION OF THE MIDDLE EAR 
 
 Nomenclature. Statistics. Symptoms. Treatment. Leeches. Paracentesis . Sub- 
 acute Catarrh. Hemorrhagic Inflammation of the Middle Ear. Aural Hemor- 
 rhage in Bright's Disease. Vascular Tumors of the Drum-head. 
 
 THE practitioner or student, who is entering upon the study of 
 aural disease, will find, I think, some advantage in beginning 
 with an outline map of the territory which he is about to tra- 
 verse. For this reason, at this point as at the beginning of the 
 discussion of diseases of the external ear, a list or classification 
 of the diseases of the middle ear is given : 
 
 I. Acute catarrhal inflammation. 
 II. Sub-acute catarrhal inflammation. 
 
 III. Hemorrhagic inflammation. 
 
 IV. Acute and sub -acute suppurative inflammation. 
 V. Acute serous inflammation. 
 
 VI. Chronic non-suppurative inflammation. 
 VII. Chronic suppurative inflammation, with its conse- 
 quences. 
 VIII. Neuralgia of the middle ear. 
 
 If we were to form our estimate of the frequency of acute 
 catarrhal or suppurative inflammation of the middle ear, simply 
 from the number of cases that are found in the statistical tables 
 of writers on these diseases, we should come to an erroneous 
 conclusion as to the number of persons who suffer, at one time 
 or another, from them. Acute catarrh of the middle ear, is 
 actually a very common disease in our northern climates. It is 
 rather difficult to find a grown person who has not, at one time 
 or another, suffered from " earache." Earache is the popular 
 name for acute catarrh of the middle ear. My own statistics 
 show that of 4800 cases of aural disease, seen in my private 
 practice, 174 were cases of acute catarrh of the middle ear, 137 
 of acute suppurative, and 3 of acute hemorrhagic inflammation 
 of the same part.
 
 STATISTICS OF ACUTE DISEASE OP MIDDLE EAE. 
 
 279 
 
 Biirkner's tables/ in a total of 43,730, only exhibit a total of 
 6180 acute affections of the middle ear. This table includes 
 acute myringitis and acute inflammation of the Eustachian tube 
 diseases that are properly included among those of the middle 
 ear. 
 
 The following table, also illustrates the comparative infre- 
 quency with which acute affections of the middle ear, are seen 
 in hospitals. It will be found, however, that the proportion of 
 acute aural diseases increases, year by year, when special hos- 
 pitals are provided. 
 
 The advance of otology has been greatly hindered by the 
 notion quite prevalent in the profession, as well as among the 
 laity, that while a nurse or mother is quite competent to treat 
 an acute aural disease, a physician, and perhaps a specialist, is 
 needed when it becomes chronic. 
 
 Table showing the Proportion of Acute Cases of Disease of the Middle Ear to the 
 Whole Number of Aural Cases. 9 
 
 Hospital. 
 
 Year or period. 
 
 Whole 
 number. 
 
 Acute in- 
 flammation 
 of middle 
 ear. 
 
 Manhattan (New York) Eye and Ear Hospital . . 
 New York Eye and Ear Infirmary 
 
 20 years 
 1889 
 
 20,103 
 3,738 
 
 3,049 
 469 
 
 New York Ophthalmic and Aural Institute 
 Brooklyn Eye and Ear Hospital 
 
 1889 
 21 years 
 
 983 
 23,729 
 
 142 
 3,203 
 
 Massachusetts Eye and Ear Infirmary 
 
 1889 
 
 3,952 
 
 362 
 
 Salem Hospital 
 
 15 years 
 
 1,276 
 
 306 
 
 St. Michael's Hospital (Newark, N. J.) 
 
 1888 
 
 615 
 
 183 
 
 Newark Eye and Ear Infirmary 
 
 1889 
 
 1,296 
 
 81 
 
 Illinois Eye and Ear Infirmary 
 
 1885-1886 
 
 1,971 
 
 124 
 
 Buffalo Eye and Ear Infirmary 
 
 1889 
 
 171 
 
 28 
 
 
 
 
 
 
 
 57,834 
 
 7,947 
 
 It will be seen from the above table, that acute affections of 
 the middle ear were about one-seventh of the whole number. 
 This corresponds pretty accurately with Biirkners statistics. 
 
 That this disproportion does not arise from an actual rarity 
 of the affection, I think a little thought will show. These pain- 
 ful diseases very often never reach a practitioner, and are treated 
 at home, a fact which accounts for their relative infrequency in 
 statistical tables. 
 
 1 Archiv fur Ohrenheilkunde, Bd. XX., 1883. 
 
 2 Sub-acute cases are not included in this table.
 
 280 ACUTE CATARRH OF MIDDLE EAR. 
 
 Every general practitioner will at once recall the fact, that 
 it is often incidentally mentioned, when perhaps he is visiting a 
 family suffering from other diseases, that one of the children has 
 had a severe earache all night, and that there has been great 
 difficulty in quieting the fearful pain. Very often, indeed, the 
 fact will be added, that the pain is not yet subdued, and that 
 the family have quite exhausted the means at their disposal for 
 relieving it ; and yet, taught by tradition and experience, they 
 do not expect anything from the physician, whose aid becomes 
 so efficacious for the pain of colic or of peritonitis. It is to be 
 feared that many physicians stand helplessly by, and allow an 
 acute catarrh of the middle ear to run on to suppuration of the 
 drum-head, or, worse still, to periostitis of the mastoid or to 
 meningitis, without an attempt at interference. 
 
 A little later, in the discussion of this affection, we shall dis- 
 cover, I think, that the means at our disposal for its relief are 
 ample, and that they have what may almost be termed a bril- 
 liant effect, when properly used ; but I wish in the outset to im- 
 press the fact upon the minds of my readers that the commonly 
 neglected earache of the household is identical with the disease 
 known as acute catarrhal inflammation of the middle ear. It 
 will then be evident that we are dealing with an extremely 
 practical subject, and one in which every family practitioner is, 
 or should be, very much interested. 
 
 The symptoms of this affection are so characteristic that in 
 the adult they point unmistakably in the most cases to its seat. 
 I say in the adult, for in young children who have not yet learned 
 to speak, the diagnosis sometimes becomes very difficult, and it 
 is not always possible. 
 
 Symptoms. The symptoms of acute catarrh may be enumer- 
 ated in the following order : 
 
 Subjective. 
 
 1. Pain, referred to the depth of the ear, or of a neuralgic 
 character, and passing from the throat to the ear. 
 
 2. A sense of fulness in the same part. 
 
 3. Noises in the ear. 
 
 4. An unnatural, hollow sound of one's own voice. 
 
 Objective. 
 
 1. Vascular injection. 
 
 2. Bulging outward of the membrana tympani. 
 
 3. Impairment of hearing. 
 
 4. Catarrh of the pharynx and Eustachian tubes. 
 
 5. Fever.
 
 ACUTE CATAEBH OF MIDDLE EAE. 281 
 
 The pain is very often the first symptom that is observed. 
 Children old enough to speak awake from sleep crying, "My 
 ear, my ear." Adults find themselves without warning attacked 
 by a pain which causes the most intense agony a pain which 
 forces the strongest men to shriek and tremble, while children 
 affected with such a disease soon cause the attendants to believe 
 that the brain must be the seat of trouble. Sometimes, however, 
 patients with good habits of observation notice that the pharynx 
 feels thickened and full, and that the throat is sore, a short 
 time before the pain in the ear. begins. I am inclined to believe 
 that most patients are aware of what, for the want of a better 
 name, may be termed a thickness of hearing, a fulness in the 
 ears, before the attack of pain occurs. This pain is described by 
 some patients as beginning in the throat and crawling along the 
 Eustachian tube. It is a disease, however, which may be said 
 to be sudden in its origin, and one which jumps at a bound to its 
 height. It will pass over the acme, in most cases, unless at once 
 arrested, into acute suppuration of the middle ear ; a disease 
 which, strangely enough, some practitioners seem to invite, 
 judging from the expression once at least commonly heard, 
 '"' It is a gathering of the ear, from which we shall get no relief 
 until suppuration is established." I intend to combat this idea 
 in the discussion of the treatment. It is certainly an erroneous 
 and mischievous view of a serious disease. 
 
 The sensations of fulness, the noises in the ear in acute 
 inflammation, are very distressing. The latter symptom, the 
 technical tinnitus aurium, usually lessens and changes its char- 
 acter with a cessation of the pain. It changes from a puffing 
 sound, like the puff of a miniature steam-engine, to a ringing or 
 buzzing sensation. The feeling of fulness usually lasts for some 
 days after the pain has passed away. 
 
 As I have said, the diagnosis of this disease is often difficult 
 in young children, because they are unable to locate the seat of 
 the pain in words. If, however, we watch a child carefully who 
 is suffering from pain in the ear, we can usually narrow it down 
 to the region of the head. Then by means of pressure upon the 
 tragus, observing if the child winces at this, we can generally 
 form a conclusion as to the origin of the pain. The disease with 
 which infantile catarrh of the middle ear is apt to be confounded 
 is an affection of the membranes of the brain. When we re- 
 member the anatomy of the ear, especially that of the tympanic 
 cavity, we can readily appreciate the fact that an acute inflam- 
 mation of the middle ear, may easily cause hypersemia of the 
 membranes of the brain through the roof of the tympanic cav- 
 ity, or of the labyrinth, through the fenestrse of the thin wall
 
 282 SYMPTOMS OF ACUTE CATARRH. 
 
 separating the tympanum from the cochlea and semicircular 
 canals. When we also consider, as shown by Politzer, that the 
 vascular communication is direct, through vessels situated in 
 this partition, we are not surprised that a congestion or inflam- 
 mation of the middle ear, especially in infants and young chil- 
 dren, may cause very serious head symptoms. Besides this, the 
 physiological process of teething, is often credited with a great 
 deal of pain, which more properly belongs to the ear. With a 
 certain class of what may be called easy-going practitioners, the 
 diagnosis of difficult dentition, is often sufficient to cover a mul- 
 titude of painful symptoms. Accordingly, gums are needlessly 
 lanced, and dangerous delays are allowed, until a discharge of 
 pus through the drum-head, makes the diagnosis for the little 
 sufferer. 
 
 Pouring warm water into the auditory canal will usually 
 temporarily relieve an infantile earache ; and in this procedure 
 we have a means of diagnosis which is always at hand. I have 
 seen children who were crying with pain from inflammation of 
 the middle ear, go to sleep in a few moments after warm water 
 has been poured into the canal. Sometimes, however, this pro- 
 cedure will fail to give relief, and we must depend for a diag- 
 nosis upon the objective symptoms, found in the color of the 
 membrana tympani, of which I shall soon speak. 
 
 Adults sometimes mistake the pain from inflammation of the 
 lining membrane of the middle ear, for what is termed neuralgia. 
 I have seen cases where an anti-neuralgic treatment by means 
 of quinine and opium, had been tried in vain for a disease which 
 was really an inflammation of the mucous membrane ; but adults 
 usually locate the seat of trouble with exactness and accuracy. 
 The pain is indeed neuralgic, and a moment's consideration of 
 the rich supply of nerves to the cavity of the tympanum, will 
 give the reason for the fact that the pain follows the course of 
 the fifth nerve. 
 
 This mistake in diagnosis is very similar to the one made 
 when acute glaucoma is thought to be neuralgia. Neuralgia of 
 the tympanic cavity is a very rare affection. When it does 
 occur, the absence of the symptoms of inflammation will indicate 
 the true diagnosis. 
 
 The objective symptoms are chiefly to- be sought in the mem- 
 brana tympani. There is sometimes a pinkish hue to the whole 
 membrane, again the vascular injection is around the periphery 
 of the drum-head, and along the handle of the malleus, while 
 the other parts of the membrane remain of their normal color. 
 An acute inflammation occurring in a drum membrane rigid, 
 thickened, and opaque from former inflammation, is more apt
 
 SYMPTOMS OF ACUTE CATARRH. 28)3 
 
 to show localized redness than the diffuse pinkish tint, that is 
 seen when inflammation occurs in a membrane that has been 
 previously healthy. 
 
 At other times the redness is so intense as almost to prevent 
 any recognition of the drum-head, except as an evenly red sur- 
 face in which no vessels can be traced. 
 
 I think there is always some increased vascularity of this 
 membrane, in every case of acute inflammation of the lining of 
 the tube and the cavity of the tympanum, so that we may find 
 in this symptom the deciding point in doubtful cases, even in 
 an infant. The membrane has, however, at times the appear- 
 ance of glass that has been breathed upon, without any evident 
 increase in vascularity, even where there is acute inflammation 
 going on in the middle ear. 
 
 The impairment of hearing is not always marked in the stage 
 of pain. The hearing power may even be augmented and be 
 painfully acute during the first stage of the disease. In cases 
 of chronic aural catarrh, in which an acute inflammation had 
 supervened, I have known many instances where the acuteness 
 of hearing was found on accurate examination to be markedly 
 increased. It may be increased also in acute cases occurring in 
 persons whose ears had been previously healthy ; that is to say, 
 sounds may seem very loud to them. In such a case there is 
 probably hypersemia of the vestibule or cochlea, besides that of 
 the tympanum. 
 
 Bulging outward of the membrana tympani is a symptom 
 that may often be observed after the first forty-eight hours of 
 an attack of acute catarrh. If the disease continue longer in 
 an acute . form, spontaneous perforation is apt to, but does not 
 always occur. This bulging outward I have most frequently 
 observed in the posterior and inferior quadrant, but also in 
 ShrapnelPs membrane, and usually in the posterior portion of 
 this membrane. It is sufficiently marked to be detected by 
 any one who is at all familiar with the examination of the 
 normal membrane. In rare cases I believe I have seen but 
 two in my experience the imperforate membrana tympani 
 will be found to pulsate synchronously with the pulsations of 
 the heart. As is well known, it is quite common to observe a 
 pulsation of the vessels of the cavity of the tympanum in cases 
 of acute and chronic suppuration of this part ; but pulsation 
 of the imperforate membrana tympani is a rare symptom. 
 There must be great increase of the tension of the membrane 
 from the pressure of the blood column or of mucus behind it 
 when this occurs. Increased secretion from the pharynx and 
 region of the posterior nares is almost always observed in
 
 284 CAUSES OF ACUTE CATARRH. 
 
 cases of acute catarrh ; but it requires but a mere mention at 
 this point. 
 
 Febrile symptoms are almost always present in cases of the 
 disease under discussion. The temperature is usually consider- 
 ably increased in a severe case, so that the general aspect of the 
 patient, suffering from great local pain, impairment of hearing, 
 and a dry, heated skin, is one of intense suffering. Yet this is 
 the disease which many physicians allow to run its course, 
 without any of the antiphlogistic treatment that they would at 
 once resort to, were any other organ of the body similarly at- 
 tacked. 
 
 In completing this description, it should also be said, that 
 there are cases of acute catarrh of the middle ear in adults as 
 well as in children, where while the symptoms of impairment of 
 hearing, a sense of stuffiness in the head, redness and bulging 
 of the drum-head, a peculiar hollow sound of one's own voice, are 
 marked, there is no considerable pain, or if there has been, it 
 has passed away before the physician has reached the patient. 
 These, however, are exceptional cases. 
 
 Causes. The causes of this disease are manifold. Any un- 
 due exposure to the influence of cold may produce acute catarrh 
 of the middle ear. Getting the feet wet, the surface of the body 
 chilled by standing or walking in the cold, are frequent causes 
 of earache. A draught of air blowing, for instance, through the 
 window of a railway carriage in rapid motion, is sometimes a 
 cause of acute catarrh. 
 
 Ducking the head under water, and allowing the water that 
 enters the auditory canal to remain there, is another cause. 
 
 Surf -bathing, especially in those people who habitually suffer 
 from catarrh of the nares and pharynx, thus may become a 
 cause of acute inflammation of the middle ear, as well as of the 
 auditory canal. The salt-water may enter the nostrils and Eus- 
 tachian tube and cause the disease, or a wave may deluge the 
 auditory canal and injure the drum-head, and thus affect the 
 middle ear. Yet, considering the great extent to which surf-, 
 bathing is practised in the United States, the number of cases 
 of inflammation of the ear caused by it is very small. I have 
 spent several summers where surf-bathing is extensively en- 
 joyed, and I have heard very little of its evil effects. I believe 
 the cases of disease of the ear caused by it, occur chiefly among 
 careless and ignorant bathers, or in those who already suffer 
 from chronic aural or naso-pharyngeal disease. Prolonged 
 bathing and diving in still water, are much more apt to cause 
 congestion of the middle ear than surf -bathing.
 
 CAUSES OF ACUTE CATARRH. 285 
 
 Many cases of aural disease are said by those who suffer 
 from them to have originated in the following way. " I got my 
 ears full of water and never could get it out," is the fanciful 
 statement of many patients who mistake the feeling of fulness 
 in an inflamed middle ear, for that from water remaining in it. 
 Surf -bathing is of such value as a tonic to many debilitated sys- 
 tems that I do not hesitate to advise it, even to patients with 
 aural disease, under proper precautions, such as : 
 
 1. Take a bath of not more than five or ten minutes in duration. 
 
 2. If the ears are affected by chronic suppuration, close the 
 meatus with cotton. 
 
 3. Never allow a wave to strike the side of the head. 
 
 4. Indulge very sparingly, if at all, in swimming or diving 
 through the breakers. 
 
 Constitutional diseases, such as small-pox, scarlet fever, and 
 measles, in which the pharynx is affected, are very common 
 sources of acute aural catarrh. Pneumonia and bronchitis very 
 often have this affection as a consequence. Coryza or cold in 
 the head, however caused, very often gives rise to acute inflam- 
 mation of the ear. 
 
 It arises in the course of syphilitic affections of the pharynx 
 and posterior nares ; but, contrary to what has been said by 
 some authors, I have found no pathognomonic evidences of syph- 
 ilis in the character of the pain or the appearance of the, mem- 
 brana tympani in such cases. 
 
 Cerebro-spinal meningitis, is also a prolific source of acute 
 inflammation of the middle ear. 
 
 The origin of acute catarrh, is chiefly to be sought for in the 
 faucial extremity of the Eustachian tube, and not in the audi- 
 tory canal. This explains the fact, that it is much more impor- 
 tant for patients liable to aural disease, to protect the external 
 surface of the body and the extremities from the cold, than the 
 meatus and auricle. 
 
 Yet it is not to be denied, that inflammation of the middle 
 ear does occasionally extend from the canal, through the mem- 
 brana tympani, and not through the Eustachian tube, for a 
 draught of air upon the side of the head will produce acute aural 
 catarrh, and if cold water enter the ear through the meatus ex- 
 ternus, and remain for a considerable time, it may also produce 
 acute catarrh of the middle ear. 
 
 The use of the nasal douche for the treatment of naso-pha- 
 ryngeal catarrh, may also produce acute inflammation of the 
 ear, as I first showed. 1 My experience has since been confirmed 
 by many other observers. 
 
 1 Archives of Ophthalmology and Otology, vol. i., No. 1.
 
 286 ACUTE CATARRH TREATMENT. 
 
 In the description of the treatment of the pharj^nx and nares 
 in the course of chronic aural inflammation, the subject of the 
 use of the nasal douche will be more fully discussed. 
 
 The occurrence of acute catarrh of the ear, in scarlatina, 
 measles, naso-pharyngeal catarrh, and pneumonia, is, I think, 
 favored, by the common practice of giving large, or compara- 
 tively large, doses of sulphate of quinine in these cases. This 
 invaluable remedy should, in my opinion, be given with great 
 caution in these diseases, since the disposition to extension of 
 the inflammation to the middle ear, exists strongly in all these 
 constitutional affections. Quinine is quite sure to aggravate 
 aural symptoms, if they already exist, and in young children it 
 may excite them. I have several times seen children suffering 
 from acute aural catarrh, in whose ears the administration of 
 quinine had, from the very first dose, steadily aggravated the 
 pain, until the discharge of pus from the tympanic cavity ex- 
 plained the high temperature, which should have been combated 
 by local antiphlogistic remedies, instead of by an antipyretic. 1 
 
 What has been said of quinine refers also with equal force to 
 the various newly found drugs for reducing temperature anti- 
 pyrine, phenacetin, and so forth. Winter-green and salicyne 
 should be used with caution in cases with sensitive ears. 
 
 Treatment. The proper treatment of acute aural catarrh is 
 predominantly an antiphlogistic one. The disease is an inflam- 
 mation of the severest form, and can only be successfully com- 
 bated by such means as local blood-letting, quiet, warmth, and 
 opium. As has been said, a neuralgia of the middle .ear, that is 
 to say, pain without other symptoms of inflammation, is ex- 
 tremely rare, yet an inflammation of the middle ear is very often 
 treated as would be a case of facial neuralgia ; or we might even 
 say, that the ordinary treatment for acute aural inflammation is 
 pre-eminently empirical and without reason. From the time of 
 the ancients down to our own day, all kinds of decoctions and 
 mixtures have been poured into the ears to relieve earache. 
 Some, of these agents are of a negative or slight value ; many of 
 them are of a positively harmful nature. To the former class 
 belong such applications as sweet-oil and laudanum, glycerine, 
 molasses, and so on. To the latter class belong Haarlem oil, 
 Cologne water, ether, and all stimulating applications. Poul- 
 tices are remedies often used ; but while they generally quiet 
 pain, their application is so dangerous to the integrity of the 
 drum membrane, especially if they be used for many hours in 
 
 1 See Medical Record, February 8, 1883, and Transactions of the Medical Society of 
 the State of New York, 1883, as well as an article on "Colds in the Head," in the 
 Transactions of the same Society of 1880, p. 342.
 
 ACUTE CATARRH TREATMENT. 287 
 
 succession, that the practitioner will do well to avoid them, un- 
 less other means cannot be employed, or when the latter prove 
 ineffectual. In some cases, however, the urgency of the pain 
 will demand that poultices be employed. The chief thing to be 
 done in this disease is to decrease the heat, swelling, and vascu- 
 larity of the parts. Applications of a stimulating nature, made 
 to the membrana tympani, certainly cannot do this ; and mere 
 emollients, such as sweet-oil, have a very transitory effect. 
 
 I would place local blood-letting as the chief and first remedy 
 in acute aural catarrh. This blood-letting should be performed by 
 means of leeches applied to the tragus, and not to the mastoid pro- 
 cess. Wilde and Troltsch have taught the profession that this 
 is the best point for the application of leeches in inflammation of 
 the ears, and the reasons therefor. At this point, the blood is most 
 easily drawn from the cavity of the tympanum the vessels sup- 
 plying it, and the drum membrane, inosculating here. The ap- 
 plication of from one to six leeches, according to the severity of 
 the disease and the age of the patient, will usually be sufficient 
 to quiet the most severe pain in the, ear, and to check the intens- 
 est form of catarrhal inflammation. I have seen almost magical 
 effects from their use. One of the most striking of the cases in 
 my note-book is the following : I was called on a very severe 
 winter's day to see a young gentleman in a neighboring city, who 
 had been suffering for two days from acute pain referred to 
 the ear. I found the symptoms of acute aural catarrh, in a red- 
 dened but intact drum membrane, congested pharynx, and so 
 forth. When I entered the room he seemed to be in mortal agony. 
 He said that he had not slept for forty-eight hours, and his anx- 
 ious countenance verified his assertion. I at once sent out for 
 some leeches, and caused one to be applied to each ear, and before 
 they had dropped from the tragus he was asleep, and went rap- 
 idly on to perfect recovery. Such cases might be multiplied, for 
 they are of frequent occurrence in hospital and private practice. 
 
 Leeches are, however, a troublesome remedy, and in country 
 districts they are not always to be had. In their absence I place 
 the use of warm water as next in efficiency. This should be 
 poured continuously into the ear, and not used by means of a 
 syringe, as I have known patients to employ the water when 
 told to pour warm water into the ear. The fountain syringe or 
 the Fayette douche (see illustration on page 120) is the best 
 means of which I know for applying warm water to the ear. 
 Sometimes the warm water is unpleasant, instead of grateful, 
 to the patient, and then the vapor of water or the smoke from a 
 cigar or pipe may be conducted into the ear. Children may some- 
 times be relieved in the beginning of an attack of acute aural
 
 288 ACUTE CATARRH TREATMENT. 
 
 catarrh, by breathing into the affected ear for a very few min- 
 utes. If leeches cannot be had, and the use of warm water or 
 of steam does not subdue the pain, cups wet or dry applied 
 around the auricle, are sometimes of use, as well as blisters. 
 
 Poultices, as I have said, are only to be used as a last resort. 
 Then they should be made small enough to be put in the canal, 
 and one may also be placed around the ear, leaving the auricle 
 free ; and their use should be given up as soon as the inflamma- 
 tion has abated. 
 
 If the patient or his friends are told to apply the leeches, the 
 exact spot upon which they are to be placed should be marked 
 with ink, or they will be put on the lobe, or on the neck, or in 
 some other position where their use will do no good. I have 
 quite often found, that a neglect to state just where the leeches 
 should be applied, has caused all the efforts to relieve pain to be 
 of no value. Rohland's styptic cotton a preparation of cotton 
 in a solution of alum prepared by Dr. Rohland, of this city, will 
 be found a very efficient means of arresting the hemorrhage from 
 a leech-bite. The bleeding should, however, usually be encour- 
 aged, by the use of warm compresses, for an hour after the 
 leech has dropped from the ear. 
 
 Scarification of the drum-head, as recommended by Blake, is 
 also of service in mild cases. It requires a much more practised 
 hand for its performance, however, than a paracentesis. 
 
 Paracentesis of the drum membrane is a very efficient remedy 
 at times, when there is bulging of the drum-head, and we see 
 that perforation is imminent ; or even in cases of prolonged pain 
 without bulging of the membrane, when the leeches have been 
 used at too late a period, or have proved ineffectual. 
 
 Schwartze, of Halle, taught us the value of this means of 
 treatment in acute cases, ad I have found it of great value. I 
 would even pass a cataract needle through the posterior portion 
 of the membrana tympani, in any case, whether bulging was 
 seen or not, when the use of leeches did not markedly diminish 
 the severe pain within a few hours. I have done so with strik- 
 ing effect in some cases. Yet leeches and warm water, if 
 promptly used, will usually check the progress of even the se- 
 verest case. Very often, however, we are not called until the 
 disease has advanced so far as to involve every part of the 
 middle ear, when periostitis of the mastoid has occurred, and sup- 
 puration seems to be inevitable. 
 
 Paracentesis of the membrana tympani should be performed 
 while the head of the patient is well supported, and a good light 
 is thrown upon the membrane by means of the otoscope attached 
 to a forehead band. A needle, such as shown on the next page,
 
 ACUTE CATARRH PARACENTESIS. 289 
 
 is the one I employ. The point of opening should be determined 
 by the seat of the greatest amount of bulging, which I have 
 found generally to be in Shrapnell's membrane, and in the pos- 
 terior and inferior quadrant of the membrane. 
 
 I have tried the instruments with an angular handle, but I 
 have, after much experience, concluded that a straight instru- 
 ment is so much more easily managed, that this facility in use 
 much more than completely balances any value from not shut- 
 ting off the light from the canal, said to belong to the other in- 
 struments. A needle, such as is used in the operation of di- 
 scission of a soft cataract, is a very good instrument for making 
 an opening into the membrana tympani. 
 
 The operation causes so little pain and it is so brief, that this 
 element does not enter into the consideration of the surgeon. I 
 have found the light of a candle about, the best and most con- 
 venient source of illumination, when the operation is to be done 
 in a sick-room, and the patient is in bed. For acute cases a 
 thorough puncture, through which the blood, mucus, or pus can 
 be drawn, is usually an opening large enough to relieve pain. 
 I have more frequently performed the operation in cases where 
 
 FIG. 81. Paracentesis Needle. 
 
 the severity of the pain has passed, and yet I have also per- 
 formed it with the happiest of immediate results when the pa- 
 tient was at the height of distress. 
 
 If we find on examination that the mastoid region is red, hot, 
 tender, and swelled, it will be often necessary to make an inci- 
 sion through its tissues down to the periosteum ; but it is only 
 very rarely that this is the case in acute aural catarrh. Such a 
 state of things is more apt to be found in acute or sub-acute sup- 
 puration, or as a result of chronic suppuration, under which 
 heads the subject will be fully discussed. 
 
 The condition of the pharyngeal mucous membrane should 
 at the same time be attended to, by means of gargles and ex- 
 ternal applications. A saturated solution of chlorate of potash 
 forms one of the best of applications to the pharynx, while the 
 neck may be enveloped in a warm-water poultice. 
 
 The Eustachian catheter and Politzer's method of inflating 
 the middle ear should be used as soon as the acute symptoms 
 have subsided, say in forty-eight hours. If employed with gen- 
 tleness, there need be no fear of aggravating the subdued in- 
 flammation into a relapse. Indeed, inflation often relieves pain 
 by emptying and ventilating the tympanum. 
 19
 
 290 ACUTE CATARRH TREATMENT. 
 
 The hearing should be accurately tested by means of the 
 watch and tuning-fork, in order to see, after the pain has sub- 
 sided, if any impairment has occurred. If only one ear be 
 uffected, careless patients will believe that the hearing is per- 
 fectly good, after the pain and fulness have passed away ; but 
 the physician should be sure of this for himself. In half-treated 
 acute catarrh, are laid the foundations for that insidious and 
 obstinate disease, chronic non-suppurative inflammation of the 
 middle ear. 
 
 While this energetic local treatment is carried on, the atten- 
 tion of the physician should be turned to the general system. 
 It will often be necessary to give a full dose of opium or mor- 
 phine at bedtime. It is somewhat remarkable, however, that 
 opium has very little effect, when used without local depletion, 
 to quiet the pain from inflammation of the middle ear. Very 
 large doses will be taken in vain, unless the local means that 
 have been described are also employetl. 
 
 The patient should be kept in the house, and in a well- 
 warmed room, during the stage of pain and fever. Pediluvia 
 and diaphoretics are hardly necessary in case the pain is once 
 subdued. The diet should be nourishing. The patient should 
 be enjoined to keep his skin in good order by means of frequent 
 bathing, in order to prevent relapses. The improper habits of 
 life, or the exposures to cold, that have induced this attack, 
 should be carefully sought out, in order that future ones may 
 be avoided. 
 
 A daily sponge-bath in a warm room, using cool water in 
 summer and tepid in winter, followed by vigorous rubbing with 
 a coarse towel, will be found of real service in preventing re- 
 lapses of aural disease. Not every patient, however, can tolerate 
 cold water, although I think every moderately well person will 
 be the better for a daily bath of the whole surface of the body. 
 A little discretion must therefore be allowed the individual as 
 to the temperature of the water used. The shower-bath and the 
 plunge, as well as the habit of pouring water into the ears, 
 should be discouraged. 
 
 The practitioner who, while treating a grave constitutional 
 disease, finds this local inflammation breaking out, should by 
 no means allow the severity or danger of the constitutional 
 symptoms to prevent him from the proper treatment of the 
 acute aural catarrh. The local and constitutional treatment 
 can well go on together ; while the neglect of the ear at the 
 proper time may lead to irreparable damage not only to the 
 health and prosperity of the patient, but it may destroy his life. 
 
 We cannot be too much impressed with the fact that a neg-
 
 ACUTE CATARRH IN THE EXANTHEMATA. 291 
 
 lected acute aural inflammation may lead, through suppuration 
 of the middle ear, with all its consequences of caries, polypi, 
 meningitis, cerebral abscess, pyaemia, to the most deplorable 
 results. 
 
 Better would it be for a child suffering from scarlet fever or 
 measles to die from the disease, than to recover from the con- 
 stitutional affection only to succumb, with great misery, to the 
 effects of the neglected inflammation of the middle ear. It is 
 to be hoped that the neglect of treatment of the ear, will not pre- 
 vail in the next generation to the extent that it does in ours* 
 
 I was very much interested in a complaint made by a dis- 
 tinguished surgeon of New York, who, in a discussion upon the 
 effects of scarlet fever and measles upon the ear, stated that 
 while writers on aural surgery said much about the neglect of 
 diseases of the ear, occurring during the course of the exanthe- 
 mata, he had found no means of doing anything to prevent the 
 breaking out of such disease while the measles or scarlet fever 
 were going on, and he did not know, after all the warnings, 
 that there was anything really to be done. Now, in answer 
 to this, it may be said that it is not claimed that otitis media 
 may be always averted in the course of scarlatina or rubeola, 
 but sometimes, if the physician be on the lookout for it, it may 
 be aborted, so to speak. If a child begin to toss its head about 
 as if in pain, or if it become hard of hearing, the tragus may 
 be at once examined to see if pressure upon it cause or increase 
 pain, the drum-head may be looked at and a diagnosis made. 
 If there be congestion of the ear, the warm douche will often 
 relieve it at once. If not, we have blisters, leeches, and para- 
 centesis of the membrana tympani. If, however, the attack 
 cannot be aborted and goes on, certainly we may by these same 
 means alleviate or stop the pain, and modify the course of 
 the disease, so that recovery of the ear will usually go on step 
 by step with the general convalescence, and the patient will not 
 barely recover of the exanthem, to suffer the horrors of chronic 
 suppuration of the middle ear. All that writers on aural sur- 
 gery ask that general practitioners shall do in cases of acute 
 inflammation of the middle ear, occurring in the exanthemata, 
 is, that they treat them as they would the same disease occurring 
 independently. 
 
 The practitioner who looks through the generally excellent 
 works on the diseases of children, will be painfully impressed 
 with the fact, that very little attention is given to the common 
 complications of infantile diseases with acute catarrh and sup- 
 puration in the ear. 
 
 The course of a case of acute aural catarrh, promptly treated
 
 292 ACUTE CATARRH TREATMENT. 
 
 in the manner that has been outlined, usually ends in complete 
 recovery, with integrity of the structure and .functions of the 
 ear. In less favorable cases suppuration occurs ;. but this is 
 usually tractable, and even then the organ may be restored to 
 complete usefulness. 
 
 It is unfortunately true, however, that an acute catarrhal in- 
 flammation of the middle ear, even under judicious management, 
 may go on to be a suppurative one, from which death may occur 
 from extension of the inflammation to the brain. More will be 
 said. of this, however, in the chapter upon acute suppuration. 
 
 It is sometimes stated that the treatment as described in 
 the preceding pages is too heroic, and that milder means than 
 leeches, paracentesis, scarifications, an incision down to the 
 periosteum of the mastoid, may be employed, not only with 
 safety, but with benefit to the patient. The use of leeches has 
 been especially objected to, on account of the local irritation 
 and even inflammation they are said to frequently cause. Par- 
 acentesis of the drum-head, it is said, is a dangerous operation, 
 and often performed unnecessarily, and so forth. To all this, I 
 can only say that acute catarrh, or acute suppuration of the 
 middle ear, are serious and rapidly progressing diseases that 
 admit of no temporizing, of no delays in active antiphlogistic 
 treatment. I have not been speaking of subacute inflammatory 
 affections, of neuroses in hysterical and anaemic subjects, but 
 of a sthenic inflammation, with its pain and its possibilities of 
 rapid advance from the tympanic cavity to the membranes of 
 the brain, to the general circulation, or when its progress takes 
 a more favorable turn, to the membrana tympani. To combat 
 this disease, only local antiphlogistic treatment will be of avail. 
 Those who wish to arrest pain quickly, to prevent dangerous 
 consequences from an extension of an inflammatory process, 
 will find the active treatment that has been here described 
 will not disappoint their expectations. Some of the arguments 
 against the means now in vogue among the modern otologists, 
 have been based on the incorrect assumption that they are em- 
 ployed in mild cases when less active means will be more agree- 
 able, and equally efficacious. I have been careful, however, as 
 I believe, to show that local blood-letting, paracentesis, and cut- 
 ting down to the periosteum, with confinement to a room, are 
 chiefly to be employed in severe cases. That an acute inflam- 
 mation of the middle ear is a severe case, certainly no one will 
 deny who has been called to treat it, or who has unfortunately 
 experienced it. 
 
 I believe as fully as any of my professional brethren, in the 
 natural course of diseases, which it is often better not to attempt
 
 SUB-ACUTE CATARRH. 293 
 
 to check ; in the vis medicatrix naturce ; in the danger of doing 
 too much for many cases, but the disease now under considera- 
 tion is one which I believe from a long and large experience can 
 only be successfully combated by what are known as local anti- 
 phlogistic means, among which leeches and the warm douche 
 take the first position. 
 
 SUB-ACUTE CATARRH OF THE MIDDLE EAR. 
 
 There is a variety of catarrh of the middle ear, very common 
 in young persons and in children, although it also occurs in 
 adults, which differs in so many respects from the ordinary type 
 of acute catarrh, that it seems to require a more extended notice 
 than the references that have been made to it in discussing the 
 latter-named affection. I have ventured to term this affection 
 sub-acute catarrh of the middle ear. It has many of the symp- 
 toms of the truly acute form. The absence of pain is the chief 
 distinguishing mark by which it is separated from the latter 
 form. Some authors, judging from their statistics, have classi- 
 fied it under the head of chronic aural catarrh. Others classify 
 it among acute affections. While the former view may not be 
 strictly incorrect for the affection that I am about to describe, 
 may last for months, and run into the strictly chronic form it 
 has, in my opinion, more of the characteristics of acute catarrh 
 in its nature, and in its readiness to yield to treatment, than of 
 chronic inflammation. 
 
 In spite of some adverse criticism, especially by German 
 authorities, I think we ma> justly draw a distinction between 
 an acute and a sub-acute affection. If we do so, we shall be less 
 likely to fall into the error of treating all recent cases of catarrh 
 of the middle ear, as vigorously as we do those that only differ 
 from them in being attended by great pain and injection of the 
 drum-head. Acute catarrh demands vigorous treatment, while 
 the sub-acute form will get on very well with mild measures. 
 
 Symptoms. The subjective symptoms of sub-acute catarrh of 
 the middle ear may be stated as follows : It is observed that the 
 patient, without suffering from pain in the ear, or if so, from 
 pain that is not long-continued, is very often so hard of hearing 
 as not to hear ordinary conversation. Very little is thought of 
 this by the friends of the patient, or perhaps by the medical ad- 
 viser ; but the trouble recurs, the attacks become more frequent, 
 and the period of impairment of hearing more prolonged, so 
 that school-life is seriously interrupted. The general health 
 may, or may not, be impaired. I have seen many such cases
 
 294 SUB-ACUTE CATARRH. 
 
 in boys and girls in excellent general health, as well as in the 
 delicate and strumous. 
 
 The objective symptoms are as follows : The pharynx is usu- 
 ally in a thickened or granular condition, the normal secretion 
 is excessive, and it may be changed in quality, and be decidedly 
 muco purulent. The tonsils may or may not be hypertrophied. 
 The membrana tympani has lost its normal neutral gray color, 
 and is of a pinkish hue. The vessels are not usually to be traced 
 upon any part of it. It may be exceedingly brilliant. The light 
 spot is usually absent, or is smaller than usual ; a fact which 
 shows that the drum-head is sunken inward. The experiments of 
 Magnus, which have been described in the tenth chapter, show 
 that any excessive pressure which pushes the drum-head inward 
 lessens, or if the pressure be great enough, obliterates the light 
 spot. The hearing, as tested by the watch, is found to be very 
 much impaired, and only such conversation as is addressed to 
 the patient, with his face toward the speaker, is heard. 
 
 This impairment of hearing in children is very often attrib- 
 uted to ''absent-mindedness" by parents, and to '"stupidity" by 
 teachers. Children are not usually absent-minded, and when 
 they are stupid, there is always a cause, which should be traced 
 out, and the poor child not treated as if it were responsible for 
 the disease that has rendered it so. Again and again, will the 
 practitioner find that he is obliged to correct the false ideas of 
 parents and teachers, who do not know that children always pre- 
 fer to hear, if they can. Malingering as to deafness is a de- 
 ception which children rarely understand, and which they can 
 never successfully maintain. A child that does not habitually 
 answer at once when addressed, should be at once carefully ex- 
 amined as to its hearing power, before it is scolded for absent- 
 mindedness. 
 
 Treatment. It is apt to be the case, that proper hygienic 
 rules have not been observed in the management of such young 
 patients. They have been allowed to eat and drink food im- 
 proper for growing persons ; for example, tea and coffee, pastry 
 and so forth, to the greater or less exclusion of simpler and 
 more nutritious substances, and thus a capricious state of the 
 appetite has been induced. In the case of boys, frequent and 
 prolonged bathing or swimming, of which ducking the head 
 under water forms the chief part, is sometimes found to cause 
 or increase the impairment of hearing. The regulation of the 
 diet of such patients, the wearing of flannel next the skin, the 
 abstaining from any habits which may be recognized as pre- 
 disposing to inflammation of delicate structures, building up of 
 the system by a proper therapeutic course, such as the exhibi-
 
 SUB-ACUTE CATARRH. 295 
 
 tion of cod-liver oil and iron, with proper attention by the use 
 of gargles to the mucous membrane pf the pharynx, will per- 
 haps in time allow Nature to relieve these cases ; but the im- 
 pairment of hearing, which is the most striking and most trou- 
 blesome symptom, will be the last one relieved, and it may not 
 be relieved at all, and the patient grow up to be permanently 
 hard of hearing. We have at our hands, however, in Politzer's 
 mode of inflating the ears a method of treatment that has been 
 fully described in the second chapter a means of instantly im- 
 proving the hearing, and thus of removing the most embarrass- 
 ing symptom in an instant. 
 
 The wonder and joy depicted on a little patient's face when 
 the world of sound opens to him again, after the air has once 
 entered the Eustachian tubes and tympanic cavities, is some- 
 thing very pleasant to see. In the absence of the air-bag, a bit 
 of india-rubber tubing inserted in one nostril, the other being 
 closed, through which air is blown from the lungs of the sur- 
 geon, will do very well. Indeed, where the subjects are very 
 young, I prefer this method, which is Mr. James Hinton's adap- 
 tation of Politzer's principle. 1 
 
 The pathological changes in these cases, which cause the 
 impairment of hearing, are probably in some cases simply plug- 
 ging of the faucial orifice of the Eustachian tube, in others of 
 the calibre of the tube and the tympanic cavity by mucus. Struc- 
 tural changes, such as thickening of the mucous membrane, 
 adhesive bands, rigidity of the ligaments of the ossicles, and so 
 forth, have not occurred. Hence I would not class these cases 
 among those of chronic catarrhal inflammation. 
 
 It is probable also that the mobility of the ossicles is inter- 
 fered with in some cases by the accumulated mucus as well as 
 by the swelling of the articulations. The restoration of the nor- 
 mal vibrations of the chain of bones, and the removal of the mu- 
 cus explain the sudden increase of hearing power by inflation. 
 
 I append three cases, two of which have been before pub- 
 lished; 2 but I have been able to follow them up, and note that 
 the recovery was perfect. I again publish them, with an addi- 
 tional one of the same character. The cases are very common, 
 and it is not therefore for their rarity that they are inserted, but 
 that they may perhaps teach how much may be done to instantly 
 relieve this form of disease. The practitioner who ignores the 
 ear will certainly pass by, among these cases, many which, if 
 properly examined and treated, would add very much to his 
 reputation, and increase his power of doing good. 
 
 1 Professor Hermann Scliwartze claims priority in tliis procedure. 
 5 American Journal of the Medical Sciences, vol. vii. , p. 64.
 
 296 SUB-ACUTE CATARRH CASES. 
 
 CASES, 
 
 CASE i. j\ s. B , aged sixteen, New York, September 1, 1865. Has been 
 
 deaf at times for a number of years, and for the last summer persistently so.. 
 His general condition is fair; is well developed. The tonsils had been so much 
 hypertrophied as to impede respiration ; but they were removed previous to his 
 coming under my observation. The pharynx secretes excessively, as well as the 
 nasal mucous membrane. There are numerous granulations scattered over the 
 pharynx. The membranae tympani are pinkish, brilliant in appearance. The 
 light spot is elongated. The watch is heard about six inches from each auricle. 
 
 Politzer's method was practised three or four times, when the hearing dis- 
 tance extended to sixteen inches on the right side, and ten on the left. A gargle 
 containing iodine and brandy was ordered to be used twice a day. He was also 
 to practice Politzer's method twice a week, in connection with the iodine inhaler. 
 The patient continued to improve, and at the present writing, April 20, 1866, the 
 treatment has been abandoned, the hearing power being nearly, if not quite 
 normal. The patient goes to school every day. He was seen by me for some 
 weeks once a week, while his father, who is a distinguished physician of this 
 city, carried out the treatment at home, which consisted in the use of the gargle, 
 inflating the middle ear by Politzer's method once in three or four days, with 
 attention to the general health. 1890. The patient is now a practitioner of med- 
 icine, and has no impairment of hearing. 
 
 CASE II. Girl, aged sixteen, at Eye and Ear Clinic in University Medical 
 College, March 28, 1866. Has not heard ordinary conversation for years, and 
 has been very much embarrassed in swallowing and breathing, on account of 
 enlarged tonsils ; general condition is fair ; the voice is extremely nasal ; only 
 hears when addressed in a loud tone of voice ; the watch is heard two inches on 
 the right side, one inch on the left ; membranse tympani present nothing strik- 
 ing in appearance, except that they are quite brilliant ; the tonsils are excessively 
 hypertrophied. The use of Politzer's method immediately improved the hearing 
 somewhat, which improvement lasted, according to the patient's statement, about 
 a day. When next seen, the tonsils were excised with the forceps and scissors, 
 a long outgrowth being dragged down from behind the soft palate on the right 
 side, which must have pressed upon the orifice of the Eustachian tube, and then 
 the iodized air was driven into the tube. The hearing distance became two feet 
 on the right side, and about six inches on the left. An iodine gargle was ordered, 
 with cod-liver oil, a half tablespoonful to be taken three times a day. The 
 patient is now under treatment, and still (April 26, 1866) continues to improve, 
 hearing very well, with no trouble in respiration. 1872. I have seen this patient 
 several times since, on account of naso-pharyngeal catarrh, and her recovery of 
 hearing proves to be permanent. 
 
 CASE HI Master (sent to me by Prof. Fordyce Barker, January21, 1873), 
 
 aged fourteen. This boy has had "a cold," and has been very hard of hearing 
 for some weeks. He is in excellent general health. The membranse tympani 
 present nothing particularly abnormal. The pharynx and nostrils are secreting 
 excessively. Hearing distance right ear, -4^ ; left ear, the watch is only heard 
 when laid on the auricle. He was seen every other day for three weeks, when 
 the Eustachian catheter and Politzer's method were used, while a gargle of
 
 HEMORRHAGIC INFLAMMATION. 297 
 
 chlorate of potash was employed at home. At the first sitting his hearing dis- 
 tance was brought up to it R. E., - 4 a 8 - left, so that conversation was heard with 
 much more ease, and when his hearing power became H on each side, and was 
 still improving, he was allowed to return to his school. 
 
 The use of the catheter when the patients will submit to it, 
 and nearly all except infants will do so, causes the action of 
 Politzer's method to be more powerful. It probably excites the 
 muscles of the tube to more vigorous contraction. When chil- 
 dren are too young to swallow on the signal, we may still employ 
 Politzer's method, by putting the tube in one nostril, closing the 
 other with the finger, and rapidly forcing in the air in spite of 
 the child's screams, which are not those of pain. During the 
 swallowing motion that the little one involuntarily makes, air 
 will enter the tube. It is highly probable that infants sometimes 
 suffer from sub-acute catarrh, which if not relieved by local treat- 
 ment passes on to a chronic process, which ends in deaf-muteism. 
 Where any doubt exists, the little patient should have the benefit 
 of it, by the use of Politzer's method, which can do no harm, and 
 may do a vast deal of good. The existence of a naso-pharyngeal 
 catarrh in an infant, should be carefully considered by the attend- 
 ing physician, lest it result in one of the tympanic cavity, and 
 there cause changes which must leave permanent impairment of 
 hearing. 
 
 The evil consequences of neglected colds in the head are not 
 always sufficiently appreciated by our profession. It is from the 
 children who suffer frequently from this affection, that the large 
 class of persons, whose hearing is greatly and permanently im- 
 paired, is annually recruited. It is of the utmost importance 
 that all cases of impairment of hearing, should be under early 
 supervision, lest a permanent defect occur. Inflation of the 
 ear, with general hygienic means, will generally relieve these 
 cases promptly. 
 
 HEMORRHAGIC INFLAMMATION OF THE MIDDLE EAR. 
 
 I believe I was the first to report 1 cases of acute aural catarrh 
 which had an unusual course and termination that is to say, 
 cases in which the course was very acute and terminated rapidly 
 in perforation of the membrana tympani without suppuration, 
 but with quite an abundant hemorrhage through the drum- 
 head. It is well established that hemorrhage into the middle 
 ear may occur in the course of kidney disease, just as from the 
 vessels of the retina ; but the two cases which I am about to de- 
 
 1 Transactions of the American Otological Society, 1872.
 
 298 HEMORRHAGIC INFLAMMATION. 
 
 scribe certainly do not come under the classification of hemor- 
 rhage from blood-vessels made atheromatous by renal disease. 
 They are, I think, to be considered as cases of acute inflamma- 
 tion of the lining membrane of the middle ear, in which the 
 morbid process has an unusually rapid and violent course, so 
 that not merely an exudation through the walls of the vessels, 
 but an actual breaking down of the walls themselves, occurs ; 
 there is then such an accumulation of the blood in the cavity of 
 the tympanum that rupture of the drum-head almost iiecessarily 
 follows.' It has been often observed that in many cases of para- 
 centesis of the membrane, for the relief of inflammation of the 
 lining membrane of the drum cavity, blood is the only product 
 that escapes. I think these cases are analogous to those which 
 I am about to record, and that they serve to explain them. 
 
 CASE I. The first case that directed my attention to hemorrhage through the 
 membrana tympani, as a consequence of acute inflammation of the middle ear, 
 was that of a young lady of rather delicate organization, who was under the care 
 of Drs. Agnew and Loring. The case was seen in consultation with the latter- 
 named gentleman, who gave me the history. The patient was deaf from what 
 seemed to be hypertrophy of the membrane lining the dram cavity ; the mem- 
 brana tympani was thickened, sunken, and immovable ; she was treated in the 
 usual manner, i.e., the catheter and Politzer's method were employed, and the 
 attempt made by them to force the drum-head outward. On the day or day 
 before I saw the patient, and about twenty-four hours after the catheter and 
 Politzer's method were used, she was seized with violent pain referred to the 
 depth of the ear ; to relieve this, paregoric was dropped into the ear. Dr. Lor- 
 ing and I saw the patient in the evening ; the pain had then somewhat abated. 
 On examination, I found, after carefully removing the fluid that had been 
 dropped in, that the membrana tympani was ruptured, and that blood was issu- 
 ing from the pulsating opening. The patient recovered after an erysipelatous in- 
 flammation of the auditory canal and side of the face. I did not see her again, 
 but Dr. Agnew examined the membrane in a few days, and could find no rup- 
 ture, and no trace of it. 
 
 I might, perhaps, be slightly in doubt as to the occurrence of a rupture and 
 hemorrhage from the membrane in this case, had I not seen one subsequently 
 which was very similar, and where, as in this case, no suppuration occurred after 
 the rapture, and consequently no scar remained. The presence of the paregoric 
 rendered it somewhat difficult to determine whether the fluid in the rupture 
 was blood or not ; but I took this fully into consideration, and determined that 
 it was. 
 
 CASE II. This occurred in a gentleman in good health, of forty-seven years 
 of age. He smoked excessively, but in other respects his habits were good. He 
 had chronic pharyngeal catarrh, but it troubled kirn very little. He did not 
 remember that he had ever had earache as a child or adult. I saw him on 
 November 7, 1871. His history was as follows: About 10 o'clock to-day, he 
 suddenly experienced a severe pain in his right ear. The pain was so acute that 
 the patient was obliged to leave his business and go home. The treatment con-
 
 HEMORRHAGIC INFLAMMATION. 299 
 
 sisted in the instillation of sweet oil and tincture of opium. There was no 
 relief, however, until about 6 P.M., when "a loud report occurred in his head," 
 and quite a free hemorrhage- occurred. The patient thought more than a tea- 
 spoonful of blood escaped. I saw him a few moments after the hemorrhage had 
 occurred. The pain had entirely subsided ; the membrana tympani was perfo- 
 rated in the anterior and inferior quadrant, and a small quantity of dark-colored 
 blood was about and in the opening, while the membrane was pulsating as in the 
 former case, or rather the blood column was pulsating in the cavity of the tym- 
 panum. This patient fully recovered without any suppuration whatever. The 
 opening healed, and the hearing, which was reduced to such an amount as to 
 be expressed by the fraction 3^, was restored to a normal standard. The treat- 
 ment consisted in the careful use of an injection of tepid water, just after the 
 occurrence of the rupture, with the subsequent use of the Eustachian catheter, 
 through which air was introduced, and Politzer's method of inflating the drum- 
 head. 
 
 It may be of interest, to note that this gentleman died some 
 thirteen years afterward of cerebral hemorrhage. I lately 
 treated a gentleman in his eighty-fourth year, who suffered 
 simultaneously from hemorrhagic retinitis and hemorrhage into 
 the middle ear. Absorption of the blood in the tympanic cavity 
 and the drum-head was followed by great improvement to the 
 hearing. I have also lately seen a case of hemorrhage into the 
 drum-head, after the escape of fluid into the tympanum while 
 gargling. This latter . case, however, is hardly like a true hem- 
 orrhagic inflammation of the middle ear which I first described, 
 and which is now generally recognized. Not only have cases 
 been reported by eminent authorities, 1 but in one hospital 2 it is 
 reported that 19 cases have been observed in thirteen years. 
 Hemorrhagic inflammation of the middle ear is usually a very 
 tractable inflammation whose violence is spent with the hemor- 
 rhage. The history of such cases, especially with regard to the 
 abatement of the pain as soon as the hemorrhage occurs, fur- 
 nishes another argument for an early perforation of the drum- 
 head, when great pain is experienced and the drum-head bulges. 
 
 Since the publication of the author's cases of otitis media 
 hemorrhagica, Dr. Mathewson, of Brooklyn, and Dr. Hackley, 
 of New York, have also observed and reported at a meeting of 
 the New York Ophthalmological Society, cases of acute inflam- 
 mation of the middle ear, in which hemorrhage occurred through 
 the membrana tympani before any pus appeared. Their course 
 was quite similar to that of those I have related, and Dr. Hack- 
 ley's case occurred in a young woman who had just passed 
 through the menstrual period, and the menses reappeared after 
 
 1 Guide to the Study of Ear Disease, by T. McBride, M.D., p. 50. Edinburgh, 1884. 
 * Brooklyn Eye and Ear Hospital Report, 18S3.
 
 300 HEMORRHAGIC INFLAMMATION. 
 
 the aural hemorrhage ceased. Dr. Pomeroy also reports such 
 a case, as follows : ' 
 
 A woman of fifty-five was seized with a chill at ten o'clock in the evening, 
 which was followed by fever and great pain on the left side of the head and in 
 the left ear. The pain continued with more or less severity for five days, when 
 Dr. Pomeroy saw the patient and found the niernbrana tympani intensely red. 
 Posteriorly and above it bulged somewhat. The right membrane was also red, 
 but did not bulge. The left membrane was opened, and after inflation the 
 auditory canal was nearly filled with blood. Two days after the membrane, 
 which seems to have closed, was again punctured and a few drops of blood 
 evacuated. The patient made an entire recovery without suppuration from the 
 ear. The patient had no renal disease and no cerebral symptoms. 
 
 AURAL HEMORRHAGE IN THE COURSE OF BRIGHT'S DISEASE. 
 
 There will, perhaps, be no better opportunity than the pres- 
 ent of alluding to those hemorrhages from the tympanic vessels 
 that occasionally occur in Bright's disease. Schwartze reported 
 such a case 3 in 1868. 
 
 The patient was a non-commissioned officer, of twenty-five years of age, who 
 suffered from albuminuria, with retinal hemorrhages. There was also enlarge- 
 ment of the liver and spleen, and infiltration of the lungs. On January 16, 
 1868, he suddenly complained of pain in his right ear, which had been previ- 
 ously sound. When Dr. Schwartze saw the patient, some hours after, the 
 membrana tympani was of a bluish-red color and devoid of concavity. Some 
 leeches were applied, but they did very little good. The next day the mem- 
 brane was of a dark-red color, so that an extravasation of blood into the cavity 
 of the tympanum was plainly evident. On the 19th there was an abundant 
 serous discharge, and when the ear was cleansed by a syringe, a small blood 
 coagulum was removed. Anteriorly and below there was a perforation in the 
 membrana tympani, about as large as the head of a pin. In the afternoon a 
 whitish mass came out of the ear, in the water that was instilled every ten min- 
 utes. This mass, which looked like a fibrous coagulum, was one and a half 
 inch long, and two lines broad, and one-half a line thick. On the 20th an- 
 other similar mass came out, and on the 22d the patient died. The discharge 
 from the ear had then become purulent. 
 
 The microscopic examination of the mass removed, when it was not quite 
 fresh, showed an extremely fine granular mateiial, mixed with numerous scales 
 of epithelium. The post-mortem examination was made on January 23d. There 
 was great hypertrophy and dilatation of the left ventricle. Both kidneys were 
 atrophied. The lungs and spleen enlarged. Pneumonia of both lungs. Re- 
 tinitis apoplectica, with retinal detachment on both sides. 
 
 EAES. Hemorrhagic inflammation of the membrane lining the right cavity 
 
 1 Transactions American Otological Society, p. 86, 1875. 
 z Archiv fur Ohrenheilkuude, Bd. IV., p. 12.
 
 AURAL HEMORRHAGE IN BRIGHT 5 S DISEASE. 301 
 
 of the tympanum ; cavity of the tympanum filled with bloody purulent fluid. 
 Membrana tympani greatly reddened and swelled, covered by a thin layer of 
 pus, and perforated as before stated. The mucous membrane of the Eustachian 
 tube was also injected, but not so markedly as the tympanic cavity. No affec- 
 tion of the labyrinth. 
 
 In the left ear, of which .the patient did not complain during life, the cavity 
 of the tympanum was also filled with a bloody serous fluid ; but there was no 
 inflammation of the lining membrane. There were small ecchymoses on the 
 mucous membrane of the naso pharyngeal space. The mucous membrane of 
 the tube was injected, and mostly so at the faucial orifice of the tube. 
 
 . In the same year that Schwartze published his case, Dr. 
 Gouverneur M. Smith read a paper before the Acadejny of Med- 
 icine, 1 in which he called attention to the fact that impairment 
 of hearing was at times one of the symptoms of Bright's dis- 
 ease, and a symptom that could not be explained by referring it 
 to uraemia. I once treated a case of obstinate suppuration in 
 the middle ear, in a man of sixty-one years of age, who, al- 
 though suffering from Bright's disease, of which he died, com- 
 plained chiefly of neuralgic pains referred to his suppurating 
 ear, for three or four months prior to his death. I have now no' 
 doubt that the renal disease, by its effect upon the tympanic 
 vessels, was the cause of the acute suppuration in the ear, and 
 that if I had seen the case when the rupture of the drum-head 
 occurred, that I would have found it hemorrhagic in its nature. 
 In a thesis for the degree of Doctor in Medicine, 2 Paul Pis- 
 sot enumerates three forms of diseases of the ear as arising in 
 Bright's disease, viz., tinnitus aurium, half deafness, and com- 
 plete deafness. This classification is so unscientific that it gives 
 no real information. The only important part of this thesis is 
 that in which it is stated that Delacharriere has found rupture 
 of the membrana tympani, vascularity along the handle of the 
 malleus, and sclerosis of the tympanum in cases of impairment 
 of hearing occurring in Bright's disease. The supposition is 
 then made that the aural symptoms may be due to an oedema of 
 the sheath of the auditory nerve. This, it is needless to say, is 
 a purely theoretical view. Even the occurrence of aural symp- 
 toms in Bright's disease of the kidney has as yet attracted but 
 little attention, and, as far as I know, they are somewhat rare, 
 and have not as yet been accurately studied. A certain propor- 
 tion of the few that seem to occur, probably depend upon hem- 
 orrhage from degenerated blood-vessels in the tympanic cavity. 
 
 1 On the Etiology of Bright's Disease, with Remarks on the Prophylaxis. Trans- 
 actions of the New York Academy of Medicine, vol. iii. 
 
 2 American Journal of Otology, vol. i., p. 136.
 
 302 VASCULAR TL T :MORS OF MEMBRANA TYMPAXI. 
 
 VASCULAR TUMORS OF THE MEMBRANA TYMPAXI. 
 
 Todd, 1 of St. Louis, reports a case of somewhat alarming 
 hemorrhage from the depth of the auditory canal, after the 
 puncture of a small swelling that hid the membrana tympani. 
 The patient had suffered twenty-two years previously from sup- 
 puration of both middle ears. As a result of this disease, his 
 hearing was impaired, and he had a throbbing noise in his left 
 ear. The arterial bleeding was stopped by a tampon, but it was 
 renewed on removing it, and the sac filled with blood as soon 
 as it was removed. Under the use of a compress of cotton mois- 
 tened with" glycerate of tannin, the sac was found, two years 
 later, to be of a whitish color and thickened. It was about the 
 size of a split pea. Dr. Todd was not able to see the membrana 
 tympani in any of his examinations. It is possible that the 
 hemorrhage was from a tumor of the drum-head or tympanum, 
 rather than from one having an origin in the auditory canal. 
 
 Buck a reports a case of vascular growth on the drum-head. 
 In the posterior superior quadrant, just behind the short process 
 of the malleus, was found a bright red fleshy mass, about a 
 millimetre or a millimetre and a half in diameter. It was soft 
 and freely movable. The patient was a lady of twenty-two 
 years of age. 
 
 I am now treating a Sister of Charity of about thirty -five 
 years of age, who has an affection of the right middle ear, with 
 a vascular growth in the drum-head. The patient was first seen 
 in the spring of 1883, about one year since. Her symptoms were 
 impairment of hearing and tinnitus. A red growth was found 
 to involve the centre of the membrana tympani, and with it the 
 handle of the malleus. It formed a ridge nearly across the 
 whole surface of the membrane. It was of a bright red color. 
 I incised it with a paracentesis needle. The tissue was rather 
 hard, and although the opening was full and bled freely, the 
 tumor did not fully collapse. Since then four incisions have 
 been made, with relief to the tinnitus, and the tumor, although 
 still existing, is quite small and is less vascular, especially at 
 the lower extremity. The patient has also been treated by infla- 
 tion of the tympanum. The incisions into the tumor were for- 
 merly followed by more bleeding than is now experienced, and 
 the patient expresses a sense of relief of the fulness in the ear 
 after the paracentesis. This tumor seems to me to communi- 
 cate with the tympanum. It may be a growth between the in- 
 
 1 American Journal of Otology, voL iv., p. 187. 
 * Treatise on the Ear, p. 372.
 
 VASCULAR TUMORS OF MEMBRANA TYMPANI. 303 
 
 tegumentary and fibrous la} 7 er. The tuning-fork is heard better 
 by bone conduction. The hearing distance varies from to , 
 according as the tympanum is free from mucus. 
 
 Buck 1 also reports a second case of vascular tumor of the 
 membrana tympani. This case was seen in a lady of sixty-five 
 years of age, who consulted Dr. Buck on account of a slight im- 
 pairment of hearing, that had existed but for a few days. In 
 the central portion of the posterior superior quadrant of the left 
 drum-head was a dark colored tumor, measuring about a milli- 
 metre at its base. It was not particularly sensitive. In the right 
 there was a similar tumor, in a corresponding situation, but it 
 was smaller. 
 
 Weir's 2 first case of intra-tympanic vascular tumor, is very 
 similar to the one of which I have just given a sketch. Re- 
 peated incisions, followed by cauterizations and inflation of the 
 middle ear, finally effected a cure. Weir's second case 3 was 
 also greatly alleviated by incisions and cauterizations with 
 chromic acid, .but the patient, a colored woman, finally died of 
 phthisis. She was greatly troubled by tinnitus, which was usu- 
 ally relieved by a paracentesis. 
 
 It is evident from the history of these cases that paracentesis 
 or incision of vascular growths of the drum-head, or tympanic 
 cavity, as well as inflation of the middle ear, are generally 
 indicated. By these means we may hope ultimately to secure 
 shrinkage of the growths and a return to a normal condition. 
 
 The causes of these vascular growths are not evident to me. 
 Those related by Buck appear to be of the nature of naevi, while 
 those of Weir and myself seem to be consequences of inflam- 
 mation of the tympanum. 
 
 DIPHTHERITIC INFLAMMATION OF THE MIDDLE EAR. 
 
 The origin and course of diphtheritic inflammation of the 
 middle ear, are so different from what obtains in an ordinary 
 acute inflammation of the middle ear, caused by cold, or even 
 from this disease occurring in the course of the exanthemata, 
 that I feel justified in devoting a few paragraphs to a special 
 discussion of it. While assisting in the case of a child of about 
 eleven years of age, who died of diphtheria, and about whose 
 hearing before his illness I had accurate knowledge, I observed 
 that he became very hard of hearing in the course of the diph- 
 
 1 American Journal of Otology, vol. iii., p. 283. 
 
 2 Ibid., vol. i., p. 120. 
 
 3 Loc. cit.
 
 304 DIPHTHERITIC INFLAMMATION. 
 
 theria which affected the fauces and nostrils. The impairment 
 of hearing continued as long as he lived. It may have been 
 caused, as the fuller experience of other writers shows, by sim- 
 ple catarrh of the middle ears, or by the formation of a croupous 
 membrane in the Eustachian tube or tympanum. 
 
 The principal writers upon the subject of diphtheria of the 
 ear are Wendt, 1 Wreden, 2 and Blau. 3 
 
 In most of the post-mortem examinations made by Wendt, of 
 diphtheritic inflammations of the ear, there was merely a co- 
 incidental hyperaemia or catarrh of the tympanum, in connec- 
 tion with laryngeal and pharyngeal diphtheria. 
 
 Wreden, however, has reported 18 cases of diphtheritic inflam- 
 mation of the middle ear, occurring in the course of pharyngeal 
 and nasal diphtheria, complicated with scarlet fever. Diph- 
 theritic inflammation generally causes great impairment of hear- 
 ing when it involves the ear, according to Wreden. His report 
 indicates that the internal ear was also affected in his cases, for 
 the tuning-fork was not heard through the bones. The drum- 
 head was half destroyed in all the cases examined by him. The 
 prognosis is worse in infants than in older children. Wreden 
 speaks well of leeches and douches of solutions of tannin, in the 
 treatment of diphtheritic inflammation of the middle ear and 
 internal ear. 
 
 Dr. 0. E. Billington, who has contributed essentially to our 
 knowledge of diphtheria, by a report of a large number of cases 
 to the New York Academy of Medicine, informed me, and also 
 stated in a public discussion, that the ear had not, in his experi- 
 ence, been affected in diphtheria, except in such cases as were 
 complications of scarlatina. Billington considers the difference 
 between the two diseases to be so marked, as to make it a diag- 
 nostic point. He has been able to trace cases of apparently 
 simple diphtheria with complicating otitis, back to a scarlatinal 
 origin. He thus agrees with the observations of Wreden just 
 quoted. 
 
 Jacobi 4 states that the ear, in the same manner as the eye, 
 may become affected with diphtheria by continuity with the 
 naso-pharyngeal space. He says a slight swelling of the mucous 
 membrane of the orifices of the Eustachian tubes in children, or 
 a moderate diphtheritic deposit may close them, and hardness of 
 hearing be the result. In such cases the patient not infrequently 
 
 1 In Schwartze's Pathological Anatomy of the Ear. 
 
 2 Monatsschrift fur Ohrenheilkunde, No. X., 1868. 
 
 3 Berlin. Med. Wochenschrift, December, 1881, p. 729. 
 
 4 Treatise on Diphtheria, p. 74.
 
 DIPHTHERITIC INFLAMMATION. 305 
 
 complains of intense pain behind the angle of the jaw and ear. 
 Jacobi also recognizes the fact, that perforation of the drum 
 membrane may result from diphtheritic inflammation of the 
 middle ear. 
 
 Wendt ' found a tubular croupous membrane or a solid cast 
 in the cartilaginous part of the Eustachian tube. Once, the 
 membranous formation involved both tympanic cavities and the 
 antrum and cells of the mastoid, and even covered the ossicula. 
 With this exception Wendt, found only hyperaemia or hemor- 
 rhage in the osseous parts of the middle ear. 
 
 Kupper 2 and Gottstein ' also report cases of diphtheritic otitis. 
 The former author gives an account of a post-mortem, in which 
 it was shown, that croupous inflammation of the mucous mem- 
 brane of the tympanum, and of the tube had occurred with an 
 intact drum-head. 
 
 Blau, 4 of Berlin, reports in full, a case of diphtheritic pan- 
 otitis, occurring after an attack of scarlatina, upon the heels of 
 which, as observed by Wreden and Billington, the diphtheritic 
 pharyngitis and otitis may quickly follow. In Blau's case the 
 hearing was completely gone. When he first saw his patient, 
 neither the tragus nor mastoid process was sensitive to press- 
 ure. A membrane was found in each auditory canal. Paralysis 
 of the facial nerve and great redness of the membrane of the 
 tympanic cavity soon followed. Periostitis and abscess of the 
 mastoid also occurred. Blau was not able to follow the case 
 to its termination. He used a douche of lime-water very fre- 
 quently with good effect in the removal of the membrane. It 
 will be seen, that it is a perfectly well-established fact, that a 
 croupous membrane may form in the middle ear, during diph- 
 theria. It is also true that the labyrinth may be involved. The 
 evidence leans toward the truth of the view of Dr. Billington, 
 that diphtheria of scarlatinal origin is the only form in which 
 otitis occurs. The reader is also referred to the report of a case 
 in the next chapter of an adult dying from meningitis consecu- 
 tive to aural disease, in which a croupous membrane was found 
 in the middle ear. 
 
 Of 147 cases of deaf-muteism lately examined by me, not one 
 was ascribed by the family or friends to diphtheria. It is prob- 
 able that the cases of diphtheria in which severe otitis occurs, 
 are generally fatal. 
 
 1 Quoted by Blau, loc. cit. 
 
 * Archiv fur Ohrenheilkunde, Bd. XL, p. 19. 
 
 3 Ibid., Bd. XVII., p. 16. 
 
 4 Berlin. Wochensclirift, loc. cit. 
 20
 
 306 DIPHTHERIA CEREBUO-SPINAL MENINGITIS. 
 
 Diseases of the middle and internal ear (panotitis Politzer) 
 occurring in the course of diphtheria, should be energetically 
 treated, if the general condition allows. At any rate, the mouth 
 of the Eustachian tube should be freely sprayed with lime-water, 
 or solutions of tannic acid, and Politzer's inflation practised, So 
 that, if possible, the tympanum may be ventilated, and the tubal 
 muscles kept at work. Poultices over the mastoid and in front 
 of the auricle, with repeated douches of the auditory canal, are 
 also to be earnestly recommended. The violence of the aural 
 symptoms in diphtheria are only equalled by what occurs in 
 severe cases of scarlatina, where I have seen the course so vio- 
 lent in an inflammation of the tympanum, that the drum-head 
 and ossicles were swept away a few hours after the first symp- 
 toms appeared in the f aucial extremities of the Eustachian tube. 
 Urgent as the general symptoms will undoubtedly be, those re- 
 lating to the ear should not be left unrelieved if possible to miti- 
 gate them. 
 
 ACUTE DISEASE OF THE MIDDLE EAR IN CEREBRO-SPINAL MENINGITIS. 
 
 The examination of deaf-mutes shows that, according to the 
 testimony of their friends and attending physicians (see chapter 
 on " Deaf-Muteism v ), many of them became deaf while suffer- 
 ing from cerebro-spinal meningitis. In my opinion, the chief 
 seat of the lesion, in a majority of these cases, is to be found in 
 the middle ear. I am sorry that I am seldom called to see a 
 case of acute cerebro-spinal meningitis, but when I am, I advise 
 the use of leeches, blisters, and mercury to combat the forma- 
 tion of an exudation or purulent formation in the middle ear. If 
 I may venture to advise my professional friends, who see this 
 disease, accompanied by impairment of hearing or deafness, I 
 would say, treat the aural affection as if it were one of acute 
 catarrh of the middle ear. The prognosis as to the hearing will 
 then not be altogether hopeless, although it is usually so consid- 
 ered. That the disease of the ear is commonly situated chiefly in 
 the tympanum, I hope to be able to prove in the discussion of the 
 causes of deaf-muteism in a subsequent chapter of this volume.
 
 CHAPTER XII. 
 
 ACUTE SUPPUKATION OF THE MIDDLE EAR. 
 
 
 
 A Consequence of Acute Catarrh. Symptoms. Causes. Course. Cases of Meningitis 
 
 Consecutive to Acute Catarrh and Suppuration. Criticisms upon the Modern An- 
 tiphlogistic Treatment. Neurotic Cases. Treatment and Cases. Acute Serous 
 Inflammation of the Middle Ear. 
 
 ACUTE suppuration of the middle ear commonly occurs as a 
 direct and recognized consequence of an acute catarrh of the 
 same part. A catarrhal process is unchecked, and passes on to 
 a suppurative one. In some cases the catarrhal inflammation is 
 unobserved we cannot, however, say that it does not occur 
 and the first intimation of any morbid action given by the ear is 
 a discharge of pus from the auditory canal. I have seen several 
 cases where. the patients have assured me that the first idea 
 that they had of trouble in the ear, was the moistening of he 
 canal from the flowing out of the pus. An examination of the 
 ear in such cases has always revealed a perforation of the mem- 
 brana tympani. We probably never see a discharge of pus from 
 the surface of the auditory canal, without previous intimation, 
 by pain or swelling, that an inflammation of the part had oc- 
 curred, while this may occur from the tympanum. It is my 
 belief that the cases of sudden and painless perforation of the 
 membrana tympani are nearly always preceded by some pre- 
 monitory symptoms, such as pharyngitis, feelings of fulness in 
 the ear, impairment of hearing, and so forth ; but that the fail- 
 ure to notice them is usually to be attributed to carelessness in 
 observation, and that it is to be regarded as another indication 
 of the common indifference to an inflammation of the ear, when 
 it is not positively painful. 
 
 Then, again, there are cases where pain is felt long before 
 the pus is discharged, but where it is mistakenly referred to 
 some other part of the body, or to a neuralgia, instead of an in- 
 flammation. 
 
 It is not to be denied, however, that there are cases of acute 
 suppuration of the middle ear, where the initial symptoms of 
 swelling of the lining membrane of the Eustachiaii tube and
 
 308 ACUTE SUPPURATION SYMPTOMS. 
 
 cavity of the tympanum, are so quickly passed over, in a few- 
 hours, or even minutes, as to be practically unrecognizable. 
 
 Such a course of the disease is frequently observed in phthi- 
 sis pulmonalis, where a membrana tympani will sometimes 
 break down from an accumulation of mucus behind it, and go 
 on to suppuration without a trace of pain. 
 
 The usual origin of acute suppuration is a violent one. The 
 severe pain of acute catarrh is unrelieved, pus is formed in the 
 cavity of the tympanum, the lining of the mastoid cells is very 
 much distended, the outer surface of the process becomes red r 
 tender, and painful, the head throbs, and the whole system is- 
 seriously disturbed. In young persons delirium occurs, and in 
 all subjects, who have acute suppuration of the middle ear, 
 there is general febrile excitement, and the condition of the pa- 
 tient is one of intense suffering. There is probably no more se- 
 vere pain to which the human system is liable, than that due to 
 the distention of the little space called the cavity of the tympa- 
 num by mucus, blood, serum, or pus. 
 
 Symptoms. The symptoms, then, of this disease are usually 
 pain in the ear and head, fever, with impairment of hearing 
 and tinnitus. The membrana tympani also exhibits marked 
 changes in appearance. 
 
 But the pain may be entirely absent, as we have seen, and 
 yet the inflammatory process, because it is sudden in its origin, 
 be fairly entitled to the adjective acute. The cases of the pain- 
 less form of acute inflammation in persons suffering from phthi- 
 sis pulmonalis before alluded to, are not as amenable to treat- 
 ment as the more acute cases. I suppose this fact is partly to 
 be attributed to the failure in the general nutrition, and also to 
 the contiguity of a diseased mucous membrane, which is con- 
 stantly acting as an exciting cause of trouble in the pharynx 
 and Eustachian tube. 
 
 The membrana tympani has usually lost its naturally trans- 
 parent appearance in a case of acute suppuration. It has a 
 boggy, sodden, or swelled appearance, and has none of its nor- 
 mal distinguishing marks the light spot and the handle of the 
 malleus. Yet this is not always the case. I have seen cases 
 where the transparency of the drum membrane was almost un- 
 impaired, and the accumulated pus and mucus which were 
 bulging it out, could be seen through it. In one case, that of 
 a young lady, I found pus not only in the cavity of the tym- 
 panum, but also between the mucous and fibrous layer of the 
 drum-head. The pus moved when the head was moved. She 
 recovered, with perfect hearing power, and a sound membrana
 
 ACUTE SUPPUKATION SYMPTOMS. 309 
 
 tympani, without an artificial or spontaneous perforation of the 
 drum-head. The treatment resorted to was the use of leeches, 
 a gargle, and Politzer's method. There was considerable pain 
 at the outset, but not the intense pain which is usually one of 
 the characteristics of acute suppuration. The patient visited 
 my office daily during the whole course of the disease, which 
 occurred in the mild weather of spring. 
 
 It is possible that some cases of so-called abscesses of the 
 membrana tympani should be regarded as examples of limited 
 suppuration in the tympanic cavity. I have not as yet seen any 
 cases, where it seemed to me that an abscess was confined to 
 the layers of the drum-head, without any communication with 
 the cavity of the tympanum or the external auditory canal. It 
 should be added, that the osseous portion of the bony canal is 
 often found to be very much inflamed, in conjunction with the 
 symptoms in the membrana tympani, the cavity of the tym- 
 panum, and the mastoid cells. I may be pardoned for remind- 
 ing the student, that it is often impossible to draw the line 
 between the affections of the three parts of the ear. Their ana- 
 tomical connections show that they must of necessity run into 
 each other, however distinctly they may be separated in their 
 origin. It is rather a predominance than an exclusive localiza- 
 tion of symptoms in a part, that gives rise to an exact classifi- 
 cation of disease. For example, an otitis media, in a young- 
 child, may very readily and rapidly pass on to an otitis" interna, 
 or inflammation of the labyrinth, and give us much difficulty in 
 deciding which was the original affection. Politzer has given 
 the name ofpanotitis to these cases. 
 
 Causes. The causes of acute suppuration of the middle ear 
 are the same as those that have been enumerated in the chapter 
 on "Acute Catarrh." The important ones are comprised in ex- 
 posure to wet, draughts, and cold inflammation of the naso- 
 pharyngeal mucous membrane being the usual starting-point. 
 
 The violent use of the posterior nares syringe in an acute 
 or subacute catarrh, will also in very rare cases set up acute 
 suppuration in the tympanic cavity ; at least I have seen it 
 do so in one instance as follows : A physician, aged twenty- 
 seven, had suffered for years from chronic naso-pharyngeal 
 catarrh. During the winter of 1872, he was attacked with acute 
 coryza and pharyngitis. He had once used the nasal douche for 
 a similar attack, and it caused such severe symptoms that he 
 was obliged to desist from it. I was in the habit of using the 
 naso-pharyngeal syringe for him at irregular intervals, in order 
 to relieve the chronic naso-pharyngitis from which he suffered.
 
 310 ACUTE SUPPURATION CAUSES. 
 
 On visiting him one afternoon, when he was suffering from the 
 acute attack, his nostrils felt so full of secretion that he requested 
 me to use the naso-pharyngeal syringe, which I did, injecting a 
 lukewarm solution of chlorate of potash. The bulb of the instru- 
 ment caused some gagging as it came in contact with the swelled 
 wall of the pharynx. In an hour or two he was attacked with 
 acute aural catarrh of the left side, which, in spite of the most 
 energetic treatment by means of leeches, went on to suppuration 
 before morning. Under appropriate treatment the patient recov- 
 ered, with a sound drum-head, and with the hearing power as 
 great as before the attack. 
 
 The fact has already been mentioned that sea-bathing some- 
 times becomes a cause of acute catarrh. In the same manner, 
 want of caution in protecting the side of the head from the force 
 of the waves, or the canal, or nostrils and Eustachian tube from 
 the entrance of water, may produce acute suppuration. 
 
 Scarlet fever, measles, diphtheria, tonsillitis, bronchitis, pneu- 
 monia, typhoid fever, whooping-cough, and cerebro-spinal men- 
 ingitis, play an important part in the production of acute aural 
 disease, and usually, except in pneumonia and cerebro-spinal 
 meningitis, the suppurative form is the one first recognized, al- 
 though as has been said, there is probably almost always an 
 unobserved stage of the milder variety of inflammation. 
 
 Injuries of the side of the head, and of the membrana tym- 
 pani, are causes of acute suppuration of the middle ear of a very 
 severe nature. This subject has, however, been discussed in the 
 chapter on " Injuries of the Membrana Tympani." 
 
 Course. The course of acute suppuration is usually violent 
 until perforation of the drum-membrane occurs ; when it gives 
 way at times with quite a loud explosion relief to the severe 
 pain is usually experienced. If no measures are -taken to re- 
 move the accumulated pus, and to check its formation, the im- 
 pairment of hearing will continue, although the pain and tin- 
 nitus may be relieved, and we shall soon have a case of chronic 
 suppuration of the middle ear, and the patient be liable to all 
 the fearful consequences of this disease. In rare cases, pus may 
 escape, however, into the Eustachian tube, and the case go on 
 to resolution with no perforation of the drum-head. This is 
 more apt to occur in children than in adults. 
 
 In the worst event of all, the suppuration may extend into the 
 brain or the blood-vessels. It may pass through the thin, and 
 sometimes porous lamella of bone which forms the roof of the 
 cavity of the tympanum, or it may go beneath into the jugular 
 vein, and thus produce blood-poisoning or pyaemia. It may also 
 extend to the labyrinth.
 
 ACUTE SUPPUEATION COUKSE. 311 
 
 The mastoid process is of course always more or less involved 
 in acute suppuration, or even in acute catarrh. Its cells form > 
 as the anatomy shows us, an integral part of the middle ear. 
 There are probably but few, if any, cases of suppuration that are 
 limited to the tympanum. Disease of the mastoid process is also 
 a dangerous complication ; but for a full discussion of the sub- 
 ject, I beg to refer the reader to the chapter upon consequences 
 of chronic suppuration. Under appropriate treatment, however, 
 the secretion of pus usually soon ceases, the membrane closes 
 up, the hearing is restored, and scarcely a trace is seen, either 
 in the anatomical structure or the functions of the organ, of the 
 disease which has raged so violently. 
 
 With a want of logic that is remarkable, some practitioners 
 invite suppuration of the drum-head, in every case of acute 
 catarrh, or "pain in the ear," and then declare, that nothing can 
 be done for the hearing when the membrana tympani is once 
 perforated. Our aim should always be to prevent or limit sup- 
 puration in the ear, but if it do occur, and even if a large portion 
 of the drum-head be swept away, we may usually, if the ossicula 
 be left, by prompt, energetic, and patient treatment, restore it, 
 and with it, the hearing power. 
 
 It should be observed, that diffuse inflammation of the ex- 
 ternal auditory canal is often a troublesome "complication in the 
 course of an acute aural suppuration with perforation. It is 
 probably caused by the irritation of the pus in the auditory canal, 
 and perhaps in some cases by the excessive manipulation for the 
 purpose of cleansing the ear. Such a complication is sometimes 
 embarrassing and distressing, for it protracts the duration of the 
 disease very much. 
 
 Acute catarrh and acute suppuration of the middle ear are 
 exceedingly amenable to judicious treatment. There are no im- 
 portant parts of the body which more certainly in the large 
 majority of cases recover from serious inflammations than those 
 that make up the middle ear. Indeed, it should not be forgot- 
 ten, that acute catarrh and acute suppuration very often run 
 their entire course, and end in perfect recovery with no especial 
 treatment. Any one who is in the habit of hearing the histories 
 of patients and of examining the membrana tympani, soon con- 
 vinces himself that young children often recover from acute 
 suppuration of the middle ear under very crude but not meddle- 
 some treatment, received from nurses and parents. This be- 
 comes an important consideration in the physician's treatment 
 of acute inflammations of the ear, for it will lead him to a wise 
 conservatism in certain cases, and a healthy skepticism as to the 
 value of drugs which therapeutic enthusiasts praise so highly
 
 312 MENINGITIS FROM AURAL DISEASE. 
 
 and with which they claim to avert a suppuration process. 
 There are, however, painful exceptions to the rule that acute 
 suppuration of the middle ear is under proper guidance, usually 
 a tractable and not fatal disease. In 1877, I attended a case in 
 which meningitis followed acute purulent inflammation of the 
 middle ear. Death occurred in about twenty-eight days from 
 the appearance of the acute aural symptoms.' The history of 
 the case is as follows : 
 
 Meningitis following Acute Purulent Inflammation of the Middle Ear Death in 
 about Twenty-eight Days from the Appearance of the Aural Symptoms Post-mor- 
 tem Examination of the Brain and Temporal Bone. On March 23, 1877, Mr. A. 
 
 H..B , aged forty-one, whom I had treated for syphilitic iritis some two 
 
 years before, sent for me, on account of a severe pain in. the right ear. I found 
 the patient, who was a well-developed man, apparently in robust health, sitting 
 up, but giving evidences of great pain. The pain was referred to the depth of 
 the right ear. There was a profuse discharge of blood and pus from the audi- 
 tory canal ; blood predominated, however. The membrana tympani was per- 
 forated. The outlines of the ossicles were not seen on account of the swelling 
 of the lining membrane of the tympanic cavity and of the remains of the drum- 
 head. There was some sensitiveness of the tragus and auditory canal, but no 
 especial tenderness of the mastoid process. 
 
 The patient stated that on a return from a visit to Memphis and Mobile, or 
 about five days before, he had a bad cold in the head, with severe neuralgic 
 pains in the same region. 
 
 Three or four days after the "neuralgia" he consulted Dr. Royal Prescott, 
 through whose courtesy I am able to present the history from that time. 
 
 Dr. Prescott says, in a note to me : ' ' Mr. B came to my office on the 
 
 evening of March 20th, complaining of pain in the right ear, and deafness on 
 the affected side. He thought that his hearing had been affected for some time 
 on that side. On examination I discovered a quantity of inspissated cerumen, 
 which I removed by gently syringing with warm water. ... I inserted a 
 few drops of warm glycerine and morphine, put in a pledget of cotton, gave him 
 an anodyne, and directed him to take a saline cathartic. He came in on the 
 following morning and reported that he had passed a tolerable night, that the 
 pain was somewhat abated, but had not wholly disappeared." Dr. Prescott then 
 ordered an infusion of opium, and directed him to remain in the house for a 
 few days. 
 
 On March 22d, according to Dr. Prescott's note, the pain had increased, 
 when hot fomentations to the ear and an anodyne were ordered. The patient 
 exposed himself in a severe storm in his last visit to Dr. Prescott's office, and 
 became worse. At this stage I saw the patient. I ordered the application of 
 two leeches to the tragus and the warm douche every hour. My associate, Dr. 
 E. T. Ely, called at nine the same evening, and found him so comfortable that 
 a hypodermic injection of morphia which I had proposed was not administered. 
 
 On the 24th, the patient was quite comfortable and free from pain, but he was 
 very restless and did not sleep well. He said that liis sleeplessness was not on 
 
 1 Medical Record, July 7, 1877.
 
 MENINGITIS. 313 
 
 ticcount of pain in the ear, but on the 25th two more leeches were applied. The 
 discharge from the meatus continued to be very abundant and bloody. The 
 warm douche was continued, and bromide of potassium was given at night. Oil 
 the 26th there was no pain in the ear, and no especial tenderness about it, but 
 his head was very uncomfortable and restless. The patient's tongue was heavily 
 furred, his pulse 96, and temperature 101. He was sleepless and without ap- 
 petite. Cerebral hypersemia was diagnosticated, and ten grains of calomel were 
 ordered at 11 P.M. From the 28th to the morning of the 30th the symptoms 
 were about the same. By the aid of morphia tolerable sleep was secured, but 
 the patient showed great anxiety and discomfort. On that morning, at my re- 
 quest, Dr. Lewis Fisher saw him in consultation, and. continued to see the 
 patient with me until his death. Dr. Fisher concurred in the diagnosis, and 
 inasmuch as the patient had suffered from syphilis, he suggested the use of 
 iodide of potassium in addition to the warm douche and morphine. On March 
 31st the patient had a severe chill at noon, which lasted for an hour, and which 
 was not followed by sweating. The temperature was 100 at about 12 noon ; 
 at 9^ P.M., 103f . The patient stated that he never had had a malarial attack, 
 although he had spent much of his life in a malarious country. The formation 
 of pus was supposed by Dr. Fisher and myself to be indicated by this chill. 
 There was, however, no tender spot about the ear, and there seemed no chance 
 of getting at the abscess, if one was forming. There continued to be a free dis- 
 charge from the meatus. We therefore decided to administer quinine, as an 
 antipyretic. We accordingly gave him twenty grains of sulphate of quinine and 
 thirty grains of bromide of potassium, following it up in four hours after with 
 fifteen grains of quinine. On April 1st the patient appeared much better. His 
 temperature was 98, his pulse 72, and there was no pain in the ear, and scarcely 
 
 any in the head. The quinine treatment was kept up. Mr. B began to sit 
 
 up and converse on business matters, and became very cheerful, although we 
 had given him a gloomy prognosis immediately after the occurrence of the chill. 
 He did not, however, sleep quite as well as a convalescent should, and on April 
 12th he suddenly complained of severe pain in his right knee-joint, and his tem- 
 perature ran up to 103^. He slept scarcely at all ; he also complained of pain 
 in his head, which was not localized. The discharge from the ear diminished 
 very much. The pain in the knee disappeared in about twenty-four hours, and 
 occurred with great severity in the back and left thigh. The mastoid process 
 was cut down upon on the 9th or 10th, but no disease of the bone or periosteum 
 was detected. On the 15th the temperature was 103|, the pulse 84, and a low 
 muttering delirium occurred at intervals. Professor John T. Metcalfe saw the 
 patient on this day, and gave his opinion that it was a case of cerebral disease 
 extending from the ear, and although he regarded the prognosis as very un- 
 favorable, suggested the use of mercurial inunctions and iodide of potassium, 
 with a very faint hope that syphilis was causing some of the symptoms. On the 
 16th the patient was scarcely ever conscious, his temperature continued at 104 
 to 104, and on the morning of the 17th he quietly died. 
 
 The autopsy was made by Dr. W. D. Spencer, five and one-half hours after 
 death. 
 
 Head. The bones, except the right temporal bone, were normal. The dura 
 mater was normal. The sinuses were filled with dark, soft coagula. 
 
 Brain. The vessels on the surface were markedly hypersemic. The vessels 
 at the base appeared normal. In the meshes of the pia mater, most markedly
 
 314 MENINGITIS FKOM AURAL DISEASE. 
 
 at the base, and equally on both sides, was seen quite an extensive fibrino-puru- 
 lent exudation, which was thicker along the course of the larger vessels ; this 
 exudation extended anteriorly to the surface of the right hemisphere, when it 
 was more sero-purulent. The lateral ventricles were markedly dilated and filled 
 with blood-stained serum. The brain substance was firm and markedly hyper- 
 femic, otherwise normal as far as examined. The connective tissue posterior to 
 the external ear and coating the mastoid bone was somewhat oedematous. (This 
 was the site of the incision down to the bone, an incision that was kept open 
 by tents.) 
 
 Description of the emporal bone : 
 
 Mastoid. There are two discolored spots on a line running outward from the 
 meatus auditorius externus. 
 
 Petrous portion. Just in front of the elevation made by the semicircular 
 canals the bone is exceedingly soft. In washing it was broken down, and the 
 whole structure here, or the roof of the tympanic cavity, is found to be in a 
 state of ulceration. An opening through the squamous portion of the bone, or 
 in the temporal fossa would be about on a" line with this ulcerated point. 
 
 Lateral sinus. The bony wall of this venous canal is discolored, thinned, 
 and softened throughout about one-half its extent. 
 
 Tympanic cavity. The ossicula are intact,, but the whole of the rnerabrana 
 tympani is gone. 
 
 We are all familiar with cases of meningitis resulting from 
 disease of the middle ear of long standing, but cases of this 
 kind following acute aural disease are fortunately more rare. 
 Indeed, we generally expect to subdue an acute inflammation of 
 the ear, if we are able to treat it antiphlogistically within a few 
 days of the outbreak of the disease. Nowhere does rational 
 therapeutics avail more than in acute affections of the ear. In 
 this case there was never a discharge from the ear, according to 
 the patient's statement, until a few hours before I saw him. 
 The affection began as an acute otitis media catarrhalis, with 
 impaction of cerumen, which the patient, until corrected by Dr. 
 Prescott, thought was a facial neuralgia a not uncommon, but 
 dangerous error. It ran a violent course, as is shown by the 
 bloody discharge and great pain. 
 
 The purulent process in the middle ear extended to the tissues 
 of the roof of the tympanic cavity, and to the labyrinth and to 
 the membranes of the brain, where the hypersemia soon became 
 an exudative inflammation of the base, extending very slowly 
 to the upper surface, and consequently leaving the intellect un- 
 impaired for a long time. The disease of the bone went on 
 slowly at the same time. The pyaemic symptoms are explained 
 by the disease of the lateral sinus. The circumstances of the 
 patient for he lived in a crowded boarding-house were not 
 favorable to the quiet that should always be secured for a pa- 
 tient with cerebral hyperaemia, and I fear that I did not lay
 
 MENINGITIS. 
 
 315 
 
 stress enough upon this requisite in the first few days. My sus- 
 picions as to cerebral hypersemia were somewhat lulled, how- 
 ever, during the first forty-eight hours, by the fact that the pain 
 in the ear nearly entirely disappeared from the first application 
 of the leeches. The only part of the case that now seems ob- 
 scure to me, and in this opinion Dr. Fisher agrees, is the reduc- 
 tion of the temperature, and the great improvement in the gen- 
 eral condition immediately after the use of the large doses of 
 quinine. We gave quinine, as has been intimated, on the 
 shadow of a hope that we were dealing with a severe case of 
 
 FIG. 82. Showing Disease of Bone in Case of Meningitis following Acute Suppuration of 
 the Middle Ear. a, Caries in front of elevation for semicircular canals ; 6, caries of lateral 
 sinus ; c, meatus auditorius internus. 
 
 malarial fever, instead of one of abscess of the brain or inflam- 
 mation of the meninges. With a diagnosis of either of the 
 latter-named, we had simply to sit down with folded arms and 
 await the dissolution of the patient. The reduction of the tem- 
 perature immediately followed the administration of the quinine, 
 and each day, as it showed a disposition to rise, the same rem- 
 edy seemed to lower it, until the septica?mic pains set in, when 
 it utterly failed. Indeed, so well was the patient for about a 
 week, that Dr. Fisher and I were inclined to change our original 
 diagnosis. Such a lull in the symptoms of cerebral disease re-
 
 316 MENINGITIS FROM AURAL DISEASE. 
 
 suiting from an inflammation of the ear, is, however, not with- 
 out precedent. 
 
 There was always an unbroken bone between the ulcerated 
 tympanic cavity and the membranes of the brain, so that the 
 fatal inflammation must have extended through some of the 
 small foramina, which abound in the temporal bone. This is no 
 new pathological observation, since it has long been known, al- 
 though not always remembered, that we may have meningitis 
 as an extension of aural disease without the occurrence of 
 caries. 
 
 Another case of this unfortunate series was reported by Dr. 
 C. S. Merrill,' of Albany, N. Y. Death occurred on the fourth 
 day after the origin of the acute inflammation of the middle ear. 
 
 The patient was a book-keeper, temperate and regular in his habits of life. 
 He had always been well, but for two or three weeks he had been a little debili- 
 tated from overwork. On November 7, 1877, he noticed for the first time a ful- 
 ness in his right ear. He consulted his family physician, who sent him to Dr. 
 Merrill. The membrana tympaui was found congested, and the hearing on that 
 side impaired. The ear was inflated by Politzer's method, and the family phy- 
 sician was advised to apply two leeches to the ear. Dr. Merrill did not see the 
 case again for two days, when Dr. Bigelow sent for him. It was then stated that 
 the leeching had entirely relieved the condition, so that all feelings of fulness 
 passed away, and the hearing became normal. The patient, contrary to Dr. 
 Bigelow's advice, resumed his office duties. But on the 9th, at 5 o'clock in the 
 morning he was attacked with severe pain, and Dr. Bigelow was sent for on the 
 next day at noon and found the pulse 160, temperature 103|, respiration 28. 
 The patient was delirious. The membrana tympani was bulging and greatly 
 inflamed. A free incision of the membrane, which was thick and resisting, 
 evacuated a large amount of pus. The next day the local inflammation had 
 greatly subsided, but coma supervened, and death occurred four days from the 
 first manifestation of aural symptoms. The post-mortem examination showed 
 meningitis. " Pus was found over the region of the petrous bone." There was 
 perforation through the roof of the middle ear, and underneath the dura mater 
 and covering the surface of the brain there were a few drops of greenish-colored 
 pus. The bone was perforated by two or three small openings. There was no 
 evidence of inflammation of the internal ear. 
 
 Dr. Merrill remarks : "The fatal termination of the case was 
 evidently due to the direct extension of the inflammation to the 
 membranes of the brain through the roof of the middle ear, 
 which in this patient was cribriform in appearance." 
 
 I also saw, in consultation with Dr. Loring, a case in which 
 death from meningitis occurred after a few days of symptoms of 
 acute inflammation of the middle ear. This patient, however, 
 Jiad had sub-acute catarrh of the middle ear at various times dur- 
 
 1 Transactions of the American Otological Society, vol. iii., p. 29. 1882
 
 MENINGITIS. 317 
 
 ing the two years preceding the attack which terminated fatally. 
 It was not a suppurative case. Dr. Welch, who made the post- 
 mortem examination, regarded it as a croupous inflammation 
 of the middle ear. I was present when Dr. Loring made a large 
 free opening in the membrana tympani, and found that it con- 
 tained no secretion. The dura mater was normal except in one 
 situation. That over the roof of the tympanic cavity and the 
 adjacent portion of bone, was very much congested and showed 
 " numerous small red points, which represent punctate hemor- 
 rhages." The roof of the tympanic cavity was found extremely 
 thin and translucent, but "it was not carious. The mucous 
 membrane of the middle ear was found swelled, softened, of a 
 bluish-red color, and coated in many places with a reddish-gray 
 opaque false membrane, averaging about one millimetre in thick- 
 ness. Punctate ecchymoses can be seen in the swollen mucous 
 membrane, but there were no coagula of blood in the cavity of 
 the tympanum." The swelling and exudation were most marked 
 on the membrane of the roof of the tympanum, on the promon- 
 tory and entrance of the Eustachian tube. There was also exu- 
 dation in the osseous portion of the tube. The ossicles were 
 movable, the labyrinth and auditory nerve were sound. There 
 was no fibrinous exudation in the pharynx, fauces, or air-pas- 
 sages. After a microscopical examination Dr. Welch, gave as 
 his opinion that the case had been one of otitis media crouposa 
 with consecutive septo-meningitis. The ' ' consecutive " was prob- 
 ably placed somewhat in doubt, because at the post-mortem ex- 
 amination it was not easy to trace the starting-point of the men- 
 ingitis of the convexity of the brain from the right middle ear. 
 The yellowish sero-purulent exudation in the sub-arachnoid 
 space and meshes of the pia mater covering the convexity of 
 the cerebral hemispheres, " was rather more abundant upon the 
 left than the right side." ' 
 
 Added to these exceptional cases of death from acute inflam- 
 mation of the middle ear, is that of a young man, who was 
 attended by my associate in private practice, Dr. Edward T. Ely, 
 with whom I saw the patient in consultation, who died in a few 
 days from consecutive meningitis, without rupture of the mem- 
 brana tympani. His first symptoms were from the ear, and 
 there were objective appearances of acute inflammation of the 
 middle ear. Symptoms of meningeal hypersemia were very early 
 in appearance, and in spite of active treatment he soon died in a 
 comatose state. No post-mortem examination was made. 
 
 The reader will observe that the thinness of the bone forming 
 
 American Journal of Otology, vol. iii., p. 126.
 
 318 ACUTE SUPPURATION TREATMENT. 
 
 the roof of the tympanic cavity was marked in two of the fore- 
 going cases. As has been pointed out by all the recent writers 
 on aural surgery, this anomaly is not uncommon, and where it 
 does exist, it must cause a peculiar susceptibility to consecutive 
 meningitis from disease of the middle ear. Since we can never 
 know beforehand in which cases this anomaly is found, and while 
 we do know, that in young children the bone is always thin and 
 porous, we may on reflection realize the possible serious char- 
 acter of any case of acute disease of the middle ear. 
 
 I can add another case of death from acute suppuration of the 
 middle ear, which occurred in my practice at the Manhattan Eye 
 and Ear Hospital. In this case, however, the rational treatment 
 was undertaken some days after the disease had fully set in, 
 and it is also altogether likely that the fatal termination was 
 hastened by the patient's bad habits. I first saw the young man, 
 who was the victim in this case, when he was pale and haggard 
 from pain and sleeplessness. The drum-head was bulging. I 
 punctured it and evacuated considerable pus. This gave great 
 relief, as he told me two days later, when he again appeared at 
 the clinic. His whole aspect was much better, and he told me 
 that he had slept well for two nights. He died in a few days, 
 just after a drunken debauch. The physician who saw him 
 informed me that he died from meningitis, consecutive to the 
 aural trouble, but I was not able to get an exact account of the 
 lesions, although the death was investigated by the Coroner, 
 and an attempt was made by some of the patient's friends to 
 prove that his death was caused by the operation (paracentesis 
 of the drum-head), which secured him the first sleep he had had 
 for some days. The most appalling evidence was given to show 
 that the "Doctors murdered him by running an instrument into 
 his brain." l 
 
 Treatment. The moral of the foregoing is plainly to be read. 
 An acute catarrh or suppuration of the middle ear should never 
 be lightly estimated. A case seen early in its course will usu- 
 ally prove very tractable and respond readily to treatment, but 
 if left to itself it may be a 'serious case. The first step in the 
 treatment is to insure quiet and freedom from care for the pa- 
 tient, if an adult. Patients with acute suppuration should usu- 
 ally be confined to their rooms. If adults, absolute freedom 
 from business or domestic employment should be insisted upon. 
 
 1 The medico-legal reader, may possibly be interested in the verdict given by the 
 Coroner's jury in this case. The following is a copy of it: "We the jury come to the 
 
 conclusion that came to his death by a rupture of the blood-vessels of the small 
 
 brain or with some instruments used by doctors unknown to the jury."
 
 ACUTE SUPPUEATION TREATMENT. 319 
 
 Each case should be watched as forming a possible starting- 
 point for cerebral meningitis. In the large majority of cases 
 such a deplorable consequence will not occur, but it would, I 
 think, be much less frequently observed, were each patient with 
 acute suppuration carefully guarded from the exciting causes 
 of cerebral hypersemia, from the beginning of the aural disease 
 until he is fairly convalescing. The room, or ward in which 
 such a patient is, should be kept free from visitors, prolonged 
 conversation, bright light, noise should not be allowed, and an 
 attempt should be made to secure physical and mental quiet. 
 To underrate the gravity of an acute suppuration, or even an 
 acute catarrh of the middle ear, is to invite peril to life. 
 
 I have seen at least two cases where, I believe, the life was 
 lost, because the patients insisted that a painful ear and a ten- 
 der mastoid process, were not sufficient causes to keep them 
 away from business and from active social life. 
 
 If the case be seen in the earlier stages that is, when the 
 pain is still present, and the membrana tympani is intact two 
 or more leeches should be at once applied, and if the appearance 
 of the membrana tympani indicate that it is about to rupture, 
 or if the pain be not quickly subdued by the use of the leeches, 
 a paracentesis of the membrana tympani should be at once per- 
 formed in the most bulging portion of the membrane. If the 
 mastoid be red, tender, and swelled, it should be poulticed thor- 
 oughly and well, and if relief be not apparent in twelve hours, 
 it should be incised down to the bone, except in the case of 
 young children, where the more yielding nature of the integu- 
 ment and the periosteum will admit of some delay. If the mas- 
 toid process be simply red and tender, but not swelled, the use 
 of leeches and poultices will probably subdue the inflammation 
 without an incision. 
 
 The ear should be douched very often, say every half hour, 
 with lukewarm or hot water, by means of a fountain syringe or 
 the Fayette douche, the temperature of the water being deter- 
 mined by the patient's feelings. This procedure the patient will 
 usually find very grateful. In case of the absence of a douche, 
 warm water may be dropped into the ear from the sponge, a 
 procedure as old as the time of Hippocrates. A douche may be 
 extemporized by the syphon arrangement of a bit of rubber 
 tubing in any kind of a vessel that will contain water. At the 
 same time, especially if the weather be cold, the patient should 
 be kept in his room, and perhaps in bed, while pediluvia and 
 diaphoretics are employed. 
 
 If the membrana tympani have ruptured, the pus should be 
 removed at least twice a day, by careful but thorough syringing.
 
 320 ACUTE SUPPURATION TREATMENT. 
 
 The quantity of pus discharged is sometimes enormous. At 
 the same time, Politzers method of inflating the ear should 
 be practised. This latter procedure gives no pain when care- 
 fully done, i.e., when the bulb is not too vigorously pressed. It 
 at once improves the hearing, helps to cleanse the ear, and pre- 
 vents the formation of adhesions in the cavity of the tym- 
 panum, and gives the patient hope and confidence. 
 
 The throat should be kept free of secretion by a gargle. The 
 chlorate of potash in a saturated solution is the one I usually 
 use. In cases of scarlet fever, the pharynx will require the 
 most careful and energetic treatment. The neck should be 
 kept warm by poultices, and the pharynx be very often cleansed 
 by the use of a nebulizer, chlorate of potash in powder placed 
 upon the tongue, and so forth. Dr. Sexton has found great 
 relief in tonsillitis from the use of the warm douche upon the 
 pharynx, by means of Davidson's syringe, or rubber tubing- 
 attached to a water-faucet, and I have confirmed this experi- 
 ence. 
 
 Relapses of pain should be combated by leeches, warm water, 
 and the internal administration of opium, or morphia, chloral, 
 and bromide of sodium combined ; but opium has very little 
 power in subduing the pain from acute aural suppuration, if 
 used without the local treatment. The administration of calo- 
 mel or other mercurials, the application of blisters, will not be 
 required. The former kind of treatment is useless, while the 
 latter aggravates the suffering of the patient. Blisters are more 
 applicable to chronic aural disease, but in the absence of leeches 
 they are useful. 
 
 If the case go on well, a physician who does not see much 
 of this form of disease, will be astonished at the rapidity with 
 which the suppuration is checked, and the membrana tympani 
 restored. The impairment of hearing will be the last symptom 
 to be fully relieved. The hearing power should be often accu- 
 rately tested by the watch and tuning-fork in the course of the 
 disease, in order that if possible we may not dismiss the patient 
 until the cure is complete. 
 
 The astringent that I usually use in acute suppuration is a 
 solution of sulphate of zinc, which is poured into the ear once or 
 twice a day, after syringing. The solution should be previously 
 warmed. Should the suppuration continue unduly, the nitrate 
 of silver may be applied in strong solutions, say from forty to 
 eighty grains to the ounce. This solution is brushed over the 
 drum-head and in the edges of the perforation. In some cases 
 it may be necessary to drop the solution into the ear, afterward 
 neutralizing it by syringing with a warm solution of salt and
 
 ACUTE SUPPURATION TREATMENT. 321 
 
 water. Indeed, it should be said once for all, that, except in very 
 rare and exceptional cases, cold fluids should not be dropped 
 into the ear. 
 
 I do not begin the use of astringents in the treatment of acute 
 suppuration, until I have assured myself by careful trial, that 
 the cleansing of the ear is not of itself sufficient to cause the 
 purulent discharge to cease. In many cases I never have occa- 
 sion to use an astringent, but the curative influence of nature, 
 impediments to her action being removed, proves to be sufficient. 
 Dr. Ely, who was for years associated with me, both in private 
 and public practice, called attention to this subject, 1 and pub- 
 lished some cases from our practice which I here insert as being 
 of great illustrative value in discussing this subject. 
 
 Dr. Ely remarks that " great labor has been required to lead 
 physicians and laymen to consider acute suppuration of the 
 middle ear as of any importance, and it is natural that many 
 practitioners having thus been laboriously awakened to its im- 
 portance should hold exaggerated ideas as to the remedies re- 
 quired for its cure." 
 
 CASES OF ACUTE SUPPURATION OF THE MIDDLE EAR TREATED WITH- 
 
 OUT ASTRINGENTS. 
 
 Case in which the Use of an Astringent aggravated the Symptoms. 
 
 Miss H , aged twenty, consulted me November 30, 1877, with acute sup- 
 puration of her left middle ear of ten days' duration. There was a free discharge 
 of pus, and no pain or swelling. I ordered syringing of the ear, and the instilla- 
 tion of a two-grain solution of sulphate of zinc twice daily. Immediately after 
 using the zinc-drops she began to have violent pain in the ear. This pain con- 
 tinued all night, and, when I saw her the next day, the auditory canal was so 
 swollen that the drum could not be seen ; the whole of that side of the face was 
 swollen and tender, and there was congestion and pain in the eyeball. There 
 was a temperature of 101 and some vertigo. Leeches, hot water, morphine, 
 and rest in bed were prescribed. The pain, swelling, and vertigo did not dis- 
 appear until the evening of December 4th. I always attributed this attack to 
 the effect of the zinc, although I have no further proof of the fact than the 
 patient's own belief of it, and the history of the case. 
 
 Cases in which no Astringents were Used. 
 
 I. Susie M , aged six, came on November llth with a history of pain in 
 
 her left ear from 6 o'clock until 11 of the previous evening. The drum-head 
 was found congested and ruptured, and there was a purulent discharge. Syr- 
 inging of the ear with warm water twice a day was ordered. On the 14th 
 there was no discharge, and the perforation seemed to be healing ; the syringing 
 was discontinued. On the 16th the perforation had healed and the hearing was 
 
 1 Archives of Otology, vol. viii., p. 178. 
 21
 
 322 ACUTE SUPPUKATION TREATMENT. 
 
 fully restored. II. Miss J. H , aged twenty-one, came on March llth, hav- 
 ing had severe pain in her left ear since 3 A.M. The drum-head was found rup- 
 tured, and there was purulent discharge. The hearing on that side was -&. 
 Leeches and the hot douche were ordered, and they seemed to arrest the pain 
 at once. After that, the ear was simply syringed occasionally with warm water. 
 On the 13th the perforation was nearly closed. On the 18th it was completely 
 
 healed, and the hearing was 1"-. III. Mrs. M , aged thirty-five, came on 
 
 March 17th, saying that she had had a cold in her head for the past week ; that 
 two or three days ago, while blowing her nose, she had felt a "cracking" in her 
 right ear, and that since then there had been a discharge from the ear. Before 
 this trouble the drum-head on that side was cicatricial from a suppuration in 
 childhood. A large perforation was found in the posterior part of the drum- 
 head, with a muco-purulent discharge. The hearing was -&. Syringing with 
 warm water, two or three times a day, was ordered. On March 19th the perfo- 
 ration was much smaller; the discharge was still abundant. On March 20th 
 there was no discharge. The next day her cold became worse, and she had 
 some fever. The following three days she had throbbing and tinnitus in the 
 right ear with reappearance of the discharge ; also had some vertigo. Was 
 taking quinine during this time. On the 25th the discharge had ceased, and a 
 
 few days later the perforation was healed. Hearing -&. IV. Mr.W , aged 
 
 forty, came on February 24th with a broken drum-head and acute suppuration, 
 in the right middle' ear. The discharge had appeared on the 19th, after eight 
 hours of pain in the ear. Syringing with warm water was prescribed. On 
 February 27th, the discharge was found to be less. On March 2d, the discharge 
 had ceased and the perforation was veiy small. A few days later, the drum-head 
 
 was found to be healed and the hearing restored. V. Master L , aged five, 
 
 came June 17th with a history of earaches, both sides, for the previous four 
 weeks. An examination showed perforation of both drum-heads and acute sup- 
 puration of the middle ears. No treatment was employed except syringing with 
 
 warm water. The patient made a perfect recovery. VI. Master F , aged 
 
 fourteen, came on April 7th with acute suppuration of the left middle ear. The 
 use of the warm douche was prescribed. On April 17th the ear was doing well, 
 and the hearing was 40- A few days after this the patient was cured. 
 
 In this case and the preceding one the exact date of recovery 
 was, unfortunately, not recorded. 
 
 VII. Miss M , aged eighteen, came on December 14th with acute sup- 
 puration of the right middle ear, of a few days' duration. She had already had 
 a chronic suppuration of that ear, following measles, which had been checked, 
 without restoration of the dram-head. Warm syringing was prescribed. On 
 
 January 14th the discharge was found to have ceased. VIII. Master V , 
 
 aged sixteen, came on June 20th with an acute suppuration of the left middle 
 ear. The discharge, which was very bloody, had been noticed by the patient a 
 day or two previously, after a night of very severe pain in the ear. There had 
 already been marked deafness on both sides, from chronic catarrh, for many 
 years. The only treatment prescribed was syringing of the ear with warm 
 water two or three times a day. On June 27th the drum-head was found to be 
 healed. There had been no discharge for several days.
 
 ACUTE SUPPURATION TREATMENT. 323 
 
 The local treatment in all these cases, consisted simply in 
 syringing the ear with warm water as often as seemed advis- 
 able. Of course, the throat and the general health received 
 attention when it seemed to be required. 
 
 Criticisms upon Local Antiphlogistic Treatment in Aural 
 
 Disease. 
 
 Papers have been written, containing elaborate arguments 
 against the use of leeches, Wilde's incision down to the perios- 
 teum of the mastoid, and other active forms of treatment of 
 acute aural disease, as if the writers who advised these means 
 in cases of necessity, always found them necessary. The crit- 
 icisms upon active treatment in acute aural disease have not 
 always been discriminate, for they have sometimes assumed 
 that the modern writers advised the use of the leeches and the 
 knife in all cases, and that they prescribed a routine treatment 
 without using their judgment as to each individual case. I am 
 of the opinion that the use of leeches, paracentesis of the drum- 
 head, and incision of the mastoid, have all the importance that 
 has been ascribed to them by modern otologists, yet I have 
 never failed to counsel circumspection in the prescription of 
 active means of treatment. I have as yet found no means of 
 internal treatment, that will supersede active antiphlogistic 
 means, such as leeching and incisions of the membrana tym- 
 pani in severe cases of acute disease of the middle ear. There 
 are many mild cases, however, even of this form of diseases, 
 or cases of an asthenic type. In these the surgeon will soon 
 find that a quiet room, the warm douche, diaphoresis, and so 
 forth, will often be sufficient with no more active means. As 
 an example of cases of acute aural disease which require 
 constitutional rather than local treatment, even when local 
 symptoms are markedly manifest, the following case heretofore 
 published l is inserted. It is a striking example of a neurotic, 
 rather than an inflammatory case, a variety which the physician 
 should always be on the look-out for, among hysterical women 
 and overworked men. 
 
 Acute Inflammation of the Middle Ear, with Inflammation of the Muscles of the Neck, 
 and Facial Paralysis of the Same Side. 
 
 May 5, 1879. Dr. S , aged forty-five, a busy surgeon and medical jour- 
 nalist, consulted me in regard to uncomfortable and painful sensations in his 
 right ear. He was somewhat anaemic, jaded from overwork, and he had an 
 anxious appearance. He described the pain as extending from the right Eus- 
 
 1 Archives of Otology, vol. viii., p. 255.
 
 324 NEUROSIS OF MIDDLE EAR. 
 
 tachian tube to the drum, laying great stress upon the pain along the tube. 
 The drum-head was red, the auditory, canal normal. There was nothing marked 
 about the pharynx. The hearing distance was not noted. Leeches were or- 
 dered to be applied to the tragus. I afterward learned that he had slight nasal 
 catarrh and headache with pain in right lower jaw, on May 4th. The next day 
 I received a note from the patient stating that he did not feel able, on account 
 of the pain, to come to my office, which was a very short distance from his. I 
 found him in bed and apparently suffering very much. He complained of a 
 pain like that from neuralgia, extending over the right side of the scalp, face, 
 neck, the right auditory canal, and the Eustachian tube. Leeches and the hot 
 douche were prescribed. The patient then told me that he had suffered very 
 severely a few weeks before from facial neuralgia ; that he then had no aural 
 trouble ; that he had had very lately an inflammation of the muscles of the op- 
 posite side of the neck. The membrana tympani was vascular, but not bulging. 
 Knowing that this patient had been very much overworked, with an insufficient 
 quantity of fresh air, and seeing that he was pale and hyper-sensitive, I con- 
 sidered the pain as out of proportion to the objective symptoms of inflamma- 
 tion, and I therefore made a diagnosis of non-suppurative inflammation of the 
 middle ear, with neuralgia of the fifth nerve. In other words, I believed that 
 the otalgic symptoms predominated over those of true inflammation. Warm 
 applications behind and over the ear were advised, as well as the use of the 
 hot douche. The hot douche was not well borne, nor was there much relief, 
 except at short intervals, from these measures. It should also be said that I 
 laid great stress upon maintaining the nutrition, and a generous diet was in- 
 sisted upon. On the fourth or fifth day the auditory canal was somewhat 
 swelled, but not tender. I incised the drum-head, but no pus or mucus was 
 evacuated. The hot douche was now freely used and afforded relief. A very 
 moderate suppuration occurred in the tympanic cavity. Morphia was adminis- 
 tered, pro re nata. The patient sat sometimes out of bed, but did only tolerably 
 well, complaining at intervals of veiy severe neuralgic pain which was relieved 
 by morphia. He took nourishment badly, except in the intervals of freedom 
 from pain. He was very much depressed in spirits. There was no tenderness 
 or any other inflammatory symptoms on the mastoid or in the pre-auricular 
 region. On May 15th ten days after I first saw the patient I went out of town 
 to fill a professional engagement, and my associate, Dr. E. T. Ely, took charge 
 of the case until May 25th, and his notes are as follows : 
 
 "Dr. S seems to be a case of acute suppuration of the middle ear, with 
 
 considerable swelling of the auditory canal ; slight discharge ; no pain. 
 
 "May 16th. More pain and swelling; no discharge. 
 
 "May 17th. Severe pain in whole right side of face and head and in the ear, 
 not controlled by douche ; no discharge ; funnel-shaped swelling of the canal, 
 not very tender. Consultation with Dr. A. H. Buck. It was decided to incise 
 the canal and reopen the drum-head. This was done under ether. The open- 
 ing in the drum-head was very free, and the canal was incised from the bottom 
 to the entrance. Three leeches were then applied to the tragus and one to the 
 mastoid. Hot douche was continued. No pus followed these incisions. 
 
 "May 18th. Pain most of last night. A little easier this morning. Dis- 
 charge of pus beginning. 
 
 "May 19th. Comfortable until evening, then great pain in ear and head; 
 temperature, 101^ ; three leeches to mastoid ; douche ; morphia.
 
 NEUROSIS OF MIDDLE EAR. 325 
 
 "May 20th. Not much pain ; weak and depressed. A.M.: Temperature, 98 ; 
 pulse, 88 ; P.M. : temperature, 100^ ; pulse, 88. Slept most of the day. 
 
 "May22d. No fever yesterday or to-day; one attack of severe pain last 
 night ; canal red and swollen ; free discharge since incision ; four leeches ap- 
 plied, and hot douchfe, for twenty minutes every two hours. 
 
 " May 24th. Pain part of every day, no fever; severe pain last evening qui- 
 eted by morphia ; slight mastoid tenderness and oadema last evening and this 
 morning ; less swelling in canal. Dr. Buck was again called in consultation ; he 
 advised opening the mastoid by trephining. Dr. C. R. Agnew was called in the 
 afternoon. He considered the case a typical one of mastoid disease of prolifer- 
 ous nature, but that no suppuration was going on there. He thought the dis- 
 ease was chiefly in the mastoid from the outset, and that there was meningeal 
 congestion. By the ophthalmoscope the veins in the right fundus seemed a 
 little fuller to Dr. A. and to Dr. Ely than in left. 
 
 May 25th. Very slight oadema and some tenderness over mastoid, and al- 
 though only one dose of the iodide of potassium prescribed the day before was 
 taken, iodism was produced. Patient was awake all night from sneezing, and 
 had some pain in the other ear. He is nervous and hysterical, buries his head 
 in the bedclothes, and refuses to be comforted. He expresses the belief that he 
 will not recover. On this date I met a gentleman with very large aural experience, 
 and we went over the case very carefully. The patient seemed to be suffering very 
 much, and he located the seat of his pain by spreading out his hands like a fan 
 over the right side of the head. The tenderness about the ear was not very great, 
 and was found in the neck and occiput as well. The ear was discharging freely 
 with healthy pus. The mastoid was so slightly cedematous that I thought its 
 condition might be due to the leeches and other applications. It did not seem 
 to me to be a case of mastoid periostitis, nor did I think there was any meningitis 
 or cerebral disease. Although I did not feel so sure of the former point as of the 
 latter, I still thought the pain was neuralgic rather than inflammatory. Inasmuch, 
 however, as Dr. Agnew had on the day before given the opinion that the mastoid 
 was markedly involved, and that there was a meningeal hyperaernia, and as the 
 gentleman now in consultation was much more decided in the opinion that the 
 mastoid was the point of the origin of the pain, and moreover, since my own 
 judgment was a little doubtful and wavering, I advised that a Wilde's incision 
 be made at once. If this incision failed to detect disease of the bone, I resolved 
 to take no further operative steps at this time, although the gentleman in con- 
 sultation afterward stated to me, that he considered this but a step in the right 
 direction, he believing that the bone should be opened, and that even if no pus 
 were found, the bone-fistula would do no harm. The incision was accordingly 
 made ; no disease of the bone was found. The wound was dressed to the bot- 
 tom with lint, and a poultice was applied. 
 
 May 28th. The pains in the head and neck are not at all relieved except 
 when morphia is used in full doses. The tissiies of the mastoid, pre-auricular 
 region, and neck were red, swelled, and tender at various points. These symp- 
 toms have increased since the incision. The depression of spirits continues, but 
 at times the patient can be made quite cheerful by light conversation, and after 
 a dose of morphia. He is taking a moderate amount of stimulants, and milk 
 quite freely. Dr. William A. Hammond was called in consultation ; his opinion 
 was that there was no disease in the cranium*, and that the pain was due to neu- 
 ralgia largely modified by malaria. He advised that 60 grs. of quinine be given.
 
 326 NEUEOSIS OF MIDDLE EAE. 
 
 in twenty-four hours, for two days, and that this treatment be followed up by 
 small doses of arsenic. This treatment was followed by an apparent alteration 
 of the pain, and not so much morphia was needed. 
 
 On June 3d the muscles of the neck were so much swelled that we pronounced 
 them in a state of inflammation, and leeches were applied. The arsenic and 
 generous diet, as far as patient would take it, with moderate doses of alcohol, 
 were continued. The neck was especially tender where nerves made their exit. 
 There was no especial tenderness on the rnastoid; the patient could scarcely 
 move his head from side to side. 
 
 June 7th. The conjunctiva and outside of lids of right eye are reddened; 
 the ability to close the right eye is impaired. 
 
 June 8th. Conjunctiva and lids less red than yesterday. Slight enlargement 
 of gland at the angle of the jaw on right side. Severe pain in the jaw and mas- 
 toid region. Morphine was freely administered hypodermically for its relief. 
 A poultice was kept on the side of the face and the head. Temperature, 101| ; 
 pulse, 100. 
 
 June 9th. Swelling at the angle of the jaw increased ; pain severe, and facial 
 paralysis on the right side well marked. The right lid does not completely close 
 in winking. The right side of the face appears rounder and fuller than the left, 
 and the mouth is slightly drawn toward the left. The tongue protrudes in a 
 direct line, and there is no deviation in the uvula. There is apparently no dis- 
 turbance of the sense of smell. Temperature, 99| ; pulse, 94. Two leeches 
 were applied behind the ear. P.M.: Severe pain; 1H. x. of Magendie's solution 
 every three hours (hypodermically). 
 
 June 10th. A.M.: Temperature, 98i ; pulse, 100. Slept well; took about 
 one quart of milk during the night. Facial paralysis increased. Ophthalmo- 
 scopic examination by Dr. Eoosa. The appearance of the fundus is the same in 
 both eyes, and nothing abnormal is seen in either. The ear discharges freely. 
 P.M.: Longer intervals of freedom from pain. No morphine since the 8th at 
 9 P.M. 
 
 June llth. A.M. : Temperature, 99|. Swelling at the angle of the jaw dimin- 
 ished. No pain since June 10th at 9 P.M. P.M. : Pain recurs ; not so severe. 
 Chloral and bromide of sodium are given for its relief. 
 
 June 12th. A.M.: Patient slept badly. Pain returned in the old regions, the 
 jaw, behind the ear, and over the right side of the head. Temperature, 98| ; 
 pulse, 94. Patient very much depressed in spirits. Morphia again administered. 
 At 5 *P.M. a consultation was held, at which were present Dr. Alfred L. Loomis, 
 Dr. Henry B. Sands, Dr. Charles E. Briddon, Dr. W. M. Carpenter, and the 
 attending physician, Dr. Eoosa. After Dr. Eoosa's statement that the pus was 
 freely discharging from the auditory canal, and that, in his opinion, there was 
 no retained pus in the bone, without claiming to decide the strictly aural points 
 of the case positively, the conclusion was reached by the consulting surgeons 
 and physicians that the patient had no symptoms of intra-cranial trouble ; that 
 there was no indication for operative interference with reference to the mastoid 
 process, or suppuration in any part of the neck ; that supporting treatment was 
 demanded. On the suggestion of Dr. Loomis the stimulant he was receiving 
 was increased to 1^ oz. of whiskey every three hours, and pushed to 2 ozs. as soon 
 as it became evident that it did not disagree with his stomach. 
 
 June 13th. Patient feels very comfortable ; has slept well ; is taking 2 ozs. of 
 whiskey in a tumbler of milk every three hours, and has not experienced the
 
 NEUROSIS OF MIDDLE EAE. 327 
 
 slightest intoxicating effect. Takes nourishment aside from the milk. Temper- 
 ature, 99 in the morning, 98| 6 P.M. ; pulse, between 96 and 100. Patient also 
 takes citrate of iron and quinine. A 8 P.M. patient again complains of severe 
 pain. Morphia administered at 9.30 P.M. 
 
 At 3 A.M. on June 14th he was seen by Dr. Ely on account of great pain. 
 Morphia was given at that time and one hour later. At 8 o'clock the pain was 
 still unrelieved, and the swelling about the angle of the jaw and the mastoid 
 process was very much increased. Morphia was freely administered p. r. n., and 
 a consultation was held at 1.30 P.M., at which three aural surgeons and one gen- 
 eral surgeon were present. The following opinions were given : Dr. , an 
 
 otologist, saw no indication for operative procedure, while he believed there was 
 mastoid disease. Dr. , also an otologist, believed that the patient was suffer- 
 ing from mastoid disease, and that trephining should be performed at once. 
 
 Dr. , aural surgeon, thought there was no serious internal trouble, that it 
 
 was external, and that the patient was probably suffering from some kind of 
 poisoning malarial? sewer gas? that no operation was advisable. The general 
 surgeon thought that pus would be found somewhere about the stylo-mastoid 
 process, and he thought that nature would relieve the patient by suppuration. 
 He laid great stress on the continued application of poultices, and he was not in 
 favor of operative interference to-day. Dr. Roosa adhered to his original opinion, 
 that the patient had a moderate inflammation of the middle ear, with great neu- 
 ralgic pain, and that the swelling of the neck and facial paralysis may have been 
 caused by the operative procedures already undertaken, and that trephining was 
 not justifiable, but that it would be injurious. It was decided to continue the 
 alcohol and to make the application of poultices very thoroughly over the neck 
 and mastoid. 
 
 An examination of the urine on June 15th gave the following result : Dark 
 straw-color, acid, sp. gr. 1024, albumen in moderate quantity, casts 2, slightly 
 granular, uric acid a little, pus a little, mucus a fair amount, oxalate of lime 
 a little. 
 
 June loth. The ear is suppurating moderately. The drum-head is gran- 
 ular, canal moderately swelled, ear easily inflated by Politzer's method. The 
 swelling in the course of the sterno-cleido-mastoid muscle, and about the neck, 
 seems to be increased, but the tenderness is. not so marked. The symptoms 
 point to abscess forming in the connective tissue, and in the muscles of the neck, 
 and over the mastoid process. Dr. Eoosa does not think there is retained pus 
 anywhere in the head, or inside of the temporal bone. There is a particularly 
 tender point, l in. in a direction directly backward and a little downward from 
 the lobe of the ear. There is scarcely any oedema about the Wilde's incision. 
 Temperature, 99; pulse, 100. 3 P.M.: The swelling has begun to subside. Dr. 
 
 , a general surgeon who had seen the patient on the 13th, saw the patient 
 
 this afternoon, and fhinks it possible there is pus in the petrous portion of the 
 temporal bone, and that the swelling may be due to a temporary plugging up of 
 the communication with the tympanic cavity. 
 
 Dr. Eoosa thinks there may be pus in the cellular tissue, but does not think 
 that it is necessarily connected with the tympanic cavity. The treatment was 
 continued. 
 
 June 16th. Pulse, 98 ; temperature, 99. Patient slept well. Dr. Eoosa 
 opened the track of the Wilde's incision with a probe. The swelling and oedema 
 in the mastoid process and about the angle of the jaw remained the same.
 
 328 NEUROSIS OF MIDDLE EAR. 
 
 Another consultation was held during the day, at which there were present 
 two general surgeons, two otologists, and Drs. Boosa and Carpenter. One of 
 the surgeons expressed the opinion that the patient's general condition had im- 
 proved since he last saw him, but he declined to express any opinion in regard to 
 the necessity for operative interference with the ear. He believed it possible 
 that the operations already performed might have aggravated the symptoms. 
 The other general surgeon inclined toward trephining the mastoid. This should 
 certainly be done in his opinion if there is a probability that there is not a free 
 opening from the mastoid cells into the tympanic cavity, and this was a point to 
 be decided by the aural surgeons. One of the otologists thought the patient 
 better, and that no operation should be done. The other aural expert believed 
 that the bone should be opened. Dr. Boosa stated that his opinion was un- 
 changed, but that he had so much respect for the opinion of the gentleman who 
 was so decided with regard to the necessity for an operation, as well as fov that 
 of the one who was inclined toward it, that he wished for further advice before 
 he declined to open the mastoid. By agreement Dr. Bobert F. "Weir, who was 
 for some years aural surgeon to the Eye and Ear Infirmary, and who is now sur- 
 geon to two general hospitals, was invited to see the patient independently and 
 alone, at 9 o'clock this evening, without knowing any of the opinions that had 
 been expressed, until his own was formed. Dr. Weir gave the following opinion : 
 that the disease is probably an inflammation extending down the external audi- 
 tory canal, in the angle close to the point where the facial nerve passes, and that 
 it may perhaps involve the mastoid process; he is inclined to think it does not ; 
 there is no indication for surgical interference for the present. The general plan 
 of treatment was therefore continued. 
 
 June 17th. An examination of the urine made this day shows specific gravity 
 1020, and a well-marked trace of albumen. No casts. The general condition of 
 the patient is improving, and the swelling about the neck is subsiding. 
 
 June 19th. Patient is still doing well. Treatment has been continued. 
 
 The patient made a good recovery, with fair hearing distance, 4% at the last 
 note, and has been ever since actively employed in his profession. 
 
 I regret very much that the early notes of this case are not 
 more full ; yet I think they are sufficiently so to give my readers 
 a fair idea of the first symptoms. It is probable, however, that 
 the mere recital has not conveyed to the minds of those who 
 have followed it a full sense of its doubtful features. They were 
 such that, taken in connection with the patient's high profes- 
 sional position, they gave me great anxiety lest I should omit to 
 do my full surgical duty to the case. -The more recent of the 
 notes were taken stenographically by Dr. W. M. Carpenter, to 
 whom the patient was indebted for intelligent and assiduous 
 care. 
 
 The point to be settled during the course of the disease was 
 this : Is there a hidden suppurative process going, on in any 
 part of the temporal bone which causes the pain, oedema, ten- 
 derness, cellulitis, myositis, and paralysis of the facial ? My 
 answer to the question was, No. The severe paroxysmal pain
 
 NEUROSIS OF MIDDLE EAE. 329 
 
 did not arouse the suspicion in my mind that there was mastoid 
 disease, because there was absolutely no well-defined tender- 
 ness, redness, or oedema until leeches and poultices had been 
 freely applied, and not until two paracenteses of the drum-head 
 and very free incisions of the auditory canal had been made. 
 
 On May 25th, when I saw the patient after an absence of ten 
 days, there was certainly a moderate amount of oedema, and 
 this led me, although I suspected it had been caused by the 
 leeching, to advocate a Wilde's incision, especially as I then 
 thought it a harmless procedure, and two otologists, who had 
 seen the patient with Dr. Ely, thought the disease markedly in- 
 volved the mastoid, although only one of them advocated any 
 operative procedure. I now think that this incision, was a mis- 
 take, and that to it we owe the increase of the inflammatory 
 symptoms in the neck and the facial paralysis. Indeed I now 
 believe, on a calm looking over of the case, that every operative 
 interference, from my first paracentesis down to the Wilde's in- 
 cision, was unnecessary, and that the traumatism needlessly 
 aggravated the painful case. The key-note was struck in the 
 proper management of the case, in my opinion, when the sup- 
 porting, anodyne and anti-malarial treatment, by means of milk, 
 alcohol, morphia, and quinine was vigorously entered upon. 
 
 I believe, furthermore, that the disease would have been 
 more easily subdued if I had gotten the patient out of his house 
 and by the seaside, before the graver symptoms set in. This I 
 urged upon the patient and his friends, but without avail. It 
 was simply a case of sub-acute, non-suppurative inflammation 
 of the Eustachian tube and tympanic cavity, occurring in an 
 anaemic, and, consequently, neuralgic and hysterical subject. 
 That he was anaemic was not only noted by me at my first inter- 
 view, but when Dr. Loomis was called in consultation, he stated 
 that he had noticed the doctor's anaemic condition for a year. 
 
 Neuralgic he certainly was, for he had barely gotten through 
 with a severe attack of facial neuralgia when the trouble oc- 
 curred in the ear. The character of the pain during the whole 
 course of the disease was not that arising from deep-seated 
 trouble in the middle ear, but rather of a disease like neuralgia, 
 in which there is an intensity at different times, and which has 
 intervals of complete cessation. It was sometimes easy to divert 
 the patient by light conversation or an anecdote, for quite a 
 long time, and on some few occasions the use of water in the 
 hypodermic syringe was followed by as much effect as the em- 
 ployment of morphia. Now, the character of a pain caused by 
 severe inflammatory action in the tympanic cavity or mastoid 
 process is such that no physician who has seen much of it would
 
 330 NEUROSIS OF MIDDLE EAR. 
 
 attempt to alleviate it by any diversion of the patient's spirits 
 or by a placebo. Only positive means, such as local blood-let- 
 ting or division of the periosteum, will subdue this. I have long 
 since recorded my experience : that morphia alone will not mask 
 the severe pain of an acute inflammation of the middle ear. As 
 Von Troltsch aptly says, an inflammation of the tympanic cav- 
 ity is essentially a periostitis, and every surgeon knows of what 
 little avail are drugs against the pain of this disease, except 
 when it occurs as a result of the deposition of syphilitic poison. 
 It should have been said before that this patient had no syphi- 
 litic taint whatever. 
 
 I considered the patient to be nervous and hysterical, because 
 he bore his pain very badly, and because he suffered from very 
 great depression of spirits. It is not usual, in my experience, 
 for a patient suffering from acute inflammation of the middle 
 ear, to dwell very much on his prospects of recovery, or to be 
 greatly depressed about his future. He is generally taken up so 
 much with the severity of his pain as to have room for nothing 
 else. Then there was something in the history of the house in 
 which the patient lived, which I failed to impress upon some of 
 the gentlemen who saw him with me, which led me to believe, 
 as was once independently suggested by Dr. Noyes, who saw 
 him two or three times, that there was an element of blood- 
 poisoning in the case, perhaps from sewer-gas. Two members 
 of the family had suffered from acute aural disease a few 
 months before, and an examination made by competent au- 
 thority late in the course of the case, showed that there was an 
 escape of sewer-gas in the cellar. I do not know that any spe- 
 cial significance is to be attached to the presence of albumen in 
 the urine, but so far as it goes, it indicates a somewhat deteri- 
 orated general condition. In analyzing the case, I come over 
 and over again to the conviction that the operations did harm. 
 That traumatism such as the patient experienced in the para- 
 centesis, and in the very free subsequent division of the mem- 
 brana tympani, and the free incisions in the auditory canal, and 
 the cut down to the mastoid bone, might induce adenitis, myo- 
 sitis, cellulitis, and that facial paralysis might result from press- 
 ure upon the nerve as it makes its way out of the stylo-mastoid 
 foramen, I think does riot admit of a doubt. Certainly there 
 never was any evidence that the facial suffered any lesion until 
 after it had left the cranium and tympanic cavity. Besides, the 
 swelling and paralysis occurred at a point of time which makes 
 it possible to believe that traumatism may have caused them. 
 
 1 Transactions of the American Otological Society, p. 89. 1875.
 
 ACUTE SUPPURATION RESULTS. 331 
 
 But, the crucial test of the correct diagnosis was in the results 
 of the case. There was no escape of retained pus either from 
 the mastoid or from the neck. It certainly was not pus which 
 caused the serious symptoms. When they were at their height 
 the discharge from the ear went on, but gradually diminished. 
 And when the patient was fairly convalescent, and up and 
 about, the old swelling and redness of the neck reappeared for 
 several hours. Besides, it should be noted that no chill occurred 
 during the progress of the case. This fact, together with the 
 clearness of the patient's intellect, gave me great encourage- 
 ment, when I was struggling against the opinion of a valued 
 colleague, who thought the patient was dying for want of an 
 
 operation. Dr. S was relieved after large doses of quinine 
 
 at a time when the pain was intense, and when these seemed to 
 fail, he was permanently cured after the full doses of alcohol 
 advised by Dr. Loomis. 
 
 From the nature of things, the general practitioner will see 
 a great deal of acute disease of the middle ear if he be on the 
 lookout for it since it occurs so often in the course of the ex- 
 anthemata and in connection with diseases of the respiratory 
 organs. It will be seen that there is nothing in the treatment 
 of this affection that will prevent the usual care of the general 
 disease. It is a great and often fatal error to wait the subsid- 
 ence of the genera] symptoms before the aural ones are allevi- 
 ated. They are quite as important as the most urgent consti- 
 tutional disturbances. Indeed, they are often the unsuspected 
 cause of most of the latter. 
 
 It only remains to be said that the results of treatment of 
 this disease are very satisfactory. I think more than seventy- 
 five per cent, of these cases are cured, that is, the membrana 
 tympani is restored and the hearing power becomes normal. As 
 has been said in another place, the old writers on diseases of the 
 ear were not in the habit of applying accurate tests as to the 
 restoration of hearing ; so that their standard of cure is not so 
 high as that which obtains among writers of the present day. 
 Many of my cases of aural disease, that have been reported as 
 improved or much improved, would have been classed under the 
 head of cured, by the less exact standard of ancient writers. 
 Where one ear only is affected, we are apt to be led into error 
 as to the amount of deafness, unless we are careful to exclude 
 the sound ear as thoroughly as may be in our examination. 
 
