A THE EAR: ITS AiNATOMY, PHYSIOLOGY, AND DISEASES. A PRACTICAL TREATISE FOR THE USE OF MEDICAL STUDENTS AND PRACTITIONERS. BY CHARLES H. BURNETT, A.M., M.D., professor of otology in the philadelphia polyclinic and college for graduates in medicine; consulting aurist to the Pennsylvania institution for the deaf and dumb; aural surgeon to the presbyterian hospital*, philadelphia ; president of the american otological society. WITH ONE HUNDRED AND SEVEN ILLUSTRATIONS. SECOND EDITION, REVaSED AND REWRITTEN. PHILADELPHIA: HENRY C. LEA'S SON & CO 1884. AA^ .fr~ Entered according to the Act of Congress, in the year 1884, by HENRY C. LEA'S SON & CO., in the Office of the Librarian of Congress. All rights reserved. DORNAN, PRINTER. ._ , _ \ DO 'Jl PREFACE TO THE SECOND EDITION. In the seven years which have elapsed since the publication of the first edition of this work the advances in the science of Otology have been very rapid and of an eminently practical character, so that in revising this second edition the Author found many alterations necessary, while other portions of the book required to be entirely rewritten, among which may be enumerated : The Abnormalities of the Auricle, Otomycosis, The Treatment of Chronic Otorrhcea, The Classification and Treatment of Aural Polypi, and the Diagnosis, Etiology, and Treatment of Aural Vertigo. Such material as has become obsolete is of course omitted, by which, and a new typogra- phical arrangement, the numerous additions have been accom- modated without increasing the bulk of the volume. In conclusion, the author takes pleasure in acknowledging his indebtedness to his covfreres in this branch of medical science, both at home and abroad ; their enthusiastic and meri- torious labors have enabled him to make his book, he trusts, more than ever worthy the kind reception accorded to the first edition. CHARLES H. BURNETT. No. 127 South Eighteenth Street, Philadelphia, August, 1884. ^345683 PREFACE TO THE FIRST EDITION. In view of the great advances which have been made of late years in Otology, and of the increasing interest manifested in it, the Author has felt that the profession might welcome a new work, which should present clearly but concisely its present aspect, and should indicate the direction in which further researches can be most profitably carried on. Such a work it has been the Author's aim to produce, and in accomplishing the task it will be seen that he has freely availed himself of the observations and discoveries of others. These he has, as far as practicable, tested by his own experience in the opportunities afforded by several years' special devotion to the study of the diseases of the ear. Considerable practice in teaching has shown him that the pathology and therapeutics of the ear cannot be properly under- stood without a more intimate acquaintance with its anatomy and physiology than is afforded by the ordinary text- books. In these departments much important work has recently been done abroad, especially in Germany, and the author is confident that the space which he has devoted to their consideration will not be considered as excessive. In conclusion, he trusts that, although the work is primarily designed for the student and general practitioner, it will not be found devoid of interest for the specialist. CHARLES H. BURNETT. No: 127 South Eighteenth Street, Philadelphia, September, 1877. CONTENTS. PART I. ANATOMY AND PHYSIOLOGY. SECTION I. EXTEKNAL EAK. PAGE Chapter I. Thk Aitrtcle. Ajiaiomy . . . . . . . . . . . . ,19 Embryolog^^ Cartihige. Muscles, extrinsic and intrinsic. Liga- ments. Bloodvessels and lymphatics. Nerves. Integument. Glands and hairs. Physiology ............. 23 Function of the muscles, voluntary and involuntary movements. Significance of size and shape of auricle. Comparative functions. Kesonant functions. Temperature of the auditory canal. Chapter II. The External Auditory Canal. ■ Anatomy ............. ^1 The temporal bone — development. Embryology. Developed bone. Styloid process ; origin and development. Temporal bone of infant. Development of bony auditory canal. Development of annulus iy\n- panicus. Segment of Eivinus. The auditory canal. Ceruminous glands. Vessels and nerves. Physiology ............. 46 The function in expelling cerumen by outward growth of skin, and by shape of canal. Chapter III. Membrana Tympaxi. Anatomy ............. 47 The three layers. 1. The dermoid or outer layer. Epithelium. Shape of membrana tympani. Color of membranti tympani. In- clinations of membrana tympani. Manubrium of the malleus. Umbo. Folds of membrana tympani. Pyramid of light. Cause of the pyra- . midal shape. Geometric divisions of the membrana tympani. An- nulus tendinosus. Inner surface of the cartilaginous groove of the malleus. CONTENTS. PAGE 2. Membrana propria or middle layer. The descending fibres of the membrana tympani. Arborescent fibrous structure of the mem- brana tympani. Constituent elements of the membrana propria. 3. Mucous or internal layer. Fold of mucous membrane for the chorda tympani. Pouches of the membrana tympani. Vascular supply. Comparative distribution of bloodvessels in the membrana tympani. SECTION II. MIDDLE EAR. Chapter I. Tympanic Cavity. Anatomy ............. 66 Ossicles of hearing. Malleus — dimensions; fixation — axial liga- ment. Incus — dimensions. Malleo-incudal joint. Stapes — dimen- sions. Joint between base of stapes and oval window. Dimensions and weight of the ossicula auditus. The tympanum. Tegmen tympani. Malleo-incudal joint — 'Sur- rounding parts viewed from above. Floor of the tympanum. Outer wall of tympanum. Pouches of membrana tympani. Inner wall of tympanum. Eminentia stapedii. Function of the stapedius muscle. Fixator baseos stapedis. Fielation of stapedius muscle to facial nerve. Tensor tympani muscle. Anterior and posterior walls of tympanic cavity. Course of facial nerve. Development of the bony canals in and about the tympanic cavity. Lymphatic cavity in the facial canal. Chorda tympani nerve. Observations of Bigelow and Sapolini. Nerves supplying the mi,icous membrane of tympanic cavity. Bloodvessels. Physiology ............. 90 Innervation of the tensor tympani muscle. Physiological nature of certain tympanic bands, heretofore considered pathological. Func- tion of round window and its membrane. Experimental researches — sources of sound. Artificial labyrinthine pressure. Deductions. Power of muscular accommodation. Action of the tensor tympani and stapedius muscles. Bibliography. Chapter II. Eustachian Tube and Mastoid Portion. Anatomy ............. 100 The tube — its name and dimensions. Bony portion of tube. Car- tilaginous portion and muscles of tube. Tensor palati muscle. Inner pterygoid muscle. Ligamenta salpingo-pharyngea. Plica salpingo- palatina and the plica salpingo-pharyngea. Mucous membrane. Ton- silla pharyngea. Ditterences in size and shape of tube. Bloodvessels and nerves of tube. The mastoid portion. Cells. Mastoid process and antrum. Limits of the mastoid cells. CONTENTS. XI PAGE Physiology ............. 112 Tlio amount of constnnt jtatulcnce of the normal Eustachian tul)e. Functions of the muscles of the tube. Conjoint physiology of the Eustachian tube, tympanic cavity, and the mastoid cells. SECTION III. INTEKNAL EAK. Chapter I. Labyrinth and Auditory Nerve. Anatomy ............. 120 The vestibule. The ampullar mouths of the semicircular canals. Macul.T cribros*. The cochlea. The canal of the cochlea. The modiolus — lamina spiralis ossea and scalffi. The semicircular canals — dimensions, ampullar enlargement, and planes. Soft parts of the cochlea and lamina spiralis. Crista spiralis, Habenula perforata and zonje. Ductus cochlearis. Organ of Corti. Pillars and arches of Corti. Inner and outer ciliated cells. Mem- brana reticularis — the surface. Membrana tectoria. The auditory nerve ; origin and distribution. Vestibular and cochlear branches. Inner and outer ends of cochlear branch. Soft parts of vestibule and semicircular canals; the membranous labyrinth. The sacculi. Membranous semicircular canals. Sacculi and ampullie — inner surface. Planum semilunare. The otoliths. Topographical arrangements of the soft parts of the internal ear. The endo- and perilymph. Physiological functions. Physiology ............. 140 Audition in the cochlea. Function of the semicircular canals. Experimental researches. Chapter II. Scheme of Kelationship between the Middle and THE Internal Ear. Description of the Middle Ear, of the Internal Ear, and of the relation they hear to each other . . . . . . . . . .153 The tympanic cavity, the foramen ovale and foramen rotundum or the fenestra. The ossicles and their supports ; their connection with the membrana tympani and the inner wall of tympanum. The tym- panum with the Eustachian tube in front and the mastoid cells behind. The internal ear, a water-containing cavity. The vestibule, with the cochlea in front and the semicircular canals behind. The mode of entrance of the nerve of hearing. Xll CONTENTS. PART II. DISEASES AND TREATMENT. SECTION I. EXA3IINATI0N OF PATIENTS. PAGE Chapter I. Instruments and Methods of their Employment. Examination of the Ear . . . . . . . . . .159 Examination of the ear by polarized light. Ear-mirror. Forehead- mirror. Otoscopes, or aural specula, G-ruber's, Politzer's, Toynbee's, E. D. Spear's, and Bonnafont's. Siegle's and Voltolini's pneumatic specula. Blake's operating otoscope. De Eossi's binocular otoscope. Blake's middle-ear miror. Position of patient's body and head. Position of surgeon. Insertion of ear-speculum. Removal of ob- stacles to a view of the membrana tympani. Forceps and cotton- holder. Basin and towel. Syringes and syringing. Examination of the Nares and Fauces, Throat, and Eustachian Tube . 171 Tobold's apparatus. Forehead-mirror and small laryngeal mirrors. Ehinoscopy and rhinoscopic examination of the mouth of the Eusta- chian tube. Eustachian Catheters . . . . . . . . . . .174 Forms of catheters ; Sexton's flexible catheter. Auscultation-tube. Air-bag or hand-balloon. Catheterization of the Eustachian tube ; in- sertion and fixation. Other methods of catheterization. Politzer's air- bag and method of inflation of the Eustachian tube and tympanic cavity. Modifications of this method by Gruber, Lucre, Holt, and others. Chapter II. Sound, Hearing, and Tests of the Latter. Sound and Hearing ........... 180 Definition of sound and hearing. Intensity, pitch, and quality. . Partial or overtones. Musical annotation. The so-called deaf points of the ear. Sound and color. Tests of Hearing 190 1. Aerial and bone-conduction of sound. Normal hearing. The watch. Record of hearing. The stop-watch. Tuning-forks. Tuning- fork in bone-conduction. In diagnosis. Three-limbed auscultation- tube. Interference-otoscope. Tuning-fork vibrating on a parietal protuberance in a normal case. 2. Speech. Perception of high musical tones. Acoustic character of vowels and consonants. Test-sentences and test- words. Whisper- ing and loud tones. Variable hearing. Hearing low tones better than high ones. Effects of position and extent of perforation in the mem- brana tj'mpani on the hearing. Testing the hearing in one-sided deaf- ness. Entotic application of the ear-trumpet. CONTENTS. XIU SECTION II. AURICLE. PAGE Chapter I. Organic Defects and Cutaneous Diseases. Organic Defects ............ 210 Absence of auricle. Plurality and abnormal position. Malforma- tions. Microtia. Congenital tistula of the ear. Cutaneous Diseases ........... 214 Simple erythema. Erysipelas. Intertrigo. Frost-bite. Pem- phigus gangra'nosus. Eczema. Subacute eczema. Acute phlegmon. Chronic phlegmon. Circumscribed inflammation of the cellular tissue. Cornu cutaneum auriculie. Secondary syphilitic eruptions. Tuber- cular syphiloderm. Idiopathic herpes zoster auricularis. Herpes zoster of the tragus. Chapter II. Morbid Growths and Injuries. Mo7-bid Growths 227 Cysts, atheromatous and sebaceous. Angioma. Vascular n»vus maternus. Fibrous or fibro-sarcomatous tumors of the lobule. Sar- coma of the lobule. Glandular hypertrophy of the lobule. Epithelial cancer. Otha?matoma — idiopathic and traumatic. Injuries ............. 242 Traumatic cleft of lobule. Knapp's Mirault-Langenbeck operation. SECTION III. EXTERNAL AUDITORY CANAL. Chapter I. Circumscribed and Diffuse Inflammation. Circumscribed Inflammation ......... 245 Symptoms. Etiology. Treatment — general and local. Diffuse Inflamtnation . . . . . . . . . , .251 Symptoms. Various forms. Causes. Treatment. Epithelial Cancer of the Auditor^/ Canal ....... 263 Otomycosis ............. 203 Forms of fungi found in the ear. Microscopic features. Myringo- mycosis aspergillina. Symptoms. Etiology. Treatment. Chapter II. Foreign Bodies in the External Ear. Foreign Bodies originating within the Ear ....... 274 Collection of cerumen in the ear. Etiology of rapid formation of cerumen. Treatment. Cretaceous bodies in the external auditory canal. Treatment. Laminated epithelial plug in the external audi- . tory canal Etiology. Treatment. Seborrhoea of the auditory canal. Treatment. Pruritus auris. Treatment. Ingrowing hairs from the tragus, resting on the membrana tympani. Treatment. XIV CONTENTS. PAGE Foreign Bodies from without ......... 284 Inanimate objects in the ear. Cases. Animate objects in the ear. Cases. Treatment. Foreign bodies in the Eustachian tube and middle ear. Removal of foreign bodies from the ear. Sexton's foreign body forceps. Partial displacement of the auricle : Operations of Buck, Green, and others Chapter III. Results of Inflammation and Injury. Results of Infiammation .......... 298 Chronic circumscribed ulceration in the external auditory canal. Etiology and treatment. Reflex ulceration in the auditory canal. Cholesteatomatous epithelial impactions in the auditory canal. Treat- ment. Sebaceous tumors, wens, in the auditory canal. Exostoses in the canal. Etiology. Osseous closure of the auditory canal. Etiology and treatment. Cutaneous closure of the auditory canal. Results of Injury ........... 311 Epileptiform manifestations from irritation in the auditory canal. Ear-cough — nature and history. Fracture of the tympanic bone. Bleeding from the meatus externus. Vicarious menstruation from the auditory canal. SECTION IV. MEMBRANA TYMPANI. Chapter I. Acute and Chronic Inflammation, Injuries, and Mor- bid Growths. Acute Inflammation ........... 315 Acute myringitis. Symptoms. Ditferential diagnosis between acute myringitis and acute otitis media. Etiology. Treatment. Abscess of the membrana tympani. Chronic Infiam,m,ation .......... 319 Ulcers in the dermoid layer. Symptoms. Etiology. Treatment. Perforation of the membrana flaccida. Cases. Treatment. Blake's tympanic syringe. Injuries ............. 339 Perforating wounds. Cases. Fracture of handle of malleus. Re- production of the membrana tympani. Medico-legal significance of injuries of the membrana tympani. Morbid Growths ............ 345 "Wart-like bodies on the drum-head. Vascular tumors, moles, and hannatoma of the membrana tympani. Endothelial cholesteatoma of the membrana tympani. Cholesteatoma of the drum-head. CONTENTS. XV SECTION V. MIDDLE EAR. PAGE Chaptkr I. Acute Catarrhal Inflammation. Subjective Symptoms ........... 348 Pain. Vacuum in the tympanum. Effects of talking, coughing, sneezing, and eructation. Hardness of hearing. Tinnitus aurium. Theories concerning its production in general. Autophony. Double hearing, or subjective echo-like sensation; paracusis duplicata; sub- jective alteration in pitch. Cases. Intratympanic pressure during phonation. Acute aural catarrh in infants. Objective Sytnptoms ........... 362 Retraction of the membrana tympani. Spontaneous rupture of the membrana tympani. Course. Etiology. Earache from teething, and from whooping-cough. Diagnosis and prognosis. Treatment ............. 367 Inflation. Anodynes. Spraying the nasopharynx. Paracentesis of the membrana tympani. Chapter II. Chronic Catarrhal Inflammation. Subjective Symptoms ........... 371 Tinnitus aurium. Hardness of hearing. Pain. Throat symptoms. Condition of Eustachian tube. Vertigo. Hearing better in a noise. Hereditary tendency. Objective Syniptotns ........... 376 Appearances in extei-nal auditory canal. Membrana tympani ; changes in color. Calcareous deposits. Changes in position of mem- brana tympani. Implication of the sympathetic and other nerves; flushing of the cutaneous surface adjacent to the ear. Cases. Condi- tion of the nares, pharynx, and throat. Loss of function in the velum. Changes in the voice. Changes in the Eustachian tube. Adenoid growths and granulations in the nasopharynx. Inflation and auscul- tation ; symptoms revealed in Eustachian tube and tympanum. Eflfects of inflation on the membrana tympani. Etiology. Chapter III. Treatment of Chronic Catarrhal Inflammation. Constitutional and Local Remedies ........ 393 1. Introductory remarks. Constitutional Remedies and hygiene. Applications to the nares, nasopharynx, and throat. Direct medication of the nares and nasopharynx by means of sprays and nasal douche. 2. Applications to the Eustachian tube. Excision of the tonsils. Clipping the uvula. Gargles. Applications to the cavity of the drum. 8. Operations with the knife on the drum-head. Permanent open- ings in the drum-head. Methods, eyelets, rings, etc. Tenotomy of the tensor tympani. Operations of Weber-Liel, Gruber, J. Orne Green, and others. 4. Removal of fluid and inspissated matter from the cavity of the drum and Eustachian tube. Cases. XVI CONTENTS. PAGE ElectTicity in Aural Diseases ......... 416 Historical sketch. Mode of application of electricity to the organ of hearine. Brenner's normal formula of the reaction of the auditorv nerve. Investigations of Erb, Moos, and Hagen, and of Sclnvartze, Schulz, and Benedikt. Intratubal electrization. Chapter IV. Diseases of the Middle Ear — Continued. Functional Disturbances .......... 421 Objective snapping noises and murmurs in the ear. Historical sketch. Simultaneous spasm in the soft palate and other muscles ot deglutition. Cases. The author's observation of cases. Etiology. Treatment. Organic Disturbances ........... 433 Extravasation of blood into the tympanum in Brighfs disease of the kidneys. Otitis media ht^morrhagica. Tubercular disease of the ear. Desquamative inflammation of the middle ear; cholesteatoma of the petrous bone. New-formed membranes and bands in the middle ear. The corpuscles of Politzer and Kessel ; "Wendt's examination. Em- bolism in the mucous membrane of the tympanic cavit3^ Malignant growths in nasopharynx, involving the ear. Primary cancer of the middle ear. History, course, and symptoms. Etiology. Treatment. Cancer of the mastoid process. Emphysematous tumor over the mastoid portion. Hairs in the mastoid cells. Traumatism of the mastoid. Case. Chapter V. Acute Purulent Inflammation. Subjective Symptoms ............ 445 Itching in throat and ear. Pain. Alteration in hearing. Vertigo, fever, and delirium. Objective Si/tnptoms ........... 447 Membrana tympani ; changes in color, spontaneous rupture. Course ............. 448 Possible fatality of the acute form of purulent inflammation of the middle ear. Cases. Etiology 451 Cold bathing ; its cft'ects on the middle ear. Acute inflammation of the tympanic cavity produced by concinjeion. Diagnosis ............. 454 General remarks. Earache from decayed and otherwise diseased teeth. Sexton's observations. Appearances of the membrana tym- pani, difl'erential diagnosis. Prognosis and Treatment .......... 450 Nature and object of treatment. Depletion and anodynes. Para- centesis of the drum-head. CONTENTS. XVll PAGE Chapter VI. Chronic Purulknt Inflammation. Etiolor/y and Symptoms .......... 459 Introductory remarks. Diphtheria as a cause. Chief syinptoins, hardness of hearing and persistent discharge. Appearances of external auditory canal. A ppearances of the drum-head and the tympanic cavity. Treatment ............. 466 Introductory ronarks. The advantages of a dry local treatment. Tables illustrative of the dry treatment. Powdered substances for in- sufflation. Chief fluid remedies to check the chronic discharge. Mode of instilling nitrate of silver. Alum and other astringents in solution, used in chronic otitis media purulenta. CuAi'TER VII. Course and Consequences of Chronic Purulent In- flammation OF THE Middle Ear. Hardness of Flearing and Deafness ........ 479 The artificial membrana tympani, history and forms. Mode of ap- plication of the artificial membrana tympani. Action of the artificial membrana tympani. Its protective function. Paj)er disks of Blake. EpUeptifor')n Manifestat'w)is and other Nervous Phenomena. . . . 485 Introductory remarks. Elioiogy and treatment. Various nervous phenomena produced by chronic purulent inflammation of the middle ear. Paralysis of the facial nerve. Cases. Alterations in gait. Irri- tation of the chorda tympani. Anomalies of taste and salivary secre- tion in chronic purulent disease of the tympanum. Vertigo and reflex psychoses from chronic purulent inflammation of the middle ear. Granulations and Polypi .......... 494 Polypoid hypertrophy of the mucous membrane of the middle ear. Treatment of granulations. Aural polypi. Classification and histology ; granulation-tumors, soft papillomata, fibromata, myxomata, angioma, cysts, etc. Organized vesicular polypus, containing necrosed long process of the incus. Symptoms of polypus in the ear. Spontaneous detachment of polj'pi. Treatment of aural polypi. Forms of instruments for the removal of polypi. Use of the snare. Treatment of ear after removal of aural polypi. Chapter VIII. Course and Consequences of Chronic Purulent Inflammation — Continued. Ulceration of the Mucous Membrane of the Tympayiic Cavity, Periostitis and Caries of various parts of the Temporal Bone, and their results . 511 Exfoliation of the cochlea. Exfoliation of the cochlea, vestibule, semicircular canals, and deeper parts. History and treatment. Mastoid disease ; symptoms and course. Periostitis of the outer sur- face of the mastoid portion of the temporal bone. Congestion and inflammation of the mucous membrane lining the air-cells of the mastoid cavity. Caries and necrosis; followed by meningitis, throm- bus in the lateral and other sinuses of the brain, embolism, pyiemia, and cerebral abscess. Cases. Treatment of mastoid disease. B XVlll CONTENTS. PAGE Artificial perforation of the mastoid portion of the temporal bone. History. Modes of perforating and trephining the mastoid. The point to be chosen for the operation. Instruments to he used. SECTION VI. DISEASES OF THE INTEENAL EAE. Chatter I. Primary and Secondary Inflammation. IntToductory Remarks .......... 527 Anomalies of formation. Ana-mia, hj-pertemia, and inflammation of the internal ear. Hyperemia of the labyrinth. Primary Iriflamination of the Internal Ear ...... 530 History, observations of Deleau and Meniere. Meniere's disease, or labyrinthine vertigo of Hinton. Observations of Brunner, and othei-s. Otitis labyrinthica of Voltolini. Etiology and treatment of primary inflammatory disease of the labyrinth. Injuries. Fracture of the base of the skull. Cases. Symptoms. Secondary hiflam.'tnation of the Internal Ear ...... 536 Deafness from concussion. Cases. Hardness of hearing, and total deafness after cerebro-spinal meningitis. Observations of various authorities. Prognosis and treatment. Disease of the internal ear from syphilis; from typhoid fever. Aural disease in rachitic aflections. Aural Vertigo ............ 5-14 Structure of the auditory nerve in connection with semicircular canals. Symptoms of aural vertigo. Differential diagnosis. External ear vertigo. Illustration. Middle ear vertigo. Internal ear vertigo : clinical history and symptoms. Central ear vertigo. Apparent motion during the vertigo. Treatment. Conclusions. Chapter II. Morbid Growths of the Auditory Nerve. Fibrous Tumors ............ 555 Cases of Landiforth, Leveque-Lasource, Boyer, Carre, and others. Sarcoma ............. 556 Cases of Voltolini and Foi-ster, Cruveilhier, Moos, and Bottcher. Symptoms. Tumor of each auditory nerve, case with ante- and post- moi-tem notes. Microscopical examination of both cochlew. Case of probable cerebral tumor ; aural notes. Pathological changes in the organ of Corti in a case of cerebral tumor. Fibj'o-sarcoma ............. 564 Observations of Bottcher. . Case of tumor involving common trunk of auditory and facial nerve. Changes in the vestibule and semicir- cular canals. Glioma of the auditory nerve. CONTENTS, XIX PAOR The Labynnth in Ileo-tyjihus ......... 666 Fatty metamorphosis of the organ of Cforti. Amyloid degeneration. Morbid States of tJie Auditory Nerve ........ 566 Hallucinations of hearing in the insane; bruit de diabte. Nervous deafness. Hysterical deafness. The effects of quinine and salicylic acid on the ear. Observations of Koosa, Spencer, Kirchner, and Weber-Liel. SECTION VII. DEAF-MUTES AND PARTIALLY DEAF CHILDREN. Chapter I. Methods or Relief and Education. Deaf-dumbness ............ 570 Introductory remarks. Congenital and acquired forms of deaf- dumbness. Modes of instruction by dactylology and lip-reading. Bell's system of visible speech. Partially Deaf Children .......... 574 Remarks and statistics. Methods to be adopted in teaching partially deaf children. Suggestions of C. .1. Blake and Samuel Sexton. Ear- trumpets. LIST OF ILLUSTRATIONS. FIG. 1. 2. 3. 4. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26, 27. The auricle Muscles of the auricle, outer surface Cartilage and muscles of auricle, posterior view Excessive pubescence of auricle .... Diagram representing the topographical relation of the component reso- nant cavities of the external ear .... Centres of development of the temporal bone . Outer surface of left temporal bone .... Inner surface of left temporal bone .... Under surface of left temporal bone Vertical section of the external auditory canal, membrana tympani, and tympanic cavity ....... The auricle and the cartilaginous part of the external left side . Posterior wall of the left external osseous and cartilai canal ......... View of the outer surface of membrana tympani . Normal membrana tympani ; left and right (Ellis) (Henle) (Gray) (Gray) auditory canal ; . (Politzer) ginous auditory . (Politzer) . (Gruber) >■ Diagram of section of stretched membrane . Geometric divisions of the membrana tympani . . . (Kessel) View of inner surface of membrana tympani .... (Gruber) Membrana tympani of a dog ......... Malleus (Henle) Ligamentous support of ossicles viewed from above . (Helmholtz) Incus ........... (Henle) Stapes ........... (Henle) Plight tympanic cavity viewed from above; malleo-incudal and incudo- stapedial joints ......... (Henle) Vertical section of the right Eustachian tube, tympanic cavity, and mastoid cells, with inner surface of the squama above, viewed from within ............. Diagrammatic representation of the formation of the so-called pouches of the membrana tympani ......... Section through the long axis of malleus at right angles to the membrana tympani, from an adult ...... (Brunner) PAGE 20 20 21 23 33 37 38 39 40 43 44 45 48 48 51 50 61 63 67 70 71 73 78 79 XXll LIST OF ILLUSTRATIONS. PIG. 28. 29. 30. 31. 32. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 4.''). 46. 47. 48. 49. 60. 51. 52. 53. 54. 55. 56. 57. 58. 59. 00. 61. 62. 63. 64. 65. 66. Inner wall of tynapanic cavity ...... (Gray) Nerves in and about the tympanum ..... (Heath) View of otic ganglion ........ (Ellis) Nerves joining the enlargement of the facial nerve ; right side (Ellis) Transverse section of the cartilaginous part of the Eustachian tube near the foramen ovale ........ (Henle) Diagrammatic section through the Eustachian tube ; the muscles ahd fasciie (Weber-Liel) The nasopharynx viewed from behind ..... (Zaufal) Diagram of the same, with descriptive numerals ..... Mastoid portion of the left temporal bone, laid open and viewed from behind ............. View of the entire right middle ear, laid open by incision from above downward, through the centre of the cavity, parallel to the long axis (Gruber) External view of a cast of the left labyrinth .... (Henle) Section of the pyramidal portion of the right temporal bone through the vestibulum, parallel with the outer wall of latter; view of inner wall (Henle) Osseous cochlea laid open ........ (Henle) Transverse section of the first coil of the cochlea of a child one and a PAGE 80 86 88 88 102 104 106 106 110 half years old . . . , . Transverse section of the organ of Corti Membranous labyrinth of man Transverse section of the bony and the membranous semicircular canal (Riidinger) (Riidinger) (Riidinger) (Waldeyer) of man .... Transverse section of an ampulla of a fish : floor and wall Otoliths from various animals .... Scheme of the membranous labyrinth of mammals Complete auditory apparatus of man ; natural size Ear-mirror ....... Illumination of ear by means of forehead-mirror Gruber's aural specula Bonnafont's otoscope Siegle's pneumatic otoscope Kramer's ear-speculum . Blake's middle-ear mirror Delicate forceps for removing foreign bodies from the ear Cotton-holder Ear-syringe with accessory conical nozzle Tin basin used in syringing ear Tobold's laryngeal apparatus . Porehead-miror ..... Eustachian catheters of hard rubber Bonnafont's nose-clamp .... Sexton's flexible catheter ; small hard- rubber catheter, natural Auscultation-tube Insertion of the Eustachian cathete (Waldeyer) (Waldeyer) (Riidinger) size 116 120 121 123 126 129 133 134 136 137 138 154 160 161 162 163 164 164 166 168 169 169 170 172 173 175 176 177 178 179 LIST OF ILLUSTRATIONS, XXlll FIG. 67. Inner view of the right half of tlie liead; antero-postcrior section; Eustachian catheter in situ (Gruher) 6S. Fixation of the Eustachian catheter in position, preparatory to inflation 69. Politzer's air-bag for Inflating the middle ear 70. Blake's tuning-fork ...... 71. Clinical tuning-fork ...... 72. Konig's rod as modified hv Blake .... 73. Portions of supernumerary auricle on a woman 74. Supernumerary tragus on a hoy .... 75. Eight auricle of hoy, eight years old 76. Left auricle of same, congenitally deformed . 77. Othivmatoma and resultant deformity (Gruher) IS. Delineation of operation on cleft lobule (Knapp) 79. Insufflation of powders into the ear under illumination by the forehead- mirror ............ 80. Early mycelial web of Aspergillus nigricans ..... 81. Formation of fruit-stalk and fructiferous head of same . . 82. Ripe aerial fructification of Aspergillus nigricans ; a. A.«pergillus gUuKUS 83. Forceps for removal of foreign bodies from the ear .... 84. Sexton's foreign-body forceps 85. Blake's middle-ear syringe ; natural size ...... 86. Blake's new tympanic syringe 87. Aural douche 88. Paracentesis-knife ........... 89. "VVeber-Liel's graduated metallic Eustachian catheter and bougie catheter of gummed silk ......... 90. Politzer's eyelet and eyelet forceps ........ 91. Politzer's monometer .......... 92. Insufflation of powdered applications to the ear ..... 93. Section of a granulation-tumor polypus, from a microphotograph of a specimen, prepared by Drs. R. W. Seiss and Walter Chrystie for the author ............ 94. Section of a soft papilloma-polypus, from a microphotograph of a speci- men prepared by Drs. R. W. Seiss and Walter Chrystie for the author 95. Wilde's snare ......... 96. Blake's Wilde's snare with adjustable [-.aracentesis-needle 97. Aural polypus-snare, with fenestrated canula; natural size 98. Sexton's polypus snare, with notched slide for fastening the ends of the wire ......... 99. Silver probe for manipulating polypi 100. Permanent platinum- wire loop on flexible shaft 101. Polypus hook 102. Mastoid sequestrum, outer surface .... 103. ^lastoid sequestrum, inner surface .... 104. Mastoid sequestrum, outer surface .... 105. Mastoid sequestrum, inner surface .... 106. Strong knife for incising softened outer mastoid table 107. Drill and bit for perforating the mastoid portion of the temporal bone (A. H. Buck) PAGE 180 182 184 193 193 200 211 211 212 212 236 243 260 265 266 266 281. 296 324 325 368 369 399 405 425 471 498 499 503 503 504 505 506 506 507 516 516 518 518 524 525 PART I. ANATOMY AND PHYSIOLOGY. SECTION I. EXTERNAL EAR CHAPTER I. THE AURICLE. ANATOMY. The external ear comprises the auricle and the external audi- tory canal. The auricle, or ear of common language, is formed of a cartilaginous sheet, from one to two millimetres thick, with various depressions and elevations. Extrinsic and intrinsic liga- ments and muscles are inserted into it; it is well supplied with bloodvessels, lymphatics, and nerves, and it is covered with skin. The auricle has no connection in its develooment with the branchial clefts,^ but is an entirely independent formation from a little ridge of skin like that which forms the ej'clid; the otic vesicle does not reach the surface, but an involution extends from the little prominence, which is to form the outer ear, towards the site of the otic vesicle; this is the meatus externus. (Moldenhauer.) All the important parts of the auricle were found by Lowe in a human embryo, only one centimetre in length, showing that this part of the body is formed before the upper and lower ex- tremities, since in the case examined there were as yet no signs of separation or differentiation into these parts. ^ The auricular cartilage is of the reticular variety, and the various depressions and elevations into which it is twisted have received the following names : helix, antihelix, fossa of the helix, fossa of the antihelix, the tragus, the antitragus, the lobule, and the concha. The entire auricle is also called the pinna. These portions of the auricle have received other names from some authors, but those given here are, perhaps, the most ^ Some recent opinions concerning the development of the external ear passages. David Hunt, American Journal of Otology, vol. i., 1879, p. 252. ^ Archiv f. Ohrenheilkunde, vol. xiii. p. 167. 