THE LIBRARY OF THE UXI\'ERSITY OF CALIFORNIA LOS AXGELES GIFT ^P/^^£ DISl'.ASI.S OF THE EAR A TEXT BOOK FOR rRALTITIOXHRS AXD STrDRXTS OF MFP/ClXf': \:\ EDWARIl HKAnroKI) DFvNCM. Pii. B.. M. D. PMurBAMlM ••» • • '■ ' ....... COLLKGE ; AV«a: iHK MBOICAL SOCimr, BTC. WITH EIGHT COI.ORKD PLATES AND ONE Ht'SDRKU AND HKTY TWO ILLUSTRATIONS IN THE TEXT N K W \' ( ) R K I) . ,.\ P I' L L T O N A N U C O M I' A N Y 1S9S Copyright, 1894, Bv D. APPLETON AND COMPANY. Electrotyped and Printed AT THE ApHLETON PrESS, U.S.A. PREFACE In the preparation of the present work it has been my aim to adapt it to the needs both of the general practitioner and the special surgeon. For this reason minute pathology has not been considered extensively. In detailing the various manijjulative procedures, I have preferred to err on the side of prolixity, for the benefit of those not familiar with the subject. It has also been my purpose to keep constantly before the reader, the fact that many diseases of the ear should not be considered by them- selves, for the reason that they are often local manifestations of systemic condition. Many works upon otology have failed to emphasize the importance of a thorough functional examination ; and none have placed the results of recent investigations at the disposal of the reader in such a manner as to enable him to use them in diagnosis. In consequence, I have written at length uj)on this subject. In advocating operative procedures upon the middle ear and in devoting much space to the subject of middle-ear operations, I am aware that I shall not have the supjjort of many distinguished colleagues. As a careful reading of the chapter will show, 1 iiave written from personal experience ; and if my results differ from those of other operators, I sug- gest that the selection of cases suitable for operation, accord- ing to the principles detailed in previous chapters, may account for the favorable outcome of the operations. In illustrating the gross pathological lesions of the con- ducting mechanism and the various manipulative measures instituted for their relief. I have adopted the plan of showing the auricle, meatus, and middle ear in the same drawing. The drawings are of natural size, and the technique of the various procedures seems to be made more clear in this manner, than by any other method. (iii) IV PREFACE. In the colored plates of the membrana tympani, the adja- cent portion of the meatus is also shown, thus reproducing as completely as possible the picture seen upon speculum exami- nation, and rendering the relative position of the parts more intelligible. In this connection I desire to express my indebt- edness to Dr. W. A. Holden for the careful manner in which he prepared these plates from clinical cases. Without his aid, these illustrations would have been impossible. The absence of extensive bibliographical citations may seem a defect, but in a work intended as a clinical guide, a complete bibliography would be impossible, and unless com- plete it would be useless. No attempt has been made, there- fore, to collate the entire literature of any subject, and the citations have been limited to those necessary to give indi- vidual investigators the proper credit for their researches. It gives me pleasure to thank the \V. F. Ford Surgical Instrument Company for the care which they have bestowed upon the illustrations of various instruments and appliances which appear in this volume. 17 Wkst 46TII Street, Nkw York City, October to, iSg4. C O N T I : NTS. SECTION I. THE ANAIOMV ANH IMIYSId'" N <>!• lid KAR. CHAPTER I, PACES The Anatomy of the Ear 3 47 The auricle— The external meatus— The bony meatus — The tym- panic cavity — I'lie ossicles — The intmtympanic ligaments — The membrana tympani — The epithelial investment of the conducting apparatus — Intratympanic folds — i he muscles — The arteries — The veins — The lymphatics — The ncr\-es — The bony labyrinth — The membranous labyrinth — The saccule and utricle — The membranous cochlea— The vascular supply of the labyrinth — The auditory nerve. CHAI'TER H, The Physiology of the Ear 48-72 Sound — Function of the membrana tympani — Function of the ossi- cles — Function of the muscles — Function of the cochlea ami semi- circular canals — KtTect of tympanic changes upon the labyrinth — EfTect of stimuli upon the auditory nerve — Reflex phenomena — Secondary phenomena — Hypcmesthesia and pancsthesia. CHAI'TER HI. Physical Exa.minaiion 73 '4' Preliminary observations — Source of illumination — The Reflecting Mirror — .Specula — Technique of Examination — Appearance of the meatus and membrana tympani — Obstacles to examination — Tym- panic trpography — Politzerization — Catheterization — Auscultatory sounds — Obstacles to catheterization — r)angers of catheterization — The examination of the nose and throat — The history. CHAPTER IV. Functional Examination 142-170 Quantitative tests — Qu.-\litative tests — Rone conduction — Differential diagnosis — Precautionary measures — Irregular phenomena — Special tests — (ialvanic reaction of the auditory nerve. vi CONTENTS. SECTION II. DISEASES OF THE CONDUCTING APPARATUS. /. DISEASES OF THE AURICLE. CHAPTER V. PAGES Congenital Malformations of the Auricle . . . 173-182 Deformities of particular parts of the auricle — Deformity or malpo- sition of the entire auricle — Auricular appendages — Polyotia. CHAPTER VI. Wounds and Injuries of the Auricle 183-186 Contused, lacerated and incised wounds — The effect of intense cold — Burns — Injuries due to the action of chemical substances. CHAPTER VII. Cutaneous Diseases of the Auricle 187-199 Intertrigo— Eczema — Pemphigus — Herpes — Syphilis — Lupus. CHAPTER VIII. Inflammatory Affections of the Auricle .... 200-205 Perichondritis — Erysipelas — .Xbscess — Othajmatoma — Thickening of the lobule — Ossification — C.angrene. CHAPTER IX. Benign Tumors of the Auricle 206-212 Fibroma — Lipoma — .\iheroma — .\ngioma — Cystoma — Papilloma. CHAPTER X. Malignant Tumors of the Auricle and of the Meatus. 213-216 Epithelioma — Sarcoma. //. DISEASES OF THE EXTERXAL AUDITORY MEATUS. CHAPTER XI. Circumscribed External Otitis 217-237 Acute CiRcuMSCRiiiKD Kxtf.rnai. Otitis or Firinclf,. .'Etiol- ogy — Pathology — Symptomatolog)- — Diagnosis — Prognosis— Treat- ment — Bloodletting— Cold — Instillations — Heat — Incision — Inter- nal medication. Chronic Circimscribed External Otitis. Significance in diagnosis of mastoid inflammation. CHAPTER XII. Diffuse External Otitis 238-266 Chronic Dipfise Extern.\l Otitis. Etiology — Pathology — Superficial — Cellular — Desquamative — Parasitic — Consecutive — CONTENTS. vii PAGES Symptomatology — Diagnosis — rrognosis — Treatment of the various varieties of the disease. .Vitte Difki'sk Kxtkrn.vi. Otitis. yEtiolog)- — Dependence upon the chronic form — Pathology — Symp- tomatology — Diagnosis — Involvement of middle ear — I'rognosis — Treatment — Local depletion — Irrigation — Cold — Incision. Croup- Ol'S AND DiPHTHERllTC EXTERNAL OTITIS. ll.tMORRHAGIC External Otitis. CHAPTER -XIII. Impacted Cerumen 267-278 >Etiolog)' — Pathology — Symptomatology — Direct and reflex phe- nomena — Diagnosis — Prognosis — Treatment — Use of the syringe — Use of the curette. CH.APTER XI\- Foreign Bodies in the Canal . . 279 284 /Etiology — Pathology — Symptomatology — Di.igiio-is — Prognosis — Treatment — Removal through the natural passage — Removal by external incision. CHAPTER XV. Exostosis of the External Alihtory Meatus . . 2S5-290 /Etiology — Pathology — Symptomatology — Diagnosis — Prognosis — Treatment. CHAPTER X\ I Wounds and Injuries of ihe Memhrana Tn.mpani 291-295 .•Etiology — Pathology — .Symptomatolog)- — Diagnosis — Prognosis — Treatment. ///. DISEASES OF THE MIDDLE EAR. CHAPTER XVH. Tubal Ciin(.estion', or Tuhal Catarrh 300-312 ittiology — Pathology — Symptomatology — Diagnosis — Physical ex- amination — Functional examination — Prognosis — Treatment — In- flation — Dilatation — Medicated vapors — Prophylaxis. CHAPTER XVI II. TUBO-TYMPANIC CONGESTION. — TUBO-TYMPANIC CATARRH . 313-322 /Etiology — Pathology — Symptomatology — Diagnosis — Physical Ex- amination — Functional examination — Prognosis — Treatment — In- flation — Incision — Internal medication. CHAPTER XIX. Acute Catarrhal Otitis Media 323-335 /Etiologv' — Pathology — Superficial structures alone affected — Symp- toms in afiults — .Symptoms in children — Inspection of discharf^e — Diagnosis — Physical examination — Functional examination — Prog- nosis — Treatment — Depletion — Dry heat — Instillations — Incision — Irrigation — Topical applications. viii CONTENTS. CHAPTER XX. PACES Acute Purulent Otitis Media 336-350 /Etiology — Pathology — Involvement of the connective tissue in the vault of the tympanum — Secondary involvement of the lower por- tion of the cavity — Extension to bony structures — Symptomatology — Evidences of mastoiil involvement — Evidences of extension to the cranial cavity — Diagnosis — Physical examination — Bulging of membrana tlaccida — Functional examination — Prognosis — Subse- quent functional condition — Chronic purulent otitis — .Ma>toid and intracranial involvement — Fatal ca>es — Ireatment — Depletion — Early incixion — Irrigation — Abortive treatment when mastoid symp- toms appear — Treatment of persistent discharge — Drainage. CHAPTER XXI. Chronic Catarrhal Otitis Media 351-387 General considerations concerning pathological characteristics sep- arating the cases into two classe>. (IIROMC IlYrKKTRoIIIIC (OTI- TIS Mkdia. /EtiologA' — Influence of repeated attacks of congestion — ynresolved acute otitis — .MTections of the upper air passages — Sex — General condition — Heredity — i'aihology — Tympanic clianges — Changes in the drum membrane — In the Eustachian tube — In the tympanic ligaments — In the labyrinth — -Symptoinatoiogy — Hilateral involvement — Intermittent character of the subjective noises and impairment of hearing — Keflex pain referred to the region of lingual tonsil — Diagnosis — I'iiy^ical examination — Altered position and den- sity of menil)rana tympani — Changes in the apparent Itreadth of malleus handle from rotation — Efiiision — Functional examination — Impairment for voice greater relatively than for shaqi sounds — Changes in the limits of audition — Condition of organ secondarily involved — Prognosis — Duration of affection — Condition of upper air passages — Degree of bilateral involvement — Age — Secondare' scle- rotic changes — rrcatment — Treatment of the upper air pas>ages — Surgical measures antl topical applications — Of the Eustachian tube — Inflation — Irrigation — l)ilatation — Topical applications — 0( the middle car — Simple inflation — Medicated vapors — Absorption or evacuation of elTu-ion — Lavage of tympanum — Tenotomy i>f tensor tympani — Mechanical support in relaxation — Surgical procedures. Chronic Hvi'kri'lastic Otitis .Media. .ICtiology — Secondary to acute inflammations of tym]>anum or to hypertrophic inflamma- tion — Idiopathic disease resulting from systemic causes — Occurrence in one ear as the result of changes in the opposite organ — Pathology — Sclerotic changes in the tympanic connective tissue — Deposit of new connective tissue — Changes in the membrana tympani — Depos- its about oval and round windows — Tension anomalies cau-ing rot.a- tion of malleus upon its long axis — Changes in the tympanic vault — Labyrinthine involvement — Condition of the Eustachian tube — Symptomatolog)' — Insidious development — Subjective noises with- out impairment of hearing — Local and reflex pain — " .Auditory fa- tigue " — Neurasthenic manife->taiions— Diagnosis — Physical exam- ination — Normal appearance of drum membrane — .\trophy of mem- brane — Malposition of ossicles — .Appearance of membrana l1acciection and their individual signifi- cance — Caric* — Use of probe — Significance of granulation tissue — Displacement of the ossicles — .\uscultatory signs — Functional exam- ination — Variat! • limits — Ffl'ect on ujiper tone limit — Bone conduction — Fl tion — Evidences of mastoid involvement — Prognosis — P. :;^cl upon audition — Cessation of discharge — Danger to life — 1 reatmcnt — Isc of syringe- — Other methods of cleansing — Treatment of the upper air passages — Instillations — Powders — kentoval of exuberant granulation tissue — Irrigation of vault of tympanum — Operative procedures — Statistics of operations — Treatment after operation — Internal medication. CHAPTER XXIII. oTin.s Media Purulknta Re.sidua 416-431 AciJTE Type, ^ttiolopy — Identical with that of acute inflamma- tion of the normal i ' ' ' — Hypenvmia of ex|)osed lining of tjnipanum omes purulent by infec- tion through canal- ! "v necrosis with devel- opment of chronic ■ — Interference with function — Discharge- i — Facial paralysis — Diagnosis — Physical exam ui.ii ion — .^eious discharge — Fxfithelium — Thickening of remnant of drum mem- brane — Signs of mastoid involvement — I'rognosis — .Mild cases — Severe cases with retention of pus — Treatment — Mild cases — Asep- sis — Topical ap]iliiations — Treatment of upper air passages — ke- moval of dead Ixme if |iresent to prevent recurrent attacks — Severe cases — Inci-ion of menibrana flaccida with cupping — Irrigation — Cold to ma.sioid. Chknductirg mechanism — Labyrinthine involvement — Determina- tion of the degree to which perceptive and conducting mechanism isafl'ected — Prognosis — S|K)ntaneous improvement — Age — Influence of labyrinthine involvement upon the prognosis — Recent and chronic cases — Treatment — { General measures — .Attention to upper air pas- sages .and Eustachian tube — Prophylaxis against otomycosis — Surgi- cal treatment — Ffl'ect of treatment upon function of opposite ear. /r. DISEASES OF THE MASTOID PROCESS. CHAPTER XXIV. The Anatomy of the Mastoid Process 432-438 Variations in presence .and location of pneumatic spaces— Location of antrum — Relations between superficial landmarks and cranial contents — Topographical variations dependent upon age. EE CONTENTS. CHAPTER XXV. PAGBS Inflammation of the Mastoid Process 439-452 Etiology — Secondary to middle-ear inflammation — Idiopathic cases — Pathology — Sclerotic changes — Caries ami necrosis — Purulent inflammation — Avenues of exit of secretion — Intracraiiiai complica- tions and channels of infection — Possibility of infection through outer surface of squama — Cholesteatoma — Symptomatology — Pain — Temperature not characteristic — Cessation of discharge — Evi- dences of intracranial involvement — Evidences of extension of thrombus from sinus into internal jugular vein — Diagnosis — Local Icndemcss — Metho'l of eliciting symptom — Involvement of meatus close to membrana tympani — Evidences of external rupture— Of rupture into digastric fo-sa — Prognosis — Importance of early recog- nition — Chronic case> — Influence of diathetic conditions — Cravity of operative measures — Treatment — Free drainage through canal — Cold to mastoid — Irrigation of canal — Objection to Wilde's incision — Early and radical operation. CH.\PTER XXVI. iNTRAiKANiAi. CoMPiicATioNs OF Tympanic Inflammation . 453-462 Otitic Mf-NINcitis. Manner in which inflammation extends to meninges — Symptomatology — Variations dependent upon location of lesicn — Ocular sym])toms — Diagnosis — Temperature — Headache — Vomiting — Prognosis — .Vdvisability of operative interference — Treatment — Cold applications — Internal medication — Surgical treat- ment. Sims rnRoMiiosis. .\vcnues of infection — Extension to internal jugular — Secondary deposits — Symptomatology — Rigors and sweating — Intermittent temperature— (ieneral sejisis — Evidences of second.iry deposits — Diagnosi^ — \'alue of fre'|uent thermometric ob- servations — I icner.il condition of patient — Prognosis — .Apparent re- covery — Latent cerebral deposits — Tre.itment — ( >|>eralivc treatment — Medication — .Mimentation. Extrai>iral AliscESS. Nature of the process — Symptomatology — Localized headache —Temperature changes — Mental condition — Prognosis — Latent deposits — Sponia- neous evacuation — Value of operative treatment — Treatment — Ne- cessity of surgical interference. Ckrkbral Ahscf.ss. Origin — Site — Latent deposits — .\septic abscesses — Symptoinatolog)- — Depend- ent upon location — Constitutional symptoms — .\sthenia — Sleejv lessness — Temperature — Di.agnosis — ( "ieneral asthenic Fymptoms — Sleeplessness — low temperature — DiflTiculties in diagnosis due to complicating lesions — Prognosis — Natural progress when not inter- fered with — Proper time for surgical interference — Results of opera- tive treatment — Treatment — Evacuation by operation SECTION III. SURGERV OF THE CONDUCTINC, APPARATUS. CHAPTER XWII. Middle-ear Operations 465-514 Prf.liminary Preparations. Instruments — Form — Construction — Sterilization — Field of operation — Necessity of asepsis — Mcthoii'ii — '" '" - involvint; Section of Intra- tyin|;iiiK icH'^or tyni|>aiu — Methods of • ■ • . ..j;.iniciU of the malleus — Divi- o and nonsuppurative cases. III. ( >_ r <"!i,iiii — Kxcision of a portion of the ni.iiuifnuni — iJi- lization of the stapes — I'lasiii oprraMMns — K — Technique when the iiirm'Tv — 1 fcasmciit alter operation — Reaction I.H «;:. Kluction of the ntemhrana tynipani — 1 ...... 1 • ,,yej — Ha-niorrhage nant of the incus — ' ... —Subsequent treat- r of riha|;<. — iM^vihlt- .icniitiiis — .Stacke's operation — :iiy — With intact drum nuinl>ranc — With dium niem- hruuc J .irtially dcitrti>cd — Si.iiisiics of author's operations showing the effect ui>on the function of .^ti— Operation .\f- - • i ocati'in of ex- pj,,, ■ 11 — Fxploration of , . > puncture of ccr« ' '^f lluid— Exploration of Cfji-i . .\fter-treatmcnt of brain absccN — Ijc.iimciii oi i-iii^ka: u.ci.ui-nis— Primary operation on mastoid— ExiKKurc of tympanic roof— Ex|>osurc of sinus— Dressing. SECTION IV. I)ISF.\SES OF THE FEKC EPTIVF MECH.\NISM. In I koi>r( Tokv Kkm.xrks 537-54° t haracter of auditon,- impairment— Comparative value of physical and functional exaniin.ition — Importance of complete history Lo- cation of the pathological process. CH.M'TER XXX. ;\N.KMIA OF THK L.VHVRINrTl 54^-543 /Ftiologv— Profuse hxmorrh.ige— Constitutional conditions— Symp- tomatolcJgy— Functional impairment— Subjective noises— Disturb- xii CONTENTS. ances of static function — Diagnosis — Physical examination — Func- tional examination — I'one limits often preserved or upper tone limit may be lowered — Deficient bone conduction — General ana;mia — Prognosis — Dependent upon cause — Treatment — Stimulants — Ton- ics — Drugs to be avoided. CHAPTER XXXI. Hyper.«mia of the Labyrinth 544 547 /Etiology — (General condition — Occupation — Concussion — Acute or chronic venous engorgement — Pathology — Dilatation of veins — Extrava.satit)n — Serous transudation — Symptomatology — \'ariations in degree and persistence of the manifestations — Diagnosis — Ab- sence of definite physical signs — Functional examination — Preserva- tion of lower tone limit — I'ppcr tone limit reiluceil — Impairment of bone conduction — Prognosis — Varies with duration and degree of process — Treatment — Acute cises — Depletion — Rest — Occlusion of canal — Pilocarpine— Chronic cases — Counter-irritation — Pilocarpine and the method of its administration — General hygienic rules. CHAPTER XXXII. Labyrinthine H.€Morrhage 548-550 i^tiology — Concussion — Direct traumatism — Blood conditions — Change* in the walls of the blood vessels — Diatheses — Pathology — Extravasation — Subsequent changes — Symjitomatology — Prodro- mata — Sutlden access of symptoms — Symptoms usually severe — Ciradual abatement of manifestations — Recurrence —Diagnosis — Value of clinical history — Functional examination — Absence of bone conduction — .\bsolute deafness or great aiiiiitory impairment — Upper tone limit reduced —Occision-il disturbances of lower tone limit — Prognosis — Varies with the severity of h.xmorrhage — Static function usually restored — Treatment — .\cute stage — Depletion — Rest — Revulsives — Chronii- ^i.u'e— Reduction of lahvrinlhiin' pn-s- sure — Prophylaxis. CHAl'TER XXXIII. Labyrinthine Emboli.sm and Thrombosis .... 551-552 .Etiology — Metastasis — Inflammation of contiguous structures — Pa- thology — Results in local anaemia — Local necrosis — Inflammation — Symptomatology — Function of organ usually not much disturbed — — Spontaneous improvement — Prognosis — Condition not progressive — Treatment — Removal of cause — Reduction of labyrinthine pres- sure — Relief of subjective symptoms — Stimulation of impoverished nerve tissue. CHAPTER XXXIV. Specific Inflammation of the Labyrinth .... 553-556 /Etiology — Hereditary or acquired syphilis — Pathology — Chronic inflammatory changes — Hypcrirophy — Changes in walls of vessels — Necrosis — Symptomatology — Sudden access in acquired form — In- vasion less sudden in hereditary cases — Diagnosis — Physical exami- nation — Recognition of concomitant tymjjanic disease — Functional examination — Deficient bone conduction — Lowering of u]iper tone limit — Diflferential diagnosis in "mixed" form — Prognosis — Intlu- ence of heredity — .\ge of local process — Spontaneous <|uiesccncc — Treatment — .Vntisyphilitic medication — Pilocarpine — lodiiie of po- tassium — Strychnine in advanced cases — Tonic treatment in heredi- tary cases. CONTKNTS. ^... CHAl'TER XXXV. Inflammation of thk Lahyrinth sfxoxdarv to Chronic ^''^^^ Suppurative and Nonsuppuraiu e Inflammation of THE Tympanum SST-qes Fatholopy— Inflamniator>- changes — Atrophic changes — Extension of'"'- '■" ■ mum— Con. iition of oval and round win- do\\~ n — Functional di>turbances — Symptoni- atoKi^. - . — Sii^niticancc of di>ap])eaiancc of tin- nitu>— \ crtij;.)— >yn.i...ilK!\ i;i\. .h imcnt of opi)o>ite ear— Diag- nosis— Thysual ex.uniiiatiuii— Al.-eiice of physical >igns in certain cases- Value of insjHrction in residual purulent cases— Functional examination- Kvi.!rniel>vtruction to sound conduction- Ne- -I'etcrniination of relative impor- liine lesion — Klectrical tests — Im- j'"'-'' ' 1 • 11 iioth sides to (letcnnine secondary inv..!\tiiii nt .1 \ healthy i>rj;an — l'rognosis— Residual purultiit c.i-es u .- l,„l ^K,^^ly or not at all— Dangers of sympathetic iiivulvcn. ment— Relief of cause in middle ear — I'reser^ation of . \cd secondarily — Special measures directed toward labyrinth— I'lltHraqiine — Strychnine — Specific treat- ment — I'crsislent stimulation by sonorous vibrations — Relief of subjective noises — Treatment of the upper air passages — Danger of treating middle ear in advanced cases. CIIAPTKK XXXVI Acute Infiammmion of the Labyrinth secondary to Acute I'irulent Otitis Media 565^-573 .l-Itiology — Ordinary causes of acute purulent otitis media — Viru- lence of process — I'athology — Tissue necrosis — Avenues of infection — Infection of cranial contents — Obliteration of labyrinth from de- posit of mw tissue — S\m|)tomaicilogy — Not characteristic in young subjects — l-.vuiiiites of labyriiuhine infection in adults — Importance of facial ]ara!\ : riiptoin — Disturbance of static function — Retrogression ii — 1 l;vniorrliage — remianent impairment of audition — I 'i r, liiysical examination — Not characteristic of labyrinthine involvement — FIvidences of caries of internal tym- panic wall — Functional examination in children unsatisfactory — In adults — I'pper tone limit much lowered — Hone conduction absent or greatly reiluced — N'ertigo^I'rognosis — I'nfavorable for comjilete restoration of function — Often fatal in children — In adults not as great a menace to life — Danger of absolute deafness less common in adult^ — Danger of causing deaf-mutism in children — 1 reatment — I'mphylaxis against infection by asepsis from the tlrst— Relief of tinnitus — Pr-it of new tissue — Sudden appearance of symptoms — Diagnostic data. 1)iaiiktes. Frequency of inllammntion in external meatus — As predisposing cause of middle-ear suppuration — I'-xtravasations in labyrinth, nerve trunk, or centres. (loiT AM> RllKi matis.m. Cutaneous manifes- tations in canal — .Arthritic inllainmation in middle ear— Changes in the blootl vessels and the results. .Mkkicinai. Si iistancks. Qui- nine — Effect on middle ear and labyrinth — Salicin and salicylic acid — Conditions contraindicating their administration — Tobacco — Effect upon higher centres. CHAPTER .\LII. Disturbances of Audition dependent upon Functional Nervous Disorders 602-607 Unimportant physical changes as a cause of manifestations in a par- ticular region — Perversion or impairment of function with no evi- dent lesion. Ni.urasthf..nia. "Auditory strain" — Psychologi- cal effect — Character of impairment of hearing — (ieneral sensory parrcsthesire — Diagnosis — Physical examination often negative — Functional examination — Perception of high and low notes — Re- duction of bone conduction — Variable results obtained by succes- sive tests — Recognition of general neurotic condition — Ilyperacusis — Auditory fatigue — Prognosis — Influence of organic changes in ear — Influence of general neurosis — Treatment — Strjchnine — Bro- mides — Rest — Change of habit of life. HYSTERIA. Degree of impairment — Sudden appearance — Subsequent course — Associated hysterical paralyses — Transference — .\bsence of subjective noises — Diagnosis — Sudden onset — .\bsence of physical changes — Cutaneous anrcsthesia — Functional cxaniinntion — Contraction of range of au- dition — Upper tone limit most affected — .Mternate variations in upper limit — Contraction of field of vision — Prognosis — 'Treatment — Attention to general neurosis— Hypnotic treatment. B xvi CONTENTS. CHAPTER XLIII. PACES Reflex Aural Disturbances 608-613 Vaso-motor changes — Trophic disturbances. External Meatus. Reflex inflammation — Cutaneous hyperresthesia — Haemorrhage. MiDDLK-EAR. Reflex Otitis media — Otalgia — Angioneurotic oedema of mastoid. Perceptive .Mechvnism. Paresthesia — Influence of visceral disorders — Interference with static function — Irregularity and transitory character of symptoms — Absence of local cause — Presence of remote lesion — Effect of one ear upon opposite organ — Physiological interdependence — Pathological correlation — Value of Electrical hyper.xsthesia m diagnosis — Prognosis — Duration of reflex symptoms — Nature of exciting cause — Treatment — Early adminis- tration of bromides — Removal of exciting cause — Anti>pasmodics — Opium contraindicated — Tonic treatment. CHAPTER XLIV. Deaf-muiism 614-618 Definition — Varieties — /Etiology. CONGENITAL Form. Heredity — Consanguinity — Nationality — Social condition — Defective mental development — Specific disease — Causes operative during intra- uterine life. .\c1" IIIK KAK. The auditorv apparatus, tliroiij^li llic ajj^ciicv of which certain forms of motion are interpreted as sound, may best be c THE ANATOMY AND PHYSIOLOGY OF THE EAR. The second pc^rtiini, the receptive mechanism, includes not only the internal ear. or labyrinth, but, in addition, the trunk of the auditory nerve, its central and cortical nuclei and fibres of association and projection. The labyrinth, then, represents but a small portit)n of the receptive mechanism, constituting the specialized end organ of the auditory nerve, through which vibrations in the labyrinthine fluid produce specific impressions upon the cerebrum. It can be seen at once how much more comprehensive the range of aural pathology be- C(jmes when this view is taken, than when anatomical divisions alone are followed. I. TllK CoXDl'CTINc; Al'lAkATUS. Under this head we include the auricle and the cartilag- inous meatus, the bony external auditory meatus, the mem- brana tvmpani. the tympanum, and the Eustachian tube. The auricle and the cartilaginous meatus together form an irregularly funncl-sha|)ed device for transmitting aerial vibra- tions to the dcejier |)arts. the auricle constituting the wide ptirtion of the funnel, the cartilaginous meatus the tubular {)()rti()n. The Auricle. — The auricle consists of a thin plate ot tibro- cartilage. oval in outline, attachetl to the side of the skull at an acute angle with the median an- tero-posterior verti- cal plane of the body. Its posterior surface is convexand smooth, while the concave anterior surface pre- sents certain irreg- ularities which merit special description. The unattached bor- der of this oval car- tilaginous plate is Fig. I.— The cirtil.-igiiioiis fr.imework of the .luricle. folded forward upon (.Uter I'oiitzer.) jt^^^^lf to such an ex- tent that the free margin appears upon the anterior or external surface, form- ing the helix. Above, the helix does not terminate at the THE AURICLE. supcro-antcrior attachment of the auricle, but is continued backward and slif)rtant. since thev enable us to turn the auricle and fibrocartilaginous canal forward on the cheek, after sejK'iration of the j)osterior. inferior, and sui)erior attachments. The Bony Canal. — In order properly to understand the osseous meatus, it will be necessary to consider somewhat in detail the development of the temporal b(Mie. This portion of the skull develops from four centers: the squamous, the petro-mastoid, the audit(jry or tymjianic. and the stylomas- toid. This last center of ossification does not concern us, but the other three are of importance, as they are all integral parts of the auditorv aj)paratus. and. with the exception (jf the pe- trous portion, all enter into the formation of the external meatus. The manner in which these various portion unite to form the temporal bone is shown in Fig. 5. which is some- what diagrammatic. The osseous meatus does not exist at birth, its {)lace being supplied bv a canal of fibrous tissue. Reference to Figs. 8, 9, and 10, drawn from specimens prepared by the author, renders this clear. At its inner extremitv this terminates in li( 4— a. 1, '1 lie iiKi-f ^anlorini. ( I'rhanlschitsch.) 8 THE ANATOMY AND PHYSIOLOGY OF THE EAR. the auditory process or the tympanic ring. The auditory process (Figs. 5 [2] and 13 [III]) consist of a thin osseous strip bent in the form of an oval, the curvilinear outline being wanting: for about an eijjhth of its circumference at the broader Fig. 5. — The development of the temporal bone, i, The squamous portion ; 2, The tympanic ring ; 3, The petro-mastoid portion. The upper figure illustrates the union of the three portions. (Modified from (Iray.) pole. The concave margin of this bonv ring is grooved for the insertion of the mcnibrana tvmpani, and is named the sulcus tympanicus, while the ring itself is called the annulus tympanicus. The free extremity of the posterior limb of the annulus is called the spina tvmpanica posterior or spina tvm- panica minor. Just below the extremity of the anterior limb a bony spine projects backward, the spina tympanica major. The spina tympanica anterior is directed forward, and con- sists of a small bony tubercle lying just beneath the larger tympanic spine. Tin: noNY mkatus. q The scjuamnus jiortion ni the temporal bone develops from a sinij^le center. Karly in Icrlal life it consists of a flat osseous scale, presenlinjj a ridj^^e upon its outer surface, which afterward becomes the zygomatic process. Below the root of this j)rocess is a shallow excavation, the aflenoid fossa. !5ehind this depression the bonv plate divides into two la- mella;, the inner of which is directetl almost horizontally inward and forms subseciuentlv the roof of the tympanum and of the mastoid antrum. The external lamella passes downward and somewhat inward :\\n\ exhibits a deep notch upon its inferior border. The annulus tvmpanicus joins the external plate of the scjuama by the union of the free extremities of its anterior and posterior limbs to the corresponding anj^Ies of the n«»fih above described. Ilie curvilinear outline of the rinj^ i- ciMUjtleted by the notched inferior border of the external plate of iIk squamous portion of the temjioral bone. riiis is shown in I'ij^. t». The circlet thus completed jjives attachment to the inner extremity of the fibrous canal, which occupies the position of the future bony meatus. As development pro- "^X:*-^ ^ L,^resses. the fibrous canal is replaced ^^ '^ ' I ^. Ti , I'lr,. 6. — Temporal Ixine of in- by osseous tissue. The annulus fam. nalur.Vl sire. (.Authors tvmpanicus is converted into a collection l)(»nv ijroovc bv ossification out- ward, and. as will be seen by ct)nsultinjj Fij^s. S. 9, and 10, the |»roccss eflects simply the separation of the superior and inferior walls, which at birth are in contact. This putter forms the atiteri«)r. interior, and posterior walls of the bony meatus, the suj>erior wall beinj; formed by that portion of the temporal bone which completes the osseous outline of the .iiinulus tvmpanicus. In the atlult temporal bone (Fig^. 7) the deep groove formed by the outward growth of the annulus tympanicus is called the auditory process. It is separated in front from the squa- mous portion of the temporal bone by a narrow fissure called the Glaserian fissure ; posteriorly the auditory j)rocess enters into the formation of the mastoid squamous suture, its postero- superior termination constituting the spinum supra-meatum. lO THE ANATOMY AND PHYSIOLOGY OF THE EAR. The external plate of the squama, which completes the out- line of the bony meatus, during development grows almost Fk;. 7. — The adult temporal bone, natural size. (Author's collection.) directly outward in a horizontal direction, and nearly at right angles to that portion of the temporal bone lying above the zygomatic process. As previously stated, the fibrous tissue which oc- cupies the place of the bonv meatus at birth is gradually replaced by / m^^^^^^ bone, and this part of the meatus, y i^^^^^^^L which at first was movable, be- comes bony and rigid. As a re- sult, the angle between the mem- hrana tympani and the superior I -^-^ * \ ^^^H ^^'''^ '*^ ^^ canal becomes appar- / ^^jJW I y ^ij^B entlv more acute as development ' advances. The actual angle of in- clination of the membrane with the horizontal plane probably does not change to anv degree after birth. The line of demarcation between Fig. 8. — The external meatus and it and the Superior wall is morc membrana tympani of a child at ., , ^ • 11 1 -ij birth, natural size. The meatus easily made out m oldcr children has been split, and the supeiior ^^^^ adultS, OU aCCOUUt of the and inferior walls have been 1 • 1 held apart. (Author's specimen.) change taking place in the meatus. THE HONY MKATUS. I 1 At birth the su{»L"ri()r and inferior walls arc in CDiitact and must be separated in order to inspect the membrana tympani. as the specimen from which Fi^^. 8 was drawn shows. In this specimen the anterior wall of the canal was cut throuj^h. Irom just in front of the tragus to the membrana tvnij)ani. and the walls separated so that the parts could be seen and drawn. When we compare this drawing with Figs. 9 and 10, repre- senting the same region in childhood and adult life, we see at once that the formation of the bonv canal may be said to have eflected this separation and made it j>ermanent. simj>lv by the deposit of bony tissue, rendering the hbrous tube rigid. FlO. g. — External mc.itU'-, mfniiir:iii.i tym- pani, anil middle car from a child five years of age, natural size. (Aiulvr''; specimen.) Ik,. H). — ^ayittal section through ex- ternal auditory meatus, membrana tvmpani, and middle ear of an adult, natural size. (Authoi's collection.) The third portion of the temporal b(jne. the petro-mastoid part, consists of an oblique triangular osseous pyramid, the apc.x of which is directed forward and inward, while its base fills up the gap between the free margin of the squamous plate of the temporal bone and the posterior crus of the annulus tymjianicus. at the same time extending forward, so that the anterior portion of this surface lies opposite the tym- panic ring. The line of union of the mastoid portion to the external squamous plate is the mastoid squamous suture. Looking at the cranial surface, we find that the petrous portion unites 12 THE ANATOMY AND PHYSIOLOGY OF THE EAR. with the inner plate of the squama, forming the petro-squa- mous suture. It is clear from the foregoing description that the base of the pyramid is made up of the outer surface of the mastoid and of that portion of the petrous bone lying below the petro- squamous suture and opposite the tympanic ring. This last region corresponds to the inner wall of the tympanic cavity, or the fundus of the external auditory meatus, the membrana tympani having been removed. The Tympanic Cavity. — The tympanic cavity is a bony chamber the inner wall of which is formed by the external surface of the petrous portion of the temporal bone. This wall (Fig. ii) presents for inspection a rounded eminence, called the promontory, covering the first turn of the cochlea. Be- hind, and somewhat beneath the promontory, there is a niche called the niche of the round window, into which the fenestra rotunda opens. This niche looks almost directly backward, and even when the parts are most favorably dis- posed for inspection, but a very '''^vLI^,A,uhi°rs;;«ir„T''' li!"!"-'' •■'••'"- <'' «.he depression is visible. Above, in the upper and posterior portion of the inner wall, is an oval fossa, the pelvis ovalis, at the bottom of which is the oval window. In F"ig. 1 1 the stapes is in position, and fills the pelvis ovalis. The posterior wall of the pelvis ovalis is abrupt, while its anterior wall slopes gradually forward until it merges into the sur- face of the promontory. The inferior wall is longer and more precipitous that the superior wall. The lumen of the fenestra ovalis looks outward and downward. At birth the pelvis ovalis is separated from the niche of the round win- dow by a deep fossa, the sinus tvmpanicus (seen in Fig. 6), which usually disappears completelv in adult life. Above the oval window there is a distinct bonv arch formed bv the encroachment of the outer wall of the aqueductus Fallopii upon the tympanic cavitv. The facial nerve passes through this canal. Directly above this bonv ridge there is another and smaller bonv crest, caused bv the projection of the hori- zontal semicircular canal outward into the cavit\- of the THK TYMPANIC CAVirV. 1 ^ middle ear. The outer wall of the aqueductiis Fallopii is occasionally incomplete, the facial nerve bcini; then exposed in its passage through the tympanum. Behind the pelvis ovalis, at the juncture of the inner and posterior walls of the tympanum, there is a small bony pyramid, through the apex ol which the tendon of the stapedius muscle passes. The plane of the inner wall of the tympanic cavity lies more nearly in the median antcro-posterior vertical plane of the body than docs that of the tympanic ring; hence the tvm- panic cavity is broader above and posteriorly, than below and anteriorly. In front of the promontorv the inner wall is smooth and gradually merges into the tvmpanic o])ening of the luistachian tube. The anterior wall of the tympanum presents at about its centre, the tympanic orifice of the Eustachian canal. Above this, and sej)aratetl from it bv a thin bony |)late, the ])roces- sus cochleariformis. is the canal for the tendon of the tensor t\ inpani muscle. The anterior wall is separated from the in- ternal carotid aiti'iv as it jtasses through the carotid canal 1)\ a thin. Ixtia plati-. Thi- osseous lloitr of the cavit\- lies at a considerable distance below the lower margin of the t\ in- ])anic ring. It is sometimes formed of fairly compact bone, but tjuitc frcquenth it is cancellous; it is in relation with the jugular fossa, which lotlges the bulb of the internal jugular \cin, and may present dehiscences, exposing the bulb to trau- matism by instruments introduced into the meatus. The i)osteri<)r wall presents, at its junction with the inter- nal wall, the pvramid, through the apex of which the tendon of the stapedius muscle passes. The opening into the mastoid antrum lies directly above this process. The external wall of the tvnipanum is fcMined chiefly by the membrana tympani (a structure which will be described presently), by the inner surface of the tympanic ring, and above by the inner margin of the external plate of the scjuama and by the angle formed bv the separation of the inner and outer plates. It becomes evident, therefore, that the tympanic cavity is prolonged up- ward for a C(onsiderablc distance above the plane of the supe- rior wall of the meatus. This portion of the cavity is the epitympanic space or recess, or the vault of the tympanum. The portion Iving below this plane is called the atrium. The Vault of the Tyvipanuni (Fig. 12). — The epitympanic space is somewhat pvramidal in shape, the apex lying at the 14 THE ANATOMY AND 1'HVS10I.0(;Y OP^ TllK KAR. Fig 12. — The internal tympanic wall and the vault of the tympanum, with the ossicles in position. (.Au- thor's collection.) angle between the two plates of the squanui. These plates, with the adjoining portions of the petrous bone and the petro- squamous suture, complete two osseous faces of the pyramid; the remaining surface and the base are partly wanting, being represented bv the openings leading into the mastoid antrum posteriorly, and into the tym- panic cayity below. When the jiarts are in their normal posi- tion this lower surface is par- tially completed by theossicula, their ligaments, and the redu- plications of the mucous lining of the tympaniun. which shut off the upper portion of the cayity more or less perfectly from the lower part. The Ossicles (F'igs. 13 and 14). — The ossicular chain is lodged within the tympanum, and scryes to transmit and modify sound vibrations. It constitutes, in reality, a lever through which the impulses transmitted to the labyrinthine fluid are increased in intensity, but diminished in amplitude. The ossicles are three in number: the malleus, incus, and stapes. According to Rathkc" and Urbantschitsch.+ the malleus and incus are developed from one nucleus, and sub- sequently become separate bones, intimately connected at their articular surfaces, while the stapes develops from a dis- tinct centre of its own. Gradenigo :{; believes that the foot plate of the stapes springs from the capsule of the labyrinth, while the remain- der develops from the second visceral arch, the two portions subsequently uniting. The Malleus. — The malleus is the largest ossicle of the series, and consists of a head and shaft joined to each other at an obtuse angle by a constricted portion called the neck. The shaft or long process is prismatic on cross section, and tapers gradually from just below the neck of the ossicle to the tip, which is sometimes bent slisrhtlv forward in the form of a hook. * Kiemenapp. und Zungenb., 1832, p. 122. t Lehrb. der Ohrenheilk., Wien, 1890, p. 229. X Med. Jahrbuch, Wien, 1887. THi: OSSICLKS. 15 \t thf junction of the shaft w itii tlu- neck there is a proniincnt l)t)nv tuliercle called tlie short jtrocess of the malleus, which is directed forward and outward. The j)risniatic shaft i»re- sents an external border for attachment to the membrana tvmpani, an internal border directed toward the labyrinthine wall, and somewhat broad anterior and [)ostcrior surfaces. It is eviflent that anv rotation of the malleus upon the loiii^ axis 111-. i.V — ;;...■-,,,-. ,,. ,.-,, i..|.., ,,,,>. . I. < •^^icular cliain <>l Icfi car. 1, Malleus ; 2. Incus ; 3, Stapes. II. « »s>.iculus chain of right ear. I, Malleus ; 2, I'rocc-sus foiianus ; 3, Manubrium ; 4, l-ong process of incus ; 5, Short pnicess of incus ; 6, Stapes. Ill, .\nnulus tympanicus. i. Anterior tubercle ; 2, Pos- terior tubercle, (kiidinger: n!ake'> translation.) (^f the manubiiiim will alter the aj)j>arent breadth of the shaft as viewed throuirh the meatus, accordin"- as the decree of rotation brinies the brf)ad anterior or posterior surface into view, or the sharp ed^e which marks the junction of these surfaces with the antericjr border. Springing from the an- l6 THE ANATOMY AND PHYSIOLOGY OF THE EAR. terior surface just below the short process is a long, delicate, bony spicule, the processus folianus or gracilis, which lies in the Glaserian fissure, and in adult life is frequently imbedded in the fibres of the anterior ligament. The external surface of the neck of the malleus is roughened for the attachment of the external lis-ament. The anterior surface of the neck and Fig. 14. — The malleus, incus, and stapes in various positions. (Rudinger : Blake's translation.) the adjoining portion of the head are deeplv grooved for the insertion of the anterior ligament. The head is irregularly spherical in shape, the spherical contour being encroached upon posteriorly by the saddle-shaped surface for articulation with the incus, while anteriorly there is a groove for the at- tachment of the anterior ligament. THE OSSICLKS. 1 7 The Incus. — The central ossicle of the chain consists of a body and two processes. The short or horizontal process — a continuation of the body — is conical in shape and extends backward, its tip resting in a little pit or fossa in the posterior tympanic wall, just below the entrance to the mastoid antrum. This depression is called the sella incudis. The body of the bone is flattened from before backward, the vertical diameter being about double the transverse. The anterior surface, forming the base of the cone, is saddle-shaped for articulatit)n with the malleus. The long or descending ramus t)f the incus is a long, tapering bony shaft, extending downward from the antero-inferior angle (A the body ; its lower extremity is bent inward so that the tip of the process is directed toward the internal tympanic wall. This free extremity is called the len- ticular j)rocess. and articulates with the head of the stapes. The lenticular process in foetal life is represented by a sepa- rate bone, the os orbiculare. The Sfi7/>es. — The innermost ossicle of the series brings the conducting mechanism into immediate relation with the re- ceptive apparatus. As the name implies, it is stirrup-shaped, and consists of a small rounded head the external face of which is hollowed out for articulation with the lenticular pro- cess of the incus ; below the head is a constricted portion called the neck, from which the crura diverge. The posterior crus is the longer and more curved. The crura terminate in an oval or kidney-shaped plate of bone, the foot-plate of the stapes, which closes the oval window. The entire stapes lies almost wholly within the pelvis ovalis, hence when the mem- brana tympani is wanting it is well protected from traumatism from instruments introduced through the canal. The stapes lies obliquely in the oval niche, being nearer to the inferior and posterior walls of the fossa than to the anterior and supe- rior. Since the posterior wall of the niche is almost vertical, the corresponding stapedial crus lies close to it, and adhesions between this wall and the posterior limb of the ossicle are of frequent occurrence. The ossicular chain is suspended in the tympanic cavity by a series of ligaments which bind the individual members of the chain to each other and to the walls of the tympanum. Ligaments of the Malleus (Fig. 15). — These are four in number : the anterior, external, posterior, and superior or sus- pensory ligament. 3 1 8 THE ANATOMY AND PHYSIOLOGY OF THE EAR. The anterior ligament is the strongest of these. It arises from the spina tympanica major and from the walls of the Glaserian fissure, some of the fibers traversing the length of the fissure and taking their origin from the spine of the sphe- Mastoid .,. ,.^ External ligament, antrum. .Anterior ligament. Stapes. Tendon of tcii- scir tympani. Fig. 15. — The tympanum from above. (Author's specimen ) noid. From this extensive origin they pass outward, upward, and backward, and are inserted into the anterior surface of the neck of the malleus and into the depression found on the anterior surface of the head. They inclose the processus folianus of the malleus. The external ligament is somewhat fan-shaped. It springs from the external roughened surface of the neck of the ossicle, from which point the fibers diverge to be inserted into the free margin of the inner extremity of the superior wall of that portion of the bonv meatus formed by the external plate of the squama. The posterior fibres, according to Helmholtz, form a distinct band called the posterior ligament of the malleus.* This portion of the external ligament, together with the anterior ligament, forms the axis band of the hammer, since the axis of rotation of the ossicle is approximately a line drawn through the attachment of these two ligamentous structures. Tlie superior ligament is a delicately rounded band of fibrous tissue running from the tegmen tympani downward to the head of the malleus. The Ligaments of the Incus. — The incus is bound to the tympanic wall by a single fibrous band, the posterior liga- * The Mechanism of the Ossicles. Translated by Buck and Smith, New York, 1873. THi: IN rKAlYMPANIC LIGAMENTS. •9 mciit, which extends from the lateral aspects of the short process near its extremity to the posterior wall of the tym- panum. At its oriiyin it is dense in structure, owin^ to tlie somewhat limited area from which it arises. From this point the fibres diverge rapidly and divide into two bundles to be inserted into a broad area on the {)osterior wall of the tvm- panimi. On account of this broad insertion it is sometimes called the fan-shaped ligament of the incus. The inferior sur- face of the short process lies in a shallow depression in the tvmpanic wall called the sella incudis. the opposing surfaces being covered with cartilage. The Ligaments of the Stapes. — The foot plate of the stapes is contined in the oval window by the stapedio-ves- tibular or annular ligament. The margins and vestibular sur- face of the foot plate and the periphery of the oval window are covered with hyaline cartilage, the annular ligament de- veloping from the perichondrium. Interossicular Ligaments. — The malleus .•lul incus are bound titg( thir by a lo(»se capsular ligament, the articular surfaces of the ossicles bf'ing covered with cartilage. The incu(lo-'«tap(.(li;iI artiiulation is similar in character. The Eustachian Tube. — Having traced the bony and car- tilaginous framework of the conducting mechanism inward 'V^ V w »-rfi^ •op Fin. i6. — Seciioii liirooj^li iaaj>ioui. tympanum, and Eustachian tube, (rolilzer.) W, W, Mastoid cells; mt, Mcmbrana tympani ; an, Antrum ; n. Vault of tym- panum ; it. Isthmus of tube ; te. Eustachian tube ; op, Pharyngeal orifice of tube. to the point where it joins the receptive portion of the audito- ry apparatus at the oval window, we have next to consider the characteristics of that passage by means of which certain delicate parts of this system can be protected by a fibrous 20 THE ANATOMY AND PHYSIOLOCxY OF THE EAR. covering- without interferinof with the transmission of sound waves. By means of the canal now to be described an equal atmospheric pressure is maintained upon either side of this protecting septum. This passage is the Eustachian tube. It is made up of two portions — the tympanic or bony, and the pharyngeal or cartilaginous portion — their point of junction being called the isthmus of the tube. The osseous segment is about half an inch in length, and, extending from a somewhat wide orifice just above the middle of the internal wall of the tympanum, narrows quickly as it passes down- w^ard, forward, and inward through the substance of the pe- trous portion of the temporal bone, until at the isthmus its diameter varies from one twenty-fifth to one twelfth of an inch. The canal is irregularly triangular in shape, the verti- cal diameter being double the transverse. This osseous tube is joined at the isthmus to the cartilaginous portion by fibrous tissue, the parts uniting at an obtuse angle, the opening of which is directed downward and forward. The pharyngeal portion measures about an inch in length, and at the isthmus its lumen corresponds to that of the osseous channel. As it extends downward into the pharynx, however, it grows wider, and at the pharyngeal orihcc measures from one eighth to one Hfth of an inch in diameter, the vertical diameter being greater than the transverse. This portion of the canal is fibrocartilaginous. The posterior wall is formed by a plate of cartilage, the upper border of which is bent first , _ ,^ forward and then downward, so that a transverse section would be hook- shaped (see Fig. 17). The space in- closed by the bending forward of the cartilage forms the superior portion of the lumen of the tube, the interval be- tween the free margin of the angular portion and the lower border of the cartilaginous plate being filled with Fig. 17.— Transverse sec- fibrous and miiscular tissue, thus com- tion of Eustachian tube. i .• ,i i ttt .i r (After Zuckerkandi.) pletmg the canal. We sec, therefore, that the posterior, superior, and a small portion of the anterior wall of the tube is cartilaginous, while the remainder of the anterior and entire inferior wall is fibrous, the passage being slitlike rather than circular on cross THK MEMBRANA TVMl'ANI. 21 section, with the anterior and posterior walls in contact except at the up[)er part. The membranous tube is attached to the inner extremity of the bonv canal, the posterior cartilaginous plate uniting with a prt)longation of the corresponding bony wall. Bevond the isthmus the tube is suspended from the base of the cranium bv fibrous bands passing to its superior wall, until it terminates in the lateral aspect of the pharyngeal vault. As described in the foregoing pages, the conducting mechanism consists of a canal, the walls of the central por- tions being osseous, while at either extremity thev are Hbro- cartilagin(jus, communicating u[)on one side with the outer surface of the body directly, while upon the other this com- munication is effected indirectly through the oral and nasal passages. This tube is brought into intimate relation with the receptive mechanism through the agency of the ossicular chain, and at this point the osseous conduit is dilated, forming the tympanum. This chamber, situated midway in the pas- sage, is occupied by a special device for bringing the two j)ortions of the auditory apparatus into relation with each other. For the protection of the intratvmpanic parts chieilv, and, to a certain extent, to aid in the transmission of sonorous impulses, a hbrous partition divides the external auditory meatus from the tymjtanum and Kustachian tube. This parti- tion constitutes the membrana tynijiani. The Membrana Tympani. — The membrana tympani con- sists of a transverse librous septum, lying in the middle of the conducting tube, and bounded by the tympanic ring, which, it will be remembered, is incomplete at its uj)per i)art. This connective-tissue lamella, called the substantia propria of the drum membrane, is inserted into the sulcus tympanicus. At the point of insertion the fibrous tissue is somewhat thick- ened, formincr the annulus tendinosus, sometimes called the cartilaginous ring. From the cartilaginous ring certain connective-tissue fibres extend outward to the periosteum of the meatus, while others, passing in the opposite direction, merge into the periosteal lining of the tympanum. The sub- stantia propria is made up of two layers. In the outer layer the fibres radiate from the tip of the malleus toward the peripheral wall, while in the internal layer they are disposed in concentric circles about this point as a centre. The manu- brium of the malleus joins the substantia propria through the 22 THE ANATOMY AND PHYSIOLOGY OF THE EAR. interposition of a thin cartilaginous lamella which extends along its outer border from the processus brevis to the umbo, the fibres of the membrane being continuous with the peri- chondrium of this cartilaginous plate. At the tip of the manubrium both the circular and radiating fibres are attached directly to the ossicle, while above this point, along the ex- ternal border, the attachment is effected through the interpo- sition of the cartilaginous plate above described. This carti- lage is firmly fixed at the tip of the manubrium, while the attachment at the short process is less firm and permits of a certain amount of separation from the short process. The superior border of the lamina propria joins the anterior and posterior extremities of the annulus tympanicus, constituting a tense, fibrous band, divided by the short process of the mal- leus into two parts. The sharply defined superior margin of the membrana propria extending from the processus brevis to the posterior extremity of the annulus is called the posterior fold The corresponding anterior fold is less prominent and shorter than the posterior. From the description it will be observed that the fibrous septum stretched across the canal is wanting where the curved outline of the annulus is com- pleted by the auditorv plate of the temporal bone. This space is the Rivinian segment or notch, and its closure will be explained later, since it is effected by the cutaneous lining of the external auditorv meatus. The Epithelial Investment of the Conducting Apparatus. — The auricle is covered with integument which is continuous with that of the face. It is somewhat loosely attached upon the posterior surface, but upon the anterior aspect is applied closely to the cartilage, the deep layer being intimatelv asso- ciated with the perichondrium. The tegumentar}' covering of the auricle is continued into the external auditory meatus, its thickness decreasing as we pass inward, until in the bony canal its deep layer forms the periosteum. The cutaneous lining of the meatus along the supero-posterior wall is thick- er and more loosely attached than elsewhere, and is richlv supplied with blood vessels. The covering of the superior wall of the canal passes from the internal margin of the audi- tory plate to the neck of the malleus, just above the short process, filling up the Rivinian notch and completely sepa- rating the external meatus from the tvmpanum. In com- parison with the remaining portion of the membrana tym- THK F.PIIIIELIAL INVKSTMENT. 23 pani, it hangs somewhat U)oselv from the canal wall, and is called the membrana tlaccida, or Shrapnell's membrane. Its fibrous layer is particularlv well developed along the anterior and posterior borders, causing it to assume a somewhat tri- angular shape. These distinct fibrous bands constitute the fibres of Prussak. They extend from the anterior and pos- terior extremities of the Rivinian segment to the base of the processus brevis, and, passing along the manubrium, are lost in the external layer of the membrana propria. The space between the anterior ligament and the membrana flaccida is called Prussak's space. The epithelial covering of the meatus continues over Shrapnell's membrane, and covers completely the external surface of the drum membrane, forming: its ex- ternal or epithelial layer. The auricle, the meatus, and the superficial layer of the membrana thus constitute an elon- gated blind pouch, not unlike the finger of a glove, the drum membrane answering to the closed tip of the glove finger. The integument of the auricle is supplied with sweat glands and sebaceous follicles. In the region of the tragus and antitragus, and for some distance within the cartilaginous canal, hair follicles arc frequently found. The sebaceous glands in the meatus are somewhat altered in structure, con- stituting the ccruminous glands. These are not distributed beyond the junction (jf the cartilaginous meatus with the osseous portion, except for a small area along the u[)per and posterior wall, where thev encroach slightly uj)on the bony canal. The glands are larger ui)on the upper wall of the canal, and are most numerous at the junction of the bony with the fibro-cartilaginous porti( ui. The tvmj)anum and Eustachian tube are lined with mu- cous membrane continuous with that of the naso-pharynx. This membrane extends outward through the tube, covering its walls and forming the lining of the tympanum. It passes over the internal surface of the membrana tympani. constitut- ing its internal layer ; in various localities it is folded upon itself as it passes over the various intratympanic structures, giving rise to the so-called reduplications of mucous membrane within the tympanum. The most constant of these reduplica- tions constitute the anterior and posterior pockets of the mem- brana (Fig. 18). while other folds whose location and disposi- tion are not as constant are also met with. The lining in the cartilaginous portion of the Eustachian tube is thick and loose- 24 THE ANATOMY AND PHYSIOLOGY OF THE EAR. ly attached, being thrown into longitudinal folds in the lower part. In the osseous tube and tympanum it is closely applied to the underlying structures constituting the periosteum. The epithelium is of the cylindrical ciliated variety in the tube and in the lower portion of the tympanic cavity, according to Po- litzer,* it changes to flat, ciliated epithelium above. The mucous membrane is supplied with mucous glands, which are extensively developed in the cartilaginous tube near the pharyngeal orifice, and diminish in number in the bony tube and tympanic cavity. In the middle ear they are mostly confined to the tubal orifice, although they are occasionally found over the promontory. The membranous portion of the Eustachian tube is quite richly supplied with lymphatic tissue, which occurs both in the diffuse form and, aggregated into masses, in the form of true lymphatic nodules. To these Gerlachf gives the name of tubal tonsil. The presence of this lymphatic tissue has also been demonstrated by Sappey,:|: Ostmann,* and Teutleuben.| The Pockets of the Metnbrana Tympani and other Reduplica- tions of the Mucous Membrane (Figs. i8 and 19). — The pockets of the membrana tympani are the most constant of the re- FlG. 18. — 1 he pockets of Fig. ig. — The malleo- incudal the membrana tym- articulation covered by the pani. (After Zuck- superior malleo-incudal fold, erkandl.) (After Zuckerkandl.) duplications which the lining of the cavity forms. The mu- cous membrane lining the tympanum is attached firmly to the drum membrane, to the bony internal wall, and to the walls of the irregular spaces which lie between the membrana tym- pani and the structures contained within the middle ear and in immediate relation with the membrane. After being re- flected over the contiguous bony and ligamentous parts it * Lehrb. der Ohrenheilk., Wien, 1S93, p. 28. f Arch, fiir Ohren., vol. x, p. 53. \ Traitd d'anatomie descriptive, Paris, 1877, p. 865. * Virchow, Archiv, vol. xxxiv. \ Zeit. fiir Anat. und Entwicklungsgeschichte, 1876, vols, iii and iv, p. 298. INTRATVMl'ANIC FOLDS. 25 hangs downward into the tympanic cavit\' in folds somewliat like a curtain. The free borders of these folds are sharj)ly marked and constitute the folds of the pockets. The anterior fold lies in front of the malleus, and the posterior behind it. The anterior pocket is the space included between the neck of the malleus behind, the annulus tvmpanicus in front, the membrana tympani on the outer side, and the spina tym- panica major and the anterior ligament on the inner side. At its apex it sometimes communicates \yith the chamber of Prussak. The posterior pocket is larger, and is traversed by the chorda tympani nerve and the posterior ligament of the malleus. Its free border — the posterior fold — may extend downward as far as the middle of the manubrium. This is a point of practical importance in middle-ear operations, since after the division of the membrana tympani, this fold, if ex- tensive, mav completely hide the incus, to the l(-)ng process of which it is frequently firmly attached. 1 have met with this condition several times, and unless one remembers the possi- bility of such an anomaly, its j)resence may prove a source of annoyance. In one case of exploratory tympanotomy per- formed under local anctsthesia. the posterior fold was long, thick, and adherent to the descending arm of the incus and to the membrana tymj)ani. An incision through the mem- brana, instead of exposing the incud()-staj)edial articulation, brousfht into view a thick vascular lamella of mucous mem- branc which demanded repeated incision before the long arm of the incus could be recognized or the inner wall of the tym- panum seen. In another instance the fold was thin, but in- vested the incudo-stapedial articulation and long arm of the incus so completely that exploratory tympanotomy revealed, immediately after displacement of the flap, nothing but a smooth, glistening surface, which appeared to be the inner wall of the middle ear. No landmarks could be made out; a fact which showed that the inner tympanic wall had not been exposed, and it was not until the mucosa was divided by a vertical incision that the promontory and the niche of the round window could be seen. In acute inflammatory condi- tions I have seen exudation encapsulated in the tympanum on account of an anomaly in the posterior pocket. The boun- daries of the posterior pocket will be made clear by bearing in mind those of the anterior space, its exact analogue. The other mucous folds within the tymjianum will not be 26 THE ANATOMY AND PHYSIOLOGY OF THE EAR. described in detail on account of their endless variety, but a general account of their usual position and direction is neces- sary, since their presence is often of great importance both as affecting the outcome of inflammatory processes within the tympanum, and increasing the difficulty of certain operative procedures. These folds differ from the true ligaments only in their density. They have been extensively studied by Blake,* Bryant, f Zuckerkandl,:}: and others. In general they may be classified, according to their direc- tion, as vertical or horizontal, and according to their situation, as those radiating from the axes of the long bones, those dis- posed about the stapes and the adjoining tympanic walls, and those stretching from the ossicular ligaments and the tendons of the intratympanic muscles to the ossicles and to the tym- panic walls. The horizontal folds may completely shut off the vault of the tympanum from the atrium, and the vertical folds may be so extensive as to inclose the entire ossicular chain except the manubrium of the malleus. The horizontal folds exert an important influence on acute and chronic inflammatory processes within the middle ear, their presence favoring the invasion of the mastoid process and cranial contents. The vertical folds not only act as ob- structors to the conduction of sound by their weight and by the increased tension which they cause, but are of great an- noyance to the surgeon in the performance of delicate opera- tions upon the tympanum, as they may completely hide important structures. Their presence, therefore, should be borne in mind in the consideration of all pathological pro- cesses within the middle ear, as in this way many appear- ances which are otherwise inexplicable may be correctly interpreted, or an operator may be able to accomplish an end which a hasty view of the cavity had led him to believe would be impossible. It need only be remembered that no hard-and-fast rule can be given for their location, and that almost any of the folds may occur together. The Muscles. — The muscles of the conducting mechanism include those passing from the auricle to the skull, the in- * Arch, of Otol., vol. xix, p. 209. f Ibid., p. 217. Burnett's System of Diseases of the Ear, Nose, and Throat, Philadelphia, 1893, vol. i, p. 55. X Schwartze's Handbuch der Ohrenheilk., Halle, 1893, vol. i, p. 21. THE MUSCLES. 2/ trinsic muscles of the auricle and canal, the intratvmpanic muscles, and those in the walls of the Eustachian tube. The auricle is bound to the skull posteriorly bv the mas- toid fascia, the fibres of which interlace with the perichon- drium and fibrous tissue of the canal, and anteriorly by the temporal fascia, which is firml)- attached to the helix. The extrinsic muscles are three in number, and are unim- portant in man, though in some of the lower animals they reach a high degree of deyelopment. They are the rctrahens aurem, attollens aurem, and attrahens aurem. The retraliens arises from the mastoid region by short aponeurotic fibres, and is inserted into the cartilage of the auricle upon its posterior and inferior aspect. Its point of origin is fixed only when the occipital portion of the occipito- frontalis is rigid. The attrahens arises from the epicranial aponeurosis at its lower border, and is inserted \\\Uy the spine of the helix upon its cranial surface. The at to/lens arises from the occipito-frontalis aponeuro- sis. The fibres converge to the point of insertion upon the upper part of the cranial surface of the auricle. The intrinsic musc/es consist of poorly developed bundles of muscular fibres distributed between the various cartilagi- nous processes oi the auricle. Theoretically, their action would serve to alter the shape of the ])inna, but from their imperfect development they are unimportant. They are situated chiefly upon the external surface of the organ. In the external meatus a few fibres of muscular tissue are found mixed with the fibrous bands which fill the incisures of San- torini. A muscular slip is occasionally found extending from the styloid process upward to the cartilaginous meatus. The intratyvipanic muscles are the tensor tympani and the stapedius. The tensor arises from the upper wall of the cartilaginous Eustachian tube and from the walls of the bony canal which inclose it. It enters the middle ear through an osseous con- duit at a point just above the tympanic orifice of the Eu- stachian tube, from which it is separated by a thin plate of bone — the processus cochleariformis. The tympanic extrem- ity of this process is pyramidal in shape, and is often called the anterior pyramid. The tendon winds about this projec- 28 THE ANATOMY AND PHYSIOLOGY OF THE EAR. tion almost at a right angle, crosses the cavity of the middle ear, and is inserted along the inner border of the shaft of the malleus just below the neck, some of the fibres passing for a considerable distance down the manubrium, and spreading somewhat upon its anterior surface. The stapedius arises from the interior of the pyramid found upon the postero-internal tympanic wall in front of and below the aqueductus Fallopii. The fibres converge into a tendon which pierces the apex of the pyramid and is inserted into the neck of the stapes at the point of union with the posterior crus. The muscles of the Eustachian tube are the tensor palati, or spheno-salpingo-staphylinus, and the levator palati, or petro- salpingo-staphylinus. The tensor palati exerts the most influence upon the lumen of the Eustachian canal. It arises from the scaphoid fossa and spine of the sphenoid bone in front of the membranous portion of the tube, some of its fibres springing from the in- ferior border of the cartilaginous hook. The muscle then passes downward in front of the membranous portion of the canal, converging into a tendon which winds around the hamular process of the sphenoid and expands into a broad aponeurosis which is inserted into the anterior surface of the soft palate and into the posterior bony margin of the hard palate, the fibres uniting with those of the opposite side in the median raphe. The levator palati springs from the quadrilateral surface on the inferior aspect of the petrous bone, near its apex, and passes downward, forward, and inward to its insertion on the posterior and superior surface of the soft palate. The body of the muscle lies along the inferior margin of the cartilagi- nous plate which forms the posterior wall of the tube, to which it is loosely attached. It is also in contact with the fibrous inferior wall. A third muscle, sometimes included in this group, is the salpingo-pharyngeus, a muscular slip, which runs from the body of the palato-pharyngeus upward and forward to be inserted into the inferior wall of the tube. The Arteries (Plate I) of the conducting apparatus are de- rived chiefly from the external carotid artery, although a few branches spring from the internal carotid. The branches of the external carotid supplying the auricle, canal, and middle PLATE The Artkrial Supi-ly of the Conductinc Ai'Pakatus. THi: ARTERIES. 29 ear are the posterior auricular, the superficial temporal, the occipital, the internal niaxiliarv. and the ascendin^^ pharyn- geal. The posterior auricular is distributed to the posterior por- tion of the auricle and the corresponding- part of the meatus. Through the stylomastoid branch which enters the stylo- mastoid foramen it supplies the mastoid cells, and sends a special branch to the stapedius muscle and to the stapes. It anastomoses with the superficial petrosal of the middle me- ningeal artery within the tympanic cayity, and w ith the tym- j)anic branch of the internal maxillary, forming with this lat- ter a complete yascular circle about the inner extremity of the meatus. The superficial temporal, through the superior and infe- rior anteritjr auricular arteries, supplies the anterior j)ortion oi the j)inna and canal, the vessels anastomosing with the branches of the posterior auricular artery; it also sends a small branch to the tympanum through the Glaserian fissure. The occipital artery sends branches to the concha, the ves- sels entering upon its cranial surface. Thi internal tnaxillary, through the middle meningeal and tympanic branches, is the most important source of blood supply, especially in early life. Before entering the cranium it sends a few twigs to the Eustachian tube. Within the skull it gives off the superficial petrosal, which enters the tympanum through the petro-squamous suture, and is dis- tributed to the roof of the middle ear, to the malleus and incus, and to a portion of the internal tympanic wall, where it anastomoses with the labyrinthine vessels, according to Politzer.