 The consequences of a neglected or improperly treated aural 
 catarrh are, that it runs into a case of acute suppuration ; but 
 those of a neglected or maltreated acute suppuration are still 
 more grave, involving as they do all the perils of long-continued
 
 332 ACUTE SUPPURATION RESULTS. 
 
 suppuration in the ear. And yet, to this day, there are medical 
 men of very great general intelligence, who think lightly of such 
 a disease, and gravely advise patients not to "meddle" with it. 
 The author has been informed by a distinguished practitioner in 
 this city, that a young man was once sent to him for advice by 
 an eminent physician, after he had passed through a severe con- 
 stitutional disease in which suppuration in the middle ears had 
 occurred, for whose ears not one particle of rational advice had 
 been given, although both membranse tympani had been de- 
 stroyed, the ossicula were gone, and the mucous membrane of the 
 tympanic cavity was granular. Such neglect needs no com- 
 mentary. 
 
 Occasionally I receive a note from a general practitioner, 
 which conveys the impression to me, that it is supposed by some, 
 that peculiar means of treatment are at the service of specialists 
 which are not in the hands of the average physician, and which 
 can only be used when a disease has become well advanced. To 
 those who hold such views, I would say, the time to treat aural 
 disease is in the beginning of the attack. Aurists or surgeons 
 have no means to combat inflammation other than those at 
 the hands of every practitioner. To wait for so-called special 
 treatment is to lose important time. Besides this, there is no 
 special, mysterious treatment that can be of avail at any time, 
 no matter in what hands. It is true that we must wait for a cat- 
 aract to ripen, before it can be removed, and then only an expert 
 is competent to operate upon it. But no such condition of things 
 exists in the progress of aural disease. Delay in its manage- 
 ment will be as fatal to a cure, as is delay in the treatment of 
 glaucoma. 
 
 The course of acute suppuration occurring in the midst of 
 a severe attack of scarlatina, is apt to be violent. The symp- 
 toms follow one another with the rapidity of those of purulent 
 ophthalmia. He who wishes to preserve the integrity of the 
 organ, must be prompt and energetic in his treatment, or the 
 drum-head and the ossicula auditus will be swept away, and a 
 profuse and fetid discharge of pus be set up within forty-eight 
 or fifty-six hours. 
 
 It should also be said as supplementary to this subject, that 
 attacks of acute aural catarrh, or of acute suppuration of the 
 middle ear, are more dangerous in persons who are affected with 
 a chronic catarrh of the middle ear. This is explained by the 
 fact, that the drum membrane is so much thickened in such cases 
 that the exit of the pus or mucus by its spontaneous perforation 
 is much more difficult. A paracentesis will be much more likely 
 to be required for them, than in those occurring in persons with
 
 ACUTE SUPPURATION CASES. 333 
 
 drum membranes of normal density and tension. I may also 
 remark, that I have seen erysipelas of the face of a severe type, 
 occur in the course of acute suppuration of the middle ear. This 
 is, of course, a serious complication, but as yet I have seen no 
 fatal results from it. More will be said of this, in the chapter 
 upon "Diseases of the Mastoid." 
 
 The following cases may be said to be fairly typical, and to 
 show the ordinary course of the different forms of acute sup- 
 puration of the middle ear. 
 
 CASE I. Acute Suppuration from Scarlet Fever Loss of the Malleus of each 
 Side Reproduction of the Membrana Tympani Great Improvement in Hearing 
 
 Power. Harry , aged nine. On February 27, 1872, I was called by Dr. G. 
 
 S. Winston, to see the grandchild of a gentleman of this city, in regard to whose 
 case I had already given advice by mail and telegraph. The histoiy was as fol- 
 lows : The boy had gone back to his school, after spending the Christmas holi- 
 days at home, in quite as good health as usual ; but soon after arriving he was 
 attacked with scarlet fever, which rapidly assumed a very severe type, so that 
 his throat was inflamed and the cervical glands were swelled, and the lining 
 membrane of the middle ears was in a state of very acute inflammation. In 
 spite of prompt and energetic treatment by the physician of the school, sup- 
 puration occurred in a few hours. After the aural symptoms occurred, the dis- 
 charge of pus became profuse, so that the ears needed cleansing every half 
 hour. The malleus bone of each ear escaped in the pus, and I have them in 
 my possession. When the severest aural symptoms had subsided, astringents 
 were used in the auditory canal, and the Eustachian tubes treated by Politzer's 
 method. 
 
 As soon as the little patient's general condition would allow, he was returned 
 to his home, and in a deplorable condition. His ears were discharging thick, 
 offensive pus, in such quantities, that it was only by the greatest diligence in 
 cleansing that they could be kept clean ; the naso-pharyngeal space was secret- 
 ing muco-purulent material in great masses. The hearing power was so much 
 impaired that it was only by speaking in a distinct and loud tone, close to the 
 little fellow's ear, that he could be made to understand what was said to him. 
 
 The family and friends believed that he would become the inmate of a deaf 
 and dumb asylum. Indeed, a gentleman a friend of the family who had a 
 child that, having lost her hearing from the scarlet fever, had learned the 
 method of speech by watching the lips, came to see Harry, and urged that very 
 prompt measures should be taken to cause him to learn lip reading, inasmuch 
 as he felt certain that he would never hear sufficiently to retain his speech. I 
 at once instructed the family to converse regularly with the little patient, to 
 read aloud to him, and to urge him to continue to, talk, while the local and 
 general treatment were carried on. This they did with a remarkable faithful- 
 ness, so that the boy, hearing what was said to him, never acquired an un- 
 natural tone of voice. 
 
 On examination it was found that the membrana tympani of each side was 
 gone, and that the cavity of the tympanum was filled up with granular mucous 
 membrane. The hearing distance for the watch was & on each side. The 
 voice of a person speaking with great distinctness was heard two feet from the
 
 334 ACUTE SUPPURATION CASES. 
 
 left ear, and one from the right. Air could be forced through both Eustachian 
 tubes. The patient's general condition was fair ; but he was suffering from 
 some abdominal effusion. Dr. T. F. Cock was called in on this account, and 
 ordered the tincture of the sesquichloride of iron. The weather being cold, the 
 boy was kept in the house, and in a warm room ; while a thorough local treat- 
 ment was entered upon. The ears were syringed by some member of the family 
 every hour during the day, if necessary ; while I visited him at first twice, and 
 subsequently once a day, and cleansed the ears with the syringe and cotton- 
 holder, inflated the ears by Politzer's method, and applied a solution of nitrate of 
 silver, of the strength of forty grains to the ounce, to the cavity of the tympanum. 
 The family applied a weak solution of sulphate of zinc in the evening. The 
 naso-pharyngeal space was cleansed by the use of chlorate of potash. A weak 
 solution of Labarraque's solution of chlorinated soda was used in the water 
 employed for syringing the ear, in order to diminish the fetid odor of the pus. 
 Under this treatment the patient. steadily improved until the discharge of pus 
 had entirely ceased from the left ear, and a membrana tympani had formed at 
 the bottom of the canal, with a small central aperture, and in the right there 
 was also a membrane, with a larger opening, and a very slight muco-purulent 
 discharge. On May llth, about three months and a half from his return to the 
 city, and about five months from the breaking out of the scarlet fever, he conld 
 hear the voice, with his face away from the speaker, for a distance of twenty feet, 
 and the watch, R. E., -fg; L., ^. He returned to school in good general health. 
 
 January 9, 1873. He still continues at school, with heaving power the same 
 as last noted. The membrana tympani of left ear is entirely closed. In the 
 right there is still a small opening, and occasionally a discharge of pus. The 
 ear is carefully cleansed at school, an astringent is still used, and Politzer's 
 method of inflation is occasionally practised. 
 
 May, 1890. The patient is now in active business life ; one ear suppurates 
 considerably. His hearing is fairly good. 
 
 The above case illustrates what can be done for one of the 
 severest cases of acute suppuration in the middle ear, resulting 
 from the pharyngeal inflammation of scarlet fever. Hundreds 
 of such subjects have become inmates of deaf and dumb asy- 
 lums, and are consequently educated in a necessarily imperfect 
 manner. This boy, although under some obstacles, has been 
 educated exactly as are his fellows, who enjoy good hearing 
 power. 
 
 CASE II. Acute Suppuration of the Middle Ear, occurring in a Child, in Con- 
 nection with the Whooping-cough Membranes Healed in about a Month. March 
 
 12, 1872. Eugene , % aged one, a rather delicate child, who is passing 
 
 through the whooping-cough. A few days ago the child cried very much for 
 some hours, and then a discharge of pus, mingled with blood, was found from 
 each auditory canal. The spasms of coughing are very severe. I was called to 
 see the little patient a few days after the discharge of pus occurred, and I found 
 on examination that both membrane tympani were ruptured, and that consider- 
 able pus was being secreted in the cavity of the tympanum. There was also 
 some naso-pharyngeal catarrh. 
 
 The following treatment was entered upon: The ears were syringed three
 
 ACUTE SUPPUBATIOX CASES. 335 
 
 times a day, with lukewarm water, and a solution of sulphate of zinc, gr. ij. 
 ad 5 ]'> was afterward dropped into the meatus, and kept there for a few minutes. 
 I saw the patient three times a week, and cleansed the ear myself. On April 
 15th, or a little more than a month from the time the perforation occurred, both 
 drum. -heads had healed and the discharge had ceased. 
 
 CASE III. Acute Suppuration in the Course of Chronic Nasal Catarrh Para' 
 centesis of the Membrana Tympani. March 13, 1873. George S , aged thirty- 
 four. He has had "catarrh" for two years, for which he has been in the habit 
 of using injections through the nostrils by means of Davidson's syringe. For 
 the past few hours he has had a pain in the ears, but more particularly in the 
 left, and he cannot he.ar well. 
 
 An examination shows that the patient has a severe form of naso-pharyngeal 
 inflammation, attended by a profuse and fetid secretion. The hearing distance 
 is, E. E., -/g-; L. E., $r. The right membrana tympani is sunken and red. The 
 left membrane is very convex ; a delicate pink tint involves the whole surface, 
 and there is no trace of the handle of the malleus nor of the light spot. 
 
 The membrane was immediately incised in the upper and posterior quadrant, 
 and a small amount of pus was evacuated. The ears were inflated by Politzer's 
 method, and the auditory canals syringed with tepid water. A leech was applied 
 upon the tragus of the right ear. A profuse suppuration occurred in the left 
 ear ; but it was soon checked by the use of a solution, gr. xl. ad j., of nitrate of 
 silver painted over the drum-head, and the patient disappeared from observation, 
 with the hearing distance if on each side, on March 22d, or nine days from 
 the date of the first visit. I afterward learned that he considered himself 
 entirely well. 
 
 CASE IV. Inflammation of Auditory Canal extending to the Membrana Tym- 
 pani Paracentesis Cure. Mrs. G , aged about thirty-five. On April 16, 
 
 1872, I was sent for, by request of Professor T. G. Thomas, to see this patient, 
 who had been suffering for a week or two from occasional attacks of severe pain 
 referred to the depth of the right ear. These attacks had been alleviated by the 
 application of leeches, but the pain continued to recur, especially at night, so 
 that the patient was unable to sleep. I found the lady suffering very much, 
 and she had been awake with pain all night. The auditory canal was found to 
 be swelled, and there were two points of suppuration in the cartilaginous part 
 of the meatus. The membrana tympani was red, but its whole surface could not 
 be seen on account of the swelling of the canal. The auditory canal was scari- 
 fied at two points, and the use of the douche ordered every hour ; iV gr. of sul- 
 phate morphia was ordered to be taken every hour, until the pain was relieved. 
 In the evening the pain not being markedly relieved, two leeches were ordered 
 to be applied to the ear one on the tragus, the other at the glenoid fossa. 
 This, with the continuation of the morphia, quieted the pain very much ; but, 
 
 on the 19th, I was called early in the morning, to find that Mrs. G had had 
 
 a recurrence of the pain, and that she was suffering very much. I then made a 
 paracentesis of the drum membrane, although the swelling of the canal was so 
 great that I could only judge of the fact of my instrument a cataract needle 
 having passed through the membrane, by the depth to which it penetrated, and 
 the yielding sensation communicated to the fingers as the needle passed through 
 the drum-head. Immediate and great relief from the pain was experienced, and
 
 336 ACUTE SUPPURATION CASES. 
 
 the patient, under the continuation of the douche, daily syringing, the use of 
 Politzer's method of inflation, on May llth she had fully recovered her hearing 
 power with a moderate amount of suppuration. 
 
 I am not able to decide whether this case was primarily one 
 of otitis externa, or otitis media. I am inclined to think that it 
 was one of the former, and that the inflammatory process ex- 
 tended to the membrana tympani from without. I suppose that 
 the membrane was unusually thick, perhaps from a previous 
 morbid process, and that this accounts for its continuing intact 
 for a longer time than usual, although a membrana tympani 
 that is invaded by disease from the auditory canal, will with- 
 stand an inflammatory action without rupture much longer, 
 than one whose mucous layer is the first affected. 
 
 CASE V. Acute Suppurative Otitis Media of some days 1 standing, Cured by one 
 Application of a Forty -grain Solution of Nitrate of Silver. February 16, 1873. 
 
 C. C , aged one year. I was asked to see this little patient by Dr. C. C. Lee. 
 
 There had been .an acute naso-pharyngeal catarrh for some time, and for a few 
 days there had been a purulent discharge from the left ear. On examination 
 the drum membrane was found to be perforate, and there was a profuse discharge 
 of pus. The ear was kept carefully cleansed, and a warmed solution of sulphate 
 of zinc poured into it ; but it did not yield in a day or two, when a solution of 
 nitrate of silver, of forty grains to the ounce, was brushed over the canal and 
 the perforated membrana tympani. At my nex't visit, the morning after this 
 application was made, the discharge had completely ceased, and the membrana 
 tympani had healed. 
 
 The foregoing cases, illustrate the ordinary type of acute sup- 
 puration occurring in subjects of different ages*. The practi- 
 tioner who has not seen much of aural disease, may be at a loss 
 when called to a case of acute suppuration of the ear, to know 
 whether its seat is in the auditory canal or the middle ear. The 
 parts should be carefully cleansed of pus before a decision is 
 made, although it should be borne in mind, as was stated in the 
 chapter on ''Acute Affections of the Canal," that suppuration in 
 the middle ear is much more frequent than the same process in 
 the external auditory canal. Indeed, an acute diffuse suppura- 
 tion of the external ear is an extremely rare disease. If an open- 
 ing in the drum-head cannot be detected by the otoscope, the 
 performance of the Valsalvian experiment by the patient, or the 
 employment of Politzer's method, and a subsequent inspection, 
 will determine the question. If the membrane be perforate, the 
 air will be heard to whistle through the aperture, and an air- 
 bubble, made by the pus or mucus, will be found at the seat of 
 the aperture. The presence of an air-bubble, before the parts 
 have been cleansed, is not, as Wilde thought, a pathognomonic
 
 SEKOUS INFLAMMATION. 337 
 
 symptom of a perforation, for I have seen this bubble when the 
 membrane was intact, but fluid was lying upon it. 
 
 SEROUS INFLAMMATION OF THE MIDDLE EAR. 
 
 An increased secretion of the middle ear, is not always either 
 of a catarrhal or a purulent character. As has been observed in 
 the account of the anatomy of this part, its lining membrane 
 sometimes assumes the character of a serous membrane. In 
 like manner an excessive secretion in the middle ear may be, in 
 exceptional cases, predominantly or entirely of a serous char- 
 acter. This may occur when the membrana tympani is sound, 
 and also during the course of a suppurative process. The mem- 
 *brana tympani, if entire, has an unmistakable appearance, when 
 serum is collected behind it in great quantity. It is somewhat 
 bulging, and through its transparent layers may be detected a 
 yellowish fluid, which may be caused to change its position by 
 movements of the head, just as hypopyon may be made to 
 change its position in the anterior chamber of the eye. The 
 subjective symptoms of this accumulation, like those from the 
 accumulations of mucus, are sometimes very annoying and 
 trying, without being absolutely painful. The movement of 
 the serum is felt by the patient at each considerable change 
 in position, especially on rising from lying down, and some- 
 times the sound of his voice becomes very distressing, and even 
 "echo" hearing and double hearing may be present, just as it 
 may be when mucus has accumulated in the ear in sub-acute 
 catarrh. The hearing power is very much affected in these 
 cases, but it may be variable, according as the serous fluid has 
 changed its position. Great pain is sometimes spoken of by 
 patients, but this is usually in neurotic or hysterical subjects, 
 for, from all I can learn, while the presence of serum in the 
 middle ear causes very annoying and disturbing sensations, 
 they are not to be compared in severity with those from the 
 accumulation of mucus, blood, or pus. Dr. Tansley ' reported a 
 case of serous inflammation of the middle ear, occurring in a 
 woman of advanced age, and because his case was not marked 
 by severe pain, he proposes to divide these cases into two classes, 
 inflammatory and non-inflammatory. To the latter he gives the 
 name of hydro-tympanum. This, I think, is a needless and un- 
 necessary refinement in nomenclature, which may possibly lead 
 to a confusion of ideas. Some cases of serous inflammation of 
 the middle ear are attended by pain, and others are not, just as 
 
 1 Archives of Clinical Surgery, July 25, 1878. 
 22
 
 SEROUS INFLAMMATION. 
 
 we may have a painless suppuration of the middle ear. But as 
 I have already observed, annoying as is a serous inflammation 
 of the tympanum, it is not usually painful in the same sense 
 that acute catarrh or suppuration are found to be. As has been 
 already said, an accumulation of serous fluid in the tympanum 
 may occur in the course of a suppurative process, and it may be 
 added, that it is very difficult to manage from the rapid reac- 
 cumulation of the serum. Serous accumulations are apt to oc- 
 cur, in my experience, in debilitated subjects. The inflamma- 
 tion may be considered, I think, as of a bastard type. 
 
 Dr. C. H. Burnett ' reports a case of repeated accumulations 
 of serous-like fluid, in the tympanum of a man fifty-five years 
 of age. The membrana tympani was opened thirty-seven times 
 by Dr. Burnett in nine years, and always with relief to the pa-* 
 tient. In an obstinate case of this kind, I once made as many as 
 five openings in the drum-head in a few weeks. The patient 
 was a very nervous woman of some fifty years of age, and al- 
 though she got relief at every operation, it was temporary, and 
 she sought other advice. Burnett entitles his case dropsy of the 
 middle ear. 
 
 Treatment. Paracentesis of the drum-head is often indicated 
 in cases of serous accumulation, although at times the fluid may 
 disappear under the treatment of the middle ear by inflation. 
 At the same time, the general health will need careful looking 
 after. Generally, paracentesis must be repeatedly performed 
 in the same case before a cure results. Delstanche's masseur 
 will be found very useful in drawing the serous-like fluid, 
 or serum, or tenacious mucus, from the tympanum. Of the 
 accumulation of serum and mucus in chronic cases, more will 
 be said in an appropriate chapter. Leeches and the warm 
 douche are of little or no avail in serous inflammation, but the 
 use of gargles is strongly indicated. By them, the action of the 
 Eustachian tube and the consequent passage of the fluid from 
 the tympanum to the pharynx, are promoted. 
 
 American Journal of the Medical Sciences, January, 1884, p. 122.
 
 CHAPTER XIII. 
 
 CHRONIC NON-SUPPURATIVE INFLAMMATION OF THE MID- 
 DLE EAE. 
 
 Frequency of this Disease. Nomenclature. Catarrh. Proliferous Inflammation. 
 Subjective Symptoms. Vertigo. Tinnitus Aurium. Insanity. Subjective 
 Symptoms of Proliferous Inflammation. Objective Symptoms. Impairment of 
 Hearing. Changes in the Membrana Tympani. Eustachian Tube. Naso-Phar- 
 yngeal Inflammation. Adenoid Growths. Pathology. Causes. 
 
 IT has been a common reproach both from the profession and 
 the laity, that the treatment of aural disease is unsuccessful. In 
 1870 one of the Boylston prize questions was as follows : ''Crit- 
 icisms on the recent opinion of a medical writer that the less 
 serious diseases of the ear may be successfully treated by a well- 
 qualified general practitioner, and the more serious affections 
 by none." When Von Troltsch, announced his intention to de- 
 vote himself to the study and treatment of aural disease, one of 
 his professional friends warned him that he might put his good 
 name in jeopardy. These incorrect ideas have arisen chiefly 
 from ignorance as to the nature and causes of diseases of the 
 ear. There is a large class of cases in this department of medi- 
 cine, that at the very best can only be alleviated, and can never 
 be cured. But many of these, have reached such a classification 
 from a point where treatment would have been of the greatest 
 avail. The prevention of a chronic aural affection is often with- 
 in the power of every practitioner, while it once having become 
 established, its cure is impossible. After many years of careful 
 study of diseases of the ear, I think it may be said that there 
 are but two classes of cases of aural disease in which we may 
 not expect very good results from treatment and care. Nearly 
 all the others are singularly tractable, when their course is 
 properly regulated. 
 
 By these two classes I mean chronic non-suppurative inflam- 
 mation of the middle ear, and the affections of the labyrinth, 
 or internal ear. 
 
 Of every thousand cases of aural disease about three hun-
 
 340 CHRONIC NON-SUPPURATIVE INFLAMMATION. 
 
 dred belong to the former class, while but a small percentage of 
 disease of the internal ear occurs. 
 
 Chronic non-suppurative inflammation of the middle ear, is 
 so insidious in its origin and progress, that it may have existed 
 for months and years before its subject is aware of it, and brings 
 himself under professional care. It may impair or nearly de- 
 stroy the hearing, with but few of the subjective evidences of 
 what is called inflammation there may be no heat, redness, or 
 pain but we find many of the other marks of diseased action, 
 in swelling, thickening, adhesions, which entitle it to be placed 
 under this head. It has also been called a catarrhal inflamma- 
 tion, because the cavity, air-chamber, and tube, which form its 
 seat, are lined by mucous membrane. We say middle ear, be- 
 cause these parts form the anatomical centre of the organ of 
 hearing. It is the same disease which Sir William Wilde under- 
 stood, but which, as it seems to me, he inappropriately called 
 chronic myringitis, or inflammation of the drum-head. But the 
 drum-head is only one of other parts that is affected in this dis- 
 ease, and may, perhaps, be scarcely at all injured, while the 
 most important changes in structure and function have occurred 
 in other parts of the middle ear. In common speech and I do 
 not mean by this, among the laity, but in the profession many 
 of the forms of chronic non-suppurative inflammations of the 
 middle ear, have been, from time immemorial, classified as ner- 
 vous. The great author whom I have just quoted, did much to 
 combat this error an error which not only kept back the growth 
 of the science of otology, because it retarded the conception of a 
 successful plan of treatment, but which also assisted to deepen 
 the reproach which for centuries has rendered aural disease 
 the bete noir of medical practice. 
 
 The reason for this classification of these affections as ner- 
 vous is found in the fact that the poor means of diagnosis, 
 which were in the hands of the profession until a few years 
 since, the absence of a simple otoscope, and the want of 
 knowledge of the value of the Eustachian catheter, and the 
 tuning-fork, did not allow of the appreciation of the delicate 
 changes which make up what the Germans call the " Krank- 
 heitsbild " the picture of the disease. There was another rea- 
 son in the fact that the poor, distressed patient, having gone in 
 vain to his usual consolers, if not curers the regular practi- 
 tioners often resorted to the charlatan. Under his wonderful 
 but distressing treatment, added to the trial of the horrible tin- 
 nitus aurium, and impairment of hearing, he became so utterly 
 worn out and so distrustful of each new adviser, that the so- 
 called nervousness was very apparent.
 
 NON-SUPPUKATIVE INFLAMMATION. 
 
 341 
 
 The common idea of nervous deafness is that it occurs chiefly 
 among the weak and sensitive ; but this notion has no basis in 
 pathology so-called nervous people are not apt to be deaf, nor 
 does their sensitive or nervous organism have much effect upon 
 their hearing power, unless it is already impaired from an in- 
 flammatory cause. 
 
 As yet. this class of cases comes as a rule to the notice of the 
 practitioner of modern otology, only when the disease is far ad- 
 vanced. 
 
 The following table shows this. It is compiled from the first 
 cases of this disease that were observed by me in private practice: 
 
 Cases of Chronic Non-suppurative Inflammation. 
 
 Number of cases of 80 years' standing 1 
 
 over 40 years' standing 6 
 
 over 20 " " 40 
 
 between 10 and 20 years' standing 133 
 
 Sand 10 " " 141 
 
 3 and 5 " " 75 
 
 1 and 3 " " 74 
 
 one year's standing 42 
 
 less than one year's standing 13 
 
 Total 525 
 
 It will be seen that by far the larger number, more than fifty 
 per centum, had observed some loss of function for more than 
 five years, while about eight per cent, had been affected for more 
 than twenty years. 
 
 I add a second table made from the last five hundred and ten 
 
 cases 
 
 Cases of 50 years' duration 1 
 
 40 " " 5 
 
 30 to 40 years' duration 6 
 
 20 to 30 " " 30 
 
 15 to 20 " " 27 
 
 10 to 15 " " 77 
 
 5 to 10 " " 112 
 
 4 years' duration 43 
 
 3 " 
 
 2 " 
 
 1 year's 
 6 months' 
 
 3 " 
 
 53 
 76 
 41 
 
 18 
 21 
 
 Total 510 
 
 It will be seen that even in the second table the proportion of 
 cases of from five to twenty years' standing is very large, nearly
 
 342 CHROMIC NON-SUPPURATIVE INFLAMMATION. 
 
 one half of the whole number, but there is a gratifying increase 
 in the number of those that have existed less than one year. 
 
 Every person has, so to speak, a superfluous amount of hear- 
 ing, which he may lose before his hearing is sufficiently impaired 
 to annoy him in the common affairs of life. People who spend 
 many hours of the day in noisy places, such as boiler-shops, on 
 board steamships, in the stock-board of Wall Street, as I have 
 seen by frequent examples, may lose very much of their hearing 
 power before they are at all aware of it. Then, again, the lower 
 classes, who labor har.d all day in the open air with their fellows, 
 and who live at night in small and noisy rooms, where the 
 demands upon the hearing power are very slight, hardly con- 
 sider its impairment as a loss of function. 
 
 Besides all this, people in general, who have no scruples about 
 confessing to impaired eyesight, very reluctantly admit a loss 
 of hearing. It thus becomes very difficult in many cases to say 
 when an impairment of hearing was first observed. 
 
 These causes have conspired, with the general ignorance of 
 the pathology and treatment of non-suppurative aural disease, 
 to render the results of treatment unsatisfactory, as well as to 
 cause patients to consult a physician at a very late stage of their 
 trouble. 
 
 I have never been fully satisfied with the nomenclature of 
 Von Troltsch, vast improvement as it was on those classifica- 
 tions which had preceded it. Some of them were crude, others 
 fanciful and altogether too refined. Von Troltsch, classified all 
 non-suppurative disease as catarrhal, and then separated those 
 in which the catarrhal symptom excess of secretion was not 
 very marked, by placing them under the head of sclerosis or 
 hardening or rigidity of the mucous membrane. After looking 
 at many ears, in which there was no trace, either in the pharynx, 
 Eustachian tube, or cavity of the tympanum, of an excess of 
 secretion from the mucous membrane, but in which there were 
 marked changes in the way of increase, hypertrophy or prolifera- 
 tion of tissue, and in others where the catarrhal symptoms were 
 very much in the background, although they existed, I felt that 
 aural catarrh was a meagre and incorrect name with which to 
 describe such a state of things. The very name "catarrh," as 
 applied to an ear with a sunken drum-head, immovable chain of 
 bones, dry pharynx, easily permeable Eustachian tubes, is repug- 
 nant to all our notions of scientific nomenclature. Whatever 
 may have been the origin or exciting cause of such cases, they 
 cannot be called catarrhal, when their examination shows such 
 a state of things as this. t ns 
 
 Gruber has made a division in his text-book, and describes
 
 CATAERHAL AND PROLIFEROUS FORMS. 343 
 
 an otitis media hypertrophica, or plastic inflammation ; but I 
 think his own description of the pathology of the disease shows 
 that he is discussing not what has hitherto been comprehended 
 under the head of sclerosis, but an extension of. a suppurative 
 process, such as causes the formation of granulations or polypi. 
 This criticism has also been made by Politzer. 
 
 My classification is founded upon clinical experience, and 
 upon the reports of the pathology of this class of cases that have 
 been made by Toynbee, and others. 
 
 Chronic non-suppurative inflammations of the middle ear 
 may be divided into two great classes, 
 
 Catarrhal, 
 Proliferous. 
 
 I choose the translation of the German word wucherung, as 
 furnishing the best term to describe the changes in the middle 
 ear, of which I am to speak ; and in what I have to say, I shall 
 attempt to be guided by these divisions. 
 
 Since the publication of the first edition of this work, the term 
 chronic non-suppurative inflammation, has been widely adopted 
 in Great Britain as well as in this country, and some authorities 
 have also accepted the term proliferous, in the sub-classification. 
 
 Some authors and practitioners would admit another classifi- 
 cation, based upon the parts involved, and speak of chronic 
 myringitis, or chronic inflammation of the membrana tympani, 
 of the tympanum, and of chronic catarrh of the Eustachian tube. 
 Whatever we may believe of acute inflammation of these parts, 
 I can scarcely accept the idea of one that has existed for any 
 considerable space of time without involving either the cavity of 
 the tympanum or the mastoid cells, or both. The nomenclature, 
 tubal catarrh, also leads, as I believe, to incorrect notions as 
 to the therapeutic value of the Eustachian catheter, and of Po- 
 litzer's method of inflating the drum cavity-. These methods of 
 treatment are useful, not so much for what they do to the tube, 
 as for their effect upon the cavities into which it opens. When 
 air-bubbles are crackling in the cavity of the tympanum, as in 
 catarrhal inflammation, or when the tube is greatly narrowed 
 by the hypertrophy of its lining membranes, but at the same 
 time we have, as we always do, in the latter case, a sunken 
 drum-head, an altered light spot, signs of proliferous inflamma- 
 tion of many of the structures making up the middle ear, I do 
 not see how we can with propriety speak of a tubal affection, 
 even if its symptoms are predominant, and even if treatment of, 
 and through, the lining membrane of the tube, does place things 
 in such a condition that Nature will complete the cure. No time 
 need be spent upon this question, which may, perhaps, seem to
 
 344 CHRONIC CATARRHAL INFLAMMATION. 
 
 some a comparatively unimportant one, had not incorrect notions 
 in the past led to an incorrect style of treatment. In former 
 times, the membrana tympani, under the assumption that such 
 an affection as an independent chronic myringitis existed, was 
 vigorously treated by instillations of various fluids, and by per- 
 foration, and of late, under the idea that we have a great deal 
 of tubal catarrh without further progress in the morbid action, 
 undue stress is sometimes laid upon applications to the mouth of 
 the tube. Politzer's method is then used as a complete substitute 
 for the catheter, when in my opinion, indispensable as it is, its 
 chief value is as an adjuvant to that instrument. 
 
 SUBJECTIVE SYMPTOMS OF CHRONIC CATARRHAL INFLAMMATION. 
 
 I think we may assume, from the history of cases, that this 
 form of disease is either a consequent of frequent attacks of 
 acute catarrh of the middle ear, or that it occurs in people who 
 have what we may call a catarrhal diathesis. Those who suffer 
 from hay fever, are very apt in time to be affected with chronic 
 catarrh of the middle ears. The disease is, therefore, unlike its 
 companion, proliferous inflammation, not at all insidious in its 
 approach. The patient suffering from this disease, who con- 
 sults us about his hearing, is usually aware that there is an ex- 
 cess of secretion in his pharynx, and that for years he has been 
 annoyed and troubled by being obliged to use a handkerchief 
 very freely, and by feelings of fulness referred to the frontal 
 sinus and tympanic cavities. There is often, also, at times, a 
 sound in the ear like the crackling of air-bubbles. The voices 
 of friends appear muffled ; and it is hard for the victims of 
 chronic aural catarrh, when the disease is advancing, not to be- 
 lieve that every one is speaking in a much lower tone than is 
 usual for them. Such patients often complain bitterly on this 
 subject, and will scarcely admit that their hearing is at all im- 
 paired, or, if so, they stoutly assert that it is one ear only, when 
 the fact is, that, with one perfect ear, it is only under peculiar 
 circumstances, certainly not in ordinary conversation, in front 
 of the patient, that a person will be observed to be at all hard of 
 hearing. 
 
 There is a feeling about this that is different from that ex- 
 pressed about diseases of the eye at least, and I believe, in most 
 maladies, patients will express their feelings, and often with an 
 exaggeration, rather than with an extenuation of the symp- 
 toms ; but, however much patients with chronic inflammation 
 of the middle ear may suffer from impairment of hearing, they 
 will often insist that they are hardly affected, or that they have
 
 VERTIGO IN DISEASE OF THE MIDDLE EAR. 345 
 
 a very little trouble in that way, when they can scarcely hear 
 loud conversation addressed specially to them. 
 
 Patients affected with chronic catarrh of the middle ear also 
 complain, as a rule, of tinnitus aurium, and a sense of fulness 
 in the ears. The ears feel as if the auditory canals were stopped 
 up. They often ask very anxiously, if there is not something in 
 the ear, and seem incredulous when the negative answer is 
 given. Vertigo is another symptom of which these patients 
 sometimes speak, and it is often considered as undoubted evi- 
 dence that there is disease of the brain. Vertigo is a symptom 
 by no means peculiar to catarrhal inflammation. It also occurs 
 in impacted cerumen, and still more frequently in proliferous 
 inflammation, as well as in affections of the labyrinth and in 
 cerebral disease. When vertigo occurs in aural disease, it is a 
 consequence of increased pressure upon the labyrinth through 
 the fenestra ovalis or of an affection of the labyrinth or brain. 
 It is by no means a serious symptom, when the cause is to be 
 found in the middle ear, for it is usually relieved by a mechan- 
 ical treatment through the Eustachian catheter. There are 
 many cases in my note-book which illustrate this, but none 
 more striking than the following : 
 
 A physician once consulted me on account of impairment of 
 hearing in one ear, accompanied by a tendency to topple over 
 on that side, which he said was a consequence of being thrown 
 from his sleigh some months before, when he suffered a concus- 
 sion of the brain. He was quite disposed to regard the tendency 
 to fall over, as a cerebral lesion, but the use of the Eustachian 
 catheter and Politzer's method of inflating the ear not only im- 
 proved the hearing, but took away the unpleasant sensation. 
 Physician as he was, he was at first disposed to smile at the 
 idea of using local means to ameliorate this brain-symptom ; 
 but he has continued to be perfectly relieved from his cere- 
 bral malady up to this time, ten years or more since he con- 
 sulted me. 
 
 The subject of aural vertigo has been very much confused 
 by the disposition, especially found among neurologists, to at- 
 tach the name of "Meniere's disease" to every case of aural 
 disease in which vertigo is a symptom. This will be more fully 
 discussed in a subsequent chapter, but it may be well to say 
 here that vertigo occurs at times in such a large variety of aural 
 cases, that it would be well to abolish the name of Meniere's 
 disease, except with reference to those cases where the origin 
 of the vertigo is undoubtedly in the labyrinth, and where it is 
 not plainly secondary to an affection of the auditory canal or 
 middle ear. As now used it describes nothing, and leads to
 
 346 INSANITY FROM AURAL DISEASE. 
 
 want of exactness in the diagnosis. I have just dismissed from, 
 my care a young woman, who became very ill from acute catarrh 
 of the middle ears, accompanied by vertigo, the tendency being 
 to pitch forward. By the use of leeches, blisters, and inflation 
 of the middle ears the symptom of vertigo was relieved in 
 twenty-four hours, and disappeared wholly in two days. The 
 leeching and the inflation both afforded immediate relief. 
 
 I have often heard patients describe the feeling of fulness in 
 the ears as a sensation as if the ears were plugged with some 
 foreign substance ; it is almost impossible for them to avoid the 
 impression that the auditory canals are plugged with cerumen. 
 Very many times, after I have examined a patient suffering 
 from chronic disease of the middle ear, I have'been asked to 
 look again to see whether I could not find some hardened wax ; 
 and on one occasion a poor fellow who I suppose was, to a cer- 
 tain extent, insane, grew very angry and called me hard names, 
 because I would not remove wax which he knew was in his ear. 
 
 Troltsch ' relates a case from Meyer, of Hamburg, where a 
 melancholic person was relieved of a sound in the ear, seeming 
 to him to be the cry of a child, by the removal of a plug of ceru- 
 men, which caused deafness on one side. The patient made a 
 rapid and complete recovery from the mental affection, after 
 the cerumen was removed. It is the opinion of Schwartze,* 
 that subjective aural sensations, which are caused by demon- 
 strable affections of the ear, may, in predisposed persons, es- 
 pecially when there is any hereditary tendency to mental dis- 
 ease, become the direct cause of aural hallucinations, that may 
 accelerate the outbreak of a disease of the brain. He mentions 
 a case where, in his opinion, and in that of one of the physicians 
 of the Insane Asylum at Halle, a threatened attack of brain dis- 
 ease was prevented by treatment of the ear. In some cases, 
 insane persons, who suffer from aural disease, distinguish its 
 tinnitus from these illusions or hallucinations. 
 
 Dr. Koppe confirms this view, and shows that in some cases 
 hallucinations disappear after treatment of the ear. 
 
 I have elsewhere reported 3 a case of the suicide of a pro- 
 fessor in one of our educational institutions, who consulted me 
 on account of impairment of hearing, but more especially on 
 account of tinnitus aurium. He said, on leaving the consulting- 
 room, that, if he felt sure that I was correct in my opinion (that 
 he would not get great relief from this very trying symptom, 
 tinnitus), he would put an end to his existence ; which he did a 
 
 1 Text-book, second American edition, p. 531 . . 
 8 Loc. cit., p. 532. 3 New York Medical Journal, August, 1869.
 
 INSANITY FROM AURAL DISEASE. 347 
 
 few months after, by blowing out his brains. A few years since 
 a gentleman, a public-school teacher, consulted Dr. Charles S. 
 Bull, while he was in charge of my patients, in regard to a sup- 
 puration of the ear, which caused considerable impairment of 
 hearing and great tinnitus. He was exceedingly depressed and 
 annoyed by the tinnitus. It is said that he committed suicide 
 on account of the depression caused by this state of his ears. 
 There can be no doubt but that this symptom is one of the most 
 distressing that can befall a patient, and that in some cases it 
 is the provoking cause of suicide. Again and again, I have 
 satisfied myself that the great depression, which is the rule in 
 persons whose hearing is impaired, was due entirely to the 
 aural disease. 
 
 Dr. O. D. Pomeroy, 1 of this city, examined sixty lunatics at 
 Blackwell's Island Lunatic Asylum, and he found disease of the 
 ear in many of those who suffered from what may be called 
 aural hallucinations, although not in so large a proportion as 
 stated by Schwartze and Koppe. 
 
 Dr. C. E. Wright 2 published a case of a patient in the In- 
 diana State Asylum for the Insane, who attempted to destroy 
 herself by putting a steel button in her ear. The patient was 
 discharged from the hospital, as having recovered her reason, 
 but became nervous and despondent, until she was relieved by 
 the removal of the button ; and a dread of insanity and of sud- 
 den death, from which she suffered, then also disappeared. 
 
 Troltsch speaks of confusion of the intellect, an inability to 
 keep up a connected line of thought, as a subjective symptom 
 of chronic aural disease, and I am enabled to verify this opinion. 
 Over and over again, have patients with chronic disease of the 
 middle ear, not suffering from pain, but from tinnitus, volun- 
 tarily informed me that these noises, together with the impair- 
 ment of the hearing, had a great effect upon their mental 
 powers. On the other hand, I have seen cases where most suc- 
 cessful men, such, for instance, as distinguished general officers 
 in the army, and celebrated writers, have suffered from boy- 
 hood with chronic inflammation of the middle ear and tinnitus 
 aurium. 3 
 
 The sounds in the ears, of which patients speak, are vari- 
 ously described ; some speak of a ringing of bells, which is per- 
 
 1 Transactions of the American Otological Society, Fourth Year, p. 46. 
 
 2 Indiana Journal of Medicine, November, 1871. 
 
 3 The late Dr. George M. Beard, has often told me of the tinnitus aurium with 
 which he was affected. He had chronic non-suppurative inflammation and described 
 the noises in his head, in graphic style. They never, however, dampened his cheerful 
 and humorous temperament
 
 348 TINNITUS AURIUM. 
 
 haps the most aggravating form ; others have likened them to 
 the murmur of trees, the hum of a tea-kettle, etc. Wilde is un- 
 doubtedly correct in stating that the descriptions which patients 
 give of the noises depend to a certain degree upon their fancy, 
 their graphic power of explanations, and not unfrequently upon 
 their rank of life and the sounds with which they are most fa- 
 miliar ; thus he says : " Persons from the country or rural dis- 
 tricts draw their similitudes from the objects and noises by 
 which they have been surrounded, as the falling and rushing of 
 water, the singing of birds, the buzzing of bees, and the waving 
 or rustling of trees ; while, on the other hand, persons living in 
 towns, or in the vicinity of machinery or manufactories, say 
 that they hear the rolling of carriages, the hammerings, and the 
 various noises caused by steam-engines. Servants almost in- 
 variably add to their other complaints that they suffer from the 
 ringing of bells in their ears ; while, in the country, old women 
 much given to tea-drinking sum up the category of their ail- 
 ments by saying that ' all the tea kettles in Ireland are boiling 
 in their ears.' ' : No description of tinnitus aurium has ever sur- 
 passed this one given by the great Irish observer. 
 
 Tinnitus aurium is usually, although not always, a subjec- 
 tively disagreeable symptom. Sometimes, however, it is not 
 unpleasant to the patient, but it may accompany its subject as 
 a pleasing musical concert. One of my patients, a young wo- 
 man having tinnitus aurium as one of the symptoms of disease 
 of the middle ear, kept a record for me of what she heard " in 
 her head." 
 
 February 13th. Morning, C sharp, B flat, F sharp in right ; 
 B in left. Night, E flat, C flat. 
 
 February 14th. Morning, E flat, C flat. Night, C sharp, B 
 flat, F sharp. 
 
 February 15th. Morning, C sharp, B flat, F sharp. Night, 
 C sharp, B flat, F sharp. 
 
 February 16th. Morning, C sharp, B flat, F sharp. Night, 
 F sharp, E flat. 
 
 February 17th. Morning, E, C sharp, A. Night, D, B, G, 
 and so forth. ' 
 
 Mr. Hinton * regarded tinnitus of a distinctly musical char- 
 acter as a sign of nervous affection. One man spoken of by him 
 was subject to sudden attacks of loss of hearing with singing 
 noise, and also complained of dimness of vision. " Dark specks " 
 were found upon the yellow spot. 
 
 1 American Journal of the Medical Sciences, Vol. LXVIII., p. 378. 
 * The Questions of Aural Surgery, p. 286.
 
 TINNITUS AURIUM. 349 
 
 Thus far I have been speaking of subjective tinnitus, of 
 sounds of which the patients give graphic descriptions, as being 
 in their head, but of which the physician can know nothing ex- 
 cept from these narrations. There is also an objective tinnitus 
 aurium, usually intermittent in character and of a crackling 
 nature. It is a rare symptom, and is always, as far as my ex- 
 perience goes, very distressing to the patient. In one case, 
 where a crackling and intermittent sound could be heard in the 
 ear both by myself and the patient, the victim was driven into 
 insanity and suicide by failure to get relief from it. This kind 
 of noise in the ear is, I believe, dependent upon abnormal action 
 of the tensor tympani, stapedius, or of the muscles of the Eus- 
 tachian tube. I have known the symptom to disappear when 
 the disease in which it arose sub-acute catarrh was relieved, 
 but I have never known it to be benefited by any treatment 
 when it occurred in conjunction with chronic naso-pharyngeal 
 catarrh. 
 
 Ordinary tinnitus should also be distinguished from a venous 
 murmur transmitted from the jugular vein, which runs just 
 beneath the floor of the cavity of the tympanum, and from the 
 pulsating sound of the internal carotid as it winds through the 
 apex of the petrous bone. This variety of tinnitus, is not neces- 
 sarily connected with impairment of hearing, but is usually 
 dependent upon anaemia or aneurism. 
 
 The cause of the common form of subjective tinnitus aurium 
 has been much discussed, but we are yet without any exact 
 knowledge as to how it is produced. We do know, however, in 
 what diseases it is usually found as a constant symptom. It is 
 a very common, almost universal, attendant of chronic non- 
 suppurative disease, and is most distressing in the proliferous 
 form, when it forms the chief complaint of the unfortunate sub- 
 jects. It also occurs in inspissated cerumen, in acute and sub- 
 acute catarrh of the middle ear. It is not a prominent symp- 
 tom in chronic disease of the labyrinth, or at least patients do 
 not speak of it as being very hard to bear. 
 
 Reasoning from the standpoint of the diseases in which the 
 ordinary subjective tinnitus aurium is generally present, I have 
 always considered it to be a symptom indicating pressure upon 
 the vessels of the tympanum and labyrinth. Dr. Theobald ' 
 seeks to explain the nature of tinnitus aurium by stating that it 
 is due to "the existence of vibrations exerted in the walls of the 
 blood-vessels of the labyrinth by the friction attending the cir- 
 culation of the blood." I have found the reasoning of Field, of 
 
 Transactions of the Medical and Chirurgical Faculty of Maryland, April, 1875.
 
 350 CAUSES OF TINNITUS AUKIUM. 
 
 London, as to the cause of tinnitus very clear. He believes, as 
 I do, that any impairment of the "pressure equilibrium" of the 
 ear will be a cause of tinnitus. He has illustrated this thesis in 
 a very satisfactory way. He remarks, abnormal pressure of the 
 air in the external auditory canal producing increased pressure 
 upon the endolymph of the cochlea will cause it, just as a sud- 
 den striking of the key-board of a piano will set in "discordant 
 vibration every note that it is capable of producing." Thus anae- 
 mia and hypersemia, Mr. Field observes, are powerful agents 
 in modifying pressure equilibrium. Overfilled arteries and ar- 
 terioles cause undue pressure on the peri- and endo-lymph and 
 excite tinnitus. 
 
 The tinnitus from quinine, salicylic acid, wintergreen, and so 
 forth, may thus be explained. 
 
 The decrease in the pressure of the blood-vessels in anaemia is 
 also called in by Mr. Field, to explain tinnitus, and he gives the 
 familiar illustrations of chlorotic young women, and patients 
 who have suffered from great hemorrhages, as examples, to 
 which may be added the singing in the ears experienced in syn- 
 cope. I have long taught this theory of increased pressure, as 
 the chief cause of subjective tinnitus aurium, and I am very 
 glad to give a new circulation to Field's more amplified and 
 better view of the disturbance of pressure equilibrium, as that 
 which causes an abnormal vascular tension or lack of tension, 
 and thus becomes the essential cause of tinnitus. 1 
 
 Patients suffering from chronic catarrhal inflammation of 
 the middle ear usually speak of the throat as troubling them 
 quite as much as their ears. In many cases, however, they say 
 nothing whatever about the throat, and even if asked about it, 
 they will insist that it is quite well, although they will often 
 admit that they raise a great deal of mucus in the morning, and 
 that they have sore-throat very often. The greater number of 
 patients with aural catarrh complain greatly of the condition of 
 their pharynx and nostrils, and, under the stimulus of the ad- 
 vertisements and books of charlatans, have generally very much 
 to say of the catarrh, although they do not always trace a con- 
 nection between the throat disease and that of the ear. 
 
 There are very many other symptoms than these which have 
 just been enumerated feelings of fulness, confusion of intellect, 
 vertigo, tinnitus, and neuralgic pains of which patients with 
 chronic catarrh of the middle ear often complain ; but they are 
 not always dependent upon the aural disease, and the examiner 
 
 1 London Medical Times and Gazette, June 8, 1878. Also, Diseases of the Ear, 
 p. 208 et seq.
 
 PROLIFEROUS INFLAMMATION. 351 
 
 may often throw many of them out of consideration, and bring 
 the patient back from the long story of headaches, dyspepsia, 
 and so forth, by asking whether, after all, if the ear and throat 
 were well, they would not consider themselves in good health, 
 when an affirmative answer is often given. 
 
 SUBJECTIVE SYMPTOMS OF PROLIFEROUS INFLAMMATION. 
 
 If we now turn to the picture of the subjective symptoms of 
 what I term proliferous inflammation, we shall find them much 
 less positive* than those of the catarrhal form. Some of the 
 patients have no subjective symptoms at all, except that of loss 
 of hearing, which is of course an objective symptom as well. 
 They have no sore-throat, no increase of the secretion of the 
 pharynx or nostrils. Others, again, complain of feelings of ful- 
 ness in the ears, and nearly all of tinnitus aurium. Indeed, I 
 think the tinnitus is apt to be more troublesome in the prolifer- 
 ous than in the catarrhal form. This we should suppose a priori 
 to be the case, because the causes in the proliferous variety of 
 middle-ear disease are constantly acting, while in the catarrhal 
 variety the temporary removal of the increased secretion will 
 often greatly alleviate this symptom, and sometimes completely 
 remove it. The origin of this form of aural trouble cannot be 
 traced back to infantile earaches, frequent coryzas, or to naso- 
 pharyngeal catarrh. It is a peculiarly insidious affection, one 
 which is usually under full headway, and which essentially im- 
 pairs the function of hearing long before the patient is aware 
 that he has any affection of the ears. The pathology of the dis- 
 ease, of which an account will be given a little later on in the 
 discussion of this subject, explains something of this insidious 
 character. 
 
 Catarrhal and proliferous inflammation may exist in one and 
 the same ear, when it will be impossible to make a differential 
 diagnosis, yet in the greater number of cases the line can be 
 drawn between the two forms. 
 
 Chronic catarrh of the middle ear, as well as proliferous in- 
 flammation may also exist in connection with chronic disease of 
 the labyrinth. The practitioner should not be too ready to con- 
 clude that the predominant or chief affection in a given case of 
 impairment of hearing, is to be found only in the middle ear, 
 simply because the patient has a naso - pharyngeal catarrh, 
 and is hard of hearing. There are means to distinguish these 
 affections, of which I shall speak fully before finishing this 
 subject.
 
 352 DISEASE OF NERVE AND MIDDLE EAR. 
 
 OBJECTIVE SYMPTOMS OF CATARRHAL INFLAMMATION. 
 
 The objective evidences of chronic catarrhal inflammation of 
 the middle ear, may be classified as follows : 
 
 1. Impairment of hearing. 
 2. Changes in the membrana tympani. 
 
 3. Imperfect action and changes in the structure of the Eus- 
 tachian tube. 
 
 4. Capability of hearing better in a noise than in a quiet 
 place. 
 
 5. Better conduction of sounds through the bone than through 
 the air. 
 
 6. Naso-pharyngeal inflammation. 
 
 If we exclude the latter, we have also the objective symptoms 
 of chronic proliferous inflammation. 
 
 The Differential Diagnosis of Chronic Non-suppurative Inflam- 
 mation of the Middle Ear from a Disease of the Labyrinth. 
 
 The tuning-fork is one of the most useful means of diagnos- 
 ticating an affection of the middle ear, from one of the labyrinth. 
 In the catarrhal form of disease its use is not as essential as in 
 the proliferous, for the good reason that the subjective and ob- 
 jective symptoms together, form such a decided picture that it 
 would be hard to fall into error as to the seat or nature of the 
 trouble. But, in the proliferous form, both sets of symptoms are 
 often of such a negative character, that without the tuning-fork 
 we are sometimes in doubt as to whether we are dealing with 
 a peripheric or central disease. 
 
 Starting from the well-established fact, that, if the auditory 
 canal of a person having healthy ears be closed by the finger, or 
 in any other way, the sound made by a vibrating body is heard 
 more distinctly on the side of the head where the ear is closed, 
 it has been shown that, in most diseases of the auditory canal 
 and middle ear, such vibrations are more distinctly felt on the 
 affected side, or, if one be diseased, that they are heard more 
 distinctly on the side of the ear affected, and on which the tick- 
 ing of a watch or the sound of conversation is not as well heard. 
 
 The differential diagnosis between a chronic proliferous in- 
 flammation of the middle ear, and an affection of the acoustic 
 nerve is important and often difficult. It is important, for while 
 local treatment of a proliferous inflammation of the middle ear 
 is often beneficial, such a treatment applied to an affection of the 
 nerve is always useless and generally harmful. Certainly it adds
 
 DISEASE OF NERVE AND MIDDLE EAR. 353 
 
 to the annoyances of the patient. The differential diagnosis is 
 sometimes difficult, because a secondary affection of the nerve 
 often exists in connection with chronic non-suppurative inflam- 
 mation of the middle ear. But, as I hope to show in this chap- 
 ter, and in those upon " Diseases of the Internal Ear," some of 
 these difficulties have been removed, so that we may now more 
 readily make a diagnosis than was formerly possible. The tests 
 which were formerly exclusively used to differentiate between 
 diseases of the middle ear and of the nerve, and which have 
 just been described, I have of late, as was said in chapter sec- 
 ond, practically abandoned, not because they were not valu- 
 able, but because the test of the aerial and bone conduction is 
 much more easy to carry out, and is more certain. When both 
 ears are diseased, it is often difficult for a patient to say whether 
 or not he hears a vibrating tuning-fork better in one ear than the 
 other, but the most stupid person can easily determine whether 
 a vibrating tuning-fork is heard better through the air, when 
 held in front of the meatus, or through the bone when placed 
 on the mastoid process. Now I believe it is a rule without 
 exception, that when the tuning-fork C is heard louder and 
 longer through the bones than through the air, the predomi- 
 nant disease is one of the external or middle ear. Of course, the 
 external ear may be readily excluded or included, by ocular ex- 
 amination. There may, however, be predominant disease of the 
 middle ear, when through any cause, wax in the canal, mucus, 
 blood, serum, or pus in the tympanum, abnormal pressure is 
 made upon the peri- and endo-lymph, and yet the tuning-fork be 
 heard better through the air. When the pressure is removed, 
 if there be remaining disease of the middle ear, the tuning-fork 
 C will be heard better through the bones. This is beautifully 
 shown in the examination of boiler-makers, who become hard 
 of hearing from their noisy occupation, and acquire disease of 
 the nerve. They are of course also liable to disease of the canal, 
 such as inspissated cerumen. Before the wax is removed in 
 certain cases, the bone conduction is better, but on removing 
 this, the hearing power remains impaired, but the tuning-fork is 
 heard, as it always is heard in disease of the nerve, better and 
 longer through the air. The table showing the results of exami- 
 nation of boiler-makers in the chapters 011 "Diseases of the In- 
 ternal Ear " will show this. 
 
 The only difficulty then, in the test with the tuning-fork is 
 that we cannot always tell on the first examination, when the 
 tuning-fork is heard better through the air, whether this be due 
 to pressure upon the labyrinth from temporary causes, or to in- 
 trinsic disease of the nerve. 
 23
 
 354 AERIAL AND BONE CONDUCTION. 
 
 By temporary causes, I mean an accumulation of wax in the 
 canal, or of mucus, pus or blood in the tympanum. These being 
 present, pressure may be made upon the labyrinth, and cause the 
 aerial conduction to be temporarily better than that through the 
 bones. We cannot, therefore, in some cases when we find bet- 
 ter aerial conduction, determine at once, that it may not be due 
 to disease of the canal or middle ear. We may be obliged in 
 some such cases, to make more than one examination before we 
 come to a positive conclusion. With better bone conduction, 
 however, we have no such difficulty and with constant use of 
 the tuning-fork in diagnosis, we become more and more confi- 
 dent and exact in our deductions. 
 
 Some years since, I suggested a new test with the tuning- 
 fork, which is stated in the following proposition. Generally 
 true, as I believe it will be found, I have abandoned its use also 
 for the simpler test of the aerial and bone conduction. 
 
 If, under the same conditions of a sound ear on one side, while 
 the hearing power of the other is impaired, the tuning-fork be 
 not heard better in the worse ear, even if the meatus be stopped 
 by the finger or the like, there is disease of the labyrinth, the 
 acoustic nerve or brain. 
 
 I employed the older tests, until constant examinations have 
 convinced me, that the one as to the aerial and bone conduction 
 is the most reliable and easiest to conduct of all those, that have 
 resulted from Miiller's first experiments. 
 
 I now use the tuning-fork simply to determine which is bet- 
 ter, the aerial or the bone conduction. At my clinics, where I 
 have a class of practitioners, I have invariably found that it is 
 considered a simple and adequate test, by those who have seen 
 it employed upon almost all kinds of patients. It is indeed a 
 very simple thing to determine whether the vibrations of a tun- 
 ing-fork are heard better through the air, or through the bones, 
 and this is the gist of the test. In some cases it is well to also 
 test the time during which the fork is heard. A simple way of 
 doing this is to place it upon the bones, after the patient says it 
 is no longer heard through the air, or vice versa. In many in- 
 stances, however, a stop-watch and a test of the duration in each 
 position, are necessary to an accurate idea as to the relative in- 
 tensity of aerial and bone conduction. 
 
 After having, in the doubtful cases of the proliferous variety, 
 settled the fact as to whether we have an affection of the middle 
 ear or of the labyrinth, the ticking of the watch and ordinary 
 conversation become the natural tests as to the impairment of 
 hearing. 
 
 The watch is an inadequate test, for the reason that has
 
 POWER OF HEARING WATCH AND SPEECH. 355 
 
 already been mentioned in the introductory chapter, that is, 
 that some persons can hear a watch quite a number of inches 
 from the ear, while they hear conversation very badly. Lucae 
 explains this fact by saying, that speech is made up of an ex- 
 tremely complicated system of tones, and sounds of most differ- 
 ent tone-heights, while the tick of a watch is made up of a class 
 of very high tones which are usually better heard than low ones. 
 But, there are cases where speech is heard much better than the 
 tick of a watch. Careful observation of the lips of the speaker, 
 by the person whose hearing is defective, may have something 
 to do with explaining this class of cases. Excluding these, how- 
 ever, I have become convinced that there is disease of the acous- 
 tic nerve, when conversation is heard relatively better than the 
 tick of a watch. I have come to this conclusion, because I have 
 almost invariably found this symptom in connection with others 
 that indicate an affection of the nerve. 
 
 In commenting upon Lucae's explanation of the occasional 
 disproportion, between the power of hearing the watch and con- 
 versation, Politzer remarks that he believes it to be due to the 
 fact that in anchylosis of the stapes, the membrane of the fen- 
 estra rotunda often remains .normal. If this be not thickened, 
 he goes on to say, that simple tones and noises may be trans- 
 mitted without difficulty through the air of the tympanum to 
 the membrane of the fenestra rotunda, while speech can only 
 be perfectly transmitted through the ossicles. " The greater the 
 impediment to the conduction of sound through the ossicles, the 
 greater is the impairment of hearing for speech." ' This expla- 
 nation is perfectly consistent with my experience, for I have 
 found an adhesive process in the tympanum more destructive to 
 the hearing power for speech, that is for ordinary conversation 
 than a disease of the labyrinth. Deaf mutes, who are usually 
 deaf from adhesive inflammation of the middle ear. are striking 
 examples of persons deaf to speech, although they may hear 
 sounds and noises through the bones. 
 
 BETTER HEARING IN A NOISE. 
 
 Persons affected with disease of the middle ear, uncomplicated 
 by secondary disease of the labyrinth, hear better in a noise than 
 they do in a quiet place. This is true of acute, sub-acute, and 
 chronic disease. But it has only been especially commented 
 upon when occurring in chronic non-suppurative cases. Con- 
 sequently it has often been mistakenly assumed, that it is always 
 
 Lehrbuch, p. 394.
 
 856 BETTER HEARING IN A NOISE. 
 
 a very unfavorable symptom. It is not necessarily so, but inas- 
 much as it is chiefly observed in cases that are actually incur- 
 able, it is not at all strange that it has been so considered. I 
 believe that important deductions can already be made as to 
 the situation of the nature of the lesion that causes the impair- 
 ment of hearing in a given case, from this symptom, and I also 
 hope that from a right interpretation of it, may yet come an 
 invention to improve the hearing power of a large class of per- 
 sons. For these reasons, I shall be quite full in my account of 
 this symptom. 
 
 In the collected works of Doctor of Medicine Thomas Willis, 
 published in Amsterdam, a little more than two hundred years 
 ago. in a chapter upon the sense of hearing, and in a paragraph 
 relating to deafness caused by relaxation of the membrana tym- 
 pani, there is ah account of a somewhat famous woman, who 
 could only hear the voice of her husband when a servant was 
 beating a drum in the same room. 1 
 
 Although this passage is often alluded to, it is seldom quoted. 
 No apology will, I think, be required for a translation of it. 
 
 "Although hearing is very little produced by the membrana 
 tympani as compared with the proper organ of the sense, yet it 
 so far depends upon it, that deprivation or diminution of that 
 sense not infrequently proceeds from its injury or impeded action. 
 Indeed, a certain kind of deafness occurs, in which, although the 
 patients seem completely to lack the sense of hearing, yet so 
 long as a great din, such as that of bombardments, or of chimes 
 of bells, or of drums, resounds about their ears, they take in 
 distinctly the conversation of those about them, and answer 
 questions intelligently, but, upon the ceasing of such tremendous 
 uproar, they immediately become deaf again. I once had it from 
 a trustworthy man, that he had been acquainted with a woman, 
 
 1 Archives of Otology, vol. xii. , No. 2, June, 1883. The original reads as follows : 
 Quanquam aMitus a tympana, velut proprio senionin organo, minime peragitur, 
 tamen iste in tantum ab hoe dependet, ut non raro d tympani actions Icesa, out impedita 
 sensus iUivs primtio, aut diminutio procedat. Enimtero surditatis specie* qucedam occur- 
 rit, in qua licet affecti au 'itus sensu penitm carere rideantur, quam-diu tamen ingens 
 fragor, uti bombardarum, campanarum, aut tympani bellici, prope aures circumstrepit, 
 adstanlium cottoquia distincte capiunt, et interrogatis apte respondent, cessante vero im- 
 mani isto strepitu, denuo statim obsurdescunt. Accept olim d Tiro fide digno, se muli- 
 erem qua licet surda fuerat, quousque tamen intra conclave tympanum pulsaretur, verba 
 quaevis clttre audiebat; quare maritus ejus Tympanistam pro ferco domestics conducebat, 
 ut ulius ope, coUoquia interdum cum uxore sua haberet. Etiam de alio Surdastro mild 
 narratum est, qui prope campanile degens, quoties una plures campana resonarent, vocem 
 quamris, facile audire, et non alias potuit. Proculdubio horum ratio erat, quod tym- 
 panum in se continue relaxatum, soni vehementioris impulsu ad debitam tetisitatem, quo 
 munere suo aliquatenus de fungi potuerit, cogeretur.
 
 BETTER HEARING IN A NOISE. 357 
 
 who, although she was deaf, would, nevertheless, distinctly hear 
 whatever was said so long as a drum was beaten within the room, 
 and consequent^ her husband employed a drummer as a house- 
 hold servant, in order that by his aid he might occasionally hold 
 conversations with his wife. I have also been told of another 
 deaf person, living near a bell-tower, who could easily hear any 
 voice whenever the bells were pealing but not otherwise. Doubt- 
 less the reason of these things is, that the membrana tympani, 
 habitually relaxed when left to itself, was forced by the shock 
 of a sound much more intense than usual, to a state of tension 
 sufficient to enable it to perform its function in some degree." ' 
 
 In the two centuries that have followed the narration of 
 Willis's observations, the symptom of hearing better in a noise, 
 has not only been given the name of the author, and is known 
 in our time as Paracusis Willisiana, but the facts as stated by 
 the author, have in turn been denied and affirmed, and while 
 many have admitted the truth of the observations, and have 
 conceded that there are some persons with impaired hearing 
 who hear better in a noise, Willis's explanation of the phenom- 
 enon has been rejected by them. The writers on aural medi- 
 cine who allude to it at all, are by no means agreed upon the 
 facts nor upon their explanation. Wilde 2 admits the credibility 
 of Willis's cases, and argues against the notion of Kramer, that 
 the auditory nerve became so excited by these loud sounds as to 
 be able to do its work better. Wilde explains the phenomenon 
 by reference to the state of the membrana tympani, and says 
 that it is remarkable that it does not occur in cases where that 
 structure has been in whole or in part removed. Later on, I 
 shall show that Wilde was in error in thinking that it could not 
 occur when there was a hole in the drum-head. 
 
 Troltsch 3 says : "These statements (as to hearing better in a 
 noise) are founded, as a rule, upon a want of exact observation, 
 as well as upon self-deception." He then relates one of Willis's 
 cases, and also one reported by an author named Fielitz. The 
 latter was that of a deaf son of a shoemaker, who could only 
 hear conversation in the room, when he stood near his father 
 and the latter pounded sole leather upon a large stone. This 
 same boy, heard well in a mill when it was in action. 
 
 I cannot agree with Troltsch, in his idea that the symptom of 
 hearing better in a noise is not a common one. As I have said 
 on several occasions, my own experience has proven that it is a 
 
 1 Opera Omnia, Amstelsedamia., apud Henricum Wetstenium. Pars physiologica, 
 Cap. xiv. , p. 09 * Aural Surgery, English edition, p. 289. 
 
 3 Troltsch : Lehrbucli, Sechste Ausgabe, p. 253, passim.
 
 BETTER HEARING IN A NOISE. 
 
 very frequent one. Rau, ' like Kramer, believed that better hear- 
 ing in a noise depends upon excitement of a torpid acoustic nerve. 
 In somewhat poetic style, he says : "If the auditory nerve be 
 awakened from its slumber by loud talking, the patient will mo- 
 mentarily hear even words spoken in a low tone very well. This 
 sometimes goes to such an extent, that the hearing is temporarily 
 restored to a considerable degree by a loud and regular sound, 
 for example, during the pealing of bells, drumming, a ride in a 
 rattling wagon, or the like." Burnett, 4 of our own country, is pos- 
 itive that the symptom is a real one, but confines it to the later 
 stages of chronic aural catarrh, " when the condition of the tym- 
 panum has become dry or sclerotic, or when the thickening of 
 the mucous membrane has become great in the moist form." 
 
 Dr. E. E. Holt ' doubts if, in any case the hearing-power is im- 
 proved by noise, and he states that, so far as he is aware, no one 
 has "ever made a careful investigation to ascertain whether the 
 claim of such persons was a real one or not." 
 
 In the first edition of this book, and in all the subsequent edi- 
 tions, I related from my personal experience the case of a mail 
 agent, on one of our railways, who, although very hard of hear- 
 ing in a quiet place, could hear very well in his car amid the 
 noise of a train. I have had frequent opportunities to study this 
 case, and there is no question as to the facts. No person who 
 did not know of this gentleman's infirmity, would ever suspect 
 him of impaired hearing while conversing in the din of a rapidly 
 going train of railway carriages. But the instant he reached a 
 quiet place, it was with the greatest difficulty, that he could hear 
 loud conversation specially addressed to him. 
 
 Politzer has no doubts as to the existence of these cases, and 
 confirms what was stated by me years ago, "that the patients 
 can understand speech during such noises much easier, and at 
 a much greater distance, than people with normal hearing."* 
 Politzer, however, states that he has observed this symptom 
 " almost exclusively in the incurable forms of affections of the 
 middle ear." 
 
 I have known of two cases where this symptom occurred, in 
 patients who regained their hearing perfectly. While the symp- 
 tom frequently accompanies incurable disease of the middle ear, 
 I believe it is a very frequent symptom in sub-acute cases, when 
 both ears are affected. Of course, it would not be observed in 
 disease of one ear only. I also have two cases under observation 
 in which the drum-heads are entirely, or nearly removed, and yet 
 these patients hear well in a noise. One of these. I published in 
 
 1 Lehrbuch, p. 292. * Treatise on the Ear, p. 386. 
 
 3 Transactions of American Otological Society, 1882. 4 Lehrbuch, p. 233.
 
 BETTER HEARING IN A NOISE. 359 
 
 the fourth edition of this book. While the occurrence of the symp- 
 tom in sub-acute cases disposes of the notion that hearing better 
 in a noise implies an incurable disease, the fact that it also may 
 exist when the membrana tympani is gone, shows that Willis's 
 explanation of the phenomenon is not exclusively, if at all, cor- 
 rect. I have never yet seen the symptom except in disease of the 
 middle ear. I believe it never occurs except in cases where the 
 nerve is sound. I have looked over my cases with great care as to 
 this point, and I have yet to see a patient who had, as I supposed, 
 disease of the acoustic nerve, and who yet heard better in a noise. 
 If this be true, the theory of an extraordinary excitement of the 
 nervous apparatus, as a cause of the phenomenon, must be re- 
 jected. Buck and Politzer, explain the symptom by a reference 
 to some effect upon the ossicula auditus, made by the great din. l 
 This is the only theory, incomplete as it is, which fulfils the con- 
 ditions made -by such cases as those just mentioned, where, al- 
 though the membranse tympani were gone, the ossicula were in- 
 tact. How the ossicles aye affected is a problem yet to be solved, 
 but when it is solved, it will be possible to invent an instrument 
 to enable those deaf from disease of the middle ear, to hear con- 
 versation not only in a noise, but in the quiet of an ordinary room. 
 This latter will, certainly, not be a task beyond the capabilities 
 of a physicist of the nineteenth century. These cases are not 
 at all rare. They are very common. The proof is overwhelm- 
 ing that a large class of persons with impairment of hearing not 
 only hear better, but hear perfectly well, in noisy places. 
 
 The statement, that these cases rest upon inexact observa- 
 tions, will soon be disproven by a ride of a few miles in a rail- 
 way carriage or in a clattering wagon, with a person deaf from 
 disease of the middle ear, to ordinary conversation in a quiet place. 
 Examinations of boiler-makers, or of those who suffer from af- 
 fections of the acoustic nerve, will, however, be disappointing 
 unless they are carefully analyzed, and will lead, as in Dr. Holt's 
 paper, from which I have already quoted, to a doubt in the mind 
 of the observer as to the reality of the symptom. I now quote 
 one of the cases in which the hearing was better in a noise, and 
 which was one of sub-acute catarrh of the middle ears, from which 
 the subject fully recovered under my observation. The writer of 
 his own case is now a practising physician in this city. At the 
 time of the occurrence of the disease he was a boy in school, 
 and I reported his case, except as to the symptom now under dis- 
 cussion, in the American Journal of the Medical Sciences 2 and in 
 the first edition of this book. Dr. B - writes to me as follows : 
 
 1 Medical Record, Julj 5, 1875. 2 Vol. Hi. , p. G4.
 
 360 BETTER HEARING IN A NOISE. 
 
 With regard to the disputed fact of many deaf persons hearing conversation 
 better in noisy places, I wish to give in brief my experience. For several years 
 previous to my sixteenth, I had been much troubled with varying degrees of deaf- 
 ness, due, as I then heard and now understand, to acute catarrh of the middle ear, 
 complicating general pharyngeal catarrh. At school I was at a great disadvan- 
 tage, suffering at times great embarrassment on account of my limited hearing. 
 Living far up-town, I was in the habit of being driven home or to the doctor's 
 by my mother. When surrounded by the noise of wheels and glass, I invariably 
 had occasion to request a moderation of her voice ; and she not infrequently made 
 the remark : " How well you hear in the carriage ! " Furthermore, on several 
 occasions, my parents were surprised to find that they could not safely carry on a 
 confidential conversation requiring only sound enough to suffice their own hear- 
 ing powers, while in a quiet room their talk would have been unintelligible. 
 
 This is only an echo of the experience of many deaf people I have ques- 
 tioned on the subject. 
 
 The other case was that of a student, of seventeen years of age, 
 and is so similar to the one just given, that I simply allude to it. 
 As I have already intimated, the power of hearing better in a noise 
 is a different subject from that of the effect of certain noisy occu- 
 pations upon the ear. Patients like my friend, the mail agent, 
 may travel for years in the din of a train, and always find their 
 hearing improved and not decreased, so long as it depends upon 
 disease of the middle ear. Neither do I know of any cases of deaf- 
 ness that have been caused by such occupations. But although 
 there is a class of patients who have been made deaf by noise, 
 often confounded with those whose impairment of hearing has 
 resulted from catarrh, they should be entirely disassociated from 
 them. Boiler-makers, and those who become deaf from an expos- 
 ure to the continuous shock of loud sounds, suffer a lesion of the 
 acoustic nerve. These patients do not hear better in a noise, but 
 they have a source of relief in quiet places, and, like ordinary 
 people, they hear better away from the din that is such a comfort 
 to a person deaf from many forms of disease of the middle ear. 
 
 I must confess to have assisted in the creation of confusion 
 in our ideas as to hearing better in a noise, and the effects of 
 noise upon the ear. In 1874, in one of the editions of this work, 
 I gave the results of my examinations of a certain number of 
 boiler-makers, and I incidentally assumed that they heard better 
 in the noise of their occupations. When the paper by Dr. Holt, 
 to which I have referred, appeared, I found that he denied the 
 correctness of my main conclusions ; that is, that the impair- 
 ment of hearing in boiler-makers is generally a result of a lesion 
 of some part of the labyrinth, and that, besides his doubt that 
 any deaf person, much less boiler-makers, ever heard better in 
 a noise, he was inclined to attribute their impairment of hearing 
 to a disease of the middle ear. I then made a new series of ex-
 
 BETTER HEARING IN A NOISE. 361 
 
 aminations upon boiler-makers, assisted by Dr. J. B. Emerson. 
 As a result of these recent investigations, which were under- 
 taken with the much better means of a differential diagnosis 
 between diseases of the middle and internal ear, now at our 
 command, I find that I cannot agree with Dr. Holt's conclu- 
 sions, except in one particular, and that is the one just men- 
 tioned, i.e., that boiler-makers do not hear better in a noise. 
 This incidental statement made by me, I now find to be entirely 
 incorrect. But that boiler-makers do suffer from a lesion of the 
 internal ear, and not of the middle ear, in so far as they have a 
 peculiar affection from their occupation, I do not think admits 
 of a doubt. The very fact that they do not hear better in a noise 
 is an incidental proof that they suffer from a lesion of the laby- 
 rinth. Boiler-makers, like men in other occupations, often have 
 impacted cerumen, and occasionally catarrh of the middle ear, 
 but the disease caused by their occupation, "boiler-makers' 
 deafness," in my opinion, is easily shown to be a disease of the 
 labyrinth. Other occupations of a similar nature, that is, occu- 
 pations amid continuous concussions, undoubtedly cause the 
 same lesion. A recent visit to an establishment where two' 
 engineers were employed for the production of electric light, 
 showed me that they had become somewhat hard of hearing, 
 since they had been engaged in an occupation exposing them to 
 the sound of regular concussions from the striking of metallic 
 plates together. 
 
 The confusion which I assisted in producing upon the sub- 
 ject was not, however, as regards the seat or cause of the aural 
 lesion, but as regards the ability of these workmen to hear better 
 in the din in which they labor. It will perhaps be remembered 
 that it has just been stated that those who hear better in a noise 
 always suffered from some form of disease of the middle ear. 
 When some years of observation had convinced me of the uni- 
 formity of this rule, I was puzzled to account for my cases of 
 so-called boiler-makers' deafness, which, in my paper upon this 
 subject, I had assumed were also improved by being in a noise. 
 I had said : "It will be observed that the subjects of it (boiler- 
 makers' deafness) hear very well in the tremendous din of a 
 boiler-shop, while they are quite deaf in an ordinarily quiet 
 place." This remark, I am constrained to say, although in 
 the other editions of this book, is strikingly incorrect. Boiler- 
 makers, as we should naturally believe, are no exception to the 
 rule, that those who have disease of the nerve hear worse in a 
 noise. Boiler-makers hear so badly in their shops that they 
 
 1 Treatise on the Ear, third edition, p. 510.
 
 362 BETTER HEARING IN A NOISE. 
 
 have a language of signs that is quite elaborate, called a "boiler- 
 makers' language." They hear no better in a noise than do 
 people with sound ears ; on the contrary, they hear better in a 
 quiet place. 
 
 If, however, a person deaf from disease of the middle ear, 
 who hears better in the noise of a railway train, enters a boiler- 
 shop, that person will hear better than the boiler-makers, or 
 than persons with sound ears. 
 
 It is only very recently that I have been able to send a pa- 
 tient suffering from chronic disease of the middle ear, who heard 
 well in a railway carriage, to a boiler-shop. I had predicted, 
 that although boiler-makers with disease of the acoustic nerves 
 and persons with sound ears, hear very badly in the dreadful 
 din, such a patient would hear well in such a place. 
 
 The patient whom I sent is a lady of about thirty years of 
 age, who has had chronic disease of the middle ears, of the pro- 
 liferous form, for many years. She cannot hear the watch at 
 all, and conversation only when directed into the ear, and then 
 with difficulty. In the cars she hears very well. She only hears 
 the tuning-fork by bone-conduction. Her account of the experi- 
 ment is as follows : 
 
 " I went with my husband (he has excellent hearing) this 
 afternoon to the boiler-shops of the Dickson Co. (Scranton, Pa.), 
 where the noise is perfectly deafening. I could distinctly hear 
 what my husband said, although he purposely spoke in a low 
 tone, while he could not hear a word I said, unless I put my 
 mouth to his ear and screamed. I think, perhaps, cars and 
 boiler-shops are the places for me to live." In a subsequent note 
 she informs me that she could not hear the watch tick, although 
 she hears conversation so easily. 
 
 In this case it will be noted that the improvement does not 
 depend upon the loud tone of the speaker. 
 
 The fact that most patients suffering from disease of the 
 middle ear hear better in a noise, especially that of a railway 
 car, I find as a result of a series of examinations extending over 
 many years, and embracing several hundreds of cases. Wher- 
 ever this symptom is not present, I have found that either the 
 disease was primarily or secondarily one of the labyrinth or 
 acoustic nerve. 
 
 I have gone with such patients to a train in motion, and I 
 have always found their statements correct. From hearing a 
 voice with difficulty directly in the ear, they have been enabled 
 to hear it twenty feet, that is to say to hear conversation at that 
 distance and with ease. In my experience they do not always 
 hear a watch tick farther, but most of these marked subjects
 
 BETTER HEARING IN A NOISE. 368 
 
 hear a watch a very short distance, if at all, in a quiet place. 
 There is, I think with Politzer, sometimes an improvement in 
 this respect also. 
 
 I have also made many tests in my clinic, in the following 
 manner, for the purpose of demonstrating this phenomenon to 
 my class. I have first tested the perception of sound by aerial 
 and by bone conduction. I have then made the room as quiet 
 as was possible, and tested the capability of the patient for hear- 
 ing conversation. Then the room has been made as noisy as 
 could readily be done by moving chairs on the tiled floor, rap- 
 ping on walls and tables, and so forth, and I have again tested 
 the hearing. Invariably have I found, that when the tuning- 
 fork was perceived on both sides better through the bones, that 
 the power of hearing was better in a noise, and also that the re- 
 verse was true. The result may be formulated as follows : 
 
 Bone-conduction better. 
 Better hearing in a noise. 
 Disease of middle ear. 
 
 Aerial conduction better. 
 Worse hearing in a noise. 
 
 Disease of acoustic nerve, either primary or 
 secondary. 
 
 This symptom would often be found in acute disease of both 
 r>ides did such diseases last long enough to admit of proper tests. 
 To say that the whole explanation is to be found in the fact that 
 the voice is raised when in a noise, is to forget that even in a 
 quiet place, with just such an elevation of the voice, these pa- 
 tients do not hear as well as they do in the noise. Besides, the 
 elevation in the voice is usually only slight, and sometimes there 
 is none at all. 
 
 I have yet to find a case where a mistake was made in a de- 
 liberate statement by a patient, that conversation was heard 
 better in a noise. When the symptom does occur, it is so 
 marked that no mistake can be made. When a patient does 
 not know whether he does or does not hear better in a noise, we 
 may assume that he does not, and when he does not, the case 
 will, I think, always be found to be one in which the nerve is 
 somewhat involved. 
 
 From all the observations I have been able to make upon 
 this subject, I think I am justified in drawing the following 
 conclusions : 
 
 1. There is a large class of people suffering from impairment
 
 364 CHANGES IN MEMBRANA TYMPANI. 
 
 of hearing in quiet places, who hear very acutely and with 
 comfort amid a great din or noise. 
 
 2. The disease causing the impairment of hearing thus re- 
 lieved is situated in the middle ear. It is usually observed in 
 the chronic, non-suppurative form of disease of the middle ear, 
 but it may also be found in acute or sub-acute catarrh of this 
 part, as well as in a chronic suppurative process with loss of the 
 whole or a part of the membrana tympani. 
 
 3. The proximate cause of this phenomenon is not as yet posi- 
 tively known. It is probably to be found in some change in the 
 action of the articulations of the ossicula auditus. 
 
 If a physicist can give us an instrument which, being placed 
 in the auditory canal, will produce sound enough to act upon 
 the ossicles, as does a great noise in a room, or the noise of a 
 railway train, we shall have found magnifying lenses for the 
 deaf. 
 
 CHANGES IN THE MEMBRANA TYMPANI. 
 
 I do not regard the appearance of the drum-head as posi- 
 tively indicative of aural disease. In some few cases, we find 
 the membrane in what may fairly be said to be a normal con- 
 dition in appearance, and yet we may have a very great im- 
 pairment of hearing, which the other objective symptoms as 
 well as the tuning-fork, show to depend upon disease of the 
 middle ear. These cases are not common, and then, if the 
 loss of hearing is great, we may conclude that the alterations 
 in structure are chiefly upon the inner or labyrinthine wall 
 of the cavity of the tympanum. I think, however, that we 
 very rarely find an absolute sinking inward of the membrane, 
 unless attended by some impairment of hearing. A sunken 
 drum-head, that is, one in which the head of the malleus stands 
 out like a miniature button, while the whole membrane seems 
 collapsed and sunken, is pretty fair evidence of the existence 
 of adhesions in the cavity of the tympanum, and of impairment 
 of hearing. 
 
 The first question in studying the membrana tympani is, 
 very naturally, what is the appearance of a normal one ? The 
 introduction of Troltsch's method of examining the membrana 
 tympani, has done more than anything else to stimulate the 
 study of its character. The ordinary anatomical text-books 
 give no true idea of this beautiful and important part. Such 
 authorities on aural disease as Kramer, Wilde, and Toynbee, 
 give descriptions of it that are far from exact. To Troltsch 
 and Politzer we are indebted for such perfect descriptions, that
 
 CHANGES IN MEMBRANA TYMPANI. 365 
 
 we now have a complete guide to the changes that may occur 
 upon it. 
 
 In order to determine what may fairly be considered a nor- 
 mal membrana tympani, I have examined a number of what 
 may be considered healthy ears. The persons whose ears were 
 thus examined were not aware that they had ever had any kind 
 of aural inflammation, even in childhood. They did not suffer 
 from naso-pharyngeal catarrh, and never had suffered from it. 
 The hearing distance, as tested by the watch, was normal, and 
 the tuning-fork was heard equally well on both sides of the 
 head. Such persons are very rare in any community, and con- 
 sequently I have only as yet examined seventeen membranes 
 belonging to this class. From these cases, and the observations 
 of others, I determine that the color of the membrane may vary 
 from a neutral gray to a dark blue ; but it is rather more in- 
 clined to a gray than to a blue. The lustre and transparency 
 vary exceedingly ; the membrane may be very brilliant and 
 transparent, so that the stapes is seen through it, and it may be 
 quite dull and hazy in appearance. 
 
 The light spot at the end of the malleus is usually triangular 
 in shape, although not always. It is, perhaps, always present 
 in some form if the hearing be normal. The head, handle, and 
 short process of the malleus are plainly visible. There may be 
 opacities at the margin of the membrane, where, as Troltsch 
 showed, the mucous membrane is thickest. The gray color may 
 be modified by a delicate pinkish injection along the periphery 
 of the membrane and handle of the malleus. 
 
 It is not uncommon to. find chalky spots or points of calcare- 
 ous degeneration in the membrana tympani. They are found 
 not only in the ears of persons with impaired hearing, but also 
 in those whose hearing power is acute. Undue weight should, 
 therefore, not be attached to these appearances. 
 
 Von Troltsch * seems to have been disposed to regard these 
 calcareous formations as connected with high degrees of im- 
 pairment of hearing, but I have not found this to be necessarily 
 the case. Politzer * regards them as the products of suppurative 
 processes that have run their course. In some cases, as we 
 know, such inflammatory affections are perfectly recovered 
 from, and if the calcareous degeneration do not occur on an 
 important part of the membrane, it probably will produce no 
 impairment of hearing of itself. 
 
 Moos has proved by one case which he observed, that a cal- 
 careous degeneration may occur in the course of a non-sup- 
 
 1 Politzer : The Membrana Tympani, p. 58. * Loc. cit.
 
 366 CHANGES IN MEMBKAXA TYMPANI. 
 
 purative process. This case was that of a woman more than 
 seventy years of age, who had chronic catarrh of the middle 
 ear. 
 
 Calcareous degenerations, as shown by the microscopic ex- 
 aminations of Politzer, usually occur in the fibrous layer. Where 
 the deposit was not very thick, the integument was quite easily 
 separated from the calcified parts. The mucous layer was a 
 little more adherent. In some cases both the external and mid- 
 dle layers were involved in the calcific process. Politzer once 
 found a true osseous deposit, together with the calcareous de- 
 generation, in one of his cases. Black or dark brown pigment 
 was also found by him and fat-globules everywhere. 
 
 An acute catarrh of the middle ear in childhood, is sufficient 
 to change the color or curvature of the membrana tympani, and 
 thus render it impossible to say that we are dealing with a nor- 
 mal membrane. The membrana tympani of the child, differs 
 from that of the adult, in being more transparent, while it is 
 rather of a yellowish tinge than gray, and the handle of the 
 malleus is not as distinctly seen. 
 
 Politzer has shown, in his work on this membrane, that the 
 triangular spot of light, which is one of the chief points for 
 study in this part, is due to the manner of the reflection of light 
 from its surface, and the factors which cause this reflection 
 have been fully detailed in the chapter upon "The Anatomy of 
 the Middle Ear." 
 
 Politzer ' believes that we can form no conclusions as to 
 changes in the cavity of the tympanum and membrana tym- 
 pani, from alterations in the size and shape of the light spot ; 
 but I cannot endorse this view. In the first place, if changes 
 have taken place in the outer layer, or layer of epidermis, the 
 reflecting power of the membrane is nearly removed, and there 
 is no light spot. Its absence certainly indicates changes in the 
 drum-head. Again, if it be smaller than usual, or if it can be 
 changed in form by the Valsalvian experiment, or by other 
 methods of inflating the middle ear, I think we may draw quite 
 positive and valuable conclusions as to the traction exerted by 
 the malleus, and as to the inclination of the membrane. I do 
 not deny that we may find an irregular or small light spot on a 
 person with normal hearing power ; but I believe that such a 
 state of things is rare, and that its shape and size will be found 
 to be, in the majority of cases, a pretty fair guide in a general 
 way, as to the loss of function. From the notes of ninety-four 
 ears affected with chronic non-suppurative inflammation of the 
 
 1 The Membrana Tympani, translated by Mathewson and Newton, p. 8.
 
 TRIANGULAR LIGHT SPOT. 367 
 
 middle ear, seen at the Manhattan Eye and Ear Hospital, and 
 recorded by Dr. D. Webster 
 
 In 59 the light spot was present. 
 "35 ' absent. 
 
 "9 ' normal. 
 
 "44 ' smaller. 
 
 " 2 ' larger. 
 
 "4 ' divided (i.e., 2 or more light spots existed). 
 
 In the last hundred cases of chronic catarrhal inflammation 
 of the middle ear, that I have seen in private practice, the fol- 
 lowing notes as to the light spot were made : 
 
 Well shaped 16 
 
 Small 48 
 
 None 17 
 
 Two 1 
 
 Interrupted 8 
 
 Fairly shaped 9 
 
 Very broad 1 
 
 100 
 
 The experiments of Magnus in compressed air, which have 
 been alluded to in the chapter on "In juries of the Membrana 
 Tympani," also prove that the non-existence of the light spot 
 does show, that the membrana tympani is forced or drawn 
 inward. 
 
 . CHANGES IN MOBILITY OF MEMBRANA TYMPANI. 
 
 If a person, having normal hearing power, forces the air 
 into the cavities of the tympanum by a prolonged inspiration 
 and expiration, with the nostrils closed, he has performed the 
 Valsalvian experiment for testing the permeability of the Eus- 
 tachian tubes, and, on examination during this act, we find that 
 the membranes moved outward and then inward. This change 
 takes place, in a healthy membrane, chiefly at the apex of the 
 light spot, or extremity of the malleus ; but it may occur in 
 other parts, especially in Shrapnell's membrane. In the ca- 
 tarrhal form of affections of the middle ear, the mobility of the 
 drum-head is not affected to any extent. It may be even pre- 
 ternaturally movable. In the proliferous variety, adhesions are 
 apt to occur between the malleus and the membrane, and be- 
 tween the other ossicula, and these will seriously affect the 
 normal movements of the drum-head and the chain of bones. 
 It is true, however, that mere swelling of the membrane, such
 
 368 MOBILITY OP MEMBRAINTA TYMPANT. 
 
 as obtains in the second stage of the catarrhal form, will, to 
 some extent, affect the motions of these parts. 
 
 It should not be thought, that the middle ear is in a normal 
 condition, because a drum membrane moves. The membrane 
 may move well, and yet the most serious changes may have 
 taken place in the cavity behind it. Patients who suffer from 
 impairment of hearing have pretty generally learned the Val- 
 salvian test or experiment, and when they are so deaf as not 
 to hear ordinary conversation at all, and have been so for 
 years, they will often triumphantl}', and with great skill, show 
 the examiner how well they can blow air into their ears, as evi- 
 dence that there can't be very much the matter with them after 
 all. The promulgation among the laity and profession of the 
 valuable character of this experiment has harmed many ears. 
 It is an experiment simply. Its chief value belongs to the ob- 
 
 FIG. 83. Siegle's " Otoscope " with Ely's Attachment of a Syringe. 
 
 server. It is an abuse of it to make it a method of treatment. It 
 can be theoretically demonstrated that it is even a somewhat, 
 although slightly, dangerous experiment to persons at all dis- 
 posed to congestion of the head and neck ; but this danger is not 
 great enough to lead the practitioner to wholly abandon it as a 
 means of treatment, were it not, as I believe, almost useless 
 therapeutically, and dangerous to the integrity of the tension of 
 the membrana tympani. I very often see patients who have 
 learned this method of treatment, and, having believed that no 
 harm could ensue from a very frequent performance of the ex- 
 periment, have been in the habit of inflating the membrana 
 tympani several times a day. A membrane that has been thus 
 treated becomes very flaccid, and flaps to and fro, at every swal- 
 lowing motion. 
 
 Siegle's instrument, a representation of which is here given, 
 enables us to form pretty accurate notions of the mobility of the 
 membrane. The air may be exhausted by means of the lips,
 
 CHANGES IN EUSTACHIAN TUBE. 369 
 
 while the membrane is carefully watched for its movement, or a 
 syringe may be used, such as Dr. Ely attached to the instrument. 
 Care should be taken that the speculum, as it should be called, 
 fit accurately in the auditory canal, so that exhaustion of the 
 air may actually occur. Of course, the otoscope must be used to 
 examine the drum-head through the glass of the speculum. 
 
 CHANGES IN THE EUSTACHIAN TUBE. 
 
 Having considered the appearance of the drum-head in cases 
 of chronic non-suppurative inflammation of the middle ear, we 
 have next to examine the Eustachian tube and pharynx, and 
 note the changes which appear there. At this point the boun- 
 dary line may be distinctly drawn between the catarrhal form 
 and the proliferous form of inflammation. In the former class 
 of cases, the pharynx and Eustachian tube show marked evi- 
 dences of morbid action ; while in the latter there are scarcely 
 any changes in the pharynx, and often no very striking ones in 
 the Eustachian tube. The pharynx, in a true case of catarrhal 
 inflammation of the middle ear, is found in one of the following 
 conditions : 
 
 . There may be great swelling of the pharynx and of the ton- 
 'sils, with or without increase in the amount of secretion. There 
 may be, however, excess of secretion, without any considerable 
 swelling. In such cases the patient is usually very conscious of 
 the trouble in his throat. He may not be aware of any pharyn- 
 geal affection, and yet have a pharynx that is considerably 
 relaxed and swollen. If these two symptoms be not present to 
 any marked extent, we usually find minute round elevations 
 scattered over the surface, or grouped in an arch under the 
 uvula. These constitute the disease known as pharyngitis gran- 
 ulosa. The pathological condition is a stoppage of the secre- 
 tions, and subsequently hypertrophy of the structure. This 
 affection is called by some authors chronic follicular pharyn- 
 gitis, and its more advanced stages glandular hypertrophy ; but 
 I prefer the simple nomenclature of pharyngitis, in the stage 
 of increased secretion and swelling, and granular pharyngitis, 
 when these characteristics of the inflammation are less promi- 
 nent, but where the granulations or hypertrophic glands are 
 very marked in appearance. If the tonsils are not enlarged, 
 they often exhibit, by a jagged appearance, the evidence of for- 
 mer disease. 
 
 Dr. Wilhelm Meyer, of Copenhagen, in 1873 ' brought to the 
 
 1 Archiv fiir Ohrenheilkunde, Bd. I., Neue Folge, p. 254, Bd. II., pp. 129, 241. 
 24
 
 370 ADENOID GROWTHS. 
 
 particular notice of the profession, a disease of the naso-pharyn- 
 geal space, which, although known by reports of isolated cases, 
 seems never to have been adequately studied until Meyer began 
 his investigations. "Adenoid growths in the naso-pharyngeal 
 space " is the title of Meyer's first paper upon the subject. These 
 growths must be known to every practitioner who sees much of 
 naso-pharyngeal disease, but they do not seem to be as common 
 in our country as in Denmark. They are developed in the course 
 of a chronic inflammation of the pharynx. They are of two 
 varieties in shape, f ollicular or tongue-shaped. The first variety 
 is more common. These cases have been described by Czermak, 
 Tiirck, Semeleder, Voltolini, and Lowenberg. The latter author 
 
 PiO. 84. Pharyngitis Gramilosa. This engraving was made from a drawing, by Mr. G. C. 
 Wright, of the pharynx of a young lady, who had suffered for many years from a chronic sup- 
 purative inflammation of the middle ear ; but it is a fair type of some of the worst cases of 
 granular pharyngitis, as seen in chronic catarrhal inflammation. 
 
 speaks of them under the head of granular pharyngitis, and 
 until Meyer's papers were published they were generally and 
 properly enough comprehended in this title. The microscope, 
 according to Meyer, after the examination of forty different 
 specimens, showed that these growths were of the same structure 
 exactly as the so-called " adenoid tissue " of His. When these 
 adenoid growths or vegetations are found in the pharynx, the 
 surrounding parts are intensely injected, swelled, and secrete a 
 delicate, often greenish mucus abundantly. The velum is most 
 swelled, so that it is very much enlarged. The mouths of the 
 Eustachian tube in this disease, according to Meyer, are very 
 often red and swelled, and covered by mucus so tenacious, that 
 it is very difficult to remove it by syringing. In some few cases 
 the mouth of the tube is narrowed to a mere fissure. Most of
 
 ADENOID GROWTHS. 371 
 
 my readers can verify this picture of Meyer's from cases they 
 have seen. Of 175 cases observed by Meyer, 130 were associated 
 with disease of the ear. By far the greater -number were cases 
 of catarrh of the middle ear, while suppurative inflammation of 
 the middle ear was found in one-fourth .of the cases. Of 1083 
 cases of aural disease observed by Meyer in 1869, 1870, 1871, and 
 1872, adenoid vegetations in the naso-pharyngeal space were 
 found in about seven and a half cases in a hundred. Meyer 
 cautions us against ascribing too great an importance to these 
 growths as a cause of aural disease, for he recognizes the fact 
 that many of these cases never come under professional observa- 
 tion and treatment, because the subjects of them are sometimes 
 troubled only with a catarrhal throat, for which they do not con- 
 sider treatment necessary. I have often been surprised at the 
 number of cases of naso-pharyngeal disease of a severe form in 
 which there is no disease of the ear. The intensity of a naso- 
 pharyngeal inflammation seems often to stop at the mouths of 
 the Eustachian tubes. A patient may have chronic naso-pha- 
 ryngeal catarrh all his life and never suffer from aural disease. ' 
 There is no doubt since Meyer's investigations, that adenoid 
 vegetations should be distinguished from simple granular pha- 
 ryngitis, with which it may coexist. These growths affect the 
 physiognomy and the speech, just as do enlarged tonsils. Pa- 
 tients speak "through their nose," say "dose" for "nose," "sogh" 
 for "song," and so forth. The resonance of the voice is very 
 much impaired by enlarged tonsils, and granular pharyngitis, as 
 well as by general hypertrophy of the naso-pharyngeal mucous 
 membrane. 
 
 Examination by the finger passed behind the palate is very 
 useful in making a diagnosis of adenoid vegetations. The rhino- 
 scope is of course a valuable aid, but they can usually be detected 
 by simple inspection of that portion of the naso-pharyngeal space 
 to be seen when the mouth is opened. 
 
 Meyer's experience, that adenoid vegetations are chiefly seen 
 . in youth, is verified by all observers. They are frequently asso- 
 ciated with cleft palate, according to Meyer, and Smith and Coles, 
 quoted by him (Lancet, 1869, p. 772). Of the prognosis and treat- 
 ment, something will be said in subsequent pages. 2 
 
 The rhinoscope will be found a valuable assistant in a few 
 cases for an exact diagnosis of affections of the naso-pharyngeal 
 
 1 Beverley Robinson seems also to have noted this. Transactions of American 
 Laryngological Association, 1883. 
 
 2 Meyer's first observations were published in 1868, in Danish, and copied in 
 Schmidt's Jahrbnch for 1869, and as he says with candor, even before this, other ob- 
 servers had published striking cases. They escaped general notice, how'ever.
 
 372 EUSTACHIAN CATHETER. 
 
 space. As a matter of fact, however, very few of us who treat 
 a great deal of aural disease, make much use of the rhinoscope. 
 It is only in exceptional cases that we find that its revelations 
 compensate for the time employed. 
 
 As I have already^ intimated in the second chapter, I use 
 much smaller catheters than those usually employed. Large 
 catheters are very difficult of introduction, and their use is gen- 
 erally very painful to the patient. I think one-half the difficul- 
 ties encountered by the inexperienced practitioner in the use of 
 the Eustachian catheter, will vanish, if he will be content with 
 hard-rubber catheters of small calibre and curve. 
 
 Very many of the patients who suffer from pharyngitis and 
 naso-pharyngeal inflammation, scarcely speak of it when asking 
 advice in regard to the disease of the ears, and it is only on 
 close questioning that they will admit that they are annoyed by 
 the accumulation of mucus in the throat, causing frequent ex- 
 pectoration, hawking, and the other symptoms of chronic pha- 
 ryngeal catarrh. At other times the catarrh, as they term it, is 
 the great burden on their minds, and they talk freely of the 
 stuffed feeling in the head, and describe their symptoms in a 
 graphic style, that has been obtained by a diligent perusal of 
 the advertising columns of the daily newspapers. 
 
 The Eustachian catheter is a very valuable means of diag- 
 nosticating not only the changes in the cavity of the tympanum, 
 but also those in the naso-pharyngeal space. In passing this 
 instrument through the nostrils it should always be used as a 
 sound, and the condition of this portion of the mucous tract 
 carefully noted. The inferior meatus is often found swollen and 
 even granular. In some cases nasal polypi may exist. There may 
 also be an abnormal position of the septum which renders the 
 canal very narrow and irregular. The manner in which the air 
 passes- through the catheter into the tube is deemed by many as 
 of much importance in the diagnosis of chronic catarrhal or 
 plastic inflammation. The passage of a full and strong current 
 almost necessarily precludes the idea of any considerable change 
 in the calibre of the Eustachian tube, unless it be atrophy of its 
 tissue. The mere fact that air can be made to enter the tube, 
 either by the Valsalvian experiment, the Eustachian catheter. 
 Toynbee's or Politzer's method ; in other words, the fact that 
 the Eustachian tube is open, so that the patient perceives the 
 fulness in the ears, which shows that a column of air has been 
 forced -against that already in the middle ear, is no evidence 
 whatever, that the ear is in a healthy condition. In my own 
 experience, closure of the Eustachian tube is one of the rarest of 
 conditions. I mean by closure such a state of things, that, by
 
 EUSTACIIIAN CATHETER. 373 
 
 trial of the catheter and Politzer's method, the air cannot be 
 made to enter the ear. 
 
 The two nostrils often differ very much in size. This differ- 
 ence is usually due to a deviation of the septum to one side or 
 the other, in consequence, perhaps, of an injury received when 
 the patient was young, and the bone was soft. In some very 
 rare cases not even the smallest catheter that can be made, can 
 be passed through the nostril of one side. For such cases the 
 catheter has usually been made longer, and introduced through 
 the opposite nostril ; but Dr. Noyes, 1 of this city, thinks that this 
 method is not reliable, because by it the air simply passes " across 
 tho axis of the Eustachian tube, and if it pass up the tube at all, 
 it can only do so after being reflected from the outer wall of the 
 trumpet orifice." 
 
 Dr. Noyes recommends a catheter of double curve for such 
 cases. The following are his directions for using it : " When in- 
 troducing the catheter, it is needful to keep the front close to the 
 septum, as well as to the floor of the nostril. Arrived at the pos- 
 terior edge of the septum, the beak should wind closely around 
 it, curving obliquely across, and turning upward, so as to point 
 toward the Eustachian orifice." 
 
 Of late years I have scarcely found any cases where a small 
 hard-rubber catheter, after the pattern figured in the second 
 chapter, could not be used, and I have ceased to use the catheter 
 of double curve, or to pass one from the opposite nostril. 
 
 In order to test the permeability of the tubes, the subsequent 
 examination of the membrana tympani and the patient's own 
 sensations become important evidences. The membrana tym- 
 pani may become reddened by the mere application of instru- 
 ments to the external canal, and to the mouth of the tube, so 
 that we must be careful to exclude such sources of error. 
 
 The diagnostic tube of Toynbee, by means of which we listen 
 to the sounds of the air passing through the tube up to the drum- 
 head, is also thought by many to be of assistance in determining 
 the patency of the tube and the size of the cavity of the tym- 
 panum. 2 Kramer claimed to determine, by the use of the diag- 
 nostic tube, the character of "exudation" and the width of the 
 tube. If there is a piercing (durchgehendes), near, rattling, vesic- 
 ular sound, he then diagnosticated the existence of a free exu- 
 dation. If, however, a sonorous, near, vesicular sound, it is 
 proof that there is no free exudation ; if there is a distant, muf- 
 fled, vesicular sound, then we are dealing with sub-mucous exu- 
 
 1 Transactions of the American Otological Society, 1870. 
 
 2 See engraving on page 73.
 
 374 DIAGNOSTIC TUBE. 
 
 dation, which is united to free exudation, and so -on. I only 
 quote these from the last edition of Kramer's book, to show to 
 what lengths a man may go in riding a hobby; for Kramer's 
 hobby was the diagnosis of the affections of the middle ear, by 
 the sounds heard through the diagnostic tube, caused by blow- 
 ing through his catheters. 
 
 The true value of the diagnostic tube is only in connection 
 with the other means that have been mentioned, the appearance 
 of the membrana tympani, and the patient's own sensations. 
 
 I think the diagnostic tube could well be dispensed with in 
 aural practice. Whether an Eustachian tube is pervious or not, 
 may be learned much more readily than by listening with the 
 diagnostic tube. The old ideas as to the importance of mere 
 permeability of the tube, have been properly lost sight of, in 
 the study of the nature of the inflammatory changes in the 
 calibre of the tube and in the tympanic cavity. I am unable to 
 get much light as to these points from the use of the tube. Yet 
 I must admit, that some of my colleagues, whose opinion I value 
 very highly, still use it. 
 
 PATHOLOGY. 
 
 After the clinical investigations of Kramer and Wilde, the 
 first great advance that was made in otology were the dissec- 
 tions of Toynbee. The museum of preparations illustrative of 
 diseases of the ear, in London, is a memorial to Joseph Toynbee, 
 that will be as enduring as scientific truth. From the time of 
 Toynbee until now, the dissection of ears of those who were 
 known to be deaf continues ; and from the labors of Von Troltsch, 
 Schwartze, Voltolini, Hinton, Gruber, Orne Green, Moos, 1 and 
 others, we have verified on the dead bodies diseases that have 
 been diagnosticated in the living one, but in many cases, we 
 have only learned, from the inspection of the ears of the ca- 
 daver, what is probably the condition of ears in life. 
 
 The pathological appearances in chronic catarrhal inflamma- 
 tion are 
 
 1. Collections of mucus or serum distending the cavity of the 
 tympanum. 
 
 2. Thickened mucous membrane. 
 
 3. Filling up of the cavity by lymph. 
 
 1 A Descriptive Catalogue of Preparations Illustrative of the Diseases of the Ear. 
 London, 1857. Archiv fur Ohrenheilkunde, Bd. I.-V. Monatsschrift fur Ohrenheil- 
 kunde. Guy's Hospital Reports. Gruber's Lehrbuch. Transactions American Oto- 
 logical Society. Moos' Klinik der Ohrenkrankheiten. Wendt, quoted by Schwartze, 
 Pathology of the Ear, p. 106.
 
 PATHOLOGY. 75 
 
 PATHOLOGY OF PROLIFEROUS INFLAMMATION. 
 
 In the form of inflammation that shows a higher formation 
 than the catarrhal, there are changes which may have resulted 
 directly from the increase of secretion ; but the stage of catarrh 
 having completely passed over, or, in some cases, never having 
 existed, these pathological appearances may be properly classed 
 together as evidences of what I have ventured to designate the 
 proliferous form. They are : 
 
 1. Connective-tissue formations in the cavity of the tym- 
 panum. 
 
 2. The mucous membrane of the tube covered by dense fibrous 
 tissue. 
 
 3. Hypertrophy of the bony walls of the tube. 
 
 4. Obstruction of the tube and cavity of the tympanum by 
 dense fibrous tissue. 
 
 5. The stapes bone completely and firmly anchylosed to the 
 margin of the fenestra ovalis. 
 
 6. An exostosis on the inner surface of the neck of the mal- 
 leus. 
 
 7. Malleus and incus anchylosed together. 
 
 8. Firm bands of adhesions in the mastoid cells. 
 
 9. False membrane on the tendon of the tensor tympani 
 muscle. 
 
 10. Partial obliteration of the cavity of the tympanum, by 
 adhesions of the membrana tympani to the labyrinth wall. 
 
 11. Hyperostosis of the petrous bone, and anchylosis of both 
 stapes. 
 
 12. Atrophy and fatty and fibrous degeneration of the tensor 
 tympani. 
 
 13. Thickenings and deposits of lime, and of large round cells 
 in the connective-tissue stroma of the fenestra rotunda. 
 
 14. Pseudo-membranous growths, sometimes filling the whole 
 cavity with an irregular network, and sometimes covering the 
 fenestra rotunda, and the tympanic orifice of the Eustachian 
 tube. 
 
 These are actual appearances of individual cases, taken from 
 Toynbee's catalogue and from the writings of the other authori- 
 ties whom I have mentioned ; some of them are perhaps con- 
 sequences of suppurative inflammation, although I have been 
 careful to exclude all cases in which there was loss of the mem- 
 brana tympani, or other positive evidence of a suppurative 
 process.
 
 376 NON-SUPPURATIVE INFLAMMATION CAUSES. 
 
 GruberV account of the pathology of otitis media hyper- 
 trophica is, that, "from some cause or other, there is first a 
 great hyperaemia with distention of the membrane, and in part 
 the new formation of blood-vessels, and increase of the inter- 
 cellular fluid. The connective-tissue corpuscles are increased. 
 The tissue of the inflamed mucous membrane is less moist than 
 in the catarrhal form. The new formations or new elementary 
 formations go on to a higher development. The most various 
 adhesions may occur, or a soft connective substance appears 
 which is either evenly spread over the whole portion that was 
 originally inflamed, and thus leads to hypertrophy of the mu- 
 cous membrane, or it may go on to granular formation. Many 
 of these new formations may also undergo regressive meta- 
 morphosis- they may undergo molecular disintegration, become 
 fatty, and be absorbed." 
 
 CAUSES. 
 
 I have endeavored, in recording the histories of about forty- 
 eight hundred cases of aural disease observed in private prac- 
 tice, to give the probable remote and proximate causes. These 
 are only to be obtained by a strictly observed system of cross- 
 questioning, since by far the greater number of patients ascribe 
 their disease to causes which are certainly very remote, if not 
 doubtful, and to others which have certainly had no influence. 
 Thus patients will assert that their loss of hearing results from 
 cold, when they cannot remember that they ever had a severe 
 cold affecting the ears, but -they conclude that it must have been 
 a cold ; others, again, declare that their throats have always 
 been well, that they seldom require to use a handkerchief, and 
 yet an examination will reveal a bad condition of the naso-pha- 
 ryngeal mucous membrane. 
 
 Judging as well as I am able, from my experience in public 
 as well as private practice, I am disposed to consider the follow- 
 ing as among the most probable causes of chronic non-suppura- 
 tive inflammation of the middle ear : 
 
 Remote. 1. A feeble state of the system, due, for example, to 
 inherited or acquired syphilis, phthisis pulmonalis, and so forth. 
 
 2. Defective hygienic management, e.g., neglect of bathing, 
 want of exercise in the open air, lack of proper food, care as to 
 dress, and so forth. . ' ; 
 
 Proximate. 1. Repeated attacks of acute catarrh of the phar- 
 ynx and middle ear, a disease popularly known as earache. 
 
 1 Lehrbuch der Ohrenheilkunde, S. 516. Wien, 1870.
 
 NON-SUPPURATIVE INFLAMMATION CAUSES. 377 
 
 2. Naso-pharyngeal inflammation. 
 
 3. Diseases of the lungs and bronchial tubes. 
 
 These proximate causes are chiefly to be made out in the 
 catarrhal form of chronic inflammation, while in the prolifer- 
 ous form, the practitioner is often greatly in doubt, as to what 
 may have been the origin or exciting cause of the insidious 
 affection which goes on so steadily to change of structure and 
 loss of function. Indeed, we are often obliged to be content to 
 acknowledge the fact of change of structure without being able 
 to definitely assign a cause for it. Why the changes that make 
 up a true case of proliferous inflammation, or one of a bastard 
 form in which the proliferous element predominates, continue 
 to advance in spite of treatment and of proper hygienic manage- 
 ment, is one of the most disheartening problems that a practi- 
 tioner who treats aural disease attempts to solve. It is not 
 strange, that cases of insidiously advancing impairment of hear- 
 ing, dependent upon illy defined, but positive causes, have ex- 
 cited the minds of physicians to adopt even what may appear to 
 be fanciful means for their cure. 
 
 The history of coryzas and earaches, and of chronic sorer 
 throats, is usually distinct enough in chronic catarrhal inflam- 
 mation, and even if there be no such history, then the appear- 
 ances of the pharynx, and the results of tactile investigation of 
 the tubes, are sufficient to allow us to determine just what kind 
 of a process has been going on. 
 
 It would be interesting to accurately trace the origin of these 
 proximate causes. We should find, I think, that the most of 
 them were due to neglect, or improper management ; for ex- 
 ample, the heads of some children are oftentimes vigorously 
 washed without being thoroughly dried they are allowed to 
 remain in water unduly long ; their legs and chests are left un- 
 covered in weather in which strong men are clad in beaver- 
 cloth, and women in furs ; they play about the streets, and sit 
 down, when tired and warm, on the damp and cold stone steps 
 of city houses ; they are held thoughtlessly by an open window 
 on a cold day ; they are warmly clad by day, but insufficiently 
 covered at night ; in short, the temperature of the body is not 
 properly regulated, and a pharyngeal catarrh passes in an in- 
 stant to the tympanic cavity, where it is an acute catarrh. If 
 the acute catarrh does not go on to suppuration, it is half re- 
 covered from under the use of anodynes applied to the outer 
 surface of the drum membrane ; in which and the tympanic 
 cavity a thickening is left which forms a good basis for a case 
 of gradual and mysterious middle -ear trouble, and with no 
 known cause. In large towns where the system of drainage or
 
 378 NON-SUPPURATIVE INFLAMMATION CAUSES. 
 
 sewerage is sometimes imperfect, foul air may be forced back 
 through the water-pipes, and becomes a cause, often unsus- 
 pected, of catarrhs of the worst type. 
 
 With older people a slight and neglected coryza or pharyn- 
 gitis is followed by a fulness in the ears, that " will wear away," 
 and which does wear away in part; but if it occurs in persons 
 who have no good hygienic habits in such matters as bathing, 
 eating and drinking, and so forth, it leaves behind a degree of 
 hyper-secretion or proliferation, which, as has been said, is the 
 foundation for repeated attacks, and, finally, of permanent 
 thickening and of adhesions. 
 
 The syphilitic catarrh of infants and young persons is the 
 frequent cause of an affection of the middle ear, which, unlike 
 its frequent companion, interstitial keratitis, is one of the worst 
 forms of disease in the obstinacy with which it resists all treat- 
 ment. The eyes may, and generally do, get well ; but, if once 
 the tympanic cavities be attacked, intra-auricular adhesions 
 occur, the membrana tympani is drawn inward, the nerve is 
 secondarily involved, and the loss of hearing often becomes al- 
 most complete. 
 
 There are no peculiar aural symptoms, by which we may 
 positively distinguish a case of chronic disease of the middle 
 ear that was caused by syphilis, from one occurring in a non- 
 syphilitic patient. Yet we may say, in general, that a syphi- 
 litic diathesis seems to cause the proliferation of tissue to be 
 more rapid and less amenable to treatment. Schwartze be- 
 lieves tha,t the pathological change in these syphilitic cases is a 
 periostitis, and this view seems to be correct. 
 
 Just how it is, that pregnant women are so often affected by 
 a proliferous inflammation of the middle ear, I am unable to 
 say ; but it is a fact, that many women have told me, that they 
 traced their impairment of hearing to their first pregnancy, and 
 that they became worse at the birth of each child. I am now in 
 the habit of warning such patients that great attention should 
 be paid to their throat and ears, by means of gargles and Po- 
 litzer's method, during the period of utero-gestation. It is the 
 proliferous form of inflammation, and not the catarrhal, which 
 I have usually observed during such cases. 
 
 Proliferous inflammation of the middle ear is often produced 
 by cerebro-spinal meningitis. In scarlet fever and measles, we 
 are more apt to have suppuration than in the former disease. 
 It has been supposed that disease of the internal ear, is more 
 frequently produced by cerebro-spinal meningitis, than that of 
 the tympanum and Eustachian tube. This, I think, is an error ; 
 but for a fuller discussion of this subject, I refer the reader to
 
 NON-SUPPUKATIVE INFLAMMATION CAUSES. 379 
 
 the chapter on "Deaf-Muteism." Parotitis also is a cause of 
 disease of the middle ear, but more frequently, perhaps, it af- 
 fects the labyrinth, if not exclusively, certainly in connection 
 with disease of the middle ear. This subject also will again be 
 alluded to. The excessive use of quinine may also, in rare in- 
 stances, cause incurable disease of the middle ear. 
 
 The causes given by patients themselves, taken from my 
 note-book, are as follows : ' ' Stuffy sensations in the head ; " 
 "going in the water very frequently;" "severe colds in the 
 head;" "when a child, the ears would stop up, and would not 
 hear well for a few days." The first manifestation was "a roar- 
 ing noise heard at night;" "chronic sore-throat;" "great deal 
 of earache;" "all the colds from which I suffer are in the head;" 
 " excessive grief;" "a sound like that of locusts was the first in- 
 dication of trouble;" "by accident discovered that I could not 
 hear from one ear;" "I have always had a great deal of sore- 
 throat;" "diphtheria;" "typhoid fever." One patient gave a 
 graphic account of a gradual loss of hearing from proliferous in- 
 flammation, in the following words : " Ten years ago I observed 
 that I could not hear the church-bells, and in four or five years 
 it began to be difficult for me to hear conversation." Another 
 ludicrously attributed his chronic catarrh to exercise upon a 
 gymnastic pole. Another was quite sure that it resulted from 
 great mental anxiety. These are fair specimens of the causes 
 Assigned by the patients or their friends for cases of the variety 
 sf aural disease now under consideration. Some of them are 
 far from being true causes, although the most of them may be 
 admitted as having at least placed the system in such a condi- 
 tion that catarrhal disease or proliferation of tissue was likely 
 to result. It is undoubtedly true, that any great mental depres- 
 sion may cause an attack of pharyngitis in a person disposed to 
 it, and that long continuance of such a state of mind will make 
 such an affection incurable. 
 
 We may, perhaps, sum up our knowledge of the causes of 
 chronic non-suppurative disease of the middle ear, by stating 
 that they are such as dispose to inflammation of mucous mem- 
 brane. Our increased knowledge of the pathology of this tissue, 
 will serve us in good stead in investigating the affections of a 
 part which is thoroughly lined by it.
 
 CHAPTER XIV. 
 
 CHRONIC NON-SUPPURATIVE INFLAMMATION OF THE MIDDLE 
 
 EAR (Continued). 
 
 Treatment of the Catarrhal and Proliferous Forms. Constitutional and Hygienic Appli- 
 cations to the Naso-pharyngeal Space. Nasal Douche. Cases of Acute Aural Disease 
 caused by its Use. Gruber's Method of Cleansing Nares. Politzer's Method. 
 Anatomy of Nasal Cavities. Nebulizers. Faucial Catheters. Removal of the 
 Tonsils. Treatment through the Eustachian Tube. Air. Steam. Vapors. 
 Fluids. Bougies. Electricity. Death from Improper Use of Catheter. Dura- 
 tion of Treatment. Prognosis. 
 
 IN the preceding chapter a table was given, showing at about 
 what time in the history of their disease, the patients from whose 
 cases it was made up, consulted the writer. It may be safely 
 asserted, that the most of these persons never underwent any 
 serious or rational local treatment until that time; so that we 
 may assume that the greater number of persons in the United 
 States who suffer from the form of disease under consideration, 
 are in the habit of waiting for a period of from five to twenty 
 years, before they attempt to get relief. 
 
 We must certainly diminish the number of these cases before 
 we can hope for brilliant results. The neglect of aural thera- 
 peutics by the last and the preceding generation now recoils 
 upon us. Patients come very late for advice about their ears, 
 because they have been taught, not by the laity, but by wise 
 and skilful physicians, that it is not prudent to meddle with the 
 ear ; that they will outgrow its diseases, as soon as their con- 
 stitution is invigorated; if young girls, that, when the men- 
 strual function comes on, their ears- will rapidly recover, and so 
 forth, while, during this time of delay, adhesions between the 
 membrana tympani and the ossicula, and the walls of the cavity 
 of the tympanum, have been forming, and hypertrophy of the 
 mucous membrane and atrophy of the tendons of the intra-auric- 
 ular muscles in short, all the changes have occurred, that we 
 have found may take place in the tympanum and drum-head. 
 
 In one respect the treatment of a catarrhal non-suppurative
 
 NON-SUPPURATIVE INFLAMMATION TREATMENT. 381 
 
 inflammation may be fairly distinguished from that of the pro- 
 liferous form. In the catarrhal form we must give a great deal 
 of attention to the naso-pharyngeal space, while in the other we 
 scarcely need to treat it. Perhaps we may classify the treat- 
 ment generally advised as follows : 
 
 1. Constitutional and hygienic. 
 
 2. Local blood-letting and counter-irritation. 
 
 3. Applications to, and operations upon, the naso-pharyngeal 
 space (chiefly applicable to the catarrhal form of the disease). 
 
 4. Applications to the Eustachian tube. 
 
 5. Applications to the cavity of the tympanum. 
 
 6. Cutting operations upon the membrana tympani and the 
 ossicula. 
 
 In the text-books of Wilde and Toynbee (books that have 
 deservedly had a wide circulation in this country, and have 
 done much to call attention to the ear) constitutional remedies 
 figure very largely in the treatment. The use of mercury and 
 iodide of potassium is strongly insisted upon. We, of the pres- 
 ent time, have grown very skeptical about the constitutional 
 treatment of such affections as chronic catarrhal, and prolifer- 
 ous inflammation of the middle ear. No thoughtful practitioner 
 will attempt to disregard the general indications of a cachexia, 
 or of a debilitated system, in which there is chronic inflamma- 
 tion of the mucous membrane of the middle ear ; but the time 
 has probably gone by when a person in fair health, suffering 
 from chronic aural catarrh, and who has no constitutional taint, 
 will be treated by alterative doses of the bichloride of mercury, 
 followed by the iodide of potassium. Ample experience has 
 shown that we can do nothing for these cases by such a treat- 
 ment, and I may say, that it has been abandoned in the infirma- 
 ries and hospitals, where large numbers of cases of aural disease 
 are seen. The constitutional symptoms of the earliest stages of 
 the disease were usually those of a coryza or acute catarrh, which 
 finally settled down into an insidious and chronic process, when 
 it has become impossible to trace the remote causes. 
 
 Of late, Dr. Theobald, of Baltimore, has warmly advocated 
 the constitutional treatment, that is to say, by internal medica- 
 tion, of the form of disease now under discussion, as well as of 
 chronic suppuration, and acute processes, but my opinions as to 
 the general inefficacy of drugs, under the limitations I have 
 given, have not changed since writing the above. Homoeo- 
 pathic practitioners attach great importance to the internal ad- 
 ministration of their peculiar medicines, in catarrhal and sup- 
 purative inflammations of the ear, but they seem to use all the 
 ordinary local means employed by the profession in general as
 
 382 NON-SUPPURATIVE INFLAMMATION TREATMENT. 
 
 well. Dr. Houghton ' recommends baryta muriatica, cotyledon 
 umbilicus, iodine lachesis, and mercurius dulcis, nux vomica (in 
 irritations of the mucous membrane of the middle ear, itching 
 in the Eustachian tube, provoking swallowing) for non-suppura- 
 tive inflammations of the middle ear as well as a host of rem- 
 edies for the other diseases of the ear. As an example of what 
 a belief in the specific value of internal remedies can produce, I 
 may quote : "As a remedy cinchona proves curative in these two 
 opposite conditions (congestion and anaemia), and acts upon both 
 cochlea and semi-circular canals." . . . Oelsemium in con- 
 junction with silicea, is said to have restored the hearing in 
 forty-eight hours in a case simulating cerebro-spinal meningitis 
 on the one hand, and simple labyrinth vertigo on the other. 
 
 In our northern climates, all people should wear flannel next 
 the skin, winter and summer, of course varying the thickness 
 according to the temperature and the strength of the individual. 
 Thick boots in the winter, and overshoes in the wet, are also 
 necessities for those who wish to avoid catarrhs. I also think 
 that the temperature of a sleeping-room should not be allowed 
 to go down at night to a point below 65 to 68 F. ; these rules are 
 especially applicable to persons disposed to inflammations of the 
 naso-pharyngeal space and ears. A whole chapter might easily 
 be written upon this subject of personal hygiene. These hints, 
 however, will be sufficient to induce the practitioner to give 
 special attention to the subject in prescribing for chronic and 
 advancing aural disease. 
 
 The causes of these forms of disease suggest a kind of con- 
 stitutional treatment, which should never be lost sight of. 
 Everything that will render a patient more vigorous, and less 
 likely to take cold, will assist materially in curing or alleviating 
 a chronic aural catarrh. We shall thus find much to do, in the 
 way of correcting improper habits of life, in regard to bathing, 
 exercise in the fresh air, ordinary clothing, sleeping apparel, and 
 the like. Hence the Turkish bath, 4 sponge-bathing, walking, 
 riding, boat-rowing, the general application of electricity, the 
 internal administration of iron, and so forth, become prescrip- 
 tions which the otologist will be called upon to give very fre- 
 quently, if he properly appreciates cause and effect. It is only 
 against specific drugs, where there is no specific diathesis, 
 
 1 Homoeopathic Therapeutics in Aural Surgery. 
 
 2 The Turkish bath is one of the best means of keeping the circulation so equable 
 that catarrhs do not readily occur. It is not a good plan, however, to allow the head 
 to be wet, during the shampooing process that follows the hot-air bath, neither should 
 patients disposed to aural disease, take the cold plunge which is often given at the ter- 
 mination of the whole process.
 
 TREATMENT OF PHAKYNX. 383 
 
 against a routine system of prescribing a constitutional remedy 
 in the vague hope that it may do good, that I have been speak- 
 ing. 
 
 The use of leeches in some cases of chronic catarrhal inflam- 
 mations that have sub-acute tendencies, is occasionally of value, 
 although they give no such marked relief as that which is 
 experienced in acute inflammation. When there are decided 
 symptoms of congestion, such as fulness and slight pain, a leech 
 may be applied on the tragus once a week, for four or five 
 weeks. Blisters are also of value in such cases. 
 
 TREATMENT OF THE PHARYNX. 
 
 The treatment of the pharynx may be classified as follows : 
 
 1. Injections of the naso-pharyngeal space. 
 
 2. Gargling. 
 
 3. Cauterizations. 
 
 4. Removal of the tonsils, large granulations, and of ade- 
 noid growths. 
 
 Injections of the naso-pharyngeal cavity by means of the 
 naso-pharyngeal syringe, and by Davidson's double-bulbed syr- 
 
 FiG. 85. Posterior Nares Syringe. 
 
 inge usually used for enemata, I have found very valuable in 
 the treatment of chronic catarrhal inflammation. The solutions 
 I use are common salt, permanganate of potash, gr. ad j., a 
 saturated solution of chlorate of potash, tar-water benzoate of 
 sodium, and so forth. Great masses of muco-purulent material 
 are often dislodged by this treatment, even in cases where ordi- 
 nary inspection does not show that any has collected. The 
 nasal douche is very frequently used for the purpose of cleans- 
 ing the naso-pharyngeal space, but it is a means of treatment 
 that is attended with considerable danger to the ear, even when 
 all proper precautions are taken. 
 
 The posterior nares syringe is made of hard rubber. It is a 
 very efficient and safe means of cleansing the pharynx and nos- 
 trils. In cases of acute inflammation of the pharynx attended 
 with considerable swelling, it should be used with care, or it 
 will abrade and irritate the mucous membrane of the posterior 
 pharyngeal wall. This abrasion may then lead to an extension
 
 384 NASAL DOUCHE. 
 
 of the inflammation along the tube, to the tympanic cavity. In 
 chronic cases I have never seen or heard of any harm being 
 done by the posterior nares syringe. 
 
 Davidson's syringe is also a safe and useful instrument for 
 
 FIG. 86. Davidson's Syringe, with a Nozzle to go below the Soft Palate. 
 
 cleansing the nares. It may be used anteriorly or posteriorly. 
 Of late years, I use it more than I do the posterior nares syringe. 
 
 THE NASAL DOUCHE. 
 
 I have published several cases that illustrate the dangerous 
 consequences that may result to the ear from the use of the 
 nasal douche, and I was the first writer to call attention to 
 this subject. The appliance is so convenient of application, 
 and it is thought to be so thorough in its work of cleansing 
 the nostrils and pharynx, that many are very loth to abandon 
 it. I am of the opinion, however, that its use should be dis- 
 countenanced by the profession. Various criticisms have been 
 made upon the published cases of injury to the ear from the 
 use of the douche, but I believe- that they have been fully met, 
 and that most of the otologists on this side of the water, are 
 agreed that the nasal douche, even when employed with all 
 proper precautions, has produced serious aural symptoms in 
 quite a large number of cases. The harmful results are prob- 
 ably due to the entrance of a large quantity of fluid, in a flood, 
 as it were, into the cavity of the tympanum along the Eusta- 
 chian tube, and necessarily in a direction contrary to the motion 
 of its ciliated epithelium. 
 
 The use of the nasal douche was first suggested by Professor 
 Theodore Weber, of Halle, Germany, and is based upon a phys- 
 iological fact that was first promulgated by Dr. E. H. Weber, 
 of Leipsic, in 1847. This fact is, that when one side of the nasal 
 cavity is entirely filled with fluid by hydrostatic pressure, while 
 the patient is breathing through the mouth, the soft palate com- 
 pletely shuts off the superior naso-pharyngeal space from the 
 mouth, and does not permit any of the fluid to pass downward.
 
 NASAL DOUCHE. 385 
 
 The fluid then parses into the opposite nasal cavity, and escapes 
 through the nostril. Professor Theodore Weber suggested the 
 use of a cup, to the bottom of which was attached a bit of rub- 
 ber tubing, for the purpose of taking advantage of this physio- 
 logical principle. The fountain syringe is now generally used 
 instead of the cup. Dr. J. L. W. Thudichum brought this appa- 
 ratus to the notice of the English-speaking profession, 1 and made 
 it more convenient, so that in America it has acquired the name 
 of Thudichum's douche. It should, however, be called Weber's 
 douche. 
 
 As early as 1869, I had found that the nasal douche was 
 sometimes a troublesome and dangerous appliance, and I added 
 a note to indicate this, in my translation of " Von Troltsch on 
 the Ear" (second edition, . page 369) ; but I was not fully con- 
 vinced that it would readily cause acute aural inflammation, 
 until the following case occurred in my practice. The case has 
 been amplified from the first record that appeared, 2 in order to 
 avoid the reiteration of explanations, that the criticisms upon 
 the case in the Monatsschrift fur Ohrenheilkunde, and by Pro- 
 fessor Elsberg, compelled me to make. 
 
 Case of Otitis Media Purulenta, and Pyaemia, from the Use of the Nasal 
 Douche. On December 12, 1868, 1 was consulted by a clergyman, forty-nine years 
 of age, in regard to a sub-acute catarrh of the middle ear, affecting both sides 
 of the head. The history of the patient was as follows : Some years before, he 
 was attacked with what seemed to be hay fever, or a form of coryza attacking 
 certain persons during the summer. This coryza became a chronic catarrhal 
 inflammation of the naso-pharyngeal space, attended by the usual symptoms 
 a sense of stuffiness of the nostrils, frequent expectoration of glairy mucus, 
 sneezing, and so forth. For the past two months the patient has been in the 
 daily habit of using Weber's nasal douche, for the purpose of cleansing the 
 nostrils and of introducing remedial agents into them. He had once before 
 tried this means of treatment, but it had caused such unpleasant feelings in 
 the ears that he was obliged to desist from employing it. A warmer solution 
 was always used in the douche, and it was employed under the direction of a 
 physician who was probably well aware of Dr. Thudichum's directions, and took 
 all the precautions which he advises in his pamphlet. This fact is mentioned, 
 because the advocates of the douche claim that it never does harm when properly 
 employed. Dr. Thudichum advises that a solution of salt and water, or milk 
 and water, but never pure water, should be used, as did Professor Weber some 
 time before. The patient was also instructed to breathe through the mouth, 
 and Dr. Thndichum observed that very often patients became confused, strag- 
 gled, breathed through the nose, and defeated the plan. It is during this ex- 
 citement, that the accident of entrance of fluid into the ear seems usually to 
 occur. For about two weeks these unpleasant sensations on using the douche 
 
 1 On Polypus in the Nose and Ozoena. London, 1869. Lancet, November 24, 1864. 
 1 Archives of Ophthalmology and Otology, Bd. I. 
 25
 
 386 NASAL DOUCHE. 
 
 have been again experienced. The patient complains of being deaf, and of hav- 
 ing a full sensation in both ears, almost amounting to pain. The membrana 
 tympani of each side is found to be reddened. An ordinary ticking watch, 
 heard by a person with normal hearing power about six feet, is only heard when 
 placed in contact with the auricle of each side. A leech was applied to each 
 ear, on the tragus, the Eustachian tubes were rendered pervious by means of the 
 catheter and Politzer's method. In a few days the membrana tympani assumed 
 a normal appearance, and the hearing was restored by means of this treatment. 
 The patient then desired that an attempt should be made to relieve the trouble 
 in the naso-pharyngeal region. The uvula and tonsils were relaxed, the whole 
 mucous membrane of the upper pharyngeal space secreted excessively, and the 
 patient had contracted a habit of constantly endeaving to clear his nostrils. 
 Fluids passed through the left nostril, but none through the right. The Eus- 
 tachian catheter, however, passed without difficulty. The nostrils were cleansed 
 by means of a nebulizer, salt and water being used in it, after which the parts 
 were swabbed out with a solution of arg. nit., gr. x. ad j. The patient improved 
 under this treatment until January 28th, when he was for some time exposed to 
 the air of a winter's day, with the head uncovered (at the consecration pf a 
 bishop), when the symptoms, which had been to a certain extent relieved, re- 
 turned. 
 
 January 31st. A gelatinous mass was found plugging up the inferior meatus 
 of the right nostril, seeming to be attached to the floor of the canal. Portions 
 of this were removed by torsion, at intervals of about three days, until Saturday, 
 February 6th, when what seemed to be the remainder of this growth was re- 
 moved. The patient left the office, saying that his nostril was much clearer, 
 and went to Yonkers, a city about fifteen miles by rail from New York. There 
 he again used the nasal douche, and again experienced a decidedly iinpleasant 
 sensation in his ears, which, however, did not amount to pain. On Sunday 
 morning and evening the patient performed his clerical duties, but with a great 
 sense of languor and uneasiness. On Sunday night, February 7th, at about 11 
 o'clock, he was awakened by a severe pain in the mastoid region of the right ear, 
 which kept him from sleep. I saw him Monday morning, at about 8 o'clock, 
 and noted the following symptoms : The countenance was anxious and flushed, 
 the skin hot, pulse about 96, right mastoid region red and sensitive, right mem- 
 brana tympani reddened, watch only heard when pressed upon the auricle. 
 The patient was asked as to the condition of the left ear ; but he said there 
 was no trouble there. An examination of the tragus and mastoid process failed 
 to exhibit any symptoms of inflammation in that ear. Two leeches were or- 
 dered to be applied to the mastoid process, and the patient was to take aq. 
 acetat. amm. At 5 P.M., the pain in the ear had entirely ceased after the appli- 
 cation of the leeches. The patient was breathing hurriedly, however, his 
 pulse was weak and frequent about 96 and he complained of pain and ten- 
 derness in the abdominal region. Morph. sulph., gr. , was ordered to be taken 
 pro re nata, and a poultice was applied over the abdomen. Tuesday, February 
 9th. The patient took two powders of morphine, and passed quite a comfortable 
 night. This morning he complains of pain in the forehead, but has none in any 
 other part of the body. The surface of the body is dry and hot. Ordered aq. 
 acetat. ammon. and nutritious diet. February 10th. Last night the patient was 
 attacked by a severe pain and swelling of the left foot, and at about 7.30 A.M. 
 lie had a severe chill, lasting about fifteen minutes, not followed by sweat-
 
 NASAL DOUCHE. 387 
 
 ing. At this time a discharge appeared from the left ear. There has been no 
 pain experienced in this part. He has not slept well, and his general appear- 
 ance is bad. Countenance anxious ; breathing labored ; pulse 96. The left 
 ankle and dorsal region of foot are red, greatly swollen, and tender. Left mem- 
 brana tympani ulcerated and discharging freely. 
 
 Dr. Foster Swift was called in consultation, and the following treatment 
 agreed upon : The foot was wrapped in an alkaline lotion. Vichy water was 
 given ad libitum, with beef-tea and wine ; morphine pro re nata. February 
 llth. Patient does not seem so well ; respiration is hurried ; the intellect is 
 somewhat clouded ; pulse about the same ; face of a sallow hue. The stimu- 
 lants are increased, so that he now takes half an ounce of brandy in milk 
 punch every four hours, day and night. Quin. sulph., gr. ij., every four hours. 
 The left ear is syringed with lukewarm water, zinc, sulph. applied, and Polit- 
 zer's method used to inflate the drums. The patient is so deaf that he only 
 hears when spoken to near the ear. 
 
 The patient was treated in this manner, until February 22d, the brandy punch 
 being steadily increased until he was taking two ounces every four hours, with 
 beef-tea, eggs, etc. His pulse was never over 100, usually about 96 ; the skin 
 had a saffron hue, and patient lay in a doze, except when the pain from his foot 
 kept him awake nearly the whole time. 
 
 Dr. George A. Peters, Surgeon to the New York Hospital, was called in con- 
 sultation a few days ago, in addition to Dr. Swift and myself, and to-day two 
 openings were made in the foot, one near the internal, and one near the external 
 malleolus. Pus was evacuated ; the dorsal region of the foot was very much 
 swollen, but no fluctuation was detected. The patient's general condition is 
 now better ; his countenance less anxious ; the respiration is not so hurried. 
 The urine was several times carefully examined during the treatment. No ab- 
 normal condition was found, beyond an acid reaction early in the course of the 
 disease. The heart was also examined, and no organic changes were found. 
 Several openings were made in the foot from time to time ; but the patient slowly 
 improved from this time until March 16th, when he was able to sit up. The 
 membrana tympani healed, and the hearing distance became about one foot on 
 the right side, and four to six inches on the left. Conversation is heard with 
 ease. Politzer's method has been practised every two days. Quinine and iron 
 have been taken in addition to the stimulants. The foot is still swelled, but aJJ 
 the openings except two have healed. April 4th. The patient has been going 
 about the house for a week. Hearing power is still further improved. A little 
 erysipelatous soreness of the foot occurred last night. The naso-pharyngeal 
 catarrh is completely gone. April 7th. Patient rode out to-day, and gets about 
 the house, employing himself in intellectual labor. Tissues of the foot still 
 swelled and rigid ; motions of the ankle-joint unimpaired. 
 
 1884 I am in the habit of seeing this patient quite often. He is still in 
 excellent health, but a very little lame from the inflammation of the foot. 
 
 The late Professor Elsberg, of this city, published a paper l 
 in which he claimed that an analysis of the cases that had been 
 published, of harm to the ear from the use of the douche, showed 
 
 ' Archives of Ophthalmology and Otology, vol. ii. , p. 77.
 
 388 
 
 NASAL DOUCHE. 
 
 that the cause was uncertain. Dr. Elsberg, has had a large ex- 
 perience in treating diseases of the pharynx, and although he 
 has prescribed and employed the douche in more than 1600 cases, 
 he has seen none of the results that I have observed. I can only 
 explain this by the presumption, that when an accident to the 
 ear occurs, the patients are more apt to consult a person who is 
 in the constant habit of treating aural disease, than to go on with 
 the treatment of the nasal catarrh. Besides, as it is believed by 
 many otologists, it is possible that the douche sets up a chronic 
 inflammation of the tympanic cavity, without any acute stage, 
 and thus the true cause of an insidious chronic catarrh is passed 
 
 PIG. 87. Vertical Section of Bones of Face (posterior half, two-thirds size. From Pro- 
 fessor Darling's museum). 1, Orbit; 2, temporal fossa; 3, antrum ; 4, inferior meatus ; 5, 
 middle meatus ; 6, superior meatns ; 7, zygomatic process ; 8, clinoid process of sphenoid 
 bone; 9, septum nasi ; 10, inferior turbinated bone ; 11, superior turbinated bone; 12, alveolar 
 process ; 13, ethmoid cells. 
 
 over, and is supposed to be an advance of the naso-pharyngeal in- 
 flammation. Of course, it is not believed by the author, that the 
 use of the nasal douche will necessarily cause aural disease, but 
 that it is a dangerous means of treatment, which should be care- 
 fully watched by the practitioner. 
 
 I append, from a paper previously published, an analysis of 
 cases in which serious results have occurred. 1 Were it expe- 
 dient to further extend the discussion of this subject, I could 
 add several more, for I am constantly hearing of them from my 
 professional friends, and seeing them in my own practice. 
 
 Loc. cit., voL Hi., No. 1.
 
 NASAL DOUCHE. 389 
 
 Injury to the Ear from the Use of the Nasal Douche. 
 
 Patient. 
 
 Instructor ' in use 
 of douche. 
 
 Fluid need. 
 
 Ear disease pro- 
 duced. 
 
 Case I. Rev. Dr. C. 
 
 A physician. 
 
 A warm solu- 
 
 Acuta otitis media sup- 
 
 
 
 tion of car- 
 
 purativa. Pyaemia. 
 
 
 
 bolic acid. 
 
 Recovery. 
 
 II. Dr. Frank. 1 
 
 Dr. Frank. 
 
 Cold water, 
 
 Acute otitis media. Re- 
 
 
 
 which he ad- 
 
 covery. 
 
 
 
 vises in all 
 
 
 
 
 cases. 
 
 
 HI. Mr. D. 
 