20 EXTEENAL EAR, commonly used in English. Henle and others give to the fossa helicis the name of fossa navicularis or scapha, and to the fossa antihelicis the name of fossa triangularis. I prefer, however, the names suggested by Gray, because they will naturally occur to any one acquainted with the anatomy of the auricle, and the combination of a few words will supply the terms necessary in the designation of the various parts of the pinna. Pi Fig. 2. The Auricle. — a. Helix, c. Antihelix. b. Fossa of the helix, d. Fossa of the antihelix. e. Tragus. /. Antitragus. h. Lobule, g. Concha. Muscles on the Outer Surface of the Cartilage of the Auricle. (Ellis.) — 1. Muscle of the tragus. 2. Muscles of the antitragus. 3. Large muscle of the heli.x. 4. Small muscle of the helix. Muscles of the Auricle. — The extrinsic muscles of the auricle are those which move it as a whole, and are the Attollens aurem, Attrahens aurem, and Retrahens aurem. The intrinsic muscles of the auricle, or " proper muscles of the ear," are seven in number. These have also been denomi- nated vestigia, a name well chosen as indicative of their condition in man. These muscles, with one exception, run between the various portions of the auricular cartilage and the externa] auditory canal. They are all muscles of animal life; but on account of their extreme thinness are pale, and lie immediately upon the cartilage, into the hbrous layer of which they are inserted by means of short tendinous fibres. They are not equally per- sistent; whether they are all equally developed at first and finally become atrophied through disease, can only be decided by a statistical comparison of the ears of adults and children.' 1 Henle, Eingeweidelehre, S. 726. THE AURICLE. 2X Five of the proper muscles are on the anterior surface and two are on the posterior surface of the auricle. Those on the anterior surface of the auricle are the tragicus, the aniitragicas, helicis major, helicis minor, and the two on the posterior surface are the transversus auriculce and the obliquus aaricuke. Fiii". 3. a -I d Cartilage and Muscles of the Auricle, Posterior View. (Henle.)— /. Cartilage of external auditory canal, e. Surface of attachment of same to the edge of the bony canal. d. Cartilage of the pinna, e. Cauda helicis. I. Eminentia scapha3. g. Eminentia foss* conchse. h. Transverse muscle of the auricle, h. Oblique muscle of the auricle. In some rare cases, a third muscle is found in the auditory canal, and is called the M. ineisurce Santorini. It lies below, and further in the auditory canal than, the M. tragicus. Ligaments of the Auricle. — The ligaments of the auricle may also be divided into an extrinsic and intrinsic set: The first con- nect the auricle with the side of the head, and the second con- nect the various parts of the cartilage together. The former, the most important, are two in number, anterior and posterior. The anterior ligament extends from the process of the helix to the root of the zygoma. The posterior ligament passes from the posterior surfac'e of the concha to the outer surface of the mastoid process of the temporal bone. A few fibres connect the tragus to the root of the zygoma. Those connecting the various parts of the cartilage together are also two in number. Of these, one is a sti^ong fibrous band, stretchino; across from the tragus to the commencement of the 22 ESTERNAL EAR. « helix, completing the meatus in front, and partly encircling the boundary of the concha; the other extends between the concha and the processus caudatus.^ Bloodvessels and Lymphatics of the Auricle. — The arteries sup- plying the auricle are, the ■posterior auricular, from the external carotid: the anterior auricular, from the temporal; and the auric- ular branch, from the occipital. The veins follow the arteries in their general distribution. The auricle is supplied with a beautiful and very rich network of capillary lymphatics, an important consideration in aural disease. Nerves of the Auricle. — The nerves are most numerous on the posterior surface of the auricle, while the concave surface and the lobule are comparatively poorly supplied with nerves. In some of the lower animals, the mole variety especially, the nervous supply of the auricle is so rich and so peculiar in its development, as to endow the auricle with valuable tactile powers.^ The nerves of the auricle are derived from the auricu- laris magnus, from the cervical plexus; the posterior auricular, from the facial; the auricular branch of the pneumogastric ; and the auriculo-temporal branch of the inferior maxillary nerve. Integume7it of the Auricle. — The cutis of the auricle is a con- tinuation of that of the face and head, which, after covering the cartilage, forms a fold at its base, called the lobule. In some rare instances the cartilage of the auricle may extend into the lobule, and then the usually harmless operation of piercing it for purposes of adornment may give rise to serious chondritis. The auricle is abundantly supplied with sebaceous glands from 0.5 to 2.0 mm. in diameter, which are most numerous and highly developed in the concha. The entire surface of the pinna or auricle is covered with downy hairs, which attain their most luxuriant growth near the meatus and on the tragus, to which fact the latter spot owes its name of "goat" or tragus. Some- times the antitragus and even the lower part of the helix may be copiously supplied with hair, as in Fig. 4, the auricle of a man fifty 3^ ears old. Sudoriferous Glands. — The sudoriferous glands are most abun- dant on the posterior surface of the auricle, an important con- sideration in the management of the ears of infants, for if their 1 Gray's Anatomy, p. 629. ^ Max Scluiltze's Arcliiv, 1870. THE AURICLE. 23 auricles are pressed constantly against the head, as is too apt to be the case, chafing of these parts must be the inevitable result. Fie:. 4. The modified sudoriferous o-lands of the cutis of the external ear are developed into ceruminous glands in the external audi- tory meatus.^ PHYSIOLOGY. The use of the extrinsic auricular muscles is usually very im- perfectly developed in man, although the ability to move the auricle is now and then met with even in the most cultivated. It has, however, been supposed, that as civilization has elevated man above a merely animal existence, the power to move the auricle freely and voluntarily, has diminished since the necessity of such a function would cease with a less savage life. Such indeed seems to be the rational view to take of the use of these muscles. That they are capable, however, of cultivation does not seem to be an uncommon observation. All are familiar with the story of Albinus, the anatomist of the eighteenth cen- tury, who could move his auricles so well, that he was in the habit of removino; his wic; in order to demonstrate to his class the power he possessed over his ears. ' Kessel, Strieker's Tlandbuch, p. 841. 24 EXTERNAL EAR. Sir Astley Cooper has recorded a case^ in which the auricles were in constant motion whenever s^reat attention was neces- sary. Two physicians of my acquaintance can move the auricles markedly with ease. I have very often seen the auricles move unconsciously in my patients, when standing behind them, and they were obliged to be more than usually attentive. But this motion was not continual ; it appeared to me to be an entirely involuntary endeavor to adjust the auricle in the most advan- tageous position for hearing. When suddenly surprised by an unusual or loud noise, I am sensible of a very marked move- ment, entirely involuntary, of my own auricles. I have seen marked contraction in the region of the tragicus and antitragicus muscles, during the application of the constant electric current by means of a ball-electrode. The power to move the auricle is not dependent, apparently, alone upon the illy developed muscles of the ear, as has been pointed out by Samuel Sexton,- of New York. Accordmg to this observer, the attoUens aurew. and attrahens aurem are aided in this performance by the orbicularis oris and the oecipiio- frontalis muscles. These last-named muscles are said to be able, by conjoint action, to make tense the fascia in front of and just above the tragus, and when this same force is exerted upon that portion of the deep temporal fascia extending along the anterior margin of the osseous meatus until lost in the anterior ligament of the auricle, the drum-head itself would be made more tense, especially the more distensible portion, known as the membrana flaccida, which is in reality a continuation of the skin of the external auditory canal. Dr. Sexton, aided by Dr. S. H. Pinkerton, made a dissection of an ear in a recent subject, in order to determine the extent of "the motion thus transmissible through the deep temporal fascia to the motor (drum-head) of the transmitting mechanism of the ear. Eirst, the deep temporal fascia was dissected up to where it is blended with the anterior ligament of the auricle. At this stage of the proceeding it was found that traction on the deep temporal fascia moved the auricle freely. The anterior attach- ment of the auricle was then divided, and a section of the petrous bone was made by sawing down through the tympanum from above, separating the incus from the stapes and bisecting the tensor-tympani muscle in its bony canal, leaving the rest of the mechanism of the middle ear intact, with the exception of a slight laceration of the drum-head at its inferior segment. It was now found that if that portion of the tensor tympani left attached to the manubrium mallei was made taut and so re- 1 Phil. Trans., London, 1800. ^ New York Medical Record, Nov. 17, 1883, p. 543. THE AURICLE. 25 tainecl in the grasp of forceps while traction was made as before on the temporal fascia, which had been dissected up, the trans- mitting mechanism responded promptly and became more tense than before. When alternate tension and relaxation were prac- tised on the fascia, the drum-head tightened and relaxed like- wise, the motion being perceptible to the eye. These apparently demonstrable influences of muscular action in the middle ear mechanism in man, are similar to those which in a more perfect manner are obtained in the horse, dog, and other animals by means of the voluntary action of their more efficient muscles." The general opinion is that a small ear, well shaped, is a sign of careful breeding, whereas the large elephantine auricle is accepted as a type of vulgarity ;^ however, the unfortunate pos- sessor of a large auricle is compensated for his so-called mis- fortune, by the popular belief that the large auricle is a sign ot good nature and generosity. This may be the modern idea, but Giotto, in his drawing of Envy, in the chapel of the Arena at Padua, represents the auricle as superhuman in size, its long axis as a continuation of that of the horizontal ramus of the in- ferior maxillary bone, and without a lobule. It is also a matter of interest that the position and shape of the auricle are race-peculiarities. In the Egyptians they are placed high on the side of the head, as may be seen in the present day, and also in the rude attempts at artistic portrayal in their very ancient monuments and statues. Prof Meyer^ states that it has already been noted by previous observers that malformations of the external ear are found in the greatest number in connection with arrested development in the region of the lirst (Iviemenspalte) branchial or visceral fissure, viz., with cleft palate, and other forms of retarded development in the bones of the head and face. The explanation of Virchow, that these changes are due to inflammatory processes in the earlier days of fptal development, seemed sufficient to Meyer, until, as he says, he instituted a careful examination of the form and position of the external ear, in a number of insane people, manifesting those pecularities described and called by him cranium progenicum. In all these cases there was a relative arrest of development of the bones of the face, especially a mal- formation of the inferior maxilla, and it should be borne in mind that the inferior maxilla is formed through ossification in the membrane of the visceral arch. The expectation of finding, in just such cases, characteristic forms of the ear, was not realized, ^ Parva' malos mores docent, macjnu' ot erectte indices sunt stultitite aut loquaci- tatis. Opera Galeni, iv. 707. Kiihn, Leip^ic, 1833. * Llidwig Meyer, Ueber das Darwinische Spitzohr. Virchow's Archiv, Band 53. Heft 4. 26 EXTERNAL EAR. and the theory appeared the less tenable the further the investi- gation was extended to numerous oases of both the insane and the sane. Pathologically, the result of the investigation is con- sidered by Meyer to be unimportant, and he expresses a belief that the significance of the form and position of the external ear is purely of a physiognomical character. In connection with a beautiful, well-formed face, we usually- find a round, well-formed, small and close-lying ear; whereas, in macrocephalic heads we find large, massive, in some cases real elephantine ears; while the narrow ear directed backward, the so-called Faun's ear, accompanies a low, retreating forehead, sharp nose, and narrow chin. A comparative examination of normal male heads seems to indicate that the position of the ear possesses a certain and constant relation to the architecture of the skull, for female heads, with a large facial angle, show a more vertical position of the auricle than is usually seen in females and in children, wdio possess, as a rule, small facial angles. In women and children we often find, in connection with a large facial angle, obliquely placed ears, so that the upper part of the helix points backward, and the posterior portion is di- rected downwards. The cause of this is to be sought for in the relation of the ramus to the body of the inferior maxilla rather than in the relations of the superior maxilla and the frontal bones to one another. The explanation of the connection be- tween the position of the ramus of the inferior maxilla and the external ears is to be referred to the development of those por- tions of the face from the same part of the branchial arch, ^ot only the position of the ears, but the elevations and depressions of the auricle vary even in the same individual. Mr. Darwin's ideas of the significance of certain prominences in the helix are thus given by that distinguished observer: "The celebrated Mr. Woolner informs me of one little peculiarit}' in the external ear [i. e., auricle) which he has often observed both in men and women, and of which he perceived the full signifi- cation. His attention was first called to the subject while at work on his figure of Puck, to which he has given pointed ears. He was thus led to examine the ears of monkeys, and subse- quently, more carefull^y, those of man. The peculiarity con- sists in a little blunt point, projecting from the inwardly folded margin, or helix These points not only project inward, but often a little outward, so that they are visible when the head is viewed from directly in front or behind. They are variable in size and somewhat in position, standing either a little higher or a little lower; and they sometimes occur in one ear and not in the other. Now, the meaning of these projec- tions is not, I think, doubtful; but it may be thought that they THE AURICLE. 27 offer too trifling a character to be worth notice. This thought, however, is as false as it is natural. Every character, however slight, must be the result of some definite cause, and if it occurs in many individuals, deserves consideration. The helix obvi- ously consists of the extreme margin of the ear folded inward, and this folding appears to be in some manner connected with the whole external ear being permanently pressed backward. In many monkeys which do not stand high in the order, as baboons and some species of maccaus,^ the upper portion of the ear is slightly pointed, and the margin is not all folded inward; but if the margin were to be thus folded, a slight point would necessarily project inward and probably a little outward. This coukl actually be observed in a specimen of the Ateles beel- zebuth in the Zoological Gardens; and we may safely conclude that it is a similar structure — a vestige of formerly pointed ears — which occasionally reappears in man."^ Prof Ludwig Meyer,^ in an article referring especially to Darwin's idea, that the common, small projections in the helix of the ear are remnants of the pointed ear of certain Simian races, says that too much importance has been attached to the deviations in the form of the auricle, but he admits that fre- quently we find irregularities in the edge of the helix. To one of these, more prominent than the others, Darwin has attached the sigaificance already alluded to. l^ow, the edge of the helix is rarely completely smooth, and even when any slight inequality of the helix escapes the eye, the finger can readily detect it. These fire really deficiencies and not absolute prominences, and the wider the loss of substance in the helix-cartilage, the more prominent will the remaining portions appear. If, in an ear where one or two such prominent remnants of the helix occur, a line be drawn joining them, it will correspond with the outline of the normal helix. That these prominences are nothing more than remnants of the helix, is proven by the fact that their inclination and curve correspond entirely with the curve of the helix. That parf of the helix which affords the most examples of the peculiarity referred to by Darwin, is best adapted to producing the longest points, since it is the widest portion of the curved helix. These changes in the ear are doubtless not produced during life, but are congenital. They are found in perfection in little children, and are more apt to occur in males than in • See also some remarks and the drawings of the ears of the Lemuroidea in Messrs. Muril's and Mivart's excellent paper in Transact. Zool. Soc, vol. vii. pp. 6 and 90, 1869. ^ Darwin, Descent of Man, vol. i. pji. 21 and 22. ^ Lvidwig Meyer, Ueber das Darwinische Spitzohr. Virchow's Archiv, Band 53, Heft 4. 28 EXTEENAL EAR. females. According to Kollman, the helix is not a separate point of development. The auricle consists originally of those formative parts which can be distinctly recognized at the end of the sixth week of foetal life, as tragus, antitragus, and anti- helix. From the latter the helix is developed. Hence we see that as interferences in the development of the tragus may cause the presence of a cleft in it, so may disturbances in the develop- ment of the antihelix cause deficiencies in the helix. Laycock' observes that men of high intellectual attainments, great capacity' for mental labor, and great force of character, have a full, perfectly ovoid ear, the helix well developed, the lobule plump, pendent, and unattached to the cheek at its an- terior margin. These characteristics are seen in all portraits of great men which Lavater gives, and are easily observed in living celebrities. The same writer also says: "In a perfect ear the ovoid lobule hangs from the cartilage with a rounded lower margin, which, at its inner border, is not confluent with the face. ISTovv, if this inner margin be adherent to the cheek, and at the same time the lobule be only a segment of an ellipse, there is more or less tendency to imperfect cerebral action. A more impor- tant form is seen when the lobe is not only soldered to the cheek, but its posterior half cut away, as it were, and the helix defective." A knowledge of these peculiarities in the ear of an individual may become of great legal value, as in the Tichborne case, in which it was shown that the "claimant's" ears were altogether different from those of the lost heir. Comparative Functions of the Auricle. — The functions of the auricle are modified by the habits of the animal, and, since in most four-footed mammals the external ear is w-ell developed, we have an opportunity of observing in them a variety of functions, acoustic and other, acquired by the auricle. The large, long, and easily moved auricles are Ibund in animals that are timid and often pursued l)y stronger and sagacious animals, while those which pursue, as lions, tigers, etc., possess auricles which are short and directed forwards. We have no positive means of finding out how sounds are modified by these |)eculiarities in the auricles of these animals. However, by ai)plying a variety of speaking-trumpets to our ears, and by alterations in the position of these artificial auricles, as well as of our own by manipulation, w^e may form, at least, an approximate idea of the modification in hearing produced by the si/-e, shape, and position of the auricle. By such experi- ' London ^NrfHliciil Tinios and (iaz.ettc, March 22, 1862. THE AURICLE. 29 ments we see that it is highly probable that ordinary sounds are augmented, and faint sounds rendered very audible to animals with largely developed auricles, by the increased resonance such organs produce, a function of the auricle useful to animals which are rapacious as well as to timid ones which are pursued. The auricle is small in seals, walruses, moles, and the manis, but largely developed in some species of the bat, and "is so con- structetl as to prevent air from rushing in while flying."^ In birds, the auricle is wanting, as it would probably greatly impede their liight, but in night birds, the power to elevate the feathers around the ear seems to indicate that they can supply themselves at will with a kind of auricle, and that their hearing is thereby augmented, a necessity due to their nocturnal pur- suits. The auricles of the mouse^ and of the hedgehog-'^ are developed into organs of touch, and the auricles of marine mammals seem to become almost useless; as in the narwhal "the opening of the ear is of the diameter of a knitting-needle,* and in the leopard seal the ears are merely openings in the surface of the skin, which are placed an inch and a half behind the eye,"^ while in the sea-otter'' the "ears are less than an inch in length," the animal being at least five feet lono-. In the water-shrew, an aquatic mammal, the antitragus serves as an operculum to the auricle, which fact seems to indicate that the auricle is no longer needed for hearing as soon as the animal ceases to live in the air. In the crocodile, also, the auricle acts as an operculum, and in the whale it is practically absent. Therefore, the fully developed auricle is needed by and found in mammals whose life and condition are aerial, and we find that it ceases to exist, or its functions are altered, in mammals inhabiting the water or living underground. The auricle of the Blamia brevicauda, a water-shrew, is a remarkably complicated structure.'' It is valvular in its function, so as to keep water from entering the external auditory canal. The auricle in this animal is folded forward, there is no lobule, hair grows on the back surface, which in the peculiar develop- ment becomes the outer surface, and fits so closely over the meatus as to look as though the animal had no external ear, and has given rise to the name of" anotus " or " cryptotus," as applicable to this creature. ^ J. Williams, Treatise on the Ear, London, 1840, p. 35. 2 J. Schobl, Max Schultze's Archiv f. Mic. Anat., 1871, p. 260, four plates. 3 Ibid.. 1872, p. 295. * Marine Mammalia of North America, by Chas. M. Scammon, 17. S. Rev. Marine, p. 108. » Ibid., p. 165. G iijij^ p ]gg ' Outer Ear of Blarina Brevicauda, Dr. Elliott Coues, U. S. A., American Journal of Otology, vol. i., 1879, p. 161. 30 EXTERNAL EAR. Resonant Functions of the Human Auricle. — As early as 1840, J. Williams, M.D., of London, attributed to the "configuration and tension of the auricle " the function of determining the "finesse of hearing." This author was led to such a conclusion by the augmentation of sound obtained by pressing forward the auricle, and surroun.ding it by the hand, but he erroneously referred the improved hearing which ensued to the overcoming of what he termed a relaxed condition of the auricle by the support of the hand. It was, on the contrary, due to the aug- mented resonance of the auricle, brought about by the relative lengthening of the external ear, by pushing the auricle out from the head, and adding to it the resonance of the hand. It is evident, therefore, that writers on the ear long ago noted the phenomena of alteration in the resonant functions of the ex- ternal auditory apparatus caused by increase or diminution of its depth and position; but that these phenomena depended upon the power of the auricle and the external auditory meatus to act as resonators was not suggested nor proven until Hemholtz's experiments in acoustics had rendered the subject of resonators clearer, and experiments on the human ear demonstrated that the most probable function of the auricle is that of a resonator, adapted to augment just those high notes or sounds most likely to be of interest and importance to man. According to Dr. Klipper,^ the auricle can reflect sound into the auditory canal only to a limited extent, "because that .part of the auricle which would reflect the sound-wave falling on it, into the auditory canal, is very small." ISTor does he believe that it is concerned in the direct collection and transmission of sound as the drum-head is, for it is neither so elastic as the latter, nor is it inserted into a bony frame. He also denies it the function of determining the direction of sound, which, he thinks, ma}^ be proven by inserting into the meatus, a tube of any kind, thus cutting ott' all participation of the auricle in the reception of sound, when it will be found that the direction of sound can still be told. This author appears to be wrong in his assertion that the auricle can have no influence in hearing, for it is well known that with the altered shape of the auricle in othsematoma, the hearing is altered. He furthermore ararues that the auricle in man is useless, because birds have none; but birds do not need an auricle, on account of the high resonance of their auditory canal, as well as the interference in flying such an appendage would entail. Dr. Kiipper, therefore, places the auricle of man in the "list of organs inherited, but no longer possessed of functions." He, however, ascribes an important part to the * A.rchiv f. Ohronlieilkniuk', vol. viii. p. 158. THE AURICLE. . 31 auricle in the lower animals, agreeing with Mliller^ that as it is supplied with so many (17) well-developed muscles, it is well adapted to catch sounds, but especially to express the passions ot" the animal, as is best seen in the horse. Dr. Kiipper, how- ever, apparently does not believe that the auricle ot" man, while losing the function so sharply seen in the lower animals, gains the higher and more delicate one, of a resonator for the nobler tones of the human voice, as shown by the author. Prof. E. Mach^ considers the auricles in the lower animals, resonators for the higher tones of ordinary sounds important for them to hear, such as the rustling of grass and leaves. This function depends partly upon the ability of the animals to place tlie auricles towards the direction of the sound, and thus to alter the clang-tint, which leads to a proximate knowledge of the direction of the sound. A remnant of such a function may still be found in the human auricle, according to Mach, which agrees with the theories advanced, previous to those of Mach, by the author.^ In the summer of 1878, while I was travelling and exposed to a great variety' of powerful. sounds, of nature and of commerce, I made some experiments on my own external ears, respecting their power of receiving all or part of the component tones entering into such complex sounds, as the rustling of leaves, the roar of Niagara, the seething and hissing noise heard in the wake of a large steamer, or in the escape of steam from a powerful locomotive or steamboat. I found that by altering the position of my auricle, that is, b}- relatively lengthening thereby the depth of the external auditory canal, I could analyze the composite sounds alluded to, for if I pressed my auricle lirmly back against my head, I heard the higher sounds, i. e., the entire sound became to my ear apparent!}" of a higher quality, whereas, if I pushed my auricle outward and forward, the deeper partial sounds became more pronounced, and the entire composite sound became louder and deeper. Drs. A. H. Buck and C. J. Blake have informed me that they have corroborated in themselves my observations and statements in this connection. In the autumn of 1873 I published my first paper, and in the spring of 1874 my second paper on what I had observed respecting the function of the external ear, especially of the auricle, as a resonator for higher notes. The first paper contained chiefiy a description of the pheno- mena I had observed; and the second paper was devoted spe- cially to their physical explanation. The substance of the first paper was the following, antedating the papers of Drs. Kiipper and Mach : Before any further explanation of the functions of the auricle, 1 Phvsiologie der Haussilugethiere. 2 Archiv f. Ohrenheilkunde, Bd. ix. S. 72, 19 June, 1874. 3 Phila. Med Times, No. 101, Oct. 4, 1873; No. 127, April 4, 1874. 32 .EXTERNAL EAR. let US briefly consider the acoustic nature of some of the or- dinary sounds which are received b}^ it. It is Avell known that every sound is composed of a collection of "partial tones" or "over-tones" which determine its timbre or clang-tint. Any one of the ordinary sounds of nature, as, for example, the roar of a cataract or of the surf, and the rustling of the leaves in a forest, is composed of a large number of partial tones, which, for the sake of simplicity, let us call deep, intermediate, and high partial tones. The ordinary normal ear does not isolate any of the partial tones of a composite sound, but perceives them as a whole. This is due to the fact that certain parts of the auricle re- sound best to the high partial tones, while other portions of it resound best to the intermediate and low partial tones, thus insuring the complete reception by the auditory nerve of all the partial tones which compose any given sound falling on the auricle. I have discovered, by experiments upon my own ear, that the region of the helix and its fossa resound to the deeper notes, the antihelix and its fossa to the intermediate notes, and that the concha, "the deep concavitj^ within the position of the antihelix, presenting a semi-spiral course towards the entrance of the auditory meatus," resounds best to the high partial tones. In order to prove this it is necessary to be in the presence of a sound possessing the characteristics of those already mentioned, when, by pressing the auricle at its outer edge gently forward, the sound instantly becomes a deeper one, from the augmenta- tion of the resonance for deep tones thus gained by the helix and its fossa. The deep tones, however, are immediately weakened or lost by placing the finger upon the helix and pressing it firmly against the head. Then it is found that the sound becomes one in which the intermediate and higher partial tones are prominent. By pressure upon the antihelix the intermediate tones become weaker, and the higher partial tones are most distinctly per- ceived, on account of their undisturbed resonance in the concha. Firm pressure upon the helix, antihelix, and concha will inter- fere with the resonance of all but the highest partial tones. In the latter instance the resonance of the meatus auditorius ex- ternus has full scope, for this part of the ear, according to Helmholtz, resounds best to notes of the fourth octave {e"-g"). Therefore, if any one of these portions of the auricle has its acoustic functions altered, either by disease or artificially, the tones to which it resounds will be weakened or lost, and the prominence of the other partial tones will change the timbre of the orioinal sound. Experiment will show that by giving prominence to a certain portion of the auricle, viz., the helix and its fossa, a sound may be rendered fuller, and hence louder, from the increased reso- THE AURICLE, 33 nance of the deeper notes which enter into its composition. This may exphiin the asserted increase of hearing in some cases of othannatoma, when the swelUng may have rendered these particuhir parts prominent, and thus have increased their reso- nant power. But if the (hsease advance and produce great swelling and rigidity of the auricle, as it usually does, we can also readily understand the impairment of hearing in these cases. One without an auricle, all the rest of the auditory apparatus being normal, can indeed hear sounds, practically very well, but they are altogether different, acoustically considered, from the complete composite sound heard by the possessor of the normal auricle. In the former case, a large number of the partial tones being lost, the clang-tint of the sound is altered; whereas in the latter case, the auricle receiving and conveying synthetically all the partial tones to the auditory nerve, the timbre of the com- posite sound is fully perceived. The substance of my second paper,^ explaining what I had observed, was as follows : The auricle, in combination with the meatus auditorius, forms a resonator of a more or less conical shape, closed at the bottom by the membrana tympani, the special function of which is to strengthen by resonance those waves of sound which possess a short wave-length. Let the accompanying diagram represent a section of the external ear, from the membrana tympani to the helix. The section is made from above down- ward, parallel to the long axis of the meatus auditorius exter- nus, and gives an ideal represen- tation of the manner in which the resonator we shall consider is built up by the auditory canal and the successive columns or cups of air, represented by the concha and foss?e of the helix and antihelix. The widest diameter of this resonant cone or funnel, or min- iature "speaking-trumpet," i. e.., the diameter obtained when the helix and lobe are made to ap- proach each other about the open- Fig. 5. ing of the external meatus as a Diagram representing the Topogra- phical RELATION OF THE COMPONENT RESO- NANT CAVITIES OF THE EXTERNAL EaR. a. Fossa of helix. 