* Within the Fallopian canal it communicates with the stylomastoid branch of the posterior auricular. The tympanic branch of the internal maxillary enters the middle ear through the Glaserian fissure, supplying the ante- rior portion of the cavity, and anastomoses with the stylo- mastoid branch of the posterior auricular upon the periph- ery of the tympanic membrane. In early life this artery is much larger than the stylomastoid, and the vascular circle about the margin of the membrane from which the numerous vessels pass outward to the posterior wall of the meatus seems to spring from the tympanic branch of the internal * Archiv fiir Ohrenheilk., vol. xl, p. 237. 30 THE ANATOMY AND PHYSIOLOGY OF THE EAR. maxillary ; hence this artery is sometimes called the auricu- laris profunda. On the internal wall of the middle ear the tympanic artery anastomoses with the tympanic branches of the internal carotid and with the Vidian branch of the internal maxillary. In ad- dition to the two branches of the internal maxillary named above, the Vidian, the descending palatine, and the pterygo- palatine arteries, all springing from this trunk, send small vessels to the Eustachian tube and to the tubal muscles ; the descending palatine anastomoses freely with the ascending palatine branch of the facial and with the ascending pharyn- geal branch of the external carotid artery. In its passage through the carotid canal the internal carotid sends branches to the tympanum, which anastomose with the tympanic and Vidian branches of the internal maxillary. The Veins (Plate II). — The veins are rather irregular in their distribution, but in general follow the course of the arter- ies. Most of the vessels from the deeper regions form a plexus upon the superior and supero-posterior walls of the external auditory meatus ; as they approach the orifice of the meatus the various venous channels anastomose freely with one an- other. Those on the posterior aspect of the canal and auricle pass into the external jugular and mastoid veins, while the an- terior branches go to join the temporal and facial veins. Some of the deeper vessels pass into the pterygoid plexus. The veins of the Eustachian tube follow the course of the arteries distributed to this region, and empty into the internal jugular directly, or occasionally communicate with the facial, the lingual, or the superior thyroid veins. Between the internal pterygoid muscle and the adjacent wall of the tube a trunk of considerable size establishes communication with the cavern- ous sinus ; near the pharyngeal orifice of the Eustachian ca- nal there is, according to Zuckerkandl,* a venous plexus com- municating with the turbinated bodies in the nasal cavities. The free anastomosis of the veins which return the blood from the deeper portions of the conducting mechanism is of particular importance from a therapeutic point of view, since this intercommunication between the various channels is comparatively superficial, and enables us to relieve deep- seated congestion by phlebotomy. The combined area of * op. cit., p. 38. PLATE II. Tin: Venous .Sijppi.y of thf. Conducting Apparatus. THE LYMPHATICS AND NERVES. 31 the veins is much greater than that of the arteries — a fact which in itself tends to cause the spontaneous resolution of anv inflammatory process which may arise. Within the tym- panum the circulatory arrangement is somewhat unique, the capillaries being very short, or entirely wanting, and the arterial blood passes directly into the veins without the inter- position of the capillary system, as demonstrated by Prussak.* The Lymphatics. — The lymphatic channels are freelv dis- tributed and anastomose both with the superficial lymph glands and with those forming the submucous lymphatic system of the pharynx. The superficial lymphatics over the mastoid, the lymph nodules in front of the auricle, and those situated in the cervical region between the platysma and the sterno- mastoid muscles are all intimately associated with the lym- phatic channels of the meatus and tympanum, while free Ivmphatic anastomosis exists in the opposite direction through the medium of the glands situated in the lateral pharyngeal walls. The Ivmph channels of the membrana tvmpani itself are arranged in three systems, one for each layer. These communicate freelv with each other and with the lymj)hatic network of the external meatus. The Nerves (Figs. 20 and 21). — The muscles of the con- ducting apparatus derive their innervation from the trigem- inus, the facial, and the cervical plexus. The cervical plexus, through the occipitalis minor, supplies the attollens aurem ; the trigcuiiuus, through the otic ganglion, supplies the tensor tympani and the tensor palati muscles ; the facial supplies the other muscles, either directly or through its ganglionic communications. The sensory nerves are derived from the cervical plexus, trigeminus, pneumogastric, and the glosso-pharyngeal trunks. The aiiriculo-temporaL a branch of the trigeminus, supplies the auricle, the upper part of the meatus, and the membrana tympani. The auricularis uiagniis, from the cervical plexus, is distributed principallv to the posterior part of the auricle and meatus, anastomosing with the auricular branch of the pneumogastric upon the posterior wall of the canal. The auricular branch of the vagus supplies the cartilagi- nous canal and a portion of the posterior surface of the auricle. The tympanic branch of the glosso-pharyngeal enters the mid- * Archiv fiir Ohrenheilk., vol. iv, p. 2go. 32 THE ANATOMY AND PHYSIOLOGY OF THE EAR. die ear through a foramen in the floor of the cavity, and is distributed to its lining membrane and to the Eustachian tube. Upon the internal tympanic wall it divides. One branch anastomoses with the fibres of the carotid plexus from the sympathetic system, forming the tympanic plexus ; an- other nerve twig, the small deep petrosal, passes through a bony foramen in the tegmen tympani to the small superficial petrosal nQTwc, which is the facial tributary to the otic ganglion ; a third emerges from the cavity to join the great superficial petrosal, which is the facial root of the Vidian nerve, the pos- terior branch of Meckel's ganglion. This branch is called the great deep petrosal. Briefly, we may describe this complex nervous anastomo- sis as follows : The glosso-pharvngeal, through its tympanic Fig. 20. — The nerves of the conducting mechanism, and tlieir anastomotic brandies. branch, anastomoses with branches from the carotid plexus, upon the internal wall of the middle ear, forming tiie tym- panic plexus ; from this plexus two branches are given off, one communicating with the otic ganglion, the other with Meckel's ganglion. We have yet to mention the chorda tympani, which, emerg- ing from the aquaeductus Fallopii above the p3^ramid, crosses the tympanic cavity from behind forward, passing between the long process of the incus and the manubrium of the malleus. It leaves the middle ear through a separate canal which lies THE RKCEPTINE MECHANISM. 33 close to the Glaserian fissure, and joins the lingual branch ot the trigeminus. It can not but be noticed how richly the conducting ap- paratus of the ear is sujiplied with nerves, especially in the deeper and more delicate parts. More will be said upon this subject in considering the physiology of the conducting mech- FlG. 21. — The nerve distribution within the tympanum. anism. but the free anastomosis between the various nerves should be particularly borne in mind, for it is due to this fact that changes within the external or middle ear or Eustachian tube may give rise to remote symjitoms, and that these re- gions may themselves be the seat of reflex disturbances. • 11. The Rkcki'tive iMechamsm. We have now described that part of the ap|)aratus of audition, concerned in the transmission of sonorcjus vibrations from without, to the point where they are brought into im- mediate relation with the end organ of the auditory nerve. Let us next consider the structures concerned in the inter- pretation of these sonorous vibrations. For reasons already given, we include under this general term, not only the internal ear, but also the auditory nerve and its centers of oriofin, as well as the various avenues of communication with other centers, and with the correspond- ing nuclei of the opposite side and with the cortical area of audition in the brain. 4 34 THE ANATOMY AND PHYSIOLOGY OF THE EAR. For convenience of description, the course of the auditory nerve will be followed from the specialized end organ found in the labyrinth, inward toward its origin, rather than in the opposite direction, which would be more strictly correct from an anatomical point of view. The internal ear comprises the osseous and membra- nous labyrinth, the former being a series of communicating chambers tunneled in the petrous portion of the temporal bone and filled with fiuid, in which the membranous labyrinth is suspended. This latter structure consists of a series of membranous tubes, also filled with fluid, called the endolymph. They follow the general contour of the osseous passages in which they lie, but do not completely fill them, the interven- ing space being occupied bv the perilymph. The Bony Labyrinth (Fig. 22). — The bony labyrinth may be described as a central chamber in the petrous portion of Flc. 22. — rhe bony labyrinth. (Riidinger, Blake's translation.) i, Round window; 2, Lamina spiralis ossea ; 3, t)sseous cochlear canal ; 4, Floor of internal audi- tory meatus ; 5, Vestibule ; 6, 7, 8, 9, Semicircular canals. the temporal bone, called the vestibule, from which various tortuous channels diverge. This central chamber is ovoid in shape, the vertical diameter being the greater and measur- ing about one fourth of an inch, while the short diameter is THE HONY LABYRINTH. 35 about one fifth of an inch. On its outer wall it presents a kidney-shaped opening, which under normal conditions is closed by the foot plate of the stapes. The inner wall ex- hibits two fossa:?, separated by a bony spine called the crista vestibuli. The anterior depression, which is occupied bv the saccule, is the recessus sphericus; the posterior, lodging; the utricle, is the recessus ellipticus. The posterior wall presents the openins^s of the three semicircular canals; these opcning^s are five in number, two canals, the superior and ])ostcrior entering the vestibule by a common channel. The entrance to the cochlear canal takes the place of the anterior wall of the vestibule. On the inferior internal wall, close to the border of the recessus ellipticus, there is a small opening, the orifice of the acjuieductus vestibuli. Through this channel the cav- ities of the membranous labvrinth communicate with the subdural space. The simicirciilar canals are three in luimber. and are so disposed that the j)lane of each canal is perpendicular to that of the other two; thev are denominated the sujierior, posterior, and external canals. The superior lies in the ver- tical plane of the long axis of the j)etrous portit)n of the tenijioral bone. The posterior is placed at right angles to this, and is also vertical, while the external canal lies in the horizontal |>lane. As the name implies, each of these bony passages bends upon itself to form a semicircle, the point of origin and termination being the vestibule. The superior and posterior canals terminate in this cavity by a common opening, but with this exception each communicates with the vestibule bv two openings, one of which may be considered the source and the other the terminus. Where the outer ex- tremity of the external canal enters the vestibule the lumen of the passage becomes dilated, forming what is known as an ampulla. The unioined vestibular extremities of the posterior and superior canals arc also ampullatcd. The Cochlea. — The entrance of this passage lies at the anterior and inferior aspect of the vestibule. It consists of a bonv tube coiled two and a half times about an osseous axis — the modiolus. From the modiolus a thin septum of bone — the lamina spiralis — made up of two thin bony plates, ex- tends into the lumen of the tube, partially dividing it into two channels. This bonv partition does not extend com- pletelv across the canal to the outer wall, the intervening 6 THE ANATOMY AND PHYSIOLOGY OF THE EAR. space being bridged by a membranous septum, which com- pletes the division of the cochlear tube. This fibrous septum is called the lamina spiralis membranacea. The lamina spi- ralis at its free border divides into a superior and inferior limbus. The space inclosed by this separation is called the sulcus laminae spiralis. At the apex of the cochlea the par- tition which divides the canal into two distinct channels is incomplete ; the termination of the septum is somewhat hook-shaped, forming the hamular process, while the passage of communication between the superior and inferior spaces is called the helicotrema. The terminal half-turn of the coch- lea forms the cupola, and in this region the lamina spiralis ossea, just before its termination, is twisted upon itself in such a manner as to inclose a funnel-shaped space called the infundibulum. The modiolus is traversed by numerous canals, the larg- est running through its axis and named the canalis cen- tralis modioli, from which secondary channels diverge into the lamina. At the junction of the modiolus with the lamina a canal ascends spirally between the layers of this bony sep- tum, passing to the very apex of the cochlea. This is called the canalis spiralis modioli. The lamina spiralis ossea, with the membranous lamina, divides the bony cochlea into two passages, as already stated. The lower is called the scala tympani, the upper the scala vestibuli. The modiolus and the lamina are so disposed that the scala tympani does not communicate with the vestibule, but leads into the tym- l)anic cavitv at the round window. In fact, we may consider the cochlear canal as beginning at the fenestra rotunda, at the inferior external angle of the vestibule, the wall at this point forming the modiolus. As the first turn passes forward and then upward from the round window, the contiguous walls of the tube and of the vestibule amalgamate and form a partition extending into the tube, which divides it into two channels, the upper of which communicates with the vestibule. The bonv partition thus formed does not extend entirely across the tube, and the septum is completed by the membranous spiral lamina. Just beyond the round window in the floor of the scala tvmpani a narrow canal extends to the inferior sur- face of the petrous bone. This is the aqutcductus cochleae, and can be traced to the subarachnoid lymph space; it affords an avenue of communication between the perilymph and the THK MKMHRANOrS I.AnVRINTH. 37 intracranial Ivmph sac. After the lamina spiralis ossea sepa- rates into two thin plates of bone, each is continued as a membranous septum as far as the outer wall of the cochlea. Here, by their divergence, thev inclose a triangular space, which extends from the round window to the apex t)f the cochlea, in a spiral direction ; this space, converted into a tube by the outer wall of the cochlea, is called the cochlear canal or scala media. Where the diverging septa join the outer bonv wall of the cochlea the periosteum is thickened and richly supplied w^ith blood vessels, especially where it joins the lower lamella, where it is called the ligamentum sj)irale. That portion of the membranous septum which is con- tinuous with the inferi(jr lamella of the osseous spiral lamina passes outward in the same jtlane as the lamina spiralis ossea, and becomes the membrana basilaris. The up|)cr leaflet forms an acute angle with this, and is called the membrane of Reissner. The manner of formation and the course of the various channels having been described, we have next to consider the lining membrane. The walls of the osseous canals and vestibule are ccjvered bv delicate tibrillated connective tissue rich in nuclear ele- ments ; this is applied closely to the osseous walls, constituting the periosteum. Its surface is covered with flat endothelial cells. The lumen of the bonv semicircular canals or peri- Ivmphatic space is traversed by delicate bands of the con- nective-tissue covering of the osseous walls, which pass to the outer wall of the membranous canals, thus dividing the peri- Ivmphatic space irrcgularlv. At the point of attachment of the membranous canals to the walls of the passage their lin- ing membrane is thickennl. The Membranous Labyrinth (Fig. 23). — The membranous labyrinth consists of a series of tubes, formed of delicate con- nective tissue, lying within the bony channels already de- scribed. The membranous simicircular canals terminate in the utricle, which lies in the recessus ellipticus vestibuli. while the membranous cochlea is joined to the saccule by a very narrow canal, called the canalis reuniens Hensenii. This entire series of tubes is filled with a clear fluid known as the endolymph. Thus far we have described two series of channels, contain- ing fluid, terminating in somewhat spherical chambers — the utricle and saccule. The membranous cochlea terminates in 38 THE ANATOMY AND PHYSIOLOGY OF THE EAR. a blind pouch (the lagena) at the apex of the bony passage in which it lies. From the adjacent aspects of the utricle and saccule a delicate canal is given off which coalesces into a common channel — the ductus endolymphaticus. This trav- erses the aqureductus vestibuli and terminates in a blind sac (the recessus of Cutogno) upon the posterior surface of the petrous bone beneath the dura. According to RUdinger,* the endolymph may pass to the dural lymph spaces through this canal. The saccule and utricle lie upon the internal wall Fig. 23. — Adult membranous labyrinth (osmic-acid preparation). (Retzius.) /, La- gena ; lis. Spiral ligament ; mb. Basilar membrane ; sv. Stria vascularis ; mts, Membrana tympani secundaria ; esc, Canalis reuniens ; s. Lower end of saccule ; ctis, Canalis utriculo-saccularis ; dr. Ductus endolymphaticus ; j/, I'osterior utricu- lar sinus ; rec, Recessus ufriculi ; aa, at', ap, Ampullne of anterior, external, and posterior canals ; vb. Vestibular cul-de-sac : ca, cc, cp. Semicircular canals ; ss. Union of posterior and superior canals ; rb, rap, rs, rti, raa, rac. Branches of auditory nerve to various portions of membranous labyrinth ; ms. Macula acus- tica of saccule ; f. Facial nerve. of the bony vestibule, but do not fill the cavity completely, considerable space being left between them and the outer wall. The intervening space is filled with perilymph, and is called the cisterna l^-mphatica. It is of practical importance to remember that the distance from the inner surface of the foot plate of the stapes to the opposite wall of the membra- nous labyrinth is about three millimetres, or one eighth of an inch. In the same manner the lumen of the bony cochlea * .\rch. fiir Ohrenheilk., vol. xxvii, p. 222. THE SACCLL1-: AND U FRICLK. 39 and semicircular canals is not completely filled bv the con- tained membranous structures; these latter are attached to the bony walls along the line of their convexity, and the periosteum is thickened along this line. Additional support is aftorded the semicircular canals bv bands of connective tissue which pass from the outer wall of the membranous channel to the osseous walls. Regarding the microscopical structure of the membranous labyrinth, it may be described as made up of a framework of connective tissue, the outer surface being covered by a reflec- ti\ tb. Basilar membrane ; lis, Spiral ligament. latter series supports two or three of the external fibres of Corti. Beyond the outer rods there are found from three to five rows of hair-cells, of the same general structure as those observed in the zona perforata. They rise, however, almost perpendicularly from the basilar membrane, thus leav- ing a space between the outer rods and the inner row of hair cells, known as Nuel's space. The rows of outer hair-cells are separated from each other by the cells of Deiters. These are broad at their base, but narrow as they approach the sur- face, and are marked along their inner border by a bright line which runs the entire length of the cell from the upper to the lower extremity. The upper extremity of this bright line, called the supporting fibre, terminates in a delicate lamella or phalanx; the contiguous phalanges form by their THE MKMHRANK OF CORTI. 43 union a reticular membrane, throu<;!i the interstices of which the outer hair-cells project. Beyond the cells of Deiters the epithelium again becomes columnar, forming the outer sup- porting cells, beyond which it resumes gradually the form found in the zona pectinata. The membrana reticularis is formed bv the union of the phalanges of the supporting fibres of Deiters's cells; its outer limit is poorly defined. It passes inward from the inner row of Uciters's cells to the summit of Corti's arch, to which it is attached. The Meinhrani' of Corti, or Mcmbraua Tcctona. — This is a gelatinous membrane arising from the upper border of the sulcus spiralis internus, just below the attachment of Reissner's membrane, and extending outward, over the papilla acustica. beyond the outer row of Deiters's cells; it is intimately con- nected with the hair-cells, but in cxactlv what manner is still a mooted tjuestion. The hair cells are supposed to be the specialized end organ of the cochlear nerve; the nerve fibres pass through the zona perforata as naked axis cylinders, and have been traced bv Katz * to the interior of the inner hair cells. Delicate fibrillx also cross beneath the arch of Corti. and have been traced to the outer of Deiters's cells and to the outer hair cells which thcv probablv enter, although this is not certain. Having describefl the peripheral termination of the au- ditorv nerve, we will next follow its fibres backward to the main trunk. From the cochlear hair-cells the filaments pass inward be- tween the laversof the osseous spiral lamina, resume their me- duUated laver, and unite to form the cochlear branch of the auditorv nerve in the tubulus centralis modioli. Where the fibres of distribution radiate from the central trunk within the modiolus a ganglionic enlargement is found, called the spiral ganglit^n. From the crista: acustica: and macula: acusticae the nerve filaments pass through minute foramina in the walls of the bonv labvrinth. The nerve filaments unite to form the vestibular branches of the auditory nerve, the fibres from the saccule forming the inner branch, those from the utricle and ampulla of the external and superior canals the superior branch, and those from the ampulla of the posterior canal the * Arch, fiir Ohrenheilk. vol. xxix, p. 54. 44 THE ANATOMY AND PHYSIOLOGY OF THE EAR. inferior branch. These foramina constitute the macula cri- brosa of the fovea spherica, and fovea elliptica. The Blood Supply of the Labyrinth (Plate III).— T/ie Arteries. — The blood supply is derived from the internal audi- tory artery, a branch of the basilar. The artery accompanies the auditory nerve to the labyrinth, where it divides into two branches, the one supplying the vestibule and semicircular canals, the other following the cochlear branch of the nerve to the cochlea, where minute vessels pass outward, forming an arterial plexus for the supply of the membranous cochlea. The minute vessels radiate from the larger arterial twigs toward the outer labyrinthine walls of the scala vestibuli and scala ty m- pani, but are most prominent in the walls of the scala vestibuli. The Veins. — The veins follow the same general course as the arteries, the smaller branches uniting to form three main channels — the vein of the cochlear aqueduct, the vein of the aquaeductus vestibuli, and occasionally a third vessel is found, the internal auditory vein, although this is the least constant branch. The vein of the aquseductus cochleae passes through the cochlear aqueduct to the internal jugular. The vestibular vein joins the superior petrosal sinus, leaving the labyrinth through the aquccductus vestibuli, while the internal auditory vein ac- companies the artery of the same name and empties into either the transverse or inferior petrosal sinus. The terminal branches of the venous channels anastomose freely with one another, forming spiral plexuses or loops. In general, it may be said that the blood current enters the laby- rinth upon one aspect, and, instead of forming a complete cir- cuit and finding an exit in the same region, passes out on the opposite side of the labyrinthine cavity, the chief avenue of venous discharge from the cochlea being the vein of the coch- lear aqueduct. Boettecher* describes a capillary twig running along the tympanic surface of the basilar membrane under the arch of Corti, which he calls the vas spirale of the cochlea. Its exist- ence has been denied byBertholdjfand Siebenmann.:}: Eichler* * Arch, fur Ohrenheilk, vol. xxiv, p. i. f Schwartze's Handb. der Ohrenheilk., 1893, vol. i, p. 711. X Arch, fiir Ohrenheilk., vol. xxxv, p. 115. * Abhandl. d. math. phys. Klasse der k. sach. Gesell. der Wissenscnaft des physi- olog. Inst, zu Leipzig, 1892, vol. xviii, No. 5, p. 311. PLATE HI TuK Vascilar Supply of the Cochlea. ^Moditied from Hyrtl.) THK AIDITORV NKKVE. 45 has made important investigations upon this subject, from which it seems probable that the capillary spiral plexus is formed by the cochlear vessels both in the sulcus internus and upon the tympanic surface of the basilar membrane be- neath the arch of Corti. The spiral plexus is particularly prominent in the lower turn of the cochlea. A somewhat similar anastomosis exists also in the ligamentum spiralc. According to Siebenmann's investigations, the internal au- ditory artery usually divides into three branches — the coch- lear, vestibular, and vestibulo-cochlear — the particular por- tions supplied bv each branch being sufficiently indicated by their respective names. The particular manner in which the trunk divides is of but small practical importance, but we should remember that the blood su{)plv of the lower turn of the cochlea is much more abundant than that of the uj'pcr portions of the spiral. If a vertical section is made through the cochlea, it w ill be found that the arterial trunks lie chiellv in the walls of the scala vestibuli, as already mentioned, while the venous chan- nels are mostly conhneil to the walls of the scala tympani. This arrangement is shown diagrammaticallv in IMate III, from which it will be seen that the arterial capillaries pass into the venous in the region of the ligamentum sj)irale. The Auditory Nerve (I'late I\^). — The auditory nerve trunk constitutes the portio mollis of the older anatomists, and is given off from the medulla at the posterior border of the pons Varolii. It arises from two roots, the lateral or an- terior, constituting the vestibular nerve, while the internal or posterior fibres form the cochlear portion. The Coc/ilear Nerve. — The posterior root, called also the in- ternal, constituting the cochlear nerve, arises from a large- celled nuclear mass in the medulla (the anterior or ventral nu- cleus) and from a smaller aggregation of cells lying to the outer side of this, the tuberculum acusticum. From the ven- tral nucleus of each side two bundles of fibres are given off, one of which is of large size and passes to the olivary body of the opposite side, the other, of smaller dimensions, to the olivary body of the same side. The crossed fibres by their decussa- tion constitute the corpora trapezoides, a name applied on ac- count of the peculiar appearance which they give to a section of the medulla in this region. From each olive four sets of fibres are given off. The larger number pass to the [posterior of 46 THE ANATOMY AND PHYSIOLOGY OF THE EAR. the corpora quadrigemina through the fillet, a small bundle passes to the spinal cord, a third passes to the region of the abducens nucleus and communicates with it, while a fourth bundle of fibres passes to the cerebrum. From the tubercu- lum acusticum a small bundle of fibres crosses the median line to the opposite fillet, uniting with those which pass be- tween the olivary body and the posterior of the corpora quad- rigemina of this side. To recapitulate briefly, most of the fibres from either cochlear nerve pass to the opposite side of the brain through the trapezoid bodies to the opposite olive, then through the fillet to the posterior quadrigeminal body, accompanied by a few filaments from the tubcrculum acusticum. A small pro- portion of the fibres in the cochlear nerve in question do not cross, but pass to the cortical centres of the corresponding side of the brain through the olive of this side. The course of the fibres from the corpora quadrigemina has not been defi- nitely made out, although the position of the nuclei in the medulla and the decussation of the fibres has been verified by physiological experiment. After entering the corpora quadrigemina the fibres are supposed to pass to the poste- rior third of the internal capsule, and from there to the first and second temporal convolutions, this being the auditory centre in the cortex accordinsr to the most recent investiira- tions. TJic Vestibular Nerve. — The vestibular nerve arises from the internal or dorsal nucleus, close to the vagus centre, but superficial to this. Branches originating in this collection of nerve cells cross the raphe, embracing in their course the nucleus of the sixth nerve and pass to the cerebral cortex, although the exact course which they follow is undetermined. A large fasciculus extends to the cerebellum, passing first through the pons, then the vermis, and finally terminates in the corresponding cerebellar hemisphere and in that of the opposite side. The dorsal nucleus communicates with the spinal cord through a fasciculus which passes downward and inward between the olivary bodies. Besides the cochlear and vestibular roots, the auditory trunk contains a bundle of fibres which emerge between the roots already described. These arise from an aggregation of cells, called Deiters's cells, lying in the medulla between the anterior nucleus and the olivary body. The branches of com- PLATE IV. The Auditory Nerve. (Modified from Freud.) THK AUDITORY NKRVK. 47 niunication with the other nuclei of the eii^lith nerve and with other cerebral centres are undetermined. We thus appreciate the complexity of the central portion of the acoustic apparatus, and may realize what manifold causes may exist for impairment or perversion of function. We must bear in mind that anv disturbance of audition of nervous origin may be variously located at any point between the cochlea, which represents the end organ of the auditory nerve, and the first and second temporal convolutions of the cerebrum, which represent the cortical auditory area. The fibres from the cochlea of either side, according to our descrip- tion, pass through the cochlear nerve to the ventral nucleus and to the tuberculum acusticum, most of the fibres passing to the superior olive of the opposite side through the corpora tra[)ezoides, and then to the corresponding posterior quadri- geminal body through the fillet ; thence to the posterior third of the internal capsule, and thence to the first and second temporal convolutions. A smaller collection of fibres from the anterior or ventral nucleus j)asses t(j the olive of the same side, through the trajtezoid bodv and to the cortical area of this side, following a course similar to that j)ursued by the fibres from the opposite olivary body; from this olivary bodv otlier fibres pass to the cerebellum, to the spinal cord, and to the abducens nucleus. The portion of the cochlear nerve terminating in tlie tuber- culum acusticum sends a few decussating fibres to the oppo- site fillet, its only other c»)mmunication being that afforded by its immediate proximity to the anterior nucleus. The vestibular nerve twigs amalgamate into a trunk, which terminates in the internal or dorsal nucleus, from which fibres pass to the spinal cord, to the cerebellar hemisphere of the same, and to that of the opposite side, and probably to the opposite cerebral hemisphere. The communication with the cerebellum is the most extensive, and this portion of the brain constitutes the important terminus of the vestibular branch of the auditory trunk. CHAPTER II. THE PHYSIOLOGY OF THE EAR. In order to understand the manner by which sound per- ception is effected, it will be well to recall the physical prin- ciples involved in sound production and transmission. Sound is a mode of motion produced by the vibration of matter. Vibrations are transmitted to the organ of hearing through any elastic medium. If the vibrations succeed each other at regular intervals and with sufficient rapidity they affect the ear collectively, rather than as separate impulses, and produce what is known as a musical sound. If the im- pulses are irregularly repeated, or if the interval between each is of considerable duration, the impression constitutes a noise, each act of transmutation of energy into motion producing an effect upon the receptive centres. When the impulses follow each other at a rate of less than sixteen per second they are observed singly ; but if at a greater rapidity, the sound becomes musical and continuous. According as the rate of vibration is slow or rapid, the note is of low or high pitch, until finally the vibrations follow each other so rapidly that the ear no longer appreciates them. From this we see that the ear possesses certain limits of perception for musical sounds, between which all regularl}'^ recurring vibra- tions impress the organ in a certain definite way. These limits are called the tone limits of the ear, and range from about sixteen double vibrations per second to thirty-two thou- sand five hundred double vibrations per second. It will be understood that the figures given represent the average limits only, in certain instances the lower limit being somewhat below the one given, while the upper limit may be higher. Quite distinct from the pitch of a note is its intensity or loudness; this depends upon the amplitude or extent of each individual vibration. Although depending upon entirely different physical conditions, pitch and intensity are, to a cer- (48) SOUND. 49 tain extent, related, since, as the vibrations increase in num- ber, the space traversed during each unit of time by a vibrat- ing body must be less. We quite unconsciously prove the truth of this statement when we remember that we associate loud sounds with high, shrill notes, while the reverse is true of tones of the lower portion of the register. In other words a given force will produce a more intense sound if it acts ujion a body in such a manner as to produce molecular vibrations rather than vibrations c?i luasse. For convenience in rec(jrding the various rates of vibration, a tuning fork, or other sounding body making sixteen double vibrati(jns per second (V. vS.), may be called C-' ; one making- double this number of vibraticjns would be called C-' ; the two notes diflering from each other bv an octave. This divi- sion of the musical scale, should be remembered as indicating that when two musical notes differ from each other bv an octave the rates of vibration are as two to one. In the above we have considered simj)Ie vibrations onlv ; but it is to be remembered that a note is seldom heard ab- solutelv pure, but is accompanied bv tones of higher pitch in the musical scale. These are called overtones, and they mcjdify the character ol the fundamental note. These overtones give the individualitv or qualitv to the various instruments used in an orchestra, and enable us to distinguish whether a given note is sounded upon a wind or string instrument. These har- monics are much more prominent in the lower divisions of tlie scale, and, as will be seen when we come to speak of the functional examination of the ear, are to be borne in mind, since bv their perception, in [)lacc of the fundamental tone erroneous deductions mav be drawn. Sound waves are proj^agated in anv medium surrounding a vibrating bodv at rates varving with the densitv of the medium. The rate of transmission is greater in solids and liquids than in gases. In gaseous media the rate of trans- mission of sound is in inverse proportion to the density of the gas. We are now prepared to studv the action of the transmit- ting mechanism of the ear from a physiological standpoint, bearing in mind that this portion of the organ subserves the purpose simplv of conducting aerial vibrations to the end or- gan of the auditory nerve, which analyzes them, so that each individual note produces certain specific effects upon the re- 50 THE ANATOMY AND PHYSIOLOGY OF THE EAR. ceptive centres. We next consider the use of the various portions of the conducting mechanism. The Auricle. — The auricle, representing the open end of a funnel, collects aerial vibrations and directs them into the ex- ternal meatus. Its angle of attachment to the skull and the variations in contour encountered in different individuals no doubt exert slight influences upon sound perception, but this fact may be practically disregarded in man, and the auricle may be removed without seriously interfering with the func- tion of audition. Among the lower animals the auricle plays a very important part in the sense of hearing, being movable, and capable of assuming various positions from volition or reflex action in order better to collect aerial vibrations from different ])oints. The External Meatus. — The external meatus constitutes a tube through which the sonorous impulses are conveyed in- ward toward the labyrinth with undiminished intensity. Even if this tube is very small in its deep portion, the function of audition may be but little impaired, the oscillations in the column of air being transmitted with undiminished intensity. If the narrowing takes place at the orifice of the meatus, acuteness of hearing is much diminished. This condition is occasionally found in the aged in whom the tissues have un- dergone a certain amount of atrophy, resulting in the collapse of the superior wall of the cartilaginous meatus to such an ex- tent that it lies in contact with the inferior wall, completely occluding the canal. Occasionally the tragus is abnormally developed, and projects backward over the mouth of the canal in such a manner as to offer an obstruction to the en- trance of the sound waves. This condition also renders the hearing less acute. As mentioned in a previous chapter, the external auditory meatus is not directed horizontally inward, but the cartilagi- nous and osseous portions join at an obtuse angle both in the horizontal and vertical plane. The cartilaginous canal is directed upward, backward, and inward, while the osseous portion extends forward, downward, and inward. Where the cartilaginous meatus joins the auricle the posterior wall pre- sents a deep fossa or depression, and the antero-inferior wall of the bony canal close to the membrana tympani exhibits a somewhat similar feature. In the cartilaginous canal this excavated portion acts with the auricle to collect the waves FUNCTION OF THK MEMBRANA TVMPANI. 51 of sound and direct them into the meatus, while bv the hol- lowing out of the antero-inferior wall of the deeper portion of the meatus, the surface presented is parabolic, from which reflected waves are directed almost perpendicularly uj)on the drum membrane. Since the meatus is a closed tube it neces- sarily j)ossesses a fundamental note, which, according to Gad,* lies in the fourth accentuated octave, representing about 4,056 V. S. The effect of the resonant action of the canal ujion audition is practically inappreciable, its primary note lying beyond the limit of the conversational voice. When, however, the middle car is filled with fluid or the drum mem- brane is much thickenetl, the rescwiant action of the canal becomes more marked and is demonstrable. This is also true when the meatus is closed with tiie finger or occluded by a foreign body, the imprisoned column of air under these conditions being set in vibration through the nudium of the crani;!) boms. The Membrana Tympani. — This structure acts at once as a prutecti\e septum to the parts hing within the middle car. aiul as a mechanical device for the recij)tion (jf sonorous vi- brations, which are then transmitted through the agency of the ossicular cluiiii to the perilymph, being brought into rela- tion with this fluid by the foot plate of the stapes. The ad- vantage gained dej)ends upon the relatively large surface which the membrana tympani presents in comparison with that of the foot {>late of the stapes. Any impluse, there- fore, acting upon the membrane is transmitted to the stapes, at which [>oint its power is much augmented. The drum membrane is usually spoken of as a tense fibrous septum, and hence should possess a fundamental note peculiar to itself. The fact is, however, that, owing to the arrangement of the radiating and circular fibres of the lamina propria, its mode of attachment to the malleus handle, its oblique position, and the relaxed condition of its upper portion— the mem- brana flaccida — its fundamental note exercises but an un- imjiortant influence upon the sense of hearing. It therefore transmits notes, varying greatly in pitch, with equal facility and without the accentuation of any particular tone, a phe- nomenon which would necesrarily occur if the membrane itself possessed a fundamental note. This impartial transmis- ♦Schwartze, Handb. der Ohrenheilk., Leipzig, 1S92, vol. i, p. 338. 52 THE ANATOMY AND PHYSIOLOGY OF THE EAR. sion of sound waves which impinge upon it, without reference to their pitch depends chiefiy upon the disposition of the cir- cular and radiating fibres in its connective-tissue layer. The circular fibres serve to obliterate any resonant action which might result from the radiating fibres being thrown into sym- pathetic vibration. In the same way the handle of the malleus aids in cutting off the overtones, acting as a load upon the vi- brating membrane and preventing the accentuation of any harmonic. The umbilication of this diaphragm at the umbo possesses a mechanical advantage, a force acting upon it being increased in intensity as it is transmitted to the malleus handle, while the distance traversed by the manubrium is correspond- ingly diminished. The Ossicular Chain. — The alternate conditions of conden- sation and rarefaction brought about by a sounding body are transmitted to the labyrinthine structures, after impact against the drum membrane, through the ossicular chain. The outer member of this chain, the malleus, is attached to the membra- na in the manner already described, while the innermost os- sicle, the stapes, is in contact with the labyrinthine fluid at the oval window. Helmholtz* has shown, from the physical laws governing the transmission of sonorous vibrations, as the dimensions of the ossicles are so minute in comparison with the length of the waves which they transmit, that they may be considered as acting cii masse — that is, each component of the chain acts as a single oscillating particle of infinitesimal dimensions, rather than as a solid bodv the molecules of which are in a state of vibration. Viewed in this manner, we have to deal with a svstem of levers through which a force applied at the tip of the malleus acts upon the stapes with increased energy, but with a corresponding diminution in the space traversed in a unit of time. As the result of experiment, the same author f found that any force acting upon the tip of the manubrium was augmented one and a half times at the incudo- stapedial articulation, the extent through which the tip of the long process of the incus moved being diminished two thirds. The preceding remarks regarding the lever-like action of the ossicles refers only to forces tending to displace the mal- leus inward. It will be remembered that in describing the * 0/>. cit., p. 12. t op. cit., p. 46. THE FUNCTION OF THE OSSICLES. 53 ligaments of the tympanum, it was stated that the anterior and posterior ligaments constituted the axis band of the mal- leus, this bone being supported at their points of insertion into its neck, and rotating about an imaginary line passing through these points and the tympanic attachments of the ligaments as an axis. The peculiar structure of the malleo- incudal articulation must also be borne in mind, the articular surface of the head of the malleus being in contact with the saddle-shaped articular surface of the incus. This articular surface is provided with a toothlike projection, so that when- ever the manubrium of the malleus moves inward, with a con- sequent outward movement of the head, this motion is trans- mitted to the incus, and bv this ossicle conveved to the stapes. If, however, the tip of the manubrium is drawn outward, the toothlike process of the incus no longer engages the mal- leus, and the articular surfaces of the ossicles become sepa- rated. From this it follows that the stai)es is but slightly displaced outward under these conditions. The practical importance of this will be seen at once when we remember how frequently the tympanic cavity is suddenly filled with air, either bv accident or design, causing an extensive out- ward displacement of the membrana tvmpani. If the articu- lar surfaces remained in contact under these conditions the effect would be to draw the stapes from the oval win- dow. The long arm of the lever above described extends from the tip of the manubrium to the short process of the incus, while the point of transmission of force to the stapes lies in this line at the tij> of the long process of the incus. The relative lengths of these two arms is in proportion of three to two, and the mechanical advantage gained is in the same ratio. The movement of the stapes is not directly inward, but rather in an oblique plane, the ossicle being rotated about its lower and posterior border. Motion in this oblique plane results not onlv from the peculiar position of the oval win- dow, but also from the manner in which the incus is fixed to the tvmpanic wall, an inward excursion of the malleus carry- ing the long process upward and inward at the same time. The obliquitv of the plane in which the ossicles are placed causes a slight movement forward in addition to the dis- placement described, the resultant motion imparted to the stapes being a rotation about its posterior and inferior bor- ders. The capsular ligament of the malleo-incudal articula- 54 THE ANATOMY AND PHYSIOLOGY OF THE EAR. tion plays an important part in the proper performance of the function of this joint. If this ligament is relaxed, the articular surface of the malleus, instead of being held closely against the corresponding surface of the incus and engaging the tooth-shaped process of the articular facet, is drawn away from the saddle-shaped articular surface of the incus, and causes but slight movement of the ossicle. This condi- tion would interfere particularly with the transmission of those notes, the wave length of which was relatively con- siderable — in other words, the lower notes of the register. Too great tension of the capsular ligament interferes with free oscillation of the ossicular chain, and consequently with the proper transmission of sound waves, particularly those of low pitch. High notes, demanding but little displacement of the transmitting mechanism, are relatively less interfered with by anomalies in the tension of the tympanic ligaments. It is interesting to note here the experiments of Politzer* regarding the effect produced by notes of various pitch upon the excursions of the ossicular chain. It was demon- strated that the oscillations of the ossicles were less extensive for very low notes than for those of the middle portion of the scale. When the pitch was very high, however, the am- plitude of the ossicular vibrations was again diminished. The weighting of the ossicular chain interfered with the trans- mission of low-pitched sounds, while the higher ones were transmitted practically without interference. As stated above, although pitch depends upon the rate of vibration and intensity upon the extent of each oscillation, a certain relation must exist between them, as is proved by the well- known fact to which Gad + calls attention — that of two notes sounded with the same intensity, the higher will seem the louder. The importance of these circumstances can not be overestimated in their bearing upon pathological conditions of the conducting apparatus, since the result of clinical ob- servation agrees with that of physiological experiment, show- ing that in affections of the transmitting mechanism alone, the impairment of function occurs first for sounds of very low pitch, the upper notes being transmitted, with a fair de- jrree of accuracy. * Arcliiv fvir Ohrenheilk., vol. vi. p. 35. f Schwartze, Handb. der Ohren., Leipzig, 1892, vol. i, p. 336. THE FUNCTION OF THF. MUSCLES. 55 The Tympanic Muscles. — We have considered above the part plaved by the ossicles alone, without rey^ard to tiie ac- tion of any muscles which miii^^ht modify their response to aerial vibrations. It is necessarv. however, to bear in mind that, in addition to their ligamentous supports, their action is modified by two muscles — the tensor tympani and the stapedius. The anatomical characteristics of these have al- readv been described. The tensor tympani muscle, actin*::^ alone, would tend to draw the ossicles inward and upward, crowding their articu- lar surfaces together and forcing the foot plate of the stapes into the oval window. This displacement would of necessity render the membrana tympani more tense; hence the name of the muscle, although its action in this direction is of but little practical importance. The action of the stapedius is antagonistic to that of the muscle just described, since by its contraction the stapes is drawn out of the oval windt)w by rotating upon the posterior margin of the foot plate, with the effect of reducing the ten- sion of the labvrinthine fluid. It is probable that one of the chief uses of these muscles is to protect the labvrinth from the injurious effects of loud sounds, or of the sudden conden- sation of air in the meatus from anv cause. Since thev act in opposite directions, they increase the elasticity of the ossicu- lar chain, the one guarding the labyrinth from sudden pres- sure from without, while the other, bv crowding the ossicula together, militates against any outward displacement of the ossicles from anv increase in intratympanic pressure. One value of this action is to guard the capsular ligament of the malleo-incudal articulation, the fibres of which would soon become stretched bv repeated condensations of air in the tympanic cavitv if it were compelled to sustain the entire pressure. The Muscles of the Eustachian Tube. — In order that the membrana tvmpani mav act simply as a transmitter and col- lector of aerial vibrations of various lengths, it is essential that its normal tension shall not be interfered with. An abso- lutely constant tension of this membrane can exist only when the atmospheric pressure is the same on either side. To pre- serve this equilibrium, the cavity of the tympanum, under nor- mal conditions communicates freely with the outer world through the Eustachian tube. Owing to the fact that the an- 56 THE ANATOMY AND PHYSIOLOGY OF THE EAR. terior and inferior walls of the membranous portion of the passage are formed almost entirely of fibrous tissue, the an- tero-posterior walls are in contact, except along the roof, where the patency is preserved by the hook-shaped process of the cartilaginous plate. Although the physical conditions admit of the canal remaining patent in this situation, it is probable that the mucous membrane lining the passage is so loosely ap- plied, that even here the lumen is practically obliterated when the parts are at rest, but that slight changes in pressure suffice to render the tube permeable in this portion. This is particularly true if the intratympanic pressure is increased, as air passes more easily from the tympanum through the tube than in the opposite direction. It is comparatively un- important whether in certain chses the canal is patent while the parts are at rest. Since the aeration of the tympanum is accomplished through the action of its attached muscles, the part played by them in audition is one of great importance. It will be remembered that the tensor palati and the levator palati are in relation with the fibro-cartilaginous portion of the Eustachian passage, the former arising in part from its ante- rior wall, while the latter passes beneath the membranous floor along the inferior border of the posterior cartilaginous wall. Contraction of these muscles increases the caliber of the tube, the tensor drawing the anterior wall and the cartilaginous hook forward, while the belly of the levator is augmented in volume during contraction and presses the inferior and pos- terior walls upward, diminishing the diameter of the canal from above downward, but making it more patent. As both of these muscles are brought into plav during the act of deglu- tition, the removal of the air within the middle ear must of necessitv take place so frequently that the equilibrium of the membrana tympani is not disturbed. Temporary variations in pressure are undoubtedly compensated for by the action of the stapedius and tensor tvmj)ani muscles. When, owing to atrophy of the tubal muscles or to obstruction of the lumen of the canal from swelling of the lining membrane or from the presence of secretion, the passage remains closed for a con- siderable period, rarefaction of the air within the tympanum is the result. This is brought about by the absorption of air into the blood circulating in the lining membrane of the mid- dle ear, and by the greater facility with which the air passes from the tympanum than in the opposite direction. This re- THE FL'NCTION OF THE COCHLEA. 57 duction in pressure within the middle ear allows the nicm- brana tvmpani and attached ossicular chain to be forced in- ward by the pressure of the atmosphere, crowding the stapes into the oval window. The Labyrinth. — The physiology of the labyrinth divides itself into an investigation of the function of the vestibule, the cochlea and the semicircular canals. The Cochlea. — The cochlea is that part of the internal ear specialized for the analysis of sonorous vibrations. Through its agency each component of any complex sound affects one portion of the terminal fibres of the auditory nerve. These various stimuli are again combined in the higher nerve centres, and are interpreted as characteristic of some particular vibrat- ing body, and hence from education enable us to judge of the conditions under which they were produced. To effect this separation of thecomjjlex aerial vibrations the undulations are transmitted by the conducting mechanism to a column of fluid, the perilymph. Recollecting the anatomy of the parts, it will be remembered that the C(jchlcar ])erilymphatic space is di- vided into two channels lying one above the other, communi- cating at the apex of the spiral by a narrow passage, the heli- cotrema, and se()arated from each other by a septum which is partially osseous and in part membranous. The membranous portion incloses between its two layers a channel, triangular on cross-section, the membranous cochlea. This canal is an elongated blind pouch, and is filled with cndolymph in which float the ultimate fibres of the auditory nerve. The upi)cr cochlear canal communicates with the vestibule, while the lower is shut of! from the middle ear by the mem- brane of the round window. The membranous cochlea termi- nates at its superior extremity as a blind sac, while below it joins the saccule. The floor of this membranous tube begins at the upper part of the round window. The perilymphatic space through the aqueductus cochlea: communicates with the subarachnoid lymph space, while the endolymphatic chan- nel, through the aqueductus vestibuli, opens into a sac be- tween the layers of the dura mater. The probability of the communication between thisdural pouch and the lymph chan- nels of the dura has already been discussed. Aerial vibrations communicated to the stapes produce a f^uid wave in the perilymph, each inward excursion of the ossicle pushing the column of fluid before it through the scala ves- 5$ THE ANATOxMY AND PHYSIOLOGY OF THE EAR. tibuli, thence through the helicotrema, and finally through the scala tympani to the round window, the membrane of which is pushed outward into the tympanum to compensate for the inward motion at the vestibular opening. Since the labyrin- thine walls are rigid in every other situation, and from the well-known phvsical law that fluids are incompressible, this motion of the perilymph is impossible unless the membrane of the fenestra rotunda is elastic. The elastic partition sepa- rating these two channels modifies to an extent the course taken by this wave in the perilymphatic fluid. This septum, consisting of two layers, the space between being filled with fluid of the same density as the perilymph, permits of the transmission of the wave motion from the upper to the lower channel without necessitating its passage through the helicotrema. It is evident that the structures within the membranous cochlea must suffer some disturbance of equi- librium from the passage of this fluid wave. An impulse causing the inward motion of the stapes is communicated to the perilymph, which in turn exerts a pressure upon the basilar membrane; this elastic septum yields to the pressure in localities varying according to the pitch (or rate of vibra- tion) of the particular note sounded. The depression of the basilar membrane at anv given point causes a change in position in the structures resting upon it: these, it will be remembered, are the hair-cells and the rods of Corti. It is probable that the hair-cells, bv the friction of their ciliarv pro- cesses against the reticular membrane or against the rods of Corti, transmit these impulses through the nerve filaments which they contain, to the receptive centres of the brain. Since the endolymph and perilymph are under equal pressure, a fact which has been proved by the investigations of Ost- mann,* it follows that all vibrations of the perilymph will not pass the entire length of the scala vestibuli and through the helicotrema before exciting similar waves in the fluid of the scala tympani, but will pass directly through the two layers of the membranous spiral lamina at any point where the resist- ance is less than that which must be overcome by the passage of the wave through the helicotrema. The fact that the di- ameter of this communicating channel is much less than that of either the scala vestibuli or the scala tympani increases the * Arch, fiir Ohrenheilk, vol. xxxiv, p. 35. THE FUN'CTIOX OF THE COCHLEA. 59 resistance in this direction and favors the passage of the wave through the elastic septum dividing the scalee. The inferior lamella of this partition is the membrana basilaris, a tissue calculated from its structure to be easily affected by changes in pressure. Investigation shows that the parallel fibres of the membrane are shortest in the lowest part of the canal, and gradually increase in length as the spiral ascends. The shorter fibres at the base of the cochlea will yield to the pres- sure caused by vibrations of short wave length, or those con- cerned in the production of the highest notes of the scale, while the slower oscillations of the low notes will travel toward the apex of the cochlea before displacing the basilar membrane. Anatomical structure and phvsical laws render it probable, therefore, that the lowest turn of the cochlea is concerned in the perception of the high notes of the scale, while the upper turns serve for the recognition of the deeper sounds. These deductions have been confirmed by the j)hys- i(jlogical experiments of Baginskv.* It seems probable that the basilar membrane is the portion of the auditorv ajiparatus designed for the analysis and per- ception of musical notes as originallv suggested by Hen- sen, and that tlie rods of Corti are not dircctlv concerned in this process, as Helmholtz at hrst believed. It is quite probable that these rods serve to damp the vibra- tions of the membrana basilaris, and to restrict them to limited portions for individual notes. The fibres of the basilar mem- brane varv in length from .041 millimetre at the base of the cochlea, t(j .495 millimetre at the apex. In number they vary from 13,000 to 20,000. It is evident, therefore, that the per- ception of the slightest variation in the rates of vibration can theoretically be perceived ; practically, differences of one sixty- fourth of a tone can be recognized bv the trained ear ; in the higher registers, differences of half a vibration per second can be distinguished by skilled musicians. Nothing has been said in the preceding pages about the influence exerted upon the transmission of fluid waves by the communication between the endolymphatic and perilym- phatic channels and the intracranial lymph spaces. It is probable that, owing to the small calibre of the communicat- ing canals, the friction of the fluid is so great that their pres- * Arch, fiir Ohrenheilk, vol. xxiv, p. 54. 6o THE ANATOMY AND PHYSIOLOGY OF THE EAR. ence is no protection against a sudden increase in tension of the lab3'rinthine fluid, sudden augmentation in pressure being compensated for by the elastic septum covering the round window. When, however, the increase in pressure within the labyrinth is very slow, such as would result from a chronic process within the middle ear with the production of new connective-tissue elements, crowding the stapes slowly into the oval window, it is probable that the equilibrium of the labvrinthine fluid would be preserved, in part at least, by its passage into the intracranial lymph spaces. The perception of musical notes bv the agency of the cochlea has been considered first on account of its complex- itv ; but it must be remembered that the maculre of the sac- cule and utricle and the crista^ of the ampullcC also contain the terminal filaments of the eighth nerve. It is probable that noises and perhaps also certain musical sounds are perceived here. It would also seem that these structures are particularly designed for the reception of vibrations of great amplitude, which are interpreted as sound, but that complex sounds are not fullv analvzed here, although certain variations in pitch are recognized. The otoliths are found here and prevent too extensive excursions of the ciline ; their presence in these regions alone rather adds weight to the theory that this por- tion of the labyrinth is designed for the reception of vibrations of considerable amplitude, whether occurring as musical notes or following each other irregularly, giving the impression of a noise. It seems certain that the ultimate analysis of musical tones can only take place in the cochlea ; and hence, from the anatomical structure of the parts, the musical notes whose perception would be first interfered witii in anv involvement of the labyrinth following a pathological process within the tympanum should be those perceived by the basilar mem- brane at the lowest part of the cochlea, or that portion close to the tympanum. Clinical experience supports this view, since in secondary labyrinthine affections we find that de- fective perception for the highest notes of the scale is an early symptom. The Semicircular Canals. — From experiments upon ani- mals and from clinical observations it is supposed that the semicircular canals are concerned in maintaining the ecjuilib- rium of the body, and in recognizing any departure from this condition. How much this function contributes to the abil- EFFFXT OF TYMPANIC CHANGES UPON THK LABYRINTH. 6l ity to judge of the location from which a given sound comes can not be determined, but it is probable that the position which the head assumes, in order that the ear may receive the maximum impression of the sounding body, conveys to the perceptive centre, through the agency of the semicir- cular canals, a certain stimulus which enables the listener to locate the approximate position of the sounding body. Re- cently Ewald * has attributed to the semicircular canals the power of interpreting a sixth special sense, which he denomi- nates as the muscular sense or muscle-tonus, holding that the perception and maintenance of stable equilibrium are regu- lated by the semicircular canals through this special sense. Such a claim is difficult to controvert. Any change in muscle- tonus must disturb the equilibrium of the body to a certain degree, and this in turn would depend for its appreciation upon the integrity of the semicircular canals. That these portions of the internal ear are the perceptive organs of the sixth special sense has not. I think, been conclusivclv proved. The Effect of Changes within the Middle Ear upon the Labyrinth. — Since the labyrinthine lluid is separated from the tvin[>aiiic cavitv bv an elastic membrane at the round window and at the oval window bv a movable osseous septum, the foot-plate of the sta|)es, it follows that changes in the tension of the ossicular chain, due U) relaxation or contraction of the elastic structures within the middle car, must cause variations of pressure in the labvrinlhine fluid. Shortening of the os- sicular ligaments and of the tensor tympani muscle will effect this change ; or the same result might be brought about by a rarefaction of the air within the tympanum, the tension then being increased by the atmospheric pressure without. Any force acting to displace the foot-plate of the stapes inward, causes a similar displacement of the labyrinthine fluid and an outward excursion of the membrane at the round window, the extent to which this membrane is moved outward depending upon its elasticity. Any sudden increase in pressure must be coinpensated for by a corresponding displacement of this elastic lamella, since the frictit)n of the fluid against the walls of the narrow aqueductus vestibuli and aqueductus cochlea; would prevent an outward flow in this direction. If the pres- sure was maintained for a considerable time, a gradual outflow * Physiolog. Untersuch. Ubcr dcr Endorg. des Nerv. Octavus. Wiesbaden, 1892. 62 THE ANATOMY AND PHYSIOLOGY OF THE EAR. of fluid through these channels would undoubtedly take place, and the equilibrium would be restored. Bezold * has shown that the excursions of the membrane of the round window are four times as extensive as those of the foot-plate of the stapes, in response to any given force dis- placing the latter inward. The area of the stapedial foot-plate is greater than that of the membrana tympani secondaria, and hence displacements of this latter structure must be corre- spondingly more extensive. When we come to consider the effect of condensation and rarefaction of the air in the tympanic cavity upon the tension of the labyrinthine fluid, the mechanism of the malleo-incudal articulation must be borne in mind. The effect of increased aerial pressure within the tympanic cavity would naturally be to force the drum membrane outward. This outward move- ment would be participated in by the malleus, and through its articulation with the incus would be communicated to this ossicle, which in turn would cause an outward movement of the stapes, with a reduction of the pressure within the laby- rintii. From the peculiar construction of the malleo-incudal joint, very extensive outward excursions of the manubrium cause a separation of the articular surfaces of the ossicle, and the stapes is displaced outward to a comparatively slight de- gree as compared with the excursion of the membrana tym- pani. The membrana tympani has but little elasticity, owing to the peculiar structure of the lamina propria, and after the maximum outward displacement has taken place it forms a rigid wall. Beyond this, any increased pressure within the tympanum, due to the introduction either of air or fluid, causes an augmentation of labyrinthine tension, the cavity be- ing closed on all sides by rigid walls, with the exception of those portions of the inner walls occupied by the oval and round windows. This increased pressure acts upon both the foot-plate of the stapes and the membrana tympani secondaria, since they constitute the areas of least resistance, and their inward displacement is opposed only by the normal tension of the labyrinthine fluid, which is slightly less than that of the normal atmospheric pressure. When the pressure within the tympanum is increased by artificial means, or as the result of pathological processes, and the cavity has attained its great- ♦ Politzer, Lehrbuch dcr Ohrenheilk., \Vien, 1S93, p. 54, EFKFXT OF TYMPANIC CHANGES UPON THE LABYRINTH. 63 est dinicnsions bv tlie maximum displacement of tlie mcm- brana tympani outward, the next result is a displacement of the membrana tympani secondaria and of the foot-plate ot the stai)es inward, increasing the tension of the perilymph. The movement of the stapes toward the vestibule is permitted bv the separation of the articular surfaces of the malleus and incus. The changes in the endolvmphatic pressure are the same as those in the perilymph. This explains the phenom- enon observed frequently after over-inflation of the tvm- panum, functional examination indicating increased labv- rinthine tension in spite of the fact that the membrana tvm- pani has been restored to its normal position. Politzer* has shown from experiments that aspiration of the tympanum — that is. artificially diminishing the aerial [ircssure within it — lowers the labyrinthine pressure instead of increasing it. We might suppose at first that this latter condition would result on account of the inward displace- ment of the ossicular chain from the pressure of the atmos- phere. This diminution of labvrinthine tension following aspiration of the tvmpanum is caused bv the reduction in pres- sure over both the oval and round windows, which more than compensates for the inward displacement of the stapes bv the atmospheric pressure froiu without. In Polilzer's experi- ments the i^ressure within the labvrinth was equal to the pressure of the atmosphere, while during life we know that it is slightlv less than this, and in this condition a moderate reduction ui tension in the intratympanic air would lower labyrinthine tension considerably. As soon as the pressure in the middle ear is greatlv reduced, labyrinthine tension must increase iium the extensive inward excursion of the stapes. The truth of these conclusions is demonstrated by the effect of aspiration and auto-inflation upon the perception of sounds of dilTerent pitch, as well as the influence which these pro- cedures exert upon the conduction of sound through the solid media of the skull. It has been proved by Bezold and Sieben- mann t that a sudden increase in labvrinthine pressure renders the perception of high notes more keen, and increases bone- conduction as a rule. The over-inflation of the tympanum has been found bv the same investigators to efTect similar changes. Aspiration of the middle ear, on the other hand, according to * 0/>. lit., p. 54. f Arch, of Otol., vol. xxii, p. I. 64 THE ANATOMY AND PHYSIOLOGY OF THE EAR. Siebenmann,* usually diminishes bone-conduction — a result which we should expect from the reduction of labyrinthine pressure. The power of hearing high notes is not particu- larly affected by this procedure, on account of the short wave- lengths of such sounds and the proximity of the area to the middle ear of the cochlea specialized for their reception. If the perception of high notes is at all affected, it is rendered less keen. Increased tension within the labyrinth from displacements of the ossicular chain inward — a condition which may be brought about from a shortening of the muscular or liga- mentous structures attached — is corrected, up to a certain point, b}' a displacement of the membrana tympani secondaria in the opposite direction. When the limit of its elasticity is reached, the perilymph can no longer vibrate. Up to this point, however, the entrance of sound waves into the laby- rinth is not prevented. Under certain pathological condi- tions the membrane of the round window becomes thickened and loses its elasticity. When this (occurs even a moderate displacement of the stapes inward may be sufficient to render vibration of the labyrinthine fluid impossible. This rigidity at the round window exerts a greater influence when sudden changes in labyrinthine tension occur from extensive and sudden displacement of the membrana tympani and ossicular chain inward, than where these changes come on gradually. When the pressure is slowly increased, a compensatory outflow of the labyrinthine fluid thi-ough the channels of communica- tion with the intracranial lymph spaces is possible; but sud- den augmentation of tension can not be relieved in this way, on account of the friction of the column of fluid against the walls of the capillary passages through which it is forced. This explains w'hy we find so great a reduction of the upper tone-limit in sudden closure of the Eustachian tube, while proliferative changes within the middle ear cause secondary labyrinthine involvement only after a long period — in the one case, pressure being increased suddenly, in the other case, gradually. The individual parts of the auditorv tract having been considered, a few words may not be out of place in levicw- ing its action as a whole. * Loc. cit. REACTION OK AlDiroRV NKRN'E TO STIMl'LI. 6; Under ordinary conditions, sonorous impulses, projected through the air, reach the end-organ of the nerve specialized for sound perception by the transmutation of aerial waves of condensation and rarefaction, through the agency of the tym- panic structures, into waves of similar character in the laby- rinthine fluid. These waves in turn impress the terminal filaments of the auditory nerve in a specific manner. Nor- mally, then, sounds are best heard through the air; it is pos- sible, however, for the fluid within the labyrinth to be set in vibration through the medium of the cranial bones, resulting in the phenomenon of sound j^crccption. When the laby- rinth is intact, musical notes arc inter[)rcted with a fair de- gree of accuracy when they reach the labyrinth bv bone- conduction — that is, when the vibrating body is brought in contact with the bones of the head. There are reasons for believing that even when the labyrinth is seriously affected the auditory nerve iiself may react to vibrations which are conveyed to it through the bones of the skull. An explana- tion ol this fact is offered by Gad,* who advances the hy- pothesis that under normal conditions the auditory nerve- trunk not only transmits stimuli resulting from the analysis of complex sounds bv the labyrinth, but is also excited by the impulses of the vibrating body acting as a mechanical stimulus. This last effect will not be prevented by the de- struction of the portion of the nerve designed for the analysis of sound, the impression received affecting the sensorium as a whole rather than as distinct individual notes. The in- creased electric irritability of the nerve, so often found where the labyrinth has been destroyed in the course of physio- logical experiments, rather adds weight to this view. Even where the labyrinth is entirely scjiarated from the auditory nerve-trunk, the excitation of the nerve by sounding bodies of different j)itch would j)n)bably produce different effects upon the perceptive centres, although the exact differences could not be defined by the subject. In this hypothesis the auditory nerve follows the laws which govern the reaction of all sensory and motor nerves to stimuli of various kinds, whether they be thermal, mechanical, or electrical. The weak point of this theorv lies in the fact that in physiological experiments one can never be certain that the cochlea has * Schwartze, Ilandb. der Ohren., 1892, vol. i, p. 348. 