 Dr. Boosa. 
 
 Warm solution 
 
 Perforation of both 
 
 
 
 of salt and 
 
 membranae tympani. 
 
 
 
 water. 
 
 Recovery. 
 
 IV. First of Dr. C. 
 
 A physician. 
 
 Warm solution 
 
 Otitis media suppura- 
 
 I. Pferdee's 3 
 
 
 of salt and 
 
 tiva. N ecrosis of 
 
 cases. 
 
 
 water. 
 
 middle ear. Perma- 
 
 
 
 
 nent deafness. 
 
 V. Second of Par- 
 
 A physician. 
 
 Salt and water. 
 
 Acute otitis media. Re- 
 
 dee's 3 cases. 
 
 
 
 covery. 
 
 Medical student. 
 
 
 
 
 VI. A Physician. 
 
 A physician. 
 
 Unstated. 
 
 Otitis media suppura- 
 
 
 
 
 tiva chronica. 
 
 VH. Patient at Man- 
 
 Unknown. 
 
 Unknown. 
 
 Otitis media acuta. Re- 
 
 hattan Eye and 
 
 
 
 covered. 
 
 Ear Hospital. 
 
 
 
 
 Vni. Mrs. C. Dr. 
 
 A physician. 
 
 Warm fluids. 
 
 Otitis media acuta. Re- 
 
 ^Mathewson's 
 
 
 
 covered. 
 
 'case. 
 
 
 
 
 IX. Dr. Hackley's 4 
 
 Unknown. 
 
 Warm salt 
 
 Otitis media suppura- 
 
 case. 
 
 
 water. 
 
 tiva chronica, super- 
 
 
 
 
 vening on old per- 
 
 
 
 
 forations. 
 
 X. Dr. Piffard's 6 
 
 Unknown. 
 
 Warm fluids. 
 
 Otitis media acuta. Re- 
 
 case. 
 
 
 
 covery. 
 
 XI. Judge . 
 
 A physician. 
 
 Unknown. 
 
 "Deafness." Recovery. 
 
 XII. Dr. Loring's" 
 
 A physician. 
 
 Warm fluid. 
 
 Otitis media suppura- 
 
 case. 
 
 
 
 tiva chronica. 
 
 Xin. Physician. 4 Dr. 
 
 A physician. 
 
 Unstated. 
 
 Otitis media acuta. Re- 
 
 Mathewson's 
 
 
 
 covery. 
 
 second case. 
 
 
 
 
 XIV. Physician. 4 Dr. 
 
 A physician. 
 
 Unstated. 
 
 Otitis media subacuta. 
 
 Mathewson's 
 
 
 
 
 third case. 
 
 
 
 
 XV. Physician., 
 
 A physician. 
 
 Warm salt 
 
 Fainting and otitis me- 
 
 
 
 , water. 
 
 dia catarrhalis. 
 
 XVI. Dr.O. D.Pome- 
 
 Dr. Pomeroy. 
 
 Warm salt 
 
 Otitis media suppura- 
 
 roy's case. 4 
 
 
 water. 
 
 tiva. 
 
 1 The name or profession of the instructor is given, in order to meet the point made 
 by the advocates of the douche, that no harm occurs when it is properly employed. 
 8 Archiv fur Ohrenheilkunde, Bd. V., p. 202. 
 
 3 The Medical Gazette, vol. vi., No. 23. Medical Record, February 1, 1870. 
 
 4 Reported in Archives for Ophthalmology and Otology, vol. iii., No. 2. 
 
 6 Reported by Dr. Pardee, loc. cit. b Verbal report to writer. 
 
 Dr. Pardee, in his paper in the Medical Gazette, claims that the douche is an in- 
 efficient, as well as dangerous instrument. He does not think that the conformation 
 of the nasal passages, allows of their being cleansed by such a flood of water as comes 
 from the douche.
 
 390 
 
 NASAL DOUCHE. 
 
 I am happy to say that since the publication of my warnings 
 against the use of the nasal douche, on account of its danger to 
 the ears, it has been very generally abandoned, and, when re- 
 commended, it is with many admonitions as to care in its em- 
 ployment. Since my publications on the subject, many other 
 writers have urged the profession to cease to recommend it. 
 Among them may be mentioned Buck, Pardee, Knapp, Beverley 
 Robinson, Shaw, Rumbold, Cornwall, and others. Buck ' makes 
 the assertion, in which I fully agree, that ''the introduction of 
 a fluid into the nasal passages in a sufficiently large quantity 
 
 PlG. 88. Vertical Section of Bones of Face (anterior half, two-thirds size. From Pro- 
 fessor Darling's museum). 1 , Anterior cranial fossa ; 2, orbit ; 3, malar process ; 4, alveolar 
 process ; 5, inferior meatus ; 6, middle meatus ; 7, inferior turbinated bone ; 8, superior tur- 
 binated bone ; 9, septum nasi ; 10, antrum ; 11, crista galli ; 12, ethmoid cells. 
 
 to bathe the orifice of the Eustachian tube (no matter by what 
 method it is introduced) is not wholly free from the danger of 
 setting up an inflammation of the middle ear" 
 
 On the other hand, such good authorities as Cassell" and 
 Burnett 3 still recommend the douche, if used with care. 
 
 Politzer 4 admits that, with all precautions, it sometimes hap- 
 pens; "chiefly in consequence of an involuntary habit of swal- 
 lowing," that fluid enters into the middle ear and causes evil 
 effects. Politzer, therefore, pours medicated solutions into the 
 
 1 Medical Record, March 24, 1877. 
 
 8 New York Medical Journal, October, 1877, quoted from Dublin Journal Med. 
 Sciences, June, 1877. 3 Text-book, p. 407. 4 Text-book, translation, p. 314.
 
 GRUBER'S METHOD. 391 
 
 nose "by means of a boat-shaped glass vessel," while the head 
 is inclined backward. The patient is told to bend his head for- 
 ward quickly the moment he is conscious that the fluid has 
 entered his pharynx. The fluid, in consequence of the closure 
 of the lower part of the pharynx, has already entered the other 
 nostril, and then it will escape freely. The patient should not 
 blow his nose until a quarter of an hour after the medicated 
 fluid is used. This method is an awkward one. I recommend 
 rather the use of Davidson's syringe as a cleanser, and that the 
 medicated applications be made by a coarse spray, or by cotton 
 on a cotton-holder properly curved. 
 
 Gruber's Method. 
 
 Gruber adopts a method of cleansing and medicating the 
 naso - pharyngeal space, for which he claims superiority over 
 the naso-pharyngeal syringe and the nasal douche. He also 
 claims that his method of treatment was promulgated a year 
 before the nasal douche was introduced to the profession that 
 is, in 1863, at a meeting of the medical profession in Vienna. 
 But Gruber spoke of his method only with reference to aural 
 disease, ' while Weber's nasal douche was recommended as a 
 means of treating the nares. Gruber's method consists in the 
 use of a two-ounce hard-rubber aural syringe, the nozzle of 
 which is well rounded off, in the following way : The syringe is 
 filled with the fluid to be injected and placed in one nostril. 
 The fluid is then forced with more or less vigor into the nostril, 
 the other being closed with the finger, if the operator desires to 
 inject the Eustachian tubes, but left open if the intention be to 
 simply inject the naso-pharyngeal space. " In the force with 
 which I empty the syringe, in the more or less perfect closure 
 of the other nasal meatus, are found the factors which more or 
 less favor the entrance of fluids through the tubes. The latter 
 effect may also be increased, after the syringe is removed, by 
 causing the patient to perform the Valsalvian experiment." ' 
 
 Gruber believes that it is the root of the tongue, as well as 
 the soft palate, that by instinctive contraction and lifting up- 
 ward shuts off the superior from the inferior pharyngeal space, 
 and prevents fluids injected by the nasal douche or by his 
 method from passing downward. This statement is proved by 
 the fact that when the soft palate is destroyed by ulceration, 
 the fluid may be made to pass out of the other nostril, as well 
 as if the palate were sound. 
 
 Monatsschrift fur Ohrenheilkunde, Jahrgang VI., Xo. 4.
 
 392 NASAL DOUCHE. 
 
 Gruber deprecates much instruction to the patient as to how 
 he shall breathe, or hold his palate, during the injection of the 
 fluid, but he prefers to leave him to his own instincts. I am 
 also convinced, that instruction to patients as to how they should 
 behave while applications are made to the naso-pharyngeal 
 space are useless. I inform my patients that they may act as 
 they please. A fluid should be used which will do no harm if 
 some of it pass into the stomach. 
 
 Dr. Gruber fully corrobates my views that the harmful effects 
 of the nasal douche, are due to the entrance of the fluid into the 
 middle ear, and he shows that however proper it may be to in- 
 tentionally inject fluid in small quantities into a diseased cavity 
 of the tympanum, it is manifestly incorrect to force it into an 
 ear that was previously healthy, with no restriction as to quan- 
 tity, as is done in the use of the nasal douche. 
 
 FIG. 89. Nebulizer for Nostrils and Pharynx. 
 
 "The current from the nasal douche is continuous, even when 
 the cavity of the tympanum is already full ; the fluid in the 
 pharynx attempts more and more to enter into the middle ear, 
 and when the pressure is very great, rupture of the membrana 
 tympani may occur. I have often seen ecchymoses on the mem- 
 brana tympani, that were caused by the nasal douche." ' 
 
 I believe the posterior nares syringe, the Davidson's syringe, 
 and the nebulizer have nearly, if not quite, supplanted the nasal 
 douche. 
 
 The solutions that may be used with benefit as gargles are, of 
 course, very numerous. The gargle that I most frequently pre- 
 scribe is a saturated solution of chlorate of potash, or benzoate 
 of sodium, 3 j. to the pint. Where there is much granular pha- 
 ryngitis, a gargle containing iodine, will probably be more effi- 
 cacious. I am in the habit of advising patients suffering from 
 chronic disease of the middle ear, suppurative or non-suppura- 
 tive, to use a gargle of cold water, by Von Troltsch's method, as 
 long as they live. The gymnastic exercise of the muscles of the 
 
 1 Gruber, loc. cit, No. 8.
 
 NEBULIZERS GARGLING. 393 
 
 Eustachian tube, is by no means an unimportant means of treat- 
 ment. 
 
 Gargling is a very efficient means of cleansing the pharynx, 
 if it be performed in the manner advised by Von Troltsch. The 
 fluid is held in the back part of the mouth, the head being thrown 
 well back, the nostrils closed by the fingers, and then the motion 
 of swallowing is performed. With a little practice, the patient 
 will become very proficient in this method. Those who are skep- 
 tical as to the virtue of gargling, and who claim that the process 
 does not cause the fluid to wash the pharynx, will be convinced 
 of the contrary by the following simple experiment : Let the 
 posterior wall of the pharynx be painted with the tincture of 
 iodine, and then a gargle of starch-water be used in the manner 
 described, and the characteristic reaction will be found in the 
 ejected fluid. 
 
 Treatment of the mouths of the Eustachian tubes, and of the 
 posterior pharyngeal wall, is of great value in the treatment of 
 catarrh of the middle ear. I usually use a solution of sulphate 
 of zinc, of five grains to the ounce, in a nebulizer. I also employ 
 nitrate of silver in weak solutions, from one to five grains to the 
 ounce. I seldom use strong solutions by means of a spray, but 
 when I- wish to use nitrate of silver in a solution stronger than 
 five grains, I find the application more safely made by means of 
 a properly curved cotton-carrier. I am using strong solutions 
 for simple catarrhal cases less and less, but I rely upon thorough 
 and frequent cleansing by Davidson's syringe and a coarse spray. 
 In the nebulizer I use a solution known as Dobell's solution very 
 much. 
 
 IjL Acid, carbol gr. vi. 
 
 Soda Bi. Borat ) - - .. 
 
 ct J T_ i C <* ft r - Xll. 
 
 Soda bicarb ) 
 
 Glycerin 1 j. 
 
 Aquae ad 3 vi. 
 
 M. 
 
 These applications are not very unpleasant, and they are 
 certainly very efficient in diminishing secretion, and in changing 
 the character of tissue. The use of the solid stick is very un- 
 pleasant to the patient, and is, I think, to be avoided. 
 
 Dr. O. D. Pomeroy, who has done much to introduce the ni- 
 trate of silver treatment of the pharynx in aural disease, uses a 
 peculiar instrument for making applications to the mouth of the 
 tube, and for inflating the cavity of the tympanum. 1 Although 
 
 1 Transactions of American Otological Society, 1872.
 
 394 FAUCI AL CATHETER. 
 
 Dr. Pomeroy names his apparatus a faucial catheter, I am in- 
 clined to think that its chief value is as a means of making appli- 
 cations to the mouth of the tube, and not of inflating the middle 
 ear. 
 
 The instrument consists of a hard-rubber tube, seven and a 
 half inches in length. Its breadth at its proximal extremity is 
 one-fourth of an inch, but it lessens toward the beak, which is a 
 little more than one-eighth of an inch in thickness. The proximal 
 extremity has a lip for the adjustment of a rubber tube. At 
 about an inch and a half from this is a perpendicular guide, 
 placed in an opposite direction to the beak of the instrument. 
 This guide serves to show the direction of the beak of the instru- 
 ment when in position. The curved portion of the tube is one 
 inch and three-sixteenths in length. At a line or a line and a 
 half from the end of the beak, is an aperture of the calibre of a 
 No. 1 Bowman's probe, for the injection of air or fluids. This 
 aperture is so placed, as to cause the air or fluid to be thrown 
 from the operator, or in the axis of the Eustachian tube. Air is. 
 injected into the mouth of the tube by simply compressing the 
 air-bag, when the catheter is in position. Fluids, of which a 
 drop or two are sucked up at each application into the beak of 
 the instrument, are forced into the tube, in the form of a fine 
 spray. 
 
 Dr. Pomeroy thinks that the use of this instrument is ordi- 
 narily simpler than the employment of Politzer's method ; but 
 in this view I cannot coincide and as a catheter, I hardly think 
 it will take the place of an instrument introduced through 
 the nose. The verdict of the profession has hitherto been for 
 the method of Cleland, as against that of Guyot, and none of -the 
 faucial instruments have, as yet, reversed this judgment. The 
 faucial catheter of Dr. Cutter, 1 ingenious as it is, will hardly 
 supersede the catheter in ordinary use, which is, as has been 
 demonstrated, an efficient instrument, and one that in ninety- 
 nine cases out of a hundred is readily introduced, and with no 
 "guess-work," as has been said, but with an exact knowledge 
 of its position. 
 
 Sulphate of zinc, of alum, sesquichloride of iron in weak so- 
 lutions, Dobell's solution, and so on, may be used with advan- 
 tage by the patient himself during the treatment of naso- 
 pharyngeal inflammation. They are most efficient when used 
 in one of the nebulizers that are now so largely employed in the 
 treatment of the throat. 3 
 
 1 American Journal of the Medical Sciences, April, 1872. 
 
 * These nebulizers, to which so many different names are given, both here and 
 abroad, are actually modifications of Richardson's local anaesthesia apparatus.
 
 REMOVAL OF TONSILS. 
 
 395 
 
 REMOVAL OF THE TONSILS. 
 
 It will often be necessary to remove the tonsils, or at least to 
 greatly diminish their size, during the treatment of chronic 
 catarrh of the middle ear. It is not prob- 
 able, that the tonsils ever grow to such a 
 size that they press upon the mouth of the 
 Eustachian tube, as is sometimes supposed, 
 but they may be so large as to seriously 
 affect the breathing, the resonance of the 
 voice, and the health of the pharynx and 
 chest. Through the last-named influences, 
 enlarged tonsils may keep up or excite a 
 chronic inflammation of the middle ear. 
 I invariably advise their removal, when 
 they are large enough to have any of these 
 injurious effects, and also, when, although 
 only moderately large, they are frequently 
 the seat of inflammation, and are honey- 
 combed with the fistulae of former inflam- 
 matory processes. For their removal, I 
 usually use the tonsil bistoury here shown, 
 holding 'the tonsil forward by the forceps. 
 One assistant is generally needed, but in 
 many instances, in the case of those more 
 than thirteen or fourteen years of age, no 
 assistant is required. The patient will 
 often be willing and able, to hold his 
 tongue down by means of the handle of a 
 spoon or a tongue depressor. In some 
 cases, I use Mackenzie's guillotine, espe- 
 cially with very young children. I never 
 saw any alarming hemorrhage, either in 
 my own practice, or in that of my former 
 preceptor, Professor Post, in whose clinic 
 I have often seen this operation performed. 
 The only cases, in which I would hesitate 
 to perform excision of the tonsils, when it 
 is required, would be in that of a person 
 known or supposed to have a hemorrhagic 
 diathesis. I can but think, that with ordi- 
 nary care, it would be impossible to divide 
 a large artery. I apply tannic acid or 
 tincture of iodine after excision. I am ^^"j 
 not always able to remove, with the bis- Knife. 
 
 FIG. 91 Tea 
 sil Forceps.
 
 396 MOUTH-BREATHING. 
 
 toury, all of the tonsil that I desire to remove at one cut, but 
 it is very unusual for the patient to decline to have a second ex- 
 cision performed. 
 
 It has generally been observed, that persons having enlarged 
 tonsils, granular pharyngitis, adenoid vegetations, or nasal ob- 
 structions, breathe through the mouth. The reasons for this are 
 evident. Dr. Cassels ' has made mouth-breathing the subject of 
 an interesting paper entitled " Shut your Mouth and Save your 
 Life." He quotes largely from Catlin, celebrated as an observer 
 of the Indian tribes of this country, who denounced mouth- 
 breathing in no measured terms in his work upon this subject. 
 Catlin says : "If I were to endeavor to bequeath to posterity the 
 most important motto which human knowledge can convey, it 
 should be in three words, Shut your mouth." It is certainly of 
 the highest importance, that the mouth should be kept closed in 
 ordinary breathing, and if the conditions are favorable, that is 
 to say, if the nostrils and pharynx are healthy, this will always 
 be done. I have quoted Cassels' paper at this point, that Cat- 
 lin's remarkable statements as to the hearing power of the In- 
 dians of America may be noticed. Catlin claims to have visited 
 two millions of individuals, living in a savage state in 150 dif- 
 ferent tribes. Among this number, he found only three or four 
 deaf-mutes, and not another individual who was hard of hearing 
 or deaf. None of the chiefs of the tribes who were questioned 
 upon this point, could remember or find an Indian who was hard 
 of hearing, and Catlin further says, according to Cassels, that 
 not a mouth-breather was known to exist in all these tribes. 
 Dr. Ely wrote his friend, the late Lewis H. Morgan, known to 
 many of my readers as a distinguished ethnologist, as to the 
 correctness of Catlin's observations among the Indians, and he 
 received the following reply : 
 
 As a rule, so far as my observation has extended, the Indians are sonnd in 
 hearing and in vision, both senses being more acute than with us. I have seen 
 cases of sore eyes among the Western Indians and which may have been attended 
 with defects in hearing. At the time, I supposed the cases due to syphilis, 
 which has been a scourge upon some of the tribes. 
 
 If you were to select a hundred Indians at random, with a hundred white men 
 the same, you would, as I believe, find a larger number of the former sound- 
 headed, limbed, and sound in the physical senses than of the latter. Moreover, 
 on general principles this ought to be the fact. 
 
 Yours truly, 
 
 L. H. MORGAN. 
 
 P. S. Catlin was a good observer. 
 
 1 Reprint. Edinburgh: Oliver & Boyd. 1877.
 
 MOUTH-BREATHING. . 397 
 
 I have no doubt but that Catlin was correct as to mouth- 
 breathers among healthy Indians, but he overlooked the fact 
 that they were nose-breathers, not from habit, but because 
 they had healthy naso-pharyngeal spaces. Secure this for the 
 human race, and they will all breathe with the mouth closed. In 
 the writings of Catlin, and in Morgan's note, there seems to be 
 an overlooking of the fact, that Indians like the Spartans, may 
 have been the survival of the fittest. Delicate children, with the 
 snuffles, will probably survive in civilization, when Spartan ex- 
 posure, or a home in an American wigwam, would soon cut 
 them off. 
 
 A curette curved to pass behind the soft palate, is a very use- 
 ful means of treating granular pharynx or adenoid growths of 
 small size. The practitioner must not attach too much faith to 
 the local treatment of chronic conditions of the fauces, by nebu- 
 lizers, probangs, curettes, and the like, or he will sometimes 
 be grievously disappointed, and accuse himself of over-med- 
 ication. 
 
 THE TREATMENT OF THE NOSE. 
 
 Of late years the authorities in nasal disease have placed 
 great stress upon operations upon the nasal cavities, for the 
 purpose of overcoming narrowing, or occlusion. It is very com- 
 mon to find a deviated septum, and consequent narrowing of 
 the meatus of one side in persons who do not seem to be aware 
 that they have any trouble in the respiratory tract. Again, 
 as has been before observed, many patients suffer from nasal 
 occlusion from various causes, including even polypi, without 
 being aware of any impairment of hearing. In some cases they 
 have a marked nasal catarrh, hypertrophic or atrophic catarrh, 
 without an aural symptom. It is not reasonable to conclude, 
 therefore, that because a patient has chronic disease of the tym- 
 panum, and at the same time nasal obstruction, that the latter 
 is necessarily the cause of the aural disease. Even if it were the 
 primary cause, there are changes occurring in the tympanum, 
 especially in the joints of the ossicles, that will not be removed, 
 after operations upon the nasal cavities have completely restored 
 their normal calibre, orliave ameliorated or cured the catarrhal 
 condition. Morbid conditions, especially swelling of the mouths 
 of the Eustachian tubes, as Dr. Clarence C. Rice has shown 
 me, may be removed by treatment, and no change result in the 
 hearing power. Dr. Daly, of Pittsburg, read a paper before a 
 section of the New York Academy of Medicine, in which he af- 
 firmed that aural writers had neglected the relations between 
 the nose and ear in their treatment, but our literature as ex-
 
 398 t TREATMENT OF THE NOSE. 
 
 hibited in these pages, and those of other authors, does not 
 show this. Yearsley, Troltsch, Meyer, and Pomeroy have 
 dwelt -fully upon the subject, long before operations upon the 
 nose became common, but aural surgeons, for reasons that 
 have been already given, have not been enthusiastic about 
 invariable relief to the hearing from the removal of nasal 
 obstruction, however important it may be, to secure patency 
 of the nasal cavities on other grounds. Operations upon the 
 nose, even when performed under pressing indications, are 
 not without danger to the integrity of the ear, from an exten- 
 sion of the inflammation caused by the operations, to the tym- 
 panum. I have seen several cases of serious otitis media result- 
 ing from this cause and also mild cases of septicaemia. 
 
 The union of practice in nasal and aural disease is greatly to 
 be desired. Ophthalmology and otology have been united as 
 specialties in Ireland and the United States, ever since the days 
 of Sir William Wilde, but such a union is unnatural ; but every 
 aural specialist should be an expert in naso-pharyngeal practice, 
 and vice versa. The next generation will probably bring this to 
 pass, and there will be then no complaints that aural surgeons 
 neglect the thorough treatment of the nose, or that rhinologists 
 cannot always discriminate between an affection of the tym- 
 panum and one of the labyrinth. When rhinologists have ac- 
 quired a larger experience in diseases of the ear, they will not be 
 so confident, as some of them now are, of curing chronic aural 
 disease by removal of nasal stenosis. It may be questioned 
 whether the nasal cavities are not of more importance to respi- 
 ration and speech, than to the hearing. 
 
 THE TREATMENT THROUGH THE EUSTACHIAN TUBE. 
 
 Among the means employed in the treatment of the Eusta- 
 chian tube, the use of the Eustachian catheter stands pre-emi- 
 nent. It is difficult to say whether we treat the tube or the 
 cavity to which it leads by the means of this instrument. We 
 may often very much improve the hearing power of a patient 
 by the introduction of the instrument between the lips of the 
 tube, even when no air, vapor, or fluid is passed through it. 
 After such a procedure it is much more easy to inflate the ear 
 by Politzer's method. Some have rather hastily, as it seems to 
 me, concluded that all, or the greater part of the effect produced 
 by the catheter, might be had by applications to the mouth of 
 the tube, and have discarded this instrument ; but I become more 
 and more convinced after twenty years of pretty steady experi- 
 ence in its use, that the Eustachian catheter is essential in the
 
 STEAM THROUGH EUSTACHIAN TUBE. 
 
 399 
 
 treatment of chronic non-suppurative inflammation of the mid- 
 dle ear. The agents to be introduced through it are : 
 
 Atmospheric air, 
 
 Fluids, 
 
 Bougies, 
 
 Vapors, 
 
 Electricity. 
 
 I have placed common atmospheric air first, because I regard 
 it as the most important of the agents to be employed. It is, 
 however, not so efficient in chronic as in sub-acute or acute 
 aural catarrh, where its effects are almost magical. In fact, it 
 may be claimed, that there are no idiopathic affections for which 
 relief is so immediately obtained as acute catarrhal inflamma- 
 tion of the middle ear, where inflations of the tympanic cavity 
 
 FIG. 92. Apparatus for Steaming the Middle Ear. 
 
 with simple air are often sufficient to cause a patient, for whom 
 the world of sound is again open, to shed tears of joy. 
 
 Among the vapors employed, the vapor of water steam an 
 old remedy, is one of the best. 
 
 Dr. C. I. Pardee ' published a paper, in which he has care- 
 fully noted the results of six cases of the most obdurate va- 
 
 1 Transactions of the American Otological Society, 1870.
 
 STEAM THROUGH EUSTACHIAN TUBE. 
 
 riety of non-suppurative disease of the middle ear, and in all 
 of these there was marked improvement, both in the hearing 
 distance and in respect to the tinnitus aurium, by the use of 
 steam through the catheter. Dr. Pardee deduced from his cases 
 the practical lesson, that in the treatment of the disease of the 
 tympanic cavity, its condition of moisture or dryness should be 
 considered, and that when dryness exists, our therapeutic efforts 
 
 should tend to re-es- 
 tablish the normal se- 
 cretion. 
 
 I am in full accord 
 with Dr. Pardee's 
 proposition, and I do 
 not therefore use the 
 vapor of water in the 
 strictly catarrhal 
 cases, but in the pro- 
 liferous inflammation, 
 where adhesions ex- 
 ist, with rigidity and 
 hypertrophy of the 
 mucous membrane. 
 
 The apparatus re- 
 quired for the injec- 
 tion of steam into the 
 cavity of the tympa- 
 num, consists of the 
 following appliances : 
 1. An apparatus for 
 generating the vapor. 
 A nickel - plated 
 copper flask is the 
 best for this purpose, 
 although a glass flask 
 used over a sand-bath 
 will do very well. The 
 only objection to the glass flask is, that the flame may leap 
 beyond the level of the water in the flask, and break it, as has 
 often occurred to me. Two glass tubes are placed in the cork, 
 and a very minute opening for the escape of steam. A piece of 
 flexible rubber tubing is placed over each of the glass tubes. In 
 the free end of one of the tubes is a nozzle adapted to the Eu- 
 stachian catheter ; in the other a tip adapted to an ordinary air- 
 bag. 
 
 2. A hard-rubber Eustachian catheter. A metallic instru- 
 
 FIG. 93. Bottle for the Generation of the Vapor of Iodine. 
 An ordinary air-bag is used for forcing the vapor into 
 the catheter.
 
 IODINE AND CAMPHOR. 401 
 
 ment cannot be used, on account of its becoming too hot to be 
 borne. Many practitioners keep the catheter in place by a 
 holder ; but I always employ my fingers for that purpose. 
 
 The steam may be gotten up by a gas burner, as shown in 
 Fig. 92, or by an alcohol lamp. If gas is to be obtained, its use 
 is more convenient. The steam should be forced in by rather 
 a quick pressure upon the air-bag. A slow movement, since it 
 causes a longer application, is apt to burn the patient's nostrils 
 or pharynx. The nozzle should be removed from the catheter 
 after each puff. 
 
 While I still think that steam employed through the catheter 
 is a useful means of treating proliferous inflammation, I have 
 nearly given it up, and substituted the application of the vapor 
 of iodine and gum camphor, chiefly on the ground of conve- 
 nience. The latter may be more easily used, and its effects 
 are, I think, as useful. The practitioner may as well know, 
 however, before he undertakes these cases, as to learn it by 
 bitter disappointment afterward, that he will cure no cases of 
 chronic proliferous inflammation of the middle ear. All he can 
 hope for, is to alleviate some cases, and stay the progress of a 
 few others. But this subject of prognosis will be more fully 
 discussed in another place. I use iodine and camphor in pro- 
 liferous disease, and fluids through the catheter in those that 
 are markedly catarrhal cases. The use of iodine in the simple 
 way that I now employ it, was suggested to me by Dr. F. H. 
 Rankin, of Newport, formerly one of my assistant surgeons at 
 the Manhattan Eye and Ear Hospital. Fig. 93 gives a clear idea 
 of the apparatus necessary. The patient holds the apparatus in 
 his hand, while the surgeon forces the vapor into the mouth of 
 the Eustachian catheter. 
 
 I formerly used the vapor of iodine alone, but I now, at the 
 suggestion of Dr. H. P. Farnham, put about two drachms of gum 
 camphor in two ounces of tincture of iodine, and force the vapor 
 from this mixture through the catheter. Besides having a posi- 
 tively curative value, it is very grateful and pleasant to the pa- 
 tient. 
 
 FLUIDS. 
 
 After all the experiments to determine whether fluids forced 
 into the tube through the catheter actually reach the cavity of 
 the tympanum, it is, I believe, pretty conclusively settled that 
 they do, and they may have a decided effect upon the lining 
 membrane of this part. 
 
 Wreden's experiments make it somewhat doubtful, whether 
 a few drops of fluid, injected through the Eustachian catheter, 
 26
 
 402 
 
 FLUIDS. 
 
 actually reach the cavity of the tympanum. All the experi- 
 ments that have been made agree, however, in one fact, that 
 where a large quantity of fluid is injected en masse, some of 
 it enters the tympanum. The usual method of injecting a fluid 
 into the mouth or calibre of the Eustachian tube is the follow- 
 ing : the Eustachian catheter is introduced in the usual way, 
 the patient having previously taken a little water in his mouth. 
 A drop or two of the fluid to be injected is then placed in the 
 nozzle of the catheter, and at the moment the patient swallows, 
 it is forced into the tube by an air-bag. 
 
 Dr. F. E. Weber, of Berlin, has invented an instrument for 
 spraying the tube and the tympanic cavity. He calls his appa- 
 ratus the "pharmaco-koniantron." It consists essentially of a 
 long and flexible Eustachian catheter, which is passed into the 
 tube as far as the junction of the cartilaginous with the osseous 
 portion. It is perforated laterally about 1 mm. from its beak, 
 and it is introduced through an ordinary metallic catheter. The 
 fluid is forced through the lateral opening in the form of spray, 
 by means x>f an air-bag attached laterally to the tube of a small 
 syringe. The fluid to be used is first driven by the syringe into 
 the nozzle of the catheter, and then forced forward by the air-bag. 
 
 As has been intimated, Dr. Wreden ' does not believe, that 
 drops of fluid injected in the manner that has been described 
 through a tubal catheter, reach the cavity of the tympanum, 
 but that they pass only to the osseous part of the tube. He does 
 not deny that injections en masse will reach the cavity of the 
 tympanum, but he thinks such injections dangerous. 
 
 Wreden advises the use of the tympanic catheter that is, a 
 catheter that passes beyond the isthmus of the tube, as a vehicle 
 for introducing drops of fluid into the middle ear. After the 
 tubal catheter, through which the tympanic one is passed, is in 
 position and fastened by means of a forehead band, and the 
 permeability of the tube has been ascertained by the use of a 
 probe 1.4 mm. in thickness, the operator drops five drops of the 
 solution to be used upon a watch-crystal or other convenient 
 receptacle, draws it up into the catheter and inserts the instru- 
 ment as far as the tympanic orifice of the tube. The drops are 
 then forced into the middle ear by the mouth. Sensations of 
 fulness in the ear, and an increase of the impairment of hear- 
 ing, usually occur, but they pass off in from six to twelve hours. 
 In about forty-eight hours the beneficial effect should be seen. 
 
 Wreden uses the following-named agents through the tym- 
 
 1 Separat-abdruck aus der St. Petersburger medicinischen Zeitschrift, N. F., Bd. 
 I., 1871.
 
 FLUIDS. 403 
 
 panic catheter, and he insists that the maximal doses should not 
 be exceeded, lest acute inflammation be excited. 
 
 1. Fused caustic potash, one-quarter to one-half grain to 'the 
 ounce of water. 
 
 2. Liquor potassse, three to five drops to the ounce of water. 
 
 3. Concentrated acetic acid, two to three grains to the ounce 
 of water. 
 
 4. Pure iodine, using one-eighth to one-quarter of a grain to 
 the ounce of a half per cent, solution of iodide of potassium. 
 
 5. Corrosive sublimate of mercury, one-twelfth to one-eighth 
 of a grain to the ounce of water. 
 
 6. Nitrate of silver, one-quarter to one grain to the ounce of 
 water. 
 
 7. Sulphate of copper, one-quarter to one grain to the ounce. 
 
 8. Sulphate of zinc, one to two grains to the ounce. 
 
 9. Iodide of potassium, two to five grains to the ounce. 
 
 10. Sulphate of atropine, one-half to one grain to the drachm 
 of water. 
 
 11. Hydrate of chloral, one to two grains to the ounce of 
 water. 
 
 Wreden uses these agents through the tympanic catheter, 
 chiefly in the proliferous form of inflammation of the middle 
 ear. These injections are made every third or fourth day, for 
 from fifteen to twenty days, and although it is not claimed that 
 the results are brilliant, they are well worthy of a trial where 
 all the ordinary means by a tubal catheter have failed. 
 
 In chronic catarrhal inflammation the agents named last on 
 the list are also used, but the caustic applications are only ap- 
 plied to the cases of proliferous inflammation the cases classed 
 under the head of sclerosis by Troltsch. 
 
 Kramer was perhaps the first to use the tympanic catheter 
 to any great extent, and his instrument is essentially the one 
 that Wreden employs. It is a hard-rubber catheter, made long 
 enough to reach the tympanic orifice, and is passed into the 
 tube through an ordinary tubal catheter. 
 
 Bishop, of London, invented a nebulizer for the faucial 
 mouth of the Eustachian tube ; but it was a very inconvenient 
 instrument, and never came into general use. 
 
 Dr. C. E. Hackley's instrument will be found a more efficient 
 means of spraying the tube. Dr. Hackley's apparatus consists 
 of an air-bag, an Eustachian catheter, with a hard-rubber nozzle 
 to fit in its mouth, a piece of rubber tubing, and a hypodermic 
 syringe. 1 
 
 1 Medical Record, No. 134.
 
 404 EUSTACHIAN NEBULIZER. 
 
 "The nozzle of the air-bag is inserted into one end of the 
 rubber tube, the tip to fit in the catheter being placed in the 
 other end. The hypodermic syringe is filled with the liquid to 
 be employed, then its point passed through the tube and out 
 through the calibre of the hard-rubber tip for the catheter, as 
 shown in the cut." 
 
 "The mouth of the Eustachian catheter B being fitted over 
 the hard-rubber tip A, and held there, if sudden pressure is 
 made on the air-bag, while the piston of the syringe is forced 
 
 FIG. 94. Hackley's Eustachian Nebulizer. 
 
 home, the liquid will be thrown through the catheter in the 
 form of spray. 
 
 " In using this apparatus for the treatment of diseases of the 
 ear, the catheter should be carefully introduced through the 
 nose, and placed in position. Then, while the diagnostic tube 
 is placed in the ear, the hard-rubber tip should be inserted in the 
 catheter, and air alone forced through to determine whether 
 the catheter be properly in position. If found to be so, the piston 
 may be pressed on at the same time that air is forced through. 
 During this experiment the catheter may be held in position by 
 clamps for that purpose, or may be held by the fore and middle
 
 POLITZER'S METHOD. 405 
 
 fingers of the left hand, while the thumb of the same hand 
 presses on the piston, the other hand being used to work the 
 air-bag." 
 
 It is well to have a small round opening made in the air-bag, 
 as at C ; while the air is being forced out this may be closed by 
 the finger, which then being removed, the air-bag quickly fills 
 again. 
 
 It may be said in general terms that the use of spray of 
 astringent fluids to the Eustachian tube, is chiefly of value in 
 those cases in which the evidences of catarrh, or increased se- 
 cretion, are strongly marked, while fluids are to be employed in 
 the tympanic cavity, when there is marked evidence of the pre- 
 dominance of the proliferous form of disease. 
 
 The injections of simple air, or of medicated vapors, in what 
 may be called the mild cases of catarrhal inflammation, will be 
 found quite as efficacious as fluids or spray. As has been al- 
 ready mentioned, steam and iodine vapors are chiefly applicable 
 to cases of proliferous inflammation. 
 
 I am in the habit of employing Politzer's method of inflating 
 the drum-cavity, immediately after the use of the Eustachian 
 catheter, in all cases of chronic disease of the middle ear, but I 
 cannot believe that it is a substitute for the catheter. It is very 
 often found that no impression can be made upon the tube or 
 middle ears by the use of Politzer's method alone, but after the 
 catheter has been passed into the mouth of the tube, and some 
 muscular spasm set up in the abductor and dilator of the open- 
 ing, that this means of treatment becomes effectual at once. It 
 is not well, however, to place the air-bag in the hands of the 
 patient and advise him to use it. Such advice will usually be 
 over-regarded, and instead of inflating the ears every other day, 
 it will be done every hour perhaps. Besides, patients are often 
 very unsuccessful in their attempts to drive air into the ears. 
 Of course there are cases in which this system of self-treatment 
 must be adopted, or none at all can be undertaken ; but physi- 
 cians who treat aural disease soon learn that, if they wish to 
 achieve the best results, the treatment must be carried on by 
 the medical adviser himself, and not be delegated to lay au- 
 thority. 
 
 Some years since, I began to inject vapors into the ear by 
 means of a simple apparatus, 1 represented on page 75. The 
 apparatus consists of a hollow bulb of hard rubber, which is at- 
 tached by a bit of rubber tubing to the air-bag used in Politzer's 
 method. Any fluid that is readily vaporized is placed upon a 
 
 1 American Journal of the Medical Sciences, vol. liii., p. 62.
 
 406 BOUGIES. 
 
 sponge contained in the bulb, and on practising inflation of the 
 ear, the vapor is forced into the Eustachian tube and the cavity 
 of the tympanum. The tincture of iodine and chloroform are 
 the agents I chiefly employ. Dr. J. S. Prout taught me the value 
 of chloroform as a means of diagnosticating closure of the tube. 
 This vapor will penetrate the ear when air or iodine are not per- 
 ceived, and when all attempts at inflation with air have failed, 
 or, as should be said, when the patients experience no sensation 
 in the ears from the use of air through the catheter, or by Po- 
 litzer's method. Great caution should be used in employing the 
 chloroform ; that is, but a few drops should be used, or the most 
 intense pain will be caused. I have seen patients jump from 
 the chair in surprise and pain, after one careful inflation, when 
 only two or three drops were upon the little sponge in the bulb, 
 and this, after attempts to cause a sensation in the ears with 
 common air had utterly failed. The use of chloroform vapor is 
 certainly a very valuable diagnostic means, although its thera- 
 peutic value is very limited. The hollow bulb was recom- 
 mended as an inhaler by Dr. Buttles, of this city, but it was 
 intended to be used in the nostrils only. The attachment to 
 Politzer's air-bag was first made by myself. 
 
 BOUGIES. 
 
 Bougies, for the purpose of dilating the Eustachian tube, are 
 highly spoken of by some writers. Bonnafont and Kramer, were 
 perhaps the first to use them. Guye, 1 of Amsterdam, also em- 
 ployed them, and published three cases of emphysema produced 
 by their use. In the first case there was emphysema along the 
 neck, as far as the sternum. In three days it passed away. 
 In the second there was suddenly considerable dyspnoea. The 
 uvula was found to be the cause of the trouble. It was very 
 much distended with air. An incision in it was made at once, 
 and the patient again breathed quietly. In the third case a fold 
 of mucous membrane in the fauces became so much swollen 
 immediately after the use of the bougie, that breathing be- 
 came difficult. Here, again, snipping the fold soon relieved the 
 breathing. 
 
 These cases probably show all the danger there is in using 
 bougies. They are, however, somewhat painful. Among some 
 five thousand private patients, I have recorded but very few 
 cases in which, after a fair trial, air could not be driven into 
 the Eustachian tube by means of the catheter or Politzer's 
 
 1 Archiv f iir Ohrenheilkunde, Bd. II. , p. 6.
 
 BOUGIES. 407 
 
 method. In cases where common air did not enter, the vapor 
 of chloroform did. In this fact, will be found my reason for not 
 resorting to the use of the bougie more frequently. Their use is 
 chiefly to stimulate the mucous membrane- lining the Eustachian. 
 tube, and thus to remove the swelling. Complete stricture of 
 the tube is too rare an occurrence to be really much considered 
 as an indication for the use of the bougies. I find in injections 
 of vapors or fluids the stimulant thus sought without any of the 
 unpleasant features of the bougie treatment, such as the produc- 
 tion of emphysema, breaking of the bougie in the tube and severe 
 pain. Dr. Noyes reports a case ' in which a fine whalebone olive- 
 tipped bougie passed into both Eustachian tubes through the 
 catheter, produced suppurative inflammation of the middle ear, 
 but Dr. Noyes, as he very recently told me, still uses bougies and 
 considers them indispensable for certain cases. 
 
 In the discussion which ensued on this case, Dr. Weir said 
 that he had tested the merits of the bougie practice for five 
 years, and felt that in cases where obstruction of the Eustachian 
 tube did not yield readily to Politzer's bag, the pump, or the 
 catheter, the bougie was of very material assistance. In a large 
 experience he had met with two accidents, purulent inflamma- 
 tion of the middle ear, and temporary emphysema of the eyelids, 
 face, and neck. These accidents occurred from neglect of certain 
 rules which he now carries out. Dr. Weir uses catgut bougies 
 on which are marked the length of the catheter, the distance to 
 the isthmus or narrowest part of the tube, 74 mm. , then, the dis- 
 tance from the point to the tympanic cavity, 11 mm., and finally 
 the width of the cavity, 13 mm. The bougies ranged from Nos. 
 2 to 5 of the French scale. 
 
 Dr. Weir's directions as to the employment of the bougies are 
 so thorough and careful that I quote them. 
 
 The instrument having been passed through an ordinary 
 Eustachian catheter, and "once engaged in the tube is pushed 
 onward as far as the isthmus, allowed to rest then a few mo- 
 ments and then withdrawn, and air gently blown in through the 
 catheter. If the air did not readily enter the tympanic cavity, 
 all forcible attempts to force it were carefully abstained from 
 and the bougie reintroduced, either then, or preferably at an- 
 other sitting, and carried only to a very short distance, say one 
 or two millimetres farther on, and the experiment resorted to, 
 to ascertain if the tube were open." Dr. Weir has found the 
 most obstructions in the first portion of the tube, though in sev- 
 eral instances he had overcome total obstructions at the tym- 
 
 1 Transactions of the American Otological Society, Third Year, p. 55.
 
 408 BOUGIES ELECTKICITY. 
 
 panic orifice. " The conical French bougies should be discarded 
 as dangerous, from the tapering ends being too long; but the 
 catgut bougies might be made slightly conical by rubbing them 
 on emery paper." 
 
 Within a short time, bougies have been again recommended 
 by Urbantschitsch, but I have not been able to substantiate the 
 opinions of those who recommend them by my own experience. 
 I fear that years of careful treatment of chronic proliferous in- 
 flammation in hospital and private practice, without curing any, 
 have made me a little too chary about the use of troublesome 
 and severe remedies for cases, for which we can expect no more 
 than slight alleviation and temporary improvement. 
 
 ELECTRICITY. 
 
 This is an agent whose real value has been much under- 
 estimated in many departments of medicine, but which I am 
 inclined to believe has been overrated in the treatment of aural 
 disease. The effects of electricity on the acoustic nerve will be 
 fully discussed in the third part of this volume, while it is only 
 necessary to say at this point, that not much is to be expected 
 from the use of electricity in chronic non-suppurative inflamma- 
 tion of the middle ear. Drs. Beard and Rockwell 1 think that 
 "the best results are obtained in those cases passing from the 
 sub-acute to the chronic stage, and that then they are brought 
 about by the mechanical action of the Faradic current, on the 
 adhesions within the middle ear." These are just the cases that 
 are amenable to treatment by the catheter, Politzer's method, 
 and applications to the pharynx. 
 
 Before closing the subject of the employment of the Eus- 
 tachian catheter in aural disease, an allusion should at least be 
 made to the singular dread of the instrument, now happily dis- 
 sipated, which obtained in the minds of the profession in Eng- 
 land and the United States. This dread seems to have depended 
 upon two cases of death from the use of the catheter which 
 occurred in the practice of Dr. Turnbull, then of London, but 
 who occasionally visited America, for the purpose of treating 
 aural disease, until his death, which occurred a short time since, 
 as I have been informed. These famous cases were reported in 
 the London Lancet. In the same journal, 2 there is a letter from 
 a correspondent accusing this Dr. Turnbull of advertising in the 
 
 1 A Practical Treatise on the Medical and Surgical Uses of Electricity, p. 566. 
 5 Vol. ii., 1839.
 
 DEATH FROM USE OF CATHETER. 409 
 
 Times in an unprofessional manner that is, by stating that he 
 could cure ''any case of deafness, not arising from organic 
 disease, by the use of a peculiar remedy." 
 
 In order that the length and breadth of this matter of the 
 death of patients from the use of the catheter, may be fully 
 presented to the profession and not continue to be darkly hinted 
 at, I quote from the Lancet 1 the account of the inquest upon 
 these celebrated cases. 
 
 On Monday evening an investigation took place at the Carpenters' Arms, 
 Hoxton, before Mr. Baker, relative to the death of Mr. Win. Whitbread, aged 
 sixty-six, which was supposed to have been occasioned by an operation lately 
 performed on him by Dr. Turnbull, of Eussell Square. It appeared that the 
 deceased, who was in the enjoyment of good health up to that time, had an 
 operation performed upon him on Thursday week by the above physician, which 
 consisted in injecting air through the nostrils for the relief of excessive deaf- 
 ness, under which he had been for some time laboring. Almost immediately 
 after he was attacked with a violent swelling in the throat, and though the 
 utmost attention had been paid to him, he expired on Thursday last. 
 
 Mr. Wickham, a medical gentleman in the neighborhood, deposed, that on 
 making a post-mortem examination of the body, he found that the inflammation 
 in the throat was not sufficient to have occasioned the death of the deceased ; 
 death was produced by extensive inflammation of the brain, which, in his opinion, 
 was occasioned by natural causes, and that neither the operation nor the inflam- 
 mation of the throat had anything to do with it. 
 
 The jury, on this evidence, returned a verdict of " Natural death by the visi- 
 iation of God." 
 
 On Friday morning, at 8 o'clock, an investigation, which occupied the greater 
 portion of the day, was entered into before Mr. Wakeley, M.P., and a highly 
 respectable jury of tradesmen, at the Plough Tavern, Museum Street, to prose- 
 cute the inquiry into the circumstances connected with the death of Joseph 
 Hall, aged eighteen, who died while undergoing an operation for the cure of 
 deafness, at the house of Dr. Turnbull, Eussell Square, on the morning of Sat- 
 urday last. The circumstances connected with the case had created an intense 
 interest, and during the proceedings the inquest-room was attended by many of 
 the leading members of the medical profession. 
 
 George Kimber merely stated that he and deceased were in the employ of 
 Mr. Jackson, ornamental composition maker, of Eathbone Place. He saw him 
 last alive on Saturday morning, about 7 o'clock, at which time he was get- 
 ting ready to go to Dr. Turnbull's to be operated upon for deafness, to which he 
 was subject ; he was in all other respects quite well and healthy. 
 
 Charles Spadbron, of Gravesend, deposed that he saw the deceased about 
 10 o'clock on Saturday morning at Eussell Square. He appeared in good 
 health. There were other patients present at the time. Mr. Lyon, the gentle- 
 man who assists Dr. Turnbull, was pressed to operate. The deceased filled the 
 instrument himself, and discharged the air by turning the cock. (The instru- 
 
 1 Vol. ii., p. 558. 1838.
 
 410 DEATH FROM USE OF CATHETER. 
 
 merit was here produced, and the witness showed how it was filled. The bottom 
 of the cylinder was held fast between the feet, and the piston worked up and 
 down by the handle until the pump became filled with air.) The operation was 
 repeated four times on deceased, biat the tube through which the air passed was 
 removed by Mr. Lyon from the right to the left nostril. On the tube being 
 taken from deceased's nostril the fourth time, he fell back in the chair, appar- 
 ently lifeless, and never spoke afterward. 
 
 In answer to the coroner, the witness stated that he had had the operation 
 performed on himself four times at a sitting ; it produced a swimming in the 
 head, and a portion of the air appeared to escape by the mouth, and the rest 
 down the throat. 
 
 Mr. James Reid, of Bloomsbury Square, surgeon, deposed to having, by 
 order of the coroner, made a post-mortem examination of the body in presence 
 of Messrs. Liston, Quain, Savage, and Lyon. Mr. Reid went into a long general 
 anatomical statement, but the only points strictly bearing on the case were the 
 following : That he found a thin layer of blood on the left side of the membrane, 
 and globules of air under it, and in the small veins of the brain. That the left 
 tympanum, or internal ear, had its lining membrane swollen, of red appear- 
 ance, and there was a slight effusion of blood in it. From the known plethoric 
 habit of the deceased, and from the fact of his having exerted himself at filling 
 the air-pump before he was operated upon, he should say the cause of his death 
 was apoplexy. 
 
 Mr. Savage, lecturer on anatomy at Westminster Hospital, was next exam- 
 ined, and differed from the last witness, and stated that there was extravasated 
 blood on both sides of the membrane, and that the tympanum of the right ear 
 was affected as well as the left. He did not consider that deceased died of apo- 
 plexy, but that the injection of cold air, through the Eustachian tubes, was the 
 primary cause of deceased's death. 
 
 Mr. Liston, surgeon to University College Hospital, stated that he was 
 present at the post-mortem examination, at the request of the coroner, and the 
 probability was, that deceased died in a continued fainting fit. He could not 
 easily disconnect the forcible injection of cold air into the tympanum from the 
 effect that followed it. In the region of the tympanum were a number of small 
 nerves, connected with the most important one in the body, which, receiving an 
 impression, would cause spasms, or other fatal affections of the heart. Nothing 
 precisely satisfactory could be come to on account of the decomposed state of 
 the body. 
 
 The coroner complained that though the subject of the inquiry had died on 
 Saturday morning, no notice of his death had been sent by Dr. Turnbull or Mr. 
 Lyon to the summoning officer of the district. He wished those gentlemen to 
 give some explanation of their conduct. 
 
 Dr. Turnbull and Mr. Lyon severally entered into an explanation. 
 
 The coroner then addressed the jury at considerable length. And in accord- 
 ance with the spirit of his observations, the jury returned a verdict of "Acci- 
 dental death," with a caution to Dr. Turnbull never again to entrust the instru- 
 ment of operation in unprofessional hands. (Times.) 
 
 There are numerous explanations for these cases ; but the 
 account of the post-mortem is not exact enough to allow us to 
 say which of them are correct. The first-named patient may
 
 DEATH FROM USE OF CATHETER. 411 
 
 have died from the emphysema produced by a wounding of the 
 tissue by the point of the instrument. An examination of the 
 tissues of the throat, immediately after the accident, would have 
 determined this point ; but there is no account of such an exam- 
 ination having been made. The experiments of Voltolini ' show 
 that all traces of an emphysema would pass off within ten hours 
 after death, so that the post-mortem examination would give no 
 information on this point. 
 
 The surgeon who determined that death was produced by in- 
 flammation of the brain, unfortunately gives no account of the 
 evidences which led to the formation of this opinion. The second 
 patient may have died in a fainting fit, or from emphysema. 
 
 The air-pump, is now scarcely used in the profession as a 
 means of injecting air into the Eustachian tubes, because the 
 air-bag is quite as efficacious, and because it is a much simpler 
 apparatus. The management of an air-press should certainly 
 never be left to the patient. 
 
 Voltolini, in the experiments to which allusion has been 
 made, killed a rabbit in a few minutes by wounding the tissue 
 of the pharynx, by a wire passed through a catheter, and then 
 blowing forcibly into the opening. He thus produced great em- 
 physema of the neck and chest. Voltolini believes that the 
 cause of death of the rabbit, was a pressure upon the larynx by 
 the emphysematous tissue, and not the pressure upon the lungs. 
 TurnbulPs patients may have both died from the same cause ; 
 but as we do not know the instrument used, or, in fact, any of 
 the details, we can only surmise the real cause. 
 
 I need hardly say that the Eustachian catheter has never 
 been even suspected of being the cause of death, since the time 
 of these cases, although it is in daily use by physicians in all 
 parts of the civilized world. 
 
 Before passing on to a consideration of the operative treat- 
 ment for this class of aural affections, a word or two should be 
 said as to the length of time a case should be treated. Inasmuch 
 as we cannot hope, in many of the cases, to do more than arrest 
 the progress of disease, and perhaps improve the condition, since 
 we cannot dismiss them as cured that is to say, with the hear- 
 ing perfectly restored, the tinnitus aurium gone we desire to 
 know how long we shall treat the ears locally. The general 
 hygienic treatment, such as the frequent employment of baths, 
 of a gargle, the exercise of great care to keep the extremities 
 warm, to avoid taking cold, and so on, should be kept up during 
 
 1 Monatsschrift fiir Ohrenheilkunde, Jalirgang VII., No. 1.
 
 412 DURATION OF TREATMENT. 
 
 a patient's life, and he should be told at the first consultation, 
 that he has a life-long warfare to engage in, unless he desires to 
 end his days with the use of an ear-trumpet. 
 
 But we cannot keep up a local treatment of the Eustachian 
 tubes and pharynx indefinitely. Those who believe that a ca- 
 tarrhal pharynx and nares can be thoroughly cured in our cli- 
 mate, that a disposition to colds in the head, can be effectively 
 subdued by the use of the spray of nitrate of silver, or the spray 
 of any other agent used by means of the most perfect apparatus, 
 will continue to use these means of local treatment until the end 
 is accomplished. But those who have been less successful in 
 such attempts, must fix some limit to the time of treatment. If 
 it be proposed to get the confidence of a patient suffering from 
 chronic non-suppurative middle-ear disease, which is progres- 
 sive in its character, it is proper to tell the whole truth a.t the 
 first consultation and say that we have no hope of making him 
 hear very well again. It is only a question of arresting the pro- 
 gress of the disease, and perhaps of increasing the hearing 
 power. To this end, about twice a year, the patient should receive 
 a course of local treatment until the disease has ceased to pro- 
 gress, for a period of time varying from three to eight weeks, 
 while the general treatment is to be a life-long course. The 
 only reason that these limits of time are fixed is, that I have sel- 
 dom seen anything accomplished in less than the shorter time, 
 or after the longer term has expired. Very many patients leave 
 us, at the outset, never to return. Some of them cannot leave 
 their families to stay in a large city while their ears are being 
 treated. This difficulty is being rapidly met. In every consid- 
 erable town reputable and educated men, who have found that 
 there is something more in aural practice than in syringing out 
 the wax and then dropping in glycerine to restore it, are giving 
 attention to otology, and the laity are beginning to reap the 
 fruits of this cultivation of a hitherto barren field. 
 
 There is another class, however, whom such advice never 
 influences. One of their family has been a victim of chronic 
 aural disease for a period varying from two to twenty years, 
 and they have at last, at the request of the family physician, 
 screwed themselves up to the courage of consulting a specialist. 
 They come in town for a day's shopping, and call upon the doc- 
 tor, meanwhile always being in a great hurry, and sending word 
 to the consulting-room, that they have come fifty miles to see 
 him. When such advice as I have delineated is given, and the 
 almost bewildered physician sits down to lay out a plan of treat- 
 ment and correct the improper habits of life that have induced 
 and maintained the disease, he finds that he is dealing with per-
 
 DURATION OF TREATMENT. 413 
 
 sons who expect magic ear-drops, vibrators, or some mysterious 
 and quickly acting agent that will restore the hearing in the 
 interim of rest of a New York shopping excursion. Of course, 
 such patients figure in the statistical tables under the head of 
 "seen but once, result unknown," although in the mind's eye 
 we can set them down as going on slowly but surely to the ear- 
 trumpet, and banishment from social intercourse. 
 
 The practitioner, young or old, will do much better in such 
 cases, both for the patient, his own reputation, arid that of the 
 profession in general, if he decline to prescribe at all for such 
 persons, for it is only under favorable circumstances, that is 
 to say, with intelligent patients, in easy circumstances of life, 
 who are attentive to advice and punctual in attendance, that 
 anything at all can be accomplished to stay the progress of a 
 well-advanced catarrhal or proliferous process in the middle 
 ear. 
 
 Even then it is not always possible. Certainly those who 
 have waited ten or twenty years, and have finally consulted a 
 physician on account of impairment of hearing, depending upon 
 chronic non-suppurative inflammation, with the idea of getting 
 relief in one or two or three visits, have nothing to hope for. It 
 is better to tell them so at once, lest we unwittingly emulate the 
 charlatans, to whom all disease is an object of attack by medi- 
 cation. Otology has suffered much, from innocent attempts to 
 accomplish that which is in the nature of things, not to be ac- 
 complished. A little frankness about chronic non-suppurative 
 disease of the middle ear, will soon awaken the laity to the ne- 
 cessity of attention to the causes of the disease, and furnish us 
 all with a larger proportion of curable cases. 
 
 I have found chronic catarrhal cases much more amenable 
 to treatment than the proliferous form. Indeed, I think the 
 former cases are frequently curable, but the proliferous variety 
 never. In its results, in spite of good local and general care, it 
 is, to my mind, very like progressive atrophy of the optic nerve 
 or chronic glaucoma. 
 
 Since the publication of the works of the modern German 
 school in this country, especially that of Troltsch, there has 
 been a tendency, in my opinion I speak for myself at least to 
 refer too many cases of progressive impairment of hearing to 
 catarrhal or proliferous inflammation of the middle ear, and dis- 
 eases of the nerve are ignored, or their existence, except as 
 secondary affections, has been even denied. 
 
 I advise the practitioner, however, to attempt to make a dif- 
 ferential diagnosis between disease of the middle ear and of the 
 nerve, especially in cases of supposed chronic proliferous in-
 
 414 DIFFERENTIAL DIAGNOSIS. 
 
 flammation. The means we have at hand for this purpose, will 
 be fully dwelt upon when we come to the discussion of disease 
 of the nerve. I will only say here, that the treatment of disease 
 of the internal ear, by the local means generally employed in 
 treatment of the middle ear, is harmful, since it aggravates the 
 conditions by inducing congestion of the labyrinth.
 
 CHAPTER XV. 
 
 THE TREATMENT OF CHRONIC NON-SUPPUEATIVE INFLAM- 
 MATION ( Concluded) . 
 
 Operations upon and through the Membrana Tympani. History from 1650 until our 
 own Day. Sir Astley Cooper's Cases. Schwartze's Statistics. Politzer's Eyelet. 
 Tenotomy of Tensor-Tympani. Galvano-cautery. Division of Posterior Fold. 
 Prout's Operation. Hinton's Removal of Accumulations of Mucus. Abandonment 
 of Operations by American Otologists. Condensed Air. Exhaustion of Air. 
 Weber-Liel and Woakes on Paretic Deafness. Results of Treatment. 
 
 AT the time of the publication of the first editions of this book, 
 operations upon the membrana tympani, the ossicles and muscles 
 of the tympanum were being extensively practised by Politzer, 
 Weber-Liel, Hinton, Orne Green, Pomeroy, and others, for the 
 relief of chronic diseases of the middle ear. Although part of 
 the treatment thus pursued was avowedly experimental, the 
 hope was pretty generally felt in the profession, that operative 
 procedures on and through the drum-head, might perhaps accom- 
 plish very much in arresting the progress of a disease, which 
 still remains incurable in a vast proportion of cases. I believe 
 that after a fair trial, we are as yet obliged to say that these 
 hopes have not been realized. After a trial of nearly all the 
 methods of operation of which I have learned, I have aban- 
 doned them, and only in exceptional instances do I ever open 
 the drum-head by incisions, except in acute or sub-acute cases. 
 It is not because the operations are dangerous, that I have aban- 
 doned them. That I have not found. But it is because they do 
 nothing to stop tinnitus aurium, or arrest progressive impairment 
 of hearing in chronic non-suppurative inflammation. It may be 
 asked, Why, then, consider the subject fully in a practical trea- 
 tise ? To this, I answer, that it is one of great historical interest. 
 for the work that has been done in this direction has been by 
 the ablest of otologists, and has at least taught us much of the 
 prognosis and nature of chronic non-suppurative inflammation. 
 Besides, much useless experimentation on the part of younger 
 observers will be avoided, if they have easy access to what has 
 been already done. There is, therefore, a justification for a full
 
 416 PERFORATION OF MEMBRAXA TYMPANI. 
 
 consideration of this subject, such as I shall endeavor to give in 
 this chapter. 
 
 The reader of otological literature will be almost appalled by 
 the amount of material on this subject. It begins with Chesel- 
 den's experiments on the drum-heads of dogs, and ends as yet, 
 with Weber's operation upon the tensor-tympani muscle, and 
 Politzers section of the posterior fold of the membrana tympani. 
 From the mass of authorities I have collected a history of this 
 subject. 
 
 I am indebted to Schwartze's brochure ' for much of the his- 
 torical sketch from the time of Riolanus up to 1845, although I 
 have greatly amplified his references to Sir Astley Cooper's writ- 
 ings, as well as to those of other English authorities, and by no 
 means, as one reviewer assumed, have I merely given a transla- 
 tion of Schwartze's interesting paper. 
 
 Johannes Riolanus (1650), of Paris, about 150 years before 
 the time of Sir Astley Cooper, who is usually supposed to be the 
 originator of the operation of perforation of the membrana tym- 
 pani, inquired if it would not be possible to improve the hearing 
 of the deaf, by destroying the membrana tympani. He was led 
 to make this inquiry from the fact that he knew of a deaf per- 
 son, whose hearing was restored by an accidental rupture of the 
 membrana tympani, by means of an ear-spoon. 
 
 It is well to remember that, until very recently, there were 
 no exact measures taken to estimate the amount of hearing, 
 and that, consequently, such phrases as "the hearing was re- 
 stored," "the hearing became perfect," as they occur in ancient 
 books, only mean that the hearing was improved, sometimes 
 very much, sometimes very little. 
 
 About a hundred years later (1722), T. Cheselden, surgeon to 
 St. Thomas' Hospital, London, well known as the inventor of 
 the operation for artificial pupil, actually operated upon dogs, 
 and I quote from his work on anatomy " the description of his 
 cases. Speaking of the membrana tympani, he says : "I found 
 it once half open on a man that I dissected, who had not been 
 deaf, and I have seen a man smoke a whole pipe of tobacco out 
 through his ears, which must go from the mouth, through the 
 Eustachian tube, and through the tympanum, yet this man 
 heard perfectly well. These cases occasioned me to break the 
 tympanum in both ears of a dog, and it did not destroy his hear- 
 ing, but for some time he received strong sounds with great 
 horror." 
 
 1 Studien und Beobachtungen uber die Kiinstliche Perforation des Trommelfells, Ar- 
 chiv fur Ohrenheilkunde, Bd. II., S. 24 . 
 
 4 The Anatomy of the Human Body, p. 250. London, 1732.
 
 PERFORATION OF MEMBRANA TYMPANI. 417 
 
 Cheselden then goes on to say that an anatomist named St. 
 Andre assured him that "a patient of his had the tympanum 
 destroyed by an ulcer, and the auditory bones came out with- 
 out destroying the hearing." I have only been able to obtain 
 the second edition of Cheselden's works, but Schwartze quotes 
 from the seventh, where the author states that he obtained per- 
 mission to perform this operation, that was then esteemed such 
 a formidable one, upon a prisoner. If the prisoner survived the 
 operation, he was to have his freedom. Unfortunately for sci- 
 ence and for the criminal, the proposed subject became ill, 
 so that the operation was indefinitely postponed. Sir Astley 
 Cooper ' says that such an outcry was aroused by the inhuman- 
 ity of the proposed operation, that Cheselden never again ob- 
 tained permission to perform it. 
 
 Dienert (1748), of Paris, in a dissertation, recommended per- 
 foration of the membrana tympani for the purpose of evacuating 
 blood or pus from the cavity of the tympanum. Itard says that 
 Julius Busson proposed the operation six years before this. 
 
 The first man who actually performed the operation as a 
 means of benefiting the hearing, was a person named Eli (1760)," 
 who seems to have been a charlatan. 
 
 Portal and Sabatier, two Paris surgeons, who lived at the 
 same time as Eli, knew nothing of his operations. Portal pro- 
 posed to puncture the membrana tympani, in the cases where it 
 was greatly thickened. Sabatier, on the other hand, proposed 
 to perform the operation upon a relaxed membrana tympani. 
 
 Wilde quotes a passage 3 from Dr. Peter Degravers, of 
 Edinburgh, who lived in 1788, and who styled himself Pro- 
 fessor of Anatomy and Physiology, which shows that he had 
 performed the operation. Degravers says : "I incised the mem- 
 brana tympani of the right ear with a sharp, long, but small 
 lancet. I left the patient in that state for some time, and after- 
 ward observed that it had united. I incised again the mem- 
 brana tympani of the right ear, but crucially, and, on removing 
 some of the parts of the membrane incised, I discovered some 
 of the ossicula, which I brought out." Schwartze naively re- 
 marks, " There is no account of the results in this case." 
 
 In the beginning of this century, at about the same time 
 
 1 Philosophical Transactions, p. 152. 1800. 
 
 2 The following paragraph is quoted by Gairal, Lincke's Sammlung, Bel. V., p. 109, 
 in proof of Eli's operation: "EstLutetirc homo quidam ELI dictus, qui surditatem 
 curare audet, dummodo malum nona paralysi nervi septimi paris oriater, en vero eins 
 methodum tympanum exscindit et suppositum inimittit. Feci experirnenta qusedam, 
 quae satis bene ipsi cessarunt." 
 
 3 Aural Surgery, English edition, p. 15. 
 
 27 
 
 *
 
 418 SIR ASTLEY COOPER'S CASES. 
 
 {1800), and independently of each other, Dr. Karl Himly, then 
 of Brunswick, Germany, and Sir Astley Cooper, proposed the 
 operation, especially in closure of the Eustachian tube. Himly 
 had demonstrated to his students, in 1797, by experiments upon 
 the human cadaver and living dogs, that the operation could be 
 easily and safely performed ; but he did not perform it on the 
 living subject until 180G. He reports a brilliant result in one 
 case only, in a person suffering from syphilitic ulcers of the 
 pharynx, who had been deaf for years from closure of the Eus- 
 tachian tube. 
 
 After Sir Everard Home had published his paper on the 
 functions of the membrana tympani, a paper to which allusion 
 has already been made in this volume, Sir Astley Cooper pub- 
 lished a careful and exact account ' of the case of a medical 
 student at St. Thomas' Hospital, in London, who had lost his 
 membrana tympani, but who, nevertheless, could hear quite well. 
 
 The student was twenty years of age, and applied to Sir 
 Astley in the winter of 1797. He was attacked at ten years of 
 age with suppuration in the left ear, and in about twelve months 
 after with the same disease in the other ear. There was a pro- 
 fuse discharge for weeks from both ears, and in the discharge 
 bones, or pieces of bones, were observable. The patient was 
 totally deaf for three months ; the hearing then began to return, 
 and in about ten months from the last attack it was restored to 
 the state in which it was when he consulted the great English 
 surgeon. Sir Astley then gives an account of the means by 
 which he decided that the drum-heads were perforated. The 
 patient having filled his mouth with air, he closed his nostrils- 
 and contracted his cheeks ; the air thus compressed was heard 
 to rush through the meatus auditorius with a whistling noise, 
 and 'the hair hanging from the temples became agitated by the 
 current of air which issued from his ear. "To determine this 
 with greater precision, I called for a lighted candle, which was 
 applied in turn to each ear, and the flame was agitated in a sim- 
 ilar manner." ' The examination of the case was continued in 
 this thorough manner. 
 
 The gentleman, when in company, was capable of hearing 
 what was said in the usual tone of conversation, and he could 
 hear with the ear in which there was no trace of a membrana 
 tympani, better than with the one in which there was merely a 
 circular opening. When a note was struck upon the piano, he 
 could hear it but two-thirds of the distance at which the ex- 
 aminer could hear it. 
 
 1 Philosophical Transactions, loc. cit.
 
 PERFORATION OF MEMBRANA TYMPANI. 419 
 
 Although this case was accessible to the profession from the 
 year 1800, it is surprising to find the belief still widely prevalent 
 among the laity and the profession, that the destruction of the 
 membrana tympani involves almost complete loss of hearing. 
 The advance in the simplicity of means of an accurate diagnosis 
 in aural disease, is nowhere more distinctly seen than in a com- 
 parison of Cooper's method of determining whether the mem- 
 brana tympani be intact or injured, with that of the surgeon of 
 the present day, who with no aid from the patient, but with the 
 otoscope, is able to state just what the condition of the part is, 
 and in a very brief space of time. 
 
 This observation led the way to the operation of perforation 
 of the membrana tympani 1 for the relief of impaired hearing. 
 The only indication that the great English surgeon spoke of was 
 closure of the Eustachian tube, which he believed arose from the 
 following causes : 
 
 1. A common cold affecting the parts contiguous to the ori-' 
 fices of the tube, and thereby preventing the free passage of air 
 into the tympanum. 
 
 2. Ulcers in the throat, from the scarlet fever, which in heal- 
 ing frequently close the Eustachian tubes. 
 
 3. A venereal ulcer in the fauces, by the cicatrix it produces, 
 may cause a closure of the tube. 
 
 4. An extravasation of blood in the cavity of the tympanum. 
 The scientific character of Astley's observations is nowhere 
 
 better shown than in these indications, which are exact, and in 
 consideration of the state of knowledge as to the means of open- 
 ing the Eustachian tube, correct. The last-named condition is 
 the only one that may be said to be incorrect. The tympanic 
 cavity might be full of blood without causing closure of the Eus- 
 tachian tube. 
 
 Sir Astley reports four cases : 
 
 CASE I. A woman, thirty -six years old, who had been affected for eight 
 years. The deafness arose from enlargement of the tonsil glands ; a puncture 
 of the drum-head was made, and while she stayed in the consulting-room for one- 
 half hour, she could hear ordinary conversation. 
 
 CASE II. Ann D , age not stated, so deaf as not to hear words unless 
 
 spoken close to the ear. She had been affected for six weeks. She could hear 
 a watch when pressed upon her ear. After the puncture she could hear the 
 watch several feet. 
 
 CASE III. J. E , aged seventeen. The hearing had been impaired since 
 
 1 Sir Astley's paper descriptive of liis operations was read June 21, 1801. See 
 Philosophical Transactions of the Royal Society of London, 1801.
 
 420 SIE ASTLEY COOPER'S CASES- 
 
 birth. There was an imperfect state of the fauces, so that he could not blow his 
 nose. The Eustachian tubes had no openings into his throat. Puncture of the 
 membrana tympani produced such a confusion that he nearly fainted, but in two 
 minutes he recovered, and, two months after, his hearing continued perfect. 
 
 CASE IV. A person was sent to Sir Astley, who had received a blow upon the 
 head, which had occasioned symptoms of concussion of the brain, and was attended 
 with a discharge of blood from each ear. He recovered from all the effects of 
 the blow but the deafness. Blood was found in the atiditory canal. After clear- 
 ing this away and perceiving no benefit, suspecting that a quantity of blood was 
 lodged in the tympanum, in a few days he punctured the membrana tvmpani. 
 Blood mingled with the wax was discharged for ten days, during which time the 
 hearing was gradually restored. 
 
 This case was undoubtedly one of fracture of the temporal 
 bone through the tympanic cavity, such as have been reported 
 by Buck and Rushmore. They have been fully described in the 
 tenth chapter. 
 
 In closing his paper, Sir Astley states that little pain is felt in 
 the operation, and that no dangerous consequences follow.' The 
 Valsalvian experiment was the means by which he determined 
 whether the Eustachian passage was open or not, for he says 
 that, when the experiment succeeds, the tube is open. Besides 
 this, the patient should be able to hear a watch placed between 
 the teeth or on the temporal bones. Cooper published his four 
 cases of good results, and. according to Schwartze and Frank, 
 he was soon inundated by deaf persons from all parts of Europe. 
 He then operated on fifty more cases, but the results were either 
 slight, null, or they lasted for a short time only. Cooper then 
 declined to see deaf patients, on account of the fact that he was 
 doing very little good, and also because his fame as a surgeon 
 was suffering from his reputation as an aurist. After the lapse 
 of more than seventy years, the dispassionate, scientific char- 
 acter of Sir Astley Cooper's writings on this subject, stands in 
 striking contrast to the charlatanism of some of those who fol- 
 lowed him in this operation. 
 
 After Cooper's operations, a great interest was excited in 
 France on this subject, and, according to the medical journals of 
 the time, quoted by Schwartze, Riber of Bordeaux, Maunoir of 
 Geneva, and others, operated, but with no permanent results. 
 
 In Germany, also, the same interest was created. Michaelis, 
 a professor in Marburg, informs his friend Hunold, of Capel, 
 
 1 Sir William Wilde states that, within a few months of his death, Sir Astley ex- 
 hibited the greatest interest in this subject, and left his consulting-room full of patients 
 for a long time, to send for a man in Bond Street, upon whom he had operated, in 
 order to exhibit him to Mr. Wilde. Vide Dublin Journal, vol. xxv., 1844.
 
 PERFORATION OF MEMBRANA TYMPANI. 421 
 
 that he had operated on one case successfully. Hunold then 
 proceeded to puncture every membrana tympani to which he 
 could get access. Finally, Hunold records that he has had the 
 brilliant result of curing or improving seventy cases out of a 
 hundred. Subsequently, it was shown by others, that these 
 results were not only exaggerated, but, that they were not even 
 at all in accordance with truth. Of Michaelis' 63 cases, in 42 
 there was no result whatever; while in 21, or one-third, there 
 was greater or less improvement. But, of all these, in only 
 one was there a permanent result six years after ; perhaps the 
 benefit was permanent in three other cases. 
 
 Schwartze says that after Hunold's marvellous accounts of 
 his successful results from perforation of the membrana tym- 
 pani, the operation became the fashion, and every one, who did 
 not have the finest hearing, allowed the drum-heads of the ear 
 to be pierced. Even the poor deaf-mutes had their drum mem- 
 branes perforated. Fashions in medicine are not confined to our 
 own time. 
 
 To stem this tide of charlatanism, Karl Himly, professor in 
 Gottingen, wrote a commentary upon the operation, and showed 
 that it was only in exceptional cases that it was of any value. 
 These exceptional cases were such as those reported by Cooper, 
 for the relief of which, since there were no means of opening the 
 Eustachian tube, paracentesis of the membrana tympani was a 
 beneficial operation ; but the profession seem not to have studied 
 Sir Astley Cooper's cases, but it was merely known that he per- 
 forated the membrana tympani with benefit to the hearing. 
 Himly's paper excited so much attention that the operation was 
 not heard of for a long time. 
 
 In England, as we have seen, Cooper abandoned the operation 
 and otological practice. Stimulated by the opportunity for enter- 
 ing an operative field, Saunders opened an aural clinic in 1804, 
 but soon closed it on account of the poor results of treatment. 
 He speaks of one case of perforation in which a good result was 
 obtained. After him came Curtis, who talks of the operation in 
 vtry general terms, but without furnishing cases. Buchanan 
 also promised to describe his cases, but he never did ; and 
 Schwartze thinks that Degravers, the Edinburgh professor, 
 from whom I have quoted, and Stevenson, are not to be relied 
 upon. 
 
 In France, Itard, Boyer. and Deleau wrote upon this subject. 
 Itard was wise enough to perforate a drum membrane of a deaf- 
 mute whose tympanic cavity was filled with masses of tenacious 
 mucus, and he succeeded in removing them after the operation 
 by syringing. This was an anticipation of Mr. James Hinton's
 
 422 PERFORATION OF MEMBRAISTA TYMPANI. 
 
 operation. In 170 other cases, there was absolutely no result. 
 He calls attention to the fact that permanent suppuration may 
 occur even when the operation is very carefully performed. 
 
 Saissy (1822), of Lyons, in his work on the ear, speaks guard- 
 edly of the operation, and of only one case where the result was 
 entirely satisfactory. Dr. Nathan K. Smith, of Baltimore, trans- 
 lated Saissy's book, and invented an instrument for perforation 
 of the drum-head, which he described in the appendix to his 
 translation ; but there is no account of the success of the opera- 
 tion in this country. 
 
 Schwartze gives very little credence to Deleau's account 
 of his successful results. He claims to have improved eigh- 
 teen out of twenty-five deaf persons and deaf-mutes, by the 
 operation. 
 
 Hendriksz, of the University of Groningen, in 1828, in an 
 inaugural thesis on the subject, which Schwartze used in his 
 historical sketch, states that in the institutions for the deaf and 
 dumb, in Berlin, Vienna, and Groningen, this operation was fre- 
 quently performed. In Groningen, 81 deaf-mutes were operated 
 upon, of whom 17 received for the moment a more or less decided 
 improvement. We hear nothing then of the operation for twenty 
 years, until Hubert Yalleroux, in 1843, wrote an essay upon the 
 danger attending it. He speaks of two cases of death from it. 
 
 Wilde, 1 in defence of the operation, when performed under 
 proper indications, says that Dr. Butcher, of Dublin, reported two 
 cases with a view of showing the ill-consequences resulting from 
 the performance of the operation, and relates the cases of two 
 young persons, a woman and a man, in both of whom it would 
 appear that death ensued from puncturing the membrane. In 
 the first instance, the only history of the case is that, prior to 
 this period, she got a severe cold, with a swelling of the glands 
 of the neck. No account is given of the cause or origin of her 
 deafness, the condition of the membrana tympani, why the 
 operation was performed, in what manner, by whom, or with 
 what instrument. According to Wilde, all that we know is, 
 that "catheterism of the Eustachian tube was performed, aftd 
 said to fail ; hence it was agreed that the membrane of the tym- 
 panum should be pierced, a small piece being drilled out of the 
 membrane of the right side." No exact account of the operation 
 and no names of the witnesses are given. Inflammation ensued, 
 and four months after she died, when the petrous bone was found 
 roughened and softened, and the membrana tympani entirely 
 destroyed. This case, certainly, with such a history, can form 
 
 1 Text-book, English edition, p. 297.
 
 PERFOEATION OF MEMBRANA TYMPANI. 423 
 
 no text for a homily against paracentesis of the drum mem- 
 brane. 
 
 The second case is equally indefinite. Wilde says all that is 
 known of the case is, that he applied to a surgeon and had his 
 tympanum pierced, "but why, or whether with a gimlet or a 
 punch, a trocar or a probe, we are not informed. At first the 
 hearing improved, and then relapsed. After some time head- 
 symptoms set in, and the man died in six weeks." On the post- 
 mortem examination, the brain and its membranes were found 
 in an inflamed condition, and a small abscess in the anterior 
 lobe of the brain, on the same side upon which the puncture was 
 made. The cause of the deafness in this case was found to be 
 a small tumor, about, the size of a bean, lying on the acoustic 
 nerve. 
 
 Paracentesis of the membrana tympani was certainly not in- 
 dicated in this case, and the two together form no more of an 
 argument against the operation, than the indefinitely reported 
 cases of death from the use of the Eustachian catheter do against 
 the use of that instrument. 
 
 The treatises on diseases of the ear, of Kramer, Rau, Bonna- 
 f ont, Toynbee, and the earlier editions of Troltsch, add very little 
 to our knowledge of this subject. 
 
 It has thus been seen, that the first indication which was set 
 down by the old authors, was closure of the Eustachian tube. 
 
 Sir Astley was incorrect in his ideas as to the closure of the 
 tube being the cause of the conditions for which he opened the 
 drum-head, but his operation was a proper one for those condi- 
 tions, so far as we can understand his cases. For example, the 
 perforation of the drum-head for the evacuation of blood was a 
 proper procedure. Again,, in the case of the woman who had 
 been deaf for six weeks, the operation was undoubtedly of ser- 
 vice, even if of only temporary value. Closure of the Eusta- 
 chian tube no longer exists in the minds of the profession as an 
 independent affection, except in extremely rare cases. When 
 its action is impeded, the congestion or swelling of its lining 
 is always associated with similar conditions in the tympanic 
 cavity. 
 
 Since the scientific use of catheters and bougies, it is no 
 longer recognized as a correct indication for perforation of the 
 drum-head. In the very rare cases in which there is an imper- 
 meable stricture from cicatrization, it would be a proper opera- 
 tion. 
 
 Thickening of the membrana tympani was another promi- 
 nent indication of the old authors not of Cooper, however. We 
 now know that a thickening of this .membrane that is confined
 
 424 SCHWARTZE' s CASES. 
 
 to the outer layers, may be removed by appropriate local appli- 
 cations, while one that has extended to the fibrous, or mucous 
 layer, or both, is nearly always accompanied by thickening of 
 the whole lining membrane of the cavity of the tympanum, so 
 that this indication may also be dismissed. 
 
 A collection of blood, pus, or mucus, in the cavity of the 
 tympanum, is, then, the only indication of the old writers which 
 may fairly be said to be up to the present standard of knowl- 
 edge. The collections are readily diagnosticated in all acute 
 and sub-acute cases, and still remain good indications for per- 
 foration of the membrana tympani. 
 
 From this chaos of illy defined indications and imitative ex- 
 periment, there came out one fact in proper form. That one 
 fact was this : That it was pre-eminently proper to perforate the 
 membrana tympani in order to remove mucus, blood, or pus, 
 which could not find an exit through the Eustachian tube. Sir 
 Astley Cooper's favorable cases showed this fact. Itard's deaf- 
 mute was also another illustration of its truth ; but, throughout 
 all the history of these cases, we do not find, until we come 
 down to Saunders,' and later to Hermann Schwartze. of Halle, 
 that one writer had been able to select this single grain of wheat 
 from the chaff. Schwartze saw what had been shown by the 
 cases that were published, and in his first article J revived the 
 operation of paracentesis, but chiefly applied it to acute disease, 
 where these accumulations of mucus, blood, or pus are likely to 
 occur. The operation is now well established as a means of 
 treatment in acute cases, and has already been described in the 
 chapter on "Acute Catarrh of the .Middle Ear." 
 
 Schwartze published a few years since, 100 cases of chronic 
 aural catarrh, in which he has performed a paracentesis of the 
 membrana tympani. Before passing on to review the methods of 
 writers who, since Schwartze's paper was published, have modi- 
 fied the simple operation and enlarged its field, so as to cause it 
 to play a great part, as they claim, in curing chronic cases of 
 catarrhal and proliferous inflammation, I will venture to criti- 
 cise Schwartze's table of results. Of his 100 cases, only 2 were 
 in persons over fifty years of age. Between forty and fifty 
 there were 3 persons, between thirty and forty 8, and only 17 
 were over twenty. The remaining 81 were under that age, and 
 46 were between one and ten years, and 35 between ten and 
 twenty. In America, cases of chronic non-suppurative inflam- 
 mation occurring in young persons are usually quite tractable 
 
 1 See Introductory Chapter, p. 27. 
 
 9 Archiv fur Ohrenheilkunde, Bd. II., p. 36.
 
 SCHWARTZE ON PARACENTESIS. 425 
 
 without paracentesis. We are chiefly anxious to enlarge our 
 therapeutic means for the cases of persons who are more than 
 sixteen years of age, and especially for those who are adults in 
 middle life. Again, in 34 of the cases, the disease, whatever it 
 was, had not existed for a year. There were only 10 cases where 
 the aural affection had lasted between five and ten years, and 
 in 6 cases only, more than ten years. ' 
 
 Schwartze, in a review of this work, seems to think that I have clone him 
 injustice in these remarks, as well as in 'the sentence where I stated that "I 
 have been in the habit of treating many of the cases that he treats by paracen- 
 tesis, by simpler means." He advises me to study the indications that he has 
 laid down, a little more exactly. I have again gone over this subject from 
 Schwartze's writings, and I am still of the opinion that many of his one hundred 
 cases are not entitled to a place among cases of chronic catarrh, as generally un- 
 derstood, and I also think that very many of them were curable without para- 
 centesis, and that scarcely any American or English surgeon would deem this 
 operation necessary for such cases. 
 
 In saying this, I am not aware of making any rude criticism upon Schwartze's 
 procedures. Certainly, I have never intended to be discourteous. But, as a 
 teacher of otology, I am bound to speak freely and frankly of any course of 
 treatment publicly promulgated, even if it come from as high an authority as 
 that of Professor Schwartze. 
 
 Schwartze's cases show that valuable as is paracentesis of 
 the membra.na tympani, in accumulations of mucus in the tym- 
 panum and in cases of catarrh of comparatively recent origin, 
 we have not found in it, a remedy for old and neglected cases 
 of catarrhal and proliferous inflammation. Schwartze's con- 
 tributions, in other words, principally affect acute and sub- 
 acute disease, or exacerbations in chronic affections. The line 
 should have been a little more distinctly drawn between the 
 cases of sub-acute and chronic inflammation, for which para- 
 centesis was performed. In other words, Schwartze has failed, 
 in my opinion, to prove by his statistics, that paracentesis is of 
 any particular value in chronic cases. That it is an important 
 means of treatment for acute and sub-acute cases, he proved, 
 and thus revived a valuable operation. 
 
 It was thought by many (1845) that, if a permanent opening 
 could be kept in a drum-head, the great desideratum would be 
 attained. Bougies were placed in an opening made w r ith a small 
 trephine, and, when it was found that this excited too much re- 
 action, a gold tube, three lines long, and having a little ridge on 
 both ends, was inserted, with a view of keeping up a permanent 
 
 1 Archiv fiir Ohrenheilkuiide, Bd. VI., p. 195.
 
 426 POLITZER' s EYELET. 
 
 opening. 1 This was years before Politzer introduced his eyelet. 
 In 1868, Politzer had a case in which he placed an eyelet in a 
 cicatrix which he had incised. Although of service in this case, 
 it has proved, however, to be beneficial only in very exceptional 
 cases, where, perhaps, repeated paracentesis would do quite as- 
 well. Several cases of accident have occurred in its use. I saw 
 one case in which the opening had closed and left the foreign 
 body in the cavity of the tympanum. I saw the case but once. 
 Dr. Noyes " reported another case, where, in attempting to in- 
 sert the eyelet, it was lodged, not in the membrana tympani, 
 but in the cavity of the tympanum. Eighteen days after, at the 
 patient's solicitation, he was placed under chloroform and the 
 eyelet removed by making quite an opening in the membrana 
 tympani. The suppuration from this opening ceased, and the 
 opening closed in sixteen days. The hearing distance was im- 
 proved, from contact with the meatus, to three and one-half 
 inches while there was an opening in the membrane ; when the 
 opening closed, the hearing went back to the first-named point. 
 This accident of escape of the eyelet into the tympanum is thus 
 one quite likely to happen, either at the time the membrane is 
 pierced, or subsequently. The suppuration which occurs is more 
 apt, however, to force the membrane into the tympanum than 
 into the canal. 
 
 The published experience of those who have performed this 
 operation does not commend it as a successful procedure, and I 
 believe that it is now very seldom performed. 
 
 Wreden (1867),' of St. Petersburg, went far beyond the prop- 
 ositions to make an opening in the membrana tympani. and 
 excised a portion of the handle of the malleus. . Inasmuch as the 
 chief vascular supply of the membrana tympani was along the 
 handle of the malleus, Wreden believed, and with correctness, 
 that, by cutting this off, there would be less probability that the 
 opening would close. He says that, when he removed two- 
 thirds of the membrana tympani and the handle of the malleus, 
 he never saw the opening fully heal. This operation never 
 found much favor, for the reason that it proved to be dangerous 
 to the hearing and even to the life of the patient. It often ex- 
 cited an otitis suppurativa of so severe a form, as to destroy the 
 remainder of the hearing power. It may be doubted, too, judg- 
 ing from analogous cases occurring accidentally, whether even 
 such an opening would not heal. The regenerative power of. the 
 
 1 Frank's Practische Anleitung, p. 310. Erlangen, 1845. 
 
 * Transactions of the American Otological Society, third year, p. 57. 
 
 1 Monatsschrift fiir Ohrenheilkunde, Bd. I.
 
 INCISION WITH GALVANO-CAUTERY. 427 
 
 membrana tympani is indeed marvellous. We need, however, 
 spend very little time over this operation, for it has been prac- 
 tically abandoned by the imitators of Wreden, if not by the dis- 
 tinguished author himself. 
 
 Voltolini, 1 following the suggestion of Erhard, made the 
 incision with the galvano-cautery, in the hope that the open- 
 ing made in this way would be longer in closing. He made an 
 incision through the centre of the posterior section of the mem- 
 brane. There was a crackling sound, as if one passed a knife 
 through a tense paper. This first operation was 011 a patient 
 who had been deaf for three years, and had suffered from fever, 
 after which he became blind from cataract and deaf from un- 
 known causes, or at least unstated ones. Immediately after the 
 deafness appeared, which is stated to have been complete, he 
 was treated by the Eustachian catheter, but without effect. 
 
 Voltolini's first operation did not result in much if any bene- 
 fit to the patient, but it proved that an opening made by the 
 galvano-caustic apparatus could be kept open longer than one 
 made by the knife. Voltolini improved the hearing of a patient 
 in whose membrane he had made an opening with the galvano- 
 cautery to such an extent, that a watch which was not heard 
 before the operation, except when laid upon the auricle, was- 
 heard more than an inch, and ordinary conversation so well 
 that the patient, who was a shop-keeper, was able to carry on 
 his business. The tinnitus aurium and sensations of pressure 
 in the head were also removed. 
 
 Gruber's (18G3) operation, which he calls "myringodecto- 
 my," consists in forming a flap in the membrana tympani by 
 means of a knife and forceps. The flap is cut off. Voltolini 
 shows that this operation is both difficult and dangerous. It is 
 difficult on account of the surgeon being obliged to work with 
 two instruments in a narrow canal. That it is dangerous is 
 shown by the histories of the cases which Gruber gives, e.g., one 
 patient had fever from the 9th to the 21st of November; and 
 quite severe hemorrhage during and after the operation, so that 
 the auditory canal was several times filled with blood. Volto- 
 lini also calls attention to the fact, that Gruber's method is but 
 a modification of the old operations with perforators : but we 
 may say, that all these operations are modifications of old ideas 
 and suggestions. In one of Gruber's cases the opening still ex- 
 isted five months after the operation was performed. 
 
 F. E. Weber (1868), of Berlin, 2 recommended the division of 
 
 1 Monatsschrift fur Ohrenheilkunde, Bd. I. , p. 39. 
 3 Ibid., Jahrgang II., p. 51.
 
 428 DIVISION OF TENSOR TYMPANI. 
 
 the tensor tympani muscle, and the "abnormal adhesions that 
 may occur in the region of this muscle." One of the chief indi- 
 cations is the relief of pressure upon the labyrinth from retrac- 
 tion of the tensor tympani. This muscle has its origin from the 
 cartilaginous portion of the Eustachian tube, and runs along 
 the edge of the bony canal, and is inserted by a well-defined 
 tendon on the inner angle and inner surface of the handle of the 
 malleus. 
 
 Weber thus advanced far beyond the idea of maintaining a 
 permanent opening in the membrane, and carried into effect an 
 old idea of dividing abnormal adhesions that may form between 
 the ossicula. 1 
 
 Dr. Weber published an article in January, 1872, in which 
 he goes very fully into the object, effect, and manner of per- 
 forming his operation. It is well known that the great Vienna 
 anatomist, Hyrtl, was the first to suggest this operation, but 
 Weber was the first to perform it. At the time of the publica- 
 tion of Weber's last article he had operated upon about fifty 
 cases. 
 
 There were two conclusions which led Weber to the per- 
 formance of this operation : 1st, The fact that had been demon- 
 strated that the tensor tympani muscle kept not only the mem- 
 brana tympani and the ossicula with their ligaments, but also 
 the labyrinth, by means of the stapes, in a state of tension, and 
 that, consequently, an increased tension or rigidity of the mus- 
 cle prevented the proper conduction of sound and increased the 
 pressure upon the labyrinth. 3d, He also reasoned that this 
 increased tension would of itself excite and maintain catarrhal 
 inflammation of the tympanic cavity, especially if there was at 
 the same time an affection of the tube, and that it might cause 
 a hindrance to the circulation in the labyrinth, with tinnitus 
 aurium, etc. In short. Dr. Weber thought it possible that many 
 varieties of non-suppurative affections of the middle ear might 
 depend upon excessive contraction of this muscle. 
 
 The tenotomy is- divided into four stages : 
 
 1. The membrana tympani is perforated with the hook- 
 shaped extremity of the tenotome, about 1 to 1 mm. in front of 
 the handle of the malleus, somewhat below and to one side of 
 the short process. 
 
 2. The hook-shaped knife is pushed forward into the cavity 
 of the tympanum the handle of the instrument being brought 
 downward and forward and thus it is made to grasp the ten- 
 don. (Just how the operator is to know when the hook is around 
 
 ~ * 
 
 1 Loc. cit., Jabrgang IV., p. 143.
 
 DIVISION OF TENSOR TYMPANI. 429 
 
 
 
 the tendon, I am unable to learn from Dr. Weber's description. 
 I suppose, however, from previous familiarity with the opera- 
 tion on the cadaver.) 
 
 3. While the hook is about or over the tendon, the operator 
 exerts a gentle, drawing pressure upon it, by turning the handle 
 of the tenotome toward the face of the patient ; the hook is then 
 turned a third upon its axis, by means of the button which acts 
 upon the cog, and the tendon is cut. A distinct crackling sound 
 is heard at the moment of the division of the tendon. 
 
 4. The hook is then brought away from its position by re- 
 versing the action of the button which acts on the cog, and the 
 instrument is withdrawn. 
 
 Dr. Weber at a. later date gives the results of his operation 
 in nine rather ponderous formulas, but they may be summed up 
 in the statement that it is claimed that the operation, in most 
 cases for which it is properly performed, diminishes tinnitus 
 aurium, vertigo, prevents many persons from becoming abso- 
 lutely deaf, and that, if a permanent result is desired, fluid must 
 afterward be regularly forced into the cavity of the tympanum, 
 by means of a Weber's pharmaco-koniantron. 
 
 Weber has reported cases which confirm his view of the 
 benefit from the division of the tensor tympani. It will be seen 
 by reading these cases, that he follows up the operation by* the 
 'most decided treatment of the middle ear, thus placing this 
 operation where, I believe, all perforations of the membrana 
 tympani should be placed, as one of the means of assisting in 
 the thorough medication of the middle ear by injections of fluid 
 and air. Although there is usually a temporary effect from the 
 letting up of the intra-auricular pressure, it cannot be compared 
 to such an operation as iridectomy for glaucoma, when the use 
 of the knife ends the treatment. 
 
 Gruber also advocated the division of the tensor tympani 
 muscle, on account of the fact demonstrated by Helmholz, that 
 this muscle moves the whole chain of the ossicula auditus, as 
 well as the malleus, inward, a fact which causes us to believe 
 that the intra-auricular pressure must be increased and morbid 
 changes caused by any excessive contraction of this muscle. 
 Gruber calls attention to the fact which he was the first to show, 
 as he claims, that the muscle is inserted not only on the inner 
 angle, but also on the anterior surface of the handle of the mal- 
 leus, and he also alludes to what we have already noticed in the 
 chapter on the anatomy of the middle ear, that the tensor tym- 
 pani is intimately connected or united to the tensor palati mus- 
 cle. This seems to indicate that the frequent affections of the 
 soft palate must have some abnormal influence upon the tensor
 
 430 DIVISION OF TENSOR TYMPANI. 
 
 tympani. Gruber considers the indications for a division of the 
 tensor tympani to be a retraction or contraction a shortening 
 of this muscle. These indications may be known by studying 
 the changes on the folds or pockets of the membrana tympani. 
 
 "If the membrane is drawn very much inward, and the lower 
 end of the malleus goes with it, while the upper retains its posi- 
 tion, and thus the posterior fold becomes more prominent, we 
 .have an indication of the abnormal sunken position of the drum- 
 head." ' Gruber admits that this sinking of the drum-head may 
 depend upon other causes than the retraction of the tensor tym- 
 pani ; but these may be readily distinguished. The excessive 
 contraction of the muscle causes the handle of the malleus to 
 appear broader, and the membrana tympani to look as if twisted, 
 in a state of what in surgical language is called torsion. The 
 .anterior ligament of the malleus, which passes from the spina 
 tympanica to the neck of the malleus, also becomes more prom- 
 inent, in retraction of the tendon of the tensor tympani. The 
 final mark of retraction of the muscle, according to Gruber, is 
 the more or less rapid reposition of the membrane in its former 
 position after the air-douche has been employed. It is certainly 
 very easy for us to verify these indications, as given by Gruber, 
 and it is to be hoped that the operation will have a fair trial in 
 the "class of cases of non-suppurative disease, for which we have 
 as yet done so little. 
 
 Gruber advises that the tendon be usually divided as Weber 
 recommends, in front of the handle of the malleus. The acci- 
 dent that may possibly happen, if the membrane is opened pos- 
 teriorly to the malleus, according to Gruber, is a perforation of 
 the carotid artery, if the carotid canal be incomplete in its bony 
 wall ; but this kind of an accident seems to be almost impossible, 
 with any care in the management of the tenotome. As another 
 argument for the anterior incision, it is stated, that the laby- 
 rinth cannot be entered if the opening be made in front of the 
 malleus, while the knife might possibly go through the foramen 
 ovalis, if the opening be made posteriorly. Gruber uses a much 
 simpler instrument than Weber's for the division of the tendon. 
 It is a narrow, needle-like knife, fastened in a handle at an ob- 
 tuse angle. The knife is three inches long, and has a blade 
 cutting only on the anterior edge. This cutting edge is ground 
 to a point, and curved to such an extent that, when the instru- 
 ment is passed one-half a millimetre in front of the malleus, 
 through the membrana tympani, the shaft of the needle stands 
 
 1 Seperat-abdruck .aus der Allgemeinen Wiener Medizinischen Zeitung, January,^ 
 1872.
 
 DIVISION OF TENSOR TYMPANI. 431 
 
 parallel to the long axis of the auditory canal. The point of the 
 knife reaches only a little above the inner margin of the handle 
 of the malleus, but does not pass far beyond the posterior seg- 
 ment of the membrana tympani. 
 
 The pain from the operation of division of the tensor tympani 
 is not usually very great, and it is seldom necessary to etherize 
 a patient for the purpose of performing it. Gruber performs the 
 operation in cases of what he terms hypertrophic or plastic in- 
 flammation of the middle ear (proliferous inflammation), where 
 the ordinary treatment has failed to benefit the case. The head 
 of the patient is held by an assistant, the drum-head well illumi- 
 nated, and the tenotome is passed through the anterior segment 
 of the membrane, and by turning the outer end of the knife to- 
 ward the face of the patient, the point is pushed around the 
 handle of the malleus to the other segment of the drum-head. 
 The incision is then elongated about three millimetres, while the 
 knife is held in the same position, and then withdrawn. There is 
 considerable resistance in the tissue when the tendon is divided, 
 and a crackling sound is heard. The hemorrhage from the 
 operation is usually very slight. The air-douche, by the catheter 
 or Politzer's method, should be used after the cutting is finished, 
 and the ear closed lightly with cotton, while the patient should 
 be kept quietly in the house and avoid taking cold. 
 
 Those who doubt whether it is possible to divide the tendon 
 without also cutting other parts, will have their doubts removed 
 by performing the operation on the dead body according to the 
 directions of Weber or Gruber, and then making an examination 
 of the parts. 
 
 Dr. Orne Green recommends that Gruber's operation be done 
 "by making the incision posterior to the handle of the malleus, 
 and with a little broader knife. 1 
 
 Hartmann uses a small knife curved on the flat and on the 
 edge, for division of the tensor tympani. The point of the knife 
 reaches about 1 mm. further outward than its upper edge. Hart- 
 mann first makes an incision into the posterior segment of the 
 membrane about 1 mm. behind the handle of the malleus, and 
 learns what changes occur in the hearing distance and in the 
 tinnitus aurium. The tenotome is then introduced into the tym- 
 panic cavity for a distance of 3 mm., whereby the knife is placed 
 below the tendon of the tensor tympani between the handle of 
 the malleus and the long crus of the incus. By slightly sinking 
 its handle the sharp point of the tenotome is forced so far to- 
 
 1 Dr. Green has some preparations made by himself in Wedl's laboratory in Vienna, 
 in which the fact that the tendon is exactly and cleanly divided in his operation, is 
 -clearly shown.
 
 432 DIVISION OF POSTERIOR FOLD. 
 
 ward the upper part of the tympanic cavity, that the tendon is 
 obliquely divided on the withdrawal of the instrument. 1 
 
 Lucae (1871) divided the posterior pocket or fold of the mem- 
 brana tympani, in what he terms "dry catarrh of the middle 
 ear " (proliferous inflammation), where there is a marked sink- 
 ing inward of the handle of the malleus, and great prominence 
 of the short process, and when the Eustachian tube is perme- 
 able. 2 Lucae uses a bayonet-shaped needle, and the incision is 
 made from below upward, in order to avoid cutting the chorda 
 tympani. If this nerve be divided, it is probably not a serious 
 accident, judging from cases of injury to the drum-head in 
 which the chorda tympani has been injured. Of 109 cases oper- 
 ated upon by this method, Lucae claims to have greatly bene- 
 fited 40, and to have improved 39, while in 24 there was no 
 benefit from the operation. 
 
 A question of priority has arisen between Dr. Lucae and 
 Professor Politzer, in regard to the performance of this opera- 
 tion, but I will not venture to discuss this subject. 
 
 Politzer performs the same operation, in order to render the 
 membrane more movable, under the name of the incision of the 
 posterior fold of the membrana tympani. The incision is a 
 longitudinal one, at right angles to the long axis of the fold, 
 between the short process of the malleus and the peripheric end 
 of the fold. 3 
 
 Voltolini (1870) advised the use of a probe, which is intro- 
 duced daily in an opening made by the galvanic cautery, for 
 some weeks after. I am not able to say whether Voltolini has 
 found this method a certain means of maintaining an opening, 
 but I am inclined to think not, from the fact that so little is 
 heard from him on the subject. 
 
 Dr. Prout (1872) divides adhesions between the membrana 
 tympani and the promontory with a very small iridectomy-knife, 
 having a long handle. His principle of operation is, to divide 
 the adhesions according to their situation. I have seen him 
 perform the operation in two cases. 
 
 In the first case* the membrana tympani was very much 
 sunken, and an adhesion to the promontory had occurred, as 
 shown by an opaque, yellow, immovable spot on the correspond- 
 
 1 Politzer: Text-book. Translation, p. 383. 
 
 2 Seperat-abdruck aus der Berliner Klinischen Wochenschrift, No. 4. 1872. 
 
 3 Translation of Politzer's Lecture, by Dr. Burnett. Philadelphia Medical Times, 
 vol. ii., No. 56. 
 
 4 Myringodectomy, followed by a decided improvement in the hearing power, in a 
 case of adhesion between the membrana tympani and the promontory. Transactions 
 of the Medical Society of the State of New York, 1872.
 
 PROUT'S OPERATION. 433 
 
 ing point of the membrane. In performing the operation, Dr. 
 
 Prout used a knife such as is here represented. 
 
 The patient was thirty -three years of age, a teacher by occu- 
 pation, and had been treated by Dr. Prout for some time 
 u previous to the operation, for advancing non-suppura- 
 tive inflammation of the middle ear, but in spite of the 
 use of the catheter, Politzer's method, and of the poste- 
 rior nares syringe, the patient continued to grow steadily 
 worse as to her hearing, and the tinnitus aurium became 
 so unbearable as almost to unfit her for her daily 
 duties. 
 
 On October 3, 1871, the patient was placed under the 
 influence of ether, and Dr. Prout having illuminated 
 the ear by means of the otoscope upon a forehead band, 
 entered the knife in front of the adhesion, and cut 
 around the promontory, with which the end of the han- 
 dle of the malleus was in contact. By means of " a little 
 cutting, picking, and teasing, a free opening was made 
 of about one and one-half lines in diameter." An at- 
 tempt was made to remove the piece of membrane ad- 
 herent to the promontory ; but the operator was not 
 certain that he succeeded. As soon as the patient re- 
 covered from the ether, she said that she heard better. 
 The warm douche was used to quiet the pain, which 
 was not severe, however. The hearing power for the 
 voice was much improved by the operation. The patie'nt 
 was able to hear reading and conversation at thirty feet 
 in front of her, while before she could on one side only, 
 and then at ten feet. There was a slight purulent dis- 
 charge for about a week after the operation ; but no 
 very severe pain. One year after the operation the 
 opening in the membrana remained of the original size ; 
 the cavity of the tympanum was dry ; the watch was 
 heard when pressed upon the auricle before the opera- 
 tion it was not heard at all ordinary conversation was 
 readily heard at the distance of twenty feet. 
 
 Dr. Prout thus succeeded in maintaining what may 
 
 Prout's fairly be called a permanent opening in the drum-head, 
 and in giving great relief to the patient for a time. A 
 
 permanent suppurative inflammation resulted from the second 
 
 case. 
 
 Mr. Hinton (1869) ' believed that mucus dried up and became 
 
 1 On Mucous Accumulations within the Cavity of the Tympanum. From the Guy's 
 Hospital Reports, 1869. 
 28
 
 434 HINTON ON ACCUMULATION OF MUCUS. 
 
 dense in the cavity of the tympanum, and thus became a cause 
 of "confirmed deafness." He therefore made an incision into the 
 membrana tympani in order to remove this hardened mucus. 
 
 Mr. Hinton's operation consists of an incision in the mem- 
 brana tympani, through which fluid is injected into the cavity 
 of the tympanum and Eustachian tube. The incision is made 
 with a lance-shaped knife, in the inferior and posterior quadrant 
 of the drum-head, and is from two to three or even more lines in 
 length. The syringing is done with some force, in order to drive 
 out of the cavity, into the Eustachian tube and pharynx, dried 
 or inspissated mucus, the collection of which, in many cases, 
 according to both pathological and clinical experience, is the 
 cause of the impairment of hearing and the tinnitus. I have 
 seen Mr. Hinton perform this operation, and two cases upon 
 which it had been performed some time before. In both these 
 cases the patients were confident that there was an improvement 
 in the hearing, and a lessening of the disturbing symptoms for 
 some months after the operation. 
 
 The process of washing out the cavity of the tympanum, 
 upon which Mr. Hinton lays great stress, is done by means of a 
 syringe fitting hermetically into the external meatus. A solu- 
 tion of bicarbonate of soda is used. The syringing, which I did 
 on one occasion at Mr. Hinton's clinic at Guy's Hospital, Lon- 
 don, immediately after Mr. Hinton had performed the operation, 
 sometimes causes vertigo, which passes away in a few moments. 
 
 Mr. Hinton once divided the chorda tympani nerve in per- 
 forming the operation of incision of the membrane. " The patient 
 felt a sudden shock running down the tongue, the corresponding 
 side of which suffered an impairment alike of general and of 
 special sensibility in its whole extent. The patient began to 
 recover in two or three days." The most frequent ill effect is an 
 inflammation of the external auditory canal ; when this is appre- 
 hended the ear should be syringed through the Eustachian tube 
 instead of the meatus. 
 
 Mr. Hinton performed his operation in sub -acute or quite 
 recent cases of accumulation of mucus in the cavity of the tym- 
 panum, as well as in those of long standing, such as have formed 
 the subject of discussion in the preceding chapters. I confess to 
 a little skepticism, however, as to the fact of inspissated mucus 
 being the sole cause of the impairmant of hearing in many of the 
 chronic cases. The post-mortem examinations of ears, whose 
 function was much impaired for a long time, that have as yet 
 been made, do not reveal this as the only lesion in many cases. 
 
 Since the above was published, I have largely added to my 
 experience in operations upon the membrana tympani, and I
 
 VIEWS OF AMERICAN OTOLOGISTS. 435 
 
 have also had the opportunity of studying some of the cases of 
 other surgeons as if they were my own. As a result of this ex- 
 perience, as I have said at the opening of this chapter, I have 
 given up all operations upon the drum membrane or upon the 
 tendon of the tensor tympani, in chronic non-suppurative cases, 
 when there is no suspicion of retained mucus in the tympanic 
 cavity. I believe that any operations yet suggested, are inade- 
 quate to relieve tinnitus aurium, improve the hearing, or even 
 to retard the advance of this form of disease. I read a paper ' 
 expressing this opinion before the American Otological Society 
 in J881, and my views were confirmed by the members who took 
 part in the discussion, by Blake, Buck, Kipp, Noyes, Burnett, 
 Bartlett, Mathewson, Theobald, as representing " as well as any 
 one statement could reflect the varied opinions of those who 
 were interested in otological questions " (Buck). It may be said 
 then, that a majority of the authorities on the treatment of aural 
 disease in the United States, have up to this time, given up these 
 operations in chronic non-suppurative cases, where there is no 
 suspicion of fluid in the tympanic cavity. If we can yet find a 
 safe means of making a permanent opening in the membrana 
 tympani, I believe we should benefit quite a large class of cases, 
 as yet unalleviated by any means. As Politzer 2 points out, this 
 permanent opening can only be useful, "when the stapes is still 
 movable, when the membrane of the fenestra rotunda is not 
 thickened or calcified, and when no labyrinthine complications 
 exist." I believe that we shall yet find some means of securing 
 a permanent opening in the membrana tympani, for we some- 
 times see cases where we find it impossible to close an opening 
 made by suppuration. The application of collodion (McKeown) 
 and paper disks (Blake) have been advised for relaxation of the 
 drum-head. I have tried the disks, but as yet without good 
 results. 
 
 In the choice of an instrument for a simple paracentesis, it 
 seems to me too much has been said. For Weber's operation, 
 Gruber's knife seems to me the best, and for Prout's operation 
 peculiar instruments are required, which will vary according to 
 the situation of the adhesions, their size, and so on ; but for the 
 ordinary paracentesis, whether we require a long or short in- 
 cision, a puncture or a flap, an ordinary cataract-needle will do 
 very well. Those who prefer an angular instrument will find 
 Blake's knife, that which is attached to his modification of 
 Wilde's polypus snare (which should be lengthened in the shank, 
 however), one of the best. The use of an anaesthetic is not at 
 
 1 Transactions, vol. ii., p. 458. * Text-book, p. 373.
 
 436 INSTRUMENTS FOR PARACENTESIS. 
 
 all necessary, except where adhesions are to be divided, and the 
 dissection is to be therefore prolonged. Some of the German 
 authors find the membrana tympani very sensitive, even under 
 chloroform ; but from what I have seen of the use of chloroform 
 on the Continent, I think many of the operators are so fearful of 
 the results of the anaesthetic, that they do not put their patients 
 fairly to sleep. If ether be used as we use it in this country, the 
 drum-head may be readily made insensible. I usually perform 
 paracentesis without ether, and often in my consulting-room. I 
 do not regard it as a serious or painful operation. The patient's 
 head should have a good rest, and the otoscope be used on a 
 forehead band, so that both hands may be free. In ordinary 
 perforations for the purpose of washing out the cavity, the pos- 
 terior and inferior quadrant is, perhaps, the best position for the- 
 incision. 
 
 On page 287 will be found a representation of the paracen- 
 tesis needle which I generally use. 
 
 Some of the instruments formerly recommended for perforation of the mem- 
 brana tympani, were probably never actually used such as one very like a. 
 cork screw, and a red-hot trochar. Cooper employed a small trochar in a canula, 
 the point of the trochar projecting at the most, one and a half lines. Since the 
 rigid canula'would be apt to hurt the membrana tympani, upon which it was 
 pressed before the trochar was pushed forward, Saissy used a canula of elastic 
 wood, which caused no pain. Itard punctured the membrane with a blunt 
 probe. Eicheraud recommended that the opening be maintained by the sub- 
 sequent use of the pure nitrate of silver, in solid form ; but I have found the 
 use of this caustic one of the most effectual means of closing an opening from 
 an old suppurative process. 1 
 
 Since the above was written, Dr. Sexton and Dr. C. H. Bur- 
 nett have revived the operations upon the drum-head and os- 
 sicles, especially the operation for the removal of the latter 
 for the relief of the tinnitus and impairment of hearing in 
 chronic non-suppurative inflammations. Dr. Sexton has read 
 several papers upon the subject, but the profession as yet re- 
 mains unconvinced, I think, as to the results of this procedure 
 in such subjects. Further experience, and the details of a fair 
 number of cases in which good results have been obtained, are 
 necessary before the judgment founded upon the failure of our 
 best men, with the same class of cases, and with the same 
 operation, is required, before removal of the ossicles is generally 
 adopted as a therapeutic resource. In Sexton's earlier papers he 
 
 1 The most complete account of tjie instruments used or recommended for perfora- 
 tion of the membrana tympani by various authorities, is found in Beck's Krankheiten 
 des Gehororganes, p. 45. Heidelberg and Leipzig, 1827.
 
 THE EFFECTS OF CONDENSED AIR. 437 
 
 advocates removal of all the ossicles, but to judge from his 
 latest reports, published in the Archives of Otology for May, 1891, 
 he removes only the malleus. ' The incus and stapes he now 
 admits are not always visible. The membrana tympani is also 
 removed. This is very apt to re-form, when the hearing does not 
 continue to be as much improved. I advise a careful considera- 
 tion of Lucae's ' cases, as well as the isolated cases of Prout and 
 Hackley, referred to in this volume, before too high hopes are 
 had as to the efficacy of this operation in any considerable class 
 of cases. But it is a sound surgical procedure, in chronic suppu- 
 rations, as a means of removing necrosed bones and hopelessly 
 morbid tissue. But this is no new discovery, and has no bear- 
 ing upon the present subject. 
 
 THE EFFECTS OF CONDENSED AIR UPON THE HEARING POWER. 
 
 From some peculiar, but unexplainable tendency in the hu- 
 man mind, to believe in marvellous cures from means not 
 usually employed by those who make the practice of medicine 
 their duty in life, we occasionally hear of persons who have had 
 their hearing restored by entering and remaining in chambers 
 such as the caisson used in bridge-building where the air is 
 condensed, or from a stay in the so-called pneumatic cabinets. 
 The exact observations of Magnus, A. H. Smith, and Green, of 
 St. Louis, show that these accounts of cure of chronic non-sup- 
 purative inflammation are not based on facts. On this subject 
 Dr. Smith 3 says : " Three cases of extreme deafness came under 
 my notice ; two of them in laborers, and one in the person of a 
 gentleman who was advised by a physician to visit the caisson 
 in the hope that he might receive benefit from the action of the 
 compressed air. In all these cases the hearing was very much im- 
 proved while in the caisson, but on returning to the open air the 
 former degree of deafness immediately reappeared." I saw the 
 gentleman to whom Dr. Smith refers, and diagnosticated his case 
 as one of chronic proliferous inflammation of the middle ear. 
 
 It might as well be claimed that deafness is cured by riding 
 in a railway carriage, because the hearing is temporarily im- 
 proved while the patient is there, as to assert that a cure is 
 found in condensed air because persons who enter an air-cham- 
 ber when the atmosphere is condensed, hear better during their 
 stay. 
 
 The only conceivable means by which a sunken drum-head 
 could be improved in position and conducting power, by remain- 
 
 1 Otological Section, Berlin Congress, 1890. 
 
 3 The effects of high atmospheric pressure, before quoted in Chapter X.
 
 438 EXHAUSTION OF AIR IN AUDITORY CANAL. 
 
 ing in a chamber of condensed air, would be the rupture of the 
 membrane from the force of the air, or the opening of the tubes 
 by the patient's efforts to overcome the pressure. Certainly 
 these ends can be accomplished in a simpler and safer way. 
 
 Dr. Smith found, however, that sounds, such as the ticking 
 of a watch, were not heard more, but less distinctly in the con- 
 densed air of the caisson ; a fact which he accounts for by sup- 
 posing that the great pressure on all parts of the auditory appa- 
 ratus opposes a mechanical obstacle to the freedom of vibration. 
 "At the same time the velocity of the waves of sound is greater, 
 and hence the pitch is higher. A deep bass voice is changed to 
 a treble, and the prolonged, heavy sound of a blast is so modi- 
 fied as to resemble the sharp report of a pistol." 
 
 Magnus ' says that the conduction of sound is better in com- 
 pressed air, and that we can hear the same tones better than in 
 the ordinary atmosphere, provided that the membrana tympani 
 is not placed in an abnormal condition that is, an over-pressure 
 allowed upon it. 
 
 EXHAUSTION OP THE AIR IN THE AUDITORY CANAL. 
 
 Politzer recommends the exhaustion of the air in the exter- 
 nal auditory canal, by plugging the meatus with cotton-wool, 
 saturated with oil, as a means of drawing out a sunken drum- 
 head, when we have reason to believe that the tensor tympani 
 is retracted. The patient closes the auditory canal in this man- 
 ner in the evening, and removes the plug in the morning. If 
 the plug be used two or three times a week, for two or three 
 weeks, and no result be obtained, Politzer considers the remedy 
 of no value. 
 
 Siegle's otoscope, or pneumatic speculum, which has already 
 been described, as a means of diagnosticating adhesions be- 
 tween the membrana tympani and the walls of the tympanic 
 cavity, was much used by the late Dr. H. Pinkney, surgeon 
 to the New York Eye and Ear Infirmary, as a means of break- 
 ing up adhesions in the tympanic cavity, and of improving 
 the hearing. Dr. Pinkney attached the syringe of a stomach- 
 pump to the apparatus, and exhausted the air by the use of this 
 instrument. The membrane should be carefully watched during 
 the process, lest too extensive ecchymosis or a rupture occur. 
 I have employed the apparatus in cases of chronic proliferous 
 inflammation, at Dr. Pinkney's suggestion, but with no satisfac- 
 tory results. I have also cupped the membrana tympani and 
 auditory canal, by placing a cup over the auricle, and exhaust- 
 ing the air by means of a syringe, but with no beneficial result. 
 
 1 Archiv fur Ohrenheilkunde, Bd. I., p. 280.
 
 DELSTANCHE'S MASSEUK. 
 
 439 
 
 FIG. 95a. Delstanche's Masseur. 
 
 DELSTANCHE'S MASSEUR. 
 
 A great advance in the treatment of adhesions between the 
 ossicles has been made by Delstanche's improvement upon 
 Pinkney's apparatus. Pinkney's instrument was efficacious in 
 his hand, but it is a 
 clumsy instrument, 
 which was displaced 
 by Ely's Siegle, pict- 
 ured on page 368. 
 This in turn gives 
 way to Delstanche's 
 instrument, which is 
 not only an excellent 
 means of testing the 
 mobility of the ossi- 
 cles, but also of treat- 
 ing cases of chronic 
 catarrh or chronic 
 proliferous inflam- 
 mation with the char- 
 acteristic rigidity of the ossicles. By means of this new instru- 
 ment I have had better success in the treatment of the rigid 
 ossicula, and I have the agreeable opportunity of modifying my 
 previously expressed opinions as to the negative results of this 
 treatment. I think it an adjuvant of considerable value in the 
 treatment of chronic non-suppurative inflammations, in the re- 
 lief of tinnitus aurium, and impairment of hearing. 
 
 "PARETIC DEAFNESS." 
 
 No account of chronic non-suppurative inflammation of the 
 middle ear, would be complete without a mention of the views of 
 Weber-Liel, as first published in his monograph on progressive 
 impairment of hearing, and in an article on affections of the 
 middle ear, 1 published in a German encyclopaedia for physicians. 
 The upshot of this view of the chronic affections of the middle 
 ear, belonging to the proliferous form, is that a derangement of 
 the tension of any of the pharyngeal, tubal, or tympanic muscles 
 will bring about secondary vaso-motor changes in all the parts 
 within the tympanum. The most frequent form of such a de- 
 rangement of tension is seen in a loss of power of the tensor 
 palati. This induces a gradually increasing loss of hearing and 
 
 : Ueber das wesen und die Heilbarkeit der haufigsten Form progressive Schwer- 
 horigkeit. Berlin : Hirschwald, 1873.
 
 440 PARETIC DEAFNESS. 
 
 tinnitus, sometimes accompanied by catarrh of the tympanum, 
 but more likely to be associated with sclerosis. The restoration 
 of the normal muscular power should be the first object of treat- 
 ment. Weber-Liel advises local electrization of the pharyngeal 
 and tubal muscles, the continuous current being the most effec- 
 tive. This must be combined with careful attention to the gen- 
 eral health. Hereditary tendency to the affection makes the 
 prognosis unfavorable. Lessening of the tinnitus is one of the 
 best signs in the course of the treatment. A very mild astringent 
 spray, introduced into the tympanum by means of the konian- 
 tron, may also be used. The tendon of the tensor tympani is 
 sometimes excessively contracted. If so it is to be divided. One 
 symptom of the retraction of the muscle is, that the malleus is 
 not only drawn in, but slightly twisted on its axis, so that its 
 anterior surface is directed a little forward. Those who wish a 
 fuller account will find it in the original, from which I have 
 quoted, or they may study the book of Dr. Woakes. l 
 
 For my part, I can but think Dr. Weber-Liel's views some- 
 what fanciful. His published cases, as has been suggested by 
 Mr. Hinton, are defective, especially as to their tests of the condi- 
 tion of the acoustic nerve. Dr. Woakes has somewhat amplified 
 the views of Weber-Liel, but his book is essentially a reproduc- 
 tion of Weber-Liel's views. Woakes attaches great importance 
 to inflammation of the gums in children in its reflex influence 
 upon the ear. He seems to think that "the only obvious con- 
 necting link between the regions interested (the teeth and the 
 ear) is the continuity of nerve-fibre," and this he finds in the 
 relations of the vaso-motor nerves. This, in my opinion, is beg- 
 ging the whole question, for the direct connection between the 
 buccal cavity and the Eustachian tube is obvious enough to 
 allow of the propagation of inflammation by simple continuity 
 of tissue, without the intervention of the vaso-motor nerves. 
 
 Dr. Woakes states that he had embodied his views on the 
 deteriorating effect on the hearing power of certain pathological 
 states of the palato-tubal muscles, in a paper which he read be- 
 fore the British Medical Association, without knowing Weber- 
 Liel's paper, although "Progressive Impairment of Hearing" 
 had been published for some time. Woakes's " Paretic Deafness," 
 however, corresponds with great exactness to Weber-Liel's "Pro- 
 gressive Impairment of Hearing," and what has been said of the 
 views of the one, may be said of the other. The objections to 
 referring cases of chronic proliferous inflammation to catarrh, 
 is one in which I fully sympathize, but I do not think we have 
 
 
 
 1 On Deafness, Giddiness, and Xoises in the Head. London, 1880.
 
 RESULTS OF TREATMENT. 441 
 
 found the way out in diagnosis, by ascribing their origin to par- 
 alysis of the pharyngeal, tubal, or tympanic muscles, nor in 
 treatment by intra-tubal electricity, hydrobromic acid, strychnia, 
 or the sesqui-carbonate of ammonia. I think it possible that 
 some of Weber-Liel's cases, as well as those of Dr. Woakes, 
 belong rather to the labyrinth than to the middle ear. For 
 myself, I think I have been in the habit, in former days, of for 
 getting that the cochlea, like the retina, may become the seat of 
 chronic disease. 
 
 RESULTS OF TREATMENT. 
 
 In my opinion,. the results of treatment of chronic non-sup- 
 purative inflammation of the middle ear, will never be very grat- 
 ifying. It is essentially an incurable affection. It may often be 
 alleviated and sometimes arrested, but in adults never cured. It 
 is pre-eminently a local disease that is to say, a person with this 
 variety of aural disease may have the best general treatment the 
 world affords, and be under the most appropriate hygienic condi- 
 tions ; he may live in a climate like that of Nice, Mentone, Naples, 
 Aiken, or St. Augustine, and then he will not recover from his 
 aural disease ; nay, more, he will continue to grow slowly but 
 gradually worse if his pharynx, Eustachian tubes, and middle 
 ear are not treated by the appropriate appliances and remedies, 
 and sometimes even if they are. And yet a change from a harsh 
 climate with long winters, to a mild one, will sometimes be of 
 avail in lessening the horrors of tinnitus aurium, and arresting 
 the advance of disease of the middle ear. Just how much can 
 be done in this way, it is difficult to estimate, for catarrhal pa- 
 tients seem to grow worse in Colorado, which is so well adapted 
 for many forms of phthisis. The changes of temperature in mild 
 climates, are also felt very much by aural patients who have 
 nasal and pharyngeal disease. One of my patients with chronic 
 proliferous inflammation, has found the tinnitus aurium greatly 
 relieved by a winter in the mountains of North Carolina. An- 
 other, with catarrhal inflammation, was happy in Florida, until 
 malaria destroyed her peace. Some patients find the seashore, 
 especially Newport and Narragansett, of benefit to the naso- 
 pharyngeal region, while others cough and sneeze, and their 
 "ears fill up" incessantly there. On the whole, I think the 
 mountains are better for aural patients in summer. But I must 
 confess that I have no exact opinions as to the influence of 
 climate upon non-suppurative disease of the middle ear. The 
 disease of the ear, is the last link in a long chain of improper 
 conditions, and should never be considered as a primary affec-
 
 442 RESULTS OF TREATMENT. 
 
 tion, as an entity to be subjugated or driven out by special 
 means adapted to many cases. It exists in this generation, in 
 larger proportion than it will in the next. For acute disease 
 will then be properly considered and treated, the hygienic man- 
 agement of the human body will be better understood. Just as 
 chronic suppuration with its consequences, is markedly lessened 
 in our own time, as the result of a wise appreciation of "ear- 
 ache," and acute catarrh, and suppuration, so will chronic ca- 
 tarrh be lessened as the importance of incipient aural disease is 
 more and more appreciated. If the picture of the prognosis of 
 chronic affections of the ear is a gloomy one to the young and 
 enthusiastic practitioner, he must find his consolation in lessen- 
 ing their number in the next decade, by a proper treatment of 
 acute aural disease in this. 
 
 There are yet, however, few medical colleges in this country 
 where the otological course is complete or exact. Worse than 
 this, attendance upon the lectures that are given, is generally 
 not compulsory. It is only in special hospitals, and post-grad- 
 uate colleges, that any adequate instruction is given, except in 
 very few instances. All this must be changed, before we can 
 expect a knowledge of aural pathology and therapeutics, and 
 with this a decrease in the proportion of neglected and incurable 
 cases. 
 
 If I were to sum up my conclusions after twenty years of work 
 in this field, I should say that 
 
 1. Chronic catarrhal inflammation in young subjects, is sus- 
 ceptible of relief and cure in a large proportion of cases. 
 
 2. Chronic catarrhal inflammation in adults, is susceptible of 
 relief and alleviation in about twenty per cent, of the cases : of 
 cure in none. 
 
 3. Chronic proliferous inflammation remains as yet incurable,, 
 and is not susceptible of alleviation or relief, either in the young; 
 or old subject, in more than five per cent, of the cases.
 
 CHAPTER XVI. 
 
 CHBONIC SUPPTJBATION OF THE MIDDLE EAE. 
 
 Consequence of Acute Suppuration. Otorrhoea an Improper Term. Often confounded 
 with Chronic Inflammation of the Canal. Kelative Frequency of the two Affec- 
 tions. Symptoms. Perforations of MembranaTympani. Treatment. Syringing. 
 Astringents. Fluids. Powders. Electricity. Artificial Membrana Tympani. 
 Cases. Prognosis. 
 
 THE chapters in which acute aural catarrh and acute suppura- 
 tion have been considered, have prepared us for the description 
 of the disease properly known as chronic suppuration of the 
 middle ear, which is a direct consequence of these affections. It 
 was formerly almost universally known and described as otor- 
 rhoea. But this term, simply meaning a discharge from the ear, 
 and being one that does not in any proper way define the seat or 
 character of the disease, should, I think, be banished from the 
 nomenclature of otology. Chronic suppuration of the middle 
 ear is the affection which, among the laity, is called "a running 
 from the ear," and which has been so lightly regarded by the 
 profession, that every year people die from its direct results, and 
 under the observation of physicians, without the suspicion that 
 the disease of the ear, and of the ear alone, was the cause of 
 their death. In this, and in following chapters, I shall attempt to 
 set forth, in a plain and simple manner, the exact nature of this 
 disease, and the reasons why it should never be neglected, but 
 always kept under the most careful observation and treatment. 
 
 The name chronic suppuration of the middle ear means a 
 great deal. It comprehends a large variety of disease in one of 
 the important parts of the body. The term chronic suppuration 
 of the middle ear, usually implies a perforation of the drum-head 
 or membrana tympani. In exceedingly rare cases, there may be 
 a suppuration in the tympanic cavity and mastoid cells, espe- 
 cially in the latter, for weeks or even months, without the occur- 
 rence of a perforation of the delicate but firm membrane that 
 forms the boundary between the middle and the external ear. 
 In all but exceptional cases, however, when chronic suppuration 
 of the middle ear is stated to be the diagnosis of a given case, it 
 is meant that the ulceration involves the drum-head.
 
 444 FREQUENCY OF AFFECTIONS OF EXTERNAL AND MIDDLE EAU. 
 
 Chronic suppuration of the middle ear is often confounded 
 with that rare disease, chronic suppuration of the external audi- 
 tory canal. Very many times patients have been brought to 
 me, with what the attending physician supposed to be merely an 
 external otitis, but which proved to be really a case of suppura- 
 tion of the middle ear, with perforation of the membrana tym- 
 pani. When it was demonstrated that the pus had its origin, 
 not from the auditory canal, but from the middle ear, it was 
 usually an easy task to convince the person affected, of the dan- 
 ger of a neglect of the disease. I feel confident that this error 
 as to the origin of the affection, is in many cases the cause of its 
 neglect. An eczema, or a so-called seborrhcea, or even a sup- 
 purative external otitis, may, perhaps, when occurring with 
 young children, be left to itself or to general hygienic attention 
 and tonic treatment with comparative impunity ; but the best 
 of such care will not usually avail to stop a formation of pus in 
 the cavity of the tympanum or the mastoid cells, unless local 
 treatment is also employed. 
 
 We might almost take it for granted, if such a practice were 
 not improper in a physician who claims to observe with exact- 
 ness, that any case of long-existing suppuration in, or discharge 
 of pus from the ear, will be found to have its origin behind, and 
 not in front of the membrana tympani. 
 
 I have already spoken of this fact of the comparative infre- 
 quency of suppurative affections of the outer ear, as compared 
 with those of the middle part of the organ ; but the following 
 table brings it out more strikingly than the mere assertion : 
 
 Table showing the Relative Frequency of Inflammatory Affections of the External 
 Ear and Suppuration of the Middle Ear. 
 
 Hospital. 
 
 Year or period. 
 
 Inflamma- 
 tion of ext. 
 and. canal, 
 including ec- 
 zema. 
 
 Suppuration 
 of middle 
 ear. 
 
 Manhattan (New York) Eye and Ear Hospital . . 
 New York Eye and Ear Infirmary 
 
 20 vears 
 1889 
 
 824 
 164 
 
 6,675 
 1,173 
 
 New York Ophthalmic and Aural Institute 
 Brooklvn Eye and Ear Hospital 
 
 1889 
 21 vears 
 
 52 
 1,245 
 
 296 
 
 6,843 
 
 Massachusetts Eye and Ear Infirmary 
 
 1889 
 
 203 
 
 679 
 
 Salem Hospital 
 
 15 vears 
 
 123 
 
 565 
 
 St. Michael's Hospital (Newark, N. J.) 
 
 1888 
 
 50 
 
 178 
 
 Newark Eve and Ear Infirmary 
 
 1889 
 
 105 
 
 374 
 
 Illinois Eye and Ear Infirmary 
 
 1885-1886 
 
 32 
 
 467 
 
 Buffalo Eye and Ear Infirmary 
 
 1889 
 
 8 
 
 48 
 
 
 
 
 
 
 
 2,806 
 
 17,298 
 
 All the cases under the heading "Inflammation of the Auditory Canal," were not 
 necessarily suppurative ; while I have been careful to place only the suppurative cases 
 in the middle ear column.
 
 STATISTICS OP CHRONIC SUPPURATION. 445 
 
 It will be seen by the table, that the cases of suppuration of 
 the middle ear preponderate over the cases of external otitis 
 of all kinds, in a proportion exceeding that of five to one. I am 
 inclined to believe that the proportion is actually even larger 
 than this, and that in some cases the diagnosis was made of 
 inflammation of the canal, simply because at the outset the in- 
 flammation was so great as not to allow of a view of the drum- 
 head, which was afterward found to be affected. If I had been 
 able to exclude the non-suppurative diseases of the canal, as I 
 have those of the middle ear, the preponderance of middle ear 
 cases would have been much greater. 
 
 Of 4800 cases of my own, observed in private practice, there 
 were 1011 cases of suppuration of the middle ear ; of these 201 
 were cases of acute suppuration, and 810 of chronic. There 
 were 265 cases of inflammation of the canal, including 85 cases 
 of eczema and 13 of aspergillus. 
 
 Symptoms. A discharge of pus is the most striking symptom 
 in chronic suppuration of the middle ear. There can hardly be 
 such a thing as a chronic suppuration in this part without a per- 
 foration of the drum-head, through which the pus escapes. The 
 term perforation, in its turn, includes a great variety of patho- 
 logical conditions. 
 
 For example, the drum-head may be entirely swept away ; 
 one-half of it may be gone ; one-third of it may be gone ; only a 
 small opening about as large as the head of a pin may exist ; 
 two openings may exist ; so that in the very appearance of the 
 drum-head we may meet the greatest difference in conditions. 
 
 Besides, polypi .may be seen through the perforation, spring- 
 ing from the tympanic cavity, or there may be small growths 
 or granulations hardly to be dignified by the term polypi. We 
 may find the opening covered by hardened wax, or even by 
 dried pus. Quite large quantities of muco-pus, pus, or of mucus, 
 or of a fluid, Jike serum, may conceal the opening and be formed 
 in a quantity sufficient to cause a constant flow into the audi- 
 tory canal, or the quantity may be very small, and only to be 
 detected on careful examination. In any consideration of the 
 diseases of the middle ear, the practitioner should remember 
 that the mastoid cells, as well as the cavity of the tympanum, 
 are an integral portion of this anatomical region. Hence it is 
 that the lining membrane of the mastoid is usually involved in 
 any inflammation of the middle ear. 
 
 As will be seen by reference to a case recorded in a chapter 
 on "The Consequences of Chronic Suppuration,"' pus may form, 
 exist for weeks in the mastoid process, and not at all involve
 
 446 CHRONIC SUPPURATION SYMPTOMS. 
 
 the drum-head. Such cases are. however, very exceptional. A 
 chronic suppuration of the middle ear, almost always involves 
 an ulcerative perforation of the membrana tympani. When the 
 former term is used, the latter state of things is understood to 
 exist, whatever other changes of structure may have occurred. 
 The discharge of pus is sometimes very profuse and constant, 
 so that it streams from the ear. This is more apt to be the case 
 in young children, although it occurs in adults. In such cases 
 the auricle and external auditory canal become red, tender, and 
 even excoriated from the irritation of the pus in which the parts 
 are bathed. In other and more numerous cases, the pus lies 
 only at the bottom of the canal upon the remains of the mem- 
 brana tympani and in the cavity of the tympanum, enveloping 
 the chain of bones, and passing into the cavities called the mas- 
 toid cells. In still other cases, there is no continuous outflow of 
 pus, either by day, or at night upon the pillow ; but at intervals 
 there is a slight increase of the unpleasant symptoms, which 
 even assume the dignity of an earache, after which a free dis- 
 charge of pus from the ear occurs. On questioning such pa- 
 tients in regard to the existence of a discharge from the ear, 
 they will usually state that none occurs, except after an attack 
 of earache, although the fact is that pus is always lying in the 
 part. If we examine such an ear when the discharge is sup- 
 posed to have ceased, we shall find at the bottom of the canal, 
 and in the cavity of the tympanum, a hardened mass of dried 
 pus covered over by cerumen or epidermis. Impacted cerumen 
 is quite a frequent occurrence in the course of a chronic suppu- 
 rative process in the middle ear. We shall often come to an 
 erroneous conclusion as to the cause of a loss of hearing, if we 
 judge of the case from the presence of hardened cerumen in the 
 auditory canal, without getting the history. 
 
 The membrana tympani presents the most varied appear- 
 ance in different cases of chronic suppuration in the middle ear ; 
 sometimes, it is entirely swept away, and all the ossicula with 
 it. The cavity of the tympanum is then an empty cavity open- 
 ing upon the canal. Again, there is a rim remaining, with per- 
 haps the incus and stapes in situ, or dislocated, but yet present, 
 while the malleus is gone. In other cases the ossicula are intact 
 and in position, but there are clearly cut, well-defined holes, 
 from one to three in number, in the drum-head. The chromo- 
 lithographs exhibit such a perforation, with the blood-vessels 
 that are about to repair it, radiating toward the opening. Some- 
 times one-half of the membrane is cleanly cut away. In fact, 
 the appearance of the membrane is as various as the number of 
 cases. The description of no one case will do for another.
 
 CHRONIC SUPPURATION SYMPTOMS. 447 
 
 Besides polypi, exostoses' may exist in the canal, or even in 
 the walls of the tympanic cavity ; the bone may be exposed, i.e., 
 denuded of its periosteum, roughened, and in a condition of 
 caries. The seventh nerve, in its passage through the aqueduct 
 of Fallopius, may be destroyed by the morbid process, when the 
 smirk and uncovered eye of facial paralysis are added to the dis- 
 gusting detail of the ravages of disease. 
 
 After these facts are brought to recollection, I think I am 
 justified in styling the term chronic suppuration of the middle 
 ear, a very comprehensive one. It is an erroneous method of 
 teaching which would describe suppuration of the tympanic 
 cavity and mastoid cells by the term otorrhcea, and I think that 
 a discussion of the treatment of a discharge from the ear, with- 
 out a comprehensive view of the important pathological condi- 
 tions which may exist in this part of the body, must be in its 
 very nature misleading. No discussion of the treatment of the 
 formation and discharge of pus from the tympanum, will be 
 profitable unless there precedes it a full understanding of the 
 anatomical -and pathological conditions which allow the pus to 
 be formed and collected. 
 
 If the middle ear were a simple canal or cavity, the principles 
 at the basis of the treatment would, perhaps, be the same that 
 they are now, but it comprises a series of anatomical parts, and 
 the details in carrying out these principles are very different, 
 and are much more varied than they would be were we dealing 
 with a simple and easily bounded space. It is the anatomy of 
 the middle ear, that makes the treatment of its diseases not an 
 entirely simple matter. 
 
 I do not think there is any one point more than another, in 
 the membrana tympani, where perforations are apt to occur. 
 Sir William Wilde, and Moos, quoted by Hinton, 1 affirm that 
 they are most frequently situated in the anterior and lower part 
 of the membrane, where the air blown through the Eustachian 
 tube impinges. Hinton, has seen quite as many in the inferior 
 and posterior segments, an experience which my own quite con- 
 firms. I have found them in every quadrant of the drum-head. 
 
 Perforations are sometimes so small as not to be easily recog- 
 nized, unless air is forced through the Eustachian tube and made 
 to pass through them. As has been stated in the preceding 
 chapter, Wilde, thought that a pulsation at the bottom of the 
 auditory canal was pathognomonic of perforation of the drum- 
 head. Where this pulsation occurs, it is a very suspicious cir- 
 cumstance : but as has been before said in this volume, a thin 
 
 Guy's Hospital Reports, Third Series, vol. xii.
 