6, Fossa of antihelix. c. Concha, m. Meatus auditorius ex- ternus. t. Membrana tympani. common centre, does not exceed the wave-length of the note to which the resonator thus formed will respond.* In order fully to 1 Phila. Med. Times, April 4, 1874. 3 34 EXTERNAL EAR. understand how this resonant power is maintained by the ex- ternal ear, and to sound-waves of what length it specially resounds, let us first consider the resonance of the meatus audi- torius externus, and the physical reasons for such a function in it. It is known that the external auditory canal resounds to the notes e'"' to g'",'^ and that the column of air which most easily xtsounds to any given note is equal to one-fourth of the length of the wave of sound produced by that note.^ Xow, the wave- length is found by dividing the velocity of sound per second by the number of vibrations executed by the sounding body per second,^ and the quarter of the result of this division, i. e., the quarter of the wave-length, will equal the length of the column of air which will act the part of a resonator for the note pro- ducing the sound-wave. In order to appreciate this fact, let us work out a simple problem in physics, with the data before us, as follows : As already stated, the notes e'" to g"' have 2640 to 3168 vibrations per second, and the velocity of sound in atmosphere at 15° C. is equal to 1122 feet per second. Therefore, the length of the wave produced by the note of 3168 vibrations per second will be found by dividing 1122 by 3168. The answer will be, about three- eighths of a foot, or four and a half inches. Now, the column of air which will resound to the note pro- ducing a wave of that length is equal to one-fourth of that wave- length, or one and one-eighth inch, which is just the short average length of the external auditory canal. Some authori- ties give one and one-fourth inch as the average length of this canal, but practically the normal human auditory canal has various lengths, passing gradually from the meatus proper into the concha. And this brings us to the second consideration connected with the phenomena of resonance manifested by the external ear, viz., that as the pitch of a note, let us say of e*' or g", falls, the wave-length must -become greater, or, in other words, as the number of vibrations per second diminishes, the wave-length increases; which is but the enunciation of a com- mon law of physics. It is now manifest that the column of air contained by the external auditory canal will not be long enough to act as a resonator for waves of sound the quarter of v\^hich is represented by one and three-fourths to two inches. Therefore, the concha is found superposed hy nature upon the external auditory canal, in order to lengthen it. We have already seen from experiments that the notes which resound to the column of air represented by the concha, i. e., the concha in conjunction with the external auditory canal, are lower than those which 1 Helmholtz's Tonempfindungen, p. 175, 1870. 2 Tyndall, On Sound, p. 174, 1809. '* Ibid., p. 84. THE AURICLE. 35 resound to the external auditory canal wlien it i.s made to act alone, which can be accomplished by pushing the concha out of place by tirm pressure of it against the head. The reason for this becomes very clear when we reflect that a note lower than those represented in the scale from e"'' to g" must have a greater wavedength, and therefore it i-equires a longer column of air as a resonator. If this lower note should fall in the octave below those notes already mentioned, the addition of the column of air in the concha to that in the meatus would supply the resonator. If to this resonator, composed of the canal and concha, we add the fossae of the antihelix and helix, we of course obtain longer or deeper resonant columns of air ; and I know from my experi- ments that notes of still greater wave-lengths than those alluded to resound to the column of air represented by that contaiiied in the fossEe of the auricle added to that of the concha and external auditory canal. By holding the hand behind or around the ear, we have the power of adding a still deeper column of air and its resonance to that of the external ear. Hence, the deaf person involuntarily places his hand to his ear, to increase, by resonance, the ordinary sound falling upon it. His hearing is thus strengthened, especially for those notes of high pitch and short wave-length to which the human voice owes its peculiar timbre or clang-tint. When the wave-length increases, as it does when the note becomes still lower than any of those alluded to, the resonance of the external ear ceases to exert any marked influence on the fundamental note. In such a case it is probable that the resonance of the room or street in which we are placed is aroused by the longer wave of sound ; but nature has supplied us, in the external ear, with an ever-present and delicate resonator for just those notes of short wave-leno-th in which the human voice is so rich and to which it owes its special timbre. We may, therefore, conclude that the external ear {i. e., the external auditory canal and the auricle) forms a resonator for those tones having loave-lengths the quarters of which are represented by the various depths of the column of air contained by the external ear. From wdiat has just been shown respecting the resonant func- tions of parts and of the whole of the auricle and external auditory canal in man, it seems fair to suppose that the entire apparatus of the external ear in all animals is adapted to strengthening the sounds uttered by them, their species, and their prey. The absence of a developed auricle in birds is not, in my opinion, an argument against its utility as a resonator in man, for the wave-lengths of the high notes which the former must both use and hear as a means of intercourse with one another, are so short that they will resound perfectly well in the shallow auditory meatus found in them. 36 EXTERNAL EAR. The auricle is supposed bj KesseP to possess the function of aiding in the determination of the direction of sound, and he attributes to this part of the ear, as I have, the power of anal- yzing sound. Temperature of the External Auditory Canal. — Dr. E. Mendel,^ of the University of Berlin, has performed a series of experi- ments to find the relative differences between the temperature of the rectum and that of the external ear under physiological and pathological conditions of the general system. In the normal condition, the temperature of the rectum is 0.02° C. higher than that of the external auditory canal. Further experiments in cases of apoplectiform and epilepti- form paralysis show that in such pathological states the tempe- rature is higher than that in the rectum. Sleep-producing doses of chloral do not materially alter the temperature of the rectum, but they reduce considerably the temperature of the external auditory canal. The amount of this depression in the ear varies from 0.04°-l° 0. It sets in in from ten minutes to half an hour after the chloral is given, and lasts until sleep is ended. Morphia has also a specific effect in reducing the temperature of the external auditory canal in varying amounts, from 0.1°- 0.45° C. This I consider important for Sturists to know, inasmuch as further experiments of MendeP show that even ice-bags fail to reduce the temperature of the external auditory canal as chloral and morphia do. 1 Archiv f. Ohrenheilkunde, vol. xviii., 1882, pp. 120-129. 2 Virchow's Archiv, 62^and, 1874. » Loc. cit., p. 141. THE AUDITORY CANAL, 37 CHAPTER 11. THE AUDITORY CANAL. ANATOMY. The Temporal or Petrous Bone. — Before considering the ana- toni}' and physiology of the external auditory canal, it will be necessary to examine into the development and anatomy of the temporal or petrous bone. The outer surface of the temporal bone represents the convex curve of a low arch, the spring line of which runs through the outer part of the middle lobe of the brain. The squamous portion, which is the larger part of this Fi"-. 6. 1 for Stjua mous poTtwti inp!iu7iiiir Zuaoyna . 2^:' ,iw. I for Audctoru proeess t foT Petrous porti on^ 1 for StyloiS, pmiCt Centres of Development op the Temporal Bone. (Gray.) surface, being thin, and the arch it spans low, the temporal bone would be verv weak in resistins; external forces, were it not for the support placed on its inner surface by the petrous portion. Embryology of the External., and Parts of the Middle Ear. — The Eustachian tube is an involution of the pharyngeal mucous mem- brane, and is not the remains of a branchial cleft. (D. Hunt.) 38 EXTERNAL EAR, The external auditory canal is an involution of the integument, formed as a burrow in the tissue which composes the first branchial arch. The membrana tjmpani is formed by the junc- tion and overlapping of the ends of the Eustachian tube and external auditory canal, the connective-tissue layer between them forming the membrana propria of the membrana tympani.^ The temporal bone develops from four distinct centres, exclu- sive of those representing the internal ear and the auditory ossicles. Pis;. 7. Left Temporal Bone : Outer Surface. — a. Squama, b. Groove for temporal artery, c. External auditory meatus, d. Zygomatic process, e. Insertion of masseter muscle. /. Glenoid fossa, g. Articulnr ridge. Ji. Glaserian fissure, i. Tympanic bone : anterior wall of external auditory canal, k. Inner end of petrous or pyramidal portion of temporal bone. /. Insertion of styloglossus muscle, m. Styloid process, ii. Insertion of stylohyoideus muscle, o. Insertion of temporal muscle, p, q. Mastoid portion, t. Mastoid process. r. Insertion of sterno-cleido-mastoid muscle, s. Squamo-mastoid fissure, u. Mastoid incisure, w. Insertion of splenius capitis muscle, v. Insertion of trachelo-mastoid muscle. These are: one for the squamous portion and the zygoma; one for the auditory process, or annulus tympanicus, which finally becomes the tympanic bone, and forms the anterior, in- ^ Von Baer, Hiischke, and Kollicker among older writers; among recent writers, D. Hunt, International Otolog. Congress, 1876, and American Journal of Otology, vol. i., 1879, p. 2-50; Moldeiihauer, Morphologisches Jahrbuch, 3tes Bd., Istes Heft. ; Urbantschitsch, review in Arcliiv f. Ohrenh., 12tes Bd., iv. Heft, S. 293. THE AUDITORY CANAL. 89 ferior, and superior part of the osseous auditory canal; anotlier for the petrous and mastoid portions, and a separate point of development for the styloid process. It appears from the anatomical investigations of Adam l*o- litzer' that the styloid process, the variable form of which is well known, originates from an individual cartilage-centre, which, not only in foetal life, but also in the new-born child, is demon- strable as a separate cartilaginous body, and that the upper end of the styloid process is not found at the externally visible base Fig. 8. Left TEjfPORAL Bone : Inner Surface. — a. Squama, b. Meningeal groove, c. Zygo- matic process, d. Semicanal of Vidian nerve, e. Hiatus of Fallopian canal. /. Cauali- culis petrosus empties into this groove, y. Porus acusticus for auditory nerve, h. Carotid canal, i. Jugular notch, r, o. Petrous or pyramidal part of bone. p. Mastoid fora- men, for vein. n. Sigmoid groove for lateral sinus. I. Groove for superior petrosal sinus. k. Eminence of superior semicircular canal, m. Petroso-squamous suture, s. Aquseductus vestibuli. of the process, but that it extends upward as far as the lower part of the eminentia stapedii, along the posterior limit of the tympanic cavity, from which it is separated by a thin osseous lamella. The Developed Temporal Bone. — Space forbids a lengthy con- sideration of tlie developed temporal bone, but a few prominent Archiv f. Ohrenheilkunde, Bd. i.\. S. 164. 40 EXTERNAL EAR. features deserve notice here, as, that under the floor of the tympanic cavity is part of the jugular fossa; that the anterior v^all is part of the carotid canal; that the roof of the tympanic cavity is a thin bony septum between the brain and the middle ear; and that the mastoid cells are separated by a thin partition of bone from the sigmoid fossa, in which runs the lateral or transverse sinus of the dura mater. In addition to these facts, may be mentioned that the entire internal ear, or labyrinth, lies in the petrous p3'ramid of the temporal bone, that the middle ear is formed by the union of the squamous, petrous, and mas- toid portions of the temporal bone, and that the osseous portion of the Eustachian tube lies in the inner end of the petrous por- Fig. 9. and. Te>u,orzympaTii7nusc LEVATOR PALATI Op*.vinc, ofcaratul ea.i,al C^nulfor JacoUons nerv.. Aijurrfuerus Cor/ilatje — (^'^rialfar Arnold-^ „^rv, JttffuJar fossa jStyhnd jiroeess- St7j.h,. mastoid foT-amen Ju^vJrt.j- Surface Auricular fisaure STyLO-PKARyNCEUS Under Surface of Left Temporal Bone. (Graj'.) tion of the temporal bone, through which the tensor tympani muscle may be said to run on its way to the tympanum. A more detailed explanation of this muscle will be given when THE AUDITORY CANAL. 41 alluding to the soft parts of the Eustachian tube. Furthermore, the levator palati, an important tubal muscle, originates at the under surface of the temporal bone, near the inner end of the petrous part; the carotid canal passes through this part of the bone, and the jugular fossa is partly formed by the temporal bone; the facial nerve passes through this bone from the brain to the face, and the aqutieductus cochlea?, the important exit for the perilymph of the labyrinth, is placed near the carotid canal on the under surface of the temporal bone. It is also important for the aurist to bear in mind that on the upper and cerebral surface of the petrous portion are the petrosal sinuses, and that these are closely connected with the cavernous sinus, which, in turn, is emptied into by the ophthalmic vein, a relationship which may often explain facial and ocular symptoms in obstruc- tion of the sinuses from aural disease. The small opening of the aquteductus vestibuli, on the poste- rior surface of the pyramidal petrous part of the temporal bone, near the entrance of the auditory nerve, must not be forgotten, as at this point purulent disease may often be found to have entered the cranial cavity from the tympanum and vestibule. The anterior wall of the external bony auditory canal forms part of the glenoid fossa, and it can thus be seen how, in certain inflammations about the ear, movements of the jaw are exceed- ingly painful. At birth the bony auditory canal does not exist; the ring from which it is developed is deficient at the upper fourth, and the canal is represented at that point by the curved lower edge of the squama. The aforesaid ring grows at last into a tube which forms the posterior, inferior, and anterior wall of the osseous external auditory canal, to which the name of tympanic bone is also given. In the new-born child the mastoid portion is also rudimentary and not fully united with the squama. At the line of imperfect union between these two parts of the temporal bone, quite large deficiencies are found in early child- hood and in some cases persist even into adult life. Development of the Bony Auditory Canal. — The osseous audi- tory canal, i.e., the inner and major portion of the entire audi- tory passage, is developed from the so-called drum ring, annidus tympanicus or processus auditorius. This ring, which is open or interrupted (for 1-2 mm.) at a point in its postero-superior periphery, has a furrow on its inner edge called the sulcus tym- panicus. This ring, united to the squamous and petrous portions of the temporal bone, gradually grows outward, and forms the antero-superior, anterior, and antero-inferior wall of the bony auditory canal. 42 EXTERNAL EAR. The two prominent points (see Fig. 6) on the anterior and upper part of the ring are called by Henle spina tymjmnica antica and postica, and are the terminal points of a ridge forming the upper boundary of a furrow called the sulcus ■maUeolaris, which finally becomes the posterior boundary of the jjetrotympianic or Glaserian fissure for the reception of the long process, processus folianus of the malleus, and the various soft parts which pass through the aforesaid fissure. Development of the Annulus Tyynpanicus. — The spina tympanica antica unites with the tegmen tympani and thus completes the petrotj^mpanic fissure posteriorly, but the spina tympanica pos- tica projects beyond or behind the tympanic margin of the squamous portion of the temporal bone, and also behind and above the drum-head, and inserts itself at last into the depression between the head and the handle of the mallet, called the neck, as shown by Henle. Considered as anatomical points these are quite insignificant, but when taken in their ph}' siological rela- tions with the support they give to the malleus they are of great importance. As the bone develops the spina tympanica antica grows away, as it were, from the spina tympanica postica, and is finally seen at a point far down on the superior wall of the bony portion of the canal, and in the fully developed broad tympanic bone. As, however, the spina tympanica postica of Henle, in the foetal bone, becomes of so much importance as the anterior point of insertion for the ligaments supporting the malleus in the developed organ, Helmholtz has given to it, in its physiological relations, the name spina tympanica major ; and to a less prominent point on the postero-superior portion of the rino; in which the drum-head is inserted, he o-ives the name of spina tympanica minor. The latter forms the posterior point of insertion for the suspensory ligaments of the malleus. The neck of the malleus fits in between these two points in such a manner that tlie anterior almost touches it. In the perfect bone this relation is not visible from without. The line of attachment of the membrana tympani also shows a slight and ill-defined depression where it passes near and be- neath these points, i. e., at its upper peripher}- above the short process of the hammer. Here the line of insertion of the drum- head is less sharply defined than it is lower down the periphery. At this ill-defined point in the upper part of the periphery of the membrana tympani, "slight pressure with a blunt instru- ment will loosen the membrane from its attachments. In fact it is more truly attached to the cutis than to the bone.'" 1 Mechanism of the Ossicles of the Ear and the Membrana Tympani. H. Hehnholtz, J5t)nii, 18G9. English translation by A. H. Buck and Normand Smith, New York, 1878. THE AUDITORY CANAL, 43 Segment of Rivhms. — This segment in the upper border of the drum-head is called the seejment of Rivinus, since it includes the foramen described by Rivinus, an opening which in some instances represents the last trace of the tirst visceral cleft, but which really has no existence in the majority of normally de- veloped adults. The Auditorij Canal. — The external auditory canal extends from the bottom of the concha to the drum-head, and consists of a cartilaginous and a bony portion, the former being about one-third, and the latter about two-thirds of the passage. The length of the auditory canal is about one inch and a quarter, and its average width is about a quarter of an inch.' The canal gradually narrows to the middle of the bony portion, Fitr. 10. ode Vertical Section of the External Auditory Canal, Membrana Tympani, and Tym- panic Cavity, Viewed from in Front. (Politzer.) — a. Upper osseous wall of the canal. n. Lower osseous wall of the same. b. Tegmen tympani. c. Osseous floor of the tympanic cavity, d. Tympanic cavity, e. Membrana tympani. /. Head of the malleus, g. Lower end of the handle of the malleus, o. Short process of the malleus, h. Body of the incus. 1. Stapes in the oval window. Ic. Fallopian canal. /. Jugular fossa, m. Glandular orifices in the skin of the cartilaginous canal. where it widens again gradually' to the drum-head. A hori- zontal section, therefore, of this canal will be proximately repre- sented by that of two detruncated cones placed together at their points of detruncation. The auditory canal is lined with skin, a continuation of that of the auricle, and not with mucous 1 Richet, eight to nine mm. at the opening, and from six to seven mm. at the fundus of the canal. (Hyrtl.) 44 EXTERNAL EAR, membrane. The skin of the canal is extended over the drum- head, forming its dermoid or outer layer, so that a glove-linger will represent very well the shape of the cutaneous lining of the canal, the finger-tip being the position of the drum-head. In the bony portion of the canal, the skin is thin and closel}' ad- herent, its silvery lustre having probably led earlier observers to call it a mucous membrane; but there is no such membrane in the external ear. In the inferior wall of the meatus there are transverse deficiencies in the cartilage called the incisurce San- torini, and there is a cleft in the upper wall of the cartilaginous part of the canal. The general course of the external auditory canal may be described as sigmoid, or as a spiral turning an- teriorly inward and downward, though there are many indi- viduals in whom the auditory canal is so straight that their drum-heads may be seen very easily by direct inspection and without dilatation of the cartilaginous part of the passage. I Fig. 11. The Auricle and the Cartilaginoits Part of the External Auditory Canal (Left Side). (Pulitzer. ) — a. Cartilaginous meatus. /;. Inner pointed end which unites with os.^eous jiart of the auditory canal, c. Fissures of Santorini. have frequently inspected the drum-head in such cases without the knowledge of the person examined, sometimes while seated in a public conveyance. Such straight canals are invariably wide ones, and much more common in the black than in the white race. Although the external auditory canal is usually spoken of as tortuous, I have observed that in the negro it is usually wide and straight, so much so, in fact, that in most cases, in this race, I have been able to see the membrana tympani without the aid of speculum and reflected light, being able to look directly down upon the drum-head. I have sometimes, though very THE AUDITORY CANAL, 45 rarely, seen the same kind of ti ^yide and straight auditory canal in the white man. Could the large auricle and auditory canal have any connec- tion with the musical talent universally found in the negro race in this country? In the white race, the wide and straight meatus, according to my ohservation, is found in individuals more than ordinarily endowed with the so-called musical ear. Upon the entire free surface of the cutis of this canal are found epidermis and soft, short hairs, together with the seba- ceous glands usually found in connection with them. Through- out the canal, especially in the bony portion, are found vascular papillae arranged in parallel rows, and glandular structures closely resembling sudoriferous glands, but which in their modi- fied form are called ceruminous glands. Fiir. 12. Posterior AVall op the Left External Osseous and Cartilaginous Auditory Canal. (Politzer.) — a. Openings of the glands in the cartilaginous portion of the external auditory canal and concha, b. Triangular space occupied by glands, inserted into the osseous part of the canal, c. Boundary between the osseous and cartilaginous parts of the canal. Ceruminous Glands. — These glands begin about two mm. from the opening of the auditoiy canal, and extend to within two or three mm. of the drum-head. They are most numerous at the junction of the cartilaginous with the bony canal, where they average as many as ten to the square millimetre. According to Buchanan, there are from one thousand to two thousand in an auditory canal. The thickness of the skin in the cartilaginous part of the auditory canal is one and a half mm. thick. 46 EXTERNAL EAR. Vessels and Nerves. — The arteries supplying the auditory canal are branches from the posterior auricular, internal maxillary, and temporal branches of the external carotid artery. The nerves are chiefly derived from the temporo-auricular branch of the inferior maxillary nerve. There is also an auricular branch of the pneumogastric nerve. The plexus of the sympathetic nerve, distributed to the external carotid artery, communicates with the otic and submaxillary ganglia, by means of the plexus distributed to the facial and internal maxillary arteries. PHYSIOLOGY. The acoustic physiology of the external auditory canal has been alluded to in speaking of the functions of the external ear as a resonator. There is one function it possesses, that of causing the ear-wax and some' small foreign bodies to be ex- truded from it, which has not been fully explained heretofore. Voltolini^ has shown that if a foreign body is wedged in a swollen auditory meatus, and the former be made smaller by any means, but especially by the galvano-cautery, the body thus reduced will be pressed out by the swollen walls of the auditory canal. This he claims to be an invariable physical process. Perhaps we may explain the natural escape of cerumen from the ear in some such way as the following: The ear-wax is mostly formed in the wide end of a detruncated cone, i. e., near the outer end of the auditor}^ canal. Therefore, as the wax forms, it presses upon the walls of the auditory canal, and the latter being widest towards the mouth, i. e., freest on the outer side of the gradually growing mass of cerumen, the latter meets with the least obstruction just in the direction of its only escape; hence it will be acted upon very much as if it remained a con- stant quantity, which is being continually pressed upon from behind, and pushed outward by a gradually narrowing auditory canal; for, as the mass grows larger, it must necessarily, with its naturally lubricated surface, slip into a broader, which is an outer, plane in the external auditory meatus, and thus at last it may be found at the mouth of the auditory canal. Unfortunately, this delicate function is constantly interfered with by those who, in endeavoring to clean out wax, push in more than they bring out, and thiis, in a short time, form obstructive plugs of cerumen. Another mode by which cerumen is aided to fall out of the auditory canal, if let alone, has been suggested to me by watch- ing the gradual outward movement of a scab on the membrana tympani, and of a similar object on the wall of the auditory ' Monatsschr. f. Olirenh , No. 9, 1872, and elsewhere. MEMBRANA TYMPANI. 47 canal. If a little tleck of blood forming on the menibrana tym- pani, or on the wall of the external auditory canal, be watched for some days, it will be observed to change its position by moving outward, strongly suggestive of the manner in which a spot over the matrix of the tinger-nail will gradually grow to the edge of the nail and disappear. I have watched little scabs of blood thus move from the drum membrane to the wall of the canal, and from the inner part of the latter similar substances may be seen to move outward to the meatus. The normal pro- gressive growth of the dermoid coat of the membrana tympani takes place most rapidly, and chiefly in the direction of the superior and posterior quadrant of the membrane.^ In some such way, I believe the outward growth of the skin of the audi- tory canal helps to force out the superabundant ear-wax. CHAPTER III. MEMBKANA TYMPANI. ANATOMY. The membrana tympani, or drum-head, is composed of three layers, viz. : the external or dermoid layer ; the middle or fibrous layer, also called the membrana propria; and the internal or mucous layer. The Dermoid Layer. — The dermoid layer of the membrana tympani is a continuation of the cutis of the external auditory canal. This may be seen if the skin of the canal be macerated properly, when the entire cutaneous lining may be removed in the shape of a glove-finger, the tip of which will represent the dermoid layer of the drum-head. In this layer there are, hov, - ever, no hairs nor follicles such as are found elsewhere in the cutis of the auditory canal. In other respects, it is true skin, but extremely thin and transparent. The Outer Surface of the Membrana Tympani. — The dermoid layer is the only one of the three layers composing the mem- brana tympani which can be inspected directly from without. "When the ear is illuminated and a normal membrana tympani examined from without, there are several prominent features in * Dr. C. J. Blake, American Journal of Otology, vol. iv., 1882. 48 EXTERNAL EAR. it which at once attract attention, viz. : its almost circular shape and peculiar polish and color; its vertical and horizontal incli- nation; the manubrium of the malleus; the short process of the latter; the folds of the membrana tympani; the flaccid portion Fig. 13. Fie:. 14. View of Outer Surface of Membrana TyJipani. (Gruber.) — a. Malleus ; manubrium, c. Short pro- cess. B. The tip of the manubrium, d. Posterior fold. RIGHT The Normal Membrana Tympani. of the drum-head above these folds, called the membrana flaccida or Shrapnell's membrane; and the bright triangular reflection of light in its antero-inferior quadrant, called the "pyramid of lightJ' Shape of the Membrana Tympani. — For purposes of convenience in description, the outline represented by the periphery of the membrana tympani is called circular. This form, however, varies between that of an ellipse and an irregular oval, while in some cases where the lateral portions of the annulus tympanicus are especially curved outward, it assumes a heart shape. It may be strictly considered an ellipse, the long diameter of which, amounting to 9-10 mm., runs from above and in front, downward and backward, and the diameter of greatest width of which runs from below and in front, upward and backward. These measurements are those o-iven by von Troeltsch, and are nearly in accordance with those of Hyrtl, according to whom the proportion between the diameters is as 4.3'"-4.0'". Since the difierence between them is so slight, and their incli- nations are so nearly vertical and horizontal, the outline of the membrana tympani may be considered circular, and the long diameter is spoken of as the vertical diameter, while the diameter of greatest width is considered the horizontal diameter. The membrana tympani is, therefore, divided into quadrants, which greatly aid in locating any point to be described. Color of the 3Iembrana Tympani. — The normal color of the membrana tympani is never flxed. Just as some normal teeth MEMBRANA TYMPANI. 