6 66 THE ANATOMY AND PHYSIOLOGY OF THE EAR. been entirely destroyed, while in cases of exfoliation of the cochlea in man, as the result of disease, the process has usu- ally been unilateral, and the part played by the unaffected ear can not be excluded with certainty. Corradi* has demon- strated by experiment, that in the porpoise destruction of both cochleae causes complete deafness; but it is not safe to say that the same result will follow in the human species. It is enough for practical purposes to remember that the exact interpretation of sound is only possible when the cochlea is intact; while it is probable that the stimulation of the nerve- trunk itself may be effected by a sounding body or other stimulus, even if the end-organ has been destroyed. The Concerted Action of the Auditory Apparatus. — It is still a question of dispute as to the exact influence exerted by the auditory organ of one side upon that of the opposite side of the body. Unquestionably the hearing is most delicate when both organs are in perfect condition. If one ear is occluded by the finger or obstructed from any pathological process, sound perception becomes less acute, and the power to distinguish the location of a sounding body is correspond- ingly interfered with. No doubt the correlation of the organs of the opposite sides depends largely upon the decussation of the fibres of the cochlear nerve in the brain, as described in the pages devoted to anatomy of the auditory nerve. It must be remembered, however, that if perfect audition presupposes the anatomical perfection of both organs, a condition might exist in which the transmission of sonorous waves by the apparatus of one side would be so incorrect as to interfere with the perception of those conveyed through the auditory organ of the opposite side. Cases are met with in which the hearing can be improved by completely occluding one ear artificially, thus excluding the sound waves from it. That in the normal subject binaural audition is better than monaural is explained, according to Urbantschitsch,f by the fact that the stimulation of the peripheral organ of the auditory nerve on one side, ren- ders the perceptive centre on the corresponding side, and which receives fibres from the opposite car, more susceptible to the action of the sound waves. This excitation of the receptive centre renders it responsive to slight stinuili reaching it * Archiv fiir Ohrenheilk, vol. xxxii, p. i. f Lehib. der Ohren., Wicn, 1890, p. 416. Arch, fiir Ohrenheilk , vol. xxxv, p. i. RKFLKX PHENOMENA. 67 throu2:h the opposite car. In support of this argument, we recall the fact that the acutencss of audition upon one side for any given s(jund will be increased if the organ of the opposite side is at the same time brought uiuier the intlucnce of sound waves of a different character ; thus, loi" instance, a watch may be more clearlv perceived in the right car if a vibrating tuning fc^rk is held close to the meatus ol the left. In this way Crl)antschitsch explains the phenomenon of para- cousis Willisii, the action of hnid sounds serving to stimulate the receptive centres, after which relatively feeble stimuli, as vibrations of sinall amplitude, may be perceived. Binaural audition, then, would owe its acuteness to the exciting action of one auditory centre uj)on the other. Politzer,* on the other hand, believes that the greater acuteness of binaural audition depends upon the lact that it represents the effect of an impulse acting upon a greater area, and hence pro- ducing a more marked impression, upon purely mechanical principles. This latter suggestion seems the more simi)le, and vet a close observation ol the phenomena produced by vari- ous pathological processes reveals the existence of such an intimate interdcjiendencc between the organs of the opposite sides, that it is hard to believe that this association does not play an important part under nc^rmal as well as under patho- logical C( indition^. Reflex Phenomena.— We have spoken at length of the ac- tion of one auditory organ upon the other, but it must not be forgotten that the nucleus of the eighth nerve of either side communicates not only with its fellow, but is intimately asso- ciated with the central nuclei of the other cnmial nerves, as well as with various spinal centres. The function of the ear is affected not only by the action of sonorous waves, but also reflexly by the action of various stimuli upon other centres with which the auditory is in intimate relati(jn. Conversely, any excitation of the sound-perceiving apparatus may effect psychical, sensory, or motor changes in remote regions of the body. The phenomenon, often observed, of starting at any sudden sound undoubtedly depends upon reflex action ; the association between particular sounds various colors and is an example of the curious efTect produced on account of the communicating fibres between the acoustic and visual * op. cit., p. 516. 68 THE ANATOMY AND PHVSIOLOC.Y OF THE EAR. centres. On the other hand, the power of audition maybe perverted or annulled reflexly, by a pathological condition affecting fibres of a nerve trunk, the centres of which are in- timately associated w-ith the auditory nerve nuclei. Phenomena dependent upon Circulatory Changes. — Througfh the intimate iclation which exists between the blood-vessels of the labyrinth, the tympanum, the higher nerve centres presiding over audition and the cervical sympathetic, it is plain that circulatory changes must exert an important in- fluence upon the function of audition, perverting or impairing it, either indirectly by inducing vascular changes within the tympanum or directly by causing circulatory changes in the end organ or ganglia of the eighth nerve. This tact is to be particularly remembered in considering certain subjective symptoms frequently complained of, experience showing that correction of vaso-motor tone often relieves the manifesta- tions. On the other hand, disturbances in the blood supply may depend upon actual organic changes in the vessels or in the blood itself. It is evident, especially in the consideration of subjective phenomena, that there exists a broad field for speculation, not only in diagnosis, but also in the selection of appropriate therapeutic measures. Secondary Phenomena. — In this same line lie those dis- turbances, both objective and subjective, which depend upon a morbid process in some other organ of the body. Here we may mention the symptoms met with in connection with con- gestive derangements of the larger viscera, and relieved only by remedies appropriate for the correction of the exciting cause. Disturbance of the auditory centres in the female is not uncommon in uterine and ovarian disorders. The relation between ocular and aural derangements has lately been emphasized by Oliver and Cleveland ; * many of these must be reflex in character. The reflex disturbances of the most importance are those occurring in the domain of the trigeminal nerve. This nerve supplies many filaments to the external and middle ear, and in the latter location, it will be remembered, a close association exists between the cranial and sympathetic nerves. As a result, any morbid condition which involves parts supplied by the trigeminus may, by * Burnett's System of Diseases of the Ear, Nose, and Throat. Philadelphia, i8g3, vol. i, p. 516. Mx»)NnARV rHF.\(^MF.NA. 69 involvement of the nerve elements which thev contain, so interfere with the trophic supply of some portion of the ear as to cause not onlv functional disturbances but even organic changes in the tissues. In this connection the inlluence of dental caries is the most familiar instance, it having been proved that decaved teeth may produce not only a functional disturbance of the organ of hearing, but also an acute inflammation of the tympanum. Most interesting, also, is the close relation bet\yeen corre- sponding parts of the auditory apparatus of the opposite sides of the body. Here, no doubt, the phenomena observed de- pend upon reflex action through the SN'mpathctic and cranial nerves and, in many cases, upon the decussation of the audi- tory fibres within the brain. The effect is at first refiex in character, but later the result of degeneration or atrophy. The so-called " sympathy " between the ear of one side with that of its fellow was recognized by Kramer.* Wharton Jones. + and many other early writers. Recently L'rbantschitsch :{: has written extensively upon the subject. The effect of increased labyrinthine tension from rigidity and displacement inward of the ossicular chain upon the func- tion of the opposite ear is made prominent l)y Weber-Liel * and by Cholewa. The writer^ has also called attention to the fact, especially in cases operated upon for chronic infiamma- tory conditions of the tymi)anum. that the function of the op- posite ear has been improved after operation. Gelle () is in- clined to look upon the temporary impairment of function observed when the meatus is closed with the finger, while at the same time a vibrating body is held close to the unob- structed meatus, as due to a reflex contraction of the ten- sor tympani muscle upon the non-occluded side, and makes use of the ex{)erinK'nt to prove tiic integrity of the upper cer- vical nerves, these being comprised in the refiex chain. It * Ohrenheilk., 1836, p. 145. f Frank's Ohrenheilk.. 1845, p. 133. X .Arch, fiir Ohrenheilk, 1893. vol. xxxv. p. i. * Monatsschr. fiir Ohrenheilk, 1S74, No. 6. I .Vrch. of Otol., vol. xix, p. 151. ^ N. V. Eye and Ear Infirmary Reports, vol. i, p. 50, vol. ii, p, 62. Wood's Reference Handbook of the Medical Sciences. New York, 1893. (Supplement.) Art. " Middle Ear Operations," .\rch. fiir ( )hrenheilk, vol. xxviii, p. 58. -JO THE ANATOMY AND PHYSIOLOGY OF THE EAR. seems to me that the manifestation can be better accounted for by the direct effect of the pressure upon the end organ of the acoustic nerve, and the transmission of the stimulus to the perceptive centres of both sides. Like other nerves, the auditory trunk may be rendered less capable of transmitting impulses either by overuse or disuse, and for the same reasons the higher receptive cen- tres may cease to functionate properly. Thus, if the ear is subjected for a long time to the action of a single sound, this particular note will, after a time, cease to be perceived as readily as at the beginning of the experiment, although per- ception for other notes of the scale will be unaffected. If, on the other hand, the nerve is allowed to remain inactive for a long period, as where serious obstruction to sound conduc- tion has rendered the ear of little practical use, it is found that even after the removal of the obstruction and the resto- ration of the conducting mechanism to a normal condition, the function of the ear is imperfect from the fact that the nerve has been so long at rest that it is not able to subserve the purpose for which it was designed. On the other hand, after the nerve trunk and receptive centres have been once excited, they react more readilv to stimuli and require less enersfv to maintain them in a condition of irritabilitv than would be required to arouse them from a state of repose. It is frequently found, in testing the hearing with a watch or other similar instrument, that the hearing distance will be greater if the sounding body is first held close to the ear and then gradually withdrawn until it is no longer heard, than if the experiment is reversed : the sounding body being gradually carried toward the ear from a point at which it is not perceived until a position is reached where it is distinctlv audible. This means simplv that the auditory nerve having once been excited, reacts to a stimulus of less intensitv than that required for its initial excitation. On account of the decussation of the auditory fibres in the medulla, it is also true that the functional activity of the ear on one side niav be increased by stimuli directed to the opposite car. Urbantschitsch * exj)lains this upon the hypothesis that the excitation of the cortical centre of one side by means of sono- rous vibrations acting upon the opposite ear renders sound per- * Lehrb. dcr Oliien., 1890, p. 416. HVPER.-ESTHKSIA AND I'AR/ESTHESIA. y\ ception more acute in the other ear on account of the decussa- tion of the auditory hbres, through which the cortical centre receives fibres from the labyrinth of the corresponding- and opposite sides. Stimulation of the opposite labyrinth increases the irritability of the centre and causes it to respond to a slighter stimulus, whether this is received through the cor- responding or opposite end organ. I have already suggested such an influence in explaining the improvement observed in the organ not operated upon in cases subjected to operative procedures. Urbantschitsch * has so extended the field of possible utility in this direction that it is of the utmost im- portance to bear the relation in mind on account of its thera- peutic usefulness. This writer urges that this stimulation of the perceptive centres may follow the action of sonorous vibrations, even if the ear acted upon is so defective as to be incapable of transmitting impulses to the degree necessary for actual sound perception on the part of the patient. In other words, when the organ of one side has been rendered entirely useless by sclerotic changes in the conducting mechanism, he deems it warrantable to relieve this physical abnormality be- fore the inlluence which it may exert u[jon the opposite side can be decided. We have discussed the effect upon the rece[^tive centres of overstimulation by sonorous waves, and also the result fol- lowing a long period of inactivity. It must be remembered that, like other nerve centres, the auditory nuclei and fibres react to other stimuli than those for which they were espe- cially designed. Pressure upon the terminal filaments, trunk, or centre of the eighth nerve excites, perverts, or destroys its function. Slightly increased pressure upon the terminal fila- ments, from congestiijn of the labyrinth, may render the nerve exceedingly sensitive, and may give rise to subjective noises (paracsthesiiu). One of the most curious effects observed from this increased activity is the persistence of auditory impressions; for example, when a certain piece of music is played upon the piano, the hyperaesthetic centre may retain a mental picture of this for a long period, and the individual be annoyed for hours afterward by the subjective impression of hearing the selection continually, exactly as it has been played originally. In the same manner it is not an uncom- * Arch, fiir Ohrenheilk., vol. xxxv, p. i. 72 THE ANATOMY AND PHYSIOLOGY OF THE EAR. mon experience for patients to aver that they hear the tick of a watch even after the sound has ceased, the impression once received being maintained for a long interval. It is of great importance to bear this in mind in testing the hearing with any instrument, such as the watch or acoumeter, where the same sound is repeated, as otherwise erroneous conclu- sions will be reached. Too great stimulation, either on account of the sudden condensation of air in the auditory canal, as when a loud ex- plosion takes place close to the ear, or by loud sounds con- tinued for a considerable period, may cause great impairment of hearing for varying intervals of time, the sudden increase in pressure, on the one hand, or the prolonged and intense excitation on the other, completely destroying either tran- sientlv or permancntlv the function of the delicate perceptive portions of the auditory system. Familiar examples of these effects are observed among artillerymen, in whom a tempo- rary impairment of hearing is not uncommon, after exercise with the great guns of the battery. Among soldiers who have been under heavy fire for many days, the prolonged and excessive excitation of the receptive centre or of the terminal filaments of the nerve has been known to produce permanent results, although usually the impairment has been but temporary. CHAPTER 111. rilVSlCAl. KXAMINATK^N. Preliminary Observations. — Before describinp;- in detail the instniniciUs needed lor the' j)roper examination of the ear, let us recall briefly the topoj^raphy of the region. The external meatus is made up of two tubes, joined at an angle in both the vertical and horizontal planes, re-entrant downward and forwanl. The fundus of this canal constitutes the drum membrane, and is continuous with its cutaneous lin- ing. The length of the entire fjassagc, measured from its out- ermost point — that is. from the tragus to the drum membrane — is thirty-six millimetres, or about one inch and a half. This should be remembered as de- termining the jiro|»er length of instruments to be manipulated in the meatus. It should also be borne in mind that of this inch and a half, a little less than one inch of the tube is cartilaginous and a little over half an inch osseous. The general direction of the cartilaginous tube is up- ward, backward, and inward, while that of the bony conduit is downward, forward, and in- ward. For the satisfactory in- spection of the deeper parts, it is evident that the axes of these canals must be made as nearly as possible coincident ; as the out- er portion is movable, traction upon the auricle uj)ward and backward tends to bring the axes into the same straight line. Fig. 25 illustrates the position assumed by the parts in the adult when the auricle is drawn upward, backward, and out- (73) Flo. 25. — Pen-drawing from adult specimen, showing the result of drawing the auricle upward and backward. The axes of the bony and cartilaginous meatus are made coincident, permitttng an inspec- tion of the drum membrane (actual size). 74 PHYSICAL EXAMINATION. ward. It will be seen that the cartilaginous and bony meatus form practically a straight canal, the angle marking their junction having been obliterated by traction in the directions named. In infants the superior and inferior walls of the meatus are in contact and must be separated before the membrana tym- pani can be seen. This is due to the absence of the bony meatus at birth. As the superior w^all of the fibro-cartilaginous tube is attached to the squama, the separation of the walls can be effected only by traction downward and backward, the in- ferior wall being pulled away, so to sj)eak, from the superior wall. Fig. 26 clearly demonstrates this fact, and it should be Fig. 26. — Drawing from specimen at birth. Traction must be made down- ward and backward to expose llie membrana tympani (actual size). Fk;. 27. — Drawing from specimen from child, aged live years. The develop- ment of the bony meatus has separated the superior and inferior walls, but traction downward will still expose the membrana tympani most completely (actual size). remembered that it: yoimg children the atiricle should be drawn outward, backward, and downward in making a specu- lum examination. In children several years old the development of the bony canal has effected this separation of the w\alls of the deep meatus, but even in these cases the membrana tvmpani is more clearly seen if the auricle is drawn slightly downward rather than upward. Fig. 27, drawn from a specimen taken from a child of five, makes this clear. Since the cartilasrinous meatus alone is dilatable, the field of inspection can not be increased in size by crowding a PRELIMINARY OBSERX'ATIONS. 75 dilating instrument beyond the ossco-cartilaginous junction. On the other hand, since such a procedure hxes the two por- tions imniovablyat their anii^le of union, the held ol insjiection must be considerably narrowed. Moreoyer, an instiunient ol greater external dimensions tiian the calibre of the libro- cartilagin(nis tube will crowd the soft parts inward toward the fibro-osseous junction, and this mass will obstruct the yiew of the deeper parts. The fundus of the canal is formed by the drum membrane. This is obliquely placed both in the horizontal and vertical planes of the h^ng axis of the meatus. The inferior margin of the membrane forms an angle with the horizontal plane of from thirty to forty degrees, while the anterior margin makes an angle ui about one hundred degrees with the vertical me- dian antero-posterior plane of the body. From the confor- maticjn of the meatus at its inner extremity, the angles which the membrana tympani makes with the posterior and suj)erior walls are somewhat greater than those made with the vertical and horizontal planes. In other words, the drum tiiembrane is really a continuation of the superior wall of the meatus, and. to a less extent, of the posterior. 1-rom this it follows that the superior and j)osterior margins of the membrane arc nearer the orifice of the meatus than the inlei ior and anterior. In the young infant the membrana tymjtani lies in the plane of the surface of the s(]uama. To be brought intcj view the operator must direct his glance uj)ward toward the sujjerior ^vall of the canal. In investigating diseases of the ear it has been the custom to lay special emjihasis upon the aj'pearance of the drum membrane as observed upon ocular ins|)ection, and to form opinions as to the prognosis of any malady largely from the information thus obtained. It should be remembered that in most cases we are consulted for an impairment or peryersion of the function of the organ, and hence, while inspection of the visible parts is very important and should be made with all the skill attainable, it is also equally important to conduct a systematic functional examination, for the discovery of the location, extent, and nature of the pathological condili(jn re- sponsible for the symptoms complained of by the patient, and to determine as well to what extent the power of sound per- ception is interfered with, the normal ear being taken as the standard in conducting: such tests. In this manner we can 76 PHYSICAL EXAMINATION. more intelligibly estimate the amount of damage done, and, combining the information obtained both from functional and physical examination, we arrive at an opinion of greater value than that obtained by ocular inspection merely. To properly examine the parts so situated as to be open to ocular inspection it is necessary to secure a proper illumi- nation of the region. From the depth and sinuous course of the auditory meatus, examination by direct illumination has never been as successful as when the light has been reflected upon the parts bv means of a mirror. The Source of Light. — We have to consider, in the first place, the source of light. If sunlight could always be de- pended upon it would, no doubt, be the best source of illumi- nation for an otoscopic examination. The direct rays of the sun, when reflected into the ear, produce such a brilliant illu- mination of the parts that detail is obscured. Diffuse day- light or light from a white cloud forms a very perfect source of illumination, but naturally can not always be obtained. I am in the habit, therefore, of advising students to accustom themselves to the various appearances as seen by artificial light. An ordinary oil lamp, if fitted with a duplex or other powerful burner, is an excellent source of illumination. The same can be said of an Argand gas-burner; even a common candle emits sufficient light to enable the surgeon to make a perfect examination, and to perform anv operation within the canal which an emergencv might demand. At least one of these means of artificial illumination can be found in anv house, and familiaritv with normal and pathological appear- ances when viewed by such light can not fail to be of great service to the otologist, who is often obliged to make an examination at the bedside. For convenience in making an examination at the bedside, as an adequate source of illumina- tion may not always be obtainable without delav, or mav de- mand the aid of an assistant to permit of a proper examination without moving the patient, it is well for the examiner to be provided for such an emergency. For this purpose use may be made of the device shown in Fig. 28, which consists of a clamp which may be fastened to a table, chair, the frame of the bedstead, or any other firm object in the room, as may be convenient. This clamp carries a jointed rod, which sup- ports a short arm for holding an ordinary candle. For city practice the ordinary fish-tail gas-burner may be substituted THi; Sc)LRCi: OF LIGHT. 17 in place of the candle, the burner being- attached lo a small metal band which fits into the candle-holder. This burner is connected with a gas fixture in the room bv means of a fiexi- f Fig. 28 — -.^uthor's portable illuminating a;iparatus. In the figure the candle and electric lamp are in position ; the gas-burner is shown in the detached drawmg on the left. 78 PHYSICAL EXAMINATION. ble pipe attached to it. This apparatus enables one to secure a fairly efficient source of illumination and to place the light in exactly the position from which he may make the examina- tion with greatest comfort to the patient and to himself, and renders the entire procedure less laborious and correspond- ingly more exact. The entire apparatus occupies but little space in the instrument bag, and greatly facilitates bedside ex- amination. A small electric lamp suitable for operative work can also be attached to the vertical rod, while a light shelf for supporting an oil lamp can be fitted upon the arm carrying the candle, if the examiner prefers this source of illumination. The different appearance of the parts viewed bv artificial light as compared with the picture seen when diffuse day- light is emploved, depends upon the fact that all artificial sources of illumination contain a preponderance of yellow ravs, and hence the reds and yellows are slightly exaggerated in the otoscopic picture. No mistake need be made if this fact is borne in mind, even by an observer accustomed to the use of white light. Since the introduction of electricity as an illuminating agent its employment in otological work has become quite common. The rays which the incandescent lamp yields are almost colorless, and any desired intensity can be obtained. The reflected image of the luminous carbon band sometimes gives rise to annoyance — a difficulty which can be obviated by the employment of a system of mirrors, the effect of which is to obliterate the image entirely and yield only a diffuse white light, which the surgeon can then reflect into the ear by means of the mirror. A manifest objection to tiie electric light lies in the fact that it is not always obtainable, although this is in a measure overcome bv the introduction of portable storage batteries. Its greatest advantage is that when ether anaesthesia is required, there is no danger of ignition of the vapor, since the luminous carbon is completely inclosed. As electricity, even when carefully handled, is a somewhat capricious agent, it is well for the operator to be supplied with an additional source of illumination in every case, so that in the event of the electric apparatus; failing, some other efficient means may be at hand. The Reflecting Mirror. — It was formerly the practice in examining the ear by means of reflected light, to direct the rays into the canal by a plane or concave mirror fixed upon a THE REFLECTINT, MIRROR. 79 short handle (Fig-. 29), and held in one hand, while the other hand grasped the auricle and supported the speculum in the proper position. Obviously the most correct information is obtainable bv the simultaneous inspection and ma- nipulation of the parts; it is necessary, therefore, that the surgeon have one hand free for the use of a delicate j)robe. At the present day the reflect- ing mirror is usually worn upon the forehead, and the |)olished surface is concave, thus bringing the luminous rays to a focus in front of the mirror. The light will be most intense at the princi{)al focus of the instrument, and the best definition will be obtained at a point just within this ; hence the focal distance of the miiior should be such that when the parts are perfectly il- luminated, the eve may be as near as possible to tlic region to be examined, while at the same time sufficient space intervenes between the ear of the pa- tient and the surface of the mirror for the manipulation of such instruments as it may be necessary to use. It is seldom practicable for the eye of the observer to be less than eight or ten inches Irom the deepest part of the region under inspection. In selecting^ a mirror, therefore, the focal distance should not be less than seven inches, nor more than eleven inches. This fact should be borne in mind in choosing the instrument, and can be most easily ascertained bv noting the distance between the inirror and the hand when the ravs of light are brought to a focus ujK)n the {)alm. Where artificial light is used, the rays are divergent, and hence the conjugate focus for such rays will be more remote than the principal focus, which is the point to which the parallel ravs are converged. It is also advisable to be provided with a mirror which will serve for an examination of the ear, and of the nose and naso-pharynx as well. For the inspection of the regions last named the focal length of the mirror should be slightly greater than of one which is suitable for otological work alone. A mirror of 8o PHYSICAL EXAMINATION. from eight to ten inches focal length for divergent rays is well adapted to general use, it being only necessary to move the source of light a little nearer the mirror when the throat or nose is to be exam- ined. If the illuminat- ing apparatus is pro- vided with a con- densing lens which renders the rays parallel, the focal distance as deter- mined by sunlight will be correct ; otherwise a mir- ror of shorter focal length for parallel rays than that given above should be se- lected. It is easy to determine wheth- er the mirror is per- fectly ground bv observing the image of the gas flame or candle at the focal point of the mirror ; if the rays are thrown upon the hand or upon a sheet of white paper, we should secure a sharply defined image of the particular flame with which we are experimenting; if the edges of the image are blurred, the mirror is practically useless for delicate work. The size of the mirror is also important; those sold in the shops are usually perforated in the centre, the mir- ror being worn in such manner that the perforation will lie over one or the other eye, thus bringing the visual ray of the examiner through the centre of the cone of reflected light. When the mirror is worn in this wav its diameter should not be greater than three and a half inches ; a diameter of two and a half inches is fully sufficient. Certain observers prefer to wear the mirror upon the fore- head, in which case the eye of the examiner does not look directly through the cone of light, the rays illuminating the parts to be inspected being reflected from them at an acute angle to the eye of the observer. When this method of exam- ination is employed the diameter of the mirror is immaterial. ¥\G. 30. — Reflectinf^ mirror, adaptcil for use both as a head or hand mirror. THE REFLFXTING MIRROR. 8i but nothing is gained by increasing the area of the reflecting surface. Still other observers wear the mirror in such way that its superior border is below the orbits, the mirror lying directly over the nose, and the examiner looks over the top of the glass rather than through its centre. It certainly seems more simple to perfectly illuminate the parts by the first method of examination, since the position which permits of the most perfect inspection gives at the same time the most perfect illumination. This, however, is a matter of practice, and after becoming accustomed to one method of examina- tion it is unnecessary to change, equally good work being possible bv all methods. It should be em|)hasized, however, that the beginner will do well to emj)l(>y one method con- stantlv, and not attempt to be- come expert at several. Sometimes the source of lii^lit Fig. 31.— Htalctelv it can not be tilted in diffcM-ent directions, or) r-. Fig. 34. — I'olitzei's hard rubber .luial speculum. 000 Fig. 35. — Wilde'.-, aural speculum. SO as to bring the various portions of the fundus into view. The exact shape is unimportant ; some examiners prefer an instrument the orifice of which is circular in outline, while others advise that it be oval, corresponding in form to the lumen of the canal as seen in cross section. The instrument AURAL SI'ECULA. 85 bearing the name of Wilde is conical, and Uie orifice circular, while in Gruber's speculum the tube is oval on cross section, and instead of being conical is somewhat funnel-shaped. This last feature is observed in the instruments of Trocltsch. Bou- cheron, Toynbee, Politzer, and others. Manv prefer a single instrument which can be adjusted to the lumen of anv canal by means of a set screw, the device resembling in construe- poo ViG. 30. — Gruber's aural specu- lum. Fig. 37. — Toynhee's aural specula. (The inslniments are too long, and the cut is introduced to show this.) lion the bivalve speculum of the rhinologist. in some in- stances it is advantageous to have one wall of the tube cut away for a certain distance in order that the meatus may be inspected after the instrument has been inserted. This end is best accomplished by emploving a wire speculum, the walls of the meatus being sei)aratcd by the elasticitv of the mate- rial of which it is constructed. In an emergency a verv serv- iceable speculum can be made with a piece of stifT note paper, twisted into the form of an elongated cone, the free edges of the paper being secured by a pin, a stitch, or by mucilage. This cone is then cut ofT at such a distance from the apex as will allow it to be easily inserted into the meatus, while in the other direction it is so cut as to reduce it to a proper length. Such an improvised instrument answers perfectly well not only for diagnosis, but also for operative purposes. In fact, I frequently use them in preference to metal specula, even when the latter are at hand. Their chief advantage is their cleanliness, the same cone never being used a second time. Whatever form of speculum may be chosen, attention to the above points will result in the selection of a serviceable instrument. Exact shape is immaterial, as constant use will soon enable the surgeon to become expert with any one of the various varieties. One possible advantage possessed by the funnel-shaped instruments, in which the outer opening is very wide, is that the examiner can more easily direct the light into the speculum than when the smaller instrument of Wilde 86 PHYSICAL EXAMINATION. is used. Whether, the interior of the instrument is polished or blackened also depends upon individual preference. The contrast of the black background mav be an advantage, but a certain amount of brilliancy of illumination is sacrificed. It is necessary to be provided with specula of various sizes, and at least three are necessary to meet the differences in diameter of the orifice of the meatus, while five or six sizes are still more advantageous. The proper diameter, accord- ing to Richards,* of the smaller end of each speculum in a set of five of the Wilde pattern is given below, and will be found valuable; 7 mm.. 6 mm., 4*66 mm., 4 mm., V5 nim. Being provided with a satisfactory source of light, a proper head mirror, and a suitable speculum, the next step will be the technique of the examination. The Technique of Examination (F"ig. 38). — The patient and examiner mav both be seated, a jx^sition which 1 decidedly prefer, or both may stand, or tb.e patient may sit while the phy- sician remains standing. The patient is best seated in a high- backed chair, in an attitude which can be maintained for some time without discomfort, the head resting against the back of the chair, the affected ear being turned toward the examiner. The surgeon, either sitting or standing, should occupv a posi- tion to the right of the patient rather than directly facing the affected side. Sitting or standing, this latter position must be an awkward one, and in the event of the examiner prefer- ring to remain seated, necessitates the separation of his knees widely, so that the chair of the patient is between them. This posture is not only uncomfortable, but for obvious rea- sons undesirable. Moreover, the operator is not able to fol- low any sudden motion of the patient's head when seated in this manner, since he is working at arm's length. When the other position is employed, a slight motion of the arm enables the operator to so follow anv sudden movement which the patient may make on account of fear or pain that the exact- ness of the manipulation is in no way disturbed. The light should be placed, preferably, on the left of the examiner, and slightly above the horizontal plane passing through the ear to be examined. In this manner any ma- nipulation of instruments with the right hand will not inter- fere with the rays passing from the lamp to the mirror. * Burnett's .System of Diseases of the Ear, Nose, and Throat, 1893, vol. i, p. 105. TFXHNIQUE OF EXAMINATION. 87 The patient, surjj^eon, and source of light being satisfac- torily arranged, it should be the invariable rule to examine the auricle, the entrance of the meatus, and the cartilaginous canal to as great a depth as possible before the speculum is introduced, as the speculum mav conceal some pathological condition at the very entrance of the meatus unless this rule is followed. In order to examine the cartilaginous canal and to prepare for the insertion of the speculum, the auricle should be grasped firmly but lightly at its upper and posterior mar- gin between the third and fourth fingers of the left hand, and Fig. 3''- 1 ''<-■ ">.uuir iiin|h-iuimi hi tm: luiiiir ii .lu.i I > ii[|).iiii. -ii'imim^ tlic position of the patient, the surgeon, the source of light, and the manner of holding the speculum. traction sh(juld be made uj)ward, backward, and outward. In examining the right ear the hand lies behind the auricle ; in examining the left ear it lies above apd anterior to it. In this manner a fairly good view of the external portion of the meatus is obtained, and any irregularities in size and shape may be noted as well as any deviation from the usual direction. The information thus derived enables the investigator to select a speculum of appropriate size, which should be grasped lightly between the thumb and index finger of the left hand, warmed over the lamp, and then introduced into the canal as lightly as possible. To effect this the operator holds the speculum between the thumb and index finger, grasping the auricle, g8 PHYSICAL EXAMINATION. as before, between the third and fourth fingers of the left hand. While the auricle is drawn upward, outward, and backward, the dilating instrument is gently introduced into the meatus, is advanced gradually by rotation upon its long axis, it being rolled, so to speak, between the thumb and index finger, while at the same time it is pushed inward. Care should be taken not to pass the instrument beyond the cartilagi- nous canal, since this is not only painful, but interferes with the mobilitv of the outer portion of the meatus, and hence limits the area exposed for inspection. The speculum must be of such a size that the walls of the canal are simjily sepa- rated by it and not stretched, as this interferes with the mo- bility of the membranous portion of the canal and prevents it being so manipulated as to make its axis coincide with that of the bony meatus. When the speculum is too large the soft parts are so crowded in front of it that the full lumen of the speculum is not available and the field is narrowed in consequence. The speculum having been properly inserted, the observer should first bring that part of the superior wall of the canal into view which lies just beyond the inner extremity of the speculum. This is done bv carrying the thumb and index tinjrer which hold the instrument downward, thus tiltins: the inner extremity ui)ward. Having recognized the superior wall of the meatus, the anterior, inferior, and posterior walls are successively brought into view bv causing the outer end of the speculum to describe a circle in the direction named, the fixed point being the inner extremity of the instrument. This manipulation is accomplished by a slight movement of the thumb and finger which grasp the outer end of the specu- lum, the digits being alternately flexed and then gradually extended until the extremity of the instrument has described a complete circle. In conducting this manipulation each wall of the meatus should be inspected throughout its entire extent, from the inner end of the speculum to where it joins the tympanic ring. Attention should be paid during this procedure to the fol- lowing points regarding the canal : Whether it is free through- out its entire length, or partially or completely obstructed. If the lumen is encroached upon, information should be ob- tained as to the nature of the obstruction, whether it be a for- eiirn body accidentally or intentionally introduced, or whether TECHNIQUK OF EXAMINATION. 89 it is made up of a mass ul impacted secretion, whose source is the ceruminous glands of the meatus, or of epithelial debris, the result of an inflammatory process, or of a parasitic growth which has proliferated in this locality. On the other hand, the deeper portion of the canal may be filled with fluid, either pus, serum, mucus, or blood. Again, the lumen of the canal may be encroached upon only oyer a certain circumscribed area, in which case the probe determines the density of the obstruction — whether it is hard or soft, tender or anaesthetic, whether inyested with normal epithelium or presenting a de- nuded surface. Its location should always be carefully noted, whether it is situated in the deeper portion of the canal or near the orifice. In other cases the canal may be narrowed uniformly throughout its entire extent. Here the density of the walls as determined by the probe is of seryice, as well as the appearance ot the outer surface. None of these more eyi- dent abnormal conditions e.xisting, the obseryer should in all cases note the condition of the integument lining the canal, determining whether it is dry and desijuamating in jdaces, or moist and reddened, or coycrcd here and there with masses of dry secretion forming crusts upon the walls. Haying critic- ally observed these different physical conditions, the suj)erior wall of the meatus should be followed inward, the angle of the speculum being gradually changed so as to bring the deeper portions into view until this aspect of the canal merges into the membrana flaccida. The outer end of the speculum being still further elevated, the eye next recognizes the epi- dermal covering of the membrana tympani and follows this until it passes quite abru[)tly into the inferior wall of the meatus. .\n examination in this manner — the superior wall being followed across the fundus of the meatus until the eve h^oks upon the inferior wall, and the posterior wall traced until it merges without a break into the anterior — demonstrates with certainty that the membrana tvmpani is {present, and. if no s(jlution in continuity has been observed, intact. This is the most satisfactory method of demonstrating that the mem- brana tympani is present and unbroken throughout its entire extent. Whenever there is a solution of continuity this regu- lar outline must be broken. In some cases, where the mem- brane is almost completely destroyed and is replaced by cica- tricial tissue which applies itself closely to the internal wall of the tympanum, a mistake may be made ; this is scarcely pos- 90 PHYSICAL EXAMINATION. sible, however, if an exhaustive examination is made, each wall being- followed until it merges into the one directly op- posite. When the membrana is extensively destroyed, as mentioned above, we find usually at some point along the posterior wall that the fundus of the canal is not continuous with this wall, but that there is a solution of continuity at the inner extremity, the epidermis not passing directly from the posterior wall of the canal to the promontory, but that a cer- tain space is left be<^ween these two regions, the width of the hiatus being easily recognized by the practiced eye. I have given this as one of the early steps in conducting the examina- tion, since the observer more readily analyzes appearances met with if the question of presence or almost complete de- struction of the drum membrane has been settled before other points are considered. We must next recognize certain landmarks at the fundus of the canal, which under normal conditions is occupied by the membrana tympani {Fig. 39). As the superior wall is fol- lowed inward, there will be seen just below the centre of the line marking its inner termination, a prominent projection, white or grayish white in color, having the appearance as though the soft parts covering it were pushed outward into the lumen of the canal by some firm body beneath. This pro- jection is the short process of the malleus, and its position changes but little, no matter how much the entire ossicle mav be displaced bv rotation about the axis from alterations in tension of the intratympanic ligaments and muscles. More- over, this portion of the ossicle is richlv supplied with nutrient vessels, and even when there is extensive caries of the tym- panic walls and of the ossicular chain, it usually escapes dis- integration. Under normal conditions the short process of the malleus appears as a prominent point, about the size of a pinhead, varying in color from a chalky white to a grayish white or even pinkish white. Extending downward and some- what backward from this point, through the middle of the membrane as far as its centre, the handle of the malleus is recognized. This process tapers gradually as it passes down- ward. At its lower extremity it is flattened slightlv from without inward, and appears a little broader than just above its termination. The shaft of the malleus is slightly curvi- linear in outline, the convexity being toward the meatus in the upper two thirds, while at the lower third it is directed THE MEM BRAN A TYMl'ANI. 9» inward and somewhat backward, lying more nearly in the plane of the membrane. The outline of the shaft, under normal conditions, appears somewhat darker than the surrounding membrane, its presence offering an obstruction to the ravs of light illuminating the fundus of the canal. The outline of the shaft is not infrequently slightly pinkish instead of white, and occasionally one or two blood vessels may be recognized trav- ersing the membrane close to the manubrium and parallel to it. This is particularly true if the speculum has remained in the canal for some time, and depends upon the venous con- gestion incident to the presence of the foreign body. The flattened termination of the manubrium at the centre of the membrane is known as the umbo. Under normal conditions the eye perceives a bright triangular area upon the surface of the membrane, extending from the umbo downward and for- ward to the periphery, the apex of the triangle Iving at the umbo, while the base of the triangle does not extend to the periphery, but fades away gradually before it reaches this line. It is evident that if we imagine the malleus handle to be prolonged to the periphery of the membrane, this struc- ture will be divided into two portions — one in front and the other behind the line, the j)Ostcrior portion being the larger. If a h(jrizontal line is drawn through the umbo to the anterior and posterior walls of the canal, these two segments will be again divided into two. For convenience in locating pathological appearances we conceive the drum membrane to be so divided, the segments being named the superior anterior, inferior anterior, inferior posterior, and sui)crior posterior quadrants according to their situation. From the short pro- cess of the malleus two bands are observed, one running backward, the other in the op- posite direction, t(^ the peripherv of the membrane. Of these, the posterior is the longer, the anterior being just barely seen under normal conditions owing to the prox- imity of the short process of the malleus to f,g. 39 —The normal the upper anterior extremity of the tym- membrana tympani . . ,, ,,.. (somewhat diagram- panic rmg, and because of the obliquity matic). of the plane in which the membrane lies. These bands are called the anterior and posterior folds of the membrane. They are caused by the difference in tension between the membrana tensa below and the membrana flac- 92 PHYSICAL EXAMINATION. cida above. These bands are sometimes very well marked, while in other instances thev are not distinct. Between the short process of the malleus and the superior wall of the meatus the membrana tvmpani presents a distinctly triangular form, the apex of the triangle Iving at the short process, from which point the sides of the triangle diverge until they are lost in the superior wall of the canal, into which they pass without any distinct line of demarcation. The sides of the triangle are clearly marked by a thickening along the lateral boundaries of this triangular area. This upper portion of the drum membrane is the membrana flaccida, or Shrapnell's membrane, and the fibres w-hich form the sides of the triangle are known as Prussak's fibres. It will be re- membered that the tvmpanic ring is wanting at Shrapnell's membrane, the curvilinear outline being completed by the free border of the outer lamella of the squamous plate of the temporal bone, which fills up the gap between the anterior and posterior limbs of the annulus. The name of Rivinian fissure or segment has been given to this dehiscence in the annulus tympanicus. It is also to be borne in mind that the lamina propria of the drum membrane is wanting over this area, the septum being comp)letcd by the tegumentary lining of the canal which passes downward over the Rivinian fis- sure, its epithelial layer being continued over the surface of the membrana tympani. Having determined that the membrana tympani is intact, or, if any solution of continuity exists, the extent and location of the defect having been made out, the observer should next note the following physical properties of the membrana or of its remaining portion : i. The color. 2. The lustre. 3. The structure. 4. The position. The Color. — The normal membrane is of a pearly-white appearance, with a slightly bluish tinge over the entire mem- brana tensa ; above the folds the parts ma}' have a faint ])ink- ish hue, even when in a healthy condition. The Ljtstre. — The recognition of variations in the lustre of the drum membrane constitutes one of the most valuable aids in the diagnosis of aural affections. Normally the parts pos- sess a peculiar sheen which can not be described in words, but is easily recognized when once seen. The triangular light spot has already been spoken of, and its persistence or ab- sence, the variations in shape, position, and e: tent, and the THE MEMBRANA TV.Ml'ANJ. 93 presence of one or more brii^ht points or light reflexes in ollicr parts of the membrane, all furnish valuable information. The lustre may be diminished or mav be entirely wanting, this latter condition always indicating a necrosis of the superficial epithelium. The Structure. — Under this term we consider the devia- tions from the normal appearance resulting from changes in the various layers of the part under examination. In health the membrana vibrans is of uniform texture throughout, ex- cept at the periphery and at the umbo, in which localities it is somewhat thickened and consequently less translucent than elsewhere. The eve is also able to make out indistinctly the circular and radiating fibres as they cross one another, giving an appearance suggestive of a finely woven fabric. Under [tathological conditions the membrana propria may undergo hypertrophy in places, in which case the uniformity of tex- tural appearance will be lost and the affected areas will appear less translucent than the surrounding ])orti()n. The same ef- fect is produced, but in a more marked degree, by calcareous deposits in the fibrous layer. These appear as opaque, lustre- less white areas, with well-defined outlines. On the other hand, as the result of pressure, cicatrization after loss of substance, etc., the fibrous layer may be very thin or even wanting in certain localities. Here the membrane will be transparent, and through the thin septum the underlying structures within the tympanum mav be easily recognized. The membrana tlaccida, containing no lamina propria, does not exhibit the peculiar woven ap])carance characteristic of the larger segment of the drum membrane ; its appearance is similar to that of the skin lining the adjacent part of the bonv meatus, except that it is more delicate in structure. Owing to ])athological changes it may become transparent and parchmentlike, or its thick- ness may be greatly increased. The Position. — Normally, the drum membrane is inclined both in the horizontal and vertical planes. In addition to this it is drawn inward at the umbo on account of its intimate con- nection with the manubrium mallei. The inclination in two planes, together with the umbilication at the centre, gives rise to the light reflex, the rays illuminating this area alone be- ing reflected directly back to the eye of the observer, without previously impinging upon the walls of the canal. Another result of the umbilication is to sive to each segment of the 94 PHYSICAL EXAMINATION. membrana a slightly convex appearance when viewed from the canal, which is most marked in the upper and posterior quadrants. In the young child the inclination of the mem- brane in the horizontal plane, as viewed through the meatus, appears more pronounced than in adult life. This greater in- clination is more apparent than real. dej)ending upon the spe- cial conformation of the parts at birth. At this period, it will be remembered, the superior and inferior walls of the meatus are in contact, the superior wall lying upon the external sur- face of the squama while the bony meatus does not exist, be- ing represented by a canal of fibrous tissue, especially well developed along the inferior wall. Having reviewed the appearance of the membrane under normal conditions, we are now prepared to recognize varia- tions caused by morbid processes. As the upper and posterior part is nearest the eve of the observer, and as this is the most extensive segment of the membrane, displacement of the entire membrane outward in this region is more apparent than else- where. If displacement be excessive the bulged posterior por- tion may overhang the anterior segment and partially or com- pletely obscure it. Sometimes the effect is to obliterate in this region the line of demarcation between the canal wall and the drum membrane, giving to the fundus a narrow appearance. On the other hand, marked retraction obliterates the normal prominence of the upper and posterior segment and exagger- ates the inclination of the upper part of the membrane in the horizontal plane, at the same time causing the inferior segment to appear more nearly perpendicular to the inferior wall of the canal. It also tends to exaggerate the apparent width of the drum membrane on account of the greater depth of the tym- panum above and behind, which allows the membrana to move inward for a considerable distance, thus bringing the anterior segment into view. As seen through the speculum, this in- crease in the transverse diameter, especially of the inferior segment, is exceedingly well marked. The most valuable in- dication of retraction, however, is afforded by a careful inspec- tion of the malleus handle. This prominent and easily recog- nizable landmark appears foreshortened in direct proportion to the degree of retraction, provided adhesions between it and the inner tympanic wall do not exist, and prevent it from as- suming the usual position which it occupies when the pressure within the tympanic cavity is lowered. Another evidence of OBSTACLES TO EXAMINATION. 95 extreme retraction is the prominence of the curved margin of the tympanic ring, which can frequently be traced throughout its entire circumference when the membrane is displaced in- ward to a marked degree. It sometimes happens, owing to the presence of adhesions, that the handle of the malleus is not foreshortened ; then the displacement of the segments of the drum membrane in front and behind the manubrium, to- gether witli the marked prominence of the annulus and the ease with which the intratvmpanic structures are seen, enable the observer to interpret the condition correctly. When the malleus handle is rtrmly bound down and the air within liic tvmpanic cavitv is rarefied, the anterior and j)osterior seg- ments of the drum membrane collapse, and the manubrium appears as a prominent ridge between the sunken areas. In front, behind, and below this ridge there are dccj) pits or fossae, where the more elastic membrane has been forced inward by the pressure of the air until it has impinged upon the inner tvmpanic wall, in children this condition is very prone to exist where adenoid vegetations are present. The appearance is not infrequently a source of error in diagnosis, being mis- taken for a total destruction of the membrana vibrans and a subsecjucnt dermoid transformation of the inner tympanic wall. Obstacles to the Examination. — The description given of the teciinitiue of the in^i)eclit»n of the ear by means of re- flected light, presupposes that an unimpeded view has been j)0ssible; occasionally, however, obstacles are encountered which render the insj)ectit)n of the deeper j)arts difficult I lere we mav mention the presence of fine hairs in the meatus preventing a perfect illumination of the membrana tympani. In such an event the examiner, after the insertion of the speculum, will find it advisable to apply a little vaseline or wax to the hairy area bv means of a cotton-tipped probe ; by this procedure the hairs are made to adhere closely to the wall of the canal, and are prevented from interfering with the examination. If the orifice of the meatus is exceedingly narrow, either as the result of congenital malformation, cica- tricial contraction, or an acute circumscribed inflammatory process, the examiner will do well to use an exceedingly small speculum. By tilting the instrument at various angles it will be possible to inspect the deeper parts over successive small areas until the necessary informaticm has been obtained. 96 PHYSICAL EXAMINATION. This is wiser than to attempt to use a large instrument which fits the canal closely, in the hope of obtaining a more ex- tended field of view. The prominence of the antero-inferior wall occasionally offers an obstacle to perfect inspection of the deeper parts ; but here again the small speculum will enable the observer to see a more extended surface than a larger instrument, provided the auricle is drawn upward and backward suffi- ciently to permit the illumination of the parts beyond the obstructing canal wall. In the same manner, if the orifice of the meatus is almost closed, as the result of an acute inflam- matory process, and the parts are excessively tender, it is pos- sible, by exercising a little care, to introduce a small specu- lum beyond the inflamed area, and to obtain a view of the deep parts. It is to be remembered that no bony meatus exists at birth, and the membrana tympani lies superficially and in nearly the same plane as the superior wall of the canal, which is closely attached to the outer surface of the squama; hence, to obtain a clear view of the membrane, the auricle must be drawn downward and backward instead of upward and backward, as in the examination in an adult (Fig. 26). In addition to what has already been said concerning the recognition of the various normal and pathological condi- tions, it is necessary to call attention to special portions de- manding particular investigation ; these are the periphery of the membrane, and that area lying above the level of the short process, the membrana flaccida. It is quite pos- sible to recognize all the conditions enumerated in the pre- ceding pages and yet to overlook a small perforation, unless the examiner, as a final step, inspects the entire outline of the annulus, following with the speculum the line of attach- ment of the membrane throughout its entire circumference. Again, that region situated above the short process of the malleus and the folds of the membrane demands careful at- tention, since it covers the articulation between the malleus and the incus, and that portion of the tympanum where the mucous lining is thrown into numerous folds as it passes from the bonv walls of the cavity over the intratympanic ossicles and ligaments. It is not uncommon to find a miimte perforation through the membrana flaccida, which might pass unrecognized unless special attention had been directed to the inspection of this locality. It should be borne in mind in TYMPANIC TOPOGRAPHY. 97 this connection that we occasionally meet with a minute oj)en- ing, just above the short process of the malleus. This was formerly supposed to be occasioned by the incomplete closure of the Rivinian segment. A small opening at this point is, according to Randall,* due to a pathological process, and there is no foundation for considering it a result of im{)erfcct development. Under all circumstances both cars should be examined, althcnigh the patient may complain of but one. The importance of this is evident if the reader will recall the remarks already made in the chapter on physiology, con- cerning the interdependence of one organ upon that of the opposite side. It is also important, since any slight anomaly in the direction of the canal or in the position of the mem- brana tvmpani will probably exist on both sides, and a source of error in the inter|)retation of appearances found in the affected organ will thus be removed. At this point we should consider the relation between the contents of the tympanum and the various (juadrants of the tympanic membrane. Fig. 12 represents the intratympanic structures and the inner wall of the middle ear, the ossicles lying in their nor- mal position. A {)ortion of the inferior and posterior wall of the canal is shown. The membrana tympani, with the excep- tion of a small cresccntic portion posteriorly, has been re- moved and the contents of each quadrant can be easily made out. In the supero-posterior quadrant the long process of the incus is seen descending in a direction parallel to the manu- brium mallei, lying behind it and at a deejjer level in the tympanic cavity. The articulation of this process with the head of the stapes is also seen, together with the posterior crus of this latter ossicle, which passes upward and inward until it is lost in the oval niche. From the head of the stapes a delicate fibrous band is observed, which extends directly backward until it is lost from view behind the margin of the tympanic ring. This is the tendon of the stapedius muscle. The tip of the descending crus of the incus (and hence the incudo-stapedial articulation) may frequently lie at a consid- erable distance below the level of the short process of the malleus. On the other hand, and especially as the result of * Trans Am. Otol. Society, 1894. 98 PHYSICAL EXAMINATION. a pathological condition, this process of the incus may run almost horizontally inward, the processus lenticularis being liidden behind the supero-posterior margin of the bony ring. In such an event the stapes itself and the sta})edius tendon are out of the range of vision. Another situation frequently oc- cupied by this process of the incus is close to and just behind the posterior margin of the bony ring. It passes downward in a direction parallel to the posterior limb of the annulus, and is brought into view if the patient's head is turned away from the examiner, permitting the illuminating rays to pass behind the projecting margin of the ring. This position of the incus is usually the result of contraction of the stapedius muscle or of shortening of its tendon. Search with a delicate probe reveals the location of the crus of the incus, the instrument being easily hooked about it and drawing it into view. If Hrmly fixed, the division of the stapedius tendon or of dense adhesions passing backward from the posterior crus of the stapes releases it and brings it into the field of vision. The upper and posterior quadrant, since it contains structures so im})ortant to the function of audition, should always be closely examined, whether the membrana tympani is intact or par- tially destroyed. Frequently the attenuation of the mem- brana in this locality, either from cicatrization or atrophy, enables the observer to recognize the above-mentioned parts through it. This is particularly so when there is consider- able retraction of the drum membrane, which then applies itself closely to the structures beneath. Below the incudo-stapcdial articulation in the lower part of the supero-posterior quadrant, and encroaching to a greater or less extent upon the postero-inferior quadrant, is seen a deep niche the ])osterior boundary of which is hidden by the margin of the annulus tympanicus, while the anterior mar- gin forms the postero-inferioi' boundary of the promontory. At this line the inner tympanic wall bends at almost a right angle, and the plane of the niche is directed backward and downward. The depression formed by this sudden bend is the niche of the round window. Sometimes it lies entirely behind the margin of the ring and out of the field of vision. The portion ol the tympanic wall occupying the middle of the field of inspection is the promontory. It covers the first turn of the cochlea, and exhibits a convex surface which en- croaches to a varying extent upon the the cavity of the ty.m- TYM PANIC TOPOGRAPHY. 99 pnnum. When this portion of the wall is unusually convex, and the niche of the round window can be seen, the pro- jecting mass will occasionally be mistaken for an exostosis unless the possibility of its anomalous prominence is borne in mind. The region corresponding to the antero-inferior cpiadrant presents nothing demanding special notice, except that the tympanic opening of the Eustachian tube may en- croach ufxin its upper part. In the majority of cases the tympanic orifice of the tube lies in the upper anterior quad- rant and may be entirely concealed by the anterit)r border of the tympanic ring. When the membrana vibrans is absent it is possible to pass a delicate probe, bent at a right angle at the tip, upward into the yault of the tympanum, both in front and behind the sh(irt process of the malleus, the angular jiortion (iisaj)j)ear- ing completely in the uj)per tympanic space. Traction outward causes the bent i»art of the j)robe to press upon ,.„. ^o._Middic car piubc. the inner extremity of the su- j)ciior wall of the canal, and the instrununt can not be rc- moycd by traction directly outward, it being necessary first to disengage its tympanic extremity from the inner margin of the su])erior wall of the meatus. As the result of caries, the superior wall of the meatus close to the tympanum may be destroyed, bringing into yiew a portion of the head of the malleus and the adjacent part of the incus, or, where the ossicles haye been destroyed or displaced, the upper part of the inner tympanic wall lies ex- posed. We then see distinctly the pclyis oyalis, and just aboye this the wall of the aqua?ductus Fallopii arching oyer it. If this last structure has been inyohed in the carious process, impact of the probe may cause twitching of the facial muscles, owing to mechanical irritation of the seventh nerve. Naturally, in inspecting the tympanic cavity where the membrana tvmpani has been destroyed as the result of dis. ease, or whei'e a flap has been reflected for the purpose of exploration, the parts which can be brought into view will largely depend both upon the position in which the head of the patient is placed and upon the correct manipulation of the speculum, so that areas hidden from the direct line of vision lOO PHYSICAL EXAMINATION. by the overhanging margins of the inner extremity of the canal may be illuminated by rays from the head mirror. Botey * has advised the use of small mirrors, which are to be introduced into the tympanic cavity for the purpose of in- specting the parts Iving beyond the direct line of vision ; but the procedure has met with little success. Blake f suggested the same method long ago, and made a practical application of it to determine the attachment of a growth springing from the inner extremitv of the superior wall of the canal. In the preceding pages we have spoken of the physical characteristics revealed by ocular inspection. The reader is not to understand, however, that the eye alone is to be used ; a delicate probe is of great service in settling a doubtful appearance, and the value of its use can not be too stronglv advocated. Where it seems unadvisable to use a metal in- strument for fear of injuring the delicate structures, a very satisfactorv substitute is found in the use of what may be termed a cotton probe, constructed as follows: A small bit of cott(^n is wt>und tightlv about the extremitv of a delicate cot- ton holder (Fig. 41 ) in such a manner that the cotton shall project for about a quarter of an inch bevond the end of the Fi<;. 