 448 ALBUMINURIA FROM CHRONIC SUPPURATION. 
 
 membrana tympani. in a state of acute catarrhal inflammation, 
 will sometimes exhibit this phenomenon when the drum-head is 
 intact. Mr. Hinton remarks in his excellent paper on "Per- 
 forations of the Membrana Tympani," from which I have just 
 quoted, "This motion (pulsating) is imparted by the blood, and 
 implies not necessarily an aperture, but a thin surface of fluid in 
 contact with a beating vessel." 1 The complete absence of the 
 membrana tympani, especially if the mucus lining of the tym- 
 panic cavity have a granular or velvety appearance, is often 
 very puzzling. Such cases will sometimes require the most 
 careful cleansing before we can determine how much, if any, of 
 the drum-head remains. 
 
 We need not enter into any detailed account of the condition 
 of the pharynx and Eustachian tubes in the affection now under 
 consideration, since this subject has been so fully dwelt upon in 
 treating of the chronic non-suppurative inflammations. It may 
 be sufficient to say here that we find in chronic suppuration, as 
 well as in all the varieties of inflammations of the middle ear, 
 except the purely proliferous forms, that the naso-pharyngeal 
 region has been the usual point of origin of the disease, and 
 that any successful management of the ear, will require great 
 attention to the pharynx and Eustachian tube. 
 
 The general health of a patient affected with chronic suppu- 
 ration of the middle ear is usually impaired, even if none of the 
 serious consequences have occurred. Such a drain upon the 
 system is not tolerated with equanimity by nature. Dr. Hack- 
 ley " has found albuminuria in a number of cases of chronic sup- 
 puration of the middle ear, where there was no apparent cause 
 for the disease, except the long-continued secretion of pus in the 
 tympanic cavity. He is inclined to think, that such cases are 
 analogous to those of the development of lardaceous kidney from 
 debilitating diseases. 
 
 The fact that a running sore is detrimental to the continu- 
 ance of good general health, would scarcely need assertion, 
 were it not that the author, in common with many others, has 
 observed a very deeply rooted idea among the laity an idea 
 that was first inculcated, and which is even now encouraged by 
 the profession that there is no harm resulting from a chronic 
 ulcerative process in the ear, when it is well out of sight. It is 
 even at times gravely asserted that such a drain to the system 
 is salutary, as if our Creator would not have made the human 
 race with such a one if it were necessary. I have seen persons 
 who allow their ears to become an offence to the nostrils of those 
 
 1 Loc. cit. , p. 630. * Verbal communication at New York Ophthalmological Society,
 
 SUPPOSED DANGER FROM STOPPING THE DISCHARGE. 449 
 
 I 
 
 about them, because they have been advised by their physician 
 that it was not best to "meddle with the ear." If my reader 
 feels that I have said too much on this subject, in the different 
 parts of this volume, I beg that he will ask himself how many 
 cases of death he has known as the result of a suppurative pro- 
 cess in the ear, consult his fellow practitioners on the same 
 point, and finally investigate the statistical tables of deaf and 
 dumb asylums. In the answers to these queries will be found 
 a complete justification of my earnestness on this point. The 
 anatomy of the middle ear, showing, as it does, the relations of 
 this small portion of the organism to the most important parts 
 of the system, to the great arterial and venous vessels, to the 
 nervous system, to the organs of respiration, is also of itself a 
 sufficient proof, of the necessary importance of a long-continued 
 suppuration in this part. 
 
 There still exists, however, even in the minds of some phy- 
 sicians, a prejudice against the stoppage of a purulent discharge 
 from the ear. In the laity this prejudice is widely spread, and 
 is chiefly dependent upon the erroneous teachings of the older 
 French writers, Du Verney and Itard. As Wilde shows, in his 
 classic article upon this disease in his text-book, "Because it 
 was observed that on the supervention of cerebral disease, dis- 
 charges from the auditory canal have lessened, practitioners 
 mistaking the effect for the cause, have been led to believe that 
 the sudden 'drying up' produced a metastasis to the brain, a 
 notion as crude as it is unsupported." There is, I believe, no 
 pathological experience on record which can sustain the quite 
 common assertion that it is dangerous to stop a discharge from 
 the ear. There are some cases on record of which there are, 
 alas ! many more than were ever recorded where disease of 
 the brain has occurred from the extension of a neglected sup- 
 puration to the cerebral membranes and substance, and the dis- 
 charge from the ear has nearly ceased but these certainly form 
 no argument against the arrest of an ulcerative process before 
 any parts beyond the cavity of the tympanum are involved. 
 
 He who believes that we can easily cause a discharge of pus 
 to cease, after caries of the temporal bone has occurred, will 
 find many cases which will cause him to doubt the efficacy of 
 his therapeutics. As well might we refuse to heal an ulcerated 
 hip-joint, as to neglect to check a discharge from a diseased 
 membrana tympani or lining membrane of the tympanic cavity. 
 
 It is doubtless true, judging from the histories of cases and 
 
 the inspection of the membrana tympani, in which cicatrices 
 
 occur, that many cases of chronic suppuration are cured with 
 
 very slight treatment, or with none at all. The fact remains, 
 
 29
 
 450 HEARING POWER WITH PERFORATION. 
 
 however, that many of the neglected cases do not so recover, 
 and after a purulent discharge from the ear has once set in, 
 "we can never tell,' 7 to quote again the words of Wilde, which 
 should be impressed upon the attention of every practitioner of 
 medicine, "how, ivhen, or where it will end, or what it may 
 lead to." 1 
 
 A careful treatment is usually required to check the dis- 
 charge and treat the ulcerated membrana tympani. and restore 
 the hearing power. Even with the most careful and skilful 
 treatment, we cannot always succeed in all of these things. In 
 some rare cases we do not succeed in any of them ; but the pa- 
 tient, in spite of our best efforts, will go on to his doom. 
 
 The degree of the impairment of hearing, in cases of chronic 
 aural suppuration, is very variable. It depends, of course, upon 
 many factors ; for example, the condition of the Eustachiaii 
 tube, and the integrity of the structure in the cavity of the tym- 
 panum. The hearing power by no means depends upon the 
 presence or absence of the membrana tympani. The chief func- 
 tion of this membrane is probably to protect the tympanic cav- 
 ity, and not merely to transmit the vibrations of the atmosphere, 
 which when conveyed to the acoustic nerve we call sound. I 
 know some persons who have large perforations in each mem- 
 brana tympani, and who yet hear well enough for all the ordi- 
 nary purposes of life, although not with perfection. One notable 
 instance of this kind is that of a busy physician of my acquaint- 
 ance. As has been already said, in the last chapter, Sir Astley 
 Cooper, in a paper published in the " Transactions of the Royal 
 Society," in 1800,* showed that there could be very good hearing 
 powers with a perforate membrana tympani ; and yet I very 
 often hear the question asked, as well by physicians as by lay- 
 men, if anything can be done when there is a hole in this mem- 
 brane ; and it is also often stoutly asserted that when this mem- 
 brane is once gone, the hearing is irrevocably lost. This false 
 idea continues to prevail, not only in spite of scientific demon- 
 stration of more than seventy years ago, but also in the face of 
 clinical facts that are every day within the reach of each atten- 
 tive physician. Truly, a lie will travel around the world, while 
 truth is putting on its boots. 
 
 The parts which form the middle ear make up a cavity which 
 has perhaps as many, if not more, important anatomical re- 
 lations than any one of similar size in the human body. The 
 cavity of the tympanum is covered above by a thin, rarefied 
 bony plate, which is in direct communication with the cerebral 
 
 1 Text-book, p. 407. * Philosophical Transactions, Part I. 1800.
 
 REMOVAL OF PUS rEKOM TYMPANUM. 451 
 
 meninges ; the floor is close to the great jugular. Its internal 
 wall is the labyrinth wall, with its two fenestrse, covered only 
 by thin membrane and opening into the ramifications of the 
 acoustic nerve and the fluid which is continuous with that of 
 the sub-arachnoid space ; while externally we have a membrane 
 of about the thickness of letter-paper. 
 
 Treatment, The proper treatment of a chronic suppuration 
 in such a space should be a matter of the greatest solicitude. It 
 involves not alone the hearing power, but also the life of the 
 patient. There is one pre-requisite to the successful treatment 
 of this affection, and that is, a complete removal of all the mor- 
 bid material that has formed in the middle ear. This is simply 
 another way of stating that the parts must be thoroughly 
 cleansed. 
 
 As we have seen in the discussion of the various affections 
 of the middle ear, their starting-point is usually in the fauces or 
 pharynx. But the ulcerative process which has been set up in 
 the tympanic cavity has broken through the membrana tym- 
 pani, and the result shows itself in the external auditory canal. 
 The problem to be solved is, how may we stop the ulcerative 
 process, heal the membrana tympani, and restore the hearing 
 power, which has been impaired by the inflammatory process in 
 the sound-conducting apparatus ? In many cases, however, we 
 may be well satisfied if two of these requirements be fully ful- 
 filled, while the hearing power is improved. A radical cure of 
 a suppurative process in the middle ear, of long standing, is, 
 from the very nature of things, sometimes impossible. 
 
 The old method of treating such a suppuration was to advise 
 the patient to syringe the ears with soap and water, put a blister 
 on the mastoid process, and at the same time the physician got 
 the system to rights by using alteratives, laxatives, and purga- 
 tives. The general principle of treatment thus held in view 
 was correct, but in the matter of the local treatment, which is 
 of far more importance than the constitutional, altogether too 
 much was left to the supposed knowledge and skill of the pa- 
 tient or his attendant. 
 
 Perhaps not more than one layman in a hundred can, with- 
 out instruction, thoroughly cleanse an ear by syringing. It is 
 generally thought that any person can syringe an ear. when the 
 facts are that no patient can properly cleanse his own ear. and 
 almost every one requires instruction before he can even syringe 
 the ear of another. In one of the preceding chapters of this book 
 (see page 133), the proper method of syringing has been care- 
 fully described, so that we need not dwell upon the subject again.
 
 452 OBJECTIONS TO THE SYKINGE. 
 
 Objections have been made to the use of the syringe. One 
 authority, for whom I have a great respect, says, in referring to 
 the cleansing of the ear from pus, and in italics, too, " The syr- 
 inge, as a rule, is not to be used." ' When differences of opinion 
 like this as to modes of treatment arise, there is not much to be 
 said except to show that one recognizes his own standpoint, and 
 the difficulties of it, and gives good heed to the contrary one. I 
 think I am not ignorant of the abuse of syringing, or of the fact 
 that much that is called cleansing the ear by syringing has no 
 right to such a name. I am also well aware of the ill effects in 
 isolated cases from syringing. I once reported " a case in which 
 a gentleman who consulted me suffered so seriously from syn- 
 cope, after a very gentle syringing of the ear, that for some 
 moments it was thought by myself and others, that he would 
 certainly die. This patient, however, would probably suffer in 
 the same way from any surgical procedure. After his recovery 
 he told me that he had once fainted in the same alarming way 
 on calling upon a surgeon who proposed to make some kind of 
 an examination. Faintness, vertigo, and nausea are also some- 
 times produced even by gentle syringing of the ear. Yet, if the 
 proper method is practised, and the proper care as to gentleness 
 be taken, it is not one case in a hundred in which any unpleasant 
 symptoms will occur. Simple a procedure as it is, the proper 
 method must first be learned. The water should be warmed ; it 
 should be injected into the concha before it is allowed to pass 
 into the auditory canal in short, until you know your patient, 
 you should alwa'ys proceed very slowly and gently with the syr- 
 inge, especially in the removal of pus. 
 
 But, in spite of all these drawbacks, none of which I would 
 underrate, I believe, as an outcome of twenty years' active ex- 
 perience in aural disease, that it remains the best means, on the 
 whole, in by far the largest number of cases of cleansing the ear. 
 I cannot think that the use of warm water to the ear thoroughly 
 and often is any more dangerous, but, on the contrary, of the 
 same amount of good as the use of the same agent in the same 
 way in cleansing fistulous ulcers, open cavities, and other parts 
 of the body which may from time to time become filled with 
 pus. I see no argument in the reasoning that, because warm 
 water may soften the tissue, its use should be avoided for the 
 purpose of cleansing a cavity which requires it. The best syr- 
 inge which I have ever seen is one to be procured in Paris of 
 Liier, which has not come into general use, which we are using 
 
 1 Diseases of the Ear, by A. H. Buck, 'p. 232. 
 s Archives of Otology, vol. ix., p. 16.
 
 METHOD OF CLEANSING TYMPANUM. 453 
 
 in the Manhattan Eye and Ear Hospital, and which I am using 
 in my private practice with great satisfaction. It is called the 
 reservoir syringe (see page 132), and it is filled without any motion 
 of the piston, so that the one action required is the discharge of 
 its contents into the ear. On the withdrawal of the piston it 
 fills itself perfectly. The India-rubber syringes sold in the shops 
 will do very well for patients to use in cases of short duration ; 
 in chronic cases a good metallic syringe is required. The foun- 
 tain syringe is valuable where prolonged irrigation is required, 
 as is also Fayette Taylor's douche. But for ordinary use the pis- 
 ton syringe, made of metal, is the preferable one for the purpose 
 of removing discharges from the ear. 
 
 Unless the practitioner has had a large experience in cleans- 
 ing ears, he should avoid the use of a syringe whose nozzle is 
 long enough and sufficiently slender to enter the auditory canal 
 as far as the junction of the bony with the cartilaginous portion. 
 Th*e slightest unexpected movement of the patient while the 
 syringe is used, may cause great harm to the lining membrane 
 of the canal. 
 
 There are several methods of cleansing ears affected with 
 a chronic suppurative process. That which I usually adopt 
 is a combination of the suggestions of Politzer, Hinton, and 
 Schwartze. It is, I think, a simple method,, and capable of be- 
 ing fully carried out by any practitioner, but not by the patient 
 or a nurse. The personal care and supervision of a medical 
 man,* are necessary to the successful treatment of any case of 
 chronic suppuration in the ear. This personal care need not 
 always be daily, although it is better to have it so ; but it should, 
 at the very least, be given twice a week, while the attendant of 
 the patient is instructed as well as may be, for the performance 
 of the duty of cleansing the ear in the intervening time. The 
 importance of the cases for which the daily attendance of the 
 physician is required, if properly set forth, will do away with 
 any objections that may be made. No one certainly would ob- 
 ject to the daily attendance of a physician upon a case of sup- 
 puration of the cornea, and I submit that a suppuration in the 
 cavity of the tympanum and membrana tympani is of equal im- 
 portance, with the disease of the organ of vision. 
 
 The method : The ear is first carefully cleansed with luke- 
 warm water by means of a good syringe. The bowl to contain 
 the water coming from the ear, should be held by the patient him- 
 self unless a very young child be the subject and be pressed 
 well into the glenoid fossa, when no water will be spilled. After 
 this the ear is filled with lukewarm water poured from a test- 
 tube, a spoon, or the like, and the meatus carefully stopped by
 
 454 CLEANSING-. -THE TYMPANUM. 
 
 a bit of cotton- wool. The Eustachian tube is then inflated by 
 means of Politzer s method, and to such an extent that a few 
 drops of the water are forced by the side of the cotton out of the 
 canal. This is, of course, conclusive evidence that the air has 
 been forced through the tube into the middle ear, and through 
 the hole in the drum-head into the external canal. The ear is 
 again carefully syringed and examined by the surgeon. 
 
 A long slender pipette, or Hartmamr s tympanic syringe, are 
 sometimes necessary to clean a tympanic cavity that is not well 
 exposed because the hole in the drum-head is small. The curette 
 will sometimes be necessary also, in order to cleanse the tym- 
 panum from inspissated pus. 
 
 Sometimes the use of the piston syringe is not well borne by 
 the patient, the shock of the water being too great. In such 
 cases the fountain syringe should be used. Instead of the thin 
 bowl, that I have recommended as a receptacle for the fluid that 
 comes from the canal, after having been injected, some practi- 
 tioners use a vessel such as depicted in the accompanying cut 
 
 FIG. 96. Vessel used in Syringing the Ear. 
 
 the " Eiterbecher " of the Germans. It is certainly very con- 
 venient on account of the fact that it adapts itself so well to the 
 glenoid fossa, but it is not deep enough if any prolonged syring- 
 ing is required. Then the bowl will do better, and on the whole 
 I think it is to be preferred. 
 
 I have known sad cases, where parents, in obedience to their 
 medical adviser, have faithfully syringed the ears of a child 
 suffering from chronic suppuration for years, but where the 
 parts have not been perhaps even once, thoroughly cleansed. 
 Exuberant granulations or polypi had sprung up, bony growths 
 had occurred, which are positive evidences of the imperfect 
 removal of pus and other hurtful material. 
 
 After the syringing, the parts should be dried by the use of 
 absorbent cotton twisted about a bit of wood, or a wire cotton- 
 holder, very carefully applied, with the aural mirror on the fore- 
 head, so that both hands are free. For self-evident reasons, it 
 would never be proper to leave fluid in a cavity upon which 
 medication is about to be applied. After you have secured 
 thorough cleansing of the ears, I believe medication is of second-
 
 REMOVAL OF GRANULATIONS. 
 
 455 
 
 ary importance. Wilde's snare and Buck's curettes are the best 
 instruments for removing polypi where instrumental interfer- 
 ence becomes necessary. ' Nothing will keep up a discharge of 
 pus from the ear, so persistently as a small polypus or granula- 
 tion. My experience is exactly the same as that 
 of Troltsch, published in his treatise on the ear, 
 in the first edition of 1862, where he states that 
 he has often seen a discharge of very long stand- 
 ing disappear, as in the twinkling of an eye, on 
 the removal of a small growth. I think the cu- 
 rettes should be made with sharp edges not 
 blunt, as first sold in the shops. The profession 
 is very much indebted to Buck and Politzer, for 
 the suggestion of these very useful instruments 
 for cleaning out the tympanic cavity and audi- 
 tory canal. I hardly know how I would get on 
 without them, after having enjoyed their use for 
 some years. Pedunculated, granulations and 
 polypi, should be removed as one of the first 
 steps in any continued treatment. Granulations 
 with a broad base are very troublesome, it be- 
 ing very difficult to remove them thoroughly, 
 even when the patient is under observation for 
 a long time. It is often necessary to etherize 
 the patient in order to free the tympanic cavity 
 from granulations. The great prerequisite hav- 
 ing been accomplished, of securing a free tym- 
 panic cavity, the question then is, What agent 
 shall we choose for the cure of the diseased 
 membrane, and, consequently, for stopping the 
 discharge ? A very great deal, of late, has been 
 said about the so-called dry treatment of suppu- 
 ration of the middle ear. There was a famous 
 peripatetic quack who practised a dry treatment 
 which was peculiarly successful. He was in the 
 habit of pouring in plaster-of-Paris, for the cure 
 of long-existing discharge of pus from the ear, 
 and the cure for a time was effectual. Much of the % so-called 
 dry treatment of to-day, will in some cases be as disappoint- 
 ing as was its prototype. The treatment by powders is, not 
 particularly new, however. The late Mr. James Hinton was 
 very much in the habit of using French chalk and other pow- 
 ders, and my former assistant, Dr. F. H. Rankin, of Newport, 
 recommended iodoform in diseases of the ear, in an article pub- 
 lished in the New York Medical Journal, some time after he had 
 
 FIG. 97. Buck's 
 Pipette.
 
 456 SOLUTIONS AND POWDERS. 
 
 successfully used it in the Manhattan Hospital. Agnew, and 
 Rider, and other authorities have long used powdered alum. 
 Treatment by powders is not, therefore 1 , a new subject, although 
 some agents, boracic acid in particular, have been used only 
 lately. In spite of all the claims for the exclusive use of pow- 
 ders, in the treatment of the ear, and valuable as is their place 
 in our therapeutic resources, I still think that instillations of 
 fluids hold the first rank, and that the use of powders is of sec- 
 ondary value. Whatever may be thought of this view, it isj I 
 think, indisputably sound doctrine that cleansing must precede 
 the use of any agents, and that thorough cleansing is impossible, 
 in many cases, without the use of the syringe. 
 
 For the healing of a diseased mucous membrane that has for 
 some weeks or months secreted pus, and which is free from 
 polypi or large granulations, I would advise that fluid applica- 
 tions be first tried. In my practice I use sulphate of zinc, from 
 one to four grains to the ounce ; sulphate of alum in the same 
 proportion. Nitrate of silver I use usually upon a cotton-holder, 
 from five to sixty grains to the ounce, or from a long, slender 
 pipette adapted to the middle ear, (see Fig. 97) in the weak 
 solutions. If a strong solution of nitrate of silver be used, it 
 should be at once neutralized with salt and water. I also use 
 alcohol, as suggested by Lowenburg, of Paris, especially in cases 
 where the tissue is granular. A preparation of resorcin in cases 
 where the mucous discharge exceeds the purulent, is also useful. 
 Boracic acid in solution seems to me to accomplish very little. 
 It is, indeed, difficult to say which are the best astringents. But 
 some cases do well with any of the ordinary astringents, and 
 some never cease to be the seat of the formation of pus, no mat- 
 ter how long, how carefully you treat them, and what agents 
 you may use. Carbolic acid and permanganate of potassium 
 have proved worse than useless in my hands. 
 
 When solutions do not act well or promptly, powders may be 
 resorted to. lodoform is valuable in some cases. My associate, 
 Dr. Ely, thinks it especially useful in those cases where the 
 tissues are pallid and have an indolent appearance. Well-trit- 
 urated boracic acid is also a useful agent, but it is by no means 
 a panacea, no matter how it is applied, or with whatsoever com- 
 binations. There are objections to powders which at once sug- 
 gest themselves when their use is advocated in treating diseased 
 mucous membranes, like those of the nose or middle ear. They 
 are not always absorbed, and they sometimes leave a trouble- 
 some, irritating mass behind. Then they occasionally impair 
 the hearing by mechanically obstructing the passage of the 
 sound waves. While a solution is poured into the ear, and in
 
 SOLUTIONS AND POWDERS. 457 
 
 from five to ten minutes that which is not absorbed may be al- 
 lowed to run out, the powder must remain until the ear is again 
 cleansed, which is not for hours. A tube made from a quill, or 
 one of the powder-blowers especially invented for the purpose, 
 do equally well for forcing the powder into the canal of the tym- 
 panic cavity. I do not employ large masses of the powder sim- 
 ply enough to give the ulcerated or carious portion a good coating. 
 Solutions are usually much better tolerated by the ear when 
 they are warm.- A lighted gas-burner, the flame of a candle, a 
 bowl of hot water, are all convenient means for heating the 
 solution which is to be used. When powder is employed, the 
 mirror should be used from the forehead, so that one may know 
 just where it has gone, and renew th application if not enough 
 is applied. 
 
 FIG. 98. Knapp's Powder-Blower. 
 
 Whatever may be said in favor of certain specifics, used 
 either as powders or solutions, certain cases of suppuration of 
 the middle ear will remain uncured in hands never so skilful. 
 They are, from their nature or their environment, incurable. A 
 case of long-standing ulceration in the tympanic cavity and mas- 
 toid is almost certain to involve more or less superficial death 
 of the bone. When there is dead bone that cannot properly 
 be removed by instruments, solutions of dilute mineral acids, 
 nitric acid and sulphuric one-quarter to one-half per cent. 
 dropped into the ear twice a day (Dr. Urban Pritchard) will be 
 serviceable. An error in treatment, an injudicious mode of life, 
 an undue exposure to wet and cold, may at any time cause the 
 smoldering disease to blaze into a condition that is fatal to life. 
 Pyaemia, meningitis, and cerebral abscess are by no means the 
 infrequent ending of some of those cases. He who has found a 
 panacea for all of them, is in a state of mind far removed from a 
 scientific consideration, of the conditions which are to be found 
 in chronic suppuration of the middle ear. 
 
 When it is said that "a moist treatment of otorrhcea in many 
 instances has a tendency to keep up rather than to check the 
 morbid discharge from the ear," ' if by this language, it is meant 
 that careful cleansing of a suppurating middle ear with warm 
 water, and the subsequent instillation of solutions, is in many 
 instances a bad surgical method, I can only answer that this 
 statement, according to my experience, is not borne out by facts. 
 
 1 Burnett: American Journal of the Medical Sciences, January, 1883.
 
 458 GRANULATIONS AND POLYPI. 
 
 The presence of granulations and polypoid growths does not, in 
 my opinion, centra-indicate the use of warm water. Their pres- 
 ence does indicate, however, a necessity for their removal, either 
 by the snare, the forceps, or caustics, pari passu with the con- 
 stant cleansing process. Over and over again, however, have I 
 seen growths shrivel and disappear, before the operator was 
 ready to remove them by cutting or twisting instruments or by 
 caustics, under the simple plan of cleansing the ear with warm 
 water. 
 
 I think it important to inflate the ears very frequently, from 
 two to four times a week, and sometimes daily, by means of 
 Politzer's method, during- the treatment of chronic suppura- 
 tion of the middle ear. The current of air is useful to dislodge 
 inspissated pus or tenacious mucus, and it assists materially in 
 the essential preliminary of all applications ; that is, a complete 
 removal of the pus. Sometimes exhaustion of the air from the 
 tympanum by Siegle's otoscope aids in getting the cavity clean. 
 An ordinary air-bag may also be used for this purpose. Those 
 cases in which there is a constant accumulation of long strings 
 of very tenacious mucus, with very little pus, are exceedingly 
 difficult to manage. The cause for this is to be found in the ex- 
 cessive catarrh of the naso-pharyngeal space, and of the Eusta- 
 chian tube, which usually accompanies this condition of the 
 tympanic cavity. The mucus is so tenacious in these cases that 
 not even the syringe or the cotton-holder will remove it, but the 
 forceps must be resorted to. Of course, fundamental treatment 
 will begin at the fons et origo, of the disease of the middle ear, 
 that of the nose and throat. I need hardly say that the general 
 condition is to be most carefully considered in all cases of chronic 
 local disease. The practitioner will often find much to do in this 
 direction, in these cases of chronic suppuration of the ear. The 
 restoration of a perforated drum-head is a most interesting re- 
 parative process. The ease and rapidity with which they heal 
 in recent cases is startling, and even in chronic cases, we are 
 sometimes agreeably surprised to see how soon a membrana 
 tympani is restored, after simple cleansing of the middle ear has 
 been maintained for a few weeks. 
 
 The caustics which I use for removing granulations, are fum- 
 ing nitric acid and chromic acid, as well as solutions of nitrate 
 of silver, from twenty to sixty grains to the ounce. Alcohol is 
 also valuable. When alcohol is employed it should be used at 
 least twice a day, and warmed before it is poured in the ear. 
 The application is painful for a few instants only. I usually 
 cause the granulations to bleed freely, by puncturing them with 
 a cataract-needle, before applying the caustics.
 
 SKIN GRAFTING. 
 
 Burnett ' thinks that zinc-drops, may supply something which 
 makes the bottom of the auditory canal favorable to the growth 
 of the aspergillus or aural fungus. As proof of this, is adduced 
 the fact that a fungus is sometimes found in zinc solutions that 
 have been imperfectly stoppered. All the harm that. fungi in 
 zinc or other solutions can probably accomplish, is to weaken 
 the solution. I consider this objection to zinc, or other solutions 
 . as unsubstantiated as yet by any facts, and doubtful even from 
 a theoretical point of view, for it is improbable that the fungus 
 would be poured into the ear, but that portion of the solution 
 which is clear. Besides, before the growths were established, 
 the next good syringing with warm water would be an efficient 
 parasiticide if any were necessary. 
 
 In June, 1878, Dr. Edward T. Ely,* my associate in private 
 practice, made use of skin grafting in the treatment of chronic 
 suppuration of the middle ear. Dr. Ely continued this practice 
 in nine cases occurring among our patients, and I have repeated 
 his experiments. This method of treatment is especially indi- 
 cated for cases where we cannot expect a restoration of the mem- 
 brane and a cessation of the discharge by the ordinary treat- 
 ment. The results obtained have not been brilliant, but in two 
 cases a substantial gain in the condition of the tympanic cavity 
 was secured. 
 
 This operation is available in cases where the membrana 
 tympani is nearly gone, and where the discharge is at times 
 considerable, but which at other times ceases. The ear is first 
 carefully dried, and after due care has been taken that all the 
 instruments to be used, as well as the hands of the surgeon and 
 his assistant, are scrupulously clean, a small bit of integument 
 is removed from the arm of the patient. 
 
 It is carefully soaked in a solution of boracic acid, and ap- 
 plied by means of a cotton-holder, silver probe, or Politzer's 
 eyelet forceps to the exposed surface of the tympanic cavity. 
 As many as three or four grafts may be applied. The canal is 
 then gently packed with absorbent cotton, and the patient is 
 advised to be very careful to avoid active exercise, riding in 
 wagons, stages, or other conveyances, in which there is much 
 motion, for two or three days. The grafts may be examined in 
 three or four days. If union has occurred the packing should 
 be continued for a few days longer. I think, from personal ex- 
 perience, that this method of treatment will be of service in a 
 limited class of cases, where an occasional period of suppuration 
 
 1 American Journal of the Medical Sciences, January, 1883. 
 * Archives of Otology, vol. ix., p. 343.
 
 460 SKIN GRAFTING NITRATE OF SILVER. - 
 
 occurs in a largely exposed tympanic cavity, over which the 
 drum-head cannot be made to heal by ordinary means, and 
 where the discharge of pus only occurs at intervals, for ex- 
 ample, during a coryza. If the grafts do not completely cover 
 the exposed tympanic cavity, they may diminish the secreting 
 surface. 
 
 Berthold, in August, 1878, two months after Ely's cases, per- 
 formed myringoplasty ' in two cases. The perforations healed, 
 apparently as the result of a new inflammation set up by the 
 manipulations and by the adhesion of a portion of the graft 
 which became a portion of the new tissue. Berthold put a piece 
 of court-plaster upon the drum membrane, which he allowed to 
 remain there three days. The object of this was to remove the 
 epithelium. The drum-head was found to be closed on the 
 twentieth day. In a second case, also, a perforation was healed 
 by this method. C. U. Tangeman, has also published an inter- 
 esting case of reproduction of the membrana tympani by skin 
 grafting. He denuded the edges of the perforation and put in 
 a piece of skin from the arm of the patient, and retained it in 
 position by collodion. The drum-heads were not entirely closed, 
 but nearly so. 2 
 
 In Schwartze's paper calling attention to the use of the 
 nitrate of silver, in what he regards as strong solutions, he 
 advises against the instillation of nitrate of silver where gran- 
 ulations or disease of the bone exists. His exact words are : 
 "The caustic treatment only promises a nearly certain result, 
 when we may exclude with positiveness the existence of gran- 
 ulations upon the exposed mucous membrane, or upon the 
 remains of the membrana tympani, and when there are no 
 evidences of ulceration of the bone." ; 
 
 The experience of American otologists has been that strong 
 solutions of nitrate of silver may be safely and profitably used, 
 even where there are granulations and polypi. Indeed, I would 
 especially recommend it for some of these cases, although I ad- 
 mit that their value is often strikingly seen in obstinate cases 
 of chronic suppuration, where the membrane is not yet in what 
 may be termed a very proliferous condition. 
 
 An efficient method of applying nitrate of silver to the whole 
 mucous tract of the middle ear, at least to the lining of the 
 cavity of the tympanum and the Eustachian tube, is the follow- 
 ing : The solution is dropped into the cavity of the tympanum 
 
 1 Monatsschrift fur Ohrenheilkunde, November, 1878. From Vortrag in Natur- 
 forscher Sammlung. CaSsel, 1878. 
 
 Archives of Otology, vol. xii. , p. 228. 
 
 3 Archiv f iir Ohrenheilkunde, Bd. IV. , p. 2.
 
 CLEANSING THE TYMPANUM. 461 
 
 through the external meatus, and then forced through into the 
 tube by two or three puffs from the ordinary air-bag used in 
 Politzer's method. Of course the patient will taste the nitrate 
 of silver, if it be used in this manner. 
 
 Mr. James Hinton, of London, recognizing the fact upon 
 which I have laid so much stress, that thorough cleansing of 
 the ear is the first requirement of all treatment of chronic sup- 
 puration in this part, advises the forcible syringing of the tym- 
 panic cavity, by means of a syringe whose nozzle is made to fit 
 into the external meatus, so as to exclude all the external air. 
 He also syringed the tympanic cavity through the Eustachian 
 tube, and used, both for this external and internal syringing, 
 solutions of carbonate of soda, say of twenty grains to the 
 ounce. I believe this latter method of washing out the cavity 
 of the tympanum, was revived and applied to cases of suppura- 
 tion by Dr. Millinger, of Vienna. I have found the washing 
 out of the middle ear, with the solution of soda, a very useful 
 adjuvant in these obstinate cases now under consideration ; for 
 it must always be borne in mind, if we would avoid great dis- 
 appointment, that these cases are usually obstinate, and often 
 trying to the patience of the practitioner. I cannot say very 
 much for the method of forcing fluid into the auditory canal, 
 with the nozzle of the syringe placed hermetically into the 
 meatus. I sometimes resort to it ; but I have usually found it 
 rather violent in its action, as it is apt to cause dizziness and 
 vertigo. 
 
 Instead of washing out the canal with a solution of bicarbo- 
 nate of soda, I think it much better to cause the patient to drop 
 in a solution of say twenty grains to the ounce, once or twice a 
 day. After this has had the effect of softening inspissated pus, 
 the ear may be syringed with warm water. 
 
 It is necessary and proper, in some cases that have resisted 
 less active treatment, to apply the solid nitrate of silver to the 
 edges of the perforated membrana tympani, as well as to the 
 tympanic cavity. It is best applied on a probe, upon the point 
 of which it has been fused, in a platinum cup placed over a 
 lighted lamp or gas-burner. This treatment, unlike the others, 
 is apt to cause pain, which usually passes away on pouring 
 warm water into the ear. It is a method, however, only to be 
 resorted to when other means fail. 
 
 As has been before said, the cleansing of the ear by the 
 medical attendant, should be performed about three times a 
 week. If the suppuration be profuse, the patient should be seen 
 daily. Here, as' in other departments of otology, we meet with 
 great prejudice on the part of the laity. They have been so
 
 462 CHRONIC SUPPURATION TREATMENT. 
 
 accustomed to be sent off with a prescription for a "running 
 from the ear," that they are amazed at being asked to come to 
 the office daily, or three times a week. Yet this will often be 
 necessary, and here as elsewhere there remains some pioneer 
 work to be done in the education of the people. 
 
 Many cases of chronic suppuration of the middle ear are not 
 cured because the treatment is carried on by the patient himself 
 or by his friends. Very few persons are capable of thoroughly 
 cleansing their own ears. No one is capable of thoroughly 
 cleansing the ear of another unless a special training for this 
 object has been undergone. In fact, a successful treatment of 
 these cases requires the care of a physician. It is easier to learn 
 to clean and dress an ordinary bone fistula, than to learn to re- 
 move the secretions from an inflamed tympanic cavity and 
 mastoid cells. He who would bring his cases to a successful 
 ending, must himself bear the brunt of the labor of treatment. 
 It cannot be given over to inexperienced hands. Whenever this 
 personal care o.f the physician is not to be obtained for these 
 chronic cases, only approximately good results are possible. I 
 have sometimes been able to train a nurse or relative of the 
 patient, so that quite thorough cleansing is effected. 
 
 Besides all this, each case should be considered by itself . Some 
 cases will tolerate thorough cleansing by the syringe, cotton- 
 holder, and curette, while others will resent all but the most deli- 
 cate handling, by fits of vertigo, fainting, and inflammatory reac- 
 tion, so that a case must be studied for a few days before it can 
 be definitely determined as to how much and what is to be done. 
 
 Dr. G. M. Beard ' thought that the galvanic current was 
 sometimes a powerful adjuvant in healing a suppurative pro- 
 cess in the middle ear, just as it is in healing ulcers in other 
 parts of the body. An electrode with a long narrow extremity, 
 covered with a little cotton, is passed into the auditory canal 
 through a rubber speculum. The canal is usually filled with 
 warm water. The electrode is connected with the negative pole 
 of the battery. The positive pole is placed either in the hands 
 of the patient or at the back of the neck. Only very weak cur- 
 rents and short applications are borne, and the treatment should 
 be cautiously conducted. Drs. Mathewson and Prout, in con- 
 junction with Dr. Beard, tested this plan of treatment in cases 
 ^at the Brooklyn Eye and Ear Hospital. The character of the 
 discharge soon begins to change under this treatment, and in 
 some cases the cure seems to have been more speedy than it 
 would have been without it. 
 
 J Verbal communication.
 
 CHRONIC -SUPPURATION TREATMENT. 463 
 
 In cases of chronic suppuration of the tympanic cavity, 
 where the opening in the drum-head is very small, or when 
 from any other reason it is very difficult to thoroughly remove 
 the pus, I have found benefit in connection with the use of 
 Politzer's method of inflation from the use of Siegle's otoscope 
 attached to a syringe, for the purpose of sucking out, as it were, 
 the fluids from the drum-cavity. After all the other means of 
 cleansing the part have been thoroughly used, it will still be 
 sometimes found that more pus may be evacuated by the suc- 
 tion method. 
 
 Hartmann's tympanic syringe, which has been mentioned on one of the pre- 
 ceding pages, is often useful in cleansing the tympanum. It consists essentially 
 of a silver tube 2 mm. in circumference and 7 cm. long. Each extremity is 
 curved, the one for the tympanum at a right angle ; the curved portion is about 
 one mm. long. The distal end of the tube is curved at an obtuse angle, and 
 has somewhat of a funnel-shaped orifice, to which a bit of rubber tubing is at- 
 tached. The tubing should be as delicate as possible, so that its weight may 
 not interfere with the position of the tube in the tympanum. The water is in- 
 jected by means of a Davidson syringe, affixed to the rubber tubing. 
 
 Dr. C. I. Pardee 1 believes that the choice of an astringent 
 may be regulated by the character of the secretion. If the se- 
 cretion from the exposed tympanic cavity be predominantly of 
 a mucous character, Dr. Pardee uses nitrate of silver. When 
 the secretion is chiefly purulent, he uses weak astringents of 
 sulphate of zinc, acetate of lead, and alum. It would certainly 
 be a great advance did we have more certain indications for the 
 use of strong or weak astringents ; but I am not prepared to 
 give a positive opinion as to the correctness of Dr. Pardee's 
 theory. I may only repeat what was said in substance in the 
 preceding part of this chapter, that any of the well-known 
 mineral astringents do very well, if the parts are thoroughly 
 cleansed, and if none of the consequences of the suppurative 
 process have as yet resulted. It should not be forgotten that 
 the pharynx and nostrils, will often require nearly as much 
 treatment as the ear. 
 
 The surgeon who is in the frequent habit of examining the 
 membrana tympani will find many cases that show how easily 
 an ulcerated drum-head will sometimes heal under very simple 
 or very crude treatment. Cicatricial drum-heads are a verjr 
 common experience in the aural surgeon's observations. A little 
 study of the history of these cases shows that in very many in- 
 stances they were healed when they were being treated with 
 what we should term neglect. All this should teach us to be 
 
 1 Transactions of the American Otological Society, Fourth Annual Meeting, 1871.
 
 464 CHRONIC SUPPURATION TREATMENT. 
 
 very careful students of the healing processes of Nature. In 
 our anxiety to see results from treatment, let us remember to 
 put ourselves in the position of Ambroise Pare, whose benedic- 
 tion to his wounded patient was, " I have dressed you, may God 
 cure you." 
 
 All cases of chronic suppuration of the middle ear, will not 
 be cured even by good treatment and favorable conditions, 
 while here and there, we are surprised to find that some un- 
 promising cases do very well, even under bad circumstances 
 and with no thorough treatment. To expect too much from 
 treatment, to do too much, is to be meddlesome in intent and 
 action. If we are to make a choice of evils, it is better to be 
 skeptical and inactive, than credulous and meddlesome. 
 
 It is an interesting fact that very few patients'suffering from 
 phthisis pulmonalis ever recover from a suppuration of the ear. 
 Even so far as the accumulation of pus is concerned, no matter 
 how long they may live, the cough usually prevents any healing 
 of the membrana tympani. I have one case under observation 
 the only one I have ever seen^-where the discharge and forma- 
 tion of pus have ceased, although the perforation of the mem- 
 brane does not close. 
 
 REMOVAL OF THE OSSICLES IN CHRONIC SUPPURATION. 
 
 All aural surgeons have observed the great benefit sometimes 
 resulting from a thorough removal of granulations, and of scrap- 
 ing or curetting the tympanum. When the ossicles are necrotic, 
 and gentler means fail to correct the discharge, much less to stop 
 it, a thorough removal of the ossicles is indicated. Schwartze 
 first suggested and performed this operation, but he is conserva- 
 tive in recommending its performance, while Sexton advocates 
 it very warmly, even on cases where it seems to me that the 
 usually efficient means already described in detail should first 
 be given a fair trial. Whatever may be said to the contrary, 
 removal of the ossicles, and only the ossicles, with however 
 good an illumination, is not a very simple operation, nor one 
 entirely devoid of danger. The inconvenience and danger of a 
 chronic suppurative aural process are, however, so great that 
 we are justified in such a severe procedure, when the continuance 
 of the discharge is due to necrotic bone that may, under anaes- 
 thesia be readily removed. No especial directions are needed for 
 such an operation. The patient should be under the influence of 
 ether. The illumination will soon fail on account of the bleed- 
 ing, but in cases such as those for which the removal of the 
 necrotic bone is performed will suffer no harm if the diseased
 
 SOLUTIONS AND POWDERS. 465 
 
 membrane be even very thoroughly scraped in removing the 
 bones. To advise the operation, however, when we cannot 
 definitely decide that the ossicles are necrosed, and the tissue 
 granular, before less radical means are given a fair trial, is un- 
 wise. Thorough scarification of the bony canal is sometimes of 
 great service in lessening a chronic inflammation of the tym- 
 panum. 
 
 THE ARTIFICIAL MEMBRANA TYMPANI. 
 
 This contrivance is at times a valuable means of treating a 
 chronic suppurative process in the middle ear. We have al- 
 ready seen that a New York layman was the actual inventor of 
 a substitute for the natural membrane. This gentleman used a 
 bit of paper moistened with saliva for this purpose in his own 
 ear, and showed it to Dr. James Yearsley, of London, who 
 seized upon the idea, and gave it to the profession, substituting 
 cotton-wool for the paper. Besides acting as an artificial mem- 
 brane, the cotton plug is sometimes used as a means of treating 
 a chronic suppurative process in the ear. It is then packed in 
 
 O 
 
 PIG. 99. Tojnbee's Artificial Membrana Tympani. 
 
 the canal quite thoroughly. When it is employed for the pur- 
 pose of improving the hearing, having been slightly moistened, 
 it is inserted under inspection that is, while the parts are well 
 illuminated by the otoscope by means of a pair of forceps, that 
 should be very weak in the spring, so that the blades may come 
 together with very little pressure, or by a probe. 1 
 
 The appropriate position for the cotton, where it will improve 
 the hearing, will be found, if it is to do any good, by placing it 
 on different parts of the exposed tympanic cavity, or the re- 
 mains of the drum-head, until the patient experiences an im- 
 provement in the hearing power. 
 
 I have taught a number of patients to use this kind of a 
 drum-head, and I have seen many others who have learned to 
 use it from other physicians. In the most cases, however, 
 Toynbee's disk is preferred, as being easier to manage. 
 
 There has been quite a good deal written of the cotton pellet 
 of late. This may serve to call it again to the marked attention 
 of the profession. Yet nothing essentially new has been said 
 upon the subject, since Yearsley brought it fully before the pro- 
 
 1 Yearslej on Deafness, p. 245. 
 30
 
 466 
 
 ARTIFICIAL MEMBRANA TYMPANI. 
 
 fession in his text-book. To Yearsley belongs all the credit of 
 quickly utilizing the strong hint given him by the New York 
 merchant with his spill of paper, and of suggesting a practical 
 use of an artificial membrana tympani. Queerly enough, an- 
 other New York merchant, who had accidentally learned to 
 improve his hearing by a little roll of paper, without knowing 
 of his immortal predecessor, or of Yearsley or Toynbee, con- 
 sulted me a few years since. 
 
 In 1853, Toynbee suggested another artificial membrana tym- 
 pani, without knowing of the previous invention. Toynbee's 
 appliance consists of a thin disk of vulcanized rubber, in the 
 centre of which is attached a fine wire about an inch long, which 
 
 FIG. 100. Method of Inserting Artificial Membrana Tympani (Toynbee). 
 
 terminates in a little ring, to enable the finger to more readily 
 grasp it when its removal is desired. An improvement upon the 
 original method of attachment of the wire, is to insert it spirally 
 into the disk, like a corkscrew in a cork. 
 
 We can never tell without trial, whether the artificial mem- 
 brana tympani will, or will not improve the hearing. Inasmuch 
 as I am sometimes asked if an artificial membrana tympani will 
 do any good, if the membrane be intact, it may be as well to 
 state, that it is only of service in cases of partial or complete 
 loss of the drum-head. Von Troltsch relates a case of a deaf 
 judge who used to improve his hearing temporarily by pressing 
 upon the membrana tympani with a probe ; but I have never 
 been able to increase the hearing power by any similar proced- 
 ure upon an imperforate membrana tympani. The improve-
 
 ARTIFICIAL MEMBRANA TYMPANI. 467 
 
 ment to the hearing that does sometimes occur when the cotton- 
 wool, or the membrane of Toynbee is used, is probably due to the 
 restoration of the interrupted continuity of the ossicula auditus, 
 or even of the stapes alone, to the fenestra ovalis and the laby- 
 rinth. Toynbee explained its benefit by stating that it occurred 
 as a result of the closure of the membrane ; but this has been 
 shown to be an erroneous explanation. Cases have been seen 
 where the perforation was not closed by the artificial membrane, 
 and yet great improvement to the hearing resulted from its use. 
 When the patient first begins to wear this membrane, it should 
 be used but for a very short time during the day. It is always a 
 foreign body, and hence it is liable to produce irritation and in- 
 crease the suppurative process. Lest any should think that the 
 artificial membrane is not a practical and valuable means of alle- 
 viating some cases, I may state that I have now under observa- 
 tion many patients, for whom I first introduced the membrane, 
 who have worn it for years, with uninterrupted benefit to the 
 hearing power. I have taught several other persons to apply the 
 membrane, and with benefit ; but inasmuch as I have not seen 
 them for a long time, it is not quite certain, although probable, 
 that they are still using the substitute for the natural membrane. 
 I am in the habit of tentatively applying the artificial membrana 
 tympani in all old cases of chronic suppuration in the middle 
 ear, when the loss of hearing is very great. If one ear be sound, 
 so that the hearing for ordinary purposes is very good, as it 
 always is under such circumstances, it is not worth while to use 
 the artificial drum-head for the diseased ear. An excessive in- 
 flammatory action in the remains of the drum-head, or in the 
 middle ear, precludes any use of the artificial membrane. The 
 patient for whom it is to be employed should also be an adult, and 
 possessed of a considerable amount of intelligence. It is not of 
 any use in the case of children, or of unusually heedless or stupid 
 adults. The wire to which the disk is attached, sometimes be- 
 comes separated in removing the membrane, and the disk of 
 rubber is left behind. This accident, although a very insignifi- 
 cant one for the disk is readily removed by syringing is very 
 apt to frighten the patient, unless he has been previously warned 
 not to be disturbed if such an accident occur, and not to allow 
 any improper attempts to remove such a foreign body. 
 
 Various modifications of Toynbee's disk attached to a wire 
 have been made. Thus, Lucae attaches the disk to a small 
 rubber tube. Burkhard-Merian uses a solid piece of india-rubber 
 instead of a wire. Politzer makes one especially to spare the 
 poor the expense of buying Toynbee's disk. A piece { ctm. long 
 is cut from the side of an india-rubber tube 2 to 3 mm. in thick-
 
 468 CHRONIC SUPPURATION TREATMENT. 
 
 
 
 ness, a hole is then made in one end and a wire handle fastened 
 in it. Politzer also recommends the use of an india-rubber tube, 
 as long as the canal, rounded off at the distal end and pushed 
 down to the remains of the drum-head. In cases in which the 
 sides of the stapes bone have been destroyed, Politzer has also 
 attached a stapes bone taken from a dead body to Toynbee's 
 disk, and introduces it, so that the bone lies in the niche of the 
 fenestra ovalis, 1 with benefit to the hearing. 
 
 Michael " instills glycerine, in some cases medicated with 
 tannin, and then collodion, and thus forms a membranous cover- 
 ing, of which he speaks highly. Hartmann a recommends, in 
 cases where the other varieties of artificial membranse tympani 
 do not prove serviceable, a noose of the most delicate and elastic 
 whalebone, wound about with cotton. 
 
 In introducing this appliance the auditory canal must be 
 straightened, by pulling back the auricle, while the bone is 
 placed in position, somewhat anteriorly in the depth of the 
 canal. Its use requires some care, but this may be said of all 
 artificial membranes ; for, as I have said, stupid adults and 
 children cannot use them successfully. Polaki uses paper disks 
 with great success. 
 
 Prognosis. The prognosis in chronic suppuration of the 
 middle ear depends upon a variety of local and constitutional 
 symptoms. If the consequences of chronic suppuration have 
 occurred, such as exfoliation and death of bone, the formation 
 of polypi, exostoses, and so on, the treatment is apt to be pro- 
 longed, and in some cases may never be entirely or even partial- 
 ly successful. Again, when the membrana tympani is entirely 
 removed, and one or more of the ossicula lost, the prognosis is 
 grave. Yet the membrana tympani has a regenerative power 
 second to that of no other membrane of the body. I have re- 
 peatedly seen it entirely restored after all but a narrow rim 
 had been entirely swept away. This has even occurred in cases 
 of long standing. The prompt healing of the drum-head after 
 operative perforation and in acute inflammation, is a matter of 
 common experience. 
 
 The state of the general system will also at times influence 
 the prognosis to a marked degree. Patients with phthisis pul- 
 monalis seldom recover from a spontaneous rupture of the mem- 
 brana tympani. The physician will find ample material for 
 general advice in some cases, and yet there are many in which 
 
 1 Politzer : Text-book, p. 492, original p. 563. 
 
 * Transactions of International Congress, London, vol. iii. , p. 434. 
 
 * Die Krankheiten des Ohres, p. 99.
 
 CHRONIC SUPPURATION CASES. 469 
 
 local treatment only is required ; while it is essential in all. We 
 may say, on the whole, that the prognosis can never be decid- 
 edly given so long as the membrana tympani is open, for this 
 membrane is essential to the safety of the ear from renewed 
 attacks of acute suppuration. All our efforts should be directed, 
 therefore, to closing up this opening. There can be no danger 
 from closing it too soon. Our chief difficulty will be in closing 
 it at all. If the membrane canno,t be restored, the tympanic 
 tissue may sometimes be made cicatricial, and thus the suppu- 
 ration be stopped. If regular and careful treatment by a phy- 
 sician, continued for months, fails to close the opening, or to 
 cause the discharge of pus to cease, the patient may perhaps be 
 given up as one for whom there is no hope of cure. The family 
 and friends should be taught to cleanse the ear thoroughly, as 
 long as any purulent inflammation occurs, and they should 
 know that the chief danger to the ear, and the general system, 
 lies in an accumulation and retention of pus. 
 
 Patients suffering from an accumulation and discharge of 
 pus from the tympanum cannot be too careful of their general 
 health. A simple cold in the head may be fatal to them by 
 causing an inflammation of the ear, followed by meningitis. 
 Every year of my practice brings to my attention fatal cases of 
 this kind. 
 
 CASES. 
 
 CASE I. Chronic Suppuration of Twelve Years' Standing Exostosis of Tym- 
 panic Cavity Patient under Treatment for more than Three Years Both Mem- 
 
 brance Tympani Healed Hearing Distance remains the same. W. P. H , aged 
 
 thirty-two. June, 1869. History : Ten or twelve years ago, from some cause 
 to patient unknown, the right ear began to discharge, and then the left. They 
 have discharged at intervals ever since. Occasionally there is pain in the 
 ear. 
 
 The hearing distance is R., $4 ; L-, - 4 V The right membrana tympani is in 
 a state of ulceration ; about one-third is gone. The lower and posterior quad- 
 rant remains. Considerable pus lies in the cavity of the tympanum. The left 
 membrane is nearly gone. There is a small granulation springing from the 
 cavity of the tympanum. The pharynx is tolerably healthy. 
 
 The patient was ordered to use warm douche daily. He visited me three 
 times a week, when the ears were cleansed by the syringe and warm water, and 
 Politzer's method, and an astringent, usually the sulphate of zinc, was instilled. 
 In November, in about four months from the time of my first seeing him, the 
 left membrana tympani had healed. The granulation disappeared with no other 
 treatment than the cleansing and the use of an astringent. 
 
 March 17, 1870. The right membrana tympani now exhibits a clearly cut 
 opening in the posterior and inferior quadrant. A small amount of pus oozes 
 from it. A minute but positive elevation of bone comes out to the opening. 
 The hearing is at times very poor, on account of the blocking of the tympanic
 
 470 CHRONIC SUPPURATION CASES. 
 
 cavity by pus. The patient has been under my observation ever since first note, 
 often coming to the office every day. Nitrate of silver, nitric acid, various as- 
 tringents, with the continuance of the douche and syringe, have been employed 
 in vain. 
 
 March 17, 1871. The patient has just passed through an attack of acute 
 catarrh, induced by taking cold. The hearing distance became - 4 u g - during this 
 attack. Leeches were used, and subsequently the catheter, steam being passed 
 through it. After the subsidence of the inflammation, the opening in the mem- 
 brana tympani was found to be very^much smaller. It was then cauterized with 
 the mitigated stick of nitrate of silver, melted upon a probe, and in a few weeks 
 it healed entirely; so that in October, 1872, he was dismissed, with H. D., 
 B., H ; L., -/if, and both drum membranes healed. 
 
 I have not attempted to give the full notes of this interesting 
 but tedious case. I have inserted it to show what perseverance 
 on the part of the patient will finally accomplish in some cases 
 of chronic suppuration. There were no peculiar means of treat- 
 ment adopted during the three years the patient was under my 
 care ; but he was informed that it might require years to heal 
 the drum-heads. He realized the danger from a continued sup- 
 puration, as well as the inconvenience and discomfort,' and he 
 determined never to give up the attempt to cure it. Very few 
 patients will submit to such a prolonged observation or treatment 
 without faltering in their allegiance to their medical adviser. 
 
 I have seen this patient while preparing tnese pages for the 
 press. Two years ago he had an acute inflammation of the right 
 ear, which subsided, but which left a small opening without 
 ulceration. His hearing distance for the watch varies, but is 
 generally very good and he hears conversation well. He is still 
 actively engaged in business as a merchant, fourteen years 
 since he left my care. 
 
 CASE II. Suppuration in both Tympanic Cavities for Fifteen Years, a ResuU 
 of the Pharyngeal Inflammation of Scarlet Fever No Treatment since First At- 
 tack Healing of one Drum-head, with Great Improvement to Hearing Power 
 
 Other Membrane still Open. Mr. A , aged twenty-six. November, 1870. 
 
 Since patient was eleven years old, when he had scarlet fever, he has had a dis- 
 charge from both ears, with great impairment of hearing. Hearing distance 
 right ear, /- ; left, - 4 L g . The membranse tympani on each side are removed by 
 ulceration. There is a large amount of pus in each canal, with granulations 
 which bleed readily. 
 
 The ears were treated by the warm douche, the syringe, and Politzer's 
 method of inflation. The latter at once improved the hearing, so that the watch 
 was heard at 4 inches, , 4 8 , on the left side. Some inflammatory reaction was 
 caused in a few days by the cleansing process, and the douche only could be 
 employed. The patient was seen from once to twice a week, and used the douche 
 and an astringent at home. One year after, his hearing distance was R., A > 
 L., H. The left membrana tympani has just healed. 
 
 April 16, 1872, or nearly a year later, having been seen at longer or shorter
 
 CHRONIC SUPPURATION CASES. 471 
 
 intervals ever since, and having kept up the treatment at his home, the hearing 
 distance of the left ear is !HJ. The patient has still occasional attacks of sub- 
 acute suppuration from right ear. His hearing power for conversation is ex- 
 cellent, aud no true pus is found in right tympanic cavity, but some stringy 
 mucus is forced out by Politzer's method. 
 
 January, 1873. The patient is still seen at long intervals. The condition of 
 the ears remains about the same. 
 
 CASE III. Suppuration of both Middle Ears, occurring without Pain Half of 
 each Membrana Tympani gone Moderate Amount of Pus Secreted Treatment did 
 not avail to Improve the Hearing Power Artificial Membrana Tympani used with 
 
 Benefit. E. K. T , aged twenty-eight. November, 1872. Three months since, 
 
 patient found, on awaking in the morning, that both ears were discharging. 
 There was no pain experienced in them. He had had naso-pharyngeal catarrh 
 for some time, which had been treated regularly by the use of the nasal douche 
 and the posterior nares syringe. The patient is not in very good general health. 
 He has had a pulmonary hemorrhage, and evidently has phthisis pulmoualis. 
 He hears the watch six inches on the right side, two inches on -the left. Hear- 
 ing distance B., A ; L., A- The pharynx is granular. The anterior and in- 
 ferior quadrant of the membrane is gone. The remainder ef the membrane is 
 white, and does not reflect light. The left membrane also has a large perfora- 
 tion, the anterior half being absent, and the remainder of the membrane looking 
 like the right. There is a moderate amount of pus secreted in the tympanic 
 cavity. The auditory canals are red and sensitive. The patient has already 
 had more or less systematic treatment, and he cleanses his ears daily by syring- 
 ing. There are great variations in the hearing power. 
 
 The patient was seen daily for some six weeks, and efforts made to heal the 
 membraiia tympani by the use of sulphate of zinc, alum, sulphate of copper, 
 and nitrate of silver, in solution and in solid form. Cod-liver oil was given, and 
 the general condition improved, but the membranae tympani did not heal in the 
 slightest, although the discharge was lessened, and the condition of the auditory 
 canals was improved. 
 
 February 15, 1873. The patient's hearing power continued to grow worse, 
 when the artificial membranse tympani were inserted, with immediate benefit to- 
 the hearing power, so that he could transact his business, which was that of a 
 commercial traveller. Hearing distance R., A ; L-j A- 
 
 April 15. The patient is still wearing the membranes with the same benefit. 
 The ears are daily cleansed by syringing, and an astringent is dropped upon 
 them. Mr. T says that he cannot hear "at all" without the artificial mem- 
 branes. 
 
 It has been a common observation with the patients who use 
 an artificial membrana tympani, that they cannot hear as well 
 after removing the artificial drum-heads as they did before 
 wearing them. Yet in som^ cases, the improvement continues 
 for hours after they are removed. The latter effect is probably 
 due to the fact that the restored continuity of the ossicula and 
 the fenestra ovalis is kept up, even after the agent that caused 
 the restoration is removed. 
 
 CASE IV. Chronic Suppuration of Ten Years' Duration Stopped in Three Days
 
 472 CHRONIC SUPPURATION CASES. 
 
 by the Removal of a Small Granulation through the Drum-head, and the Application 
 
 of Nitrate of Silvei Hearing Power Improved. R. R . November 8, 1872 
 
 (sent to me by Dr. H. C. Eno). When the patient was sixteen years old he 
 " got cold in the right ear;" the ear was very painful; it discharged and has 
 continued to do so ever since. It has been under careful treatment for some 
 months, and does not discharge as much as it did. The hearing distance is ^. 
 
 On examination, a slight amount of pus is found upon the membrana tym- 
 pani. On removing this, a small granulation is seen perforating the membrane 
 in the anterior and inferior quadrant. 
 
 November 9. The granulation was removed by means of a pair of angular 
 forceps. A solution of nitrate of silver, gr. xl. ad 3 j., was applied in the open- 
 ing, after a thorough cleansing of the ear by syringing and Politzer's method. 
 
 November 10. The opening of the membrane has closed. The patient 
 remained under observation until November 22d, and suppuration did not again 
 occur. The hearing distance became -A. 
 
 1870. This membrane continues sound, although the patient has had eczema 
 of the canal and perforation in another part of the membrane once, since the one 
 here described healed. 
 
 It may be thought that these cases illustrate the bright side 
 of the treatment of chronic suppuration ; but I do not think they 
 are any more than average specimens of cases of simple ulcera- 
 tion, that is, ulcerations unattended by death of bone. When 
 caries or necrosis of any part of the walls of the cavity has 
 occurred, the prognosis is very unfavorable for a perfect arrest 
 of the morbid process. I have not found so much difficulty in 
 relieving uncomplicated cases of chronic suppuration, as in find- 
 ing patients who were patient enough to submit to the tedious 
 treatment necessary to a cure. Distrust of the advice of the 
 profession is nowhere more common than in cases of chronic 
 suppuration, in regard to which the laity have been taught two 
 erroneous and contradictory doctrines, first, that a discharge 
 from the ear is seldom checked ; second, that it is dangerous to 
 arrest it, if we can.
 
 CHAPTER XVII. 
 
 THE CONSEQUENCES OF CHRONIC SUPPURATION OF THE 
 MIDDLE EAR. 
 
 Chronic Suppuration and its Results Inevitably Dangerous to the Health and Life of 
 the Patient. Refusal of Life Insurance Companies to take Risks of such Cases. 
 Cicatrices and Adhesions in the Tympanum. Polypi. Exostoses. Mathewson's 
 Operation for their Removal. Cases. 
 
 IF a chronic suppurative process in the middle ear, remained a 
 simple ulcer, with none of the consequences that are very liable 
 to result from it, it would, perhaps be a condition of things to be 
 preferred to a chronic proliferous process in the same part. For 
 in simple chronic ulceration, the hearing power is often very 
 good, the tinnitus aurium is not usually excessive, and some- 
 times does not exist, and it may generally be relieved by simple 
 syringing and inflation of the ear. These are the symptoms 
 which are so trying, in the non-suppurative form of disease, 
 that people have become insane on account of them. But the 
 almost inevitable consequences of chronic suppuration in the 
 middle ear, are dangerous to the health and life of the patient. 
 Hence the importance of the subject, and the interest which 
 every physician should take in arresting the advance of this 
 disease. 
 
 It is in view of these consequences, that English life insur- 
 ance companies are said to decline to insure the lives of persons 
 that are affected with chronic suppuration of the middle ear. 
 A little consideration will show that any person who has a hole 
 in the membrana tympani, and an ulcerative process in the 
 parts beyond, has a much less chance for long life than one 
 whose brain and vascular circulation are not thus exposed t& 
 the ravages of disease.. Very few persons, comparatively, who 
 suffer from chronic suppuration, live out their days, while many 
 of them die very young. 
 
 Among the possible and not infrequent consequences of 
 chronic suppuration of the middle ear are 
 
 1. Cicatrices and adhesions in the drum-head and tympanum. 
 
 2. Polypi.
 
 474 CONSEQUENCES OF CHRONIC SUPPURATION. 
 
 3. Exostoses. 
 
 4. Mastoid disease. 
 
 5. Caries and necrosis of the temporal bone. 
 
 6. Cerebral abscess. 
 
 7. Pyaemia. 
 
 8. Paralysis. 
 
 CICATRICES AND ADHESIONS. 
 
 In some fortunate cases of chronic suppuration, as we have 
 seen, an end is finally reached by a closure of the membrana 
 tympani. This may even occur when one or all of the ossicles 
 have been removed. The impairment of hearing may be very 
 great, with a neoplastic membrana tympani, but the danger to 
 life and to the general health, is much lessened by a closure of 
 the tympanum. Healing of the ulcerated membrana tympani, is 
 therefore a result to be desired, even if the hearing be not as 
 great after this has occurred, as it was when it was perforate 
 and ulcerating. The drum-head, however, may not close, and 
 yet its edges cicatrize and adhere to the tympanic wall. The 
 tympanum then will be converted into a dry chamber, its mu- 
 cous membrane so altered that it scarcely secretes, and only 
 under great provocation takes on inflammatory action. It is 
 sometimes difficult in such cases to determine what is left of the 
 normal furniture of the tympanum, such a mass is it, of displaced 
 and neoplastic tissue. If the stapes bone still remain, or even its 
 foot-plate, it is sometimes possible to use an artificial membrana 
 tympani with great benefit ; but generally the adhesions and 
 cicatrices involve so much of the air chamber, with perhaps an 
 extension into the tissues of the labyrinth, that literally nothing 
 can be done for the patient, except to leave his ears to them- 
 selves. Bad as this condition is, it is a more favorable one than 
 when the ulcerative process still continues, with perhaps some 
 one or more of the results that are now to be described. 
 
 POLYPI. 
 
 Celsus and Pliny, used the term polypus for a tumor springing 
 from any cavity of the body. The name was adopted under the 
 old system of nomenclature, when an exact knowledge of the 
 nature and structure of growths or parts was not regarded in 
 giving them a name. It is an unfortunate one, for there is 
 scarcely any resemblance between the many -footed aquatic 
 animal, after which morbid growths were called, and the exub- 
 erant granulations or tumors which arise from the cavity of the
 
 POLYPI. 475 
 
 tympanum and the auditory canal. It is probably too late, or 
 too early, to effect any change in the nomenclature, and we 
 must be content with the name aural polypi for all the growths 
 that occur in the ear, except for those of an osseous structure or 
 a cancerous nature. 
 
 The best classification of aural polypi, seems to me to be that 
 of Steudener, ' who divides them into three varieties : 
 
 1. Mucous polypi. 
 
 2. Fibromata. 
 
 3. Myxomata. 
 
 To this we may add a fourth class : 
 
 4. Angioma ; a case of which, as occurring in the ear, was 
 first reported by Dr. A. H. Buck. 2 
 
 Cases of epithelioma, sarcoma, and cholesteatoma have also 
 been reported, but they do not properly belong to the subject of 
 aural polypi, although they are sometimes confounded with the 
 simple growths, and perhaps arise from them. For the sake of 
 convenience, their consideration will be deferred until the be- 
 nignant tumors have been considered. Kessel* also reports a 
 peculiar growth, which is called a clot of blood in process of 
 organization, but it hardly requires a separate classification. 
 
 The mucous polypi are altogether the most frequent of those 
 found in the ear. The fibromata, or polypi, made up of denser 
 connective tissue than the mucous growths, are next in fre- 
 quency. Buck, thinks that about one in ten. of all the polypi 
 that have been microscopically examined, belong to the class of 
 fibroma. Myxoma, has been reported by Steudener only, so far 
 as I have been able to find. 
 
 Nature of Aural Polypi. In an article published in 1864, 4 I 
 attempted to show on clinical grounds, that aural polypi were 
 analogous in structure to exuberant granulations, occurring as 
 direct results of an ulcerative process. This view at once clears 
 up the nature of these growths and takes away the fictitious 
 importance which the view that regards them as independent 
 tumors caused them to assume. Professor Theodore Billroth, 
 in 1855, whose monograph I had not then seen, examined seven 
 polypi which were found in the external auditory canal, and 
 Kessel " quotes him as stating that the chief contents of those 
 polypi were granulation material, although he states that the 
 
 1 Archiv fur Ohrenheilkunde, Bd. IV., p. 203. 
 
 2 Transactions of the American Otological Society, 1870. 
 
 3 Archiv fiir Ohrenheilkunde, Bd. IV., p. 187. 
 
 4 American Medical Times, August C, 1864. 
 
 5 Archiv fiir Ohrenheilkunde, loc. cit.
 
 476 
 
 POLYPI. 
 
 existence of ciliated epithelium and the vascular network en- 
 titles them to the rank of independent tumors. Bill roth's idea 
 as to the nature of mucous polypi is perhaps the most correct 
 and the simplest. They consist of a delicate but loose stroma 
 of connective tissue. In the meshes of this connective tissue 
 are round, spindle-shaped, or stellate cells, and they are covered 
 by a single or multiple layer of epithelium cells. 
 
 The fibrous polypi consist of a dense connective tissue, hav- 
 ing but few cellular elements in its fibres and covered by pave- 
 ment epithelium. 
 
 FIG. 101. Section of Aural Polypus, Case T. A, Layer of laminated epithelium, similar to 
 that of skin ; , B, epithelial cones, the commencement of gland formation ; C, loose con- 
 nective tissue, containing round and spindle cells and some fibres ; D, blood-vessels. 
 
 Angioma is made up of newly formed vessels, or of vessels 
 in whose walls are newly formed elements. It is quite a com- 
 mon variety of tumor, although the case to which allusion has 
 already been made, is the only one that has been reported as 
 having been found in the ear. Virchow ' named the form which 
 Dr. Buck examined, angioma cavernosum, because it was char- 
 acterized by the existence of a network of blood spaces, occupy- 
 ing the place and doing the work of capillary vessels. 
 
 It may be said in general terms, however, that aural polypi 
 are growths covered by laminated epithelium, and that they 
 consist of loose connective tissue, containing round and fusi- 
 form cells and a proportionately large number of blood-vessels. 
 Their internal structure in some cases gives evidence of the for- 
 mation of glands. 
 
 Dr. H. C. Eno, formerly Pathologist to the Manhattan Eye 
 
 1 Die krankhaften Geschwiilste, IIL Bd., Hf. I., p. 307.
 
 POLYPI. 
 
 477 
 
 and Ear Hospital, and Surgeon to the New York Eye and Ear 
 Infirmary, examined three specimens of aural polypi, which I 
 removed from the auditory canal, and made drawings of their 
 structure. These drawings will, I think, better illustrate the 
 nature of these growths than further remarks. 
 
 CASE I. Thomas G , aged twenty-three. March 14, 1871. Brooklyn 
 
 Eye and Ear Hospital. 
 
 History. Seven days ago extensive swelling in meauricular region ; granu- 
 lations springing out of auditory canal. 
 
 Diagnosis. Abscess of anterior wall of auditory canal, with polypoid growth 
 arising from same point. 
 
 Treatment. Polypus removed and abscess opened ; ordered chloral hydrate, 
 gr. xv. ; if does not sleep well to-night, to come at 12 M. 
 
 March 16th. Continue treatment. 
 
 March 18th. Touched polypus with nitric acid. 
 
 March 21st. Much better ; touched with argent nit. mit. 
 
 It should be said that the usual point of origin of aural pol- 
 ypi, is the cavity of the tympanum. They may arise from the 
 auditory canal, but if so, they are the result of suppuration, that 
 has been prolonged, or that has been augmented by the use of 
 
 J 
 
 FlG. 102. Section of Aural Polypus, Case II. A, Epithelium ; B, substance of polypus, 
 made up of a mass of round cells about the size of white blood-corpuscles ; O, C, capillary 
 vessels, containing white blood-corpuscles. 
 
 poultices, and which have rapidly broken down the integument 
 of the canal, and rendered it more like its neighbor, the mucous 
 membrane of the tympanic cavity. Polypi and granulations 
 often, however, have their seat in the canal, but they are usu- 
 ally accompanied by the same growth in the deeper parts, when 
 the whole character of the tissue lining the canal has been
 
 478 
 
 POLYPI. 
 
 changed by an ulcerative process, extending from the tympanic 
 cavity. As will be seen by comparing the illustrations of Case 
 I. , which arose from the auditory canal, with those that sprang 
 from the cavity of the tympanum, the only essential difference 
 is that the epithelium is thicker. 
 
 CASE n. Mary Jane N , aged thirteen. January 10, 1872. Manhattan 
 
 Eye and Ear Hospital. Otitis media suppurativa, with polypus in right ear. 
 Polypus nearly fills auditory canal. Discharge from both ears from scarlet 
 fever since a child. Large perforations in membranes tympani. Polypus re- 
 moved with snare. 
 
 FIG. 103. Section of Aural Polypi. A, f, and D, same as in Fig. 101 ; E, gland lined with 
 cylindrical epithelium ; f, transverse section of the same. 
 
 CASE HE. Mary Ann McC , aged fourteen. January 24, 1871. Man- 
 hattan Eye and Ear Hospital. 
 
 History. Discharge from right ear since a child. Cause unknown. 
 
 Diagnosis. Otitis media suppurativa, with polypus of right ear. 
 
 Hearing. B., watch heard on contact. L., normal. 
 
 Meatus. E., full of pus. 
 
 Treatment. Syringed. January 31st. Two polypi removed with snare. 
 Douche and syringing. Politzer, warm douche. Nitric acid to stumps. Hear- 
 ing distance increased to 2". 
 
 Aural polypi are more rarely found by the physicians of to- 
 day than by our predecessors, for the simple reason that aural 
 diseases are more carefully observed, and they have no such 
 opportunities to occur, as were enjoyed when a discharge of 
 pus from the ear was not treated. A tumor can scarcely arise 
 from a tympanic cavity or an auditory canal that is kept thor- 
 oughly free from the pus of a chronic suppurative process.
 
 MALIGNANT GROWTHS. 479 
 
 MALIGNANT GROWTHS. 
 
 The malignant growths that have as yet been found in the 
 ear, and which may be mistaken for malignant polypi, are epi- 
 thelial carcinoma, fibrous and medullary carcinoma. Gruber ' 
 relates a case where an epithelial carcinoma originated in the 
 integument in the region of the mastoid bone, gradually de- 
 stroyed the mastoid process, and finally reached the mucous 
 membrane of the middle ear. The membrana tympani was de- 
 stroyed by the growth. The patient heard a watch when laid 
 upon this ear ; he had no tinnitus aurium, and so few symp- 
 toms beyond extremely slight lancinating pain, that after the 
 tumor had existed for three years, he still did his work as a day 
 laborer. 
 
 Dr. Robertson," reports a case of supposed polypus in the 
 ear, which proved to be, on microscopic examination, a specimen 
 of " fasciculated sarcoma corresponding to plates of tumors con- 
 stituted by embryonic tissue, found in the ' Manual d'Histologie 
 Pathologique,' by Cornil and Ranvier of Paris." An attempt to 
 remove the growth by cutting off pieces of it caused a hemor- 
 rhage of fourteen fluid ounces in a few moments. The hemor- 
 rhage was arrested by a tampon of cotton dipped in a solution 
 of persulphate of iron. 
 
 Cholesteatoma, the pearl tumors of J. Miiller, have also been 
 found in the cavity of the tympanum, arising from an inflamed 
 or ulcerated mucous membrane. They consist, according to 
 Gruber, 3 of small degenerated epithelial cells, between which 
 lie cholestearine crystals and other fatty material. They some- 
 times destroy the bone by pressure, and they may even extend 
 into the cranial cavity. 
 
 Osteo-sarcoma of the cavity of the tympanum, extending 
 into the auditory canal, was also observed by Boke. 4 The pa- 
 tient died of meningitis. Wilde 6 reports an interesting case of 
 osteo-sarcoma. A boy of seven years of age. in apparently good 
 health, was brought to Mr. Wilde on account of a discharge 
 from the external auditory canal. A small polypus was dis- 
 covered. It was removed, but it returned quickly on the third 
 day. It was again and repeatedly removed, but it recurred 
 again and again, and subsequently the child was seized with an 
 epileptic fit. A fluctuating point was then found upon the mas- 
 toid process ; this was cut down upon at once, and the opening 
 gave exit to a large amount of pus. The abscess communicated 
 
 1 Text-book, p. 597. * Transactions of the American Otological Society, 1870. 
 
 3 Lehrbuch, p. 597. 4 Gruber, loc. cit. 5 Text-book, p. 280.
 
 480 TREATMENT OF POLYPI. 
 
 by a fistula with the external auditory canal. A fungous 
 growth soon sprouted up through the incision. Repeated at- 
 tacks of epilepsy occurred, and death soon ensued. Upon ex- 
 amination there was found an osteo-sarcoma of the petrous 
 and mastoid portions of the temporal bone. Wilde thinks that 
 the original disease was in the bone, and that the aural dis- 
 charge and fungus were but secondary appearances. The his- 
 tory is not detailed enough to allow us to state with any posi- 
 tiveness the first cause of the affection, but it may have been 
 an ulcer in the tympanic cavity, which secondarily involved 
 the bone. 
 
 These malignant tumors of the ear should be carefully dis- 
 tinguished from the benign mucous and fibrous polypi that are 
 the frequent results of a neglected suppuration. Yet it should 
 be remembered that the malignant growths may be also the 
 result of the same original process. This fact adds to the im- 
 portance of the subject. Perhaps some of the cases of death 
 from the removal of aural polypi should be referred to the ex- 
 tension of the malignant disease, rather than to the excision of 
 a tumor from the ear. 
 
 Treatment. The treatment of an aural polypus should be- 
 gin with the removal of the growth. I have said begin with 
 deliberation, because it is a mistake to suppose that the removal 
 of the polypus will be any more than the beginning of the 
 treatment of the disease of which the polypus is a symptom. 
 Besides, aural polypi often spring up very rapidly, even after 
 they have been thoroughly removed, and when they are simple 
 growths ; moreover, we are often obliged to remove them sev- 
 eral times from the ear, especially where we cannot have full 
 control of our patients and cause them to attend to the after- 
 treatment. 
 
 Wilde's snare, as modified by Blake (Fig. 104), will be found 
 the best instrument for the removal of well-defined polypi with a 
 pedicle. In Wilde's snare, the bar which carries the slide, and 
 the arm which supports the wire used in cutting off the polypus, 
 are in one piece. Dr. Blake has substituted a movable tube of 
 German silver (d) for the fixed arm. "This tube expands at 
 the outer ends into a flattened head (/), having two openings 
 for the passage of the wire ; the inner end of the tube fits into 
 a broad band on the slide-bar (&). The ends of the wire passing 
 down the tube are fastened to a pin on the upper part of the 
 slide (c), below which is a ring, by which traction can be made." 
 The instrument is better than Wilde's, because it can be turned 
 in any direction without injuring the walls of the canal. A
 
 POLYPI TREATMENT. 
 
 481 
 
 it 
 
 paracentesis needle may also be used in the handle, but 
 should be rather longer than the one in the cut. 
 
 Scissors may sometimes be used with advantage to remove 
 aural polypi. I have found those that are here represented very 
 convenient, especially for the removal of growths from the 
 walls of the auditory canal. 
 
 FIG. 104. Blake's Modification of Wilde's Snare, with Paracentesis Needle. 
 
 Forceps may sometimes be employed, although I prefer the 
 snare, scissors, and curette to all other mechanical means for re- 
 moving polypi or granulations. Forceps, unless used with great 
 gentleness and care, may wrench more than the morbid growth 
 from the cavity of the tympanum, and thus do great harm. 
 
 Very small pedunculated growths may be often removed by 
 the simple angular-toothed forceps, figured on page 59 of this 
 work. True exuberant granulations, having no pedicle, but 
 arising from a broad surface, usually resist treatment with 
 great obstinacy, because they are difficult to reach and entirely 
 
 FIG. 105. Scissors for the Removal of Aural Polypi. 
 
 remove with instruments, and because they usually qover cari- 
 ous or necrosed bone. Caustics are perhaps the only means of 
 removing such growths. The agents I usually employ for such 
 cases are strong solutions of nitrate of silver from forty to four 
 hundred and eighty grains to the ounce and fuming nitric 
 acid. The nitrate of silver may be poured in upon the part, 
 and then neutralized by the subsequent instillation of a solution 
 of common salt. 
 
 Dr. O. D. Pomeroy ' reports a case of " the removal of a poly- 
 
 1 Medical Record, vol. vi. 
 31 
 
 Reported by D. Webster, M.D.
 
 482 
 
 POLYPI TREATMENT. 
 
 poid granulation of ten years' standing, by four applications of 
 a forty-grain solution of nitrate of silver." A pipette was used 
 to drop the nitrate of silver upon the growth. Although it is 
 evident from the history that the dis- 
 -ease which allowed the formation of the Q 
 polypus a chronic suppuration from 
 scarlet fever had existed for ten years, 
 it does not certainly appear that the 
 polypus had been in the ear so long. 
 The polypus is said to have sprung from 
 the membrana tympani, which was per- 
 forate, however. 
 
 I am in the habit of treating granu- 
 lations that arise from the cavity of the 
 tympanum, where it is somewhat dan- 
 gerous to use forceps, scissors, or snare, 
 by numerous punctures with a cataract 
 needle. The puncturing causes consid- 
 erable hemorrhage. After the blood is 
 wiped away a caustic should be applied. 
 Nitric or chromic acid may be thus used, 
 by means of a glass rod, a cotton-holder 
 armed with cotton, or a bit of wood. 
 
 The pain from these applications is 
 usually so little that even children will 
 bear them without shrinking. The 
 granulations are of such a low grade of 
 organization that they have very little 
 sensitiveness. There are, of course, 
 many other agents than those that have 
 been mentioned, which may be profit- 
 ably used in cauterizing the bases of 
 polypi that have been removed by in- 
 struments, and in destroying fungous 
 granulations. Chromic acid is very 
 much employed, as well as the acid ni- 
 trate of mercury. 
 
 Dr. Edward H. Clarke often injects 
 a solution of the perchloride or persul- 
 phate of iron into the interior of a poly- FlG io6._ Buck's Curettes, 
 
 PUS. and With the happiest results. 1 TWO for clearing auditory canal and 
 ;, , , ,, ii- f tympanum. 
 
 or three drops of the liquor fern per- 
 
 chloridi, of the liquor ferri persulphatis, are injected into the 
 
 growth by means of a hypodermic syringe. 
 
 1 On Polypus of the Ear, p. 61.
 
 POLYPI TREATMENT. 483 
 
 Dr. Hackley drops a few drops of the persulphate of iron upon 
 small granulations, and he informs me, that after years of ex- 
 perience with this remedy, he is well satisfied with the results 
 of its use. I have lately used it and I think it shrivels the 
 smaller growths very well. But I now chiefly use the curette 
 for small growths. 
 
 The galvano-cautery is said to be an efficient and painless 
 method of removing granulations from the cavity of the tym- 
 panum. Dr. Blake does not consider it a painless method of 
 perforating the drum-head however, he having witnessed its 
 operation, in Vienna, in some experiments made by Politzer, 
 Chemani, and Moos. Allusion has already been made to this 
 means of puncturing the membrana tympani. In each of the 
 cases observed by Blake, where an attempt was made to per- 
 forate the membrana tympani with a galvano-cautery, the pain 
 was so severe that further attempts were abandoned. It is prob- 
 able, however, that it is not so painful a process when used to 
 remove granulations. Schwartze 1 speaks very highly of the 
 galvano-cautery for the purpose of removing morbid growths. 
 Although the pain is considerable, much more severe than from 
 t the use of the pure nitrate of silver, the reaction is slight. 
 Schwartze also believes that the galvano-cautery is a more effi- 
 cient means of removing the growth than the ordinary caustics. 
 
 No difficulty will usually be found in the removal of large or 
 pedunculated polypi or granulations. It is only by those that 
 are small and flat, arising from dead bone, and which are very 
 rapidly reproduced, that difficulty will be found. Each surgeon 
 will soon learn how he can best deal with the former variety, 
 whether with forceps, snare, or curettes. The latter form, espe- 
 cially if buried, so to speak, in the tympanic cavity, will often 
 tax the surgeon's skill and ingenuity to the utmost. The use of 
 alum will sometimes shrivel the granulations so as to cause a 
 pedicle to show itself. lodoform, as has been said, is a good ap- 
 plication to pale growths. Alcohol is also valuable. It should 
 be used at least three times a day, and warmed before it is 
 dropped into the ear, when used for polypi. It causes consider- 
 able pain, but it is only of short duration. It is well to begin 
 with a fifty per cent, solution. 
 
 Free incisions into the granulations, down to the bone, by 
 means of a narrow Graefe's cataract knife, are also effective, 
 especially in recent cases. 
 
 No matter which of the methods that have been detailed, be 
 employed in removing an aural polypus, the subsequent treat- 
 ment will be the same. The case, after the removal of the: 
 
 1 ArcMv fur Ohrenheilkunde, Bd. IV., p. 8.
 
 484 CASE OF POLYPUS. 
 
 growth if caries, necrosis, or exostosis do not exist is one of 
 simple chronic suppuration, that should be managed in the man- 
 ner that has been set forth in the preceding chapter. The re- 
 moval of the polypus may improve the hearing very much, or it 
 may scarcely benefit it. If the polypus were a mere mechanical 
 obstruction to the entrance of sound, its removal would of course 
 at once restore the hearing power; but, as has been seen, it is 
 much more than that. The prognosis in regard to the hearing 
 power in cases of aural polypi should always be guarded. The 
 hemorrhage from their removal is usually trifling. If it be 
 excessive, as in Dr. Robertson's case of carcinoma, a tampon 
 saturated in sulphate of iron will arrest it. I usually employ 
 Rohland's styptic cotton for the arrest of hemorrhage from the 
 base of a polypus, if the use of cotton-wool do not check it at 
 once. Hot water is also a good styptic. 
 
 Blake's Middle Ear Mirror. 
 
 Dr. Blake has invented a middle ear mirror, for the purpose 
 of examining cases of suppurative inflammation of the middle 
 ear more accurately than can be done with the aural speculum. 1 
 It is said to be especially useful in detecting the exact site of 
 small granulations. The use of Dr. Blake's instrument, as he 
 himself states, " is of necessity limited to a very small number 
 of cases, as both a moderately wide meatus and a comparatively 
 large opening in the membrana tympani must exist, to permit 
 of the introduction of a mirror of sufficient size." The instru- 
 ment was first constructed to accurately determine the origin of 
 a growth which was external to the membrana tympani, but 
 which was hidden from view by the conformation of the external 
 auditory canal. 
 
 The mirror is attached to Weber's tenotome, the cutting-hook 
 being replaced by a polished steel mirror of from one-sixteenth 
 to one-eighth of an inch in diameter. In some cases Dr. Blake 
 thinks a larger mirror may be used. "The mirror is made by 
 flattening out the end of the shaft, bending it at the proper 
 angle, tempering and polishing it. The shaft is ductile, so that 
 the angle of the mirror can be varied at will. Shafts of various 
 lengths, with mirrors of various sizes, may be used in the same 
 handle, and the mirror may be rotated by movement of the stud 
 in the handle." 
 
 Polypus in the Auditory Canal for Forty -one Years Removal. The most 
 remarkable case of polypus in the ear, that I ever saw, was one that came to me 
 
 1 Transactions of the American Otological Society, 1872, p. 83.
 
 BONY GROWTHS. 485 
 
 in 1875. The subject of the disease was fifty-six years old. He stated that he 
 had had a discharge from his ear ever since he was a small boy, and that he was 
 positive that he had had a polypus in the ear for forty-one years. The right 
 auditory canal was found to be filled with a polypus, and there was a slight 
 amount of pus in the canal. The patient stated that he had taken great care of 
 his ear and his polypus during all these years. He brought with him a peculiar 
 kind of cotton, which he had used to cleanse the canal and to plug the rneatus. 
 After I gave him the advice to allow the removal of the growth, he accepted it, 
 but with many misgivings and great reluctance. He seemed to believe that the 
 most serious consequences would follow the removal of the growth. It was ef- 
 fected very easily by a snare. It was attached by a pedicle to the upper and 
 posterior wall of the canal. The membrana tympani was whole, but cicatricial. 
 The hearing power was nil. The growth did not recur, and the patient has 
 suffered no evil consequences from its removal. I have no doubt, after careful 
 investigation, that this gentleman's account of the number of years the polypus 
 had been in his ear, was strictly correct. As Dr. Ely remarked, when we were 
 advising the patient to allow the tumor to be removed: "It was a case of a 
 man attached to a polypus." 
 
 For the benefit of the student and young practitioner, we 
 may formulate our knowledge of aural polypi as follows : 
 
 I. True aural polypi are morbid growths analogous to ex- 
 uberant granulations. 
 
 II. They are the result of a long-continued, or recent and 
 violent purulent inflammation of the cavity of the tympanum 
 or external auditory canal usually of the former. 
 
 III. Their removal is usually but the beginning, of a treat- 
 ment of the disease of which they are consequences and symp- 
 toms. 
 
 IV. The hearing power of the patient will not be restored, 
 although usually improved by the removal of an aural polypus. 
 
 V. Malignant growths occur in the ear, which assume the 
 form of, and may be mistaken for, simple polypi. 
 
 BONY GROWTHS. 
 
 Exostoses, hyperostoses, or bony growths sometimes occur 
 in the osseous portion of the auditory canal and in the cavity of 
 the tympanum. They may be divided into two great classes 
 the congenital and acquired forms. With the congenital we 
 have very little to do. Inasmuch as they are not consequences 
 of chronic suppuration, they do not usually, if ever, become a 
 source of trouble, and are generally seen incidentally that is, 
 when a patient's ear is being examined for some disease inde- 
 pendent of the exostosis. In these congenital cases the whole
 
 486 BONY GROWTHS. 
 
 calibre of the canal is sometimes lessened by a general thicken- 
 ing of the bone, but more frequently the growths extend from 
 one point, with a pretty well defined pedicle. 
 
 Professor S. Moos ' believes that osseous tumors in the exter- 
 nal auditory canal are relatively frequent, and he has observed 
 three cases of the symmetrical formation of exostoses in both 
 auditory canals, in persons who consulted him for a catarrh of 
 the middle ear. "The tumors developed invariably from the 
 upper wall of the external auditory canal, close to the drum- 
 head, and opposite Shrapnell's membrane." None of the pa- 
 tients had ever suffered from gout, rheumatism, syphilis, or a 
 suppuration in the ear. Moos, thinks that these cases, were con- 
 sequent upon irritative processes occurring at the time when the 
 annulus tympanicus, unites with the squamous portion of the 
 temporal bone. Dr. Gruening reported two similar cases at a 
 meeting of the New York Ophthalmological Society, in April, 
 1872. These congenital bony growths do not require treatment, 
 and should not be interfered with. 
 
 When the subject is old, and the auditory canal is naturally 
 narrowed by the alteration in position in the lower jaw, some 
 trouble may be experienced from the impaction of wax in the 
 ear in cases of congenital exostoses, inasmuch as the usual 
 means of its removal the motions of the jaw cannot produce 
 the same effect upon the narrow passage. 
 
 Bonnafont " reports an interesting case of an aural exostosis, 
 which, so far as I can judge from the history,. which is not very 
 detailed nor exact, seems to have been congenital, and to have 
 continued to grow after birth. It completely obliterated the 
 auditory canal: "Observation d'un cas de surdite complete de 
 Voreille gauche du a V obliteration du conduit auditif par une 
 tumeur osseuse, siegeant pres la membrane du tympan, et guerie 
 par la trepanation de la tumeur" There was no history of pre- 
 vious pain or suppuration. By the use of a point of nitrate of 
 silver, for six sittings, the bone was exposed at the centre of the 
 growth, and it was then removed by boring into it with a rat- 
 tail file. In ten applications of this file, which were not very 
 painful, an opening was made. A whalebone probe was then 
 fastened in the opening. This opening was kept up for some 
 months, and after it was made the tick of the watch was heard 
 for some inches. Some years after, the opening through the 
 exostosis still remained. 
 
 1 Archives of Ophthalmology and Otology, vol. ii., p. 136. 
 
 2 Monatsschrift fiir Ohrenheilkunde, Jahrgang II., No. 8, lue a 1'Academie Im- 
 periale de Medecine, May 26, 1868.
 
 BONY GROWTHS. 487 
 
 Professor H. Welcker, ' of Halle, in an article upon bony growths in the ear, 
 found upon the dead subject, gives some interesting facts in regard to these for- 
 mations. Welcker quotes from Seligman, who found exostoses very frequently 
 in the external auditory canals of the skulls of American Indians, that had been 
 misshapen by pressure exerted upon them in infancy. ' ' Of six such skulls, five 
 were found to have this kind of exostosis." Seligman was inclined to believe 
 that these growths were a peculiarity of race ; but Welcker does not agree with 
 him, because he found them in other Indians not of the tribe whose skulls were 
 examined by Professor Seligmau, and whose bones had not been changed by 
 pressure. Welcker also adds that these exostoses are not extremely rare among 
 the cultured population of Europe, and as shown by the text-books and C. O. 
 Weber's collection, the external auditory canal is a favorite position for them. 
 Welcker thinks that Seligman's observations show that exostoses of the external 
 auditory canal are more frequent among the Indian tribes than among the people 
 of Europe, although he does not think there is any race peculiarity in them. 
 The exostoses found by Seligman, in such relative frequency among North 
 American Indians, seem to plainly belong to the class of congenital growths 
 which have been reported by Moos, Gruening, and Agnew ; but I have no doubt 
 that their origin was, as Moos states, due to some local irritation, which caused 
 ,a proliferation of bone. 
 
 Dr. Victor Bremer," of Copenhagen, also reports a case of removal of an 
 exostosis from the auditory canal. There was a bony growth in each ear. The 
 right canal was entirely closed by an osseous growth situated 22 mm. from the 
 meatus. A fine flexible saw was tried, and its use given up. With a pair of 
 scissors he then succeeded in cutting off a small piece of the tumor. The dental 
 engine, as suggested by Dr. Mathewson, was then tried, but Dr. Bremer feared 
 to continue it, fearing that he would injure the niembrana tympani. The scis- 
 sors were again used, and in a short time he found that he had cut through the 
 tumor and the probe touched an elastic body. The suppuration was then free 
 and the granulations were numerous. The granulations were touched with 
 nitrate of silver. The canal was kept open for fourteen days with laminaria 
 digitata. In five weeks the hearing was restored. When the hearing was com- 
 plete, it was found that an oblong opening 4 mm. long had been made in the 
 tumor. This case is so superficially reported that it is impossible to say 
 whether the exostosis was congenital or acquired. It is more likely to have been 
 the latter, and to have been the result of long-continued inflammation of the 
 bony canal. 
 
 Prof essor William Turner 3 describes an exostosis of the canal, in an adult male 
 skull obtained near Pisaqua, Peru. Both passages were nearly closed by hard, 
 ivory-like exostoses. These were pedunculated, and on the left side, when the 
 integument existed, they must have blocked up the canal. The exostoses on 
 both sides grew upon that part of the wall of the canal formed by the auditory 
 plate of the expanded tympanic ring. In the adult skull of a flatheaded 
 Chenook Indian, from the district of the Columbia River, Professor Turner 
 found the right external auditory canal partially closed by a broad-based exos- 
 
 1 Archiv fur Ohrenheilkunde, Bd. I., p. 171. 
 
 8 American Journal of Otology, vol. i., p. 228. Annales des Malades de 1'Oreille. 
 Paris, December 31, 1878. 
 
 * Journal of Anatomy and Physiology, xii., part 2, p. 200.
 
 488 ACQUIRED EXOSTOSES. 
 
 tosis, which grew from the posterior wall formed by the tympanic plate. There 
 was also a linear-shaped exostosis deeper in the canal. Professor Turner ob- 
 served narrowing of the external auditory canal, in several specimens of Peruvian 
 skulls not artificially deformed. 
 
 Dr. C. J. Blake, has examined the skulls of the mound-builders of Tennessee, 
 from the collection of the Peabody Museum in Cambridge, Mass. Dr. Blake 
 confirms Professor Turner's opinion that the modification in the shape of the 
 external auditory canal so often found in aborigines of America is not due to the 
 artificial elongation of the skull induced in certain tribes by pressure in infancy. 
 Dr. Blake's attention was drawn to the subject by the late Professor Jeffries 
 Wyman, who found exostoses of the auditory canal in 6 out of 334 Peruvian 
 crania. Dr. Blake examined 195 skulls. In 36. exostoses were found in one or 
 both canals, as well as nan-owing of the canals. Fifty Californian skulls, taken 
 from graves in the island near Santa Barbara, were measured for the sake of 
 comparison with those of the mound-builders. The average vertical diameter 
 was found to be more than a millimetre greater in the former, and the antero- 
 posterior diameter more than 3 mm. greater. Of 108 California crania, 5 had 
 exostoses in one or both canals, and in 3 of the 5 a corresponding narrowing 
 of the canal. Dr. Blake does not think there can be any positive opinion, as yet, 
 as to the cause of these exostoses in the aborigines of various countries. There 
 were no evidences of syphilis, in the bones of the Californians examined. He ' 
 has found that the majority of the cases of exostosis, he has seen in aural prac- 
 tice " occurred in certain families, in the male members of successive genera- 
 tions, the most marked instance being in the three successive generations of one 
 family in which there is no tendency either to gouty or rheumatic disease." Dr. 
 Blake also examined 37 skulls from mounds in Arkansas. Exostoses of the 
 auditory canal were found in 6 of the 37 skulls. Careful search was made for 
 evidence of syphilitic disease, by examination of the long bones, but none was 
 found. The 6, containing exostoses came from one mound. 
 
 INFLAMMATORY OR ACQUIRED EXOSTOSES. 
 
 The cases of acquired exostoses are a much more serious 
 matter than the congenital affections of the same kind. They 
 arise in the course of a chronic suppuration of the middle ear ; 
 they usually grow with more or less rapidity, and they may 
 finally block up the tympanic cavity and cause retention of pus 
 with all its fatal results. Such a case will be found at the close 
 of this section. They are the results of a local irritation, which 
 has caused in the first place a periostitis, and secondarily an 
 enlargement of bone. This local irritation may be either the 
 constant presence of pus on the walls of the canal, or the exten- 
 sion of the inflammation of the lining membrane of the cavity 
 of the tympanum, a membrane which is essentially a periosteum, 
 to the true periosteum of the osseous canal. 
 
 Toynbee, was inclined to ascribe great importance to the 
 existence of a rheumatic, gouty, or syphilitic diathesis in these 
 cases of acquired and growing exostoses. In his work upon the
 
 ACQUIRED EXOSTOSES. 489 
 
 ear, he details nine cases of bony growths in the external audi- 
 tory canal, which he evidently regards as an independent dis- 
 ease, and he remarks that "they seem to be the result of a rheu- 
 matic or gouty diathesis." In 1866, I published four cases l in 
 which there was no such diathesis, but in which the growths 
 were general enlargements of the periosteum, and of the bone 
 structure beneath. They were morbid growths consequent upon 
 local irritation. A more complete experience has substantiated 
 this view. Besides, a careful examination of the history of Mr. 
 Toynbee's cases causes the doubt to be raised whether a diathesis 
 had much to do with the formation of several of them ; while 
 some of the others probably belonged to the congenital form. 
 In Case III., reported by Toynbee, a discharge had existed from 
 the ear for eleven years. There was a perforation of the mem- 
 brana tympani. In Case VI. there was also a discharge. In 
 Case VII. the exostosis was found to be the base of a polypus. 
 In Case IX. there had been a discharge from the ear when the 
 patient was a boy. Nine cases are reported in all ; but the his- 
 tories are not very fully given. 
 
 Virchow " says that local influences are in very many cases 
 the exciting cause. "Some have, indeed, educed the frequent 
 cases where certain constitutional diseases, especially rheuma- 
 tism, arthritis, syphilis, scorbutus, rachitis, have produced bony 
 tumors, as being something opposed to these local causes. Un- 
 doubtedly the field of these conditions was formerly too ampli- 
 fied, and we may say that scorbutus is now almost entirely 
 excluded from the list of causes, and that the gouty enlarge- 
 ments of bone are no growths, but only deposits ; but we cannot 
 deny the influence of the other so-called dyscrasia, especially of 
 the rheumatic, syphilitic, and rachitic diatheses. In spite of 
 this, their influence should not be over-estimated." 
 
 Polypi, are frequently found upon the exostoses that arise in 
 the course of a suppuration in the ear. This is, of course, proof 
 that the tissue beneath is one that has been recently the seat of 
 inflammation. 
 
 Dr. Agnew 3 has seen quite a number of cases of exostoses 
 arising in cases in which the membrana tympani was sound, 
 and which he believes were due to local irritation after birth, 
 such as the use of instruments for the purpose of cleansing or 
 scratching the canal, the formation of furuncles in the same 
 part, and so forth. 
 
 The cases of acquired exostosis, that I have seen, with very 
 
 1 New York Medical Journal, vol. ii. , p. 424. 
 
 " Die Krankhaften Geschwiilste II. Bd. Halfte I., p. 73 et seq. passim. 
 
 3 Verbal communication, New York Oplithalmological Society.
 
 490 EXOSTOSES -TREATMENT. 
 
 few exceptions, arose in connection with suppuration in the 
 middle ear. In one exceptional case, the exostosis was so large 
 that the condition of the inembrana tympani could not be posi- 
 tively known, and, unfortunately, I saw the case but once. 
 
 From all the evidence I can gather, I am inclined to think 
 that all exostoses of the canal may be finally traced to local in- 
 flammation. Blake's cases, in the aborigines, as well as his 
 cases occurring in private practice, and my own, pretty thor- 
 oughly dispose of syphilis as a prominent cause. I do not think 
 the evidence for a rheumatic diathesis as a factor, has as yet 
 been made tenable. All the cases of which we have full his- 
 tories, go to sustain the view, first clearly and fully put forward 
 by myself, of local irritation as the determining cause. To this 
 theory I still adhere. Troltsch, in the first edition of his book, 
 also remarks that he usually considers the growth of exostoses, 
 an incident of catarrh of the tympanum. 
 
 Treatment. The treatment of exostoses, unless they are so 
 large as to prevent access to the tympanum, should begin by a 
 treatment of the suppuration that has caused them to appear. 
 If we cannot heal the perforated and ulcerating membrana tym- 
 pani, as may be the case, we should keep the middle ear scrupu- 
 lously free from pus, so that no blocking-up may occur. The 
 patient should be taught to cleanse the canal and tympanum. 
 Small growths may be painted with the tincture of iodine. If 
 the exostoses are large enough to close, or nearly close, the canal, 
 Mathewson's operation for removal of these growths by a -drill 
 in a dental engine should be performed. Dr. Mathewson first 
 performed this operation upon Case VI., here reported, in 1876. V 
 
 The machine used was Elliott's suspension dental engine. 
 The patient was under ether. The integument covering the 
 growth was first removed by a dental instrument known as a 
 sealer. The bony growth was then perforated at several points; 
 near its centre with small drills about one and a half millimetre 
 in diameter. The larger drills, 2 to 3 mm. in diameter, were 
 next used to enlarge the openings. The probe, on account of the 
 great bleeding, was the chief guide in the operation. "The ex- 
 cavation was continued cautiously," says Mathewson, " till the 
 largest drill about three millimetres in diameter passed freely 
 through with room to spare." The operation consumed about 
 half an hour. The purulent discharge, that ensued was treated 
 by the warm douche and a weak solution of nitrate of silver 
 subsequently. The swollen and granulating soft tissue finally 
 
 1 Report of the First International Otological Society, p. 86. New York : D. Apple- 
 ton & Co., 1877.
 
 EXOSTOSES CASES. 491 
 
 shrivelled and disappeared, and the discharge ceased, with a good 
 opening, through which the posterior and lower part of the drum- 
 head could be seen. The hearing arose nearly to the normal 
 standard. After Mathewson's brilliant result, his operation was 
 generally adopted. Field, of London, seems to have had the 
 most experience in the use of the dental engine for the removal 
 of exostoses. 1 His results, justify all that Mathewson claimed 
 for the operation. 
 
 Exostoses seem to be a much more frequent result of aural 
 disease in England than in this country ; at any rate, there are 
 many more cases reported by English experts than by those of 
 the United States. 
 
 If the membrana tympani be intact, as it is in many cases of 
 bony growths, even in those where there was at one time sup- 
 puration in the tympanum, the cases are much easier to manage. 
 There being no pus to rest upon them, they do not usually grow, 
 and if the ear be kept carefully clean and free from wax, they 
 need not be interfered with. 
 
 CASES. 
 
 The following cases will give a fair idea of the course of 
 bony growths that are consequences of chronic suppuration and 
 chronic inflammation : 
 
 CASE. I. Mr. C , aged thirty-nine, was seen in April, 1864, in consulta- 
 tion with Dr. C. B. Agnew, under whose care he had been for some time. He 
 had lost, before coming under observation, the hearing of his right ear by in- 
 flammation and caries of the middle and internal ear. Previous to the above 
 date, Dr. Agnew bad removed a sequestrum, consisting of the cochlea and semi- 
 circular canals, from the depths of the external auditory canal of the ear, and 
 
 thus terminated the inflammatory action. In early life Mr. C had also 
 
 Buffered from "inflammation" of the left ear, producing the bony growths in 
 the external auditory canal, which render his case the subject of present de- 
 scription. He now hears with this ear a watch tick at a distance of five inches. 
 In the auditory canal, near the meatus, are two bony enlargements, which rise 
 from the anterior and posterior walls, and project in a conical form, so as to 
 occupy at least three-fifths of its calibre. These tumors have all the physical 
 appearance of exostoses, and seem to have originated in periosteal inflammation. 
 They have been steadily treated for many weeks by the local application of the 
 saturated tincture of iodine, and certainly not diminished in size. Pressure 
 upon them excites pain and induces an increase of swelling in the skin which 
 covers them, and thus temporarily adds to the deafness. The entire absence of 
 hearing in the fellow-ear, and the failure of simple means to render the exos- 
 toses smaller, have suggested the propriety of some surgical operation for their 
 removal. Such a proceeding has been thus far postponed by the occurrence of 
 an acute attack of inflammation in the parts, extending to the tympanum, with 
 
 1 Diseases of the Ear, p. 57.
 
 492 EXOSTOSES CASES. 
 
 symptoms of more than usual cerebral irritation. From this disagreeable com- 
 plication he has entirely recovered under Dr. Agnew's care. 
 
 His general health being impaired, he went abroad, and while in London 
 consulted Mr. Toynbee, who used bougies, hoping to dilate the canal ; but, ac- 
 cording to Mr. C 's statements, they caused much pain and accomplished 
 
 nothing. Through Dr. Agnew's courtesy, I again saw the patient in the spring of 
 1865, and found that the growths had so much increased that only a small probe 
 could be passed between them, and the hearing more impaired. The patient 
 could still, however, hear the watch tick, but only when laid on the auricle. 
 
 The patient whose case is here given, died about two years 
 after, of inflammation of the membranes of the brain, induced 
 by suppuration in the cavity of the tympanum, the pus not be- 
 ing able to find an outlet on account of the presence of exos- 
 toses. Dr. Agnew exhibited the brain and temporal bones before 
 the New York Pathological Society. The history of the other 
 ear of this unfortunate patient will be found in the section on 
 caries and necrosis. 
 
 CASE n. A gentleman, aged forty, whom I saw but once, in June, 1864. 
 He states that he had a " running " from his right ear for a number of years. 
 For some two or three years past he had observed that the ear was stopped up. 
 He was accustomed to remove the accumulating discharge by thrusting in a 
 match armed with cotton. Thfere is seen a bony growth arising from the pos- 
 terior wall of the meatus, and involving the whole calibre of the canal, except a 
 space large enough to admit an ordinary-sized silver probe. Through this open- 
 ing a slight amount of purulent discharge constantly makes its way. There was 
 some hypersemia of the pharynx, and there was a small ulcer on one of the ton- 
 sils. The patient was in excellent general health, was rather a free liver, and 
 said he had constitutional syphilis : but no good evidence of its existence now 
 existed. The patient had never had rheumatism or gout. 
 
 CASE III. Mr. S , aged twenty-five, Connecticut. February 6, 1865 (a 
 
 patient sent to me by Dr. Alfred North, of Waterbury, Ct.). When the patient 
 was three or four years of age he had scarlet fever, at which time his ears began 
 to discharge, and they have continued to do so at intervals ever since, with at- 
 tacks of pain in the ears, which sometimes lasted for weeks, and prevented him 
 from any occupation for the time. Eight years ago his ears were examined and 
 polypi discovered, one of which was removed by caustics. The attacks of pain 
 have continued to occur, the discharge continues, and his healing is become 
 more and more impaired. He is just now suffering from acute pain, referred to 
 the left ear. He hears the watch about one inch from each ear. 
 
 In the right meatus there is seen a bony growth reaching nearly out of the 
 orifice of the external meatus, and arising from the posterior wall. The space 
 between the growth and the anterior and upper wall is about large enough to ad- 
 mit of the introduction of a camel's-hair brush. In the left meatns there is seen 
 a gelatinous granulation, also reaching nearly out to the orifice of the meatus. 
 
 On blowing air into the cavity of the tympanum, by means of the Eustachian 
 catheter, air and fluid are heard making their exit into the external meatus ; but 
 the blocking up of this passage prevents their emergence. On the right side
 
 EXOSTOSES CASES. 493 
 
 pus may be seen in the orifice between the bony growth and the wall of the 
 meatus. 
 
 The confinement of the fluid in the middle ear accounts for the pain in the 
 left side, and the indication of treatment was to secure its free exit. This was 
 done by removing the gelatinous growth by torsion, the patient being ether- 
 ized, and rendering the Eustachian tubes permeable by the use of the well- 
 known means the catheter and Politzer's method. The granulation was found 
 to have its origin from a general bony expansion of the meatus. This growth 
 had no one point of attachment, but involved all the sides of the meatus, 
 somewhat more expanded externally, giving the bony canal rather a funnel- 
 shaped appearance. The bone was roughened. The pain in the ear disappeared 
 as soon as these means had been taken for securing an outlet to the pus, con- 
 stantly secreted from the cavity of the tympanum, and passing through the per- 
 forated membrana tympani, and the hearing was so much improved that the watch 
 was heard about four inches from the left auricle. He remained under treat- 
 ment for a few days, and then returned to Waterbury, and has been under the 
 careful and able observation of Dr. North, who has applied remedies of various 
 kinds to the left meatus, the patient keeping the Eustachian tubes permeable 
 by means of gargles and Politzer's apparatus. The last time I saw the patient 
 was in October of this year (1865), when the following note was made : "He had 
 had no attack of pain in the ear since the first date. There is still a consider- 
 able discharge of pus from each ear. He hears ordinary conversation well, and 
 the watch ten inches from his left ear, and two inches on the right ; a gain of 
 one inch and nine inches respectively." The bony growth on the right side has 
 not increased any, and that on the left is now smooth, and has a somewhat 
 glistening appearance. June, 1868. Patient still remains free from any disturb- 
 ing symptoms. 
 
 Dr. North writes me, March 25, 1873, that "the patient's general health is 
 good. He hears ordinary conversation readily, and Dr. North's watch eight and 
 one-half inches from the left auricle and one and one-half from the right. The 
 bony growth has a smooth, shiny appearance, and only admits the passage of an 
 ordinary-sized probe. The discharge from the ear is slight and of a watery 
 nature. He has no pain in either ear. Any increase of the impairment of 
 hearing is always relieved by an application of tincture of iodine to the bony 
 growths." 
 
 CASE IV. Woman, aged twenty-seven, at the New York Eye and Ear Infirm- 
 ary. No reliable history could be obtained from the patient as to her ears, 
 except that she had been occasionally hard of hearing for some years. She was 
 quite sure that she never had had a discharge from the ears ; was in good gen- 
 eral health, and had always been so. She could hear the watch two feet from 
 the left auricle, and twelve inches from the right. The left membrana tympani 
 showed evidences of previous inflammatory action, there being thickening of its 
 mucous and fibrous layers. There is a bony enlargement of the posterior wall 
 of the right meatus, so large as to prevent any view of the membrana tympani. 
 The patient was seen but a few times, not contimiing under treatment. 
 
 CASE V. Mr. W , aged twenty -three, a patient sent to me by Professor 
 
 Fordyce Barker, of this city. Had scarlet fever when young, and since that 
 time has suffered from purulent discharge from the ear, and has been quite deaf.
 
 494 EXOSTOSES CASES. 
 
 General health is excellent. No gouty, rheumatic, or other diathesis. Hears 
 ordinary conversation very near at hand with very great difficulty. The watch 
 is heard when pressed upon the right meatus ; not at all on left. A gelatinous 
 polypus was found attached to the hypertrophic posterior wall of the auditory 
 canal. It was removed by torsion, and nitric acid applied to its roots. On left 
 side there is a pedunculated bony growth, arising from the posterior wall, nearly 
 occluding calibre of canal. Naso-pharyngeal catarrh. June, 1868. Patient has 
 been under observation since first date. Now hears conversation much better ; 
 watch at a distance varying from one to two inches on right side. Secretion of 
 pus, which when patient was first seen was profuse, is now slight. Growths 
 remain the same. 
 
 CASE VI. Miss , aged twenty-five. March, 1873. I was asked by Dr. 
 
 E. G. Loring to assist him in the examination, under ether, of a case of tumor 
 blocking up the external auditory canal, with a view to its removal if practicable. 
 The tumor was so sensitive to the touch of a probe that no thorough examina- 
 tion could be made. The patient was about twenty-five years of age, and had 
 suffered a great deal from what she called rheumatism of the back, but which 
 seemed to have been neuralgia. She was rather small and delicate, but in fair 
 general health. She was placed under the influence of ether, and a thorough 
 examination was made by Dr. Loring, Dr. Pardee, and myself. The tumor 
 arose from the posterior portion of the osseous canal of the right ear, and nearly 
 occluded the passage. There was a minute opening between it and the anterior 
 wall, through which a No. 2 Bowman's probe could be passed into the cavity of 
 khe tympanum. The tumor was of bone, and covered by a movable integument, 
 which was red and very sensitive. On passing the probe into the minute open- 
 ing that has been mentioned, it could be passed under the growth, and when 
 pressed upon the growth was seen to move slightly. 
 
 The history of the case was, that there were frequent attack* of pain in the 
 ear, without discharge, until the patient was eleven years old, since which time 
 there has been no true "earache," and no discharge, although the parts are 
 tender, and there is a great feeling of fulness in the ear. The watch is not 
 heard at all on the affected side. The tuning-fork is heard better than in the 
 other ear, which is normal. The examination, during the anaesthetic state, of 
 the tumor by the probe, caused it to be very sensitive when the patient recov- 
 ered from the ether. The aural douche was used to quiet the pain. The pa- 
 tient was advised to continue to use the douche ; but inasmuch as there was no 
 pus in the tympanic cavity, and the removal of the growth seemed to involve 
 considerable danger from periostitis, any further treatment was delayed until 
 urgent symptoms should arise. May 8, 1873. There is considerable pain in the 
 depth of the ear, and Dr. Loring and I advise that some operative means be 
 taken to remove the growth. 
 
 The history of this case indicates that there was originally 
 a suppurative action, for we can hardly believe that very severe 
 pain occurred so frequently as was stated, until the patient was 
 eleven years old, with no suppuration. The exostosis, which 
 probably then began, has been growing ever since, until it has
 
 EXOSTOSES CASES. 495 
 
 reached the present limits, where it seriously threatens the fu- 
 ture of the patient. 
 
 The danger which seemed to exist, when I wrote the fore- 
 going paragraph, was happily averted by Dr. Mathewson's first 
 operation with the dental engine. The case came into his hands 
 in 1876, and he devised and executed a method of removing 
 these bony growths, which as yet remains the best that has ever 
 been suggested or performed. 
 
 CASE VII. October 23, 1883. Miss , aged twenty-one. When seven 
 
 years of age she had scarlet fever ; both ears discharged excessively during the 
 progress of the disease. Had loss of motion of the right side for thirteen 
 months after. The left ear still discharges. There is no aerial conduction on 
 the right side and the bone conduction is better than the aerial on the left side. 
 Hears the voice about one foot from the left side. There is a bony growth in 
 the left auditory canal, arising from the posterior wall and about half closing the 
 opening into the tympanum. There is no drum-head in either ear. 
 
 CASE VIII. March 6, 1884. Mr. A. J , aged thirty-eight (sent to me by 
 
 Dr. Jones, of Chicago). When the patient was eighteen years old, the left ear 
 was injured by the explosion of a cannon near his ear. He was thrown into the 
 water, and did not think of his ear for a day or two. He then observed that he 
 could not hear well. His ears have never been quite right since, especially 
 at times. His hearing distance is: E., ^; L., g. The tuning-fork is heard 
 much better in each ear by bone conduction. There are small bony growths aris- 
 ing from the anterior wall of both auditory canals. The membranse tympani are 
 opaque on each side. The patient was not sure as to whether he had ever had 
 a suppuration in his ears. He had chronic naso-pharyngeal catarrh as well as 
 a decided inflammation of the middle ears. There was no evidence of the ex- 
 istence of either syphilis, gout, or rheumatism. 
 
 Dr. Cocks reports ' an interesting case of a pedunculated bony 
 growth in the auditory canal, which formed the base of a poly- 
 pus. It was so like a polypus in appearance, that a snare was 
 put about it, and it was fortunately broken off. The growth 
 sprang from the posterior wall of the canal, at the junction of 
 the osseous and cartilaginous portions. 
 
 'Archives of Otology, vol. xii., p. 59.
 
 CHAPTER XVIII. 
 
 THE CONSEQUENCES OF CHEONIC SUPPUKATION OF THE 
 MIDDLE EAR (Continued). 
 
 DISEASES OP THE MASTOID PROCESS. 
 
 Periostitis. Caries and Suppuration. Trephining or Opening the Mastoid. His- 
 torical Account of the Operation. Cases. 
 
 As we have seen, in considering the diseases of the middle ear, 
 and in discussing its anatomy, the mastoid process is necessarily 
 involved in any severe inflammation of the tympanum. This 
 may also be the case in an acute or chronic inflammation of 
 the auditory canal, for the mastoid process opens into this part 
 also. Yet there is a form of inflammation of the mastoid pro- 
 cess, which assumes such importance, and overshadows the in- 
 flammatory action in other parts, to such a degree, that it de- 
 mands an especial study, and especial treatment. The usual 
 treatment of an acute inflammation of the external and middle 
 ear soon causes the symptoms of the inflammation of the lining 
 membrane of the mastoid cavities to subside ; but when the 
 mastoid process is involved in the course of a chronic suppu- 
 rative process, the ordinary treatment will not avail. More 
 prompt and decisive means are usually required. Under such 
 circumstances, diseases of the mastoid often assume such pro- 
 portions of severity and danger, that we are justified in speak- 
 ing of them as independent affections requiring especial notice 
 and treatment. Severe disease of the mastoid is a complication 
 or consequence of chronic suppuration in the middle ear, only 
 second in gravity, to an extension of the inflammation to that 
 portion of the dura mater covering and running into the tym- 
 panic cavity. 
 
 The diseases of the mastoid process that may arise as a con- 
 sequence of a chronic inflammation of the middle ear may be 
 divided into the following varieties : 
 
 1. Inflammation of the periosteum. 
 
 2. Caries, with formation of an abscess in some part of the 
 cavity.
 
 MASTOID PERIOSTITIS. 497 
 
 It is true, as has been already indicated, that the first form 
 often arises in the course of an acute catarrh, and that it perhaps 
 always exists to a more or less extent in this disease ; but it is 
 no less true that a chronic suppurative process that has been go- 
 ing on quietly for years perhaps, will suddenly become an acute 
 inflammation of the mucous membrane and periosteum of the 
 part, and require especial and prompt treatment. The mucous 
 membrane lining the mastoid cells is so closely connected to the 
 bone, that, like the mucous membrane of the cavity of the tym- 
 panum, it is essentially a periosteum. 
 
 Caries and necrosis, a,re of course the same affections that 
 occur so frequently in other parts of the middle ear, and from 
 the same cause imperfect removal of pus. 
 
 Sclerosis or hyperostosis should also be mentioned as one of 
 the results of chronic inflammation of this part. During the 
 operation for perforation of the mastoid it is often found, as 
 shown by Agnew's case, 1 and subsequently by Buck's 1 and 
 Schwartze's 3 statistics, in a state of sclerosis. Anatomical inves- 
 tigations indicate, that this is oftener a congenital rather than a 
 pathological condition. If the bone is not pneumatic, it is cer- 
 tainly in a worse condition for the reception of a chronic inflam- 
 matory process, than if it were full of air-cells. 
 
 Disease of the mastoid is usually seen in plain connection 
 with an affection of the tympanum. In the nature of things 
 this must necessarily be so, for the mastoid process and the 
 tympanum are merely parts of one anatomical space, and no 
 complete separation of their inflammations is possible. But this 
 is not always so. A few weeks ago, I evacuated a drachm or 
 more of pus from the mastoid cells of a young child, through the 
 auditory canal, while the membrana tympani remained intact and 
 apparently uninjured. The patient made a good recovery, and 
 although I could not determine on account of the patient's age 
 she was about three years old whether or not there was a 
 catarrh of the tympanum, there was certainly no serious inflam- 
 mation except in the mastoid. It was markedly red, swelled, 
 and tender. From the history, given by the child's mother, I 
 do not doubt, that the case was one of suppuration of the mid- 
 dle ear, especially affecting the mastoid portion of this part. 
 Other cases of so-called primary periostitis have been published, 4 
 
 1 Transactions of the American Otological Society, July 20, 1870. 
 
 8 Treatise on the Ear. 
 
 3 Archiv fur Ohrenheilkunde, Bd. IV.-XX., passim. 
 
 4 Knapp: Report of International Otological Congress, Xew York, 1876, p. 80. 
 Gruening: Medical Record, June 4, 1881. Cornelius Williams: Archives of Otology, 
 vol. xiii., p. 22. W. Cheatham: Louisville Medical Journal, October 26, 1878. 
 32
 
 498 MASTOID PERIOSTITIS. 
 
 but a careful reading of the histories shows that while the per- 
 iosteum of the mastoid, was undoubtedly more severely affected 
 than the lining membrane of the other parts of the middle ear, 
 it is by no means certain that the mastoid inflammation was not 
 actually secondary to that of the tympanum, although the latter 
 may have run its course, by the time the former was under full 
 headway. Buck J also doubts if we may correctly speak of a 
 primary periostitis of the mastoid process. He says that he has 
 never seen a case, to which he would feel justified in giving the 
 title of primary idiopathic mastoid periostitis. Buck explains 
 the cause of the apparently primary cases of mastoid disease, 
 occurring in young children, as I do, in supposing that the pus 
 from the tympanum found an easier escape through the mastoid 
 than through the membrana tympani. Mastoid periostitis, as 
 well as caries and abscess, are usually results of disease of the 
 Eustachian tube and the tympanum. 
 
 Symptoms. The symptoms of mastoid periostitis are usually 
 so distinct as to arrest the attention of the medical adviser as 
 soon as they occur. 
 
 During the course of an acute or chronic suppurative process 
 in the middle ear, the patient begins to complain of great pain 
 behind the ear, the mastoid process becomes red, tender, and 
 swelled. This is the usual course, although at times the pain is 
 not referred especially to the mastoid, even when it is evidently 
 involved, as shown by the redness or tenderness of the part. 
 The pain is usually of the severest kind, preventing the patient 
 from sleep and from his usual occupations, although he may not 
 be confined to the house. 
 
 One of my cases, reported on a subsequent page, as well as 
 others, shows that an inflammatory process may extend to the 
 periosteum of the mastoid, without pain or tenderness of this 
 part, but there are then symptoms in other parts of the skull, 
 especially in the occiput, which considered in connection with 
 the inflammation of the middle ear, will keep the surgeon on his 
 guard. Besides, these cases are entirely exceptional. 
 
 The early diagnosis of this affection is by no means an un- 
 important matter. A delay in the recognition of the true state 
 of things, allows of the extension of the disease to the brain 
 through some of the numerous foramina which transmit the 
 minute branches of the middle meningeal artery. Pus may 
 also be carried into the circulation through the mastoid vein 
 which passes to the lateral sinus. 
 
 1 Diseases of the Ear, p. 355.
 
 MASTOID PERIOSTITIS. 499 
 
 Dr. One Green ' has shown, by the report of three cases, that 
 phlebitis of the emissory veins of the mastoid may occur in the 
 course of inflammation of the middle ear and lateral sinus 
 oftener than has yet been observed. Dr. Green quotes cases 
 from Kolb, Taylor, Moos, and Burchardt-Merian, which indi- 
 cate this. 
 
 In Green's cases, the phlebitis was due to an extension of an 
 inflammation of the lateral sinuses. In all of the cases the 
 "prominent and characteristic -symptom was the peculiar indu- 
 ration of the tissues of the neck, such as characterizes a cellulitis 
 dependent upon phlebitis, and one of the best examples of which 
 is seen in phlegmasia alba dolens." Death occurred in all of Dr. 
 Green's cases. In one of them, so far as could be determined 
 by the history, there was no external periostitis, but no autopsy 
 could be obtained in any of the cases. It is probable that phle- 
 bitis of the emissory veins is more frequently a consequence of 
 disease of the mastoid process than has hitherto been supposed. 
 
 Professor Alfred C. Post, of this city, who was one of the 
 first surgeons in this country to give diseases of the ear the 
 same attention that was paid to other parts of the body, has 
 seen several cases where disease of the brain and death have re- 
 sulted from the non-recognition of mastoid disease, as I learned 
 from his lectures during the sessions of 1856-59. 
 
 Many neglected cases run their course, however, with great 
 suffering to the patient, and with much loss of function, with- 
 out destroying life. This is proven by the frequency with which 
 mastoid cicatrices are seen in our aural clinics. The history of 
 such patients usually shows that they have had a narrow es- 
 cape, but that nature has at last given relief by an external 
 opening through which the pus and dead bone made their way. 
 
 Treatment. The treatment of mastoid congestion and peri- 
 ostitis* is very simple. If the symptoms, although positive, be 
 of a mild type, from two to six leeches should be placed upon 
 the mastoid. After the bleeding has subsided, a poultice should 
 be applied. The patient should be kept in-doors and in bed. If 
 the pain and tenderness are not relieved in twenty-four hours, 
 an incision should be made through the integument and perios- 
 teum down to the bone. The incision should be from below 
 upward, lest the knife should slip and pass into the tissues of 
 the neck. The opening should not be a puncture, but a cut of 
 from three-quarters to an inch and a half long, or even longer, 
 according to the age of the subject. The incision should be 
 
 American Journal of Otology, p. 187. 1879.
 
 500 WILDE'S INCISION. 
 
 parallel to the attachment of the auricle. Even if the posterior 
 auricular artery be wounded, the bleeding can be readily ar- 
 rested by pressure or torsion. I have never found any alarming 
 hemorrhage. A free escape of blood is desirable. The surgeon 
 who has not made this incision in cases of mastoid periostitis 
 will, perhaps, be surprised at the depth of the tissues when they 
 have become infiltrated from an inflammatory action of some 
 days' standing. I have sometimes been amazed at the depth to 
 i which the scalpel entered, especially when pus has formed. Pus 
 will not be found in the majority of the cases, but the indica- 
 tions for an early, free, and deep incision are imperative when 
 we find redness, tenderness, and swelling of the mastoid process 
 in connection with an inflammatory process in the ear. 
 
 It is only when the symptoms are not severe, although posi- 
 tively existing, that a little delay, that is of a few hours, may 
 be admissible for the use of leeches, and the careful continuous 
 application of poultices. If the symptoms are decidedly ameli- 
 orated in a few hours, still further delay is justifiable. This, it 
 should be said, however, is only true of cases of a mild type. 
 
 In view of the dangerous character of mastoid periostitis, it 
 will be better to err on the side of a free and thorough incision, 
 the so-called Wilde's incision, from Sir William Wilde, who first 
 advised it, than to be too late in other cases. The cases that 
 have been reported as recovering without the knife and from 
 internal medication, by the use of such drugs as the sulphide 
 of calcium, are, in my opinion, cases such as have recovered 
 in my hands, as well as in those of my colleagues at the Man- 
 hattan Eye and Ear Hospital, without any drugs whatever. To 
 keep a patient in bed, and in a quiet room, with proper ventila- 
 tion and warmth, and besides to nourish him well, and to use 
 poultices and the warm douche, is to institute a very thorough 
 treatment for many diseases of the ear. Beyond these means, 
 in many cases nothing is required and without them nothing 
 whatever can be accomplished. 
 
 Although I have classified periostitis and caries of the mas- 
 toid, among the consequences of chronic suppuration, it goes 
 without saying, that it sometimes arises in the course of acute 
 and primary disease. It should also be understood that when it 
 occurs in chronic suppuration the acute symptoms also affect 
 the tympanum. 
 
 There is a phlegmonous inflammation of the skin and connec- 
 tive tissue over the mastoid, especially in young subjects, gener- 
 ally arising from disease of the auditory canal, which is never 
 serious, although painful. A little experience in the differential 
 diagnosis of diseases of the middle and external ear, will soon
 
 MASTOID PERIOSTITIS TREATMENT. 501 
 
 enable the practitioner to distinguish these harmless cases of 
 swelling and tenderness of the skin and connective tissue of 
 the mastoid from periostitis. Furuncles, and other inflamma- 
 tions in the auditory canal may cause an oadema and inflam- 
 mation of the parts about the mastoid, that will not require an 
 incision. A little care in observation will show, however, that 
 while these cases simulate a periostitis in the swelling and red- 
 ness, there is not the exquisite tenderness and dreadful suffer- 
 ing of a true periostitis. The mastoid gfcand may enlarge during 
 the course of an acute catarrh, or in strumous subjects who 
 have no aural disease, but such an enlargement will hardly be 
 mistaken for a periostitis. 
 
 If the incision.be made in the early stages of mastoid peri- 
 ostitis, pus will not be found, but the relief to the pain from the 
 hemorrhage, and from the letting up of the great tension of 
 the inflamed periosteum, will be no less marked than if sup- 
 puration has occurred. The incision will be as useful as the di- 
 vision of the periosteum in a case of paronychia a comparison 
 which Dr. Post has been in the habit of making in lecturing 
 upon these cases. 
 
 After the incision, a poultice should be applied, and the open- 
 ing maintained by the insertion of a tent a longer or shorter 
 time, according to the severity of the accompanying symptoms. 
 The importance of maintaining the opening for some time in 
 cases of chronic suppuration, was very well illustrated by the 
 following case : 
 
 In June, 1872, I saw in consultation with Dr. E. G. Loring, a 
 somewhat remarkable case of chronic suppuration in the middle 
 ear, with mastoid periostitis, in a gentleman of more than seventy 
 years of age, in which the opening was maintained by Dr. Lor- 
 ing, by means of trimming up the edges with scissors, the use 
 of caustic, a drainage-tube, and so forth, for some three months. 
 Dr. Loring found that the instant the opening was allowed to 
 close, pain in the back of the head, and in the depth of the ear, 
 began to recur, which threatened even the life of the old gentle- 
 man who was the subject of the disease. The patient finally 
 made a perfect recovery from the mastoid disease, and he is ac- 
 tvely engaged in the daily care of large business affairs. The 
 mastoid periostitis in his case was a consequence of an un- 
 usually severe acute suppuration of the middle ear, which 
 swept away the drum-head in a short time. 
 
 The treatment of the greater number of cases of periostitis is 
 not usually so tedious as the case just reported. With the inci- 
 sion and a few hours of poulticing, if the bone be not diseased, 
 the acute symptoms subside very rapidly, and the patient is soon
 
 502 MASTOID PERIOSTITIS CASES. 
 
 about his usual affairs. Although patients are generally to be 
 confined to their room, or house at least, during the time of the 
 acute symptoms, some of them go about enough to visit the sur- 
 geon at his consulting-room, especially in the spring weather, 
 and with no bad results. 
 
 CASES. 
 
 CASE I. Periostitis of the Mastoid from Acute Suppuration Recovery without 
 Incision. B. S , aged nineteen. July 25, 1884. One week ago, after bath- 
 ing he had pain in his right ear, which has continued at intervals. He now has 
 severe pain referred to the forehead and the neck. The patient is thin and 
 haggard. H. D., B., -$; L., to- The bone conduction is better than the aerial 
 in the right ear, and the reverse is true of the sound ear. Eight auditory canal 
 swelled. Eight membrana tympani swelled and red. There is tenderness over 
 the whole surface of the mast-old and down into the neck. On inflation the 
 hearing distance of the ear increased to 3-. The patient was seen by nay asso- 
 ciate, Dr. J. B. Emerson, in consultation with Dr. Fisher, of Hoboken. It was 
 agreed that the patient be put to bed. Two leeches were applied to the niastoid- 
 The hot douche was ordered to be used every two hours, and poultices were applied 
 in front and behind the auricle. The patient began to be more comfortable at 
 once. The drum-head perforated spontaneously on the third day. On the 
 fourth day he was up, with no pain except at long intervals. In eleven days the 
 drum-head had healed, and in twenty days the patient was practically well 
 (H. D., $8)1 and he left town for the country. 
 
 CASE II. Periostitis of Mastoid occurring during an Exacerbation in a Case of 
 
 Chronic Suppuration of both Middle Ears Recovery without Incision. J. L. S , 
 
 aged twenty-six. Farmer. February 21, 1883. Ten years ago he had the small- 
 pox, which left him somewhat hard of hearing. Five years ago he had a severe 
 cold, which very much increased the trouble. During January of this year, he 
 had the measles, with severe pain in both ears, and a purulent discharge from 
 the left. There was also a slight swelling of each mastoid, but it disappeared 
 in about four days. One week ago this swelling returned. Each mastoid process 
 is swelled and tender. Both drum-heads are perforated, but neither discharges 
 freely. No aerial conduction in either ear. The patient was seen at my office, 
 but he was advised to go to the hospital, which he did. He was then put to 
 bed, two leeches were applied to each mastoid, and the hot douche was used 
 often. The next day the tenderness of the mastoid was markedly diminished. 
 The poultices and hot douche were continued, and in eleven days he was free 
 from all pain and tenderness about the ears. 
 
 These cases illustrate very well, how with circumspection, we 
 may sometimes substitute leeches and poultices, for Wilde's in- 
 cision and poultices. 
 
 The two first of the following cases are from the notes of Dr. 
 David Webster, when he was House Surgeon in the Brooklyn 
 Eye and Ear Hospital, where they were under my care, and are
 
 MASTOID PERIOSTITIS CASES. 503 
 
 striking evidences of the prompt relief afforded by timely inter- 
 ference : 
 
 CASE III. Chronic Suppurative Otitis Media Cessation of Discharge Mastoid 
 Periostitis Incision Recovery. Eliza N -- , aged eighteen, had a discharge of 
 pus from the right ear for two months. The discharge suddenly ceased, and the 
 patient was attacked with severe pain and swelling over the mastoid, which grew 
 worse and worse for several days, and caused her to visit the hospital. Dr. 
 Roosa diagnosticated mastoid periostitis, and at once (May 10, 1869) made a free 
 incision down to the bone. No pus was found, but there was free hemorrhage, 
 which was encouraged by the use of warm water. The membrana tympani was 
 found to be removed by suppuration, but there was a slight discharge from the 
 canal. A tent was placed in the wound and a poultice applied over it. 
 
 May llth. Patient has had no pain acd has slept well. The tent was re- 
 applied and the poultice continued. 
 
 May 16th. The swelling of the mastoid is gone. There has been at no time 
 a discharge of pus from the incision, but there was a copious one from the 
 meatus. The patient was very pale when first seen, but the administration of 
 iron and the cessation of pain have restored the normal condition. She has not 
 since returned to the hospital. 
 
 Chronic Suppurative Otitis Media Mastoid Periostitis Incision 
 Recovery. William G - , aged thirty, came to the Manhattan Eye and Ear 
 Hospital, June 13, 1870. In December, 1869, he first experienced a sharp pain 
 in the left ear, which was most severe at night. This pain continued for two 
 months, at the end of which time a discharge occurred from the ear, which has 
 continued more or less until now. Two months later the mastoid process became 
 swelled and tender, and it was opened and poulticed by a physician. A great 
 quantity of pus, as the patient says, was discharged, and the pain, which had 
 been severe, was relieved. About four weeks after this the pain in the ear again 
 occurred, and the patient presented himself at the hospital. He presented the 
 appearance of a great sufferer ; he was pale and haggard ; his hands were tremu- 
 lous, and his countenance was anxious. He complained of great pain, referred 
 to the depth of the ear and to the head. The mastoid process was red and hot, 
 but not swelled or tender. The auditory canal was exceedingly sensitive. The 
 membrana tympani had been removed by suppuration, and there was a thin 
 coating of pus on the floor of the cavity of the tympanum. Air was forced into 
 the middle ear by Politzer's method, and leeches were applied to the tragus and 
 mastoid. On the next day warm water was freqitently instilled. 
 
 June 14th. The pain in the ear has decreased, but there is more redness of 
 the mastoid. Leeches, to be followed by a poultice were ordered. I did not 
 see the patient after his second visit, in consequence of my absence from town, 
 until the 20th, when I found fluctuation in front of the meatus, as well as great 
 tenderness over the mastoid, with an increase of the constitutional symptoms. 
 The patient was then admitted as an in-patient, and having given him a dose of 
 whiskey on account of his very shattered condition, I proceeded to make free 
 incisions down to the bone in front of and behind the ear. The bone was not 
 denuded or roughened. A tent was inserted and a poultice, the latter to be 
 renewed every three hours. The patient slept well that night for the first time 
 in some weeks, taking a dose of fifteen grains of hydrate of chloral.
 
 504 MASTOID PERIOSTITIS CASES. 
 
 June 28th. The patient has since been free from pain. The incisions have 
 nearly healed. There is a slight discharge of pus from the auditory canal. He 
 hears a watch when it is laid upon the ear. His general condition is now very 
 good, and he is discharged at his own request. 
 
 It is somewhat remarkable that this patient experienced so 
 many painful symptoms of mastoid disease for so long a time, 
 and yet escaped without disease of the bone. His affection was 
 never more than a disease of the lining membrane, with some 
 periostitis, while in a case hereafter to be detailed, of much less 
 severity, death of the bone occurred, and meningitis, with a 
 fatal result, supervened. I now think that a free incision should 
 have been made over the mastoid when I first saw the patient, 
 although there was then only some redness of the process and 
 no tenderness, the pain being referred to the depth of the ear. 
 In the light of my present experience, in all cases where there is 
 deep-seated pain referred to the tympanum, which is not at once, 
 that is to say, in a few hours, relieved by leeching, poultices, 
 and the warm douche, even if the mastoid cells do not seem to 
 be involved, I should consider myself as giving the patient the 
 benefit of a doubt by such a depletion as a free incision will afford. 
 
 CASE V. Chronic Suppurative Otitis Media of Years' Standing Exacerbation 
 
 Mastoid Abscess Incision Recovery. Gracie B , aged thirteen. April 25, 
 
 1872, 1 was summoned to Newburgh, by Dr. S. Ely, to see a case in consultation, 
 which Dr. Ely justly regarded as urgent. The patient was a healthy girl, who 
 had had a discharge from her left ear for years, and who for the past few weeks 
 suffered from an exacerbation of the disease, with acute symptoms. Dr. Ely 
 had observed that the mastoid process had become red, and swelled, and tender 
 within the last few days. We found the patient in bed, and evidently in great 
 suffering, with considerable constitutional disturbance, hot skin, and frequent 
 pulse. The neck was very much swollen, as was the whole integument of the 
 mastoid. There was a profuse discharge of pus from the ear. On consultation 
 it was agreed that an opening down to the periosteum should be made at once, 
 which I proceeded to do, the patient being under the influence of ether. The 
 opening was surprisingly deep, so that the knife passed through three-quarters 
 of an inch of tissue before the bone was reached. Pus escaped quite freely. 
 The wound and the ear were syringed with lukewarm water, and an examination 
 made for a fistula, but none was found. The bone was denuded of periosteum. 
 The membrana tympani had been long since removed by suppuration. The pa- 
 tient had a fair night, sleeping without an anodyne, and rapidly recovered after 
 the opening had been made. A poultice was applied for a short time, and then 
 the opening was allowed to heal. The ear was treated in the usual manner in 
 cases of chronic suppuration. 
 
 June 19th. The patient came to town to visit me. On examination, the 
 membrana tympani was found to be removed by ulceration, and a small amount 
 of pus lay in the tympanic cavity. The cicatrix on the mastoid is one inch long 
 and one-half inch from the auricle. The patient states that the wound healed 
 in about one week after it was made.
 
 CAUIES AND ABSCESS OF MASTOID. 505 
 
 CARIES AND ABSCESS OF THE MASTOID. 
 
 Caries and abscess of the mastoid result from an extension 
 of the inflammatory process that has been described under the 
 head of periostitis. The inflammatory process advances to sup- 
 puration. Sometimes, and perhaps in the greater number of 
 cases, the suppuration is not extensive and finds an outlet in a 
 narrow fistula. This form is, of course, more dangerous than 
 mere periostitis ; and yet cases of caries and necrosis are some- 
 times relieved at the cost of much unnecessary suffering to 
 the patient, by Nature's slow process of casting out diseased 
 bone. 
 
 An argument for temporizing with an undoubted case of 
 suppuration within the mastoid cells, has sometimes been de- 
 duced from this tedious manner in which Nature sometimes 
 relieves a case without inducing a fatal result. But every sur- 
 geon should certainly endeavor to spare his patient the discom- 
 fort and danger of protracted suppuration,*by carrying out the 
 rules of his art, which demand an early, free, and deep incision 
 whenever pus is to be found. 
 