49 are bluish or yellowish-white, so it is with the drum-head, which though perfectly normal may be bluish or yellowish-gray, though more frequently it is found to be the former. The normal color of the drum-head is usually spoken and written of, as "pearl- gray," but whatever color the membrana tympani may be said to have, that color must always be modified by the physical condi- tions brought about by stretching a nearly transparent membrane over a darkened cavity. And this is a modification not sufh- ciently taken into account by observers. There is, therefore, from the cause just mentioned, an admixture of black with the delicate gray of the membrane,butitis very difficult to jmint a trans- parent or translucent object, and therefore very difticult to ascribe even a name to the color of a normal membrana tympani, since its appearance is partly due to the color which its own substance reflects and partly to the color it transmits from the cavity of the drum, the latter feature of course being modified in every imaginable degree by the thickness or thinness of the membrana tympani, as well as by the various conditions and colors of the contents and mucous lining of the tympanic cavity. Moditications of color similar to those in the membrana tym- pani can be in a measure produced artificially, if we stretch a piece of gold-beater's skin, delicate tissue paper, or sheet gutta- percha over a rather shallow cavity darkened by covering it in this manner. The color of the membrane thus formed will be composed of the latter's own peculiar tint as an opaque sub- stance and the color of the cavity over which it is stretched and which it transmits. " That part of the membrana tympani just behind the lower end of the manubrium, and over the promontory of the cochlea, is rendered yellowish-gray by the rays of light reflected from the yellow bone of the inner wall of the tympanic cavity" (Politzer). Of course, all these shades of color vary a little, even in the normal state; but greatly during pathological processes in any part of the structures entering into the formation of the drum- head. The membrana tympani owes its peculiar lustre to the delicate and shining epithelium of the dermoid layer. If a fresh mem- brana tympani be placed in a solution of nitrate of silver, the peculiar cement-like substance between the scales of this epi- thelium will become tinged, while the scales themselves will remain uncolored, and thus a distinctly marked preparation will be made in which the various shapes of the epithelial scales become demonstrable under the microscope. The slightest maceration or exfoliation of this delicate epi- thelium deprives the membrana tympani of its beautiful gloss. The dermis of the drum-head is thickest in children. 50 EXTEKNAL EAR. The Inclinations of the Membrana Tymjxini — Another important fact which attracts the attention of one examining the ear is, that the membrana tympani, in its normal condition, is inchned outward at an angle of 45° in its vertical plane, and in its hori- zontal plane is inclined 10° towards the right on the right side and 10° towards the left on the left side. If the planes of both membranffi be extended downward until they intersect each other, the angle which they will thus form will be equal to about 130°-135°. Of still greater importance than this, however, is the direction of the walls of the auditory canal from the plane of the mem- brana t^-mpani. Thus if a perpendicular be drawn from the upper pole of the drum-head to the inferior wall of the auditory canal, it Avill strike the latter about 6 mm. from the inferior pole of the membrane. A similar result will be obtained by drawing a perpendicular from the middle of the posterior periphery of the drum-head to the anterior wall of the auditory canal, from which fact it becomes very evident that the antero-inferior part of the mem- brana tympani is further removed from the external opening of the auditory canal than the postero-superior part.^ The membrana tympani is inclined the most in ver}^ young children, being in the early years of life almost horizontal in position, and, on account of the shallowness of the auditory canal at that time, the membrane is very superticial, especiall}- at its upper part. In some instances there is observed a physiological variation in the obliquity of the membrana tympani, and a tilling in with osseous tissue, of the segment of Rivinus. Hence, on inspection there is found a large portion of the iield at the fundus of the canal taken up by the upper wall of the canal, which seems to dip down to join the membrana tympani on a line with its folds. In these cases there is very little or no membrana flaccida. This condition I have observed in the feeble-minded with some other defective cranial development. Moos and Steinbriigge^ have observed in the same individual, a cretin, with defective cranial development, a difference of the inferior angle of the membrana tympani, of 40°, on each side. The dillerence in such cases may be from 10° to 50° greater than normal. The Manubriam of the 3Ialleus. — Running from above down- ward and backward to the centre of the membrana tympani is seen the ridge formed by the manubrium of the malleus. This slightly elevated ridge, entirely opaque and decidedly 1 Gruber, Studien iiber das Troininelfell, p. 4. '^ Archives of Otology, vol. xi., 1882. MEMBRANA TYMPANI, 51 winter than the surrounding druni-head, divides the mcmbrana tynipani into two unequal parts, the anterior being the smaller and the posterior the larger. At the upper end of this ridge is the short process of the malleus, projecting sharply outward, somewhat above the general surface of the handle of the liammer. In general appearance it is not unlike a pimple with yellowish contents. The low^er end or tip of the ridge, which curves slightly for- ward, is flatter, broader, and yellower than the rest of the outer covering of the manubrium. This is due to the fact that the bone proper is spade-shaped at this point, and also because the radial tibres of the membrana propria centre at this lower part of the bone. The lower end of the manubrium draws the mem- brana tympani inward very markedly, and forms that depressed spot in the centre called the umbo. The convex shape of the drum-head from the tip of the manu- brium outward towards the periphery is due to the compara- tively large number of circular libres at a point between the umbo and periphery, which constrict, as it were, the radial fibres, so as to form a kind of funnel. Fie 15. Fio;. 16. U Pressure or traction applied to the centre of a membrane stretched over a ring, tends to draw the former into a cone, a vertical section of which is represented by the line A u a' in Fig 15. But if a smaller concentric ring be placed at b c so as to resist the indrawing force at u, the curve assumed by the membrane is represented by the line a u a' in Fig. 16, and the whole membrane is drawn into a concavo-convex shape. 52 EXTEENAL EAR. The Yellow Spot at the End of the Manuhrmm of the Malleus. — This spot is not a pathological appearance, but a purely phj'sio- logical condition. It is part of the cartilaginous structure at the end of the hammer. Dr. Trautmann,Mvho has made a special study of the spot, concludes that : 1. Its physiological significance is the same as an epiphysis of a long bone. 2. The diagnostic value of the yellow spot is apparent in cases of thickening of the membrana tympani, when the former will disappear much sooner than the sharp edge of the malleus. 3. Opacities of the membrane with thickening change the color of the yellow spot. 4. When the malleus is twisted on its long axis the form of the spot wdll be altered. 5. If the spot does not move during alterations in the atmospheric pressure in the canal, by means of Siegle's specu- lum, it is fair to conclude that either ankylosis of the malleus or its adhesion to the inner wall of the tympanic cavity has oc- curred. In the latter instance the differential diagnosis is aided by the necessary foreshortening of the handle of the hammer. Folds of the Membrana Tymipani. — From the short process of the manubrium of the malleus two delicate ridges may be seen, one passing forward, the other backward to the periphery. These are the so-called folds of the m.embrana tympani. They are formed by the pressure outward of the short process of the malleus. They are important topographical as well as diag- nostic points of the membrana tympani. Above these folds is the so-called membrane of Shrapnell,^ or membrana flaccida. It owes its flaccidity to the small amount of fibrous tissue en- tering into its composition, and to the loosely stretched cuta- neous and mucous layers of the membi^ana tympani, which here come together. In this membrane somewhere, there was once said to he a normal opening, the foramen of Rivinus, named after the writer, who first called attention to its supposed existence in 1717. Ever since, the dispute has turned upon several points, viz., first, whether there is such an opening; secondly, is it nor- mal or pathological; and, lastly, in what part of the membrane is it found. Although a number of distinguished observers, among whom may be quoted Patruban, Gruber, Politzer, and Ilj'rtl, have investigated this point in the anatomy of the membrana tym- pani, the question was for a long time an open one, until Hyrtl denied the existence of a normal opening in the membrana flaccida, either in the adult or in the infant cadaver. He, how- 1 Archiv f. 0., Bd. xi. pp. 99-113. ^ Henry Jones Shnipncll, not Odo Shrapnell, as several German authors have called him. This author's d(!sci'i])tioii of the memhrana flaccida is found in the London Med. (Jazette, vol. x. p. 120. MEMBRANA TYMPANI. 53 ever, admits tliat a Irani of devdopmod in the membrane in the neio"lil)or]iood of the Riviiiiau segment may, in some cases, lead to the formation of a quasi foramen, but the normal existence of such a foramen is not proven, iSuch testimony as Hj^rtl's is incontrovertible in the author's opinion, and can never be over- thrown by the assertion that the opening is so small that the anatomist must look for hours with a magnifying glass in order to find it; nor can I understand how a foramen should be so small as to require such persistent search with a magnifying glass, and yet, when found, be large enough to allow a bristle to pass in and through it, Pt/ramid of Light. — The pyramid of light is a name applied to the beautiful triangular reflection of light emanating from the antero-inferior quadraut of the uormal membrana tympani. The apex of this triangular reflection touches the tip of the manu- brium of the malleus, and its base lies on the periphery of the membrana tympani. It forms, with the handle of the malleus, an obtuse angle anteriorly, wdiich becomes greater as the incli- nation of the membrana tympani to the auditory canal dimin- ishes. Its average height is from 1 J to 2 mm., and its average width at the base is from 1| to 2 mm. This reflection, which has been called an isosceles triangle from its general appearance, is, strictly considered, pyramidal in shape, and hence the name applied to it b}^ most writers of the present day. The causes of the formation of this pyramid of light, or, in other words, the optics of this important spot, have been vari- ously explained by a number of careful observers. Wilde, the first to describe it, believed it to be due to the convexity of the membrane, but other observers since that time, among whom may be named Politzer,^ Gruber,^ Voltolini,^ and Trautmann,^ have most clearly shown that such a convexity is not the only cause of the formation of the pyramid of light. From the more recent investigations, it is most conclusively proven that there are three elements indispensable to the formation of this pecu- liar reflection of light, viz., a shining surface, the inclination of the membrane, and its peculiar funnel-like shape. In these three conditions may be found the solution of three very im- portant questions, viz.: 1. Why do we see such or any reflection from the membrana tympani? 2, Why do we see this one ^ Die Beleuchtunsjsbilder des Trommelfells im kranken und 2;esunden Zustando, Wien, 1865. '■^ Anatomisch. Physiologische Studien, iiber das Trommelfell und die Gehor- kniichelclien, "Wioii, 1867. •^ Monats.schr. f. Ohrenh., Jahrg. vi., No. 8. * Archiv f. Ohronheilkunde, Band ii., N. F., 1873. 54 EXTERNAL EAR. ill the antero-inferior quadrant? And, 3. Why is its shape pyramidal? The first condition, viz., the reflecting surface, is supplied by the lustrous epithelium of the dermoid layer of the membrana tympani, and thus an answer is given to the first question. The second condition, viz., the peculiar inclination of the membrana tympani, so places the membrane that, by the modi- fications of its surface brought about by the traction inward at the umbo, the only possible spot from which light can be re- flected is just where the pyramid of light is seen. This point will be more fully explained further on. The third condition, viz., the funnel shape of the membrana tympani, will explain the pyramidal shape of this reflection, upon the physical law pertaining to concavo-convex mirrors. Not one of these conditions is suflicient of itself to produce a normal pyramid of light on the drum-head. That the lustre of the dermoid layer is an important factor in producing this pecu- liar reflection, may be easily proven by syringing an ear in which the pyramid of light is seen in its normal condition. After a slis^ht maceration of the dermoid laver has been thus produced, and its shining surface destroyed, the pyramid of light will be found to have disappeared or to have become dulled or distorted. In order to prove that the peculiar inclinations of the mem- brana tympani, respecting the walls of the auditory canal, have also their part in the formation of the pyramid of light at that point where it is normally found, viz., in the antero-inferior quadrant, it is only necessary to inspect a normal drum-head in which the reflection of light, in question, is found, during the inflation of the tympanic cavity by the Valsalvan or any other method. It will then be seen that the pyramid of light becomes altered in its ■position in respect to the malleus. That this reflection can come only from the antero-inferior quadrant is further shown b}^ an experiment of Politzer's, as follows: If the auditory canal be removed from the membrana tym- pani, so that the latter is attached only to the annulus tym- panicus, and the membrane then be revolved, so that other parts of its surface successively assume the position of that from which the pyramidal reflection formerly came, we shall perceive on each of these parts a reflection almost exactly like the original pyramid of light, excepting behind the manubrium, where, owing to the difterent curve of the membrane, the reflection in question will be somewhat difterent, both in shape and brilliancy. The third important condition in the formation of the pyramid of light, is the funnel shape of the membrana tympani, to which is due, according to Trautmann, the pyramidal shape of the re- flection under consideration. MEMBKANA TYMPANI. 55 The Onise of the Pi/raiindat Shape. — It is already known that tho membrana tympani is drawn inward in such a way by the niannbrium of the malleus and the peculiar distribution of fibres in the membrana propria, that its general shape may be likened to that of a shallow concavo-convex funnel or the flower known as the "morning-glory" or convolvulus. '^ As its surface is very polished it may be considered a convex mirror, which, for the sake of better explaining the pyramidal shape of the light spot of the membrana t^ympani, we may con- sider a convex mirror composed of an indefinite number of sec- tions of convex mirrors with radii varying from that of a mere point to that of the circle which the periphery forms. Now, since it is a law of physics that the image reflected from convex mirrors varies in size directly as the radius of the mirror, we shall have in the composite convex mirror represented by the drum-head, an image, which at the centre, i.e., at the point of the manubrium, is a mere point of light, but which gradually enlarges towards the periphery, until we perceive a triangular spot with its base on the periphery, the height of which depends on the distance of the centre of the mirror from the periphery, and the breadth of the base of which depends on the dimensions of the periphery; the greater the latter the wider the base of the triangle of light. Dr. Trautmann thus sums up the causes of the pyramid of light : " The normal membrana tympani has quite a high degree of superficial lustre, is inclined at an angle of 45° in its vertical plane, and in its horizontal plane it is inclined 10° towards the right on the right side, and 10° tow^ards the left on the left side. Furthermore, it is drawn inward so as to form a concavo-convex funnel, the point or apex of which lies in the centre of the an- terior periphery of the yellow, sickle-shaped expansion at the end of the anterior edge of the manubrium of the malleus, the angle at which the walls of the funnel meet is greater than a right angle, the depth of the funnel is equal to about 2 mm., and the distance from the apex to the periphery is 2|-3 ram. anteriorly, and 3 mm. posteriorly. " But a reflection of light from the surface of the membrana tympani, were it flat, could not reach the eye of an observer, because the rays of light from without, on account of the incli- nation of the membrana tympani, would fall upon the plane surfaces of the same, at a very acute angle, and since the angle of reflection is equal to the angle of incidence, the rays of light reflected from the planes of the membrane, the latter having an inclination of 45°, would strike the inferior wall of the external auditory meatus, and in consequence would be unable to reach the eye of the observer. * Yoltolini, loc. cit. 66 EXTERNAL EAR. " The relations are, however, different, when we consider the 'reflection of light' which is found in the concavo-convex, funnel-shaped tract. On account of the vertical inclination of 45° of the membrana tjmpani and of its horizontal inclination of 10°, and also because of its concavo-convex shape, the antero- inferior quadrant of the membrana tyrapani is drawn at right angles to the illuminating object. Since, now, the illuminating body and the eye are in the same line, or should be, in order to obtain the best possible illumination of the membrana tympani, only the ra3'S of light which fall perpendicularly upon the antero- inferior quadrant can reach the eye, since all other rays are reflected at such an angle that they strike the walls of the audi- tory canal ; therefore, the only reflection of light seen by the observer comes from the antero-inferior quadrant of tlie mem- brana tympani."^ Geometric Divisions of the Membrana Tympani. — KesseP has suggested a division of the membrana tympani into two grand tracts, one above, the other below the folds of the drum-head, ae, ed. The upper tract is subdivided into three sectors, viz., aeb, bee, and ced, Fig. 17. The sectors are bounded below by the folds of the membrana tym- pani, and above by the annulus tym- panicus and the segment of Rivinus, b c. The middle sector, bee, is sepa- rated from the other two on each side by the two suspensory ligaments, be, ec, of the handle of the hammer. Between the anterior suspensorj' liga- ment, b e, and the anterior fold of the membrana tympani lies the anterior sector, and between the posterior suspensory ligament and the posterior fold of the membrana tympani lies the posterior seg- ment. The inferior division of the membrana tympani, viz., that portion below^ the folds, is divided into an anterior segment beginning at the anterior fold of the membrana tympani and extending to the pyramid of light, and the posterior segment extends from the pyramid of light to the posterior fold of the membrane. According to Kessel, making the pyramid of light the inferior boundary between these segments is not arbitrary, but has a 1 Loo. cit., p. 28. ^ Ueber den Einfluss der Binnenmuskeln der Pankonliohle auf die Bewegungen und Schwingimgen des Trommelfells am todten Ohre. Archiv f. Ohrenheilkunde, N. F., Band 2, ISTi. MEMBRANA TYMPANI. 57 good reason in the fact tliat the radial fibres, niimiiig downward and forward, i. e., in the tract of the triangle of light, from the point of the manubrinm of the malleus, in a drum-head of normal position, arc shorter, and, therefore, tenser and more retracted than those iibres which run directly backward and forward from the manubrium. Anwilus Tcndinosu^. — Before considering the membrana pro- pria, the structure from which the fibres of this middle layer of the membrana tym])ani originate demands a short description. This is the so-called annulus tendinosus,^ or tendinous ring of Arnold. It is a mass of iibrous tissue arranged around the periphery of the membrana tjmpani, effecting the union between the latter and the inner edge of the external auditory canal. The annulus tendinosus is not found, however, at that part of the periphery of the membrana tympani corresponding to the Rivinian segment, nor is it always visible from without, even when present in its normal position, around the periphery close to the annulus tympanicus. The fibres of the membrana propria, the origin of which has just been explained, are not inserted directly into the bone of the manubrium, but into a cartilaginous groove which receives the manubrium and short process. This peculiar structure was discovered and has been fully described by Gruber.^ It presents in general the appearance of a deep groove, when seen from behind after the removal of the malleus. As shown by Gruber, this groove is closed at its upper end so that it forms a cartilaginous cap, which covers in the short process on all sides; its lower end, on the contrary, is oj)en behind, and it gradually becomes shallower, /, f., flatter, until it is at last lost in the sub- stance of the membrana tympani. It extends from a little above the short process to a point h mm. below the spade-like end of the manubrium. Inner Surface of the Cartilaginous Groove. — The inner surface of this cartilaginous 2:roove, which is in contact with the mal- leus, is lined by a very delicate layer of connective tissue, be- tween which and the malleus there is found a small amount of fluid resembling synovia. As this condition of discontinuity between the malleus and the inner surface of the cartilaginous groove is considered normal by Gruber, it is fair to presume that, such being the case, the malleus can make a certain amount of motion in this groove, and that therefore there is here a kind of joint. I have seen in Grubcr's clinic, and often in my own practice, ^ The annulus cartilagineus of the older writers. ^ Studien iiber das Trommelfell, Vienna, 1867, u. s. \v., pp. 20-27. 58 EXTERNAL EAR. cases which appeared to have two short processes projecting from the upper end of the manubrium. Such an appearance is explained by Prof. Gruber as the result of a dislocation or slip- ping upward of the entire malleus out of this cartilaginous groove ; the upper of the " two short processes " in such a case is the true bony short process, whereas the lower one is the aforesaid cartilaginous cap, moulded over the short process, and held in the original position of the true short process by the membrana tjmipani. This condition, Gruber calls subluxation of the cartilage from the short process. Kollicker^ regards this hyaline cartilage as a remnant of the cartilaginous malleus of foetal life, and he thinks it is very possible that the osseous mal- leus is formed about the cartilage, as is the case in the processus spinosus, in which instance the layer of connective tissue found bv Gruber between the cartilao-inous groove and the malleus, and the comparatively easy separation of the two from each other become perfectly explicable, but Kollicker does not admit that there is a normally developed and constant space between these two structures. The Membrana Propria: the fibrous or middle layer of the 3Iem- brana Tympani. — Having considered the anatomy and the inspec- tions of the outer or dermoid layer, the anatomy of the middle or fibrous layer of the membrana tympani demands attention. The membrana propria can be subdivided into two distinct and delicate layers, viz., an outer, composed entirely of radiate fibres intimately connected with the dermoid layer of the drum- head ; and an inner layer, composed entirely of circular fibres, in close relation with the mucous membrane composing the internal layer of the membrana tympani. These component layers of the membrana propria are named, briefly, the radial and the circular layer. The fibres composing the former arise from the annulus tendinosus and the upper wall of the auditory canal, and are inserted into the manubrium of the malleus, cen- tring for the most part at its spade-like tip. The fibres compos- ing the circular layer arise partly from the annulus tendinosus, but the majority of them arise from the substance of the mem- brana tympani itself (von Troeltsch). Some of them are inserted into the malleus. Of the former kind, viz., those arising from the annulus ten- dinosus, Gruber says : " Tliey form a very acute angle with the annulus tendinosus, assuming in their progress downward the course of the fibres of the circular layer." These fibres, Gruber thinks, have either been overlooked heretofore, or considered radial fibres. The circular fibres are most numerous a short distance from the periphery of the membrana tympani. The ' Gewehclehrc, ]). 707. MEMBRANA TYMPANI. 59 regfion of their irreatest thickness is in the outer third of the membrane, where they are twice as numerous as the radial fibres; the thickness of the circular layer at this point being 0.02G'", while that of the radial layer is equal to 0.018''' (Ger- lach). They are much less numerous at the middle third of the membrane, and almost wanting at the central part of the drum- head. A knowledge of the arrangement of these fibres is im- portant when considering pathological changes which may have taken place in the membrana tympani, and also in explaining the peculiar concavo-convex shape of the drurn-head. " If the radial fibres of the membrana tympani were not united by trans- verse ones, they would be stretched in a straight line. In point of fact, however, they maintain a curved shape, with the con- vexity looking toward the meatus; hence we conclude that the radial fibres are drawn toward one another by circular fibres, and that the latter are also made tense at the same time. There is, in fact, in the membrana tympani at rest, no other force capa- ble of holding the radial fibres in a curved position, except the tension of the circular fibres."^ The Descending Fibres of the Membmivi Tympani. — In addition to the two layers already described as forming the membrana propria, there is still another layer composed of descending- fibres, first described by Gruber. These fibres are external to the radial fibres, and arise from the upper segment of the annulus tendinosus, and, lying very close to each other, are inserted into the sides and median line of the cartilaginous groove already described. The "various layers of the membrana propria, i. e., the three just described as the radial, circular, and descending fibres, are lightly bound together by a very delicate kind of connective tissue. On the other hand, they cling very firmly to the annulus tendinosus, cartilaginous groove, dermoid and mucous layers, as shown by Gruber. Arborescent Fibrous Structure of the Membrana TymjMni. — There is in the membrana tympani a set of fibres arranged in a peculiar way and first described and named by Gruber the dendritic fibrous structure^ of the drum-head, "They arise near the periphery, about in the middle of the posterior segment, pretty far apart, but as they proceed on their upward course in the posterior segment they approach each other, in order to divide again, at some distance from the manu- brium of the malleus, into several branches, usually about three, which run in different directions, and are finally lost by inter- ^ Helmholtz : ]\Iechanism of the Ossicles of the Ear and the Membrana Tym- pani, English translation hv Buck and Smith, New York, 1873. '^ Dentritisches Fasergebilde. 60 EXTERNAL EAR. twining with the fibres of the membrana propria."^ These ■fibres are not confined to the posterior segment, but traces of them are found throughout the membrana tympani. At their peripheral portion they are between the two layers of fibres composing the membrana propria, but as they approach the centre they are in intimate connection with the mucous layer of the membrana tympani. These fibres are of dense connective tissue, closely resembling tendon. When treated with acetic acid, they exhibit the peculiar connective-tissue corpuscles already alluded to as being found in the membrana propria. Prof. Gruber further shows that the fibres entering into the composition of this structure, become most beautifully manifest when viewed by polarized light, when they appear much more brilliantly illuminated than the other tissues of the membrana tympani. Respecting the function of this structure we are told that in all probability it is an apparatus for relaxing the mem- brane, although it cannot be shown as yet that it is a muscular structure. Constituent Elements of the Membrana Propria. — The labors of Toynbee, v. Troeltsch, Gerlach, and Gruber have added to the knowledge of the nature and dimensions of the constituent ele- ments of the membrana -propria. It consists chiefly of connective tissue of that variety halfway between the ordinary fibrillated and the homogeneous connective tissue of Reichert, as shown by Gerlach. The fibres are 0.004'" broad and 0.002'" thick, and on account of their ribbon-like shape they were once supposed to be unstri- ated muscle fibres, which they are not. On these fibres, certain peculiar spindle-shaped corpuscles are found. The latter were supposed to be peculiar to the membrana tympani, and have been called "corpuscles of the membrana tympani," or the " corpuscles of v. Troeltsch," after the observer who first drew attention to their existence. They are, however, connective- tissue corpuscles of Virchow. They are about 0.002'" long and from 0.005'" to 0.010"' wide at their broadest part, with from two to three processes. According to Gruber, these bodies are found in two varieties in the membrana tympani, viz., the spindle-shaped and the stellate variety. The Internal or Mucous Layer of the Membrana Tympani. — The internal layer of the membrana tympani is composed of mucous membrane, a^'refiection of that lining the tympanic cavity. It is thickest at that point where it leaves the cavity of the middle ear and passes over the periphery of the drum-head. It grows ' Gruber, Studicn liber das Trommelfell, p. 35. MEMKKANA TYMPANI. 61 gradually thinner as it approaches the centre of the meniln'una tympani, where \t is extremely delicate. On the inner surface of this layer various observers, among whom ma}' be named Politzer, Gerlach, and Kessel, have found villi or papilhe. They are said by G ruber to resenjble intestinal villi in their appearance. They are usually found in delicate children. These villi may be globular or iinger-shaped, the diameter of the former being from 0.10"' to 0.12"', and the length 0.12'" to 0.14'"; the finger-shaped ones vary in length from 0.10'" to 0.12'", and in wtdth 0.06'" to 0.08'". (Gerlach and Gruber.) Since Gerlach could not discover any nerves in these bodies, and as some of them are connected" with the mucous membrane only by means of pedicles, he is disposed to regard them as villi rather than as papillae. Fold of 3Iucous Membrane for the Chorda Tympani. — The nm- cous membrane of the tympanic cavity covers the entire inner surface of the membrana tympani; near the upper boundary of the latter it is reflected over the chorda tympani and back again to the drum-head. By this mears a duplicature or fold of mucous membrane is formed, the opening of which is turned towards the surface of the membrana tympani, and in the cul-de-sac or inner edge of which the chorda tympani is found. Pouches of the 3Iembrana Tym'pani. — The fold is adherent to the inner surface of the neck of the hammer, and being thus divided into an ante- rior and posterior portion, contri- butes to make the inner boundaries or sides of the two pouches of the membrana tympani described by von Troeltsch. Further explanation of the pouches will be given under the consideration of the contents of the tympanic cavity. Fisr. 18. View of Inner Surface of Mem- brana Tympani. (Gruber.) — a. Manubrium of malleus. b. The tip or lower eud of manubriuui. C. Head of malleus, i). Body of incus. E. Short process of incus. F. Processus lenticularis of incus. G. H. Chorda tympani. i. Inser- tion of tensor tympani. Vascular Supply of the 31embrana Tympani. — The membrana tympani obtains its blood-supply from the tympanic branch of the inferior maxillary artery, and also by means of a short, direct branch from the internal carotid in the carotid canal. By the latter channel, the membrana may be- come quickly engorged. 62 EXTERNAL EAR. Comparative Distrihiitmi of Bloodvessels in the Ifembrana Tym- 'pani. — In a series of investigations upon the inembrana tympani of the mammaha, I have found in the dog, the cat, the goat, and the rabbit, an arrangement of the bloodvessels not hereto- fore described, and totally different from that in man.