41. — Col toil holder. shaft, it being wound so tightlv as to offer considerable resist- ance upon pressure, and constituting really a prolongation of the probe. This cotton tip can be bent at any desired angle, and is firm enough to retain its shape, and vet not so firm as to injure the delicate structures encountered. It is less disagree- able to the patient than a metallic instrument, while it is of equal service to the examiner. An instrument constructed in this manner can be introduced through a small perforation in the membrana tympani. or into a sinus in front of or behind the short process, and be carried into the upper part of the cavity. Tactile impressions resulting from the proper manipulation of the instrument afford valuable information. The mobilitv of the membrana and ossicles should be de- termined as the next step of the. examination. This may be * Rev. mens, de laryntjol.. vol. .x, p. 68i. f Trans. Am. Old. Society, 1872. THK I'NEIMAIIC SI'ECULl'M. lOI done by making use of Siegle's speculum (Fig. 42). It con- sists of a hard -rubber speculum, the wider extremity of which is screwed tightly into one end of a short cylinder of the same material as the speculum, while the extremity in- troduced into the canal is covered with a small bit of rubber tubing to effect an air-tight closure of the meatus. The op- I'lc. 42. — siegle's pneumatic speculum. positc end ol the cylinder is closed by a caj) wluch makes an angle of fortv-hve degrees with the axis of the instrument. In the centre of this cap is an opening covered with glass. Upon one side of this cylindrical chamber is an opening into which a short tube is screwed. The free extremity of the tube is connected with a small air j)ump, bellows, or atomizer bulb by a short piece of flexible-rubber tubing. After the speculum has been carefully inserted into the external auditory meatus, the air in the canal can be exhausted bv means of the small air pump or rubber bulb with which the instrument is provided, or the flexible tube may be held between the lips and the air withdrawn in this manner. The densitv of the air in the meatus can be increased if desired by reversing the direction of the current. The glass in the outer extremity of the instrument permits the examiner to watch the different motions of the membrana tvmj)ani and ossicles, caused bv the alternate condensation and rarefactifjn of the air in the canal. Were the glass at right angles to the axis of the speculum, the reflection of the illuminating rays would inter- fere with the view of the deeper parts, but this is avoided if it is placed at an acute angle. Under normal conditions the drum membrane moves outward each time the air in the canal is rarefied, and passes in the opposite direction when condensa- tion is effected, the motion being most evident in the postero- I02 PHYSICAL EXAMINATION. superior quadrant. The malleus at the same time rotates about the axis band, the short process remaining almost im- movable, while the long process participates in the outward excursion of the membrane. Areas over which the membrane is adherent to the inner tvmpanic wall are easily recognized, since they are not affected by changes in the air pressure. It is also important to note closely the motion of the malleus, f(^r if bound down at its tip any outward excursion is impossible. Under these circumstances it either remains fixed, the mem- brane bulging beyond it in front and behind, when the air is exhausted, or it may move slightly outward at its upper part when there is relaxation of the structures in this locality. Sometimes intratvmpanic adhesions fix the malleus in such a manner that, instead of rotating about the axis band, it rotates upon its long axis. This is frequently observed in cases where the entire ossicular chain and the membrana are drawn inward as a whole by adhesions, the membrane, therefore, giving no marked evidence of malposition except that it appears farther from the entrance of the meatus than usual. When the ex- cursions of the malleus are changed in character, so that rota- tion takes place about the long axis of the ossicle, we are warranted in assuming the piescnce of extensive intratvm- panic adhesions, together with some relaxation at the malleo- incudal articulation. The use of a magnifving lens in connection with the pneu- matic speculum is seldom of advantage, the unaided eye dis- tinguishing variations from the normal quite as readily as when a lens is used. Our physical examination has thus far been confined to those parts of the conducting mechanism which can be inves- tigated by sight and bv touch. We now have to call to our aid the sense of hearing for the examination of parts not ac- cessible to ocular inspection. These parts are the Eustachian tube and the tvmpanic cavitv. Inflation of the Tympanum. — Since the tympanum com- municates with the pharvngeal vault through the Eustachian tube, a sudden condensation of air in the vault of the pharynx will cause a corresponding increase in air pressure in the mid- dle ear, provided the Eustachian tube is open. The tym- panum is separated from the external meatus onlv by the thin membrana tynipani, and the examiner, by insertitig a flexible tube into the meatus of the patient while the other extremity INFLATION OF THK TYMPANUM. 103 is inserted into his own auditory canal, is able to recognize the moment when the air enters the tympanum, by its impact upon this delicate partition. The sound produced in.dcr nor- mal conditions when the tvmpanum is suddenly inflated we mav denominate, for convenience, the sound of inijiact. it is of sharp, metallic character, and is due to the stretchini;; of the membrana tvmpani by the sudden condensation of the air within the middle ear. This sound seems to t)riginate in the ear of the observer on account of the extreme thinness of the interposed partition, and the direct conveyance of the sound waves to his ear. lender normal conditions but a single sharp metallic click or snap is heard. This mav be followed later by a similar sound of lower pitch and of less intensitv, due to the return of the membrana to a condition of equilibriimi in \irtue of its elasticity. A familiaritv with these signs in health enables the observer to interpret cor- rectly the significance of any modification in their character In;. 43. — Auscultation lubc. due to jiathological conditions. It is sometimes stated that auscultation is a procedure of little diagnostic value, but I can onlv sav that the otologist w ho would take this ground, might be compared with a physician who would consider himself able to judge of intrathoracic conditions without availing himself of auscultation of the chest. Auscultation certainly affords us a valuable means of recognizing certain conditions within the tvmpanimi and Eustachian tube, if practiced suffi- ciently long to enable one to interpret the significance of the various sounds heard. Methods of Inflation. — The earliest method of inflation of the middle ear is that which bears the name of its discoverer, Valsalva. It is executed by the patient compressing the ala^ nasi between the thumb and finger of one hand, thus closing the nostrils ; at the same time the mouth is closed and the at- I04 PHYSICAL EXAMINATION. tempt is made to force air through the nostrils — in other words^ to blow the nose. The result is that the air is forced into the tympanum, since all other avenues of exit are closed. The procedure is frequently valuable as a diagnostic measure, as the surgeon can observe the effect of the increased intratym- panic pressure upon the drum membrane, bv an inspection of the part while the patient performs the inflation. Depending as it does upon the patient himself for its efficiency, this pro- cess possesses but little therapeutic value. The most universally employed method of inflating the middle ear is that first brought into prominence by Politzer,* and bearing his name. To force air through the Eusta- chian tube by this procedure,^ the surgeon makes use of a balloon-shaped rubber bulb, to which a tube of the same ma- terial is attached; the sudden c(jmpression of the bulb by the hand, expels the air through the free end of the tube with considerable force. This ex- tremitv of the tube is provid- ed with a hard-rubber lip, so shaped that it mav be inserted into the nostril of the patient, or in some instances it is coni- cal in form so as to occlude the nostril. In inflating with this instrument, the nose piece is held in position by the fin- gers of the surgeon's left hand, the other nostril being oc- cluded at the same time by compressing the alie of both sides ; the patient is then directed to take a small quantity of water into the mouth, and to swallow it at a given signal. Coinci- dent with the act of deglutition the physician compresses the bulb, which he holds in the right hand, by quickly and firmly closing the fingers upon it, thus driving the air within it into the pharyngeal vault, and from thence into the tympanic cavi- ties through the Eustachian tubes. The action of swallowing shuts off the pharyngeal vault completely from the oro-phar- 1- IG. 44. — rolitzer's air-bag. * Wien. med. Woch., 1863, No. 6. POLirZKRIZA riON. 105 vnx, bv the elevation of the soft palate, the muscular action effecting this, at the same time serving to render the tube more ])ermeable, in the manner alreadv described in consider- ing the function of the tubal muscles. Various modifications of this procedure have been devised, the success depending largely upon the intelligent co-operation of the patient. The act of swallowing must be coincident with the compres- sion of the inflating bulb ; otherwise, the naso-pharyngeal space will not be shut off. and an imperfect operation will be the result. When this occurs, the operator not only fails to carry out the measure intended, but occasions great discom- fort to the j)atient, and occasionallv to himself, for the sud- den entrance of the air into the oro-pharvnx forces the water which the patient is attempting to swallow, either into the larynx, bringing on a severe seizure of coughing, or out of his mouth, deluging himself and operator as well. The modifications of the Politzer method have been de- signed to obviate such accidents. One of the best is to direct the patient to close his lips and then pufT out the cheeks, as though trying to whistle with the mouth closed. Another fairlv successful method is to repeat rapidly the letter K, or anv syllable containing the K sound. Either of these proced- ures, causing an elevation of the soft palate, efTects a fairly perfect closure of the pharvngeal vault. These modifications are of particular convenience in children, and render the ojjcr- ation much less uncomfortable. In infants the act of crying produces sufficient closure of the naso-pharygneal space to allow of a successful inflation of the middle ear, if the air bag is forciblv compressed while the child is crying. There can be no question of the value of Politzer's method both as a diagnostic and therapeutic [)rocedure, but its use should, I think, be restricted to certain cases, and it should not be adopted to the exclusion of catheterization of the tube. A few words will not be out of place here regarding the selection of a proper inflating bulb, or Politzer bag, and of a proper tip for the instrument. The error usually made is to choose an unnecessarily large bag. A large instrument is cumbersome and at the same time less efficient, since it can not be so grasped that the hand is able to compress it quickly. The lumen of the delivery tube is frequently so small in pro- portion to the size of the bag, that when a sudden effort at compression is made, verv little air is forced out, the ten- Io6 PHYSICAL EXAMINATION. sion in the bulb almost immediatclv reaching such a degree that further compression is impossible. The use of a small bulb, of not more than four ounces' capacity, is attended with more satisfactory results; the instrument can be easily held in the palm of the hand, so that the fingers encircle it, and can be almost completely emptied when the hand is quickly closed upon it. The actual air pressure obtainable with a bulb of moderate size is greater than with one of large di- mensions. It is immaterial whether the air bag is provided with a valve which allows the entrance of air, but closes when the bulb is compressed, or whether it has but a single open- ing, in which case the free end must be removed from the nostril after each act of inflation. When this last form of bag is employed it must be removed from the nostril before the pressure upon the bag is relaxed; otherwise, the mucus from the nasal cavitv will be sucked up into the tube. To prevent this accident it is als(^ important that the tip be wiped imme- diately after removal, either with cotton or with a towel, and before allowing the bag to refill. It is more convenient cer- tainly to use a bag provided with a valve, although even here, if the nose piece is allowed to remain in position, a certain amount of mucus may be aspirated from the nasal cavitv. The objection to the valve lies in the fact that it is liable to get out of order. This difTicultv may be obviated by cutting a hole in the side of the ordinary bag, and covering the open- ing with the hand during the act of compression ; as the fin- gers are relaxed it is uncovered, thus allowing the balloon to fill readily. This is certainly more simple than any automatic valve, and demands onlv a little attention on the part of the operator to see that perfect closure of the opening is effected at each act of inflation. Pcrs(MialIv, I often use a vcr}- small bulb of a capacity of about two ounces, such as is supplied with the ordinarv hand-ball nasal atonii;ccr. The valves in these instruments are fairlv well made, and do not get out of order rcadilv. The one which I prefer has two valves, one allowing the air to enter at the distal end o{ the bulb, while at the same time a valve at the opposite extremitv closes the channel between the bulb and the nasal cavitv of the patient, preventing the entrance of mucus. This small bulb is also particularly adapted for use with the catheter, it being only necessary to change the tip. Regarding the particular form of tip suitable for insertion CATHETERIZATION. I07 into tlic nostril, inrliviclual j)rcfcrcnce will probably be the best guide. Manv advocate the use of a small, curvctl hard- rubber ti{). This tube is inserted into the inferior meatus, where it is held between the fingers and thumb of the left hand, which at the same time compress the ala? nasi so tightlv as to allow no air to escape. I have never been able to use this in- strument to my own satisfaction, although there is no question that it is perfectly efficient in other hands. The objection to its use is that the introduction of the tube into the nostril mav be painful, if the septum is considerably deflected, and even when the greatest care is used, slight hjemorrhage may follow the {procedure. If this form of tip is chosen, care should be taken that its calibre is am{)le, permitting a large volume of air to pass through it. As the instrument is usually sold in the shojxs, the bore is very small in comparison with the ex- ternal diameter of the tube. It is also wise to cover the end (jf the tube to be introduced into the inferior meatus with a piece of thin rubber tubing, as an abrasion of the nasal mu- cous membrane is less liable to be caused if this is done.. For my own use I prefer a conical tip, which occludes the anterior nasal opening perfectly by the coaptation of its surface with the soft walls of the opening into which it is in- serted. This conical tip may be constructed either of glass, hard rubl)cr, or aluminium, and care should be taken that the opening through it is of sufficient size to allow a free i)assagc of the air when sudden condensation is effected. In children this conical tip is unquestionably more elTectual and more easily manipulated than the oiu' pii'viou'-lv mentioned. Catheterization of the Eustachian Tube. — By this manipu- lation the surgeon directs a current of air into the tympanum of one side t)r the other, by means of a canula. which is passed through the nasal passages into the vault of the pharynx and inserted directh' into the Eustachian orifice. Before giving a detailed description of the method of intro- ducing the instrument, a lew words mav be said concerning the catheter itself (Fig. 45). It consists of a tube ■ — t — — ^ | iwi^ of either hard rubber, 9 © O © © pure or coin silver, or ^w.. ^s.-The Eustachian catheter. fjf German silver, about eight inches long, bent in the arc of a circle at one extrcmit}', while at the other it is expanded into an elongated funnel, I08 PHYSICAL EXAMINATION. which constitutes about an inch of its length. The canula? vary in external diameter from No. 3 to No. 6 of the French scale. The expanded end of the catheter is provided with a guide ring, fastened to that wall of the tube corresponding to the concavity of the arc described by the pharyngeal extrem- ity, for the purpose of informing the observer of the position of the beak of the instrument when in the nasal cavity. De- cided preference should be given to the pure silver instru- ments, since the curve can be easily changed to meet the necessity of anv individual case. German silver possesses too little flexibility to permit of the instruments being easily bent, while the hard-rubber instruments, although they can be molded into anv form, after they have been heated, usually possess so small a lumen in comparison with the external diameter of the tube, as to render them unfit for use. Even in the pure silver instruments this objection occasionallv exists, the walls being unnecessarily thick, and attention should be directed to this point in selecting the catheter. Care should also be taken that the margin of the lumen of the pharvngcal extremitv is smooth, so as not to abrade the mucous membrane with which it comes in contact. Hartmann * advises that the tip shall be slightly bulb-shaped for this reason. This is not necessary if care is taken that the margins of the opening are slightly inverted, making the periphery perfectly smooth. As to the proper size of catheter, it is ordinarily stated that the largest instru- ment which can be introduced through the nasal passages should be employed, and in some instances an instrument of large calibre is of service. It should be remembered that the width of the isthmus of the tube is never greater than one tenth of an inch, and usually its diameter is less than this ; therefore there can be no advantage in using a catheter whose calibre is many times greater than this. If the tube is obstructed, a small instrument is even more efficient, since the column of air will exert a greater pressure than when a large instrument is used. Any advantage gained bv an instrument of large size is, I think, more than counterbalanced by the in- creased delicacy of manipulation which the smaller allows, enabling the operator to locate it more exactlv. Regarding the proper curve of the instruments, this must of necessity vary in different cases, according to the width of the pharyn- * Krank. des Ohres, Berlin, 1889^ p. 44. CA rilK IKRIZATION. 1 09 g-cal vault, the prominence of the tubal oritices, and the irregu- larities met with in the nasal chambers. Buck* advises that the curve of the catheter be long and gradual, and finds this form adapted to a greater nimiber of cases than one in which the radius of the arc is shorter. This shape is especially valuable where the inferior meatus is ob- structed by a ridge located rather low down on the septum. Many times a sharper curve, such as advocated bv Urbant- schitsch,t will be found tt) give a more perfect inflation. Herein lies the advantage of the pure-silver instrument, since it can be molded easily into any desired form, according to the demands of each case. It is of some importance that the catheter shall not be so long that when in jiosition it projects more than an inch and a cpiarter bcvond the nasal opening. It is more difficult to maintain the instrument in a fixed posi- tion if it projects farther than this, since anv slight motion serves to displace it from the tubal orifice. When the project- ing portion is short verv little leverage can be obtained, and there is less possibilitv of inflicting injury upon the delicate structures encountered, in the event of rough manipulation. The particular device to be used for effecting inflation has been discussed thoroujrhlv, each form havinjr its advo- catcs. The ordinary Politzer bag is most commonly em- ployed, the delivery tube terminating in a conical tip which fits into the outer end of the catheter exactly ; or, in some instances, the tip is larger than the mouth of the catheter, the bag being so held at the moment of compression that the tube is applied as closely as possible to the mouth (jf the cathe- ter, but not fitting into it tightly, thus preventing undue pres- sure at the moment of condensation of the air. When a valve- less air bag is used in this manner it must be removed after each act of compression to allow it to refill, and the repeated adjustment to the lumen of the catheter can not but disturb the position of the instrument, and be a source of discomfcjrt to the patient. It is much simj)ler to make use of the ordinary atomizer bulb, provided with a valve at either extremity and connected with the catheter by a piece of rubber tubing about twelve inches long. The delivery tube is joined to the catheter through the interposition of a conical tube ground to fit the catheter exactly ; this allows a free manipulation of * op. cit. \ Lehrb. der Ohren., Wien, 1890, p. 8. no PHYSICAL EXAMINATION. the bulb, without any motion being imparted to the catheter when it is once in position. When this apparatus is used the hard-rubber tube is fitted into the catheter before the instru- ment is introduced into the nose, the small size of bulb ren- dering it possible to grasp this in the palm of the hand, while the fingers of the same hand hold the catheter and manipulate it during its passage through the nasal cavity (Figs. 46 and 47). This allows of great freedom of manipulation, on account of the length of the tube which joins the catheter to the bulb. After the catheter is once in place the fingers of the left hand fix it, while with the right hand the surgeon comj^rcsses the bulb as many times as may be necessary. Xo motion is com- municated to the instrument as the bulb is emptied, and no discomfort attends the operation. Certainly from a humane point of yiew this method is to be preferred ; and it may also be said that since the mechanical irritation is reduced to a minimum the therapeutic value is also greater. Lucae* advises the interposition of an clastic bulb be- tween the inflating bag and the catheter to serve as a re- ceiver, wliich is filled by the compression of the inflating bag. The elasticity of this second bulb permits of the introduction of a continuous current of air into the tympanum. It has never in my experience seemed necessary that the current of air should be continuous, and for diagnostic purposes cer- tainly, it would be of less value than an intermittent current. Many Continental otologists advocate the use of a higher air pressure than can be obtained by any of the above instru- ments, and emj)loy some form of air pump to secure the proper amount of tension. In such an instrument the air is forced by the pump into a large receiver, j)rovided with a gauge for registering the degree of condensation. The Eustachian catheter is connected with this receiver by means of a flexible tube, and the air is allowed to escajie through the instrument by means of a properly adjusted cut-off. When the Eustachian tube is so much obstructed that catheter inflation is impossible with the ordinary air bag, some method should be emj^loved to determine the exact nature of the obstruction, rather than to attempt to perform inflation with very high air pressure. The same remark will apply to the use of anv form of foot bellows for a similar purpose. Re- * Archiv fiir Ohrenheilk., vol. ii, p. 308. CATHETERIZATION. II I f^arding- all of these devices, it should be borne in mind that, as a diagnostic measure, considerable information is gained by estimating the amount of force necessary to empty the bag by compressing it in the palm, in order to secure a free entrance of air into the tympanum, as evidenced by auscul- tatory signs. The hand and ear of the operator then act tt)gether, allowing him to interpret the relation between the intensity of any particular sound heard, and the force neces- sary to secure the degree of pressure requisite to force the air into the tympanum and produce the sound. An appropriate catheter and inflating apparatus having been selected, the next step is the technique of inserting the instrument. The plan which seems most simple will be first described, after which other methods will be detailed. The inflating bulb is held in the palm of the right hand, while the catheter, having been propcrlv connectctl with it, is grasped lightly between the thumb and index and middle fin- gers of this liand, much as a pen is held. The shaft of the iii^t t iimi'nt points Fig. 4f). — Introduction of the Kus- tachian catheter (first step). Fic;. 47. — Introduction of the Eus- tachian catlieter (second stej)). directly ii])war(l. while the curved pharvngcal portion lies in the horizontal {)lane, the orifice of the catheter looking forward. The patient should be seated in a chair with a high back, and the head should be inclined forward slightly, while at the same time he should be directed to close the lips tightly and breathe slowly and quietly through the nostrils. The operator, either standing or sitting at the right of the pa- 1 12 I^HVSICAL EXAMINATION. tient, tilts the tip of the patient's nose upward with the ball of the left thumb, the index and middle fingers resting upon the nose just below the bridge. From this moment the left hand is not removed from the patient's nose until inflation has been accomplished and the catheter has been removed. The tip of the nose being elevated, the extremity of the catheter is introduced into the nostril {see Fig. 46) ; as soon as the instru- ment has passed the slight ridge at the nasal orihce the opera- tor carries the hand holding the instrument upward luitil the catheter assumes a horizontal position. In this position, with the tip kept constantly upon the floor of the nasal cavitv, the catheter is passed directly backward through the inferior meatus until the posterior pharyngeal wall is encountered (Fig, 47) ; it is then drawn forward about three eighths or one fourth of an inch, and. remembering that the guide ring on the shaft indicates the direction in which the pharyngeal ex- tremity points, the instrument is rotated upon its long axis until the ring points almost directly outward toward the side to be inflated. The hand is then elevated a little and carried slightly toward the opposite ear, causing the pharyngeal ex- tremity of the instrument to descend, and at the same time to press lightly against the lateral pharyngeal wall. By drawing the catheter a little outward, the tip will be felt to impinge upon the posterior lip of the tube ; it is to be drawn over this, the tip being turned slightly downward, if neces- sary, to eflfcct this without undue force. As soon as the ojierator knows by the sense of touch that the promi- nent posterior lip has been passed, the catheter is rotated upon its long axis until the guide ring points upward and outward toward the ear. while at the same time the outer extremity of the instrument is moved toward the opposite side, thus pushing the pharyn- geal extremity well into the mouth of the tube. When care- fully placed, the sense of fixation imparted to the hand is un- mistakable. At this juncture the left thumb is moved so as to pass beneath the catheter and support it. The instrument is thus held firmly against the margin of the nostril, by the thumb below and the first three fingers, resting upon the ->»^ Fir,. 48. — Introduction of the Eustachian catheter (tlic in- strument fixed in the mouth of the tube). AUSCULTATORY SOUNDS. 1,3 bridge of the nose, above (Fig. 4S) ; at the same time the tip of the nose is pressed upward as before. The right hand is now- free to compress the bulb, forcing the air through the catheter into the middle ear, its entrance being recognized by sounds heard through the auscultation tube. As already stated, the value of auscultation for diagnostic purposes can not be overestimated, and the catheter is much superior to other methods of inflation when the operation is performed as a diagnostic measure only. The amount of manual pressure necessary to force the air into the tympanum is also of importance in determining the degree of obstruction present, and this may be roughly estimated by the operator with each act of compressing the bulb. The various sounds produced afford exact information as to the physical condi- tion of the mouth of the tube, of the tubal canal, and of the tympanum. These advantages are not offered by the Politzer method of inflation, since the efticiencv of the procedure de- ])ends entirely ujxjn the ability of the patient to close the naso-pharyngeal si)ace completely at the jtrojier moment, in catheterization the operator has the entire control of the ])ro- cedure, and from knowletige derived by the sense of touch as to the exact location of the catheter, and by an estimate of the force emjjloyed during tlie act of inflation, lie is able to derive valuable information from the various auscultatory sounds elicited (.luring the ex[»eriment. Auscultatory Sounds. — We may consider that the sounds heard through the auscultation tube are produced either at the piiarvngeal orifice of the tube, or within the lumen of the canal, or within the tympanum. Frequently the ear analyzes the impressi(jn made upon it during such an examination, re- solving the combination of sounds heard, into the several sim- ple soimds produced at each of these locations. The determination of the point at which a given sound is generated consists in measuring its intensity or its proximity to the ear of the examiner. Since the tympanum of the pa- tient is separated from the lumen of the diagnosis tube simply by the drum membrane, any sound produced by the air entering the tympanum will appear to originate in the ear of the examiner. We also remember that, on entering the tym- panum, the current passes from a narrow canal into a cavity of comparatively large size, and we should expect that its character would be modified by this change in the physical U4 PHYSICAL EXAMINATION. conditions, so that the pitch would be lowered and the cjual- ity softened. On the other hand, sounds originating^ in the Eustachian canal would be of higher pitch, but would impress the listener as though they came from a greater distance from his ear than the tympanic sounds. Auscultation sounds originating in the naso-pharynx or at the pharyngeal orifice of the tube will seem still more distant, being heard quite as well with the open ear as through the auscultation tube. T/w Normal Tympanic Bruit. — With the parts in a normal condition the surgeon hears with each compression of the bulb of the inflating apparatus a soft, dry, blowing sound, together with a slight but distinct percussion sound due to the impact of the current of air upon the drum membrane. This last is compared bv Deleau * to drops of rain as they fall upon foliage in the forest during a shower. The " blow- ing sound " is produced bv the passage of the aerial current through the catheter and Eustachian tube into the cavitv of the tvmj)anum ; the "impact sound," by the obstruction offered bv the membrana tvmj)ani to the farther progress of the air. With the membrane in a prt)per position and under ni)rmal tension, this last sound is but slightlv marked, and may be so indistinct as to be entirelv overlooked. It is possible, however, with care, to make out the tvmjianic. tu- bal, and pharvngeal ci)niponents of the auscultation sound in almost every instance. We have next to examine the vari- ations which the normal auscultation sound undergoes when the various parts are not in a condition of health. We will consider these according to the special region in which they arise. I. Tympanic Sounds. — (^) An exaggeration of the "impact sound " indicates a considerable displacement outward of the membrane under the influence of the increased tympanic pres- sure. Hence the membrane must have been retracted, oc- cupving an abnormal position — a fact already determined bv previous speculum examination : or, if occupying a normal position, it must have been so relaxed as to admit of consid- erable outward displacement by the aerial condensation. If this last condition exists a secondarv sound will be heard, as the hand holding the bulb relaxes, thus allowing the pressure * Acad, de Sci., Dec. 7, 1829. TYMPANIC SOUNDS. II5 in the niiddle ear to diminish, bv the escape of the air Iruin the tvmpanuin throuj^h the tube into the pliarvny;eal vault. The amount of air forced backward in this way, and conse- quently the intensity of this secondary sound, will depend upon the resiliency of the membrana tympani and the exact- ness with which the catheter fits the pharyns^eal orihcc. This secondary sound is sharp and similar to tne original " imjjact sound," but less intense. Sounds haying their origin within the tympanum are heard so distinctly that those not accustomed to the use of the auscultation tube will frequently describe them as origi- nating within their own ear. {/>) If now the tympanic cayily is hlled with fluid the nor- mal "blowing" and " impact " sounds undergo a change, so that a rough bruit is observed in place of the *' blowing sound," accomjjanied and followed by a series of sharp crack- ling rales following each other at irregular intervals, and persisting for a short period as the inflating bulb is allowed to retill. This rattling apjjcars to be in the ear of the exam- iner, and conveys the impression of a current of air being driven through a collection of fluid. The quality of these rfdes gives some hint as to the nature of the fluid. Crepita- tation of a hne, high-j)itched character is heard when the fluid is watery, but the rales are coarse, low-pitched, and bubbling when the liquid is thick and viscid and adheres to the walls of the cavity. These distinctions are ul but little importance, as the exact nature of the fluid is of no moment. It must also be remembered that even if fluid is present, it may lie out of the course of the current of air which enters the cav- ity, and the auscultation sound may afford no evidence of its j'rcsence. (<•) When the cavity of the tympanum is cttmpletelv hlled with fluid no crepitation is heard, as the air fails to enter the middle car at all. and the normal " blowing sound " is also wanting. The " impact sound," however, is heard as the current of air enters the tube and impinges upon the fluid contained in the tympanum. The [percussion sound. hf)w- ever, loses its sharp character, appearing indi'^tinc t. distant, and low-pitched. (<'/) Any solution of continuity in the drum membrane is easily discovered upon forcing air through the Eustachian tube, provided the opening through the membrana is not Il6 PHYSICAL EXAMINATION. completely shut off from the Eustachian canal by adhesions. The character varies with the size of the opening, being high-pitched and whistling when this is small, and of a blow- ing quality when the area destroyed is greater. With exten- sive destruction of the membrana the air is felt to enter the canal of the examiner and to impinge upon the walls of the meatus. The pitch of the note heard when the perforation is of moderate size will depend somewhat upon the thickness of its edges. Where the drum membrane is greatly swollen the edges do not vibrate freelv and the sound is rather low- pitched. Where the thickening is not excessive, and espe- ciallv if the membrane is fairly tense, a high-pitched note, known as the " perforation whistle," is heard. [e] Certain sounds comparable to those heard when two moist surfaces are forcibly separated are frequently per- ceived upon inflation, and, from their apparent j)roximity to the ear of the examiner, evidentlv originate within the tym- panic cavity. They are caused by the separation of the membrana from the inner tympanic wall, by the act of infla- tion, and are met with in cases where slight hypersecretion has taken place, allowing the two opposing surfaces to adhere. Occasionally these signs indicate the rupture of newly formed adhesions. (/) When the middle ear is the seat of adhesive inflam- mation, which diminishes the size of the cavity by drawing the drum membrane inward, or when this structure itself is thickened and rigid from connective-tissue hyperplasia or from calcareous deposits, or where the tympanic orifice of the tube has been greatly narrowed, the tympanic factor of the bruit is practically lost, and the sound seems distant. This is observed most frequently in patients of advanced years. 2. Tubal Sounds. — In passing through the Eustachian canal the column of air is thrown into vibration, producing sounds which vary in character according to the patency of the pas- sage, the condition of the walls, and the presence or absence of moisture. When the air is not heard to enter the tym- panum, but the listener is conscious of a distant harsh blowing sound with each act of inflation, the catheter being correctly placed, but one interpretation can be made of the sign — it must indicate stenosis of the channel. The location of the ob- struction is determined by observing the relative distance at which the sound appears to be from the ear of the examiner. TUBAL SOUNDS. 117 It approximates more nearly to the pure pharyngeal sound according as the barrier is located nearer this orifice. When the bruit is fairly constant in quality and intensity, the nar- rowing may be looked upon as depending upon some organic change in the tubal walls. On the other hand, if its character changes with each act of compression of the air bag, then it is probable that the lumen of the tube is closed either by a plug of secretion or by tumefaction of the lining membrane. In the first instance the listener hears a harsh, moist, rasping sound, the pitch of which varies each time the air is forced inward, while occasionally the current will be heard to rush into the middle ear. This is caused by the momentary displacement of a mass of tena- cious mucus which occludes the channel, permitting the air to enter. Prolonged inflation usually dislodges the obstruc- tion and allows the current to enter the tympanum with each compression of the bulb. When the tube is narrowed in calibre at any j)()int by slight swelling or by a hyj)erplastic process, the blowing sound is of higher pitch, according to the degree to which the channel is narrowed, being of the squeaking or whistling character when the stenosis is nearly complete. When due to a hyperplastic process the sound yaries but little as intlation continues, while it it depends simply upon swelling of the walls of the passage, the mucous membrane being at the same time moist, the bruit changes considerabh" in ciuality as the operation is continued, moist, crackling, or snaj)ping sounds being heard from time to time, which modify the high-{)itched, whistling note. The sensation of proximity to the observer is wanting, and this fact indicates the tubal origin. When the walls of the tube are in contact, as the result of oedema, the air frequently fails to enter the passage when an attempt is made to compress the bulb, the catheter, if properly located, seeming to be completely occluded. A slight move- ment of the instrument and repeated efforts at inflation pro- duces a distant clicking noise, followed by a high-pitched whistle, and the air is felt to rush into the middle ear sudden- ly. This phenomenon repeats itself during the operation, the air entering the tympanum only after the bulb has been com- pressed several times, and then but in small quantit}*. It is scarcely necessary to call attention to the signs ob- served where the tube is abnormally patent ; one need only Il8 PHYSICAL EXAMINATION. remember that the intensity of the tympanic sound must be greater if the tube is of wide calibre than if it is narrowed. The same is true of the intensity of the tubal sound itself. At the same time there will be no resistance to compression of the bulb. 3. PJiaryngcal Sounds. — These sounds are easily recognized by their variable character ; they are heard also quite as well through the air as through the diagnosis tube. Even when a perfect inflation is made under normal conditions a soft, indis- tinct blowing sound, depending upon the escape of a certain amount of air into the pharyngeal vault, is heard with the open ear. With partial or complete occlusion of the Eustachian canal, or when its pharyngeal orifice is filled with secretion, this sound becomes louder, and, if the trumpet-shaped orifice of the tube contains viscid mucus, is of a hoarse, rasping qual- ity as the air bubbles through it. While these sounds may be heard even when the instrument is correctly placed if the parts are swollen and inflamed, still they most frequently in- dicate that the catheter has been improperly manipulated, and that the tip lies in Rosenmiiller's fossa, behind the tubal ori- fice. Occasionally the catheter is pressed so forcibly against the lateral wall of the pharynx as to com})lctely occlude the lumen, and no air can be forced through the instrument upon attempting to perform inflation. A forcible effort at infla- tion may partially overcome the resistance, giving rise to a harsh, rasping sound as the current passes from the instrument and overcomes the elasticity of the mucous membrane which has occluded the opening. Sometimes, instead of lying ex- actly in the pharyngeal orifice, the instrument impinges upon the posterior lip of the tube. The pharyngeal bruit will pre- dominate if this is the case, and will be of a particularly dis- cordant, vibratory character, the cartilaginous plate forming the posterior wall of the tube being thrown into irregular vi- brations each time the bag is emptied. While the preceding description of these sounds may seem complicated, their recognition is simple after a little practice, and it is easy to recognize any undue prominence of the tubal, tympanic, or pharyngeal factors of the bruit. The informa- tion gained by close attention to this method of examination will amply repay one for the labor expended in jierfecting him- self in it. But one method of introducing the catheter has been given METHODS OK CATHETERIZATION. 119 as yet, for the reason that it has seemed better to take this one as the standard, and to describe the variations in technique which niav be resorted to when this hrst method, for any rea- son, is not successful. It is advisable for the beginner to ad- here closelv to one method of catheterization rather than to re- FiG. 49. — Vertical section through nasal chambers and pharyngeal vault of adult. The lower portion of the septum, opposite the inferior turbinated body and the inferior meatus, has been removed, exposing the course followed by the cathe- ter. The Eustachian orifice is well marked. (Author's specimen.) sort to several as soon as difficulties arise, it being more easy to become expert in the manipulation by the constant use of one method. Loewenberg * modifies the technique in the following man- ner : When the pharyngeal extremity of the catheter is felt to impinge upon the posterif^r wall of the naso-pharvnx the in- * Arch, fiir Ohrenheilk., vol. ii, p. 12. I20 PHYSICAL EXAMINATION. strument is rotated upon its long axis so that the guide ring shall be directed toward the opposite ear ; the catheter is then drawn forward until its concavity is felt to engage the posterior margin of the nasal septum ; it is then rotated downward through an angle of one hundred and eighty degrees, until the guide points toward the ear to be inflated, while at the same time the catheter is carried toward this side. According to the writer quoted, when rotation has been completed, the beak of the instrument will be found to lie in tj A Fig. 50. — A section made in the same manner as that shown in I'ij^. 4(), showing the conformation of the parts in a child of live years. The pharyngeal vault is tilled with adenoid vegetations, and the tubal orifice is less marked and lies farther forward than in the adult. (Author's specimen.) the mouth of the Eustachian channel. The jirolonged manipu- lation is rather prone, in my experience, to cause a contraction of the muscles of the soft palate, and therefore constitutes a source of discomfort to the patient. The variations in the ex- act position of the tubal orifice and in the transverse diameter of the naso-pharynx, detract much from the special value of this method. The same technique had previously been advo- cated by Frank.* Beyer f prefers to rotate the instrument * Lehrb. der Ohreii., 1S45, p. 101. f Annal. des nial. de I'oreille, 1S77, vol. iii, p. 6g. METHODS OF CATHETERIZATION. 121 upon its long axis, as S(3on as the tip passes the choana:, as recognized by the diniiiiished sensation of resistance to the entrance of the instrnment, until its extreniitv [loints to the afTected side. Its exact insertion into the tubal orifice is effected by pressing- the beak outward toward the later- al pharyngeal wall. This method is oc- casionally of service when the parts are irritable, and the o|)- erator knows, from previousexpericnce, the exact location of tlie tubal opening. Triquet * follows almost thesameplan, but rotates the cath- eter before it leaves the inferior meatus, vo that it inav bt arrest- ed bv the tubal prominence as it is pushed farther backward. Wolff + and Cirubcr:}: advise that aftci- the instrument, with the pharvngeal extreniitv directed downward, has been passed through the inferior meatus until the pharyngeal wall is reached, it shall be drawn forward until it is arrested by the soft palate ; it is then advanced slightlv toward the pos- terior pharvngeal wall, after which the angular jjortion is rt)tate(l toward the ear to be inflated, causing the extremity to enter the tubal mouth. Kramer** suggests that use be made of the reflex contrac- tion of the soft palate, which is excited bv the ])resence of the catheter, to cause the instrument to assume its correct posi- tion in the tubal mouth. Having carried the catheter backward to the posterior wall of the naso-pharvnx, it is drawn forward over the prominent posterior lip until it impinges upon the soft palate. This manipulation is followed by a contraction Fic. 51. — \ section throuj^h the nasal pass.igcs and naso-pharynx in an infant, shnwing ilic turbinated bodies and tulial orifice. 1 In- lii)s of the lul)e are poorly defined. A similar condition is fieite of all j)recautions, the in- strument should be held perfectly still fluring the period of muscular s[)asm, as any attemj^t to withdraw or advance it adds seriously to the discomfort. Relaxation is sure to take place in a few seconds, and then the instrument can be carried to the proper position or removed, as seems desirable. Re- flex cough occurring during the act of catheterization should be managed in the same maimer. It is to be remembered that when the instrument is once in position, coughing, swallow- ing, or any other muscular movement does not interfere with it in the slightest, and when ct^rrectly placed its j)resence causes no discomfort. It occasionally hai)j)ens that, bv mistake, the catheter is passed through the middle meatus instead of through the in- ferior channel. This need never occur accidentally if the head of the patient is maintained in a slightly flexed position. The almost irresistible impulse on the part of the patient to ex- tend the neck causes the instrument to enter the middle me- atus, even when it is passed horizontally inward. With the head bent slightly forward this can not occur. It must be borne in mind, in conclusion, after discussing the {)rincipal difficulties met with, and suggesting measures to avoid and overcome them, that the utmost gentleness must be exercised throughout the entire performance of the operation. The catheter should be allowed to find its way into the pharyngeal vault, and should be allowed to rotate one way or the other, as may seem necessary to avoid obstacles. It is only neces- sary for the operator to pirevent its passage into the middle meatus. When the nasal channel is extremely irregular com- plete rotation about the long axis of the catheter frequently occurs during its course from the anterior to the posterior 128 PHYSICAL EXAMINATION. nasal opening. The slightest pressure is sufficient to advance it when properly directed, and no force should be used. Any haemorrhage following catheterization is a reproach to the operator in every instance. It is true that an occasional abra- sion of the nasal mucous membrane occurs at the hands of the most careful manipulator, but one should always feel that there is no excuse for the accident. It is a procedure in which gentleness and care should be combined with skill, and he who can not exercise these is incompetent to carrv out the operation. As to the use of cocaine for the production of local anaes- thesia, it mav be said that since the drug has come into com- mon use, it is frcquentlv employed for this purpose in cathe- terization. It ccrtainlv diminishes the discomfort attending the passage of the instrument through the nose, if the channel is irregular or narrow, and at the same time by shrinking the turbinated bodies increases the width of the nasal passage. It mav be stated, however, that imder normal conditions the inferior meatus is not sensitive to the presence of the instru- ment, and observations upon quite a large number of cases in reference to this point have convinced me that quite as much discomfort follows catheterization when local anaes- thesia is employed, as when no cocaine is used. In many, the disagreeable sensation as of a foreign body in the pharynx, due to the drug, constitutes a much greater source of dis- comfort than that produced by the introduction of the instru- ment without local anaesthesia. No objections can be raised to the use of cocaine, however, and it is alwavs wise to em- ploy it in cases where the nasal passages are so tortuous as to necessitate rather prolonged manipulation. Moreover, the knowledge on the part of the patient that the drug has been used, certainly produces a i)n)found mental imjM-ession, and relieves any anxietv as to the discomfort to be endured. The drug is best a|)plied in a ten-per-cent solution, a small ciuan. tity being hrst sprayed into the nostril by means of an ordi- nary hand-ball atomizer. A few moments suffice to secure contraction of the turbinated tissues, during which time it is well to have the head inclined a little forward to prevent the passage of the solution into the pharyngeal vault. Next, a cotton holder, mounted with a small pledget of cotton mois- tened with the same solution, is to be passed through the in- ferior meatus, along the course to be traversed by the cathe- DANGERS OF CATHETERIZATION. 129 tcr, the manipulation being conducted luider illuinination from the head mirror. The applicator should not be carried be}ond the choanal if the unpleasant sensation of fullness in the pharynx which the drug causes is to be avoided. If there is reason to suspect that the naso-pharvnx will be ini- usually irritable — a condition with which we frequently meet in cases of acute naso-pharyngitis — it is well to anaesthetize the mouth of the tube as well as the nasal passages. This is done by means of the cotton-tipped probe, the extremity t)f which is bent to correspond to the curve of the catheter. Under inspection, this instrument is to be passed through the nasal passage exactly as the catheter would be introduced, care being taken that the patient's mouth is closed, and quiet nasal respiration continued. The same manipulation em- ployed in the introduction of the catheter enables the cotton- tipj)ed probe to be inserted into the orifice of the Eustachian canal, care being taken that the jiledget is not saturated with the solution, as otherwise a considerable quantity will be spread over the pharyngeal mucosa. When the orifice of the tube is reached, the applicator is allowed to remain in this position for a few seconds to ablate comj)letelv the sensi- tiveness of the mucous membrane; catheterization is now easily performed. In addition to securing local anasthesia by the introduction of the cotton pledget in the manner al- ready described, the o|)erator accomplishes another purj)Osc, since he cleanses the orifice of the tube and removes any in- spissated secretion which mav be present, and which would be an obstruction to successful intlation. The Dangers of Catheterization. — I'rom the fact that three deaths have followed the procedure it is looked uj)()n by those unacquainted with the ojieration with a certain de- gree of perturbation. Inflation in these fatal cases was per- formed by means of compressed air, the degree of condensa- tion being extreme. This method, as already stated, is seldom used at present, and it is safe to say that no damage can be done with any form of hand apparatus devised for the purpose of inflating the middle ear through a catheter. Death in these cases was probably caused by suffocation from submucous emphysema, due to the air having been forced beneath the mucous membrane, the surface of which had been abraded by the extremity of the catheter. The oc- currence of emphNsema need not of necessity be followed by 10 •30 PHYSICAL EXAMINATION. serious results, although the symptoms which supervene arc always alarming to the patient, and may be disturbing to the operator. When this accident occurs, the air may either be absorbed spontaneously, or, if the emphysematous area is ex- tensive, the condition may demand relief by surgical interfer- ence. Puncture of the tissues suffices to evacuate the air and to relieve the symptoms at once. It should be stated, how- ever, that if even ordinary care is used in catheterization, em- physema will never be produced, and one who can not intro- duce the Eustachian catheter without abrading the mucous membrane of the naso-pharynx had better not introduce it at all. The onh' possible excuse for the accident would be cathe- terization immediately after the introduction of the Eustachian bou£:ie ; therefore it should be the invariable rule never to in- fiate the middle car at once after the passage of such an in- strument. Occasional! v, inflation of the tvmjianum, cither by Polit- zer's method or bv the introduction of the catheter, is followed by immediate dizziness, due to the sudden disturbance of lab\- rinthine pressure. No judgment can be formed beforehand concerning the likelihood of this occurrence. It is alwavs well when the procedure is conducted for the first time to begin the inflation very gently, allowing but little air to enter the tympanum at first, and gradually increasing the strength of the current if unpleasant symptoms do not supervene. The dizziness, which is sometimes so severe that the patient falls from the chair and becomes unconscious for a moment, is terrifying, but not dangerous. Where the membrana tym- pani is very thin, either as a result of a previous inflammatorv process with the subsequent formation of cicatricial tissue, or from atrophic changes, a forcible inflation may rupture it. It follows, therefore, that the use of Politzer's method or cathe- terization should be preceded by an inspection of the drum membrane. The Comparative Value of Politzerization and Catheter- ization. — lla\iiig now considered these two methods ot forc- ing a current of air througii the Eustachian tubes antl into the middle ear. a few words as t(^ their relative value mav not be out of place. As a means of diagnosis, inflaticMi l)v the catheter is always preferable, as it enables the surgeon to estimate the force nccessarv to propel the air through the canal, to observe the effect upon the auscultation sounds resulting fiom varia- CATHETERIZATION COMPARED W iril POLITZERIZATION. 131 tions in the strength of the air current, and to repeat the ex- periment as often as he may desire. Moreov'er, success or failure in accomplishing the end lies entirely in the hands of the operator if the catheter is employed, while when the air bag is used by Folitzer's method, the success or failure lies quite as much with the patient as with the surgeon, as it de- pends upon his ability completely to close the naso-pharvn- geal space by elevation of the soft palate. In the adult the auscultatory sounds are so weak when Fo- litzer's method is used that very little information is gained by using the diagnosis tube. In children under twelve vears of age, however, the Eustachian canal is quite short, and its calibre comparatively large in proportion to its length. At this age catheterization is somewhat difficult, while the air bag htted with a jtroper nose piece usually opens the tube per- fectly, and the sounds produced within the tvm|)anum are suf- hciently strong to be perceived through the diagnosis tube. As a diagnc;stic measure, then. Folitzer's method should be used in voung children antl in those cases where the nasal passages are obstructed to such an extent that the introduc- tion of the catheter is well-nigh imp(»ssible. As a therapeutic measure the catheter is decidedlv supe- rior to Folitzer's method, allowing as it does the inflation of either ear without disturbing the organ of the opposite side and permitting the application of various medicated vapors directlv to the membrane of the tube and tympanum, without bringing them in contact with the mucous membrane of the nasal cavitv. When Folitzeration must be employed from necessity, the action of the air may be confined to one ear by the insertion of the finger into the opposite meatus, thus compressing the air in the canal and rendering anv appreciable outward dis- j)lacement of the membrana tvmpani impossible. The ad- vantage of catheterization, mentioned in comparing the two methods for diagnostic purposes, holds good in this connec- tion as well — that catheter inflation allows an exact gradua- tion of the force employed, the bulb being pressed more or less strongly as indicated by the freedom with which the air passes into the middle ear. The objection so frequently raised against catheterization — that the instrument inflicts a certain amount of traumatism on the structures against which it impinges — need scarcely be mentioned. It is quite true 132 PHYSICAL EXAMINATION. that harsh catheterization always does -more damage than good, but harsh catheterization is never to be employed, for, as before stated, the exercise of care will enable even the be- ginner to introduce the instrument without inflicting any in- jury, even if he is not successful in directing the instrument into the pharvngeal orifice of the tube. The Examination of the Nose, Naso-pharynx, and Phar- ynx. — Under no circumstances should tlic surgeon consider his physical examination complete until he has inspected the regions above mentioned which, by their anatomical position, exert a powerful influence upon the ear both in health and in disease. As the mucous membrane lining the nasal cavities and the naso-pharvngeal space is continuous with tliat lining the mid- dle ear, an intimate relation exists between the nerve and blood supjilv of the two regions, rendering tiie car particu- larly susceptible to reflex disturbances depending ujjun some intranasal exciting cause, as well as to circulatorv changes from alterations in the blood and Ivmph current within cither the nasal chambers or the pharyngeal vault. After a satis- factory otoscopic examination has been made, the next step should be to inspect the oral cavity by means of reflected light, observing the condition of the mucous membrane in the mouth ; the presence of carious teeth ; the appearance of the posterior pharyngeal wall, whether it is div or moist; whether it presents the smooth, velvety appearance of a nor- mal mucous membrane, or is studded here and there with irregular elevations, indicative of the presence of small lymph nodules just beneath its superficial epithelial lavcr In this connection attention need scarcely be called to the importance of observing those two large masses of lymphoid tissue situ- ated between the pillars of the fauces — that is, the faucial ton- sils. Under normal conditions the tonsils do not project be- yond the faucial pillais. and special effort must be made to see them in a condition of perfect health, bv crowding the ante- rior faucial pillar against the lateral wall of the pharvnx, or turning the head of the patient first to one side and then to the other, to permit the observer to look obliquely across the cavity of the mouth, in order that they may be brought into view. Anv projection of these bodies beyond the pillars of the fauces constitutes an abnormitv. The vault of the pharynx next demands investigation. In EXAMINATION OF THK L'PrER AIR PASSAGES. 133 very young children posteri(jr rhinoscopy is impossible, and here resort may be had to digital examination. In this pro- cedure the mouth of the patient should be held open by a cork inserted far back between the jaws, or better by the use of a mouth gag. The index finger, with the palmar surface down- ward, should then be introduced into the opposite angle of the mouth. It should then be passed rapidly along the dorsum of the tongue until it meets the posterior pharyngeal wall, when, by quickly turning the palmar surface upward, it is passed behind the soft palate into the naso-pharyngeal space, the palate yielding readilv to gentle but firm traction. By drawing the finger forward the nasal septum should now be recognized and ftjUowed upward until the roof of the cavity is felt. The sensation imparted to the examining digit should be observed: whether the membrane is soft and spongy, in- dicative of the f)rcscnce of an abnormal amoimt of Ivmphatic tissue, or whether it differs but little from the sensation im- parted bv the mucous membrane covering the posterior wall of the oro-pharvnx. These facts having been determined, the tip of the finger is turned first to one side and then to the other, and easilv appreciates the luistachian jnomincnces, after which it is withdrawn ; by sweeping along the posterior wall of the naso-pharvnx in making its exit, the presence of any abnormal amount of lymphoid tissue in tin's location is determined. The presence of adenoid tissue in the vault (j1 the piharynx afTects the ear in two ways. If the mass is large, by direct pressure upon the Eustachian orifice the supi»ly of air in the tympanic cavity mav be disturbed. This fact will be ap- preciated by reference to Fig. 50. It is evident that the en- larged pharyngeal tonsil, seen in this drawing, lies so closely to the posterior lip of the tube that any increase in volume would interfere with the patency of the canal. Any slight in- crease in volume of the mass will close the lumen of the tube, after which the intratvmpanic air is gradually absorbed by the blood which circulates through vessels in the walls of the cavitv. With each act of swallowing, at which time the tube opens momentarilv, the air is aspirated into the naso- pharynx, the tube closing so quickly that the passage of air into the tvmpanum does not take place. In this manner a passive congestion of the mucous membrane of the middle ear is produced, a condition which constitutes practicalh- the 134 PHYSICAL EXAMINATlOxN. first stage of an inflammation, and, if long continued, results in permanent tissue changes. I am inclined to think the more important manner in which adenoid growths, especially those of moderate size, affect the organ of hearing is by the obstruction to the ve- nous return current from the tympanum and labyrinth. It must not be forgotten that the pharyngeal tonsil constitutes nothing more than a lymphatic gland, and, in virtue of its presence, may exert sufficient pressure to partially obstruct the venous flow from the tympanic cavity. Any condition which affects, for a considerable period, the circulation within the middle ear, will also cause a disturbance of the labyrin- thine circulation from an alteration in the tension of the fluid contained. Such changes in the labyrinth, however slight, render this portion of the economy particularly susceptible to inflammation, cither as the result of infection or of mechan- ical irritation, the most fruitful source of the latter being the crowding inward of the ossicular chain by atmospheric pres- sure, when the tension of the air within the tympanum is re- duced. Evidence is not wanting, from a clinical point of view, that even in very early life the labyrinth may be af- fected by the presence of growths of this kind. We not un- commonly find instances of tubal catarrh in children in whom these growths are present; instead of presenting, upon func- tional examination, the reactions characteristic of the affec- tion, these cases show a diminution of bone conduction, and sometimes a hyperaesthetic condition of the auditory nerve, both of which phenomena indicate an irritative lesion of the labyrinth. In very young children it is of the utmost impor- tance to determine the presence or absence of a growth of this kind, even where the history seems to show that the child is entirely deaf, for, as articulate speech is acquired simply by imitation, an impairment of audition which in an adult or in a child of a few years of age would be practically insig- nificant, in a child so young that the function of audition has never been exercised, may give rise to all the symptoms usu- ally found in a deaf-mute. , The oro-phar\'nx and the pharyngeal vault having been examined in the manner stated, attention should next be di- rected to the anterior nares. The nasal cavity should be inspected by anterior rhinoscopy, the tip of the nose being tilted up by means of the thumb of the left hand, the hngers EXAMINATION OF THE UPPER AIR PASSAGES. 135 of the hand resting upon the forehead for support, while the nasal orifice is dilated gently with a self-retaining speculum (Fig. 54). The patient's head should be flexed slightly for- ward, in such a position that the floor of the nasal cavity will be nearly horizontal. When the light from the head mirror is directed into the cavity the observer inspects first the inferior meatus, and remarks if any deformitv of the septum is present, ] , • • -x. » ^ 10 Ilti- 54- — Bosworth's nasal determming Its extent, na- Ij speculum. ture, and location, as well as the size, shape, and color, of .the inferior turbinated body ; whether it is turgescent and occludes the inferior meatus to a considerable extent, or whether its mucous membrane is of the normal light rosv tint, and its rich venous plexuses are not abnormallv engorged. Under normal conditions, where no deformity of the septum exists and the turbinated tissue is not swollen, the observer can readily see the posterior wall of the naso-j)harvnx bv anterior rhinoscopv, and, in fact, the au- thor has found this one of the most simple methods of deter- mining the presence of hvpcrtroj)hicd Ivmphatic tissue in this region. This portion of the examination is rendered more complete if a weak solution of cocaine is sprayed into the an- terior nares. before an attem[)t is made to inspect the naso- pharynx in this manner. The ana.thesia this produces renders it the simplest possible procedure to add to our information bv touching the various parts under inspection with a cotton- tipped probe passed through the anterior nares. The inspec- tion of the lower meatus and naso-pharynx having been com- pleted, the head is now^ tilted backward, and the observer di- rects his attention to the uppter part of the nasal chamber. In the anterior portion the eye recognizes readily the tip of the middle turbinated bod}', which, normally, is of a somew^hat lighter color than the lower turbinate and less freely supplied with venous channels, for which reason its mucous membrane seems to be more closely applied to the bon}- framework, the entire structure projecting less into the lumen of the passage than does the inferior turbinate. Any deviation from this normal appearance should be carefully noted as constituting a source of obstruction to nasal respiration. It should be re- meinbered that the furrow or hiatus beneath the middle tur- 136 PHYSICAL EXAMINATION. binated body contains the opening of the frontal, anterior, ethmoidal, and maxillary sinuses; consequently it should be inspected with special care for the presence of a j)urulent dis- charge which, when lying here, is almost pathognomonic of an inflammation of one of these accessory cavities. This also is the region from which nasal polypi most frequently take their origin, and the possible presence of these growths must always be borne in mind during this stage of the examination. We have spoken only of the hypertrophic condition, since this is the lesion usually presented in cases which come under the observation of the otologist. It must be remembered, how- ever, that precisely the opposite state of affairs may constitute a morbid condition — that is, instead of an hypertrophy of the lining membrane, this may be abnormally thin, the turbinated bodies lying close to the outer wall of the passage and project- ing but little into the lumen. When the condition is extremely well marked, they are discernible with some difficulty. Under these circumstances the mucous membrane, instead of being moist, has a dry, glazed appearance, while in the sulci be- tween or beneath the turbinated bodies, large greenish-yellow crusts are seen. These result from the inspissation of the nasal secretion, which, owing to the atrophy of the lining mem- brane, is wanting in fluidity. The naso-pharynx also, instead of showing the presence of lymphatic tissue, may appear glazed, and may be covered, to a greater or less extent, with a thick, tough mucus, usually in the form of a scale or shell, which spreads irregularly in all directions from the median line. This naso-pharyngeal condition is seldom found before the age of twenty, and is usually due to retrograde changes in the lymphoid tissue of the region, which in early life had un- doubtedly been moderately but not excessively hypertrophied. Instead of disappearing completely after the age of puberty, as is often the case, interference with this retrograde process occurred for some reason, with the result that the fibrous elements of the pharyngeal tonsil persisted and increased in density, while the cellular elements disappeared. This local condition constitutes the lesion in the cases of so-called naso- pharyngeal catarrh, or chronic naso-pharyngitis. The ap- pearance described can be recognized both by the anterior rhinoscopic examination, and by posterior rhinoscopy as well. By posterior rhinoscopy we are enabled to obtain a view of those structures which are hidden from direct inspection EXAMINATION OF THE UPPER AIR PASSAGES. 137 by the curtain of the soft palate. This is accomplished by means of a mirror introduced into the mouth, with the reflect- ing surface directed upward, so that the image of the region in question is reflected in the mirror. In order to conduct this examination the patient is seated facing the surgeon, the arrangement of the light and the relative positions of the pa- tient and operator being the same as those already given un der the description of otoscopy. The head of the patient is inclined very slightly forward so that the hard palate lies in the horizontal plane. The surgeon now depresses the tongue with the tongue depressor held in the left hand, crowding the organ downward while, at the same time the instrument is Fig. 55. — B.jsworth's tongue depressor. Fig. 56. — Folding tongue depressor. Fig. 57. — TUrck'.s tongue depressor. rotated slightly by elevating the handle, the blade resting upon the incisor teeth, thus exerting slight forward traction. In this way efforts at retching on the part of the patient are avoided, as the base of the tongue, instead of being crowded into the throat, a circumstance which always results in ex- citing an efTort of deglutition, is drawn forward out of the pharynx. The patient is directed to breathe quietly, and at an opportune moment, when the palatal muscles are re- laxed and the velum hangs vertically downward, the rhino- ,.8 PHYSICAL EXAMINATION. scopic mirror, previously slightly warmed over the lamp, is carried rapidly into the mouth and made to assume a position to the one side or the other of the uvula. The rays of light from the head mirror are directed upon the surface of the rhinoscopic mirror, which, as the inclination of its polished surface is about one hundred and thirty-five degrees, directs the rays impinging upon it into the retronasal space. At first Fig. 5S. — Rhinoscopic mirror. the handle of the mirror should be carried slightlv downward, which brings into view the posterior margin of the nasal sep- tum ; this should be followed upward until its narrow edge is seen gradually to broaden and finally to disappear in the ujiper wall of the naso-pharvnx. In bringing the septum into view the presence of an hypertrophied posterior extremity of either lower turbinated bodv will easily be recognized by its marked encroachment upon the lumen of the corresponding posterior nasal orifice. In the same manner mvxomatous growths, springing from the nasal cavities and extending into the naso- pharvngeal space, will also be easily discovered. Any in- crease in the Ivmphatic tissue near the pharvngeal roof will be at once evident, as its presence renders it impossible fc^r the observer to follow the outline of the septum upward to where the divergent edges are lost in the pharyngeal roof the expanded portion of the septum being concealed bv the hvpcrtrophied Ivmphatic tissue. By graduallv elevating the handle of the mirror the entire roof and a portion of the posterior wall of the naso-pharvnx are brought into view, and by rotation of the mirror upon the long axis of the shatik each lateral wall of the cavity is inspected and the prominent posterior lip of the Eustachian tube upon either side easily recognized. Behind this we observe the fossa of Rosenmiil- ler, while in front is the orifice of the Eustachian tube, wiiich varies in shape from a slitlike depression, to an opening with distinctly circular borders. (Fi(;s. 49-51.) PRErARATK^N OF InSTRUMKXT.S. Before concluding the subject of the physical examination, a few words will not be out of place concerning the care of instruments used in conducting the examination. Too much PREPARATION OF INSTRUMENTS. 