 After the detailed account that has been given of the symp- 
 toms of mastoid periostitis, it is perhaps unnecessary to dwell 
 at length upon the clinical features of caries and abscess. It is, 
 moreover, oftentimes impossible to draw the line between a case 
 of periostitis and one of caries. 
 
 In many cases the symptoms of caries of the mastoid do not 
 differ essentially from those of mastoid periostitis. There is 
 the same redness, tenderness, and swelling of the process, at- 
 tended by deeply seated and intense pain. In others, how- 
 ever, the redness, tenderness, and swelling are entirely absent, 
 while the pain referred to the depth of the ear will be the only 
 marked symptom. This pain is not relieved by leeches, and 
 anodynes .will only veil the symptoms for a brief period. Usu- 
 ally, however, even in the insidious cases, tenderness will be 
 shown upon firm pressure on the part. Yet the surgeon may 
 cut down upon a bone to find it diseased, when he had not been 
 previously able to positively diagnosticate this state of things. 
 It may be said, however, in general terms, that any deep-seated 
 pain referred to the mastoid or its region, occurring in the 
 course of an inflammation of the ear, should be looked upon 
 with suspicion, even if there be no redness, tenderness, or swell- 
 ing of the process itself. 
 
 The auditory canal is often involved in cases of. caries of the 
 mastoid. A fistulous opening is sometimes found leading from
 
 TREPHINING THE MASTOID. 
 
 this part into the mastoid cells, in which case granulations are 
 usually found in the canal. The presence of granulations in the 
 canal should lead us to examine the part very carefully to see 
 if a fistula may not be found. In certain cases it may be easier 
 to remove dead bone through the external meatus. A clinical 
 fact of some importance in the diagnosis of mastoid disease is 
 the one that the chronic or acute suppurative process in the 
 middle ear is often very much less violent, or entirely checked, 
 at the time of the outbreak of the periostitis. This fact applies 
 to both forms of the disease. Yet it is a mistake to suppose 
 that mastoid periostitis, or caries, may not occur while a free 
 discharge of pus is taking place from the jar. 
 
 Treatment. The first step in the treatment of a case of sup- 
 posed caries of the mastoid, is to divide the tissues over the 
 process down to the bone, as was recommended for cases of 
 mastoid periostitis. If a fistula be found, it will be simply nec- 
 essary to enlarge this, so as to give a free exit to the pus. This 
 enlargement is besf made by a drill worked cautiously in the 
 track of the fistula. A good funnel-shaped external opening 
 should be left, so that the pus may freely escape when it reaches 
 the surface, and not burrow beneath the tissues, but chiselling 
 is unnecessary and meddlesome surgery. If there be no fistula, 
 an opening should be made into the cells, into the mastoid an- 
 trum preferably, by a drill or a small trephine. Here those 
 who prefer the chisel may use it, but I like the other instruments 
 much better, because the scar they leave is insignificant. Before 
 opening the bone, the periosteum should be stripped off, so as to 
 leave a good field for the operation. The instruments should 
 be usually entered on the boss of the mastoid, which is usually 
 just on a line with the meatus, and worked cautiously downward 
 and inward. It is impossible to say in advance to what distance 
 one must go, for this varies. 
 
 Schwartze says, " Never go deeper than 25 mm." Buck says, 
 " It is better, I believe, to place the extreme limit of depth at 
 20 mm., or about three-fourths of an inch." ' 
 
 By reference to the anatomy of the mastoid process it will 
 be seen that the thickness of the outer layer of bone varies 
 somewhat in different cases. The operation should go on very 
 slowly, frequent pauses being made to see how deep the instru- 
 ment has gone. It is impossible to say in a given case at 
 what depth we shall reach the cells, or free spaces, and thus 
 make an outlet for the pus. Dr. Agnew was obliged to go to the 
 depth of five-eighths of an inch in one of his cases, and then 
 
 1 Treatise on the Ear, p. 369.
 
 TREPHINING THE MASTOID. 
 
 507 
 
 FIG. 107. Schwartze's Chisels for 
 Opening the Mastoid. 
 
 found only sclerosed bone. Dr. D. C. Ambrose, of this city, re- 
 moved a piece one inch long from the mastoid process of a 
 young woman of twenty years of age. The cell-structure will 
 ordinarily be found at a depth of from one-sixth to one-fourth of 
 an inch. In infants the outer shell of bone is so thin that true 
 trephining will probably never be required ; but any firm in- 
 strument will make the required opening. In case of an emer- 
 gency, a surgeon has been known to use a common gimlet to 
 open the mastoid process. The lat- 
 eral sinus will always be avoided by 
 keeping the instrument as directed 
 above. In extremely rare cases the 
 position of the sinus is abnormal and it 
 will be impossible to avoid it. In case 
 it is opened or great bleeding occurs 
 from the mastoid veins, the opening 
 should be plugged with oakum and a 
 compress applied. Cases have done 
 well where the sinus has been opened, 
 and septicaemia has resulted. 1 
 
 The after-treatment is the same as 
 
 that of an operation for necrosis in other bones. The wound 
 should be dressed from the bottom with oakum or iodoform 
 gauze, and not allowed to heal too rapidly. The patient should 
 be kept free from all noise and excitement, and very carefully 
 watched until the fistula has healed, which may be for months. 
 I think a long tent made of old and thin cotton-cloth, much 
 better than the silver, or rubber drainage-tubes. The fistulous 
 opening should be dressed at least once a day. Of late, in- 
 stead of a cotton or linen tent, on the suggestion of one of my 
 staff, Dr. Frank N. Lewis, I have used a drainage-tube made 
 of a quill with more satisfaction than any other. Dr. Wilson's 
 trephine for use on the mastoid is ingenious and safe. By it the 
 distance to which we go may be easily and exactly regulated. 
 
 In some cases I have one such under observation, which 
 was operated upon by Dr. E. T. Ely the fistula cicatrizes 
 throughout its course, but never closes. I have also seen a 
 case, kindly sent me by Professor Sayre, where an opening 
 made by a bullet also left a permanent opening without suppu- 
 ration or other inflammation. The patient, who received the 
 wound in the late civil war, wore a cover to the opening. 
 
 I have seen 59 cases of affections of the mastoid process, 
 in 5,797 cases of aural disease occurring in private practice. 
 Occasionally I have omitted to record one which I have seen 
 
 1 In other cases opening the sinus has been followed by no evil consequences.
 
 508 CARIES AND ABSCESS OF MASTOID CASES. 
 
 in consultation, but there are not many such, so that the record 
 is tolerably exact. 
 
 Thirty -three cases occurred in my practice at the Manhattan 
 Eye and Ear Hospital in eighteen years. The total number of 
 cases that have been diagnosticated as affections of the mas- 
 toid, in all the aural departments of this institution for eigh- 
 teen years is 110. 
 
 Here there is a source of error, for some cases that entered 
 the hospital, and were diagnosticated as simple catarrh or sup- 
 puration finally became cases of mastoid disease. Besides this, 
 many made but a few visits and never returned, so that we 
 knew nothing in many instances of the ultimate results. At 
 the close of the paper will be found statistical tables in more or 
 less detail of the total number of cases. 
 
 CASES. ' 
 
 A summary of all the cases here reported shows as follows : 
 Summary of Cases in Private Practice. 
 
 Number of cases treated, males 33 
 
 Number of cases treated, females 26 
 
 59 
 
 Result. 
 
 Died 9 
 
 Cured 36 
 
 Believed 10 
 
 Unknown 4 
 
 59 
 
 The disease of the mastoid occurred in the following-named 
 affections : 
 
 Acute catarrhal inflammation of the middle ear 11 
 
 Acute suppuration of the middle ear 25 
 
 Chronic suppuration of the middle ear 18 
 
 Primary mastoid periostitis 1 
 
 Inflammation of the external auditory canal 2 
 
 Exostosis of the masfcoid 1 
 
 Neuralgia of the middle ear 1 
 
 59 
 
 Operations. 
 
 Wilde's incision m^de with evacuation of pus 9 
 
 Wilde's incision without pus 11 
 
 Mastoid opened by enlarging fistula 10 
 
 Opened without finding fistula 4 
 
 Opened through external auditoiy canal 2 
 
 42
 
 CARIES AND ABSCESS OF MASTOID CASES. 509 
 
 Summary of Cases Treated in the Author's Clinique at the Manhattan Eye and 
 
 Ear Hospital. 
 Number of cases treated . . 33 
 
 Result. 
 
 Cured 14 
 
 Relieved 5 
 
 Died 1 
 
 Unknown 14 
 
 33 
 
 Disease. 
 
 Acute catarrh of the middle ear 2 
 
 Sub-acute catarrh of the middle ear 1 
 
 Acute suppuration, middle ear 8 
 
 Acute suppuration of the middle ear, with rnastoid fistula 1 
 
 Sub-acute suppuration of the middle ear 1 
 
 Chronic suppuration, middle ear 11 
 
 Chronic suppuration of the middle ear, with mastoid fistula ... 4 
 
 Chronic suppuration, middle ear, with polypus 1 
 
 Chronic catarrh of the middle ear 1 
 
 Primary inflammation of the mastoid 2 
 
 Impacted cerumen with mastoid periostitis 1 
 
 33 
 
 Operations. 
 
 Wilde's incision 7 
 
 Wilde's incision, pus evacuated 5 
 
 Opening mastoid with a drill 14 
 
 Treated without operation 7 
 
 33 
 
 Cases in which death occurred. There were ten of such cases 
 in private practice and "one in the hospital cases. One of the 
 deaths was probably not induced by the aural disease ; but the 
 others are undoubtedly to be classified in this way : 
 
 CASE "LSuppurative Inflammation of the Middle Ear soon after Birth Mas- 
 toid Periostitis Incisions Death. Boy, aged three months, seen in consultation 
 with Dr. M. W. Williams. There was an abundant discharge of pus from the 
 tympanum. Considerable oedema of the mastoid, and evidences of meningitis. 
 Dr. Williams had incised the tissues down to the bone before I saw the patient. 
 I repeated this incision a few days after. No pus was found. Inasmuch as 
 there was free drainage from the tympanum, no further operation was performed. 
 The patient died in a few days afterward. 
 
 CASE II. Suppuration of the Middle Ear fw Six Years Death. Female, 
 aged fifty. Four years ago she had an attack of severe pain and swelling in the 
 right ear from which she recovered, but a discharge remained. One year ago 
 she had acute inflammation of the mastoid process. The integument and peri- 
 osteum were incised, pus discharged for two months and then ceased. Two 
 weeks ago the inflammation recurred in the same part. There was intense pain
 
 510 CARIES AND ABSCESS OF MASTOID CASES. 
 
 in the ear, and an offensive discharge from it; the latter continued. H. D., R., 
 
 o> -k'j sV 
 
 The patient has been living in a malarial district, and has taken largely of 
 quinine. 
 
 The left auditory canal is narrowed and crooked, and filled with pus. The 
 drum-head is nearly gone, and there is caries of the tympanum, the mastoid 
 cells, and posterior wall of the auditory canal. Dr. E. T. Ely saw the patient 
 for me at first, and advised the application of six leeches and the hot douche 
 every three hours. In a few days the patient was much better, the mastoid was 
 not tender, but there was intense pain in the head and constant vertigo. The 
 bones of the tympanum were gone, and the foramen ovale probably opened. I 
 learned afterward this patient died very soon after Dr. Ely and I saw her, which 
 we did but a few times, when we were dismissed. 
 
 CASE III. Acute Suppuration of the Middle Ear Mastoid Periostitis Menin- 
 gitis Death. This case has already been published in full (Medical Record, July 
 6, 1877). It is simply necessary to say here the patient died of meningitis, 
 from acute suppuration of the middle ear, in twenty- eight days from the first 
 attack of aural inflammation. Wilde's incision was made, but no disease of 
 the bone was found, and the post-mortem examination showed that such an 
 opening would have been in vain. 
 
 CASE IV. Chronic Suppuration of Right Middle Ear Mastoid Swelling Ab- 
 scess Opened with Drill Died about Three Months after from Meningitis. Male, 
 aged twenty. Under the writer's observation for about fourteen days. 
 
 The patient has had a discharge from his right eye ever since infancy. The 
 drum-head of that side is gone, and there is a very free discharge of pus from 
 it. The whole surface of the mastoid is swelled and excessively tender. A free 
 incision was made down to the bone and a fistula was found leading into the 
 tympanum. This was enlarged and a tent introduced and poultices applied. 
 The patient remained under daily observation in New York for eight days, when 
 he returned to his home to be under the care of his family physician. I saw 
 him once or twice afterward. He did well until July or August, when he died 
 suddenly at a watering-place, as I was informed, from meningitis. 
 
 CASE V. Bronchitis Acute Suppuration of the Right Middle Ear Chills Sim- 
 ulating Ague and Fever Mastoid Abscess Opened with a Drill Death Four Days 
 
 after. D. I , aged sixty -nine, on April 6, 1886, was sent to my office by Dr. 
 
 M. H. Williams with the following history : He had acute bronchitis three and a 
 half months before, which in about two weeks was followed by earache. This 
 ceased when the ear began to discharge, but the suppuration has continued ever 
 since. The ear was carefully cleansed with warm water, and an astringent in- 
 stilled, and the ear was inflated by Politzer's method. There was occasionally 
 some bleeding from the tympanum on cleansing. 
 
 The patient has excellent care under good hygienic conditions. To-day the 
 patient has no pain, slight tinnitus occurred, but no other aural symptom. 
 
 H. D., jiy ; L., ^J. Bone-conduction better than aerial on that side. When the 
 tuning-fork is placed on the sound mastoid it appears to be heard on the dis- 
 eased side. This is a symptom which, as is well known, is quite often seen, and 
 when it is, always, in my opinion, indicates advanced disease of the tympanum and 
 cells, not necessarily suppuration however, with greatly increased resonance of
 
 C A HIES AND ABSCESS OF MASTOID CASES. 511 
 
 these parts. The nares are in a catarrhal condition. The posterior half of the 
 drum-head is swept away, the remainder is red ; a rather thick discharge from 
 the tympanum. No tenderness, pain, swelling, or redness of the mastoid. 
 Simple cleansing was advised. Nearly a month after, on May 4, 1886, I again 
 saw the patient at his house and got the following history from Dr. Williams. 
 The patient was doing fairly well until April 31st, when he had a chill followed 
 by fever. He has had a chill nearly every day since. The mastoid is slightly 
 tender at the apex, there is no oedema and no pain, but that side of his head 
 feels uncomfortable. The next day the uncomfortable sensation had increased, 
 and the usual incision was made through the integument and the bone opened 
 with a drill. The depth reached was about half an inch, when pus flowed out 
 in considerable quantity. A tent was inserted and a poultice applied. In the 
 evening the patient was very comfortable. Temperature, 98. Pulse, 78. 
 
 May 6th. The patient had a chill lasting half an hour, and his temperature 
 went up to 104^. Two days after, he died, herniplegia having occurred. 
 
 CASE VI. Chronic Suppuration of Long Standing Great Pain in the Head 
 Delirium Opening of the Mastoid Death. Male, aged twenty-five. This pa- 
 tient was seen twice in consultation. The history was that he had had a sup- 
 purating ear on the right side for many years, and occasionally he has been laid 
 up with earache. He has been sick now for two weeks. Pulse, 90. Tempera- 
 ture. 104. The tympanum is suppurating moderately. The apex of the mas- 
 toid process is tender upon firm pressure, but there is no pain except in the 
 head, and that is not severe. The previous treatment has been the use of 
 quinine and the application of leeches. 
 
 The diagnosis was meningeal hypersemia, from acute suppuration supervening 
 upon chronic suppuration. Four leeches were advised, and poultices around 
 the ear. I heard nothing more of the patient until fifteen days later. I was 
 again sent for. The physician in attendance concluded that the high tempera- 
 ture was due to malarial poisoning, and has given large doses of quinine. Hie 
 also made an incision through the periosteum of the mastoid process, which has 
 nearly healed. The patient is- now delirious, flinches when pressure is made 
 upon the mastoid. The mastoid was opened with a small drill into the cells. 
 No pus was found. The blood was exceedingly dark, but there was no serious 
 hemorrhage. The patien.t died three hours later. At my first visit to this patient 
 I thought, and expressed my opinion, that the pus that formed on this case was 
 probably inaccessible, for I supposed that the apex of the petrous bone or the 
 roof of the tympanum rather than the mastoid was the principal seat of the 
 disease. I did not concur in the use of the quinine, and never supposed that 
 there was any determining malarial element in the case. When I got consent 
 to opening the mastoid I did not hesitate, however, for I think many lives have 
 been lost because concealed pus has not been evacuated in such cases. With my 
 present convictions, in dangerous suppuration of the tympanum I shall always 
 lean toward opening the mastoid, believing as I do that such an opening secures 
 the best drainage possible for the tympanum. Much as I deplore unsuccessful 
 cases, I shall never hesitate to perform what I believe to be an operation almost 
 without danger in a doubtful and dangerous case. In a case to be described 
 hereafter, occurring in the Manhattan Eye and Ear Hospital, in my service, and 
 operated upon by Dr. Emerson with my assistance, a case almost desperate, life 
 was, I think, saved by a timely trephining, although no pus was found.
 
 512 CARIES AND ABSCESS OF MASTOID CASES. 
 
 CASE VII. Chronic Suppuration of the Middle Ear since Infancy Acute 
 Otitis Spontaneous Opening of the Mastoid Process Enlargement of the Opening 
 
 Phthisis Pulmonalis Death. C. P , aged twenty-one. It is doubtful if 
 
 death in the following case was due to the aural disease. Certainly it was not a 
 result of any operative interference or other treatment. About three months 
 after he was seen by Dr. Ely and myself, in consultation with Dr. F. A. Utter, he 
 died of phthisis pulmonalis. The history stated that the patient had had a dis- 
 charge from the left ear for a long time from early youth. Four weeks ago he 
 had violent pain in the ear, extending to the side of the head and neck, a swell- 
 ing in the mastoid opened spontaneously a few days since. The patient is veiy 
 pale and weak. Temperature, 98|. Pulse, 120. The entrance to the auditory 
 canal is obstructed by granulations from the posterior wall. There is a small 
 sinus 'below the tip of the mastoid. Rough bone is felt at the bottom. He has 
 no pain now. The opening was enlarged and a tent inserted. The tissues are 
 very boggy. 
 
 The patient got better so as to be up and about, a free opening into the mas- 
 toid cells was maintained, but the patient died in three months after. 
 
 CASE VIII. Chronic Suppuration of the Middle Ear Extensive Necrosis of 
 tlie Mastoid Process Epithelial Tumor extending into the Cranial Cavity No Ex- 
 ternal Swelling Death. In consultation with Dr. Mathewson. This case has 
 been fully reported elsewhere (" Transactions of the American Otological Society, 
 1878 "). This patient was a young married woman, in good general health, who 
 had had a purulent discharge from the left ear for ten years. When first seen 
 by Dr. Mathewson, and subsequently by myself, she was suffering 'pain from the 
 ear. There were fungous granulations springing out of the tympanum. There 
 was no swelling; tenderness, or pain in the mastoid. 
 
 Four months after first coming to Dr. Mathewson he opened the mastoid, 
 which was still not swollen or tender, and very extensive necrosis was found. 
 Two months after I again saw the patient. There was considerable pain in the 
 head and ear. The mastoid opening was nearly closed. The canal was ob- 
 structed by granulations. The next day Dr. Mathewson removed many pieces 
 of dead bone ; a wide opening remained down to the dura mater. The patient 
 died two months later, eight months after she came under Dr. Mathewson's 
 care. A full account of the post-mortem examination of this interesting case 
 appears in the report. From this it appears that the growth had its origin in the 
 tympanum, and that the mastoid was affected only at a late stage. 
 
 CASE IX. Acute Suppuration of the Middle Ear Redness and Swelling of the 
 Mastoid Bronchitis Fistula of Mastoid Enlarged Death. Male, aged three. 
 Seen in consultation with Dr. Emerson. The patient has had a discharge from 
 his left ear for the past six weeks. For two weeks there has been redness of the 
 mastoid process of that side, and slight swelling. There is no fluctuation nor 
 tenderness on pressure. The auditory canal is much swollen. Dr. Emerson 
 advised the hot douche and poultices, and nine days after he was called by Dr. 
 Harrison to see the patient again. He learned that the little patient had had 
 pain for two days. The swelling of the mastoid had nearly disappeared. There 
 was no redness, but there was pain on pressure. The next day I saw the pa- 
 tient with Dr. Emerson. He made a Wilde's incision, found a fistula in the 
 bone, which he enlarged. The patient slept well the night after this, but he 
 died three days after in a convulsion.
 
 CARIES AND ABSCESS OF MASTOID CASES. 513 
 
 DEATHS PROM CASES OCCURRING IN HOSPITAL PRACTICE. 
 
 The only death I have seen from aural disease in my service 
 at the Manhattan Eye and Ear Hospital for eighteen years was 
 that of a patient under the care of Dr. Emerson and myself. 
 
 CASE X. Sub-acute Suppuration of the Middle Ear Mastoid Tenderness Open- 
 ing of Bone No Fistula or Pus Found Death in Forty-two Days. Male, laborer, 
 aged thirty-seven, was treated as an out-patient for two weeks before he entered 
 the hospital. He said he had a painful ear for three weeks before this. The 
 warm douche and leeches have been used. On admission to the hospital, on 
 June 9, 1877, he complains of dizziness and pain. He was found to have a 
 sub-acute suppurative process in the middle ear. He apparently improved 
 under local treatment for three days, when he had a chill and his temperature 
 went up to 103. 
 
 The mastoid was opened by Dr. Emerson, assisted by myself, on that day. 
 The bone was drilled to the depth of one inch. No pus and no fistula were 
 found, and there was no softening of the external plate. The temperature fell 
 to 100 that evening, but it rose the next day to 103. The patient was chilly, 
 nauseated. He continued to suffer from nausea for several days ; his tempera- 
 ture ranged from 101 to 103, and on June 21st it arose to 105. On this day 
 his pulse was increased to 80 for the first time. It had before ranged from 
 72 to 76. He now has delirium at times. He is given quinine and bromide of 
 potassium. On the 22d he had a chill lasting an hour. The discharge of pus 
 from the ear is scanty. He continued in about this way for three days, when his 
 temperature fell to 98^, and the next day to 97. He continued to have chills, 
 and on June 28th his pulse was 120. An examination of the optic nerve and 
 retina showed nothing abnormal. The patient died of septicaemia on July 31st, 
 nearly two months after his admission. 
 
 The purulent infection was in the roof of the tympanum or 
 at the apex of the petrous "bone. We were not hopeful of the re- 
 sults of opening the bone, but we desired to obtain an outlet for 
 pus, but in this we were not successful. 
 
 Cases in which a cure resulted after operation : ' 
 
 CASE XI. Caries of the Mastoid from Chronic Suppuration of the Middle Ear 
 
 Mastoid Opened Three Times Recovery. Miss X , aged twenty-six. As 
 
 this case is reported in my book on the Ear, p. 529, I will simply say that the 
 patient was under observation and treatment for some eight months. Although 
 the bone had been opened twice before I saw the case, once with a chisel, the 
 patient, who is a teacher, was unable to do any mental work on account of pain 
 and dizziness. After a thorough opening up of the old fistula with a drill, and 
 subsequent persistent curetting of granulations, the patient entirely recovered ; 
 the drum-head did not heal, however ; she resumed her duties, which, ten years 
 later, she still continues to perform without trouble from her ear. 
 
 To my mind, a case of mastoid disease arising in the course 
 
 of a chronic suppuration always, or nearly always, involves a 
 
 tedious course varying from two to six months if cure results. 
 
 It is otherwise with the same form of disease arising in the 
 
 83
 
 514 CARIES AND ABSCESS OF MASTOID CASES. 
 
 course of acute catarrh and acute suppuration. In such cases 
 the recovery may be rapid and death also may speedily result. 
 He who succeeds in curing cases where he has opened the mas- 
 toid de novo, or enlarged a fistula, must expect weeks of rather 
 dreary work -of keeping the opening free, by frequently curet- 
 ting the granulations, picking away the minute fragments of 
 dead bone, pushing in a tent, a drainage-tube, or the like. With 
 such patience, success will generally crown the effort. 
 
 I am very unwilling to operate upon a case unless either one 
 of my staff, or myself, or a competent surgeon, alive to the im- 
 portance of the prevention- of retention of pus, have the subse- 
 quent charge of the case. The after-treatment, I think, invokes 
 much more skill than the operation. 
 
 CASK XII. Caries of Mastoid of Nasal Bone and of Jaw Removal of Pieces of 
 Dead Bone from Various Parts Recovery. Female, aged five. This case also 
 illustrates what has just been said on the subject of keeping up the openings in 
 the bone until the last of the unhealthy tissue is removed. 
 
 The child was apparently a healthy one of healthy parents. She was sent 
 to me by the late Dr. Lewis Fisher, and she was under the care of Dr. Ely and 
 myself for more than four years. A mastoid fistula existed when I first saw 
 her, when she was three years of age. Dr. Abbot, dentist, of this city, had the 
 care of the caries of the jaw ; she was etherized several times, to keep open the 
 original enlargement of the bone fistula and to remove granulations from the 
 tympanum. Finally she recovered, with a neoplastic non-suppurating tympa- 
 num, and the mastoid fistula healed. 
 
 Several cases have recovered without perforation of the mas- 
 toid by getting the patient in bed under the charge of a trained 
 nurse, and the free use of the warm douche, leeches, and poul- 
 tices. Most of the patients who have been thus relieved have 
 been of decided neurotic tendencies, and although they have 
 had great tenderness and pain in the mastoid, have probably 
 never had more than periostitis. No caries occurred, except in 
 some instances caries of the wall of the auditory canal, when it 
 opens into the mastoid. 
 
 But I have written upon this subject at some length in pre- 
 ceding pages. 
 
 A case which I have lately seen, in consultation with Dr. F. 
 W. Ring, and which we treated together in the Manhattan Eye 
 and Ear Hospital, re-illustrates the points I have endeavored to 
 make. 
 
 CASE XIII. Acute Suppuration m both Middle Ears Red, Sensitive, and Ten- 
 der Mastoid Increase of Temperature No Operation Recovery. Mrs. G , 
 
 aged twenty-five. November 30, 1886. Five months previously the patient suf- 
 fered from acute suppuration of both middle ears, while in the West Indies. 
 The suppuration and pain have continued at intervals ever since-
 
 CARIES AND ABSCESS OF MASTOID CASES. 515 
 
 Occasionally she is quite well. She has been under Dr. Ring's care for more 
 than two months. Under his treatment the right drum is now healed ; R., H. D., 
 |.| ; bone conduction better ; L., H. D., L g ; B. C., better. There is pus in the left 
 tympanum. The mastoid of that side is reddish, painful, and tender. The 
 temperature at about 11 A.M. was 102, and had been for a few days. She was 
 anaemic and neurotic. She lived in a boarding-house and had insufficient care. 
 On the advice of Dr. Ring and myself she was admitted to the hospital. She 
 was kept in a quiet room, was fed with milk, chiefly stimulants, latterly cham- 
 pagne was given pro re nata, massage. Her temperature sank to normal in a few 
 hours after getting under hospital care. The right drum -head again broke 
 down, but finally healed. Locally the hot douche and poultices were used. She 
 was discharged cured. She went to Chicago, had a mild attack of acute suppura- 
 tion without mastoid trouble, from which she completely recovered in twenty 
 days. 
 
 One of my cases at the Manhattan Eye and Ear Hospital, 
 one in which I found a fistula in the bone and enlarged it, 
 developed acute facial erysipelas. The temperature, without 
 the administration of medicine, fell in one day from 104 to 97. 
 The shock was great, but the patient rallied and made a good 
 recovery. The drum-head healed. Facial erysipelas also oc- 
 curred in another case where the operation of drilling the bone 
 was performed by Dr. F. Tilden Brown, then one of my assist- 
 ants. This case may be found in this book, page 524. 
 
 The following case, which occurred in private practice in 
 consultation with Dr. E. M. Pulling, and has a peculiar interest 
 from the fact that descending optic neuritis resulting in atrophy 
 occurred. 
 
 CASE XIV. Willie X , a"ged six. April 10, 1885. Has had pain and dis- 
 charge from his right ear for some days. He is in bed. Temperature 100. 
 The right membrana tympani is perforate. There is inspissated pus in the 
 tympanum. The mastoid process is red and swelled. An incision was made 
 down to the bone, about one ounce of thick pus was evacuated. The perios- 
 teum was found to be extensively diseased, but no fistula in the bone was found. 
 The patient slept well that night and recovered. Case went on well as to 
 the ear. Dr. Pulling afterward made counter-openings to prevent burrowing, 
 but no opening in the mastoid bone was ever made, and on March 2d, of 
 this year, I again examined him. I found two linear scars on the mastoid, the 
 membrana tympani is sound and has good light spot, and is of good color. 
 H. D., ja ; A. C. , better than B. C. 
 
 The peculiar interest in the case is found in Dr. Pulling's 
 account of the subsequent progress of the case and in the results 
 of the ophthalmoscopic examinations which I made. Dr. Pulling 
 writes : " After you last saw Willie he had meningitis, lasting 
 four to five weeks. He took bromides in full doses, with aconite 
 and so forth, when the temperature rose. His condition gradu-
 
 516 CARIES AND ABSCESS OF HASTOID CASES. 
 
 ally improved, and at the end of two months or more from the 
 date of your last examination his health seemed quite well 
 established. About this time, however, it was observed that his 
 vision was becoming defective. The impairment of sight I as- 
 sumed to be due to constriction of the optic nerve from contrac- 
 tion of the tissues about it." 
 
 The patient, March 2, 1887, has only perception of light in the right eye and 
 T So on the left. Both optic papillae are in a state of white atrophy. The lateral 
 vessels have all disappeared from the right papilla. 
 
 It is no new observation to find basilar meningitis in the 
 course of acute inflammation of the tissues of and adjacent to 
 the temporal bone. Our attention has been called by Kipp, 
 Andrews, and others to the usefulness of ophthalmic examina- 
 tions in the course of diseases of the mastoid, but I think it very 
 unusual for a patient to recover from a suppurative inflam- 
 mation of the tympanum, with mastoid periostitis, to become 
 blind from optic neuritis and subsequent atrophy. 
 
 CASE XV. Scarlet Fever Acute Suppuration of the Right Middle Ear Pain in 
 the Head Swelling and Redness of the Mastoid Incision through the Periosteum 
 
 Fistula Found and Enlarged Still under Treatment. Miss W , aged fifteen. 
 
 The patient was attacked by scarlet fever on November 3, 1886. On the 13th 
 she was seized with a severe pain in the head and with pain in the ear. These 
 pains continued for several days until the membrana tympani broke, when the 
 pain was materially relieved. 
 
 The pain in the head continued, however, accompanied by a free purulent 
 discharge from the auditory canal, until February 5th about three months. I 
 then saw her for the first time, and found the patient anaemic and evidently 
 suffering. The right membrana tympani was nearly gone, and the tympanum 
 velvety. The left drum-head was intact. No tenderness or redness of the mas- 
 toid. The hot douche was prescribed, and the ear kept clean. Four days after 
 the patient had severe pains through the temples at the apex of the mastoid. 
 Leeches were applied, and relief given for two or three days, but on February 
 14th the pain reappeared. There was found to be considerable swelling and 
 redness of the mastoid. At 5 P.M. the temperature was 101$ . 
 
 An incision was made, the periosteum removed, and a fistula found leading 
 from above the middle of the process into the tympanum. Some pus came 
 from this. This was enlarged with a drill. A tent and poultice applied. She 
 began to improve the next day, and her condition at this writing, a little more 
 than four weeks from the operation, is as follows : No headache, anaemia dis- 
 appearing, scarcely any discharge from the tympanum, and a moderate sup- 
 puration passes through a drainage-tube inserted into the mouth of the fistula 
 in the bone. Temperature normal. Patient goes out. 
 
 March 31st. Fistula in bone has healed. Membrana tympani restored. 
 H. D., -&. Subsequently the hearing became normal.
 
 CARIES AND ABSCESS OF MASTOID CASES. 517 
 
 CASE XVI. Chronic Suppuration of the Middle Ear Mastoid Periostitis 
 Openings down to the Bone Enlargement of the Fistula Patient still under Treat- 
 ment. H. B , aged sixteen, was brought to me March 4, 1887, by Dr. W. H. 
 
 Cummings, of Honesdale, Pa., on account of pain in the head, dizziness, and 
 occasional swellings of the mastoid process. 
 
 The hearing distance on the right side is normal. The drum-head is cica- 
 tricial and intact. The left mastoid process is depressed, and has a minute 
 opening, about which the tissues are boggy. A fine probe passed into it can 
 with difficulty be made to enter the bone. The auditory canal was half-filled 
 with sanious pus. It was believed that the tympanum and mastoid were the 
 seat of purulent inflammation, and that they were not well drained. 
 
 That day the patient was etherized at the Post-Graduate Hospital, a free 
 incision was made down to the bone, the minute fistula enlarged with a drill 
 and the gouge. The tissue of the mastoid was found to be very soft, and an 
 opening into the tympanum, about one-fourth of an inch in diameter, was easily 
 made. A large quantity of cheesy, inspissated pus, as well as that of a fluid 
 quality, was evacuated. The patient is steadily improving, has no headache or 
 dizziness. Whether or not he will have a permanent fistula remains to be seen. 
 The mastoid tissues have been previously opened several times down to the 
 bone, but not into it, but for the first time thorough drainage has been secured. 
 
 May, 1891. A fistula still exists and is probably permanent. The patient 
 made an excellent recovery. 
 
 CASE XVII. Acute Suppuration of the Right Tympanum Mastoid Red, Tender, 
 and Swelled Fistula Found Enlarged Relief Still under Observation. On 
 March 1, 1887, I was asked by Dr. W. A. Dayton to see a female child, aged 
 six, with the following aural history : During the holidays she had the earache 
 several times, generally in the night, with some regularity, at about 1 A.M. 
 These attacks continued at intervals until February 22d, when they became 
 more c<mstaftt. Her pulse was then 115. Her tongue was coated, the skin dry. 
 The tympanum discharged very moderately ; the mastoid process became red, 
 tender, and swelled. Leeches and poultices were applied with only partial relief. 
 
 On March 1st I examined the ear. I found the drum-head perforated, caseous 
 pus lying upon its remains, the mastoid as above described. I advised an 
 incision down to the bone, in the usual way. This was made by Dr. Dayton ; 
 no pus was found, but a small fistula was discovered about one-fourth of an inch 
 above the apex of the mastoid, with softening of the bone about. This was 
 enlarged and a tent introduced. 
 
 March 2d. The relief has been very great. 
 
 March 19th. There has been no pain since the operation. The wound, 
 previously syringed with weak carbolized water, has been tightly packed every 
 day with a twelve-inch tent. 
 
 Granulations have sprung up in the wound rapidly ; these have been trimmed 
 away daily with curette and scissors. The use of a four per cent, solution of 
 cocaine has rendered the treatment almost painless. 
 
 There has been no pus (from the beginning) save that which comes away on 
 the tent. The child has been kept in bed, in a bright, sunshiny room, and 
 allowed a generous diet, meats only prohibited. 
 
 In this case the inflammation has been rather plastic than suppurative, or 
 predominantly^ of the former character. The case made a complete recovery.
 
 518 CARIES AND ABSCESS OF MASTOID CASES. 
 
 CASE XVIII. Acute Suppuration of the Tympanum Severe Pain Diplopia 
 Mastoid Opened No Pus No Fistula Recovery in Four Months Fistula closed in 
 
 about a Year. A. M , aged forty-six, colored. June 25, 1885. For five weeks 
 
 this patient states that he has suffered from a purulent discharge from the left 
 auditory canal. For much of this time he has suffered much pain. He now 
 has a suppuration of the tympanum, and complains of severe pain. Two 
 leeches were applied to the tragus, and morphia was administered hypoderini- 
 cally at bedtime. Warm douche to the canal. 
 
 July 5th. The patient has been very comfortable for a portion of the time, 
 but he has had considerable pain ; referred to the left side of the head. Be- 
 sides the hot douche, poultices have been applied about the ear at times. It 
 has been necessary to give morphia every night. The discharge has been pro- 
 fuse. This evening his temperature is 101. 
 
 July 6th. The patient has homonymous diplopia, the left external rectus 
 being paralyzed. 
 
 July 7th. Diplopia and pain continued. At about 4 P.M. the mastoid was 
 opened with a drill. Dr. Emerson operated, assisted by Dr. Roosa. No pus, 
 no fistula were found. A tent was placed in the opening and a poultice applied. 
 
 July 9th. The patient has had no pain since the operation. Paralysis of 
 the external rectus continues. The examination with the ophthalmoscope de- 
 tects no lesion of the fundus oculi. 
 
 July llth. Yesterday a free discharge of pus occurred from the mastoid 
 cells. He also had pain in the head and back of the neck, lasting three or four 
 hours. This is the first since the operation, and at 5 P.M. his temperature 
 was much higher and his pulse more frequent than at any time since the opera- 
 tion. This morning he is sweating profusely. The discharge from the ear is 
 abundant. 
 
 The patient was taken from the hospital for a time, but reappeared in a few 
 days. 
 
 August 6th. He is now up and about his room. His temperature from Au- 
 gust 5th to the 12th ranged from normal in the morning to 104 in the after- 
 noon. 
 
 The fistula in the bone is free, and the patient has no pain. 
 
 On August 20th the patient again left the hospital. He reported daily, and 
 was readmitted in about a month. The granulations were removed from the 
 sinus by a curette, and the opening kept free. On October 14th he was dis- 
 charged, without pain ; the diplopia disappeared. Some thirty days since, the 
 fistula still existed. The patient made a perfect recovery, and is still living. 
 The fistula closed ; abscesses occurred in the neck. 
 
 In another case, alluded to in this chapter, 1 diplopia also oc- 
 curred during the course of erysipelas, which supervened upon 
 the operation of opening the mastoid. It is remarkable that no 
 pus was found 6n opening the mastoid. It soon, however, made 
 its way through, and the fistula thoroughly drained the tympa- 
 num, and thus gave relief, and recovery ensued. I can but think 
 that a fatal result might have ensued had not the mastoid been 
 opened. 
 
 1 Archives of Otology, VoL XII., 1883.
 
 CARIES AND ABSCESS OF MASTOID CASES. 519 
 
 CASE XIX. Acute Suppurative Inflammation of the Tympanum Healing of the 
 Drum-head in Two Weeks Masto id Abscess Removing of Pus Opening of Mas- 
 toid Subsequently, Deep Abscesses of the Neck Recovery. C. P , aged twenty- 
 three. Patient was admitted to the hospital on September 3, 1886, and gave 
 the following history : 
 
 Three months previously he had an acute suppuration of the left tympanum. 
 The drum-head is said to have healed in two weeks. After this he suffered from 
 severe headaches from the occiput around to the frontal region. A swelling be- 
 hind the ear occurred a month ago, and since that time he has not suffered 
 much from pain. The mastoid region is found to be swollen, but not red or 
 tender. His hearing distance is -||>, and the meinbrana tympani is intact. The 
 neck is also swollen down to the clavicle. On September 26th, Dr. Emerson 
 opened the mastoid cells with a drill. Pus was found in the cells. A tent and 
 poultice were applied. In four days the great swelling of the neck had sub- 
 sided, and pus was freely discharging from the opening in the bone. The pa- 
 tient is anaemic and feeble. Whiskey and iron and "milk are given. The swell- 
 ing of the neck reappeared and became greater than before the operation. An 
 incision along the sterno-cleido-mastoid was made by Dr. Roosa on October 17th, 
 and a careful dissection made under the muscle, and a large quantity of pus 
 evacuated. lodoform dressing was applied and a rubber drainage-tube intro- 
 duced. An exploratory incision made some days before failed to find pus, but 
 the operation of to-day showed that it has been burrowing for a long time. 
 From this time the patient began to recover, and was discharged from the hos- 
 pital on December 10th, with one drainage-tube leading down to the bone, but 
 not in it. For a long time previously the patient had three drainage-tubes 
 one into the fistula of the mastoid, one along the side of the sterno-cleido-mas- 
 toid, and one over the border of the occipital bone. For some time they com- 
 municated with each other. This patient finally made a complete recovery, 
 
 The marked feature in this case was the complete healing of 
 the membrana tympani with almost complete restoration of the 
 hearing, while the disease went on in the mastoid bone and ex- 
 tended from there deep into the cervical tissue. 
 
 CASE XX. Acute Suppuration of the Middle Ear Mastoid Abscess Fistula 
 
 Operation Relief. Bertha X , aged thirteen, was brought to me by her 
 
 father, a physician, February 28, 1885, suffering intensely at times from pain 
 referred to the left ear. The history states that she had severe pain in the ear 
 on the Christmas-day preceding, and that the ear had soon begun to discharge 
 pus, and that it has continued to do so. The hearing distance is - c -. The bone 
 conduction is better than the aerial on that side. The drum-head is gone pos- 
 teriorly, and there is a free discharge of pus from the tympanum. The mastoid 
 region is red, swollen, and tender. The mastoid is of a delicate anaemic type. 
 
 On the same day the mastoid was incised, pus evacuated, a fistula leading 
 into the tympanum was found and enlarged. A tent was applied. Relief to the 
 pain soon followed. The patient was treated in the Manhattan Eye and Ear 
 Hospital for some three, months. The bone about the fistula was found ex- 
 posed. The fistula was enlarged with a drill at the time of the operation, and 
 kept open by the use of the curette ; granulations sprang up very readily. 
 
 July, 1890. ^The fistula healed entirely in 1888. Patient is well.
 
 520 CAEIES AND ABSCESS OF MASTOID CASES. 
 
 The prominent feature in this case is the fact that the fistula 
 did not heal in a year after the operation. This may have been 
 due to two causes : 1, the delicate health of the patien.t ; 2, the 
 care of the patient at home that is, in regard to keeping the fis- 
 tula and tympanum clear has not been quite as thorough as 
 when the patient was under daily treatment at the hospital. To 
 keep a fistula free from granulations often causes so much pain 
 that a tender parent, even if a physician, will not always do it. 
 
 CASE XXI. Acute Suppuration of the Middle Ear Thickening of the Tissues 
 over the Mastoid No Tenderness or Pain Recovery u-ithout Operation. Mrs. 
 
 H , aged thirty-three, was brought to my office on June 11, 1886, by Dr. 
 
 John C. Peters, who desired my opinion as to treatment of her ear. The patient 
 stated that some twelve weeks before she was seized with a pain in the right ear. 
 After using the nasal douche* there was soon a discharge of pus from the auditory 
 canal, which has continued ever since. The hearing distance on the right side is 
 -^ ; on the left, ||. At times she has considerable pain in the ear and the right 
 side of the head. The tissues over the mastoid process were considerably 
 thickened, but there was no redness, swelling, or tenderness. The drum-head 
 was perforate, about half of the mernbrarre being gone, and there was a free but 
 not excessive discharge of muco-pus. The patient, who was a well-developed 
 woman, appeared to be in a high state of nervous excitement. She stated that 
 she had been under the care of several physicians, and that this morning the 
 last one whom she had consulted advised that the mastoid be opened to-day ; 
 another had said she had syphilis, and so forth. Before she had made the 
 statement in regard to an operation, I had advised Dr. Peters that his patient 
 be kept in her room and that the ear be treated by the use of the warm douche 
 and poultices, the latter in case of pain ; after the statement as to the urgent 
 need of an operation I again went over the case, but in view of all the symptoms 
 I concluded that the drainage of the tympanum was sufficient, and that what 
 was now needed was absolute mental and bodily quiet. The patient was treated 
 in the manner indicated, leeches were applied to the tragus the next day, and 
 poultices were used in front and behind the ear. The temperature remained 
 normal, and while she was under my observation (some ten days) she steadily im- 
 proved, and finally became well as to her general health and had no pain referred 
 to her ear. There remained an opening of the membrana tympani when she 
 was last seen by me, and a slight muco-purulent discharge, but I have been in- 
 formed by her mother, within a few days of writing this, that the patient, now 
 nine months since, is perfectly well. 
 
 In this case the patient's natural disposition and undisci- 
 plined mind led her to exaggerate her symptoms, especially as 
 regards pain. Then again, she has kept herself in a state of ex- 
 citement by running about to various physicians, when the 
 actual objective conditions were really not at all grave. At any 
 rate, I felt that with a tympanum well open, a mastoid scarcely 
 tender on the very firmest pressure upon the apex, with no fever, 
 and a brief history of aural disease, in a person excited by her
 
 CARIES AND ABSCESS OF MASTOID CASES. 521 
 
 frequent change in advisers, that delay was certainly proper. 
 Much as I advise opening the mastoid when the indications are 
 even moderately plain, and the conditions are urgent, I am al- 
 ways very anxious not to perform an unnecessary operation. 
 The case belongs to the same class as Case XIII. , and the one 
 narrated on page 51 4, and before alluded to in this article, where 
 neurotic symptoms predominated over the inflammatory. I 
 ought to add that, after a thorough examination, neither Dr. 
 Peters nor myself thought the patient had syphilis. 
 
 If operative procedures are necessary for the drainage of the 
 tympanum, certainly, as .a rule, they are best and most safely 
 performed through the mastoid cells. In some instances these 
 may be best reached, however, by an opening in the auditory 
 canal. Such an operation as this, however, is not to be con- 
 founded with operations which aim to remove the remains of 
 the drum-head and the contents of the tympanum. Such oper- 
 ations may be indicated in cases where only the tympanum is 
 involved, but if the drainage of the ear is insufficient, and the 
 mastoid cells are at all implicated, opening the mastoid is a much 
 more rational and less difficult operation than removal of the 
 ossicles. 
 
 All of us know that even the operations for the removal of 
 granulations deeply seated in the tympanum become very diffi- 
 cult on account of the free bleeding, which soon renders all 
 exact and delicate manipulation almost impossible. 
 
 CASE XXII. Acute Suppuration of the Middle Ear Vertigo Mastoid Caries 
 
 Trephining Fistula Closed in Fifty-six Days. May 2, 1879. Mr. S , aged 
 
 forty-seven. Boiler-maker. Has been hard of hearing and has had tinnitus 
 "always." Seven weeks ago he was attacked by inflammation in the ear, caused 
 by exposure to cold and dampness. He now has suppuration in the left tym- 
 panum, the drum-head being perforate. He also complains of vertigo and 
 shooting pains running up over the forehead, down toward the occiput. H. D., 
 B., -fy. The warm douche and poultices behind the ear were advised. In a day 
 or two leeches were applied on the tragus and upon the mastoid, and the patient 
 was kept very quiet. The purulent discharge from the tympanum is free. He 
 has slight pain in the tympanum and mastoid at night. Quinine was used, but 
 without benefit. On May 28th he was having rather more pain and vertigo, the 
 latter only when moving about. Slight tenderness over one or two points of 
 the mastoid by very firm pressure. No thickening of the integument. Copious 
 discharge from the ear. The canal is narrowed, and firm granular swelling at 
 the bottom. No marks of drum-head or tympanum visible. Patient can attend 
 to business, that of a superintendent. The pain is intermittent. An incision, 
 the patient not being under anaesthesia, about one inch long was made down to 
 the bone. The bone felt softened and rough, but was not carious except at one 
 spot. A probe was worked through this spot until it penetrated into the audi- 
 tory canal. The opening was enlarged with the drill. No pus was found. The
 
 522 CARIES AND ABSCESS OF MASTOID CASES. 
 
 opening was plugged with lint and a poultice applied around the ear. The 
 external excision was made T-shaped before the drilling was undertaken. The 
 patient had some pain and dizziness until midnight. Absolute rest was advised. 
 There is no fever. The patient did well until July 7th, with only gradual decrease 
 of vertigo and pain. Last night he had an increase of dizziness and a feeling of 
 numbness in the lips on the left side. The fistula in the bone has been closed 
 for a week. The fistula in the soft tissues is still kept open. The canal looks 
 well, and there is only a moderate discharge from the tympanum. The air is felt 
 in the ear on inflation, but there has been no perforative whistle for the last few 
 weeks. 
 
 July 21st. The mastoid fistula has closed. Patient feels very well. H. 
 D., ^ ; voice, 50'. 
 
 August 5th. The patient has been in the country since last date. Has had 
 dizziness for about ten minutes after tipping back in a barber's chair, and he 
 also suffers from it if he tips his head to the left, or lies on the left side. No 
 vertigo in walking. 
 
 August llth. Frontal headache for the past two days. More dizziness. 
 Numbness of the left side of the nose and lip. Nothing wrong seen about the 
 ear. Ordered bromide potash, ten grains every two hours, and five grains ol 
 blue pill to-night. The patient recovered from this attack, took a voyage to> 
 England and back, and on November 29th he was seen and a final note made- 
 There is now a slight purulent discharge from the tympanum. He had a slight 
 bloody discharge from it, after climbing to the ball of St. Paul's Cathedral. The 
 upper and posterior segments of the membrana tympani are now cicatrized. 
 An opening exists below. The surface scar is granular. He complains of sore- 
 ness of the left nostril and numbness of left side of upper lip (see August llth).. 
 Face seems a little drawn, and uvula seems to tip a little to the right side. The? 
 patient has no vertigo or pain. 
 
 This patient was hard of hearing from the usual cause in a 
 boiler-maker, but upon this supervened the inflammation of the 
 tympanum and mastoid. The inflammation of the latter was 
 only suppurative in a very narrow track, whatever it may have 
 been in other parts. The tympanum, as shown by the facial 
 paresis, was markedly affected. The first positive relief to his. 
 pain and vertigo came from the enlargement of the mastoid fis- 
 tula by the drill. 
 
 CASE XXIII. Caries of the Mastoid from Chronic Suppuration Exacerbation 
 
 of Otitis Media Mastoid Opened Three Times Recovery. Miss X , aged 
 
 twenty-six. January 11, 1877. Six years ago, patient states that she had a dis- 
 charge from the left ear without apparent cause. It has continued more or less 
 ever since. Last September she took cold, and had severe pain with delirium. 
 Swelling of the mastoid occurred, and in the last week of September it was- 
 cut. A free discharge of pus occurred and relief of the pain. The incision 
 healed in a few days and the pain returned. The mastoid cells " were pierced "" 
 in October. The patient comes to me on account of continued pain and occa- 
 sional dizziness. The left auditory canal is red, sensitive, and full of pus. 
 There is a large cicatrix on the mastoid and a sinus running downward and for-
 
 CARIES AND ABSCESS OF MASTOID CASES. 523 
 
 ward toward the auditory canal. The physician who opened the bone afterward, 
 wrote me as follows : " I found a fistulous opening where the mastoid had pre- 
 viously been lanced. I at once made a free opening through the soft tissues 
 into the cells. No pus was found. A fistulous opening existed between the 
 osseous and cartilaginous meatus down quite into the middle ear. The opera- 
 tion afforded very great relief from the urgent symptoms. But as the wound 
 contracted pain recurred." 
 
 About a month after, the Doctor again opened the wound, cut away as much 
 of the diseased tissue as possible with a chisel, following the fistulous track. 
 The probe detected diseased bone at the depth of one and one-quarter inch. 
 Relief again occun-ed. Some time after, a small piece of bone came away. The 
 wound closed, but on January 6th swelling and pain in the mastoid again be- 
 gan. The next day the wound again opened, and at this point she came under 
 my care. After vainly attempting to get permanent relief from the pain, by 
 keeping the fistula open with a tent, and treating the tympanum through the 
 auditory canal, I determined to open the wound freely and enlarge the bone 
 fistula. Accordingly, on April 7th, the patient was etherized. The external 
 opening was enlarged, and the surface of the bone carefully examined. It was 
 found to be smooth. The fistulous opening into the tympanum through the 
 osseous canal was then enlarged with a drill, and the outer opening was made 
 funnel-shaped. The fistula was treated by being dressed to the bottom with a 
 tent, and healed June 23d, a little more than two months after the opening had 
 been enlarged. The patient hao- been free from pain since a few days after the 
 operation. The tympanum was treated through the auditory canal, by thorough 
 cleansing with a syringe and curette, there being a great disposition to the in- 
 spissation of pus and the formation of granulations, but she finally entered upon 
 her duties as a teacher, which she continues (June, 1884) to perform. When 
 last seen, in 1882, a part of a cicatricial membrana tympani existed, there was a 
 free dischai-ge from the tympanum, and a granulation in the upper part. Under 
 the use of iodoform this became better. 
 
 The final success in this obstinate case was due, I think, to a 
 persistent care of the tympanic cavity, which was left free from 
 pus and granulations, while the osseous fistula was being healed 
 from the bottom. In opening the mastoid, the surgeon should 
 remember that the operation has become necessary because the 
 pus is not thoroughly evacuated from the tympanum through 
 the canal. There will, therefore, often be found much to be 
 done in treatment of the canal and tympanum. 
 
 The following case occurred in my own clinic, and although 
 treated mainly by Dr. Ely and Dr. Brown, I saw the patient 
 frequently, and advised in the later stages of treatment. It was 
 reported by Dr. F. Tilden Brown in -a special journal, 1 but it is 
 of sufficient importance to be inserted here, since it illustrates 
 what has been said of the occasional difficulty in diagnosis as to 
 the presence of pus in the mastoid cells. 
 
 1 Archives of Otology, vol. xii., 1883.
 
 524 CARIES AND ABSCESS OF MASTOID CASES. 
 
 CASE XXTV. A Case of Abscess of the Mastoid, with Entire Absence of Tender- 
 ness, Heat, en- Swelling over the Suppurating Part, with a constant Distant Pain near 
 the Occipital Protuberance Trephining Recovery Occurrence of Erysipelas dur- 
 ing Convalescence. John M , aged forty-eight, came to Dr. Roosa's clinic 
 
 at the Manhattan Eye and Ear Hospital on September 14, 1882. Examination 
 by Drs. Edward T. Ely and F. T. Brown showed a muco-purulent discharge 
 from the right ear, partial loss of the membrana tympani, diminished calibre of 
 the auditory canal, no swelling or redness behind the auricle, no tenderness on 
 pressure or percussion over the mastoid, inability to hear a watch on contact, tun- 
 ing-fork heard but by aerial conduction. The sole cause of his coming to the 
 hospital was great pain at a point along the right superior curved line, two 
 centimetres from the occipital protuberance ; occasionally radiating along the 
 right border of the parietal suture over the frontal bone to its interior angular 
 process ; thence above and below the orbit. 
 
 Previous History. No direct injury, but had a fall on back of head one month 
 before. Had never had syphilis ; was perfectly temperate, and had always been 
 well until the fourth of last June, when he experienced gradually increasing 
 pain in the right ear. Morphine gave temporary relief. Five days after, a dis- 
 charge appeared. The pain continuing, a blister was applied behind the ear, 
 and on June 16th, he was able to go to work, but returned in a few hours with 
 still greater pain. For the three weeks following morphine (hypodermically) 
 was given twice daily; this failing, chloroform inhalation was resorted to. Late 
 in July, Wilde's incision was made at the New York Eye and Ear Infirmary, but 
 the pain became, almost at once, more intense. A few days later a bone-opera- 
 tion was proposed, but the patient's family objecting, he came with a letter from 
 his physician to the Manhattan Eye and Ear Hospital. Here careful watching 
 for two days and nights verified his story of pain, sleeplessness, and loss of 
 appetite, but no abnormal temperature was detected. 
 
 The result of a consultation was to defer operation until thorough anti-neu- 
 ralgic treatment had been tried. Quinine, alcohol, and galvanism were ordered. 
 Five days later the patient was no better, and perforation of the mastoid was 
 determined upon despite the absence of satisfactory local symptoms. It was 
 performed by myself under the advice of Dr. Ely. The periosteum was healthy, 
 and on its section the bone presented a similar appearance. Brainerd's drill 
 sunk one and a half centimetre, entered a cavity, when about four grammes of 
 pus came away. A warm solution of boracic acid, thrown into the meatus audi- 
 torius, found exit through the wound, bringing pus. The dressing was antiseptic 
 and directed to favor free drainage and prevent occlusion. Pain was at once 
 and permanently removed. Two weeks later the patient went home, but returned 
 daily for dressing. The discharge now amounted to three grammes in twenty- 
 four hours, and a watch could be heard on contact. On the evening of Novem- 
 ber 4th, pain was felt about the auricle, followed by a chill with subsequent 
 fever ; the pain prompted a vigorous application of camphorated oil. Toward 
 morning the patient vomited. I was sent for the following night, when I found 
 him with a pulse of 90 ; temperature, 103 ; tongue coated ; bowels constipated ; 
 pupils normal in response to light. Probe passed readily, but the discharge 
 was slight. The tissues about the wound and over the parotid region were 
 oadematous and but slightly sensitive ; this pallor suggested serous rather than 
 haemostatic injection, and might have been either the erysipelatous cause, or 
 the blistering effect, of camphorated oil applied to relieve deeper pain. The
 
 CAEIES AND ABSCESS OF MASTOID CASES. 525 
 
 diagnosis of erysipelas was made on the fourth day ; this disease, still indiffer- 
 ently marked, had extended to the left malar bone ; pulse was 98 ; temperature, 
 103|; delirious through the night ; sight was indistinct ; had convergent squint ; 
 pupils responded feebly to light ; had moderately rhythmic vibrations of the right 
 forearm. I was again led to doubt the absence of meningitis, and called Dr. 
 Boosa in consultation, who, on examination, found slight cerebral impairment 
 and homonymous double vision existing ; the ocular media were clear. Optic 
 disks not seen on account of want of illumination. The mastoid perforation was 
 free, and afforded no evidence of retained pus, although the discharge was 
 greatly diminished. For this reason Dr. Boosa and myself concluded that 
 meningitis due to adjacent suppurative mastoid disease did not exist, and that 
 the diplopia, with other nervous symptoms, was due to a peripheral hypersemia 
 of the pia mater, by continuity of tissue with the facial erysipelas, resulting in 
 irritation of the sixth nerve at its point of exit. 
 
 This belief proved to be correct, for the intensity of the symptoms subsided, 
 and in eight days convalescence began. The discharges from both channels had 
 ceased, and one week later the wound completely closed. This was an agree- 
 able surprise, for in its relationship to disease of the mastoid, I viewed the 
 erysipelas as analogous to epididymitis succeeding a gonorrhoaa, and I expected 
 a return of the discharge as the erysipelas subsided. 
 
 Dr. Brown gave the following points as being of special 
 interest in this case : 
 
 1. The entire absence of tenderness, heat, or swelling over 
 the suppurating mastoid, while there was a constant pain re- 
 ferred to a point near the occipital protuberance. 
 
 2. The difficulty in differentiating the symptoms of facial 
 erysipelas from those of meningitis. 
 
 3. The direct suggestion made by the case, of the value of 
 active counter-irritation in the treatment of sub-acute or chronic 
 suppuration of the middle ear. 
 
 I lately had under treatment at the hospital, a man, aged 
 forty-five, upon whom I performed the operation of trephin- 
 ing the mastoid process for caries and abscess, in whom facial 
 erysipelas developed in three days after the operation. Al- 
 though he became very ill, having for some time a temperature 
 of 105, he recovered. The mastoid caries occurred during the 
 course of acute suppuration of the middle ear, which he very 
 much neglected. Although the patient was three weeks in 
 bed from the facial erysipelas, the occurrence of this disease 
 hardly seemed to retard the recovery of the abscess of the 
 mastoid. 
 
 Besides the dangers of erysipelas and pyaemia from suppura- 
 tive inflammation of the mastoid, it is not uncommon to meet 
 with inflammation of the connective tissue of the neck, with 
 the formation of abscesses. In one of my cases the life of the
 
 526 
 
 CARIES AND ABSCESS OF MASTOID CASES. 
 
 patient was at one time threatened by the numerous abscesses, 
 and his swallowing was for some days extremely difficult on 
 account of the pressure upon the pharynx. 
 
 Table Showing the Relative Frequency of Affections of the Mastoid in Certain Eye 
 and Ear Hospitals, and in the Writer's Private Practice. 
 
 Name of Institution. 
 
 Total Num- 
 ber of aural 
 cases. 
 
 Num- 
 ber of 
 years. 
 
 Affections 
 of the 
 
 mastoid. 
 
 Operations. 
 
 Manhattan Eye and Ear 
 
 14,720 
 
 17 
 
 110 
 
 Wilde's incisions and open- 
 
 Hospital. 
 
 
 
 
 ing of mastoid, 105. 
 
 
 
 
 
 
 (Wilde's incision, 94. En- 
 
 
 
 
 
 largement of a fistula, 5. 
 
 
 
 
 
 Perforation, 6.) One open- 
 
 
 
 
 
 ing through auditory canal. 
 
 Brooklyn Eye and Ear 
 
 18,366 
 
 18 
 
 91 
 
 126 Wilde's incisions and 
 
 Hospital. 
 
 
 >. 
 
 
 perforations of the mas- 
 
 
 
 
 
 toid. 
 
 New York Ophthalmic 
 
 14,634 
 
 17 
 
 112 
 
 Wilde's incisions, 108. Per- 
 
 and Aural Institute. 
 
 
 
 
 forations of the mastoid, 
 
 
 
 
 
 22. Opening through au- 
 
 
 
 
 
 ditory canal, 1. Total, 131. 
 
 Massachusetts Chari- 
 
 9,533 
 
 3 
 
 62 
 
 Operations not fully re- 
 
 table Eye and Ear In- 
 
 
 
 
 corded. 
 
 firmary. 
 
 
 
 
 
 Newark Charitable Eye 
 
 3,021 
 
 3 
 
 22 
 
 15 
 
 and Ear Infirmary. 
 
 
 
 
 
 Illinois Eye and Ear In- 
 
 2,464 
 
 4 
 
 8 
 
 16 
 
 firmary. 
 
 
 
 
 
 New York Charity Hos- 
 
 20 
 
 1 
 
 1 
 
 1 
 
 pital. 
 
 
 
 
 
 Author's Private Prac- 
 
 5,797 
 
 22 
 
 59 
 
 42 
 
 tice. 
 
 
 
 
 
 Percentage of Affections of the Mastoid. 
 
 Aural cases. 
 
 Mastoid cases. 
 
 Per cent. 
 
 14,720 
 
 109 
 
 0.74 
 
 18,366 
 
 91 
 
 0.49 
 
 14,634 
 
 112 
 
 0.76 
 
 9,533 
 
 62 
 
 0.65 
 
 3,021 
 
 22 
 
 0.72 
 
 2,464 
 
 8 
 
 0.32 
 
 20 
 
 1 
 
 0.05 
 
 5,797 
 
 59 
 
 1.01 
 
 68,555 
 
 464 
 
 .67
 
 STATISTICS OF MASTOID CASES. 
 
 527 
 
 
 
 . OB i 
 
 off do 
 
 ft 02 
 
 re, memb 
 mpani hea 
 
 2 
 
 6 
 
 Q O 
 
 f 
 
 3 
 
 a 
 
 fe 
 
 o 
 
 s 
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 p 
 
 a 
 
 <D 
 a 
 
 o 
 GQ 
 
 ^ a 
 
 1 
 
 ^ flfS 1 
 
 S . ^ 
 
 ilde's 
 Poultice 
 
 Acute suppuration 
 middle ear. 
 
 ,-H <D 'd 
 
 111 
 
 
 ^ ~ 
 
 111 
 ' 
 
 
 ^a^a 
 
 o o 
 
 O o> 
 
 2 ^ 
 
 
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 528 
 
 STATISTICS OF MASTOID CASES. 
 
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 PL 
 
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 889 9
 
 
 STATISTICS OF MASTOID CASES. 
 
 8 " i*2 
 
 ^'S * 1 S 
 .s a) ft * 
 
 - 
 
 r "7j 
 
 529 
 
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 2 
 
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 2 
 
 
 
 2 
 
 
 
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 mained open 18 
 months. 
 
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 r< ^CO t4 C3 
 
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 00 
 
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 1 
 
 ! 
 
 Some months. 
 
 18 months. 
 
 CO 
 
 
 +a 
 
 a 
 
 CO 
 
 OQ 
 
 00 
 
 
 Mastoid trephined 
 byDr. Mathe wson. 
 
 Leeches. Wilde's 
 incision. No pus. 
 
 Wilde's incision. 
 No pus. 
 
 "o 
 
 "o 
 
 1 
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 Q) &4 
 
 M 
 
 
 
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 as 
 
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 bc'g 
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 Paracentesis of 
 membrana tym- 
 pani. Wilde's in- 
 
 cision. No pus. 
 Wilde's incision. 
 Dr. Chas. Phelps. 
 Fistula found. 
 
 Enlargement of 
 mastoid fistula. 
 Necrosed bone 
 removed. 
 
 Fistula enlarged. 
 Granulations re- 
 moved. 
 Wilde's incision, 
 
 and enlargement 
 of fistula with 
 drill. 
 
 M 
 
 M 
 
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 34
 
 530 
 
 STATISTICS OF MASTOID CASES. 
 
 
 
 
 - 
 
 ' 
 
 . 
 
 -l 
 
 2$ 
 
 PnQ 
 
 S3 S3 E3 
 
 OOO 
 
 S3 
 
 C) 
 
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 9*l*i "3 '3 E/ s 
 
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 J S 
 
 "* O CO 
 CO .CO CO
 
 531 
 
 tOa o 
 
 ft ' 
 
 < oi O 
 
 g.s 
 .1; 
 || .9 
 
 Under treatment. 
 Membrana tympani 
 healed. 
 
 results unknown to three. 
 
 Believed. 
 
 a 
 
 1 
 
 o^ 
 
 Believed. Fistula 
 still open. 
 
 'oj 
 CD 
 
 CD 03 
 
 1 
 
 a " 
 S 1 
 
 1 
 
 1 
 
 O 
 
 T3 
 1 
 
 O 
 
 <a CD 
 1 1 
 
 Relieved. 
 
 . 
 
 s 
 
 5 
 5 
 
 m 
 o' 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 
 .a 
 
 months. 
 
 months. 
 
 1 
 
 i 
 
 9 
 
 1 
 
 1 S 
 
 >^ 
 
 months. 
 
 month. 
 
 months. 
 
 !i 
 
 CO 
 
 t 
 
 
 
 lO 
 
 ^3 
 
 co 
 
 CO 
 
 
 
 
 
 CO 
 
 
 
 
 
 2 
 
 Leeches. Poul- 
 tices. Incisions 
 
 in auditory canal. 
 Quinine internally. 
 Poultices. Hot 
 douche. 
 
 Wilde's incision, 
 with enlargement 
 
 i|| 
 
 Mastoid opened 
 with drill. 
 
 Opening of mastoid 
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 532 
 
 STATISTICS OF MASTOID CASES. 
 
 
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 STATISTICS OF MASTOID CASES. 
 
 
 
 
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 535 
 
 
 
 
 
 
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 536 HISTORY OF MASTOID OPERATIONS. 
 
 HISTORICAL SKETCH OP OPERATIONS UPON THE MASTOID PROCESS. 
 
 It is now about a hundred years, since a Danish surgeon, 
 Berger, of Copenhagen, who evidently suffered from chronic 
 non-suppurative inflammation of the tympanum, or from dis- 
 ease of the labyrinth, misled by the indications laid down 
 by the surgeons of his time, died from meningitis induced 
 by an operation for perforation of the mastoid process. " A 
 martyr to the operation," says one of the writers of his day. 
 Beck ' states that Berger was old and deaf, and that after the 
 bone was opened injections would not pass through the opening 
 into the nose or mouth. Fever, sleeplessness, vomiting, and de- 
 lirium followed, and the patient died in eleven days. There 
 was suppurative meningitis. Where the bone was opened it 
 was two lines in thickness, while the perforator entered for five 
 lines. 
 
 Like perforation of the membrana tympani, trephining the 
 mastoid, having been successfully performed under proper in- 
 dications, was widely recommended for cases for which it could 
 do but harm, and poor Berger's life paid the penalty for a want 
 of knowledge on the part of the surgical writers of his day. If 
 the operation had been performed many times, in such cases 
 as those of Dr. Berger's, there would have been many more 
 martyrs. 
 
 A regimental surgeon, Jasser, in 1776, performed the opera- 
 tion upon the ear of a soldier who had suffered long from a 
 chronic suppuration with occasional acute attacks attended by 
 great pain. The mastoid was swelled : the patient was half 
 insane with pain. Jasser made an incision on the mastoid about 
 an inch long and found a drop of pus. Encouraged by this, he 
 cut down upon the whole length of the mastoid bone. He found 
 the surface roughened. With a probe he went quite deeply into 
 the mastoid cells. He injected fluid into the opening ; it came 
 out of the nose, and, at the same time, a large quantity of pus 
 was discharged from the external meatus. The patient im- 
 mediately exclaimed that the pain had left his ears. He went 
 quickly to sleep and rested uninterruptedly for ten hours. In 
 three weeks the opening behind the ear had healed, the discharge 
 from the auditory canal had ceased, and the patient heard 
 better than before. Stimulated by this, Jasser performed the 
 same operation upon the same person, upon the other ear, from 
 which there was no discharge, but in which the hearing was 
 
 1 Handbuch, p. 60.
 
 HISTORY OF MASTOID OPERATIONS. 537 
 
 impaired. Here the hearing is said to have also been improved, 
 although there was no caries of the bone. The operation got its 
 name from Jasser, although, as every medical reader knows, it 
 had been proposed by Riolanus more than a hundred years 
 before Jasser's time, and Petit had opened a mastoid with a 
 gouge and hammer in 1750. The first named had proposed the 
 operation for deafness and tinnitus caused by stoppage of the 
 Eustachian tube. 
 
 Then we come to Valsalva's case, published nearly a hundred 
 years after the suggestion of Riolanus, which has been claimed 
 by all the authors as a case of perforation of the mastoid, and in- 
 jection through it of the middle ear. One writer (Von Troltsch) 
 states that an otorrhcea was thus cured by Valsalva. I have 
 examined the original passage in order to verify this claim made 
 for Valsalva, and I find that there is no such claim by Valsalva 
 himself. He simply states that he injected a fistula existing in 
 this part, in the case of a nobleman ; with what result he does 
 not say. The folio wing is the side-note to the passage : ' " Obser- 
 vatio ulceris adprocessum mamillarem, per quod injecta, statim 
 in oris cavitatem, licet undequaque illcesam transmittebantur." 
 The passage itself is as follows : " Adeoque mitto prolixius con- 
 firmare per quondam meam in vivo homine observationem, de 
 nobili scilicet viro, ulcere ad processum mamillarem, cum hujus 
 carie laborante in quod quce injiciebantur, illico ad fauces per- 
 veniebant adeoque a tympano, quo per illius processus sinuosi- 
 tates ascendebant, per tubam certe derivebantur," etc. 
 
 This passage may be translated as follows. After speaking 
 of the Eustachian tube as a passage to the pharynx, Valsalva 
 says : " I beg to confirm what I have said, by an observation 
 made on the living subject, a nobleman, who was affected with 
 caries of the mastoid process. The fluids that were injected intc- 
 this ulcer passed through the sinuosities of the mastoid process 
 into the tympanum, and thence through the tube to the fauces." 
 Valsalva is here demonstrating the function of the Eusta- 
 chian tube. He makes no claim to have perforated the mastoid, 
 but he simply asserts that he has injected a fistula in the mas- 
 toid, and that the fluid thus injected passed into the mouth. I 
 cannot find any evidence in the passage or the context that his 
 patient was cured of an obstinate otorrhcea, as asserted by Von 
 Troltsch, so that I think Valsalva must be left out, so far as any 
 evidence from this passage goes, in the enumeration of those 
 who have recommended or performed the operation of which we 
 are speaking. 
 
 'Tractatus de aure Humana, 1742, p. 89.
 
 538 HISTOKY OF MASTOID OPERATIONS. 
 
 Morgagni declaimed against the operation, not on good 
 grounds, however, but because he supposed there was no open- 
 ing of the mastoid cells into the tympanum. Petit, however, 
 recommended the operation for caries and abscess of the mas- 
 toid. Jasser seems to have lost his head after his first properly 
 performed and successful case, and he probably was the cause 
 of the widely spread recommendations of this surgical procedure 
 for all kinds of aural cases. If Jasser had rightly understood 
 the indications for opening the mastoid indications which were 
 plain in his first case and which were not to be found in the 
 second, a valuable surgical procedure would not have been 
 practically ignored by the profession for nearly fifty years. It 
 required about this length of time before surgeons would "med- 
 dle with the mastoid." The operation was, however, occa- 
 sionally performed by independent surgeons, when pus was evi- 
 dently retained in the bone, but very few reports are found of 
 these cases. Troltsch ' finds seven cases prior to 1858. In the 
 operative surgery of Sir Charles Bell, 2 as early as 1812, he says : 
 " We learn from this view of the subject how carefully we ought 
 to attend to symptoms when there is disease of the ear, lest it 
 should become irrevocably bad, and end in communicating the 
 disease to the brain. We must bleed and purge and foment to 
 allay the pain and inflammation if it' be active, . . . and 
 when we can ascertain that there is caries in the posterior angle 
 of the bone, with danger of the confinement urging the progress 
 of the diseased action of the brain, we have to apply the trephine 
 and penetrate into the cells of the bone." But here, as in all the 
 writings until our own generation, there is a notable absence of 
 any careful account of the early symptoms of mastoid disease. 
 No one would be able from these general descriptions to diagnos- 
 ticate and successfully treat the early stages of the affection. 
 Dieffenbach, 3 in 1848, utterly condemns the operation, and agrees 
 with Itard in saying that it should be entirely abandoned. He 
 believes that a carious process would be increased by opening 
 the bone. As great a man as Sir William Wilde * evidently does 
 not understand that the bone ought to be opened under certain 
 circumstances. He alludes to artificial perforations of the pro- 
 cess for the purpose of throwing injections into the middle ear, 
 or to relieve deafness in cases where the Eustachian tube had 
 been closed, an operation, he continues, which has long since 
 been exploded, not only as ineffectual but positively hazardous. 
 
 1 Virchow's Archiv, 1861. 
 
 * A System of Operative Surgery, first American edition. 
 
 8 Troltsch' s Lehrbuch Sechste Auplage, p. 499. 
 
 4 Text book, p. 363, English edition.
 
 WILDE'S INCISION. 539 
 
 Although he had given a name to an incision through the peri- 
 osteum of the mastoid for the relief of periostitis of this part, 
 and although he alludes to fistulas being formed in this bone in 
 the course of chronic suppuration, he gives no sign that there 
 might be cases in which it would be wise to go farther than the 
 periosteum and open the bone. Indeed, in many cases where 
 Wilde's incision was performed, a little search would have found 
 an opening that nature was trying to make. But the improper 
 indications of " closing of the Eustachian tube, tinnitus aurium, 
 deafness," were so confounded with the one proper one of reten- 
 tion of pus, that even Wilde could not separate them. 
 
 Toynbee had a very large experience in fatal cases of mas- 
 toid disease, and yet all he has to say upon the subject of the 
 operation is : " Perforation of the mastoid process also suggests 
 itself, and this operation may doubtless be performed in those 
 cases, when the matter is pent up in the cavity of the ear, and 
 is causing such urgent and serious symptoms as are likely, if 
 not relieved, to terminate in death. I have never performed 
 this operation, but I should not scruple to dp so in a case in 
 which the life of the patient was threatened." ' 
 
 Good surgeons everywhere followed Wilde in his advocacy 
 of a free and deep incision down to the bone. In this city, the 
 late Professor Post regularly lectured upon affections of the 
 mastoid, and often made Wilde's incision, but he also considered 
 the operation of opening the process, as one only or chiefly re- 
 commended for affections where it would be useless if 'not 
 dangerous. 
 
 Prompted by a happy experience into which he entered 
 rather timidly, Troltsch in 1861 published a paper in Virchoiv's 
 Archives upon the subject of perforations of the mastoid, which 
 probably did more than any other one thing, to bring the sub- 
 ject clearly before the profession. He there reports a ca.se in 
 which he had, in 1858, perforated the mastoid with a blunt probe. 
 He collected the scattered cases from the literature of the 
 subject, and seems to have been the first writer after Berger's 
 martyrdom, who was wise enough to show that opening an 
 ulcerated mastoid to remove dead bone, concealed pus, and 
 secure thorough drainage, was a proper and often necessary 
 operation. According to Troltsch's own words, although the 
 indications would now be considered imperative and clear, he 
 opened the softened mastoid with fear and trembling. He says : 
 " I went to work with uncommon care, even with dread." 
 
 Troltsch's case was one of those that I have found more 
 
 Disease of the Ear, London, 1860, p. 341.
 
 540 OPENING THE MASTOID. 
 
 frequently than any other that is to say, one in which a fistula 
 had been made in the bone by the suppurative process. 
 
 Troltsch seems to have hesitated after making a Wilde's in- 
 cision. He looked up the accessible literature of the subject, 
 and he found some cases where life was apparently saved by 
 the operation. All the authorities, however, were in doubt 
 about the propriety of performing it, and he continues : 
 
 ''What was more natural than that such an operation ap- 
 peared to one who had scarcely practised medicine for a year, as 
 an affair to be well weighed, and that I treated the case with 
 great circumspection and almost in an experimental manner." 
 " I think," he says, " if I had not achieved my end with a simple 
 probe, then I would scarcely have desired to act more vigorously 
 with other instruments." But Troltsch had been a student of the 
 great Irishman. He had often seen him divide a red, tender, 
 painful, and swelled mastoid down to the bone, and he imitated 
 him in this case, and in spite of the authorities, in two days he 
 went farther, when the pus escaped and relieved the sufferings 
 of his patient. 
 
 In February, 1862, Lawrence Turnbull 1 published two cases 
 in which he made an incision down to the bone, and a third in 
 which two months after he had opened the external tissues, he 
 perforated the surface of the bone with a sharp hollow probe, 
 and applied nitrate of silver freely. A month later he again 
 broke down a part of the bone, and nineteen days later he 
 removed a large piece of bone, which was found to be movable 
 with the probe. This was an operation very like that of Troltsch, 
 although the German surgeon only waited a few days before 
 venturing to go into the cells with a probe, while the American 
 delayed for two months. In spite of its exclusion from some 
 tables, TurnbulPs case belongs to the same category with that 
 of the reviver of the operation. It was operated upon but three 
 years after Troltsch's case, and only one year after it was 
 published. 
 
 In 1863 Pagenstecher * published two cases, with some re- 
 marks upon the nature of affections requiring the opening of 
 the mastoid. He declares the technique of the operation to be 
 simple and easily acquired. This is an article written in a truly 
 surgical spirit. In 1868 James Hinton reported 3 a case in which 
 he perforated the mastoid cells with a trocar, the next day 
 after he had made an incision through the periosteum. The 
 
 1 Philadelphia Medical and Surgical Reporter, vol. vii., p. 463. 
 Archiv fur kliniche Chirurgie, Bd. iv. , p. 322. 
 3 Times and Gazette, London, vol. ii., p. 378.
 
 OPENING THE MASTOID. 541 
 
 case was one of chronic suppuration of the tympanum. Mr. 
 Hinton speaks of fourteen cases of perforation of the mas- 
 toid for the evacuating of matter reported by various authors. 
 Twelve he says were successful. In one of the fatal ones 
 pyaemia occurred. He says the operation is suitable to two 
 classes of cases : 1, Those in which the matter collects in the 
 dependent mastoid cells ; 2, those in which caries takes place 
 in the roof of the pyramid. He recommends the centre of the 
 mastoid for perforation in the former case, and in the latter 
 the upper part of it, about on a level with the roof of the meatus. 
 His recommendations are evidently inspired somewhat by Pa- 
 genstecher's paper. 
 
 In 1864 A. B. Crosby, living in the mountains of New Hamp- 
 shire, probably not knowing of Troltsch's writings, but perhaps 
 having Sir Charles Bell's sound advice in mind, opened the mas- 
 toid, in three cases where he suspected the presence of pus, with 
 a gimlet. Although this was in 1864, the cases did not get to 
 general professional knowledge until 1873. Relief was given in 
 all the cases. Some years after, in 1872, I was present when 
 Agnew again opened one of these gimlet cases and found a scle- 
 rosed condition of the bone, one well known to the early writers. 
 
 By this time, 1864, the operation begins to be freely spoken 
 of. Ludwig Mayer, of Worms, Jacoby, of Breslau, Follin, 
 and others reported cases. Jacoby had a considerable experi- 
 ence, and wrote two or more valuable papers in the Archives 
 of Otology. He proposed instruments, gave tables, and so 
 forth. 
 
 Schwartze first appears in the literature on this subject in 
 1864 (Praktische Beitrage, 1864), as having, some days after he 
 had made a Wilde's incision, opened the roughened exposed 
 bone with a probe, in the case of a child aged one year and a 
 quarter. The bone, he says, was very easily perforated. In 
 August, 1869, he, with Koppe, reported a case of reflex epilepsy, 
 with caries of the temporal bone, cured by an operative perfora- 
 tion of the mastoid process. He used a trephine. 
 
 In 1870 Agnew, at a meeting of the American Ophthalmo- 
 logical Society, reported the case to which I have already 
 alluded. At the same meeting, I reported two cases in which 
 I had opened the mastoid cells through a minute fistula, in each 
 case with a stiff probe. 
 
 To those cases was added a history of the operation, which 
 I believe was the first complete account that appears in any 
 language since the time of Berger. In this paper I attempted to 
 lay down certain indications for the performance of the opera- 
 tion. After seventeen years of added experience I do not know
 
 542 OPENING THE MASTOID. 
 
 that I can materially alter these rules, although I have some- 
 what amplified them.' 
 
 In 1873 A. H. Buck began his writings upon the subject of 
 opening the mastoid with a report of thirty-five cases occurring 
 in various parts of the world, six of which are his own. 
 
 In the same year Schwartze and Eysell a published an his- 
 torical account of opening the mastoid with a table of sixty- 
 three cases, seventeen of which were from their own practice. 
 This publication of cases has continued until the present day. 
 
 Although it seems clear to most writers that all these steps 
 have led to a point where we see that opening the mastoid pro- 
 cess in many cases is a perfectly justifiable and a life-saving 
 surgical procedure, the voice of specialists in this country is not 
 quite unanimous upon the subject. The weight of authority 
 seems to me, however, largely in favor of the operation, under 
 the ordinary indications. In a discussion two years since, Straw- 
 bridge 3 said that he had seen over four thousand cases of puru- 
 lent middle-ear disease in the last twelve years, and yet he had 
 not trephined a single mastoid, nor had he seen a death, except 
 in one child, six months old, that died a few hours after he first 
 saw the case. Dr. Theobald (Zoc. cit.) stated that his experience 
 accorded with that of Dr. Strawbridge, although he had not 
 seen so many cases. He had never opened the mastoid in the 
 living subject. He had seen mastoid symptoms disappear under 
 active constitutional treatment. These experiences, however, 
 seem to stand by themselves. Nearly all of those who have 
 seen many cases of aural disease have been obliged, occasion- 
 ally at least, to open the mastoid. To me it seems as if the 
 field of operation in this direction were likely to be enlarged 
 rather than diminished. I have elsewhere advised a thorough 
 search for pus, and by an opening through the bone in all cases 
 when death seemed to be threatened from cerebral abscess. The 
 only point in the subject that remains open for discussion, seems 
 to me to be the one pertaining to cases in which the only object 
 is to secure better drainage of the tympanum, the mastoid itself 
 being perhaps sound. ' No one with surgical education will deny 
 that it should be opened when there is pus in it which has no suf- 
 ficient outlet. No one, on the other hand, would consent to open 
 it to fulfil such indications -as those which deceived poor Berger. 
 
 I lay comparatively little stress upon methods of operation. 
 Schwartze forsook the trephine at an early day and took up with 
 chisels. In this he has many followers. I have continued to 
 use a stiff probe and a drill or a trephine. Buck continues to 
 
 1 Transactions of the American Otological Society, 1870. 
 1 Archiv flir Ohrenheilkunde, neue Folge, Bd., 1873. 
 3 Transactions of the American Otological Society, 1883.
 
 OPENING THE MASTOID. 
 
 543 
 
 use the drill, occasionally the chisel, while Crosby preferred a 
 gimlet. 
 
 For many decades aural surgery was almost exclusively in 
 the hands of men who were en- 
 deavoring to cure the incurable, 
 by injecting vapors and fluids 
 through the Eustachian tube in 
 cases of chronic non-suppurative 
 inflammation of the tympanum. 
 Their results were deplorably bad. 
 Otology was in such bad repute 
 that no one would meddle with 
 the ear or investigate its curable 
 affections. 
 
 Sir Astley Cooper, after bene- 
 fiting one patient by a paracen- 
 tesis of the drum-head, although 
 he failed in all subsequent at- 
 tempts, filled his waiting-room 
 with the incurable deaf, whom he Fia 107a - - Wll80n ' s Trephine.! 
 speedily drove out lest they should injure his reputation as a 
 surgeon. Thus, in one way or another, aural surgery became a 
 true terra incognita, about which the most absurd tales got 
 full audience, and in which very few capable and honest men 
 labored. In these latter and better days the light of scientific 
 and honest investigation has so cleared the pathways in otol- 
 ogy that even if one direction vary here and there, we may 
 walk with a fearless tread. 
 
 So far as propositions in regard to operations upon the mas- 
 toid can be formulated, I should say : 
 
 I. The integument and periosteum of the mastoid process 
 should be freely divided in all cases, when there is great pain, 
 tenderness, and swelling in this part. 
 
 II. Such an incision should also be made, whenever severe 
 pain, referred to the middle ear, constantly exists, and which is 
 not even temporarily relieved by the use of leeches, poultices, 
 the warm douche, and so forth. 
 
 III. The bone should be thoroughly examined by the aid of 
 such an incision, whenever we have good ground for suspecting 
 that the bone is diseased or pus is retained in this part. 
 
 IV. The mastoid process should be perforated after such an 
 incision, whenever the bone is found softened, and if a fistulous 
 opening is discovered, this should be enlarged. It should also 
 be perforated, when the suppuration of the middle ear involves 
 the mastoid cells or antrum to such an extent, that thorough 
 
 1 This new instrument is a very safe one, and easily managed.
 
 544 OPENING THE MASTOID. 
 
 drainage cannot be secured through the membrana tympani or 
 external auditory canal. 
 
 When general septicaemia or pyaemia has developed, even if 
 it has its starting-point in the mastoid, as it sometimes does, it 
 is of no use to chisel or drill the mastoid process. Purulent in- 
 fection of the whole system having occurred, it is then too late 
 to give an outlet to hardened pus at one point. I am led to this 
 remark, because I have seen two cases in which the mastoid was 
 opened, when the internal organs were already the seat of ab- 
 scesses, the tympanum and mastoid were dry, and all hope of 
 recovery should have been abandoned. Such operations only 
 bring the procedure, even when undertaken under proper condi- 
 tions, into disrepute. 
 
 I would not lead my readers to think that I consider the open- 
 ing of the mastoid process as a trivial procedure, the indications 
 for which, need not be carefully considered before it is under- 
 taken. Yet hesitation, when the way is plain, or when the 
 chances are largely on the side of the necessity of the removal 
 of pus, cannot be too sternly condemned. No drug has yet been 
 discovered, which can be substituted for the scalpel, or trephine, 
 when pus has actually formed in the mastoid cells. I wish, how- 
 ever, to repeat what I have said before on the subject of surgical 
 operations. I am in full accord with the great English surgeon, 
 Sir James Paget, who, in his admirable lectures, expresses many 
 times his hesitation to perform any surgical operation, however 
 trivial, that is not absolutely required. We have no right, I 
 think, to perform operations to clear up doubtful diagnoses ; if 
 in case the operation proves to have been unnecessary, the pa- 
 tient will be decidedly the worse for it. If we put ourselves in 
 the place of our patients, what we may regard as a trifling thing, 
 " a mere cut," will not be so esteemed. A mere cut, when un- 
 necessary, may have the most serious consequences, and all the 
 history and symptoms should be carefully weighed before even 
 that is undertaken. Such care will never prevent prompt, rapid, 
 and thorough surgical interference when demanded. 
 
 In teaching medical students, I have always found them, 
 when fully awakened to the dangers of neglecting certain dis- 
 eases, to be more apt to do too much, than too little, especially 
 with the knife and active drugs. It is possible also that the cry- 
 ing ignorance and neglect of the previous decades in regard to 
 the treatment of aural disease, has had a tendency to cause us 
 who see many of the affections of the ear, to lean toward the 
 side of surgical operations upon the drum-head and mastoid. 
 This is a leaning no less dangerous to the cure of some cases, 
 than was the steering toward Scylla or Charybdis to the safe 
 navigation of ancient mariners.
 
 CHAPTER XIX. 
 
 THE CONSEQUENCES OF CHEONIC SUPPUEATION OF THE MIDDLE 
 EAE ( Concluded). NEUEALGIA OF THE MIDDLE EAE. 
 
 CARIES AND NECROSIS OF THE TEMPORAL BONE. 
 
 Cases. Treatment by Operation and Internal Medication. Fatal Hemorrhage. Cere- 
 bral Abscess. Pyaemia. Paralysis. The Ophthalmoscope in detecting Cerebral 
 Disease of Aural Origin. Neuralgia of the Middle Ear. 
 
 THE surgeon is often baffled in his efforts to check a discharge of 
 pus from the ear, because it conies frorti a part of the bone the 
 walls of the tympanum that has been softened by a carious pro- 
 cess. It is not always possible to positively decide that the bone 
 is in this condition, for the part thus affected may be sufficient 
 to maintain a suppurative process, and yet be very small and 
 hidden from view. Even the proper use of a probe in a diseased 
 cavity of the tympanum, in order to enable us to decide as to the 
 existence of caries, is a delicate matter, and should be under- 
 taken with care, lest important parts be penetrated. The care- 
 ful surgeon is, therefore, often in doubt as to how much of the 
 bone may be invaded, even when he finds a superficial point 
 that gives evidence of disease. The probe cannot be used in the 
 ear as a diagnostic means, with that freedom that it is employed 
 in solid parts that have no such important and delicate sur- 
 roundings. 
 
 All parts of the temporal bone may become carious as the 
 result of a chronic suppurative process. The osseous portion of 
 the auditory canal is one of the favorite positions for such a 
 morbid change. The upper wall of this canal is but a short dis- 
 tance from the dura mater and the cerebrum, and we have 
 already discussed the relations of the mastoid cells to the lateral 
 sinus. Thus we may have inflammation of the brain and affec- 
 tions of the venous circulation, even when the caries is confined 
 to the external ear. It is probable, however, that caries of the 
 auditory canal is usually the result of a chronic suppuration of 
 
 35
 
 546 CARIES, OP TEMPORAL BOTJE. 
 
 the middle ear, and not of a primary and independent affection 
 of the peripheral portion. An exception to this has already been 
 noticed in one of the chapters upon disease of the auditory canal. 
 The anatomical relations of the cavity of the tympanum, than 
 which there are none more important in the whole body, neces- 
 sarily involve serious consequences from caries of any part of 
 its walls. These consequences also necessarily include great 
 impairment of the hearing, while we may have meningitis, cere- 
 bral abscess, pyaemia, paralysis, or fatal hemorrhage. Indeed, 
 in the treatment of any of these consequences of a chronic sup- 
 puration, we are always treading upon dangerous ground, which 
 may break under our feet at any moment. In some fortunate 
 cases, however, none of these unpleasant results, except the loss 
 of hearing, occur ; the diseased bone is thrown off, and the parts 
 heal. Nearly the whole of the temporal bone may be cast off in 
 this manner without involving the life of the patient. 
 
 It has already been seen that the ossicula auditus may be- 
 come carious and lost in the course of an acute suppuration. 
 The same thing may occur in the course of a very chronic pro- 
 cess, and small points of dead bone are frequently found when 
 the cavity of the tympanum has been for a long time exposed 
 from a loss of the membrana tympani. It is shown, however, 
 from reports of cases by myself and others, that caries may 
 occur with an intact drum-head. Dr. Orne Green 1 also pub- 
 lished a report of a post-mortem examination, that illustrates 
 the same fact. Dr. Geo. E. Francis, of Worcester, made the 
 autopsy. 
 
 A man twenty-five years of age, who was subject to catarrh, 
 had had a discharge from his ear for two years ; at times acute 
 symptoms occurred. Two months before death he could not 
 hear conversation. He also had cerebral symptoms, dizziness, 
 headache, double vision, and partial paralysis, but of what 
 regions is unknown. He died comatose, and at the autopsy a 
 collection of pus was found in the brain, just over a carious spot 
 communicating with the tympanic cavity. The pus lay directly 
 upon the bone. 
 
 Dr. Green examined the bone, and found a sinus through the 
 upper osseous wall of the auditory canal, just above and external 
 to the small process of the malleus. The point of an ordinary 
 probe could be inserted in this opening, and it communicated 
 with the auditory canal and the small cavity in front of the 
 handle of the malleus. From this cavity it passed backward 
 and inward into a circular cavity about one-quarter of an inch 
 
 1 Transactions of the American Otological Society, 1871.
 
 NECROSIS OF TEMPORAL BONE. 547 
 
 in diameter in the cancellated structure of the bone. The roof 
 of bone over this cavity had entirely disappeared, so that there 
 was a direct communication with the brain. All the walls of 
 this space were irregular and carious. " The membrana tympani 
 was entire and apparently healthy, and of normal transparency 
 and thickness in every part below the small process of the mal- 
 leus bone." 
 
 The head of the malleus and the whole of the incus were 
 wanting, but it could not be positively stated, that they were 
 not removed during the dissection. They must certainly have 
 been in a softened, diseased condition, or they would not have 
 escaped so readily. Von Troltsch reported a similar case to 
 this, and called attention to the little cavity, which is a part of 
 the tympanic cavity, and is situated just above and external to 
 the head of the malleus. In a normal condition, it is separated 
 from the auditory canal by an extremely thin layer of bone. 
 Von Troltsch dissected a specimen in which he found a polypoid 
 growth springing from this point and projecting into the canal. 
 
 Dr. O. D. Pomeroy ' reported a case of exfoliation of the whole 
 of the temporal bone, except the lower part of the external audi- 
 tory canal and the inner part of the petrous portion. The patient 
 recovered, of course with loss of hearing and facial paralysis. 
 The patient was a boy aged twenty months, and had a dis- 
 charge from the ear, accompanied by severe pain for three 
 months before Dr. Pomeroy saw him. There was mastoid peri- 
 ostitis, and an incision was made. Two days after another was 
 made, and the bone was found uneven and rough, and there was 
 a fistula leading into the mastoid cells. For three months after, 
 the child did moderately well, although there remained consider- 
 able swelling in front of the auricle. At the end of this period, 
 a small piece of dead bone was observed behind and a little above 
 the external auditory canal, and in about a month afterward it 
 became movable, and was grasped by forceps and some traction 
 was made upon it, but so much hemorrhage was caused that the 
 attempt to remove it was given up. 
 
 Six months after the child was doing well. The aperture 
 through which the sequestrum passed had closed. The dis- 
 charge of pus was moderate and the general health of the child 
 was good. 
 
 Wilde, a Agnew, 3 Gruber, 4 and Voltolini 5 have reported cases 
 of the extraction through the external meatus of the whole of 
 
 1 Transactions of the American Otological Society, 1872. * Text-book, p. 37. 
 3 Von Troltsch on the Ear, American edition. 4 Lehrbuch, p. 542. 
 
 6 Monatsschrif t f iir Ohrenheilkunde, Jahrgang IV. , p. 84.
 
 548 NECROSIS OF LABYRINTH. 
 
 the internal ear, during the life of the patient. Wilde's case 
 occurred in the practice of Sir Philip Crampton. The patient 
 was a young lady, who, after the most urgent symptoms of in- 
 flammation of the brain, with paralysis of the face, arm, and 
 leg, and total loss of hearing of one side, recovered from the 
 head symptoms and paralysis of the extremities after a copious 
 discharge of pus from the ear. " One day Sir Philip, perceiving 
 a portion of loose bone lying deep in the cavity of the meatus, 
 drew out the whole of the cochlea and semi-circular canals." 
 
 Dr. Agnew's case occurred in a patient who suffered from 
 exostosis consequent upon chronic suppuration of the opposite 
 ear, and who afterward died of brain disease dependent upon 
 retention of pus by the exostosis. The case as regards the ex- 
 ostosis will be found on page 486 of this work. 
 
 The patient was a gentleman of thirty-eight years of age, 1 
 who had suffered from chronic suppurative inflammation of 
 the middle ear for the greater part of thirty-two years. Three 
 years before the patient came under Dr. Agnew's observation, 
 after a severe exacerbation of the aural inflammation, complete 
 loss of hearing occurred in the ear, and paralysis of the facial 
 nerve of that side. Granulations continued to recur constantly. 
 On April 16, 1862, the patient was in a deplorable condition ; he 
 had suffered for months from pain in the ear, loss of sleep, loss 
 of appetite, and dizziness. The concha was swelled and ex- 
 tremely tender ; a pear-shaped polypus, of fibrous character, 
 which was kept bathed in very fetid pus, projected from the 
 meatus. Dr. Agnew placed the patient under the influence of 
 chloroform, and removed the polypoid mass by means of Wilde's 
 snare. In attempting to get the snare about the base of the 
 polypus, he encountered a solid body in the middle ear, which 
 proved to be the necrosed internal ear. An incision was then 
 made into the auditory canal, in order to enable the forceps to 
 grasp the sequestrum. Dr. Agnew's report says : " Having got 
 the body in the grasp of the forceps, a slight rocking motion, 
 with traction, enabled me to extract it." The whole of the in- 
 ternal ear vestibule, semi-circular canal, and cochlea were 
 found to be removed. This patient lived four years after this, 
 and never had any painful symptoms from that side of the head 
 afterward. 
 
 Gruber's case occurred in a child, thirteen years of age. 
 Both cochleae were exfoliated, and yet the patient recovered, 
 with no facial paralysis an evidence that the cavity of the 
 tympanum was left in a comparatively sound condition. 
 
 1 American Medical Times, vol. vi., p. 183.
 
 NECROSIS OF TEMPORAL BONE. 549 
 
 Voltolini's case was one that occurred in the practice of Dr. 
 A. Jacobi, of Berlin. The whole labyrinth was removed from 
 the ear of a child that is still living. The substance of the 
 cochlea was not fully united with the surrounding bony sub- 
 stance of the petrous bone, which, as Voltolini remarks, is evi- 
 dence that the disease dates back to an early period in the life 
 of the child. 
 
 Toynbee ' reported four cases of necrosis of the cochlea and 
 vestibule, in which the parts had been exfoliated during life. 
 One of them is Wilde's case, already quoted. The patients were 
 adults, with the exception of one, a child of seven years old. 
 
 I also add to the literature, the following case." 
 
 A Case of Acute Inflammation of the Middle and Internal Ears (Panotitis), 
 Followed by Facial Paralysis and Necrosis and Removal of the Whole Petrous Por- 
 tion of the Temporal Bone, with the Annulus Tympanicus Recovery. H. G , 
 
 fonr years of age, female, was sent to Dr. Roosa, February 1, 1884, by Dr. S. 
 G. Carpenter, of Chester, N. Y., who furnished the following history : 
 
 "On June 25, 1883, the patient was attacked with scarlet fever; eruption 
 was copious ; temperature, 105 F. ; eruption began to decline on the sixth day. 
 The throat was affected early ; the tonsils, uvula, and pharynx were covered 
 with a dense diphtheritic membrane on the second day ; the nares were also 
 affected, and discharged an irritating mucus. Soon after the ears began dis- 
 charging. Her general condition was one of coma, from which she could be 
 partially aroused by the handling necessary to cleanse the throat and nares. At 
 the time that the eruption began declining, sloughing occurred in both tonsils. 
 On the tenth day facial paralysis was first noticed on the left side. A little 
 later a puffy swelling made its appearance over the mastoid, which eventually 
 suppurated. There was complete deafness for a time, but later the hearing 
 of the right ear became partially restored." 
 
 Her condition when first seen at the office was as follows : There was com- 
 plete left facial paralysis ; discharge from both ears, that from the left being 
 very fetid and profuse ; there was a fistula in the mastoid leading down to rough 
 bone ; granulations in both tympanic cavities. The general condition was good. 
 
 February 2d. Dr. Roosa made an incision, under ether, through the skin 
 and periosteum of the left mastoid, enlarged the existing sinus in the mastoid 
 cells with a drill, and removed the granulations from the tympanum with a 
 sharp curette. The mastoid cells and ear were washed out with a weak solution 
 of chlorinated soda, and a tent inserted in the wound. 
 
 March 13th. The opening in the mastoid was enlarged, under ether, and 
 small particles of dead bone scraped off by Dr. Roosa. 
 
 March 14th. There is now an opening down into the mastoid cells about 
 the size of the end of a little finger. In dressing the wound a small fragment 
 of bone about the size of a three-cent piece came away. The patient soon after 
 this was placed in the Manhattan Eye and Ear Hospital, and from this time the 
 notes were made by Drs. Beard and Hale, House Surgeons. 
 
 1 Archiv fur Ohrenheilkunde, Bd. I., p. 113. 
 "Archives of Otology, vol. xiv., No. 1, 1885.
 
 550 
 
 CARIES AND NECROSIS. 
 
 March 29th. Considerable swelling about mastoid ; the auricle was pushed 
 forward. A great deal of fetid pus was discharged both from the canal and the 
 opening. This condition lasted until April 30th, when loose bone was dis- 
 covered, and a piece of the size of an infant's little finger was removed by Dr. 
 Roosa. 
 
 . On May 29th the patient was again placed under ether, and the granulations 
 removed and the carious mastoid cells gently scraped by Dr. Roosa. 
 
 From this time until September 23d the wound was dressed twice daily, 
 being cleansed with Labarraque's solution by means of the syringe, and a tent 
 of linen was pushed well to the bottom of the wound. The discharge was very 
 fetid and profuse ; granulations were frequently removed, but no tendency to 
 heal was shown, although the patient was in good health ; she had no head 
 symptoms or pain. The wound was dressed with great difficulty on account of 
 the sensitiveness of the ear to all handling. 
 
 The ophthalmoscope showed no lesion or change in the fuudus of either eye. 
 
 On September 23d it was discovered that a piece of bone not only filled the 
 entire opening, but caused tumefaction below. On the next day the patient 
 complained of pain in the ear. 
 
 September 25th. The patient was placed under ether, the wound enlarged 
 vertically, and the bone grasped with dressing-forceps and with slight difficulty 
 removed by Dr. Emerson. There was little hemorrhage. 
 
 It was found that the portion of bone removed was the whole of the petrous 
 portion of the temporal bone, photographs of which, taken of the actual size, 
 are herewith exhibited. 
 
 For a few days after the operation the discharge and odor were greater than 
 ever, fine particles of broken-down bone continually coming away. On the day 
 following, the malleus bone was washed out in perfect condition. 
 
 On October 14th another sequestrum, which proved to be the annulus tympani- 
 cus, was removed, without ether, by Dr. Roosa. Since then there has been great 
 and constant improvement. All discharge and odor disappeared within a week. 
 
 January 20, 1885. A fistula of one and a quarter inch in depth remains. 
 The discharge from it is usually not sufficient to soil the dressings. The edges 
 are contracting. It is probable that a permanent but small fistula will remain. 
 (See Fig. 4.) 
 
 FIG, i. 
 
 FIG. 2. 
 
 FIG. 3. 
 
 The first specimen (Fig. 1) is the entire petrous portion of 
 the left temporal bone. It measures If inch in length, f inch
 
 551 
 
 in breadth, and f inch in thickness. The posterior surface is 
 considerably eroded, and shows near its centre the first turn of 
 the cochlea (1). Posterior to this is the internal auditory canal 
 (2), i f an mc k m depth. At the lower edge is the groove for 
 the superior petrous sinus (3). 
 
 The anterior surface shows the eminence for the superior 
 semicircular canal in perfect condition ; anterior to that the 
 bone is eroded, and the tract of the facial nerve where it leaves 
 the internal auditory canal and euiters the tympanum is shown. 
 The outer or tympanic surface (Fig. 3) shows the following 
 objects : Beginning at the apex, the bony groove for the Eusta- 
 chian tube (1) ; in front of that, the promontory (2) ; above this, 
 the ovale (3) ; and below, the foramen rotundum (4) ; above and 
 external to this is seen aqueeductus Fallopii (5) ; and posterior, 
 the mastoid cells ((5). 
 
 The second specimen (Fig. 2) is the annulus tympanicus and 
 part of the bony external auditory canal. The cut is a view 
 of the internal surface, actual size, and shows the groove for the 
 
 FIG. 4. 
 
 membrana tympani (1) and the mastoid cells (2). It measures 
 1^ inch in length, f inch in breadth, and i of an inch in its thickest 
 portion. 
 
 In Toynbee's cases the sequestra were not removed until after 
 death. This fact deprives them of much of their importance. 
 Mr. Shaw, of London, has published a case of exfoliation of the 
 whole of the internal ear and part of the petrous bone. ' As the 
 case so nearly resembles the one here reported, the main facts 
 are quoted : 
 
 1 Transactions of the Pathological Society, vol. vii., London, 185&
 
 552 CARIES AND NECROSIS. 
 
 "Boy, seven years of age, otorrhcea from scarlet fever two and a half y ears 
 ago. Facial paralysis of left side, and complete deafness. Left external ear 
 projected considerably beyond its proper level ; irregular piece of bone, sur- 
 rounded with granulations, protruded from the meatus into the concha." Mr. 
 S. " first extracted the piece of bone which projected into the concha ; this 
 appeared to have been the posterior border of the external meatus of temporal 
 bone. The cartilaginous tube having been ulcerated by the pressure of the 
 bone fragment, the point of the little finger could be passed to some depth, and 
 another piece of bone was felt rolling freely in the cavity ; this was removed 
 with dressing-forceps with some difficulty. Patient made good recovery, paral- 
 ysis remaining. The bone removed was nearly the whole of the petrous portion 
 of the temporal bone ; it measured one inch in length and one-half inch in 
 thickness and weighed twenty-two grains. On one side, nearly in its centre, 
 was an opening and cavity, the internal auditory meatus. Depth of canal was 
 three-fifths of an inch, showing that the whole of the internal meatus was in- 
 cluded. On the side of the specimen in relation to the brain the surface pre- 
 sented the cancellated appearance peculiar to diploe, when it was concluded 
 that the process of separation had taken place in the diploe, and that the cor- 
 tical layer had retained its vitality, and that, remaining in contact with the dura 
 mater, served as a barrier to prevent the disease from extending to the cere- 
 brum. The opposite aspect of the bone shows the inner wall of the tympanum, 
 etc." 
 
 Dr. Pollak, of St. Louis, has also reported a similar case of 
 loss of the petrous portion of the temporal bone. 1 
 
 There was no diploe in the case here reported, and the bone 
 showed markings, such as the uneroded groove for the superior 
 petrosal sinus and the eminence, which conclusively proves that 
 it was separated from the dura mater throughout the most, if not 
 all, of its extent. 
 
 How this could happen without the meninges becoming 
 inflamed, the sinuses obstructed, and the internal carotid artery 
 affected, is not easily seen. 
 
 There were absolutely no head symptoms, except the coma 
 occurring during the acute stages of the scarlet fever. From 
 this fact, and the fact that the paralysis came on soon (within 
 ten days) after the beginning of the scarlet fever, we think we are 
 justifiable in thinking that the internal ear and petrous bone 
 were primarily affected with a purulent inflammation, and that 
 it was not, as is generally the case, the result of secondary in- 
 flammation extending from the middle ear. 
 
 From the first we maintained a perfect and free drainage of 
 the products of inflammation, both from the ear and mastoid 
 opening. To this the child is most probably indebted for her 
 life. 
 
 The operative interferences were only made when nature. 
 
 1 Archives of Otology, vol. x., p. 361.
 
 NECROSIS OF TEMPORAL BONE. 653 
 
 unassisted, proved insufficient for her task of giving a free exit 
 to purulent and dead material. The child took no drugs during 
 the eleven months that she was under our care. 
 
 FIG. 108. Left Temporal Bone, from FIG. 109. Inner Surface 6f the same 
 
 Case I. Exterior view, showing the exter- Specimen, showing : e, The vestibule ; d, d, 
 nal meatus : a, Prom which the anterior wall the windings of the cochlea, which have been 
 has been removed, as has also the inner wall exposed by sawing away portion of the bone; 
 of the middle ear; 6, the mastoid process. e, the tympanum, communicating with/, the 
 
 mastoid cells, which have been exposed by 
 chipping away a thin layer of bone. 
 
 The above engravings illustrate the ravages which chronic 
 suppuration makes upon the bony tissue of the ear. They were 
 made from photographs of the bones, and are from the collection 
 of Dr. C. E. Hackley, who kindly allowed this use of them. 
 
 History. CASE I. (Figs. 108 and 109). Left temporal bone from a man who 
 had phthisis, and died suddenly of pneumo-thorax, August, 1866. His hearing 
 distance was nothing for the watch, nor could he distinguish words, though he 
 seemed to hear the sound of the voice. He was very much debilitated when he 
 entered the New York Hospital, consequently no thorough examination was made 
 of his ears. He had profuse discharge from .both ears, and polypi on both sides. 
 On the left side, the post-mortem examination showed polypus attached in the 
 middle ear and extending forward into the meatus, and backward into the mas- 
 toid cells; membrana tympani gone; stapes only one of ossicles present; mem- 
 b,rane of fenestra rotunda gone. 
 
 CASE II. (Fig. 110). Left temporal bone from , who entered the New 
 
 York Hospital August, 1866, with great fever and pain in the left ear ; had 
 been sick two days. His disease ran much the course of typhoid fever, without 
 marked head symptoms other than the acute pain in the ear (which only existed 
 the first few days). When a child he had discharge from the ear and post-aural 
 abscess and disease of mastoid process. 
 
 On the autopsy, pus was found under the dura niater and in mastoid cells ;
 
 554 
 
 NECROSIS OF TEMPORAL BONE. 
 
 the -whole temporal bone was gone from the infiltration of pus through it ; the 
 membrana tympani was completely destroyed ; the base of the stapes was the 
 only part of the ossicula remaining ; there was an opening from the outer part, 
 of the bony meatus upward into a cavity which also had an opening outwardly. 
 
 A- 
 
 G~ 
 
 FIQ. 110. Left Temporal Bone, sawed through External Meatus, Middle Ear, and Coch- 
 lea. The pieces are turned to one side, showing : a, Mastoid process ; 6, 6, external meatus, 
 ending in c, the middle ear ; at d there was an opening downward through the bony meatus, 
 and at e an opening upward, by which there was a free communication with f, the mastoid 
 cells, which were separated from the interior of the cranium by a very thin layer of bone at 
 g ; h, h, show the cochlea sawed through. (From Dr. Hackley's collection.) 
 
 CASE V. (Fig. 111). August 18, 1868. H. O applied at New York Eye 
 
 and Ear Infirmary, on account of pain in right ear, saying he had a " kernel " 
 (wax ?) removed from his ear two years previously, by one of the surgeons of that 
 institution. The right membrana tympani was found injected, right Eustachian 
 
 Flo. 111. Right Temporal Bone, from Case V., showing the Cranial Surface of the Bone. 
 At a the bone was very thin, and broke away when the dura mater was removed ; the bone 
 was much hollowed out about 6, the middle ear. (From Dr. Hackley's collection.) 
 
 tube obstructed. H. D. Right ear pressed; Left, ^f. Applications of warm 
 water, with occasional leeching, were ordered. After some time the walls of 
 the meatus swelled so that the membrana tympani could not be seen. Under 
 varying treatment the state of the case was sometimes better, sometimes worse, 
 till March, 1869. During his attendance the patient twice stopped coming, 
 thinking he was well, when he complained of pain over the right side of the
 
 CARIES OF TEMPORAL BONE. 555 
 
 head, starting from the ear. Expecting meningitis, he was taken as an in-patient 
 at the Infirmary, April, 1869, treated again with leeches, cold to head, bromide 
 of potash, and tonics. About May i, 1869, he showed occasional delirium, and 
 contraction of the muscles of the nape of the neck ; had retention of urine ; 
 pulse 110-130 ; temperature 102. Died May 10th. No discharge from ear for 
 thirty-six hours preceding death. On autopsy, twelve hours after death, we 
 found the brain slightly congested ; the right optic nerve (which went to an 
 atrophied eye) was atrophied both before and behind commissure ; the menin- 
 ges of the base of the cerebellum, and upper part of the spinal cord, were cov- 
 ered with lymph and bathed in sero-pus (about two oz.) ; right auditory nerve 
 very red ; periosteum over the posterior part of the right temporal bone was very 
 easily detached ; the bone under it was greenish, infiltrated with pus ; the pas- 
 sage from the middle ear to the mastoid cells was much enlarged, with only 
 a thin wall of bone between it and the brain. On detaching the pericranium 
 this wall was broken through. Membrana tympani entirely gone ; the promon- 
 tory was roughened ; the stapes was the only one of the ossicles left in posi- 
 tion. 
 
 Fig. 112, from a photograph given me by Dr. Sexton, is a 
 view of the extensive ravages of diseaseof the temporal bone, 
 perhaps of a traumatic origin. I first saw the case upon Dr. 
 
 FIG. 112. Caries of Squamotm and Mastoid Portion of Temporal Bone. (From Dr. Sexton's 
 
 collection.) 
 
 Sexton's invitation, and some time afterward, I was present 
 when Dr. George A. Peters, under whose care he then was, per- 
 formed the operation which is described in the following notes, 
 kindly furnished me by Dr. Peters. 
 
 St. Luke's Hospital Aural Polypi Mastoid Disease Dr. Peters, attending 
 surgeon. George R , aged forty-four, car driver, native of the United States.
 
 556 CAEIES OF TEMPORAL BONE. 
 
 Admitted April 13, 1876. He was a sailor for several years, and received a good 
 many blows about the head at that time. He denies any venereal complaint. 
 Up to a year ago he was perfectly healthy ; at that time he had frequent attacks 
 of vertigo, losing consciousness for a brief period. 
 
 In June, 1875, he had quite a large abscess opened behind the right ear ; 
 there was a free discharge of pus, and in due time it closed. Some few months 
 ago he noticed that the right side of his face was paralyzed. About this time 
 his doctor told him, that his right ear contained polypi. 
 
 On admission his condition is pretty fair. Has had no marked attacks of 
 vertigo for past few months ; but his dizziness has increased and has become 
 almost constant, so that be has been unable to work. Often feels a desire to 
 wheel around and around. There is marked paralysis of face on right side, and 
 the patient imagines there is loss of power on same side, but examination does 
 not seem to confirm his idea. There is a fluctuating tumor behind right ear. 
 
 April 25th. Exploratory puncture made, and 3 ij. of dark brown-colored 
 serum was withdrawn. Since then the tumor has again become quite tense, and 
 careful examination reveals marked pulsation. This impulse is probably due to 
 pulsations of some branches of posterior auricular artery. 
 
 Drs. Loring and Roosa advise the removal of polypi and an incision into 
 tumor. 
 
 May 5th. The patient was etherized, Dr. Peters operating. Polypi could not 
 be snared, so they were evulsed. Incision, three inches long, was made into the 
 tumor ; the incision was perpendicular, and just over squamous suture extend- 
 ing down beyond the mastoid process. No pus was evacuated, only serum 
 tinged with blood. No large vessels were severed, not even a small artery, to 
 which a ligature could be applied, and yet there was such a general and profuse 
 oozing, that the wound had to be plugged, and a tight compress applied. Many 
 small flat pieces of bone were taken away, and on passing finger into wound the 
 mastoid portion of temporal bone was found to be extensively diseased and 
 broken down ; so that the impulse of the brain could be perceived at the bottom 
 of the wound. The amount of blood lost was considerable. 
 
 May 6th. He rallied very well from operation, but complains of extreme 
 weakness. Does not suffer much pain. 
 
 May 7th. Temperature and pulse not much above normal. Dressing re- 
 moved, bleeding quite profuse. Compress reapplied. 
 
 May 9th. Compress removed. On looking into wound, the entire bottom 
 of it (about the size of an old-fashioned cent) is seen to pulsate. Finger easily 
 detects the pulsation, and here and there can perceive pieces of dead bone. 
 There is still considerable oozing. Compress reapplied. An occasional dose of 
 opium given. 
 
 May 10th. He is stronger and better. No bleeding on removing com- 
 presses. Wound washed out with carbolic water and dressed with lint soaked 
 in carbolic oil. 
 
 May 15th. He sat up to-day. Carbolic lint dressing continued. Pulsations 
 still perceptible. Fragments of bone can be felt and any attempt to remove 
 them causes bleeding. 
 
 May 26th. Wound granulating and filling up rapidly. Can still detect a 
 slight pulsation at bottom of wound. The intense headaches, of which he com- 
 plained constantly before the operation, have entirely disappeared. Discharged 
 cured.
 
 NECROSIS OF TEMPORAL BONE. 557 
 
 The patient succumbed to the disease finally, from menin- 
 gitis. 
 
 The history of the following case was given me by Dr. Cooper, 
 of New Jersey, together with the specimen : 
 
 Male, aged sixty-five. Gradually increasing bladder-disease for five years. 
 Enlarged prostate. Cystitis. 
 
 First part of December, earache. Severe discharge in twenty-four or forty- 
 eight hours. Three years before, trouble in same ear. Discharge was less, but 
 the ear continued to trouble him. Pain behind it. 
 
 January 5th. Sudden and severe pain in -head, in front and back. Stupor 
 in twelve hours, and died January 8th, in morning. 
 
 Head opened. Dura mater congested, and lymph at base of brain. Abun- 
 dant pus, extending to the medulla. 
 
 FIG. 113. Caries of Petrous Portion of Right Temporal Bone (two-thirds size). 
 
 Fig. 114 is from a specimen furnished from a case reported 
 by me in 1875. 1 
 
 The patient was a man of twenty-five years of age, who suf- 
 fered from suppuration of the right ear for four years or more 
 before his death. 
 
 In consultation with Dr. Cameron and Dr. McKay, I saw 
 the patient once, when he was dying from purulent infection, 
 pleuro-pneumonia. The drum-head was entirely gone, and 
 there was considerable inspissated pus lying in the tympanum. 
 He had been suffering for some weeks from pain in his head 
 and ear, with profuse purulent discharge. There was never 
 any tenderness over the mastoid. For several days his tem- 
 perature ranged from 102 to 103.5. On May &th he had a chill, 
 and on the 9th Dr. Cameron found pleurisy of the left side. On 
 the same day another chill occurred, and on the llth pleurisy of 
 the right lung was detected, and double pneumonia. 
 
 1 Transactions of the American Otological Society, p. 92.
 
 558 
 
 PUS IN LATERAL SINUS. 
 
 The discharge from the ear became more abundant, there 
 was copious .expectoration, the head symptoms were greatly 
 alleviated, the mind became clear. But five days after, chilly 
 sensations were again experienced and they were followed by 
 intense pain over the region of the lateral sinus. Five days 
 after this I saw the patient when he was unconscious, and, as 
 has been said, there was a free discharge from the ear. There 
 was also exophthalmus. He died the next day. 
 
 The post-mortem examination was made by Drs. Cameron, 
 McKay, Ely, and myself. 
 
 Brain. General congestion of the substance of the brain 
 and very marked fulness of the vessels on the surface. No soft- 
 ening. No purulent collection ; thrombosis of the right internal 
 jugular ; pus in the right lateral sinus. 
 
 Thorax. Suppurative pleuritis of the right lung. The entire 
 
 FIG. 114. Caries of Lateral Sinus of Right 
 Temporal Bone (two-thirds size). 
 
 FIG. 115. Caries of Squamous Portion of 
 Temporal Bone (right side, actual size). 
 
 surface of the lung was covered with pus. There was also pus 
 in the right lateral sinus. There were pus and serum in the 
 pleural sac. 
 
 Temporal bone. There was no trace of the membrana tym- 
 pani nor of the ossicles. The bony wall of the right lateral 
 sinus was carious. The upper surface of the petrous bone was 
 of a bluish color. The cochlea and semi-circular canals were 
 not examined. 
 
 Of Fig. 115 I can furnish no history. 
 
 Prognosis. The prognosis of caries and necrosis of the tem- 
 poral bone depends upon several factors. To a marked degree 
 it is influenced by the age of the patient. Young children will 
 throw off quite large portions of the bone, and yet escape with
 
 CARIES AND NECROSIS PROGNOSIS. 559 
 
 their lives, while older persons will usually succumb to one of 
 the many consequences, such as pyaemia, hemorrhage, abscess, 
 which may result from death of bone in this part of the body. 
 'The situation also of the dead bone will influence the prognosis 
 of caries to a marked degree. Caries of the mastoid, especially 
 "when occurring in young children, is very often recovered from. 
 Caries and necrosis of the walls of the middle ear is of course 
 the most dangerous of all that may occur, especially caries of 
 the upper and lower wall. It has been seen that the whole inter- 
 nal or labyrinth wall may be destroyed, and the contents of the 
 external ear be exfoliated, and yet the patient recover. In 
 these cases the necrosed internal ear seems to have passed 
 through a sound tympanic cavity. 
 
 The prognosis of caries and necrosis of the temporal bone is, 
 however, always grave under any circumstances, and no life 
 can be said to be what the life insurance companies call a good 
 risk, if a chronic suppurative process has gone on to this extent. 
 The ossicula auditus may be thrown off with comparative im- 
 punity, as we see by cases all about us; yet even these cases, 
 unless the suppuration has entirely ceased, belong to a class of 
 whose results we must always stand in dread. Until the parts 
 have healed, and some kind of a neoplastic membrana tympani 
 has formed, we are not safe in giving a decidedly favorable 
 prognosis. 
 
 Although the hearing power is often much better when .the 
 drum -head is gone or perforated, than when it is present in a 
 cicatricial and thickened condition, it is much better to make 
 every attempt to restore or close it. The presence of this mem- 
 brane is essential to the safety of the patient from consequences 
 much more serious than impairment of hearing. 
 
 Treatment. It is impossible to give any specific rules for 
 treating caries and necrosis of the temporal bone. Each case 
 must be judged by itself, under the general rules of treatment 
 that have been given as appropriate for chronic suppuration ; 
 the chief of these rules, I may venture to repeat, are a thorough 
 removal of the accumulating pus before it has time to produce 
 its corroding and destructive effects, and careful attention to 
 the general health and habits of the patient. 
 
 It will often be necessary to open the mastoid, and to cut into 
 the bony wall of the canal to remove dead bone that is obstruct- 
 ing a free outlet of pus. Those who will study the abundant 
 literature of operations upon the diseased temporal bone, will, 
 I think, be convinced that there is a large field here for skilful 
 .surgical interference. Life has been saved in many cases, a
 
 560 
 
 CONSTITUTIONAL TREATMENT. 
 
 very long and tedious suppuration prevented in others, by the- 
 timely creation of a fistula in the bone, with the result of secur- 
 ing that sine qua non in cases of the constant formation of pus, 
 thorough drainage. 
 
 Of late the attention of the profession has been called to the 
 alleged value of the sulphide of calcium, which drug, according 
 to Ringer, has "the property of preventing and arresting sup- 
 puration " in cases of suppurations of the middle ear. Dr. Sexton l 
 argues earnestly, for the value of this drug in cases of disease of 
 the mastoid and temporal bone, as he does for its employment in 
 furuncular and external applications. I am not at all convinced 
 that this drug, or any other, has any such specific value as is 
 claimed for it. 
 
 Dr. Theobald,* in a paper before alluded to on the constitu- 
 
 FIG. 116. A diagram designed to show the relations of the Tympanic Cavity to the Mas- 
 toid Cells, the Jugular Fossa, and the Cavity of the Cranium. The inner wall of the cavity 
 is exposed to view, with the round and oval windows and the promontory. M, Mastoid cells ; 
 J, jugular fossa; E, Eustachian tube ; B, base of brain. (A L. Ranney.) 
 
 tional treatment of ear disease, thinks the profession has gone 
 too far in exclusively local treatment, and quotes a case of Dr. 
 Buck's, from his book (p. 307) to support his views. It was that 
 of a little girl of six years of age, who had alarming cere- 
 bral symptoms in connection with a severe attack of acute in- 
 flammation of the drum of each ear. The membranes of the 
 drum were red and bulging. A free incision was made. On the 
 following day the child was in a state of partial coma; pulse 
 140. Upon the advice of consulting surgeons mercury was given 
 internally and externally (calomel and inunctions of the oleate 
 of mercury), as well as bromide of potassium. An active dis- 
 
 1 The Treatment of Diseases of the Middle Ear and Contiguous Parts "by Milder 
 Measures than those Commonly in Vogue. Medical Record, vol. xxi., No. 3, p. 57. 
 
 2 Chapter XIV., his book.
 
 CONSTITUTIONAL TREATMENT. 561 
 
 charge established itself during the night, and the child made a 
 rapid recovery. Dr. Theobald believes that the change in this 
 case was due to the mercury, but I think we have all seen just 
 such changes occur where no drug was used, but when the sup- 
 puration was encouraged by poultices, and the warm douche, or 
 even when nothing was done. Dr. Theobald is an earnest advo- 
 cate for the use of mercury in aural disease, and quotes with ap- 
 proval Sir William Wilde, who valued the bichloride of mercury 
 so highly in acute and chronic aural disease. I have given mer- 
 cury a fair trial in public and private practice, and as I have 
 already said in this book, I shall probably never go back to its 
 use except as a tonic, in persons who have no syphilitic taint, 
 much as I value the experience of Dr. Theobald, who recom- 
 mends it so highly in almost every form of inflammation of the 
 ear. On the other hand, I am more and more in favor of the 
 early search for retained pus, so that if found, it may be liberated 
 in time. 
 
 Gruber 1 mentions one means of treating caries of the tem- 
 poral bone, in which I have no experience, but of which he gives 
 a favorable report, in some cases where the severe pain was not 
 relieved by local antiphlogistic and anodyne treatment. This is 
 the actual cautery. The iron is applied at several points over 
 the mastoid process. After the bony slough is removed, an 
 irritating salve may be applied to continue the counter-irrita- 
 tion. Dr. Post, of this city, also speaks well of the actual cautery 
 as a less painful means of treating mastoid periostitis than the 
 incision. I have no doubt, judging from my experience in a case 
 of Dr. H. G. Newton's which I saw in consultation where 
 Dr. Newton trephined the mastoid process for continuous and 
 severe pain referred to the middle ear, but without finding dead 
 bone, that such openings will do very much to relieve the deep- 
 seated pain of caries that is referred to the ear and the brain. 
 
 The facilities for treating chronic suppuration, since we have 
 Politzer's method of inflating the tympanum, are much greater 
 than those enjoyed by our predecessors. We may, by the em- 
 ployment of this method, more thoroughly cleanse the tympanic 
 cavity from pus than by the simple use of the syringe. 
 
 A patient with extensive caries of the temporal bone should 
 be made aware of the gravity of his condition, so that he and 
 his friends may be on the lookout for serious symptoms, which 
 may be promptly treated, and that they may not fall into the 
 error of supposing that no harm can possibly come from "a 
 simple running from the ear." 
 
 If polypi or granulations have occurred in connection with 
 
 1 Lelirbuch, p. 552. 
 36
 
 562 FATAL HEMORRHAGE FROX CARIES. 
 
 caries of the canal or tympanic cavity, they should be removed 
 with care, lest severe hemorrhage occur, or other harm to the 
 parts. The galvano-cautery has proved an efficient and safe 
 means of removing such granulations, 1 and of causing the bone 
 to heal. 
 
 Fatal hemorrhage has occurred from caries of the bony 
 canal, in which the internal carotid passes through the apex 
 of the petrous portion of the temporal bone, as well as from 
 destruction of the bony wall that separates the mastoid process 
 from the lateral sinus, and also from the breaking down of the 
 thin plate of bone that forms the floor of the cavity and sepa- 
 rates it from the jugular vein. Fortunately for the lives of 
 many patients, there is a tendency to thickening, or hyperplasia 
 of the bony walls of the tympanum, in some cases, and thus 
 they are protected from the corroding effects of pus. 2 
 
 Hessler 8 has recently collected nineteen cases of hemorrhage 
 from the internal carotid, in consequence of caries of the tem- 
 poral bone. One of these is Billroth's case, here quoted from 
 Gruber. A case in Hessler's own practice led him to look up 
 the literature of the subject, which he found uncollected. This 
 was that of a woman, who died suddenly, while suffering from 
 caries of each tympanum, from an enormous hemorrhage from 
 the mouth, nose, and right ear. In thirteen of the cases col- 
 lected by Hessler the diagnosis was rendered certain by a post- 
 mortem examination. One of these was his own. In the six 
 remaining cases, although a necroscopy was not had, it is prob- 
 able that death resulted from hemorrhage of the carotid. 
 
 He closes his valuable article with an account of three cases, 
 in which the section after death revealed complete absence of 
 the osseous canal of the carotid, and although this canal had 
 been surrounded by pus, no hemorrhage had occurred. 
 
 The first case quoted by Hessler is from Boinet (Archiv gen. 
 de Med., xiv., 1837). The patient, had suffered for seven years 
 from chronic suppuration. He had then severe hemorrhages in 
 two days and died. The second is from Chassaignac's treatise 
 
 1 Archiv ftir Ohrenheilkunde, Bd. VI., p. 116. 
 
 2 Gruber : Lehrbuch, p. 543. Gruber states that Billroth has tied the common 
 carotid artery for a case of aural hemorrhage, which occurred not from caries, but 
 from a congenital defect in the bony wall. The hemorrhage ceased for ten days after. 
 After all attempts to restrain the hemorrhage were fruitless, Billroth ligated the left 
 carotid, and two days after the patient died from severe hemorrhage from the right 
 ear, the nose, and mouth. A child, for whom parents would not allow the operation, 
 died from the same cause. Koeppe reports a case of hemorrhage from the lateral 
 sinus, through the nose and ear. This was in consequence of destruction of the bone. 
 
 1 Archiv fur Ohreuheilkuude, Bd. XVIII. , p. 1 et seq.
 
 FATAL HEMORRHAGE FROM CARIES. 563 
 
 on "Suppuration," I., page 529. He had suffered from aural 
 disease for six months, suppuration and facial paralysis for six 
 weeks. He also had tuberculosis of the lungs. He had three 
 hemorrhages in three days and died. Plugging the external 
 auditory canal only caused the blood to run out through the 
 Eustachian tube. Two cases are quoted from Toynbee. In one 
 of his cases, the patient also had phthisis pulmonalis. The fifth 
 case is from Baizeau (Gaz. d. Hop., page 88. 1861). Here also 
 was phthisis. The patient was a soldier, twenty-three years of 
 age. For ten months he had had chronic suppuration of the 
 ear. The hemorrhage occurred after coughing. The common 
 carotid was tied, but the bleeding recurred and the patient died. 
 In the sixth case, from Choyan, there is no mention of disease 
 of the lungs. There were three hemorrhages, in a patient who 
 had suffered for several months from chronic suppuration (Ar- 
 chiv gen. de Med., May, 1866). Broca, in 1866, reported a case 
 of tuberculosis of the lungs, caries of the temporal bone, with 
 several hemorrhages. The hemorrhage was stopped by ligation 
 of the common carotid, but the patient died soon after from 
 tuberculosis. 
 
 The remainder of this series of cases also tend to show, that 
 fatal hemorrhage, from caries of the bony surroundings of the 
 carotid artery, is especially apt to occur in phthisical patients. 
 In one case, that of Piltz, the patient was syphilitic. His lungs 
 were sound. The carotid was tied in three of the nineteen cases. 
 In none of the cases, however, was the hemorrhage permanently 
 arrested, but in one case death did not occur for two months and 
 a half. The time from the first hemorrhage until death varied 
 from five minutes to thirteen days in those cases, in which the 
 carotid was not tied. In two of the cases in which the carotid 
 was tied, death occurred in twenty and twenty-four days respec- 
 tively. Thus far, no essential results have been obtained from 
 treatment, either by the tampon, digital compression, or ligation 
 of the carotid. The nature of the disease, forbids any but a bad 
 prognosis. When the bleeding is not from the carotid but from 
 the tympanum, or a polypus springing from this part, the prog- 
 nosis is generally good. Thorough plugging the bottom of the 
 canal, with the use of persulphate of iron, will generally arrest 
 the hemorrhage, but here we are not dealing with a large vessel. 
 
 CEREBRAL ABSCESS. 
 
 The proceedings of pathological societies and surgical rec- 
 ords show, that abscess of the cerebrum more frequently results 
 from disease of the middle ear than from any other single cause.
 
 564 CEREBRAL ABSCESS. 
 
 Of seventy-six cases of cerebral abscess collected by Drs. Gull 
 and Button, 1 twenty-five, or about one-third, were directly trace- 
 able to chronic suppurative processes in the middle ear. Le- 
 bert," in his article upon this subject, considers that aural dis- 
 ease is the cause of cerebral abscess in about one-fourth of the 
 published cases. 
 
 Toynbee's catalogue contains ten cases of cerebral abscess 
 from aural disease. 
 
 There is usually caries in connection with the cerebral ab- 
 scess, but cases have occurred in which, although the disease 
 of the ear extended to the brain, there was no death of bone. 
 The anatomy of the cavity of the tympanum, especially of the 
 roof, or tegmen tympani, where a process of dura mater actu- 
 ally extends into the tympanic cavity, and where there may 
 normally be a gap in the bone, has taught us how easily this 
 may occur. The cause of the extension of a suppurative pro- 
 cess to the brain is undoubtedly very often that which Mr. 
 Toynbee so clearly sets forth in his chapter on this subject 
 that is, the non-escape of the pus externally through the mem- 
 brana tympani. The perforation of the membrana tympani in 
 acute inflammation usually prevents any such disaster as the 
 passage of the pus to the brain or the circulation. 
 
 Rupture of the membrana tympani is, therefore, a conserva- 
 tive process, if suppuration has once been established ; for there 
 is no other safe way of escape for the pus, except through the 
 Eustachian tube a means of exit which is one of the last that 
 nature chooses. Abscess of the brain in acute disease was only 
 once observed by Mr. Toynbee, but it has since been observed 
 by myself. 
 
 A direct communication usually takes place between the 
 diseased mastoid or petrous portion of the temporal bone and 
 the brain substance through the meninges, but the dura mater 
 and other membranes may be healthy, and even a portion of 
 healthy brain may lie between the diseased bone and the cere- 
 bral, abscess. The chronic disease of the ear may be going on 
 very well, until some mechanical injury exposure to cold, or 
 the like sets up an acute process, which extends to the brain 
 through the delicate bony walls of the tympanic cavity, or the 
 cancellous structure of the mastoid bone. 
 
 Patients suffering from chronic suppuration of the middle 
 ear cannot be too much guarded against blows or falls upon the 
 ear, or against exposures to sudden changes of temperature, 
 
 1 Reynolds' System of Medicine, vol. ii. , p. 544. 
 * Virchow's Archiv, Bd. X., p. 391.
 
 CEREBRAL ABSCESS. 565 
 
 draughts of air, or the like; for the histories of many cases 
 show that meningitis, cerebral abscess, and pyaemia may, from 
 such exciting causes, be the determination of a purulent dis- 
 charge from the ear. 
 
 The symptoms of disease of the brain are sometimes very 
 insidious. At times there is a chill or a convulsion, or nausea 
 and vomiting ; at others, only increased pain in the ear, fol- 
 lowed in rapid order by paralysis, coma, and death. In very 
 rare cases there are absolutely no symptoms, except those of a 
 chronic suppurative process in the ear, until death occurs. 
 
 The table of fatal cases of aural disease resulting from 
 chronic suppurative processes, added to this chapter, was com- 
 piled from various sources, in order to show the variable char- 
 acter of brain symptoms supervening an otitis media purulenta, 
 and the anxiety with which such a case, especially if united 
 with caries on necrosis of bone, should be regarded. 
 
 It is interesting to note how slowly the profession came to 
 recognize the fact that when pus was found in the brain com- 
 municating with the ear, that it was on its way inward, and 
 not making an external opening. It seems to have been hard 
 for the medical men of a few generations back, to believe that 
 aural disease could cause any serious affection, or that it was a 
 matter of much account, although people were dying all about 
 them from the results of aural disease alone. Lebert ' says that 
 Morgagni, "with his good tact and close observation of Nature," 
 discovered that the ear was often the cause of purulent affec- 
 tions of the circulation and brain substance; but Itard took a 
 step backward, and discovered a kind of cerebral abscess which 
 broke out through the ear. Lallemand again placed the subject 
 in its right light, and showed, what we now clearly see, in cases 
 of cerebral abscesses occurring in connection with suppuration 
 of the ear, that the organ of hearing was the part first affected. 
 
 It is generally believed that a suppurative process in the ear 
 is necessary for the production of an abscess of the brain, and 
 this is probably the fact ; but one case that I observed, leads me 
 to suspect that there may be such a thing as a chronic cerebral 
 abscess leading to disturbing aural symptoms, such as tinnitus 
 aurium and pain in one side of the head, without any primary 
 aural affection. I treated a gentleman of about twenty-nine 
 years of age, for some months, for such symptoms as have been 
 indicated, and when he died a cerebral abscess was found. He 
 could hear the watch only three inches from the left ear, which 
 was the affected one, and the drum membrane was sunken. I 
 
 1 Virchow's Archiv, Bd. IX., p. 382.
 
 566 CEREBRAL ABSCESS. 
 
 supposed the case to be one of chronic proliferous inflammation 
 of the middle ear. The patient got no relief ; he became very 
 despondent on account of his tinnitus aurium and pain, gave up 
 his business, and died at Sag Harbor, L. I., of malignant pus- 
 tule, about two years and a half after I first saw him, and three 
 years and a half after his first aural symptoms. Dr. George A. 
 Sterling, of that place, made a post-mortem examination. He 
 found "great injection of the pia mater over petrous portion of 
 temporal bone, and an abscess about the size of a ten-cent piece 
 in the brain substance. It was bounded by inflammatory adhe- 
 sions, and contained about ten drops of pus. The abscess was 
 situated on the left side, in the superior lobe, one inch from the 
 median line and two inches from the coronal suture." This pa- 
 tient never had a suppurative inflammation in the ear, and it 
 is possible that the cerebral abscess was the cause of his very 
 distressing symptoms, although the data are not full enough to 
 allow us to give a positive opinion. There is no account of an 
 examination of the temporal bone. 
 
 Through the labors chiefly of Macewen, of Glasgow, great 
 advances have been made in the diagnosis of cerebral abscess 
 resulting from aural disease. What is much more important, 
 lives have been saved by timely interference. The danger of 
 exposing and cutting into the brain was formerly considered as 
 very great, but surgical experience has shown this to be greatly 
 exaggerated, and no aural surgeon should now hesitate to tre- 
 phine the skull in the spheno-temporal fossa, in a case where 
 there is reasonable grounds for believing that we may have 
 cerebral abscess. I have great satisfaction in noting that what 
 was said upon page 553 of the last edition of this work was 
 prophetic. It was then said that " surgery has certainly some- 
 thing to hope for in the more careful search for pus beneath the 
 skull." Operations for cerebral abscess are now well established 
 among the legitimate and necessary procedures in surgery. 
 Personally I have operated but once as yet, and then without 
 success, but cases are being constantly reported * where a suc- 
 cessful result has been obtained. One of the late ones will be 
 found in a paper by Dr. Pritchard * of London. 
 
 PYAEMIA. 
 
 It is well known that pyaemia, or metastatic abscesses (sep- 
 ticaemia), from the entrance of pus into the circulation through 
 the mastoid veins or the lateral sinus, may result from aural 
 
 1 Archives of Otology, vol. p. 
 
 * Transactions International Congress of Otology, Brussels, 1888.
 