^ Prussak," in his brochure upon the circulation of the blood in the tympanum of the dog, has represented the general topog- raphy of the vascular sj-stem in the membrana tympani of that animal, but he does not point out the ultimate loop-like arrange- ment of the vessels distributed over the surface of the membrane. The plate which accompanies his article seems to indicate that the delicate vascular loops have been broken by the force of injection, and thus have escaped the eye of the observer. In my investigations I have found that from the periphery of the membrane a series of vessels run directly towards the manu- brium of the malleus; then each vessel, at a point from one-half to one-third of the distance between the periphery of the mem- brane and the manubrium of the malleus, turns abruptly upon itself and returns to the periphery, and thus there is formed a series of vascular loops at nearly equal distances from one another around the edge of the membrane. A similar series of loops run both anteriorly and posteriorly from the manubrium of the malleus towards the periphery of the membrana tympani, a diagram of which may be seen in Fig. 19, representing the membrana tympani of a dog magnified eiffht diameters. This arrangement of vessels in the membrana tympani is constant in the dog, the cat, the goat, and the rabbit, in conse- quence of which a portion of the membrane between the annulus tympanieus and the manubrium of the malleus remains free from capillaries in its normal condition, and it is probable, though not yet proven, that ordinary disturbances in the circulation are not likely to interfere with the vibrations of the membrane in these animals. These vascular loops do not exist in the guinea-pig, an animal which has in its membrana tj^mpani an arrangement of vessels peculiar to itself. The general appearance of the membrana tympani of the guinea-pig, under the microscope, is much more transparent and debcate than that of any of the previously mentioned animals. The vessels in the membrane of the guinea-pig are arranged in the form of a net, with coarse mesh of quadrangular or pentagonal shape. The radiate fibres are strongly developed in comparison with the circular fibres, which are sparsely dis- ' Amei'ioan Journal of the Medical Sciences, January, 1878. * Vcrhandlungen der Kiuiiglich. Sachsischen Gcsellschaft der Wissenschaften zu Leipzig, 1868. MEMBRANA TYMPANI. 63 tributed throughout the texture of the membrane. They are, however, readily seen, and present an appearance as pecuHar to the membrana tynipani of the guinea-pig, as the shape of the mesh of the network of bloodvessels in the membrane of this animal. In no other membrane have I seen as distinctly the Fiu-. 19. Membraxa Tympani of a Dog. — -The wood-cut is from a drawing of a chloride of gold preparation made by and in the pos.se.ssion of the author, a, a. Vacancy left by manu- brium of malleus, h, h, h, h. Vascular loops, c, c. Ordinary capillaries. blood-corpuscles lying within the capillaries as in that of the guinea-pig. • The membranes which show these loops and other vascular arrrangements most distinctly are such as have been colored with a solution of the chloride of gold (one-half per cent.). The vascular arrangement can be seen, but not very satisfactorily, in membranes which have been treated with osmic acid or a solu- tion of carmine. The best specimens, showing not only blood- vessels, but in manv cases the delicate nerves of the membrane, I have obtained by preparing the membrana tympani of the dog in the following manner: Remove the membrane from the animal as soon as possible after death. In the majority of my experiments, the animal had been dead but a few minutes. Steep the membrane a few seconds in concentrated acetic acid; then lay it in a solution of chloride of gold, which should be 64 EXTERNAL EAR. kept at a temperature somewhat above that of the blood, for one-half hour. After this treatment, the membrane should remain twenty-four hours in glycerine, or water slightly acidu- lated with acetic acid, and exposed to the light till it assumes a delicate purple hue. The older the preparation becomes, the more distinctly are the vessels colored. I have some prepara- tions, mounted in glycerine, now almost a year old, which are better than the day they were made, since the gold has taken an increasing hold upon the tissues of the vessels and nerves. After a number of trials, I prefer leaving the membrane in glyce- i-ine acidulated with acetic acid, since it demands less care in respect to renewal, and I am never chagrined at finding the specimen destroyed by the evaporation of the water. By this process the loops^ and the nerves accompanying them, are most likely to be rendered visible. The arrangement of the nerves, not represented in the wood- cut, is best described as fork-shaped. The prongs embrace the loop; the handle unites with a similar projection from the oppo- site series of loops. As a rule, the vessels color more readily under the action of chloride of gold than the nerves. How this might be in clear weather, I am not prepared to say, as all of my experiments were performed in the cloudy weather of a Vienna winter, notwithstanding which, the nerves frequently became richly colored. This method of coloring vessels and nerves I have applied only to the membrana tympani, and, hence, I can claim no supe- riority for it in connection with other tissues. When it succeeds, it is superior to any injection of this very delicate membrane, since the vessels and nerves are rendered visible with a distinct- ness characteristic of the action of chloride of gold, a reaction to which attention was first called by Cohnheim. The bloodvessels are rendered distinct, without becoming opaque, so perfectly in most cases that we can detect the blood- corpuscles lying within the capillary. The vessel, furthermore, retains its normal calibre and position, whereas, when we resort to injections, the vessels are apt to be unduly distended, are necessarily opaque, extravasation of coloring matter may take place, or the vessel may be ruptured. The method is more convenient than injection, and as no mechanical force is used, the field of the microscope must of necessity present a very true picture of the tissues as they are in their normal state. The application of this method of color- ing to the membrana tympani of man shows the absence of the vascular loops already described, and reveals an arrangement of the vessels similar to that obtained by other observers with injections. The arrangement of the vessels is not unlike the vascular AIEMBRANA TYMPANI. 65 network in the membrana tympaiii of the guinea-pig. In man, however, the mesh is much finer, the vessels coarser. The librous layer is, on the other hand, very thick, and is more equally composed of radiate and circular fibres than the mem- brane in tlie guinea-pig. Since the membrana tympani of man is supplied by a dense network of vessels, the gold method of coloring it is superior to the usual method by injection, as the entire preparation is less opaque than when the vessels are filled with Prussian blue, carmine, etc. It may, therefore, be concluded that : 1. There is a distribution of vessels in the membrana tym- pani ot man peculiar to him. 2. There is a distribution of vessels in the membrana tympani of the dog, the cat, the goat, and the rabbit, constant in, as well as peculiar to them. 3. A distribution of bloodvessels exists in the membrana tympani of the guinea-pig peculiar to it. SECTION 11. MIDDLE EAR CHAPTEE I. TYMPANIC CAVITY. ANATOMY. Under the term Middle Ear are included the tympanic cavity and its two very important adjuncts — the Eustachian tube in front, and the mastoid portion of the temporal bone, and its cells, behind. Ossicles of Hearing. — In the tympanic cavity of all mammals, are three small bones : the malleus or hammer; the incus or anvil ; and the stcpes or stirrup. Anatomists of a later day have shown that the once so-called OS orbiculare, or os Si/lvii, does not exist as a separate ossicle. That which once received this name is the processus lenticularis of the lon^^ process of the incus, which fits into a corresponding depression in the head of the stapes. The Malleus. — The malleus, or mallet, received its name from Vesalius, and although some anatomists have failed to see the resemblance to this implement, the ossicle still retains its name, and is divided into head, neck, and handle. At the junction of the handle with the neck, are two important processes, viz. : the short process on the outer surface, which, when in its normal situation, pushes the membrana tj'mpani ahead of it, and points towards the auditory canal, and the process of Bau or Folius, which passes anteriorly into the Glaserian fissure. In the foetus and new-born child, this process is about 3J lines long, and can then be removed whole. After birth it unites with tlie under wall of the Glaserian fissure, and when the malleus is removed, only a short piece of the former long process is found attached to it. This remnant was all that was known of the long bony TYMPANIC CAVITY 67 process, to the older anatomists, and it has been called the pro- cessus Folianus,^ after Folius, who, in describing this process, alluded only to the remnant. This process, in its most perfect osseous state, was fully described by Jacob Rau^ in his lectures, and his pupils, Valentin^ and Boerhaave,^ call him the discoverer of it. Hence in its perfect state it is called the processus Ravii, after Rau or Ravius. This process has also been called the -processus longiis seu spinosus. Fig. 20. Right Malleus : A, from in front ; B, from behind. (Magnified 4 diaui.: Henle.) — fi. Head. b. Short process, c. Long process. (V. Manubrium, e. Articular surface. /. The neck. It is united to the Glaserian fissure, in adults only, by a mass of ligamentous tissue, which favors slight motion in any direction. The head and neck of the malleus project into the tympanic cavity, and are entirely free from the membrana tympani. The rounded, smooth surface of the head is directed anteriorly, while the surface which articulates with the incus is directed backward. The long diameter of its articular surface runs vertically; the short diameter, horizontally. In the direction of the former, the articulating surface has been said to resemble a saddle, for the surface is divided a little below the middle by a horizontal ridge, and depressed on each side of it. This articulating surface is also concave in the direction of its short diameter, i. e., from without inward. If a shallow oval basin, the long diameter of which is con- siderably greater than its short diameter, be placed across a ridge, and then bent downward, and at the same time slightly twisted on itself, the cavity thus formed will fairly represent the articulating surface of the malleus. 1 Caelius Folius, Venice, 1645. Nova auris interna^ delineatio. * .Jacobus Kavius, Professor of Anatomy and Surgerj' in the University of Levden.. 3^ 1719. * Pndectiones, p. 358. 68 MIDDLE EAR. The neck of the malleus lies between the head and the manu- brium. It makes, with the former, an angle of about 135° when viewed from in front. It has three surfaces: a broad inner one directed towards the tympanic cavity, bounded in front by the processus Ravii, or long process, and behind by the long, low bony elevation for the insertion of the tendon of the tensor tympani; an anterior surface, lying above the ridge joining the processus brevis and the processus longus, and extending to the angle made by the head of the malleus with the neck, and separated from the posterior surface by a sigmoid-shaped ridge for the insertion of the ligamentum mallei externum of Helmholtz. The posterior surface lies between the aforesaid sigmoid ridge in front, the edge of the articulating surface of the malleus above, the low, long process behind, and a line drawn from the insertion of the tensor tympani to the short process below. Of all the surfaces of the neck, the posterior glides most gradually into the manubrium. The handle or the manubrium of the mal- leus, that part of the bone inserted into the membrana tympani, has also three surfaces, which may be considered prolongations downward of those of the neck. Since they all gradually approach each other and are united in the tip or point of the manubrium, the latter may be said to resemble a three-sided bayonet, one ridge of which passes from the short process directly downward to the tip, and is consequently turned towards the external auditory canal. The point or lower end of the handle of the malleus is flattened into a small disk, one surface of which is turned towards the auditor}' canal. This spot is plainly visible as the pale, round centre of the umbo. The long axis of the handle of the hammer is convex poste- riorlv and inward, so that when viewed from without the manubrium appears concave on its anterior and outer surfaces. This is especially marked at the lower third on the anterior surface, so that the manubrium normally appears curved decidedly forward near its lower end, of course in the plane of the mem- brana tympani. Along the ridge of the manubrium, directed towards the external auditory canal, several little node-like prominences are not uncommonly seen. These are not patho- logical, but purely physiological. Their origin is obscure. Dr. A. H. Buck^ has described a hook-shaped termination anteriorly, of the manubrium mallei in a boy thirteen years old. The manubrium of the opposite side had been destroyed by otorrhoea, so that it was impossible to make a comparison be- tween the mallei in this case. Wagenhauser^ observed in a laborer, forty-two years old, a broad manubrium, presenting in 1 N Y. Medical Record, Dec. 16, 1862. 2 Archiv f. Ohvcnhoilkunde, Bd. xix. S. 57, 1882. TYMPANIC CAVITY. 69 the lower third a rectangular bend, forward and below. There were no evidences or history of disease in this ear. Dimensions of the Malleus. — The malleus is nearly 9 mm. long; its manubrium is between 4 and 5 mm. long, and its head is 2.V mm. thick. The latter is the greatest diameter of any part of the bone, which gradually tapers to the point of the handle. The long diameter of the articulating surface of the malleus is about 3 mm. ; the short diameter is between 1| and 2 mm. Fixation of the Ifalleus. — The malleus is held in position by four ligaments, viz. : Ligamentum mallei antorius, ligamentum mallei superius, ligamentum mallei externum, and the liga- mentum mallei posterius. The ligoinentam /iiallei anterius is a broad band of fibres which holds the processus Folianus against the spina tympanica major. This ligament may be said to arise from the spina* tympanica major and to be inserted along the neck of the malleus all the way from the processus Folianus to the head of the malleus. A part of it also runs from the pro- cessus Folianus to the short process of the malleus below, and the membrana tympani above, aiding thereby the division between the anterior and posterior pockets of the membrana tympani ; another fold of the same ligament runs from the pro- cessus Folianus downward with a free margin, as far as the line corresponding with the insertion of the tensor tympani muscle. This aids in making the limiting wall between the anterior pocket of the drum-head and the tympanic cavity. The round ligdnientuin mallei superius descends obliquely down- ward and outward from the tegmen tympani to the head of the hammer. Its function is to prevent the malleus from being forced outward. The ligamentuiji nidllei externum is a very important collection of satin-like, tendinous fibres, which radiate from the sigmoid crest on the front of the neck of the hammer and are inserted into the sharp edge of the segment of Rivinus on the temporal bone. It prevents the hammer from being forced inward, and, being inserted above the axis of rotation of the hammer, it prevents the manubrium, which is below the axis of rotation, from moving too far outward towards the auditory canal. The ligamentum mallei posiicum is really the posterior edge of the ligament just described as the external ligament of the hammer. As the line followed by this bundle of fibres passes through the spina tympanica major, and as it represents pretty closely the axis of rotation o^ the hammer, Helmholtz has suggested that it should be considered a separate ligament, and has given to it the narne it bears. As this ligament and the ligamentum anterius are in a me- 70 MIDDLE EAR. chanical sense one ligament, although the hammer intervenes between them, Helmholtz has called the two sets of libres the axial ligament of the malleus. Axial Ligament of the Malleus. — The plane of this ligament is not quite horizontal, being a little higher in front than behind. In all its motions as a lever the hammer swings about this axis-ligament as a fixed point. All above the short process of the malleus is above, and all below the short process is below, the axis-ligament. The ligameMiun mallei anterius of Arnold was once described as a muscle, the laxator tympani major.^ It is not, however, anything more than a ligament which originates from the spina angularis of the sphenoid, passes through the petro-tympanic fissure,^ and is inserted into the malleus. Under the name of ligamentum mallei posticum seu mamibrii, the liga)/ientinii mallei externum of Arnold, Lincke describes a liga- w^i Fig. 21. aVA. Ligamentous support of Ossicles viewed from above. (Helmholtz.) — l-h. Attach- ment of the ligamentum mallei e.xternum. 1-. Head of hammer, i. Body of incus. /. Point of its short process, a. Entrance to the Eustachiafi tube from the tympanum. <■. Stapes, d. Tendon of stapedius muscle, h. Tendon of the tensor tympani, leaving the cochlear process, y-g. Chorda tympani, marking the free edge of the folds of mucous membrane, bounding the pouches, n. The upper tendinous fibres of the ligamentum mallei anteriu.*, originating above the spina tympanioa major, m. j. Malleo-incudal joint. ment wdiich passes from the upper edge of the end of the external auditory canal to the short process of the malleus, and occupies the position of a supposed muscle, once called the M. laxator tympani minor, or M. mallei exterior seu Casserii. It is now universally acknowledged that muscular fibres do not exist here.^ 1 Sommering. 2 Gla.serian fissure. ^ Henle, Eingeweidelehre, p. 745. TYMPANIC CAVITY, 71 Incus or Anvil — The middle one of the three auditory ossicles is the incus or unvil. The name is derived from the shape of its upper half. This small bone is divided into a body and two processes, viz., a short and long one. The former of these two processes is also called the horizontal process. It is held to the posterior and to the upper wall of the tympanic cavity by liga- ments.^ This is an important point in the mechanism of the auditory ossicles.^ The longer process is also called the de- scending ramus of the incus. (Fig. 22, e.) It curves gradually Right Incus. (Magnified 4 diam.: llenle.) — A. Inner surface. B. View in front. Aa. and Be. Body. 6. Short process, e. Long process, d. Processus lenticularis. /. Articular surface for the head of the malleus, c. Surface which lies in contact with wall of tympanic cavity. outward, i. e., towards the external ear, away from the vertical plane of the body of the incus, assuming a slight sigmoid shape; at its tip it curves rather sharply inward, to unite with the head of the stapes by means of the processus lenticularis. The narrowest part of the incus is at the middle of the body of the bone; beneath this part it widens out again anteriorly into the important tooth wdiich locks with the malleus in all its inward movements, and posteriorly into the descending ramus or long process. The articulation between the malleus and incus is a true joint, in which is found a meniscus.^ If this articulation is viewed on its outer surface, i. e., on that side towards the external auditory canal, it would seem that the incus quite overlapped or embraced the head of the malleus ; when viewed from its tympanic side, however, it appears that the largest share in the joint belongs to the malleus. This is 1 Ligamentum incudis posterius et ligamentum incudis supcrius. ^ Henle calls this the incus-tympanic joint, " an amphiarthrosis between the articulating surface of the short process of the incus, and a prominence on the posterior wall of the tympanic cavity. The articulating surface on the incus is covered with a thin layer of librous cartilage." ^.Riidinger. 72 MIDDLE EAR. due to the wonderfully peculiar structure of this joint, the true nature and function of which were first pointed out and ex- plained by Helmholtz in 1869/ Dimensions of the Incus. — The greatest length of the incus is in a vertical line passing from the top of the body of the bone through the long process. It measures 7 mm. The horizontal upper edge of the body measures 5 mm. Its greatest thickness, 2^ mm., is at its articulating surface for the malleus. Malleo-inciidal Joint. — Before Helmholtz's investigations, the shape of this articular surface was usually described as resem- bling a saddle. In order to gain a clearer idea of the mechanism of this joint, Helmholtz makes use of a different comparison. "It is, in fact, like the joint used in certain watch-keys, where the handle cannot be turned in one direction without carrying the steel shell with it, while in the opposite direction it meets with only slight resistance. As in the watch-key, so here, the joint between hammer and anvil admits of a slight rotation about an axis drawn transversely through the head of the hammer toward the end of the short process of the anvil ; a pair of cogs oppose the rotation of the manubrium inward, but it can be driven outward without carrying the anvil with it."^ It is of the kind of joint known as ginglymus. The mechanism of this joint is best understood when it is known that the malleus, as a whole, is a lever, the fulcrum of which passes just below the short process. This, of course, leaves the head and neck, i. e., the articulating surfaces for the malleo-incudal joint and all the free tympanic parts of the malleus, above the line of support of the lever, the manubrium being below. The latter is the Jong arm of the lever, and consequently all its movements are re- peated in an opposite direction on the head of the malleus. Each inward movement of the manubrium, therefore, causes a slio-ht outward motion in the head of the malleus and a firm locking of the malleo-incudal joint, by which the incus is carried about an axis drawn transversely through the head of the hammer toward the end of the horizontal or short process of the incus. The incus being also suspended as a lever, about the line just named, when all above that line moves outward, all below the line moves inward, i. e., as the upper part of the incus is moved outward the long process swings inward and carries the stapes ahead of it, thus forcing the foot-plate of the latter into the oval window. 1 Mechiinik dor Gehorknochelchen und des Trommelfells, Bonn ; also Pfliiger's Archiv f. Physiologie, 1 Jahrgang. 2 Helmholtz's Mechanism of the Ossicles of the Ear, etc., English translation by Buck and Smith, 1873, p. 33. TYMPANIC CAVITY. 73 The Stapes or Stirrup. — The smallest bone iu the body and the innermost of the three anditory ossicles is the stapes or stirrup. Its name is derived from the striking resemblance it bears to a stirrup. It is divided into a head or capitulum, a neck, two branches or legs (crura), and a foot-plate or basis. The head, wliicli is like a cup-shaped button, is placed at the junction of the two crura. It is designed for the reception of the processus lenticularis of the incus, with which it forms a ball-and-socket joint. There is a meniscus in this joint, accord- ing to Riidinger.^ On the posterior surface of the head of the stapes the stapedius muscle is inserted. c ^ a Right Stapes. (Magnified 4 diam. : Henle.) — A. Prom within. B. From in front. C. From beneath, d. Foot-plate or base. d. Capitulum. c. Anterior, a, posterior shaft or crus of stapes. The two crw^a or branches fxvQ furrowed on their inner surface, which makes them lighter, yet does not deprive them of strength. They arise from the brms with tlie pars petrosa, the sulcus ])etros])henoidalis for the reception of the cartilaije of the tube. (Rii- diuger. Die Ohrtrompete, p. 2.) \ 102 MIDDLE EAR, Fill-. 32. wall, the shorter portion represents that of the anterior or outer wall, and the curve shows the position of the roof of the Eus- tachian tuhe. (Fig. 32.) It will be seen, therefore, that this part of the tube is not a complete and round cartilaginous canal, but rather a flattened tube, the posterior wall and roof of which are made entirely of cartilage, while the anterior wall is of cartilage only in its upper part, its lower portion being muscular^ and completing the tube. The upper part of the inner cartilaginous wall, as well as the roof of the tube, is fastened to the base of the skull by means of the basilar fibro-cartilage. The lower end of the inner wall is movable. That part of the cartilage of the Eustachian tube which curves forward to form the upper part of the outer or anterior wall of the tube, is widest and most movable in its middle portion ; it is narrower and more tirnil}' fixed at its two extremities, viz., above, where it is joined to the jagged bony edge of the osseous canal, and below, to the pterygoid process. The calibre of the tube, in the main, is not round, but cleft-like, and slightly sigmoid in shape; however, that portion of the calibre lying in the curve formed by the cartilage as it turns for- ward, i. €., that part lying entireh' within cartilaginous boundaries, is round and more open than the rest of the lumen of the tube, owing, probably, to the stiff- ness of the cartilage. This fact would always insure at least a portion of the tube's being more likeh' to be free from obstruc- tions or from having its two sides stick together. To this more patulous part, Riidinger has given the name of safety-tube (Sicherheitsrohrc), and to the cleft-like calibre of the tube below this rounder lumen, he has given the name of" accessory cleft" (Hilfsspalte), " since, according to Du Bois Eaymond, these terms express most clearly their physiological importance."^ ^ Formeilj', this part of the canal was called uieinbranous, but since muscular tissue is so intimately concerned in its formation, Kiiding-er proposes to call it muscular, as beini;- more truly descriptive. 2 Riidinner, Ohrtrompete, p. 7. Transverse Section or the Carti- laginous Part of the Eustachian Tube near the Foramen Ovale. (Henle.) — b. Section of the internal carotid. , No. 12. * Monatsschr. f. Ohrenh;, No. 2, 1875. 106 MIDDLE EAR. The Plica Salpingo-palaima and the Plica Salpingo-pharyngea. — The two folds of mucous membrane known as the plica sal- pingo-palatina' and the plica salpingo-pharyngea, are greatly concerned in the form and expansion of the mouth of the Eusta- chian tube, both in its condition of rest, and also in the active and passive movements of the soft palate. The intimate con- Fio-. 34. nection between the movements of the soft palate and the Eusta- chian tube is dependent not only on their common muscles, but upon the two folds just named. The former fold constitutes the anterior edge of the tubal mouth, and is intimately connected with the tensor palati muscle. The latter fold, the salpingo- Fig. 35. The Nasopharynx viewed prom Behind. (Zaufal.) 1. Plica salpingo-pharyngea. 2. Pliea salpingo-palatina. 3. Septum narium. 4. Superior turbinated bone. 5. Middle turbinated bone. 6. Inferior turbinated bone. 7. Curve of the tubal cartilage. 8. Mouth of Eustachian tube. 9. Tubal ridge. 10. Fossa of Rosenmiiller. 11. Levator palati. 12. Azygos uvula>. 13. Posterior tubal sulcus. 14. Anterior tubal sulcus. 15. Uvula. 16. Arcus palato-pharyngeus. pharyngea, is of more importance, according to Zaufal, and is formed as follows : The under part of the lip of the Eustachian mouth in the pharyii.\ gradually narrows into a mere fold of mucous membrane, very rich in glands. To tliis fold, a few EUSTACHIAN TUBE AXD MASTOID PORTION. 107 centimetres in length, the name of plica salpingo-pharyngea has been given.' It rnns in tlie same direction as the plica salijingo- palatina, from the posterior and under end of the tubal ridge downward on the side of the pharynx, dividing the latter from the upper lamina of the velum, to unite with the posterior edge of the levator palati muscle. Mw-ods Meinbroiic of fhe JE'/sfacliian Tube. — The mucous mem- brane of the Eustachian tube is a continuation of that of tlie pharynx. It is supplied vrith ciliated epithelium, the cilia of which move in a direction from the tvmpanic cavitv towards the pharynx, thereby favoring the passage of fluids from the cavity of the drum and tube into the throat. The Eustachian tube is very rich in glands at certain places; although the upper concave portion of the cartilaginous roof of the canal is entirely free from glands, the sides of the tube, in the pharvngeal portion, are richly supplied with " acinous mu- cous o'lands," emptvino' into the folds of mucous membrane, as shown bv Riidino-er. These mucous ojlands do not difter from those of the oesophagus and pharynx. In the upper portions of the tube, towards the tympanic cavity, all glands become sparse. In addition to the glands just named, Gerlach" has shown that the mucous lining of the cartilaginous portion of the tube is richly supplied with follicular glands, which are most numerous at its middle part. Placed still deeper in the submucous connective tissue, are numerous acinous glands. The follicles of the tubal mucous membrane are about half as large as those of the pharynx, but take in the entire depth of the mucous membrane. Tons'dla Phari/ngea. — According to the investigations of San- torini^ and Luschka,* it is shown that the lining structures of the roof, and to a great extent the hinder wall of the nasal part of the pharynx, are composed of a tissue so strikingly like the substance of the tonsils that it has been named the " pharyngeal tonsil.'" Luschka states that this spongy tonsillar substance, of a maxi- mum thickness of 7 mm., which he has never failed to find, extends from the posterior boundar}- of the roof of the nasal cavity to the edge of the foramen magnum of the occipital bone, where it assumes a more or less uneven surface, or, breaking up into separate sebaceous glands, is gradually lost in the pos- terior wall of the pharynx. The same kind of structure forms ^ E. Zaufal, Archiv 1". Olironheilkunde, vol. xv., 1879, p. 97. 2 Zui' Morphologie der Tuliii Eustachii. Sitzuiii;#ljerichte d. Erlanger Physi- calisch-Med. Soc. "Abstract by von Troeltsch, A. f. 0., vol. x. p. 53, 1875. ^ Parma, 1775. * Der Schlundkopf de.s Menschen. Tubingen, 186S, pp. 20-27. 108 MIDDLE EAR. the chief constituent of the recessus pharyngeus, and extends in a thinner layer over the ridge of the pharyngeal mouth of the Eustachian tube. Differences in Size and Shape of 3Iotith of Eustachian Tube. — Urbantschitsch^ has described great variations in the shape and size of the pharyngeal mouth of the Eustachian tube. These variations occur not only in those of the same age, but also in the same individual. The variation in form of the cartilaginous part of the tube is observed to occur in both the posterior and anterior wall. The former may terminate in a sharp point, or it may be very blunt and rounded at the lower and posterior end ; it may also be corrugated on the surface towards the lumen of the pharynx, or curled decidedly upward and forward towards the so-called floor of the tube. Another curious devia- tion found in the posterior wall of the tube is a bifurcation, the hinder limb pointing backwards, the anterior curling forwards. The various deviations in shape, position, and direction of the walls of the tube, descril)ed by Dr. Urbantschitsch, apply only to the mouth, and not to the cartilage in its upper and inner parts. They may, in many cases, cause a widening or a narrow- ing of the mouth without producing changes further up the calibre of the tube. According to the same authority, the direction of the pharyn- geal mouth of the tube is generally oblique from above and in front, backward, and downward ; in exceptional cases, the axis of the mouth of the tube may run vertically or even horizon- tally. Bloodvessels and Nerves of the Eustachian Tube. — The arteries supplying the Eustachian tube are the ijharyng&d from the external carotid, the middle 7neninge(d hranch of the internal maxillary, and various small branches of the internal carotid. The nerves are distributed as follows: The tensor palati, or the dilatator tuba? muscle, is supplied by a branch from the otic ganglion, and also by a motor branch from the internal ptery- goid nerve, a muscular branch of the smaller division of the inferior maxillary nerve. The levator palati muscle is supplied by the facial nerve through its connection with the A'idian and petrosal nerves, as well as by a branch from the vagus. The inner diUitor of the tube, the salpingo-pharyngeus, is supplied by the glosso-pharyngeal nerve. The inner pterygoid muscle is supplied l)y the inferior maxillary nerve. The mucous mem- 1 Anatomiscbc Bemerkuns:;en iilior die (iostalt und Lage des Ostium pharyngeum tuba' beim Menschen. A. f. O., \o\. x. j)]). 1-7, 1875. EUSTACHIAN TUBE AND MASTOID PORTION. 109 l)rane of the tube is supplied by branches of the glosso-pharyn- geal nerve, which also supplies the mucous membrane of the tympanic cavity. 