139 Stress can not be laid upon, the necessity of absolute asepsis. All metal instruments should be sterilized by boiling in a two- per-cent sodium-bicarbonate solution before each examina- tion. If rubber catheters are to be used, each patient should possess his own instrument, while if silver catheters are used they should be sterilized in the manner above ^described. In cleansing the ear with a syringe, an aseptic solution or, better still, an antiseptic solution should always be employed. A solution of bichloride of mercury in the proportion of i to 5,000 is sufficiently antiseptic to prevent infection of the tym- panic cavity if the drum membrane is accidentally perforated during the process of cleansing the canal. The tip of the ear syringe should be boiled immediately before use, or, if this is not convenient, the extremity should be covered by a small piece of soft-rubber tubing, which is renewed each time the syringe is used. As the prolonged boiling of tenijiered instruments is inju- rious, these may be thoroughly cleansed with cotton and then dipped for a moment in the boiling soda solution, alter which they are immersed in a five-per-cent solutii^n of carbolic acid for several minutes. It is scarcely necessary to call attention to the necessity of personal cleanliness on the part of the operator, and yet perhaps this is occasionally forgotten. These measures have been recommended by many writers to avoid specific infection chiefly. In this coimtrv, where specific disease is not as common as upon the Continent, the above precautions are scarcely necessary for this purpose, but they are necessary to prevent purulent infection of the middle ear. If the above precautions are adopted in every case, the extent to which operative procedures within the middle ear can be carried is surprising. In no region of the body, per- haps, is asepsis more important, and nowhere certainly has it been so utterly disregarded. Thf. History. A very important part in the intelligent investigation of any affection of the ear, involving a partial loss or per- version of its function is the general history of the patient, together with an exact account of the aural affection. It is scarcely necessary to give more than briefly the various 140 PHYSICAL EXAMINATION. subjects which should be investigated, before any decided opinion is given as to the nature of the affection or the prob- able course which it will pursue. These facts influence our opinion not only as to the favorable or unfavorable progress of the disease, but in no small degree enable us to determine the relative value of the various data with which our physical and functional examinations furnish us. The age of the pa- tient, the occupation, and the habits of life should be first con- sidered. The history of any previous illness must be investi- gated with great care, particularly concerning the occurrence in childhood of anv of the exanthemata and other kindred diseases, and later in life of any of the continued fevers. A not unimportant factor is the presence of an hereditary taint — tuberculous, specific, gouty, or rheumatic — as well as the existence of chronic aural disease in any other members of the family. The habits of the patient regarding the use of opiates, stimulants, tobacco, indulgence in the luxuries of the table, or the fact of his having been called upon at any time to undergo severe mental strain or physical exertion, must also receive consideration. Special attention should also be paid as to whether, at any period of life, it has been necessary for him to take continuously large doses of the various drugs which arc known to have a specific action on the auditory organs. Next the status pncscns should receive attention, particu- larly with reference to the digestive system, and here it must not be forgotten that the mouth is responsible for quite as much aural disturbance as the stomach, and inquiry should be made into the condition of the teeth. Any previous or present condition referable to the pelvic organs must also be inquired into. Much information may frecpicntly be obtained by observing the general behavior of the subject in respond- ing to the various questions, it being remembered that, in patients of a decidedly neurotic tendency, care must be ob- served in the interpretation of the apparent results obtained by a functional examination, the mere fact that they are under examination often disturbing them to such a degree that their answers are entirely imtrustworthv. When we C(^me to the special history — that is, that part which bears dirccth' upon the aural affection for whicii they seek advice — the length of time which this has existed must, if possible, be determined. It is of special imjtortance to inquire into the condition of the cars in childhood, as not infrequently THE HIST(Mrevi(jusly detailed, and having arrived at a conclusion concerning the extent of impairment by the functional examination, the next step should be to locate the pathological condition either in the sound-conducting or the sound-perceiving apparatus. Many of the methods employed for this purpose bear the names of the investigators who first demonstrated their value. The test most commonly spoken of is that of Weber, who, as the result of a series of investigations, found that when a vi- brating tuning fork w^as placed upon the skull in the antero- posterior vertical median plane and the meatus of one side was closed, the sound of the fork was heard more strongly in the ear which was occluded. In the same way if the struc- 152 FUNCTIONAL EXAMINATION. tures of the middle ear were bound down by adhesions, if the cavity was filled with fluid, or if the ligamentous tissues were so relaxed that the weight of the drum membrane and the attached ossicular chain constituted an obstruction to the passage of sonorous vibrations from the external canal to the parts beyond — under all of these conditions the vibrating tun- ing fork was heard better in the obstructed ear. The deduc- tion was inevitable that, in a case in which impairment of hearing existed upon one side alone, or in which impairment existed on both sides to an unequal degree, the perception of the tuning fork from the median line of the head would be stronger in the ear in which the pathological condition in the conducting mechanism was more marked. In other words, the fork would be better perceived by bone conduction in the poorer ear. If the organ upon one side was normal, the fact of the fork being heard better in this car would locate the pathological condition of the opposite side in the perceptive rather than in the transmitting apparatus. The second classical test was devised by Rinne,* who was the first to determine that the normal ear perceived a vibrat- ing tuning fork, held before the canal, for about twice as long a time as when the shank of the fork rested upon the mastoid process. In cases where the canal was occluded, or where an obstructive lesion was present within the tympanum, it was found, after the fork had ceased to be heard in front of the ear, that its vibrations could still be recognized when the handle of the instrument was bnought in contact with the mastoid. In applying this method of investigation then, if, in a given case in which the hearing is impaired, the duration of bone conduction is greater than that of air conduction, the in- ference would be that the im])airmcnt is due to some lesion of the conducting apparatus, and, pathological conditions of the canal being excluded bv phvsical examination, the loca- tion of the morbid process must of necessitv be the tvmpanic structures. If, on the other hand, the hearing is impaired and the normal relation between bone and air conduction is preserved, although both are found to be reduced, the seat of the disease must be the perceptive portion of the organ of hearing. While both of these facts are of undoubted value, the * Prager Viertcljahresschrift, 1S55, vol. i, p. 71, vol. ii, pp. 45-155. RINNE'S TEST. 1 53 accumulation of clinical evidence from the investigation of a large number of cases, has convinced those interested in Otol- ogy that in many instances they can not rely absolutely upon these reactions to indicate the site of the lesion. The first fact with which we are impressed in a careful reading of these experiments is that very little attention seems to have been paid to the pitch of the fork used in conducting the tests. From what we know bv experiment (see Physi- ology) of the effects of increase of tension in the iiitratvmpanic structures, or the weighting of these parts or of tiie tvmpanic membrane, it can easily be seen that if the impairment of hearing is very slight and the fork used in making the test is of moderately high pitch, an absolute reversal of the relation between the bone and air conduction mav not take place, since the api)lication of a load to the drum mcinbiane or ossicles interteres principallv with their vibration in their re- sponse to the lower notes of the scale. This fact is recog- nized bv Lucic and by Bczold,* the latter restricting the aj)- plicability of Rinne's exj)eriment to those cases in which the whispered voice is not understood at a distance greater than three and a half feet. It must be remembered, that in arriv- ing at this conclusion regarding the aj)j)licati()n of Rinne's test, a tuning fork making about 512 V. S. was used, liy the use of forks of lower pitch the test bcc(Miies applicable to cases in which the degree of impairment is much less than this. It is seldom wise, however, to determine bone conduction with a fork of lower pitch than 128 V. S., since a fork lower than this is felt rather than heard, and comparatively few patients are able to distinguish between the two sensations. If a fork making 512 V. S. is used in cases where the impair- ment is slight, instead of looking for an al)solute reversal of the relation between bone and air conduction, a com[)arison should be made between the time during which the fork is heard when held in front of the canal and that during which it is perceived when placed uf)on the mastoid. It will be found that bone conduction is increased relatively, although Rinne's test will be positive. Sucii a result is called " a di- minished positive." For clinical purposes, however, it would be impossible to conduct the test in this manner, as the dura- tion periods would then need to be determined with great * AUg. Wien. med. Ztg., 1887, p. 183. 154 FUNCTIONAL EXAMINATION. exactness, and reliable results could be obtained only by complicated apparatus. Following in this same line, Schwabach * has found that where obstruction exists in the conducting mechanism, the absolute period of bone conduction exceeds that of the normal ear. Pomcroy.f in applying this test insists upon the ears being tightly stopped with the fingers. In other words, he compares the maximum bone conduction to be obtained from the normal ear with that to be elicited from the organ under examination, combining really the test of Schwabach with that of Weber. The determination of the absolute bone conduction in sec- onds, not only consumes considerable time, but the result obtained must vary with the age of the patient, and with dif- ferent examiners. The variations in the force of the blow setting the fork in vibration also constitute a source of error. It is much simpler, if the examiner possesses a normal ear, to follow the plan suggested by Gardiner Brown.:}: who con- ducts the test as follows: The tuning fork is set in vibration, and the handle is held against the mastoid of the patient until the sound is no longer heard, this fact being communi- cated to the examiner by the {Kiticnt raising his hand. The handle of the fork is then applied to the mastoid of the ex- aminer, and if he perceives the sound, it is fair to assume that the bone conduction of the patient is below the iK^rmal stand- ard. If, on the contrary, he no longers hears it, the inference is that the bone conduction is normal. For general purposes, the data obtained in this manner are sufficientlv exact, when taken in connection with results arrived at by applying the other tests for determining the location of the lesion. Reviewing briefly the facts stated in the preceding pages, it will be seen that lesions of the conducting mechanism are characterized by — I. A loss or impairment of audition for the lower notes of the scale, and as the degree of impairment of hearing in- creases, the lowest note which can be perceived, or the lower tone limit, as it is called, becomes elevated. II. The relative duration of bone conduction as compared * Zeitschrift fur Ohrenheilkunde, vol. xiv. f Diseases of the Ear, New York, 1883, p. 337. X Lennox Browne, The Throat and its Diseases, London, 1SS7, p. 535. DIFFERENTIAL DIAGNOSIS. 155 with air conduction increases, the inversion of the ratio being more marked for the lower notes of the scale and affecting these first, the change occurring with the higher notes in proportion as the pathological condition increases, and conse- quently as the impairment of function becomes more marked. III. Lesions of the conducting apparatus interfere very slightly with the perception of the highest notes of the scale by air conduction — in other words, have very little effect upon the upper tone limit. In the same manner diseases of the receptive mechanism are characterized by — I. No elevation of the lower tone limit. II. No change in the normal relation between the duration of bone conduction as ci)mpared with air conduction, the absolute duration of both, however, being reduced. III. Abscjlutc deafness for certain notes of the scale, usually in its uj)per portion, thus frequently lowering the upper tone limit. This is almost invariably the case when the conditic^n is sccondarv to changes within the tvmpanum. Our plan of functitjnal examination, then, is essentially as follows : The cjuautitativc dctcrutitiation of tlic luarmg by vwans of : a. The watch, if the impairment is slight. /;. The acoumeter, if the degree of impairment is more marked. c. The determination of the hearing distance by means of the "forced whisper" by making use of numbers of two figures. The qualitative deteruiination of the hearing : a. The determination of the lower tone limit, using for this purpose the fork already described, illustrated in Fig. 61. The record shows the lowest number of vibrations perceived by the patient as a musical note, the different rates of oscilla- tion being obtained bv changing the position of the clamps as alreadv explained. h. The determination of the upper tone limit by means of the Galton whistle, recording the highest number of vibra- tions perceived bv the patient as a musical sound. c. The determination of absolute bone conduction. In determining the absolute bone conduction in any given case the rate of vibration of the tuning fork, as has already been stated, must be taken into account. In patients under 156 FUNCTIONAL EXAMINATION. forty years of age the most convenient fork to be employed is one tuned to the note " C," making five hundred and twelve double vibrations per second. In patients over forty, a fork making two hundred and filty-six double vibrations per second gives the most accurate results. For the benefit of those who do not care to make, a special study of aural diseases, and hence to whom a multiplicity of devices for determining the actual functional condition of the ear is rather objectionable, it may be well to enumerate the instruments with which satis- factory work can be done. In the first place, it is necessary to be provided with a low- pitched tuning fork, such as the one shown in Fig. 6i, fitted with clamps, by means of which the rate of vibration can be changed by altering their position upon the limbs of the fork. The highest note obtainable with this instrument is one of sixtv-four vibrations jicr second. This instrument will enable the observer to determine defects in the transmission of the lower notes of the scale, a condition which is characteristic of the lesions of the conducting apparatus. It niav not be possi- ble for him to determine the lower tone limit, as it may lie above the highest note obtainable with this fork; but if the lower tone limit lies above 64 V. S., the inference must be that the sound-conducting apparatus is not in a normal con- dition. For the determination of the upper tone limit the observer must be provided with a Galton whistle. The modi- fied form, devised by the author and shown in Fig. 62, gives a greater range than the original instrument of Galton, and is I'"lG. 62. — The auilior's moiiinc.TUon ol ih Gallon whistle. preferable when onlv a limited number of tuning forks are at hand. This whistle enables tests to be made through a compass of from about sixteen hundred and seventy-seven vi- brations per second to about forty thousand vibrations per second, the increased length of the instrument augmenting the compass ; it thus supplies the place of the higher tuning forks. For the determination of bone conduction, if but one in- strument is to be used, the C fork, making 512 V. S., is the INSTRUMENTS. n \) best for general use, since its construction is comparatively simple, and overtones interfere but little with its primary note. The instrument (Fig. 63) devised by Blake, and mak- ing 256 V. S., is also exceedingly well adapted to this pur- pose. In this fork the overtones are avoided by increasing the weight of the branches at their free ex- tremities. With these three instruments a fairly accurate functional examination can be made, and the deductions drawn from the data thus obtained will scarcely ever be misleading. A more extended examination w ill simply confirm, in .most instances, the opinicMi already lormed as the result of the investigation with the above limited num. ber of instruments. It is of advantage, of course, to have appliances at hand for the producticjn of all the ncjtes of the musical scale, antl BczoKl - has ck\ised a scries of tuning forks and oi wiiul instruments which produce musical notes on the principle (»f a closed organ pipe, and by whicli the in- vestigator can obtain any note of the scale between the high and low limits of audition. The series consists of eight tuning forks, two organ pipes, and one Gallon whistle. Hven lor a very exhaustive investigation of any case it is scarcely necessary to multiply the arma- mentarium to this extent, since by means of the low fork already mentioned, together with the modified Galton whistle and the series of five forks recommended by Ilartmann f (I'ig. 64), perfectly satisfactory work can be done. Each of the five forks in this set is tuned to the note C ; the lowest fork making one hundred and twenty-eight vibra- tions per second, while the highest registers two thousand and forty-eight vibrations per second, each fork being tuned an octave higher than the one below it. This particular range is chosen as it includes those fundamental notes which may be called essential to perfect audition — that is, the range of notes employed in ordinary conversation. In addition, the Fig. 63. — Blake's tun- ing fork. The rate of vibration indi- cated on the handle (512) refers to single vibrations. * .Vrchiv fiir Ohrenheilk., vol. xxx, p. 283. t Krank. des Ohres, Berlin, 1889, p. 32. 1^8 FUNXTIONAL EXAMINATION. 8 Gallon whistle will enable an investigation as to the power of the patient to perceive those notes of the scale lying above the highest fork of the Hartmann series. I have employed these instru- ments for some time, and have seldom been misled in the deductions made from the results thus ob- tained. In making these quali- tative tests certain pre- cautionary measures are necessary : for example, to avoid the production of overtones in using the J fci II Fig. 64. — Ilartinann's series of tuning forks. large tuning fork with the clamps so placed as to produce the lowest obtainable rate of vibra- tion — that is, twenty-six vibrations per second. It care is not taken, an overtone will be produced when the fork is struck, and this may be perceived by the patient to the ex- clusion of the very low primary note of the fork. In every instance, therefore, the observer should make certain by hold- inof the vibratinir fork for a moment before his own ear be- fore it is used to test the patient, that the primary note alone is elicited. It must also be remembered in testing air con- duction with tuning forks, that the fork may be held in front of the ear in such position, that its note will not be perceived, on account of the interference of the sound waves, which completely neutralize each other and cause absolute silence. This phenomenon depends entirelv upon certain physical facts, as pointed out long ago by Weber.* That this inter- ference may take place the fork is held so that cither of the four angles of the parallelogram inclosed by the branches is directed toward the meatus. During the complete rota- tion of the fork upon its long axis, therefore, there will be four periods during which the note is heard, alternating with four periods of complete silence. It is hardly necessary to * Die Wellenlehre, Leipzig, 1825, p. 506. PRECAUTIONARY MEASURES. 1 59 say, in conducting the functional examination, that care must in any case be exercised that each of these positions is avoided. Urbantschitsch * has also demonstrated that when the vibrat- ing fork is carried toward the ear from before backward it is not heard as it passes the anterior and posterior margins of the meatus, and the same phenomenon is observed as it passes the superior and inferior boundaries of the meatus, if carried from above downward. In testing absolute bone conduction it often happens that the patient confuses the feeling of vibration communicated by the instrument to the cranial bones with the perception of the tone which it produces. This is particularly true when forks of low pitch are employed in making tests, and in cases of al- most absolute dcatncss. The first error can be avoided bv using a fc^rk of higher jiitch, the second bv bringing the vibrat- ing fork in contact with some other portion of the body, as, for instance, by pressing the handle uj)on the elbow or knee, and questioning the patient as to whether the sensation is ex- actly the same as when the instrument is applied to different parts of the cranium. If it is, it naturally f(jllows that he has confused the tactile sensibility with the auditory sense, and his statements are consequentlv unreliable. It should also be remembered that the feeling of vibration is much more marked when the handle of the fork is slender than when it is of considerable thickness, and this should be borne in mind in selecting an instrument for testing bone conduction. In using the Gallon whistle the instrument is held close to the entrance of the canal and the current of air is so regu- lated as to produce the most perfect musical note obtainable with the scale in any given position. Here the individual tested mav not distinguish between the blowing sound pro- duced by the air and the high-pitched musical note which he should hear. If the length of the tube is increased so that a distinct whistle is at first heard and then graduallv reduced by advancing the obturator by turning the screw, thus pro- ducing notes successively higher in pitch, he will easily dis- tinguish the point at which the whistling sound disappears and the blowing or puffing sound is heard. If the screw is then turned in the opposite direction until the whistling * Lehrb. der Ohrenheilk., Vienna, 1890, p. 37. l6o FUNCTIONAL EXAMINATION. sound is again perceived, a reading of the scale will give the true uj)per tone limit. Further, the patient should be made to describe the character of the sound in his own words and without any suggestion on the part of the surgeon, as the latter can easily infer from the reply, whether the impression is that of a musical note or simply the blowing due to the current of air. It would seem, therefore, a matter of no great difficulty to make a fairly accurate differentiation between diseases of the sound-conducting and sound perceiving-apparatus. We meet with a large class of cases, however, in which both portions of the auditory organ are at fault, the perceptive aj^paratus being secondarily affected as the result of pathological condi- tions in the sound-conducting mechanism. Here, then, the results obtained by the above tests may be confusing. In order, therefore, to interpret correctly the data obtained from such an examination, it is necessary to inquire somewhat closely into the causes which are operative in the production of the phenomena ahead v described. It is conceded that the augmentation of bone conduction in pathological conditions of the meatus and middle ear which cause an obstruction to the j)assage of sonorous waves inward, is due to the fact that it prevents the passage of undulations out- ward from the ear when the vibrating bodv is brougiit in con- tact with the cranial bones in the same manner as it offers a barrier to their propagation in the opposite direction when the source of sound is held near the meatus. Stcinbruegge * con- siders that the absolute or relative increase in the bone con- duction in these cases is due to a condition of hvpcra?sthesia of the auditory nerve resulting from the mechanical irritation to which its terminal fibres are subjected. While this condi- tion of increased irritability may be present in many cases, it is certainly not the cause of the increased bone conduction in most instances, other symptoms of auditory hvpersensitive- ness being wanting in many cases. Further, an examination of the condition of the auditory nerve by means of the gal- vanic current fails to support Steinbrucgge's hypothesis. Gradenigof has shown that lesions of the conducting ap- paratus do in some instances cause the auditor}- nerve to re- * Archives of Otolojry, vol. xvii, p. 117. f Arch, fiir Ohrenheilk., vol. xxvii, p. i. IRRKC.l'LAR PHENOMENA. l6l spond more easily to the i^ahanic current than under normal conditions; and this fact should be remembered, as it enables us to interpret results, which would otherwise seem contra- dictory, obtained by functi(jnal examinations in certain cases. The experiments of Siebenmann * demonstrate that an increase in the labyrinthine j^ressure prolongs bone conduc- tion, as evidenced bv an examination before and after \'al- salva's inflati(jn (the latter prctccdure. as is well known, in- creasing the tension oi the labyrinthine fluid). In cases where the membrana tympani had been destroyed the laby- riuihine pressure was increased by j»ressing the head of the stapes inward by means of a ])r()be. We should expect, therefore, to find a jiroloiiLration oi the interval during which the tuning tork is heard when brought in contact with the cranial bones, in all cases where sjieculum examination shows either a depressed drum membrane, or the presence of adhesions within the tympanum, diauiiig the ossicular chain toward the inner tynijianic wall. This is usu- ally the case, but occasionally we find that the reverse is true. The latter condition can be explained ui)on the hy- pothesis that the condition of increased tension has lasted so long that the function of the auditory nerve has been, to a certain extent, ablated by the mechanical pressure, and that the case is no longer one of intratymj)anic disease pure and simple, but that an actual pathological condition is present within the labyrinth, depeniient upon the disturbance within the middle ear. When the intratvmpanic changes are cotiiji;iiaiiv(. ly sud- den, as in cases of simj)le congestion and a-dema of the Eustachian tube with displacement of the drum membrane and of the entire ossicular chain inward, we observe that, in addition to an augmentation of bone conduction, the upper tone limit is usually c(jnsiderably hnvered. This is easily explainable when we remember that the highest notes of the scale are perceived by the lowest portion of the cochlea. This portion of the labyrinth, lying as it does in immediate relation to the foot plate of the stapes and the membrane of the round window, will be easily affected not only by changes in the position of the base of the stapes and of the membrana tympani secondaria, but also by circulatory disturbances * Arch, of Otol.. vol. xxii, p. i. l62 FUNCTIONAL EXAMINATION. within the tympanum. It is not strange, therefore, that the very highest notes of the scale should be no longer heard when any sudden change of position takes place in the ossi- cular chain, or when the tympanic mucous membrane be- comes engorged with blood, interfering with the motility of the ossicles. If the interference with the function of the cochlea depends simply upon a slowly increasing pressure, the equilibrium of the labyrinth is but slightly disturbed, owing to the direct communication of both the endolvmphic and perilymphic spaces with the lymph channels within the cranial cavity. In such cases, therefore, very little disturb- ance of the upper tone limit is observed, although the intra- tympanic structures mav be completely bound down by adhe- sions and drawn inward toward the external labyrinthine wall. The channels of communication, however, between the labyrinthine and intracranial lymphatic spaces are so narrow, that any sudden increase of pressure causes a dis- turbance of equilibrium in the labyrinthine fluid, and hence lowers the upper tone limit. It is wise, in view of this inti- mate association between the labyrinth and the tympanum, to repeat the qualitative tests after a restoration of the nor- mal air pressure within the tympanum by inflation, to guard against all possibility of error. In addition to the tests given above, mention should be made of certain other methods of investigation which lie at our disposal in making a differential diagnosis. Among the most important of these are the following: Bifij^'s* Rxpcriuunt. — This test, flrst described by the above-named author, is essentially a modification of Weber's experiment. It is conducted as follows: A vibrating tuning fork is applied either to the forehead or vertex in the median line, and is held in this position until its note is no longer perceived. If at this moment the finger is inserted into the external auditory canal of either side, the note of the fc^i^k will again be heard. This second interval during which the fork is perceived is called the period of secondary perception for the tone. If the conducting apparatus is normal this sec- ondary perception interval is well marked ; while if its dura- tion is shortened, the presence of some obstructive lesion of the conductins: mechanism may be inferred. If the interval * Wien. med. Blaiter, i8gi, No. 41. GELLE'S TEST. 163 of secondary perception is of normal duration, while at the same time there is an interference with the auditory appara- tus, as evidenced by subjective or objective symptoms, the conducting mechanism must be in a normal condition, and the seat of the morbid process must lie within the labvrinth in the auditory nerve or be due to changes within the ccrebi'al hemispheres or medulla. (jil/c's Test. — Gelle * proposes to test the mobility of the ossicular chain, and especially of the stapes, by compressing the air in the external auditory meatus and observing the effect upon the perception of the note of a tuning fork in con- tact with the skull. If the foot plate of the stapes is movable, with each condensation of air within the meatus the sound of tlic fork becomes much diminished in intensity or may be lost, reappearing again as the pressure is relieved. The condensa- tion is effected by means of a small air bag provided with a flexible rubber tube, the free extremity f)t which carries a conical tip which can be inserted air-tight into the canal. If the labyrinth is affected, either primarily or secondarily, the tone will also be diminished, but tiie increase in pressure will produce a sense of dizziness and sometimes tinnitus. Rohrcr+ considers this test valuable when taken in con- nection with Rinne's test. According to his investigations, when Rinne's experiment was negative Gell6's test yielded a negative result in seventy-three per cent of the cases tested and a positive result in but twenty-three per cent. When Rinne's test was positive Gelle's test yielded negati\e results in twelve per cent and positive results in eighty-eight per cent of the cases examined. The patients selected in these experiments of Rohrer's were cases in which the hearing was very much impaired — so much, in fact, as to make it more than probable that a laby- rinthine lesion co-existed with the pathological process within the tympanum. Rohrer lavs particular stress upon the value of Gelle's experiment in determining the secondary involve- ment of the labyrinth following an inflammatory process within the middle ear, in which case Rinne's test very fre- quently yields negative results; if Gelle's test gives negative results as well, the inference that the labyrinth is affected is * Trihune medical, Oct. 23, 1881. \ Lehrb. der Ohrenlieilk., Vienna, 1891, p. 66. 164 FUNXTIONAL EXAMINATION. fullv warranted. In cases where the hearin^;^ is very much impaired, and Rinne's test is positive, Gelle's test is also usuall}' positive, if the labyrinth is affected. Eitclbcrgs Test. — Another experiment, calculated to differen- tiate between lesions of the labyrinth and those of the middle ear, is that of Eitelberg.* It depends upon the principle that a nerve continuously irritated by any one stimulus becomes fatigued after a certain time and performs its function less readily. It follows, therefore, that when the {perceptive tract is in an abnormal contlition this effect will be produced more readily than in a state of perfect health. In i)erforming the test a large tuning fork is made to vibrate in front of the ear for a period of fifteen or twenty minutes, the instrument be- ing set in vibration repeatedly by as nearly as possible the same initial force as soon as its oscillations become weak. If after the nerve has been subjected to this continuous stimulus the perception interval has not been much shortened, the re- ceptive apparatus is assumed to be in a normal conditic^n. As the value of this test depends greatly upon the intelligence of the patient, its application is somewhat limited. A much simpler demonstration of auditory fatigue is constantly jjre- sented, in cases where prolonged testing with sounds which are of a similar character as, for instance, the watch, acoimieter, or the whisper yield results which differ greatly from each other, and the ability to perceive the sound steadily decreases as the patient becomes fatigued. We otten note a similar con- dition of the nerve in what may be termed the j>ersistencc of an auditory impression ; for instance, in testing a patient with the watch it will often be stated that the sound is heard cither after the watch has been stopped or has been removed to such a distance that it is impossible for the sound to be heard. This depends upon the fact that an impression once made upon the auditory centres is retained by them for a longer period than normal, demonstrating the fact that they arc no longer in a state of health. Gradcnigo s Test. — Gradenigo + finds in cases in which the acoustic nerve-trunk is afTected that it quickly loses its power of reacting to sonorous stimuli if the quality of the sound remains unchanged. In other words, the nerve is quickly * Wien. med. Presse, 1SS7. No. 10. t Handbuch der Ohrenheilk. Von Schwartze, Leipzig, 1S93, vol. ii, p. 403. CIRAUKNICOS TEST, 165 fatigued. If, however, it is allowed to rest for a short time, it is again able to perform its function. The simplest method of practicing this test is by the use of a tuning fork of about fifteen hundred or two thousand vibrations per second as the source of sound. Such a fork is perceived from fifty to sev- enty seconds under normal conditions. In cases of torpidity of the auditory nerve, if this fork is set in vibration and held close to the ear its note ceases to be audible after a much shorter interval. If it is now removed a short distance from the ear, for a few seconds, and again carried close to the meatus, it will be again perceived. This manoeuvre mav be repeated several times during one period of vibration of the fork. It seems that the auditory nerve when in this condition is easily fatigued, but after an interval of rest it mav react to a weaker stimulus than that which failed to excite it after it had been subjected to tliat one for a certain time. Ciradenig(j* asserts that when the auditorv nerve trunk is involved the interference with function is particularlv maiktd for the tones of the middle j)ortion of the scale, the verv high and verv low tones being well perceived. In all of these tests, dependence must be placed u])()n the statements of the jtatient, and much of the accuracy must de- pend uj)on the intelligence and the correctness with which he answers questions. Methods have been devised to avoid the necessity of introducing this element of error in deter- mining the location of the morbid j)rocess. Thus Lucaef conducted an exhaustive series of experiments w ith an instru- ment which he termed the interference otoscope. The device consisted of a tuning fork, the vibrations of which were main- tained at a constant amplitude by the action of the electric current. The fork was placed so that its vibrations were collected by a funnel-shaped receiver, the smaller end of which was prolonged as a flexible tube terminating in three branches. One of these terminal divisions was inserted into each external auditory meatus of the patient, while the third was inserted into either auditorv canal of the examiner. It is thus seen that the vibrations of the fork would be conveyed through the tubes to both ears of the patient and to the ear of the examiner as well. Any obstruction in the sound-con- * Op. cit., p. 395. f Arch, fiir Ohrenheilk., vol. iii, p. 186. l66 FUNCTIONAL EXAMINATION. ducting apparatus, as we know, renders the transmission of vibratory impulses more difficult in proportion to the degree of obstruction, and, as the sound perceived by the examiner represents not only the vibrations coming directly to his ear — from the fork — but also the waves reflected from the ears of the patient, it would be possible, by alternately closing the tubes upon the one side and the other, to estimate any variation in the intensity of the sound thus produced. It is evident that the sound would be more intense in proportion as the transmitting mechanism offered an obstruction to the inward progress of the impulses. In other words, the more intense sound should come from the poorer ear if the conduct- ing apparatus alone were affected. Great care must be taken, in conducting this test, that the tubes of the binaural stetho- scope shall be cxactlv equal in length, and also that the ear- pieces shall fit the meatus exactlv, in order that all of the reflected waves mav pass backward through tiie tube and into the ear of the examiner. This test has been somewhat modi- fied bv Jankau * in the following manner : A vibrating tuning fork is placed upon the vertex of the patient and the receiver is dispensed with, while the auscul- tation tube of the examiner terminates in a Y tube, the free extremities of which join the tubes occluding the external canals of the patient as in the other instrument. Under these conditions the tone conveyed to the ear of the examiner is re-enforced by the action of the external meatus, which acts as a resonator, augmenting the sound of the fork. Under normal conditions, both ears being the same, there is no ob- struction to the vibrations through the cranial bones to the labyrinthine fluid, from which they are communicated to the ossicular chain, to the membrana tvmpani, and in turn to the air in the canal, which re-enforces the sound bv its action as a resonator. If, however, an obstruction, due to an increased tension of the labvrinthine fluid, exists, which prevents the passage of the sound waves outward from the labvrinth to the ossicular chain, this resonant action will to an extent be diminished, and the observer will perceive that the sound from this side is less intense. In other words, the weaker sound will come from the jxjorcr car, if the impairment of function is due to increased labvrinthine tension. If, on the * Arch, fiir Olirenheilk., vol. xxxiv, p. 190. C.ALXANIC Rl. ACTION. 167 Other hand, the vibrations of the labyrinthine fluid are not impeded, but the tympanic structures external to the stapes are in a state of increased tension, the resonant action of the canal will be increased on account of the rigidity of its walls, the condition favoring- a more perfect reflection of the sound waves ; in which case the stronger tone will come from the poorer ear. Jankau's clinical investigations and experiments seem to confirm this supposition. The difficulty of avoiding errors of experiment are so con- siderable here that the chief use of the procedure will be as a confirmatory test. Tlic Galvanic Reaction of the Auditory Xcrve. — As has been stated, the auditory nerve differs very little from other spe- cial or general structures of a similar nature. In the study of nervous diseases in general, great attention has been paid to the reactions of nerve tissue under electrical stimulation, and the changes in the electrical phenomena which morbid processes cause. Special attention was given by Brenner * to the effect produced bv the galvanic current upon the audi- tory nerve, and he was the first to formulate the reaction of the normal acoustic nerve. According to this auth(^r. uj)on the application of the galvanic current, a sharp sound is [)ro- duccd at the moment of cathodal closure (c. c). which, as the current is continued, is transformed into a c<»ntinuous sing- ing sound (c. d.). At the moment of cathhotograph.) deformity in this rci^ion is cleft lobule, the appearance re- sembling^ closelv that seen when the lobule has been torn in the direction of its loui^ axis, by the forcible removal of an ear- ring from the ear. Auoiiialit's of the Tnii^Ks. — The tra<;us may extentl back- ward and be of such size as to olTer an actual obstruction to the entrance of sound waves into the meatus. McBride:}; has observed a case in which there was a rudimentary traijus as- sociated with other abnormities of development. Anomalies of the Autitragiis. — Malformation here is exceed- inglv rare. Szenes* observed an instance in which two spurs of cartilage projected from the antitragus into the canal. *Arch. tiir Psychiatrie, 1S87, vol. xx, p. 2. f Arch, fiir Ohrenheilkunde, vol. xxiv, p. 185. J Edinburgh Med. Journal, April, 1881. *Arch. fvr Ohrenheilkunde, vol. xxvi, p. 140. l-jd CONGENITAL MALFORMATIONS OF THE AURICLE. II. An anomalous shape or a malposition of the entire auricle. This condition in its most pronounced form is commonly known as microtia, and depends upon an arrest or perversion of the process of development which results in so complete a malformation that the distinctive parts of the external ear are no longer well defined. The condition may be unilateral or bilateral, and is frequently associated with co-existent malfor- mation of the deeper parts of the auditorv apparatus. For this reason the condition merits special attention. Microtia is associated in the majoritv of instances with a complete ab- FiG. 66. — Microtia. sence of the external auditorv meatus, or, in cases where the canal exists, it is a rudimcntarv structure ; the ossicular chain is frequently poorly dcvcl(){)cd or absent, and an anomalous condition is common in the labvriiith as well. The deformity mav not be conhned to the ear alone, but the entire side of the face mav be poorlv developed. The ap- pearances vary i^reatly in different cases, and an attempt to describe them would be but a recital of particular instances. Fii^. 66 is a drawing- of a case observed bv the author. In this case the left car j)rescnted an anomalous formation of the MICROTIA— MALPOSITION— TREATMENT. 1/7 antihclix (see Fic^. 65), while there was well-marked microtia upon the right side. At birth the right ear was much more deformed than the picture shows it to be, the helix at that time being adherent by its antero-superior border to the in- tegument in front. The cutaneous surfaces separated sponta- neously a few weeks after birth. Treatment. — Where the deformity is but moderate an at- tempt at correction by a plastic operation may be made i\\ early childhood. Regarding any attempt to form an artifi- cial meatus, the results have been so unsatisfactory that it is seldom desirable to operate for this purpose. If the rudi- mentary canal is present, its size may be increased by surgical measures, but the frequent malformation of the deeper struc- tures commonly renders the operation futile in improying the function of the organ, if any attempt is to be made to restore tlie j)atency of the canal, it should be delayed until the j^alient is old enough to giye information in regard to the power of sound perception either through the air or through the cra- nial bones. 'J'he techni(|ueof the operation for re-establishing the meatus will be described under jxilyotia. The j)lastic operation on the auricle for the relief of the deformity, how- ever, may be done very early. When a high degree of de- ff)rmity is present, it seems advisable to excise the entire au- ricle and supply its place by an artificial device rather than attempt its restoration by surgical measures, which will at the best leave a misshapen organ. From a practical point of view, one of the most interesting conditions included in this group is that in which the angle between the organ and the lateral aspect of the skull is con- siderable. This constitutes a deformity amenable to treat- ment, and. especially in the female sex, one for which we are occasionally consulted. If noticed in infancy, or even in early childhood, the simjjlcst plan for correction is to coat the pos- terior aspect of the auricle and the adjacent cutaneous surface of the head with colkjdion, the ear being then pressed to the side of the head and held in position until it adheres. If nec- essary, several light strips of gauze may be passed over the top of the auricle, holding it closely to the side of the head, and fastened with collodion. Persistence in this plan of treat- ment will usually be successful in correcting the condition. In adult life little can be gained by this method, and resort must be had to some operative measure. This is best effected 13 178 CONGENITAL MALFORMATIONS OF THE AURICLE. by removing an elliptical segment of the integument from the posterior surface of the auricle, the posterior incision passing just beyond the line of attachment to the auricle; the integu- ment is then dissected up from the posterior surface of the auricle for a sufficient distance to permit of an approxima- tion of the edges of the wound. Occasionally it is necessary to excise a segment of the cartilaginous framework as well,' in order that the ear may be restored to the proper position. Usually the difficulty is sufficiently well overcome by approxi- mating the edges of the cutaneous wound without removing any of the cartilaginous framework, the tension due to the elasticity of the cartilage being easily overcome by the su- tures. Under aseptic precautions and with care, a perfect po- sition can be secured. General anaesthesia is usually neces- sary, although it is possible to perform the operation under local anaesthesia. It is well to operate upon the two organs separately, using the first as a standard to which the other is made to conform. III. The presense of some anomalous anatomical condi- tion, such as supernumerary appendages, fistulae, etc., in the region of the ear, the auricle being present either in its nor- mal form or being more or less misshapen. Auricular Appoidagcs, the General 1-onn of the Ear being preserved. — Abnormities belonging to this class are the sim- plest with which we have to deal. The most frequent region for the appearance of supernumerary appendages is the re- gion of the tragus. A case of this sort occurring in mv own practice is shown in Fig. dj. The prominent cartilaginous process constituting the deformity was located just above the right tragus, was about three fourths of an inch in length, and projected forward and outward. The tragus itself could be felt, but was rudimentary. Barth * cites an instance in which a rudimentary mam- mary gland was located just below the lobule upon one side. A condition belonging to this class constitutes what is known as " fistula congenita auris " (Fig. 68). Its occurrence is due to an arrest in development of the auricle itself, or, as is believed by some, it indicates an incomplete closure of the first visceral cleft during foetal life. That this is considered a * Virchow's Archiv, vol. xii, part iii. AURICULAR APPENDAGES— FISTULA. 1/9 somewhat rare malformation is probably due to the fact that it seldom gives rise to symptoms, and consequently many cases pass unnoticed. Four cases of this deformity came under my own observation during a period of about a year. Fig. 68 represents an appearance which is fairly- typical. The deformity may occur either upon one side alone, or it may be bilateral. In one of my cases the fistula was located just above the tragus, while in another the orifice of the tract was situ- ated one inch above this point and presented an opening about one sixth of an inch in diameter through which a probe could be passed downward and inward for half an inch. On Fig. 67. — Auricular appendage. Fig. 63. — Fistula congenita auris. {a, fistula.) the opposite side the site of the fistula was occupied by a shal- low depression which did not admit even the finest probe. Dccasionallv a slight discharge exudes from the orifice of the fistula, and in a case reported by Pfiiiger* the appearance of a purulent discharge from such a source was alwavs preceded by acute pain in the ear. Where the walls of the sinus se- crete, a blocking of the orifice may cause a retention C3'st of considerable dimensions. An instance of this is cited by Ur- bantschitsch.+ The most common location for such fistulas is in the vicinity of the tragus, although they are occasionally * Monatsschrift fiir Ohrenheilkunde, 1874, No. it. \ Lehrbuch der Ohrenheilk., third edition, l8go, p. 94. l8o CONGENITAL MALFORMATIONS OF THE AURICLE. met with in the helix and in other localities. Burnett * states that these fistulce may lead into the tympanic cavity. Treatment. — The appendages should be removed bv means of the knife. The operation is exceedingly simple. When they present in the region of the tragus it is well in excising the growth to form a tegumentary flap from the cov- ering of the anterior surface of the appendage, which can be folded backward over the stump, bringing the line of the su- ture close to the entrance of the meatus, as the cicatrix is less visible in this position. Fistula congenita auris demands no treatment excepting in those instances where a retention cyst has been formed by the occlusion of the orihce of the sinus. This condition is re- lieved by a simple incision and the evacuation of the contents of the tumor, the walls being curetted with a sharp spoon to secure an obliteration of the cavitv. Polyotia. — This term is apj>lied to a congenital deformitv in which, in addition to microtia, certain supernumerary growths are met with in the immediate vicinitv of the car, but entirely distinct from the deformed auricle. Occasionally they occur with a perfectly normal au- /^ riclc, the fact that thev are ^•^ not attached to it distin- guishing them from the au- ricular appendages already described. The condition is sometimes associated with congenital aural fistula, as in the case reported by Biirkner.f The deformity mav be bilateral or unilat- eral, and the supplementarv organ mav present a varietv of shapes, the most common being that of a small wartlike excrescence situated upon the cheek in front of the external meatus. When this multiple deformity exists there is usually considerable variation in Fig. 69. — Polyotia. * A Treatise on the Ear, Philadelphia, 18S4, p 211. f Archiv fiir Ohrcnhcilkunde, vol. xxii, p. 20J. POLYOTI A— TREATMENT. iSl size and shape between the members of the group. As already stated, a normal auricle is seldom found, although this may be the case. The condition usually occurs in con- nection with microtia. An instance of this kind, observed by me, is depicted in Fig. 69. The auricle upon the affected side was represented by a cutaneous fold, beneath which there was a cartilaginous framework. This was bent forward upon the cheek, covering the normal site of the meatus. Upon the pos- terior surface there was a well-defined groove between the cartilaginous and noncartilaginous portion. About three fourths of an inch in front of the anterior margin of this de- formed auricle was a small, wartlike prominence representing a second and rudimentary i>inna, it being situated toofarante- riorly to rcj)rescnt the tragus. The hbro-cartilaginous lamella already mentioned was freely movable, and just beneath its attachment a slight depression could be felt. It was impossi- ble to determine wiicther the external auditory meatus was present or not. 'J'he ear of the opposite side was normal. The remarks made under microtia, regarding a faulty development or a comj)lete absence of the deeper portions of the auditory ajiparatus ajtplv ecjually well to the condition of p)oh"i>ti;i. Treatment. — The small sui)ernumerary appendages are usually easily removed, where they are large enough to con- stitute a serious deformity. The disfigurement which they cause is usually slight, however. For a correction of the larger malformed mass remaining, a plastic operation may be attempted, although, as in microtia, inore satisfactory results may be expected by a complete removal of the deformed member, its place being supplied by an artificial substitute. Concerning the establishment of the meatus surgically, the remarks already made under microtia apply equally well here. Even if it is possible to construct the meatus, it is scarcely possible to secure a condition of permanent patency. When it seems desirable to attempt this operation the tech- nique is as follows : The field of operation being rendered thoroughly aseptic by shaving the parts and cleansing them with soap and water, and subsequently with ether, an incision is made just behind the attachment of the deformed pinna. The soft parts are divided, exposing the bone, after which the anterior flap, in- cluding the periosteum, is turned forward upon the cheek, ex- l82 CONGENITAL MALFORMATIONS OF THE AURICLE. posing the region normally occupied bv the external auditory canal. A thorough search must next be made for any open- ing in the bone which may represent a rudimentary meatus, and if such a channel is discovered it should be cautiously en- larged, by means of either chisels or burs, the latter being propelled by an ordinary dental engine or an electric motor. When no fistula is present the bone may be cautiously exca- vated in the region corresponding to the proper position of the meatus. Great care is necessary during the entire pro- cedure, as damage may be done to important adjacent struc- tures. After the canal has been formed our means for secur- ing its patency will consist in the insertion of an aluminium or rubber tube, which will separate the opposite raw surfaces and allow the deep parts to be thoroughly cleansed, during cica- trization. As the anterior flap when replaced would cover the newly formed channel, it should be perforated over the orifice of the meatus bv making two incisions bisecting each other at right angles. Four triangular flaps are thus formed, which are to be inverted into the orifice of the canal and maintained in position for the first few days by a gauze pack- ing, alter which the metal or rubber tube already mentioned is to be employed. As soon as healthy granulations sjiring up, a method which suggests itself as exceedingly feasible would be Thiersch's method of skin grafting, as we might thus hope to secure a tegumentary lining to the passage and prevent its contraction during cicatrization. Such an opera- tion should only be performed at the earnest solicitation of the parents, in the case of a child, or, if the patient has reached adult life, only after the extreme uncertainty of the result has been fully explained. CHAPTER VI. WOUNDS ANT) INJURIES OF THE AURICLE. It is seldom that \vc see incised or punctured wounds in this particular portion of the body, although occasionally we are called upon to treat deformity which has resulted from wounds of this character inflicted at some preceding period. Here the ordinary rules of plastic surgery will enable us to secure satisfactory results. In performing any plastic opera- tion upon the auricle it is well to remember that when the entire thickness of the external ear is involved all sutures should be inserted upon the posterior surface of the organ, accurate approximation of the cutaneous edges being secured by j>assing the stitches dcej)ly into the cartilaginf)us frame- work, but not bringing them out through the integument covering the anterior surface. In the treatment of lacerated wounds, which are more frequentl}' met with, we should attempt to save as much tis- sue as possible, erring rather in this direction than in that of removing any part which possibly may possess suflicient vitality to survive. The edges of the wound should be thoroughly cleansed, and as a primary procedure a few sutures may be applied, holding the parts as nearly as possible in their normal position. It is a simple matter after the circula- tion has been thoroughly re-established to secure a more exact approxiiTiation and relieve whatever deformity may be present. As the auricle is composed so largely of cartilage, any severe bruising of the tissue is likely to be followed by a sharp peri- chondritis, and unless there is so much laceration as to contra- indicate the plan, it is well to anticipate such an attack by the employment of cold locally for the first twenty-four hours after the injury has been received ; subsequently proper atten- tion may be given to the correction of deformity. Contused wounds of the auricle without laceration of the integument are of frequent occurrence. Such an injury re- (183) l84 WOUNDS AND INJURIES OF THE AURICLE. suits either in the formation of a hasmatoma — an effusion of blood beneath the perichondrium — or in an acute perich(jn- dritis; in either case the appearance is almost identical. The injured region is occupied by a somewhat spherical tumefac- tion, the normal outline entirely disa|)pearing. Upon palpa- tion we discover that the contents of the tumor are evidently fluid. The surface varies considerably in color, according to the particular manner in which the injury was inflicted, and, to a less extent, the character of the fluid contained. If this is blood, the surface is of a dull deep-red color, while if the tumefaction is an evidence of a perichondritis, with an effusion of serum, the surface is of a much lighter tint, being either of a bright-rose tinge, or occasionally not differing widely from the integument covering the unaffected portion of the member. Either condition may remain quiescent for a long period ; may disappear spontaneously, leaving but slight, or marked deformity ; or, as a third possible termination, the contents may suppurate and be evacuated spontaneously. Where the contents consist of extravasated blood the car- tilaginous framework has usually been fractured, and certain portions will almost inevitably become necrotic and exfoliate with the production of considerable deformity. On the other hand, a simple perichondritis, where no fiacture has taken place, may disappear without seri(ouslv changing the contour of the ear. Among professional wrestlers and boxers, the ear is fre- quently subjected to violence not sufficient to j^roduce an acute perichondritis, but enough to cause a mild inflammation of the perichondrium, so slight as to give rise neither to dis- comfort to the patient nor to appreciable deformity immedi- ately after the injury. This chronic inflammation Anally gives to the ear an appearance which is somewhat characteristic, known as " prize-fighter's ear," all the delicate outlines of the anterior surface of the pinna being obliterated by the deposit of new tissue in various localities. Occasionally the deformity reaches such a high degree as to resemble closely the condi- tion resulting from a severe acute perichondritis with cartilagi- nous necrosis. Treatment. — The treatment of an acute perichondritis re- sulting from contusion consists, first, in the local application of cold, provided the case is seen within twenty-four hours after the injury has been inflicted. During this period the effusion TREATMENT OF CONTUSED WOUNDS. 185 of serum will scarcely reach aiiv considerable amount, and our efforts should be directed to the purpose of |)revcntin*^ the extravasation of fluid. The most convenient way of aj)- plyini^ cold is by means of the ice ba^, sh(jwn in Fig. 70. The mastoid region I '^ " should be covered by a pad of cotton / m_*_ so as to support the bag against the - posterior surface of the auricle, while ' the anterior surface may be covered b\ / ~" a small flat ice bag. , ! When seen at a later period and aftc : \ / effusion has taken place efTorts should ^^ be directed toward the relief of the de- formity, it is a simple matter to as- pirate the efTused fluid, and cause the ,-.^ -^ \ 1 1 .„ ' ' riG. 70. — Aural ice bag. auricle to resume a perfectly normal ap- pearance, but unfortunately the result is often but temporary, efTusion taking place again very soon. It is scarcely neces- sary to say that in aspirating the fluid, strict antiseptic pre- cautiart affected is either of a dull pinkish color, the surface being glossy and polished, as though tlie skin were ver\ thin and tightlv draw n. or in other cases the superficial ej)itlRlium is cast off too rap- idlv, covering the surface here and there with minute whitish crusts or scales. From the efforts of the jiatirnt t(» relieve the pruritus these scales are picked off, frecpientlv causing a slight abrasion of the surface, and increasing the activity of the local process. On palpation the skin feels hard, leathery, and thick, especiallv where the patient has subjected it to mechanical irri- tation for the relief of the itching. Over the unbroken surface the thickened integument has a peculiar smooth, glossy feel. De Rossi* has described a case in which the entire cartilagi- nous framework of the auricle became necrotic as the result of chronic eczema. It seems probable that there must have been some underlving cause other than eczema, to produce this destruction of tissue. Treatment. — Our treatment should be directed to the re- moval of the local exciting cause and to the relief of the con- stitutional element of which the disease is but a local manifes- tation. Thus in the acute form the dietarv of the patient will frequentlv need correction, and the elimination of certain arti- * Archiv fiir Ohrenheilkunde, vol. xxi, p. 193. IQO CUTANEOUS DISEASES OF THE AURICLE. cles of food or the addition of others will be followed by sat- isfactory response to local applications. Diathetic conditions must be managed according to general rules. Moderately large doses of alkalies, either in the forni of Rochelle salts, bi-carbonate, acetate, or citrate of sodium, frequently bring about a favorable termination where local treatment alone has been useless. Turning to the local measures to be employed, any dis- charge from the meatus must receive proper attention, as its presence excites the cutaneous infiltration. In the acute form our first efforts are to relieve the subjective symptoms. To this end cold applications in the form- of evaporating lotions are of service. The ordinarv lead and opium wash is a favor- ite rcmcdv in the acute stage, but is disagreeable on account of the color which it imparts to the skin, and because of its characteristic odor. Such objections do not apply to the fol- lowing : IJ Liquor plumbi subacctat 3 j ; Bismuthi subnitrat 3 ss. ; MorphiucX i^r. ij ; Glycerini ^] ; Aqua3 rosa" q. s. ad 3 viij. M. Sig. : Apply locally as a wet dressing. Shake before using. Instead of cold applications, better results are sometimes obtained, especiallv where the thickening is inconsiderable and the discharge from the surface profuse, by employing the local remedy in the form of a powder rather than as a solution. Here we may use the oxide of zinc, subnitrate of bismuth, starch, lycopodium, stearate of zinc, etc. Where the affection causes a most intense burning of the skin an oleaginous sub- stance is the most desirable vehicle. The following ointment may be used : 5t Bismuth subnitratis 3 ij ; Acidi borici 3 j ; Morphine gr. j ; Unguenii zinci oxidi 3 ss. ; Petrolati q. s. ad 3 j. The same emollient cfTcct is obtained bv cmploving the stearate of zinc in combination with boracic acid and sub- nitrate of bismuth, and the oily vehicle is avoided. ECZEMA— TREATMENT. 191 (^winf^ to the frequency with which any condition attended with an increased secretion leads to the development of an aspcrgillus within the external auditory meatus, it is advisa- ble it the disease continues for any considerable period and in- volves the parts about the orifice of the canal, to add salicylic acid to any oleai:^inous preparation which may be employed as a local application, for the purpose of preventing the devel- opment of such a parasite. In order to act in this manner the salicylic acid must be present in the ointment in the propor- tion of about one and a half to two and a half per cent, a de- gree of concentratic^n which does not act as an irritant to the sensitive cutis. Eitelberg * has employed an ointment of cre- olin in the strength of about two per cent with success. Where crust formation is a prominent feature of the affection. as occurs when the acute stage has passed, all aqueous solu- tions are contraindicated. The crusts should first be removed by softening them with olive oil or vaseline, after which the surface may be medicated either with one of the above oint- ments or with a jiropcr powder. Salicylic acid in alcohol in the strength of twenty to forty grains to the ounce may occasionally be cmjiloycd, although in mv own c\]icrience alcohol has j)rovcd of but little service in ec/enia of the auricle. It should be remembered that the exposure of the denuded surface to the air is undesirable, and that the affected parts should be constantly protected by some non-irritant or slightly astringent ointment, such as the oxide of zinc, cold cream, or simple vaseline. Nitrate of silver in aqueous sohitiDU has many advocates as a remedy for the disease. It is customary in using this remedy, to begin the treatment with a solution of about ten grains to the ounce, the strength being increased until the de- sired effect is obtained. I have seen excellent results follow the application of such a solution, after the thickening has been reduced, as the stimulating effect of the astringent lotion has- tens the development of a protecting epithelial layer. Where the thickening of the integument is marked, a con- dition which must exist when the disease has persisted for any length of time, it will be impossible to effect a permanent cure without relieving the affected area of the serous infiltration. * Wien. med. Press., 1888, No. 13. 192 CUTANEOUS DISEASES OF THE AURICLE. It may be possible, without doing this, to cause a temporary improvement, and to succeed in causing the part to become covered with a thin layer of superficial ejjithelium ; as soon as the treatment is discontinued, however, the disease will recur in an aggravated form, and where there is much induration we should direct our attention to this at once. For this purpose the area involved may be thoroughly scoured with green soap, the alkali which this contains causing a temporary stimulation of the surface, through which the tissues are relieved of the serous infiltration, by the free exudation of fluid. This process may be repeated every second or third dav until the integu- ment regains its normal texture, after which the use of emol- lient and astringent applications will cause a speedy return to a normal condition, and effect a permanent cure. A similar result mav sometimes be obtained by an ointment containing chrysarobin, or pvrogallic acid, or oil of cade. The ammoni- ated mercurial ointiucnt also serves a similar purpose. Mv best results in this class of cases have been obtained by employing the acetum cantharidis, which quickly relieves the engorge- ment of the deeper lavcrs of the integument, while at the same lime the intense pruritus is alleviated. Considerable care is to be exercised in applying this remedy, since if it is used in too large quantities the surface may be blistered and the pa- tient be subjected to considerable discomfort. The acetum cantharidis is to be applied to the afTected areas by means of a cotton mop, the parts being first lightly brushed with the solution and the application repeated on the following day if no effect has been produced. As a result of the application of this remedy a free serous transudation takes place, and soon the parts become covered with a normal epithelium, the ex- uded serum drying upon the surface in the form of a thin yel- lowish crust, which can either be removed with the aid of the forceps on the second dav, or, if left to itself, will become dis- integrated and exfoliate as a thin, scaly desquamation. If the action of the cantharidcs is too vigorous the application of some oleaginous preparation for twenty-four hours will re- lieve all discomfort. The application of the cantharides may be repeated at frequent intervals until the infiltration has en- tirely disappeared. We should add, in closing, that constitutional medication and local applications must go hand in hand in combating the affection under consideration. PEMPHIGUS— HERPES. 193 Pemphigus. — This is a somewhat rare cutaneous disease, but is occasionally observed. Its characteristic appearance differs in no way from pemphigus developing upon other portions of the body. The condition manifests itself in the formation of large blebs filled with a clear serous fluid. Al- though the favorite site for the development upon the auricle is the margin of the heli.x and the lobule, it is occa.'-ionallv found in other situations. From local infection, this serous fluid mav bect)me turbid, but it is rarely purulent. The bulku rupture spontaneously at the end of a few days, and if the walls are not destroved, j)rotcct the denuded area which they cover, and are subse- (piently cast off in the form of scales, their former site being marked by a slight redness of the integument. On the other hand, if the sac is entirely destroyed an eroded surface is left. This seldom persists for any length of time, becoming rapidly dry, the integument remaining slightly reddened in this situation. Xo pain attends these local manifestations, and the disease is of importance simply on account of the fact that the patient is ordinarily afflicted by several successive crops of bulku, which are a source of annoyance because of the dis- figurement. The best results are obtained bv j>uncturing the thin en- velope which incloses the fluid, and coating the collapsed sac with a lavcr of flexible collodion to protect the surface be- neath. The internal use of arsenic is the best prophylactic measure against recurrence. Herpes. — This condition is extremelv rare, although a search through otological literature furnishes us with quite a number of instances of the affection. The disease is esscn- tiallv the same as herpes zoster, differing from it only in the l(3calitv of the cutaneous manilcstation. Neurotic subjects are particularly predisposed to the affection, although it oc- casionallv attacks those in perfect health. Indiscretions in diet, faulty assimilation, and improper and insufficient food may be mentioned among the other predisposing causes. As an exciting cause, exposure to cold is the most important ; while in a case reported by Chatellier,* it was caused by local irritation. The particular pathological condition is obscure, but probably consists in a neuritis of the trophic nerves which * Annales des mal. cle I'oreille., 1886, No. 6. 