 PYAEMIA. 567 
 
 disease. A case of the late Dr. Ely and myself, which resulted 
 in recovery, is an interesting one. It has already been pub- 
 lished/ but chiefly with the view of pointing out the interest- 
 ing fact, that the recovery occurred without the use of medicine. 
 It is important enough to be inserted in this connection, for it 
 illustrates more than one point in aural practice. I quote from 
 Dr. Ely's account of the case : 
 
 Chronic Suppuration of both Middle Ears Mastoid Periostitis Wilde's Inci- 
 sion Opening of Cells by a Probe Relief for Seven Days Chill Pyaemia 
 
 Recovery. Louis S , aged fifteen, has had chronic suppuration of both 
 
 middle ears for many years. During the past year he has been treated in the 
 clinic of Dr. Roosa and myself at the Manhattan Eye and Ear Hospital, and 
 nothing unusual has been observed about his case until lately. On the after- 
 noon of January 20th he \vas brought to me with well-marked mastoid periostitis 
 on the right side. The cause of this inflammation was not evident. The red- 
 ness, tenderness, and swelling were confined chiefly to the anterior two -thirds of 
 the mastoid process, and the swelling was not very great. There was severe 
 pain in that side of the head, and marked constitutional disturbance. An im- 
 mediate operation was advised, but was declined by the family. The boy was 
 taken into the hospital, however, and four leeches were applied. When seen by 
 me at half-past eight the next morning, he was decidedly worse. There was 
 high fever a temperature of 104 and great pain in the right side of the head. 
 With the assistance of the house-surgeon, Dr. Cox, I made a Wilde's incision, but 
 found no pus. The bone exposed by the incision seemed sound ; but after con- 
 siderable burrowing under the anterior flap of the wound, I detected a softened 
 spot in the bone through which a stiff probe was gradually worked into the 
 mastoid cells, and a small quantity of thick pus then escaped. After the fistula 
 had been enlarged, a tent was inserted, a poultice applied, and the hot douche 
 ordered to be used every two hours. The operation was performed under ether. 
 The bad symptoms were immediately relieved. At 1 P.M. the temperature was 
 1014, and it fell rapidly to the normal. The mastoid tenderness and swelling 
 subsided. The patient seemed to be making a speedy recovery, and I considered 
 him out of danger. The wound was syringed with carbolized water and the tent 
 changed twice a day ; and the ear was douched frequently with hot water. Ex- 
 cepting that some pain persisted in the frontal and right temporal regions, there 
 appeared to be a progressive improvement in all respects until January 27th. 
 Early in the morning of that day he suddenly had a chill, and the temperature 
 at 9 A.M. was 104^. He complained of pains in various parts of the body, espe- 
 cially in the left knee-joint, the throat, and along the right external jugular vein. 
 All these points were very tender, particularly the track of the vein, but there 
 was no external redness or swelling. The discharge from the wound became 
 less. Between this date and February 8th he presented well-marked symptoms 
 of pyaemia. He had irregular chills and sweats, and a temperature varying 
 irregularly between 99i and 105. His tongue at first was brown and dry, and 
 then became very red, dry, and glazed. There was great prostration, a rapid 
 pulse, and a dusky pallor of the skin. There was marked increase of the previ- 
 ous deafness on both sides. He was restless at night, and may have had slight 
 
 'Archives of Otology, vol. x., p. 41.
 
 568 PYAEMIA. 
 
 delirium, judging from the account of his friends who sat with him ; but no 
 delirium was observed by any of his medical attendants. His pupils always 
 appeared normal. He had some cough and complained of pains in his chest, but 
 I could find nothing abnormal by physical examination. Several copious clay- 
 colored stools occurred. His general condition was so alarming that I thought 
 he would surely die ; and this was the opinion also of Dr. Koosa, who saw him 
 frequently in consultation with me. An unfavorable prognosis was given to the 
 family. 
 
 Additional features of his sickness may be gathered from the following some- 
 what incomplete notes, which I made from time to time : 
 
 January 28th. Pains the same as yesterday. Pains also in right axilla, along 
 the inner edge of the right biceps muscle and in the right knee. All these 
 points very tender. 
 
 January 29th. Discharge from the wound more abundant, of dark brown 
 color, and fetid. [This continued for five days.] Pains the same. 
 
 January 31st. Pains and tenderness along each clavicle. A red and tender 
 swelling about the size of a walnut has appeared over the left sterno-clavicular 
 articulation ; distinct sense of fluctuation. 
 
 February 2d. Pains and tenderness along clavicles, shoulders, and arms. 
 Less tenderness along jugular vein. 
 
 February 5th. Bed and painful swellings, apparently glandular, in the neck, 
 below mastoid, right side. [Deep suppuration occurred in the tissues of the 
 neck subsequently, and the pus was evacuated through the mastoid opening.] 
 
 February 12th. Swelling over clavicle gone. [All who examined this swell- 
 ing had diagnosticated fluid contents, but no incision was made into it.] Opened 
 an abscess in the gum over the second molar tooth, right upper jaw, and evac- 
 uated considerable pus. The whole right side of the face was flushed, swollen, 
 and tender. A probe in the incision passed about I| inches upward over the 
 exterior of the bone. "Patient sits up for the first time. 
 
 There were no unfavorable symptoms after this date. The convalescence 
 was slow, and the patient was not strong enough to leave his room until Febru- 
 ary 20th. He went out February 26th. At that time there was a free discharge 
 from the mastoid fistula and from the ear, and the hearing was -fa. 
 Below is a partial record of the temperature : 
 January 21st. 9 A.M., 104^ ; 1 P.M., 101i ; 7 P.M., 10H. 
 " 22d. 9 A.M., 101 ;'7r.M., i01. 
 " 23d. 9 A.M., 100 ; 7 P.M., 99^. 
 
 24th. 9 A.M., 99 ; 7 P.M., 99. 
 " 25th. 9 A.M., 981 ; 7 P.M., 98. 
 " 26th. 9 A.M., 99 ; 7 P.M., 98. 
 " 27th. 9 A.M., 104i ; 7 P.M., lOlf. 
 " 28th. 9 A.M., 104| ; 12 noon, 104| ; 7 P.M., 103i. 
 " 29th. 9 A.M., 104* ; 12 noon, 105 ; 10 P.M., 103f . 
 " 30th. 9A.M., 100J ; 2 P.M., 103. 
 " 31st. 9 A.M., 100 ; 19 P.M., 99. 
 
 From February 1st to February 8th. The temperature varied between 99 
 and 101. 
 
 This case is interesting not only on account of its fortunate 
 termination, but because it serves to illustrate the natural course
 
 PYAEMIA. 569 
 
 of the disease in question ; for, throughout his illness, the patient 
 took no drugs whatever. This plan of treatment was adopted at 
 the outset from my conviction that no drug would arrest the 
 septic poisoning, and that the large doses of quinine often used 
 were capable of doing harm. This view was shared by Dr. Roosa 
 in all my interviews with him ; but it evidently excited wonder 
 in the minds of some of the medical visitors who happened to be 
 attending the clinics at the time. This very common feeling of 
 surprise at seeing any alarming sickness treated without the use 
 of what is by so many considered essential, shows that many 
 minds can profit by the study of just such a narrative as has 
 been given above. 
 
 Aside from the matter of drugs, this, boy, of course, had a 
 great deal of medical treatment, in the best sense of the words. 
 He had a quiet room to himself with an open fire ; some member 
 of his family sat with him each night, and he had the efficient 
 nursing made possible through the kind supervision of Dr. Cox, 
 as well as the latter's constant medical observation. I visited 
 him often myself, and every small detail regarding food, stimu- 
 lants, dressings, etc., received thoughtful consideration. For- 
 tunately, food was well borne during the entire period. The 
 diet consisted of milk, to which- was added a little sherry wine 
 at first, and afterward a little whiskey. Poultices were kept 
 applied over the jugular vein and upon the painful swelling over 
 the left sterno-clavicular joint. The free action of the bowels 
 was doubtless useful in eliminating the poison, as has been re- 
 marked of other similar cases. Might not large doses of quinine 
 (through their astringent action) have tended to check these 
 desirable movements of the bowels, in addition to the depressing 
 effect they might have had upon the nervous system ? 
 
 As soon as the crisis of this boy's illness had passed, the im- 
 provement in the expression of his face and in his whole aspect 
 was so striking that it would naturally have been attributed to 
 any medicine that he might have been taking at the time. Still 
 more natural would such an inference have been regarding the 
 rapid disappearance of the abscess for such I believe it was 
 over the clavicle. 
 
 Another interesting point is that the sanitary condition of 
 the hospital was considered to be unusually bad then. 
 
 I examined this patient a few days ago (May, 1890). There is 
 a very slight purulent discharge from each tympanum, which is 
 carefully removed by the patient and occasionally by one of the 
 surgeons of our hospital. He is in excellent hetilth, hears con- 
 versation, addressed particularly to him, about two feet away.
 
 570 PYAEMIA. 
 
 Mr. Prescott Hewitt, 1 in 1861, related a case of pyaemia, and 
 with the like happy result of recovery. Mr. Hewitt's case was in 
 substance as follows : A young lady, eighteen years of age, had 
 a discharge from the ear, as a consequence of hieasles. About 
 four weeks after the occurrence of the discharge she was seized 
 with severe chills, which were followed by much fever, a furred 
 tongue, and typhoid symptoms, with suppression of the dis- 
 charge. When Mr. Hewitt saw the patient the chills continued, 
 the skin had assumed an earthen hue, and the fever was intense. 
 The intellect was clear, but there was pain extending down the 
 side of the neck, along the course of the jugular vein, and the 
 head was inclined to that side. There was swelling at the base 
 of the neck. In eight days pus appeared in one of the sterno- 
 clavicular articulations. In a few days one knee became in- 
 volved, and symptoms of pneumonia appeared, which soon sub- 
 sided. In about seventeen days from the beginning of the 
 phlebitis swelling and pain occurred over one of the hip- joints, 
 a deep abscess formed, but it was opened early, and the joint did 
 not become involved. The patient ultimately recovered under 
 treatment by wine and morphia. 
 
 This case and the others reported in this volume, give the 
 clinical features of purulent infection from suppuration in the 
 ear. The pathological characteristics of the disease are seen in 
 the table of fatal cases appended to this chapter. Professor Le- 
 bert 3 has given us the fullest account of the inflammations of 
 the sinuses that may lead to purulent infection. 
 
 At this writing, May, 1891, I have under my care, at the Manhattan Eye and 
 Ear Hospital, a case of septicaemia, occurring after an operation upon the inas- 
 toid, in which there was profuse venous hemorrhage, probably from the mastoid 
 veins. The patient is recovering. Another case occurring in the course of an 
 acute otitis media suppurativa, is also in the same hospital, under the care of 
 Dr. Emerson. 
 
 Dr. Hessler, 8 of Halle, has recently collected the published 
 cases of pyaemia in acute suppuration of the middle ear. He 
 includes but one of mine, and that he doubts somewhat. There 
 are eight cases in his table. The case of mine which Hessler 
 reports is that recorded in discussing the nasal douche. He is 
 inclined to consider it a case in which two diseases happened to 
 occur at the same time an acute inflammation of the middle ear 
 and a septic phlegmon of the left foot. I am tolerably familiar 
 with the symptoms of pyaemia, and although the case was origin- 
 ally reported to show the harmful results from the use of the 
 nasal douche, and not the symptoms of pyaemia, I well re : 
 member the discoloration of the veins of the neck, the chills, 
 
 1 London Lancet, February 2, 1861. Virchow's Archiv., Bd. IX., p. 381. 
 
 3 Archiv. f iir Ohrenheilkunde, Bd. XX. , p. 223.
 
 PARALYSIS. 571 
 
 the abscesses, and the pyaemic odor, which plainly marked this 
 case as one of pyaemia, not only to me, but to Dr. Swift and 
 Dr. Peters, who attended the case with me. The history shows 
 that pus found ' its way into the circulation from the tympanum 
 through the jugular vein. If Dr. Hessler had carefully exam- 
 ined the Transactions of the American Otological Society and 
 the Archives of Otology he could have added two cases to 
 his table from my practice, which, whatever my first case was, 
 were typical cases of pyaemia. To return to my first case, how- 
 ever, coincidental phlegmonous inflammation of the foot seems 
 to me out of the question as a diagnosis, just as much as i^ 
 endocarditis, which another German authority made for me, in 
 reviewing the case.' 
 
 Because it was not stated in the history that the chest was 
 examined, Dr. Weber-Liel assumed that an endorcarditis might 
 have been overlooked, as does Dr. Hessler. It is hardly neces- 
 sary to say that the patient had no endocarditis, and that the 
 patient's chest, as well as other parts of the body that are not 
 mentioned in the case, were carefully examined. Hessler ad- 
 mits, however, that, not having himself seen my case, he may 
 be mistaken in his opinion of it. 
 
 PARALYSIS. 
 
 Paralysis of the seventh nerve, as it passes through the tym- 
 panic cavity, in the Fallopian canal, must of necessity be a 
 consequence of many suppurative and carious affections of this 
 part, and yet it cannot be said to be a frequent affection in the 
 course of chronic suppuration of the.middle ear. In the greater 
 number of the cases in which it occurs it is permanent, from 
 the fact that the nerve tissue is destroyed by the ulcerative pro- 
 cess ; but I have seen several cases of temporary paralysis of 
 the seventh, which were probably due to pressure upon the 
 nerve-trunk ; for, the functions of the nerve were finally re- 
 stored, and the face resumed its normal appearance. 
 
 Paralysis of other parts of the body, and complete hemi- 
 plegia, may occur in the course of meningitis and cerebral ab- 
 scess ; but these necessary consequences of the destruction of 
 brain substance hardly require a separate notice. 
 
 It is possible that a blood-clot might form between the dura 
 mater and the bone, from rupture of a branch of the middle 
 meningeal, from caries of the temporal bone, and hemiplegia be 
 induced by pressure communicated to the motor tract, or, as 
 Mr. Hutchinson says, as quoted by Dr. Hughlings Jackson, 3 by 
 squeezing the blood from the corpus striatum. or thalamus op- 
 
 1 Monatsschrift fur Ohrenlieilkunde, 1869, p. 180. 
 * Reynolds' System of Medicine, vol. ii., p. 505.
 
 572 PARALYSIS. 
 
 ticus. The author has published two cases of hemiplegia, oc- 
 curring in coincidence with chronic suppuration of the middle 
 ear, 1 which are here reproduced as good illustrations of the sub- 
 ject, although it is not claimed that they should be regarded as 
 positively consequences of chronic suppuration. A boy, ten 
 years of age, was brought to me for advice on May 10, 1869. He 
 had had a discharge from the left ear since he was an infant, 
 and about four weeks ago he was affected with a number of 
 paralytic symptoms that came on gradually. He became un- 
 able to speak distinctly, or to swallow his food properly, and 
 finally he could not walk steadily. There was paralysis of the 
 seventh pair on the left side, and of the left arm and leg, so that 
 he could not grasp well, and he dragged his foot in walking. 
 These symptoms came on gradually, in the course of some 
 hours, a fact which indicated hemorrhage between th'e dura 
 mater and the bone. The right membrana tympani was intact, 
 but thickened, and it had no light spot. The left was ulcerated 
 and perforated. Its remains were very vascular. His hearing 
 distance was ^" from the right ear, and -fa" from the left. 
 Under the usual treatment the membrana tympani healed, and 
 the hearing power became normal. The paralysis was nearly 
 gone when he disappeared from observation. 
 
 June 8, 1870. The patient was again brought to me, and 
 his mother stated that he was seized with dizziness and loss of 
 sight while at school. He became so affected that he was fif- 
 teen minutes going two or three blocks, and he was stupid when 
 he reached home, although he had complete control of all his 
 limbs. He had sight enough to go about, but not to read. Two 
 months after this attack his vision was ^ with the right eye, and 
 i with the left. The field of vision was greatly limited on the 
 periphery. The ophthalmoscope did not detect any lesion in 
 the fundus oculi. Under expectant treatment the boy slowly 
 recovered his vision. 
 
 The second case was that of a farmer, aged sixty-two, whom 
 I saw in October, 1869, in consultation with Dr. Losee, of Red 
 Hook, N. Y. The patient had suffered from chronic suppura- 
 tion of the right ear, since he was a child. Occasionally acute 
 attacks would occur, culminating in abscesses of the mastoid. 
 For six years past, the ear had been very quiet. About six 
 weeks before I saw the patient, he was seized with hemiplegia 
 of the left half of the body, coming on in the course of a few 
 hours. When I saw him he was slowly recovering from the 
 paralysis. The hearing power on the right side was completely 
 destroyed. The cavity of the tympani was exposed and empty. 
 
 1 Transactions of the American Otological Society, 1870.
 
 OPHTHALMOSCOPE IN AURAL DISEASE. 573 
 
 There was a cartilaginous band extending across the canal, 
 which I divided, and found that it contained small bits of dead 
 bone, which seemed to come from the posterior wall of the canal. 
 The patient fully recovered from the paralysis, and is still living. 
 Dr. Hughlings Jackson, 1 in lecturing upon epileptic, or epi- 
 leptiform convulsions occurring in connection with discharges 
 from the ear, says, that arguing from the fact that cerebral or 
 cerebellar abscess may follow disease of the ear, "it becomes 
 legitimate to inquire if minute changes in tracts of the brain 
 may not occasionally follow a disease of this apparatus, which 
 changes may allow occasional discharge of nerve force." He is 
 anxious to learn if epileptiform seizures occurring in cases of 
 discharge of pus from the ear, may not result from minute 
 changes in venous tracts. There are still great gaps in our 
 knowledge of epilepsy and paralysis dependent upon aural dis- 
 ease. 2 Dr. Jackson urges that in all cases of hemiplegia in chil- 
 dren the ear should be examined, and that in such autopsies the 
 possibility of venous thrombosis from aural disease should be 
 borne in mind. 
 
 THE OPHTHALMOSCOPE AS AN AID TO DIAGNOSIS IN DISEASES OF THE 
 BRAIN RESULTING FROM AURAL DISEASE. 
 
 Dr. Kipp 3 called the attention of the profession to this sub- 
 ject. Since then I am constantly availing myself of the assist- 
 ance of the ophthalmoscope, in cases of chronic suppuration 
 with serious symptoms. I cannot say that I have been able as 
 yet to make a diagnosis by the examination of the entrance to 
 the optic nerve, the retina, and its vessels, that I did not make 
 from the study of the general symptoms and of the ear, yet I 
 think that a more general use of this assistance in diagnosis 
 may develop important results. Whenever we have a case of 
 acute or chronic suppuration of the ear, with symptoms of cere- 
 bral disease, such as severe pain in the head, vertigo, nausea, 
 vomiting, or delirium, the ophthalmoscope may be of service in 
 determining whether disease of the base of the brain exists or 
 not. That there is effusion along the course or at the origin of 
 the external muscles of the eyeball during the course of menin- 
 gitis and meningeal hypersemia from aural disease is well estab- 
 lished. One such case is recorded on page 524 of this book, where 
 recovery ensued. Dr. Kipp found double optic neuritis in four 
 cates of meningitis from aural disease. Two of them recovered. 
 In the first case the optic disks swelled so much as to completely 
 
 1 British Medical Journal, June 26, 1869. 
 
 2 The relations of epilepsy to aural disease will be discussed somewhat in the chap- 
 ter upon Diseases of the Internal Ear. 3 Archives of Otology, 1879, p. 147.
 
 574 OPHTHALMOSCOPE IN AURAL DISEASE. 
 
 obliterate their margins. The arteries remained of normal size, 
 but the veins became enlarged and tortuous. There was also 
 paresis of the sixth nerve of the right eye. In five months there 
 was no abnormal appearance in the optic papillae except that 
 they were whiter than normal. In twenty-six months the child 
 was well as to her eyes, both optic disks and retinae were normal 
 in appearance, and vision was normal. There was still some 
 discharge at intervals from each ear, and the drum-membranes 
 were perforated. In the second case, which was a fatal one, 
 optic neuritis appeared in ten days after Dr. Kipp saw the case. 
 In this there was central caries of the mastoid cells, abscess of 
 the right middle lobe of the brain, and thrombosis of the right 
 lateral sinus. In the third case reported by Dr. Kipp optic 
 neuritis was found after the patient had been suffering from 
 acute suppuration with mastoid abscess for a month. It may 
 have existed long before this, but the patient did not come under 
 Dr. Kipp's observation for sometime after the serious symptoms 
 appeared. The disks became very much swelled, so that a glass 
 of nine inches focal distance measured the hypermetropia at the 
 optic papillse, while at the maculae the retinae were of normal 
 refractive power. In six months the patient was in excellent 
 health, without discharge from the ears, and the optic disks 
 were of normal color and flat. The vision was perfect. In the 
 fourth case there was meningitis, thrombosis of the lateral sinus. 
 The retinal vessels were found full and tortuous two days after 
 the appearance of acute symptoms. The patient died on the 
 eleventh day and before this had well-marked optic neuritis. 
 Albutt * and Wreden a had previously noted optic neuritis in cere- 
 bral disease from otitis. Both of Albutt's cases recovered. In 
 Wreden's case, the intra-cranial disease was caused by a neo- 
 plasm originating in the nasal cavity. 
 
 It is an exceedingly interesting fact, that even the serious 
 forms of optic neuritis seen in connection with acute suppura- 
 tion may be entirely recovered from. No especial drugging was 
 resorted to in these cases, but the treatment was pre-eminently 
 local. Had even small doses of any drugs been administered 
 they might have been quoted, in spite of the energetic use of the 
 knife, poultice, and drainage, as proofs of the specific power of 
 medicines in arresting suppuration. 
 
 Dr. J. A. Andrews 3 followed up this subject by reporting four 
 cases, in which optic neuritis was observed in connection with 
 aural suppuration. In one case recovery occurred. Andrews 
 
 1 On the Use of the Ophthalmoscope, Appendix, 42 and43. 
 
 5 Archives of Ophthalmalogy and Otology, vol. v., No. 1, p. 75. 
 
 3 Transactions of the American Otological Society, 1883, p. 138.
 
 CEREBRAL ABSCESS. 575 
 
 would accept oedema of the optic disk in chronic suppurations of 
 the middle ear, that were not behaving well, as an indication for 
 opening the mastoid, and if not with the expectation of liberat- 
 ing pus, at least to establish free drainage from the middle ear. 
 Andrews quotes a case from Zaufal ("Inaug. Dissertation," 
 Zurich), of a student, aged sixteen, who suffered from purulent 
 otitis media and optic neuritis. After the mastoid was opened 
 the neuritis subsided and the patient made a good recovery. 
 
 An interesting discussion followed the reading of Dr. Andrews' paper, to 
 which those specially interested are referred. 
 
 In one case of death from meningitis following acute sup- 
 puration of the ear, that came under my observation, the post- 
 mortem examination showed that the pus might perhaps have 
 been reached by trephining the mastoid process, although this 
 part of the temporal . bone gave no signs of disease during the 
 progress of the case, and an incision was made down to the bone 
 for the purposes of examination. After much consideration of 
 these cases, I am greatly inclined to advise that a thorough 
 search should be made for pus, and by an opening through the 
 bone, in all cases where death seems to be threatened from a 
 cerebral abscess. I can see no reason why the surgeon should 
 sit with folded arms, when there is a certainty on one side that 
 death must ensue without interference, and a possibility on the 
 other that the use of the trephine might save life by the evacua- 
 tion of an abscess. Surgery certainly has something to hope for 
 in the more careful search for pus beneath the skull. Trephin- 
 ing for abscess of the cerebrum cannot be a more dangerous pro- 
 cedure than when undertaken for depressed bone, or for epilepsy. 
 In saying this, I have no desire to retract anything of what was 
 said in a preceding chapter upon the performance of unnecessary 
 surgical operations. Most of the searches for the pus in abscess 
 of the brain would probably result in failure. I have myself 
 failed in the one case in which I attempted it, but one success 
 would atone for many failures, for it would save a life. 
 
 The table on the following pages, which I have compiled from 
 various sources, illustrates in a striking manner the fatal con- 
 sequences of some cases of aural disease. Taken in connection 
 with the fact already stated, -that suppuration of the ear is more 
 frequently the cause of cerebral abscess than any other one dis- 
 ease, these cases form a complete justification, if one were 
 needed, for the giving up so much space to the consequences of 
 chronic suppuration of the middle ear. If the table shall startle 
 some mind hitherto inattentive to this subject, into a realization 
 of its grave importance, and lead to a more careful consideration 
 of an ulcerated middle ear, it will have accomplished its object.
 
 576 
 
 CASES OF CEREBRAL ABSCESS. 
 
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 NEURALGIA OF THE MIDDLE EAR. 583 
 
 NEURALGIA OF THE MIDDLE EAR, 
 
 Neuralgia is usually understood to be a disease of the sen- 
 sory nerves, characterized by paroxysmal pain, without the 
 objective appearances of inflammation, and which occurs in the 
 course of nerves. In this sense neuralgia of the ear is an ex- 
 tremely rare disease. Yet it does sometimes occur, and when 
 it does, the pain is generally referred to the tympanic cavity 
 and the osseous portion of the auditory canal. Its origin is 
 sometimes to be found in carious teeth, and in the existence of 
 malarial or syphilitic poisoning. 
 
 Acute inflammation of the middle ear, of a catarrhal or even 
 of a purulent form, was formerly often mistakenly supposed to 
 be neuralgia. Better means of diagnosis, and a consequently 
 better knowledge of morbid appearances, have greatly dimin- 
 ished these errors, but even to this day the diagnosis of otalgia, 
 figures more largely than it should. 
 
 The supply of sensory nerves to the tympanum, Eustachian 
 tube and auditory canal, is so large, that it would be strange if we 
 did not occasionally meet with a case of pain referred to these 
 parts, without any redness of the drum-head and canal, or swell- 
 ing of the tube. Undoubtedly, if the seat of pain could be ex- 
 amined in such cases, the nerve-tissue or its covering would 
 show a pathological condition, either to the naked eye or the 
 microscope, yet there are no inflammatory symptoms, in the 
 ordinary sense of the term, in neuralgia of the ear, except pain, 
 with perhaps sensitiveness of the canal and mastoid process. 
 Neuralgia of the ear may occur in debilitated and overworked 
 persons, and also in chronic catarrhal and chronic proliferous 
 inflammation, as well as in chronic suppurations in anaemic 
 subjects, and in the course of secondary syphilis. In neuralgia 
 of the middle ear from diseased teeth, like that of the eyeball 
 and eyelids, there are no inflammatory symptoms, but in the 
 earache occurring from difficult dentition, either the reflex pro- 
 cess leads very rapidly to trophic changes, or the pain in the 
 ear, like that of the gums, is of inflammatory origin from the 
 start. The continuity of the mucous membrane of the mouth 
 with that of the bony Eustachian tube and tympanum, which is 
 especially close in young children, is sufficient ground for sus- 
 pecting that the pain in the ear in such subjects, is simply an 
 inflammation that has extended from the gums to the middle 
 ear. Be this true or not, and I believe it is, infantile earache, 
 occurring in dentition, is practically an inflammation, as gener- 
 ally understood, and not a neuralgia.
 
 684 NEURALGIA OF THE MIDDLE EAR, 
 
 Great importance is ascribed by certain writers to the condi- 
 tion of the teeth in the causation of diseases of the ear. Sexton * 
 says that of fifteen hundred aural cases seen by him "perhaps 
 one-third owe their origin or continuance, in a greater or less 
 degree, to diseases of the teeth." This is a surprising statement 
 to me, for on a careful consideration of my own cases of aural 
 disease, now reaching in public and private practice more than 
 ten thousand in number, I have notes of but very few, not more 
 than one in a hundred, where it seemed to me that the condition 
 of the teeth had any positive influence in causing or maintain- 
 ing the aural disease. The cases that I have seen, were chiefly 
 among infant children, who suffered from acute otitis media, at 
 the same time with an inflammation of the gums. I have, how- 
 ever, seen a few cases where ulcerating teeth produce what is 
 apparently reflex neuralgia of the middle ear. I have also in 
 my ophthalmic practice seen paresis of accommodation and 
 keratitis instantly relieved, and ultimately cured, after the re- 
 moval of carious teeth. I am very far then from denying that 
 decaying teeth, or swelled gums, may produce reflex disturb- 
 ances in the ear, but I think the number of cases of aural disease 
 thus caused is small. Infantile earache during dentition is usu- 
 ally an acute catarrh or acute suppuration of the middle ear, 
 and not a neuralgia. This inflammation is, I think, even after a 
 consideration of the theories of Woakes," caused by an extension 
 of the inflammation of the mucous membrane of the mouth and 
 pharynx to that of the Eustachian tube. When a reflex aural 
 disease is induced by the condition of the teeth, it is usually of a 
 neuralgic and not inflammatory character, although of course, 
 if the disease of the nerve or of its sheath, or whatever neural- 
 gia may be, be continued long enough, changes in other tissues 
 may occur. 
 
 Dr. C. H. Burnett 3 reports the case of a physician, who con- 
 sulted him on account of impairment of hearing, tinnitus, and a 
 peculiar sense of discomfort in the left ear. The drum-head 
 was "lustreless, opaque, and retracted." In a year neuralgia in 
 the post-auricular region, with a constant and pounding tinnitus, 
 synchronous with the pulse and a peculiar tapping noise not 
 synchronous with the pulse. There was also ear-cough, but* not 
 excessive. All of these symptoms came on and kept up during 
 excessive pain in the first molar tooth in the upper maxilla of 
 the same side. This tooth was filled ten years before and the 
 
 1 American Journal of the Medical Sciences, vol. Ixxix. , p. 18. 
 
 2 Deafness, Giddiness, and Noises in the Head. Second edition, p. 16 et seq. 
 
 3 The Specialist and Intelligencer, November 1, 1880.
 
 NEURALGIA OF THE MIDDLE EAE. 585 
 
 aural symptoms had first shown themselves six months after 
 the tooth was filled. An abscess finally formed, and the tooth 
 was extracted, with instantaneous relief from all forms of tinni- 
 tus, tapping sounds, and neuralgia in the ear, and the ear-cough 
 and the hearing became much better. 
 
 Bonnafont 1 devotes considerable space to neuralgia of the 
 ear, and says that the disease rarely attacks both ears at once, 
 but that it readily passes from one to the other, in consequence 
 of the sympathy between the two sides of the fifth pair. There 
 is apt, according to the same author, to be injection of the con- 
 junctiva and lachrymation, in connection with otalgia. 
 
 The seat of otalgia may be, according to Bonnafont, in the 
 auditory nerve, the chorda tympani, or the nerve-supply of the 
 tympanic cavity. Bonnafont advises instillation into the ear 
 of a concentrated decoction of poppy-heads, and cataplasms or 
 blisters on the auricle and mastoid process. 
 
 Gruber 2 reports a case of typical otalgia cured by the use of 
 iodide of potassium. Quinine was tried, but proved of no service. 
 
 Gruber thinks it possible that there was an exudation press- 
 ing upon the nerve in this case. The symptoms were spasmodic 
 contraction of the left side of the head, with pain in the ear 
 occurring at irregular intervals ; the longest intermissions were 
 a few days. The hearing power was normal, and there were no 
 pathological objective symptoms. 
 
 I have seen and treated cases of neuralgia of the middle ear, 
 which I thought to be of malarial origin. In one case, that of a 
 physician of twenty-seven years of age, who had suffered for 
 some months from acute pain referred to the tympanum and 
 mastoid process, recovery promptly ensued on the use of quinine. 
 I have seen a few others in hospital practice, but I have no notes 
 of the progress of the cases. Each case of neuralgia of the ear 
 should be studied by itself. The diagnosis is of great impor- 
 tance, for one of the most valuable of remedies for neuralgia, 
 quinine, is usually very harmful when administered in the course 
 of catarrh or suppuration of the middle ear. Indeed in large 
 doses, it is also harmful in all the inflammations of various 
 parts of the ear. Its use should be avoided in all persons who 
 have hypersemia of the auditory apparatus, or in those who 
 readily suffer from inflammation of the middle ear. I have seen 
 neuralgia in the ear in the course of syphilis, usually as one of 
 the later manifestations. Here of course the usual anti -syphilitic 
 treatment by means of mercury and potash will be of service. 
 
 1 Traite theorique et pratique des maladies de 1'oreille. Paris, 1873, p. 557. 
 8 Monatsschrift fur Ohrenheilkunde, Jahrgang III., No. 9.
 
 586 NEURALGIA OF THE MIDDLE EAR. 
 
 If the cause of neuralgia be once found, whether it be a decayed 
 tooth, the poison of syphilis or malaria, or general aneemia, the 
 treatment will be simple enough. From all I have seen, I can- 
 not believe that there is any considerable number of chronic 
 aural diseases of the non-suppurative variety, that are in any 
 way caused by the condition of the teeth. It is not very rare, 
 however, to find a neuralgic disease added to a chronic -suppura- 
 tive process, when there is no active inflammation going on, and 
 also in the course of the non-suppurative disease of the same 
 part. Until it can be proven that people with sound teeth have 
 a particular immunity from disease of the ear, it is hardly 
 proper to assume that what may be a coincidental condition, 
 decayed teeth ill-fitting and improperly constructed plates for 
 false teeth are actually causes of any considerable proportion 
 of the cases of chronic aural disease. 
 
 I have carefully examined the teeth of my aural patients for 
 some years, and I have failed to find that there was any strik- 
 ing connection between chronic disease of the ear and bad teeth. 
 Indeed, some of the most distressing cases I have known, were 
 in people with particularly good teeth. 
 
 CASES. 
 
 The following case illustrates the subject of trophic changes 
 in the middle ear, which were perhaps caused by a neurosis, in 
 its turn produced by dental irritation. The patient lives in 
 Italy, and I have never learned whether the diagnosis proved 
 to be correct. 
 
 CASE I. Deafness, Tinnitus, Itching, and'Pain in the Left Ear for Two Years 
 Neuralgia of Jain and Face on same Side, Disease about and in Last Molar Tooth. 
 
 September 15, 1882. Mrs. , aged forty. Has had deafness, tinnitus, pain, 
 
 and itching in left ear for two years. Neuralgia of jaw, face, shoulder, and arm 
 of left side for some time. Dizziness and nausea quite often for some time ; 
 dizziness without nausea before. Has had a great deal of neuralgia before, and 
 is subject to headaches. Hearing distance, right ear, }$ ; left ear, IS- Tuning- 
 . fork heard on vertex, but in left ear (?). Bone conduction better than aerial on 
 each side. The patient has a hard swelling high upon gum above last molar 
 tooth of left side. She has had an ulcerated tooth there with similar swelling, 
 requiring lancing, further forward. Present swelling increasing in size ; not 
 tender. Right membrana tympani opaque ; fair light spot ; fair position ; left 
 membrana tympani opaque ; fair light spot ; fair position. 
 
 Inflation only felt after two trials with chloroform. Hearing distance left 
 ear, after inflation, i$. 
 
 Diagnosis. Neuralgia and trophic changes in tympanum from irritation of 
 fifth nerve. 
 
 Advice. Inflation, and advised to have the gum and tooth treated.
 
 CASES OF NEURALGIA OF THE MIDDLE EAK. 587 
 
 CASE II. Primary Syphilis Miscarriage Nocturnal Pains in the Shin Banes 
 Sore Tliroat Neuralgia of Tonsil, Ear, and Eyeball No Impairment of Hearing 
 on the affected side Sub-acute Catarrh of the Middle Ear on the other side. Mrs. 
 
 O , aged twenty-four, February 21, 1884. Patient was married three years 
 
 since. Three months after marriage she miscarried, and soon after had severe 
 nocturnal pains referred to the shins, and closely following severe pains in the 
 head. Two years after marriage she had sore throat. Six weeks ago she had a 
 very sore throat, and severe pain referred to the tonsil, Eustachian tube, middle 
 ear of the right side. This pain continues, although not constantly, and is much 
 worse at night. The patient has been under careful treatment by mercury, pot- 
 ash, and great attention to the nutrition for the whole time since the mis- 
 carriage. She is in fair condition, but suffers very much from the pain in the 
 throat and ear. Her husband states that he contracted syphilis two years before 
 marriage, but that he had no symptoms at the time of the marriage. He had a 
 chancre, alopecia, papular eruption, and indurated cervical glands. None of 
 these symptoms, except the latter, now exist. 
 
 The hearing distance for the watch on the right side is about J$. Aerial con- 
 duction better than that through bone. On the left side the hearing distance is 
 reduced to - 4 a 8 -, and the aerial and bone conduction are about the same. There is 
 no pain whatever on this side. The patient is not aware that she is at all hard of 
 hearing. Does not know that she ever had any earache as a child. Both drum- 
 heads are sunken and opaque, and the light spots are small. The pharynx is 
 secreting an excessive amount of muco-purulent material. It is also swelled. 
 There has never been any dizziness in the course of the disease. The upper 
 teeth are false. One of the molars on each side is absent ; the other teeth are 
 not sensitive. On inflation the hearing distance of the left ear became normal. 
 
 Thanks to the frankness and intelligence of the husband of 
 ihis patient, I was enabled to get a full history of the syphilitic 
 origin of this case, the wife being ignorant of it. My diagnosis 
 was neuralgia of the fifth nerve of the right side, of syphilitic 
 origin, and sub-acute catarrh of the left tympanum. It was a 
 striking instance of the different forms of disease in one and 
 the same person. On one side was a syphilitic, well-marked 
 neurosis, and on the other a syphilitic catarrh. 
 
 "While preparing these pages for the press, Dr. Ramsdell, one 
 >f the staff of the Manhattan Eye and Ear Hospital, called my 
 attention to a case of severe neuralgia of the middle ear, which 
 occurred in the course of a chronic suppuration of the tym- 
 panum. The pain was decidedly different from that occurring 
 from an increase in the inflammation, for example, in mastoid 
 periostitis, being of an intermittent character. It was relieved 
 by large doses of opium, and the inflammatory process made no 
 advance while the neuralgia was under full headway. A true 
 inflammation of the lining membrane would have only been re- 
 lieved by antiphlogistic means. The patient was an ansemic 
 woman of twenty-two years of age.
 
 CHAPTER XX. 
 
 ANATOMY AND PHYSIOLOGY OF THE INTERNAL EAR. 
 
 The Vestibule, Semi-circular Canals, Cochlea, and Auditory Nerve. Physiology of 
 
 the Internal Ear. 
 
 GALEN named the internal ear the labyrinth, although he did 
 not attempt to describe its various parts. This name it con- 
 tinues to bear, although so much labor has been given to its 
 exploration, that we now have the thread to guide us through 
 its devious passages. Yet in our own time, a part of this in- 
 ternal ear the cochlea is still the subject of vigorous research 
 and heated discussion, and different views are yet entertained 
 by competent authorities as to the true description of its com- 
 ponent parts. I shall attempt to give the student such an ac- 
 count of its anatomy as shall serve as a basis for the study of 
 its physiology and diseases, without entering into the discus- 
 sion of the points still unsettled. 1 
 
 The internal ear may be conveniently studied by dividing it 
 into the following parts : 
 
 1. The vestibule. 
 
 2. The semi-circular canals. 
 
 3. The cochlea. 
 
 4. The auditory nerve. 
 
 We shall first study the osseous envelope of these parts, and 
 then consider their contents ; the latter being, of course, far 
 more important. 
 
 THE VESTIBULE. 
 
 The vestibule is considered by all authorities to be an essen- 
 tial part of the internal ear. A part answering to the vestibule 
 is to be found in all animals in whom an auditory apparatus 
 can be detected. It is the seat of the principal expansion of the 
 auditory nerve upon the saccule. This saccule floats in the peri- 
 
 1 In compiling this anatomical sketch, the text-book of Henle has formed the basis 
 of the description of the microscopic anatomy of the labyrinth.
 
 592 
 
 THE VESTIBULE. 
 
 lymph, and communicates through that fluid with the membrane 
 of the fenestra ovalis, and consequently with the air in the tym- 
 panic cavity. 
 
 The vestibule is an irregularly shaped osseous cavity, the 
 diameter of which from above downward, as also from behind 
 forward, is about one-fifth of an inch. It is about one-tenth of 
 an inch between its inner and outer wall. The semi-circular 
 canals open into it by five orifices behind the cochlea, by a 
 single one in front. The fenestra ovalis is on its outer wall ; 
 above this is the anterior opening of the horizontal semi-circular 
 
 FIG. 117. The Left Vestibule, with the 
 Semi-circular Canals, from an Adult, seen 
 from within (Rudinger). 1, The horizontal 
 semi-circular canal ; 2, the upper semi-cir- 
 cular canal ; 3, the posterior semi-circular 
 canal; 4, a bristle is passed through the 
 aqueductus vestibuli, and passes into the 
 opening of two canals, and appears on the 
 upper wall of the vestibule ; 5, the mouths 
 of the osseous ampullae of upper and hori- 
 zontal semi-circular canals ; 6, the opening 
 of the lower ampulla of the posterior semi- 
 circular canal, below the numbers 6 and 7 ; 
 7, the lower opening, in which the bristle is 
 seen, represents the opening of the common 
 passage for two semi-circular canals. 
 
 FIG. 118. The Vestibule (after Rudin- 
 ger). 1, The osseous lamina spiralis of the 
 cochlea, beginning below and posteriorly on 
 the wall of the vestibule ; 2, the scala tym- 
 pani and the fenestra rotunda ; 3, the scala 
 vestibuli ; 4, fenestra ovalis ; 5, the posterior 
 inferior wall of the lower ampulla, with the 
 inferior macula cribrosa, which serves as a 
 passage for the fibres of the vestibular nerve 
 to the lower ampulla ; 6, fovea rotunda, or 
 recessus hemisphaericus ; in its centre are a 
 number of fine openings, the macula cribrosa 
 media ; through these the fibres of the middle 
 branches of the vestibular nerve pass to the 
 round saccule, which is the blind vestibular 
 end of the scala vestibuli ; 7, the upper por- 
 tion of the recessus bemillipticus, in which is 
 the upper macula cribrosa ; 8, the lower por- 
 tion of the recessus hemillipticus, which 
 passes without any distinct dividing line into 
 the semi-circular canals. 
 
 canal ; on its inner are several minute holes, making up the 
 maculae cribrosse for the entrance of a portion of the auditory 
 nerve from the internal auditory canal. At the posterior part 
 of the inner wall is the orifice of the aqueductus vestibuli, a 
 fine canal penetrating the vestibule from the posterior surface 
 of the petrous bone, and contains a tubular prolongation of the 
 lining membrane of the vestibule, ending in the cranial cavity, 
 between the layers of the dura mater. 
 
 The maculae cribrosae on the inner wall of the vestibule, are
 
 VESTIBULE AND SEMI-CIRCULAR CANALS. 593 
 
 to be seen with the naked eye on the newly born, but in the 
 adult they are only to be seen by means of the microscope. 
 Henle describes four little groups, each having five openings, 
 and each series of foramina make up what is known as a ma- 
 cula cribrosa. Through the macula cribrosa superior, the nerves 
 pass to the utricle and to the ampullae or flask-shaped openings 
 of the anterior vertical and the horizontal semi-circular canals. 
 The nerve -fibres to the posterior semi -circular canals pass 
 through the inferior macula cribrosa, and those to the saccule 
 through the macula cribrosa media. Finally, through the fourth 
 macula cribrosa, passes the twig of the small branch of the 
 cochlear nerve. The scala vestibuli of the cochlea begins on the 
 anterior apex of the vestibule. 
 
 The outer wall of the vestibule is interrupted by the fenestra 
 ovalis, but it is so completely and smoothly closed by the base 
 of the stapes bone, that the inner surface of this wall of the ves- 
 tibule appears even. On the inner wall are two depressions, 
 called respectively the recessus sphsericus and the recessus 
 ellipticus. A minute elevation between them is called the crista 
 vestibuli. 
 
 The crista vestibuli runs above into the pyramidal elevation 
 pyramis vestibuli ; below it divides into two branches, which 
 enclose a space called recessus cochlearis. 
 
 Just above the recessus ellipticus opens the ampulla or flask- 
 like orifice of the anterior vertical semi-circular canal. The 
 recessus ellipticus is partly bounded below by a shallow furrow, 
 sinus subciformis. The two vertical canals open at the junction 
 of the posterior and inner wall. On the same line, but a little 
 higher in the middle of the posterior wall, is the posterior open- 
 ing of the horizontal semi-circular canal. The lower opening of 
 the posterior vertical canal is in the angle formed by the poste- 
 rior, lower, and inner wall of the vestibule. The anterior am- 
 pulla of the horizontal canal lies on the outer wall between the 
 fenestra ovalis and the ampulla of the anterior vertical semi- 
 circular canal. 
 
 THE SEMI-CIRCULAR CANALS. 
 
 The semi-circular canals are half-elliptical or C-shaped canals 
 which proceed from the vestibule and return to it again. They 
 are three in number. The horizontal lies with its convexity 
 directed laterally. The other two are vertical in position, form- 
 ing a right angle with each other. The two openings of the 
 anterior vertical semi-circular canal are near each other and at 
 about the same height. The openings of the posterior vertical 
 38
 
 594 
 
 SEMI-CIRCULAR CAXALS. 
 
 canals are above each other. The horizontal canal is surrounded, 
 as it were, by the two vertical ones. 
 
 There are considerable variations in different individuals, in 
 the length and curvature of the semi-circular canals, yet the 
 general shape of these parts remains the same. 
 
 FIG. 119. Section of Temporal Bone of Right Side through the Cochlea (anterior view, 
 actual size). 1, Mastoid cells; 2, internal auditory canal; 3. modiolus and lamina spiralis; 
 4, cochlea ; 5, superior semi-circular canal ; 6, horizontal semi-circular canal. 
 
 The length of the anterior vertical canal, measured on the 
 convex border, with the ampulla and the common crus, is about 
 -f of an inch ; that of the posterior is | of an inch, of the horizon- 
 tal of an inch. The part common (canalis communis) to the 
 two vertical canals is from ^ to | of an inch in length. The 
 diameter in a grown man varies from to - of an inch. 
 
 FIG. 120. Osseous Cochlea and Semi- 
 circular Canals, with Stapes Bone. Left 
 Ear of Adult (after Rudinger). 
 
 FiG. 121. Right Osseous Vestibule, 
 Semi-circular Canals, Cochlea, and Ossi- 
 cula Auditus of Newly Born (after Ru- 
 dinger). 
 
 Wharton Jones makes their calibre about one-twentieth of an 
 inch in a direction from the concavity to the convexity of their 
 curve. 
 
 Since the semi-circular canals all open at both ends into the 
 vestibule, there would be six orifices were not one of the orifices 
 common to two of the canals. There are, consequently, five. 
 These openings are called ampullae (flasks) from their shape, and 
 are more than twice the diameter of the tubes. The inner
 
 SEMI-CIRCULAE CANALS. 
 
 595 
 
 extremity of the superior vertical canal has a common open- 
 ing into the vestibule with the posterior vertical. 
 
 FIG. 122. The Right Osseous Labyrinth of a Newly Born Subject opened on its Posterior 
 Surface (after Riidinger). 1, Cochlear f enestra ; 2, the osseous spiral; 3, the osseous spiral 
 canal of the cochlea canalis spiralis cochleae divided by the spiral into two parts, scalaj, or 
 stairways, the lower the scala tympani, the upper the scala vestibuli ; 4, the basis of the inter- 
 nal auditory canal, with the entrance to the Fallopian canal and the maculae cribrosse. The 
 latter receive the fibres of the auditory nerve, and the vessels entering with it into the laby- 
 rinth ; 5, the osseous vestibule, opened on its posterior wall ; 6, the posterior semi-circular 
 canal ; 7, the upper semi-circular canal ; 9, horizontal semi-circular canal. 
 
 According to Henle, 1 in the later years of life the semi-cir- 
 cular canals increase in length ; the horizontal canal increases 
 
 FIG. 123. Section of Right Temporal Bone, showing Osseous Semi-circular Canals (actual 
 size). 1, Internal auditory canal ; 2, superior semi-circular canal ; 3, external semi-circular 
 canal ; 4, posterior semi-circular canal. 
 
 the most, and the anterior vertical the least. The canals also 
 increase very slightly in width ; about 0.7 mm. according to 
 Pyrtl. 
 
 THE COCHLEA. 
 
 This part of the internal ear is so named from its resemblance 
 to a common snail ; a resemblance which is very marked. It is 
 one of the most remarkable instances in the whole body of the 
 compact packing of very important parts. 
 
 1 Lehrbuck, p. 762.
 
 596 COCHLEA. 
 
 The osseous cochlea lies in front of the vestibule, and behind 
 the carotid canal, and forms the promontory by pressing out, as 
 it were, the bone toward the tympanic cavity. Inward it strikes- 
 upon the blind end of the internal auditory canal. The cochlea 
 is aptly compared to a tube tapering toward one extremity 
 where it ends in a cul-de-sac, and which is coiled like the shell 
 of a snail round an axis or central pillar. Then we must 1 sup- 
 pose this tube divided into passages by a thin partition running 
 throughout its length, and spirally around its axis. 
 
 The tube of which the cochlea is formed the canalis spiralis 
 cochleae, is about an inch and a half long, about one-tenth of an 
 inch in diameter at its commencement, and about one-twentieth 
 at its termination. It makes two turns and a half turn, in a di- 
 
 c m 
 
 a e 
 
 FIG. 124. Osseous Cochlea (Right) of the Newly Born, opened from the Outer Surface 
 (after Henle). * v, Scala vestibuli ; t, scala tympani ; I .s, lamina spiralis ; c s, crista 
 semilunaris; a c, inner opening of the aqneductus cochlea; c m, canalis centralis; s m, 
 canalis spiralis modioli. 
 
 rection from below upward, from left to right in the right ear, 
 and from right to* left in the left ear. The apex of the coil is 
 directed forward and outward. The base of the spiral tube runs 
 into the vestibule. The cul-de-sac at the apex forms a kind of 
 vaulted roof called the cupola. 
 
 The first turn of the cochlea has a circular sweep of a quarter 
 of an inch, and is wider than the rest. It is separated from the 
 second turn by a soft bony substance, which extends a little 
 way between the second and third. The axis is composed of 
 the internal walls of the tube of the cochlea and the central 
 space circumscribed by their turns, in which space are the fila- 
 ments of the cochlear nerve running In small bony canals. The 
 axis is about one-seventh of an inch in thickness at the first turn,
 
 COCHLEA. 597 
 
 but it becomes thinner from the second turn, on to its termina- 
 tion. The axis terminates within the last half coil or cupola, in 
 'a delicate bony lamella, which resembles the half of a funnel, 
 divided longitudinally, and called the infundibulum (funnel). 
 Wharton Jones compares the appearance of the axis of the 
 cochlea after the outer walls have been removed, to the ordinary 
 pictorial representations of the tower of Babel. 
 
 The cavity of the cochlea is divided into two parts or pas- 
 sages, called scalce, by a thin osseous and membranous spiral 
 lamina, lamina spiralis ossea. The lower one communicates 
 with the cavity of the tympanum through the fenestra rotunda, 
 the upper with the recessus hemisphsericus (see Fig. 118, of the 
 vestibule). The former space is therefore called the scala tym- 
 
 FlG. 125. Section through Cochlea and Vestibule (left side, actual size. From Professor 
 Darling's museum). 1, Carotid canal ; 2, broken styloid process ; 3, first turn of cochlea ; 4, 
 vestibule ; A, A, superior semi-circular canal ; B, B, external semi-circular canal ; C, aquae- 
 ductus Fallopii ; Z>, auditory nerve channel. 
 
 pani, the latter scala vestibuli. In the scala tympani, just 
 above the membrana tympani secondaria, which closes the fen- 
 estra rotunda, is an opening, called the entrance of the aque- 
 duct to the cochlea. The two scalse communicate at the apex 
 of the cochlea by a common opening called the helicotrema ( 
 twisted foramen). This communication exists in consequence 
 of the want of a lamina spiralis in the last half coil of the 
 canal. 
 
 Two very small canals called aqueducts open by one ex- 
 tremity into the labyrinth, and by the other on the surface of 
 the petrous portion of the temporal bone.
 
 598 
 
 MEMBRANOUS LABYRINTH. 
 
 PERIOSTEUM OF THE LABYRINTH. 
 
 The periosteum that covers the walls of the osseous canal 
 is, with the exception of that on the outer wall of the cochlea, 
 very delicate. Henle ' compares the periosteum of the labyrinth 
 to one of the parts of the choroid, because it is strewn with nu- 
 cleated pigment cells. There are also calcareous deposits. It 
 
 FIG. 126. Periosteum of the Labyrinth 
 (after Henle). 
 
 FIG. 127. Periosteum of the Outer Wall of 
 the Cochlea (after Henle). 
 
 is very difficult, according to Henle, to separate the periosteum 
 of the labyrinth, without also detaching bits of bone. The 
 periosteum is abundantly supplied with blood-vessels. 
 
 THE MEMBRANOUS LABYRINTH. 
 
 Utricle and Membranous Semi-circular Canals. 
 
 The utricle is an elliptical tube, situated on the median wall 
 of the vestibule. Its longest diameter corresponds to the height 
 of the vestibule. By means of a fine vascular and nervous net- 
 work, and a very delicate connective tissue, it is fastened to the 
 recessus ellipticus of the vestibule. 
 
 The membranous semi-circular canals are but the lining of 
 the osseous canals, and, of course, of the same shape. The 
 membranous canals open into the utriculus with five openings, 
 just as do the osseous tubes in the vestibule. At the ampullae, 
 the membranous canal fills up the osseous very completely ; but 
 there is some space between the other parts. The walls of these 
 
 1 Lehrbuch, p. 774.
 
 MEMBKANOUS LABYKINTH. 
 
 599 
 
 structures are transparent, as clear as water, and of great deli- 
 cacy. After the endolymph is removed, they fall together and 
 arrange themselves in rigid folds. There is, 
 however, a point that is firmer, called the 
 macula acustica, situated on the median 
 wall of the utricle, where a twig of the 
 auditory nerve reaches this wall. The por- 
 tion of the ampulla that contains the termi- 
 nation of the nerve, and which is detected 
 by the naked eye as a whitish-yellow spot, 
 is also of firmer consistency. This point is 
 called the crista acustica by Max Schultze. 
 It comprises about one-third of the wall of 
 the ampulla. It is sometimes surrounded by a pigmented line 
 and also receives nerve-twigs. 
 
 The wall of the membranous semi-circular canals is from 
 0.02 mm. to 0.03 mm. in thickness, and is composed of various 
 layers. 
 
 The membrana propria is of reticulate and nuclear fibrous 
 tissue, of which the periosteum also consists. It is perforated 
 
 FIG. 128. Utricle and 
 Membranous Semi-circular 
 Canals of the Left Side. 
 
 FIG. 129. A Piece of the Wall of .the Utricle, with the Otoliths (after Henle). 
 
 by blood-vessels. There is a basal membrane next the mem- 
 brana propria, and on the inner surface pavement epithelium. 
 
 The macula and crista acustica that have been mentioned, 
 are thickenings of the membrana propria, caused by the min- 
 gling of connective tissue, and the ending of the nerves. 
 
 The otolith of the utriculus of the mammalia is a smooth, 
 irregularly demarcated and uneven mass of chalky white pow- 
 der. It was called otoconia by Breschet, ear-sand by Lincke,
 
 600 DUCTUS COCHLEAEIS. 
 
 and ear-crystal by Huschke. The powder is held together by 
 an almost mucous substance, and consists of crystals of carbo- 
 nate of lime, of varying shape and size. The largest are only 
 0.012 mm. long and 0.008 mm. broad. They are too small to 
 allow the crystal form to be recognized. Henle says it is un- 
 known how the otolith is fastened on to the wall of the utricle. 
 
 SACCULE. 
 
 The saccule-is of the shape of a broad flask with narrow 
 neck. Its body (about T ^ inch in diameter) lies in the recessus 
 sphsericus of the vestibule. The neck (canalis reunicus, about 
 3^ inch long and y^ inch in diameter) of this bottle or flask pro- 
 ceeds from the lower wall, downward and backward, and sinks 
 into the upper wall of the vestibular end of the ductus cochle- 
 aris, at nearly a right angle, so that a blind sac is formed at the 
 junction of the two parts. Henle compares it to the passage of 
 the oesophagus into the stomach, and of the small intestine into 
 the ccecum. 
 
 THE DUCTUS COCHLEARIS (LAMINA SPIRALIS MEMBRANACEA OF THE 
 
 OLD ANATOMISTS). 
 
 The ductus cochlearis begins with the blind sac in the vesti- 
 bule that has been described, and passes through the whole 
 cochlea to the apex, in which it ends again as a blind sac. The 
 lower end rests in the recessus cochlearis, and the upper in the 
 cul-de-sac of the cupola. The ductus cochlearis is attached on 
 one side to the lamina spiralis ossea, and on the other to the 
 outer wall of the osseous cochlear canal. On a transverse sec- 
 tion the ductus cochlearis is seen to be triangular in shape, and 
 has, of course, three walls or sides. Two of these walls diverge 
 from the edges of the lamina spiralis, and the other corresponds 
 to the portion of the cochlear wall, between which the insertion 
 of the two others is made. The lower wall of the ductus coch- 
 learis, which is turned toward the scala tympani, is called the 
 tympanal ; the upper, which separates the ductus cochlearis 
 from the scala vestibuli, is called the vestibular wall. 
 
 On the osseous border of the lamina spiralis is a soft struc- 
 ture, only to be seen in the uninjured specimen of the cochlea, 
 which lengthens the lamina spiralis toward the calibre of the 
 ductus cochlearis. It is called by Henle the limbus laminse spi- 
 ralis. It is developed from the periosteum of the lamina spi- 
 ralis. This structure gradually decreases in breadth and height 
 from the base to the apex of the cochlea. The edge of the osse-
 
 DUCTUS COCHLEAEIS. 601 
 
 ous lamina recedes more and more at the same time from the 
 free border of the limbus. This free border becomes a furrow, 
 called by Huschke the sulcus spiralis, having, of course, two 
 lips. The upper lip is the labium vestibulare ; the lower, the 
 labium tympanic um. The vestibular wall of the ductus cochle- 
 aris passes off from the upper surface of the lamina spiralis in a 
 line nearly corresponding to the inner attachment of the limbus 
 laminae spiralis, so' that the latter is almost completely drawn 
 into the ductus cochlearis. 
 
 The upper surface of the vestibular lip of the limbus lamina 
 spiralis is covered by striae, which on front view resemble the 
 anterior surface of the incisor teeth, and hence Huschke calls 
 them the auditory teeth. These furrows, or striae, are filled by 
 
 FIG. 130. Transverse Section of a Cochlear Spiral, from a Cochlea softened in Hydro- 
 chloric Acid (after Henle). The dotted lines indica.te sections of the membrana tectoria and 
 the auditory rods ; I s. lamina spiralis ; II s, limbus laminae spiralis ; s v, scala vestibule ; s t, 
 scala tympani ; d c, ductus cochlearis ; I s p, ligamentum spirale ; v, membrana vestibularis ; 
 *, membrana basilaris ; c, outer wall of ductus cochlearis ; *, bulging of this wall. 
 
 small rounded cells. Their number may run as high as 2500. 
 The limbus is composed of connective tissue, running in a radi- 
 ate direction in the furrows, or striae ; beneath these furrows the 
 connective tissue is reticulate. 
 
 Henle compares the labium vestibulare to a roof over the 
 sulcus spiralis, and the labium tympanicum to a floor. Within 
 the labium tympanicum run very fine nerve-fibres from the tis- 
 sue of the auditory nerve to the ductus cochlearis. The labium 
 tympanicum consists of two layers, which include the nerve- 
 fibres between them, and then unite beyond it in a sharp border, 
 from which the membrana basilaris proceeds. This membrana 
 basilaris, according to Henle. appears as a process of the upper 
 layer of the labium tympanicum. There is, however, a struc- 
 ture between them, which corresponds to the periphery of the 
 nerve bundles.
 
 602 CORTl'S ORGAN DUCTUS COCIILEARIS. 
 
 On the outer portion of the upper surface of the labium tym. 
 panicum are four radiate striae, which Henle considers as marks, 
 of the nerve bundles running on the lower surface of this layer. 
 At 'the periphery of these there are other openings. 
 
 The membrana vestibularis is attached to the beginning of 
 the upper border of the ridge of the spiral and to the outer 
 cochlear wall. There are three layers in this membrane, which 
 by Kolliker is called Reissners membrane. It is epithelial tissue, 
 which in embryonal life seizes upon the vestibular side of the 
 cochlear canal. This membrane has a number of blood-vessels. 
 
 The membrana basilaris is well shown in the preceding figure, 
 and being the part upon which rests the organ of Corti, has at- 
 tracted very much 'attention from anatomists. It is a continua- 
 tion of the labium tympanicum. It gradually increases in breadth 
 from the base to the apex, in the same proportion that the lamina 
 spiralis with its limbus decreases in size. Its breadth in the 
 newly born, in the middle of the first turn or coil of the cochlea, 
 is 0.17 mm.; at the end of the second, 0.45. This space is divided 
 into two parts or zones. The inner was called by Kolliker, the 
 habenula tectu, and the outer by Todd and Bowman, the zona 
 pectinata. Henle gives the two parts the simple names of inner 
 and outer zone. On the inner zone are found the structures 
 making up what is known as Corti's organ, from their discov- 
 erer, Marchese Corti. 1 The outer zone is rather broader than the 
 inner. 
 
 The basis of the membrana basilaris is a structureless mem- 
 brane. On the outer zone especially are peculiar knobby points. 
 Upon this structureless membrane are the parts known in their 
 totality as Corti's organ. The fibres of this structure are ar- 
 ranged along the whole length of the membrana basilaris. 
 There are spaces between them, so that they have a certain 
 resemblance to the keys of a piano. 
 
 The ligamentum spirale is the means of attaching the mem- 
 brana basilaris to the outer wall of the cochlear canal. The 
 fibres of which it is composed are like those of periosteum. 
 
 The cavity of the ductus cochlearis is divided into parts by a 
 membrane running parallel to the membrana basilaris. The 
 upper part is filled with endolymph, the lower contains what 
 Henle calls the terminal auditory apparatus. The membrane 
 which divides the ductus cochlearis into two parts is called the 
 membrana tectoria by Claudius, but Corti's membrane by Kol- 
 liker. The membrana tectoria is divided into three zones. The 
 
 1 Corti was formerly prosector to Professor Joseph Hyrtl, and made the first exact 
 microscopic examination of the lamina spiralis ossea, and membranacea.
 
 CORTl'S RODS. 
 
 middle zone is the denser ; the inner is structureless and has 
 numerous openings. The outer zone is made up of a very fine 
 and friable network. It is probable, according to Henle, that 
 the membrana tectoria is firmly fastened, and that it is riot 
 possible for it to press closely upon the parts covered by it. 
 
 TERMINAL AUDITORY APPARATUS. 
 
 The most .important, physiologically speaking, of this termi- 
 nal apparatus are the auditory rods, called also Corti's teeth, or 
 Corti's fibres. They are arranged in regular order, very like the 
 cords, hammers, or keys of a piano. They are shaped like a 
 Roman S, having slender cylindrical bodies and broad ends con- 
 taining granular protoplasm. There are two rows of these fibres, 
 an inner and an outer. The inner rods arise from the membrana 
 
 PIG. 131. From the Terminal Auditory Apparatus of a Cat (after Henle). i, Outer ends of 
 the inner fibres ; e, outer fibres ; 3, outer covering cells ; 4, epithelial cells. (500 x 1.) 
 
 basilaris, on which their internal extremities are fastened, more 
 or less abruptly, toward the membrana tectoria, without, how- 
 ever, being united to the latter. The outer rods or fibres join, 
 with their inner extremities, the outer end of the inner fibres. 
 Their external terminations rest 011 the membrana basilaris. 
 There are two varieties of the inner row of fibres or rods ; one is 
 smooth and elliptical in shape, the other cylindrical and broader 
 at each end. 
 
 The outer row of rods is cylindrical in shape, and th'ey stand 
 at a greater distance apart than the inner. The estimated num- 
 ber of inner pillars is 6000, of the outer 4500. The inner row of 
 fibres is always shorter than the outer. They join together and 
 form a roof over the inner zone of the membrana basilaris. The 
 base of this roof is 0.1 mm. in breadth. The structure of these 
 rods, as shown by the action of reagents, is a tissue as hard as 
 cartilage.
 
 AUDITORY NERVE. 
 
 Henle calls the terminations of the two rows of rods upon the 
 membrana basilaris, the lower extremities ; and the extremities 
 which join to make the roof, the upper extremities. The cells 
 found in the ductus cochlearis, auditory cells, are nucleated, 
 round, and cylindrical. A layer of them covers the sulcus spi- 
 ralis, Reissner's membrane, and the outer wall of the ductus 
 cochlearis. Upon the inner pillars lies -a single row of conical 
 cells with large nuclei. They send processes into the rows of 
 small cells lying next toward the sulcus spiralis, the granular 
 laj^er. The ends turned toward the heads of the rods bear tufts 
 
 2 4 ** 
 
 FIG. 132. FIG. 133. 
 
 FIG. 132. Profile View of Outer and Inner Rods. 
 
 Fig. 133. Membrana Basilaris (b), with the terminal nerve-fibres (n) and the inner and 
 outer rods ; and 1 , inner ; 2, outer floor cells ; 4, attachment of the roof cells ; **, epithelium. 
 
 of stiff immovable cilia. These cells are called inner hair-cells. 
 Their number is computed at 3300. On the outer rods lie three 
 or four rows of double nucleated cells, connected by slender pro- 
 cesses to the membrana basilaris and membrana reticularis, and 
 bearing also tufts of cilia. Their number is computed at 18,000. 
 The cilia of the cells are received in the lamina reticularis in 
 corresponding rows of openings. Waldeyer regards the cells, as 
 also the rods of Corti, as epithelial structures. Henle describes 
 another layer of cells lying on the membrana basilaris as floor 
 cells. 
 
 The membrana reticularis is the second of the component 
 parts of the terminal auditory apparatus. It arises from the 
 articulation of the rods or fibres, and extends to the outer wall 
 of the cochlea parallel to the lamina basilaris. It is supposed to 
 be a ligament to bind the rods together. The tissue of the lam- 
 ina reticularis is not less firm than that of th rods, but it is 
 delicate. 
 
 AUDITORY NERVE. 
 
 The Auditory Nerve (Nervus acusticus). The auditory 
 nerve, or portio mollis (soft part of the seventh nerve), is the 
 nerve of the sense of hearing, and is^istributed exclusively to 
 the internal ear. The auditory nerve arises by two roots in the
 
 AUDITORY NERVE. 
 
 605 
 
 medulla oblongata. One ganglionic nucleus of origin is in the 
 floor of the fourth ventricle. The other is in the cms cerebelli 
 ad-medullam. The roots of the nerve are connected, on the 
 under surface of the middle peduncle, with the gray substance 
 of the cerebellum, with the flocculus, and with the gray matter 
 at the border of the calamus scriptorus. The nerve winds 
 around the restiform body, from which it receives fibres, and 
 passes forward across the posterior border of the crus cerebelli, 
 in company with the portio dura, or facial nerve, from which it 
 is partly separated by a small artery. It then passes into the 
 meatus auditorius internus, where some minute filaments con- 
 nect them together. 
 
 4 3 
 
 r 
 
 It 2 
 
 FIG. 134. Expansion of the Right Cochlear Xerve, seen from the Base of the Cochlea, 
 from a Labyrinth softened in Hydrochloric Acid (after Henle). 1, The branches entering 
 through foramina ; 2, twig passing into the modiolus ; 3, network in the osseous lamina spi- 
 ralis ; 4, network on its border ; 1 1, labium tympanicum ; z i, zona interna ; 2 e, zona externa 
 of the membrana basilaris ; I , ligamentum spirale. (15 x 1.) 
 
 The auditory nerve is remarkable for the delicacy of its 
 structure, which caused the older anatomists to give it the 
 name of portio mollis^ It has only a very thin iieurilemma. 
 
 At the bottom of the meatus the facial nerve enters the Fallo- 
 pian canal, the auditory divides into two branches, vestibular 
 and cochlear. 
 
 The cochlear nerve gives off a small branch, which passes to 
 the vestibular extremity of the ductus cochlearis, and through 
 the fourth macula cribrosa, to the partition wall of the two sac- 
 cules in the vestibule. From the trunk of the nerve a number 
 of fine twigs arise, which pass through foramina direct to the 
 lamina spiralis of the lower coil of the cochlea. The remainder 
 of the cochlear nerve enters the modiolus, and is divided into 
 anastomotic divisions. The fibres become separated from the
 
 606 AUDITORY NERVE. 
 
 trunk in a line corresponding to the course of the canalis spi- 
 ralis modioli, and permeate this canal. Here, by the addition 
 of ganglion cells, they become gangliose strise, and finally end, 
 at almost a right angle to the trunk, in the osseous lamina spi- 
 ralis. 
 
 The vestibular nerve, after a slight gangliose expansion, 
 divides into three branches : 
 
 1. Superior. This passes through the macula cribrosa supe- 
 rior, and ends by three branches to the utricle and ampulla of 
 the superior vertical and horizontal semi-circular canals. 
 
 2. The middle passes through the macula cribrosa media to 
 the saccule. 
 
 3. The inferior passes through a bony canal of its own to 
 the ampulla of the inferior vertical semi-circular canal. The 
 terminal nerve-fibres pass from the lamina spiralis through fine 
 holes in the labium tympanicum, and in the membrana vesti- 
 bularis into the ductus cochlearis. 
 
 They run in a radiate direction, pass through the granular 
 layer, where some end in inner hair-cells and others run be- 
 tween the rods of Corti and across the tunnel formed by them, 
 to end in outer hair-cells. There are probably other nerve-fibres 
 running in a spiral course among the granular layer and the 
 outer hair-cells. 
 
 Todd arid Bowman regard the vestibular nerve as direct pro- 
 longation of the white matter of the brain. 
 
 In the internal auditory canal, the portio mollis forms a con- 
 nection with the portio dura by means of a few fascicles of 
 fibres, which constitute what Wrisberg called the "portio inter- 
 media." It is not decided whether the connecting link proceeds 
 from the auditory to the facial nerve, or from the latter to the 
 former. Todd and Bowman believe it probable that the facial 
 nerve sends some filaments to the blood-vessels of the labyrinth 
 and the muscular structure of the internal ear. 
 
 The internal auditory canal (meatus auditorius internus) 
 
 begins at about the centre of the petrous portion of the temporal 
 
 bone by a large orifice with smooth rounded edges, and runs 
 
 directly outward about one-eighth of an inch to end in a blind 
 
 fossa. 
 
 There are four depressions in the fossa. These are perfo- 
 rated by fine foramina, through which the fibres of the acoustic 
 nerve enter the labyrinth. Three of them correspond to the 
 maculae cribrosa. The fourth lies opposite the base of the coch- 
 lea. It is spiral-shaped, has spiral-shaped openings, and is called 
 the tractus spiralis foraminosus.
 
 BLOOD-VESSELS PHYSIOLOGY. 607 
 
 BLOOD-VESSELS. 
 
 The blood passes to -the internal ear through the auditiva 
 interna artery, which is a branch of the basilar, according to 
 Hyrtl. The basilar comes from the vertebral and the vertebral 
 from the subclavian. After the internal auditory artery has 
 entered into the meatus auditorus internus, it divides into a 
 vestibular and cochlear branch. The cochlear branch divides 
 in numerous branches which pass through the foramina of the 
 tractus spiralis foraminosus into the modiolus, and then go on 
 between the layers of the lamina spiralis, and are finally lost in 
 the spirals of the cochlea. The vestibular artery passes through 
 the posterior wall of the vestibule in numerous fine twigs to the 
 soft structures of the vestibule and semi-circular canals. The 
 stylo-mastoid artery is said to give several small branches to 
 the labyrinth. It is important to observe the fact to which Von 
 Troltsch calls attention that the blood-supply of the labyrinth 
 and of the middle ear are nearly separate and independent of 
 each other. This may explain the relative infrequency of the 
 extension of disease of the middle ear to the internal ear. 
 
 THE PHYSIOLOGY OF THE INTERNAL EAR. 1 
 
 The vibrations of the atmosphere are conveyed through the 
 ossicles and fenestra ovalis to the perilymph of the labyrinth. 
 They pass as waves over the vestibule, semi-circular canals, and 
 other parts of the labyrinth, and are there transmitted to the 
 endolymph. A vibration passes from the vestibule into the scala 
 vestibuli of the cochlea, and passing down the scala tympani 
 ends as an impulse against the fenestra rotunda. The variations 
 in pressure of the fluid of the labyrinth, which is surrounded by 
 particularly firm bony walls, thus excited by the motions of the 
 foot-plate of the stapes bone, are compensated for by a move- 
 ment of the membrane of the fenestra rotunda. The helico- 
 trema, the small opening through which the two scalse of the 
 cochlea communicate, allows the membrana basilaris with the 
 parts lying upon it (Corti's organ) to be set in motion. Buck's in- 
 vestigations lead him to believe that "no communication exists 
 between the two scalse in the immediate vicinity of the cupola," 
 unless the opening spoken of so vaguely by the authors, be micro- 
 scopic in size." This negative assertion has not been confirmed 
 
 Foster: Text-Book of Physiology. Hartmann : Lehrbuch. Hensen : Handbuch 
 xler Physiologie von Hermann, Leipzig, 1880. Politzer : Lekrbuch. 
 2 Treatise on the Ear, p. 12.
 
 608 
 
 PHYSIOLOGY OF INTERNAL EAR. 
 
 by other anatomists, and the opening is still described by those 
 who have written since Buck's statement was made. 
 
 The exact function of the individual portions of the labyrinth, 
 in spite of the investigations of the physiologists, is not yet posi- 
 tively settled. According to Helmholtz, the vestibule and am- 
 pullae are adapted to the perception of noises, irregular vibra- 
 
 Labyrinth or internal 
 ear. 
 
 FIG. 135. A diagram designed to illustrate the Physiology of the Labyrinth (Professor A. 
 L. Ranney). 1, External auditory canal ; 2, the membrana tympani ; 3, the tympanic cavity 
 with its chain of bones connecting 2 with 4; 4, the fenestra ovalis ; 5, the utricle, communi- 
 cating with the semi-circular canals (11, 12, and 13) ; 6, the saccule, communicating with the 
 scala vestibuli of the cochlea (s v) ; 7, the ampullae ; 8, the fenestra rotunda, opening from 
 the scala tympani (s <) into the cavity of the tympanum (3) ; 9, the Eustachian tube, allowing of 
 the entrance of air from the pharynx into the tympanic cavity ; 10, the internal auditory 
 canal, transmitting the acoustic nerve ; 11, 12, and 13, the semi-circular canals; 14, the open- 
 ing of the mastoid cells into the tympanic cavity (3) and the external auditory canal (1) ; s v, 
 the scala vestibuli of the cochlea ; s <, the scala tympani of the cochlea ; c, the cupola. 
 
 tions, while the cochlea perceives periodic vibrations tones. 
 Helmholtz also showed that it is probable, that the part of the 
 cochlea near the fenestra rotunda vibrates more easily to high 
 notes, or those with many vibrations in a second, while that in 
 the cupola vibrates more readily to low tones. The membrana 
 basilaris of the cochlea increases in width from the lowest wind- 
 ing of the cochlea to the cupola. Helmholtz says that the mem- 
 brana basilaris has a system of cords corresponding to its stripes, 
 of which, for certain tones, only a limited number vibrate. The 
 perception of the high tones is caused by the lower section of the 
 membrana basilaris, and of the low or deep ones by the superior
 
 PHYSIOLOGY OF INTERNAL EAR. 609 
 
 parts. This corresponds with the clinical experience, that pa- 
 tients deaf from exudations in the middle ear, encroaching upon 
 the labyrinth, hear low tones, when they cannot at all perceive 
 high ones. The case of atrophy of the acoustic nerve in the 
 first whorl of the cochlea, reported by Moos and Steinbrugge, 1 is 
 also strong evidence in support of this view. The patient was 
 sixty-three years old. His ears were examined fourteen days be- 
 fore his death. He suffered from loss of hearing and constant 
 tinnitus. The loss of hearing is said to have occurred suddenly. 
 He could not hear the voice at all on the right side, and 3 metres 
 on the left. He died of carcinoma of the right anterior central 
 convolution, he also had carcinoma of the stomach. In the ear 
 was found, as has been said, atrophy of the nerve-fibres of the 
 first cochlear whorl. The external ear, and middle ear, except 
 the junction of the stapes with the vestibule, were in a normal 
 condition. There was rigidity of the articulation. There was 
 also sclerosis of the cells of the mastoid process. The patient 
 during life was found very deficient in the power of hearing high 
 notes. It has been shown by Moos and others, that the power 
 of hearing conversation well, involves capability of hearing 
 high notes. 
 
 Although Helmholtz's theory of the function of the cochlea 
 is not everywhere positively accepted, the weight of evidence 
 seems to be in favor of the view, that it has a higher function 
 than the vestibule, and that by it an analysis of tune is made. 
 The place that Corti's rods long held as the terminal organs of 
 hearing must, however, be abandoned, for Hasse found in birds 
 that possessed the power of hearing musical tones and speech, 
 that while Corti's cells were developed the rods of Corti were 
 wanting. 
 
 The view that the cochlea alone is for the perception of tone, 
 is put somewhat in doubt by Ranke's and Henseii's experi- 
 ments. On microscopical examination of living heteropodes, 
 Ranke found the auditory cilia vibrating rapidly and moving 
 toward the otoliths, in the aural vesicle. Hensen, in experiment- 
 ing upon crabs, showed that when tones were produced a certain 
 number of cilia vibrated to certain tones. 
 
 The semi-circular canals seem to have nothing to do with the 
 hearing function, but since the experiments of Flourens it is gen- 
 erally, although not universally, accepted that they are the parts 
 chiefly concerned in maintaining the equilibrium of the body. 
 
 The greater number of authorities regard them as the organ 
 of the sense of equilibrium, but this view is not everywhere 
 
 1 Zeitschrift fur Ohrenheilkunde, Bd. X., p. 1. Archives of Otology, vol. x., p. 1. 
 39
 
 610 AUDITORY NERVE. 
 
 accepted. Bottcher, on the basis of experiments like those of 
 Flourens, believes that the symptoms seen after injury of the 
 semi-circular canals are due to a simultaneous injury of the cere- 
 bellum. Moos agrees with this author from clinical observa- 
 tions made upon patients. In accordance with the views of 
 Lussana and Berthold, he thinks that the disturbances of co- 
 ordination after injury of the semi-circular canals are excited by 
 a reflex transmission of the irritation from the ampullar nerves 
 to the cerebellum. 
 
 Hogyes, quoted by Politzer, 1 says that the terminations of 
 the auditory nerve in the vestibule are a peculiar apparatus to 
 regulate the movements of the eyes and probably also those of 
 the muscles for the preservation of the equilibrium of the body. 
 Lussana separated the semi-circular canals, without at the same 
 time irritating the nerves of the ampullae or vestibule, and even 
 after the labyrinth was entirely destroyed, no disturbances of 
 co-ordination were seen. Politzer's experiments with the supe- 
 rior semi-circular canal, showed that the fluid of the labyrinth 
 could be influenced by pressure or exhaustion of the air in the 
 auditory canal or tympanum. A manometric tube was placed 
 in the superior semi-circular canal after having been filled with 
 fluid. On pressure from the canal or tympanum the fluid arose, 
 and on exhaustion it sank. These experiments were verified and 
 amplified by Helmholtz and others. 
 
 Sensory Centre of Auditory Nerve. 
 
 Ferrier a finds the sensory centre of the auditory nerve in the 
 temporal lobe of the cerebrum. Its anatomical connection with 
 the nuclei and roots of the nerve has not been proven. Ferrier 
 observed on electric irritation of the superior temporal convo- 
 lution on the exposed brain of cats, dogs, and monkeys, a sud- 
 den elevation of the auricle of the opposite side, and on destruc- 
 tion of the temporal lobe deafness of the opposite ear. Munk, 3 
 quoted by Politzer, got the same results, by experiments on 
 dogs. He thinks they indicate a decussion of the fibres of the 
 auditory nerve in the brain. 
 
 Munk believes, as quoted by Politzer, that if the parts of the 
 temporal lobe, termed "hearing spheres," were removed, and 
 the ear of the same side destroyed, the animal would be deaf. 
 Munk also believes that the posterior part of the hearing sphere 
 
 1 Text-book, translation, p. 682. 
 
 s The Functions of the Brain, p. 171. New York, 1876. 
 
 3 Text-book, p. 684.
 
 DIRECTION OF SOUND. 611 
 
 perceives low tones, and that the anterior section in the neigh- 
 borhood of the fissure of Sylvius is for the perception of high 
 tones. 
 
 Determination of Direction of Sound. 
 
 It was formerly supposed that the direction of sound was 
 determined by the aid of the semi-circular canals. It seems, 
 however, from clinical experience, that the direction of sounds 
 is determined by the two ears acting together, for many pa- 
 tients have assured me that simultaneously with the loss of one 
 ear, they have lost in great if not complete measure, the ability 
 to tell from whence sounds came. It is probable that the two 
 ears are not necessary for the determination of the quality of 
 tones. If this be true, there is no advantage in binaural stetho- 
 scopes, other than that which may be gained by having both 
 ears closed to distracting external sounds.
 
 CHAPTER XXL 
 
 DISEASES OF THE INTEBNAL EAE. 
 
 Difficulty in Diagnosis. Clinical and Pathological Advances. Differentiation between 
 Diseases of Middle and Internal Ear. Nervousness and Nervous Deafness. 
 Symptoms of Primary Disease of the Cochlea. Acoustic Neuritis. Atrophy of 
 the Acoustic Nerve. Ca^es. The Tuning-Fork in Diagnosis. Deafness to Cer- 
 tain Tones. Double Hearing. Electricity. Syphilitic Disease of the Cochlea. 
 Cochlitis. Cases. 
 
 WITH our present knowledge, any discussion of the diseases of 
 the internal ear, is based upon a less secure foundation of patho- 
 logical and clinical experience, than is the case in the consid- 
 eration of diseases of the external and middle ear. Until the 
 greater questions in the physiology and anatomy of the laby- 
 rinth are positively settled, we cannot be sure of our classifica- 
 tions of disease. But the great barrier to our accurate knowl- 
 edge of diseases of the labyrinth such a knowledge as we have 
 in studying the affections of the optic nerve and retina is found 
 in the fact, that the otoscope as yet only enables us to see the 
 tympanum and mouth of the Eustachian tube, while the oto- 
 liths, the semi-circular canals, and the whorls of the cochlea 
 remain hidden by an apparently impenetrable bony case. In 
 spite of all this, clinical and pathological study, are slowly giv- 
 ing us access to what was once as much a maze to the thera- 
 peutist, as to the anatomist. A certain class of diseases of the 
 internal ear, can now be made out with as much accuracy as 
 diseases of the heart, lungs, or kidneys. We can, in some in- 
 stances, even classify the diseases of the semi-circular canals 
 and cochlea, for some of them are to be plainly distinguished. 
 
 In this chapter, then, I shall endeavor to set forth in a simple 
 manner, how we may, in many instances, differentiate between 
 diseases of the middle and internal ear. It is not long since the 
 average description of diseases of the tympanum and Eusta- 
 chian tube, assumed that they belonged to the internal ear, for 
 all the parts beyond the membrana tympani were classified as 
 internal. It is a great step forward, to have clearly separated 
 the middle ear from the labyrinth, the real internal ear. I have
 
 PRIMARY DISEASE OF AUDITORY NERVE. 613 
 
 no doubt that before many years, medical science will as clearly 
 separate the diseases of the two parts as it has its anatomy. 
 There is much to be gained in practice, by a careful considera- 
 tion of what is already known of the differential diagnosis of the 
 diseases of the middle and internal ear, and I shall attempt to 
 make this as clear as my experience and deductions from that 
 experience, will permit. I wish it to be understood, however, 
 that I believe we are but in the infancy of our knowledge of this 
 subject. Just as explorations in an hitherto scarcely traversed 
 country, have a great attraction for the enthusiastic traveller, 
 so I believe, will the medical explorer find very much to interest 
 him in the diagnosis of diseases of the labyrinth and acoustic 
 nerve, for this field is the ultima Thule of aural territory. 
 
 The affections of the internal ear may be classified in a gen- 
 eral way, as follows : Primary and secondary diseases. The 
 latter class has been somewhat discussed in the various chap- 
 ters on "Diseases of the External and Middle Ear." They are 
 generally recognized, and do not often excite discussion. I will, 
 however, speak of some of their symptoms again somewhat 
 fully in this chapter, after the primary affections have been 
 studied. 
 
 Primary affections of the auditory nerve, or what were called 
 cases of nervous deafness, were at one time supposed to be very 
 common. This was chiefly due to the teachings of Kramer and 
 the preceding authors. Wilde and Troltsch, gave us more cor- 
 rect notions as to the relative frequency of the diseases of the 
 central apparatus, and proved that the diseases of the middle ear 
 were more common than those of the labyrinth that so-called 
 nervous deafness was comparatively rare. 
 
 Clinical experience has, however, brought me more and more 
 to the conviction, that the rebound from the ideas of Kramer, who 
 at one time classified the majority of cases of aural disease under 
 the head of nervous affections, to those of Wilde and Troltsch, 
 the latter author tracing almost all cases to an inflammation 
 of the middle ear, has been excessive, and that there is a larger 
 proportion of cases, which are primarily affections of the laby- 
 rinth than has generally been believed by the profession for the 
 past twenty years. 
 
 Before I discuss the symptoms and causes of affections of the 
 nerve of hearing, a few words may be proper, as to what in 
 general terms is understood by impairment of hearing, depen- 
 dent upon disease of the central apparatus, or by nervous deaf- 
 ness. 
 
 When a patient is debilitated and unstrung, unsteady in mus- 
 cular movement, anxious and despondent, and is at the same
 
 614 NERVOUSNESS AND NERVOUS DEAFNESS. 
 
 time affected with a chronic affection of the middle ear, he is 
 often supposed to have a nervous disease of the ear. It is quite 
 doubtful, however, if in such cases the auditory nerve is at all 
 affected. There are certainly no symptoms of derangement of 
 the auditory nerve, in the general debility, unsteadiness, and 
 anxiety that are popularly denominated nervousness. Affec- 
 tions of this nerve make the subjects deaf, and sometimes cause 
 them to stagger in their gait, but they do not always render them 
 nervous or unsteady in the ordinary acceptation of those term's. 
 Besides, it cannot be said that nervous people are especially 
 liable to deafness from lesions of the labyrinth, any more than 
 they are to atrophy of the optic nerve. On this point Mr. Hin- 
 ton ' says, that it is difficult for him to accept debility, nervous 
 or other, as a cause of nervous deafness. He has not found that 
 the cases of deafness which appear to him as properly classed 
 among the nervous ones, occur especially in the debilitated. 
 
 With this view I am in full accord. So-called nervous people 
 are not especially apt to have a disease of the acoustic nerve, 
 but their impairment of hearing often depends upon chronic in- 
 flammations of the tympanum, its ossicles, muscles, and lining 
 membrane. The nervousness in some instances results from the 
 distressing tinnitus, and the impairment of hearing, for there is 
 no affliction more depressing than impairment of hearing. There 
 are, however, symptoms more or less objective, that enable us 
 to diagnosticate with tolerable exactness a disease of the inter- 
 nal ear. It is not wholly an undiscovered country. 
 
 PRIMARY DISEASE OF THE COCHLEA OR OF THE TRUNK OF THE 
 ACOUSTIC NERVE. 
 
 There is one symptom of this affection that is pathognomonic, 
 and that is absolute deafness. There is no disease of the exter- 
 nal ear, and none of the middle ear, I think, which will make a 
 patient deaf to all sounds. No matter what may be the patho- 
 logical condition, how firmly the auditory canals or tympana 
 may be plugged, sounds conducted through the bones will still 
 be heard ; but when the cochlea and the vestibule with their 
 contents are destroyed, no vibrations are perceived, and absolute 
 deafness exists. But such cases are very rare. There are very 
 few absolutely deaf persons in the world. Hence this pathog- 
 nomonic symptom is seldom observed. When it is, of course a 
 diagnosis is easily made. But the labyrinth may, I believe, be 
 invaded by disease, and even the terminal filaments of the 
 
 Nervous Deafness. Reprint from Guy's Hospital' Reports, 1867.
 
 PKIMAKY DISEASE OF INTERNAL EAR. 615 
 
 nerve in the cochlea, or the nerve-trunk itself be diseased, and 
 yet very considerable hearing remain. Reasoning by analogy, 
 this would appear to be true, for we may have even advanced 
 atrophy of the optic nerve and retina, and yet a fair degree of 
 vision. It has been too hastily assumed, I think, that because 
 considerable hearing power remained, therefore the cochlea could 
 not be invaded. We must go much deeper in symptomatology 
 than absolute deafness, if we desire to find the causes of disease 
 of the acoustic nerve. 
 
 1. The ability to hear the tuning-fork better and longer 
 through the air than through the bones of the head, is a symptom 
 of disease of some part of the labyrinth, either of the vestibule, 
 the cochlea, or acoustic nerve. But this symptom is not pathog- 
 nomonic of primary disease of the labyrinth. It is always found 
 when the labyrinth is invaded, but in many instances it is a 
 temporary phenomenon dependent upon abnormal pressure ex- 
 erted upon the labyrinth by the ossicles or the drum-head. If we 
 add to the above symptom the word constantly, so that it shall 
 read, the ability to constantly hear the tuning-fork better 
 through the air than through the bones, we shall be nearer to 
 a definition of a symptom of primary disease of the cochlea. 
 Even then we must exclude cases where the pressure has become 
 permanent, and where, after all, the disease of the labyrinth is 
 secondary to one of the stapes bone, or other part of the tympa- 
 num. This much we may say, however, that better aerial than 
 bone conduction indicates either primary or secondary disease 
 of the central apparatus of hearing. 
 
 2. The ability to hear better in a quiet place, u-hen all dis- 
 tracting noises are absent, is a symptom of disease of the laby- 
 rinth. It must be taken, however, when applied to primary 
 disease, with the same limitations as to constancy as the test by 
 the tuning-fork. 
 
 3. The ability to hear conversation relatively farther than 
 the tick of a watch, is also a symptom of disease of the cochlea 
 or nerve. These symptoms, namely better aerial than bone 
 conduction, better hearing in a quiet place, relatively better 
 capacity to hear the human voice than the tick of a watch, 
 when found grouped together in the same patient, to my mind 
 unmistakably stamp the case as one of disease of the acoustic 
 nerve. It will be observed that I have said nothing of vertigo, 
 of double hearing, of incapacity to hear one's own voice, which 
 are generally considered to be symptoms of disease of the laby- 
 rinth. I have purposely omitted any enumeration of these more 
 marked symptoms at this point, for I would like to impress 
 upon my readers my belief that there is a class of cases of affec-
 
 616 DIAGNOSIS OF PRIMARY DISEASE OF INTERNAL EAR. 
 
 tions of the cochlea, or vestibule, or trunk of acoustic nerve, 
 whether of one or of all, I do not pretend to know, which have 
 no very marked symptoms, such as absolute deafness, vertigo, 
 or double hearing. I will give instances of these in this chapter, 
 and will lay stress upon them, for these cases, if I am right, are 
 constantly mistaken for disease of the middle ear. It is from a 
 long series of investigations^ that I have come to the conclusion 
 that such cases are more common than has been before believed. 
 
 I ought also to say, that in diseases of the labyrinth, noise 
 not only impairs the hearing power, but it often also distresses 
 and annoys the patient, whereas persons who are very deaf 
 from disease of the middle ear, are delighted when they can be 
 in a noise. 
 
 To repeat, whenever the following train of symptoms occurs 
 in a case of impairment of hearing, I believe w.e may conclude, 
 in the light of our present knowledge, that we have to do with 
 disease of the internal ear. 
 
 1. Tuning-fork C 2 is heard better through the'air. 
 
 2. Hearing is better in a quiet place. 
 
 3. Conversation is heard relatively better than a watch. 
 
 4. Noise is annoying to a more marked degree than is usual 
 to people who hear well, or to those who are deaf from disease of 
 the middle ear. 
 
 5. Inflation of the tympanum renders the hearing worse. 
 
 To make a clear diagnosis these symptoms must exist to- 
 gether. I will not deny that some cases with this chain of symp- 
 toms, may be secondary affections of the sensory apparatus, 
 although I think these symptoms generally indicate that the 
 primary lesion is in the labyrinth. It is no proof that a disease 
 of the ear is situated in the tympanum, because the drum-head 
 has not a normal appearance. I think this fact has been lost 
 sight of, and that occasionally cases of disease of the nerve have 
 been put down to the middle ear simply because a drum-head 
 was sunken or opaque. How few so-called normal membrana 
 tympani are to be found, only he who has searched for them 
 among people with good hearing power, can certainly know. A 
 disease of the tympanum in childhood may leave its traces upon 
 the membrana tympani without sensibly impairing the hearing 
 power. The condition of the ossicles and of the lining of the 
 tympanum have the most to do with determining the hearing 
 power, when the nerve is sound. To them and not to the drum- 
 head should we look for information as to the middle ear. Be- 
 sides, changes may occur in the drum-head, secondarily to dis- 
 ease of the membranous labyrinth and trunk of the acoustic 
 nerve. Disease may travel outward as well as inward
 
 ACOUSTIC NEURITIS AND ATROPHY. 617 
 
 CASES ILLUSTRATIVE OF PRIMARY DISEASE OF THE ACOUSTIC NERVE 
 ACOUSTIC NEURITIS, OR ATROPHY OF THE ACOUSTIC NERVE. 
 
 CASE I. I. P. H , aged fifty-nine, farmer. Sent by Dr. G. W. Holmes, 
 
 April 26, 1880. The patient thinks he has been growing hard of hearing for a 
 year. The son (Dr. H.) believes that this period could be extended back to 
 three or four years. He has some tinnitus, but this symptom does not seem to 
 be a marked one. His ears have never received any treatment. He hears the 
 watch E. -%, L. -% ; my voice, in a room fifty feet long, twenty-five feet. The 
 aerial conduction is said by him to be twice as loud as that through the bones. 
 He has large auditory canals. Both membrame tympani are depressed. The 
 light spots are fully formed. There are opacities at the margin. Common air 
 and vapor of chloroform, used by niy attachment to Politzer's bag, redden the 
 drum-heads, but the patient does not feel them enter the drum, nor does the 
 hearing improve after the ears are inflated. 
 
 The points in favor of a diagnosis of disease of some part of 
 the labyrinth or acoustic nerve in this case, to my mind are : 
 
 1. The lessened conduction by bone. 
 
 2. The fact that although his ears have never before been 
 inflated, no improvement results from forcing air into the tym- 
 pana. 
 
 3. The voice is heard much better relatively than the tick of 
 a watch. 
 
 Those who are inclined to make a diagnosis of disease of the 
 middle ear from the appearance of the membrana tympani 
 alone, will perhaps make one in this case. 
 
 CASE II. Mr. S , aged forty six, sent by Dr. E. Dupuy, October, 20, 1880. 
 
 This patient is a large, well-developed man of great intellectual activity, who is 
 engaged in great enterprises in the Western States. He leads a very irregular 
 life, eats very rapidly and very much, takes long journeys very often, but he is 
 not intemperate in the use of alcohol or tobacco. He began to have attacks of 
 vertigo and nausea five years ago, so that he would be obliged to lie down for 
 hours. He had to lie on his back ; could not turn on his side or his belly. He 
 thinks he observed tinnitus and impairment of hearing after the first attack. 
 Ever since his hearing power has been variable. He hears worse in a -noise; low 
 tones are heard best; music is disagreeable. He has no pain in his ears; the attacks 
 of vertigo are growing less frequent. Has a sense of general dizziness. Some- 
 times he falls in the street. He has flatulent dyspepsia. He never has had any 
 venereal disease. Says he lias been prescribed for by " twenty aurists." 
 
 For the watch his H. D. is K. / , L. / ; voice, three feet. The tuning-fork 
 "C" is heard on the teeth " slightly ; " not at all on the forehead, nor on any 
 point of the skull, except on the tip of each mastoid. The aerial conduction is 
 much better than the bone on each side. His pharynx is granular. Both mem- 
 brane tympani are somewhat depressed ; they are not of good color, and the 
 light spots are small. The air enters each ear by Politzer's method, and after 
 inflation the H. D. on the left side is ^ ; before it was -fa.
 
 618 ACOUSTIC NEURITIS AND ATROPHY. 
 
 This I believe to be a mixed case, that is to say, one of the 
 middle ear and of the labyrinth. But I believe the disease of the 
 middle ear to be of slight importance, and not to be the cause of 
 the great loss of hearing and the head symptoms. In this case 
 my diagnosis is based upon : 
 
 1. The suddenness of the symptoms. 
 
 2. The fact that the patient hears worse in a noise. 
 
 3. That he hears low tones best. 
 
 4. That music is disagreeable to him. 
 
 5. And that the aerial is better than the bone conduction. 
 The variableness of his hearing power, which, however, is 
 
 never good, as I found by several careful examinations, is due, 
 I think, to the catarrh of the tympanic cavities and Eustachian 
 tubes, which he undoubtedly has. I do not think the symptoms 
 of labyrinthine pressure are secondary to those of the middle 
 ear, because he has submitted at various times to anti-catarrhal 
 treatment, with no marked benefit. Speculation as to the path- 
 ology of the lesion of the acoustic nerve is perhaps useless ; yet 
 I cannot but suppose that in this case either an inflammatory or 
 a hemorrhagic exudation has occurred. There is no record that 
 the patient's urine was examined. I think it was with a nega- 
 tive result. A regular life was advised for the patient, but this 
 he declined, and I anticipate that I shall one day hear that he 
 has succumbed to central disease. 
 
 CASE III. J. J. Me , postal agent, aged forty. Sent by Dr. Collins, 
 
 March 11, 1881. When a boy suffered from tinnitus. Until one year and a half 
 ago heard well. Attention was called to his impairment of healing by his 
 friends. Does not hear as well on the railway cars as other people. His occupation 
 keeps him on the railway more than half of the time. It is worse when he is 
 tired ; appears to be in good health ; never has had venereal disease ; temperate. 
 H. D., E. A, L. -A-. 
 
 Voice, about one foot from the ear, not well even there. 
 
 The bone conduction is somewhat better than the aerial on both sides ; both 
 are feeble. 
 
 Membrana tympani of right side is hyperaemic ; there is no light spot. Left 
 side Mt. is pale, and there is no light spot ; pharynx normal. 
 
 In this case, there is, I think, disease of the middle and in- 
 ternal ears, but I think that of the labyrinth predominates, on 
 the following grounds : 
 
 1. Inability to hear better, or even as well as ordinarily, in 
 the noise of a railway carriage. 
 
 2. Feeble bone and aerial conduction. 
 
 3. Absence of nasal and pharyngeal symptoms. 
 
 I think acoustic neuritis has supervened upon a chronic non- 
 suppurative inflammation of the middle ear; that he had an
 
 ACOUSTIC NEURITIS AND ATROPHY. 619 
 
 affection of the middle ear in childhood is shown by the testi- 
 mony as to tinnitus, and the appearance of the drum-head. 
 
 Then again, the tuning-fork, although feebly heard through 
 the air as well as through the bones, is rather better heard 
 through the bones than the air. But that he had serious disease 
 of the acoustic nerve is, I think, indicated by the fact that he not 
 only did not hear better in the noise of a railway carriage than 
 when in an ordinarily quiet place, but that he heard worse than 
 people in general. The hypersemic drum-head unattended by 
 pain indicates, I think, hypersemia of the whole apparatus, and 
 I would classify this also as a mixed case, but one in which the 
 nerve was predominantly and chiefly affected. 
 
 CASE IV. J. S , lawyer, aged fifty-eight. Ten years ago the patient ob- 
 served that he could not hear distinctly. He suffered also from "catarrh." He 
 hears no better in a car or carriage. His sense of taste and smell are defective. 
 His throat and nostrils have been treated a great deal, but he grows slowly 
 worse. His hearing distance for the watch is ?" e - d on each side. He hears con- 
 versation very well, in a quiet place, when it is addressed to him. The aerial 
 conduction is better than that through the bone on each side. Both drum-heads 
 are opaque, and the light spots are small. 
 
 CASE V. Mrs. L. X , aged fifty-one. Has had much trouble during the 
 
 last year, and has grown very "nervous." She also suffers from tinnitus aurium, 
 but she does not consider herself hard of hearing, for she hears conversation 
 easily. Is very anxious, fears she will have serioiis head trouble. Hearing dis- 
 tance ?? y on the right side, on the left J-? . Aerial and bone conduction are about 
 
 48 4 o 
 
 the same on the right side. Aerial louder than bone on the left. The right 
 auditory canal is eczematous to a slight degree. The right menibrana tympaui 
 is opaque. The left is also, and there is a small light spot. The pharynx is 
 normal. The patient has been treated through the nose and throat without 
 benefit. 
 
 It is useless to multiply these cases. They are not rare, 
 but they are commonly supposed to be cases of catarrh of the 
 middle ear. They are, I believe, actually affections of the acous- 
 tic nerve or labyrinth. What their nature is, more exactly than 
 this, I cannot say, but I suspect some of them to be cases of 
 acoustic neuritis, and that they finally end in atrophic changes. 
 I know of no local treatment that is of any use. What may be 
 done by the injections of pilocarpine is yet to be shown. Polit- 
 zer uses a two per cent, solution of the muriate subcutaneously. 
 He injects four drops of this solution at first, and gradually in- 
 creases the dose to ten drops daily. If the results are no better 
 than those obtained by the hypodermic injection of strychnia 
 in atrophy of the optic nerve, not much is to be expected from 
 the remedy. Yet the prognosis in this class of cases is not so
 
 620 PKESBYKOUSIS ABSOLUTE DEAFNESS. 
 
 bad as in a slowly advancing case of catarrh or of proliferous 
 inflammation of the middle ear. The disease generally occurs 
 after middle life, and I think many of the patients preserve the 
 power to hear conversation addressed specially to them, lectures, 
 sermons, and so forth, up to an advanced age. They hear badly 
 in a theatre, however, where the dialogue is animated. Persons 
 who, after middle life, lose much of their hearing from dis- 
 ease of the tympanum and Eustachian tube, soon become un- 
 able to hear conversation, and are much more disabled than 
 those who suffer from chronic acoustic neuritis or atrophy. It is 
 possible that there is a failure of the power of the tensor tym- 
 pani and of the stapedius muscle in advancing life, which ren- 
 ders it impossible to properly regulate or focus, so to speak, the 
 sound image upon the terminal apparatus. In such cases the 
 patient's hearing for his range, is as good as that of those with 
 active muscles, and young crystalline lenses. There may be in- 
 deed a presbykousis as well as a presbyopia, but these cases may 
 be distinguished from those I am attempting to describe. 
 
 Treatment. The treatment of acoustic neuritis, or atrophy 
 of the chronic form, should be based upon the general condition 
 and habits of the patient. Care and worry, indigestion, the 
 menopause in women, will often be found to be at the origin of 
 them, and no special treatment can be undertaken until each 
 case is studied by itself. But inflation of the ears and active 
 treatment by the Eustachian tube, invariably make these people 
 worse, and such means are to be strictly avoided. 
 
 POSITIVE SYMPTOMS OP DISEASE OF THE LABYRINTH. 
 
 From the report of recent cases treated by the muriate of pi- 
 locarpine, I am greatly inclined to give this drug a further trial. 
 I am also disposed to hope for something from it in cases of dis- 
 ease of the middle and internal ear, from the very good results 
 I have had from its use in choroiditis. It is best used hypoder- 
 mically, using six to ten minims of a two per cent, solution at 
 bedtime. It is necessary to produce considerable diaphoresis 
 and to continue the treatment, occasionally allowing interrup- 
 tions of two or three days, for four weeks. 
 
 When absolute deafness exists, we certainly have disease of 
 the acoustic nerve. We may, it is true, have mere impairment 
 of the hearing, and yet find disease of the labyrinth ; but if the 
 deafness is absolute, or nearly so, we must conclude that the es- 
 sential part of the organ of hearing is invaded. It is a very rare 
 thing, indeed, that the impairment of hearing from disease of 
 the middle ear becomes so profound that words spoken into the
 
 THE TUNING-FORK. 621 
 
 ear through a^tube cannot be distinguished ; but in many of the 
 cases of deafness from cerebro-spinal meningitis, from fevers 
 from apoplexy of the labyrinth, from injuries, no words, how- 
 ever conducted to the ear, can be made out by the patient, he 
 cannot hear his own voice, and total deafness, not merely great 
 impairment of hearing, exists. The auditory nerve may have 
 some perception of sound in these latter cases ; but these per- 
 ceptions can only be compared to the flashes of light seen by 
 amaurotic patients. 
 
 This is in accordance or in analogy with what we observe in 
 diseases of the eye. When absolute blindness occurs, we know 
 that we are dealing with an affection of the central or percep- 
 tive apparatus. Opacities of the cornea, cataract, iritis, do not 
 destroy the perception of light. This is only done by diseases 
 of the retina, optic nerve, or brain. 
 
 SYMPTOMS OF DISEASE OF THE MIDDLE EAR AND LABYRINTH. 
 
 Other symptoms of disease of the internal ear, such as ver- 
 tigo, nausea, vomiting, tinnitus aurium, double hearing, are 
 also seen in affections of the middle ear, when the nerve expan- 
 sion in the labyrinth is involved by undue pressure. A stagger- 
 ing gait, or loss of equilibrium, is also a symptom of disease of 
 the internal ear, and especially of the semicircular canals. But 
 even when this symptom occurs, it is not possible to determine 
 from it alone whether the disease of the internal ear is a pri- 
 mary or secondary affection. 
 
 THE TUNING-FORK 
 
 As I have repeatedly said, the tuning-fork is very valuable as 
 a means of diagnosis in suspected nerve-deafness. As we have 
 seen in the second chapter, the tuning-fork is heard more dis- 
 tinctly if the ear be stopped with the finger or the like, while 
 the hand is placed upon the forehead or teeth. If a person be 
 affected with disease of the internal ear, it is a clinical fact that 
 such a stoppage of the meatus does not usually at all intensify 
 the sound of the tuning-fork. Besides, if one acoustic nerve be 
 diseased, while the other is sound, or if one be affected much 
 more than the other, the tuning-fork is heard more distinctly on 
 the sound or better side, just the contrary from what is found in 
 disease of the middle ear. 
 
 If a tuning-fork (pitched in bass C) be placed on the vertex 
 or on the mastoid process, and allowed to vibrate until the notes 
 are no longer heard, and its prongs be then brought close to the 
 ear, if the ear be normal the tone will be heard again, 
 called Renne's positive experiment. According to Lucae, in
 
 622 THE TUNING-FORK. 
 
 those cases of impairment of hearing, where the fork is heard 
 again after having ceased to be heard on the vertex or mastoid, 
 when placed close to the ear, there is disease of the internal ear. 
 When it is not heard again there is disease of the external or 
 middle ear. I have had some experience with this test, and I 
 believe it to be a good one. But like many other methods of 
 using the tuning-fork for a differential diagnosis, when em- 
 ployed alone, it is not sufficient to enable us to speak positively 
 as to its diagnostic value. 
 
 At my suggestion, Dr. J. B. Emerson, Surgeon to the Man- 
 hattan Eye and Ear Hospital, 1 undertook the examination of 
 persons with normal hearing power, by means of the tuning- 
 fork. The results he obtained are a positive contribution to the 
 subject. It is to the tuning-fork that I think we must look as 
 yet, for that much-to-be-desired means of making a diagnosis 
 between a chronic affection of the middle ear and a similar one 
 of the acoustic nerve. Fifty persons with normal hearing were 
 carefully chosen from a hundred, said to have normal hearing. 
 Two forks were used, one 32 ctm. long, with cylindrical prongs 
 and handle giving a note more than an octave below the middle 
 C. C 1 = 264 double vibrations. This tuning-fork is called "A," 
 in Dr. Emerson's tests. 
 
 Another fork, about 17 ctm. long, with rectangular prongs 
 and conical handle, giving a note one octave above middle C, 
 and called "C*" 528 vibrations. 
 
 The average duration of time in seconds during which these 
 forks were heard is shown by the following table. The table 
 was made up from fifty cases of persons who had no disease of 
 the ears. 
 
 " In every case the A fork was louder when heard through 
 bone, and the C a fork, when heard through air. 
 
 " The average duration in seconds was as follows : 
 
 " A fork- 
 Air conduction 31 
 
 Bone conduction 18 
 
 Excess in air conduction 13 
 
 "C 2 fork- 
 Air conduction 36 
 
 Bone conduction 16 
 
 Excess in air conduction 20 
 
 " A and C 2 forks- 
 Air conduction 34 
 
 Bone conduction 17 
 
 Excess in air conduction . . .17 
 
 1 The complete paper will be found in the Archives of Otology, Vol. XII., p. 03.
 
 THE TUNING-FORK. 623 
 
 " A and C 3 are both heard longer through aerial than through 
 bone conduction. 
 
 " The difference between air and bone conduction is less for 
 the A note than for the C 3 note ; A being heard about 1.75 times 
 longer through air than through bone; while C" was heard 
 about 2.25 times longer through air than through bone. 
 
 " For both A and C a , the average duration is twice as long 
 through the air as it is through the bone." 
 
 Dr. Emerson also examined fifty persons suffering from dis- 
 ease of the middle ear, with the same tuning-fork, and he con- 
 cludes as follows : 
 
 1st. Relying on the statements of patients in regard to the 
 loudness of tuning-forks, as a test in ear troubles, will lead to 
 error unless account is taken of the fork used. As a rule, in 
 normal ears high notes are heard louder through aerial con- 
 duction, and low notes louder through bone conduction. This 
 is true also, to a limited extent, in diseased ears, as verified by 
 the thirty-nine cases cited. 
 
 2d. The relative duration of aerial and bone conduction is a 
 better test. In normal ears, in all cases the tuning-fork is heard 
 longer through air than through bone, the proportion being 
 greater for high than low notes ; and for the middle C (C") it 
 should be heard about twice as long through air as through 
 bone, the average duration in my cases being for bone seven- 
 teen seconds, and for air thirty-four seconds. Any marked de- 
 parture from this indicates disease. 
 
 3d. In external- or middle-ear disease this proportion is re- 
 duced, and in well-marked cases the average bone conduction 
 remaining the same or being increased, the aerial conduction 
 will be reduced until it becomes equal to, or much less than, bone 
 conduction. In one hundred ears tested, the average duration 
 was for bone seventeen seconds, for air thirteen seconds, or 1.3 
 longer through bone than air. This reduction obtained also in 
 the thirty-nine cases in which air conduction was louder than 
 bone, the average duration in those ears being equal. 
 
 4th. When the bone conduction is longer than aerial conduc- 
 tion, and yet much less than the average duration of bone con- 
 duction for normal ears, it is an indication not only of middle-ear 
 trouble, but that the nervous apparatus is involved. 
 
 5th. If the proportion between bone and air remain the same, 
 and the hearing power much lowered, it is probably an indica- 
 tion of disease of the internal ear. Air conduction markedly 
 exceeding bone conduction, the bone conduction may be entirely 
 lost, and yet air conduction continue to a limited extent. 
 
 The two following cases illustrate this :
 
 624 DEAFNESS TO CERTAIN TONES. 
 
 CASE I. Mr. , aged forty-five. Chronic alcoholism. H. D., Right ear, - 4 a ; 
 
 A tuning-fork heard louder through bone, C* louder through air ; duration of A 
 tuning-fork through air, thirty seconds ; duration of C-, forty-five seconds ; dura- 
 tion of A through bone, twenty seconds, of C' 2 through bone, twenty-five seconds. 
 Left ear, -/- ; A tuning-fork heard louder through bone, C' 3 heard louder through 
 air ; duration of A through air, thirty seconds, of C 2 through air, forty seconds ; 
 duration of A through bone, fifteen seconds, of C 5 through bone, fifteen seconds. 
 
 CASE II. Mr. , aged twenty-three. Meningitis. H. D., Eight ear, -& ; A 
 
 heard louder through bone, C' 2 through air ; duration of A through air, ten sec- 
 onds, of C' 2 through air, twenty-five seconds ; duration of A through bone, three 
 seconds, of C 2 through bone, five seconds. Left ear, -fa ; A heard louder through 
 bone, C' 2 through air ; duration of A through air, ten seconds, of C 2 through air, 
 twenty-five seconds ; duration of A through bone, five seconds, of C' 2 , ten seconds. 
 
 It is from experiments such as these, and long experience 
 with patients, that I have come to the conclusion that the best 
 method we have of diagnosticating or of assisting in the diag- 
 nosis of doubtful cases of disease of the internal ear, is the tun- 
 ing-fork " C 2 ," generally known as *' C," the second one described 
 in Dr. Emerson's tests. If the tuning-fork "C a " be heard louder 
 and longer through the air when placed near the ear, than it is 
 when placed on the mastoid process, we probably have a disease 
 of the nerve, while if it be heard better through the bone, we 
 have disease of the middle or external ear. For the sake of 
 brevity, we may say, if, in cases of impaired hearing, aerial 
 conduction be better and longer than bone conduction, we have 
 disease of the internal ear. If bone conduction, be better than 
 aerial, there is disease of the middle or external ear. 
 
 The test with musical tones of various heights is of impor- 
 tance in detecting partial defects in hearing tones, but it cannot 
 be relied upon as an exclusive test, as some authors are disposed 
 to make it. 
 
 Galton's whistle is a good means of testing the capacity for 
 hearing high or low tones. 
 
 In some cases of disease of the middle ear, of one side, the 
 aerial conduction disappears entirely, and the conduction through 
 the bones is so intensified by the blocking up of the tympanum 
 and the rigidity of the ossicles, that when the tuning-fork is 
 placed upon any of the bones of the skull, even upon the mastoid 
 of the sound side, its vibrations seem to the patient to proceed 
 from the diseased ear. 
 
 DEAFNESS TO CERTAIN TONES. 
 
 If Helmholtz be correct in his theories, deafness to certain 
 tones must of necessity be due to some affection of the cochlea, 
 and this is an affection sometimes seen, as has been known 
 since the experiments of Wollaston, who found that some per-
 
 DOUBLE HEARING. 625 
 
 sons were unable to hear the chirping of a cricket, which is the 
 highest tone known. If we accept the theory of Helmholtz, 
 that Corti's organ in the labyrinth is a resonance apparatus, and 
 that individual fibres of the auditory nerve in the cochlea are 
 tuned for certain notes, the pathology of such cases becomes 
 clear. It should be remembered, however, that this symptom, 
 as well as double hearing, like tinnitus aurium, may be merely 
 secondary to an affection of the middle ear, which causes press- 
 ure upon and hypersemia of the cochlea. 
 
 DOUBLE HEARING. 
 
 One of the first, if not the first, accounts of this phenomenon, 
 is by Sir Everard Home, who described it in an article on " The 
 Membrana Tympani." l His case was that of " a music master" 
 who perceived a confusion of sounds in his ears after catching 
 cold. He discovered that the pitch of one ear was half a note 
 lower than that of the other ; and that the perception of a single 
 sound did not reach both ears at the same instant, but seemed 
 as two distinct sounds following each other in quick succession, 
 the last being the lowest and weakest. 
 
 Mr. Home naively remarks that " this complaint distressed 
 him for a long time, but he recovered from it without any medical 
 aid." This was a case of true double hearing, corresponding 
 fairly well to double vision. Since then cases have been reported 
 by Gruber," Moos,' Knapp, 4 S. M. Burnett, 6 myself, and others. 
 In Knapp's case the patient heard all tones of the middle octave 
 of a piano two tones higher than in the sound ear. The ear 
 was affected with suppuration of the tympanum. Burnett's case 
 was also that of a professor of music, who observed that an A 
 tuning-fork, when held before the right ear, sounded from f to a 
 tone flat. Ten years after he observed that the same fork, when 
 held before the same ear, sounded one tone higher. His hearing 
 distance was T V for the watch, and the membraiia tympani was 
 healthy in appearance. This patient seems to have been unable 
 to detect this false hearing of one ear, unless he held a tuning- 
 fork before the meatus. It was consequently rather a curious 
 phenomenon than a source of annoyance to the subject of it. 
 
 It will be observed that the cases of Home and Knapp are in- 
 stances of true double hearing that is, two distinct sounds were 
 heard simultaneously, one true and the other false. This is dip- 
 lakousis, to which the addition of an adjective, binauralis, is 
 
 1 Transactions of the Royal Society, 1800. J Lehrbuch, p. 626. 
 
 3 Klinik der Ohrenkrankheiten, p. 319. 
 
 4 Transactions of the American Otological Society, 1871. 
 
 5 Archives of Ophthalmology and Otology, vol. v. , p. 527. 
 
 40
 
 626 CASES OF DOUBLE HEARING. 
 
 only confusing. Burnett's case is one of false hearing. When the 
 true notes are heard and then a false one, or when the last notes 
 are repeated or echoed, we should speak of echo-hearing. 
 
 Double hearing and echo-hearing exist very often as symptoms 
 of pressure upon the labyrinth from disease of the middle ear, 
 or possibly from independent disease of the labyrinth, but such 
 symptoms are generally complained of only by people of good 
 musical education, and affect only the higher notes of the scale. 
 
 Sometimes the same condition prevails in both ears, and all 
 notes are heard false. This should also be called echo-hearing. 
 
 In 1877 I saw and treated, for a short time, a patient who 
 presented the following curious phenomena of hearing : With 
 the right ear he can hear the high notes of a piano better than 
 the low ones ; in walking on the sea-shore he hears the crickets 
 in the grass, but not the roar of the waves ; he can hear the 
 chirping of insects and the movements of their bodies easily ; the 
 tick of a watch is heard normally, f-f , and yet he cannot hear 
 the tones of the human voice at all well. With the left ear, 
 whose hearing distance for the watch is but ^, the power of 
 hearing conversation is so good that the patient, a young man 
 of seventeen, carries on his studies at college with no particular 
 difficulty. 
 
 Acute Suppuration of Right Middle Ear Hypercemia of Labyrinth of Same 
 
 Side True Double Hearing. P. A. S , aged twenty-five; pianist. October 
 
 18, 1875. Seen with Dr. E. G. Loring. This patient is suffering from an acute in- 
 flammation of the right middle ear, presenting the usual symptoms, but he also 
 presents the phenomenon of so-called double hearing. In striking any musical 
 instrument piano, organ, or violin he hears the half-note above in addition to 
 the one struck. He hears both notes together. The false note gradually dies out, 
 leaving finally only the sound of the note struck. He observes this when both 
 ears are open, and when the sound one is closed. He has never tried closing 
 the diseased ear. This phenomenon lasted about three weeks. It disappeared 
 gradually, the false note being nearer and nearer to the true one, until it finally 
 blended with it. 
 
 At my request this patient sent me an account of his case, 
 which is here reproduced. 
 
 About the year 1851 (when only one year old), I was taken sick, and I ailed 
 for about twelve or fourteen months, but I recovered. As long as I can re- 
 member back, I complained of my hearing ; the left ear was all right, but it 
 seemed to me that I could have done just as well without the right ; hearing 
 with one and hearing with both was all the same thing. 
 
 My parents took me to a physician, who cleaned and syringed it for me, but 
 nothing else was done to it. When I was about six years (that is, after this 
 physician had cleaned it), it began to discharge a little. It really did stop run- 
 ning, but the hearing never improved. I studied music, and could always boast
 
 CASES OF DOUBLE HEAKINGK 627 
 
 of as true an ear as any musician could wish for. In the autumn of 1874 I went 
 to Germany to improve myself further in my profession, and one morning, sit- 
 ting in a Leipzig Gewandhaus-Concert (this was in January), I felt a tickling in 
 the defected ear, and to my surprise it had discharged again. I went at once 
 
 to Dr. M , who told me, " the drum of the ear was almost gone, and it had 
 
 been an old complaint, but the running he could stop easily." He gave me 
 some ear-drops, which had no effect on it at all. Then I had no pain. In July 
 I returned to America. In August (the month after) I experienced the first 
 pains ; the inside, the whole frame and cheek-bone felt as if it would split. That 
 time I came under the treatment of Dr. Loring, who then told me, " the drum 
 was entirely gone." He stopped the pain, and the running also diminished, and 
 I had good hopes of its being well soon. I kept on syringing with warm water 
 and putting in ALUM, SODA, SALT, NITRATE OF SILVER, etc. , as the Doctor saw fit to 
 use. One day in December, 1875, the same old pain (which had kept me awake 
 many a night) came back again, and to my astonishment found that my hearing 
 was affected in the most alarming manner. Any sound that struck the ear felt 
 as if I had got a box on the ear, but what most frightened me was that I heard 
 incorrectly. For instance, when I struck C on the piano, I would hear this very 
 C; but in addition I heard the C sharp, which is just half a note above. Now 
 imagine my confusion ; by striking the common chord of C (C, E, G), I not only 
 heard this, but at the same time C, E, Gil being the common chord of CJJ. 
 I feared very much I would have to give up my profession and take hold of 
 some other occupation, which, I believe, would have been enough to drive me 
 crazy. 
 
 At first these two notes (or chords) would sound about equally loud and 
 keep sounding wrong until both died away, but after a week or so this wrong 
 note C5 would sound like a perfect Ctj only at the instant of the key of C be- 
 ing struck, but gradually as the sound diminished and the vibrations became 
 fewer, this Cfi would get lower until, when the note became quite faint, I would 
 at last hear nothing' but the true C. 
 
 Playing on an organ this would not be the case, as the sound cannot be 
 diminished in the same way as on the piano ; there I would hear the wrong 
 note, Cj>, with the right one, C, as long as the sound could be heard. 
 
 On the violin it was worse yet (from the reason, I suppose, of its being nearer 
 the head, and the notes being more acute). I could not for the space of four 
 weeks play the violin at all, as I knew not when I played right or wrong, for on 
 that instrument the wrong note C> predominated the one I should only have 
 heard (C) by far. The C indeed sounded very faint. If anybody else played 
 the violin, the wrong notes would not predominate quite so much. 
 
 With my own voice it was worse yet. If I played on the piano I could tell 
 what notes I ought to have heard, but in singing I had no idea how near I sang 
 the right note. So everything sounded double and confused. 
 
 The first time I became aware of this bad state was at an evening service at 
 St. Luke's Hospital, where I played the organ. After service I told some one 
 that the people had sung most awfully out of tune and something must also be 
 wrong with the organ, when I was answered that the- music had never sounded 
 better. So playing on my piano, I found that my own hearing was the sole 
 cause of these discords. I remained in this state for about two weeks. Then
 
 628 ECHO HEARING. 
 
 instead of hearing a note with the additional HALF A TONE higher (C and C), I 
 heard C and a note between C and C^l (this tone cannot be produced on keyed 
 instruments, only on strings) ; after a few days more the wrong note got to be 
 nearer the right one, yet (perhaps $ above, and by and by -, L b - above) still I heard 
 both instantaneously. The harder I struck a key or note, the louder would the 
 additional wrong one sound, but the better the ear got, the purer and clearer 
 would my hearing be. At the end of about five weeks this haunting false note 
 was quite gone, and ever after that I heard only the note I struck and nothing 
 else, and now I attend to my profession, as well and cheerful as I can wish for. 
 
 Deafness from Chronic Suppuration, Left Ear ; Impacted Wax, Right Ear 
 
 Echo Hearing with One Ear. Miss L , aged twenty. Had a discharge from 
 
 left ear a long time ago, and has been deaf on that side since. Had a great 
 deal of earache when small. Noticed impaired hearing in right ear about three 
 weeks ago. Slight tinnitus at times, but no pain or discharge. No cause 
 assigned. Since right ear has become deaf, she has been annoyed by " a dis- 
 agreeable vibration like an echo " in her right ear, after singing a high note or 
 hearing another do so. Has not noticed it in instrumental music. Does not 
 sing herself higher than F or G. 
 
 H. D. E., iS, L., A. 
 
 Hears a whisper twenty feet with ease. Piano-test gives a negative result. 
 Pharynx looks well. Has some impacted wax in both auditory canals. Drum- 
 heads are opaque. After removing wax and inflating ears, H. D. became R. , 
 5o, L-, 4o"- The echo disappeared on the same day, and two months after had not 
 returned. 
 
 It is hardly necessary to more than allude to the symptom of 
 tinnitus aurium in primary disease of the labyrinth. It scarcely 
 differs from the sounds heard by those who suffer from chronic 
 non-suppurative inflammation, although in many cases of total 
 deafness no tinnitus exists, and, so far as my observation ex- 
 tends, tinnitus aurium is more frequent and disturbing in chronic 
 disease of the middle ear, than in chronic affections of the laby- 
 rinth. 
 
 PAIN AND SENSITIVENESS TO SOUNDS. 
 
 Pain is a marked symptom of acute inflammation of the mem- 
 branous labyrinth. All affections of the acoustic nerve are, 
 however, generally accompanied by extreme sensitiveness of 
 the ear to loud, jarring, discordant, or even ordinary sounds. It 
 is then necessary to keep the patient in a very quiet place. I 
 have several times been compelled to order the patient away 
 from the city to the quiet of the country. In all cases of this 
 kind the auditory canal should be protected by plugs of cotton. 
 Nausea, vomiting, and convulsions, as well as opisthotonos and 
 delirium, may be symptoms of labyrinth disease, as well as of 
 cerebro-spinal meningitis and of acute catarrh of the middle ear.
 
 PRIMARY INFLAMMATION OF LABYRINTH. 629 
 
 I 
 
 Voltolini is quite positive that there is a primary affection of 
 the labyrinth that is sometimes mistaken for cerebro-spinal men- 
 ingitis, and he has written several papers, 1 illustrated by cases, 
 to sustain his position. Although his ideas have been rejected 
 by some other writers, I do hot think the question can be at all 
 considered as a settled one. After a careful consideration of the 
 history of very many cases of supposed cerebro-spinal meningitis 
 occurring in young children, there is at least a strong suspicion 
 in my mind that Yoltolini is correct in this view, and that an 
 affection of the labyrinth may occur in young children, and be 
 erroneously supposed to be cerebro-spinal meningitis. I have 
 had very few opportunities of studying cases of cerebro-spinal 
 meningitis, although I have seen a large number of deaf persons 
 in whom the loss of hearing was said, upon good professional 
 authority, to have occurred during the course of this disease. It 
 is very much to be desired, for the clearing up of some points in 
 the nature of this disease and its relations to the acoustic nerve 
 and internal ear, that those who are accustomed to examine and 
 treat cases of aural disease should have opportunities of seeing 
 cases of cerebro-spinal meningitis in their acute stages. The 
 bonds between specialism and general practice should be very 
 close, if real advance in this or in other directions is to be 
 made. 
 
 The symptoms of that form of inflammation of the membran- 
 ous labyrinth that has been mistaken for cerebro-spinal menin- 
 gitis, should be carefully considered in order that the practitioner 
 may be able to clear up the doubts which have been thrown upon 
 the existence of this disease. Gruber, 2 and Schwartze unite with 
 me in believing that such a disease may occur. If we find a 
 child suddenly taken with severe vomiting, which is followed by 
 stupor or delirium, without paralysis, and with but slight opis- 
 thotonos, such as children have with acute otitis media, and 
 if we see this child recover in a few days, except that it is 
 absolutely deaf, and walks with a staggering gait, I think it is 
 more reasonable to think of an affection of the ear as the 
 cause of these symptoms, than of a disease of the brain and 
 spinal cord. 
 
 Having seen many cases in which such a history was clearly 
 given, I must believe in a primary acute inflammation of the 
 labyrinth, and I trust the attention of physicians will be directed 
 to the differential diagnosis between this affection and cerebro- 
 spinal meningitis. 
 
 1 Monatsschrift fur Ohrenheilkunde, Bd. I. and VI. 
 s Lehrbucli, p. 552.
 
 630 SYPHILITIC COCHLITIS. 
 
 THE DIAGNOSIS OF DISEASES OF THE INTERNAL EAR BY THE MEANS OF 
 
 ELECTRICITY. 
 
 In the former editions of this work considerable space was 
 given to this subject, but I have become convinced that the con- 
 clusions of those who believe they were able to diagnosticate 
 disease of the labyrinth by means of the galvanic current, are 
 fallacious. I do not think it has yet been demonstrated that we 
 determine the situation or character of a lesion in the ear, by 
 means of electricity, and I do not advise the student of aural 
 disease to concern himself with the various theories upon the 
 subject. 
 
 I will now discuss some of the well known causes of primary 
 disease of the labyrinth. 
 
 DISEASE OF THE COCHLEA (COCHLITIS) FROM SYPHILIS. 
 
 Syphilitic affections of the middle ear are perhaps more com- 
 mon than those of the labyrinth. For example, in the course of 
 the earlier symptoms, among which is pharyngitis, and so forth, 
 we often have tubal and tympanic catarrh, which is not to be dis- 
 tinguished from an aural catarrh arising in the course of an- 
 other disease, so far as the ear is concerned. There may be also 
 in the course of the later periods of the disease, a syphilitic exu 
 dation into the tympanum, and about the ossicles. There is, 
 however, a disease of the labyrinth and acoustic nerve occurring 
 in syphilis. This disease has some characteristics of its own. 
 It is analogous to certain forms of what are known as brain or 
 nerve syphilis, such for example as lesions of the ocular motor 
 nerves, and the medulla. I have given it the name of syphilitic 
 cochlitis, simply because it seems plain to me that it is as well 
 defined, as being chiefly a disease of the cochlea, as are certain 
 affections of the semi-circular canals of the optic nerve and 
 retina. The cases of diseases of the ear in inherited syphilis, 
 which I have had the opportunity of studying, seem to me to be 
 chiefly diseases of the peripheric and not of the central part of 
 the organ of hearing. Just as we have disease of the cornea 
 and iris as the more frequent lesions of the eye in congenital 
 syphilis, so do we have tubal and tympanic catarrh, originat- 
 ing from the snuffles in infantile and congenital syphilis. 
 
 Mi*. Hutchinson ' is of the opinion that all the cases of aural 
 disease occurring in the course of inherited syphilis, which he 
 
 1 A Clinical Memoir on Certain Diseases of the Eye and Ear, consequent on Inher- 
 ited Syphilis, p. 182. London, 1863.
 
 SYPHILITIC DISEASE OF LABYRINTH. 631 
 
 inspected, are "due either to disease of the nerve itself or to 
 . some change in non-accessible parts of the auditory apparatus. " 
 I think that Mr. Hutchinson has not attached enough import- 
 ance to the throat symptoms in his cases, and that thus he has 
 been led to give diseases of the labyrinth an undue preponder- 
 ance in aural affections resulting from syphilis. The fact that 
 the Eustachian tubes are " pervious " goes but a very little way 
 to sustain the theory of labyrinth disease, and Mr. Hutchinson 
 admits that his cases showed changes in the membrana tympani, 
 but not "adequate" ones. After or during the course of the 
 snuffles of syphilitic children, we are very sure to have catarrh 
 of the middle ear. The following case illustrates the difficulty 
 of making a positive differential diagnosis between middle ear 
 and labyrinth disease in the existence of a syphilitic diathesis : 
 
 Acute Pain in Right Side of Head along the Course of the Fifth Nerve, followed 
 by Impairment of Hearing and Tinnitus Aurium Gradual Loss of Hearing more 
 marked on the Right Side Primary Syphilis One Year since followed by Mucous 
 
 Patches and Erythema. Mr. X , aged twenty-nine, May 26, 1873, was sent to 
 
 me for advice, by Dr. E. Hubbard, of Bridgeport, Conn. The following history 
 was given by Dr. Hubbard and the patient : One year ago he had a chancre in 
 the urethra, followed by mucous patches and erythema. He was treated by the 
 use of mercury and iodide of potassium, and recovered very rapidly from those 
 symptoms. About five weeks ago the patient was seized with a severe pain in 
 the track of the fifth nerve, with tinnitus aurium. The tinnitus was compared 
 by the patient to the peep of a chicken, although this variety of noise was not 
 the only one observed. There was no pain in the ear itself. The general health 
 is excellent. The hearing had gradually diminished in the right ear since the 
 pain and tinnitus occurred. The pain subsided in a short time ; the tinnitus 
 still continues. The hearing distance is R., ^ s g e - d ; L., 1|. The tuning-fork is. 
 heard more distinctly in the better ear. When the right ear is closed by the 
 finger, however, the tuning-fork is heard better in that ear. The mernbrame 
 tympani of both sides are sunken, that of the left more so. The light spot is 
 nearly obliterated on the right side. There is a small one on the left. Inflation 
 of the ears by Politzer's method improves the hearing a very little on each side. 
 The pharynx is secreting excessively. 
 
 I suppose this to be a case of sub-acute catarrh of the middle 
 ear, with a secondary affection of the labyrinth. The tuning- 
 fork indicates that there is labyrinth disease, and yet the test is 
 not positive, because, when the right ear was closed, the sound 
 of the fork was intensified on the side of the closed ear. The 
 appearances of the drum-head, and of the pharynx, as well as 
 the results from the employment of Politzer's method, are, how- 
 ever, positive proofs that some catarrh of the middle ear exists. 
 The patient is under treatment, both constitutional and local. 
 
 Mr. Hutchinson speaks only of hereditary syphilis in his book,
 
 632 SYPHILITIC COCHLITIS. 
 
 but there is the same tendency to catarrh of the pharynx and 
 Eustachian tubes in inherited syphilis as in any other form. 
 
 There are cases, however, of disease of the ear occurring as a 
 result of syphilis, when all the marked symptoms are derived 
 from the labyrinth. If diagnosticated at all early in their course, 
 they are susceptible of relief and cure by the free use of mercury 
 and iodide of potassium. My recent experience has been in such 
 gratifying contrast to that which I had had when the first edi- 
 tion of this book was published, that I am very glad to report it 
 for the purpose of illustrating what has just been said. In the 
 cases now about to be quoted, I think we are perhaps justified 
 in going a little farther in our classification than merely to state 
 that there is disease of the labyrinth. We may, perhaps, diag- 
 nosticate disease of the cochlea, or at least say that the affection 
 of the cochlea is predominant in certain cases, just as we may 
 speak of disease of the semi-circular canals, when vertigo and 
 staggering are the predominant symptoms. Syphilitic cochlitis 
 may perhaps be a proper name for this class of cases. 
 
 Before quoting the cases in question, I will tabulate certain 
 conclusions which afford a guide to the determination of the 
 situation and character of the lesion where there is a doubt. 
 
 1. Disease of the cochlea, as of the other parts of the laby- 
 rinth, usually, although not always, manifests itself suddenly. 
 The patient can definitely fix upon a time when he became deaf, 
 and when he began to have tinnitus aurium. This is true even 
 when one side only is affected. The one-sided deafness would 
 not be so quickly recognized were it not usually accompanied by 
 tinnitus, vertigo, and often by unsteadiness of gait. Sudden 
 loss of hearing and the sudden occurrence of tinnitus, vertigo, 
 and staggering, are not, however, entirely peculiar to labyrinth 
 disease, since it is well known that we sometimes, although 
 rarely, have the same symptoms in cases of inspissated cerumen 
 and catarrh of the middle ear. They are therefore only of path- 
 ognomonic value in connection with the objective examination 
 and tests. 
 
 2. The tuning-fork C" is heard more distinctly through the 
 air than through the bones. 
 
 3. The examination of the membrana tympani and the em- 
 ployment of the methods for inflating the middle ear. will usu- 
 ally give us reasonable conclusions as to the situation of a given 
 disease of the ear, so that at the least we may exclude collec- 
 tions of fluid in the tympanic cavity in making a differential 
 diagnosis between disease of the middle ear and of the laby- 
 rinth. 
 
 4. The piano, or any very similar musical instrument, will
 
 SYPHILIS OF THE LABYRINTH. 633 
 
 aid us in determining whether or not disease of the cochlea ex- 
 ists. The examination of cases that were unquestionably affec- 
 tions of the labyrinth shows that the power of appreciating low 
 tones is the last to suffer, and the first to recover in most cases 
 of disease of this part of the ear, so that these will be heard 
 when the high ones are either not heard at all, or are heard 
 4 'false" or doubled. From our present knowledge of the phys- 
 iology of hearing, when these symptoms are present, we must 
 conclude that the cochlea is the seat of disease, even if it be 
 secondarily affected. 
 
 5. The diagnosis of syphilis of the labyrinth depends in a 
 great measure upon the same kind of evidence as that from 
 which we conclude that a case of optic neuritis or choroiditis is 
 syphilitic ; that is to say, the history and the presence of other 
 symptoms such as an eruption, mucous patches, etc. It should 
 not be forgotten, however, that the occurrence of labyrinth dis- 
 ease, in a person who has probably had the initial lesion of 
 syphilis, even if no other symptoms are present, is a very sus- 
 picious circumstance, which should lead to a careful weighing 
 of the indications for and against a mercurial treatment. 
 
 I prefer to say disease of the cochlea, instead of disease of 
 the labyrinth, when the prominent symptoms, as in the cases 
 now reported, are great impairment of hearing, the inability to 
 hear certain tones, and the production of false ones. These are 
 evidences, I think, of cochlear disease, whatever else we may 
 have. Tinnitus is a symptom common to many forms of aural 
 affections, while vertigo and unsteadiness of gait are chiefly to 
 be referred to undue pressure from the base of the stapes upon 
 the semi-circular canals, and not to disease of the cochlea. I 
 think too much stress has been laid upon increased pressure 
 upon this latter-named part of the ear, to the neglect of disease 
 having its origin in the tone-perceiving apparatus the cochlea. 
 "Meniere's disease "has always seemed tome an unfortunate 
 name, since it has been indiscriminately applied. It ought not 
 to be used unless it refers to a case such as that in which a hem- 
 orrhage into the semi-circular canals was found. Of late, cases 
 in which the cochlear symptoms are, at least, the predominant 
 ones, are sometimes styled cases of "Meniere's disease," when 
 they have very little in common with cases of hemorrhage. It 
 is interesting to notice that we are always assisted in a diag- 
 nosis of supposed cochlear disease, if the patient have a musical 
 education. I believe all the cases of double hearing that have 
 been reported occurred in persons enjoying a musical training. 
 Certainly other patients have had the same symptoms, but they 
 have been unable to appreciate them. The power of hearing
 
 634 SYPHILIS OF THE LABYRINTH. 
 
 certain tones can, however, be accurately tested in all patients 
 except young children. 
 
 The pathological investigations of syphilis of the internal ear 
 have not been numerous, but we are not entirely without them. 
 Moos ' reported a case of secondary syphilis, in which deafness, 
 annoying tinnitus aurium, and osteocopic pains in the skull were 
 complained of. The hearing was rapidly destroyed. Death. 
 At the autopsy the right external and middle ear were found 
 intact, sclerosis of the petrous portion of the temporal bone, 
 periostitis in the vestibule and small-celled infiltration of the 
 membranous labyrinth, anchylosis of the stapes to the fenestra 
 ovalis. Trunk of the acusticus unchanged. 
 
 Gruber has also reported a similar case. 2 Grubers patient 
 died of typhus fever. A post-mortem examination of the ear 
 showed vascular injection of a high degree in the soft tissues of 
 the labyrinth as well as thickness of these parts, in connection 
 with marked hypersemia of the mucous membrane of the tym- 
 panum. The patient, who was syphilitic, and who had been 
 very slightly hard of hearing at times from catarrh of the 
 tympanum, became suddenly absolutely deaf, with occasional 
 attacks of vertigo when he first became deaf. The vertigo 
 disappeared, but the deafness remained. 
 
 I have never believed that the affection which I have de- 
 nominated cochlitis involved the cochlea solely, but that it 
 affected that part of the ear predominantly, just as a patient 
 may have severe hypersemia, and even inflammation of the 
 external auditory canal, quite secondary to the main trouble in 
 the middle ear. 
 
 It would be very convenient indeed, if we could separate 
 diseased parts from each other by a line as distinct as that 
 in facial erysipelas, or, to use a geographical comparison, as 
 marked as the separation of Mexico from the United States by 
 the Rio Grande ; but to give the exact line of demarcation in 
 disease is very often impossible. It must be named from the 
 .predominance of the symptom in certain parts or organs. 
 
 CASES. 
 
 CASE I. Sudden Loss of Hearing and Tinnitus Primary Syphilis Alopecia- 
 Eruption Anti-syphilitic Treatment Cure. W. M , aged thirty-seven. The 
 
 patient states that five weeks ago, on one particular day, he observed that his 
 hearing was impaired and that he had a noise in his ears. From that time to 
 this he has grown worse. He also states that his hearing is worse at night. 
 
 1 Medical Record, from Centralblatt ftir Chirurgie, August 19, 1877, from Vir- 
 chow's Archives. 2 Lehrbuch, p. 617.
 
 CASES OF SYPHILITIC COCHLITIS. 635 
 
 About six months ago he had a chancre ; three months later he had alopecia ; 
 and there is now a copper-colored papular eruption upon his wrists and arms. 
 