'Jlw Mastoid Portion of the Temporal Bom "ml its Celts. — The mastoid portion is that highl}' important part of the middle ear situate behind and partly below the cavity of the tympanum. It corresponds to the protuberance behind the auricle. This hollow portion is developed parti \' from the squamous portion, but chietly from the petrous part of the temporal bone. As is well known, the temporal bone is formed from three distinct pieces, the squama, the annulus tympanicus, and the petrous pyramid. The squama is divided into two parts, viz., the vertical and the horizontal portions. The horizontal portion is sub- divided into an inner and an outer lamella, the latter of which forms part of the air-cavities of the mastoid portion. This por- tion of the temporal bone has a distinct existence by the fifth fcetal month. The mastoid portion is really a continuation of the petrous part of the temporal bone, backward and downward. In the new-born child it extends half an inch beyond the hind- most boundary of the squama, and forms a three-sided pyramid, the point of which is behind, the base of which is in front towards the tympanum, and the sharp free edge of which is directed downward. The outer surface of this pyramid corre- sponds of course to the outer wall of the mastoid portion, the inner surface divides the mastoid cavitv from that of the cranium, and the upper surface is in the same plane with, and is a con- tinuation backward of, the upper surface of the petrous portion of the bone. All of these features are most clearly seen in the new-born child. The uj^iper surface of the mastoid portion unites with the postero-external edge of the roof of the tympanum. This is marked by a furrow until immediately after birth, when it usually becomes invisible. In a child a few months old, the outer sarfire shows a defi- ciency at its upper and anterior edge, in the shape of a fissure named the nuistoid-squamous. Sometimes, at this early age, the fissure is not at all marked, its place being represented by a series of irregular openings varying from two to three mm. in diameter, as though union between the squama and the outer mastoid wall was alreadv far advanced. The inner surface is quite concave, and over it runs a furrow, which at last is fully developed into the sigmoid sinus. The mastoid fommina are found near that point where the upper and under edges of the mastoid portion meet. In some cases the foramina are not complete until the occipital bone joins the mastoid edges. These openings are for the passage of 110 MIDDLE EAR, arteries to the dura mater, and for small veins which connect the transverse or lateral sinus with the veins of the scalp. Mastoid Cells. — "Within the mastoid portion are found the mastoid cells. These are a series of bony air-chambers of variable size, communicating with one another b}' means of foramina in their thin walls. They communicate with the tym- panic cavity by means of the mastoid antrum, and are lined by a continuation of the same mucous membrane lining the Eusta- chian tube and tympanic cavity. The quantity and development of these cells vary, not only in different individuals, but in the same individual, on the two sides. It is of the highest impor- tance to understand their general distribution in the adult bone, in order to diagnosticate and treat inflammatory processes arising there, or which have spread to that part from the tympanic cavity. Fio". Sfi. Mastoid Portion op the Left Temporal Bone laid open and viewed from behind. — A. Mastoid cells extending from the mastoid process below, upward and inward, over the lateral sinus is. c. The zygoma. In the mastoid portion of the child it is found that the septum dividing the mastoid cavity from the sigmoid sinus is very thick, and hence inflammation is not likely to pass from the former to the latter, as it is in adults, in whom this septum is always thin. Hence, in very young children, meningitis very rarel}', if ever, occurs from inflammation of the mastoid cavity, from which in- flammation tends to pass outward rather than inward, not only because the dividing septum between it and the sigmoid sinus is EUSTACHIAN TU15E ANJ) MASTOID POKTIOX. Ill thick, but because, as already stated, tlio outer wall of the mastoid portion is imperfect in early childhood. Tliis is the reverse of what we find in the adult, so that in the latter, every- thing- favors a passage of disease of the mastoid cells inward towards the brain, while in the child the conditions are in favor of a passage outward of disease in this region. A depression sometimes occurs in the sigmoid groove of adults near the foramen jugulare. This is supposed to be due to the interference in the circulation of blood, bv a ridge of ])one, which is found immediately behind the edge of the jugular foramen in such cases. In some instances, instead of depressions at tliis point in tl#e sigmoid sinus, erosion of the bone is found, and a true perforation exists.^ The lower pointed part of the mastoid portion is known as the masfoid process; to it the sterno-cleido-mastoid muscle is attached. The development of the mastoid process is greater in the strong and muscular, while it is less developed in the weak and in children. The mastoid portion is also subject to ditfer- ences in development in different races, being small and solid in negroes, w'hile in Mongolians it is found much more highly developed than in Caucasians, as shown by Welker. By the eighth month of tVetal life the mastoid cells are very distinctly seen as depressions in the bone of the mastoid portion. These cells are not developed first at that part of the foetal tem- poral bone which, at a later period, corresponds to the mastoid process, but from the upper and hinder parts of the mastoid an- trum, i. e., from above downward, as demonstrated by Schwartze and Eysell.2 In the first year after birth the mastoid cavity loses its pyra- midal shape by assuming a more ovoid form, and the mastoid cells are formed gradually. Those which are included in the upper and outer portion of the mastoid portion where it joins the squama, are the most highly developed at this time, and lined with mucous membrane, while the mastoid process as yet contains no air-cells. From this time on, the external difter- ences of this part of the temporal bone are much less than the differences in development of the air-cells within, for the latter are subject to the greatest variations in number and distribu- tion, as can readily be seen in the. skulls of adults. The masfoid "nfr'n/t, wdiich is a connecting air-chamber between the tympanic cavity and the air-cells of the mastoid portion, is of a triangular shape. Its position is somewhat above, in front of, and further inward, than the rest of the mastoid cells. Its walls, with the exception of part of its outer wall, are formed ' Hiuierwaiis, ^[oiiatssehrif't fur Ohroiiheilkunde, No. 5, 1880. » Archiv f. Ohix-nh.. Daiul i., 1873. 112 MIDDLE EAR. by the petrous part of the temporal bone, and communicate by numerous perforations with the mastoid cells, with which it is surrounded on all sides excepting in front and on the inner side. Anteriorly it has a wide opening into the tympanic cavity, and on its inner side it is bounded by that part of the petrous bone covering in the horizontal semicircular canal. It is stated in a valuable paper by Schwartze and EyselP that the general shape of the mastoid cells is that of a hollow pyramid, and that their axes run like the radii of a hollow sphere, towards their centre, viz., the mastoid antrum. The air-containing cavities fill the entire mastoid portion of the temporal bone, and in most cases they spread doA\^iward and outward to the very point of the mastoid process. Limits of the 3Iasfoid Cells. — The mastoid cells extend as far backwards as the Emissarium mastoideum, where they are in close contact with the outer side of the g-roove for the mastoid sinus, and they are found as far forward as the external auditory canal. Mastoid cells are also found continuous with those which reach as far forward and upward as the petro-squamous suture, above the point where the outer table of the mastoid portion is nearest the inner table, that is, the outer wall of the sigmoid o-roove. In a temporal bone shown in Fig. 36, in which the section of the mastoid portion has been made in the plane of the pos- terior surface of the petrous portion, and carried through the mastoid where the inner and outer tables nearly meet, charac- teristic air-cells are seen lying. In a tent-like space, half an inch high, the apex of which points into the cranial cavity, and the floor of which is in the same plane as the upper surface of the petrous portion, cells of the mastoid are also seen. The outer side of this tent-shaped cavity shows on section that it is continuous with and a part of the outer wall of the mastoid portion, which has grown inward, away from the squama. The lowest limit of the mastoid cells is the tip of the mastoid process. Those cells which are developed from the petrous part of the bone are the largest; those which arise from the squama and lie over the external auditory canal are the smallest. PHYSIOLOGY. Some investigators and writers, among whom are Lucse and Schwartze, have thought that every act of breathing is conveyed to the drum-cavity by a normal tube, and they have declared that this can be shown not only by the oscillations of the mano- 1 Archiv f. Olireiihcilk., IJund i. pp. 168-159, 1873. \ EUSTACHIAN TUBE AND MASTOID PORTION. 113 metric column placed iu the external auditory canal, but also by direct observation of the motion of the drum-head at each respi- ration. Politzer, on the contrary, denies this, believing that the tube is opened only at swallowing, and the facts are in his favor. Mach and Kessel think the movements of the drum-head ob- served by Lucfe and Schwartze are due to a to-and-fro motion of the column of mucus, in the capillary safetj'-tube, produced by rarefaction and condensation of the air at the faucial mouth of the Eustachian tube. L. Blau,^ of Berlin, reports two cases of movement in the membrana tynipani, at each respiration. In both cases the membrana showed pathological alterations; in one it was ad- herent to the promontory, and in the region of the pyramid of light a small spot was seen to bulge outward at each inspiration, and to sink inward at expiration. In the second case, the patient complained of a clicking in his ear, which could also be heard objectively. In the membrana, in this instance, two cica- trices could be seen, one in front of, the other behind the malleus. The latter, during the respiratory acts of the patient, was seen to move in and out, as the membrana did in the previous case. Swallowing produced neither movement nor the objective sound. During regular respiration through the nose the relation of the parts about the faucial mouth of the Eustachian tube does not materially change. The pharyngeal opening of the tube either remains at rest or opens and closes slightly with succeed- ing inspiration and expiration, after a few moments coming as^ain to rest. On pronouncing the vowels, particularly «, e, and i, the mouth of the Eustachian tube opens downward and forms an oblique triangle on the lateral wall of the pharynx.^ According to a subsequent paper by Zaufal,^ Bidder^ was the first to examine the normal relations of the parts in the naso- pharyngeal space. His investigations were succeeded by those of Schulr' and Voltoliui,'' the latter being the first, however, to view the tubal ridge through the intact nose. Subsequently observations of these parts were made by Michel, in 1873, and by Zaufal, in 1875. The latter examined the movements of the tubal opening by means of long funnels armed with mirrors, in- troduced into the nares and passed back into the naso-pharynx.'^ It is now generally conceded, through the labors of Riidinger 1 Arcliiv f. Ohrenheilkunde, Bd. xix. S. 209, 1883. ' Die nornialen Bewenungen der Eachenmiinduno; der Eustachischen Kohre. Prof. Zaufal, Archiv f. Ohrenh., Band ix., 1875, S. 133, 228. ' A. f. Ohrenh., Bd. x. S. 19, 1875. * Dorpat, 1838. ■• Wiener Med. Wochenschr., No. 3, 1858. s jsGl. ■ Archiv f. Ohrenh., Bd. xii. S. 250, foot-note. 8 114 MIDDLE EAR. and others, that there is a small part of the normal Eustachian tube, the so-called safety-tube, in its upper part, under the carti- laginous hook, always wide enough open to allow a recoil of air to occur from the drum-cavity, if the drum-head is suddenly driven in, as in explosions, and also to permit a slow equaliza- tion of pressure in the tympanic cavity, from the pharynx, in- dependently of the act of swallowing. But this safety-canal is not wide enough to allow con-stant ventilation of the drum- cavity to go on. Therefore, to insure ventilation of the tym- panum, the normal tube is opened at every act of swallowing. Prof. Moos,^ after a careful study of the Eustachian tube, con- ducted chiefly by transverse sections of the frozen preparation, concludes that the tube when in a state of rest is closed at a point just behind the funnel-shaped end of the faucial opening, and that the closure extends over about two-flfths of the length of the canal. On the lower surface or floor of the tul»e the closure is etiected by.the longitudinal folds of mucous membrane which, as seen in cross-section, form a considerable prominence, practically a valve, the size of which is subject to individual varia- tions. On the opposite surface of the canal, under the cartilage hook or roof, there is another prominence of mucous membrane, heretofore overlooked. These two prominences or folds of mucous membrane, judging from analogues in animals, seem to facilitate, by their i-apid and easy unrolling, the patefaction of the tube. The islands of cartilao;e described bv Zuckerkandl,- and hinted at by Rlidinger,^ are regarded as fibro-cartilage, having physio- logically the function of sesamoid bones, in the mechanism of the tube, by their connection with the submucous tissue, the fascia or ligamenta salpingo-pharyngea and the tendon of the tensor veli. In the horse the inner belly of the abductor tubie is inserted into such a cartilaginous disk. That the Eustachian tube is practically closed, except at swallowing, is further proven by observations on themselves by Poorten,* Riidinger,' and Yule, in all of whom, when the tube was either voluntarily opened as in Yule, or involuntarily opened as in Riidinger and Poorten, the voice was heard abnormally loudly and painfully. The same is proven by the observations of "W". Flemming, of Prague.^ Mr. Yule^ has given an account of the muscular process seen to occur in his own throat during the voluntary act of opening * Beitrilge zur normalen unci pathologischen Anatomie uud zur Physiologie der Eustachischen Rohre, Wiesbaden, 1874. Blake's Report, 1875. American Otolon-ical Society. 2 Cenralblattt,'0.38, 1874. » Qp. cit., p. 3. ■ * Monatsschr. f. O., No. 2, 1874. » ibid., Xo. 9, 1872. « Ibid., No. 6, 187'>. ' On Opening and Closing the Eustachian Tube. C. I. P. Yule. Journal of Anat. and Physiol., viii., 1873. EUSTACHIAN TUBE AND MASTOIT) POKTION. 115 the Eustachian tube, a power which he seems to possess. AVheii he makes the contractions for opening the tube, it is noted : "First, that the vehim palali does not change either its position or its shape — in fact, that it remains unmoved ; and further,, that it does not become tense, but hangs as soft and tlaccid to the touch as at ordinary times of rest. Secondly, that the only parts that do move are the two posterior pillars of the pharynx ; and their motion is ample and decided, and altogether unmis- takable. They both move inwards simultaneously towards the middle line, moving from their old position from one-half to three-fourths of an inch. This action is not spasmodic, but perfectly steady, and can be sustained for some considerable time at will, the pillars maintaining their new position all the while." Mr. Yule is quite satisfied and certain that during this period the Eustachian tube is open, and he concludes that from the iiaccid condition of the velum, and also from the fact of its position and form remaining unaltered, the tensor and levator palati can have no participation in the opening of the tube in his case, and that the muscles most evidently concerned are the palato-pharyngei. Mr. James Hinton' taught that, since the salpingo-pharyngeus is united at its lower attachment with the palato-pharyngeus, and as this muscle during swallowing is drawn inwards, the salpingo- pharyngeus is drawn inwards also, and so draws the projecting cartilaginous lobe of the tube, to which it is attached superiorly, away from the opposite w^all. Therefore, the new direction given to the salpingo-pharyngeus by the movement inwards of the pillars of the fauces, is the cause of the opening of the tube. This seems to give but a partial explanation of the mode by which opening of the Eustachian tube is accomplished. In the process, as thus explained, it would seem that the tensor palati and the anterior wall of the tube are supposed to remain fixed, the movement being confined to the muscle attached to and operating upon the posterior wall. In swallowing, however, the velum palati is thrown into motion, and the anterior wall of the Eustachian tube is thereby drawn away from the pos- terior wall. At the same time, doubtless, the muscles acting upon the posterior wall of the tube are forced into contraction, and help to draw the two walls apart. Riidinger- agrees with Rebsamen that the opening of the Eustachian tube is brought about by the action of several muscles. The former supposed that the three muscles — the di- lator of the tube or tensor veli, the levator veli, and the sal- pingo-pharyngeus — act simultaneously; by the action of the first, the cartilage hook is fixed and drawn outward ; by the ^ Questions of Aural Suru'erv, p. 101. London, 1874. ^ l3ie Ohrtronipete, Munich, 1870, p. 6. 116 MIDDLE EAR. action of the other two the posterior wall is drawn inward and upward, the result being a patuleuce of the Eustachian tube. Fig. 37. T K K' T' T" H W \ D C AV AV W View of the entire Right Middle Ear, laid open by an incision from above down- ward, THROUGH THE CENTRE OF THE CAVITY, PARALLEL TO THE LONG AXIS. (Gruber.; Above the line A B, the outer half: below the line, the inner half. — T, T', T". Eustachian tube. T'. The isthmus. T". The tympanic opening. K, K'. Section of the cartilage; between these points the groove of the so-called membranous part of the tube is seen, below which the muscles of the tube are seen in section. H. The manubrium of the mal- leus, with a remnant of the tendon of the tensor tympani. Behind the manubrium may be seen the descending process of the incus ; above, the articulation of the malleus and the incus. Between the manubrium of the malleus and the shaft of the incus may be seen the chorda tympani running from behind and below, upward and forward, which also marks the edge of the folds of the membrana tympani. AV. Entrance to the mastoid cells. W. Large cavity in mastoid cells. The inner half; below the line A B.— CC. Part of the petrous portion of the carotid canal (opened). N, M. Eustachian tube. L. Canal of the tensor tympani muscle. F. Rostrum cochleare with part of the tendon of the tensor tympani. G. Promontory on the inner wall of the tympanic cavity ; on the posterior boundary the niche of the round window. E. Stapes. D. Transverse jiart of the Fallopian canal. C. Eminentia pyra- midalis with the tendon of the stapedius muscle still attached to the head of the stapes. "\V. Entrance to the mastoid cells. -W. ^Mastoid cells. EUSTACHIAX TUBE AND MASTOID PORTION. 117 AVhen the muscles relax, tlie natural elasticity of the cartilage causes it to resume its original })osition, and the tube becomes narrower. Moos coincides with the view respecting the action of the tensor veli upon the anterior hook of the tubal cartilage, but rejects the idea that the levator veli assists in widening the Eustachian tube. By direct inspection of the pharyngeal end of the Eustachian tube, Dr. MicheP has observed that, at the act of swallowing, the velum palati rises and pushes a fold of nmcous membrane into the tubal opening between the tubal ridge and the outer edge of the posterior nostril. At the termination of the act of deglutition the velum falls back to its original position and the mouth of the tube is freed from the above-named fold. These observations of Dr. Michel have been conlirmed by subsequent study of the faucial end of the Eustachian tube in a young man who had lost by necrosis all the osseous contents of the nasal cavities and the bony roof of the nose.^ In this case the entire nasal cavity and the nasopharyngeal space were exposed to view, and the cavity from one tubal mouth to the other, with the insertion of the velum palati, could be seen at a glance. The observations already made by Dr. Michel were thus supplemented by watching the act of swallowing in this young man. It was found that during this act, two long vertical ridges form on the posterior pharyngeal wall behind the lower end of the tubal prominence. These produce an upward move- ment and project from 1 to IJ cm. above the surface of the velum, but leave a space about 1 cm. broad between them. In singing, instead of such ridges, moderately thick folds are formed. From the formation of these ridges Dr. Michel is led to suppose that the floor of the tube is pushed upward by the combined action of the levator palati and the pterygo-pharyngeus, the latter by its contraction and consequent thickening pushing up- ward the former muscle. The tendency in swallowing, therefore, would seem to be to force the floor of the Eustachian tube upward and its tw^o walls apart. Dr. Fournie,^ after careful experiments, has come to the fol- lowing conclusions : 1. The Eustachian tube is always oj)en and in direct communication with the air of the pharynx. 2. The ^ Das Verhiiltniss dei" TuVjcnmunduns; zum Gaumensegel am Lebenden be- trachtt't durch die ]^ase. Berlin. Klin. "VVochenschr., 1873, 34. ^ Neue Beobachtuni!;en iiber das Verhalten der Rachenmiindunt;- der Tuba und iiber die Thiitimkeit der .Musculatur des Selilundkopfe?. Berlin. Klin. AVochenschr., No. U, 187.5. See abstract by Dr. Zaufal, Archiv f. 0., Bd xi. t>. 00-63. * Cono;rt'S de Beims. Eevue Mensuelle de Larync;oIon;ie, d'Otologie, et de Ehin- ologie, iffo. 3, Oct. 1880. 118 MIDDLE EAR. tubal muscles, the peristaphylinus internus and externus, and the pharyngo-staphyline fascia, are intended by their contraction to shut and not to open the tube. Conjoint Physiology of the Eastachian Tube, Tympanic Cavity, and the llastoid Cells. — According to the carefully conducted experiments of Mach and KesseP on the functions of the tym- panic cavity and the Eustachian tube, it is shown that sound- waves will produce the greatest eflect when, in the middle ear, the following three conditions are maintained, viz. : 1. The Eustachian tube must, as a rule, remain closed. 2. It must, however, be opened occasionally for purposes of ventilation. 3. The tympanum should be in connection with large, irregular cavities. These conclusions are based on the following observations and facts : The length of most of the audible sound-waves is so great that the entire head of the hearer is, as it were, submerged in the wave of sound, and in the case of deeper sounds, all of the superficial parts are subjected to the same variations in pressure. If, then, the membrana tympani were exposed equally on both sides to the waves of sound, it could not be set into perceptible vibrations on account of this simultaneous and equal pressure on both its surfaces. Therefore, these observers conclude that "the waves of sound will produce the best effects upon the membrana tympani when it is unexposed on one side to the sound-waves, i. e., when the Eustachian tube is closed. On the other hand, it must be remembered that a difference in the atmospheric pressure on both sides of the membrana tympani is a serious interference with the mobility of the mem- brane. Therefore, the Eustachian tube must be opened now and then in order to restore the equilibrium in the pressure of the air on each side of the membrane, which may have been in- terfered with by various physical causes. The capacity of the tympanum must not sink below a certain limit if variations in pressure of a given amount are to produce vibrations of the membrana tympani of a corresponding amount; for if the capacity of the tympanum is small, then very slight excursions of the membrana tympani will produce considerable expansive power of the inclosed air, which will operate against further increase in the vibrations. ' Die Function der Trommelhohle und der Tubii Eustachii Sitziingsberichte der k. k. Academic d. Wissench., 1872. See also Archiv f. Olirenh., N. F., Band ii. S. 110-121. EUSTACHIAN TUBE AND MASTOID PORTION. 119 This is a very important circumstance in the consideration of the excursions produced by deep tones. In order that tke latter may be received, the tympanum must liave a certain depth and a generous capacity. Therefore the tympanum is in connection with the cavities of the mastoid process, and those of other por- tions of bone. A larger tympanum with perfectly regular out- line and form would be impracticable from its great resonance. Therefore, the irregular, spongy, bony cavities, with which the ear is connected, appear to be of the greatest advantage. SECTION III. INTERNAL EAR. CHAPTER I. LABYKINTH AND AUDITOKY NERVE. ANATOMY, The internal ear, sometimes called the labyrinth, is composed of a bony portion or case, and a membranous portion contained in the latter. p" The bony portion of the internal ear consists of the vestibule, the central portion, with which the cochlea is connected ante- riorly, and the semicircular canals posteriorly. The Vestibtde. — The vestibule is a small cavity situate just beyond the inner wall of the tympanum. This wall is common to both cavities, and in it is the oval window, into which fits the foot-plate of the small stirrup bone. A section of the vestibule parallel to its tympanic wall is round or elliptic, but a section at right angles to this, and running parallel to the floor of the tympanum, is in general of a pear shape, the point of which is directed forwards. This of course indicates that there is a general ten- dency on the part of the four walls of the vestibule to unite anteriorly near the cochlea. The average distance of the outer from the inner wall of the vestibule, is from 3 to 4 mm.; its long diameter, running between its anterior and posterior limits, is about 5 mm., as given by Henle. External View of a Cast of THE Left Labyrinth. (Henle.) — /. Fenestra cochlea; or round win- dow, a. Fenestra vestibuli, or oval window, b. Ampulla of su- perior semicircular canal, e. Am- pulla of posterior semicircular canal, d. Common shaft of union of these two canals, c. Ampulla of the horizontal semicircular canal- g. Tractus spiralis foraminosus. LABYRINTH AND AUDITORY NERVE, 121 On the inner walls are found two depressions separated by a narrow, sharp ridge; the anterior depression is the recessus sphar'iCKs for the reception of the sacculus rofin)diis, and the posterior depression is the recess'is elU-pHcus, in which lies the utrkidas. The ridge between these grooves is the rrisfa vesf'hi/h\ Fisr. 80. Section of the Pyramidal Part of the Right TE^rP0RAL Bone. throl(;ii the Vesti- Bi'LUM Parallel with the Outer Wall of Latter: View of Inner Wall. (Henle.) — a. Common opening of the superior and posterior semicircular canals, b. Sinus sulci- formis. c. Ampullar end of anterior vertical or superior semicircular canal, d. Recessus ellipticus. e. Crista vestibuli. /. Section of the small canal which conveys the branch of the vestibular nerve to the pyramid of the vestibule, g. Section of the facial canal. !i. Recessus sphivricus. i. Canal of the tensor tympani. j. Scala vestibuli. k. Lamina spiralis. I. Scala tympani. in. Inner opening of the aquajductus cochlea', v. Crista semilunaris, o. Recessus cochlea', p. Fo.ssa jugularis. q. Ampullar opening of the posterior vertical, or posterior semicircular canal, r, r. Sections of this canal, s. Pos- terior opening of the horizontal semicircular canal. The latter finally terminates above the oval window, on the outer wall, in a sharp point named the pyramis vestibuli. Below, the crista vestibuli divides into two branches, the one skirting along the lower edge of the recessus sphcericus, and the other running backwards towards the ampulla of the posterior semicircular canal. These branches inclose the recessus cochlearis of Reichert. The recessus ellipticus is further bounded below by a shallow furrow, the sinus suJciforwis. The AiiipiiJlar Mouths of the Seuncircular OmaJs. — On the upper wall of the vestibule, just above the recessus ellipticus, is the ampullar opening of the superior semicircular canal ; in the angle between the posterior and inner \\q\\ near the inner open- ing of the aquffiductus vestibuli, is found the ampullar opening of the common end of the superior and posterior semicircular canals. At about the same height in the centre of the posterior 122 IXTEKNAL EAR. wall is the posterior opening of the horizontal semicircular canal. The lower opening of the posterior semicircular caual is in the angle formed by the union of the posterior, the inferior, and the inner wall of the vestibule. The anterior ampullar mouth of the horizontal semicircular canal is in the outer wall between the oval window and the ampulla of the superior semicircular canal. Macidce Crihrosce. — These are groups of tine microscopic open- ings through which the nerves enter the vestibule. The superior group is found at the upper spinous termination of the crista vestibuli ; a second group is in the recessus sphsericus, and a third is situate at the ampullar opening of the posterior semi- circular canal. Through the superior cribriform spot nervous filaments pass to the utriculus and to the ampullae of the superior and the horizontal semicircular canals, through the middle crib- riform spot nerves pass to the sacculus, and through the lower spot the ampulla of the posterior semicircular canal is supplied. Reichert has described a fourth cribriform spot, in the upper part of the recessus cochlearis, near the origin of the lamina spiralis. This gives admission to a filament from the smaller branch of the cochlear nerve, which is distributed to the septum between the sacculi in the vestibule.^ The Cochlea. — The bony cochlea may be described very briefly as an osseous canal twisted spirally two and a half times about a bony pillar. This shape closely resembles that of a snail-shell, and has suggested the name of the cochlea. The bony cochlea may be divided into the spiral canal, modiolus, and the lamina spiralis ossea, which, projecting from the modiolus into the calibre of the canal of the cochlea, termi- nates above at the helicotrema in what is named the hamulus. The Canal of the Cochlea. — The cochlear canal starts at the ex- treme outer and lower corner of the vestibule, and winding outward and forward makes in its first half turn the promontory of the inner wall of the tympanum. Each turn of the cochlea is shorter than the previous one, and rising above and beyond it outwardly forms the peculiar resemblance indicated by its name. The height of the cochlea is equal to the diameter of its base, and measures about 4 or 5 mm. The entire length of the cochlear canal is from 28 to 30 mm. The liiodioliis, which may be considered as representing the axis of the cochlea, is nearly in the axis of the porus acusticus 1 Henle, op. cit., p. TOO. LABYRINTH AND AUDITORY NERVE. 123 internus iiiul about at right angles to the long diameter of the pyramid of the petrous bone. The point of the cochlea is directed outward, forward, and downward. The latter part of the cochlea, the cupola, is separated by a thin plate of bone from the canal of the tensor tympani muscle, while in front the coils are very close to the carotid canal. The diam- eter of the canal of the cochlea is about 1 mm. at its widest part; from the beginning of the hist half turn it becomes much Fiu-. 