14 194 CUTANEOUS DISEASES OF THE AURICLE. supply the parts involved. These are the auricularis magnus and the auriculo-temporal, the former coming from the cervi- cal plexus, the latter from the third branch of the trigeminus. The onset of the affection is commonlv marked by severe constitutional disturbance, such as an acceleration of the pulse, an elevation of the temperature, varying in degree from ioo° to 102° Fahr., or even 103° Fahr., headache, and a feeling of general lassitude. The characteristic subjective evidence is the intense neuralgic pain, which may be confined to the ear or may spread over the entire side of the face, following the general area of distribution of the nerves involved. Since the pain may precede the eruption by several davs, the exact diag- nosis is often difficult. When the eruption appears, we find the portion of the auricle involved covered with groups of vesicles which rise from a reddish base and are filled with clear serum. Occasionally they coalesce and form a bullous eruption. The anterior surface of the auricle is generally the region attacked, although in a case reported bv Green * the posterior surface was involved. The manifestation is ordinarily unilateral, but Wagenhaiiserf observed an instance in which it was bilateral. Although usually confined to the auricle, the affection may spread to the canal. A few davs after their appearance the vesicles rupture, their envelope becomes dry and is cast off in the form of minute scales, leav- ing the integument beneath of a somewhat reddened or brown- ish hue. In cachectic individuals superficial ulccratiiMi may persist for a considerable time over the site of the vesicles. The constitutional symptoms, which have been so marked before the vesicles appear, usuallv abate when the eruption becomes well marked, although this is not an invariable rule, and the general symptoms may persist for a long period after the local lesion has entirely disappeared. Since diathetic conditions are a prominent causative factor, the patient seldom escapes with a single attack of the dis- ease, a second or third recurrence being the rule. Treatment. — Measures directed toward the relief of the condition divide themselves into those for the control of the constitutional symptoms and those for the relief of the local * American Journal of Otology, vol. iii, No 2. •f Arch, fiir Ohrenheilkunde, vol. xxvii, p. 159. HERPES. TREATMENT— SYPHILIS. I95 manifestations. Our first measure should be a thorougii cleans- ing of the alimentary canal by a brisk saline purge, the dietary of the patient being at the same time restricted so as to em- brace only the simplest articles of food. When the febrile movement is prominent the ordinary antipyretics, such as antifebrin, antipyrifi, or phenacetin, should be administered, the last-named drug exerting a favorable influence upon the neuralgic pain. When the pain is of unusual severity, aconitia in doses of one five hundredth of a grain, repeated every hour fcjr three or four doses until the constitutional effects of the drug are felt, after which the interval should be increased to every three or four hours, can be relied upon to give re- lief. Before the appearance of the eruption, cold applications are grateful. Iced cloths, the aural ice bag, or a cold lead- and-opium lotion may be employed for this purpose. The vesicles are best treated by dusting them with a bland powder to prevent their early ruj)ture, and where they are C(jnfluent they may be coated with collodion, for the same purpose. if the vesicles are infected and the serous fluid becomes purulent, their contents should be evacuated by means of a small knife, and the cxjiosed area be dusted with icido- form, iodol, dermatol, or touched lightly with a solution of nitrate of silver, to hasten the reparative process. An emolli- ent ointment containing morphine or oj)ium is occasionally of value. It has been suggested, as a rational means of con- trolling the disease, that counter-irritation, by means of the actual cautery or bv vesicants, be cm|)loyed over the trunk of the nerve involved, but little success lias attended this method of treatment. Regarding the subcutaneous injection of morfthine over the affected nerve, it should be remembered that dishgurement occasionally follows the use of the hypo- flcrmic needle, and it seems that the advantages are not suf- hcient to warrant the physician urging this plan of treat- ment. Syphilis. — Any syphilitic lesi(^n may appear upon the pin- na, although a cutaneous manifestation of this constitutional disease is of rare occurrence in the region under consideration. Ziicker* has reported an instance in which the initial lesion was situated upon the tragus, the part being of a dark-pur- plish color, and swollen to twice the natural size. There was *Zeit. fiir Ohrenheilkunde, vol. xiii, p. 167. 196 CUTANl^OUS DISEASES OF THE AURICLE. concomitant enlargement of the submaxillarv and parotid glands. The erythematous syphiloderm undoubtedl}'' attacks the auricle but, since it causes no symptoms to call attention to its presence, is usually overlooked. The macular eruption is more frequently observed on account of the distinctive appearance to which it ^ives rise. Occasionallv it spreads into the canal, for a considerable distance. According to Taylor,* those parts supported by cartilage are more fre- quently attacked. The papular svphilide is of interest chiefly on account of the superficial ulcerations to which it occa- sionally gives rise. In an instance under my own obser- vation such an ulceration had developed at the junction of the lobule with the integument, just below the mastoid. The erosion was sharply defined, the surface only slightly depressed, and but a slight areola was present. The appear- ance resembled an intertrigo so closely that an exact diag- nosis was made only upon the failure of the erosion to clear up under ordinary local treatment, and its prompt disappear- ance upon specific medication. A specific eruption of a tubercular character is occasion- ally observed. The ulcerated areas are covered by large crusts, upon the removal of which the outline of the affected portion is seen to be sharply defined. Either the anterior or the posterior surface of the external car may be attacked. A correct diagnosis is possible by bearing in mind the sharph defined outline of the specific ulceration, its reddish color in contradistinction from the irregular grayish-white color of tubercular or lupoid ulceration, its slightly depressed surface, which is comparatively smooth, in contradistinction to the nodular appearance observed in the affections just named, and the history of an antecedent specific infection. The appearance of a gummy tumor in the external car is one of the rarest manifestations of the constitutional poison. Baratouxf has reported an instance in which the infiltration was multiple. The deposit presents as a hard, smooth tumor, of a deep-red color, and in the early stages does not fluctuate upon palpation. At a later period the centre of the mass be- comes necrotic, the disintegrated tissue finally breaking down * Cited by Rupp, Journal of Cutaneous and Genito-Urinan- Diseases, Oct., 1891. f Cited by Rupp, Ice. cit. SYPHILIS, TREATMENT— LUPUS ERYTHEMATOSUS. 19; to form pus, which is evacuated spontaneouslv. unless pre- vented by the institution of surgical measures. When left to itself the local necrosis results in the development of a deep ulcer. Treatment. — The treatment of specific lesions of the auri- cle corresponds to that of similar conditions in other portions of the body. If a gummatous deposit is found before disin- tegration has begun, an effort should be made to cause its absorption, although this at first mav seem hopeless. Where ulceration has taken place before the patient comes under observation, large doses of the iodide of potassium should be at once administered, and for a time local treat- ment should consist simplv in keeping the parts clean, since the reparative process which this drug institutes, frequently preserves tissues which seem so disintegrated that the surgeon would have no hope of saving them. After the internal med- ication has been persisted in for a short time, and its antag- onistic action on the constitutional infection is observed in the ulceration, we should no longer hesitate to remove all those portions which are manifestlv be\t)nd repair. The sharp spoon is to be called into requisition, and all softened tissue thoroughlv scraj)e(l awav. The dressing is carried out upon general surgical j)rincij)k'S. Lupus Erythematosus. — This adcction usuallv attacks the auricle secondarilv, some other portion of the face being the starting point. At first it jnesents as a sharply defined red- dened area, slightlv elevated above the surface of the skin, over which it soon spreads in all directions. The integument involved becomes thick, injected, and separated from the nor- inal cutis bv a rather sharp line of demarcation. The surface is frequentlv traversed by minute veins. Owing to the in- terference with the blood supply, the superficial epithelium is thrown off more rapidlv than under normal conditions, giving the surface a glazed appearance. As the disease encroaches more and more upon the healthy integument, its starting point becomes somewhat depressed and of a lighter color, owing to the gradual sclerosis of the infiltrated tissue. The disfigurement constitutes the entire inconvenience which the affection entails, there being no pain, pruritus, or perversion of sensation. Although usually unilateral, I remember one instance in which the entire face, including both auricles, was involved. 19$ CUTANEOUS DISEASES OF THE AURICLE. A mistake in diagnosis is practically impossible, although to a certain extent the disease resembles eczema. In the lat- ter affection the intense pruritus, the presence of some local exciting cause, the brighter color of the affected part, and the moist surface, together with the more rapid progress, will usuallv render a differential diagnosis easy. Treatment. — Locally we mav employ yigorous friction with a strong alkaline soap to relieye the infiltration, after which an astringent or soothing ointment may be applied. Another plan is to employ counter-irritation in the form of tincture of iodine. An ointment containing either iodine and iodide of. potassium or pyrogallic acid in the strength of from one to four per cent is also yaluable. In the seyere cases, the galyano-cautery, the curette, or eyen the knife may be employed, although as a rule these yigorous measures are not followed by satisfactory results. Lupus Vulgaris. — Dermatological literature teaches us that this is one of the rarer cutaneous affections, and its loca- tion in the external ear is still more unusual. In the early stages we find upon some portion of the auricle one or more small hard nodules which cause a slisfht sensation of itching^ ; the efforts of the patient to relieye this abrade the surface of the eleyation, which soon becomes coyered with a brownish crust. As the disease adyances the infiltrated areas increase in size and number. Those which appear subsequently un- dergo the same changes already described as characteristic of the original deposit. The progress of the affection is slow but steady. The ero- sion of the surface gradually becomes deeper and constitutes a true ulceration, the areas of local necrosis being almost im- mediately coyered by brownish crusts which do not separate spontaneously. When the crusts are remoyed artificially the ulcer appears but slightly depressed, its margins are poorly defined, there is no areola, its boundaries merging impercep- tibly into the normal integument. Still later there seems to be an effort at spontaneous cicatrization, which results in con- siderable deformity due to a shrinking of the cicatrix. The affection does not cease spontaneously, and will almost surely inyolye the entire auricle unless checked by local measures. Treatment. — When first seen, it is our duty to remoye the inyolvcd area as completely as "possible, proyidcd the disease is in its earliest stage and limited in extent. In many cases LUPUS VULGARIS— TREATMENT. 199 the complete exxision of the infiltrated portion of the auricle is the simplest and best measure. Another method is to thor- oughly curette awav the deposit with a sharp spoon, care being taken that the healthy tissue immediately surrounding tiie deposit is encroached upon. The curettement should be followed by the application of some chemical agent, lactic acid being probably the best. This should be used in concentrated solution, and should be thoroughly rubbed into the tissues. From the fact that the canal, and even the middle car, may be attacked if the progress in the auricle is not checked, the surgeon is fully justified in excising the entire auricle if this is so infiltrated as to permit of no other means of eradicating the disease. CHAPTER VIII. INFLAMMATORY AFFECTIONS OF THE AURICLE. Perichondritis. — We have ahead v describee] an inflamma- torv condition of the cartikii^inous traniework of the external ear following an injury to the part. Occasionally such a con- dition is met with as an idiopathic affection, or is a complica- tion of an acute inflammation of the external auditory meatus. The particular part of the auricle affected will depend largely upon the locality occupied by the inflammatory process in the external auditory meatus, the dis- ease spreading bv contiguity of structure, when depending upon such a cause. The symptoms to which the disease gives rise are a feeling of heat in the external ear, quickly followed by severe pain. The auricle soon begins to increase in size, while over the affected area the skin is of a bright-red hue, due to an increased arterial vascularity. As the disease ad- vances the pant becomes more and more swollen, and the nor- mal outline of the auricle entire- ly disappears. This is due to an effusion of fluid between the car- tilage and perichondrium, dis- secting this last named structure from the underlying cartilage. The fluid is at first serous, but quickly becomes purulent. The deformity varies con- siderably, according to the particular area involved. Where the inflammatory condition \vithin the meatus involves the anterior wall, the tragus alone is the part usually affected, (*oo) Fig. 71. — Deformity following peri- chomlrilis. PERICHONDRITIS— ERYSIPELAS- ABSCESS. 201 while if the circumscribed inllanimatorv process is situated upon the posterior or superior walls of the canal, the peri- chondritis is apt to be extensive, and is accompanied by marked deformity. If unrelieved by therapeutic measures the fluid is evacuated spontaneously. In such an event several sinuses appear either upon the anterior or posterior surface of the pinna, and close spontaneously only after a prolonged period. A high degree of deformitv is the usual result in those cases which are allowed to progress without surgical interference (Fig. 71). Treatment. — The treatment of the condition is identical with that advocated in considering perichondritis due to traumatic causes, with the cxcej)tion that aspiration of the tluid is not admissible, since its purulent character precludes the possibilitv of a favorable result, in the severe cases the j>rocedure advocated bv Ciruening * of " through-and- ihrough " drainage is probablv the most advisable j)lan of treatment. This consists in thoroughlv opening the ab- scess bv means of incisions which pass comi)letely through the substance of the auricle from the anterior to the pos- terior surface, strips of iodoform gauze being subsequently passed through the openings thus made. In a case under the care of the author the tragus was the j)art involved, and a rapid cure followed free incision, with a thorough curetting of the cavitv. Erysipelas. — This affection occurs as a comj)licati(jn of facial ervsipelas. and requires no special consideration either as regards the clinical course which it runs, or the treatment to be instituted for its relief. Abscess. — An abscess of the auricle involving its cartilagi- nous portion constitutes in realitv a perichondritis, a con- dition which has already been described in detail. Occasion- ally we meet with a localized collection of pus in that portion of the auricle consisting of fibrous and fattv tissue — the lobule. Most frequently the affection depends upon a local infection, either from an earring or following the oj)cration of piercing the ears. Evacuation of the abscess by incision is followed by com[)lcte and rapid recovcrv. Occasionallv we find a superficial abscess in other portions of the auricle, the cartilaginous framework being uninvolved ; * Archives of Otology, vol. xix, p. 22. 202 INFLAMMATORY AFFECTIONS OF THE AURICLE. these constitute really retention cysts, and are caused by the blocking up of the orifice of a sebaceous follicle with sub- sequent disintegration of the retained secretion. In the early stages, when the condition is one of retention only, removal of the obstruction is all that is necessary. After decomposi- tion has taken place, however, the proper procedure is to in- cise the tumor freely, after which the lining membrane is to be dissected out or thoroughly curetted, to prevent recur- rence. Othaematoma (Fig. 72). — A transudation of sanguineous fluid beneath the perichondrium is frequently met with as the result of an injury. Occurring, however, without the history of traumatism, the origin of the condition has been a matter of no little speculation. While hcema- toma auris is frequently met with among the insane, numerous au- thentic reports are found in which the affection has occurred sponta- neously, in persons of perfectly sound mind. Age seems to exert but little causative influence, Weil * having reported a case occurring at the age of fifteen months. The condition is present usu- ally upon one side only, although in a case reported by Brunnerf its occurrence upon one side was followed, a year later, by a similar condition in the opposite organ. From the fact that it has been frcquentlv observed among the insane it is possible that some intracranial lesion may be responsible for its occurrence. The investigations of Brown- Sequard :{; would add weight to this view, since they show that section of the restiform bodies in dogs will produce the local lesion in question. It is quite probable that in many cases an injury which has been entirely forgotten is the real cause of the pathological condition. Flesch ** believes that Fig. 72. — Othaematoma. * Monatsschrift fiir Ohrenheilkunde, 1883, No. 3. •f- Archiv fiir Ohrenheilkunde, vol. v, 26. J Canstatter Jahresbericht, 1869, vol. ii, p. 27. * Archiv fiir Ohrenheilkunde, vol. xx, p. 291. OTH>EMATOMA— TREATMENT. 203 certain variations in the structure of the auricular cartilages predispose to the extravasation of blood, but advances no theory as to the cause of the anomalous structure of the car- tilage. It can only be said, therefore, that the a;tiological factor in a proportion of the cases is still unsolved. The affection consists essentially in an effusion of blood, which separates the perichondrium from the cartilage. Oc- casionally we find, on examining the walls of the cavity, that small plates of cartilage have been forcibly torn from the framework of the auricle during the process of extravasation. The tumefaction appears, as a rule, somewhat suddenly. It may be preceded by a feeling of burning or pruritus, but usu- ally there are no prodromal symptoms. The anterior surface of the auricle is usually involved to a greater or less extent, and the obliteration of the normal outline is correspondingly complete. The integument covering the tumor is either normal in color or, if the effusic^n is large in amoimt, may ap- pear pale on account of the pressure. After its appearance, the effusion mav disapj)tar spon- taneously, or it mav be evacuated bv si)ontaneous rupture, or the contents of the cyst may suppurate. Absorption is so uncommon that we should never wait for its occurrence, while it is probable that traumatism is resjxjnsible for the spontaneous evacuation of the fluid in most cases, whether this occurs with or without sujijniration. Treatment. — The treatment varies according to the size of the tumor and nature of its contents, whether this consists of blood alone or whether purulent infection has already oc- curred. When there are evidences of pus formation free evacua- tion should be at once resorted to, the case being treated as one of simple perichondritis. Where the tumor is small and of recent occurrence, simple pressure by means of a compress held firmly in place by a roller bandage should first be tried. This method, combined with systematic massage of the auricle, is valuable in man}'^ instances. In tumors of large size resort may be had to aspiration, followed by the compress, bandage, and massage. Where the effusion is of such proportions as to cause consid- erable tension of the overlying tissues, evacuation by free incision is the most advisable procedure, the cavity being afterward thoroughly curetted to remove all necrotic tissue Z04 INFLAMMATORY AFFECTIONS OF THE AURICLE. and to favor a rapid obliteration of the space bv granulation and adhesion. After thus thoroughly removing the contents of the cyst the wound should be packed firmlv with iodoform gauze, and subsequently managed according to the rules of general surgerv. It should always be remembered that in the severe cases considerable deformity of the auricle ma}- follow, and the patient should be warned accordingh'. Thickening of the Lobule. — This condition consists of a hypertrophy both of the connective tissue forming the frame- work of the lobule and of the glandular structures of the re- gion, as the result of a chronic inflammatory process. The most frequent cause of the affection is mechanical irritation, occasioned by the wearing of a ring in the ear, the margins of the artificial opening through which this is passed instead of cicatrizing and becoming covered with normal epithelium remaining denuded, and thus afford an avenue for the entrance of infectious germs. Some metals are easily acted upon bv moist air, and are particularly prone to cause such a condi- tion, the products of their oxidation destroying the newly formed epithelial cells and leading to the result above given. When this process has continued for some length of time the pendent portion of the auricle becomes elongated, thickened, tender to the touch, and in soiuc cases the seat of spontaneous jiain. The chief annoyance to which it gives rise, however, is the deformity. Occasionally the lodgment of more virulent bacteria upon this denuded surface produces small abscesses. Treatment. — The treatment of the condition is simple, and consists first in the removal of the local cause. If the deformity has reached a high degree a plastic operation may become necessary for the removal of the superabundant tissue. Ossification. — Curiously enough, this condition is exceed- ingly rare, although several instances have been mentioned in otological literature. The causes which may be considered to be active in its production seem to be malnutrition, severe local inflammation, or some profound disturbance of the cir- culation of the part, such as exposure to intense cold. When osseous tissue has once been deposited, the recognition of the affection is exceedingly simple. The auricle becomes stiff, inflexible, and boardlike to the touch. The ossification may be limited either to a small area or mav involve a con- siderable portion of the organ. OSSIFICATION— GANGRENE. 205 In a case reported by Linsmavcr * the bony deposit ex- tended into the floor of the canal. The helix, scaphoid fossa, and antihelix are the regions most frequently afTccted, and the condition may be present upon one or both sides. Relief is demanded both on z^ccount of the deformity and also because of the pain which any pressure upon the rigid oigan causes, as when the patient attempts to lie upon the affected side. Treatment. — The treatment consists in a remoyal of the abnormal deposit where this is of limited extent. Where a large part of the auricle is inyolyed amputation of the entire organ is justifiable. Gangrene. — Complete necrosis of the tissues making up the iraniew(jrk and coverings of the external ear is occasion- ally met with in cases which have not been subjected to any severe traumatism. A marked general cachectic condition, following an acute illness which has lowered the vitality of the patient greatly, or such as may be occasioned by some prolonged suppurative process accompanied by bony necro- sis, frequently acts as a predisposing cause. If we combine with such a condition slight but continuous pressure upon the auricle, as might occur in a patient confined to bed for a long period and lying upon one side for a considerable inter- val of time, the pressure might be sutlicient to determine the process under consideration. Treatment. — The treatment is sufficiently indicated by the causes oj^erative in j)r()ducing the alTecticjn. Suj)porting and stimulating measures arc to be adopted for the removal of the predisposing cause, while care is to be taken to prevent any pressure ujjon the auricle, bearing in mind the ease with which local nutritive processes are interfered with when the general tone of the body is greatly lowered. If the process has already developed we should attempt, by means of warm applications, to restore the circulation of the region to its normal state, and at the same time to favor spontaneous separation of the necrotic tissue if local necrosis has occurred. Where the necrosis is but superficial, the application of strong chemical caustics may hasten repair, the local irrita- tion exciting a reactive inflammation which in itself becomes a valuable therapeutic measure, causing the early exfoliation of the slough and the development of healthy granulations. * Wien. Klin. Woch., 1889, No. 12. CHAPTER IX. BEXI(;X TUMORS OF THE ALRICT.E. Fibroma. — A fibroid tumor is one of the most common of the beni2;n neoplasms which is met with upon the auricle. The lobule is the part usually involved. The negro race -is especiallv liable to the affection, and among- this people the growths frequentlv attain a large size. Local irritation at- tendant upon wearing / ./ ^^ ,. . ornaments in the ear is the most common ex- citing ^etiological factor. Although the lobule is the part most frequentlv affected, the concha is occasionallv the site of a growth of this charac- ter, and in a case report- ed by Ilabermann* the external meatus was par- tially occluded by the tumor, which sprang from the concha. Upon phvsical exam- ination the tumor pre- sents a hard surface, which is usuallv smooth, but occasionally nodu- lar. Microscopicallv the mass is made up of dense, white, fibrous connective tissue. In a case reported bv Anton + (Fig. y}) the growth was a soft fibroma and contained nianv connective-tissue cells in- terspersed between the fibres. Fig. 73. — Soft fibroma filling the concha. (Anton.) * Archiv fiir Ohrenheilkunde, vol. xviii, p. 76. f Ibid., vol. xxviii, p. 2S5. (206) FIBROMA— LIPOMA— ATHEROMA. 207 These growths are of especial interest on account of the fact that thev frequently recur after removal, the recurrent tumors occasionally assuming a malignant tvpe, especially after repeated operations of excision have been instituted. Treatment. — The operative treatment is simi)le. The mass is to be circumscribed with the knife, the incision extending through the entire thickness of the affected part and Iving completely outside of it, within healthv tissue. After the neo- ])lasm has been extirpated the edges of the wound are to be brought together by sutures, and the parts dressed according to general surgical rules. Recovery is usually uninterrupted. Where the tumor involves the lobule the incision should be so located as to effect the removal of redundant tissue and enable the parts, upon replacement, to be molded into a form symmetrical with that of the lobule of the opposite side. In addition to puie fibromata, tumors are occasionally met with which are made up of a mixture of fibrous tissue with myxomatous, cartilaginous, or other elements. In a case re- ported by Haug * the growth was Ivmphangio-fibroma. Lipoma. — A true fattv tumor has, so far as I know, never been found upon the auricle itself. Thev are (jccasionally met with, however, in its immediate vicinitv, usuallv just beh^w the lobule. Kipp + has re{)orted a case of fibro-lipoma of the concha, the microscope showing the presence of cavernous tissue as well. Atheroma (Figs. 74 and 751. — A tumor of this character results from blocking up of the sebaceous follicles with which the integument covering the external ear is suj)plicd. The secretion which the glands produce is imjirisoned by the ste- nosis of the orifices of the ducts, dilates the gland cavitv. and gives rise to a tumefaction of varving size. Where the gland is active, the rapid formation of its product may produce so much pressure as to cause spontaneous rui)ture. On the other hand, after attaining a certain size the obstruction in the duct mav be overcome, allowing a suflficient amount of the contents to escape to relieve the tension without restor- ing the normal patency of the tube. This process may be repeated indefinitely, and the patient presents with the his- tory of a recurrent discharge from the growth at varying * Archiv fiir Ohrenheilkunde, vol. xxxii, p. 161. ■}• Transactions of the American Otological Society, vol. iii, part iii. 208 BENIGN TUMORS OF THE AURICLE. intervals. Again, the pressure may be so severe as to excite an inflammation within the sac, witli the consequent produc- tion of a purulent discharge. The lobule is a favorite seat for these growths, or the junction of the lobule with the skin of the neck. Marian * has re- ported a case in which the neoplasm filled the concha. Where spontaneous evacua- tion has not taken place dissection usually reveals a distinct sac. Where the con- tents of the cyst have undergone infection and rupture has occurred as the result of an inflammatory process, the lining mem- brane is usually so amalgamated with the surrounding tissues as to render its rec- ognition as a dis- tinct structure dif- ficult. Under the mi- croscope the con- tents of such a tu- mor is found to be made up of seba- ceous material, degenerated epithelial cells, with an occasional admixture of cholesterin crystals. Treatment. — This condition is best combated by surgical interference. This consists in the removal of the growth. An incision is made through the overlving integument, and the tu- Fi... 75.— Sebaceous tumor of ■ ,, , ^, , , the lobule. (Claiborne.) mor IS shelled out from the envelope withotit rupture of tiie sac. In this wav a possible recur- rence is giiarded against. Such a procedure, however, is frequentlr impossible, the sac being oj)cncd and its contents being evacuated in spite of the greatest care. In this event the entire sac should be completely dissected out from the structures with which it has become amalgamated. It is well after making such a dissection to thorotighly curette the cav- ity by means of a sharp spoon, in order that every vestige Fig. 74. — .\lheronia. Archiv fiir Ohrenhcilkunde, vol. xxv, p. 66. ATHEROMA— TREATMENT— ANGIOMA. 209 of the ciivclopiiii^ membrane may be removed. Where the mass is of but small dimensions and spontaneous discharge has taken place, a thorough curetting of the sac, followed by the application of a strong solution of nitrate of silver, may cause complete obliteration of the cavitv and prevent a re- currence. Angioma. — A neoplasm of this character is seldom met with in the external ear, and the reported cases have varied greatly both in the area involved by the neoplasm and in the degree U) which the vascular abnormitv has developed. In a case reported by Chimani * the condition was one of cirsoid aneurism which was present upon the left side of the head at birth, and subsecpiently extended until a large portion of the auricle was involved, j)articularlv the posterior aspect of the organ. The external ear was displaced outward, and was of a dark purplish-red color; a distinct murmur was perce{)tible over the growth. The condition improved sc^newhat under injections of perchloride of iron, although recurrence took place at a subsequent period. The mass was completely dis- sipated by a repetition of the same treatment. Occasionally an exposure to cold, as in Kipp's f case, seems to be responsible for the affection, although in many instances they are congenital, differing only in degree from the com- mon birthmark or port-wine stain. Although we do not consider the condition as perilous to life, Jungken;}: has reported an instance in which luvmorrhage from the growth terminated fatally. Treatment. — We arc usually consulted on account of tiie deformit\ which these growths cause, and the measures for their relief must depend upon their size and character, and the coincident presence of a similar condition upon some (Jther portion (^f the face. When involving only the integu- ment and consisting of a small stain, repeated applications of the galvano-cautery usually obliterate the abnormitv. Where the mass is of large size and the vessels are more fully devel- oped, complete excision is the best procedure. This may be effected by seizing the base of the mass with a clamp and re- moving it /;/ iofo, ligating the stump in several portions. In other instances the clamp may be dispensed with, and the * Archiv fiir Ohrenheilkunde, vol. viii, p. 63. ■f Transactions of the American Otological Society, Jul)', 1885. J Schwarlze, Ohrenheilkunde, p. 77. 15 210 BENIGN TUMORS OF THE AURICLE. mass dissected out, the vessels being divided between two ligatures, thus preventing excessive haemorrhage during the operation. The employment of the ligature to cause the growth to slough away slowly is scarcely advisable. Injections of fluids for the purpose of coagulating the con- tents of the tumor are not free from danger, since by the dis- lodgment of a clot, embolism of important vessels may fol- low, or general sepsis may result. The emplovment of the galvano-cautery knife or loop for the excision of such a neoplasm should only be undertaken if a clamp is used, and even if the mass were removed in this manner most would prefer to ligate the pedicle in several por- tions rather than to trust to a closure of the vessels by the action of the incandescent blade or wire. Where the tumor increases rapidly in size at the site of its first appearance and other areas of the integument become involved in regions entirely distinct from the original location, we have to deal not only with the lesion as it appears upon the external ear, but by our measures for the relief of this, we should aim to prevent a similar condition from developing subsequently in neighboring regions. This can onlv be ef- fected, I think, by shutting off the arterial supply of the entire region by the ligation of the trunk from which the various vessels spring. After such an operation the dilated vessels will in many instances be obliterated, while those remaining will be much diminished in size, and any remaining angioma- tous masses can be treated upon the rules already laid down. It should be remembered that the vessels upon one side of the face anastomose freely with those upon the opposite side, and less radical measures than those given above may not be sufficient to obliterate the condition. Cystoma (Fig. "jG). — It is still a matter of discussion as to what particular form of neoplasm this term should be applied. Many use it to designate a localized tumefaction upon the auricle due to a circumscribed collection of fluid not de- pendent upon traumatism. Many again apply to similar con- ditions the term hasmatoma or perichondritis, although there may be no evidence of a sanguineous effusion or of an inflam- matory process, and although the history may reveal no ade- quate cause for the occurrence of either affection. The for- mer view seems to me the more tenable and is advocated CYSTOMA. 21 I bv Ilartmann,* whn applies the name of cvst of the auricle to tumors of this description. This opinion is supported by the appearance of the interior of the sac, upon incision of the tumor. There is no evidence of any inflammation of the perichon- drium ; there are no fibrinous clots, nor anv other evidence of a previous traumatism. The devel- opment seems to depend upon an effusion of serum simplv. Exposed cartilage, however, is occasionally found within the cvst. These tumors make their ap- |)earance, as a rule, upon the an- terior surface of the auricle, which they involve more or less com- j)letely. The overly ing integu- ment is normal in color and not tender to the touch. The tume- laction aj)pears quite suddenlv. and shows little or no tcndencv to increase in size, relief being demanded simjtlv on account of the deformity. Harsh manipulation or contusion of the part may cause an inflammation of the cartilage, but this condition is superadded, and not a part of the original {)rocess. The cause of the affection is naturally hypothetical. It may possibly be due to a degeneration in the cartilagiiu^us framework of the auricle, somewhat similar to that which causes the spontaneous develo|)ment of a ha:matoma auris. Treatment. — The treatment consists in repeated aspira- tion ui the fluid or of evacuation bv incision, after which the cavity is obliterated by packing the wound with gauze. Fischenischf has obtained good results bv massage in these cases. Manipulation in C(jnjunction with aspiration is cer- tainly worthy of trial. After evacuation of the contents of the cyst in this manner the walls should be kept in contact 1)\ means of a j^roperly constructed clamp or bv a firm bandage. Certainly the surest method of treating these cases is by incision. This should be made in one of the natural folds so Fig. 76. — Cystom.a of auricle. * Zeitschrift fiir Ohrenheilkunde, vol. xv, p. 156, and vol. xvii, p. 232. f Archiv fur Ohrenheilkunde, vol. xxv, p. 299. 212 BENIGN TUMORS OF THE AURICLE. as to prevent deformity. After the sac has been thoroughly cleansed by irrigation, the margins of the incision may be sutured, a few strands of horsehair being passed through the sac to act as a drain. By this method a slight irregularity may remain at the upper and lower extremities of the incision at the points of entrance and exit of the horsehair drain. To avoid this, the entire wound upon the anterior surface may be sutured, and drainage secured by puncturing the cartilage so as to make an opening upon the posterior surface of the auricle. By securing drainage through this channel, and allowing the incision upon the anterior surface to unite bv first intention, the probability of recurrence is reduced and all dcformitv avoided. Papilloma. — Simple papillomata are found upon the auricle only in the form of warts. Two instances of anomalous devel- opments in the epidermal layer have been reported, which might properly be classed under this term. These were ob- served by Buck, * and consisted of a dense, hornlike pro- tuberance springing from the outer and posterior portion of the helix, in one of these the excrescence attained a length of three fourths of an inch, while the base was nearly as broad. Its growth had undoubtedly been favored by harsh methods of treatment. The mass was removed, and complete recovery followed. * Manual of Diseases of the Ear, New York, iSSg, pp. 52, 53. CHAPTER X. MALIGNANT TUMORS OF THE AURICLE AND OF THE MEATUS. It is comparatively seldom that the external ear is the primary seat of a malisj^nant neoplasm, although the condition is occasionally met with. Any portion of the external ear may be the site of the primary deposit, from which situation the neoplasm may spread in any direction until a lar^re area is involved. In some instances the trrowth orij^inates in the ex- ternal auditory meatus, the auricle bein«^ attacked subsequent- ly, or the reverse may be true, the growth appearing first upon the pinna and extending into the auditorv meatus. Malignant neoj)lasms of the dccj)er portions of the ear or mastoid process are still more infrequentiv nut with. The most common malignant growth which affects the region in question is cj)illiclioma, sarcoma being of rare cjccurrence. Epithelioma. — The same causes operative upon other por- tions of the bodv in the j)r(Kluction of malignant growths, act here to produce the condition. In a number of instances per- sistent mechanical irritation has seemed to be the most prom- inent causative factor. In these cases a slight abrasion of the external ear subsequentlv becomes the seat of a malignant ulceration on account of the persistent efiforts of the patient to relieve the local discomfort to which it gives rise. Individuals under the age of fifty are seldom attacked, although in one instance a malignant growth developed at the age of nineteen. The progress of these tumors is usually slower than in the other regions of the bodv, several years being required for them to reach any considerable size. Secondary enlargement of the cervical glands is not ordinarily present, and for this reason the prognosis in malignant disease of the auricle is relatively better than that of a similar condition in other portions of the body. Even where glandular infiltration has occurred there seems to have been little tendencv to sys- temic infection, and removal of the original mass and of the affected lymphatics has been, in the majority of cases. efTec- (213) 214 MALIGNANT TUMORS OF THE AURICLE AND MEATUS. tual in curing the disease. That systemic infection is so slight in cancer of the external ear is probably due to the fact that the infectious material is absorbed from cartilaginous tissue very slowly, and that the local lesion develops to such an extent that it demands removal before extensive glandular infiltration has taken place. The physical characteristics are almost unmistakable. No ulceration resembles in appearance that presented by an epi- thelioma. Before ulceration has taken place it may be im- possible to decide the character of the neoplasm, although from the fact that it docs not resemble any of the benign growths found here, diagnosis by exclusion is simple. After the superficial tissues have broken down the eroded surface appears reddened, moist, irregular in outline, and some- what raised above the healthy integument surrounding it. It bleeds easily on touch, and is frecjuently tender. Interfer- ence \yith the nutritive supply of the cartilage causes this to become necrotic, and with the process of exfoliation inflam- matory reaction occurs. Such a condition is characterized by the presence of exuberant granulations the same as in a simple perichondritis, and during this stage an errop in diag- nosis may occasionally be made. The true character of the tumor can be made out by removing a small portion and sub- mitting it to a microscopical examination. The removal of a small fragment is easily accomplished by means of the cold wire snare, and this aid to diagnosis should always be em- ployed before a positive opinion is given. On account of the occurrence of exuberant granulation tissue, microscopical evi- dence of a negative character does not exclude malignant dis- ease, although positive cyidence settles the question beyond a doui)t. Treatment. — The results of treatment are unusually favor- able. If the mass is removed by radical measures there seems to be slight tendency to a recurrence. Lymphatic infiltration should be dealt with at the same time, and it is only in ad- vanced cases that a fairly favorable prognosis is unwarrant- able. The treatment should be the same as that of maligtiant neoplasms in any portion of the body, earl}' removal by the knife being the only safe procedure. Care should be taken that every vestige of the growth is excised, the incision pass- ing beyond the limits of infiltration and lying in perfectly healthy tissue. The exact plan to follow will vary with the EPITHELIOMA— TREATMENT. 21 5 different cases. If the auricle alone is involved, and the in- hltration is extensive, it is best to amputate the pinna at once. If possible, when this is done care should be taken to pre- serve enough of the integument about the orifice of the meatus to permit of its being sutured to the skin of the face, thus securing a patulous external canal lined with epidermis. Where, however, the growth has extended ever so slightly into the canal, the auricle and the entire cartilaginous meatus should be removed. When this is necessary it is almost hope- less to attempt to secure a patent external meatus, although the effort should be made. For this purpose a drainage tube, either of soft rubber, silver, or aluminium, should be kept con- stantly in the canal in order to preserve its lumen. Such a device may be worn for a long period, and be rem(n-ed once daily for the purpose of cleansing the passage, being quickly replaced to prevent the occlusion of the canal by the granu- ha'um tissue. Even after such a tube has been worn many months the attempt frequently fails. It may be possible in some instances to employ skin grafting, either by Thiersch's method or by twisting a small flap from the adjoining region into the orifice of the canal, and thus secure a proper tegumen- tary lining. I have tried neither of these methods, since the procedure was not suited to the two cases which came under my observation. In one instance, where the growth involved the posterior wall (jf the canal, the meatus was ccjmpletclv ob- literated in spite of persistent efforts to maintain its patency. In a second case a perfectly patent canal was obtained by uniting the integument of the anterior wall of the passage with the margin of the cutaneous incision through the ^kin of the face, the cutis being dissected uj) for a considerable dis- tance to permit disjtlacement toward the meatus. Coaptation of the edges was not attained, and this does not seem to be necessary. The sutures may cut through at the end of a few hours and still perform a very important function, the parts being held in position for a sufficient length of time to become so firmly fixed by plastic effusion as not to retract to any ex- tent after the sutures have given way. In the instance named, a considerable portion of the wound healed by granulation, and there was scarcely any deformity, and but slight con- traction at the entrance of the meatus. In excising a growth of this character involving a large portion of the auricle, a little care will enable the operator to 2i6 MALIGNANT TUMORS OF THE AURICLE AND MEATUS. replace the parts in such a manner as to prevent disfigure- ment. Where the parotid gland is involved, it is seldom wise to attempt extirpation, although in a robust patient it is per- missible. As the facial nerve passes through this large glan- dular mass, it is well to warn the patient of the possibilitv of facial paralysis following the operation. No special suggestions are necessary concerning the course to be pursued with the lymphatic enlargements. These are dealt with on general surgical principles. The employment of the galvano-cautery, the cold snare, chemical caustics, etc., for the removal or the destruction of a malig- nant neoplasm of the auricle seems to the author scarcely justifiable, although manv have used the potential cautery upon small growths of this character, with eminently satis- factory results. Sarcoma. — Occasionallv a sarcomatous neoplasm origi- nates primarily in the external ear, or, on the other hand, this organ mav be involved bv contiguity of structure from a similar growth in the cervical rcgi(jn. The growth exhibits no preference for any j)articular region, any part of the exter- nal ear being equally liable to inyolvement. T'xtension to the external auditory meatus has occurred, and the possibility of this should always be borne in mind. Such an extension to the canal renders extirpation of the growth less easy and the pos- sibility of its occurrence constitutes a plea for early operation. The tumor varies in appearance according to its situation, and differs from an epithelioma in that ulceration of the sur- face does not take place until a comparatively late period. The mass is less firm than an epitheliomatous tumor, is usu- ally more vascular, the surface being frequently traversed by tortuous blood vessels. The tumor may grow slowly and exist for many years without giving rise to symptoms suffi- ciently urgent to demand operative treatment ; on the other hand, these tumors sometimes increase rapidly in size and demand interference at an early period. Treatment. — The successful treatment depends upon the complete removal of the growth, and in these cases, owing to the increased vascularity of the mass, it may be wise to cm- ploy the cold or incandescent 6craseur or the galvano-cautery knife. If the mass- is completely removed at the point of pri- mary deposit, recurrence seldom occurs. Systemic infection is rare. //. DISEASES OE THE EXTERXAL AUDITORY ME A TUS. Diseases of the external auditory canal nuiv be divided int(3 two classes as rci:^ards their causation, duration, and extent. As regards causation, either primary or secondary. As rcii^ards duration, either acute or chronic. As rcc,rards extent, either circumscribed or dilTuse. While intlammatory chanjj^es in this reg^ion are often sec- ondary to some coexistini:;^ c«)ndition of the tvmi)anum, either circumscribed or diffuse inflammation may occur as an idio- pathic disease both in the acute and chronic form. CllAI'Il K XI. CIRCl'.MSCKir.ED EXTERNAI OTITtS. A( I Ti: Circumscribed External Onus. Olitis fxtcma cifiumscripla acuta. lurunclt. i^tiolog:y.— The occurrence of a circumscribed inflamma- tion w iihin the auditory canal is usually due either to mechan- ical irritation, the result of scratching the ear with the finger or with some blunt or sharp instrument; to inoculation in the same manner; to a loss of superficial epithelium as a result of some cutaneous disease, the abraded surface forming the point of entrance for pathological bacteria; or, where the tym- panum is the seat of a purulent inflammation, the local infec- tion may take place through the ducts of the glands with which the meatus is supplied. It is doubtful, probably, whether all cases are not the result of some local infection, but certain constitutional con- ditions predispose strongly to the disease under considera- tion. The local lesion sometimes appears without any dis- (217) 2i8 CIRCUMSCRIBED EXTERNAL OTITIS. cernible source of local infection — in other words, it occurs as an idiopathic disease. Marked impairment of the general health, disturbance of the digestive system, anemia, and dia- betes render an individual particularly susceptible to the maladv. Pathology. — From the anatomical structure of the meatus, it follows that as the external or fibro-cartilaginous portion is freely sujiplied with glands, this is the part most usually attacked. The inferior, posterior, and superior walls are more frequently affected than is the anterior. Usually the focus of the inflammation is situated near the oritice of the meatus, although it may be located in any pt)rtion of the canal, and occasionallv is met with in the osseous part. The abscesses occur usually in groups rather than singly, due to the fact, probably, that infectious material from the same source has inoculated several glands simultaneously. The disappearance of one " crop " is apt to be followed by an- other, thus prolonging the course of the affection. This is especially true where any diathetic condition is present. Loewenberg* lays great stress upon the fact that certain micro-organisms are found in the pus discharged from these small abscesses. Schimmclbusch,+ working in the same line, likewise attributes the local abscess to the presence of a ba- cillus, but has shown that an abrasion of the normal epithe- lium is necessary in order that the germ may develop at any point. It has alreadv been stated that an asthenic constitu- tional condition in many cases predisposes to the formation of these abscesses, the power of resistance to anv morbid pro- cess under these circumstances being much reduced. There is considerable evidence to show that a trophic disturbance caused by some obscure condition in the nerve trunks which supply the meatus may also be the prominent causative factor. Urbantschitsch ^ has reported instances where a derange- ment of the trophic nerves of one side, due to a local lesion, was followed very quicklv by the development of a furuncle in that portion of the canal of the opposite side, supplied by the corresponding nerve. I myself have seen two cases * Dcutsch. Med. Woch., iS88, No. 28. ■)• Arch, fiir Ohrenheilk., vol. xxvii, p. 252. ^ Lehrb. der Ohrenheilk., Vienna, 1890, p. 107 ; Arch, fiir Oiiren., vol. xxxv, p. 5. rATHOLOGV— SYMPTOMATOLOGY 219 whicli were uiuloubtetlly ol a reflex truplio-neurotic character. One occurred in a boy, aj^ed htteen. wlio suffered from a severe traumatic external t)titis, llie abscess beiui^ located on the posterior wall ol the canal. Notwithstanding^ the fact that the patient was in excellent general condition, the oppo- site canal, which was apparently healthy up to this time, was similarlv alTected about four days after the incision of the hrst abscess. The identity in the location of the abscess upon either side and the absence of anv other exciting cause, seemed to place this second furuncle in the category under discussion. In the second case the development of a small, circumscribed area of inflammation upon the floor of the right meatus was followed within tuentv-four hours by an exactly similar condition in the same location upon the oppo- site sitle. In this short interval the local process had reached maturitN'. and when the patient was seen the sectjiid abscess was discharging, although the region hail l)ecn inspected with great care less than twcntv-four hours |)reviously. and was, at that time, in a perfectly normal condition. We must believe, therefore, that the cause may be reflex in character even in cases where the general health is unim- paired. After infection has taken place, the inflammatory pro- cess advances rapidly, the central portion of the affected area losing its vitality and being discharged either in the form of pus or sometimes as a distinct mass ol necrotic tissue. Ordi- narily the inflammation does not extend deeply by contiguity of structure, but when very severe the underlying tissues may become affected, developing a perichondritis of the canal or auricle. This is particularly aj)t to take place when the furuncle is located on the anterior wall, the entire tragus be- coming involved. Excej)tionally, the affection may lead to a diffuse external otitis, which, Sj>reading along the j)osterior wall of the canal, may give rise to periosteitis of the osseous portion, and may thus bv extension involve the middle ear itself. In either event extension to the mastoid cells may occur. Symptomatology. — The first svmjitoms with which the dis- ease is ushered in is usually a feeling of fullness or discomfort in the ear. or sometimes a slight itching sensation, causing the patient to press the finger against the tragus. Soon, how- ever, he finds that this part is tender upon pressure, and a little later spontaneous pain in the ear becomes very well 220 CIRCUMSCRIBED EXTERNAL OTITIS. marked. At this juncture the hearing becomes considerably interfered with, owing to the stenosis of the meatus resulting from the tumefaction. For the same reason there is fre- quently tinnitus, usually rather high pitched in character, which increases as the affection progresses. This may be due either to stenosis of the canal or to the congestion of the deeper structures from the increased blood supply. The pain increases in severity, so that within twenty-four hours from the first feelings of discomfort it may be almost un- bearable, while the ear continues to be very tender to the touch, especially w-hen pressure is exerted in front of the tra- gus. From the intimate relation between the cartilage of the tragus and the intermaxillary articulation the motions of the lower jaw are interfered with, and mastication frequently be- comes so painful that the patient can take liquid food only. The spontaneous pain is especially severe at night and fre- quently may prevent sleep, although during the day the pa- tient may be able to follow his vocation. If the abscess is located upon the anterior wall of the canal the parts in front of the ear appear swollen and slightly turgescent. If, on the contrary, the posterior wall of the canal is affected, one of the frequent symptoms noticed is an undue prominence of the auricle, the external ear being crowded somewhat forward and standing out more prominently from the side of the head than does its fellow on the opposite side. When the furuncle is in this location, also, the slightest pressure upon any por- tion of the pinna causes intense suffering. When the abscess is situated upon the posterior wall, a not infrequent symptom, and one to which the patient is apt to attach undue gravity, is a marked oedema of the integument behind the ear. Infiltration of the cervical glands, and also of the pre-au- ricular glands, is of common occurrence, tiie former giving rise to a hard, irregular swelling extending from just below tiie lobule downward along the course of the stcrno-mastoid muscle to the angle of the jaw, while in the latter case the side of the face immediately in front of the ear presents some irregular induration due to an inflammation of the lymjihatic nodules in this region. The parotid gland itself mav also par- ticipate in this inflammatory process, causing its outline to become distinctly defined both to ocular inspection and to palpation. This is due to secondary engorgement of the gland, and consequently suppurative inflammation of the paro- DIAGNOSIS. 221 tid occasionally complicates a circumscribed cxtenial otitis. Occasionally we find directly behind the auricle, a rather prominent i^roup of small lymphatic <;lands ; when these are present a localized infiammation upon the posterit)r wall of the canal is attended by considerable infiltration of these structures, in which case the (vdema before spoken of is re- l)laced by an irregular induration which is so poorly defined in its limitations, that it may be mistaken for an inllammatory condition of the mastoid periosteum. Constitutional symptoms are, as a rule, not well marked. The attack may run its course in an adult with scarcely any elevation of temperature, or the temperature may be sliture of the abscess, the discharge of its contents causing an abatement of all the distressing manifes- tations. As stated under Pathology, however, these abscesses ordi- narily appear in groups, so that in the course of a few days the symptoms already narrated are repeated. If the inflam- matory process extends to the tympanum or to the mastoid cells, the pain becomes more intense and the constitutional symptoms also are more marked. The temperature rises, the pain instead of being localized involves the entire temporal region, or may manifest itself as a severe general headache. The impairment in hearing and the subjective disturbances become more marked, and the gravity of the affection is evi- denced by the increased prostration from which the patient suffers. Diagnosis. — It would seem that the diagnosis of such an affection would present no difficulties, but this is frequently by no means simple. In the early stages the patient is not able to localize the pain, but complains simply of a feeling of discomfort and heaviness in the head, and may even ignore CIRCUMSCRIBED EXTERNAL OTITIS. the ear entirely and refer all the painful sensations to the pres- ence of carious teeth. An inspection of the ear at this period may reveal absolutely nothing. If, however, we supplement ocular inspection b}' carefuUv testing the sensitiveness of the walls of the canal by means of a cotton-tipped probe, usually some one point will be found where pressure causes the pa- tient to wince slightly. Too much stress can not be laid, how- ever, upon the necessity of first inspecting the ear without the use of the speculum, the auricle being drawn upward and backward, or in a very young child downward and backward, and the entrance of the meatus first examined by reflected light before the introduction of any instrument. It is well, also, to press gentlv upon the posterior, inferior, superior, and anterior walls of the canal with the cotton-tipped probe before introducing the speculum, in order to recognize any tender point which might escape detection after the insertion of the instrument. \'crv frequently, at an carlv stage, this tender- ness may be the onlv evidence suggestive of the local lesion, if this examination is made before the speculum is inserted, a very slight tumefaction may be observed encroaching upon the lumen of the canal, from one of its walls. This area may not differ in color from the surrounding parts, or it may be of a slightly pinkish or red- dish hue. This alteration in color is seldom notice- able, and the insertion of the speculum may entirely ob- literate the local swelling. The deeper parts should be tested, after the speculum has been introduced, by means of the probe in the manner already described, and the presence of one or more tender points be looked upon with suspicion. If the local process is more advanced the areas of tume- faction are easily recognized (Fig. yy); if the inflammatory process is located near the orifice of the canal, the introduction of the speculum may be painful. As many patients, however, wince slightly upon Fio. 77. — Otitis externa acuta circumscripta, at the entrance of the canal involving the superior and posterior walls, (Natural size.) DIAGNOSIS. the introduction of anv instrument into the meatus, this sijj^n should be accepted with considerable caution. As has been stated, circumscribed inflammation of the canal is usually located in the movable portion, and although occasionally occurring in the osseous segment, anv localized tumefaction in this region should be looked upon with great suspicion, especially if situated upon the superior posterior wall, since in this locality the mastoid antrum is separated from the meatus bv a comparatively thin plate of bone, and an inHam- niation within the mastoid cells often causes an encroachment upon the lumen of the canal in this localitv. When this is the condition otoscopic ex- amination gives the impres- sion of a canal w Inch rapid- ly becomes narrow at the fundus, the line of demar- cation between the drum membrane and the sui)erior and posterior walls of the meatus being poorly de- fined. In some instances only a small slitlike open- ing is visible at the inner extremity of the canal, the membrana tympani being com{)lctcly hidtlen from view except over this area (Fig. 78). Such a condition means, almost invariably, a collection of tluid within the mas- toid antrum, and always indicates an affection of the deeper structures, although the j)r()cess may have had its origin in the external meatus : in other words, the affection is no longer confined to the meatus, but involves the middle ear. On the contrary, in furuncular inflammaticMi the greatest narrowing is at the orifice of the meatus, and if the speculum can once be carried past this obstruction, which lies comparatively near the external opening of the canal, an unobstructed view can be obtained of the j)arts that lie beyond. Where a cir- cumscribed external otitis occurs in an ear which is already the seat of a purulent inflammation of the tympanum, the location of the tumefaction in the superficial meatus will fre- quently enable us to distinguish between a simple circum- Fio. 78. — Otitis cxtcnia acuta of the repa- rations to relieve the pain seems to me to be a measure of practi- cally no value whatever. A glance over the literature on the subject affords sufficient evidence of this, 1 think, on account of the large number of remedies which have been advocated. Thus we find recommended solutions of morj)hinc, atropine, subacetate of lead, cocaine, menthol, oil of eucalvptus, dilute carbolic acid, veratrine. and, in fact, all the drugs of the j>harma- copa'ia which have a real or imagined analgesic local action. It must be remembered that the absorption of any remedy from the unbroken skin takes place verv slowlv and produces, therefore, when a{)plied to the cutis, almost no effect aside from that due to the evaporation of the li(|uid. with the con- sequent production of a certain amount of cold. The small amount of benefit to be derived from such applications is more than counterbalanced, in mv opinion, bv the sodden condition of the ejiidcrmis, which is produced by the reten- tion of the liquid in the canal, making subsequent instru- mental manipulations much more difficult, and masking to a very great degree the local appearance upon speculum ex- amination. No remedies should be emploved locally unless the epi- dermis has already been exfoliated over a considerable sur- face, a condition with which we not unfrequently meet as the Fic. 8i. — The Lcitcr coil. 230 CIRCUMSCRIBED EXTERNAL OTITIS. result (jf a previous chronic inflammation. When this condi- tion is present, any of the before-mentioned drugs, either singly or in combination, may be beneficial. They are most conveniently used in the form of gelatin bougies, as advocated by Gruber* under the name of amygdale aurium. They con- sist essentially of small conical suppositories of gelatin, the drug being incorporated in their substance; the heat of the canal dissolves the gelatin, and the drug is thus brought directly into contact with the walls of the canal and even distributed over the inflamed surface. Previous to their in- sertion the canal should be thoroughly cleansed with a mild antiseptic solution, after which the suppository is inserted and the orifice of the meatus closed by a small pledget of cotton. This method is certainly preferable to the use of oleaginous preparations, and mav to an extent relieve the pain if the superficial epidermis has desquamated. Care should be taken, when any of the stronger alkaloids are used in the external meatus, to determine positively that no perforation of the membrana tympani is present, since when this condition exists absorption may rapidly take place, either from the mucous membrane of the middle ear or by passage of the drug into the pharynx and subsequently into the stomach — an event which would be followed by constitutional effects. If mor- phine is to be used, it should be in the form of the alkaloid itself and not in the form of one of the salts, since the simple alkaloid is mcjre readily absorbed endcrmicallv than an\' of its combinations. The cocaine ear bath may relieve the local pain somewhat, after the exfoliation of the superficial layer of the epidermis, and is principally indicated where the sur- geon intends to incise the canal, in the course of a few hours, as the slow absorption mav produce a certain amount of local ana;sthesia. While cocaine is of great value as a local anaesthetic, its local analgesic action is somewhat limited, and for this pur- pose we may more advantageously employ an alcoholic solu- tion of menthol, dilute carbolic acid, creosote, oil of eucalyp- tus, thymol, oil of cloves, or some other aromatic oil. Of these remedies, menthol is perhaps the most efficacious in relieving the pain, which frequently is not confined to the ear, but may manifest itself as an intense neuralgia of the * Lehrbuch der Ohrenheilkundc, Vienna, iSSS, p. 292. TREATMENT— HEAT. 231 various branches of the fifth nerve. This use of menthol was first advised by Cholewa.* In addition to the relief of pain, its action as a germi- cide makes it particularly valuable, as it affords a means of combating the local infective process and of preventing the formation of other abscesses. It is best applied bv inserting into the canal a long, narrow pledget of cotton jircviouslv saturated with a ten- to twentv-jier-cent solution of the drug in alb(jlenc or olive oil. The relief obtained is often consid- erable. The only objection to its use is the fatty vehicle with which it is incorporated. As the menthol is antisej)tic, this is unimportant, it may be avoided by using an alcoholic solution of menthol in tlie manner above described, or a five- per-cent solution may be dropped into the canal at intervals, if, for any reason, we prefer to use carbolic acid or creosote, the preparations should not contain more than ten percent of the drug. Menthol will probablv prove of more value than anv of the other drugs mentioned above. When a j)atient is observed at a stage tcxj late for us to hope to abort the attack, the local abstraction of blood and the use of cold applications arc worse than useless. The application of heat, however, is advantageous, as it relieves, to a very great degree, the intense suffering. Moist heat, however, is objectionable. The pernicious [)ractice, so com- mon, of applying a poultice to the car, or (jf putting the heart of a roast onion into the canal, the outer lavers being applied to the outside to retain the heat, can not be too strongly con- demned. Such procedures favor the development of suc- cessive crops of furuncles bv causing a maceration of the epidermis lining the canal, and aid subsequent local infection. While heat, theref(jre, is one of our most valuable agents, it should be employed as drv heat. This may be secured by filling an ordinary flat bottle with hot water, wrapping it in several layers of flannel, and resting the head upon it. A more elegant form of application is the small Japanese pocket stove which is sold in the shops, which when once lighted affords us a means of applying dr)' heat locally, the small box being wrapped in flannel and either secured to the side of the head by means of a few turns of a bandage — its light weight rendering this practicable — or, after being enveloped in sev- * Therap. Mo.iatshcft, 1889, No. 6. 232 CIRCUMSCRIBED EXTERNAL OTITIS. eral layers of cloth, it may be placed upon the pillow and the patient ma\- rest the ear upon it. The common hot-water bag, found in every household, can be used in this manner, but its employment requires that the patient shall be continu- ally in the recumbent position, and this is sometimes undesir- able. In addition to these measures, if we wish to apply heat more directly to the parts, I sometimes direct patients to cut off the finger-tips of an old kid glove and fill them with salt, the open extremity being closed either with a few stitches or by a few turns of linen thread. These small salt bags may be warmed upon a common tin plate on a stove, or over a gas flame or oil lamp, after which they may be inserted into the meatus. The salt retains its heat for a considerable period, especially if the external parts are kept warm by resting the head upon a hot-water bag or similar device. Bearing in mind that the process is essentially one of local infection, our efforts should be directed, not only to the relief of tiie local condition, but to the prevention of the same in- fective process at other points in the canal. The canal should be thoroughly cleansed with a warm antiseptic solution by means of the syringe, using either carbolic acid, in the pro- portion of one to sixty, or the bichloride of mercury solution, about one to eight thousand. After syringing, which must be thoroughly but gently done, the ear is to be carefully dried with small pledgets of cotton rolled upon the cotton holder, the manipulation being conducted under ocular in- spection by means of reflected light. The canal should next be filled with an alcoholic solution of boric acid of the strength of twenty grains to the ounce. As the sensibility of the canal varies considerably in different subjects, the instilla- tion of alcohol may cause pain, and it is well to test the sensi- tiveness of the parts by touching the walls of the canal with a pledget of cotton previously moistened in the solution. If this causes pain the solution may be diluted with water, the quantity of water being rapidly diminished at each suc- cessive application as the sensitiveness of the parts becomes less. The instillation of this alcoholic solution should be re- peated at least four times during the twenty-four hours, and it is often advantageous to repeat it still more frequently. The syringing of the canal not only removes any discharge, together with exfoliated epithelial cells, but often relieves the pain to a very marked degree. Although frequent syringing TREATMENT— INXISION. 