 Hearing distance: B., ^; L., ^. 
 
 The tuning-fork is heard better in the left ear. The pharynx is granular and 
 in a hypersecretive condition. The drum-heads both show small light spots. 
 The usual treatment for catarrh of the middle ears has been employed since the 
 attack of tinnitus and the loss of hearing, but without success. 
 
 The patient was. immediately placed upon anti-syphilitic treatment, which he 
 carried out with but moderate faithfulness, but he began at once to improve. 
 Two months after his tinnitus was relieved, and the hearing distance was: B., 
 pr|8.d. L ^ ^ After this he went under the care of Dr. Sturgis for other symp- 
 toms of syphilis, and he informed me that he heard very well. 
 
 CASE II. Syphilitic Ulcer on Os Uteri Loss of Hearing Alopecia-Eruption 
 
 Recovery. Mrs. X , aged thirty-one. April 8, 1875. Seven weeks ago this 
 
 patient, who was brought to me by her husband, a physicia'n, began to observe 
 an impairment of hearing, accompanied by a dull pain and by tinnitus. 
 
 Hearing distance: B., it ; L., -fa. 
 
 The husband, and the note of a physician who had supervised the treatment 
 of the patient, state that she had not been well since the birth of her child in 
 August last, when an abrasion (syphilitic?) was found on the os uteri. This, the 
 husband says, was probably produced by infection from his own finger, upon 
 which was the initial lesion of syphilis, contracted in attending a case of labor in 
 a syphilitic patient. 
 
 The symptoms from which Mrs. X suffered before the loss of hearing 
 
 were neuralgic pains about the eyes, hypersemia of the optic disks, papular erup- 
 tion on the chest, and alopecia. There are now traces of the eruption, and the 
 patient has a poor appetite, pains in her legs, and some neuralgia about the 
 eyes. The treatment was anti-syphilitic in the beginning, but has not been very 
 thoroughly carried out of late. The pharynx is granular, and the left drum has 
 no light spot. The usual treatment for catarrh of the middle ears has been pur- 
 sued to some extent, but with no benefit, for the aural symptoms are increasing. 
 
 A thorough anti-syphilitic treatment was undertaken, and, according to a 
 note from the husband and a verbal communication from the physician who first 
 observed the case, the patient progressed steadily to recovery under this manage- 
 ment. No local treatment was used after the case was seen by me. I hardly 
 think general treatment would have been sufficient had the tympanic disease been 
 predominant. 
 
 CASE III. Venereal Sore Loss of Hearing Vertigo Double Hearing Re- 
 covery. Mr. U , aged thirty-three. August 30, 1876. The patient states 
 
 that toward the end of last June he observed dulness of hearing and tinnitus in 
 both ears. Soon after he discovered that he was totally deaf as to the left ear, 
 and the right ear has been gradually growing worse. 
 
 On August 1st he began to have attacks of vertigo and staggering, and has 
 had several since. He had a venereal sore on his penis about February 15th, 
 and says he had mucous patches in his mouth and throat about the middle of 
 March. 
 
 Hearing distance: B., &; L., - 4 %. 
 
 He hears words when spoken distinctly into the right ear. The drum-heads
 
 636 SYPHILITIC COCHLITIS CASES. 
 
 are both dull in color and have no light spots. The air enters both tympanic 
 cavities freely upon the employment of Politzer's method, and reddens the drum- 
 heads, but causes no improvement in hearing. 
 
 A diagnosis of syphilitic disease of the labyrinth on both sides was made by 
 my associate, Dr. E. T. Ely, who saw him first ; and after the patient had seen 
 Dr. E. L. Keyes in consultation, he was put upon a course of inunction with the 
 oleate of mercury, mercurial baths, and iodide of potassium internally, in steadily 
 increasing doses. 
 
 On September 9th he was already better. He could hear the voice much 
 better ; the attacks of vertigo continued, but there was no more staggering. 
 
 A more complete examination showed some peculiar symptoms which throw 
 some light upon disease of the cochlea, and which are therefore now detailed. 
 The noises of the street jar the patient's head very unpleasantly. He cannot 
 distinguish sibilants s sounds like/, etc. The notes of the piano become dis- 
 cordant at fifth C. They do not so^nd double, "but false. In the higher notes 
 the seventh note sounds more like the octave than the octave itself. 
 
 September 12th. There is a little more improvement in the hearing. He 
 hears notes truly about an octave higher than on the 9th. When an upper note 
 is struck he also hears with this the half note above. He still complains of the 
 unpleasant effect of the noisy streets. The drugs have been steadily continued, 
 and with no unpleasant effects. He is allowed to leave New York and go to the 
 sea-side. 
 
 September 19th. Patient now hears conversation with the right ear at ten 
 feet. The left ear seems to have no power whatever. The dose of potash has 
 now reached seventy-five grains three times a day. 
 
 October 5th. Hears the voice at twenty feet with ease. All but the last two 
 notes of the piano are heard correctly. In words / still sounds like .s. Is taking 
 one hundred and twenty grains potash at. a dose three times a day. The patient 
 fully recovered his hearing power for ordinary conversation, and resumed his 
 profession. The recovery was confined to the right ear. 
 
 It is possible that we have not paid enough attention to the 
 protection of inflamed or hyperaemic ears. Boiler-makers may 
 protect their ears from the destructive hyperaemia caused by the 
 concussions to which their work exposes them, by plugging the 
 meatus ; and telegraph-operators may suffer from an impair- 
 ment of hearing induced by exposure to the continuous clicking 
 of a telegraph instrument. In the case just reported, the patient 
 experienced great relief from the change of residence from near 
 the noisy pavements of New York to the quiet of the sea-side ; 
 and I believe where noise produces such a degree of irritation as 
 was complained of in this case, we should carefully select a resi- 
 dence for the patient with a view to keeping him out of noise. 
 In ophthalmic therapeutics a great deal of care is often necessary 
 to protect the eyes from the light ; and in acute aural disease, 
 and perhaps in some forms of chronic affections, the same care 
 should be exercised lest the ears be exposed to loud or continu- 
 ous sounds.
 
 SYPHILITIC COCHLITIS CASES. 637 
 
 CASE IV. is one that I saw at the Manhattan Eye and Ear Hospital, through 
 Dr. E. T. Ely, who had charge of the patient at the Eastern Dispensary, and 
 
 who diagnosticated disease of the labyrinth. Mr. L , aged twenty-two. 
 
 September 7, 1876. Complains that two days ago he was suddenly attacked by 
 complete deafness in the left ear, accompanied by noises like "the blowing off 
 of steam." These symptoms have continued, and he has also had slight vertigo 
 and feeling of unsteadiness most troublesome when he turns his face upward. 
 He had a venereal sore on his penis two years ago, and subsequently sore mouth, 
 falling of his hair, and iritis. Was treated for syphilis by reputable physicians. 
 
 Hearing distance : E., 4$; L., - 4 V Tuning-fork heard only on the right side. 
 Drum-heads somewhat sunken, with dull color and dull light spot. Air enters 
 middle ears readily through Eustachian tubes, but it does not improve the 
 hearing. 
 
 September 20th. Patient has been treated for catarrh of the middle ears, 
 without any benefit. Anti-syphilitic treatment was advised at his first visit, but 
 he has refused it thus far. 
 
 The diagnosis in this case has not been subjected to the cru- 
 cial test of treatment. Its syphilitic character cannot therefore 
 be so strongly emphasized. Yet when a history of general syphi- 
 lis is so distinct and a labyrinth affection occurs, I think we may 
 safely conclude that the latter is at least modified by the venereal 
 poison, if not actually caused by it. 
 
 CASE V. Syphilis Sudden Deafness and Tinnitus Symptoms of Disease of 
 
 Cochlea Benefit from Treatment. Mr. S , aged twenty-eight. First seen 
 
 March 24, 1877, with the following history : About one month ago he noticed 
 deafness and tinnitus in the right ear, and, a few days later, in the left. Is not 
 sure but that both sides were affected at the same time. Trouble advanced 
 rapidly, and in three weeks he was so deaf that he ' ' couldn't hear anything but 
 loud noises." Never had any pain or discharge. Tinnitus at first was "like 
 somebody tapping on a tumbler ; " now it resembles "the wind blowing." Had 
 some dizziness and nausea when first attacked. Never vomited. Never has 
 noticed any unsteadiness of gait. Has no vertigo now, except when he runs or 
 takes a very long stride in walking. Hearing is worse in a noisy place. Thinks 
 he hears low notes better than high ones. 
 
 Had a chancre eighteen months ago. Gives no history of any secondary 
 symptoms, except of "sores in his mouth." Has taken mercury and iodide of 
 potash since a week after his aural trouble began, but without benefit. 
 
 Thinks he took cold a few days before his deafness began, as he had "a 
 stiffness " of his neck and shoulders. 
 
 H. D. : R., 4^; L., ^. Loud voice one foot behind back. Hears words, 
 through speaking-tube, in each ear. Hears all notes of piano, but does not 
 appreciate difference between low and high ones correctly. 
 
 Tuning-fork heard better on right side. Pharynx looks well. Has ulcera- 
 tions on edges of tongue ; Eustachian tubes pervious ; no effect from inflation. 
 Right drum-head pinkish, good light spot ; left drum-head looks well. 
 
 Diagnosis. Syphilitic inflammation of cochlea. 
 
 Was seen by Dr. Sturgis in consultation, who found "an undoubted history 
 of syphilis," with objective evidences of the disease still apparent.
 
 638 SYPHILITIC COCHLITIS CASES. 
 
 Patient was ordered to take a mercurial vapor-bath daily ; daily mercurial 
 inunction ; iodide of potash, beginning with 60 grains a day, and gradually in- 
 creasing. 
 
 April 6th. E., -&; L., &; voice, 2 feet. 
 
 April 13th. E., A ; L., A ; voice, 2 feet E. E. ; 6" L. E. 
 
 April 21st. E., -A- ; L., -& ; voice, 4* feet E. E. ; 1* feet L. E. Taking 339 
 grains iodide potash daily, with mercurial inunction each night. 
 
 May 25th. E., - 4 * 8 - ; L., &; voice, E., 8 feet; L., 4 feet. Taking 118 grains 
 iodide of potash with 20 drops tincture iodine, three times daily. Inunction as 
 usual. 
 
 June 4th. E., ^ ; L., ^ ; voice, E., 4 feet; L., 3 feet. With face toward 
 speaker, hears loud conversation 10 feet. Has always shown great difference 
 in hearing power for different letters. Hears now w and c best. 
 
 June 25th. E., -^ ; L., ^ ; voice, 6 feet right side ; 4 feet left side. With 
 back to speaker, hears loud conversation at 2 feet. Some sentences at 12 feet 
 und more. Facing speaker, hears ordinary conversation easily at 4 feet, and 
 some sentences at 20 feet. Has great difficulty with sounds of m, n, b. and p. 
 Says he heard the crickets in the grass at the sea-shore but not the sound of 
 the waves yesterday. Noises of street disturb him. 
 
 June 29th. Left the city, with orders to continue treatment. 
 
 July 20th. Writes that he has gained six pounds since June 29th. 
 
 August 12th. Writes that he "hears everything quite naturally, except 
 music." Sound of running water in ears continues. Gaining flesh and feeling 
 remarkably well. Thinks his hearing is still improving a little. 
 
 The record of this case ends here for the present. The patient's highest 
 daily dose of potash was 369 grains. The remedies agreed well with him, aiid 
 only had to be interrupted a few times, for two or three days, on account of 
 causing disturbance of the stomach. Inflation of the middle ears never pro- 
 duced any apparent effect. 
 
 CASE VI. Syphilis Sudden Tinnitus Recovery. Mr. P , aged forty-five. 
 
 July 2, 1877. In July, 1876, noticed a ringing sound in his left ear upon arising 
 in the morning. A few days later noticed the same sound in his right ear. The 
 tinnitus has remained ever since, and has increased in intensity. In October he 
 noticed that his hearing was impaired. The deafness has been increasing until 
 three weeks ago, since which time it has appeared to remain the same. Has been 
 treated for aural catarrh by two competent aurists (by one for a period of six 
 weeks), without any benefit. Has been treated by electricity also, without bene- 
 fit. Never had any internal medication. Has occasional dizziness. Health good 
 in all other respects. 
 
 Had a chancre in July, 1876, before tinnitus was noticed. Sore appeared 
 fourteen days after intercourse, healed slowly, and was accompanied by bala- 
 nitis. Never has been aware of any secondary affection of any kind. 
 
 H. D. : E., A ; L., &. 
 
 Loud voice, six feet at right side of head and twelve feet at left side. Tun- 
 ing-fork heard alike both sides, as nearly as he can judge. All the notes of a 
 piano " sound alike " to him. Band music sounds very discordant. General 
 appearance of both drum-heads is healthy. Pharynx normal. Tubes open. No 
 effect from inflation. 
 
 Diagnosis. Disease of cochlea, both sides, of syphilitic origin?
 
 SYPHILITIC COCHLITIS CASES. 639 
 
 Advised a half -drachm of twenty per cent, solution oleate mercury rubbed 
 into skin daily, and iodide of potash in increasing doses, beginning with 5 grains 
 three times a day. 
 
 August 14, 1877. H. D., /$ both sides; heard conversation thirty feet be- 
 hind back easily. B. E., notes of piano between sixth c and seventh e are not 
 heard. Four uppermost notes heard naturally. L. E., notes sound natural up 
 to sixth g ; from there to seventh e they sound ' ' all alike, and have no music in 
 them ; " above e they are natural again. Hears band music well now ; before it 
 was very discordant to him. Violin music is still discordant to him. His own 
 voice sounds more natural to him. Is sure himself that he hears everything 
 much better. 
 
 This patient left town at this time, expecting to return, but did not do so. 
 The remedies disagreed with him sometimes, and he was unnecessarily timid 
 about increasing the doses. He never took more than 42 grains iodide potash 
 three times a day. A statement frora this patient, in March, 1878, says that he 
 considers himself well. 
 
 CASE VII. Syphilis Symptoms of Cochlear Disease Slight Improvement. 
 
 Mr. C , aged thirty. Seen at Manhattan Eye and Ear Hospital. Patient 
 
 was perfectly deaf so far as the voice was concerned. Could not hear the 
 watch with which he was tested at all. The vibrations of the tuning-fork 
 were also not heard. All communication with him had to be held in writ- 
 ing. He could hear finger-nails against the left ear after three weeks, and the 
 tinkling of the street-car bells. In five weeks he could hear tuning-fork quite 
 well with the left ear. Later he heard the watch -/-$ with the same ear. All his 
 symptoms pointed to a disease of the labyrinth, and it was considered to be 
 syphilitic. He had contracted syphilis a year before, and had been treated 
 for it from the outset ; still he had had secondary symptoms. Six months later 
 he felt so well that he gave up treatment. Then he was taken with violent 
 pains in his head, and observed impairment of hearing and tinnitus. In a week 
 his hearing was "all gone." He resumed anti-syphilitic treatment, but the 
 deafness and tinnitus have remained. 
 
 This patient was treated with mercury and potash in increasing doses, and 
 carried out all directions faithfully for a long time. His general condition im- 
 proved, but no change was evident in his hearing except that mentioned above. 
 One day he came, saying that on the day before he had heard the word Mexico. 
 On trial, he was found to hear this word every time it was spoken into his left 
 ear. He did not hear any of the component letters of the word (as x or o) when 
 spoken into his ear, nor was any other word ever found which he could hear. 
 At this time he was taken with pulmonary hemorrhages, and specific treatment 
 was stopped. He has been in failing health ever since. 
 
 It is undoubtedly true that affections occur in syphilitic pa- 
 tients (from suppression of the perspiration, for example), which 
 would have occurred all the same had they not been syphilitic ; 
 and yet the exposure or imprudence having once caused the 
 attack of inflammation, it immediately assumes the character 
 of a syphilitic affection by reason of the syphilitic blood, whose
 
 640 SYPHILITIC DISEASE OF LABYRINTH. 
 
 increased flow to the part and the exudation go to constitute the 
 inflammation. The complete failure of the anti-catarrhal treat- 
 ment, although all these patients showed some catarrhal symp- 
 toms, was another striking evidence of the real nature of the 
 cases ; for we seldom meet with cases of catarrh that do not 
 respond to some extent to the use of the catheter, Politzer's 
 method, and so forth, while in acute or sub-acute diseases of the 
 labyrinth, this treatment often aggravates the symptoms.
 
 CHAPTER XXII. 
 
 DISEASES OF THE INTERNAL EAR (Concluded). 
 
 The Effects of Quinine. Cerebro-spinal Meningitis. Meningitis. Disease of the 
 Spinal Cord. Parotitis. Acute Inflammation of Membranous Labyrinth mistaken 
 for Cerebro-spinal Meningitis. Hemorrhages and Effusions. Injuries. Concus- 
 sions. Aneurism and Tumors. Disease of Semi-circular Canals. Pathology. 
 Treatment. 
 
 THE EFFECTS OF QUININE UPON THE LABYRINTH. 
 
 IN a paper read by me before the Society of Neurology and Elec- 
 trology MI April, 1874, ' I classified four of the cases of disease of 
 the internal ear then reported, as perhaps cases of congestion 
 and inflammation of the base of the brain and labyrinth, caused 
 by the internal administration of quinia. My remarks at that 
 time led to a discussion, in which Dr. Jacobi and Dr. Hammond 
 participated. To attempt a settlement of some of the questions 
 involved, I undertook some experiments upon the human sub- 
 ject, as did Dr. Hammond upon animals. I believe these were 
 the first experiments to determine the effects of quinine upon the 
 ear. They have been followed by others, and considerable clin- 
 ical experience has been published, as to effects of quinine upon 
 the eye as well as the ear, so that the views of the profession are 
 now clearer than before the subject was thus opened up. 
 
 I think large doses of quinine may cause temporary affections 
 of the labyrinth, which are made known by tinnitus aurium and 
 impairment of hearing. This congestion is not, however, con- 
 fined to the membranous labyrinth, but it may also occur in the 
 tympanic cavity and in the auditory canal. It is so well known 
 that buzzing in the ear is caused by quinine, that many persons 
 who are becoming gradually deaf from chronic catarrhal or pro- 
 liferous inflammations of the middle ear, and who,' as is the case 
 with most other persons in our country, have taken some quinine 
 in their time, jump at the conclusion that the quinine caused the 
 impairment of hearing from which they suffer. Exact exam- 
 ination often shows that many such patients have never taken 
 
 1 American Journal of the Medical Sciences, vol. Ixviii. , p 400. 
 41
 
 642 EFFECTS OF QUININE. 
 
 quinine enough to cause, or even to cure any disease. I object, 
 however, to the use of quinine in aural disease, in any considera- 
 ble doses ; for I have been convinced by experimental and thera- 
 peutical experience that it has a peculiar power of producing 
 congestion of the ear. In 1874 ' I published a case, which is re- 
 produced on page 168, which proves this. My experiments with 
 quinine upon the healthy human subject were begun upon Dr. 
 William A. Hammond May 7, 1874. 
 
 The optic papillae and the membranae tympanorum were the 
 parts examined, as well as the ocular conjunctivse and auricles. 
 " The vision was normal, --. Refraction, emmetropic ; pulse, 
 90 ; ocular conjunctivse white, decidedly free from hyperaemia ; 
 palpebrae congested at outer and inner canthus. There was no 
 tinnitus aurium. Membranae tympanorum were entirely free 
 from evidence of blood-vessels. (I will omit the details of the 
 examination of the optic papillae, since we are concerned only 
 with the effect of quinine upon the auditory apparatus.)" 
 
 Dr. Hammond took gr. x. of sulphate of quinine at 8.30 P.M. 
 At 9 P.M. the ocular conjunctivas were congested at the outer 
 and inner canthus ; palpebrae conjunctivas were markedly con- 
 gested over the whole surface. There was no change in appear- 
 ance of the drum-heads. 
 
 " 10 P.M. Head feels full ; left ear rings ; auricles burn ; face 
 is decidedly flushed ; auricles are red, especially the lobe of right, 
 where there is a localized congestion so marked as to resemble 
 an ecchymosis. There is now a vessel along each malleus. The 
 optic papillae are pinkish from apparent enlargement of lateral 
 vessels. 
 
 " 10.30 P.M. Right drum-head is very much injected along the 
 handle of the malleus and the upper margin ; left is less red, 
 but still shows vascular injection. Both papillae are pink, left 
 more so than right ; face flushed, eyes suffused, ocular conjunc- 
 tivas decidedly congested, slight headache, tinnitus in both ears. 
 
 "11 P.M. The redness of the auricles is diminishing, espe- 
 cially the circumscribed spot on the lobe of the left one ; the face 
 still flushed ; tinnitus continues ; no headache ; subject feels 
 exhilarated ; drum-heads still injected along the malleus ; vision 
 normal." 
 
 It should be said that Dr. Hammond, the subject of these 
 experiments, is a very large and well-developed man. and that 
 he smoked a mild cigar during the evening. 
 
 On May 28, 1875, I repeated the experiment upon Dr. E. 
 T. E , aged twenty-four, a man of about five feet six inches 
 
 1 Transactions of the American Otological Society.
 
 EFFECTS OF QUININE. 643 
 
 in height, well developed, in good health and vigor. He stated 
 that he never had had otitis. The hearing distance is |-| on 
 each side ; refraction -emmetropic. He has no tinnitus aurium. 
 The drum-heads are free from vessels, and normal in appear- 
 ance ; optic papillae normal. At 11.05 A.M. Dr. E takes gr. x. 
 
 of sulphate of quinine. At 11.35 there is a very fine vessel 
 along the right malleus ; no change in the left. At 12.30 there 
 is some redness at the periphery of the left drum-head, but the 
 vessel on the right has disappeared. At 1 P.M. the redness has 
 disappeared from both sides. No change is observed in the 
 optic papillae. There is no tinnitus, and no sense of exhilara- 
 tion. No tobacco or other stimulant was used during the time 
 of observation. 
 
 June 23, 1875. Dr. C , aged twenty-five, about five feet 
 
 nine inches in height, rather spare. Refraction myopic, ^ v. = 
 ff. Drum-heads absolutely free from congestion. No vessel on 
 or along malleus. Optic papillse are both flushed. 
 
 At 10.16 A.M. takes gr. xv. of sulphate of quinine. 11 A.M., a 
 vessel is seen along malleus of right membrana tympani ; and 
 left membrana tympani presents no change. There is slight 
 vertigo. 11.30. There is a sense of heat and tingling over the 
 whole surface of the body. Sense of fulness in ears and head. 
 The handles of both mallei are injected. The hands are tremu- 
 lous, and the subject gives general evidence of nervous excite- 
 ment. There are sounds of a high note in the ears. The ears 
 feel warm. At 12.30 the injection of the malleus is disappear- 
 ing, as are the vertigo and tremor. At 12.50 the mallei are still 
 injected. Motions of the jaw cause peculiar and unpleasant 
 sense of vibration in the ears. 
 
 Although these experiments are but three in number, they 
 are sufficient, I think, to justify the view I expressed in the 
 American Journal of the Medical Sciences, October. 1874, that 
 the effects of quinine upon the ear were due to congestion. 
 That view was contested at the time of reading the paper. ' by 
 Professor Jacobi, on the ground that some observations that had 
 been made in Germany, as well as clinical experience, seemed 
 to show that anaemia, and not congestion, was one of the effects 
 of the use of quinine ; that is to say, it was claimed that con- 
 traction and not dilatation of the vessels was produced by the 
 drug. Dr. Hammond's experiments upon animals, and. what is 
 much more conclusive than even experiments upon animals, 
 large clinical experience, some of which is given us by such 
 observers as the late Von Graefe. 2 confirm the view deduced 
 
 1 New York Society of Neurology and Electrology. 
 8 Archiv fur Ophthalmologie, Bd. III. 2, p. 396.
 
 644 EFFECTS OF QUININE. 
 
 from my observations, that the tinnitus aurium following the 
 use of quinine is the result of overfilled blood-vessels, and is not 
 the anaemia of blood-vessels not containing the normal quality 
 or quantity of fluid. 
 
 It should also be stated, that I have experimented upon two 
 other physicians, giving each ten grains of quinine at a dose. 
 I have no notes of these cases, but I may say that in one case 
 congestion of the drum-heads and of the optic papillae followed, 
 with tinnitus aurium, while in the other absolutely no effect was 
 produced. The former subject was a full-blooded man who had 
 suffered from congestion of the cerebral meninges. The gentle- 
 man upon whom no effect was produced had been in the habit 
 of taking quinine, and was rather anaemic. 
 
 Dr. Hammond ' published some experiments on this subject 
 in a paper in which he gives the literature of the subject, and 
 particularly the experience of M. Melier (Experiences et Ob- 
 servations sur les Proprietes Toxiques du Sulfate de Quinine. 
 Memoires de VAcademie Royale de Medecine, etc., p. 722). Melier 
 is very decided as to quinine causing deafness, as are other 
 writers ; but observations as to the immediate effect of the drug 
 upon the membrana tympani or other parts of the ear do not ap- 
 pear, except in the account of Dr. Hammond's own case. 
 
 The observations that have been made upon the f undus oculi, 
 after the administration of large doses of quinine, indicate that 
 the secondary effect of toxic, or large doses of this drug, is to 
 empty the blood-vessels. It has been assumed, I think, that is- 
 chaemia of the retina is the first consequence of a poisonous or 
 large dose. But the fundus oculi has not yet been examined in 
 such cases, as soon as the loss of vision occurred. 
 
 The following case reported by me," awakened such attention 
 to the effects of quinine upon the eye as well as ear, that the 
 experiments upon animals were continued, and clinical reports 
 were furnished from various sources. They have, as it seems 
 to me, nearly all served to confirm the views, that I was the first 
 to clearly express, as to the possible danger fr.om the use of this 
 drug, and the opinion that congestion is the primary effect of a 
 large dose. 
 
 A Case of Poisoning from the use of the Compound Tincture of CincJiona, producing 
 Permanent Contraction of the Visual Fields and Temporary Impairment of Sight 
 and Hearing. 
 
 On July 3, 1878, Dr. L. M. Yale asked rne to see a case of loss of sight, of 
 which the following history was obtained : Mr. B , aged fifty, a man of very 
 
 1 Psychological and Medico-Legal Journal, October, 1874, p. 232. 
 * Archives of Ophthalmology, vol. viii. , p. 392.
 
 EFFECTS OF QUININE. 645 
 
 intemperate habits as regards the use of alcohol. He had been accustomed for 
 years to drink enormously of brandy and whiskey at intervals, but there were 
 periods of varying length, from one to three or four months, of total abstinence 
 from intoxicating drinks. 
 
 Mr. B was told that the use of the tincture of cinchona would relieve 
 
 him from his periodic craving for alcohol. On June 24th of that year he began 
 its use, with a view of correcting his intemperate habits. On that day, as 
 well as on the 25th, 26th, 27th, and 28th, he continued to take the compound 
 tincture in ounce and two-ounce doses, at short intervals, literally drinking it as 
 a beverage from a quart bottle, in which he had caused an apothecary to place as 
 strong a preparation as possible. On the 28th, although he had taken none of 
 his ordinary alcoholic stimulants, his clerk thought from his conduct that Mr. 
 
 B had been drinking heavily. Dr. Yale estimated that in these days the 
 
 patient took an amount of the tincture which would be equivalent to 125 ' grains 
 
 of an alkaloid of cinchona. Mr. B has no recollection of any occurrence 
 
 after the 27th. He is confident that he took no alcohol, except that contained 
 in the preparation of cinchona, during these days. This, however, may be 
 doubtful, for the clerk of the hotel to which he went when in what proved to 
 be a semi-conscious state on the 28th, states that while he lay in bed he was 
 constantly ringing the bell for liquor. It is possible that during this time some 
 
 doses of alcohol were added to those of cinchona, although Mr. B does not 
 
 believe this to be the case. On the morning of July 1st he was seen by Dr. 
 Hills in the absence of Dr. Yale. He found the patient stupid or half -conscious, 
 with flushed face and conjunctivse, and apparently unable to see or hear. Mr. 
 
 B remembers Dr. Hills' visit on Sunday, and knows that he was then blind 
 
 and deaf. Dr. Yale saw the patient on Monday and Tuesday, July 2d and 3d. 
 His hearing power improved so much in that time as to become apparently nor- 
 mal, but his vision remained very much impaired. On the day I saw Mr. B , 
 
 the 3d, he was groping about his room, apparently in excellent general health and 
 with good hearing. V., K. E. = quantitative perception of light. L. E. counts 
 fingers at one foot. The ophthalmoscope showed lessened size of the arterial 
 vessels ; no abnormity in the veins, lessened number of vessels on the papills?, 
 but no marked paleness. No changes observed in tlie membrana tympani. The 
 patient was advised to take strychnia in increasing doses and nutritious diet. 
 On July 6th he was able to walk about. V. = f S each eye, but the visual fields 
 were very much contracted, so that vision was telescopic. 
 
 On July 16, 1878, both visual fields were found concentrically limited. The 
 measurements, drawn on a blackboard 14" distant, were as follows : Eight field, 
 vertical, 9 inches ; horizontal, 7 inches ; limitation most marked on temporal 
 side. Left field, vertical, 7 inches ; horizontal, 8 inches ; limitation more 
 
 regular. B found this symptom rather novel than troublesome. The optic 
 
 papillae looked very pale, and the arteries were narrow. July 23d, V. = if], each 
 eye. Patient states that he can see perfectly well in a straight line, but that 
 when walking about a room he has some difficulty in seeing small articles of 
 furniture. 
 
 September 10th. The same condition is maintained. The strychnia was 
 taken until -fa grain had been reached at a dose, and was continued for two 
 months. The visual field remains as on July 16th. 
 
 1 This amouHt was afterward found to be nearer 50? grains.
 
 646 EFFECTS OF QUININE. 
 
 April 23, 1879. Mr. B 's condition remains substantially the same. He 
 
 continues to abstain entirely from the use of alcohol, and carries on a large busi- 
 ness successfully. His vision is still ftf each eye. The visual field has increased 
 somewhat in the left eye. It now measures 9 inches vertically and 16 inches 
 horizontally. F. of B. E. 6" vertically, 9" horizontally. Limitation most 
 marked at upper-inner quadrant. The optic disks are pale and the arteries small. 
 There are no other ophthaimoscopic appearances. 
 
 Mr. B- had taken no alcohol for some months prior to his 
 
 beginning the use of the cinchona, and he took none until he be- 
 came unconscious on the fourth or fifth day. Although he went 
 about and transacted business on the fourth day, he has no rec- 
 ollection of what he did. When found he had an empty bottle 
 (holding a quart) in his room, labelled and giving positive evi- 
 dence of having contained cinchona. He certainly did not take 
 many drinks, if any, after he reached the hotel, for the clerk, 
 knowing his former habits, and supposing him to be suffering 
 from an ordinary debauch, refused to answer his demands. It 
 is not known that he took anything but the cinchona at any time 
 after he began the treatment of the alcohol habit. 
 
 We have here, then, a case of hypersemia of the vessels of 
 the ear from the use of cinchona and alcohol a hypersemia 
 which passed away without going on to an exudative process ; 
 but the same condition in the vessels supplying the retina con- 
 tinued until a true vasculitis, with its consequences, resulted. 
 
 The following case was considered to be one of chronic catarrh 
 of the middle ears, with affection of the cochlea. While under 
 treatment it happened to furnish an illustration of the effects of 
 quinine upon the ears : 
 
 Injury of the Cochlea from Cannonading Effects of Quinine on the Ear. Dr. 
 
 P , aged fifty-one. In 1870 was exposed to heavy cannonading, after which 
 
 he had sudden tinnitus and impairment of hearing on both sides. The symp- 
 toms passed away in great measure within a short time. Since then he has had 
 the tinnitus only occasionally. The deafness has not been enough to annoy him 
 until lately. Thinks the right ear has always been the worse. A year and a half 
 ago he noticed that he heard the click preceding the striking of his clock, but 
 did not hear the strike. Now he hears the strike, but not the click. Hears 
 worse in a noisy place. Has been troubled with irritation and excess of secretion 
 in pharynx for a long time. Health otherwise excellent. 
 
 H. D. B. E., -&; L. E., ^. Voice, fifty feet behind back. 
 
 Tuning-fork placed on teeth is heard alike. Plugging either ear makes no 
 difference. Placed on forehead or vertex is heard alike, but better on left side 
 when plugged. Placed on mastoid heard better on left side than on right ; 
 plugging left ear intensifies sound of fork; plugging the right ear makes no 
 difference. All the notes of the piano are heard well with the left ear. The 
 right ear has partially lost its perception of some of the lower and some of the 
 upper notes, but hears the others well.
 
 EFFECTS OF QUININE. 647 
 
 Eight drum-head : Opaque. Light spot, narrow and divided. 
 
 Left dram-head : Opaque. Good light spot. 
 
 Pharynx catarrhal. 
 
 Inflation for three weeks improved the hearing for the watch to & on both 
 sides. 
 
 One morning, while under treatment, the patient came complaining of great 
 "stuffiness" and tinnitus in both ears. During the preceding twenty -four hours 
 he had taken thirty-eight grains of quinine for neuralgia. The hearing for the 
 watch was ^.r R. E., and A L. E. There was intense redness along each malleus- 
 handle. (The day before the hearing had been - 4 s t f each side, and no redness of 
 the drum-heads existed on that day, or had ever been seen before.) Inflation did 
 not improve the hearing at all, although it had never failed to do so before. 
 At the next visit the conditions were as usual. 
 
 Several weeks after stopping treatment, the hearing had relapsed to its 
 former state. 
 
 In an inaugural dissertation Dr. Hans Brunner ' has collected 
 the cases of amblyopia caused by quinine, and also gives the re- 
 sult of experiments made with the drug. Until the observations 
 of Briquet, Paris, 1855, who saw four cases of temporary blind- 
 ness found in four persons from daily doses of from 3 to 5.0 
 grammes, they are not of any importance. Briquet thinks that 
 impairment of vision occurs less frequently than impairment of 
 hearing. Dr. Virsinier, of Louisiana, quoted by Brunner, has 
 seen deafness occur without blindness, but never blindness un- 
 accompanied by deafness. One of his patients, during an attack 
 of intermittent fever of a pernicious variety, took 4.0 grammes 
 of sulphate of quinine within six hours, and just as much during 
 the same time in an enema. On the next day the patient was 
 deaf and blind. 
 
 Dr. Baldwin, of Alabama, has warned the profession on sev- 
 eral occasions of the dangers to sight, hearing, and even life, 
 from large doses. 
 
 Weber- Liel," quoted by Brunner, verifies my views as to con- 
 gestion of the ears being caused by quinine. Kirchner. 3 in an 
 article upon the effects of sulphate of quinine upon the tempera- 
 ture and circulation, states as the result of his experiments, that 
 quinine causes inflammatory processes and permanent patholog- 
 ical changes in the ear. He believes that the cause for these con- 
 ditions is to be found not only in a hypercemia of short duration, 
 but also in paralysis of the vessels with congestion and exuda- 
 tion. 
 
 I believe that the tinnitus aurium and impairment of hear- 
 
 1 Ueber Chininamaurose. Dissenhoffen, 1882. 5 Loc. cit., p. 36. 
 
 3 Berlin. Klin. Wochenschrift, 1881, p. 725.
 
 648 EFFECTS OF QUININE. 
 
 ing, following the use of quinine, depend upon congestion of the 
 ultimate fibres of the auditory nerve in the cochlea, and that the 
 redness of the drum-heads is merely an index of the former con- 
 dition. 
 
 Since the publication of the last edition I have had the oppor- 
 tunity of carefully examining a patient with typhoid fever, who 
 was profoundly under the influence of quinine, so that she could 
 not hear ordinary conversation, a person with good hearing be- 
 fore the administration of the quinine, and who perfectly recov- 
 ered her hearing power after the effects of the quinine had 
 passed away. The patient heard the tuning-fork better through 
 the air than the bone, indeed, the bone-conduction-was nearly 
 destroyed. This completes the chain of proof that the lesion in 
 deafness from quinine is in the internal ear. 
 
 In the treatment of deafness from quinine I have used strych- 
 nia with great benefit. Mercury and potash should not be 
 given, nor should depletives be used in any form. 
 
 Since the publication of the last edition of this work, I have 
 seen a very interesting case of deafness following the use of 
 quinine, which I reported in full elsewhere. 1 It was that of an 
 officer of the navy, about forty-nine years of age, who, having 
 excellent hearing, took twenty grains of sulphate of quinine one 
 evening after a wetting from exposure to a storm, and woke up 
 profoundly deaf. He never had had syphilis. The use of leeches 
 and the internal administration of mercury was begun the day 
 the deafness occurred, but the patient continued profoundly deaf, 
 with very unpleasant head symptoms, until strychnia and alco- 
 holic stimulants were used, when he immediately began to im- 
 prove. He ultimately recovered the hearing of one ear in good 
 proportion, but the other remains profoundly deaf. 
 
 Fortunately most of the cases of deafness caused by quinine 
 fully recover. In some, however, most deplorable results occur. 
 It is a drug that should never be lightly administered to any 
 person, and especially to any one already affected with aural 
 disease, unless in the rare cases of malarial neuralgia of the 
 middle ear. 
 
 Kirchner found diminution in the perception of a vibratory 
 tuning-fork placed upon the bones of the head, and also a dimin- 
 ished perception of the higher tones. Orne Green," on reviewing 
 the literature of this subject and giving his own large clinical 
 experience, quotes my views and their corroboration by Kirchner 
 with approbation, and states : From our present knowledge, both 
 clinical and experimental, we are justified in asserting that the 
 action of quinine upon the ears is to produce congestion of the 
 
 1 International Congress of Otology, Brussels. 1882. 
 
 J Boston Medical and Surgical Journal, vol. cviii.. p 220.
 
 CEREBRO-SPINAL MENINGITIS. 649 
 
 labyrinth and tympanum, and sometimes distinct inflammation, 
 with permanent tissue changes. 
 
 DISEASE OP THE ACOUSTIC NERVES CAUSED BY CEREBRO-SPINAL 
 
 MENINGITIS. 
 
 Cerebrospinal meningitis has been generally supposed to be 
 the cause of many cases of disease of the auditory nerves. That 
 it frequently causes great loss of hearing, and sometimes abso- 
 lute deafness, no one with the least clinical experience will deny. 
 A large proportion of the deaf-mutes of the present day are said 
 to have lost their hearing in the course of cerebro-spinal menin- 
 gitis. I believe, however, that although the trunk of the acoustic 
 nerve and the labyrinth may become diseased, and perhaps pri- 
 marily in some cases, that the lesion of the ear that most fre- 
 quently occurs in the disease is an inflammation in the tympa- 
 num. Judging from the analogous process that occurs in the 
 eye, this seems a plausible view. We do not usually have optic 
 neuritis when the eye becomes affected in cerebro-spinal men- 
 ingitis, but choroiditis a peripheric and not a central affection. 
 The pathological investigations in this direction have been few, 
 apparently because general pathologists are not much inter- 
 ested in the ear, and those who concern themselves with its dis- 
 eases have few opportunities to make post-mortem examinations 
 in cases of cerebro-spinal meningitis. The clinical facts are 
 against the theory of disease of the nerves. There is scarcely 
 ever facial paralysis in conjunction with the deafness. It is 
 hard to conceive of suppuration of the trunk of the acoustic 
 nerve, without any affection of the facial, and although this ab- 
 sence of facial paralysis does not prove Voltolini's view, nearly 
 all the cases of loss of hearing said to result from cerebro-spinal 
 meningitis, actually depend upon inflammation of the membra- 
 nous labyrinth. It assists us to believe that the first lesion may 
 often be in the tympanum. The evidence furnished by the drum- 
 heads, which are so often sunken, although not conclusive for 
 we may have secondary disease of the tympanum as well as of 
 the labyrinth is another point in the clinical evidence. Then 
 the tuning-fork, in many cases, notably in deaf-mutes, is heard 
 through the bones, when it is not at all perceived through the 
 air. Disease of the acoustic nerve has, however, been found 
 in post-mortem examinations of cases of this disease. Wie- 
 meyer, quoted by Moos, 1 remarks that he does not consider it 
 improbable that "the deafness and impairment of hearing may 
 be produced by different causes," but he states that Luschkaand 
 himself found the acoustic nerve, up to its exit from the skull, 
 so completely embedded in masses of exudation, that Professor 
 
 1 Archives of Ophthalmology and Otology, vol. ii. , p. G22.
 
 650 CEREBRO-SPINAL MENINGITIS. 
 
 Luschka felt justified in supposing that the inflammation and 
 exudation following the course of the nerves might easily, in 
 some cases, extend into the labyrinth. Moos, in this same 
 paper, gives a report of the necroscopy of two cases in which 
 there was found pus in each tympanum, also in the vestibules, 
 and ampullae, and the cochlea. Both the acoustic and facial 
 nerves in the meatus auditorius were surrounded by pus. The 
 second case presented similar appearances. 
 
 It has been pretty generally assumed that these cases were 
 cases in which the trunk of the acoustic nerve was primarily 
 affected, but it is by no means certain that the primary trouble 
 here alsjo was not in the tympanum whence it may have ex- 
 tended to the labyrinth and nerve. 
 
 The cases reported by Heller ' show that he considers it pos- 
 sible, from his microscopic examinations, that the suppuration 
 in the tympana and labyrinth may have occurred simultane- 
 ously with the changes in the cerebral and spinal membranes. 
 Lucse * reports a case which more fully supports the view of a 
 primary affection of the labyrinth in cerebro-spinal meningitis 
 than do any of the preceding cases. In his case there was 
 merely congestion of the tympana, while the Eustachian tubes 
 were in a normal condition and the labyrinths were in a state 
 of suppuration. " The purulent inflammation of the base of the 
 brain along the vessels of the acoustic nerve, up to the cochlea, . 
 was more exactly traced on both sides." Knapp s found "symp- 
 toms of hypersemia or catarrhal inflammation of the middle ear, 
 either during the febrile stage of the disease or during the period 
 of convalescence" in many cases. Knapp also examined two 
 temporal bones of a patient who had become deaf and died from 
 cerebro-spinal meningitis. In one ear the outer and middle ears 
 were normal, while the acoustic nerve was softened by suppura- 
 tion. While the accompanying facial appeared to be normal, the 
 acoustic nerve of the other side had not suffered, but numerous 
 pus-cells were found around it. The labyrinth was not examined. 
 
 Moos, 4 however, reports the post mortem of a case of cerebro- 
 spinal meningitis, in which the nerve was found to be sound, 
 excepting some congestion of the sheath up to the meatus audi- 
 torius internus, while there was extension of the inflammation 
 from the dura mater into both tympanic cavities. 
 
 Von Troltsch says that a few post-mortem examinations 
 show that the morbid changes causing deafness in cerebro- 
 spinal meningitis are sometimes found in the fourth ventricle. 
 
 1 Archiv fur Ohrenheilknnde, Bd. IV., p. 55. 
 * Ibid., Bd. V., p. 188. 
 
 3 Transactions of the American Otological Society, 1873. 
 
 4 Archives of Ophthalmology and Otology, vol. iii., No. 2, p. 177.
 
 CEKEBRO-SPINAL MENINGITIS. 651 
 
 Professor J. Lewis Smith 1 says that "inflammation of the 
 middle ear, of a mild grade and subsiding without impairment 
 of hearing, is common." Dr. Smith also says that suppuration 
 of the tympanum may occur. According to his statistics, about 
 one in every ten patients becomes deaf. 
 
 I have seen congestion of the tympanum in recent cases of 
 the disease under discussion, and I have seen many where the 
 labyrinth was the seat of disease, but whether primarily or sec- 
 ondarily so, I cannot say. It is probable that the inflammatory 
 process sometimes, and, as I think, generally, follows the blood- 
 vessels into the tympanum rather than along the acoustic nerve, 
 for in most of the cases I have seen there is still some hearing 
 power by bone-conduction, to me a positive indication that some; 
 power remains in the acoustic nerve. . 
 
 The following cases illustrate the clinical appearances : 
 
 CASE I. Cerebro- Spinal Meningitis Bilateral Deafness Both Drum-Heads 
 
 Sunken. December 30, 1869. E. M. W , aged thirteen, five years ago this 
 
 winter had an inflammatory disease of the head and joints, and when he recovered 
 from this affection became deaf. He does not hear words in any way. He feels 
 the tuning-fork placed on the bones in each ear. The membranse tympani of both 
 sides are sunken ; the pharynx and nares are in a healthy condition ; air enters 
 both tympanic cavities. 
 
 CASE II. Cerebro-Spinal Meningitis Absolute Deafness Both Drum-Heads 
 
 Sunken. C. M , boy, aged four years and eight months, heard and talked 
 
 well until about a year ago, when he had a fit of sickness, which the parents de- 
 scribed very imperfectly, but which was attended by some loss of power in the 
 limbs. There was at one time some discharge of pus from one of the ears. The 
 child does not seem to hear sounds at all ; the vibrations of a large tuning-fork 
 are not perceived. Both drum-heads sunken and pinkish. 
 
 CASE III. Cerebro-Spinal Meningitis Deafness Absolute Membrane Tympani 
 
 Nwmal . May 22, 1872. D. W. K , aged twenty-one, a little more than three 
 
 months since was attacked by some disease of the head, and for two weeks was 
 stupid or delirious. There were some little spots on the neck. When he be- 
 came conscious, he could not hear ; he has remained deaf ever since. There 
 seems to be absolutely no hearing power ; cannot hear the voice even when con- 
 veyed to the ear through a tube ; and is equally unconscious of the sound of the 
 tuning-fork or the piano. The membranse tympani are of normal color, trans- 
 parency, and position ; air enters the tympanic cavities. 
 
 CASE IV. Cerebro-Spinal Meningitis Sunken Drum-Heads. George S , 
 
 aged twenty-five months, when fourteen months old had congestion of the brain ; 
 was unconscious, paralyzed, and had spots on the skin. Was found to be deaf 
 when he recovered. Both membranae tympani are sunken. 
 
 CASE V. Cerebro-Spinal Meningitis Sunken Drum-Heads. May 31, 1873. 
 
 John D , aged nine, eight weeks ago to-day was seized with a pain in his head 
 
 at about 8 o'clock A.M. The pain was said to be across the forehead. At 11 
 o'clock he had convulsions. There was spasm, especially of the hands and 
 
 1 Medical Record. December 8, 1883.
 
 652 MENINGITIS. 
 
 throat, at 8 P.M. ; complained of headache, and at 11 P.M. he vomited. He be- 
 came unconscious, and remained so until 4 A.M. Ten days after the attacks he 
 was deaf, and still continues to be so. He states that there is a whistling sound 
 in his ears. He took large doses of quinia, and soon recovered from all the symp- 
 toms, except a little uncertainty in his steps, and even now he has a somewhat 
 tottering gait. He does not hear the watch at all ; but can distinguish sounds 
 conducted into his ear through a tube. The tuning-fork, when placed upon the 
 teeth, produces a buzzing noise. The drum membranes are very much sunken, 
 and of a pinkish hue ; show a small light spot. 
 
 CASE VI. - - Cerebro-Spinal Meningitis Normal Membranes Tympani Slight 
 
 Amount of Hearing Power as Tested by Piano. March 17, 1874. D. B , aged 
 
 twenty-one, a little more than ten months ago was attacked with a chill, which 
 was attributed to sitting upon a stone in the front of the house during the month 
 of May. After the chill the patient became delirious, and his neck was stiff, and 
 he had no use of his arms or legs. This state of things continued for one week. 
 As soon as he became rational he was found to be deaf, and his left side re- 
 mained paralyzed. He gradually recovered from the paralysis, though his deaf- 
 ness continues, and he staggers in his walk. Hearing distance : right, ; left, 0. 
 The tuning-fork is faintly heard in both ears ; he is sensible of the tones of his 
 own voice, and talks in a natural tone, modulating fairly. He thinks his right 
 ear is the better One. By means of a conversation tube connected with the 
 keys of a piano, he is enabled, through the medium of the right ear, to distin- 
 guish the C, D, and E of the treble, as well as all the bass notes. With the 
 left ear he cannot distinguish the treble, the bass notes alone being audible. 
 This is in accordance with the law of acoustics, that the impression of the bass 
 or low notes remains longer on the ear, thus proving that the patient had still 
 a slight trace of hearing power remaining in the cochlea, and that the state- 
 ment that he heard better with the right ear was correct. The membranae 
 tympani are transparent, the pharynx is granular. The patient has been for 
 some weeks under competent treatment, but without perceptible benefit. 
 
 CASE VII. Cerebro-Spinal Meningitis Normal Membrane Tympani. May 2, 
 
 1872. Virgil T , aged five, four weeks ago was seized with a severe pain in 
 
 the head ; soon vomited, and was delirious at times, especially on waking from 
 sleep. He complains of pain in the back and neck, and also of pain in his right 
 ear. Four days after the attack began he was found to be deaf, which symp- 
 tom increased after a second attack of pain. Apparently there is an entire ab- 
 sence of hearing power. There is nothing marked in the appearance of the drum 
 membranes. He totters in his gait. 
 
 INFLAMMATION OF THE ACOUSTIC NERVE AND LABYRINTH FROM 
 
 MENINGITIS. 
 
 It is well known that inflammation of the base of the brain 
 may extend to the trunk of the acoustic nerve and to the laby- 
 rinth. The following cases are examples of this form of disease 
 of the internal ear : 
 
 CASE 1. Meningitis Gradual Deafness. June 25, 1870. W. K J , aged 
 
 twenty-seven, complains of increased impairment of hearing. Had scarlet fever 
 when a child, after which he felt a diminution in the hearing power. Last winter 
 had congestion of the brain and hemiplegia of left side. His right ear became 
 decidedly worse at this time. He has recovered from the hemiplegia. There is
 
 MENINGITIS. ,653 
 
 no tinnitus aurium. The hearing distance on the right side, ; left, }f. Tun- 
 ing-fork is heard better on right side. The right membrana tympani is sunken, 
 and has no light spot. The left is also sunken, and exhibits two reflections of 
 light. Inflation of the ears improves the hearing on the left side. 
 
 CASE II. Basilar Meningitis Bilateral Deafness. April 30, 1872. William 
 
 E , aged twenty-seven, says that seven weeks ago he could hear well, but 
 
 after an attack of fever attended by delirium, he found, when restored to con- 
 sciousness, that he had lost his hearing. There is a roaring noise in the left ear, 
 but no other aural symptom. He can hear the watch when laid upon the' right ear, 
 but not at all upon the left. The tuning-fork is also heard more or less distinctly 
 in the right ear. The right drum-head is somewhat sunken, the left very much so. 
 
 CASE III. Meningitis Inflammation of Cerebral Meninges and Labyrinth Ex- 
 posure to Direct Rays of the Sun. September 8, 1873. Laura , aged twenty- 
 two months. The mother states that when the child was eight months old, and 
 teething, she was unduly exposed to the direct rays of the sun, and was there- 
 upon suddenly attacked with convulsions and was ill for three weeks afterward. 
 The physician in charge observed that she was losing her hearing, and the mother 
 thinks that she has not heard since that period. The drum-heads are both very 
 much sunken and have no light spot. 
 
 CASE IV. Basilar Meningitis Effusion about Auditory Nerve Intermittent 
 Character of Attacks Epilepsy Deafness Recovery. January 29, 1885. Moses 
 
 B , aged twenty-nine, merchant, previous to July last heard perfectly well. 
 
 He has had intermittent fever at different times for two years ; had also an attack 
 of sunstroke. In July he lost the hearing in one ear, and for four weeks he was 
 deaf with both ears. After a course of counter-irritation his hearing gradually 
 returned. He has taken a large quantity of quinia. Some weeks ago, while at 
 Petersburg, Va., his hearing power again failed, and at the present time he can- 
 not hear words at all ; even the ticking of the watch is not perceived. He can- 
 not hear the tuning-fork when placed upon the head, but feels it when on the 
 teeth. The drum-heads are somewhat opaque, and there is granular pharyn- 
 gitis. He complains of a severe pain in the top of his head, and of a knocking 
 sound in the interior. His countenance is very anxious, appetite poor, but he 
 walks well. There is no history of syphilis. He had a severe fall upon his 
 head, striking the occipital region, when he was seven years of age. I saw the 
 patient first at my clinic at the University Medical College, and the next day at 
 my office in consultation with his family physician. I advised iodide of potas- 
 sium, but I did not see him again for two months, when, at the instance of Dr. 
 William A. Hammond, he called upon me, and to my great delight I found that 
 he could now hear conversation with ease, and the watch at twenty inches ; 
 hearing distance f| on each side. He had been under Dr. Hammond's care for 
 about four weeks. 
 
 Dr. Hammond treated the case by means of the iodide of 
 potassium mixed with the bromide. This treatment relieved 
 the cephalalgia and epilepsy. Subsequently he administered 
 arsenic in consequence of the intermittent type of the epilepsy. 
 The hearing power was suddenly restored on one side, and the 
 other soon became better also. 
 
 Through the courtesy of Dr. H. G. Miller, of Providence,
 
 654. DISEASE OF SPIRAL CORD. 
 
 have been furnished with the following interesting history, and 
 1 was also afforded the opportunity of seeing the case : 
 
 CASE V. Meningitis Inflammation of Both Auditory Nerves Recovery of 
 One. December 29, 1873. H. S , a student of Trinity College, early in Octo- 
 ber had an acute affection of the cerebral meninges and of internal ear, leaving 
 him totally deaf in one ear, and nearly so in the other. I saw him first about ten 
 days after the commencement of the trouble. His condition then was : External 
 and middle ears perfectly normal ; subjective noises very troublesome, and ex- 
 treme giddiness on walking, and especially on attempting to go down-stairs, and 
 also on turning the head in either direction. Hearing distance : right ear, contact 
 for a watch of 30' ; left ear, 0. Tuning-fork heard by bone conduction in right ; 
 not at all in left. I put him on bromide and iodide of potassium, and soon began 
 the use of the constant current. The right ear improved rapidly, and in about 
 five weeks hearing distance became normal. For some time after that, however, 
 through the two octaves of the piano, from middle C upward, he heard, in addi- 
 tion to the note struck, another less than a semitone above, which produced a 
 most disagreeable clang, and rendered music very unpleasant to him. I then 
 saw Dr. Blake in consultation about the left ear. We found in it perception for 
 higher sounds than normal, and that this perception was prolonged by the con- 
 tinued current ; and advised the continuance of the electricity, and also the use 
 of valerianate of zinc and conium. Since that time there has been but little 
 change. He has at times heard the watch faintly, but cannot always be sure of 
 it. The auricle of the affected ear was quite numb. No further treatment was 
 advised. 
 
 CASE VI. Meningitis Deafness Normal Membranw Tympani. Sallie A , 
 
 aged thirteen, three months ago was attacked with severe headache and vomiting; 
 delirium at times, but generally consciousness retained. In three weeks the fever 
 subsided. There was no paralysis. She did not hear well after being ill a few 
 days. Was attacked on Saturday, and on Wednesday it was observed that she 
 did not hear words, even when spoken very close to her. The patient com- 
 plained then, as now, of severe tinnitus aurium ; does not hear the watch at all. 
 The tuning-fork is heard well and naturally. Jarring sounds hurt her head. 
 There are no marked changes on the membrana tympani. 
 
 INFLAMMATION OF THE INTERNAL EAR FROM DISEASE OF THE SPINAL 
 CORD AND MEDULLA, TYPHOID FEVER, AND SCARLET FEVER. 
 
 I have seen several cases of locomotor ataxia in which there 
 was considerable impairment of hearing. In these cases the 
 cause has not usually been a coincidental catarrh of the tym- 
 panum, but an affection of the acoustic nerve. The tuning-fork 
 was heard better through the air, the voice better than the watch, 
 noises were distressing, and the hearing was made worse by 
 inflation. I have watched one such case for some eight years, 
 and although the general symptoms of the patient have some- 
 what increased that is, his locomotion is not so good, and his 
 nutrition is more impaired the hearing power remains about the 
 same. With the same degree of disease of the middle ear, he 
 would by this time have been much worse. 
 
 Typhoid fever sometimes produces disease of the middle ear,
 
 SCARLET FEVER CEREBRO-SPJNAL MENINGITIS. 655 
 
 sometimes of the labyrinth, and occasionally of both parts in 
 the same subject. There is apparently an anaemia of the laby- 
 rinth after certain cases of continued fever, for while the symp- 
 toms are those of disease of the nerve, they partially recover as 
 convalescence goes on. In some cases it is possible that the dis- 
 ease of the labyrinth is caused or increased by quinine which 
 has been given during the illness. 
 
 Scarlet fever usually causes a suppuration of the middle ears, 
 and no further disease, but in some rare instances the inflamma- 
 tion is not suppurative and attacks the labyrinth. 
 
 CASE I. Scarlet Fevei Deafness No Change in the Pharynx or the Outer 
 
 Ear. January 28, 1870. S. M. J , aged five, had a mild attack of scarlet fever 
 
 when he was eight months old ; the mother discovered that the child was deaf 
 four months afterward. There appears to be no hearing power. The tuning- 
 fork causes no sensation. The pharynx and nares are in a healthy state, and the 
 membranse tympani show no changes. 
 
 In not extremely rare instances, as it appears from the tables 
 of institutions for the deaf and dumb, pneumonia causes diseases 
 of the internal and middle ear. I once saw, in consultation 
 with the late Professor Little, a case where deafness followed 
 pneumonia, which followed a mild attack of cerebro-spinal men- 
 ingitis. 
 
 CASE II. Cerebro-Spinal Meningitis (?) Pneumonia Profound Deafness 
 
 Sunken Di-um-Head. November 27, 1883. Maggie B , aged five. Dr. Little's 
 
 account of the case was as follows : ' ' This child was taken sick about two weeks 
 ago with symptoms that pointed toward cerebro-spinal meningitis. On the fifth 
 day these symptoms subsided and an examination showed pneumonia of the left 
 lung. Two years ago sh.e had a similar attack. She now seems to be deaf." 
 The father stated that the child had been deaf for a week ; she complains of 
 tinnitus in her left ear. "When the child was taken sick she had fever and fre- 
 quent vomiting. The latter symptom occurred for two days. On the fifth day 
 pneumonia appeared. She recovered, and while convalescing, one week ago, 
 deafness came on. She does not hear the voice or loud sounds conveyed through 
 the air. It is impossible to learn whether she hears the tuning-fork by bone or 
 not. Both drum-heads are sunken, and the left is congested and exhibits two 
 light spots. Treatment was of no avail. On June 4, 1884, I saw her again. She 
 was deaf to all sounds through the air, but seemed to hear the vibrations of the 
 tuning-fork when placed upon the bones. This, I think, was a metastatic in- 
 flammation of the middle and internal ears, but I think the disease began in the 
 tympana, and that some degree of power remained in the nerve. It is a case 
 which throws some light upon the nature of aural disease in cerebro spinal men- 
 ingitis. 
 
 DISEASE OF THE INTERNAL EAR FROM PAROTITIS. 
 
 Of a total number of five thousand cases of aural disease, seen 
 in private practice, of which I have notes, only ten seemed to 
 have been caused by parotitis. Specialists in this country and in
 
 656 DEAFNESS FROM PAROTITIS. 
 
 Germany have seen very few of such cases. Of late great in- 
 terest has been shown in this subject, as shown by cases re- 
 ported by Buck, 1 Brunner," Knapp, 3 Moos, 4 Harlan, and others, but 
 very little has been added to the statements of Toynbee, Hinton, 
 and myself, made by the first-named author in his text-book, in 
 1860, by Hinton, in 1874, in his "Questions of Aural Surgery," 
 and by myself in an article on "Diseases of the Internal Ear,'' 
 in the American Journal of the Medical Sciences. Toynbee and 
 Hinton, and lately Dalby, speak of disease of the ear after 
 mumps as if it were a common one. In this they differ from 
 the German and American authorities, who speak of it as a rare 
 affection. Hinton says : " Next, or perhaps equal, in frequency 
 to scarlatina, in this respect, stands mumps, which has an effect 
 on the nervous apparatus of the ear which has as yet received 
 no explanation, and affords no clue to the use of remedies ; 
 every part of the ear being normal, so far as examination can 
 extend, but the function is almost abolished. ' But some cases 
 (the italics are mine) of damage to the ear from mumps present 
 an intermediate character, showing clear signs of a tympanic 
 disorder mixed with the nervous symptoms. The similarity of 
 the nerve affection that follows mumps to that which ensues 
 upon parturition, is very striking; and the resemblance is in- 
 creased by the fact that quite frequently the latter affection also 
 is accompanied with symptoms of a catarrhal character." 
 
 After all that has been written, it still remains doubtful as 
 to how the ear is invaded, and whether the disease is generally 
 a primary one of the labyrinth or of the middle ear. That it is 
 occasionally at least a disease of the middle ear, the last of the 
 cases reported by me, 6 and here reproduced, plainly shows. The 
 first cases which I reported were observed before I knew the 
 full value of the tuning-fork in diagnosis, and I am unable to 
 say of some of them whether they are cases of disease of the 
 internal or middle ear. 
 
 CASE I. Parotitis Deafness of One Side Patient first seen Three Years after 
 the occurrence of the Mumps. H. A. H , aged twenty-three, student of medi- 
 cine. Three years ago the patient had a slight attack of the mumps. During it he 
 lost the hearing of the right ear. Hearing distance : R., **?$* ; and L., ||. The 
 membrana tympani appears to be normal. There is considerable tinnitus aurium. 
 The patient was treated through the Eustachian tube for about two months. 
 
 1 American Journal of Otology, vol. iii., p. 203. 
 
 2 Archives of Otology, vol. xii. , p. 102. 
 
 1 Ibid., vol. xi., p. 385. 4 Ibid., p. 13. 
 
 * Archives of Otology, vol. xii., p. 1.
 
 DEAFNESS FROM PAROTITIS. 657 
 
 The tinnitus was usually diminished for an hour or so after the applications 
 through the catheter. 
 
 In this case there was certainly disease of the middle ear. It 
 will be observed that the watch was heard upon the mastoid 
 process, while not upon the meatus. The case was seen in 1866, 
 when I was not aware of the value of the tuning-fork in making 
 a differential diagnosis of disease of the middle ear. Yet, from 
 the results of the treatment, I am confident that there was an 
 affection of the middle ear ; also the nerve may have been af- 
 fected. 
 
 CASE n. Disease of Labyrinth of One Side after Parotitis Patient first seen 
 One Year after Loss of Hearing occurred. June 14, 1871, MissB , aged twenty- 
 one. Patient states that she had the mumps one year ago. After recovery, she 
 observed a buzzing sound like that made by insects. She has not heard with 
 the ear since. At this time there is an unpleasant fulness in the ear. 
 
 The hearing distance from the right ear is normal. From the left, it is <&-. 
 
 The membranse tympani are normal. The tuning-fork is heard only on the 
 right side. 
 
 The patient was seen again in September of the same year. She then stated 
 that she had vertigo occasionally. In other respects the condition was the 
 same. 
 
 The evidence is clear that the labyrinth was the chief, if not 
 the only, seat of the aural disease in this case. The foregoing 
 cases are those published in the American Journal of the Medi- 
 cal Sciences, loc. cit. 
 
 CASE III. Disease of Labyrinth of Both Sides after Scarlet Fever, Measles, 
 and Mumps Patient first seen Thirty -one Years after Loss of Hearing occurred. 
 
 September 15, 1873, Henry N. X , aged thirty-four. The patient states that 
 
 when two or three years old he had the measles, scarlet fever, and mumps in 
 one year, and that his hearing has been defective ever since. He never had any 
 discharge from the ears, and he rarely had tinnitus. 
 
 H. D., R. -^ ; and L., ^ (?). 
 
 The tuning-fork is heard better on the better side. The right drum-head is 
 somewhat sunken. The left one looks well. 
 
 Inflation of the middle ear produces no change in the hearing power. 
 
 The meagreness of the history does not enable me to say 
 whether the loss of hearing was observed immediately after the 
 attack of parotitis, or after the measles, or scarlet fever. The ab- 
 sence of ulceration at any time, however, inclines me to believe 
 it to be a true case of loss of hearing as a result of parotitis. 
 
 CASE IV. Impairment of Hearing of Left Ear, occurring during attack of 
 Parotitis Disease of Eight Ear had occurred previously from Scarlet Fever- 
 Patient first seen about Five Months after attack of Mumps. October 1, 1875, 
 42
 
 658 DEAFNESS FROM PAROTITIS. 
 
 Mrs. J. S. C , aged about thirty-five. The patient states that she had scar- 
 let fever at the age of eighteen. She has suffered from greatly impaii'ed hearing 
 on the right side ever since. Last May she had the " mumps." During the 
 course of the disease, she found that she was deaf in the left ear. She heard 
 well on one day, and the next day she found herself deaf. There was no pain 
 in the ear, and no discharge from it. She has suffered from tinnitus aurium 
 since. She hears the watch on the right side (on that of the ear deaf from scar- 
 let fever), ^. L. ear when pressed upon the mastoid, /J-. She has naso-pha- 
 ryngeal catarrh. Both dram-heads are of good color, and have good light spots. 
 
 The diagnosis made was disease of the middle ear on the 
 right side and disease of the labyrinth on the left. The grounds 
 for the diagnosis of the 'labyrinthine disease are, however, not 
 given, except in the statement that the deafness occurred sud- 
 denly, and that inflation caused no improvement in the hearing. 
 Unfortunately, I do not remember the case with enough clear- 
 ness to give any more detailed account of the reasons for be- 
 lieving that the ear affected by scarlet fever was chiefly so in 
 the middle part, while the other had a lesion of the nerve. 
 
 CASE V. Impairment of Hearing of One Side after Mumps Inspissated Ceru- 
 men Hearing Improved after its removal Patient first seen Ten Years after the 
 
 Parotitis had occurred. October 12, 1875, C. H. T , aged twenty-eight. The 
 
 patient states that he had the mumps ten years ago. After that he observed 
 that the watch was heard better in front of the right ear than of the left. He 
 did not regard the condition of his ear very much until last summer, when he 
 had a sore throat and dyspepsia, when his attention was again called to his ears. 
 He then observed a drumming noise in the left ear, and some impairment of 
 hearing. The hearing distance was found to be R., $; L., ^^-. The tuning- 
 fork was heard better in the worse ear. The pharynx was granular. The right 
 drum-head was very much sunken, and there were opacities in it. The light 
 spot was of good size. The left membrana tympani was covered by hard wax. 
 When it was removed the drum-head was found to be sunken, and it had no 
 light spot. On removal of the cerumen, the hearing distance arose from to 
 -&, and after inflation to ^. 
 
 The history and examination show that this was a case of 
 disease of the middle ear. It is probable that the hearing power 
 was only slightly impaired, until the attack of inspissated ceru- 
 men, which reducecl it so much as to call the patient's attention 
 to it. From my data, I believe that the average hearing power 
 of the side affected by the parotitis was fj>-. 
 
 CASE VI. Double Parotitis followed by Absolute Deafness Patient seen Thirty- 
 two Days after occurrence of Deafness. February 26, 1875, Mabel O , aged 
 
 four and a half. The patient had parotitis about thirty-two days ago. She 
 recovered promptly. Five days after began to suffer from impairment of hearing, 
 and in twenty-four hours she became deaf. For two or three days there was
 
 DEAFNESS FROM PAROTITIS. 659 
 
 some unsteadiness in her walk, also occasional vomiting. The little patient 
 was very weak. 
 
 The patient was found to be absolutely deaf. The drum-heads were normal 
 in appearance. No improvement resulted from treatment. That this was a case 
 of disease of the labyrinth is indisputable. 
 
 CASE VII. Sudden Deafness of One Ear after Mumps Patient seen a Year 
 after the Disease occurred. May 3, 1880, R. W. H , of Australia, aged twenty- 
 three. The patient states, that he became deaf rather suddenly in the left 
 ear, after an attack of mumps about a year ago. He also had a low fever. Just 
 as he was recovering from the mumps, he found that he was hard of healing on 
 the left side. He could hear the ticking of a* watch however. He has remained 
 hard of hearing from that time. H. D., R., f ; L., - g . The bone conduction for 
 tuning-fork C is better than aerial on the left side. Both membranse tympani 
 are opaque. No improvement to the hearing resulted from inflation. 
 
 This is, I think, a clear case of disease of the middle ear after 
 parotitis ; that the internal ear may also have been affected, 
 will not be denied. Yet the probabilities are, that the disease 
 was situated exclusively in the middle ear. The tuning-fork 
 test is, I think, very reliable in determining the situation of the 
 lesion, and that certainly positively indicated disease of the 
 middle ear. 
 
 CASE VIII. Parotitis Three Weeks before Deafness Two Weeks since Dizzi- 
 ness for One Week Dulness of Hearing in the Right Ear also, which soon passed 
 
 away Constant Tinnitus. June 25, 1881, W. D. C , aged forty-one, sent 
 
 to me by Dr. J. W. S. Gouley. 
 
 H. D., R., 5 ; L., /^ (?). The tuning-fork is heard only in the right ear. It 
 is not heard at all by aerial conduction on the left side. 
 
 As I said, in discussing this case in- the Archives, although 
 it had become one of the labyrinth on the left side, it may have 
 begun in the middle ear, for on the other side there was a slight 
 affection of the middle ear, which passed away. I see no reason 
 why a slight affection of the middle ear may not have extended 
 and become a serious affection in a part that tolerates only a 
 very slight lesion ; certainly the labyrinth is in direct communi- 
 cation by blood-vessels with the tympanic cavity, which, in 
 turn, through the auditory canal and the mastoid process is 
 directly connected with the parotid gland. 
 
 CASE IX Parotitis a Year before Patient was seen by the Writer Hearing 
 
 was found to be Impaired soon after. March 11, 1882, Janet R , aged twelve, 
 
 sent to me by Dr. J. W. S. Gouley. The patient had parotitis on both sides 
 a year ago. She make a slow recovery. Her hearing was found to be impaired 
 soon after, and it has remained so. Her general health is fair. 
 
 H. D.: R., it ; L., - 4 V She cannot say in which ear the vibrating tuning-fork
 
 6.60 DEAFNESS FROM PAROTITIS. 
 
 is heard, when placed upon the forehead or teeth. In the left or bad ear the 
 bone conduction is better than the aerial. 
 
 The drum-heads are slightly sunken and the light spots are small. The 
 hearing is diminished immediately after inflation. 
 
 The patient was seen a few times, but as she seemed to be rather worse for 
 treatment of the middle ear, she was dismissed unimproved. 
 
 This case seems to me to be a clear one of disease of the 
 middle ear, although I will not undertake to say that there was 
 not also a lesion of the labyrinth. The fact that she invariably 
 became worse after inflation of the ear inclines me to think so. 
 But the fact that there was still considerable hearing power left 
 in the ear, inclines me to the belief that the affection was pri- 
 marily in the middle ear. 
 
 CASE X. Parotitis on -Each Side Chill Fourth or Fifth Day after Great Im- 
 pairment of Hearing Recovery of One Side after Inflation of the Middle Ears 
 
 Improvement in the Other. Robert B , aged eight, was brought to me by his 
 
 mother on April 24, 1882, with the following history : About three weeks before 
 he was attacked with mumps, affecting each side. On the fourth or fifth day 
 after the mumps appeared, he had chilly sensations one evening, probably in 
 consequence of the lowering of the temperature of the room in which he was. 
 The next day he had a high fever ; he vomited ; and on that day it was observed 
 that he did not hear well. His hearing has not become worse since, perhaps he 
 is slightly better. He was treated by his attending physician by being kept 
 warm, and injections of a warm solution of chlorate of potash were daily made 
 to his throat. He did not improve much, however. On examination it is 
 found that he hears loud conversation four feet behind his back. Watch : 
 
 R., YS ; L-, irV- 
 
 The tuning-fork is heard much better through the bones than through the 
 air, on each side. 
 
 The right membrana tympani is of good color. There is a well-formed light 
 spot, and it is not sunken. In the left membrana the light spot is small. 
 
 On inflation of the middle ear by Politzer's method, the hearing distance for 
 the watch becomes V on the right side and 4$ on the left, while the voice is 
 now heard 30 feet. 
 
 The patient remained under observation until June. He was treated by the 
 use of Politzer's method of inflation, by syringing tl naso-pharyngeal space 
 with a solution of chlorate of potash ; and he took cod-liver oil. He then went 
 abroad with his parents. He was directed to continue the treatment, according 
 to circumstances, during the summer. When he returned in October, he could 
 hear general conversation with ease, but on the right side the watch was only 
 heard when laid upon the ear, and on the left side for 8 inches. B., 7 \ ; L., ^\. 
 Voice, 30'. About a month afterward, while under treatment, after the escape 
 of quite an amount of dark-colored viscid material from his nostrils, the patient 
 said that sounds were unusually loud. On examination the next day it was 
 found that the hearing distance of the right ear was -h , and the left 1 . After 
 inflation the hearing distance of the left ear became normal, while the right re- 
 mained unchanged. At the present time the patient has passed through an
 
 DEAFNESS FROM PAROTITIS. 661 
 
 attack of inflammation of the auditory canal and tympanic cavity from exposure 
 to cold, but his hearing has become normal on the left side, while it remains 
 impaired on the right. 
 
 February 9th. B., H ', L- if. Voice on right side, with normal ear closed, 
 20 feet. The patient is still under treatment. 
 
 October, 1890. This patient has now become a young man. The tuning-fork 
 still shows that the situation of the disease is. in the tympanum and not in the 
 labyrinth. He hears conversation well. The right ear is still better than when 
 the note of February, 1883, was made. 
 
 This case of impairment of hearing after mumps is a very 
 plain one. It is undoubtedly a case of disease of the middle ear 
 and not of the nerve. The tuning-fork and the results of treat- 
 ment indicate this. Yet he had symptoms that are sometimes 
 associated with an affection of the labyrinth. It is quite pos- 
 sible that such an affection might have occurred in the course 
 of any acute disease, if the patient were exposed to a chilling 
 of the body. I am confident, however, that a similar process 
 would sometimes be found, if all the cases of impaired hearr 
 ing occurring after mumps were observed by an otologist as 
 early as this one was. Most of the cases seen by an aurist are 
 only seen some time after their occurrence, when the history 
 is very vague. The chief symptom is said to be sudden deaf- 
 ness. In this case the deafness was sudden. Had not infla- 
 tion come to its. relief, within a few weeks, this might have 
 been called a metastatic case ; and I believe the labyrinth 
 might have been invaded by the extension of the inflamma- 
 tory process through the fenestrse. I see no reason as yet to 
 change the opinion expressed in this book, 1 and in my article, 
 from which I have quoted, that in some cases the occurrence 
 of inflammation of the ear after mumps is by direct exten- 
 sion of the inflammation to the auditory canal, middle ear y 
 and labyrinth. That there may be a form of so-called meta- 
 static inflammation, I do not deny. Whether the channel of 
 communication is through the blood, cannot as yet be deter- 
 mined. To my mind the probabilities lie in that direction. The 
 theory of a metastatic inflammation in these cases is usually 
 not based upon the study of the symptoms at the time they oc- 
 curred, but upon reasoning from analogy : for example, it is said, 
 because the testes and breasts are sometimes affected by meta- 
 static inflammation, therefore a disease of the ear, occurring 
 after mumps, is also a metastatic affection. Hinton, as is seen 
 by the quotation, thought a catarrhal inflammation of the mid- 
 dle ear one of the causes, in some cases at least, of the impair- 
 
 1 Fourth edition, 1878, p. 539.
 
 662 INFLAMMATION OF MEMBRANOUS LABYRINTH. 
 
 
 
 ment of hearing often seen after mumps. As I have shown, my 
 last case was certainly of this character. 
 
 Every one admits that cases of extension of suppurative in- 
 flammation of the parotid gland to the external auditory canal 
 are not uncommon. Probably this extension may take place 
 through the fissures of Santorini. If a suppuration may extend 
 in this way, why not a catarrhal process ? We are not without 
 examples of the extension of an inflammation to the middle ear 
 from the auditory canal and outer layer of the drum-head. 
 Every physician at all accustomed to see much of aural disease 
 has seen cases where from a draught of cold air, the entrance of 
 cold water or irritating substances, an inflammation has been 
 set up in the middle ear by extension, and where the symptoms 
 in the auditory canal have passed away long before those in the 
 middle ear have been relieved. 
 
 As a result of my observations I conclude 
 
 1. An acute catarrh of the middle ear may occur during the 
 course of mumps, and be attended by fever and vomiting. 
 
 2. This catarrh may extend from the parotid gland, through 
 the auditory canal and outer layer of the drum-head, or through 
 the mastoid process. 
 
 3. An affection of the labyrinth may occur simultaneously, 
 or by extension from the middle ear. 
 
 4. It is probable that there are cases where the disease during 
 the course of mumps is transferred to the labyrinth, in the same 
 manner that an inflammation sometimes occurs in the testes 
 and the breasts, but this cannot be considered as proven until 
 more detailed experience is furnished of cases observed a few 
 hours after the impairment of hearing occurs. 
 
 Noyes showed an interesting case of deafness after mumps 
 at the New York Ophthalmological Society. It occurred in an 
 adult. The loss of hearing was accompanied by a staggering 
 gait. Only one ear was affected, and on this side there was also 
 
 metastatic orchitis. 
 
 
 
 ACUTE INFLAMMATION OF THE MEMBRANOUS LABYRINTH MISTAKEN 
 FOR CEREBRO-SPINAL MENINGITIS. 
 
 As has already been said. Voltolini l was the first writer to 
 call attention to the subject. The discussion which his views 
 have excited has been at times a heated one, but it has done 
 great good in calling the attention of general practitioners to the 
 possibility of mistaking a disease of the ear for one of the brain 
 or medulla. 
 
 The symptoms of epidemic cerebro-spinal meningitis, as given 
 
 1 Monatsschrift fiir Ohrenheilkunde, Jahrgang I., No. 1.
 
 ACUTE INFLAMMATION OF MEMBRANOUS LABYRINTH. 663 
 
 by Clymer, 1 are "great prostration of the vital powers, severe 
 pain in the head and along the spinal column, delirium, tetanic 
 and occasionally clonic spasm, and cutaneous hypersesthesia, 
 with, in some cases, stupor, coma, and motor paralysis, attended 
 frequently with cutaneous haemic spots." Dr. Clymer's definition 
 is so comprehensive and guarded that it would be difficult to say 
 that the symptoms of labyrinth-disease, as given by Voltolini, 
 may not accord with those of cerebro-spinal meningitis. I am 
 inclined to think that Dr. Clymer has made his definition very 
 comprehensive, in order to take in the sporadic cases. Volto- 
 lini regards these as affections of the labyrinth. Voltolini says, 3 
 " The children are attacked quite suddenly, and without appar- 
 ent cause ; consciousness is soon lost as a rule, but the head is 
 frequently grasped with the hands. There is severe fever, a 
 fixed countenance. They bury the head in the pillow. There 
 are sometimes slight symptoms of paralysis, but they are never 
 permanent ; occasionally there is vomiting. Sometimes the dis- 
 ease has something of an intermittent character. The cerebral 
 symptoms soon disappear, but the patient is found to be per- 
 fectly deaf, and walks with a staggering gait." 
 
 Voltolini lays particular stress upon the absence of facial pa- 
 ralysis in these supposed cases of cerebro-spinal meningitis, and 
 he asks, how is it possible to have an exudation in the medulla 
 oblongata, at the origin of the auditory nerve, without having 
 at the same time one of the facial, when the fibres of the two 
 nerves are so near each other ? Knapp cannot agree with Vol- 
 tolini in his idea of primary inflammation of the membranous 
 labyrinth, and has discussed the subject quite fully in a "Clini- 
 cal Analysis of Inflammatory Affections of the Middle Ear." 1 
 Knapp's argument against Voltolini's view is embraced in the 
 following question: "If the same complex symptoms in some 
 cases produce deafness, in others blindness, and in many others 
 neither, Avhy should we call the first group otitis labyrinthica, 
 mistaken for meningitis, while in the second group the depen- 
 dence of the ocular affection on the cerebro-spinal disease may 
 be demonstrated?" It is no answer to Voltolini's arguments 
 to say, as has been said, that cases of inflammation of the mem- 
 branous labyrinth are "abortive" cases of cerebro-spinal menin- 
 gitis. Voltolini went too far in thinking that there was no such 
 disease causing deafness as cerebro-spinal meningitis ; but be- 
 cause so-called "spotted fever" does exist, and transmits dis- 
 
 1 Reprint from the American edition of Aitken's Science and Practice of Medicine, 
 1872. 
 
 8 Monatsschrift fur Ohrenheilkunde, loc. cit. 
 
 3 Archives of Ophthalmology and Otology, vol. ii. , No. 1.
 
 664 ACUTE INFLAMMATION OF LABYRINTH. 
 
 ease to the auditory and optic nerves, this fact furnishes no 
 evidence that primary affections of the nerve-trunks, or of their 
 expansions, may not occur, just as we may have primary optic 
 neuritis. But here, also, gaps in our knowledge are to be filled, 
 a task that must be performed by the post-mortem examinations 
 made by the practitioners of the present or future. 
 
 CASE I. Severe Headache and Vomiting Partial Delirium Deafness in a Few 
 Days No Paralysis Recovery from all Symptoms but Deafness. May 3, 1873. 
 
 Sallie A , aged thirteen. Three months ago this child was attacked with 
 
 vomiting and pains in the head. She became only slightly delirious. There was 
 no paralysis of any kind. The hearing was found to be impaired in a very few 
 days, and she became deaf soon, and has remained so. She was taken sick on 
 Saturday, and on Wednesday she heard as badly as now. She is now perfectly 
 deaf, but concussions hurt her ears. She walks with difficulty, that is, the gait 
 is staggering. 
 
 CASE II. Convulsions Deafness. March 25, 1872. Martha , aged 
 
 eleven, when sixteen months old, had some kind of convulsions, and since has 
 been deaf. Had spoken words and given other evidences of hearing before 
 this. She never had any disease of the head, nor discharge from the ear. She 
 cannot now hear the ticking of a watch, nor words spoken into the ear ; but the 
 vibrations of a tuning-fork are plainly perceived. Both membranse tympani 
 are sunken. 
 
 CASE III. Inflammation of Labyrinth from Cold, Induced by Lying Down while 
 
 in a State of Perspiration. June 9, 1873. George O'B , aged thirty-one, agent, 
 
 one day last summer lay down while in a state of profuse perspiration. The next 
 day he observed a singing noise in his right ear, and that then he did not hear 
 well on that side. There were also darting pains across his head and the back 
 of the auricle. Is anxious and worried. States that he had an acute inflamma- 
 tion of the head some time since. Hearing distance : right ear, ; left, if. The 
 membranse tympani show no signs of disease. The tuning-fork is heard most 
 distinctly on the left side. 
 
 CASE IV. Pmn Paralysis Deafness. Maria L . aged three, when two 
 
 years and a month old, awoke one night screaming with pain. She did not roll 
 her head, or become unconscious, but lost power over her limbs, and had general 
 febrile excitement. She was ill for one week, but it was two months before she 
 could walk. On recovery she was found to be deaf, and is now almost, if not en- 
 tirely, devoid of hearing. The membranae tympani of each side altered in cur- 
 vature and color. 
 
 The practitioner will judge for himself as to how much in- 
 flammation of the spinal cord, or membranes of the brain, there 
 is in such cases as these. 
 
 HEMORRHAGES AND EFFUSIONS. 
 
 I think we have a right to conclude, from the clinical history 
 of certain cases, that a hemorrhage or effusion of serum into 
 the membranous labyrinth may occur without any well-defined 
 cause. Of course, in atheromatous degeneration of other blood-
 
 HEMORRHAGES. ; 665 
 
 vessels of the body, we may also suppose that such a hemor- 
 rhage sometimes occurs. The following case is a fair type of 
 what is meant by hemorrhage or effusion into the labyrinth : 
 
 Profound Deafness of Both Ears, accompanied by Vomiting, and Loss of Equilib- 
 rium, occurring in One Night. A healthy young man aged twenty-two consulted 
 me at the instance of Dr. Howard Pinkney, and gave the following history : 
 His occupation was that of a wagoner. He was attacked one night with vomit- 
 ing and dizziness, and in a few hours he found himself completely deaf in both 
 ears. He could not hear the loudest sounds. The nausea and dizziness con- 
 tinued for about two weeks. He was so weakened that he could not get out of 
 bed, but he retained his intellect and consciousness, and he stated that there 
 was no paralysis of any part of his body ; he could lift his head, his arms, move 
 his legs, and all parts of his body. There were no cases of cerebro-spinal men- 
 ingitis in the place where this attack occurred. He had had a suppuration in 
 the right ear some years before, and could not hear well from that ear before 
 this attack. It is now three months since his deafness came on, and he is no 
 better. The patient is ruddy and in vigorous health; there is no cardiac or 
 renal disease. He has not had syphilis. He walks with a staggering gait. His 
 intellect is unclouded. He has tinnitus aurium, which he compares to the 
 chirping of crickets. The vision is good. He is still dizzy at times. An ob- 
 jective examination showed evidences of old inflammation in the right membrana 
 tympani, but there was no inflammatory action going on. The membrane was 
 transparent, except on the posterior and inferior quadrant, where it was sunken 
 and adherent to the wall of the tympanic cavity. The left 'membrana tympani 
 was normal. He did not hear the watch at all, nor words spoken through a tube 
 placed in the external meatus. Air enters both Eustachian tubes. The tuning- 
 fork was not heard better when the ears were stopped. 
 
 
 I think there is no reasonable doubt that this was a case of 
 hemorrhage into the semi-circular canals and the cochlea. I 
 have seen several such, and some where no vomiting occurred, 
 but sudden deafness with absolutely no premonition. We are 
 still in need, however, of post-mortem investigations to establish 
 our theories founded on clinical experience. Inasmuch as such 
 patients do not usually die of disease of the labyrinth, we have 
 not the same facilities for clearing up a diagnosis that we 
 have in fatal affections. 
 
 INJURIES OF THE OSSEOUS LABYRINTH. 
 
 In the chapter upon fractures of the temporal bone, it was 
 seen that there were such injuries which involve the tympanum 
 only, but there are also cases in which both the osseous and mem- 
 branous labyrinth are injured, and absolute deafness results. 
 
 CASE I. Severe Fall Complete Deafness on One Side Normal Drum Mem- 
 branes. September H, 1865. E. M , aged eleven, five years ago, or when six
 
 666 CONCUSSIONS. 
 
 years old, had a severe fall down stairs, striking his head, and he has been totally 
 deaf on the right side ever since. The drum-heads of both sides are normal. He 
 cannot hear the ticking of the watch on the right side, except when upon the 
 mastoid region, the meatus being closed. The air is easily forced through both 
 tubes by Politzer's method and by the experiment of Valsalva, but no improve- 
 ment to the hearing results. 
 
 CASE 31. Profound Deafness from Blows on tJie Head. St. Vincent's Hos- 
 pital, January 6, 1868, a patient under the care of Dr. J. L. Little. This man, 
 aged forty-five, was severely beaten in a fight some few months since ; he was 
 unconscious for four days, and, when restored to consciousness, was perfectly 
 deaf, in which condition he still remains. His gait is irregular ; he finds great 
 difficulty in keeping his head in an erect position, even when supporting it with 
 his hand. Marks of blows are still traceable over one eye and the right mastoid 
 process. There seems to be an entire absence of hearing power, as found by all 
 the tests capable of application. He seems very much dejected, but is well 
 nourished. Both membranse tympani, especially the left, appear sunken, and 
 have lost their transparency. Air enters both ears by Politzer's method ; the 
 pharynx is in fair condition. 
 
 I think we may fairly conclude, in this case, that the blows 
 produced an inflammatory action in the nerve, as well as in the 
 meninges of the brain and the parts of the middle ear, and this 
 is probably the ultimate lesion in the case of blows and falls. 
 The blood-vessels are perhaps at first ruptured ; and we know, 
 from post-mortems in similar cases, that suppurative inflamma- 
 tion of the labyrinth and basilar meningitis have resulted. In 
 ophthalmic practice we observe cases in which atrophy of the 
 optic nerve follows severe injuries upon the side of the head ; 
 but this atrophy sometimes presents no ophthalmoscopic appear- 
 ances at first or at least very few, and may affect but one nerve. 
 In other cases, hyperaemia or inflammation precede the atrophy. 
 
 CONCUSSIONS OF THE LABYRINTH (BOILER-MAKERS' DEAFNESS). 
 
 Workmen employed in hammering large iron plates, such as 
 are used in making the boilers of large steam-engines, are very 
 apt to lose much of their hearing power. So many of these 
 cases are seen at ear infirmaries, that at one time "Boiler- 
 makers' Deafness " figured as a separate disease of the ear in 
 the statistical reports of one of our institutions where aural dis- 
 ease was treated. Examination of such cases has shown me 
 that the lesion causing the impairment of hearing and deafness 
 must be sought for in the labyrinth, and that it is probably due 
 to concussion of the fibres of the nerve in the cochlea and semi- 
 -circular canals. 
 
 Concussions of the labyrinth, from cannonading, such as are
 
 BOILER-MAKERS' DEAFNESS. 667 
 
 sometimes experienced by soldiers and sailors, the impaired 
 hearing and extreme sensitiveness of the ears sometimes ob- 
 served in telegraph operators, belong to this class of labyrinth 
 affections. 
 
 There can be no hesitancy in believing that the continual 
 recurrence of a kind of sound, that has no musical, but, on the 
 contrary, an unpleasant character, must at last cause a hyperse- 
 mia of the ultimate nerve-fibres of the cochlea. The incessant 
 shock of the drum-head by the blows from dozens or even hun- 
 dreds of hammers upon vibrating plates must agitate these 
 fibres in such a manner as to finally put them out of tune, as 
 certainly as the constant use of a piano will at last loosen its 
 strings. Clinical experience confirms this view, and my own 
 observations and investigations in reference to boiler-makers' 
 shops seem to demonstrate the following facts : 
 
 I. Boiler-makers are nearly all hard of hearing. 
 
 II. The impairment of hearing is generally attributable to 
 some lesion of the labyrinth, probably of the cochlea. 
 
 Superadded to this serious trouble, tympanic or middle ear 
 catarrh or impacted wax are very frequently present, but these 
 must be regarded as purely coincidental. Boiler-makers are con- 
 stantly exposed to sudden and marked changes of temperature, 
 and hence often catch cold, intensifying and increasing by this 
 means the aural affection. 
 
 Should a man, already suffering from disease of the middle 
 ear, begin to work in a boiler-shop, he will, of course, suffer in 
 a much greater degree, and the organ be more susceptible of 
 additional injury, than a man who is in the enjoyment of a 
 sound organ of hearing. Dr. D. R. Ambrose has shown me a 
 case which confirms this view. In the same way, a telegraph 
 operator who has pharyngeal catarrh, and consequently a 
 swelled Eustachian tube, which is not always capable of per- 
 forming its proper function, will be more sensitive to, and suffer 
 more acutely from, the concussions of the instrument, than he 
 who has a healthy throat. The existence of tympanic and tubal 
 catarrh will cause the Eustachian passage to be less pervious, 
 or even at times entirely closed ; and thus aggravate the un- 
 pleasant conditions existing when waves of sound that have to 
 go but a short distance, and are besides inclosed in tubes, and 
 thus increased in intensity, impinge upon the molecules that 
 make up the ultimate fibres of the auditory nerve. 
 
 Those who work inside the boilers as riveters, and who thus 
 have shorter waves of sound striking upon their ears, lose their 
 hearing power most completely, as is evidenced by the testi- 
 mony of all old boiler-makers. It is not easy, in the absence
 
 668 BOILER-MAKERS' DEAFNESS. 
 
 of post-mortem investigations, to define the exact nature of the 
 lesion, but it may be a passive congestion of the contents of the 
 cochlea. 
 
 Boiler-makers speak in graphic language of the effects of the 
 din upon their ears. Said one of them tome : "Those heavy 
 hammers jar every nerve in the body." They do not find much 
 relief from wearing cotton in their ears, except when first enter- 
 ing the shop. An experienced workman, however, told me that 
 all old boiler-makers had learned to equalize the pressure and 
 reduce the shock by opening the mouth frequently. Of course, 
 by this procedure they open the Eustachian tube more freely. 
 
 My reasons for believing that the lesion in these cases is- 
 situated in the nerve predominantly, are that the aerial conduc- 
 tion is always louder than the bone conduction, as tested by 
 the tuning-fork " s ," and that it is heard longer than by bone 
 conduction. The only apparent exceptions to this rule were 
 those in which, in addition to the lesion of the acoustic nerve, 
 there was also inspissated cerumen. When the wax was re- 
 moved, however, and the cases were transposed into their proper 
 place, of diseases of the acoustic nerve produced by concussion, 
 the tuning-fork was heard through the air louder and longer 
 than through the bone. I consider all the other tests that we as 
 yet have, for the differential diagnosis of affections of the mid- 
 dle and internal ear, as so much inferior to this, although of 
 great corroborative value, that I am constrained to consider all 
 observations upon boiler-makers that have not been made in 
 this way, as so defective as to tell nothing of the true seat of 
 the disease. In addition to the test by the tuning-fork, the ex- 
 amination of the hearing power by the voice shows that these 
 patients hear better in a quiet place than in a noise. As has 
 been suggested by many writers, there is no doubt that some- 
 thing might be done to avert the consequences of those concus- 
 sions in producing disease of the acoustic nerve, if workmen 
 could be induced to wear ear protectors ; but from some reason or 
 other, they are, as a rule, quite averse to wearing cotton in their 
 ears, or any contrivance for protecting their ears from the effect 
 of a great and constant concussion. Almost all boiler-makers 
 say that they were deafer at first than after they had become 
 accustomed to the occupation ; and they all say that they hear 
 better after a period of rest, for example from Saturday to Mon- 
 day. 
 
 That excessive sound must necessarily be as harmful to the 
 nerve of hearing, as is excessive light to that of sight, is a 
 natural deduction from our knowledge of the effects of the 
 waves that produce those two senses, and all experience con-
 
 BOILER-MAKERS' DEAFNESS. 669 
 
 firms the belief that there may be an acoustic neuritis produced 
 by noise, as well as an optic neuritis caused by exposure to a 
 glare. 
 
 The cases upon which my conclusions as to boiler-makers' 
 deafness depend are as follows : ' 
 
 CASE I. Boiler-maker Twenty Years Disease of the Acoustic Nerve. John. 
 
 F , aged thirty-five. Has been in the business for twenty years. Hearing 
 
 was good when he began ; began hearing noises in his ears ; then became hard 
 of hearing gradually. Cannot now hear a lecture. Does not hear better in the 
 noise of the shops, but he assists his ears by watching the lips of those speaking 
 to him. Was most deaf after working in a boiler. Did not use cotton, because 
 it made him worse when removed. Hissing tinnitus all the time. Hearing : B., 
 ? P 8 , a5rial conduction best ; air duration, 23 seconds ; bone, 11 seconds. L., ? 3 ? , 
 aSrial conduction best ; air duration, 20 seconds ; bone, 9 seconds. M. T. : E., 
 good color, good light spot, not sunken ; L., sunken, two light spots, good color. 
 .Says that he has never had catarrh. 
 
 CASE II. Boiler-maker Thirty Years Disease of Acoustic Nerve. X. Y- , 
 
 forty-six years of age. Has been in the business for thirty years. Hearing was 
 good when he began his work. Now cannot hear well when spoken to. Thinks 
 he hears better in a noise, because people speak louder. No pain at any time, 
 but has noises, and hearing failed gradually. Has used cotton, but does not 
 like it. Hearing: E., ^, aerial conduction best; watch not heard on mastoid ; 
 aerial conduction, 26 seconds ; bone, 12 seconds. L., g, aerial conduction best ; 
 watch not heard on mastoid ; aerial conduction, 21 seconds ; bone, 8 seconds. 
 M. T. : E., opaque, no light spot, vascular along handle of the malleus; L., 
 opaque, sunken, no light spot. Pharynx sound. 
 
 CASE III. Boiler-maker Twenty-four Years Disease of Nerve One Side of 
 the Middle Ear and Nerve on the Other. Forty-seven years of age. Has been in 
 the business twenty -four years. Hearing was good before he began it. Sissing 
 tinnitus. Deafness came on gradually, but was worse when he was "holdnig 
 on"; no pain. Cotton did no good. Hearing : E., &, aerial, but no bone con- 
 duction ; duration of aerial conduction, 6 seconds ; bone, 0. L., 4 U , aerial, feels 
 something ; bone conduction distinct ; duration of aerial conduction, ; bone, 
 12. M. T. : B., opaque rim, vascular malleus, no light spot ; L., good color, 
 vascular malleus, no light spot. Pharynx catarrhal ; uvula elongated. 
 
 CASE IV. Boiler-maker Twenty-four Years Disease of Acoustic Nerves. 
 Fifty-one years of age. Has been in the business twenty-four years ; previous 
 to which his hearing was very sharp, now is very poor. Sissing tinnitus ; does 
 not hear any better in the shop or car. Wears cotton at times. No pain in ear. 
 Health good. Voice at four feet. Hearing: E., -J^, aerial feeble; no bone 
 conduction ; aerial duration, 5 seconds ; bone, 0. L., $, aerial feeble ; no bone 
 -conduction ; aerial duration, 6 seconds ; bone, 0. M. T. : E., opaque (wax) ; 
 ;L., opaque on periphery, no light spot. Pharynx in good condition. 
 
 1 Reprinted from Archives of Otology, vol. xii., p. 111.
 
 670 BOILER-MAKERS' DEAFNESS. 
 
 CASE V. Boiler-maker Twelve Years Disease of Acoustic Nerve. Agecl 
 twenty -five. Has been in the business twelve years. Hearing is good ; no pain 
 or noises. Hearing : B., &, aerial best ; aerial duration, 21 seconds ; bone, 7 
 seconds. L., i?, aerial best; aerial duration, 20 seconds; bone, 10 seconds. 
 M. T. : B., good light spot, opaque on periphery and above ; L., good light 
 spot, opaque. Catarrhal pharynx. 
 
 CASE VI. Assistant in Boiler-shop for One and a Half Year. Works ten 
 hours per day. Thinks his hearing is good enough. Hears ordinary conversa- 
 tion with his face away from the speaker about twenty feet. Hearing : B. E., 
 aerial conduction louder; air duration, 10 seconds; bone, 5 seconds. L., J 4 f, 
 aerial conduction louder ; air duration, 16 seconds ; bone, 4 seconds. M. T. : 
 B., small light spot, opaque ; L., small light spot, vascular. Pharynx healthy. 
 
 CASE VII. Boiler-maker Thirteen Years Disease of Middle and Internal 
 Ears. Has been in the business thirteen years. Hearing always good. Never 
 protected nis ears. Had a pain in left ear once, but no discharge. Whispers 
 heard by others not heard by him. Does not hear better in noise. Hearing : 
 B., ^, bone conduction best ; aerial duration, 10 seconds ; bone, 9 seconds. 
 L., ^, bone conduction best; aerial duration, 13 seconds; bone, 7 seconds. 
 M. T. : B., good color and light spot; L., sunken, opaque, small light spot. 
 Tonsil enlarged. Pharyngitis. 
 
 CASE VIII. Aged Eighteen Boiler-maker for Fifteen Months Disease of 
 Acoustic Nerve. Has been in business fifteen months. Hearing good when ho 
 came. Not so good now. Hissing tinnitus. No pain. Does not hear better 
 in noise. Hearing: B., -/-, aerial best; aerial duration, 12 seconds; bone, 9- 
 seconds. L., H, aerial best; aerial duration, 14 seconds; bone, 7 seconds. M. 
 T. : B., small light spot, prominent short process ; L., no light spot, prominent 
 short process Slight pharyngitis. 
 
 CASE IX. Thirty Years a Boiler-maker Inspissated Cerumen Disease of 
 Acoustic Nerve. Aged forty-nine. This subject is what is technically called a 
 "holder-on." His duties keep him inside of the boiler holding on to the rivets. 
 The shock of sound is much greater here than in the open air of the shop. 
 Thirty years a boiler-maker. Three and a half years in navy. Ears were good 
 when he went into the present business. Hears better when he gets away from 
 noise. Voice, 6'. Watch, VV, each side. Tuning-fork : B. E. , aerial louder, 8 ; 
 bone louder, 3. L. E., aerial louder, 8 ; bone louder, 4. Inspissated cerumen 
 on each side. After removal of large plugs of very hard wax, H. D. for the voice 
 increased to 18', and the watch was heard, when pressed on each side, i p s . The 
 dui-ation of the aerial conduction was increased, but no change in the intensity 
 with which it was heard. 
 
 It is interesting to note in this case that the aerial conduc- 
 tion was louder and longer, even when the ear was plugged 
 with wax. This shows a more marked lesion of the nerve, than 
 the other cases in which inspissated cerumen was found for in
 
 BOILEK-MAKEKS' DEAFNESS. 671 
 
 these latter the bone conduction was better until the wax was- 
 removed, when the aerial conduction was found to be as is usual 
 in those suffering from boiler-makers' deafness. 
 
 CASE X. Boiler-maker Thirty-one Years Disease of Acoustic Nerve. James 
 
 L , forty-seven. Boiler-maker thirty-one years. First job was that of 
 
 riveter, and in twenty days could not hear well ; tinnitus like bees ; never had 
 earache ; healthy ; rheumatism ; voice 20 '. Hearing : B., -/- ; L., -/-, aerial 
 conduction better each side ; E., aerial, 12 seconds ; bone, 8 seconds ; L., aerial, 
 9 seconds; bone, 9 seconds. M. T. : E., good light spot, good lobe; L., good 
 light spot, good lobe. Both opaque on periphery. Healthy pharynx. 
 
 CASE XI. Boiler-maker for Twenty Years Inspissated Cerumen removed from 
 Both Sides Disease of Acoustic Nerves. Aged thirty-nine. Has been twenty 
 years in the business. Ears were sound when he began ; had an occasional 
 earache as a boy. He can't hear a whisper; does not hear well in a boiler-shop. 
 Watches the mouth and gestures. Hears the voice in a quiet room 40'. Watch: 
 E., - 4 a 8 - ; L., -&-. E. side the aerial conduction is better ; on the left the bone con- 
 duction is better. E. , aerial conduction is heard 12 seconds ; bone, 6 seconds. 
 L., a6rial conduction is heard 12 seconds; bone, 8 seconds. Pharynx is sound. 
 Inspissated cerumen is found on each side. After it is removed the watch is 
 heard better on each side ; e.g., E., ^ ; L., / ff . Eelative distinctness of bone 
 and aerial conduction not changed. Duration of the sound about as before. 
 
 CASE XH. Boiler-maker Twenty-five Years Inspissated Cerumen Both Sides 
 Disease of Acoustic Nerves. Aged forty-three. This man has been a boiler- 
 maker twenty-five years. He had good hearing when he began his work. 
 Never had an earache. Hears the voice in a quiet room 30 '. Watch -~"g- on 
 right side, ^ g on left side. E. side, bone conduction much more distinct ; L. side, 
 the same. Duration: E., aerial conduction, 5 seconds ; bone, 12 seconds ; left 
 side, aerial, 14 seconds ; bone, 11 seconds. Inspissated cerumen, each side, re- 
 moved. After removal of wax watch was heard - 4 3 - and - 4 A j on the right and left 
 sides respectively, instead of J^. and ^. The aerial conduction became better in 
 each ear. Duration as follows: E., aerial, 18 seconds; bone, 13 seconds; L., 
 aerial, 22 seconds ; bone, 12 seconds. 
 
 As is seen, the peripheric trouble (inspissated cerumen) 
 masked the disease of the acoustic nerve in this case, but when 
 the wax was removed the lesion of a boiler-maker's ear was 
 found to exist. 
 
 In Case VII. the bone conduction was decidedly louder than 
 the aerial, but the tuning-fork was heard much longer through 
 the air than through the bone. The left drum-head was sunken 
 and opaque, and there was considerable throat trouble. From 
 these data I conclude that there is disease of the middle as well 
 as of the internal ear in that case.
 
 672 
 
 BOILER-MAKERS' DEAFNESS. 
 
 
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 BOILER-MAKERS' DEAFNESS. 673 
 
 From all the observations I have been able to make upon this 
 subject, I think I am justifiable in drawing the following con- 
 clusions : 
 
 1. The hearing power of persons working in such a din as 
 that of a boiler-shop invariably becomes impaired. 
 
 2. The lesion caused by this occupation is one of the mem- 
 branous labyrinth, or of the trunk of the acoustic nerve. 
 
 3. Persons thus affected do not hear better in a noise. Their 
 hearing power is better in a quiet place, and becomes better 
 after prolonged absence from the exciting cause of their im- 
 paired hearing. 
 
 4. The cases of inspissated cerumen, catarrh of the middle 
 ear, occurring among boiler-makers, are such as occur among 
 those employed in various occupations and only mask and com- 
 plicate the fundamental primary trouble, so long known as 
 boiler-makers' ' deafness. 
 
 Other occupations of a similar nature, that is, occupations 
 amid continuous concussions, undoubtedly cause the same le- 
 sion. A recent visit to an establishment where two engineers 
 were employed for the production of electric light, showed me 
 that since they had been engaged in an occupation exposing 
 them to the sound of regular concussions from the striking of 
 metallic plates together, they had become somewhat hard of 
 hearing. 
 
 CASES OF TINNITUS AURIUM AND IMPAIRMENT OF HEARING FROM 
 OTHER KINDS OF CONCUSSIONS. 
 
 CASE I. Tinnitus Aurium, without Impairment of Hearing, Occurring from 
 Listening to a Telegraph Instrument Hypercemia of Acoustic Nerve ? W. G. 
 
 B , aged thirty-seven, states that he has been a telegraph operator for about 
 
 twenty years, and that he has had tinnitus aurium for about two years. Hear- 
 ing distance : right, f ; left, ||. Both membranse tympani have good light 
 spots ; there is some granular pharyngitis. The patient is confident that the 
 vibrations of the telegraphic instrument have caused the noise in his ears. The 
 sound of the instrument is very unpleasant to him, and he is obliged to protect 
 his ears, while at work, by cotton plugs. Indeed, his ears have got into such a 
 sensitive condition that jarring sounds of any kind are extremely annoying to 
 him. The patient is in good general health. 
 
 CASE II. Impairment of Hearing of One Side, ascribed to Occupation as Tele- 
 graph Operator. May 4, 1870. Mr. B , aged twenty-seven, about a year ago 
 
 1 For an account of my first examination ' of the hearing of boiler - makers, the 
 reader is referred to this work, edition of 1877, and to the American Journal of the 
 Medical Sciences, 1874, vol. Ixviii., p. 380. 
 43
 
 674 CONCUSSIONS OF ACOUSTIC NERVE. 
 
 discovered that the hearing power of his left ear was somewhat impaired. Three 
 months ago he was troubled with a continuous noise in that part of his head. 
 He is a telegraph operator, and has been accustomed to use his left ear leaning 
 his head over the machine on that side and intently listening. He believes 
 that this is the cause of his loss of hearing. The drum-heads look very much 
 alike, both exhibiting peripheral opacities, but in other respects having a normal 
 appearance. The pharynx and nares seem to be healthy. Inflation of the ears 
 has no effect upon the hearing. The watch is not heard at all on the affected 
 side, nor is the tuning-fork. 
 
 CASE HI. Exposure to Cannonading Tinnitus Impairment of Hearing for 
 
 the Watch, but not for Ordinary Conversation. February 11, 1868. W. B. X , 
 
 aged twenty-five, observed some difficulty in hearing ten years ago ; and, after 
 being exposed on a gunboat to severe cannonading, while an officer in the navy, 
 he became worse, although he has scarcely any tinnitus aurium. Hearing dis- 
 tance : right ear, -/ ; left ear, -&. Both drum-heads appear to be normal. Air 
 enters each Eustachian tube freely, but inflation causes no improvement in the 
 hearing power. 
 
 I have had ample opportunity to test the hearing power of 
 this patient in conversation, which he hears so well (in spite of 
 the fact that his power of hearing the watch is much impaired), 
 that he has never been considered, by any but his most intimate 
 friends, as very hard of hearing. Persons who can hear the 
 watch no better than he, are usually, if not always, very much 
 troubled to hear conversation, even when addressed especially 
 to them ; and yet the patient in question can join in general con- 
 versation carried on in an ordinary tone, and can hear lectures, 
 aiid so forth, with perfect ease. 
 
 My friend Dr. Rhoades, surgeon in the United States Navy, 
 informed me that, during an experience in several naval en- 
 gagements large and small, during our late civil war, he never 
 saw a rupture of the membrana tympani from cannonading. 
 He has seen sailors who said they were hard of hearing from 
 cannonading. These men usually complained of tinnitus. Some 
 of them got better, and some worse. Sailors usually keep the 
 mouth open during the firing. 
 
 The following case also illustrates the effect of concussion of 
 the labyrinth. It is possible that an injury of the labyrinth more 
 readily occurs when the membrana tympani is in a relaxed 
 condition, as was probably the case in this instance, the sub- 
 ject being surprised by the wave of air that unexpectedly forced 
 upon the endolymph. Any one who has received an unexpected 
 whisper in the auditory canal, may remember how long a tin- 
 nitus aurium continued which it seemed to produce. 
 
 CASE IV. Loss of Hearing from a Kiss upon the Ear. Mrs. H , aged 
 
 forty-two, seen through the kindness of Dr. O. B. Douglas. Last winter (1878),
 
 CONCUSSIONS OF ACOUSTIC NERVE. 675 
 
 her husband came up behind her as she sat reading, and kissed her suddenly 
 upon the right ear, taking her completely by surprise. She suffered a great shock 
 and had a roaring in the ear for some time. The incident made her very ' ' ner- 
 vous " for two or three weeks afterward. During the past summer she was told 
 by her relatives that she was becoming deaf on the right side. She paid no at- 
 tention to it until six weeks ago, when she tried her right ear with her watch and 
 found she could not hear it. She gives satisfactory evidence of having heard a 
 whisper well with the right ear during last winter and spring. Has had occa- 
 sional tinnitus during the past few months after taking cold. Enjoyed music 
 very much formerly, but does not now. The piano practice of the children at 
 home annoys her. Whistling is particularly disagreeable. All noises disturb 
 her somewhat, so that she has "felt afraid that she was becoming nervous." 
 General health is good. Menstruates regularly. No cardiac trouble detected. 
 Father died of paralysis. 
 
 H. D., K., / - ; L., ft. 
 
 Tuning-fork on teeth or vertex seemed louder in the left ear. Is slightly in- 
 tensified in right by plugging, but much more in left. Aerial better than bone- 
 conduction on each side. 
 
 The drum-heads are about alike and show nothing to account for deafness. 
 Air enters the right drum by both catheter and Politzer's method, but does not 
 alter the hearing. All notes of the piano are heard, but she says they do not 
 sound " clear," even with both ears open. Dr. Douglas examined the naso- 
 pharyngeal space and the mouths of the Eustachian tubes and found nothing 
 abnormal. 
 
 This seemed to be a case of deafness from affection of the 
 labyrinth, with no apparent cause except the kiss upon the ear. 
 The concussion from the kiss may have caused the loss of hear- 
 ing at once ; or, as seems more likely, it may have produced 
 changes in the labyrinth, which, in combination with the general 
 nervous shock, served as a foundation for a gradual loss of hear- 
 ing subsequently as, for instance, by some atrophic process. 
 
 Mr. Hinton was inclined to think that in all instances of loss 
 of hearing, apparently from slight causes, it might be found that 
 some previous source of injury to the ear had existed. He quotes 
 some cases to illustrate that view. He speaks of a concussion 
 sometimes jarring the labyrinth, not into complete paralysis, but 
 into a state of extreme liability to this condition. 1 
 
 ANEURISM TUMORS. 
 
 Aneurism of the basilar artery, cerebral tumors, and, in fact, 
 all varieties of intracranial disease, may cause tinnitus aurium 
 and impairment of hearing ; but all such cases require special 
 study, and hardly demand a detailed notice. Griesinger says 
 that the symptoms of disease of the nerve, or its expansion, aris- 
 
 1 Questions of Aural Surgery, p. 208.
 
 676 TUMORS OF CEKEBRUM. 
 
 ing from aneurism, are : Difficulty in swallowing ; occasionally 
 spasmodic deglutition ; impairment of hearing, or even complete 
 deafness, often appearing at intervals, with great tinnitus ; dif- 
 ficulty of respiration and articulation ; interference with the ex- 
 cretion of urine, without any impairment of the intellectual 
 functions ; and, finally, paraplegia. Von Troltsch states that a 
 constant sensation of knocking in the back of the head is also a 
 suspicious symptom. 
 
 Dr. Hughlings Jackson believes that deafness (excluding 
 cases manifestly due to disease of the apparatus of hearing) is a 
 rare complication of intracranial disease. It is very much less 
 common than optic neuritis. Dr. Jackson has not yet seen an 
 autopsy which showed that deafness had depended upon adven- 
 titious products, nor upon "any sort of disease of either cerebral 
 hemisphere." One case ' is recorded, however, which Dr. Jack- 
 son quotes, of tumor of the left cerebral hemisphere, where 
 there has been deafness of both ears. Dr. Jackson thinks that 
 deafness does not result from intercranial tumor, or other ad- 
 ventitious product, unless the auditory nerve is actually in- 
 volved or pressed upon. 
 
 According to Schwartze, 8 it has been estimated by Calmeil 
 that impairment of hearing occurs in about one-ninth of all 
 cases of cerebral tumors. Aural symptoms occurred, in 77 cases 
 of tumors of the cerebellum, 7 times ; in 26 cases of tumors of 
 the pons, 7 times ; in 27 cases of tumors" of the middle lobe, 3 
 times ; but not once in 27 tumors of the anterior lobe, nor in 14 
 cases of the posterior lobe, and 4 of the fourth ventricle. 
 
 Deafness of one side, according to Cruveilhier, quoted by 
 Schwartze, was one of the first symptoms in a number of cases 
 of central tumors. Schwartze further says, that impairment of 
 hearing on both sides not unfrequently occurs in tumors of the 
 cerebellum, and when from the situation of the tumor we know 
 that it does not press directly upon the nerve-trunk of the oppo- 
 site side, nor upon its origin in the medulla, and when there are 
 no symptoms of paralysis of other cerebral or spinal nerves, 
 Schwartze thinks that there may be a neuritis or oedema in 
 these cases. 
 
 DISEASE OF THE SEMI-CIRCULAR CANALS. 
 
 In the beginning of the preceding chapter it was said, that it 
 is now possible to diagnosticate disease of the cochlea and of the 
 semi-circular canals, as distinguished from diseases of the other 
 
 1 Royal London Ophthalmic Hospital Reports, vol. iv., part iv., p. 420. 
 
 8 Handbuch der pathologischen Auatomie, by E. Klebs. Gehororgan, by Schwartze.
 
 DISEASE OF SEMI-CIRCULAR CANALS. 677 
 
 parts of the labyrinth. I think this has been shown to be true 
 as regards the cochlea. As to the diseases of the semi-circular 
 canals, the late P. Meniere, 1 of Paris, reported a case which has 
 become classical. The deductions from it have not always been 
 justified by the facts. The term Meniere's disease has been used 
 so indiscriminately, especially by neurologists, that it has con- 
 fused our ideas as to the significance of vertigo, nausea, and ina- 
 bility to walk without staggering, when they occur in connection 
 with sudden loss of hearing. In one of Meniere.'s cases he found 
 a kind of bloody exudation in the semi-circular canals, while the 
 brain, the cerebellum, and the medulla were sound. This case 
 was that of a young woman, who, while menstruating, took cold 
 from riding on the top of a diligence. The other cases, nine in 
 number, are clinical accounts of cases of sudden deafness, in 
 which it is probable that the semi-circular canals were pressed 
 upon or diseased, for there was vertigo and a staggering gait. 
 Some of these cases were perhaps of tympanic origin, certainly 
 some were cerebral rather than aural, and the pressure upon the 
 semi-circular canals was not from any exudation within them. 
 As has been seen in the preceding pages, aural vertigo is by no 
 means always dependent upon disease of the labyrinth. 
 
 Meniere read his first paper upon the subject before the Acad- 
 emy of Medicine in Paris, January 8, 1861, and in it he claimed 
 that the lesion causing the following train of symptoms, namely, 
 vertigo, dizziness, uncertain gait, nausea, followed by deafness, 
 was situated in the semi-circular canals. Whether or not cases 
 were all to be referred to the labyrinth as their point of origin, 
 they cannot, with our present knowledge of pathology, certainly 
 be referred to the semi-circular canals. There is a vertigo of 
 tympanic origin, also one proceeding from primary disease of the 
 labyrinth, as well as one from the cerebrum. All of these forms 
 may be accompanied by sudden deafness. The deafness from 
 the impaction of cerumen is sudden in occurrence, so also that 
 from exudation or hemorrhage into the tympanum, as well as 
 that from hemorrhage into the labyrinth. These all may be ac- 
 companied by vertigo. A classification, then, which groups 
 under one head of disease, all cases of vertigo attended by deaf- 
 ness, is crude, and should be rejected. Each case should be 
 studied by itself, when it will be possible, in many instances, by 
 a, careful study of the principles that have been laid down in 
 this and similar works, to determine the seat and nature of the 
 lesion. Meniere did an inestimable service to the profession in 
 directing attention to the ear as the seat of disease, formerly 
 
 1 Gazette Medicale de Paris, 1861, pp. 29, 55, 88, 239, 279, 597.
 
 678 PRESS UKE UPON SEMI-CIRCULAR CANALS. 
 
 supposed to be in all cases situated either in the brain or the 
 stomach. The profession must now go further and determine 
 what part of the ear is affected in individual cases. 
 
 Dr. Ormerod ' has called attention to the fact, obvious to any 
 one who reads Meniere's cases, that "the paroxysms of vertigo 
 and vomiting are more sudden, more violent, more definitely 
 paroxysmal " than the vertigo from chronic disease of the middle 
 ear, and that what Hughlings Jackson calls the "vital symp- 
 toms " perspiration, pallor, and faintness are more marked. 
 Yet, as this writer admits, the vertigo from acute disease of the 
 middle ear may be paroxysmal and severe, although then the se- 
 verity of the symptoms, taken in connection with others, may be 
 of value in making up a diagnosis as to the seat of the lesion, it 
 cannot be said to be a pathognomonic guide. As before said in 
 this work, I have seen the most alarming vertigo faintness ap- 
 proaching to coma from syringing the ear. 
 
 CASE I. Sudden Deafness Vertigo Infantile Earaches Syphilis Years pre- 
 viously. E. B. L , aged fifty-one. November 26, 1881. The patient state* 
 
 that as he attempted to dance at a ball a year and eight months ago, he found he 
 could not hear a sound. He rubbed his ears vigorously and the power of hear- 
 ing returned. The next morning he had vertigo to such an extent that he could 
 not get out of bed, could not even hold up his head. There was also nausea for 
 a day or so. When he finally got about he staggered in his gait. He has been 
 an overworked man for five or six years. He had syphilis twenty-one year* 
 ago chancre, eruption, alopoecia, sore throat. H. D., Bight ear, *?$- ; left, -Y\. 
 Bone conduction is better than aerial on the right side. The aerial is the same 
 as bone on the left. Hears worse in a noise. Bight membrana tympani, poor 
 light spot ; left, opaque, light spot only on periphery. His head is now improv- 
 ing. Tinnitus aurium is not very troublesome. When he had vertigo, the sensa- 
 tions were of turning to the right. No vertigo for the past six or seven weeks. 
 The second examination showed that the aerial conduction was better on each 
 side. There is a history of earaches as a child. The drum-heads are cicatricial. 
 He has been subjected to thorough treatment by mercury several times, he says. 
 His ears feel better after inflation. 
 
 This was a case of chronic disease of the middle ears, in 
 which the labyrinth, especially the semi-circular canals, became 
 secondarily affected, by pressure, it may be supposed, and not 
 from any disease in them. To call such a case one of Meniere's 
 disease, is not to give any very definite idea of its nature. The 
 history of earaches, the appearance of the drum-heads, the syphi- 
 litic disease of years before, combine to give us an accurate no- 
 tion of the causes and nature of the disease. 
 
 CASE LT. Sore Tliroat Great Loss of Hearing Inability to Walk Straight. 
 General X , aged forty-four. Seven years ago while he had a sore throat, 
 
 1 Brain, vol. vi., p. 33.
 
 PRESSUKE UPON SEMI-CIRCULAR CANALS. 
 
 he found himself very hard of hearing, with inability to walk straight. " He 
 could not control his lower limbs." Noise made his hearing much worse. Hear- 
 ing distance : Eight ear, ^ ; left, ^$. Aerial conduction better than by bone on 
 left side. Both drum-heads are tympanitic. He can now walk pretty well. 
 
 In this case there may have been a tympanic hemorrhage, such 
 as I have seen in the course of acute catarrh, which caused the 
 want of ability to walk for I have seen failure of power of main- 
 taining the equilibrium from such a cause or the lesion may 
 have been in the medulla. That it was of tympanic origin seems 
 to me more probable. The proper way to describe cases of ver- 
 tigo and inability to walk straight in cases of aural disease is to 
 speak of them as of peripheric (external auditory canal), tym- 
 panic, labyrinth or cerebral origin. It is possible in many cases 
 to make such an analysis of the cases of pressure upon, or dis- 
 ease in, the semi-circular canals. These cases are not of the 
 severe type of those presented by Meniere, but they are such as 
 are constantly, as it seems to me, improperly and insufficiently 
 described by this name. More serious cases of the same charac- 
 ter may be found in other parts of this boolc. 
 
 EPILEPSY AND AURAL DISEASE. 
 
 The relation of aural disease to epilepsy, has been mentioned 
 in the discussion of foreign bodies and ear cough, but it cannot 
 be said that the subject has yet been fairly studied, except from 
 the point of the reflex origin of epilepsy from suppuration of 
 the tympanum, foreign bodies in the auditory canal, and so forth, 
 although I have seen cases of epilepsy apparently caused by such 
 diseases, and I have also seen epileptics who suffered from 
 chronic non-suppurative disease of the middle ear. Ormerod 
 found that of 100 cases of undoubted aural disease, as deter- 
 mined by Dr. Urban Pritchard and Mr. Cumberbatch of St. Bar- 
 tholomew's Hospital, "seven had had bona fide epileptic fits." 
 This the writer states is a large proportion, for Niemeyer, as 
 he says, estimates that there are only six cases of epilepsy to 
 every 1,000 persons, while Russell Reynolds maintains that this 
 estimate is far too high. I have no doubt, as suggested by 
 Ormerod, that aural disease and disease situated not only in the 
 peripheric portions, but in the labyrinth, may excite epilepsy ; 
 but more investigation is required upon this subject. 
 
 Pathology. In passing over the subject of the causes of dis- 
 ease of the internal ear, we have alluded to the pathology of the 
 affection ; but it may be well to tabulate the post-mortem ap- 
 pearances that have been found in the labyrinth. Inasmuch as
 
 680 PATHOLOGY OF INTERNAL EAR. 
 
 very few of these appearances have been accompanied by the 
 history of the case, they have not the importance that they 
 would otherwise have had. Yet they may be of service as a 
 basis for future investigation. 
 
 Absence of auditory nerve 1 
 
 Atrophy of auditory nerve 10 
 
 Suppuration 1 
 
 Tumor upon 1 
 
 Hemorrhage upon 2 
 
 Thickened membranous labyrinth 11 
 
 Atrophy of membranous labyrinth , 22 
 
 Congestion 1 
 
 Suppuration of membranous labyrinth 3 
 
 Serum in labyrinth 3 
 
 Opaque fluid in labyrinth 3 
 
 Black pigment-cells too abundant 5 
 
 Distention of blood-vessels of cochlea 3 
 
 Fluid, opaque 4 
 
 Pus in cochlea 1 
 
 Thickened lamina spiralis 1 
 
 Osseous wall of semi-circular canals incomplete 3 
 
 Enlargement and congestion of blood-vessels (Hinton ') 4 
 
 Hypersemia of the various parts, or of the whole contents 
 of the labyrinth, has been found in typhus and puerperal fever, 
 in acute tuberculosis, and in cases of poisoning by carbonic 
 oxide gas ; also in meningitis, and in cases of disturbances of 
 circulation from disease of the heart, and in emphysema of the 
 lungs. Hypersemia of the labyrinth may result from vaso-motor 
 disturbances of innervation. 
 
 According to Erb, 8 atrophy of the acoustic nerve occasionally 
 occurs in tabes dorsalis. 
 
 Tumors sarcoma, neuroma, and gummata may enter the 
 meatus auditorius internus. 
 
 Treatment. In addition to what has already been said as to 
 the treatment of disease of the internal ear, it may be proper to 
 add, that before any treatment is entered upon, the situation of 
 the lesion and its cause should be made out if possible. With- 
 out this all treatment will be like working in the dark, and 
 worse than useless. True inflammation of the membranous 
 labyrinth should be treated by absolute quiet and rest, leeches 
 to the mastoid and tragus, pedeluvia, and purgations. The use 
 of quinine and cold applications to the head should be avoided, 
 
 1 Questions of Aural Surgery, p. 255. 
 8 Ziemssen's Handbuch, p. 142.
 
 TREATMENT OF INTERNAL EAR. 681 
 
 as well as all inflations of the tympanum. Syphilitic affections 
 of the labyrinth, if treated at an early stage and vigorously, by 
 the mercury and iodide of potassium treatment, may recover. 
 Traumatic affections of the labyrinth are usually hopeless from 
 the start, as far as restoring the hearing is concerned ; but much 
 can be done by quiet, leeches, counter-irritation and the like in 
 removing the symptoms of tinnitus, vertigo, double hearing, and 
 so forth. 
 
 Chronic affections of the labyrinth are, unless of a syphilitic 
 origin, so far as my experience goes, utterly hopeless. Elec- 
 tricity has a much-vaunted reputation, among inexact observ- 
 ers, for its cures of nerve-deafness ; but there are no authentic 
 cases on record of a cure of a true inflammatory affection 
 of the labyrinth by this agent. The only seeming exception 
 to this rule is a case" reported by Moos, 1 which he entitles " Re- 
 covery from Complete Nervous Deafness." The constant cur- 
 rent was used successfully in what seems to me to have been a 
 case of impairment of hearing occurring in the course of an 
 hysterical affection. The patient had acute articular rheuma- 
 tism, and in the fifth week hysterical symptoms appeared. 
 There was great sensitiveness of the ear, such as occurs in other 
 parts of the body in hysterical women, and increased hearing 
 power. The patient lay for nine days without moving on the 
 right side, and thus an ulcer of the concha was caused. She 
 took large doses of quinine for these nine days, when impairment 
 of hearing occurred, and continued to increase until the patient 
 was communicated with in writing. In the eleventh week te- 
 tanic spasms occurred. The galvanic current was then em- 
 ployed, twelve elements being used. The symptoms, except 
 the deafness, soon subsided, and a thorough course of galvani- 
 zation of the ears restored the power of the right one perfectly, 
 and of the left in all respects, except the inability to distinguish 
 the highest note of the seven-octave piano. 
 
 I confess I do not feel the enthusiasm over this case which is 
 exhibited by Professor Moos, which, according to his hopes, is to 
 " toll the knell for all the opponents of the therapeutic value of 
 electricity in aural disease." In my opinion the loss of hearing 
 was caused by the quinine, and the partial recovery due to the 
 fact that its use was suspended. 
 
 Beard and Rockwell 2 give their views as to the value of elec- 
 tricity in the treatment of diseases of the auditory nerve and 
 labyrinth in the following cautious language: "Cases of nerv- 
 
 1 Archives of Ophthalmology and Otology, Bd. I., No. 2. 
 
 * A Practical Treatise on Medical and Surgical Electricity, pp. 571-72.
 
 682 TREATMENT OF INTERNAL EAR. 
 
 ous deafness, or of deafness resulting from various pathological 
 conditions, with which a morbid condition of the auditory nerve 
 is complicated, and all cases of tinnitus aurium, whatever may 
 be their supposed pathology, should only be regarded as hopeless 
 after the failure of persevering and varied treatment by elec- 
 tricity, although perfect or approximate cures will be obtained 
 only in a small percentage of the cases. The treatment of opac- 
 ity and thickening of the drum, and of chronic inflammation 
 (with the consequent adhesions and other morbid changes) of 
 the middle ear and Eustachian tube, offers a fair and important 
 field for electrical experiment." 
 
 Dr. Knapp says: 1 "I have tried it electricity in nearly all 
 reported cases, but without a shade of improvement." 
 
 Dr. Sexton writes me that he has experimented with electri- 
 city in aural disease for two years, both in private and public 
 practice. He is convinced of the correctness of Brenner's for- 
 mula ; but in all his cases, Dr. Sexton says, "there was no marked 
 improvement in the hearing." " In a few cases of impaired hear- 
 ing, where there were the accompanying symptoms of dizziness 
 or nervous headache, the advantages of the treatment were de- 
 cided." 
 
 My own experience has been purely negative. I have never 
 seen any improvement, in any forms of nerve-deafness, from 
 the use of electricity in any form. I fear, that we must abandon 
 the hopes entertained by some, of the powers of this subtle agent 
 in those as yet mysterious diseases, the affections of the inter- 
 nal ear. 
 
 The anaemia of the labyrinth that sometimes occurs after 
 typhoid fever, and perhaps after other serious diseases of an ex- 
 haustive character, may be successfully combated if it be not 
 treated by the usual means for disease of the middle ear. In- 
 flation, either by the catheter or Politzer's method, should be 
 avoided. Counter-irritation over the mastoid, and tonics will 
 often be of service ; while quinine, salycilic acid, and other agents 
 which excite tinnitus aurium should be avoided. The patient 
 should be kept away from noisy places, and avoid any exposure 
 to loud sounds. It is well to cause such subjects ; on going into 
 the open air during convalescence, to wear cotton or wool in 
 the external meatus, in order to protect their ears from the 
 shock of noises. 
 
 1 Archives of Ophthalmology and Otology, vol. ii., No. 1.
 
 DEAF-MUTEISM 
 
 AND 
 
 MECHANICAL ASSISTANCE TO THE HEARING.
 
 CHAPTER XXIII. 
 
 DEAF-MUTEISM MECHANICAL ASSISTANCE TO THE HEAEING. 
 
 Acquired and Congenital Cases. At what Age are Children Conscious of Sounds ? 
 Causes. Tables of Examination of 147 Cases. Hearing-trumpets. Audiphone. 
 
 THERE is no logical reason for the discussion of deaf-muteism 
 in a treatise upon the diseases of the ear, as a subject apart by 
 itself, any more than there is for the consideration of blind- 
 ness in a work upon the eye. But long-established custom 
 among writers on otology renders it proper that a few pages 
 should be given to this important theme in this text-book. I 
 shall, however, say nothing upon methods of instruction of deaf- 
 mutes, but refer my readers to the appropriate treatises and au- 
 thorities for knowledge on this subject. 
 
 Deaf-muteism is caused by diseases of the middle and inter- 
 nal ears. These diseases are of various kinds, and have been 
 fully discussed in the preceding chapters of this work. The 
 only reason that deaf persons become mutes is that the disease 
 of the ear occurs either before birth, or so shortly after, that 
 its victim is unable to learn to imitate speech. There are no 
 changes in the larynx that prevent deaf-mutes from articulat- 
 ing distinctly, except those that may possibly come from disuse 
 of the organ. 
 
 Persons who become completely deaf later in life, do not lose 
 the power of speech ; but they usually speak in an unnatural 
 tone, because they are unable to hear their own voice with dis- 
 tinctness. Deaf-mutes may be divided into two great classes. 
 
 I. The acquired cases, or those in whom the disease of the 
 ear has occurred after birth, from some traceable cause. 
 
 II. The congenital cases. 
 
 It is very difficult to come to a correct conclusion as to the 
 relative frequency of congenital and acquired deaf-muteism. 
 The tables that are made up by the directors of schools for the 
 deaf and dumb are not trustworty, because they are taken from 
 the statements of persons who are seldom exact observers the 
 parents or friends of the children. The late Dr. George M.
 
 686 DEAF-MUTEISM. 
 
 Beard and myself ' examined two hundred and ninety-six cases 
 of deaf -muteism, with their histories, in the schools of New York 
 City, and Hartford, Conn., and the result of our examination 
 was, that about sixty-one per cent, of these cases were probably 
 congenital, and that the remaining thirty-nine per cent, were 
 acquired. Wilde's statistics show that about fifty per cent, are 
 of the acquired form. The exact truth as to the time when the 
 deafness occurred is something very difficult to ascertain. It is 
 not easy to learn, even when great pains are taken by persons 
 well competent to observe, whether a very young infant hears 
 well or not, although we may easily satisfy ourselves whether 
 or not loud sounds are perceived. 
 
 Children appear to be conscious of sounds during the first 
 days of their life, while at the third month they show an appre- 
 ciation of particular sounds, such as chirping, whistling, and the 
 like. From the first month to the third is perhaps the earliest 
 period at which an opinion can be formed as to the hearing of 
 an infant. I find on inquiry among mothers, that their opin- 
 ions vary excessively upon this point. Some affirm that they can 
 decide whether their children have good hearing within a few 
 days of their birth, while others say that a month or two is re- 
 quired. Infants seem to hear sounds conducted through solid 
 media almost immediately ; that is, within a few days after birth, 
 while hearing of tones through the air appears much later. They 
 will very soon notice a jar, such as a stamp on the floor, while 
 for the human voice time is needed. Moreover, an inflammation 
 of the ear, if not of the suppurative variety, may run its entire 
 course in a young child, and never be recognized by physician 
 or friends as a case of aural disease. It is well known, and the 
 fact has been before alluded to in this volume, that a suppurative 
 inflammation of the middle ear, in an infant, is sometimes first 
 recognized as such when the pus breaks through the membrana 
 tympani. The fact that such severe processes may go 011 in the 
 ears of children, and escape recognition, renders it very probable 
 that even Wilde's proportion, in which he gives fifty per cent, as 
 the proper one for acquired deaf -muteism, is too low a one. I 
 am inclined to think that there are many more cases of children 
 becoming deaf after birth, than of intra-uterine deafness. 
 
 It does not require absolute deafness in a young child to pro- 
 duce deaf -muteism. A case of chronic aural catarrh, that would 
 only inconvenience a grown person, will make an infant so stupid 
 that it will soon cease to attempt to imitate speech. We have 
 all grades of hearing power in so-called deaf-mutes. I have 
 
 1 American Journal of the Medical Sciences, voL liiL , p. 401.
 
 DEAF-MUTEISM CAUSES. 687 
 
 seen two or three cases of children who were being educated in 
 deaf and dumb asylums, who could hear words Spoken into their 
 ears in a very loud tone. In one case the parents found it too 
 much trouble inasmuch as no physician could be found who 
 would treat the suppurating ear to teach their child to speak. 
 He was consequently losing his speech, and also having his life 
 placed in peril by the neglect of the ulcers in his ears. 
 
 Some asylums for the deaf-mutes in this country are not at- 
 tended by physicians competent to examine and treat the ear. 
 Many of the inmates require constant and special care of their 
 ears ; especially is this true of those affected with suppuration of 
 the ears, of whom there are about twenty per cent, in the asy- 
 lums. A certain and valuable degree of hearing might be ob- 
 tained in a few of these cases by intelligent local treatment. 
 
 Deaf-mutes should be taught to speak by imitation of the lips 
 of the speaker. The sign language has been for so many years 
 the means for educating deaf-mutes in this country, that lip 
 training has not yet obtained its proper place with us ; but it is 
 fast winning it. The next generations will exhibit many more 
 deaf-mutes who can converse with any member of society, and 
 who will not be limited to the comparatively few who know the 
 language of signs. I know an accomplished young lady, entirely 
 deaf from acute suppuration of the middle ears, with whom I 
 have often conversed, who takes her full part in the conversa- 
 tion of a large family. 
 
 Causes. The causes of deaf-muteism are very graphically 
 set down in the reports of deaf and dumb asylums, but unfortu- 
 nately these assigned causes are usually incorrect. Thus, "colic," 
 "a burn," "a fall," "fits," "mother marked," ' etc., figure in 
 such tables as causes of deaf-muteism. Many of the so-called 
 facts in such tables have been derived from unscientific obser- 
 vers, who sometimes have very positive opinions as to the 
 causes of disease, and who believe that in a severe fright to the 
 mother, the marriage of cousins, etc., ample causes are found 
 for deaf-muteism. The investigation of the proximate causes 
 of deaf-muteism show, as has been said, that their victims have 
 become deaf from' precisely the same kinds of diseases, and in 
 about the same proportion, as obtains in impairment of hearing 
 or deafness occurring at a time of life that prevents the subjects 
 from becoming dumb as well as deaf. Of the 296 cases exam- 
 ined by Dr. Beard and myself, in only 22 cases was the drum- 
 head found to be normal, and in 200, or more than two-thirds of 
 
 1 On the Etiology of Acquired Deaf-Muteism, by Clarence J. Blake. Reprint from 
 Boston Medical and Surgical Journal.
 
 688 - DEAF-MUTEISM CAUSES. 
 
 the whole number examined, there was chronic pharyngitis or 
 tonsillitis. Of the 114 acquired cases, the membrana tympani 
 was perforated in 29 cases. Thus, suppurative inflammation 
 does not seem to cause as large a proportion of deaf-muteism 
 as is usually supposed. In some of the cases, however, the 
 membrana tympani had once been perforated and had healed. 
 In Blake's statistics, 1 forty per cent, of those examined, 41 in 
 number, were classed by him as acquired cases. In 12 of these 
 acquired cases the membrana tympani was perforated or de- 
 stroyed on one or both sides. In 13 of the 17 cases, the deafness 
 was traceable to the pharyngitis of scarlet fever or measles. 
 
 The remote causes, or the causes that tend to produce dis- 
 ease of the ears in intra-uterine or infantile life, form a very in- 
 teresting study, but we have as yet no very accurate data upon 
 which to discuss them. It is an open question, perhaps, whether 
 intermarriage tends to produce disease of the ear in young sub- 
 jects or not, whether it tends to lead to arrested development in 
 young children ; for there is no doubt that some cases of con- 
 genital deafness depend upon want of proper development of 
 the auditory nerve and labyrinth. I was informed at Hartford, 
 that a certain part of our country, which is somewhat isolated 
 from the other parts of the Union, and where intermarriages 
 are the rule, furnished a proportionately large contingent of 
 cases of congenital deaf-muteism. The cases from this district 
 that I saw were in persons somewhat deficient in intellect, and 
 we may consider their etiology as identical with that of idiocy, 
 feeble brains, or partial development of other parts of the body, 
 such, for example, as spina bifidis, coloboma iridis, etc. It is not 
 probable that deaf-mute parents are likely to beget children who 
 do not hear, for the simple reason that in the large proportion of 
 cases, the deafness depends upon inflammatory action, which is 
 not transmitted, except possibly as a tendency or by anatomical 
 conditions. Deafness dependent upon imperfect development of 
 the ear or brain may be inherited. 
 
 Voltolini's inflammation of the membranous labyrinth is 
 probably one of the proximate causes of acquired deaf-muteism. 
 Von Troltsch showed that a purulent process is a very common 
 appearance in the tympanic cavities of half-starved foundlings. 
 I suppose that the mal-nutrition of parents may be traced as re- 
 mote causes for such affections of the middle ear. 
 
 We may sum up the causes of deaf-muteism, as developed in 
 clinical histories and in examinations on the dead subject, as 
 follows : 
 
 1 Reprint from Boston Medical and Surgical Journal.
 
 DEAF-MUTEISM CAUSES. 689 
 
 1. Inflammation of the middle ear, resulting in suppuration, 
 or adhesions, anchylosis of the ossicula auditus, and so forth. 
 
 2. Inflammation of the nerve or labyrinth, resulting in sup- 
 puration or thickening of the membranous labyrinth, deposits 
 in it, and so forth. 
 
 3. Arrested development, or absence of some parts of the es- 
 sential part of the auditory apparatus. 
 
 These are the causes which are shown in the table given by 
 Moos, 1 in his account collected from various authorities, of sec- 
 tions of the ears of sixty deaf-mutes, and they agree well with 
 the clinical examinations and histories. 
 