40. Osseous Cochlea i.aih open. (Magnified 4 diam. : Henle.) smaller. A transverse section of the cochlear canal varies iu shape, being sometimes elliptical and at others semicircular. Its more common shape is that of a segment of a circle, the point of which is directed towards the axis of the cochlea. The thickness of the dividing wall between the turns of the cochlea is 0.3 mm. at the lower turn, and 0.0-3 mm. at the upper part of the canal. The Modiolus and Ldmina Spiralis Ossea. — The general shape of the modiolus is pyramidal. At its base the diameter is 2 mm., at the apex 0.5 mm., and its height is 2.50 mm. The modiolus is not only the bony axis about which the coch- lear canal is twisted, but it is traversed by numerous canals for the transmission of the branches of the cochlear nerve, which is finally distributed like fringe on a bony shelf running spirally around the modiolus and projecting into the canal of the cochlea. This bony shelf is the lamina spiralis ossea. The Scalce. — The lamina s})iralis ossea divides the canal of the cochlea into its scalae. The npper one of these is the scala ves- tibuli, beginning at the vestibule and continuing to the helico- 124 INTERNAL EAR. trema ; the lower one, the scala tympaiii, may be said to beghi at the helicotrema and end at the round window. The general relation of the spiral bony lamina to the scalfe, and the relation of the latter to each other, will be understood, perhaps, better if the reader imagines himself starting from the vestibule along the upper surface of the bony partition between the scalse, and continuing until he reaches, at the helicotrema, the sharp hook-like end of the bony lamina. At this point he must imagine that what has been the floor of the scala vestibuli now becomes the upper surface or roof of the scala tympani. If the scala tympani be traversed, in imagination, two and a half turns will reach the membrane of the fenestra rotunda. The lamina spiralis ossea forms only part of the division between the scal;^ ; as it does not pass as a bony septum from the modiolus to the opposite wall of the canal, the separation of the two sealse from each other is not complete until the soft parts are added to the osseous structures. The lamina spiralis is thicker at its lower end than at the top of the modiolus. At the former point it may amount to 0.3 mm., but at the upper part, only to 0.15 mm. The width of the lamina spiralis is 1.2 mm. at the lowest part, and 0.5 at the upper part. The Semicircular Canals. — To the yjosterior part of the vesti- bule are attached the three semicircular canals. These are named, according to their positions and planes, the superior, the posterior, and the horizontal semicircular canal. Although there are three distinct canals, there are but Ave openings from them into the vestibule. This is due to the fact that two of the canals, the superior and the posterior, are joined to a common shaft just before they reach the vestibule. The position of these openings on the wall of the vestibule has been described already (p. 121). At one end, each of the canals has a dilated portion, its ampullar enlargement. These enlarge- ments contain soft parts of similar name and shape, the ampulla? of the membranous semicircular canals. The latter will be de- scribed later. Dimensions of the Semicircular Omals. — The length of the posterior semicircular canal is the greatest of the three, amount- ing to 22 mm. The length of the superior canal is 20 mm. and that of the horizontal canal is only 15 mm., as shown by Hushke and Henle. The common shaft of the superior and posterior canals is from 2 to 3 mm. long. A transverse section of these canals is elliptical. The long diameter is to the shorter as 2 : 3 or 3 : 4. The longer measures, in man, from 1.3 to 1.7 mm. (Henle). LABYRINTH AND AUDITORY NERVE. 125 Aiiipulbir Ei'laiyciJicut. — Tlie shape of the anipulhe is that of an ellipsoid. The ampulla of the superior and of the posterior canal is sharply defined from the rest of the canal as well as from the vestihule by a ridge, but the horizontal semicircular canal glides gradually into its ampullar end. The height of the ampulla, in the centre, is about 2.5 mm., not quite as great as the lono;er diameter of its calibre. The Pbiiics of the Sc)iiicirc>(l"r Onials. — The superior and the posterior canals are in vertical planes at right angles to each other. The horizontal semicircular canal, as its name shows, is in a plane at right angles to that of both the others. The top of the superior canal points upwards, making thus a visible ridge on the anterior surface of the petrous bone. The top of the posterior canal points directly backwards, as does that of the horizontal semicircular canal. Soft Pm-ts of the Cochlea. — If a transverse section of the canal of the cochlea be examined under the microscope, the manner in which the canal is subdivided into its scal?e wall be seen. This division is lirst indicated by the projection of the lamina spiralis ossea into the calibre of the canal. The free end of this bony shell would, therefore, form a good point for beginning the consideration of the topographical arrangement of the different parts of the cochlea. Soft Parts of the Lamina Spiralis Ossea. — Upon the upper sur- face of the lamina spiralis ossea is placed the vestibular lamella, and upon the under surface is jjlaced the tympanal lamella of the lamina spiralis ossea. Through the bone lying between these lamellpe runs the nerve on the way to its termination at the organ of Corti and the ciliated cells, a description of which will follow later. The tympanal lamella is continued in the same plane, directly across from the under edge of the lamina spiralis ossea to the opposite wall of the cochlear canal. Here it is joined to the latter at the thickest point of a cushion of connective tissue called the ligamentum spirale of Henle. The division of one scala from the other is now complete, by the formation of this, the nieiiibrana hasUaris. This membrane does not seem to be very elastic, according to recent observations of AValdeyer. The upper or vestibular lamella of the lamina spiralis ossea is the thicker of the two. About half way between its origin and the point of the spiral bony lamina, the vestibular lamella is thickest, from which point it seems to taper to the edge of the bony shelf on which it lies. At this thick part there rises a delicate membrane, the mem- 126 INTERNAL EAR. rig. 41. f~,. x—^ Transverse Section of the First Coil of the Cochlea of a Child one and a half YEAR old. (Magnified 100 diam.: Waldeyer.i) — The membrana tectoria is sketched from another preparation ol the same cochlea. SV. Scala vestibuli. ST. Scala tympani. y. Ductus cochlearis. n. Vestibular lamella of the lamina spiralis ossea. ir. Tympanal lamella of same. x. Cochlear nerve. Ji, n. Osseous wall of cochlea, g, o. Periosteum. /, ;>. Cushion of connective tissue (lig. spirale of Kiilliker) partially loosened from the bony wall, and thickened near the ductus cochlearis, into a special fibrous mural layer for the latter, i. Stria vascularis, o. Point of union between the periosteum and the cushion of connective tissue. /. Lig. spirale; Henle. j. Lig. spirale accessorium, with the vus prominens. /.•. Sulcus spiralis externus. 6, e. Reissner's membrane; only the two end- pieces shown ; the rest indicated by a dotted line, h, c. Crista spiralis, c. Its most prominent part in profile; the so-called "auditory teeth." d. Membrana tectoria. t'. Sulcus spiralis internus. u. Point of entrance of the nerve (Habenula perforata). 11, I. Membrana basilaris. u, q. Corti's organ. e, q. Zona denticulata. ^ r. Zona arcuata. 7, /. Zona pectinata with epithelium, t. Region of the inner ciliated cells. «. Thinnest part of the membrana basilaris under Corti's organ. ;•. Region of outer ciliated cells. ^ Strieker's Handbuch, etc., p. 922. LABYRINTir AND AUDITORY NERVE. 127 brane of Reissiier, which springs across the scala vestibuli, and is fastened at a point on the opposite wall of the cochlea about 40° above its starting-point. This is a most important mem- brane, since it forms the upper or vestibular l)oundarj of the ductus cochlearis. The membrane of Reissner is said to consist of a thin connec- tive-tissue basement lamella, rich in vessels. On its vestibular surface large-celled, serous epithelium is found, and on its tym- panal surface a single layer of regularly arranged, cubic epi- thelial cells. It will now be seen that the cochlear canal is really subdivided into three canals — the scalee already named and the ductus coch- learis which is formed at the expense of part of the scala vesti- buli. The ductus cochlearis may, therefore, be said to lie upon the membrana basilaris above the grand division-line of the scal;^, and should indeed be imagined as slipped into a triangu- lar-shaped canal lying between the scalfe at their outer edges. The scalfe are lined with periosteum covered with large, flat epithelium. The}' are tilled with perilymph, and are in com- munication with each other only at the helicotrema in the cupola of the cochlea. The ductus cochlearis is not in communication with them at any point; it begins and terminates in so-called blind ends. The scala tympani ends at the membrane of the round window, but the scala vestibuli is in free communication with the vesti- bule. Q'ista SinraUs. — From the point where the membrane of Reissner is attached to the vestibular lamella of the lamina spiralis ossea, there extends a crest or ridge of connective tissue and developed epithelium called the crista spiralis, the serrated edge of which is called by some anatomists, "aural teeth. "^ From this free peculiar edge rises the membrana tectoria, which extends as far as the beginning of the organ of Corti. The space between the crista spiralis and the point of junction between the lamina spiralis ossea and the membrana basilaris, is called the sulcus spiralis internus (y. Fig. 41). Corti's organ extends from the junction of the membrana basilaris and lamina spiralis ossea to a middle point on the former membrane. From this point the epithelial lining of the ductus cochlearis pursues a less complicated course outward and upward over the wall of the duct. Just above the attachment of the membrana basilaris to the outer wall, at the spiral ligament, there may be seen a promi- nence known as the accessory spiral ligament, but which really ^ Gehorzahiio of Hushke. 128 INTERNAL EAR. seems to form a passage for a vessel named the vas prommens. Between these two points lies the sulcus spiralis externus. Above the vas prominens, between it and the upper and outer attachment of Reissner's membrane, is found the stria vascularis. Habemdn Perforata and the Zonce. — The habenula perforata is situate at the extreme thin edge of the osseous spiral lamina, and gives exit to the nerve-branches. The zona derdiculata extends from the crista spiralis to the outer end of Corti's organ; the zona arcuata, from the inner to the outer ciliated cells; and the zoim pectiiiata extends from the outer boundary of the organ of Corti to the spiral ligament of Henie. These names are descriptive of the appearance of the region extending from the crista spiralis to the ligamentum spirale, when viewed from above. According to the investigations of AValdeyer, three varieties of tissue can be discerned in the iirst stages of development of the cochlea. At that time the most external layer is a carti- lascinous mass connected with the base of the skull. In this mass is a collection of embrj'onal mucous tissue, within which is imbedded the epithelial labyrinth vesicle. From the latter, which at last becomes the sacculus, a hollow sprout, lined with epithelium, grows before the eighth week, and pushing its way into the mucous tissue, is forced by the surrounding cartilage to curl itself up into a spiral shape. This is the Iirst trace of the ductus cochlearis. At one point the cartilaginous capsule is not closed, and here the cochlear branch of the auditory nerve enters. The bony portion of the cochlear capsule, is divided into a compact inner layer, a tabula vitrea, and the more porous modiolus and lamina spiralis. In the latter is found the canalis ganglionaris, in which lies the spiral ganglion of the auditory nerve. The inner surface of the periosteum of the canal is covered with a layer of simple, large, tlat, nucleated cells, similar to those found on the surface of serous membranes. Dudas Cochlearis. — From the foregoing description of the three divisions of the cochlear canal it must have been seen already that the most important of these is the ductus cochlearis. It is indeed from the epithelial lining of this important capsule that the highly organized contents of the cochlea are developed, so as to be the recipients of the terminal filaments of the audi- tory nerve, after it passes the habenula perforata and reaches the cavity of the ductus cochlearis. The most important of these structures is the organ of Corti. LABYRINTH AND AUDITORY NERVE, 129 The Marquis of Corti^ was the first to describe tliis apparatus, and it has from that time justly borne his name. Kolliker and Deiters subsequently enriched the knowleds^e possessed respect- ing this important apparatus of the internal ear. • The best treatise on the structure of the cochlea and the dis- tribution in it of the auditory nerve has been written by Prof. Transverse Section of the Organ of CoRrr. (Magnified 800 diam. : Waldeyer.) — y, 0. Homogeneous layer of the membrana basilaris. n. Vestibular layer of the same, corresponding to the radii of the zona pectinata. p. Tympanal layer with nuclei, granular cell-protoplasm, and transversely cut connective-tissue fibrillje. y. Labium tyrrpanicum of the crista spiralis. w. Continuation of the tympanal periosteum of lamina spiralis ossea. !(. Thickened origin of the membrana basilaris immediately beyond the point of entrance of the auditory nerve h. r. Vas spirale. i>. Bloodvessels, x. Nerve fasciculus. a. Epithelium of the sulcus spiralis internus. d. Inner ciliated cell. c. Its basilar pro- cess. About the latter and above the point of entrance of the nerve are some cells and fine, granular matter in which the nerve-fibrils are distributed (granular layer), e. Inner part of the capital of the inner pillar and the point where the cilia of the inner ciliated cells are situate. /. Point of junction of the arches : the body of the outer pillar is severed in the middle; behind it appear the body and base of the next pillar at q. t. Base with part of the granular protoplasm of the inner pillar. (/, i, and /. Three outer ciliated cells. m. Basilar part of two other ciliated cells. I. Hensen's supporting cell, e, k. Lamina reticularis. «. Nerve-fibril distributed to the first ciliated cell, g, and traceable through the arch as far as the point of entrance of the auditory nerve at b. Waldeyer.' Dr. Gottstein, his colaborer, has added the most important facts concerning the ultimate distribution of the audi- tory nerve to the outer ciliated cells. 1 Von Siebold and Kolliker's Zeitschr. f. Zoologie, 1851. ^ Strieker's Manual of Physioloo-y. 130 INTERNAL EAR. Organ of Cortl. — The position on the membrana basilaris oc- cupied by the organ of Corti has ah'eadj been pointed out. (Fig. 41, u-g.) _ ^ An idea of the general structure and appearance of this won- derful central portion of the ductus cochlearis can be gained by consulting Fig. 42. The Pillars and Arches of Corti. — Upon the upper or vestibular surface of the membrana basilaris are two sets of pillars, an inner and outer row, uniting above and forming a Series of arches. The pillars, like the arches, are named after Corti. They are about 3000 in number, according to Kolliker. A head, head-plate, foot, and body are parts into which anatomists have divided the pillars. At the junction of the pillars, the head of the outer is Utted into a depression between the head and head- plate of the inner pillar. (Fig. 42,/:) The kind of tunnel thus formed by the arches of Corti is tri- angular in outline, the longest side of which corresponds to the membrana basilaris. This tunnel extends over the entire length of the lamina spiralis almost to the end of the hamulus, as de- scribed by Waldeyer. As a rule, the height and width of the arches increase towards the hamulus, as shown by Hensen. Inner Ciliated Cells. — On the inner side of the arched roof thus formed is found the single row of inner ciliated cells. The latter are lost at their lower end finally, in what is termed the "gran- ular layer." Their upper ciliated ends are received into corre- sponding head-plates of the inner pillars. Their cilia, arranged in dense tufts or plots, are extremely stiff and strong. The Outer Ciliated Cells. — There are five rows of the outer ciliated cells. They are arranged in parallel rows beyond the row of the external pillars, and underneath the membrana reti- cularis. The Membrana Reticularis. — The membrana reticularis, as its name indicates, is a net-like structure. It is one of the most complicated parts of Corti's organ, extending from the junction of the pillars to the so-called support-cells at the outermost row of the ciliated cells. Into the meshes of this delicate reticulate membrane, fit the tufts of cilia of all the outer ciliated cells. A profile view of this arrangement can be seen in Fig. 42, at i and J. The Surface of the Membrana Reticularis. — Viewed from above, the membrana reticularis presents not only a very beautiful, but an equally complex appearance. It will be seen that the ciliated LABYRINTH AND AUDITORY NERVE. 131 cells occupy alternate openings in the mesh of the reticulate membrane in both directions, thus giving a checker-board ar- rangement to the ciliated tufts and the intermediate spaces. To the former, the framework supporting the cilia, the name ring has been applied bv Bottcher, and the finger-shaped interspaces have been called the pludangcs by Deiters. The latter are tilled out by a delicate membrane, according to Waldeyer. Over the entire organ of Corti, close to the membrana reticularis, is placed the membrana tectoria or Corti's membrane. Membrana Tectoria. — Of this membrane, Waldeyer states that it begins immediately at the point of attachment of Reissner's membrane on the crista spiralis in the form of an immeasurably fine layer, covers the crista, while lying close to it, and at the same time increases greatly in thickness. It attains its greatest thickness in the sulcus spiralis internus, and terminates, as shown by Hensen, Gottstein, and Waldeyer, in a free and ex- tremely delicate edge in the neighborhood of the outermost row of ciliated cells. (See Fig. 41, d.) The constituent elements of Corti's organ have now been described as briefly and in as condensed a way as possible. Of this wonderful organ, Waldeyer says that, if there be left out of consideration the peculiarities of the inner ciliated cells, the apparently complicated structure of Corti's organ reveals really a simple plan. Several rows of cylinder-cells (double cells) are arranged in regular order on a broad zone of the spiral shelf. These rows are parallel to each other, and are held firmly in their position between two membranous boun- daries, the membrana reticularis and the membrana basilaris. Two sets of these cylinder cells, the pillar cells, become devel- oped for the purpose of forming a firm arch of support for the whole. Specially worthy of note is the fixation of the outer ciliated cells, which, by means of j^rocesses and their head-piece, are immovably held between the membrana reticularis and the basilar membrane. These cells, together with the pillars of Corti, are the exclusive peculiarity of man and other mammals. To this apparatus, i. e., to its peculiar ciliated cells, the terminal filaments of the auditory nerve are directly sent. The Auditor'/ Nerve; Origin and Distribution. — According to the investigations of Stieda in 1868, with whom Waldeyer agrees, the auditory nerve springs by two roots from the medulla ob- longata. The fibres of one of these are more delicate than those of the other. It originates from a ganglionic nucleus on the floor of the fourth ventricle. The second root, which is said by Stieda to contain larger axis-cylinders than any other nerve, springs from a special large-celled ganglionic nucleus in the crus 132 INTERNAL EAR. cerebelli. This root acquires, soon after it leaves the medulla, a small ganglion, like one of the posterior roots of the spinal cord. Both roots soon unite into a common trunk, but divide again in the porus acusticus internus, into two branches, the vestibular and cochlear branches. Vestibular and Cochlear Branches of the Auditory Nerve. — The first contains a small ganglion, intumescentia ganglioformis Scarp?e, and divides into the ampullar branches and those for the utriculus and the sacculus. The cochlear branch, which is by far the larger of the two, gives oiF a small fasciculus to the septum membranaceum be- tween the sacculus and the utriculus, and to the macula crib- rosa, and then enters the first turn of the lamina spiralis, from which point it continues its course throughout all the windings of the spiral lamina. Ampullar Branches. — Duval and Laborde^ showed that some of the fibres of the auditory nerve originate in a collection of motor cells in the bulb, and further, that these fibres are continued in the inferior cerebellar peduncles. The conclusion, therefore, is that there are two sorts of fibres in the auditory nerve, viz., sensory and motor, and the branch possessing the latter function sends fibres to the ampullae a,s well as to the cerebellum, and thus may be explained the reflex phenomena of disturbed equilibrium, from irritation in the ampulla and semicircular canals. Inner and Outer Nerve-ends of the Cochlear Branch. — The ulti- mate fibres of the auditory nerve in the cochlea are named the inner and the outer terminal filaments, in accordance with their distribution to the inner and outer hair-cells. According to Waldeyer, both sets of fibres, as they emerge from the openings in the lamina spiralis ossea, pass through the "granular la3'er" which lies directly over their point of exit. The inner nerve-fibres then pass directly to the inner hair-cells. These fibres are large, and are considered as true axis-cylinders. The outer nerve-fibres are distributed, as shown by Gottstein, between the pillars of Corti, at about half the height of the arches, to the inner row of the outer hair-cells, and perhaps to the more distant rows. The origin of the auditory nerve, being so near the origin of the pneumogastric nerve, would help to explain the sympathy which seems to exist between an aural disease and the respira- tory and the digestive tracts. 1 De I'oreille, etc., Dr Gelle. Paris, 1881, p. 323. LABYRINTH AND AUDITORY NERVE. 133 There also seems to be a s_ympathy between the ear and the emotions. May not cases of apparently hysterical deafness be traced to some such central nerv'ous connection? Fig. 43. Soft Pt/rts of the Vestibule . — The surgeon standing beside the patient, in front of the ear to be looked into, should gras}) the auricle at its upper and posterior margin, gently between the index and middle finger of his left hand, and pull the auricle a little up- ward and backward. This is always to be done by the left hand, no matter which ear is examined. This leaves the right hand free to hold the mirror. The patient should be placed, and the surgeon should stand so that the light may fall on the mirror towards the surgeon's right side, or directly from in front — never from the left in the above position of patient and examiner. These rules of position of light, patient, and physician are especially important when artilicial and reflected light is used. Insertion of Ear-speculum. — With the auricle grasped as directed above, between index and middle finger of the left hand, the speculum or ear-funnel may be gently inserted in a direction slightly downward, inward, and forward, or in general terms towards the patient's nose, by the other hand, and then grasped by the thumb and index of the left hand. Or it may be inserted by the thumb and index of the left hand at the same moment the index and middle fingers grasp the superior posterior margin of the auricle. In the latter instance a very gentle and slight rotation will be all that is sufficient to place the ear-funnel properly. The speculum being now in the meatus, light is to be reflected into it from the mirror. The first point to be decided upon, in making an examination of the ear, is whether the auditory canal is entirely free from obstruction or not. If it is, then the eye of the observer should, after ascertaining the state of the wall of the canal, seek the membrana tympani. The chief obstacle in such a search is usually the misdirection of the axis of the funnel. This, instead of being made to correspond with the axis of the auditory canal, is directed most usually, by the unskilled, so as to fall on the sides of the canal or only partially on the drum-head. Hence it is not at all uncommon to hear a diagnosis made for the mem- brana tympani, which is based entirely on a view^ of the condi- tion of the skin lining the auditory canal. What should be seen at the fundus of the canal is described on p. 47, yet it will be a long time before the eye can accommo- date itself to the conditions of illumination in the external ear, so as to interpret fully what it sees. The experienced e3'e is able to resolve into depressions, elevations, curves, etc, that which is projected entirely in the same plane by the beginner. 168 EXAMINATION OF PATIENTS. Removal of Ohstades to a View of the Memhrana Tympani. — It requires but a small object, a few stitF hairs, or a flake of cerumen or of epithelium, to obstruct the view of the drum-head. All such obstacles are most easily removed by a few syringefuls of warm water ; this, however, will render the drum-head a little macerated, and hence deprive it of whatever lustre it ma}' have had. This must be borne in mind in looking at the drum-head after warm water has been syringed upon it. Therefore, when it is especially desirable that the amount of natural lustre in a given case should be estimated, an obstructive substance might better be gently and most carefully lifted or wiped out of the canal. The former is most readily accomplished by the delicate forceps shown in Fig. 56, while the canal is thoroughly illumi- Ym. 50. Delicate Forceps for Removing Foreign Bodiks from the Ear. nated by the forehead-mirror (Fig. 50, p. 161). If the obstruc- tion to vision can be wiped or swabbed out, the cotton-holder, with its little wad of cotton at the roughened end, will enable one to do this. The Cotton-holder. — This is a most useful instrument, both for cleansins: the ear and convevins: medications to diseased surfaces in the organ. The shaft is made flexible for an inch or two, as indicated in the wood-cut, and roughened at the tip. At the latter point, a small tuft of absorbent cotton may be coiled, and then used, as already indicated, for cleansing, and for treating the ear. AVhen the cotton is to be removed, it should be twisted ofl"in a direction opposite to that in which it was wound about the end, and not submitted to a flame, as has been done, greatly to the detriment of the instrument. During all these procedures for removing small obstructions to a good view of the drum-head, the canal is supposed to be INSTRUMENTS AND METHODS OF E M 1' LO ^' .M K .\ T 169 Fisr. ;j/. Fiii. 58. I most carefully illuininatcd by light reflected from the forehead- mirror, and the operations perfoi'ine, Sexton's Flexi- ble Catheter. SjfAi.L Hard-rub- ber Catheter. 178 EXAMINATION OF PATIENTS. the surgeon's own ear ; at the other end there should be a black end-piece, for the patient's meatus. In using the auscultation- tube, one end should rest snugly in the meatus of the ear cathe- terized, while the other end must rest equally well, though not too tightl}', in the examiner's ear. Let it be supposed, for example, that the patient's left ear is to be catheterized, and that the auscultation-tube is also to be used. Let the examiner place his end of the auscultation-tube in his left ear, bring the tube loosely around behind his neck Fie. 65. AusccLTATiON-TUBE. — Black end for patient's, white for surgeon's, ear. and over his right shoulder, placing the other end of the tube in the patient's left ear. If the tube be thus supported, it is less in the way of the surgeon, and less likely to fall either out of his or the patient's ear. The method usually given in most works on aural surgery, is to allow one end to rest, for instance, in the patient's left ear, while the other end is resting in the surgeon's right ear. In such a case, not only will the tube hang down between the patient and surgeon and be in the way, but the mere weight of the ausculta- tion-tube when thus suspended is sufficient to drag it out of place. The Air.-bag or Hand-balloon. — The general appearance of the hand-balloon is given further on, in the figure of Politzer's ap- paratus. The use of this bag is to force air through the catheter into the Eustachian tube and tympanic cavity. It is of the greatest importance that the end-piece at the point of the balloon- like bag, the so-called "mount," should fit accurately into the catheter, and, like it, be of hard rubber. Fig. 62, D. This hand air-bag is of the greatest importance and usefulness, for with it not only air, but medicated solutions, first placed in the catheter by a pipette, may be forced through the catheter and into the Eustachian tube. It is very uncommon that more impelling force is needed in catheterization of the Eustachian tube than can be exerted by means of the hand as it squeezes the air from this bag. ZaufaP suggests placing a capsule for holding a disin- 1 Arch. f. Obrcnh., Bd. xvii. S. 1. INSTKUMENTS AXD METHODS OF EMPLOYMENT 179 f I fectantin connection with the air-bao-. During the ex|»ulsion of the ail- from the bag, great care shoiUd be taken not to force the axis of the bag out of line with that of the catheter, for, if this should occur, either by an upward or downward movement of the hand and wrist, the catheter if of hard rubber Avill be very apt to l)reak, if of silver, to bend. In compressing the air-l)ag, no motion should occur, except in the lingers of the right liand or the hand employed in compressing the bag. A little" practice will enable the operator to make only such a motion with the fingers, though at first there is an almost involuntary tendency to Ilex the hand laterally on the wrist towards the ulna, at the same moment the fingers are made to squeeze the bag. The bag must be removed from the catheter after each inflation, in order to renew the air in it. Any other form of inflation whereby this removal is obviated, tends to draw fluids from the nares into the catheter. Catheterizntio)} of the Eustachian Tube. — Provided with the three instruments described in the preceding pages, viz., a catheter. Fig. GG Insertion of the Eustachian Cathetkr. an auscultation-tube, and a hand air-bao;, the surgeon mav en- deavor to catheterize the Eustachian tube, /. e.,he may endeavor 180 EXAMINATION OF PATIENTS. to place the beak of the Eustachian catheter in the faucial end of the Eustachian tube, so as to enable him to force air into the latter, and if that be patulous, the air may pass into the tym- panic cavity. In catheterizing the Eustachian tube, the patient may sit or stand at the surgeon's option ; as a rule, it will be more desirable for the patient to sit, since it is more comfortable for him, and will hence better enable him to hold still. Let the patient, then, sit down with the hips well back in the chair, and his spinal Fio-. G7. Inner View op the Right Half of the Head; Antero-i'osterior Section. (Gruber.) — o. Superior turbinated bone. Hi. Middle turbinated bone. ii. Inferior turbinated bone. Ji. Rosenmiiller's fossa, bounded in front by tlie cartilaginous lip of the tube; in front of the latter is the pharyngeal opening of the Eustachian tube, in which the catheter /.• is placed. column and head erect. The latter maj- be placed against the wall or the back of the chair, should the latter come above the patient's head. Then, with the auscultation-tube adjusted as described, the surgeon should place the fore and middle lingers of his left hand on the patient's forehead a little above the root INSTRUMENTS AND MKTHODS OF EMPLOYMENT. 