233 of the canal is not advocated bv the majority of writers, it has been my custom, especially in dispensary practice, to direct the patient to cleanse the ear in this manner several times dailv. alter which the alcoholic solution mav be instilled in the manner already described. If the case is seen twice daily by the suri^eon the patient need not use the syringe at home, but may instill the boric-acid solution without previous cleansing of the canal. It is seldom necessary for the surereon to see the case as frequently as this, however, and equally good results are obtained if the canal is syringed by the pa- tient twice or three times dailv, the alcoholic solution beincr used after each irrigation. The surgeon should, if j)Ossible, see the patient dailv for the first few days. While all of these methods possess a certain amount of value the measure which stands pre-eminent in the treatment of this affection is that of early incision. To this, I think, we should always resort if our efforts to abort the attack hv local bloodletting are not successful, or if the patient is seen at so late a stage as to ]>reclude the possibility of it. It is not advisable to wait until the formation of pus has taken ])lace, or even until local tumefaction is so extensive as to be easily recognized by ocular insi)Cction. The process is most fre- quently tieepiv situated at first, and becomes superficial only a short time bef(jre spontaneous ruj)ture occurs. Testing the walls of the canal by means of a cotton-tipped f)robe in the manner already described will enable the surgeon to recog- nize the alTected area as certainly as if local tumefaction were present. The point of greatest tenderness should be incised deeply and freely with a sharp, short, strong, curved bist(jury, the incision being carried through the perichondrium or peri- osteum, as the case may be. It must be of sutlrtcient length to relieve all tension. This procedure is excessively painful — in fact, I know of no measure employed in surgery which causes such exquisite suffering as the early incision of a localized in- flammatory area in the canal, but the relief afTorded fully jus- tifies the surgeon in inflicting this momentary pain. 'J'he beneficial results obtained depend not only upon the relief of tension, but also upon the very free bleeding which follows, this latter result being also beneficial in reducing the liability to the development of a similar condition in some other part of the canal. General anaesthesia is seldom required, as when a properly formed instrument is used it is only necessary to 234 CIRCUMSCRIBED EXTERNAL OTITIS. make the initial puncture under ocular inspection, the sur- geon being able to control the extent and direction of the incision by his tactile sense quite as well as bv the sense of sight. The pain mav be somewhat lessened by the use of cocaine ear baths, previously mentioned, or by freezing the part with the chloride-of-methyl spray. This process is in itself quite painful, and is scarcely of advantage, as the pain is but momentary even when no local anaesthetic is used. After the focus of intlammation has been incised the rules already given concerning cleansing of the parts should be carried out, with the exception that any alcoholic solution applied to the canal must be considerably reduced in strength, as otherwise severe pain would be produced by its instilla- tion. The cleansing may be effected cither by the ordinary ear syringe (Fig. 82), the small soft-rubber-ball svringe, or, if considerable pain persists, a continuous irrigation of the canal mav be employed. This mav be carried out by using the ordinary foim- tain syringe. A warm antiscj)tic solution, cither of bichloride of mercurv. one to eight thousand, or of boric acid, in the proportion of twenty grains to the ounce, may be allowed to flow over the parts continuously for a period of ten to twenty minutes. If this is done immediately after inci- sion, the attendant pain quickly disappears, ^vhile the warmth of the application favors free ha?morrhage from the wound. This local depletion both relieves the pain and renders the reparative process more rapid. After free incision the relief is usually immediate, and in the course of twenty-four hours the parts assume more nearly their normal contour. The discharge, however, continues for a few days, during which time the infection of adjacent areas is very liable to take place unless attention is paid to the systematic cleansing of the parts, as above advised. Ordinarily the abscess cavity be- comes completely obliterated and the canal wall resumes a perfectly smooth and normal outline ; exceptionally, where the process has been very deep seated and a considerable area has been involved, exuberant granulations spring up about the margins of the opening. If very large, these may be re- moved by means of the cold snare or sharp curette. Usually, however, they are so small as to require siiuple cauterization Fig. 82. — Hard-rubber ear syringe. TREATMENT— INTERNAL MEDICATION. 235 bv a chemical ai^cnt. \Vc may employ for this purpose cither chromic acid or nitrate of silver, the former to be applied in substance, a minute bit of the acid beini^ fused upon the tip of a metal probe and applied lig^htly to the efflorescent tissue, after this has been previously dried bv a pleds^^ct of cotton ; anv excess of acid must be immediately wijied awav bv means of a cotton-tipjK'd probe, as otherwise the ai^ent quicklv spreads over tiie walls of the canal, and severe diffuse inllam- mation mav result. The nitrate of silver may be used in the same manner, or mav be applied as an aqueous solution of from two hundred and forty to four hundred and eight v grains to the ounce. I |)refer the chromic acid, as in mv hands, at least, it has never caused any reaction, while oc- casionallv the silver preparations excite a severe secondary inflammation of the walls of the canal. If the destructive process has invt)lved not only the integument, but also the underlving cartilaginous or bony structures, rather extensive necrosis mav take j)lace, retarding the healing process to a marked degree. In such an event it is well thoroughly to curette the cavitv. removing all diseased tissue by means of the sharp sj)oon, alter which rapid healing ensues. In addition to the local measures here advocated, the con- dition of the general health should alwavs be borne in miiitl as furnishing a prominent predisposing cause of local disease. Especial attention should be jiaid to the gastro-intestinal canal ; constipation, if present, should be relieved, or disorders of the digestion corrected bv the administration of alkalies or acids, as seem indicated. One of the most common causes under- lying this afTection is simple anaemia. This is best combated bv the use of some of the ferruginous pi-ei)arations. Prob- ably no specific exists upon which we can depend to {pro- duce anv marked elTect upon the prt)gress of the local in- flammation. Sulphide of calcium, so much used in general furunculosis, has been frequently advocated, and for a con- siderable period I administered it regularly in every case, but was unable to perceive anv beneficial results from its action. If its use seems indicated in any instance, it is best given in the form of a pill containing one sixth of a grain of the drug. One pill is to be taken every hour for six doses, after which the interval mav be reduced to every two hours. After this medication has been continued for twenty-four or thirt3^-six hours the doses may be repeated less frequently, say at inter- 236 CIRCUMSCRIBED EXTERNAL OTITIS. vals of every four or six hours. It will generally be found, however, to exert very little action upon the disease. The internal administration of drugs intended to relieve the in- tense suffering of the patient is alwavs advisable in the very early stages. There can be no question that the relief of pain for a period of six or eight hours, when the process is in its incipiencv, does exert a certain permanent beneficial action, the tendency being to increase the resisting power of the pa- tient. By relieving the pain or rendering it more bearable, our efforts toward aborting the attack will be more successful. It is to be borne in mind also that the pain will continue for only a comparatively short period of time ; hence, the admin- istration of opiates is not open to the objection that the pa- tient is liable to acquire the opium habit. In the later stages of the affection analgesics are contraindicatcd, as they may mask mastoid involvement. Chronic Circumscribed External Otitis. But few words need be said in consideration of a circum- scribed local inflammation of long duration. It is usually svmptomatic of some affection of the deeper-seated struc- tures, either cartilaginous or bony. In the former instance it results from a very severe form of the disease just described, while in the latter case it is usuallv indicative of some patho- logical process within the mastoid cells, and is situated in the bony canal. The condition which clinically may be considered as belonging to this group, although from a pathological point of view it should be placed elsewhere, is that met with when suppuration takes place in the sebaceous cyst located in the meatus. These neoplasms usuallv occur on the an- terior or inferi(jr walls 01 the canal, near the orifice, and either discharge spontaneously, or, if their contents have been evacu- ated by surgical means', persist for a K)ng period, the lining membrane being of such a nature that adhesive inflammation with resultant obliteration of the sac is impossible. The cavity refills slowly after each evacuation of its contents, and the symptoms of obstruction of the meatus due to the pres- ence of the tumor, together with intermittent discharge at somewhat irregular intervals, are repeated for an indefinite period, I'nder these circumstances simple incision does no good, and will afford but temporary relief. The lining mem- brane of the sac must cither be dissected out entire, or, if this CHRONIC CIRCUMSCRIBED EXTERNAL OTITIS. 237 is impossible on account of the location of the tumor, it must be completely destroyed by the curette, after which recovery is pronijjt. We shall consider circumscribed inflammation of the bony meatus dependent upon mastoid inflammation in the section devoted to mastoid disease. CHAPTER XII. DIFFUSE EXTERNAL OTITIS. This afTcctic^n may occur in either acute or chronic form, and, as its name imj)lies, constitutes an inflammation of the ex- ternal auditory meatus, in which the local condition, instead of beini^ confined to a small area, involves cither the entire canal or a very large portion of it, the line of demarcation between the normal and affected areas not being clearly marked, but mergincr orraduallv into each other. Since the acute form of the disease is frequently dependent for its cause upon a pre- viously existing chronic inflammatory process, we will con- sider, first, the chronic, and afterward the acute affection. Chronic Diffuse External Otitis. This general term applies to the superficial extent of the lesion rather than to its severity, and comprises every degree of chronic inflamniatory condition of a diffuse character, from those cases in which only the superficial layer of the epider- mis is involved to instances where not only the cutaneous lining is affected through its entire depth, but the cartilagi- nous and bony framework as well. iEtiology. — This disease is less dependent upon constitu- tional conditions than is the circumscribed form of inflam- mation. Traumatism plays a very prominent part in its prd? duction. The impression so common among many that the external auditory meatus must be subjected to thorough cleansing by means of the corner of the towel wound up so as to permit its entrance into the lumen of the canal, or by the introduction of various ear sponges, ear spoons, etc., furnishes one of the most fruitful sources of mild but persistent inflam- matory conditions of diffuse character. Wounds of the canal walls, either inflicted by mechanical violence or resulting from the bites of insects which find their way into the meatus, are also among the most frequent causes of the disease. The ap- (238) ETIOLOGY— PATHOLOGY. 239 plication of oleaginous substances to the walls of the canal, for the relief of pain in the ear, or sometimes for toothache, is practiced not uncommonly among the laitv, and furnishes a source of irritation to the lining of the canal. Foreign bodies, introduced bv mistake or design, bv their presence aUnie fre- quently cause a condition of diffuse iiitlamniation. The most common cause of the condition is some affection of the mid- dle ear attended by a purulent discharge. When the walls of the canal are continually bathed with such a secretion, thev socjn lose the superficial layer of ejiithelium tiirough the com- bined action of warmth and moisture. Thus a tlenuded sur- face is left, through which infection may take place. This is more commonly met with among that class of indiyiduals who pay little attention to habits of cleanliness, and hence make no effort t(j keep the passage free from secretion by frequent irri- gation. Among the more uncommon causes is the develop- ment of vegetable parasites within the canal. These minute organisms attach themselves firmly to the walls of the mea- tus, and grow for an indefinite period. As their growth con- tinues they become firmly imbedded in the deeper layers of the integument, and their removal results in the loss of the su- perficial epithelium antl an exposure of the underlying cells. It is probable that the condition never engrafts itself upon a perfectly healthy integument — that is. one in which the horny layer of the skin is unbroken throughout the entire extent of the canal. If. however, the integument at any jtlace is abraded, the moist surface forms an excellent soil lor the de- velopment of a parasite. Having once taken root, the fungus may increase indefinitely bv subsequent growth. The con- tinued presence of fungi produces an effect similar to that of a foreign body — that is. it causes an inflammation of the lining of the canal. Constitutional causes, we have said, are not important fac- tors in the production of this disease ; we make one excep- tion, however, in the case of eczema of the canal, which, like eczema in other parts of the body, is an evidence of some dia- thetic condition. Fathology. — An affection dependent upon such a variety of causes must necessarily present physical characteristics differing greatly. Under the milder types we would include those cases of augmented glandular activity resulting in an increase in amount of the secretion from the sebaceous follicles 240 DIFFUSE EXTERNAL OTITIS. with which the skin is supplied. When the inflammation in- volves the inter-glandular tissue, as in eczema of the canal, there is a certain amount of infiltration of the deeper layers of the cutis, causing- the superficial epithelium to be cast off more rapidly than under normal conditions. According to the de- gree of the infiltration of the integument, a greater or less amount of serum exudes, which, washing away the desqua- mated cells when the transudation is profuse, leaves a red, smooth, glistening surface; or when less fluid is poured out it dries upon the walls of the meatus, forming with the desqua- mated epithelial cells yellowish crusts, which adhere to the canal walls and partially or completely occlude the passage. If the process is allowed to progress, actual hypertrophic changes take place in the basement membrane and the meatus is gradually converted into a tube of very small calibre, the opposing walls lying nearly in contact. An inflammation of the external canal occurring in the bony portion, where the cutaneous lining is verv thin, and where it constitutes the peri- osteum, mav extend to the osseous tissues and produce the symptoms which characterize an inflammation of the mastoid process, or, where the Rivinian segment is imperfectly closed, it may pass bv continuity of structure into the tympanum and excite an inflammation within this cavity. When the inflammation of the canal is due to the presence of a foreign bodv, or follows a wound of the canal, a circum- scribed acute inflammation, or the development within the meatus of a vegetable parasite, the changes which take place vary in intensity, but are of the same character as those above described. The superficial epithelium is thrown off rapidlv, the deeper lavers of the cutis are infiltrated with round cells and become thickened, and tissue hypertrophy finally results. In the more severe cases tissue necrosis may take place or by extension the underlying bone mav become involved. In some cases we find the activity of the inflammatory process directed especially toward a rapid proliferation of the superficial epithelial laver of the integument. The flat pave- ment cells are thrown off rapidly, and, aggregating in the mea- tus, form a compact mass, which completely fills the deeper portion of the canal. From the increase in the blood supply incident upon inflammation a small amount of serum is tran- suded ; the fluid moistens the compact epithelial mass and causes it to increase in voknuc. lu this way great pressure PATHOLOGY 241 is exerted upon the surroundino^ bony walls, which may be absorbed or become necrotic, or the pressure may be so grad- ual as to interfere but little with the nutrition of the parts, and result in a dilatation of the deeper portion of the meatus by crowding backward that part of the wall which separates the canal from the mastoid cells, so as to obliterate the pneu- matic spaces of this portion of the temporal bone. In the above consideration we have followed the extension of the process from the canal inward toward the deeper por- tions of the conducting channel. But a dilTuse external otitis may be of a consecutive nature: that is, the deeper parts may be involved first, and by extension produce an inflammation of the walls of the meatus. This is particularly true where the deep osseous canal is the site affected. The upper and pos- terior portions of the canal at this point form the inferior or anterior walls of the mastoid process; hence, an inflammation involving the mastoid antrum and the smaller pneumatic spaces frecjucntlv produces an inllammation of the canal in this region ditfuse in character, the jtroccss bfing as much a mastoid jjcriostitis as it the outer wall of the mastoid. Iving immediately behind the ear, were the j)art affected. While it lies beyond the province of this work to give any detailed account of the niicroscf)pic apj)earances of the various forms of vejreta- ble parasites found in the meatus, certain characteris- tics which are common to all of these should be under- stood, in order that a diag- nosis may be made between the purely epithelial or des- quamative type of inflamma- tion and ihat form dependent upon the [)resencc of fungi. These fungi present under the microscope long fibres or hyphas of a double contour, either completely transparent or slightly granular. These fibres divide into branches dichotomously (Fig. S3), which terminate in a globular head or fruit-sac (sporangium) (Fig. 84) 17 Fig. 83. — I >cvelopment of a fungus. G, G, .Sporangia ; //, Hyphae. ((jruber.) 242 DIFFUSE EXTERNAL OTITIS. filled with minute spherical spores. Examination of the fruit- sac at a certain stage of development will show thin filaments radiating from a central stalk toward the periphery through the mass of minute spores. These fresh filaments in turn Fig. 84. — Microscopical characteristics of otomycosis. 6", G, Sporangia ; //, Hyph«. (Gruber.) develop sporangia, and the process repeats itself indefinitely. The recognition, then, of the mycelial filaments or of the fruit-heads containing the spores establishes the diagnosis of parasitic inflammation. Symptomatology. — The svmptoms differ in severity in ac- cordance with tiic degree of intensity of the local process. In mild cases a sense of constant irritation or itching in the canal is the most prominent symptom, the patient continuallv at- tempting to relieve this by the insertion of the tip of the little finger as far into the meatus as possible ; this, naturally, only tends to aggravate the condition it is intended to relieve. When, either from increased glandular activity, as in sebor- rhoea, or from actual inflammation, as in eczema or otomvcosis, the canal becomes to an extent occluded, either bv the scale- like sebaceous crusts, or by aggregations of epithelium re- sulting from eczema, or bv masses of vegetable fungi, certain symptoms dependent upon this occlusion manifest themselves. These mav consist in an iiupairment of the hearing, varying in degree according to the extent of (obstruction, or there may be tinnitus caused by the congestion which the presence of the SVM PTOM ATOLOGY. 243 foreign substance induces, or certain reflex symptoms may manilest themselves, such as severe pain spreading over the distribution of the fifth nerve, headache, either general or local, and, rarely, disturbances of a graver nature, dispropor- tionate in severity to the local condition. Thus, instances of epileptiform attacks have been traced to inflammatory condi- tions within the canal, while svmptoms referable to the oppo- site ear may also be produced by a chronic inflammation of the external auditory meatus of one side. A symptom fre- quently complained of is that of autophonv. the patient's own voice seeming to come from the affected side. This occurs only when the lumen of the canal is considerably narrowed. Cough is a not infrequent symptom of the affection, and may, in fact, be the fust to attract the attention of the patient and cause him to seek advice. In all cases of cough, even al- though apparently exjilainable upon other causes, it is always well to examine the exteiiial auditory meatus, as an accumu- lation (jf any foreign material, resulting cither from desquama- tion of the ejjithelial lining of the canal or from the aggrega- tion of a mass of aspergillus, may cause a reflex cough. As the affection increases in severity a discharge may make its a[)pearance at the orifice of the meatus. This discharge is ordinarily scanty, and, in fact, may be so small in amount as to appear in the form of crusts about the margin of the meatus, the fluid elements having been cvaj>orated. When more pro- fuse the discharge is watery in character, but is never large in amount. In the milder cases, due to an inflammation of the glandular structures alone, the discharge aj)i)ears in the form of minute scales, which are oily to the touch, on account of the fatty matters which they contain. Occasionally, in cases of very long duration, the inflammation, instead of producing a fluid discharge, causes a j)r()liferati()n of the epithelial lining of the meatus. The superficial ej»ithelial cells are rapidly cast off, and, aggregating intt) masses, remain in the canal for a long period. These masses of desquamated epithelium absorb the watery secretion which the thickened cutaneous lining of the canal exudes, and as the process continues increase steadily in size. From the fact of their slow increase in volume these epithelial plugs exert a great amount of pressure upon the walls of the canal, leading, in some cases, to a dilatation of the bony canal, either by causing an absorption of the osseous tis- sue or by crowding the thin bony wall upward and outward 244 DIFFUSE EXTERNAL OTITIS. toward the mastoid cells, which become correspondingly di- minished in size. At the same time the osseous tissue under- goes certain structural changes as the result of this mechanical irritation, so that, instead of presenting the ordinary cancellous appearance, it becomes converted into a hard, ivorv-like sub- stance of uniform density. This change may extend through- out the entire mastoid, all the airspaces being obliterated with the exception of the antrum, or, if the pressure is still greater, the bony walls of the canal may be absorbed entirely, and the upper part of the tympanic cavity and the mastoid cells may thus be continuous with the external auditory meatus. Glandular enlargement is not uncommon as the result of chronic inflammation oi the external meatus, and when the glands just below the lobule are effected a mistake in diagno- sis is possible, the case i)rcsenting manv of the characteristics of a perforation through the tip of the mastoid process. We have spoken of dilatation of the bonv canal as the re- sult of a desquamative inllammation with the consequent ab- sorption or displacement of the bonv walls. The ojipositc effect mav be produced, however, if, instead of causing a des- quamation of the supcrhcial epithelium, the deeper lavers of the integument are the seat of inllammation; in these cases the lumen ot the canal iiiav l)cct)ine verv narrow — in fact, it mav be so diminished in si/e as to admit onlv the smallest probe. This diminution in calibre is due to an actual hvper- trophic osteitis rather than to any thickening in the soft parts. This change frequentlv takes place in the cases of diffuse ex- ternal otitis which accompany a chronic suppurative process within the middle ear. Instead of narrowing the calibre of the canal uniformlv, certain limited areas within the canal may be affected, producing what is known as an exostosis or a circumscribed bony growth, which projects to a greater or less extent into the passage. These growths are most fre- quently situated near the drum membrane, and, according to their size", interfere with the function of audition. Diagnosis. — The diagnosis of chronic diffuse external otitis will be determined both by external manijuilation and by ex- amination by means of the speculum. \Vc have to distinguish by palpation between an affection contmed to -the canal and one involving the mastoitl {)rocess, as the superior and a por- tion of the posterior walls of the meatus form the anterior and inferior wall of the mastoid pr(,)cess. It would seem that this DIAGNOSIS. ^45 fliffcrentiation is rather supcrlluous. but the author intends here to separate those cases in which the affection of the canal is the prominent feature, tlic mastoid bein<^ involved to so slio^ht an extent as to trjve rise to no svmptoms and to require the emj)lovment of no sjiccial measures, from those cases in which tlie affection of the canal is merelv s\riij)tomatic of a deep-seated inflammation within the mastoid, in which treat- ment must be directed to the mastoiil inllatumation as the pri- mary disease. When the affection is conlmed to the canal, pressure behind the ear, directed backwartl and inward, will fail to elicit tenderness ; if the pressure is exerted in such a way as to move the tibro-cartilaCCSS nas Spread tO the growth of the fungus in these situations, (imin membrane the cast (Natural sue.) . Will lorm a bnnd sac, the closed extremity bearing the imprint of the various landmarks of the membrana tympani. This deposit is due to the growth of low vegetable organisms upon the walls of the meatus. The special species of plant life can only be determined by micro- scopic investigation ; the varieties met with are extremely numerous, but as the treatment of the different forms does not vary essentially it is unimportant to discuss the condititMi at length in a treatise devoted particularly to clinical otology. Certain macroscopic features, however, enable us to make a reasonably accurate diagnosis as to the particular variety of plant present in a given case. A white deposit usually con- sists of the aspergillus glaucus. Another variety is the asper- gillus flavus, the microscopic features of which are shown in Fig. 86, while more rarely we find the walls of the canal and the surfaces of the membrane covered with irregular black spots, a little smaller than the head of a pin, which are the DIAGNOSIS. 247 ^ ^ f" sporangia of the aspergillus niger. The growth of this latter is seldom as extensive as that of the other two varieties. A microscopic examination alone will enable us to distinguish with certainty between otomycosis and the milder forms of des(iuamaiive inflammation involving the canal. The greater C(^nsistency of the epithelial plug and the imbricated arrange- ment of the scales usually give the observer a hint as to the nature of the condition present. It is probable that in no case do these U)w forms ot vegetable lite take root upon a perfectlv health v cutaneous sur- face ; it is necessary that the epithelium should be wanting over a small area at least, in order that the plant may de- velop. Hence it is, that para- sitic inflammation of the mea- tus is usuallv coexistent with some condition of the external canal or lA the middle car char- acterized bv the presence of moisture. The cj)ithclium of the canal is thus softened and thrown off. leaving a surface which forms an excellent site for the dc\(.lo|>ment of a low form of plant life, the growth being stimulated at the same time bv the presence of moistuie. The mere j)resence of aspergillus spores in anv aggregation of foreign matter which mav be removed from the meatus does not warrant a diagnosis of parasitic inflammation of the canal, since it is usual to hnd them in ceruminous masses, or upon anv foreign bodv which has remained in the canal tor a con- siderable length of time. It is onlv when they constitute the bulk of the mass that this constitutes a lesion proper. The diagnosis of the desquamative form of inflammation will be based uj)on the presence in the deep meatus, of a com- pact mass, whitish in color, which, although easily penetrated bv the probe or curette, is removed with considerable diffi- culty. The walls of the canal are ordinarily moist and pre- sent a sodden appearance, the superficial epithelium being easily wiped off bv means of the cotton pledget, which, upon investigation, is found to be covered with thin white flakes of Fig. 6", Sporangium ; //, llypha. ((jiul)cr.) 248 DIFFUSE EXTERNAL OTITIS. irregular size and shape. If the probe is immersed in water these are seen to spread out and float upon the surface, but are not dissolved by the fluid ; they are really the epidermal cells lining the canal, which have been thrown off by the in- flammatory process. The obstructing mass is an aggregation of these cells, and, though easily penetrated by any instru- ment, which may remove a considerable quantity each time it is inserted, is very difficult to remove completely. Even when the fundus seems entirely clear we often find, in at- tempting to dry the parts perfectly, that the cotton pledget brino-s away more of these white scales, so that the complete clearing out of the meatus is a matter of no small diflficulty. The entire epithelial plug presents an appearance not unlike a wad of unsized paper that has been moistened in water, and, in fact, is often mistaken for a foreign body of this kind, which has found its way into the canal. Where the inflammation is of what may be called the symptomatic tvpe — that is, merely an indication of a deeper- seated intlaminatorv process within the mastoid — we usuall)'^ fmd that tiic superior and posterior walls of the canal close to the membrana tympani are most involved. The canal lumen at its deepest part is narrowed by an apparent sinking of the walls, and at the fundus, instead of a well-defined line of de- marcation between the drum membrane and canal walls, it ap- pears as if the superior and inferior walls were separated only by a narrow slit, through which a small area of the membrane is seen. The chief point of diagnostic importance is the dif- ference between this condition and that seen in circumscribed otitis externa. In this latter form, after the speculum has been introduced into the canal, the membrana tympani is distinctly seen, and appears normal in extent as the obstruction lies near the orifice of the meatus. In the disease under consideration the introduction of the speculum is easy, but the canal be- comes more obstructed as we approach the fundus, owing to the fact that the disease is a periostitis of the deeper part of the canal (Fig. 78). It is of extreme importance, especially in children, to recognize this condition early, as it is one of the best indications that a previously existing middle-ear inflam- mation has involved the deeper structures, or that an accumu- lation of pus in the tympanum has passed out through the Rivinian fissure along the superior and posterior aspects of the meatus (Fig. Sj). In either case the condition is one PROGNOSIS. 249 which requires prompt treatment in order that serious con- sequences mav be averted. The apj^earancc j^resentcd by a chronic diffuse otitis, resulting in either uniform narrowing of the meatus or isohited bony deposits or exostoses, offers no ditiicultics in diagnosis. When the hitter condition is |iresent. care need oidv be taken to so cleanse the j)arts that the observer mav be cer- tain that the localized en- croachment uj)on the lumen of the canal is beneath the integument instead of super- ficial to it. It would seem al- most impossible for this mis- take to be made, but masses of hardened cerumen occasion- allv j)resent the appearance of an exostosis, the surface of which is covered b\- a thin la\er of cerumen. ll\ mians of the curette any foreign substance is easily removed from the canal wall, ami the true condition becomes a|)[)arent at once. Prognosis. — The course pursued by the disease we are here considering is as varied as tiie causes which underlie it. The simj)ler varieties are unattended bv anv grave results, al- though somewhat obstinate to relieve. Where the deej)er |)arts aie involved, where the disease is of long standing, or where the condition is svmptomatic. the prognosis is frc- (pientlv grave. Im|K)rtant regions may suffer secondarily, bv extension directlv from the canal, or the condition with- in the meatus may. if unchecked. s[)rcad to the middle ear and result in anv of the sequela; of asevere inffammation with- in the tvmj)anum. Where the disease is secondary to an in- tratvmpanic affection the gravitv of the prognosis depends more upon the condition of the middle ear than upon the changes within the canal. As regards the impairment of function, the power of audition may suffer either from the narrowing of the meatus throughout its entire extent or by the develojiment of circumscribed bony deposits. In some instances the chronic congestion of the deeper structures Fig. S7. — Appearance observed in infancy wlicn fluid fmm tlio tynip.nnuni esc.ipcs throujjh the kivinian lissurc. (Nat- ural .size.) 250 DIFFUSE EXTERNAL OTITIS. caused b}' a chronic inflammatory process within the mea- tus, may lead to functional impairment. In the descpiama- tive form of inflammation the pressure exerted by a mass of epithelium may produce fatal results by absorption of the bony walls and exposure of the cranial contents. This may occur without any symptoms of middle-ear inflammarion, or the membrana tvmpani may be destroyed and a suppurative otitis media result. Sometimes the mass, while not leading to such grave results, seriously impairs the function of the ear by chronic adhesive processes within the tvmpanum from the long-continued pressure. In other cases the pressure causes labyrinthine changes. Treatment. — In the mild cases of chronic diffuse otitis externa treatment is largely directed to the relief of the dis- tressing pruritus from which the patient suffers. The crusts arising cither from involvement of the sebaceous glands in seborrhcea or from cutaneous infiltration in eczema should be removed by some bland oily application, such as vaseline or olive oil, after which, in the glandular variety of the dis- ease, it will be sufficient to apply once each dav a slightly stimulating ointment, such as the unguent, hvdrarg. ammoniat., diluted with ten parts of vaseline or cold cream, or the un- guent, hvdrarg. oxidi flavi mav be employed in about tlie saiTje strength. In eczema the various measures detailed under eczema of the auricle will be found valuable. It is im- portant, in order that the treatment may be eflficacious, that the patient should refrain from scratching the ears, as this increases the local inflammation. For this purpose we may add either cocaine or morphine to the above ointments. It is well for these patients on retiring to insert into the ear a pledget of cotton smeared with such an ointment, as they frequently injure the parts during sleep. The use of water in any inflammatory condition of the canal attended with infil- tration of the integument is to be absolutely forbidden, as it tends to increase its activity. In the parasitic variety the fungus should be removed as completely as possible by means of the curette, forceps and cotton pledget, great care being taken to avoid abrading the epidermis of the canal. In these cases the walls of the mea- tus will be found very sensitive, and the complete removal of the parasite will be difficult. The occasional application of a ten per cent, solution of cocaine during the operation will af- TREATMENT. 251 ford considerable relief and will facilitate the operation. It is not well to prolon^f undulv our elTorts at removal or to in- flict severe pain. After as much as possible has been removed a solution of bichloride of mercurv, one to eight thousand, in fifty per cent alcohol, or a saturated alcoholic solution of bo- racic acid, or a two-pcr-cent alcoholic solution of salicvlic acid, as Siebenmann* recommends, should be applied to the ])arts bv means of the cotton pledget. It is sometimes well to employ a powder instead of the above solutions. The walls of the canal mav be lightlv dusted with boracic acid or a mixture of boracic acid and salicylic acid in the proportion of twentv to one. In this wav we avoid the presence t)l moisture, a condition which we know faNors the grcjwth of tiic fungus. It is well to see the patient dailv at first, and at each sitting to remove as much of the deposit as possible. When the canal seems free the antisep- tic solution should be placed in the hands of the patient, and he slunikl be directed to instill ten or twelve drops of either ])reparation into the canal twice or three times daily. By this means anv new growth is prevented and a complete cure efTected. Remembering that an otomvcosis is often depend- ent upon a suppurative intlammation of the middle ear. it is scarcelv necessary to state that this affection, if present, must be treated j)roperlv in order to prevent the recurrence of the condition. Prophylactic measures against development of organisms within the meatus should be taken in all cases of aural disease which come under the observation of the surgeon. A com- mon cause of the milder varieties of this affection depends upon a habit so common among the laity of instilling oily so- lutions into the ear for the relief of pain. Not only should this be forbidden, but the surgeon should be {)articularly care- ful in cases where it is necessary to use oily substances within the meatus that none of the fatty material remains in the canal when the patient is discharged. To be certain of this it is ad- visable u})on dismissing the patient to wipe the canal thor- oughly with a cotton jiledgct moistened in alcohol. In the desquamative form, the first indication is to remove the mass of epithelium filling the canal. This is by no means simple where the disease has persisted for a long time, espe- * Arch, of Otol., vol. xviii, p. 235. 2;2 DIFFUSE EXTERNAL OTITIS. ciallv as attention is frequently drawn to the condition for the first time by an acute inflammation of the parts, rcsultini^ in so much swelling that the calibre of the canal is greatly reduced. Our first efforts at removal should be by the use of a warm antiseptic solution injected into the ear by means of the syringe. This will usually bring away the superficial portion of the mass, and occasionally all of it. Frequently, however, the deeper portion of the canal remains obstructed, and it will be necessary to use the blunt curette in order completely to re- move the collection. When the canal is swollen and tender, as frequentlv occurs from an acute exacerbation, the manipu- lation is extremely difficult, and sometimes a general ana:?s- thetic is necessary. In using the curette, we should first at- tempt to separate the mass from the canal along one wall, and afterward break it up by inserting the instrument be- tween it and the canal wall and removing small portions suc- cessivclv until a narrow channel has been made between the canal wall and the foreign bod v. Hv directing the stream of water from the syringe toward this channel, the entire mass mav usualh' be brought awav, although it mav be necessary to remove the entire collccti(jn piecemeal with the curette. If it is impossible to insert the curette between the ei)itlHlial aggregation and the canal wall at any point, owing to the ten- derness of the meatus, our efforts are sometimes more success- ful if a passage is tunneled directly through the centre of the plug, after which, by carrying the curette into this channel and then pressing it in toward the opposite wall of the canal, the portion included between the instrument and the wall may be removed ; the process must be rejjcated until the mea- tus is perfectly clear. Where the condition has remained unrecognized for a long time, the bony meatus close to the drum membrane may be very much dilated, and the foreign body attain such dimen- sions as to render its removal from the meatus in its entirety impossible. At the same time the deep meatus has been so dilated that the manipulation of an}^ instrument, such as the curette or a spoon, is very much restricted. These epithelial masses may invade the cells of the mastoid process through the absorption or necrosis of the bony walls from pressure. It occasionally becomes necessary to open the mastoid in order completely to eradicate the disease. Such cases have TRKATMIA'T 25^ been reported, but an element of tloubt always remains as to whether thev were not cases of cholesteatoma oriirinatingf within the tvmpanum and invading the canal secondarily. After the canal has been thoroughly cleared, our efforts should next be directed toward putting the epidermis in n(jrmal conditicjn. Here powders are t)f special benefit, as they relieve the sodden condition of the parts more (juickly than do fluid preparations. For this purpose boracic acid may be dusted over the walls of the canal, or a mixture of boracic acid and iodoform, or iodol. if the odor of iodoform is objectionable. Ouite recently the introduction of dermatol into surgery has given us a drug particularly adapted to these cases. These measures should not be trusted to the hands of the patient, but should be carried out by the surgeon — at hrst daily, the interval being increased as the case progresses, rhe oxide of zinc mixed with boric acid, in the proportion of one part of oxide of zinc to two of boric acid, may also be used with advantage in the milder forms of the disease. When necrosis has occurred it will first be necessary to re- move the dead bone, after which the case may be managed on general surgical principles. It granulation tissue develops, a thorough cleansing of the j)arts may be sulVicient to cause it to disappear; if large in amount, it should be removed by means of the cold snare or destroyed /'// si/u by the gaU vano-cautery, nitrate of silver, or chromic acid. The last agent yields better results and is more easily manijiulated than the others. Where the disease is (jf the symptomatic \aricty much more energetic measures must be undertaken, and if the i)ain is intense, cold applications to the mastf)id j)rocess are indi- cated. This is most easily efTected by using the Leiter coil (Fig. 81) or the aural ice bag (Fig. 70). The local abstrac- tion of blood by means of the artificial leech may also give relief where the pain is very severe. It is to be applied be- hind the ear over the mastoid process, since the symjjtomatic variety is indicative of the fact that this region is afTected. From a healthy adult from two to four ounces of blood may be removed ; and in the very early stages this plan of local bloodletting, followed by the application of cold, may pre- vent further progress. If this fails, or if the condition has advanced too far to be aborted, a long deep incision should be made throuirh the tumefied tissues which are seen to 254 DIFFUSE EXTERNAL OTITIS. encroach upon the lumen of the canal close to the membrana tympani. This incision completely divides the soft parts down to the bone. The short curved bistoury is carried into the canal as far as the drum membrane, and is plunged quickly into the bulging- supero-posterior wall until the point is felt to impinge upon the bone; it is then drawn outward, the point still being pressed firmly upon the bone. In this way the periosteum is divided and tension relieved. The in- cision should not be less than half an inch in length, and may be even longer; the bleeding is vcrv free, a fact which con- tributes largelv to the benefit derived. It is to be borne in mind that the external otitis here is a manifestation of an infiammatory process within the upper part of the tympanum itself. We are therefore, in making the initial puncture, to carry the knife upward, backward, and inward beyond the inner extrcmitv of the bony canal, through the membrana flaccida, into the tympanic vault (Fig. 87). The incision is completed in the manner above described by drawing the knife outward along the supero-posterior wall of the meatus. In this way the mucous folds within the tvmpanum are di- vided, and the congestion within the middle ear reduced. Where the tumefaction in the canal is due to the presence of pus, evacuation through the meatus is not sufficient, and it is imperative that the mastoid cells should be at once opened and every vestige of diseased bone removed. Where the inflammation has led to a diminution in the calibre of the meatus through hypertrophy of the bony walls, it is sometimes necessary, in order that the function of the organ may be preserved, to attempt a restoration of the channel to its normal size. When a very small passage re- mains, gradual dilatation, if systematically carried out for a long time, may prove satisfactory. This is best accomplished by inserting into the canal a small aluminium tube, which will just pass through the constriction. The jiatient is to wear this for one or two days, when it is to be removed and a little larger tube inserted. It is seldom possible, however, to promise that the tul^e may ever be dispensed with perma- nentl3% for when it is removed the parts very quickly resume their original position. The diameter of the meatus may be very considei"ably increased by carrying out this treatment, and the patient should learn to insert the tube himself, wear- ing it durmg the day and removing it at night. Its presence ACUTE DIFFLSi; I.X IKRNAL OTITIS. 255 causes no inconvenience, and effectually relieves the impair- ment of hearinjs^ clue to the diminished size of the passa^^e. I'omerov has suggested the use of small rubber tubes stretched (»ver a silver probe to enable them to be inserted through the stricture. After thcv have been propcrlv placed the probe is withdrawn and the tube resumes its original dimensi(jns, thus exerting bv its elasticity a constant dilating force against the surrounding walls. This {>lan has proved advantageous in some cases, but relapses have taken place, even after the con- dition was apj)arently cured. Where the channel is so nar- low that only a fine probe can be passed, and the use of a tube is imj)<)ssible. it is well, for the first few davs, to carry a verv small, tightly wound pledget t)f cotton through the constriction bv means of the forcej^s ; this cotton jdedget ab- sorbs moisture from the walls of the canal, increases in size, and dilates the passage slightly. In this way sufficient space may be gained to permit the insertion of a small tube, after wliich one of the plans already described may be carried out. The removal of any portion of the bony wall by means of cutting instruments is seldom attended by good results where the narrowing is symmetrical. If the passage is encroached upon bv an exostosis, this may be removed. This condition u ill be treated in a later chapter. AcuTK Diffuse External Oiitis. JEtiology. — The acute form of the disease usually occurs as an exacerbation of a i»revious chronic condition ; occasion- ally, however, it presents as an idioj>athic disease, either from exj)osure to cold or as a complication ol some j)rolound con- stitutional infection, as epidemic influenza, scarlet fever, typhus and typhoid fevers, etc. The most frecpient cause is a puru- lent otitis media, the tissues of the canal becoming infected By the purulent discharge in which they are bathed. This last va- riety does not include those cases already denominated under the term symptomatic. Injuries of the canal from mechanical violence or from the action of the potential or chemical escha- rotic agents may also give rise to an acute diffuse inflamma- tion of the parts. An occasional cause is the occurrence of a furuncle in the meatus, the condition becoming general and involving the entire canal after the circumscribed process has fully developed. Pathology. — The changes consist in a diffuse inflammation 256 difpt:se external otitis. of the cellular tissue of the walls of the meatus. In the first stage the parts are intensely congested, after which there is a free transudation of the fluid elements of the blood, causing oedema ; the interstices between the connective-tissue fibres become infiltrated with new cells, and if allowed to continue unchecked pus formation results. It is seldom, however, that this occurs, as relief is sought before this stage is reached. The tissues break down in this region at a vcrv late period, on account of their density and firmness, and remain infiltrated for a long period before local necrosis results. Symptomatology. — The subjective symptoms are pro- nounced and succeed each other rapidly. The first sensation is one of fullness or discomfort in the canal, quickly followed by intense pain. The constitutional disturbance is frequently quite marked, the temperature being elevated from two to three degrees above normal ; considerable prostration is pres- ent ; the patient suffers from headache, loss of appetite, and all those symptoms indicative of an inflammatory process in dense cellular tissue. From the swelling of the parts the meatus is rapidly occluded and the function of audition is markedly in- terfered with. Subjective noises are often ])rcscnt, but the pain is so severe that they are seldom complained of. In ad- dition to the spontaneous pain intense pain is elicited upon touching the auricle. After a short period the surrounding lymphatic glands may become infiltrated, especially those ly- ing immediately behind and below the auricle, any movement of the jaws is painful, and in severe cases the mouth is opened with ditficultv. Diagnosis. — W'c have to dilTcrcntiate between a circum- scribed inflammation of the meatus, an acute affection of the middle ear and mastoid, and the disease under consideration. The symptoms complained of by the patient do not differ, ex- cept in severity, from those characteristic of the circumscribed external otitis. The constitutional disturbance, however, is much more marked and the progress of the disease more rapid. The insertic^n of the speculum ordinarily causes but little pain and the outer third of the meatus is often found to be nearl}^ normal in size. Deeper, however, the lumen is much diminished, the encroachment usually being from the supero- posterior wall, which seems to project downward and for- ward into the canal. The swelling is more pronounced as we ap[iroach the fundus and a considerable portion of the DIAGNOSIS. 257 / drum membrane is hidden from view. Where the membrana tympani lies very oblicjuely to the sujieriorand posterior walls it aj)parently mer^^es intt) these without any line of demarca- tion. This is particularly the case in infants, owing to the ab- sence of t!ie bony meatus ; in the adult, however, if the canal alone is involved the observer recoijnizes that a portion of the drum membrane is concealed from view, but that the swollen wall of the canal is not continuous with the membrana tvm- pani {Vig. 8S). A sulcus can be recognized between the mem- brana tvmpani and the tumefaction. In very severe cases the swelling may be so great as to occlude the meatus com- |)letelv, the oj)posite walls lying in contact. The surface of the tumefaction is slightly moist, jnesenting a dead- white CiAur, due to the local necrosis of the superficial ej)ithelial cells. If these are wiped away the surface ap- pears reddened and moist. This desquamation of the suj)erficial cells is often a verv |)r<)minent feature of the disease antl mav render the diagnosis extrenielv dif- ficult. These cells, as thev are rapidh" cast off, accumu- late in the canal and. owing to its contracted calibre, are with great difTiculty cleared away so as to permit a view of the small portion of the drum membrane not hidden bv the swollen canal wall. The swelling is intensely painful to ma- nipulation with the [»robe ; pressure in front of the tragus or efforts at crowding the canal upward or forward are attended with s:vere pain. There may be considerable cedema over the post-auricular region, and the auricle may be displaced out- ward and forward from the side of the head more or less promincntlv. Palpation along the anterior border of the sterno-mastoid muscle reveals considerable infiltration of the Ivmphatic glands. When this condition occurs with cedema over the mastoid the differential diagnosis between diffuse ex- ternal otitis and perforation at the tip of the mastoid is possi- ble only by speculum examination alone. It is exceeding!}' 13' Fig. 88. — Acute diffuse external otitis, i»- voivinfj pdstcro - supciior canal wall. (Natural bi/.c.) 258 DIFFUSE EXTERNAL OTITIS. important in these cases to prolong the speculum examination sufficiently to determine the coexistence of anv inflammatorv condition within the tympanum. This is particularly true in the case of children, since an acute purulent otitis media, if severe, may be accompanied by a diffuse inflammation in the external meatus, and the early recognition of the true nature of the disease is a matter of great importance. The surgeon should therefore obtain a view of the drum membrane, al- though this may require considerable time and inflict a certain amount of suffering upon the patient. Where the parts are very much swollen and the view is obstructed bv desquamated epithelium, the persistent use of small cotton-tipped probes will enable us to clear this away, and to reduce the swelling by pressure sufficiently to permit an inspection of the drum membrane, or at least of a portion of it. If this is normal in C()l(jr we are warranted in the assumption that the disease is confined to the canal alone. Prognosis. — The progress of the affection will depend largely uj)()n the causation. If it is idiopathic the prognosis is good ; if dependent upon traumatism, either mechanical, chemical, or thermal, the outcome will depend upon the se- verity of the injury inflicted. As complicating an acute or chronic process within the middle ear the severity of the lesion within the tympanum furnishes an index of the probable out- come of the case. When arising from a previous chronic in- flammation of the canal witht)ut any special exciting cause, the disease is usually mild in character. The degree of constitu- tional disturbance docs not indicate the probable severity of the attack, as in the early stages ; the general symptoms are usualh- vviv well marked even in mild cases. Treatment. — The first efforts should be directed toward relieving the severe pain which the patient suffers, and the attempt should be made possible to abort the process before the stage of pus formation is reached. For the relief of pain, both local and general measures are indicated. A sufficiently large dose of morphine or some preparation of opium should be administered, either by the mouth or, if the severity of the attack demands it, by the hypodermic method. The patient should be confined to bed and kept as quiet as possible; it is also well to obtain a certain amount of revulsive action by the administration of a saline cathartic. If seen very early, we may resort to local bloodletting, removing, bv means of TREATMENT. 259 the artificial leech, not less than two ounces of blood. The site from which this is removed will depend somewhat upon the regi(jn in which the process seems to be most severe, but as a rule in the diffuse form of inflanunation the best results are obtained by the abstraction of blood from the mastoid region ; here preference should be given to the artificial leach rather than to the natural. Imtnediatciv after the ab- straction of blood tlie Leiter coil should be aj>plied to the mastoid region, or the aural ice bag mav be used if this is more agreeable to the i»ati(.-nt. It lor auv reason local de- pletion seems inadvisable, we mav proceed at once to apply the ice coil or ice bag. In acklition to this, considerable re- lief is often obtained by fre(juently irrigating the canal bv means of the ear syringe, or, better, bv emploving the foun- tain syringe. A weak antiseptic solution, as of bichloride of mercury, one to eight thousand, or a saturated aqueous solu- tion of boric acid, is to be used for this purpose. The warm lluid should be allowed to How into the meatus for a period ot from live to fifteen minutes, according to the relief which it affords. In this manner the parts arc cleansed and the analgesic effect of the warm douche obtained. It is not neces- sary to remove the ice coil from the mastoid region in order to carry out this measure, and although the two would seem to be apparently oj)i)osite in action, the effect obtained is otten very satisfactory. This plan of treatment should not be persisted in for more than twenty-four hours, at the end of which time, if the svmj)toms are not so much relieved that the patient is able to rest without the use of an opiate, and comi)laiiis ol but little or no S|)ontaneous pain, more active measures are demanded. At this [)eri(Kl no treatment, to my mind, is so efficacious as a dee[) free incision in the canal, relieving at the same time tiie tension of the parts and effect- ing l(jcal depletion. In order to be efficacious, the incision should be deep and of considerable length. The site of elec- tion is usually the posterior or postero-superior wall of the canal. Under illuminatiarativelv simple. The danger is that it may either extend to the bonv or cartilaginous structures, on one hand, or mav involve the tympanic cavity secondarily, in which case we have to deal with a sujipurative process w ithin the middle ear. Moreover, where extension to the t\ tni»anum occurs, it is the upper part of the cavity which is involved. As this portion of the tympanum is richly sup- plic(l witli celluL'ir tissue, the comj^lication constitutes a men- ace to lite. Croupous and Dh'iitiikritk Extprn.m. Otitis. The diseases included imder the above heading constitute, in reality, but minor subdivisions of diffuse external otitis. Since the epidermis covering the meatus differs in no respect from that covering other portions of the body, we have no reason to presume that it should be exempt from the above special types of inflammation. Under favorable conditions the germ either of croupous or of diphtheritic inflammation may find lodgment within the meatus and produce there its characteristic exudation. The croupous form is less com- 262 DIFFUSE EXTERNAL OTITIS. monly observed than the diphtheritic. Like a croupous in- flammation in other portions of the bodv, it is characterized by a white, thick, velvety deposit on the surface of the mem- brane involved, consisting of coagulated fibrin containing within its meshes white blood corpuscles. This deposit lies immediatelv upon the surface, and can be detached from the underlying structures without the rupture of blood vessels. It is probable that certain conditions of the general health render the patient particularly prone to this form of inflam- mation. Tiie condition known as hvperinosis, or an increase in the hhiiii elements in the blood, is undoubtcdlv the chief predisposing factor. Given this general condition, and a simple inflammation of the epidermis lining the meatus, the lodgment of the specific germ of croupous inflammation w ill ordinarilv be followed bv a change fri)m the simple type to the croupous form. The diphtheritic form, on the contrarv. is most frequently observed as a comj)lication of otitis media, dej)endent upon either a diphtheritic inflammation of the fauces or the angina of scarlatina, although it occasionally occurs as a primary affection. When occurring as a complicating lesi(5n, the source of infection is usually the middle ear; a purulent in- flammation here, with subsequent rupture of the membrana tympani, being followed by a purulent discharge which con- tains the specific diphtheritic germ. Such an otitis media is accoinpanied by a diffuse external otitis in most cases. The external meatus is therefore in a condition favorable to the lodgment and development of the diphtheritic germ. The [)hysical examination reveals, in the early stages, the walls of the meatus covered with a white deposit, or, if ob- served only in the period of necrosis, with a gravish-white membrane, which is firmly attached to the underlying skin, and can be removed only bv the use of considerable force, the removal being attended with the rupture of blood vessels. When spontaneous exfoliation has taken place, the exposed areas show a loss not only of the superficial epithelium, but also of the deeper layers, the condition being one of true ulceration. The fibrous structures of the cutis are also aflect- ed, becoming swollen and encroaching markedly upon the lumen of the passage. The condition, whether of primary or secondary origin, presents the same picture, and its recogni- tion is not difficult. It might be confounded with croupous TRKATMKNT. 263 inflammation, but if \vc bear in mind that a croupous deposit separates from the underlx intj parts without hasmorrhage, the mistake need not be made. The severe type of desquamative inflammation of the canal, either occurring primarily or de- pendent upon an otitis media purulenta, mav also lead to error. Here, however, the deposit is not membranous, but consists simply of necrotic epithelial cells suj)erimposed upon each other. There is no destruction of tissue, and upon re- moval no ulceration remains. In the same wav an asj)erj^illus w-ithin the canal mav be mistaken for a diphtheritic iiitlam- mation, but the microscope will easily reveal the true ciiarac- ter of the disease. The history of the case will also enable a dilTerentiation to be made between the various conditions. The presence of a croupous or diphtheritic deposit in the external canal, when occurring as a secondary disease, is u*^u- ally no serious matter, since the surface |)resented for the absorj)tion of the toxine of the diphtheria bacillus is one through which this takes place very slowly ordinarily. In cases where the dij)htheritic deposit in the canal is but a sec- ondary feature of the general infection the outcome depends upon the seveiity of the origitual disease without reference to the local manifestation in the auditory meatus. Occasionally suQh deposits occur primarily, tbe germ gaining access to the external canal in some unknown way, and taking root there upon an abrailed surface which has resulted from a traumatic or other cause. In such instances only very slight constitu- tional symptoms are a|)t to be present, and the danger to be feared most is that the inflammation of the external canal may extend inward and involve the tympanum, the mucous lining of which would |)ermit general infection more easily than wt)uld cutaneous lining of the canal. CVou|tous deposits are of trivial importance aside from the local pain which is pres- ent, and this is no more severe than in simple diffuse inllam- mation. Treatment. — The treatment of the local conrlition consists in the tliorough and frequent cleansing of the surlace involved to prevent the membrane from spreading by contiguity of structure, thus increasing the extent of the surface through which the jioison may enter the circulation. A diphtheritic membrane in any situation will be exfoliated spontaneously at the end of from three to eight days. If removed by violence before this time, blood vessels are opened, and the raw surface 264 DIFFUSE EXTERNAL OTITIS. becomes covered very quickly by a new deposit, while the laceration of the vessels rather favors the absorption of tlie poison. It is wise, therefore, to confine our efforts to keeping the parts thoroughly cleansed, in this manner diminishing the activity of the germ, taking care that our efforts are not so vigorous as to excite any inflammatory reaction on the sur- rounding parts. To effect a thorough cleansing of the canal we may resort to the use of the ear syringe, or, perhaps bet- ter, the fountain syringe, employing a solution of lime water, which is allowed to flow into the canal for from five to ten minutes. In this way portions of the deposit already necrotic are removed, and a certain amount of solvent action is exerted upon the transudation which is still firmly attached to the parts beneath. Antiseptic solutions may be used here, the strength of the solution being somewhat greater than that employed for ordinary cleansing purposes. In this way the deposit is rendered inert, while at the same time, by its pres- ence, it protects the surface to which it is attached, and when it exfoliates spontaneouslv the denuded surfaces are protected by the presence of granulation tissue, which offers a barrier to local infection. In addition to irrigation, certain medicinal preparations may be applied to the deposit by means of the cott(jn ap{)lica- tor; of these, I think the solution of ferric sulphate in the full strength is bv far the most efficacious. This causes a rapid necrosis of the superficial layers of the pscudo membrane, while at the same time it exerts no irritating action, even if it touches parts which have not yet become affected. This local necrosis inhibits or stops completely the growth of the germ, putting an end both to its toxic effect upon the general system and to its further local propagation. A croup- ous exudate may be managed in exactly the same manner, its separation being more easily effected than one of a true diph- theritic character. In this form, after the iron solution has been applied, it is often possible to remove a considerable portion of the deposit by means of the forceps without inflicting any injury upon the cutaneous lining of the canal. The adminis- tration of constitutional remedies will be governed by the same rules which ap])lv to similar deposits located in the fauces. Remembering that a croupous exudation has for its predisposing cause a certain blood condition, it is wise to ad- minister the tincture of the chloride of irc>n in large doses. H.-EMORRHAGIC EXTKRX AL OTITIS. 265 with the hope of cutting short the attack. In the same man- ner a cli[)htheritic membrane appeariiiij: in the meatus, if ac- comj)anie(l bv tlie characteristic constitutional s\ niptoms of septic infection, demands the free use of stimulants and such drugs as mav be believed to mitigate the action of the poison. The various local complications do not dilTer from tlui^e al- readv mentioned under acute external otitis. II.l.M()KKH.\(;iC EXTKKNAl. OlIIlS. Under this term Polit/er* has described a disease of the external auditory meatus characterized bv the presence of vesicles upon the walls of the canal. The inferior and anterior walls are usually the seat of the manifestation, although the other walls are occasionally afTected. These vesicles are filled with a bloody fluid, and if allowed to remain, disappear spon- taneously at the end of a few davs. their site bemg marked by an excoriated area. The disease ma\ ott ui eithir as a primarv affection or as a comj)lication of an acute inllammatt)rv j>rocess within the tympanum. The constitutional svmptoms are verv well marked, and consist of intense local pain, which frecpientlv assumes a neuralgic character, sjjreading over the entire side of the head : the temperature is elevated to from i)<)° to 102°, and there is a marked prostration ; occasionallv delirium is present. The occurrence of this condition in the severe forms of tvmpanic inflammation which complicate constitutional dis- eases of the infectious tvpe, particularlv epidemic influenza, seems to show that the condition is indicative rather of a marked general infection than of anv distinct local patho- logical process. In cases where we meet with this form of external otitis as an idioj^athic disease, I am luore inclined to consider it as either a tropho-neurosis similar in manv re- spects to herpes, or, if the deeper lavcrs of the canal arc in- volved, as an accidental complication of a simple diffuse otitis. The latter view is that taken bv Gruber,t and this seems to be entirely tenable. It is not improbable that the extravasation of blood cuts short the inflammatorv process in the same manner as local depletion bv artiticial means, when the above measure is employed therapeuticallv in inflammation of the canal. • Lehrb. der Ohrenheilk., Stuttgart, 1893. p. 154. t Lehrb. dcr Ohrenheilk., Vienna, i883, p. 289. 