 Treatment. There is certainly no peculiar treatment neces- 
 sary for the deafness of young children, which renders them 
 mute, because they cannot learn to imitate speech ; but I cannot 
 refrain from alluding to the lingering remains of the barbarism 
 of the past centuries, which neglects the care of the ulcerated 
 membrana tympani, and the swollen throats of the poor mutes 
 who suffer from chronic suppuration and catarrh of the middle 
 ear. Although the educational wants of deaf-mutes are now 
 well attended to, their medical treatment is sadly neglected in 
 the asylums and schools of our country, as well as at their homes. 
 It was not until the seventh century that the deaf-mutes were 
 thought worthy of an education. The twentieth century will 
 probably arrive before every school or asylum for these unfortu- 
 nates has in attendance a physician who knows how to examine 
 and treat a diseased ear. These schools are not hospitals, it is 
 true ; but there is always in them quite a large proportion of 
 young patients who still suffer from a disease which, although 
 it has fully destroyed the hearing, is not yet stayed, and which 
 often goes on to destroy life. I refer, of course, more particu- 
 lary to the suppurative forms of disease. 
 
 According to the census of 1880, there were in the United 
 States 33,878 deaf-mutes. Of these we may believe that fifty per 
 cent, belong to the acquired cases. How many of these belong 
 to what may fairly be called preventable diseases, it would not 
 be possible to say ; but certain it is, that if diseases of the ear 
 had always rejoiced in the same attentive treatment as many of 
 the less essential parts of the body have received, the number of 
 these unfortunate mutes would have been greatly lessened. 
 
 The following table shows the results of an examination of 
 the hearing power and membranae tympani of 147 deaf-mutes, 
 with a statement of the causes assigned for their loss of hearing. 2 
 
 1 Klinik der Ohrenkranklieiten, p. 341. 
 s Archives of Otology, vol. xiii. , No. 1, March, 1884. 
 44
 
 690 
 
 EXAMINATION OF DEAF-MUTES. 
 
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 EXAMINATION OF DEAF-MUTES. 
 
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 EXAMINATION OF DEAF-MUTES. 
 
 Remarks. 
 
 Is very anaemic. 
 
 Four out of six brothers 
 and sisters are deaf. 
 The mother and father 
 are cousins. Feels the 
 
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 Has a deaf-mute brother. 
 
 Hears through speaking- 
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 & 
 
 
 JfJS & 
 
 a* 
 
 | 
 
 
 I -a 
 
 ^ .- . 'c rH 
 
 
 
 
 
 -3 
 
 
 rt "- 1 
 
 
 
 T ~- 
 
 ID 
 
 || 
 Sg 
 
 fl ^a G = 9- 189-11 M 
 
 DC , . &0 ^5 _ JSOr^H Ci S .8 
 
 I 1 
 
 2 : * Q a - 
 
 ^"o-^-S ^"o *" 
 
 
 
 
 
 P 
 
 i 
 
 |* 
 
 vj 
 
 *& -* 
 
 -- 
 
 s 
 
 
 
 3 
 
 CT 1 o^ 1 ^ tiCi^ X. 1 ^ ? 
 
 
 
 
 
 Jp 
 
 i 
 
 r^ Q 4 '5 
 
 O ** e 
 
 9 
 
 2 
 
 
 Saj^HSooSS 
 
 
 
 
 
 o 
 
 
 S W O 
 
 6D m o! 
 
 I 
 
 r3 
 
 
 O O 02 02 
 
 
 
 
 
 
 
 02 O 
 
 r> 
 
 
 
 
 3Sl 
 
 CO 00 CQ 
 
 
 
 
 
 02 ^ 
 
 
 CO 
 
 .. 
 
 1 
 
 
 I* 
 
 II jt -1 - 1 
 
 2 g d 
 
 00 03 GO 
 
 
 
 
 
 . 
 
 
 09 
 
 
 cc 
 
 
 ** 
 
 C^ O ^^ Q) 
 
 
 
 
 
 * 
 
 
 C^ O 
 
 
 K 
 
 
 flfi 
 
 cv. 6 jv. 6 
 
 55 ^ 
 
 
 
 
 
 0) 
 
 
 o. c. 
 
 k* 
 
 O 
 
 ^ 
 
 
 -> 
 
 
 
 
 
 
 
 
 
 
 
 
 g atD . 
 
 M*s 
 
 ^l 
 
 M W CM <W 
 w w c3 C3 
 
 
 
 
 
 1 
 
 
 <i) <E 
 
 w 
 
 | 
 
 
 P*f 
 
 g g g g 
 
 
 
 
 
 
 
 8 g 
 
 d 
 
 d 
 
 
 5 S-P 
 
 OOOO 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ,., & * 
 
 PQ P5 PQ PQ 
 
 
 
 
 
 
 
 m 
 
 W 
 
 e 
 
 
 s*g 
 
 - - - - 
 
 
 
 
 
 
 
 
 
 
 -. 
 
 
 5 = 3-3 
 
 
 
 
 
 
 
 
 
 
 
 
 o 
 
 
 
 
 
 
 
 
 
 
 
 
 ^Y 
 
 O 00 <M (M 
 
 rH rH rH i- 
 
 
 
 
 
 o 
 
 rH 
 
 
 rH rH 
 rH rH 
 
 05 
 
 t- 
 
 
 1 
 
 838.8 
 
 
 
 
 
 $ 
 
 
 O < 
 
 t- 
 
 X 

 
 EXAMINATION OF DEAF-MUTES. 
 
 693 
 
 
 No perception of tuning- 
 fork on hand. 
 
 a 
 
 
 
 I 
 1 
 
 feD 
 
 n 
 
 If 
 
 8 
 
 _ c^ c3 
 
 S^^'S 1 - s -sj^. 
 
 ^ W 
 
 Tuning-fork on hand is 
 felt up to the ear on 
 both sides. 
 Can hear some sounds. 
 Feels the fork on hand 
 the same as on mas- 
 toid. 
 
 
 ^ 
 
 
 i- 
 
 -*a . 
 
 3 ^ 
 
 ffi 
 
 1 
 
 _i.r> 
 
 
 I 
 
 ^ ' ' 
 
 3 1 
 
 a 
 
 i 
 
 i 
 
 ^3 a 
 
 to o 
 
 a a 
 
 S M 
 
 a 
 
 g 
 
 1-1 
 
 jjl 
 
 
 I 
 
 1 
 
 Sunken, small 
 
 spot. 
 Sunken, good c 
 no light spot. 
 Cicatricial. 
 
 rM 
 
 oT 
 
 1 
 
 ft 
 
 O 
 
 li 
 
 02 
 
 SJ4 
 
 fl ri 
 
 13 PI S 
 
 J = 
 
 ft o 
 
 B*"2 
 
 H O O 
 
 |8*| 
 
 1 t 
 
 "^ 
 
 a _^ 
 
 ^ 2 h 
 
 * 8 
 
 QQ PH 
 
 opaque. 
 Obscured by 
 narrowness o 
 
 1 
 fl 
 
 O 
 
 M 
 
 a 
 
 "o 
 ft 
 
 05 
 
 Vascular along 
 
 "3 
 
 CC 
 
 r 1 05 
 
 Good light spot, 
 fair color. 
 Sunken, no light 
 spot. 
 Obscured by wax. 
 
 -i-T 
 o 
 ft 
 
 
 
 i. 
 
 a a 
 
 o 
 
 r4 
 
 1| 
 5" 
 
 Cicatricial, with cen- 
 tral perforation. 
 
 a 
 
 O rrt 
 
 O Q 
 
 -> 
 Jo" 
 
 *rt f^1 
 02 
 
 ef o 
 It 1 
 
 w -a, 
 
 no -*3 CT^ 
 
 , cl ^ 
 'o.^P fl 
 
 "3 fl> 
 
 > cc 
 
 Invisible from nar- 
 
 rowness of canal. 
 
 ef 
 
 O) 
 
 M 
 
 a 
 
 J3 
 
 Eo 
 
 ^ 
 
 I 
 I 
 
 good light spot. 
 
 Opaque, calcareous, 
 de generation, 
 small light spot. 
 
 
 
 
 o 
 
 
 
 
 
 
 
 
 
 (K 
 
 
 
 6 
 
 "Si 
 
 6 
 
 O g 
 
 
 
 05 
 
 
 05 
 
 
 
 
 * 
 
 
 I s 
 
 K 
 
 H 
 
 
 
 H 
 
 
 
 
 
 6 
 
 ~ 
 
 1 
 
 1 
 
 & 
 
 
 
 ev. 
 
 
 O 
 
 !z! 
 
 
 d 
 
 
 
 
 
 2 
 
 *a 6JDT3 
 
 2 ror^j 
 
 
 
 
 
 
 
 
 K 
 
 O j^ 
 
 <5 
 
 ** el * 
 05 .pj M 
 
 ^ 5 S 
 
 4) c8 O 
 
 GQ 09 
 
 
 
 02 
 
 
 05 
 
 
 fH 
 
 !z; 
 
 ^ 
 
 
 to S "^ 5 
 
 (H H 
 
 ew 
 
 
 *H 
 
 
 
 
 
 
 
 CD _g O 
 
 ill 
 
 
 
 
 
 
 
 
 
 
 
 CD 
 
 
 
 
 
 
 
 
 
 * 
 
 & - 
 
 * 
 
 1 
 
 8 
 
 o o 
 
 }?, ^!J 
 
 CV. 
 
 
 ^ 
 
 
 * 
 
 
 C 
 
 ^ 
 
 
 
 . 
 
 s 
 
 E E 
 
 8 
 
 
 
 
 
 . 
 
 
 *3 
 
 *H C3 
 
 8 
 
 "3 
 
 3 
 
 *S "3 
 
 *s 
 
 
 3 
 
 
 rS 
 
 
 O 
 
 C3 0> 
 
 ID 
 
 03 
 
 m 
 
 CJ O 
 
 QJ 
 
 
 CD 
 
 
 
 
 Tl 
 
 O> 15 
 
 13 
 
 n^ 
 
 13 
 
 ^ 'd 
 
 ^ 
 
 
 ""d 
 
 
 'S 
 
 
 i 
 
 o 
 
 
 
 1 1 
 1 ( 
 
 I 
 
 i 
 
 pq 
 
 1 
 
 s s 
 
 pq pq 
 
 a 
 
 o 
 
 W 
 
 
 1 
 
 W 
 
 
 I 
 
 PQ 
 
 
 00 
 
 00 t- 
 
 00 
 
 OS 
 rH 
 
 rH 
 
 rH rH 
 
 00 
 
 
 CO 
 rH 
 
 
 CO 
 rH 
 
 
 
 
 O rH 
 
 S* 
 
 CO 
 
 ^ 
 
 IQ CD 
 
 t- 
 
 
 CO 
 
 
 rrs 
 
 
 CN 
 
 co co 
 
 CO 
 
 CO 
 
 co 
 
 CO CO 
 
 CO 
 
 
 CO 
 
 
 CO 

 
 694 
 
 EXAMINATION OF DEAF-MUTES. 
 
 
 
 GO ?H 5-1 
 
 rH Q) <D 
 
 o 
 
 03 
 
 -4-^ o3 
 
 * 
 
 5 
 
 
 ^^ 
 
 
 OS 
 
 
 
 r ^ i-H '-t-^ 
 
 
 rrf ^ 
 
 
 
 
 
 bo 
 
 
 
 i o 
 
 . 
 
 .2=" 
 
 .S 
 
 
 & 
 
 
 
 
 
 
 r'""i ^~< "^ 
 
 c3 " 
 
 'o m 
 
 
 
 rrt rl *T? 
 
 
 S 
 
 
 
 _ x 
 
 0) =*H 
 
 "' _ 
 
 
 
 '^ c3 
 
 
 3 
 
 a 
 
 
 c3 
 
 i-C O 
 
 r^H 
 
 r*^ 
 
 
 
 
 Q 
 
 ^. 
 
 
 < 
 
 * % 
 
 ^ 
 
 ' 
 
 
 g> 
 
 
 03 
 
 8 
 3 
 
 
 1"w 
 
 -- 
 03 .03 
 
 o n 
 
 3 ft 
 * O 
 
 
 QJ 
 
 
 ^ 
 
 
 
 w O 
 
 00 02 
 
 "! | .,_( 
 
 
 
 rH ^^) ' ^ 
 
 
 
 
 
 ' -4-> 
 
 03 =3 
 
 
 ~ i i 
 
 
 ^3 p o 
 
 . 
 
 O 
 
 
 
 
 
 
 *> * 
 
 
 g bo be 
 
 T3 
 
 a 
 
 El 
 
 
 
 <2 
 
 M Q 
 
 S S r 1 
 
 M S m 4 
 
 
 c3 fl fl 
 
 a 
 
 as ?3 
 
 
 
 EH' 
 
 '& 
 
 S 
 
 D 
 
 
 w 
 
 
 g 
 
 Left membrana 
 tympani. 
 
 Present, obscured 
 by wax. 
 
 Present, no details 
 discoverable. 
 
 43 
 
 1 
 
 ta 
 
 1 
 "cS 
 
 a 
 
 "o "o 
 
 02 03 TJ 
 
 1 si 
 .SP ."aj 
 
 I a> o 
 
 S g^r^ g 
 
 Io-p 
 eg O 
 
 03 
 
 3 
 
 Q 
 
 O 
 
 I 
 
 O 
 
 "o 
 
 J| 
 
 o M 
 
 1 
 
 O 
 
 Good color, sunken, 
 small light spot. 
 
 Opaque, no details 
 by reason of nar- 
 rowness of canal. 
 
 1 
 
 a" 
 
 ~o 
 
 "o 
 
 *"^ t -^ 
 
 i O 
 
 J & 
 
 f?- . 
 
 o> 
 
 as, 
 P ^ 
 
 1 
 ^ a 
 
 | 
 
 i 
 
 || 
 
 i 
 ^ 
 
 a 
 
 s'c 
 
 a 
 
 "1, 
 
 03 
 
 43 
 
 n 
 
 
 
 ^ |S 
 
 .^P 
 
 "-! 
 
 II 
 
 & 
 
 <u 
 ft 
 
 oo - 
 
 SJ 
 
 -i 
 
 
 
 
 ^*"^ 
 
 bo 
 
 11 
 
 " m ' ' ^ 
 
 ^i" 1 
 
 - 03 
 
 L 
 
 'o ' ' 
 
 o 
 
 S-2* 
 
 M 
 
 S 
 
 || 
 
 O 
 
 ; 
 
 1 
 
 S d ^ H 
 
 Illil 
 
 11 
 
 If 
 
 
 
 9 
 iM 
 
 11 
 
 \A 
 
 fc'J 
 
 
 *< "* 
 
 
 Q 
 
 
 J^ 1 CO 
 
 <*^. O3 
 
 rjj 
 
 o M 
 
 cj - 4 - 1 
 
 
 02 
 
 
 O 
 
 o o 
 
 o . 
 
 o 
 
 00 
 
 o 
 
 to 
 
 s 
 
 
 
 
 
 
 
 
 
 
 ^ 5 e 
 . o^ o 
 
 r-5 J3 3 
 
 03 
 
 o 
 
 
 
 03 
 
 03 
 CV. ( 
 
 03 
 
 0) 
 
 H 
 
 00 ^ 
 
 <u - 
 
 d 
 
 09 
 
 
 
 ^ 
 
 sii 
 
 HfgB 
 
 1 
 
 d 
 
 d 
 
 =v. g 
 
 C5 
 
 to 
 
 J- 
 
 d 
 
 o 
 
 d 
 
 " 8 
 
 
 
 
 
 
 02 
 
 
 
 
 a <B & . 
 
 03 
 
 03 
 
 " 
 
 . 
 
 03 
 
 . 
 
 _ 
 
 
 OT 
 
 
 
 
 
 
 
 0) 
 
 
 
 9 
 
 8 
 
 H 
 
 H 
 
 
 H 
 
 H 
 
 
 
 H 
 
 >H 
 
 lllg 
 
 s c ~ 
 
 "8* 
 
 d 
 
 to 
 
 1 
 
 1 
 
 c^. O 
 
 * 
 
 d 
 
 4 
 
 d 
 
 OQ 
 1 
 
 5& 
 
 
 
 
 
 ^^ 
 
 49 
 
 rH 
 43 
 
 c3 
 
 i i on 
 
 03 
 
 CJ * 
 
 M 
 
 ^ 
 
 
 
 * 
 
 -4^ 
 
 i 
 
 
 fl-g 
 
 *"* 
 
 S.1&I 
 
 X C8 
 
 <M 
 
 1 
 
 *H 
 
 | 
 
 M 
 
 03 
 
 *M <*4 
 
 03 03 
 
 rH 03 
 
 h 
 
 i 
 
 g 
 
 ft 
 
 g 
 
 ^'^" W E 
 
 
 8 
 
 'S 
 
 
 CO _00 
 
 O 
 
 2 
 
 03 ."4 
 
 oo .2 
 
 ill! 
 
 5S^ s 
 
 a a S q 
 
 I^JI 
 
 g o a-a 
 
 1 
 m 
 
 1 
 
 PQ 
 
 1 
 
 s a 
 
 
 
 PQ PQ 
 
 Cerebro 
 meningi 
 years." 
 
 ^ 93 
 
 "0 03 
 ft 
 
 02 *** 
 
 0) s 
 ft ^ 
 
 OQ >> 
 
 Cerebro 
 meningi 
 
 - g 'S: 2 
 
 -^.S3 
 
 lls 
 
 <O <D rt r< 
 
 r^Q 3 
 
 o 
 
 
 
 
 
 2 
 
 
 z 
 
 2 
 
 ^ 
 
 -.UM\ 
 Ut 3V 
 
 rH 
 
 CO 
 
 r-i 
 
 - 
 
 GO m 
 
 T-l 
 
 T-H 
 iH 
 
 CO 
 
 O 
 rH 
 
 rH 
 
 T 1 
 
 d 
 
 S 
 
 1-1 
 * 
 
 (M 
 
 
 
 CO -* 
 
 
 
 2 
 
 CO 
 
 
 
 * 
 
 28 
 
 Oi 
 *
 
 EXAMINATION OF DEAF-MTTTES. 
 
 695 
 
 g.A^'tf 
 
 ~- i - i Q o5 } i 
 
 S CD 5)0 50 
 
 
 * -u ^ . o 
 
 -J 
 
 ^ EL* 3 CD 
 
 mi 
 
 2&S 1 * 
 s g:-s -. 
 
 .2 &c;c , 
 
 l a || ||| |S| 
 
 ,2" 1 1 1 ' | 3 | || 
 
 S ^ 'SL-? j" 1 " 5 | TS 2 J3 
 
 i*< F* 3 -2 JB (3 S^CD 
 
 o * hrt c a 
 S '5VS 
 *< * "S 1 
 
 b^ 1 ^ 
 
 ^rS ^ *> ^ 
 
 
 2 ^ '3 S ^ 
 
 J3 
 
 P'if 
 
 o CD^~ 
 
 a&S'S 
 n 
 
 O ,J3 *3 -^ O'S ^ *'*-' flr^J 
 
 C,^VH 0^0 
 
 ^ C3 3 
 G g oo 'g 
 
 g pO O -ri ^ ; 
 fe 
 
 3 
 
 2 
 3 
 
 
 
 00 S "^ CO >FH 
 p>^ CD CD CD 
 
 2 3 802 
 
 10 
 
 ^ 
 
 CD CD 
 '8 CD 
 
 flr4 
 
 4* 
 
 * B "^ ^ ^ 2 
 
 -g 
 
 CD" 
 
 _2 
 
 
 
 
 S< S S "S .S 5 
 
 A 
 
 g,-g 
 
 .S 3 
 
 
 i-H 
 
 CO C p^ i"H 
 
 4F 
 
 aic 
 
 rH 
 
 
 
 CO 
 
 
 
 CO 
 
 
 
 
 
 _^, tT iT- ^ 
 
 ^_s jgj -a 
 
 & 
 
 5 
 
 O 
 
 o 
 
 
 
 be o o -^ 
 
 ^a jT 
 
 'bC 
 
 So 
 
 
 
 S o -^ 
 
 f T[J_^S 
 
 '^ 
 
 
 
 jf 
 
 
 ^H ^ 
 
 
 
 ! 
 
 a to 
 
 |t 
 
 
 
 
 
 
 
 
 O 
 
 O O 02. 
 
 O 
 
 cc 
 
 02 
 
 
 
 
 a 
 
 1 
 
 " ' 3 O 
 
 &i i 
 ^ ^ !* g,-g 
 
 bco > 2 o>gL 
 
 O 
 
 5 _ 
 
 CD" . 
 
 H 
 
 5 
 
 ^.P 
 
 'fljl'a 1 
 -|| 
 
 c3 O J 
 
 
 
 
 r^-3 ^ CO ^ CO 
 
 '_ _: - 
 
 S- 1 
 
 tjj > 
 
 
 * 
 
 T3 g -g g -g 
 
 - ~ 
 
 1=3 
 
 2 
 
 
 O . CO 
 
 ||g -gg> ^g) 
 
 
 |8 
 
 f S?l 
 
 
 o 
 
 O 02 02 
 
 O 
 
 c^ 
 
 o"" 
 
 
 
 -4J 
 
 
 
 CD 
 
 
 
 Wi ^ " CO 
 
 CO 
 
 02 
 
 'T^ 
 
 
 o- 
 
 ^ ^4J C> CD 
 
 CD 
 
 CD 
 
 ^a 
 
 
 
 8^ H 
 
 H 
 
 H 
 
 
 
 
 ^' . 
 
 
 CD' 
 
 
 
 
 ril^ O 
 
 Q 
 
 a 
 
 6 
 
 
 
 '* " * 
 
 ^ 
 
 o 
 
 
 
 c-. 
 
 1 - 1 
 
 i< 
 
 CD 
 
 6 
 
 
 0. 
 
 d 5,. 6 
 
 6 
 
 CD 
 O 
 
 o 
 
 
 3S 
 
 53 -j fl ^j fl -ta 
 
 *= 
 
 If 
 
 08 
 
 
 -H ~ 
 
 IH ^ '""t C3 . c3 
 
 rt (3 
 
 |H ^ 
 
 rt " 
 
 
 
 P4 A SH 
 
 PH 
 
 2_ 
 
 p. 
 
 
 ? '-3 
 
 to .2 co .2 co .2 
 
 co .2 
 
 K .2 
 
 x .2 
 
 
 2 IK 
 
 O 'Si). P 'Sb a3 p bc- 
 ja .2 "OQ* ^ .2 ^3 r3 .2 a: 
 
 p 'sb. 
 
 P 'So. 
 
 <-< ^ * 
 
 : ? -Oj 
 
 
 8 a a 
 
 B 91 
 
 CD rt CD 
 
 o a >> 
 
 ^f3*3 CDjJCJ DS^ 
 
 c32S SS2 32 
 o3^ o33 oai>> 
 
 CD S CD 
 
 O 3 >* 
 
 'S 'S 
 53 2 
 O a 
 
 >-.o 3 > 
 
 
 <M 
 
 l-H 
 
 CO CM O 
 i-H l-l l-H 
 
 r-t 
 
 o 
 i i 
 
 CO 
 1 I 
 
 
 
 
 rH CM CO 
 O O lO 
 
 O 
 
 o 
 o 
 
 o 
 o 

 
 696 
 
 EXAMINATION OF DEAF-MUTES. 
 
 
 tc 
 
 fl 
 
 
 s * y-s'-s'S'g & 
 43 a i o-^^ ci.a 
 
 ||'S|llt| 
 
 1 
 
 3 perception of tuni 
 fork on forehead. 
 
 
 iji0ii> 
 
 lit 'ta|f 
 
 fs|l5||f| 
 
 =l 8 'g"*sf ; 
 
 flljjllljll 
 
 lilliVllll 
 
 
 fc 
 
 
 fe ft W 
 
 tt 
 
 
 
 ^a* 
 
 -tT ri 0) ^T ** 
 
 
 a 
 
 
 a 
 
 OS 
 
 g,^ 1-^3 
 8 - ft'^ 
 
 
 
 1 
 
 S'o 
 
 j! 
 
 i 
 
 o 
 
 I 
 
 
 
 !< 
 
 ( Q) 
 
 a -s 5 w 
 
 ^^ 0^ 
 
 SP j- ft d 6 3> 
 
 rt H O J3 ^S 
 
 "*^ ** st? 
 
 9 
 
 5i 
 
 .^ i^ 
 
 O ^5 
 
 3 
 
 iH 
 
 O 
 
 M 
 
 I 1 
 
 ft 
 
 O rrj 2 
 
 11 If |H 
 O A OQ O 
 
 i 11 
 
 5 
 
 
 -*j 
 
 -tf fl 
 
 O O) 
 
 5 ? o ' 
 
 i 
 
 d 
 a 
 
 JP 
 
 s^ 
 
 fl 
 
 a | gfJ 
 
 
 
 . 
 
 3 
 
 s 
 
 
 CD 
 
 g'S 
 
 5 
 
 g ^3 
 
 2 ft o o ^ f' 
 
 fe 
 
 8g 
 
 --. 
 
 
 "StS 
 a 1 ! 
 
 & I S.SF1 
 
 ~ ^_w ^i i ^ 
 
 T 
 
 I* 
 
 5 
 
 aT . 
 
 &~o 
 
 o" 
 
 CD 
 
 ^a 
 
 I s 
 
 |! |! Ill 
 
 O* O cc 
 
 11 
 
 6_ 
 
 
 i 
 
 
 
 
 g|g 
 
 -1 2 
 
 a 3 " 3 
 
 o5 
 
 ^03 O3 
 
 05 ^* 
 
 |- 
 
 PH 
 
 ^ JH 
 
 QJ W W 
 
 j^US 
 
 O 
 
 BO 
 
 
 fe 
 
 
 O 
 
 
 
 
 
 * a fl - 
 
 
 
 c3 
 
 O O cv. 
 
 O3 ^ ' 
 
 3l|i 
 
 
 }Z5 
 
 
 
 H" 
 
 * 
 
 03 i 
 
 to . 
 
 -S 
 
 ri 
 
 . 0) 
 
 "S)C IQ C 
 
 'qj fl 
 
 G 03 
 
 CO 03 
 
 5R ^ s 
 
 gJ gs 
 
 PM o 
 
 ^ 
 
 t2 tS 
 
 ^H ^H 
 
 H o^~ 
 
 _ 
 
 DO 
 
 
 N 
 
 t^ 
 
 ill I 
 
 .3 
 
 ^ 
 
 6 6 
 
 00 ~ ' 
 
 
 k5 
 
 * 
 
 X * 
 
 tS 
 
 l llr . 
 
 'es''* 
 
 'e8 CC1 
 
 i -*H 00 E CO rt 
 CO ^j 03 ^3 * 
 fl ^, 03 O 03 a 
 
 - M*S 
 
 S.* ^"g 
 
 'ft* 
 
 rH 05 
 
 p-l 03 ^, g fH "H 
 
 
 rf 1 
 
 OS 03 
 
 !0 .2 
 
 00.2 Q 03 
 
 d 
 
 rH rQ O 
 
 -.5 a 
 
 t3 BS rj a> 
 
 1 *3 
 
 , -4- 
 
 1 -In "^ fl ' 
 
 ~S r^ ^ 
 
 liii 
 
 ii 1 
 
 I**! 
 
 "Cerebrc 
 meuine 
 
 o? o .3 a 
 
 5 a S 
 
 fi 9 ! 
 
 O) fl a 
 >^^) B > 
 
 SOD S rg 2 >T! - O 
 fl.iD B S 
 
 i >6 > a il 4" IB 4 BfH 
 
 !a^-*e^ "Ss 1 * 
 
 i^mcaoeo x"^ 
 
 I ^B M Q ft 0^ ft Qi Q^ 
 
 O ^ ^-02 ^ 02 ^O 
 
 rt 03 a; QU 
 >5 5 n >^ S 
 
 03 03 V ^ s 03 
 0} ft r^ 
 
 S ^3200 o 
 
 u^y 
 
 CO 
 
 1-1 
 
 CO 
 
 US i 1 U5 O 
 TH iH i 1 i 1 
 
 
 
 | 
 
 t^ 
 
 to 
 
 00 
 in 
 
 OS O i I (N 
 IA ca eo ca 
 
 ca
 
 EXAMINATION OF DEAF-MUTES. 
 
 697 
 
 rj i^ <p rt 
 Ori-fl O 
 
 W 
 
 *=> rt ** 
 A -S ,=5 
 
 '&? 
 
 H W 
 
 .& co 
 
 . 
 
 3.2:3 ^ 
 
 EH 525 
 
 'I 
 
 81 
 
 O 2 
 
 d a 
 
 -S. 
 .a> 
 
 _ 
 
 ni i t 
 
 cc 
 
 4^ < 
 
 S 
 
 CO 
 
 02 
 
 02 
 
 - 
 
 OQ 
 
 -is! 
 
 
 02_ 
 
 "i 
 a 
 
 
 PH 
 
 O 
 
 
 ^s^B 
 
 a-3 ^ 
 
 00 g 00 
 
 CO 
 
 CS .^3 OB 
 
 a 
 - 
 
 02 
 
 ' 5-2 
 
 i at! 
 
 [ .^p-^ 
 
 l||s 
 'l a 
 
 02 
 
 P 
 
 a: 
 
 O i-i (-1 
 X CO 
 
 CO 
 
 S 
 
 T: 
 
 1 P s 
 
 02 P-l 
 
 02 
 
 O 
 
 to 
 
 i 03 00 !-, 
 
 l 00 r**t-t 
 
 I R O CO T3 s 
 
 a." 
 
 02 .S 
 
 o'EL 
 
 b. 03 
 
 
 
 ^ a 
 
 C<J CO 
 
 03 "a 
 
 CO 
 
 >02 
 
 Sa><i>S*!-^ < 
 O S **O 9 ^02 ^ 
 
 SigiSi S 
 
 02 ^3D ^32 f^ 02 ^
 
 EXAMINATION OF DEAF-MUTES. 
 
 a 
 
 .3 
 
 - ' 
 
 s a -3 ? & 
 
 sg s g S M 
 
 O r-( 4^ ^ > *= 
 
 "-"Is 3 
 
 o 
 
 M 
 
 fill 
 
 P3 H 
 
 Si S- 
 
 ~ ~ 
 
 PH 72 
 
 t meinbra 
 tympani. 
 
 ^H 53 
 
 1 
 
 
 - 
 
 1 
 
 
 
 flS 
 
 n 
 
 2 . o 
 
 cc 
 
 I _rf "*^ L~, 
 
 i-a g,g 
 
 o 
 
 
 ht mem 
 tympan 
 
 " 
 
 S 
 
 I -1 
 
 S ^ 00 
 
 [IPs 
 
 03 
 <D O 
 
 
 
 1 
 
 J 
 
 
 S* 5 
 
 fto 
 
 =3 & 
 
 cc 
 
 a 
 ^ 
 
 5^ 
 
 CD 
 f3 
 
 1 
 
 S 
 
 03 IT? -* 3 S 
 
 -a 
 
 S.3 
 
 
 i I s 
 
 
 ; w -. ii 
 
 a a if s 
 S *< 
 g o a-o 
 O 
 
 at a3y 
 
 -g 05 
 =3 O 
 
 s a 
 
 o 
 
 !zj 
 
 d 
 
 fc ^ szi 5z; 
 
 c> o* d 
 fc 525 fc 
 
 93 
 
 "S 
 
 <M r^ CO 
 
 " S'eS 
 
 cu CD >73 aj 
 
 > > 
 
 CD <D 
 
 WS-t^S jjS-k=S-*^C 
 
 05 05 ^ CD CD 
 
 a ?3 i? a 
 
 CO 
 
 OOQJCJO^ O C3 O ^ O 
 
 00 00 
 
 GO 00 
 
 id CO t 
 
 00 00 00
 
 EXAMINATION OF DEAF-MUTES. 
 
 699 
 
 c^ 
 'S-** 
 
 ^*d 
 a 2 
 
 .s-sTS 
 
 T3^2 2 
 
 ?3 .3 ^ 
 d^ ^ 
 
 ~^ 
 
 
 s 
 
 _w 
 
 i > ' e3 fn 03 S 
 
 'B Be *3 * S 9 TJ 
 
 -^ !> P /. -^- ^ M 
 
 lll^l! 
 
 Ie5^2 r 3-ti' a 
 
 -M 5 O J^ S3 5^ 
 
 -si 
 
 vuricles. 
 
 sounds 
 
 ^ 
 o 
 
 r 
 
 1 
 
 Hi 
 
 
 i! 
 
 1 
 
 le interrogatio 
 (?) is used w 
 
 o 3.2 
 
 o S 
 
 S ^ 
 
 =*^ .-! 
 
 03 d-3 
 
 Vi c3 o 
 te 
 M ^03 
 9 0,d 
 03 -*J -u 
 
 sometimes wl 
 
 ^^3 ftSr-j g.2 
 
 Mt^.al" 3 ! 
 be-- 1 ( *.-s^ r 
 
 .2 4^ d g'H g - 
 
 liilsl^l 
 
 > 0,0^1-g^ ^4n 
 
 g S 
 
 and elbow. 
 .>n prominent i 
 
 Q 
 
 a 
 
 o 
 
 oc 
 
 S 
 
 0) 
 
 rd 
 
 spoken throug 
 
 J8j 
 
 s * 
 
 60^ 
 
 .a a* 
 
 
 
 ' Q 
 O) {j 
 
 m d 
 
 ) 
 
 H 
 
 
 
 rH 
 
 PH 
 
 > 
 
 o 
 
 
 w 
 
 
 B 
 
 
 
 
 
 So" 
 ^'o 
 
 i 
 
 
 'Sb *i 
 , | 
 
 
 ^ 
 
 o 
 E 
 
 1 
 
 fH~ 
 
 'o "o 
 
 _ 
 
 3 
 
 'S 
 
 i 
 
 
 
 rfi 
 O O 
 
 ceo 
 
 r^ 
 ^ 
 
 2 
 
 o b 
 
 .d - 
 1 
 
 
 .SPa 
 
 h 
 
 O 
 
 a 
 
 r^ ^ 
 0^ 
 
 1 
 
 8 
 
 
 
 v QU 
 
 at 
 
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 700 
 
 EXAMINATION OF DEAF-MUTES. 
 
 ig*d 
 
 f g-o o 
 
 
 Mil 
 
 6 
 !Z5 
 
 d 6 6 ^ 6 g 
 Sz; 
 
 < 
 
 O- 
 
 3 s 
 
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 wise stated by paren 
 or gnardiann, and af 
 at which they si 
 deafness appeared. 
 
 [nflammation 
 brain at 1 ye 
 and 7 months." 
 
 to fl >^" 
 
 1 .Srnl I 
 
 S 00 "S^ 
 
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 CO "T? 
 
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 "Unknown." 
 
 ew 
 
 
 
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 00 
 
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 6 
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 S 
 
 iH iH rl tH TH 
 
 8 
 
 8
 
 EXAMINATION OF DEAF-MUTES. 
 
 701 
 
 kl CO fl 
 
 ii| 
 
 a as ~S 
 
 j) CU 
 
 582 
 0} O O 
 
 O3 -rt fl 
 t* P O 
 
 Id 
 02 
 
 any other. 
 Hears through speaking- 
 tube. 
 Has a feeble - minded 
 brother. 
 Hears the voice through 
 the speaking-tube. 
 Hears through speaking- 
 tube. 
 
 S S-S-a " i A-a a & 
 
 saS^aa)^3Sfl 
 
 ^ i '8i8y M i 
 
 isg^ jf'fsl 
 
 ftiiijti^ 
 
 ^J^^lllfig- 
 j|$| Si-al-s 
 
 PH 
 
 Has a deaf-mute sister. 
 The tuning - fork on 
 mastoid seems to make 
 veiy little impression, 
 as shown in his face. 
 Says it feels the same 
 on hand as on mastoid. 
 But as usual when one 
 says he feels it, it is re- 
 corded as bone condnc* 
 
 t.irm. 
 
 1. 
 
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 702 
 
 EXAMINATION OF DEAF-MUTES. 
 
 t mcmbrn 
 tyinp'ani. 
 
 m 
 m 
 
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 a 
 
 K_ 
 
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 "^5~
 
 EXAMINATION OF DEAF-MUTES. 
 
 703 
 
 2 *" 'T ~S fcC^ * 
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 bD p a) ej ft a 
 
 gesture is made by 
 many others, 
 ining-f ork felt as far as 
 the ear whan applied 
 to the hand. 
 
 v r 53'C ^ bOJ=! 2 S c ' 
 
 IliSillllll 
 
 lUlli. WlltJll 11) W HJJ- 
 
 plied to the mastoid, 
 and a lower note when 
 it was applied to the 
 hand, 
 ears words spoken 
 through a tiibe in both 
 ears with difficulty. 
 Left ear the better 
 one. 
 
 t-H 
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 pi 
 
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 704 
 
 EXAMINATION OF DEAF-MUTES. 
 
 
 S3 
 
 
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 bo D * "si 
 
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 d 
 
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 Left membrana 
 tympanl. 
 
 ;-. 02 0) S 
 
 5s i & ^E 
 
 ^.SP c'-i' D 
 
 .- 1 ^ (B 2^3 
 OJ ^ Ol . 
 p3 "^ p 43 pi =_, JM 
 
 g'S cfa g 
 
 p^ co p., 02 p A oe 
 O O OQ 
 
 fl * 
 02 O > 
 
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 Obscured by w 
 
 M\ 
 
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 55 
 
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 rH 
 
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 es 
 
 s ^h> 
 
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 I I 'i| 
 
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 r<4 2 TS, K 
 
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 43 
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 fl 
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 9 
 
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 > = 
 
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 02 
 
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 i 
 
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 s ai^ as-af^ 
 
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 || 
 
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 3 be as 
 
 
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 43 
 
 SV. 
 
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 JS^ic 
 
 do o 
 
 s 
 
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 6 
 
 
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 H 
 
 
 
 
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 o 
 
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 ^ 
 
 
 Cause stated by parents 
 or guardians, and age 
 at which they say 
 deafness appeared. 
 
 "Convulsions at 1 
 year." 
 'Convulsions at 1^ 
 years." 
 
 " Hydrocephalus." 
 
 "Hydrocephalus at 
 1 year and 7 mos." 
 " Hydrocephalus at 
 2 mouths." 
 "Fever at 5 years." 
 
 CO CO 
 
 I 1 
 
 
 
 43 43 
 
 tl >-l 
 to <o 
 
 OJ 
 g fe 
 
 "Pneumonia at 1 
 year and 9 rnos." 
 
 " Pneumonia at 8 
 months." 
 
 ^8^ 
 
 iH CO <N 
 rH rH iH 
 
 <M <N OS 
 
 TH TH 
 
 kO t^ 
 
 tH TH 
 
 TH 
 
 o 
 
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 o 
 
 
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 C 
 
 K 
 
 TH iH fH 
 
 TH iH TH 
 
 rH iH 
 
 
 TH
 
 EXAMINATION OF DEAF-MUTES. 
 
 705 
 
 
 
 
 '^11 sl^ 
 
 o'l ^^1' S I 
 
 -^S r^ -2-5 
 
 ll ||8l| 
 
 ft 'S * . 
 f lig"g 
 
 - 1 i s'-B 
 
 rt^rS^ 
 g fl^rg 
 
 of fork ex- 
 hand to ear. 
 
 
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 ^ o 'g 
 
 s 
 
 
 
 
 
 ^, +=> 03 CO O 
 
 g M 
 
 
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 to H u 
 
 
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 ^H -u .;; .,-1 oa 1) 
 
 ^g-S 
 
 O +H 
 
 "-J3 rjj 
 
 g (=1 
 o 03 
 
 . -" 
 
 
 <* 
 
 
 02* f> 
 
 
 [> 
 
 
 j-. 
 
 fen Q) 
 
 I rH r-. r ' -|.^ 
 
 n 
 
 
 rrj * 
 
 ft 
 
 cJ """* 
 
 ~*^ Q fl r-^ 
 
 ^ ' 
 
 
 O ^ 
 
 to 
 
 a 
 
 r| * 
 
 S &> . ^.2 rH 9 
 
 ll* 
 
 ft 
 
 H 
 
 ,_, 
 
 O 
 
 ^ -*i" 'S fl ^ 
 
 CQ 
 
 Go 
 
 PI 
 
 1 
 
 CQ 
 
 Srf 
 
 ||l|| 2a^ 
 
 Is 
 
 43 
 
 S 
 
 * "i, 
 
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 'o 
 
 
 rj 
 
 e3 ^ Jj ^to 
 
 >s ' 1 
 
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 o & 
 
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 39 
 
 1 
 
 02 
 
 a-iaS's ^33 g^ 
 
 Ei1 |sl |l 
 
 fe 02 02 
 
 02 
 
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 I 
 
 02 
 
 
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 || 
 
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 rH 
 
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 t 
 
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 H 
 
 
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 r 
 
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 rf gi ^ 2 5 
 
 as 
 
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 7s 
 
 Id 
 
 'o 
 
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 02 
 
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 CO 
 
 ni -* * 
 
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 3 
 
 rH 
 
 co 
 
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 45
 
 706 STATISTICS OF DEAF-MUTEISM. 
 
 The following table shows the statistics of deaf-mutes in this 
 country in 1880 : 
 
 Total 33,878 
 
 Males 18,567 
 
 Females 15,311 
 
 Native 30,507 
 
 Foreign 3,371 
 
 White 30,661 
 
 Colored 3,217 
 
 Total population of the United States : 
 
 Native 43,475,840 
 
 Foreign 6,679,943 
 
 i 50,155,783 
 
 In the year 1867, in conjunction with the late Dr. George M. 
 Beard, I examined 296 deaf-mutes with a view of contributing 
 something to our knowledge of the causes x>f deaf-muteism. The 
 results of these examinations were meagre, and they were made 
 to appear even less complete than they were in reality, because 
 the editor of the journal in which they were published ' could 
 not give us the space to publish the tables upon which our con- 
 clusions were founded, and because the tables were, lost so that 
 they could not be published elsewhere. Since the use of the 
 tuning-fork has come to play such an important part in aural 
 diagnosis, it has been made available also in the examination of 
 deaf-mutes. De Rossi, 2 of Rome, has made the most complete 
 examinations of which I know, as to the hearing power of deaf- 
 mutes. He examined seventy individuals with the speaking- 
 tube and tuning-fork. Twenty- seven heard the voice, four the 
 watch, thirty-nine the tuning-fork vibrating in the air. Nearly 
 all of the seventy perceived the vibrations through the bones, 
 eleven only had no perception by bone-conduction, and De Rossi 
 found only three cases of what he termed total deafness. These 
 examinations of De Rossi seem to me to furnish more reliable 
 data than the cases of Toynbee and Kramer, and chiefly because 
 the examination by the tuning-fork and speaking-tube was not 
 made by them. Accordingly, I have imitated the examinations 
 of De Rossi in those I have made. The imitation was an uncon- 
 scious one, however, for it was not until I had nearly finished 
 my examinations, that I found from a scanty reference in Hart- 
 
 1 American Journal of the Medical Sciences, vol. liii., p. 399. 
 
 2 Relazione sopra 1' Ospizio del Sordi-Muti de Roma. Quoted by Hartrnann. 
 "Deaf-Mutism." Translation, p. 84.
 
 CAUSES OF DEAF-MUTEISM. 707 
 
 tnann's book on deaf -muteism, that De Rossi had preceded me in 
 these tests. 
 
 The tuning-fork seems to me a very important means of de- 
 termining the seat of the lesion, in cases of impairment of the 
 hearing in which muteism does not result. I was desirous to 
 know what it would indicate in those who are dumb as well as 
 deaf. I found in the institution for the improved instruction of 
 deaf-mutes in this city, the most ample opportunities for exam- 
 inations. Every facility was afforded me by the principal, Mr. 
 Greenberger, and I desire to thank him not only for the advan- 
 tages he so liberally afforded me, but also for his valuable assist- 
 ance given in a truly scientific spirit. I was also assisted by 
 Dr. J. B. Emerson and Dr. George J. Bull, without whose aid I 
 should not have been able to accomplish the work of examining 
 so many pupils. I used a " C * " tuning-fork in the examination 
 as to the aerial and bone-conduction. The tests by speaking- 
 tube were made by Mr. Greenberger, and I have relied wholly 
 upon his statements as to that point. 
 
 TABLE I. One Hundred and Forty-seven Cases of Deaf -Muteism (causes stated by 
 
 parent or guardian). 
 
 No. No. 
 
 Born deaf 44 Whooping-cough 2 
 
 Cerebro-spinal meningitis 27 Spinal trouble 1 
 
 Scarlet fever 16 Mumps 2 
 
 Brain fever ... 13 Pneumonia 2 
 
 Meningitis 4 Gastric fever 1 
 
 Measles 7 Cholera iufantum 1 
 
 Fall on head 7 Intermittent fever 1 
 
 Unknown 7 Syphilis '. 1 
 
 Convulsions 4 Varioloid 1 
 
 Hydrocephalus 3 
 
 Fever 3 147 
 
 In regard to this table, I can only say that it is as reliable as 
 any that it seems possibl to get from any institution. As far 
 as the statements as to scarlet fever, measles, cerebro-spinal 
 meningitis, meningitis, mumps, and syphilis go, I think it may 
 be considered trustworthy. When we enter the domain of con- 
 genital deafness, or such causes as "spinal trouble," "fall on 
 head," "convulsions," there is great uncertainty as to the actual 
 cause. Yet these causes are taken from blanks carefully filled 
 out by the parents or guardians, many of them very intelligent 
 people of the higher walks of life, who send their children to be 
 under Mr. Greenberger's care. The causes are more accurately
 
 708 CAUSES OF DEAF-MUTEISM. 
 
 given, than in the other institutions in which I have made ex- 
 aminations. It will be seen there were only fifty-one cases, add- 
 ing together the congenital and "unknown," or a little more 
 than thirty per cent., which may, with much probability, be con- 
 sidered congenital cases. In our tables of 1867, we classified 
 sixty -one per cent, as congenital cases. Hartmann's tables 1 
 show that of 8404 deaf-mutes 5546, or more than sixty-five per 
 cent., were considered as congenital cases. His statistics are 
 apparently made up largely of official and not personal examina- 
 tions ; for in the examinations made in Berlin by Hartmann him- 
 self, one hundred and eighty-five in number, only forty-five are 
 classified as congenital cases ; and those made by Cohn, in Bres- 
 lau, show about the same proportion that is, of one hundred 
 and thirty deaf-mutes, fifty-seven are said to have been born 
 deaf, while in other parts of Germany, and in Ireland, the pro- 
 portion of congenital cases is much larger. I regard the official 
 tables of all countries as valueless, except as to the total number 
 of deaf-mutes. Those who collect them, are usually entirely 
 incompetent for the sifting of evidence necessary to get even 
 approximate truth upon this point. 
 
 TABLE IL Results of the Examination with the Tuning-fork C" of One Hundred 
 and Forty-seven Deaf -Mutes. 
 
 There was no aerial conduction on either side, while bone con- 
 duction existed in . . . .' 74 
 
 Bone conduction on one side, both bone and aerial on the 
 
 other, in 1 
 
 No bone or aerial conduction on one side, bone conduction on 
 
 the other 10 
 
 Bone and aerial conduction, both sides 7 
 
 Bone and aerial conduction on one side, bone on the other .... 13 
 
 Neither bone nor aerial conduction on either side 12 
 
 No bone or aerial conduction on one side, both bone and aerial 
 on the other 1 
 
 118 
 
 In twenty-nine cases the subjects were too young or were 
 otherwise incapacitated for intelligent answers : hence no con- 
 clusions could be formed, except that the large majority of 
 them probably heard the tuning-fork by bone conduction. 
 
 I will now present a series of tables made in consonance with 
 the supposed cause of the deafness. 
 
 1 Loc. cit. , p. 64.
 
 CAUSES OF DEAF-MUTEISM. 709 
 
 TABLE in. Scarlet Fever being Cause of Deafness, Condition of Membrana Tym- 
 
 pani (16 cases, 32 ears). 
 
 Absent 1 
 
 Opaque and cicatricial 4 
 
 Sunken, opaque, small or no light spot 11 
 
 Perforate and ulcerating 9 
 
 Congested 2 
 
 If eoplastic and perforate 1 
 
 Neoplastic 2 
 
 Not well seen 1 
 
 Perforate, no discharge 1 
 
 32 
 
 Tuning-ForTc Test. 
 
 No aerial conduction but bone conduction 17 
 
 Bone and aerial conduction 3 
 
 No bone or aerial conduction 8 
 
 Unreliable 4 
 
 32 
 
 Age of patients at time of becoming deaf : 
 
 From 2 to 3 years 2 
 
 3 " 4 " 8 
 
 4 "5 " 3 
 
 5 "6 " 1 
 
 6 "7 " .. 1 
 
 8 "9 " 1 
 
 16 
 
 There is in these scarlet fever cases a large proportion 8, or 
 one in 4 where disease of the nerve certainly existed. It will 
 also be remarked that there is a large proportion of cases of 
 ulcerative disease. That an ulcerative disease of the tympanum 
 may more readily involve the internal ear than a plastic or catar- 
 rhal inflammation, is probably true. Yet the starting-point of 
 otitis in scarlet fever is usually the middle ear. 
 
 TABLE IV. Measles Cause of Deafness, Condition of Membrana Tympani (1 cases, 
 
 14 ears). 
 
 Sunken, no light spot, opaque 5 
 
 Congested .... 1 
 
 Sunken light spot 1 
 
 Not well seen , 5 
 
 Opaque, but good light spot 2 
 
 14
 
 710 CAUSES OF DEAF-MUTEISM. 
 
 Tuning-Fork Test. 
 
 Bone conduction but no aerial conduction 6 
 
 Bone and aerial conduction 1 
 
 No bone or aerial conduction 1 
 
 Unreliable 6 
 
 14 
 
 It will be noted that only one case occurs here of those of 
 whom a reliable test could be made, in which it is possible that 
 disease of the nerve alone exists that is, the case in which there 
 was neither bone nor aerial conduction. 
 
 Age at which deafness occurred : 
 
 Under 1 year 3 
 
 From 1 to 2 years 3 
 
 " 2 " 3 " 1 
 
 7 
 
 TABLE V. Cerebro- Spinal Meningitis Cause of Deafness, Condition of Membranes 
 Tympani (27 coses, 54 eari). 
 
 Cicatricial 6 
 
 Opaque 6 
 
 Sunken, fair light spot 10 
 
 " good color 8 
 
 " small or no light spot 16 
 
 Not well seen ^ 3 
 
 Opaque, good light spot 1 
 
 Cicatricial and perforate 2 
 
 Congested and sunken 1 
 
 Congested 1 
 
 54 
 
 Tuning-Fork Test. 
 
 Bone conduction only, no aerial conduction 34 
 
 Bone and aerial conduction 5 
 
 Neither bone nor aerial conduction 8 
 
 47 
 Unreliable 7 
 
 Here the proportion of cases in which it may be conjectured: 
 that the nerve alone is involved, was not as large even as in 
 scarlet fever. There were only eight ears of a total of fifty- 
 four, or about one in seven. It is in this disease, that an affec- 
 tion of the nerve has been often assumed to be the most frequent 
 cause of the deafness.
 
 CAUSES OF DEAF-MUTEISM. 711 
 
 My clinical experience has been against this view, and I 
 believe that the few post-mortem examinations that have been 
 made of persons with aural disease in cerebro-spinal meningitis, 
 go to support the view of that experience, which is that a lesion 
 beginning in the middle ear, is in a large percentage of cases the 
 cause of the deafness. 
 
 TABLE VI. Deaf ness said to be Congenital, Condition of Membrana Tympani (44 
 
 cases, 88 ears). 
 
 Normal color and light spot , ,. .. II 
 
 Sunken, opaque, or no light spot 34 
 
 Obscured by wax 10 
 
 Opaque, large light spot 1 
 
 Sunken, opaque, but good light spot 14 
 
 Congested, sunken, and small light spot 5 
 
 Obscured by narrow canal 6 
 
 Cicatricial and perforate 3 
 
 Opaque, calcareous 1 
 
 88 
 Tuning-Fork Test. 
 
 Bone conduction, but no aerial 48 
 
 Bone and aerial . 8 
 
 Neither aerial nor bone 14 
 
 Unreliable 18 
 
 88 
 
 Here the proportion of cases of apparent nerve or central 
 disease is quite high fourteen to forty-eight,, or a little more, 
 than one to three, 
 
 TABLE VII.'' Brain fever," " Inflammation of Brain,*' "Meningitis* and " Con- 
 gestion of Brain" said to be the Cause of Deafness, Condition of Membrana 
 Tympani (15 coses, 30 ears}. 
 
 Sunken, opaque, small, or no, or double light spot 12 
 
 Normal \ 
 
 Sunken, good color, good light spot 7 
 
 Cicatricial 4. 
 
 Not well seen 3 
 
 Perforate and ulcerating 3 
 
 30 
 Tuning-Fork Test. 
 
 Bone conduction only i 
 
 Aerial and bone 4. 
 
 Uncertain g 
 
 30
 
 712 CAUSES OF DEAF-MUTEISM. 
 
 Age of patients when deafness occurred : 
 
 Less than 1 year 2 
 
 From 1 to 2 years 5 
 
 ' 2 "3 ' 1 
 
 ' 4"5 ' 2 
 
 ' 5 "6 1 
 
 6"7 ' 3 
 
 ' 8 "9 ' 1 
 
 15 
 
 TABLE Vlil. Fall on Head Cause of Deafness, Condition of Membrana Tympani 
 
 (7 coses, 14 ears). 
 
 Not well seen 5 
 
 Sunken, opaque, fair or good light spot 2 
 
 Sunken, no light spot 2 
 
 Good light spot but sunken 2 
 
 Sunken, congested 1 
 
 Good light spot 1 
 
 Small " " 1 
 
 14 
 
 Tuning-Fork Test. 
 
 Bone conduction only 8 
 
 Neither bone nor aerial 1 
 
 Bone and aerial conduction 1 
 
 Unreliable 4 
 
 14 
 TABLE ESL Cause Unknown (7 coses, 14 ears). 
 
 Opaque, sunken, good light spot 4 
 
 Not well seen 1 
 
 Opaque 1 
 
 Good color, fair light spot 1 
 
 Small light spot 1 
 
 Opaque and sunken 2 
 
 Sunken, small light spot 2 
 
 " good light spot 1 
 
 Opaque, good light spot 1 
 
 14 
 
 Tuning-Fbrk Test. 
 
 Bone conduction only 10 
 
 Uncertain 4 
 
 14
 
 CAUSES OF DEAF-MUTEISM. 713 
 
 TABLE X. Convulsions Cause of Deafness, Condition of Membrana Tympani 
 
 (4 cases, 8 ears). 
 
 Opaque, small light spot, good color 2 
 
 " sunken, good light spot 2 
 
 Opaque 2 
 
 " small light spot 2 
 
 8 
 Tuning-Fork Test. 
 
 Bone conduction only 5 
 
 Aerial and bone conduction 3 
 
 8 
 Age at which deafness occurred : 
 
 Less than 1 year 1 
 
 From 1 to 2 years 3 
 
 TABLE XI. Syphilis Cause of Deafness, Condition of Membrana Tympani (1 
 
 case, 2 ears). 
 
 Bight much sunken, no light spot ; left slightly sunken, medium-sized light 
 spot. 
 
 Tuning-ForJc Test. 
 Kight, no aerial conduction, but bone conduction ; left, same. 
 
 In this case, the only one found, there was a syphilitic his- 
 tory ; notched teeth ; the subject has had interstitial keratitis. 
 The disease seems to be confined to the middle ear. 
 
 TABLE TCTt. Hydrocepfialus Cause of Deafness, Condition of Membrana Tympani 
 
 (3 coses, 6 ears). 
 
 Not well seen 1 
 
 Sunken, perhaps perforate 1 
 
 " small light spot . 2 
 
 Opaque, no light spot 2 
 
 Tuning-Fork Test. 
 
 Bone conduction only 6 
 
 Age: 
 
 Less than 1 year 1 
 
 From 1 to 2 years 1 
 
 Unknown * . . 1 
 
 3
 
 714 CAUSES OF DEAF-MUTEISM, 
 
 TABLE XIII. Spinal Meningitis Cause of Deafness, Condition of Membrana Tym* 
 
 pani (3 coses, 6 ears). 
 
 Not well seen ............................ ................ 2 
 
 Sunken, opaque, good light spot ............. ..... . .......... 1 
 
 Opaque and cicatricial ..................................... 1 
 
 Sunken, no light spot ...................................... 2 
 
 6 
 Tuning-Fork Test. 
 
 Bone conduction only ...................................... 6 
 
 Age: 
 
 From 2 to 3 years ......................................... 1 
 
 " 5 "6 " ......................................... 1 
 
 " 6 " 7 " ......................................... 1 
 
 3 
 
 TABLE XIV. Varioloid Cause of Deafness, Condition of Membrana Tympanr 
 
 (1 case, 2 ears). 
 
 Not well seen ............................................. 1 
 
 Good color, good light spot, sunken ......................... 1 
 
 2 
 
 Tuning-Fork Test. 
 
 Aerial and bone conduction . ................................ 1 
 
 Bone conduction only ..................................... 1 
 
 2 
 
 Age at which deafness occurred : one year and four months. 
 
 TABLE XV. Pneumonia Cause of Deafness, Condition of Membrana Tympani: 
 
 (2 cases, 4 ears). 
 
 Sunken, small light spot ................................... 1 
 
 Not well seen ............................................ 1 
 
 Opaque, sunken, no light spot .............................. 2 
 
 Tuning-Fork Test. 
 
 Bone conduction only ..................................... 2 
 
 Uncertain ................................................ 2. 
 
 4 
 Age: 
 
 Less than 1 year .......................................... 1 
 
 From 1 to 2 years ......................................... 1 
 
 2
 
 CAUSES OF DEAF MUTEISM. 715 
 
 TABLE XVI. Whooping- Cough Cause of Deafness, Condition of Membrana Tym- 
 
 pani (2 coses, 4 ears). 
 
 Good light spot, sunken, opaque 1 
 
 Opaque, small light spot 1 
 
 Sunken, good color 1 
 
 Sunken and congested 1 
 
 4 
 Tuning-Fork Test. 
 
 Uncertain 1 
 
 Both aerial and bone conduction 1 
 
 2 
 Age: 
 
 " In infancy " 1 
 
 Whooping-cough, intermittent fever at two years and nine 
 months . . 1 
 
 TABLE XVEL Cholera Infantum Cause of Deafness, Condition of Membrana Tym~ 
 
 pani (1 case, 2 ears). 
 Sunken, no light spot 11 
 
 Tuning-Fork Test. 
 
 Bone conduction only 2 
 
 Age one year. 
 
 TABLE XVill. Gastric Fever Cause of Deafness, Condition of Membrana Tympani 
 
 (1 case, 2 ears). 
 
 Sunken, opaque, small light spot 1 
 
 Sunken, good color, small light spot 1 
 
 Tuning-Fork Test. 
 
 Bone conduction only, and that feeble 2 
 
 Diseases at two years and eight months. 
 
 TABLE XIX. Intermittent Fever Cause of Deafness, Condition of Membrana Tym- 
 pani (1 case, 2 ears). 
 Small light spot 2 
 
 Tuning-Fork Test. 
 Bone conduction only 2 
 
 Intermittent fever and spasms at two years.
 
 716 CAUSES OF DEAF-MUTEISM. 
 
 TABLE XX. Mumps Cause of Deafness, Condition of Membrama Tympani (2 
 
 coses, 4 ears). 
 
 Bight opaque, small light spot ; left fair light spot, good color, 
 
 sunken 2 
 
 Bight and left cicatricial 2 
 
 4 
 
 Tuning-Fork Test, Unreliable. 
 Age: 
 
 A few months old 1 
 
 Six years 1 
 
 2 
 
 TABLE XXI. Fever Cause of Deafness, Condition of Membrana Tympani (3 coses, 
 
 6 ears). 
 
 Sunken, two light spots 2 
 
 Sunken, small light spot 2 
 
 Opaque, small " " 1 
 
 Cicatricial 1 
 
 6 
 
 Tuning-Fork Test. 
 
 Both aerial and bone conduction 2 
 
 Bone conduction only 4 
 
 6 
 Age: 
 
 Nine months 1 
 
 Five years 2 
 
 3 
 
 TABLE XXII. Coses in which Words or Letters could be Heard through a Speaking- 
 tube placed in the Ear ; l Condition of Membrana Tympani (16 coses, 32 ears). 
 
 Opaque 6 
 
 Sunken 15 
 
 Good color 4 
 
 Good light spots 8 
 
 Small " 6 
 
 INo " " 6 
 
 Two light spots 1 
 
 Cicatricial 5 
 
 Calcareous 1 
 
 Vascular 1 
 
 Perforated 2 
 
 Not well seen . . 3
 
 CAUSES OF DEAF-MUTEISM. 717 
 
 Tuning-Fork Test. 
 
 Both aerial and bone conduction 4 
 
 Bone only 2 
 
 Bone both sides, aerial on one side 3 
 
 Bone and aerial on one side, neither on the other 1 
 
 Neither bone nor aerial on either side 2 
 
 Unreliable 4 
 
 16 
 
 Disease Causing Deafness. 
 
 Born deaf ^ 5 
 
 Measles 4 
 
 Cerebro-spinal meningitis 3 
 
 Brain fever 1 
 
 Convulsions , 1 
 
 Scarlet fever 1 
 
 Unknown ... 1 
 
 16 
 
 To this last table, the words of Mr. Greenberger should be 
 added : 
 
 " Th,e speaking-tube is used in these cases to assist the schol- 
 ars to speak better after they have learned to pronounce them 
 from the lips. There is not a pupil in the school who could be 
 taught to speak a word from hearing it through the tube alone, 
 but they will recognize words with which they have become fa- 
 miliar through lip-reading." 
 
 A study of these tables, especially with reference to the con- 
 duction of sounds to the ears or auditory centres through bone, 
 indicates to me that a large percentage of these deaf-mutes lost 
 their hearing from disease of the middle ear, and that the acous- 
 tic nerve was still capable of appreciating sound. It will be 
 observed that in the column of the table in which the answer 
 as to the perception of the sound of the tuning-fork through 
 bone is given, it is stated in many instances that the subject of 
 examination states that he or she "feels" it. I have endeav- 
 ored to make the tables a mirror of what actually occurred in 
 the examinations. It may be stated that to feel the vibrations 
 of the tuning-fork is not to hear them, but I am inclined to think 
 that in most instances, if not all, this perception is actually a 
 perception of sound. A little thought as to what sound is will, 
 I think, substantiate this view. We found, as will be seen, a 
 small contingent who did not respond in any way to the vibra- 
 tions of the fork. In this small contingent the functions of
 
 718 CAUSES OF DEAF-MUTEISM. 
 
 the nerve were probably destroyed. It is natural to suppose 
 that about the same proportion of infants and very young chil- 
 dren would suffer a lesion of the middle rather than the internal 
 ear, in case the organ is attacked by disease, as would be the 
 case in adults, and this seems to be indicated by these tables. 
 
 The deaf-mutes from whom these tables are made up, are, 
 so to speak, selected cases, for all or nearly all of them have 
 good intellects and are capable of being taught. There do not 
 appear among them, therefore, any cases in which there is a 
 lack of ordinary cerebral development. In classifying unse- 
 lected deaf-mutes, or- those taken from the whole number to be 
 found in a district or county, the number of those deaf from 
 disease of the central apparatus would, of course, be increased. 
 
 It is interesting to notice that a larger number of the cases 
 are attributed to cerebro - spinal meningitis than to any one 
 cause. There were 27 cases of this kind to 16 of scarlet fever. 
 " Brain fever " or meningitis plays an important part, in tlie 
 etiology, for there were 17 cases among the total number of 147. 
 I cannot but hope that the careful instruction of the public and 
 the profession, as to the necessity for the treatment of suppura- 
 tion of the ear, has borne fruit, in the prevention of many cases 
 of destruction of the ears by the means used to stop the inflam- 
 mation. In the examinations made by Dr. Beard and myself 
 some eighteen years ago, there was a larger percentage of cases 
 caused by scarlet fever and producing suppuration in the middle 
 ear. We seem as yet without means of successfully treating an 
 inflammation of the ear, when it occurs in the course of cerebro- 
 spinal meningitis. If there be an inflammation of the mem- 
 branous labyrinth, which is mistaken for this disease, it is as 
 yet not at all recognized by the profession at large. 
 
 The observations of Mr. Lawson Tait ' upon the congenital deafness of white 
 cats have an interesting bearing upon the situation of the lesion in deaf-mutes. 
 Mr. Tait says of a cat that lived in his house for eleven .years, that he was deaf 
 to impressions conveyed through the air, "but his intelligence could be reached 
 by impressions conveyed through solid media." When he was wanted, he would 
 respond to a peculiar stamp on the floor. After this interesting statement, Mr. 
 Tait passes, as it seems to me, out of the region of facts, to state that " human 
 deaf-mutes are those in whom deafness is cochlea r as well as tympanic." From 
 this premise he concludes that cats are not mutes because their deafness has a 
 tympanic origin. But human mutes emit sounds of various kinds as well as 
 animals who are deaf. The origin of the muteness is to be found in the 
 non-ability of hearing, and not in the situation of the lesion that causes the 
 deafness. The post-mortem investigation of Mr. Tait's cat was most interest- 
 ing. It was made by Drs. Cumberbatch and Dr. Gibbs. All tlie structures in the 
 
 1 Nature, December 13, 1883, and January 10, 1884.
 
 CONGENITAL DEAFNESS OF CATS. 
 
 719 
 
 ear were found to be normal, save the tympanic membranes, " in which there were 
 triangular gaps extending from the roof to just below the centre, the bases of 
 the gaps being directed upward, and the anterior sides being formed by the 
 handle of the mallei. The gaps appeared to be congenital and were quite sym- 
 metrical." All the other parts of the ear were normal. The auditory nerves were 
 of normal size and structure. 
 
 MECHANICAL APPARATUS FOR ASSISTING THE HEARING. 
 
 The hearing-trumpet remains as yet the best means, in the 
 greater number of cases, of increasing the hearing power. The 
 audiphone invented by Mr. Rhodes, of Chicago, is of equal value 
 in some cases, and is preferred by those who are able to use it. It 
 is more easily held, and less conspicuous. I think no one is 
 benefited by a hearing-trumpet or audiphone, unless the loss of 
 
 FIG. 136. Hearing-Trumpets. 
 
 FIG. 137. Auricles. 
 
 hearing be due to disease of the middle ear, or to a want of 
 power over the tympanic muscles occurring in old age, which 
 I would style presbykousis. As yet, hearing-trumpets and the 
 audiphones must be carefully tested by the patient himself be- 
 fore it can be certainly known that he will be materially assisted 
 by them. I have lately seen a case of watering of the eyes, that 
 seemed to be caused by the use of the audiphone. The patient 
 stated that great lachrymation occurred whenever she used the 
 instrument for a long period, which lasted for some time. If 
 she did not use it for a few hours, the watering would lessen or 
 disappear. Many patients speak of the fatigue of listening with 
 a hearing-trumpet, while others never seem to experience any 
 such sensation.
 
 720 
 
 AUDIPHONE. 
 
 The accompanying figures give a fair idea of the general 
 form of the most useful hearing-trumpets, and of the audiphone 
 and its use, as well as of the so-called auricles. The latter ara 
 unsightly but of some value. 
 
 FiO. 138. The Audiphone in its nat- 
 ural position ; used as a fan. 
 
 FIG. 139. The Audiphone in tension; 
 the proper position for hearing. 
 
 Politzer has invented a small instrument in the form of a 
 hunting-horn, whose narrower inner end is placed in the meatus, 
 while its outer and broader part lies on the auricle, so that its 
 opening is directed straight back against the concha. Politzer 
 
 FIG. 140. Method of Using the Audiphone. 
 
 states that the principle of his instrument is based on the physio- 
 logical fact that sound acting on the ear is heard more loudly 
 when the surface of the tragus is enlarged posteriorly by plac- 
 ing a small solid plate upon it. I have not yet seen any marked 
 benefit to the hearing from Politzer's instrument.
 
 INSTRUMENT FOR IMPROVING HEARING. 721 
 
 One of my patients, Rev. Richard Walsh, has lately invented 
 a hearing-tube, with a mouth-piece lined with cork, which seems 
 to have some advantages over the ordinary hearing-trumpets. 
 Cork is an excellent conductor of sound. Walsh's ear-trumpet 
 has been patented, and is now in the market. 
 
 I am not without hope, as I have already said in this work, 
 that we shall yet make an apparatus which will improve the 
 hearing of such persons as are deaf from disease of the middle 
 ear, and who hear well in a noise, as well as for those who are 
 presbykousic. Those deaf from disease of the nerve, must re- 
 main without aid, just as those who suffer from disease of the 
 optic nerve or retina cannot find lenses that will enable them to 
 see.
 
 DESCRIPTION OF THE CHROMO-LITHOGRAPHS. 
 
 FIG. 1. Normal membrana tympani. 
 
 It is impossible to exactly render the normal tint of this beautiful structure, 
 but this lithograph seems to me to approximate this to a very satisfactory 
 degree. 
 
 FIG. 2. 1 In this case, that of a man thirty-two years of age, a purulent in- 
 flammation of the middle ear had existed for nearly two years. There was a 
 perforation in front of the malleus, which finally healed under the application 
 of nitrate of silver, forming the cicatrix shown in the drawing, and also a small 
 circular opening through the "pars flaccida" the space within the opening, 
 and around the malleus-incus articulation being filled with small granulations. 
 After the closure of the lower perforation, these were treated by application of 
 saturated solution of arg. nit. on a cotton-tipped probe, with good result. The 
 outer layer of the membrana tympani, above and behind the processus brevis, 
 was much thickened and congested, and this condition (as shown in the draw- 
 ing) continued after the closure of the inferior perforation. This plate is of 
 value, as exhibiting a comparatively rare form and position of perforation of the 
 membrana tympani, and one not readily amenable to treatment. 
 
 FIG. 3 represents a small perforation, the consequence of purulent otitis 
 media, occurring in a boy twelve years of age, and of one year's duration. 
 There were no granulations at the time when the drawing was made, and the 
 perforation was in process of healing, as is shown by the congested blood-vessels 
 extending from the periphery toward the perforation. This drawing exhibits 
 the want of clearness of the outline of the malleus, as the result of thickening 
 of the outer layer of the membrana tympani, and also the prominence of the 
 processus brevis and of the posterior fold, in consequence of the concavity of 
 the membrana tympani. Through the perforation is seen the congested mucous 
 membrane of the middle ear. 
 
 FIG. 4. A case of purulent otitis media, in a boy twelve years of age. This 
 drawing represents faithfully the granulations occurring on the membrana tym- 
 
 1 The cases here described were treated by Drs. C. J. Blake and H. L. Shaw, of 
 Boston.
 
 DESCRIPTION OF CHEOMO-LITHOGRAPHS. 723 
 
 pani, and also the thickening of the membrana tympani, subsequent to the per- 
 foration, and during the continuance of the purulent inflammation. This case 
 was convalescent at the time the drawing was made, under the application of 
 astringents to the middle ear, and the granulations were rapidly diminishing 
 under the application of arg. nit. In this drawing, also, is shown the peculiar 
 arrangement of the blood-vessels passing from the superior wall of the meatus 
 into the membrana tympani, to assist in forming the manubrial plexus, and 
 which are congested in consequence of the diseased condition of the tympanum 
 and membrana tympani. 
 
 FIG. 5 represents a case of chronic catarrhal inflammation of the middle ear, 
 accompanied by great concavity of the membrana tympani. The processus bre- 
 vis is very prominent, and both anterior and posterior folds of the membrana 
 tympani are consequently elongated. The handle of the malleus is much fore- 
 shortened, and the lower end nearly in contact with the promontorium, as is 
 shown by the lighter color of the membrana tympani at this point, the light rays 
 being reflected directly from the white surface of the promontorium. The con- 
 cavity of the membrana tympani is further evidenced by the character of the 
 light reflection, which, instead of being a perfect cone, as represented in Fig. 1, 
 is represented by two small points of light, one close to the end of the malleus, 
 and one at the periphery ; the intermediate space representing a surface of such 
 degree of concavity that the light thrown upon it from the mirror is focussed at 
 a point within the meatus. 
 
 FIG. 6 is a type of cases of chronic catarrhal inflammation of the middle ear, 
 of long standing, in which the mucous coat of the membrana tympani has become 
 uniformly thickened, with but a slight degree of concavity of the membrana 
 tympani ; the latter condition in this case is principally evidenced by the prom- 
 inence of the manubrium and processus brevis, and of the posterior fold. The 
 same dull gray color is found, as a result of thickening of the mucous coat of 
 the membrana tympani, followed by acute inflammation of the middle ear. 
 
 This drawing exhibits also the appearance characteristic of, and the form 
 peculiar to, large calcareous deposits. The light reflex is wanting, in conse- 
 quence of the presence of the calcareous deposit at the point at which this ap- 
 pearance is found in the normal membrana tympani. 
 
 FIG. 7 represents a condition common to chronic catarrhal inflammation of 
 the middle ear. In this case the malleus is in contact with the promontorium, 
 and the continuance of the atmospheric pressure from without has carried the 
 membrana tympani inward, rendering the malleus exceedingly prominent. The 
 light color of the central portion of the membrana tympani is due to the reflec- 
 tion of light from the inner wall of the tympanum, and not to thickening of the 
 mucous coat. This condition is found where the trouble has been confined 
 principally to the mucous membrane of the Eustachian tube and anterior portion 
 of the tympanum, without the thickening of the inner coat of the membrana 
 tympani, which is shown in Figs. 5 and G. 
 
 FIG. 8 exhibits the result of purulent inflammation of the middle ear of 
 long standing, in a boy ten years of age. At the time of the drawing the dis-
 
 724 DESCRIPTION OF CHROMO-LITHOGEAPHS. 
 
 charge had ceased, under treatment with dry cotton packing applied daily, 
 and the mucous membrane was returning to a normal condition. There were 
 two large perforations, divided by a narrow bridge of thickened membrana tym- 
 pani. The short process of the malleus was very prominent, and the manubriuni 
 in contact with the promontory. The remainder of the membrana tympani was 
 much thickened. The slight congestion about the short process, and along the 
 manubrium, was due to the pressure of the cotton plug, as there was no evi- 
 dence of a process of repair about the edges of the perforation.
 
 N 2. 
 
 N9 3 
 
 N? 4. 
 
 N9 5. 
 
 N? 7.
 
 INDEX OF AUTHORS. 
 
 Achilini, 5 
 
 Agnew, 0. R., 104, 325, 456, 487, 489, 491, 
 
 492, 497, 506, 541 
 Agricola, Rudolphus, 21 
 Albini, O. S., 86 
 Albutt, 574 
 Alcmseon, 4 
 Allen, Peter, 36, 76 
 Ambrose, D. R,., 507, 667 
 Andrews, J. A., 574 
 Apollonius, 15 
 Archigenes, 16 
 Arcularius Johannes, 19 
 Aristotle, 4 
 
 Arnold, F., 11, 205, 234, 253 
 Asclepiades, 15 
 Aurelianus, 17 
 Ausspitz, 118 
 
 Baldwin, 647 
 
 Banze, Marcus, 22 
 
 Bartlett, 435 
 
 Beard, George M., 408, 483, 681, 706 
 
 Beck, Karl Joseph, 25, 28, 102 
 
 Benedetti, Alexander, 19 
 
 Berengario, 5 
 
 Berger, 27, 536 
 
 Bernard, Claude, 268 
 
 Berres, 9 
 
 Berthold, 460, 610 
 
 Billington, C. E., 304 
 
 Billroth, Theodor, 103, 475, 562 
 
 Bing, 58 
 
 Bishop, Edward, 403 
 
 Blake, Clarence J., 37, 57, 64, 102, 111, 
 
 144, 147, 181, 255, 256, 435, 480, 483, 
 
 484, 654, 688 
 Blau. 304, 305 
 Bochdalek, 9, 217 
 Bock, 11 
 Boerhaave, 88 
 Boke, 479 
 
 Bonnafont, 11, 37, 406, 423, 486, 585 
 Bottcher, 13, 610 
 Bowman, W., 602, 606 
 
 Boyer, 421 
 
 Bozzini, 66 
 
 Brandeis, 115 
 
 Brendel, 9 
 
 Bremer, V., 487 
 
 Breschet, 11, 599 
 
 Briddon, C. K, 326 
 
 Brodie, Sir Benjamin, 195 
 
 Broca, 563 
 
 Brown, F. T., 515 
 
 Brugsh, G., 4 
 
 Brunner, 235, 647, 656 
 
 Buchanan, Thomas, 11, 28, 177, 421 
 
 Buck, A. H., 18. 36, 46, 106, 136, 138, 156, 
 167, 190, 235, 256, 259, 273, 302, 303, 
 324, 359, 390, 420, 435, 455, 475, 497, 
 498, 506, 542, 560, 607, 656 
 
 Biickner, 124 
 
 Bull, Charles S., 148, 347 
 
 Bull, George J., 707 
 
 Bumsted, 106 
 
 Burkner, 213 
 
 Burnett, C. H., 36, 88, 106, 256, 338, 358, 
 390, 436, 584 
 
 Burnett, S. M., 150, 625 
 
 Busson, Julian, 26, 417 
 
 Butcher, William, 422 
 
 Buttles, M. S., 406 
 
 Cameron, 557 
 
 Camper, 10 
 
 Capivacci, 19 
 
 Cardan, Jerome, 21 
 
 Carpenter, 195 
 
 Carpenter, W. M., 326 
 
 Cassebolim, J. H., 9 
 
 Cassells, J. Patterson, 37, 390, 303 
 I Casserius. Julius, 7 
 ! Catlin, 396 
 
 Celsus, 15, 474 
 
 Cerlata, Peter de la, 18 
 
 Chassaignan, 562 
 
 Choyan, 563 
 
 Cheselden, Thomas. 416 
 
 Chimani. 105, 114, 483 
 
 Clarke, Edward H., 35, 194, 482
 
 726 
 
 INDEX OF AUTHOR* 
 
 Clarke, Lockart, 207, 209 
 
 Claudius, 13 
 
 Cleland, Archibald, 25, 70 
 
 Cloquet, 11 
 
 Clvmer, Meredith, 662 
 
 Cock, Thomas F., 334 
 
 Cocks, David C. , 495 
 
 Coggin, David, 58 
 
 Cohen, 68 
 
 Coles, 371 
 
 Columbo, 6 
 
 Conta, von, 51 
 
 Cooper, Sir Astley, 27, 37. 254, 416, 417, 
 
 418, 423, 436, 449, 543 
 Cornwall, 390 
 Corti, Marchese, 13, 609 
 Cos, 3 
 Cotugno, 9 
 Cousins, 127 
 Cox, 569 
 
 Crampton, Sir Philip, 548 
 Crosby, A. B., 541 
 Cruveilhier, 676 
 Cumberbatch, 679, 718 
 Curtis, John Henry, 28, 38, 421 
 Cutter, Ephraim, 394 
 Cuvier, 6 
 Czermak, 67, 370 
 
 D 
 
 Dalby, W. B., 35, 656 
 
 Dalton, 267 
 
 Darling, William, 196 
 
 Darwin, 88 
 
 Degravers, 417 
 
 Deiters, 13 
 
 Delafield, F., 156 
 
 Deleau, 28, 199, 422 
 
 Delechorriere, 301 
 
 De Vigo, 20 
 
 Dieffenbach, 538 
 
 Dienert, 417 
 
 Dioscorides, 17 
 
 Di Rossi, 35, 64, 707 
 
 Dominic, Cotugno, 9 
 
 Draper, 147 
 
 Duchenne, 86 
 
 Du Verney, 8, 22, 190, 449 
 
 E 
 
 Ebers, George, 3 
 
 Eisell, 235 
 
 Eli. 417 
 
 Elsberg, Louis, 69, 188, 385 
 
 Ely, E. T., 99, 162, 312, 317, 322, 369, 396, 
 
 456, 459, 485, 504, 524, 567, 636, 637 
 Ely, W. S., 131 
 Emerson, J. B. , 54, 156, 164, 361, 502, 622, 
 
 707 
 
 Empedocles, 4 
 Eno. Henry C., 470 
 Eraaistratus, 4 
 
 Erb. 680 
 
 Erhard, Julius, 34 
 
 Esser, 87 
 
 Eve, F. , 105 
 
 Eustachius, Bartolomrneus, 4, 6, 2o2 
 
 F 
 
 Fabricius of Aquapendente, 7 
 
 Fabricius of Hilden, 22, 205 
 
 Fallopius, Gabriel, 6, 19 
 
 Faruham, H. P., 401 
 
 Field, George P., 36, 349, 491 
 
 Fielitz, 357 
 
 Fischer, Alexander, 10 
 
 Fisher, Lewis, 313 
 
 Fisher, 502 
 
 Flint, Austin, Jr., 267 
 
 Follin, 541 
 
 Forest, Peter, 20 
 
 Fox, Cornelius B. , 207, 209 
 
 Francis, George E., 546 
 
 Frank, Martel, 31, 62, 104, 389, 420 
 
 Gadesden, 18 
 
 Galen, 4, 5, 15, 16, 501 
 
 Garrod, 121 
 
 Gerlach, 12, 224 
 
 Geynes. 5 
 
 Gibbs, 718 
 
 Goethe, 253 
 
 Goodwillie, 68 
 
 Gottstein, 305 
 
 Graefe, von, A., 643 
 
 Graham, 112 
 
 Green, John, 264, 437 
 
 Green, J. Orne, 18, 144, 151, 190, 208, 270, 
 374, 415, 431, 499, 546 
 
 Greenberger, 707, 717 
 
 Griesinger, 675 
 
 Gross, S. D., 167, 189 
 
 Gruber, Ignaz, 60 
 
 Gruber, Josef, 9. 34, 75, 83, 94, 128, 182, 
 207, 217, 261, 342, 374, 376, 391, 427, 
 429, 479, 548, 561, 585, 625. 629, 634 
 
 Gruening, E., 116, 121, 183, 486, 487 
 
 Gudden, 110 
 
 Guidi, 18 
 
 Gull, Sir William, 564 
 
 Guye, 406 
 
 Guyot, 25, 70 
 
 H 
 
 Hackley, Charles E., 261, 277, 299, 389, 
 
 403, 448, 483, 553 
 Haeckel, 88 
 Haller, 10 
 Hallier, 147 
 
 Hammond, W. A., 325, 641, 653 
 , Harlan, G. C., 656
 
 INDEX OF AUTHORS. 
 
 727 
 
 Harless, 87 
 
 Hartmann, J., 21, 37, 431, 468 
 
 Hassenstein, 147 
 
 Hecksher, 203 
 
 Heller, 650 
 
 Helmholtz, H., 62, 220, 234, 256, 429, 608, 
 
 624 
 
 Helmont, von, 22 
 Hendriksz, 422 
 Henle, J., 595, 598 
 Hensen, 87, 256, 257, 609 
 Heraclides, 15 
 Herodotus, 14 
 Herophilus, 4 
 Hessler, 562, 569, 570 
 Hewitt, Prescott, 570 
 Himly, Karl, 418, 421 
 Hinton, James, 13, 32, 36, 295, 348, 374, 
 
 415, 421, 433, 447, 448, 453, 455, 461, 
 
 540, 656, 675 
 
 Hippocrates, 4, 14, 15, 18, 23, 190 
 His, 370 
 
 Hoffman (of Westphalia), 33, 62 
 Hoffmann, Friederich, 24 
 Hogyes, 610 
 Holt, E. E., 76, 358 
 Home, Sir Everard, 10, 27, 177, 218, 418, 
 
 623 
 
 Horst, Gisbert, 20 
 Houghton, 382 
 Hubbard, Robert, 631 
 Hun, E. R., 107 
 Hunold, 421 
 Hunt, David, 102 
 Hunt, William, 102 
 Huschke, 11, 601 
 Hutcliinson, Jonathan, 571, 630 
 Hyrtl, Joseph, 9, 13, 84, 85, 94, 217, 428, 
 
 595, 607 
 
 Ingrassia, 6 
 Itard, 28, 421, 449 
 
 Jackson, Hughlings, 571, 676, 678 
 
 Jacobi, A., 304, 643 
 
 Jacobson, 11 
 
 Jacoby (of Berlin), 541 
 
 Jaeger, Edward, 62 
 
 Jasser, 536 
 
 Johannes, 11 
 
 Jones, Handfield, 200 
 
 Jones, H. Macnaughton, 36 
 
 Jones, T. Wharton, 11, 218, 594, 597 
 
 Joux, Amedee, 97 
 
 K 
 
 Kessel, Adolph, 475 
 
 Kessel, J., 177, 218, 222, 224, 236, 240, 256 
 
 Keyes, 636 
 
 Kinne, 189 
 
 Kipp, C. J., 105, 115, 435, 516, 573 
 
 Kirchner, 648 
 
 Knapp, H., 35, 114, 133, 151, 189, 390, 
 
 625, 650, 650, 663, 682 
 Koiter, Volcher, 7 
 Kolb, 499 
 Kolliker, 13, 602 
 Koeppe, 205 
 Koppe, 246, 541 
 Kramer, W., 28, 60, 151, 357, 364, 373, 403, 
 
 406, 423, 613, 706 
 Krause, 235 
 Kuchenmeister, 143 
 Kupper, 88, 205, 305 
 
 Lallemand, 565 
 
 Langenbeck, 190 
 
 Lavater, 97 
 
 Lebert, 565, 570 
 
 Lewis, F. N., 507 
 
 Lewis, W. B., 148 
 
 Liel, Weber, 35, 141, 198, 402, 414, 410, 
 
 427, 428, 439, 484, 571, 647 
 Lincke, 3, 4, 24, 37, 599 
 Listen, 410 
 Little, J. L., 655 
 Loomis, A. L., 326, 331 
 Loring, E. G., 64, 107, 272, 316, 389, 494, 
 
 501, 556, 627 
 
 Lowenburg, 140, 151, 194, 370, 456 
 Lucae, Augustus, 12, 13, 57, 257, 355, 432, 
 
 467, 650 
 Luschka, 649 
 Lusitanus, 21 
 Lussana, 610 
 
 M 
 
 Macewen, 566 
 
 Mach, 55, 87, 255, 256 
 
 Maclagan, 206 
 
 Magnus, 12, 264, 367, 437, 438 
 
 Marcellus, 17 
 
 Marinus, 4 
 
 Mathewson, A., 34, 299, 389, 435, 402, 437, 
 
 490, 495 
 Maunoir, 420 
 Mayer, Ludwig, 143, 178, 197, 203, 250, 
 
 252. 254, 346, 541 
 McKay, 557 
 McKeown, 435 
 Meckel, 10, 11 
 Meiiiere, 13, 276, 677 
 Merian, Burkhardt, 467, 499 
 Merkel, 253 
 Merrell, 316 
 Metcalfe, John T., 313 
 Meyer (of Hamburg), 111 
 Meyer, Wilhelm, 369, 371 
 Michael, 468 
 Michaelis, 420
 
 728 
 
 INDEX OF AUTHORS. 
 
 Millinger, 461 
 
 Miot, 37 
 
 Moldeiihauer, 190 
 
 Monro, Alexander, 10 
 
 Moos. S., 13, 34, 35, 222, 365, 374, 447, 486, 
 
 487, 499, 609, 625, 634, 649, 650, 656, 
 
 681 
 
 Morgagni, 8, 10, 538, 565 
 Morgan, Lewis H. , 397 
 Miiller, Johannes, 11, 354, 479 
 Munk, 610 
 Mussey, 105 
 
 Newbourg, 60 
 
 Newton, Homer G. , 34, 561 
 
 Niemeyer, 677 
 
 North, Alfred, 492 
 
 Noyes, H. D., 330, 373, 407, 426, 435 
 
 o 
 
 Ormerod, 678, 679 
 
 Pacini, 143 
 
 Pagenstecher, 540 
 
 Paget, Sir James, 544 
 
 Pappenheim, 234 
 
 Paracelsus, 19 
 
 Pardee, C. L, 390, 399, 463, 494 
 
 Pare, Ambrose, 20, 464 
 
 Patruban, 9, 216 
 
 Paul of ^Egina, 17, 190 
 
 Paullini, 23 
 
 Pechlin, 204 
 
 Peters, George A., 387, 555, 571 
 
 Petit, Antoine, 26 
 
 Petit, J. L., 24, 537 
 
 Petrequin, J. E., 176 
 
 Pierce, 175 
 
 Piffard, H. G., 389 
 
 Pilcher, George, 30, 200 
 
 Pinkney. Howard, 438 
 
 Pissot, 301 
 
 Pliny, 4, 17, 474 
 
 Plutarch, 4 
 
 Politzer. Adam, 9, 13,- 33, 34, 37, 45, 55, 
 56, 57, 74, 105, 139, 167, 189, 204, 214, 
 217, 219, 221, 235, 237, 256, 257, 260, 
 306, 309, 343, 355, 363, 390, 415, 416, 
 432, 435, 453, 458, 467, 483, 610, 720 
 
 Pollak, 214, 552 
 
 Pomeroy, O. D., 37, 106, 114, 167, 300, 
 347, 389, 393, 415, 481, 547 
 
 Pooley, T. R., 115 
 
 Portal, 417 
 
 Post, Alfred C., 499, 501, 539, 561 
 
 Prescott, Royal, 312 
 
 Pritchard, U., 457. 679 
 
 Prout, J. S., 48, 406, 432, 462 
 
 Prussak, 222 
 Pythagoras, 4 
 
 Quain, 207 
 
 Ramsdell, E. B., 587 
 
 Ranke, 609 
 
 Rankin, F. H., 157, 401, 455 ' 
 
 Ranney, A. L., 560, 608 
 
 Rau, 30, 358,423 
 
 Reid, James, 410 
 
 Reiner, 37 
 
 Reynolds, Russel, 679 
 
 Rhazes, 18 
 
 Riber, 420 
 
 Rice, Clarence C., 397 
 
 Rider, 456 
 
 Richeraud, 436 
 
 Ringer, S., 139 
 
 Rinne, 88 
 
 Riolanus, 416, 537 
 
 Rivinus, 8 
 
 Robertson, Charles A., 479, 484 
 
 Robinson, Beverley, 371, 390 
 
 Rockwell, A. D., 408, 681 
 
 Rohland, 288 
 
 Riidinger, 34, 234, 247, 250, 254 
 
 Rufus (of Ephesus), 4 
 
 Rumbold, 390 
 
 Rushmore, 274, 420 
 
 Russell, 209 
 
 Ruysch, 9 
 
 Sabatier, 417 
 
 Saissy, J. A. , 28, 422, 436 
 
 Sands, H. B., 326 
 
 Sappey, 90, 92, 207 
 
 Sassonia, Hercules, 20 
 
 Saunders, J. C., 10, 27, 37, 421 
 
 Savage, 410 
 
 Scarpa. Antonio, 10 
 
 Schalle, 204 
 
 Schaar, 57 
 
 Scheibenzuber, 182 
 
 Schlemm, 11 
 
 Schmiedekam, 261 
 
 Schmiedel, 9 
 
 Schneider, 87 
 
 Schultze, Max, 599 
 
 Schwartze, Herman. 13, 27, 34, 56, 103, 
 143, 190, 205, 288, 300, 346, 374, 378, 
 416, 417, 420, 421, 422, 424, 453, 460, 
 483, 497, 506, 541, 542, 629, 676 
 
 Seebeck, 255 
 ! Seligman, Professor, 487 
 ; Semeleder, 67, 370
 
 INDEX OF AUTHORS. 
 
 729 
 
 Sequard, Brown, 111 
 
 Serapion, 18 
 
 Sexton, Samuel, 89, 320, 555, 560, 682 
 
 Shaw, Henry L., 270, 390, 551 
 
 Shrapnell, 11, 216, 265 
 
 Simrock, 277 
 
 Sirns, J. Marion, 196 
 
 Smith, Andrew H., 262, 437 
 
 Smith, Gouverneur M. , 301 
 
 Smith, J. Lewis, 651 
 
 Smith, Nathan R. , 422 
 
 Smith, Thomas, 106 
 
 Soemmeriug, Thomas George, 11, 234 
 
 Speir, E. D., 196 
 
 Spencer, W. D., 313 
 
 Steinbrugge, 13, 609 
 
 Stenon, Nicholaus, 8 
 
 Sterling, George A., 566 
 
 Steudener, F., 148 
 
 Stevenson, 421 
 
 Strawbridge, 542 
 
 Sutton, 564 
 
 Swieten, Van, 25 
 
 Swift, Foster, 381, 571 
 
 T 
 
 Tagliacottzi, Caspar, 21 
 
 Tait, Lawson, 718 
 
 Tangeman, 460 
 
 Tansley, J. O., 75, 337 
 
 Taylor, R. W., 106 
 
 Taylor, Fayette C., 128 
 
 Teole, 10 
 
 Teulon, Giraud, 64 
 
 Theobald, S., 349, 381, 435, 542, 560 
 
 Thudichum, 385 
 
 Thurman, 110 
 
 Tod, David, 10 
 
 Todd, Robert B., 302, 606 
 
 Tortual, 253 
 
 Toynbee, Joseph, 11, 12, 13, 32, 33, 60, 74, 
 110, 162, 205, 254, 257, 266, 364, 374, 
 375, 381, 423, 465, 488, 489, 539, 551, 
 568, 656, 706 
 
 TrSltsch, Anton von, 12, 13, 18, 23, 32, 34, 
 47, 60, 61, 96, 128, 169, 181, 190, 204, 
 207, 222, 223, 235, 236, 237, 250, 254, 
 266, 276, 287, 330, 339, 342, 346, 357, 
 364, 365, 374, 385, 403, 413, 423, 455, 
 466, 490, 537, 539, 607, 613, 650, 676, 
 688 
 
 Tiirck, 66, 370 
 
 Turnbull, Lawrence, 35, 408, 540 
 
 Turner, 487 
 
 t 
 
 Dibantschitsch, 37, 204, 408 
 
 Valleroux, Hubert, 422 
 
 Valsalva, Autoine Maria, 2, 8, 9, 12, 24, 
 
 77, 253, 537 
 Van der Hoeven, 10 
 Varolius, Constant, 7 
 Velpeau, 243 
 
 Vesalius, Constant, 5, 6, 7 
 Vieussens, Raymond, 8 
 Virchow, Rudolph, 109, 476, 489 
 Virsinier, 647 
 Vogel, I., 143 
 Voltolini, Rudolph, 13, 34, 67, 185, 220, 
 
 235, 370, 374, 427, 432, 549, 629, 649, 
 
 663, 688 
 
 W 
 
 Wakely, T., 166 
 
 Waldeyer, 604 
 
 Wallis, John, 23 
 
 Walther, 9 
 
 Watham. Jonathan, 26 
 
 Weber, C. O., 484 
 
 Weber, E. H. (Leipsic), 11, 55, 384 
 
 Weber, Theodore, 384 
 
 Webster, David, 174, 367, 502 
 
 Weir. Robert F., 69, 94, 156, 265, 276, 303, 
 
 328, 407 
 Welch, 156, 317 
 Welcker, H., 487 
 Wendt, 235, 304 
 Wilde, Sir William, 2, 31, 38, 60, 66, 110, 
 
 166, 181, 206, 287, 340, 357, 364, 374, 
 
 381, 417, 422, 447, 449, 479, 500, 538, 
 
 561, 613 
 
 Williams, Joseph, 30 
 Williams, A. D., 35, 132 
 Willis, Thomas, 22, 356 
 Wilson, F. M., 92, 189 
 Winslow, 10 
 
 Woakes, 36, 208, 440, 584 
 Wood, John, 181, 207 
 Wollaston, 254, 622 
 Wreden, Robert, 143, 147, 151, 180, 304, 
 
 402, 427, 574 
 Wrieht, C. E., 347 
 Wyman, 488 
 
 Yale, L. M., 645 
 Yearsley, James, 30, 465 
 
 Zaufal, 68 
 Ziemssen, 86 
 Zinn, 9 
 
 Zoja. Giovanni. 243 
 Zuckerkandl, E., 240
 
 INDEX OF SUBJECTS. 
 
 A BSCESS of cerebrum, 474, 563, 566 
 J\. of mastoid, 505 
 
 of membrana tjmpani, 308 
 of neck, 524 
 Acoumeter, 45 
 Acoustic nerve, 4 
 
 Actual cautery in uon suppurative inflam- 
 mation, 427 
 
 Adenoid vegetations in pharynx, 370 
 Adhesions in middle ear, 474 
 Aerial conduction of tuning-fork, 54, 353, 
 
 621 
 Air, atmospheric, through catheter, 73, 
 
 399 
 
 Air-bubbles in chronic catarrhal inflam- 
 mation, 344 
 in perforation of the membrana tym- 
 
 pani, 445 
 
 Air, condensed, effect of, 263, 437 
 Air, exhaustion of, from external auditory 
 
 canal, 437 
 Alchohol in suppuration of middle ear, 
 
 456, 458, 481 
 Albuminuria from chronic suppuration of 
 
 middle ear, 448 
 Alum powder in chronic suppuration of 
 
 middle ear, 456 
 
 American Otological Society, 34 
 Anatomy of ear, progress in. 4 
 Anchylosis of malleus and incus, 4, 375 
 
 of stapes, 375 
 Aneurism, 673 
 Angiomata, 105, 476 
 
 cases of, 121 
 
 Angioma cavernosum. 476 
 Anodynes, 130, 138, 290, 320, 585 
 Anterior rhinoscopy, 68 
 Anti-helix, 82 
 
 Antiphlogistic treatment, 323 
 Anti-tragus, 4, 82 
 
 muscles, 84 
 
 Antrum mastoideum, 239 
 Annulus tympanicus, 92, 222 
 Aquseductus Fallopii, 6, 230 
 Artificial membrana tympani, 30, 465 
 Aspergillus, 
 
 cases of, 142, 151-154 
 
 Aspergillus, 
 
 causes of, 145 
 
 symptoms of, 146 
 
 statistics of, 445 
 
 treatment of, 150 
 
 varieties of, 146 
 Astringents, 
 
 in acute suppuration of middle ear, 
 320 
 
 in chronic inflammation of external 
 canal, 136 
 
 in chronic suppuration of middle ear, 
 456 
 
 in eczema, 120 
 
 Atropia in diffuse inflammation of audi- 
 tory canal, 133 
 Attollens auriculam, 83 
 Attrahens auriculam, 83 
 Audiphone, 720 
 Auditory canal, external, 
 
 abscess of, cases of, 169 
 
 affections of, 123 
 
 anatomy of, 90 
 
 angles formed with membrana tym- 
 pani, 92 
 
 blood-vessels of, 96 
 
 caries of bones of, 156 
 
 cast of, 92 
 
 chronic inflammation of, 136 
 
 chronic suppuration of, 1 37 
 
 circumscribed inflammation of, 137 
 
 closure of, 18, 155 
 
 condylomata of, 154 
 
 curvatures of, 91 
 
 desquamative inflammation of, 137 
 
 diffuse inflammation of, 124 
 anodynes used in, 131 
 cases of, extending to tympanum, 
 
 335 
 
 causes of, 126, 311 
 incisions in, 136 
 objective symptoms of, 125 
 popular remedies for, 131 
 resume of treatment for, 132 
 subjective symptoms of, 124 
 treatment for, 128 
 
 diphtheritic inflammation of, 155
 
 732 
 
 INDEX OF SUBJECTS. 
 
 Auditory canal, external, 
 eczema of, 117 
 examination of, 59-64 
 foreign bodies in, 179 
 furuncles of, 137 
 
 causes of, 137, 140 
 
 treatment of, 138 
 inspissated cerumen in, 158 
 length of, 92 
 lining of, 93 
 
 lower animals, comparison of, 94 
 narrowing of, 155 
 nerves of, 96, 207 
 ossification of, 94 
 of dogs and cats, 94 
 parasitic inflammation of, 143 
 
 cases of, 144 
 
 causes of, 145 
 
 symptoms of, 146 
 physiology of, 96 
 polypi in, 126, 489 
 relations of, 95 
 sarcoma of, 156 
 statistics of affections of, 125 
 suppuration of, 137 
 
 cases of, with inspissated cerumen, 
 
 174 
 
 syphilitic ulcers of, 154 
 nlceration of, 136 
 Auditory canal, internal, 4, 606 
 Auditory nerve, 
 
 atrophy of, 617 
 
 cases of, 617-619 
 concussion of, cases of, 673 
 distribution of, 10, 603 
 disease of, from cerebro-spinal menin- 
 gitis, 649 
 
 cases of, 651 
 inflammation of, 617 
 inflammation of, from meningitis, 652 
 
 cases of, 652 
 origin of, 604 
 . primary disease of, 614 
 
 cases of, 617-619 
 treatment of diseases of, 620 
 Aural clinics, 37 
 
 Aural disease, extending from the pha- 
 rynx, 38, 65 
 
 in constitutional disease, 310, 331 
 first successful system of treating, 32 
 hallucinations in, 346 
 hemorrhage in Bright's disease, cases 
 
 of, 300 
 Aural douche, 14, 128, 319 
 
 syringe, 133 
 Auricle, 
 
 absence of, in mammalia living in 
 
 water, 84 
 anatomy of, 81 
 aneurism of, 105 
 angiomata of, 105 
 
 cases of, 121 
 
 Auricle, 
 
 arrested development of, 101 
 
 artificial, 719 
 
 blood-vessels of, 86 
 
 calcareous formations in, 121 
 
 chondritis of, 113 
 treatment of, 116 
 
 deformity of, 101 
 cases of, 102 
 
 detachment of, for removal of foreign 
 
 body, 190 
 cases of, 191 
 
 ear-rings causing tumors of, 103 
 
 eczema of, 117 
 
 epithelioma of, 116 
 
 erysipelas of, 120 
 
 fibro cartilaginous tumors of, 103 
 
 fistula of, 102 
 
 horny growths of, 106 
 
 indicative character of, 97 
 
 inflammation of, from wearing ear- 
 rings, 83 
 
 injuries of, 121 
 
 intrinsic muscles of, 84 
 
 malformation of, 98 
 
 movements of, 86 
 
 muscles of, 83 
 
 mutilation of, supposed by ancients a 
 cause of sterility, 22 
 
 myxo-fibromata of, 104 
 
 nerves of, 87 
 
 operation for fibro cartilaginous tu- 
 mors of, 104 
 
 othsematomata of, 107 
 
 perichondritis of, 113 
 treatment of, 116 
 
 physiology of, 87 
 
 plastic operation on, 99 
 
 prominence "of, 98 
 operation for, 99 
 
 sarcoma of, 117 
 
 sebaceous tumors of, 104 
 
 superfluous, 101 
 
 syphilis of, 106 
 
 tumors of, 103 
 
 vascular tumors of, 107 
 Aurilave, 127, 165 
 
 Authorities consulted in historical sketch, 
 39 
 
 "DINOCULAR otoscope, 64 
 
 _D Bleeding from the ears in fracture of 
 temporal bone, 272 
 
 Blisters in acute suppuration of middle 
 
 ear, 320 
 
 in auditory disease, 132 
 in disease of internal ear, 681 
 in non suppurative inflammations, 382 
 
 Blood-letting, local, 128, 287, 302, 319, 
 381, 499, 681 
 
 Boiler-makers' deafness, 360, 666 
 cases of, 669-672
 
 INDEX OF SUBJECTS. 
 
 733 
 
 Boiler-makers' deafness, 
 
 causes of, 667 
 
 complicated with, aural catarrh, 667 
 
 pathology, 668 
 
 resume of knowledge of, 673 
 
 treatment of, 680 
 
 tuning-fork test in, 668, 670 
 Bone conduction in aural disease, 54, 353, 
 
 622 
 
 Bony growths, 485 
 Boracic acid, 456 
 Bougies, danger of use of, 77, 405 
 Bright's disease, 
 
 cases of cerebral hemorrhage in, 300 
 
 /CALCAREOUS formation in auricle, 121 
 \J in membraua tympani, 365 
 Canal, external auditory, 90 
 
 diseases of, 123 
 Canal, internal auditory, 4, 606 
 
 growths in, 680 
 Canalis reunicus, 600 
 Carcinoma in the tympanum, 479 
 Caries of auditory canal, 1 56 
 
 mastoid, 500, 505 
 
 petrous bone, 557 
 
 teeth, 584 
 
 temporal bone, 24, 545 
 
 treatment of, 559 
 
 tympanic process, 156 
 Catarrh of middle ear, acute, 278 
 
 chronic, 343 
 
 sub-acute, 293 
 
 Cats, congenital deafness of, 718 
 Cauterization of the pharynx, 383 
 
 of polypi, 456 
 Caustics, 458, 481 
 Cerebral abscess, 455, 563 
 
 cases of, tabulated, 576-582 
 Cerebral symptoms, from inspissated ceru- 
 men, 175 
 
 cases of, 169 
 Cerebral tumors, 673 
 Cerebro-spinal meningitis, causing 
 
 acute catarrh of middle ear, 285 
 
 acute suppuration of middle ear, 310 
 
 deaf-muteism, 306, 710 
 
 disease of acoustic nerve, 649 
 
 proliferous inflammation of middle 
 
 ear, 378 
 Cerumen, 
 
 absence of, 163 
 
 composition of, 176 
 
 function of, 176 
 
 increased formation of, in disease, 160 
 
 inspissated, 158 
 cases of, 168-175 
 
 removal of, 166 
 Ceruminous glands, 93 
 Chloroform, use of, 406 
 Cholesteatoma, 475, 479 
 
 Chorda tympani nerve, 217, 226, 238 
 
 section of, 435 
 
 injury of, 266 
 Chromic acid, 482 
 Chromo- lithographs, 722 
 Cicatricial membrana tympani, 463, 474 
 Circumscribed inflammation of external 
 
 ear, 123, 137 
 
 Climate in aural disease, 441 
 Cleansing the ears, method of, 134, 451 
 Cochlea, 8, 9, 10 
 
 anatomy of, 595 
 
 disease of, 614 
 treatment of, 680 
 
 physiology of, 608 
 
 syphilis of, 630 
 Cochlear nerve, 605 
 Cochlitis, 620 
 
 cases of, 634 
 
 Cold in the head, neglect of, 297 
 Concha, 82 
 Concussion of labyrinth, 666 
 
 cases of, 669, 673 
 Concave mirror, 63 
 Condensed air, 263, 437 
 Condylomata, 154 
 
 Congenital deafness of white cats, 719 
 Constitutional disease in aural disease, 15, 
 
 310, 331 
 
 Conversation, test for hearing, 45 
 Corti's organ, 602 
 Corti's rods, 13, 602 
 Cotton as artificial membrana tympani, 4G5 
 
 as a cleansing agent, 454 
 
 plugging the ears with, in sea-bathing, 
 127 
 
 styptic, 288, 482 
 Crista acustica, 599 
 Cupping external auditory canal, 437 
 
 D 
 
 EAF-MUTEISM, 685 
 cases of, tabulated, 690-705 
 cases in which words could be heard 
 
 through speaking-tube, tabulated, 
 
 716 
 
 causes of, 687, 706 
 caused by cerebro spinal meningitis, 
 710 
 
 cholera infantum, 715 
 
 convulsions, 713 
 
 fall, 712 
 
 fever, 716 
 
 gastric fever, 715 
 
 hydrocephalus, 713 
 
 intermittent fever, 715 
 
 measles, 709 
 
 mumps, 716 
 
 pneumonia, 714 
 
 scarlet fever, 709 
 
 spinal meningitis, 714 
 
 syphilis, 713 
 
 varioloid, 714
 
 734 
 
 INDEX OF SUBJECTS. 
 
 Deaf-muteism, 
 
 caused by whooping cough, 715 
 
 congenital, 711 
 
 education of, 20, 23 
 
 examination of, with tuning-fork, 708 
 
 forms of, 685 
 
 treatment of, 689 
 Deafness, absolute, 620 
 
 not observed on account of occupa- 
 tion, 342 
 
 supposed incurable, 14, 18, 19 
 work of the devil, 22 
 
 to certain tones, 624 
 Delstanche's masseur, 439 
 Dentition, 282, 584 
 Detachment of auricle, 18, 190 
 
 cases of, 191 
 
 Determination of direction of sound, 611 
 Diagnosis, differential, of middle and in- 
 ternal ear, 352 
 
 tube, 73, 373 
 Diffuse inflammation of external auditory 
 
 canal, 124 
 Diphtheritic panotitis, 305 
 
 inflammation of middle ear, 303 
 Diplakousis, 625 
 Disease of brain from aural disease, 20, 
 
 200, 273, 312, 445, 495, 575 
 Disease of middle ear and labyrinth, 621 
 Disproportion in hearing the tick of a 
 
 watcli and human voice, 49, 615 
 Dobell's solution, 393 
 Double hearing, 625 
 Douche, aural, 128, 319 
 
 nasal, 309, 384 
 Dropsy of middle ear, 338 
 Ductus cochlearis, 600 
 
 EAR-ACHE, ancient treatment of, 14-17 
 I Ear-cough, 204 
 Ear-drops, 23 
 
 Ear-disease, neglect of, 291, 341 
 Ear muffs, 127 
 Ear-protectors, 127 
 Ear-rings, tumors from use of, 104 
 Ear-sand, 599 
 Ear-spoon, 15 
 Eczema of auricle, 117 
 
 of auditory canal, 117 , 
 
 statistics of, 445 
 Electric light, use of, 63 
 Electricity in diagnosis, 630 
 
 in non-suppurative inflammation of 
 middle ear, 408 
 
 in disease of labyrinth, 681 
 Eminentia stapedii, 236 
 Emphysema from catheterization, 409 
 Endolymph, 599 
 
 Entotic application of hearing-trumpet, 58 
 Epilepsy from aural disease, 178, 205, 679 
 
 cases of. 205 
 
 Epithelioma of auricle, 116 
 of middle ear, 475, 479 
 Erysipelas in aural disease, 546 
 
 of auricle, 120 
 Eustachian catheter, 69 
 
 cause of coming into disrepute, 26 
 danger in using, 408 
 difficulty in introducing, 72, 373 
 discovery of, 25 
 
 in chronic non - suppurative inflam- 
 mation, 372 
 introduction of astringents through, 
 
 401 
 
 method of using, 70 
 Eustachian tube, 
 anatomy of, 244 
 blood-vessels of, 77, 252 
 bougies for dilating, 405 
 broken catheter in, 204 
 changes in, 369 
 closure of, 24, 372 
 
 diagnostic tube in examination of, 73 
 escape of pus through, 310 
 examination of, 69 
 
 with bougies, 77 
 
 catheter, 69 
 
 Politzer's inflation, 74 
 
 Valsalva's inflation, 77 
 
 probes, 25 
 
 rhinoscopy, 67 
 first description of, 6 
 first catheterization of, 25 
 foreign bodies in, 180, 203 
 
 case of, 203 
 function of. 247, 257 
 history of discovery of, 6, 252 
 inflation of tympanum through, 73 
 in infants, 247 
 injections of, 25, 39 
 means of examination of, 69 
 measurements of, 244 
 muscles of, 249 
 naming of, 7 
 nebulizer for, 404 
 nerves of. 252 
 
 opened by act of swallowing, 74 
 shape of, 28 
 smoking through, 416 
 spraying through, 403 
 treatment of, in aural disease, 398 
 vapors in treating, 28, 399 
 Examination of 
 
 auditory canal, 59 
 membrana tympani, 60 
 patients, 44 
 
 the ear by sunlight. 29, 63 
 Exhaustion of air in auditory canal, 437 
 Exostosis, 164, 447, 485 
 cases of, 491-495 
 causes of, 488 
 inflammatory, 488 
 in skulls of Indians, 487
 
 INDEX OF SUBJECTS. 
 
 735 
 
 Exostosis, 
 
 treatment of, 490 
 
 External auditory canal, 
 anatomy of, 90 
 diseases of, 123 
 
 External ear, 79 
 
 Eyelet, Politzer's, 426 
 
 FACIAL paralysis, 199, 446, 571 
 Facial nerve, 6, 231 
 Fainting from syringing, 452 
 Faucial catheter, 394 
 Febrile symptoms in acute aural catarrh, 
 
 284 
 Fenestra ovalis, 6, 8, 229 
 
 rotunda, 10, 229 
 Fibromata, 475 
 Fistula of auricle, 102 
 
 mastoid, 523 
 
 Fluids through Eustachian catheter, 401 
 Fluid treatment of chronic suppuration of 
 
 middle ear, 456 
 Foramen of Rivinius, 9, 218 
 Forceps, angular, 59 
 Foreign bodies in the ear, 179 
 case of, 196 
 
 causing cerebral symptoms, 199 
 epilepsy, 199, 205 
 facial paralysis, 199 
 hemiplegia, 200 
 inspissated cerumen, 164 
 polypi, 200 
 danger of indiscreet treatment, 185, 
 
 193, 200 
 
 death resulting from removal of, 200 
 detachment of auricle for, 193 
 
 cases of, 191, 193 
 diagnosis of. 203 
 different kinds of, 180, 198 
 hairs of canal on membrana tympani, 
 
 202 
 
 inanimate, 183 
 molten lead, 200 
 reflex symptoms from. 204 
 removal of, 16, 22, 186, 194, 198 
 statistics of, 179, 197 
 supposed, 185, 201 
 
 Toynbee's artificial membrana tym- 
 pani as, 189 
 
 treatment, 184, 186, 202 
 Forehead band, 63 
 Forficula auricularis, 181 
 Fossa navicularis, 82 
 sigmoidea, 239 
 triangularis, 82 
 Fracture of handle of malleus, 276 
 
 temporal bone, 272 
 
 French chalk in chronic suppuration, 455 
 Fungus in solutions, 459 
 Furuncles in auditory canal, 137 
 Fused nitrate of silver, 461 
 
 nALVANISM in disease of labyrinth, 
 
 VJ 681 
 
 Galvano-cautery, 483 
 
 Gargles, 393 
 
 Gargling, Von Troltsch's method of, 393 
 
 General treatment of aural disease, 290 
 
 Glands, ceruminous, 8, 93 
 
 Glycerine, 166 
 
 Granulations, 458, 482 
 
 Graphium pencilloides, 146 
 
 Gummata, 680 
 
 TJ ABENULA tectu, 602 
 JiL Haematoma, 107 
 Hairs on membrana tympani, 202 
 Hallucinations, 178, 346 
 Harmonium test for hearing, 58 
 Hearing better in a noise, 22, 355, 363, 
 625 
 
 cases of, 356. 359, 362 
 
 double, 625 
 
 echo, 628 
 
 tests of, 45 
 
 trumpet for, 719 
 
 not lost by absence of membrana tym- 
 pani, 24, 450 
 
 disproportion of watch and voice test, 
 
 49, 615 
 Helicis major muscle, 84 
 
 minor muscle, 84 
 Helicotrema, 9, 597 
 Helix, 4, 81 
 Hemorrhage in auditory canal, 273 
 
 in caries of temporal bone, 562 
 
 in internal ear, 666 
 Hemorrhagic inflammation of middle ear, 
 
 297 
 
 Hot water as a styptic, 484 
 Hydro-tympanum, 337 
 Hygiene in aural disease, 382, 412, 440 
 Hyperostosis, 164, 485 
 
 TLLUMINATIOX of the ear, 61, G3 
 
 J_ Incisurse majoris articula3 Santorini, 
 
 85, 91 
 
 1 Incus, 232 
 : Infirmary for treatment of ear diseases, 
 
 28 
 
 Inflation of middle ear, 
 effect of, 74 
 in children, 74 
 
 in diseases of internal ear, 616 
 Politzer's method, 33. 74 
 modifications of, 75, 76 
 Valsalva's method, 77 
 with catheter, 73 
 Insanity, vascular tumors in, 107 
 Insects in the ear, 181 
 Inspissated cerumen, 
 cases of, 168-175 
 causes of, 163 
 diagnosis of, obsciired, 160
 
 736 
 
 INDEX OF SUBJECTS. 
 
 Inspissated cerumen, 
 
 frequency of occurrence, 158 
 
 mental depressions from, 100, 178 
 
 pain caused by, 161 
 
 proper classification of, 159 
 
 statistics of, 158, 176 
 
 structure of, 174 
 
 suppuration with, 162 
 
 symptoms of, 160 
 
 symptom or result of disease, 158 
 
 treatment of, 166 
 ancient, 21 
 
 tuning-fork test in, 161 
 Inspissated mucus, 483 
 Internal auditory canal, 606 
 Internal ear, 591 
 
 anatomy of, 591 
 
 blood-vessels of, 607 
 
 diagnosis of diseases of, by electricity, 
 630 
 
 disease of, from spinal cord and me- 
 dulla disease, typhoid fever and 
 scarlet fever, 654 
 
 disease of, from parotitis, 655 
 
 diseases of, 612 
 pathology of, 679 
 
 hemorrhage into, 664 
 
 inflammation of, 662 
 
 injuries of, 665 
 
 necrosis of, 548 
 
 physiology of, 607 
 
 symptoms of primary disease of, 614 
 
 syphilis of, 630 
 
 treatment of diseases of, 680 
 Intra-auricular pressure, 13 
 Iodine vapor, 399 
 lodoform, 456, 483 
 Iter chordae anterius, 228 
 
 posterius, 228 
 
 TACOBSON'S nerve, 9 
 U Jugular vein, 451 
 
 T7ONIANTRON, 440 
 
 T ABYRINTH, 
 Jj acute inflammation of, 662 
 anatomy of, 591 
 anaemia of, 684 
 concussion of, 666 
 differential diagnosis of diseases of, 
 
 621 
 
 effects of quinine on, 641 
 effusion into. 664 
 
 case of, 665 
 first mentioned, 5 
 fluid of, 9 
 
 hemorrhage into, 664 
 injuries of, 665 
 
 cases of, 665 
 leeches in disease of, 681 
 
 Labyrinth, 
 
 membranous, 598 
 
 pathology of disease of, 679 
 
 periosteum of, 598 
 
 sounds painful in disease of, 628 
 
 symptoms of primary disease of, 6C9 
 
 syphilis of, 630 
 cases of, 631 
 
 tonics in disease of, 681 
 
 treatment of disease of, 680 
 Lamina spiralis ossea, 597 
 Lamps for aural work, 63 
 Larvae in the ear, 181 
 Lateral sinus, pus in, 558 
 Laxator tynapaui muscle, 7 
 Leeches in, 
 
 acute catarrh of middle ear, 287 
 
 acute suppuration of middle ear, 319 
 
 circumscribed inflammation of audi- 
 tory canal, 138 
 
 diffuse inflammation of auditory 
 canal, 128 
 
 disease of labyrinth, 681 
 
 mastoid periostitis, 499 
 Levator auriculum, 83 
 Levator veli palati, 251 
 Ligamentum incudis superius, 234 
 
 mallei anterius, 234 
 
 mallei superius, 234 
 
 obturatorium stapedis, 234 
 
 spirale, 602 
 Light spot, 
 
 cause of, 218 
 
 in non-suppurative inflammation, 8G6 
 
 measurements of, 219 
 
 modifications of, 220 
 
 normal, 365 
 Lobe, 83 
 
 Local antiphlogistic treatment. 323 
 Lung disease in ear troubles, 377 
 
 MACULA acustica, 599 
 Maculae cribrosae, 592 
 Malaria a cause of aural neuralgia, 585 
 Malformation of auricle, 97 
 Malignant growths, 116, 479, 680 
 Malingering, 58 
 Malleo-incus joint, 234 
 Malleus, 5, 232 
 
 fracture of, 276 
 handle of, 218 
 Manubrium, 232 
 Mastoid, 
 
 abscess of, 496, 505, 521 
 anatomy of, 238 
 blood-vessels of, 243 
 cells of, 239 
 caries of, 505 
 cases of, 509-525 
 first operation for, 25 
 treatment of, 506 
 development of, 243
 
 INDEX OF SUBJECTS. 
 
 737 
 
 Mastoid, 
 
 enlargement of glands of, 501 
 
 hyperostosis of, 497 
 
 indications for trephining, 443 
 
 in acute suppuration, 811 
 
 lining of cells, 240 
 
 oedema of, 499 
 
 periostitis of, 496 
 cases of, 502 
 dangers of, 498 
 treatment of, 499 
 
 sclerosis of, 497 
 
 septicaemia and pyaemia following 
 disease of, 544 
 
 statistics of cases of disease of, 508, 
 527-535 
 
 trephining, history of, 536 
 
 varieties of, 241 
 
 Wilde's incision, 500 
 Meatus auditorius externus, 82 
 
 interims, 5 
 Mechanical apparatus for assisting hearing, 
 
 719 
 
 Membrana basilaris, 601 
 Membrana flaccida. 11, 216 
 Membrana tympani, 
 
 abscess of, 309 
 
 artificial, 22, 30, 465 
 
 attachment of malleus to, 222 
 
 bulging of, 283 
 
 calcareous degeneration of, 365 
 
 case of direct violence to, 272 
 
 changes in mobility in non-suppura- 
 tive inflammation, 367 
 
 color of, 219 
 
 condition in acute catarrh, 282 
 
 cyst of, 259 
 
 diameters of. 214 
 
 diseases of, 259 
 
 effect of inflation on, 74 
 
 examination of, 59 
 on cadaver, 261 
 
 first described, 4 
 
 function of, 254 
 
 Hinton's operation on, 434 
 
 inclination of, 213 
 
 inflammation of, 335 
 
 injuries of, 259, 265-275 
 case of, 269 
 
 layers of, 221 
 
 light spot of, 218, 365 
 
 loss of, not a cause of total deafness, 
 22, 417 
 
 lymphatic vessels of, 226 
 
 measurements of, 213 
 
 minute anatomy of, 221 
 
 nerves of, 224 
 
 normal, 218 
 
 objects for observation on, 218 
 
 openings in, 8, 216 
 
 ossification of, 366 
 
 paracentesis of, 27, 288, 431 
 
 Membrana tympani, 
 
 perforation of, 30, 309, 415, 445 
 
 pigmentation of, 366 
 
 position of, 213 
 
 Front's operation on, 433 
 
 pulsation of, 283 
 
 resisting power of, 262, 265 
 
 rupture of, 260, 266, 272 
 cases of, 262 
 
 scarification of, 288 
 
 secundarius, 229 
 
 shape of, 215 
 
 structure of, 11, 213 
 
 sunken, 365 
 
 thickness of 221 
 
 vascular tumor of, 302 
 Membrana reticularis, 604 
 
 vestibularis, 602 
 Membranous labyrinth, 598 
 Meniere's disease, 345, 633 
 Meningitis, cases of, from inflammation 
 
 of ear, 312, 316 
 
 Mental depression from inspissated ceru- 
 men, case of, 162 
 Microtia, 100 
 Microzotes, 141 
 Middle ear, acute catarrh of, 278 
 
 bulging of membrana tympani in, 
 283 
 
 causes of, 284 
 
 course of, 292 
 
 febrile symptoms in, 284 
 
 hearing in, 283 
 
 hot douche in, 287 
 
 induced by quinine, 286 
 
 leeches in, 287 
 
 mastoid complications of, 289 
 cases of, 517, 524, 527 
 
 neglect of, 280 
 
 resulting from constitutional disease, 
 285, 291 
 
 resulting from use of nasal douche, 
 285 
 
 statistics of, 279 
 
 symptoms of, 280 
 
 treatment of, 286 
 Middle ear, acute suppuration of, 307 
 
 causes of, 309 
 
 consequences of neglect of, 331 
 cases of, 321, 323, 333 
 
 mastoid complication of, oil 
 case of, 502, 509 
 
 pain in, 307 
 
 phthisis pulmonalis complicating, 308 
 
 prognosis of, 331 
 
 symptoms of, 308 
 
 termination of, 311 
 
 treatment, of 318 
 Middle ear, anatomy of, 213 
 
 diseases of, 278 
 
 physiology of, 254 
 Middle ear, chronic catarrh of, 343
 
 738 
 
 INDEX OF SUBJECTS. 
 
 Middle ear, chronic catarrh of, 
 
 causes of aural hallucinations in, 316 
 
 objective symptoms of, 352 
 
 pathology of, 374 
 
 subjective symptoms of, 344 
 
 treatment of, 380 
 Middle ear. chronic suppuration of, 
 
 astringents in, 456, 463 
 
 cases of, 469^472 
 
 causes of, 443 
 
 cleansing of tympanum in, 461 
 
 cleansing with cotton in. 454 
 
 confounded with inflammation of ex- 
 ternal auditory canal, 444 
 
 consequences of, 473, 496 
 
 danger to health and life from, 448, 
 473 
 
 dry treatment of, 457 
 
 electricity in, 462 
 
 Eustachian tube in, 448 
 
 general health in, 468 
 
 granulations in, 455 
 
 healing of membrana tympani in, 463 
 
 impaired hearing in, 450 
 
 inflation in, 454, 458 
 
 inspissated cerumen in, 445 
 
 inspissated pus in, 461 
 
 life insurance in, 473 
 
 mastoid complications in, 445 
 cases of, 502, 509 
 
 method of cleansing, 453 
 
 objections to use of syringe in, 452 
 
 pain in, 446 
 
 perforation of membrana tvmpani in, 
 442 
 
 phthisis pulmonalis complicating, 464 
 
 polypi in, 474 
 
 prognosis of, 468 . 
 
 removal of ossicles in, 464 
 
 results of long-standing, 446 
 of neglect, 448 
 
 skin-grafting in, 459 
 
 statistics of, 444 
 
 supposed danger of stopping dis- 
 charge, 19, 449 
 
 symptoms of, 445 
 
 syringing, 451 
 
 treatment of, 451 
 
 warm solutions in, 457 
 
 warm water in, 451 
 
 "Middle ear, croupous inflammation of, 317 
 Middle ear, diphtheritic inflammation of, 
 
 303 
 JVIiddle ear, hemorrhagic inflammation of, 
 
 297 
 Middle ear, hypertrophic inflammation of, 
 
 376 
 
 Middle ear, neuralgia of, 583 
 Middle ear, non-Buppurative inflammation 
 of, 339 
 
 changes of membrani tympani in, 364 
 
 differential diagnosis of, 352 
 
 Middle ear, non suppurative inflammation 
 of, 
 
 duration before advice is sought, 341 
 
 operations for, 414 
 
 paracentesis in cases of, 416 
 
 pathology of, 375 
 
 prognosis of, 441 
 
 statistics of, 341 
 
 supposed nervous deafness, 341 
 
 symptoms of, 344, 351 
 
 treatment of, 380 
 
 Middle ear, proliferous inflammation of, 
 343 
 
 causes of, 376 
 
 constitutional remedies in, 381 
 
 pathology of, 375 
 
 prognosis of, 411 
 
 symptoms of, 351 
 
 treatment of. 381 
 Middle ear, physiology of, 254 
 Middle ear, sympathetic inflammation of, 
 
 267 
 Middle ear, sub- acute inflammation of, 293 
 
 cases of, 296 
 
 pathology of, 295 
 
 symptoms of, 293 
 
 treatment of, 294 
 
 Middle ear, serous inflammation of, 337 
 Middle ear, statistics of occurrence of dis- 
 ease of, 213 
 
 Mineral acids in chronic suppurative in- 
 flammation, 458 
 Mixed cases, 352 
 Modiolus, 7 
 Mouth-breathing, 396 
 Mucous polypi, 475 
 Mumps, cause of disease of ear, 655 
 Muscida lucilia, 182 
 
 sarcophaga, 182 
 Muscles of auricle, 83 
 
 of tympanum, 256 
 Musculus incisurse majoris auriculae San- 
 
 torini, 85 
 Myringa, 7 
 Myringitis, 260 
 Myringodectomy, 427 
 Myringomykosis, 144 
 Myringoplasty, 460 
 Myxomata, 475 
 
 \TARES in chronic catarrh of middle ear, 
 1> 372 
 
 proliferous inflammation, 351 
 Nasal catarrh, case of acute suppuration 
 
 from, 335 
 Nasal douche, 309, 384 
 
 case of inflammation and pyaemia 
 
 from, 385 
 Nasal pad, 76 
 Nasal speculum, 68 
 Naso-pharyngeal inflammation, 377 
 Nausea from syringing, 452
 
 INDEX OF SUBJECTS. 
 
 739 
 
 Nebulizer, Eustachian, 403 
 
 naso-pharyngeal, 392 
 Necrosis of, 
 
 auditory canal, 156 
 
 labyrinth, 548 
 
 temporal bone, 505, 545 
 case of, 553 
 case of, with membrana tympani 
 
 intact, 547 
 Nervousness, 614 
 Neuralgia of ear, 583 
 
 cases of, 586 
 
 Neuroma of internal auditory canal, 680 
 Nerve, auditory, inflammation of, 652 
 Nerve deafness, 54, 612 
 
 diagnosis of, 614 
 Nitrate of silver, 393, 456, 481 
 Nitric acid, 481 
 Noise, hearing better in, 355, 363, 625 
 
 OBLIQUUS auricula?, 85 
 Ophthalmoscope in aural disease, 573 
 Ossicula auditus, 232 
 
 adhesions of, 375, 474 
 
 coverings of, 9 
 
 dimensions of, 233 
 
 discovery of, 5 
 
 functions of, 256 
 
 ligaments of, 233 
 
 loss of, case of, 333 
 
 mechanism of articulation of, 234 
 
 necrosis of, 333, 546 
 
 periosteum of, at birth, 223 
 
 removal of, 464 
 
 Osteo-sarcoma of tympanum, 479 
 Otalgia, 583 
 Othsematomata, 107. 
 
 cases of, 109 
 
 forms of, 107, 112 
 
 pathology of, 109 
 
 treatment of, 113 
 Otic ganglion, 237 
 Otology, 
 
 definition of, 2 
 
 hindrance to advance of, 38 
 
 progress of, 1 
 Otoconia, 599 
 Otolith, 599 
 
 Otomyces purpurus, 146 
 Otorrhoea, 443, 446 
 Otoscope, 
 
 binocular, 64 
 
 Blake's operating, 65 
 
 interference, 58 
 
 Siegle's, 78, 368 
 
 Von Troltsch's, 61 
 
 PAIN and sensitiveness to sound, 628 
 Panotitis, 306, 309 
 
 Paracentesis of membrana tympani, 288 
 death following, 422 
 first performed, 416 
 
 Paracentesis of membrana tympani, 
 
 for accumulations, 424 
 
 history of, 415 
 
 indications for, 435 
 
 instruments for, 435 
 
 statistics of, 424 
 
 with galvano-cautery, 427 
 Paracusis Willisiana, 22, 357 
 Paralysis of seventh nerve, 571 
 
 case of, from acute inflammation of 
 
 ear, 323 
 Parasitic inflammation of ear, 143 
 
 cases of, 144, 151 
 Paretic deafness, 439 
 Parotitis, 655, 716 
 
 cases of, 656 
 Pathology, 
 
 of labyrmthian disease, 679 
 
 of non-suppurative inflammation, 374 
 Pencillimn, 150 
 Pencillium glaucum, 146 
 Perilymph, 591 
 Periostitis, mastoid, 496 
 Pharmaco-koniautron, 429 
 Pharyngitis granulosa, 369 
 Pharynx, 
 
 astringents in treating the, 393 
 
 examination of, 65 
 
 gargles in treating the, 392 
 
 Gruber's method of cleansing, 391 
 
 injection of, 383 
 
 in acute catarrh of middle ear, 280 
 
 in acute suppuration of middle ear, 
 320 
 
 in chronic catarrh of middle ear. 350 
 
 in chronic suppuration of middle ear, 
 448 
 
 in non-suppurative inflammation of 
 middle ear, 369 
 
 in proliferous inflammation, 331 
 
 treatment of, 383 
 Phlebitis in mastoid disease, 499 
 Phlegmosa alba dolens, 499 
 Phlegmonous inflammation of neck, 49'.) 
 Piano test for hearing, 58 
 Plaster of Paris in suppurative inflamma- 
 tion of middle ear, 455 
 Pneumonia, case of aural disease from, 
 
 655 
 Polypi, 
 
 cases of, 477, 484 
 
 cause of, 477 
 
 classification of, 475 
 
 in external auditory canal, 125 
 tympanic cavity, 474 
 
 nature of, 475 
 
 on exostoses, 489 
 
 origin of, 475 
 of name, 474 
 
 puncture of, 482 
 
 removal of, with curette, 482 
 with caustics, 455
 
 740 
 
 INDEX OF SUBJECTS. 
 
 Polypi, 
 
 removal of, with forceps, 481 
 
 with snare, 480 
 resume of our knowledge of, 485 
 
 treatment of, 480-484 
 Post nasal syringe, 25, 383 
 Poultices in 
 
 acute catarrh of middle ear, 288 
 
 mastoid periostitis, 501 
 Powder-blower, 457 
 Pregnancy, cause of aural disease, 378 
 Presbykousis, 620, 719 
 Probing, danger of, 158 
 Processus lenticularis, 233 
 
 folianus, 233 
 
 gracilis, 233 
 Proliferous inflammation of middle ear, 
 
 351 
 
 Promontory, 230 
 
 Pulsation in tympanic cavity, 447 
 Pyaemia, 310, 457, 524, 566 
 
 cases of, 385, 567 
 Pyramid, 230 
 Pyramis vestibuli, 593 
 
 QUININE, effects of. 379, 641 
 case of aural disease from, 171, 642 
 
 "DECESSUS cochlearis, 593 
 ft Record of patients, 44 
 Reflex symptoms, 204 
 Reissner's membrane, 602 
 Register of hearing power, 48 
 Resection of tympanic ring, 201 
 Resorcin, 456 
 
 Restilorm bodies, section of, 111 
 Retrahens auriculam, 83 
 Rhinoscopy, 66, 371 
 Rivinian foramen, 9, 216 
 
 segment of membrana tympani, 216 
 
 SACCULE, 600 
 Salpingo-pharyngeus muscle, 251 
 Santorini incisurae, 85 
 Sarcoma of auricle, 117 
 
 internal auditory canal, 680 
 Scala tympani, 597 
 
 vestibuli, 597 
 
 Scarlet fever, cause of aural disease, 285, 
 333, 654. 709 
 
 cases of, 333, 655 
 Sciatic nerve, effect on auricle of irritation 
 
 of, 111 
 Sea bathing, cause of acute suppuration, 
 
 310 
 Semi-circular canals, 
 
 anatomy of, 593 
 
 bony, 594 
 
 disease of, 676 
 case of, 678 
 
 first described, 5 
 Sensory centre of auditory nerve, 610 
 
 Sentences, test for hearing, 46 
 
 Serous inflammation of middle ear, 337 
 
 Shrapnell's membrane, 11, 216 
 
 Siegle's otoscope, 78, 368 
 
 Sinus subciformis, 593 
 
 Skin-grafting for loss of membrana tym- 
 
 pani, 459 
 
 Small-pox, cause of aural disease, 714 
 Snare, 
 
 Blake's, 480 
 
 Wilde's, 480 
 Sonofactors, 48 
 Sound of one's voice in aural disease, 284 
 
 determination of direction of. 611 
 Speaking-trumpets, 719 
 
 tubes, 16, 719 
 Speculum, 
 
 anterior nasal, 68 
 
 bivalvular, 60 
 
 Elsberg's, 69 
 
 first used, 18 
 
 for ear. 60 
 
 hinge, 66 
 
 pharyngeal, 66 
 
 Siegle's. 78, 368 
 
 Spheno-staphylinus muscle, 246, 249 
 Spina seu crista helicis, 81 
 Stapedius muscle, 7, 235, 257 
 Stapes, 6, 232 
 
 anchylosis of, 24, 375, 474 
 Steam, use of, 398-400 
 Stemphyllium, 147 
 Sterility, ancient idea of cause of, 22 
 Styptic cotton, 484 
 Sulcus spiralis, 601 
 Sulcus pro membrana tympani, 92 
 Sulphate of zinc, 459 
 Surf-bathing, protection of ears in, 284 
 Supposed foreign body in ear, 200-202 
 Suppuration of middle ear, acute, 307 
 
 chronic, 441 
 Syringe, 133, 451 
 
 first used, 20 
 
 method of using, 134 
 Syringing, 
 
 for foreign bodies, 187, 195 
 
 furuncle, 138 
 
 inflammation of external auditory 
 canal, 135 
 
 inspissated cerumen, 166 
 
 naso-pharynx, 383 
 
 parasitic inflammation. 150 
 
 pharynx, Gruber's method, 391 
 
 suppuration of middle ear, acute, 319 
 
 chronic, 451 
 Syphilis of external ear, 154 
 
 internal ear, 630 
 
 middle ear, 378 
 
 TEETH in relation to aural disease. 584 
 Temporal bone, caries of, 24, 545 
 Tensor palati muscle, paralysis of, 439
 
 INDEX OF SUBJECTS. 
 
 741 
 
 Tensor tympani, 
 
 action of, 12 
 
 attachment of, 8, 235 
 
 discovery of, 8 
 
 function of, 256 
 
 tenotoiny, of 427 
 Termination of diphtheritic inflammation 
 
 of the middle ear, 305 
 Tests of hearing power. 45 
 Therapeutics, progress of, 13 
 Tinnitus auriuin, 281 
 
 cause of, 349 
 
 different sounds of, 348 
 
 effect on the mind, 346 
 
 objective, 349 
 
 Tones, deafness for certain, 624 
 Tongue specula, 66 
 
 Tonsils in non-suppurative inflammation 
 of middle ear,.369 
 
 removal of, 395 
 Toynbee's disk, 465 
 Tractus spiralis foraminosus, 606 
 Tragicus muscle, 84 
 Tragus, 4, 82 
 Trausversus auriculae, 85 
 Traumatism, cause of suppurative inflam- 
 mation of the middle ear, 310 
 Trephine, Wilson's, 543 
 Trephining of mastoid, 506 
 
 history of, 536 
 Triangular spot of light. 218 
 Trichothecium roseum, 146, 148 
 Tubulus hirsutus, 1 78 
 Tumors of auricle, 103 
 
 of brain. 673 
 
 of membrana tympani, 302 
 Tuning-fork, 
 
 discovery of, use of, 19 
 
 duration of vibration, 55 
 
 effect on membrana tympani, 13 
 
 explanation of, 56 
 
 history of its use. 52 
 
 in disease of middle ear, 54, 352 
 
 in disease of internal ear, 54, 58, 615 
 
 in disease of labyrinth, 621 
 
 method of using, 52-57 
 
 test for hearing power, 45, 51, 621 
 Turkish bath, 382 
 
 Tympanic syringe, Hartmaun's, 463 
 Tympanum, 
 
 a series of anatomical parts, 447 
 
 agents used through catheter, 403 
 
 blood-vessels of, 236 
 
 catheter for, 70, 401 
 
 definition and description of, 227 
 
 injecting with fluids, 434 
 
 lining membrane of, 236 
 
 measurements of, 228 
 
 nerves of, 237 
 
 objects for examination. 228 
 
 openings in walls of, 229 
 
 relations of, 231, 450 
 
 roof of, 230 
 
 syringing of, through Eustachian tube. 
 461 
 
 syringing, 452 
 
 UMBO, 219, 224 
 Urine, ancient instillation of, 23 
 Utricle, 598 
 
 TTALSALVIAN experiment, 24, 77, 366 
 Y Vapors in non suppurative inflamma- 
 tion, 398 
 
 Vernix caseosa. 94 
 Vertigo, 345, 452 
 Vestibule. 
 
 anatomy of, 591 
 
 physiology, 607 
 Vestibular nerve, 606 
 Vomiting, effect of, 268 
 
 WAKM oil, use of, 13 
 Warm water, instillations, 14, 282, 
 
 451 
 
 solutions, 457 
 
 Watch as a test of hearing, 47, 50 
 Whooping-cough, 715 
 
 case of acute suppuration of middle 
 
 ear from, 334 
 Wilde's incision, 499 
 Worms in the ear, 15, 17, 23, 181 
 
 ZOXA denticulata, 13 
 pectinata, 13, 602
 
 Date Due 
 
 01979 
 
 II 
 
 CAT. NO. 23 233 PRINTED IN U.S.A.
 
 
 W200 
 R78lp 
 
 1891 
 Roosa. Daniel B S 
 
 A practical treatise on the diseases 
 of the ear 
 
 CALIFORNIA COLLEGE OF MEDICINE LIBRARY 
 
 UNIVERSITY OF CALIFORNIA, IRVINE 
 
 IRVINE, CALIFORNIA 92664