266 DIFFUSE EXTERNAL OTITIS. Treatment. — The primary indication for treatment is to relieve the constitutional symptoms, the local condition being unimportant and recpiiring but little attention. The intense suffering must be relieved by the administration of free doses of morphine hvpodermically. When the neurotic symptoms are well maikcd the administration of bromide of sodium in full doses will do much to render the patient more com- fortable. Complete rest should be insisted upon. The diet of the patient should consist mostly of fluids for the hrst twenty-four or forty-eight hours. The disturbance of the nervous system frequently brings about severe constipation, which in turn increases the severity of the local pain. It is well, therefore, early in the affection to administer calomel in small repeated doses until the effect upon the intestinal canal is obtained, its action being aided, if necessary, by a saline cathartic. Locally very little need be done, the condition within the canal being kept under observation in order that any tendency toward inflammation of the middle ear may be readily recognized and proper measures instituted to check it. It the vesicles are of considerable size thev mav be opened with a delicate knife, the walls of the vesicles being jireserved as much as possible to protect the denuded areas within the canal. In case of spontaneous rupture the site of the vesicles may be lightly dusted with zinc oxide, lycopodium, bistnuth, or any bland powder which will protect them until they are covered by normal epithelium. Occasionally these vesicles are located upon the tympanic membrane, in which event the pain is of unusual severity and the constitutional symptoms are correspondingly increased. In such cases it is wise to open the vesicles as soon as thev appear, since almost imme- diate relief follows. Care should be taken that the canal is in a thoroughly aseptic condition before the operation, and the operator should guard against introducing the knife too deeply for fear of wounding the deeper lavers of the drum membrane, and of opening into the tvmpanic cavitv. The local tenderness renders manipulation difficult, and, unless the head is firmlv held bv an assistant, either of the above accidents is liable to occur. The sensitiveness of the reofion may be reduced somewhat by filling th.e canal with a ten-per- cent aqueous solution of cocaine about twentv minutes before the operation is to be performed. This solution must, o/ course, have been j)reviously sterilized liy boiling. CIIAi*Ti:K XIII. IMl'AC Ti:i) CKKIMIN. Willi i: constitutiiiLj a condition which differs in no respect from tliat present when any foreij:^n body is present in the meatus, this disease is of such common occurrence that it seems wise to consider it under a separate chapter. /Etiology. — The causes which lead to this condition de- pend eiilier upon the production of an increased amount of the normal secretion of the ceruminous glands, or uixm an interference with it^ regular discharj^e from the canal. In health cerumen is continually formed by the j^lands found in the meatus, and is discharj^ed from the canal constantly, but in such small quantities that its |)resencc is unnoticed. Any obstructive conditit)n interferini; with this process leads to an accumulation of the secretion within the meatus, and il it exists for a lonp: period of time a considerable mass will ac- cumulate, varying in size and density accordinc^ to the activity of the secretory process and the lenjjth of time that the ob- struction has existed. The conveyance of the product along the meatus is effected j)rincipally by the acti(jn of the jaws during mastication and sj)eaking. With every motion at the intermaxillarv articulation the anterior and inferior walls of the canal are moved, on account of the intimate relation be- tween the tragus and the capsular ligament of the articulaticjn. This motion, when the canal is of normal size and shape, acts in such a manner that any foreign body within the fibrous meatus is moved constantly toward its orifice. If the canal presents certains anomalies in curvature or if the orifice is very narrow, the force may have exactly the reverse effect, and any body lying within the passage may be carried in the opposite direction — that is, deeper and deeper into the canal toward the drum membrane. If a small mass of cerumen collects in the canal its mere presence causes an increased amount of secretion from the glands lying in the immediate (267) 263 IMPACTED CERUMEN. vicinity, while, at the same time, it acts as an obstruction to the outward passage of the product of the glands lying deeper within the channel. Although the causes stated are those most frequently operative in the production of the impaction of cerumen, it must be remembered that the secretory power of any gland may be modified by interference with its nerve supply. Under certain conditions we are warranted in considering that the disease is of a troj)ho-neurotic character. It is certain that the op[iositc condition, or one in which the cerumen is dimin- ished in quantity is frequentlv encountered in proliferous in- flammalioa oi the middle ear. Prolitcrous otitis media fre- quentlv depends upon some perversion of the troj)hic nerve supply, and we are warranted in assuming that an increased amount of cerumen mav occasionally occur from tro{)ho- neurotic causes. Pathology. — Upon removal of these masses from the mea- tus they are found to contain not only the oily substance which is normally secreted bv the parts, but also certain vegetable spores, the presence of which is purely accidental. The mass is occasionally covered by desquamated epithelium, while not infrequently we find in the centre a foreign body which has f(nmd its way into the meatus at some time and has formed a nucleus, about which the normal secretion has collected. This description applies to the simple cases of impacted cerumen. When, however, the masses attain considerable size the pathological process is more complex, and there is in addition a chronic desquamative inflammation of the deep canal dependent iij)on the presence of the foreign bod v. For the same reason the glands are probably stimulated to increased activitv. As long as the mass consists of cerumen only, no considerable changes are wrought upon the bon the condition vary with the size of the mass, with its location, and with the amount of secondarv inllammation which its presence has excitetl. The lumen of the meatus may be encroached up(jn to a considerable extent without anv nc^ticeable impair- ment of the auditorv function, or witjjout the aj)j>carance of anv subjective svmptoms, such as tinnitus, autophonv, or a feelinj^ as if the canal were stopjtctl. On the other hand, a very small mass mav be so situated as to ijive rise to jiromi- nent svm[)toms. It it is in such a position tiiat the membrana tympani is pressed upon, the sidjjective svmptoms arc apt to occur early, and the function of the or^an may be ajipreci- ablv interfered w ith, even thoujjh tlie mass be small. A^ain, a lar^e collection of cerumen mav lie in the cartiia}:jinous meatus and almost completely occlude its lumen without causini^ any symptoms referable to the ear. Frequently the first intimation of any trouble will be the occurrence of sud- den impairment of hearinjx foUowiniif a phuifje bath, when, on cominyf out of the water, the ear feels "stuffv" and full. These sensations are at first attributeil to the presence of water in the canal. The efforts of the patient to remove this failinij to relieve the discomfort, he seeks advice, and an examination reveals the presence of a mass which, from its size, must have been in the canal for a considerable period of time. The sudden access ul the svmptoms is due to the displacement of the pluij bv the water which has entered the meatus, causinc^ it to assume a |)osition where it com- pletelv obstructs the passae^e. In other cases the patient be- comes conscious that the jtower of hearing- is gradually but constantlv diminishing : coexistent with this impairment f)f function subjective noists make their aj>j>eaiance, at first causing but little annoyance, but subsequently becorninp^ so loud and persistent as to cause him to seek relief. Where the occlusion is marked the patient often comjilains of au- tophonv, hearing his own voice as if it came from within the head. This svmptom is particularlv marked where the affection is confined to one side. Occasionally the mass may give rise to a severe neuralgia, not confined to the ear alone, but spreading over the temporal and supra-orbital regions, and sometimes involving the entire trigeminal di'=;tribution. 2-JO IMPACTED CERUMEN. Sometimes this affection of the sensory nerves produces a feeling not so much of pain as of numbness, involving the aural region or the entire side of the face. One of the most common reflex disturbances is cough. So common is this that examination of the ear is essential in the investigation of every case when complaint is made of this symptom alone. This cough is spasmodic in character, and from its severity may induce so much congestion of the larynx as to mislead the physician into believing that the larvngeal condition is the cause rather than the effect of the symptom. Not only is the auditory function perverted or impaired, but also the mental condition of the patient may be disturbed. The patient graduallv finds that he is unable to concentrate his thoughts upon anv one ])articular subject, and that all mental processes are slow. The condition may become so marked as entirelv to unfit him for any occupation requiring the exercise of his mental faculties. This disturbance is de- pendent entirelv upon reflex action, and not upon the impair- ment of the hearing. Attention is particularly drawn to it from the fact that parents are often inclined to consider chil- dren inattentive when they are really suffering from a reflex disturbance dependent upon some pathological process within the ear. In these cases, unless attention is particularlv directed to this organ by an inij^airment of hearing, serious errors are liable to occur. Under this same head we must remember that interfer- ence with the function of the ear of the opposite side may result from the presence of a foreign body within the meatus. While this phenomenon is rarely prominent, every one who has carefully tested the hearing in both ears, in cases where the canal of one side has been occluded by a foreign body, must have noticed that we seldom find the ear on the unaf- fected side normal, although the patient may be conscious of no impairment, and if questioned will usuallv reply that the other ear is perfectly sound. When we remember the in- fluence which a sounding body held before one car has upon the sensitiveness of the organ of the opj^osite side, it is not strange that an occlusion of the external canal upon one side may seriouslv intertcre witii tlie hearing power of the oppo- site ear. So far we have considered simply reflex disturbances of a DIAGNOSIS. 271 sensory nature ; many cases have been reported, however, in which epileptiform seizures have resulted from the presence either of impacted cerumen or of some other foreign body within the external auditory meatus, the attacks being entirely relieved upon its removal. Dizziness may occur from the lirect pressure of the impacted cerumen upon the drum membrane, by which the attached ossicular chain is crowded inward, increasing labyrinthine [tressurc ; it may result also from reflex disturbances due to circulatory changes within the semicircular canals or the intracranial centres. When the impaction takes {)lace in an ear which has pre- viously been the seat of purulent inflammation, in addition to the symptoms already described, serious consequences may result fnmi the obstruction to the free outflow of discharge. This is particularly apt to occur in cases of chronic purulent otitis media of long duration, where the discharge is small in (juantity as a rule, but may be suddenly increased in ann>unt from exposure to cold or some other cause. In these cases, the scant discharge, mixed with the normal cerumen, dries in the canal and forms crusts, sometimes ui almost stony hard- ness, which prevent the exit of any fluid which may be formed within the middle ear during an acute inflammation of the parts. It is possible here for the pent-up secretion to fuid entrance into the cranial cavity, and cause death by in- volving the intracranial structures. Diagnosis. — It is impossible to make a diagnosis upon ratioiKil sviuptoms alone, but objective examination at once reveals the condition. Upon inspecting the parts, occlusion of the canal is at once evident, and the determination of the exact nature of the mass before removal is of no importance. .\ttention, however, should be given to one point in the ex- amination of these cases: it is the presence on the postero- superior wall of the canal of a mass consisting apparently of cerumen, which extends along this aspect of the meatus in- ward over the drum membrane, entirely or partially covering it. This appearance is almost always indicative of a pre- ceding suppurative process within the tympanum, the foreign body being really inspissated secretion, mixed with a certain amount of normal cerumen. Before removing this, the patient should always be warned that the ear may discharge after the mass has been removed. The subsequent otorrhoca does not depend upon the removal of the mass, but upon a pre- 272 IMPACTED CERUMEN. viously existing intratympanic suppuration. If not warned beforehand the patient may scarcely understand this. Where the meatus is entirely occluded, and a view of the deeper parts is impossible, this condition may be present, and it is often wise for the surgeon to protect himself even here, al- though it is not of as great im- portance as when the mass oc- cupies the situation above de- scribed. Prognosis. — The presence of a mass of cerumen in tiie exter- nal auditory meatus does not of itself constitute a menace to life, nor does it i)revent a complete restoration of the auditorv func- tion after the reuKJval of the for- eign body. The serious conse- (juences which occasionally fol- lt)w the presence of these masses is due to secondary pathologi- cal changes which they excite, either bv causing hvperxmia and subsequentlv inflamma- tion, as the result of their pressure, or by setting up an in- flammatory process of desquamative type in the external auditorv meatus, with a resultant absorption of the surround- ing bonv walls or a perforation of the membrana tvmpani. When the affected ear is the seat of a chronic purulent otitis media, the presence of any foreign matter within the canal which mav prevent the free discharge of pus from the middle car renders the patient liable to all the serious consequences which mav follow pus retention in any other part of the body. It seems curious that a mass c^f cerumen can offer sufficient resistance to pent-up secretions to cause them to seek an exit through the cells of the mastoid process, or to discharge into the cranial cavit}', rather than to force their wMy past the obstruction in the external auditorv meatus. The fact, however, remains that a mass of cerumen, lodged in the meatus for a considerable time, will obstruct this passage so completely that no discharge can escape. The osseous walls of the mastoid cells vield more easilv to the pressure of pent-up secretions than does this mass of fatt}* matter. Again, Fig. 89 — Crust on supero-posterit)r wall, covering a perforation in the mcmbraiia tvmpani. (Natural size.) I'KOl.NOSIS. ^71 in these cases the mere presence of this collection within the meatus excites a certain amount of chronic inflammation of the epidermis lining the canal, this inflammation being usu- ally of the dcsciuamative tvpe. The slight amount of dis- charge from the tNinpanic cavity mixing with these desqua- mated epithelial cells forms a mass which is exceedingly fii in. and which, increasing gradually in size, is capable of causing absorption of the osseous walls. The extent to which this may progress is unlimited, and c\tii the cranial cayit\- may be invaded and a purulent inlection of its contents may re- sult. In cases where the tympanic membrane remains intact, the pressure of the mass may force this structure inward against the bony tympanic wall, and by pressure cause an atrophy of the fibrous layer of the membrane. At the same time the desquamative inflammation excited by the plug of cerumen involves the superficial layer of the drum membrane as well as the canal walls. The epithelial cells which have been cast off may adhere so firmly to the atrophic membrana tympani that upon removal of the foreign body this delicate septum may be ruptured in spite of the greatest care. Hven if the membrane \s ruptured. comj)lete restoration of lunc- tion max take place, although the accident adds a certain amount of gravity to the condition. It is always well, there- fore, for the surgeon to |)rotect himself by giving a guarded prognosis in any case of ceruminous impaction in the canal, in which the mass seems to be of considerable firmness, and when there is evidence that it has existed for a long time. The effect upon the opposite ear should always be borne in mind, and a careful test of the hearing power uj^on both sides should be made before and after removal. If the accumula- tion is recent, complete restoration of the normal hearing power may be confirlently expected. If, however, we have reason to believe that the canal has been obstructed for sev- eral years, it is probable that the hearing will not be perfect even after the foreign body has been remf)ved. Moreover, since complete occlusion of the meatus makes it impossible for the observer to inspect the condition of the deeper parts, an absolute opinion should be given only after the obstruction has been thoroughly cleared awav and the fundus of the canal exposed to view. These masses within the meatus exert considerable pres- sure upon the surrounding walls, and their sudden removal 19 274 IMPACTED CERUMEN. often causes a transitory hyperaemia of the parts, which par- ticularly predisposes to the development of a circumscribed inflammation, and the appearance of a furuncle following the operation is by no means of rare occurrence. In other instances, this sudden increase in blood pressure causes a rupture of the superficial vessels, developing a blood bleb upon the walls of the meatus, usually upon the inferior wall, close to the membrana. This may attain such a size as to obstruct the canal considerably, while its color so nearly re- sembles that of the ccruminous deposit as to be mistaken for it. The operator is liable to inHict considerable violence upon the patient before the mistake is discovered, unless he bears the possibilitv of this occurrence in mind. In one instance coming under the observation of the author this sudden removal of support to the blood vessels was followed bv a serous transudation into the tympanum. The amount of fluid etTuscd was so great as to cause intense pain from pressure upon the membrana tympani. A free incision through the membrana gave exit to the tluid, and was fol- lowed instantly by relief. Treatment. — The first indication in a case of this char- acter is to remove the mass, and it can not be too strongly insisted upon that when an effort to remove such an accumu- lation from the external auditorv canal has been instituted, it should not be discontinued until the canal has been completely cleared. An exceedingly pernicious habit is practiced, not only by physicians without special training but by many otologists as well, of ordering these patients to instil a few drops of an alkaline solution into the ear at regular intervals for the pur- pose of softening the mass of cerumen, to render removal more easv at a subsequent period. As we know nothing of the conditions of the deeper parts, it seems strange that this method of procedure has ever been countenanced. The symptoms caused by the obstruction may be so indefinite that almost any condition mav coexist, and to allow the patient to pass from observation without determining defi- nitely the presence of any coexisting pathological condition within the t-vmpanum is certainly unwise. Another reason for condemning this plan lies in the fact that these masses may consist largelv of dry epithelial cells, and the absorption of moisture will considcrablv increase their volume. In this TRE ATM i: N T— S V R I NG I NG. 275 manner great pressure will be exerted upon the walls of the meatus, causiui^ intense sutTerinj; to the patient, and frequently leading to a circumscribed external otitis. The cardinal rule, therefore, should alwavs be to remove the collection at the first sitting. The instrument which is best adapted for this purpose is the ordinary ear syringe (Fig. 82). In a large majority of cases thoroughly syringing the car will remoye such a collection in a few moments. The solution to be used is a matter of considerable importance, for, as the condition of the deeper parts is unknown, the fluid should be of such a character thai its entrance into the tympanic cayity, through the accidental rupture of the drum membrane or through a preyiously existing perforation, would be followed by no serious consequences. The syringe, therefore, must be perfectly asej)tic, and the solution used should j)Ossess anti- septic properties. A solution of the bichloride of mercury — I to 5,000 or I to 8.000 — is the one which I j)refer. The fluid should be used at a lukewarm temperature, the sensations of the patient being the guide to the exact temperature to be employed. Since the removal of the obstruction in this man- ner dej>ends upon the passage of a stream of water between it and the canal wall, and the gradual crowding outward of the mass by this current, the stream should be directed where the greatest space exists between the foreign b(j(ly and the canal wall. NaturalU . it the current imj)inges directly upon the centre of the obstruction, this will be driven inward rather than outward. If, on inspection, we find that the in- spissated secretion is firmly attached on all sides to the walls of the passage, it is frequently advisable to begin the f)rocess by removing a small portion of the mass close to the canal wall with a blunt curette, in order that the stream may be able to p)ass the obstruction. The force to be used in the procedure is best guided bv the sensations of the patient ; the syringing should never be painful, although in certain in- stances the mere entrance of the stream of water will cause considerable dizziness. It is well to begin bv using very little force, gradually increasing it as may be necessary. If we were certain that the drum membrane were in its normal con- dition it would be almost impossible to rupture it by the use of the ordinary ear syringe. As it may be atrophic, however, care should be taken that no undue violence is employed in our efforts at removal. Where inspection reveals the canaJ 2/6 IMTACTED CERUMEN. completely stopped by the mass, and the use of the curette in the manner already described seems inadvisable, the plan usually followed is to direct the syringe so that the stream of water will impinge first upon the superior wall of the canal, next the posterior, then the inferior, and last upon the ante- rior wall. If the circumference of the canal is followed in this order, the instances will be rare in which the plug will not be rapidly displaced, the water at some particular point gain- ing entrance between the wall and the obstructing body, and rapidly forcing it outward with each successive discharge of the syringe. We occasionally meet with cases which resist all efiforts at removal in this manner ; in such an event the blunt curette must be used, and the collection removed piece- meal. Here it should be borne in mind that the upper and posterior portion of the drum membrane is nearer the opera- tor than the lower and anterior porti(5n ; it is unsafe, there- fore, to undermine the deposit by following the anterior wall of the canal and then attempt its removal by crowding the curette upward against the remaining portion, endeavoring to displace it by traction outward. If the drum membrane is sunken, pressure will be brought directly against this struc- ture and much suffering will certainly follow, and in many instances it will be ruptured. It is wiser, therefore, to follow the posterior wall of th- canal inward, effecting removal of the mass by pressing the curette down- ward and forward toward the anterior wall, at the same time employing trac- tion outward, removing in this way so much of the mass as lies between the curette and the opposite canal wall. After the' drum membrane has been once brought into view, the remaining fragments may be displaced either by the syringe or by the use of the curette, following any particular manipulation that may seem adapted to the de- mands of the individual case ; but until this structure is seen, Fig. 90. — Method of removing cerumen with the curette. (Natural size.) TREATMENT— USE OF THE CURETTE. the plan above laid down is the one which should be fol- iuwed. Where the canal is exceedingly sensitive we may vary the manipulation by removing the central portions of the mass first, a thin layer of cerumen being left on all sides closely adherent to the walls ol the meatus; this tubular rem- nant is then broken down by introducing the curette into the channel thus prepared, when, by pressing the instrument toward the wall of the meatus, the included fragment mav be extracted. If the op>erator should be so unfortunate as to rupture the membrana tympani, the first care should be thor- (jughly to cleanse the entire field by means of an antiseptic solution, and thus reduce to a minimum the chances of in- fection of the tympanum. A rather curious condiii.ui .i..i(-.i was observed in one of my cases was the sudden effusion of a large quantity of serum into the middle ear following the removal of a mass of impacted cerumen which had lain in the canal for many years. The only explanation that could be offered in this case was that the blood vessels of the tympanum had been so c^: i by the a the canal that they ha ;eir tone, i rrn?? sub- jected them quite suddenly to the pressure of the ir- rent. and resulted in a rapid transudation of the f\u: ts «^f the blood ; in this case a minute rupture of th'_ .ic drum membrane occurred. A few hours after the operation the patient was suffering intense pain : the middle ear was full of a sero-sanguinolent fluid, which passed out as rapidly as possible into the canal through the small j>crforation which had been made. Feeling confident that no inflammatory con- dition could be present in so short a time, as strict antiseptic precautions had been taken throughout the entire procedure, the pain was attributed simply to the pressure of the fluid within the tvmpanum. A long incision close to the posterior attachment of the membrana tympani to the tympanic ring evacuated the fluid, the knife dividing the mucous membrane upon the internal tympanic wall at the same time that the section of the drum membrane was effected. Relief *.v2« im- mediate, and in thirty-six hours the opening h.; m- pletelv, the patient regaining perfect hearing a: t::e ten davs. After a large mass of cerumen has been removed, it is well to insert a pledget of cotton into the meatus, directing 2/8 IMPACTED CERUMEN. the patient to remove it upon retiring for the night, after which it need not be replaced. Since these masses ordinarily contain a certain number of parasitic vegetable organisms, the patient should be seen once or twice subsequently to guard against the development of these parasitic growth: . It is advisable during the interval between the visits that an alcoholic solution either of boracic acid, in the proportion of forty drains to the ounce, or of salicylic acid, ten grains to the ounce, should be instilled into the canal twice daily; this will effectuallv destroy any vegetable spores which may re- main, and render a reaccumulation less liable to occur. This plan of treatment is also indicated, since, in removing the mass, it is not unusual that small areas may be abraded and render the occurrence of an acute circumscribed external otitis probable. No case should be considered thoroughly cured until the entire cutaneous lining of the meatus is per- fectly normal. rii.\rri;!>: xi\. roKKU.N i5t)i)ii:s IN rnK i, anai,. iEtiology. W'c liavf already dcscribctl, under Impacted Cerumen, the varicjus symptoms which mav arise from the presence of any foreij^n substance witliin the external audi- tory canal, but here the presence of the foreign body in the canal is due to natural causes. The symptoms occasioned by a foreign body in the external auditory canal, \yhich has either developed there sjxmtaneously or has obtained lodg- ment there by accident or design, are exactly similar. We shall therefore omit a repctitit)n of the symi>tomatology, and confme ourselves to the consideration of the nature of the substances which are met with in this locality, and the meas- ures which may be necessary to effect their removal. Pathology. — These foreign substances may be divided into two great classes: the inorganic and organic. The inor- ganic substances which have been removed from the external meatus are almost infinite in number. Children seem t(j take special delight in introducing into the meatus any article which can be made to enter it. Thus we trecjuently find buttons, glass beads, pebbles, sand, broken glass — in fact, anything which chance ma\ throw in tluir wa\ — introduced into this passage. A pernicious habit, frecjuently ad()j)ted, is the introduction of cotton into the ears of a child when it is taken out of doors on a cold day ; the mother often neglects to remove this, and the child may subsecpiently crowd it deeply into the meatus in its efforts to disKjdge it. In this situation it may remain, often for many years, and it is not uncommon in dispensary practice to find a small plug of cotton forming the nucleus of a mass of impacted cerumen, the patient being unable to state when the foreign substance was introduced. Among the organic substances found are apple seeds, watermelon seeds, cherry pits, the shells of edible nuts, small 28o FOREIGN BODIES IN THE CANAL. pieces of straw which have been used by the patient to scratch the ear, or minute splinters of wood which may have been broken off in the canal during a similar effort on the part of the patient. Occasionally the body of a dead insect is found, the insect having gained entrance to the meatus accidentally, and, being unable to escape, has remained there until removed by artificial measures. A living insect usually causes such marked symptoms by its presence in the canal that immediate efforts are instituted for its removal. When leeches are carelessly applied to the region of the ear — the meatus being allowed to remain open during the operation — the animal may detach itself from the point of application, and, making its way into the meatus, may attach itself to the drum membrane and cause intense suffering. Sometimes the eggs of the common house-fly ^re deposited in the canal and subsequently become developed into living insects, constitu- ting a condition distressing to the patient and disgusting to the observer. Symptomatology. — Very little need be said about the symptoms produced by a foreign body, as we have already discussed the subject thoroughly under Impacted Cerumen. That a foreign substance may lie in the meatus for a num- ber of years without giving rise to any symptoms, and then suddenly make its presence felt by manifestations of unusual severity at first, appears strange ; yet this is easily under- stood, if we consider that an irregularly shaped body may, in this locality, exert no pressure on the surrounding walls, but if suddenly displaced ever so little may impinge upon delicate and sensitive parts. Any foreign substance which increases in volume by the absorption of moisture is particu- larly liable to produce symptoms of increasing severity. Beans or seeds which when dry may be easily dropped into the canal become moistened by perspiration, and attain such a size that their spontaneous exit becomes impossible. While this increase in volume may not be sufficient to constitute a source of discomfort, the introduction of water into the meatus while bathing may bring about this result. Again, if there is at the same time a suppurative otitis media, the discharge from the tympanum will cause a foreign body to increase in volume. The local irritation which a foreign body exerts upon the walls of the canal increases the secre- tion from the cutaneous lining, the superficial epithelium is DIAGNOSIS— rROGNUSIS. 28 I thrown off rapidly, and the canal is hlled with these white, moist scales. This condition is particularly favorable for the development of the various forms of parasitic growths, or of a local infectious process ending in a circumscribed or diffuse inflammation of the walls. Naturally all of these manifesta- tions are more common among the classes who pav little attention to personal cleanliness, or are exposed to surround- ings which render local infection especially easy. When the middle ear is the seat of suppuration, the for- eign bodv may interfere with projH'r drainage, and then symptoms of pus retention ensue. Diagnosis. — The recogniti(jn of anv foreign substance lying within a perfectly patulous canal is exceedingly sim- ple. Unfortunately, however, these i)atients arc seldom seen immediately after the introduction of the foreign body and before efforts have been made to effect its removal. These attempts at the hands of the patient are necessarily unskillful, and result in the intlicticjn of considerable injury to the sur- rounding parts, if the case is inspected at the end of a few days, the canal may be so swollen that the deeper parts are entirely invisible, the softer tissues prolapsing about the for- eign body and completely hiding it ; while at the same time the secretion from the parts, the desciuamated e{)ithelium, and the presence of dried blood which has followed the efforts at removal, so distort the normal appearance that an exact diagnosis is a matter of great difficulty. The parts may be so tender that only the smallest si)eculum can be introduced, while manipulation may be impossible. . Under these condi- tions, our diagnosis must depend entirely uj)on the history ; when this clearly indicates the nature of the affection with which we have to deal, it is unwise to jtrolong the examina- tion, as the indications for treatment are identical, no mafUr what the nature of the substance may be. Prognosis. — The outcome of the condition will depend more upon the local disturbance which is ])resent than upon the nature of the foreign body or its location. The parts in some cases are exceedingly tolerant, while in others compara- tively harmless substances may give rise to severe symptoms. Probably nothing increases the gravity of a case to such an extent as unsuccessful attempts at removal, the body itself doing less harm than unskillful efforts in this direction. When the condition has existed for a considerable period. 282 FOREIGN BODIES IN THE CANAL. the presence of profuse purulent discharge will indicate that the tympanum has been invaded, while involvement of the mastoid cells or interference with the outflow of pus will be evidenced bv characteristic signs. Treatment. — The instrument which should be employed for the relief of this condition is the ear syringe. It is prob- ably safe to say that our first efforts should always be to clear the canal, if possible, by this means alone. Although it may seem perfectly simple to remove the foreign body with the forceps, with hooks, or similar instruments, attempts to grasp hard, smooth objects usually result in crowding them deeper into the canal, where thev become impacted and are removed with great difficulty. A stream of water thrown with con- siderable force into the meatus is usually sufficient to dislodge any obstruction, while it inflicts no violence upon the parts. The only instance in which it may be wise to attempt re- moval by manipulation is in the case of seeds or dried vege- table substances, which may increase in volume so rapidly when moistened as to fill the canal completely. If a sharp hook can be made to penetrate such a foreign body to a con- siderable depth, this is usually the simplest measure for its removal. Forceps should only be used where the body is thin and flat, and may be grasped easily in the jaws. When the contour of the body is more or less spherical, the efforts to grasp it will usually result in the instrument slipping and actually crowding the obstruction toward the fundus of the canal. Continued efforts in this direction mav often force the object against the tympanic membrane, and even into the mid- dle ear. It is sometimes possible to introduce a blunt curette between the object and the canal wall until the instrument has passed the obstruction ; the instrument is then withdrawn, and the foreign body removed with it. It mav be necessary, in the case (3f small, soft objects, to disintegrate them in the canal by instruments, and remove thcni piecemeal. This is particularly true of seeds, the shell being broken, and the soft interior removed by the curette, after which the remain- der of the shell can be easily taken away. The necessity of auccsthesia must be determined in each individual case. It is an error, however, to prolong the efforts at removal where the patient is extremely nervous, on account of the damage which may be done to the surround- ing parts ; and, unless they meet with prompt success, the TREATMENT— EXTERNAL OPERATION. 283 patient should be thorout^hly ancesthetized before continuing the operation. In some rare instances, where the condition has been neglected, the meatus may become so small that it is impossible to extract the foreign body through the natural passage. Under these circumstances a more radical jiroce- dure becomes necessary. The patient being thoroughly anjusthctizcd. the parts above and behind the ear are shaved, thoroughly scrubbed with soap and water, washed with a hvc-pcr-cent carbolic solution and subseciuentlv with ether, the external meatus having been previcnislv syringed with a two-pcr-ccnt carbolic solution or some other antiseptic fluid, and tamponed with iodoforin gauze. An incision is then made from just below the insertion of the lobule, upward along the line of attach- ment of the auricle to a point just above the meatus, and then forward as far as the helix ; the fibro-cArtilaginous canal* is then loosened fn^m its attachment bv means of the periosteum elevator, the instrumetit being ap|)lied first below and then behind, the superior wall being detached last, in the same way the {periosteum of the canal is sej)arated from the bone, and the fibro-cartilaginous tube is divided transverselv as near the drum membrane as possible. This anterior flaj). consisting of the auricle and iiit- s<»it parts of the meatus, is turned forward, and entrance is thus gained to the bonv meatus directly, and the path to the tor- eign body is shortt-ncd bv the length of the cartilaginous canal. This amount of gain is inconsiderable when we remember that the parts are covered with bhiod, and the view to a degree ob- structed bv the hemorrhage. If the fibrous canal is swollen, as the result of secondary inllammation. and this is the only obstacle to the removal of the foreign body, we may be able to extract it at once after the flap has been turned forward. In case the object is found so firmly fixed in the canal that efforts at extraction are still futile, the lumen of the meatus can be enlarged with a chisel by carefully chipping away the bone from the posterior wall until sufficient space is ob- tained to remove the object. It is better to enlarge the pas- sage by the removal of a portion of the osseous wall than to attempt to extract the body by forcible manipulation. The operation presents no difficulties, and we should never delay in adopting this plan whenever extraction through the natural passage seems impossible. If, in (^ur efforts, the tympanic 284 FOREIGN BODIES IN THE CANAL. cavity has been unavoidably opened, this feature does not add to the gravity of the condition. The parts should be thoroughly cleansed, and the wound in the tympanic mem- brane will soon close, and, as a rule, the middle ear suffers very little from the accident. After the purpose for which the operation has been undertaken iS accomplished, the soft parts should be replaced, and the line of incision sutured by a con- tinuous subcutaneous catgut suture ; a rubber tube should be inserted into the meatus, both for the purpose of drainage and to keep the parts in position. Sufficient drainage is se- cured in this way, and primary union throughout the entire length of the incision should be looked for. If there is but little inflammatory change in the tissues of the meatus as the result of the presence of the foreign body, a light tampon of iodoform gauze may be inserted instead of the drainage tube. This should extend to the fundus of the meatus to secure proper drainage, and will be found to support the walls of the canal sufficiently. Unless the temperature indicates the necessity for doing otherwise, the dressing may remain un- touched for six days, when the parts will have united com- pletely. If there has been much previous laceration of the soft parts, it is usually wise to change the dressing at the end of the second or third day. If much discharge is found at this time the canal should be irrigated ; but if the parts are dry this is not necessary. The tube may be removed at the first dressing and the tampon of gauze substituted. The only unpleasant sequel which can result from the operation is the possible narrowing of the canal from cicatricial contraction, and this can be avoided if the parts are properly apposed after the operation and held in position for twenty-four or forty-eight hours. CHAPTER XV. EXOSTOSES OF THE EXTERNAL AUDITORY MEATUS. ^Etiology. — The development of a new growth of an osse- ous character in the external canal has been attributed to various causes. It was formerly supposed that a gouty or rheumatic diathesis predisposed to the condition, although statistics fail to bear out this view; and the same may be said of specific disease. Persistent irritation of the external auditory canal, espe- cially bv the presence of a purulent secretion such as occurs in individuals suffering from neglected purulent otitis media, seems to be the most common certain cause for the develop- ment of these bony growths. Race also exerts a decided influence, the growths being more commonly met with among Europeans than among the inhabitants of our country, al- though among the aborigines the}' were of frequent occur- rence, as is proved bv an examination of skulls discovered through archasological research. The natives of the Ha- waiian Islands also manifest the condition quite commonly, and from their aquatic habits this fact lends great weight to the argument that the irritating action of salt water exerts a most important influence in the formati(^n of these osseous growths. Their occasional occurrence in successive generations in the same family seems to point to a certain hereditary predis- position, although this is far from proved. Pathology. — The portion of the canal in which these growths are most frequentlv found is either the junction of the cartilaginous and bony meatus or the deeper portion of the osseous channel. They occur in two forms, either as dis- tinct pedunculated masses, or as protuberances from the bony wall arising by a broad base. In structure they may be either cancellous or hard as ivory. A single bony mass may be present, or, as more frequently happens, they are multiple, projecting into the lumen of the canal from various aspects. (285) 286 EXOSTOSES OF THE EXTERNAL AIDITORY MEATUS. Where the canal is obstructed by multiple growths, it preserves its circular form in a modified degree, the space left between the obstructing masses lying in the axis of the meatus. Where a single excrescence of large size is the cause of occlusion, the meatus is converted into a slitlike passage by the approximation of the growth to the opposite wall. Symptomatology. — A small bony tumor in the external canal gives rise to no subjective evidence of its presence, and even where the deposit is multiple the condition may be dis- covered only by accident. When they attain a sufficient size to obstruct the passage to a considerable degree, the func- tion of audition is interfered with. Certain other subjec- tive symptoms now make their appearance : the ear feels full and stopped up, there is autophonia, and quite commonly subjective noises. The normal secretion from the walls of the meatus may collect beyond the tumor, and, being unable to find exit on account of its presence, becomes impacted, and exerts a steadily increasing pressure upon the membrana tympani and the walls of the bony meatus. This pressure tends to increase the condition from the mechanical irritation which it causes. If the accumulation is not removed arti- ficiallv, the pressure may excite an acute inflammation within the middle ear, or an acute external otitis. This is especiallv prone to occur if water is introduced into the meatus, causing the mass to suddenly increase in volume. On the other hand, an acute inflammation of the middle ear, arising from another cause, may lead to serious results on account of the obstruc- tion to the exit of the fluid products of the inflammation. For this last reason exostoses of large size become a menace to lite, and when once discovered the patient should be cau- tioned to submit to an examination periodicallv at the hands of an expert, in order that no extensive accumulation of ceru- men shall take i)lace bevond the obstruction and cause com- plete occlusion. The degree to which these masses interfere with hearing varies considerably. Even when the meatus is excecdinglv narrow the power of audition mav not be noticeably impaired in the ordinarv intercourse of life. Diagnosis. — Otoscopic examination usually renders the diagnosis clear at once. Where the growth is pedunculated, bulging, and broad, and especially if the surface is covered by a thin laver of cerumen, the examiner may at first be mis- DIAGNOSIS— PROGNOSIS. 2S7 led as to the character of the obstruction, the appearance pre- sented in these cases being quite similar to epithelial debris mixed with cerumen closely applied to the wall of the meatus. Manipulation by means of the curette at once reveals the true character of the formation. Upon removal of the layer of dried secretion upon the surface by means of the curette, the integument is frequently found to be eroded and exccssivch- tender to the touch, rndoubtedly the efforts of the patient to remove these crusts when the growth is near the orifice of the canal acc(^unts for the steady growth in manv instances. Located close to the drum membrane, ami presenting as one or more small rounded protuberances, these bony excrescences may resemble closely a localized bulging in Shrajjucl's mem- brane, but here again the probe reveals the true condition. The clinical historv, and the resistance offered to tiic im- pact of the jtrobe, discloses the true nature of the mass. The same points distinguish it from a circumscribed external otitis, or, wiierc the neoplasm arises from a broad base, from a symp- tomatic iliffusc otitis externa. Prognosis. — These neoplasms follow a different course in different cases. The progress followed by any individual growth is probably more dcjtendent uj)on the causes opera- tive in its production than uj>on any other condition. Thus, if it is secondary to a [)uruk-nt inllammation of the middle ear, the mass will undoubtedly increase in size until the irri- tating discharge has been controlled. Those cases depending upon diathetic conditions alone undoubtedly advance less rap- idly, and here the increase in size is seldom sufficient to de- mand operative treatment unless an intercurrent acute inflam- mation of the tympanum takes place, necessitating the removal of the exostosis to secure {)roper drainage. After removal the growth does not tend to reappear. We are seldom able to restore, however, the normal lumen of the meatus, even though the tumor is completely taken awav. The local irri- tation which must nccessarilv follow the operation excites a certain amount of inflammation in the bony tissue which leads to hypertrophy of the wall of the bony canal, anri consequent narrowing of its lumen. The possibility of an exostosis degenerating into a malig- nant neoplasm should be borne in mind, especially when it is situated near the orifice of the meatus and constitutes a source of local discomfort. Under these condition^ thf j>,itifnt con- 288 EXOSTOSES OF THE EXTERNAL AUDITORY MEATUS. tinually irritates the canal in this region by the introduction of the finger or some blunt instrument to relieve the pruritus — a process which serves to keep the integument over the bony growth denuded of its superficial epithelium. From this constant local' irritation a benign osseous tumor may as- sume the form of an osteo-sarcoma. These remarks would scarcely apply to growths located in the deep canal. Regarding the function of the organ, the remarks already made concerning the increase in the size of the tumor may be taken as an index of its probable effect in this direction. Lesions of this character endanger life only when they act as an obstruction to free drainage from the more deeply situated partswhcn these are the seat of an inflammatory process. Treatment. — Where the exostosis is deeply located, of small size, and gives rise to no symptoms, operative treatment is unwarrantable. It is well, however, to keep the patient under observation, the ear being examined at long intervals to ascertain whether the growth is progressive or has ceased to increase in size. It is surprising how narrow the meatus may become and yet impair in no degree the function of audition. When multiple growths are present, if the hearing is not noticeably impaired, interference is scarcely called for, al- though the patient should be advised to submit to an occa- sional examination in order that any secretion which may have collected mav be removed before it has become im- pacted so firmly as to prevent its dislodgment without great difficulty. Sea bathing should be interdicted, on account of the irritating effect of the salt water, and at the same time the patient should be cautioned against allowing fluid of anv sort to enter the meatus, since by this means any collection of cerumen or of desquamated epithelial cells may become so augmented in volume as to excite severe pressure symptoms. Where the obstruction of the meatus is almost complete, so as to interfere with the function of audition, or where the slightest increase in size would entirely close the canal, it is our duty to remove the exostosis. The precise manner in which this is to be done will vary according to its location, its form, and the individual preference of the operator. When the growth springs from a narrow base, and is situ- ated near the entrance of the bony canal, it is usually an easy matter to separate it by a chisel introduced into the TREATMENT. 289 meatus, and if carefully conducted the procedure does not endang-er the parts within the tympanum. When more than one growth is present, or when the c()rti(jn of the membrana. Irritating sub- stances introduced into the canal for the relief of pain in the ear, or for tor)thaclie. may produce a superficial inflam- mation of the lining membrane of the canal and oi the drum membrane: in the same maimer a vegetable parasite grow- ing within the meatus causes a diffuse external otitis. When moderate in degree, such an inflammation amounts to nothing more than a dermatitis, the superficial epithelium being exfo- liated and the deeper layers exj)Osed. When the inflamma- tion is of greater intensity actual tissue necrosis takes j)lace. and the drum membrane may be perforated, thus exposing the tympanic cavity not only to infection from the air, but also to the direct action of the substance which has excited the inflammation within the canal and has caused the perfora- tion in the membrana tympani. As a result of this we have inflammation of the middle ear grafted upon the already ex- isting inflammation of the external meatus. Perforation of the membrane from inflammation within the tympanic cavity is of secondary importance to the original disease, and pre- sents no characteristic features. Pathology. — From the introduction of instruments into the canal injury to the membrana tym])ani is usually effected (291) 292 WOUNDS AND INJURIKS OP^ THE MEMBRANA TYMPANI. in the upper and posterior quadrant, since this region is most accessible, the angle formed between the cartilaginous and bony canal protecting the anterior portion of the membrane from injury. When the rupture follows a sudden condensa- tion of air in the meatus, either from a blow upon the ear or from an explosion, the rent is most frequently situated in the postero-superior quadrant, from the fact that the greatest breadth of the tympanic cavity lies in this region. Owing to some irregularity in the position of the structure an accident of this character may produce a rupture in the anterior por- tion of the membrane. Following traction upon the auricle the upper part is most frequently torn, and here the rupture is usually confined to the region of Shrapnell's membrane, the membrana vibrans being to an extent protected by its loose attachment to the membrana flaccida. Openings into the tym- panic cavity are usually single when of traumatic origin, but occasionally multiple perforations are found. They vary in shape from a simple rent, the edges of which are only slightly separated, to an irregularly circular opening, as occurs when the force is considerable, or when the membrane is very tense. If the septum is tightly stretched the elasticity of the struc- ture separates the edges of the tear, giving the appearance of a certain loss of substance. Following the introduction of chemical irritants, the de- struction depends upon tiic activity of the chemical agent in- stilled. We have purposely omitted the cases of rupture follow- ing severe injuries of the cranium, since here the aural affec- tion is of but slight imjiortance in comparison with the frac- ture of the base of the skull or the cerebral concussion. The drum membrane in these cases may be injured either by a blow upon the side of the head, which suddenly compresses the air within the canal, or by a blow upon the skull which, by the force of impact, subjects the bony ring to great pres- sure at one point, and causes it to yield slightly, rupturing the attached membrane. Where the middle ear becomes secondarily involved, the pathology does not differ from that of a middle-ear inflamma- tion from any other cause except in the fact that it is usually purulent. Symptomatology. — When the drum membrane has been torn, tile iirst s\nij)tom is severe pain, referred to the deeper SYM1TO.MATOLO(;Y — DIAGNOSIS. ^93 part of the origan. Coincident with this there is a very de- cided impairnicnt in hearing and the development of loud subjective noises. X'ertigo ordinarilv t)ccurs following a blow upon the ear. but this is due rather to a sudden increase in labyrinthine tension than to rupture oi the niembrana tym- pani. V^ery soon the patient is ct)nscious of a watery dis- charge within the meatus, and the acute pain which was pres- ent immediatelv after the injury becomes dull, throbbing, and more diffuse. U[)on blowing the nose the attention is at once attracted by the passage of the air through the car, with the production of a high-pitched whistling sound. If secretion is present the high-pitched note is followed bv bubbling sounds as the air passes through the fluid. Where the rent is large, the pain is usually of shorter duration than when but a small opening is present. The reason of this is that the copious serous transudation which immediately follows the injury finds a ready means of exit from the tympanic cavity, and produces less pressure u|»on the parts than where but a small opening exists. The subsequent i)r()gress ol the case will vary according as the middle ear is or is not involved. In the fir.'^t instance a rather long-continued suppurative i)r()cess not infrequently follows, while, if the Ivmpanum escapes, the rent of its outer wall mav close perfectlv in a few days, leaving no symjitoms behind. Diagnosis. — A recent rupture is easily made out on exami- nation, its ii regular contour being marked by a delicate line where the rupture is linear (Fig. 91), or by an apparent loss of substance over the affected region where a circular opening is present. Through this opening the mucous lining of the middle ear appears red and congested, throw- ing a bright reflex back to the eye from the moisture upon the inner tympanic wall. The history of traumatism in the region of the ear, or of any injury to the skull, followed by an aural discharge, should lead to a careful ex- amination for anv evidence of injury to the drum membrane. Where the rent occurs close to the margin of the ring it may escape recognition, unless the entire line of attachment of the membrane be inspected. Wounds in Shrapnell's membrane are less easilv recognized than those in mcmbrana vibrans, 1" ic. 91. — Linear rupture of the membrana tym- pani. 294 WOUNDS AND INJURIES OF THE MEMBRANA TYMPANI. owing to the natural flaccidity of this part. Evidences of a previous rupture are the presence upon the surface of the drum membrane of minute blood clots, corresponding in position to the outline of the rent, and the coexistence of delicate radiating vessels along this line which impart a slight pinkish tinge to the affected area. These vessels become visi- ble, owing to the increased vascularity incident to the repara- tive process. The presence of minute blood clots in the meatus also points to a previous injury. These appearances are of practical value only in medico-legal cases, where we may be called upon to determine the effect on the ear of a previous injury. Prognosis. — An opening made into tne tympanic cavity as a surgical procedure is one of the simplest operative meas- ures employed. It is quite different, however, if the open- ing occurs as the result of an accident, when the meatus may contain an abundance of infectious material, which thus gains access to the mucous lining of the tvmpanum ; here it is easily absorbed and produces characteristic results. On account of this, an accidental rupture of the mem- brana tympani at the hands of the surgeon in attempting to reuKn-e a foreign body, either with the svringe or curette, is seldom followed by untoward results ; while the same acci- dent inflicted at the hand of the patient might lead to fatal consequences. In the one case, if proper precautions have been taken, the parts are in a thoroughly aseptic condition before the traumatism has occurred, and hence no infection follows, while the reverse is true in the latter instance. In general, the prognosis both for the ultimate closure of the opening and the restoration of the power of audition is fairly good, if the case comes under observation before a chronic purulent inflammation has supervened. If this has occurred, the result will depend upon the condition of the parts as revealed by the examination, independent of the cause which has produced it. Treatment. — As the surgeon, no matter how expert, will occasionally wound the membrana tvmpani, no instrument should be inserted into the meatus before this channel has been thoroughly cleansed. Even in removing foreign bodies by means of the svringe, the solution employed should be antiseptic in character, in view of the fact that the tympanum may be accidentally entered. Under these conditions it is TREATMENT. 295 only necessary to dry the parts lii^htly with cotton, dust a little boric acid along the margins of the wound, and occlude the meatus with a pledget of sterilized cotton. A little se- rous discharge may follow, in which case the patient is direct- ed to change the cotton as frequently as it becomes saturated. No other treatment is necessary, the parts resuming their normal condition in from twelve to twenty-four hours, even when vcrv free serous discharge has suj>ervcncd. When seen at a later jjeriod, or in cases where it is prob- able that infection has taken place, local bloodletting from the region in front of the tragus may abort the intlanmiation. If the opening through the drum membrane is exceedingly minute, and the middle ear contains a large amount of fluid, the wisest plan is to make a free incision through the drum membrane, at the same time incising the opposite internal wall of the tympanum. This evacuates the contents of the cavity and depletes the vessels ii|)on its inner wall. The measure is followed almost invariably bv a j>rompt disap- pearance of the symjttoms, the wound closing in from twenty- four to forty-eight hours. We sometimes meet with cases in which Nature has already sealed the opening by the deposit of a small blood clot upon the external surface of the drum membrane. No attempt should be made to remove this un- less there is severe pain, as healing invariably takes place if the clot is allowed to remain. Interference with it may pos- sibly infect the cavity and be followed by severe inflammation of the middle ear. Acute or chronic otitis media following the accident calls for the treatment indicated under the dis- cussion of these diseases. ///. DISEASES OF THE MIDDLE EAR. The entire middle ear, from the pharyngeal orifice of the Eustachian tube to the inner surface of the membrana tym- pani, is covered with mucous membrane; this is supplied with glandular structures, in some parts very richly, while in other parts they are rather sparsely distributed, for the purpose of keeping the membrane moist. The pathological processes met with here may involve either the entire region or some single portion of it. Consid- erable confusion exists at present in the classification of dis- eases of the middle ear, and manv cases in which the Eustachi- an canal alone is affected are classified as cases of otitis media, while, on the other hand, certain manifestations within the tym- panum dependent not upon inflammatory changes, but upon certain conditions of the blood vessels distributed to the parts, are also considered under the same title. It should be remem- bered that the fluid effused in a simple inflammation of a mu- cous membrane is an increased amount of the normal secre- tion of the membrane, and nothing more. The presence of a purulent effusion as the primary result of such an inflamma- tory change in a cavity lined with mucous membrane is im- possible ; in order that the fluid shall be purulent, infection must take place from the outside, or the inflammation must be infectious from the first, and involve not only the mucous membrane, but the underlying connective-tissue structures. The affections in which the mucous membrane alone is in- volved have been denominated as catarrh of the middle ear. From the derivation of the term, this name indicates simply an increased amount of secretion. Such an inflammatory pro- cess may involve the Eustachian tube alone, giving rise to tubal catarrh or catarrhal salpingitis, or both the tube and the tym- panum may be involved, in which case we have a tubo-tym- panic catarrh or salpingo-tympanitis. In this last-named dis- ease the inflammatory process is chiefly confined to the tube and seldom goes beyond the stage of congestion, changes tak- (296) EXPLANATION OF PLATE V. 1. Appearance of the membrane in tubal catarrh. Exaggeration of an- terior and posterior folds. Short process prominent. Malleus handle fore- shortened (indicating marked retraction I. Light reflex lost. No evidences of congestion in membrane or tympanum. 2. The normal membrana tympani. The congestion along the posterior border of the manubrium was due to the i)roIonged presence of the speculum in the canal. 3. Otitis media purulenta residua, with caries of the malleus and incus. There is a small perforation above the short process. The malleus handle is adherent to the internal tympanic wall, which is partially covered with a non- secreting membrane. This is wanting posteriorly over the niche of the round window, and anteriorly over the entrance to the Eustachian tube. 4. Purulent otitis media, with extensive destruction of the membrana vibrans and displacement of the ossicles. The long arm of the incus, the posterior crus of the stapes, and the niche of the round window are visible. 5. Chronic catarrhal otitis media (hypertrophic formi. Malleus shaft rotated upon its long axis and apparently increased in breadth. There are several areas of calcification in the membrane. 6. Serous effusion in middle ear, with congestion of membrana flaccida. The level of the fluid is distinct. This condition is often present in tubo- tympanic congestion. (296 a) PLATE V. 4. Dr. W. A. Ho/den, ad. nat. del. EXI'I.ANA I ION C)l- I'l.ATK VI. 7 Chronic catarrhal otitis media (hvperplastic changes subsequent to hypertrophic inHammationi. Membrane retracted. Malleus handle fore- shortened, and apparently narrow from rotation upon long axis. Adhesions beneath iriembrana flaccida. as shown by depression above short process. 8. Retraction of membrana tympani. with slight foreshortening of the malleus handle. This appearance is often obsened in |)atients with enlarge- ment of the pharyngeal tonsil, who suffer from repeated attacks of tubal or tubo-tympanic congestion. The membrane becomes relaxed and attenuated, and smks inward upon the internal tympanic wall, so that the long arm of the incus and the incudo-stapedial articulation are easily recognized. 9. Intense congestion of membrana flaccida and of manubrial plexus. The membrana vibrans normal in parts not adjacent to extensive vascular picxu.:. Such an appearance characterizes the first st.ige of acute purulent otitis media. 10. .Acute purulent otitis media, with bulging of membrana flaccida and displacement of adjacent wall of meatus. The membrana vibrans is partially hidden, but the portion visible is normal in color. 11. Chronic purulent otitis media. There is a perforation above the short process, through which a mass of granulation tissue protrudes. The mem- brana vibrans is wanting over the tympanic orifice of the Eustachian lube. 12 Otitis media purulenta residua. Perforation in posterior inferior quad- rant. The appearance is characteristic of acute congestion as it occurs in these cases. The turgescence is confined to the regions richly supplied with blood vessels. PUTE VI. 10. 11 12. Dr. W. A. Holden, ad, nat. del. I'RKLIMINARV t)BSP:R\'AT10NS. ^O" ing place in the cavity of the middle ear beins: almost entirely secondary to this and depending- upon the physical condition of reduced pressure within the tympanum, due to closure of the Eustachian canal. The disease is reallv salping^itis. which secondarily has given rise to certain physical changes within the drum cavity discernible upon otoscopic examination, and scarcely deserves recognition as an individual affection. The separation of these two varieties is made more for convenience in classification than for any other reason. In other instances the tym|»anum is the primary seat of a superficial inflammation with no involvement of the connective- tissue framework. In such cases the changes are usually con- fined to the lower j)ortion of the tympanic cavity or to the atrium. The ej)itymi)anic space is not involved, and the in- flammatc^ry process results in the pouring out of an increased amount of normal secretion, which fills, more or less com- pletely, the middle ear. The mucous membrane covering the internal surface of the mcmbrana tvmpani particij)ates in the process, and the mcmbrana may be so infiltrated as to rup- ture from the increased pressure caused by the pent-u[) secre- tion, riie rupture of the membrane in such a case depends not so much ujion a deep-seated inflammatory process as upon the increased j)ressure to which the membrane is subjected from the secretion within the cavity, although in severe cases it is probable that the entire thickness of the membrane is involved on account of the free anastomosis between the vessels of the inner and outer layers. After perforation has taken place thi^ form of inflammation may become changed in character from the infection of the dischaifje from with- out. after which it runs the ty[)ical course of a jnirulent in- flammation. Such are the changes present in those cases where a sim- ple catarrhal inflammation occurs within the middle-ear tract. Both in tubo-tympanic catarrh and in acute catarrhal inflam- mation of the middle ear we may have a solution of continuity in the drum membrane ; in the tubo-tympanic form this rup- ture is due simply to the pressure of the fluid with which the cavity is filled. It is probable that rupture never occurs in these cases if the membrane is not atroj)hic from a previous pathological process. This fluid is ncjt the result of inflam- mation, but of a serous transudation simply from the overdis- tendcd vessels. The fluid collects in the atrium although 298 DISEASES OF THE MIDDLE EAR. transudation may take place from the numerous reduplica- tions in the upper part of the cavity, the fluid entering the atrium in obedience to the laws of gravity. In acute catarrhal tympanitis the transudation is of inflammatory origin, and this inflammatory process may be a factor of some impor- tance in causing the rupture of the membrane, although it is certainly not the principal one. Here the atrium alone is affected, although the tympanic vault mav be involved sec- ondarily from subsequent infection of the discharge. Where the inflammation is purulent from the start we have those structures primarily involved which are richly supplied with connective-tissue elements. By recalling the anatomy of the tvmpanic cavity we remember that the vault of the tvm- panum contains numerous duplicatures of mucous membrane, these being so fully developed in some instances as to com- pletelv fill the entire epitvmpanic space; the connective-tissue framew(^rk of these folds presents a favorable site for the growth of the bacteria of suppuration. When infection of this tissue occurs we have an inflammation set up which dif- fers in no respect from a cellulitis in any other portion of the body ; tissue necrosis takes place quite rapidly, and the secre- tion resulting from the inflammation is purulent in character from the outset. The fluid products find exit either into the atrium and then into the canal, or the membrana flaccida may be ruptured and an outlet afforded in this way, or the secre- tion mav find its way into the mastoid cells or even into the cranial cavitv when egress in other directions is prevented. Purulent inflammation occurs, as we should expect, in the more severe tvpes of acute infectious diseases such as scarla- tina, diphtheria, variola, general pya^mic infection, etc. As above stated, it may occasionally follow a simple catarrhal in- flammation by infection of the discharge and subsequent in- oculation of the connective tissue [n the tympanic vault through this secretion. Under the forms of chronic inflammation involving the portion of the conducting mechanism under consideration, we have those resulting directly either from a previous simple catarrhal inflammation or from a purulent process. We include in this group those cases which give the history of repeated attacks of acute middle-ear inflammation, but in whom the membrana tvmpani is not perforated. Other cases present in which the membrana tvmpani has been destroyed rKLLl.MlNAKV OBSLRX'A TIONS. 299 over a small or lar^^c area and a permanent perforation re- mains. These ai^ain divide themselves into cases in which the discharge still continues after the acute disease has run its course, and those in which the residue of the former at- tack remains, the affection having either ceased spontaneously or vielded to treatment, restitution ot the necrosed parts not having taken place. A third class of cases comj)rises that varictv where the in- nainiiKilion is chronic from its inccjdion and is characttiized bv a deposit of new tissue. [0 this we give the term hyper- plastic inflammation. Although we may hnd this condition where a previous purulent inflammation has existeil resulting in local necrosis, it is usuallv met with where no such loss has taken place. No sharp dividing line can be drawn be- tween this variety and those following an acute catarrhal in- flammation which has failed to resolve, and to whicii the term hvpertro|)hic is applied. CHAPTER XVII. TUBAL CONGESTION, OR TUBAL CATARRH. (Acute Salpingitis. Eustachian Catarrh.) .Etiology. — This affection of the Eustachian tube usually arises from an acute coryza or an acute naso-pharvnj^itis, although it mav be met with as a primary affection from exposure to cold. Occasionally it complicates light attacks of the exanthemata in voung adults. It may depend upon the entrance of some irritating fluid into the Eustachian tube while bathing, or in using the nasal spray. Rarely it follows a blow upon the external surface of the body in this region. The chief predisposing cause is some obstructiye lesion of the nose or naso-pharynx. The presence of adenoid yegeta- tions is a particularly potent factor in its causation, since these masses easily become engorged with blood, causing yenous hyperasmia of the walls of the tube, narrowing or com- pletely closing its lumen. At the same time, the presence of this soft tissue in the yault of the pharynx afTords lodgment to pathogenic bacteria inhaled during the act of inspiration, from which locality tiiey easily find their way into the canal. Imjiaircd general health, no doubt, renders one more liable to the disease. Pathology. — The pathological conditions are to be con- sidered under two heads : First, the actual changes present in the tubal mucous membrane. Second, the changes occurring in the middle ear depend- ent upon the obliteration of the tubal lumen. Within the tube the condition is essentially one of simple venous hyperasmia, or the membrane may be the seat of a very mild inflammation following the venous engorgement. The mucous membrane becomes swollen and flabby, the walls of the tube lying in contact with each other and adhering closely on account of viscid secretion. The first change of SYMPTOMAIOLOGY. 3OI venous hypera^Miiia results in a transudation of the fluid ele- ments of the blood from the increased pressure. When the process becomes fully developed, the secretion is thick, tena- cious, i^lairy, white in color, and by its presence may occlude the channel completely. The changes are usually most marked in the cartilaginous part of the tube, the osseous segment be- ing but little afTected. When the Rustachian canal is obstructed from any cause the air c(jntained within tlie tymi)anic cavity disappears quite rapidly from absorption. This results in diminished atmos- pheric pressure within the tympanum, and a crowding inward of the drum membrane and the entire ossicular chain by the external atmospheric pressure. If tiie canal remains closed sufficiently long, we shall find the drum membrane so dis- placed that it touches the opposite internal tympanic wall in the region of the tip of the long process of the malleus. At its upj)er and lower poles its firm attachment prevents dis- placement. Symptomatology. — An attack of this character, occurring in the couisc ol an ordinary cold in the head, is usually char- acterized by a rather sudden onset of the symptoms. The patient complains of a feeling of stuffiness or heaviness in the ears, as though the external meatus were occluded by a for- eign body, one of the most characteristic symi)toms being the desire to insert the hnger into the meatus in order to "clear the ear," as the patient expresses it. This mani|)ulati()n is sometimes attended bv momentary relief from the exhaus- tion of the air within the meatus when the finger is suddenly witiulrawn. Sometimes, in addition to this feeling of discom- fort, there is a sensaticjn of actual pain referred to the upper part of the pharynx or the region of the tonsil. In rarer in- stances this pain is complained of in the region of the larynx, the sensati(jn being as though a foreign body had become lodged at the root of the tongue. Accompanying this, there is some pain radiating upward toward the ear, but when closely questioned we find that no actual pain is prr