181 I of the nose, and with his thumb he should lift u[) the tiji of the patient's nose and hohl it u[t until the catheter is well inserted. AVith the tip of tlie patient's nose held up as just described, let the surg-eon gras}* the catheter as he would a penholder, between the thumb and foretinger of the riu'lit hand, holdinjr his hand down about as low as the patient's chin, towards which the palm of the catheter-hand should be turned. Xow insert the beak of the catheter into the nostril corresponding to the ear to be catheterized, and with a compound upward and forward motion carry the instrument along the floor of the nose until the beak reaches the nasopharynx and at last touches the pos- terior pharyngeal wall. The ring at the proximal end of the catheter, which the surgeon keeps always in sight, should point directly downward upon the arrival of the beak of the catheter in the nasopharynx. AVith the catheter's distal end at the posterior pharyngeal wall, the beak may be turned outward toward the ear to be catheterized. By this motion the beak will slip into the fossa of Rosenmiiller. The mistake is usually made at this point, in supposing the catheter's beak rests in the mouth of the Eusta- chian tube, and unsuccessful attempts at inflation may be made. But in order to place the beak in the mouth of the tube, the following manipulation becomes necessary. After the beak of the catheter has been turned into the fossa of Rosenmiiller, draw the catheter forward, letting the beak slip over the posterior lip of the Eustachian tube, and as soon as this is done turn the catheter so that the ring-indicator will point towards the ear catheterized, at an angle of 45°; at the moment this movement is made Avith the catheter, its beak slips into the faucial ex- tremity of the Eustachian tube. Of course, this is easily said, less easily done; but with a little practice the touch is soon educated, and the Eustachian catheter can be inserted into the mouth of the tube with great ease. Fixafioti of the Easfafhian O'theter. — After the catheter has been thus put in place, let the thumb and foreflnger of the left hand grasp the instrument close to the nose, while the remaining three fingers are braced above the root of the patient's nose, at the point formerly occupied by the middle and index fingers, during the elevation of the tip of the nose by the left thuml), and the insertion of the catheter by the right hand. With the catheter thus fixed in position, and the auscultation- tube passing from the patient's ear to the ear of the examiner, the latter may gras]^ the hand air-bjig and make inflations into the tube- and tympanum. If the Eustachian tube is pervious, air will be heard to enter it with more or less force. As a rule, 182 EXAMINATION OF PATIENTS. two or three inflations with the contents of the air-bag will be sufficient, both in force and in number, to properly and safely ventilate the middle ear. When considerable stimulation is demanded by the atonic condition of the muscles and mucous membrane, numerous inflations, even as many as a dozen, may be made with entire safety. In using the Eustachian catheter, the only danger is from emphysema; but this can never occur unless the mucous membrane has been abraded by the unskilful introduction of the catheter. Even should such abrasion occur. Fig. 68. Fixation of the Eustachian Catheter in position, preparatory to inflation. emphysema might not be produced unless very powerful infla- tions were to follow. The two fatal cases which occurred, during inflation, in the practice of a well-known London quack, were caused, probably, by the use of a powerful air-pump; but air-pumps are no longer used, or at least very rarely, by respon- sible men. There is certainly no record of a case of death from emphysema resulting from gentle inflation made by the hand air-bag. Where death has occurred from emphysema of the pharynx and the parts about the larynx, the fatal result has most prob- ably been brought about just as it is in oe'dema of the glottis. The treatment, therefore, should have been the same and just as I I I INSTRUMENTS AND METHODS OF EMPLOYMENT. 183 prompt in the foniier as in the hitter luahidy, /. c, free scarifica- tion of the putfed-np parts in order to permit the air to escape from the cellular tissue beneath the mucous membrane. As the Eustachian catheter is in constant use all over the world, and as the only cases of death which were ever suspected of being causeil by its use occurred at the hands of a quack, the latter, and not the instrument, should be held accountable for the un- fortunate result. Death in cases of emphysema produced in the above way might be due to pneumothorax. Voltolini proved this to be the cause of death in a dog, into the naso-p)haryngeal region of which he first introduced a catheter, then a wire, by which he wounded the mucous membrane of the parts near the opening of the Eustachian tube. By a powerful introduction of air he produced sudden death, and a post-mortem examination of the animal showed that air had entered the pleural sac and produced collapse of the lungs. There was no emphysema of the vocal cords nor of the larynx. Other Methods of Catheterization. — Josef Gruber recommends a somewhat different method from the foregoing. Thus, after the catheter has been introduced through the nose and has reached the hinder wall of the pharynx, let the instrument be drawn straight outward until its curved beak lies against the soft palate. Then push the catheter a short distance (from half an inch to an inch) inward, and turn the beak outward towards the ear. It will be found that, as a rule, the beak will slip into the mouth of the Eustachian tube. A somewhat less complicated method is that known as Lowenberg's. In this method the catheter is introduced in the usual way through the nose until it reaches the posterior wall of the pharynx. Then let it be turned inward and drawn forward until the curve of its beak touches the septum narium. If now with a downward turn the point of the catheter be made to describe a semicircle, the beak will usually slip into the mouth of the Eustachian tube. All of the above efforts at insertion of the point of the catheter into the mouth of the Eustachian tube, as well as inflation, may be greatly helped by an act of swallowing on the part of the patient at the precise moment the instrument is to be inserted into the mouth of the tube, or just as the air-bag is emptied through the catheter. Politzefs Air-hag and 3Iethod of Inflation of the Eustachian Tube and. Tympamc Cavity. — Dr. Adam I*olitzer has given to the profession a most valuable means of inflating the nasopharynx, Eustachian tubes, and tympana. The instrument bears his name, l>eing known as Politzer's air-bag, and the method of its employment is know^n as Politzer's method of inflation. The 184 EXAMINATION OF PATIENTS. Fig. 69. instrument consists chiefly of an ordinary air-bag such as is used for forcing air through the Eustachian catheter. Instead of the conical tip of the ordinary hand air-bag, the instrument devised by Politzer is supplied with a somewhat bulbous tip, to which is attached a piece of black rubber tube 8 cm, long, which forms the pliable connection between the air- bag and the nose-piece. The latter piece is made of hard rubber, and varies from 3 to 4 mm. in diameter. It is curved slightly at the beak and resem- bles at this point a coarse Eustachian catheter. In fact, one may extemporize a Politzer's apparatus by attaching an ordinary hard-rubber catheter to the hand air-bag. But in this case the dis- advantage is in the stiffness of the catheter and its great liability to snap in half. Politzer's method of inflation depends upon the physiological fact that, at the moment of swallowing, the velum palati rises and thereb}^ draws the anterior wall of the Eustachian tube from the posterior. At this moment the faucial extremity of the tube is so patulous that air forced through the nares, not being able to pass downward into the fauces and mouth, because the velum palati prevents it, will b}^ following the course of least resistance pass into the tube and usually into the tympana. In order to accomplish this result at the desired moment, the patient is in- structed to take a sip of water and retain it in his mouth until told to swallow. After the water has been thus taken, let the surgeon place the curved nose-piece into either nostril and compress the nostril in front of the nose-piece. The usual error is made in trying to compress the ala of the nostril down upon the nose- piece. This is very painful to the patient, is apt to make him jump, and thus the surgeon is defeated. The index linger should compress the other nostril so that no air from the bag shall escape outward through the nose. The point of the nose- piece should be directed outward against the ala, rather than inward against tlie bony septum. If tlie latter is done, and it usually is the mistake of beginners, the septum will be painfully Polit/.er's Air-bag for In- flating THF, Middle Ear. — (One-third natural size.) > INSTRUMENTS AND METHODS OF EMPLOYMENT. 185 pressed if not wounded, and bleediiii;' from the nose may be the very undesirable result. In using this method of inflation one ear of the patient may be connected by the auscultation-tube to the ear of the surg-eon; but this is by no means necessary, since, as a rule, when the method is properly carried out, a peculiar resistance or recoil ensues in the inflation-bag, which the surgeon soon learns to recognize. By the very nature of the phj'siological process called to aid in Politzer's method of inflation, both ears are likely to be in- flated at the same time. The fact that one ear cannot be isolated \ ^ at will during this mode of inflation should be borne in mind. If for any reason such isolation on the part of either ear should I H be demanded, the surgeon must resort to the catheter. The ■ force of the Politzer inflation, however, can in any case be I ^ augmented on either side by pressing the tinger flrmly into the canal of the ear opposite to the one it is specially desired to I ventilate. B3' some, it is supposed that this latter modiflcation is aided by holding the head over towards the shoulder opposite to the ear which is to receive the greater amount of inflation. As in such a position the ear on the upturned side is highest, it is to be supposed that the air may take its course more readily _ toward that ear than the one turned downward and flrmly W stopped by the finger. Instead of swallowing water to insure the elevation of the palate, the surgeon may command the patient to say "hick" or "hack" (Gruber), or "a a" (Luc?e), or he, the patient, may simply pufl:" out his cheeks with closed lips (E. E. Holt); thus forcing the root and dorsum of the tongue against the velum, or the patient may puflT air from his lips, as suggested by J. 0. Tansley. The latter method, however, is not an agreeable one for the operator, standing, as he does, in front of the patient. In very 3'oung or unreasonable children who cannot or will not swallow, but cry, Politzer's method is invaluable, for, as he taught long ago, the more the child cries the more firmly does it lift up the velum palati and favor the surgeon's attempts at inflation of the tj'mpana; 11 186 EXAMINATION OF PATIENTS. CHAPTER II. SOUND, HEAliING, AND TESTS OF THE LATTER. Sound is motion imparted to the auditory nerve by undula- tions in the air. A shock from a vibrating body, conveyed to the air immediately surrounding it, is propagated by a wave of undulation, not of progression, to other particles of air. This wave of sound at last reaches the membrana tympani, and trans- mits itself, by the aid of. the latter and the ossicles of hearing, to the fluid of the labyrinth and to the nerve of hearing. Hearing is the perception of such sonorous undulations of the air. It implies a free access of air to the drum-head, a perfect oscillation to and fro of the chain of ossicles, unimpeded move- meiit of the stapes in and out of the oval window, and a normal percipient organ in the lab3'rinth. If any of these requirements is wanting, the hearing will be defective, the degree varying from hardness of hearing to total deafness. The vibrations in the air may be periodic or irregular, /. e., they may be of equal length and duration, or they may be unequal and crowded upon one another in the greatest confusion. The former would pro- duce musical sounds or tones, and the latter noises. Intensity, Pitch, ir.—Y)i\ Y. Urbantschitsch' pointed out, some time ago, a phenomenon connected with the organ of hearing. He has shown there are some points near the ear, at which a vibrating tuning-fork cannot be heard, and he calls these "deaf points." By following his directions any one can verify his experiments. Thus, if a tuning-fork held perpendicularly in front of the ear be started from the lower edge of the zygoma and moved backward towards the occiput, so that the upper end of the fork passes the lower end of the tragus, two points w^ill be reached where, though the vibrations of the fork are felt by the fingers, the ear will for a moment perceive no sound, until this deaf point is passed. The fork is then heard for a short interval until it reaches the second deaf point, after which the vibrations are heard once more as the fork is gently passed on its way backward towards the occiput. The same points are peceived if the vibrating fork is passed in the opposite direction, L e., from behind forwards in the line above described. The position of the first point is at the lower end of the tragus: the second, is at a point where the helix intersects the line of motion o-iven above. If a tuning-fork held horizontallv be passed vertically upwards before tlie ear, the same kind of deat point is found in the region of the crista helicis. This phe- nomenon remains the same whether the tuning-fork is passed in the same line, at a greater or less distance from the ear. A further investigation led to the discovery of so-called "deaf fields" in the form of two small triangles, the first of which lies in front and above, the other behind and above. The apex of the anterior triangle lies at the lower end of the tragus, already spoken of, from which point the sides diverge gradually towards 1 CentralbliUt f. d. :\rod. Wissenscli., Xo. 8, 1872 ; M. f. O., Xo. 2, 1872. I I I I SOUND, HEARING, AXl) TESTS OF THE LATTEK. 189 tlie frontal and parietal bones. The general tendency of these lines is npwarcl; at the frontal protuberance they are 2—3 cm. apart. The apex of the second triangle is at the lobule of the auricle or near the lower part of the helix. The sides diverge in the direction of the lateral surface of the })arietal and occi[)ital bones. At a point corresponding to the uppermost part (^f the helix they are about 2-3 cm. apart. Dr. Emii Berthold/ of Konigsberg, explains these phenomena as entirely unconnected with the physiology of the ear, but entirely due to the interference of the vibrations of the fork. Thus, if a vibrating tuning-fork is moved slowly past the mouth of a bottle, the fundamental note of which corresponds to that of the fork, the air in the bottle will be set into consonance with the note of the fork excepting at the moment when the sound- waves entering the mouth of the bottle are quenched by inter- ference. This will happen, says Dr. Berthold, when the Urst tine of the fork has just passed the inner edge of the bottle, and asrain when the second tine has almost reached the inner edo^e of the bottle, /. ^., at two points which correspond to the tragus and the helix. Sound and Color, — Dr. J. A. ^ussbaumer,^ of Vienna, has com- municated some ver}' interesting facts relating to subjective perception of color produced in himself and in his brother by objective perception of sound. The note "small e" on the piano produces in the former the subjective perception of the color of dark yellow ; in the latter the impression of dark blue. There are some colors which no note calls up; blue, yellow, brown, and violet are most frequently produced. There is no red nor green, nor perfectly black and white in any notes. Dr. J^ussbaumer, however, perceived green once, upon heai"ing suddenly a peculiar noise. Colors are also perceived by him in dreams if noises are dreamed of. The author endeavored to represent the subjective tint of the fundamental note as a mixture of single tints corresponding to the separate partial tones, and he was in a measure successful. Dr. J. Baratoux^ explains these peculiar phenomena by the supposition that the color-centre may be aroused not only by the retina, but by other senses. Thus, it can be supposed that certain cells of the auditory centre are connected with elements of the color-centre, so that by stimulation of such auditory cells, a certain perception of color will be aroused. 1 Monatischrift f. Ohrenheilkunde, No. 5, 1872. '■^ Ueber subjective Farbenemplindungen die durch objective (Tehnrempfiiidung erzeugt werden, Wiener Med. 'Wocheiischr., Nos. 1, 2, 8, 1873. ^ L'Audition Coloree, Kevue Mensuelle de laryngologie, etc., No. 3, 1883. 190 EXAMINATION OF PATIEJSTTS. TESTS FOR HEARING. Aerial and Bone Conduction of Sound. — Sound is norniallv con- veyed to the auditory nerve by the passage of sound-waves into the external auditory canal, and 1)y the oscillations of the mem- brana tympani and ossicles which these sonorous waves produce. Sound may also be conveyed to the auditory nerve by the vibra- tions it produces in the osseous tissues of the head ; the waves of sound, in the latter instance, being conveyed directly to the walls of the labvrinth, and thence to the terminal lilaments of the acoustic nerve. The former mode of conveyance of sound is called aerial, and the latter mode, bone-conduction of sound. In bone-conduction it is probable that some of the waves of sound falling on the ossicles set them in motion, and thus some of the sound is conveyed to the perceptive apparatus in the labyrinth. Normal Hearing. — No precise standard of normal hearing has ever been defined. The normal ear hears all sounds that fall on it ; but it cannot be said, // priori, where good hearing ceases and defective hearing begins, for in many senses these are rela- tive terms. The sense of hearing must be regarded as composite, i. e., it consists in the ability to hear a number of difl'erent sounds both periodic and irregular in their vibrations. Such sounds can be heard singly or together. Hence, the sense of hearing may be said to lie in a collection of nervous elements, which can be aroused separately or together. The latter is shown by the well- known fact that more than one sound can be heard at the same time. The Wd. iii., 18iJ7. SOUND, HEARING, AND TESTS OF THE LATTER. 197 111 order to make practical application of these laws, Lucne devised his interference-otoscope, by which the relative amounts of reflection from l)otli ears could be determined in a given case. The results obtained by the use of the interference-otoscope (in connection with normal ears) are thus summed up by Lucre : 1. The normal oro-an of hearino; reflects a certain amount of the sound-waves entering the external auditory canal. 2. The reflection increases in all chano-es of the sound-con- ducting apparatus, esi)ecially in the middle ear, Avhich directly or indirectly lead to an increased tension of the membrana tympani. 3. The examination of those with normal hearing, by means of the interference-otoscope, shows that the diiferent sensibility of both ears for the same tone is caused by the difl^'erent amounts of reflection brought about by different tensions in the two sound-conducting apparatus. Respecting the diseased ear, the conclusions are: 1. The interference-otoscope shows in the majority of cases of disease, in analosfv with the observations made on those with normal hearing, a ^rw/er reflection of sound from tbe worse ear. '1. This is found in a number of cases in which the ear-mirror and the Eustachian catheter reveal disease in the external or I, middle ear. 3. In the numerous cases of ambilateral chronic catarrh of the middle ear, without perforation of the membrana tympani, the examination usually reveals a greater^ though sometimes a less^ reflection from the worse ear; in the latter instance, a simultaneous disease of the labyrinth may be supposed and the prognosis becomes much less favorable, 4. The greatest utility of this method of auscultatory exami- nation lies in the not uncommon cases in which all other diagnostic means fail to show morbid changes in the external and middle ear; here, too, as a rule, a stronger reflection is observed on the worse side, which points to a deep-seated disease of the sound-conducting apparatus. Only in some few cases does the examination reveal a less reflection from the worse ear, in which cases a primarv disease in the labvrinth mav be assumed with great certainity. Tuning-fork Vibrating on a Parietal Protuberance in <( Normal Case. — If a vibrating tuning-fork be placed on either parietal protuberance of a person with normal hearing, it will be heard in the opposite ear. This is most easily perceived when a large and powerful tuning-fork of deep note is used. This phenomenon, if it may be so termed, will often lead to confusion in diagnosis, inasmuch as the examiner would expect the fork to be heard 198 EX'AMINATION OF PATIENTS. best in the ear nearest to which the fork is placed. As it is heard best in the more distant organ, a conclusion might be made that the latter is diseased in its conducting parts. Care must, therefore, be taken to have the vibrating instru- ment in the central line of the head, either on the vertex or glabella, or held in or on the teeth. This may be due to the fact that vibrations which fall perpendicularly on the membrana tjmpani produce the strongest vibrations, and hence a tuning- fork placed on the parietal protuberance, or on the side of the head, will be heard chiefly in the opposite ear. This is very distinctly perceived if both meatus are stopped, but it is equally perceptible, as any one can lind out by experimenting upon him- self, with the meatus open. The tuning-fork finds its greatest usefulness in testing by bone-conduction. While it has never fully realized in this way all that was hoped for it as an aid in diagnosis, it is still the best means, and a very good one, too, of determining how much sound is perceived by the auditory nerve, through the bones of the head. Its musical nature, as well as its powerful vibrations, renders it far superior to the watch as a test for the conducting power of the bones of the head, unless the ticking of the watch be made to occur with great force. But should the ticking of the watch equal in intensity the vibrations of the tuning-fork, the former could never approach the latter in musicalness. The tuning-fork is a means of comparison between bone- conduction and aerial conduction of sound, in the same person. For, if the vibrating tuning-fork be held on the vertex until its note is no longer perceived by the examined, and then held before his ear, if he now perceive that the tuning-fork is still vibrating, it is fair to conclude that the sound-conducting apparatus is normal. But, if the fork, when no longer heard through the air beside the ear, be heard without being re- struck as soon as it touches the vertex, the conclusion is inevitable that there is some impediment in the sound-con- ducting part of the ear. This is all the more convincing if it be borne in mind that there is being used the same note, and one, too, crrowino; a little weaker all the time. For, if vibra- tions of a tuning-fork cease to be heard in front of an ear, by aerial conduction, but are able to communicate themselves while growing constantly weaker, through the bones of the head, the inference of great derangement in the middle or external ear — the aerial sound-conducting parts — cannot be avoided. Speech. — By hearing speech the intellectual development of the human being is accomplished. There is no sound so fami- liar and none for which all so fondly long at times, as that of SOUND, HEARING, AND TESTS OF THE LATTER. 199 our native totiijue. One with <2:o()d liearino^ can never realize the feelings of a deaf person so vividly as when travelling in a strange land, surrounded by people speaking with one another happily, gayly, and with varying expressions, but in a language unknown to the lonely traveller. Such a one falls into the posi- tion of an invalid, is treated with a kind of pity, and alas, finds himself growing a little suspicious and morose. The deaf person feels the loss of hearinti: the voice of others more than the loss of power to hear anything else. To recover the ability to hear the familiar tones of his friends' voices he would gladly give up all other hearing. So great is this struggle to hear what b pothers say, that the deaf gradually learn to understand the words of others by watching their lips. The power to hear other sounds well, may begin to fail without the knowledge of the patient, but all his endeavors are concentrated almost un- I Iconsciously to catch the varying sounds of speech. If I have known young physicians to be almost deaf to the ticking of a watch without knowing their loss, for their ability to hear speech was good. All aurists are aware that patients are constantly surprised to learn the amount of their deafness I ftas soon as the face is averted from the speaker. The failure in hearing in this respect is often tirst detected by the patient in the summer-time, when all are accustomed to sit on porches or in the parlor, in tw^ilight and the dark. As i pthe daylight fades and the faces of those around are no longer plainly visible, the hitherto apparently hearing person becomes aware that he is o-rowino- deaf. This is often assigned to the night air, but in reality it is due to the loss of vision in the darkness. The surgeon will often gain great aid by a knowledge of these facts, and also by observing how a partially deaf patient will look at the person addressed. Those of delicate sensibility soonest become aware of their defective ability to hear the voice, for speech is not only a deli- cate sound, but it is highl}' valued by the cultured as a means of social intercourse. Those of less sensibility are not aware of their loss of hearing for speech, for they still hear loud sounds, and even music so called, for the latter is comparatively much more powerful than the tones of speech. I ■ The value of speech as a qualita^ve test for hearing has been shown by Donders, Helmholtz, and 0. Wolf. But why it was that a patient could hear some words much better than others, though spoken at the same distance, was not explained and applied until Dr. Wolf, of Frankfurt-on-the Main, published his investigations respecting the acoustic characters of the various elements of speech.^ 1 Sprache iind Ohr., 1S71. 200 EXAMINATION .OF PATIENTS. The human ear perceives, as music, tones varying from 16 vibrations to 20,000 vibrations in a second. Preyer^ has lately placed these limits from 15 vibrations to 40,960 vibrations in a second. Blake ^ has shown that the human ear, in some in- stances, distinctly hears, as musical tones, 35,000 to 40,960 vibrations in a second. Speech, according to Wolf, embraces only eight octaves, viz. : K. of 16 vibrations, and S. of 4324 vibrations in a second. It may be said, therefore, to lie entirely within the limits of music. Fig. 72. Perception of High Musical Tones. — With the view of ascer- taining the power of the ear to perceive high musical tones, Dr. Blake ^ has performed a series of most valuable experiments with Konig's rods. The latter are steel rods devised by Mr. Konig, of Paris, for making accurate acoustic tests with notes of highest pitch. In order to get a clear tone, it is necessary to suspend the rods by means of loops of silk, or line wire. To obtain the points at which the threads should be attached to the steel rods, the length of the rod should be di- vided by 4.3. Thus, if the length is 70.5, this divided by 4.3 = 16.4. The latter would be the distance from each end, at which the loop of the suspending thread should pass round the rod. Then Dr. Blake sug- gests that in order to obtain a deter- mined intensity of tone, a small steel pendulum, swinging through an arc of 90°, be suspended to the same beam as the steel rod. If the pen- dulum is made to swine; over .the arc on which a graduated scale may be placed, the intensity of the blow can always be known and reproduced exactly, if necessary. With this in- strument. Dr. Blake has found that the perceptive power of hearing high ifiusical tones varies with the age. At about the age of 12 or 13 years, a tone of 40,960 vibrations jper secovd was heard 34 feet; at the ages of 18 to 20 years, the same tone was heard at distances of onl3- 13 to 16 feet, while at 34 feet KiiNiG Ron AS MoinriKi) ry BLakk. ' .Jona, 187G. "•' Transactions American Otological Soc, 1872-3. ^ Summary of results of experiments on the perception of higli musical tones. Trans. Amer. Otol. Soc, 1872. SOUND, HEARING, AND. TESTS OF THE LATTER. 201 only tiie tone of 3(3,864 vs. was liearcl. At the ages of from 28 to 30 years, only tones of 32,768 vs. were perceptible, while above the age of 50 years the limit of perception, at the same distance, had still further diminished, and in a greater variety of degree. Dr. Blake's further investigations showed that these changes in perceptive power were due to thickening of the membrana tympani, the latter causing diminution of the power to hear the high tones. An apparent exception occurs, where in addition to thickening, especially in the young, the membrana tympani is drawn in. The increased tension of the latter con- dition makes the membrana tympani more sensitive to high tones, and thus the thickening of the membrane is somewhat counterbalanced. In two cases of voluntary contraction of the tensor tympani, the perception increased from 3000 vs. to 5000 vs., during the contraction of the muscle, above the limit of perception observed when the muscle was not contracted. Further experiments of Dr. Blake showed that when the membrana tympani is perforated, especially at the posterior and superior periphery, the ear can perceive higher notes than when the membrane is intact. This was found to be the case both w'hen perforations had been made by disease, and after artificial perforations. In one instance, after Politzer's eyelet had been inserted into a thickened drum-head, a steel rod, with a tone of 80,000 vs., was distinctly heard 3 inches from the ear. In a later paper I)r. Blake' bases the claims of high musical tones, to value in diagnosis, upon the following facts : " That the limit of perceptive power of the cochlea exceeds the limits of sound-transmitting power of the structures of the middle ear in their normal condition ; that the structures of the middle ear in their normal condition, therefore, present a barrier, as it were, to the passage of sonorous vibrations above a given point ; and that the perceptive power of the internal ear remaining the same, morbid chano-es in the middle ear result in a variation in the limit of their transmission of musical tones." This varia- tion may be either above or below a certain standard point; this point, as already stated, was found to be about 40,000 vs. When the membrana tympani is perforated the ear may per- ceive musical tones of 100,000 vs.; the difference between this tone and the tone given as the normal standard may be regardene«;. Transactions American Otol. Soc, vol. i. p. 438, 187?.. 202 EXAMINATION OF PATIENTS. Acoustic Character of Voivels and Consonants. — The distance at which separate vowels can be heard has not yet been established, but they are endowed with the greatest strength of tone, being heard and understood at a distance at which all the consonants are inaudible. The intensities of vowels given here are such as are obtainable when words containing the given vowels are uttered. The consonants dilfer very greatly from each other in strength of tone, as will be shown further on. Vowel-sounds are composed of a number of beautifully har- monic over-tones, which accompany the fundamental note and strengthen that of the mouth. A good musician can hear a perfect accord when a vowel sound, especially A, is uttered with clearness, which is said by Wolf and Appunn to be most ob- servable when the sound is made in the open air, where the sound-waves escape with greater precision than in a room. Dr. Wolf has shown that the broad sound of A has the most over- tones, five in all, and is heard the furthest, 360 paces. The sound of Oo has the fewest over-tones, three in all, and is heard with the most difficulty of all the vowels. It can be heard distinctly 280 paces. The vowel 0, containing many beautiful harmonic over-tones, is heard nearly as far as the broad A. The German E, about equivalent to the English A, is heard 330 paces, and the English E is heard 300 paces. The English I is somewhat more powerful (340 paces) than A, but weaker than the broad A or the O sound. Oi is nearly equal to E. Weakest of all diphthongs is Ou, as in out; it is a little stronger than Oo. Consonants. — Consonants may be classified, according to their acoustic and physiological laws, under two heads, viz., those which areself-sounding, and those which are sound-borrowing.^ The former are such as possess a sound entirely independent of association with a vowel sound, and one that can be defined respecting its pitch, intensity, and timbre. The latter are such as must be either preceded or followed by a vowel in order to render them audible, and hence the name of sound-borrowing consonants has been applied to them by Dr. Wolf, of Frankfurt- on-the-Main. H is the weakest of all consonants when pronounced without a vowel. It is lost at the distance of a few paces, JSText in strength is B, Ba being heard further than Ha. B alone is heard at a distance of 18 JDaces. The deeper a note is, the less effect it has upon the ear. The high notes are the most valu- able in this respect, as shown by Moos. R, with only 16 vibra- tions in a second, is not distinguishable further than 41 paces. K and T stand next; they are both heard equally well at 63 ' " Selbsttonende " and " Tonhorgende," Wolf; Spracho und Ohr., pp. 14, 15. SOUND, HEARING, AND TESTS OF THE LATTER. 203 paces. T resembles pretty closel)- ii simple note, but it luis a pitch which appeals more readily to the ear, and is, therefore, heard much better than B, wliich is otherwise very similar to it. K is formed with relatively favorable circumstances, l)y means of a powerful movement of the root of the tongue. The soft F is heard somewhat further than the foregoing letters, i. e., 67 paces. S is perceived at a relatively greater distance than the foregoing, on account of the pitch of its fundamental note, ^which by its sharp character attracts the ear. * "To its properties as a sibilant consonant it owes its ability to express disapprobation in public assemblies, to cry down opposing sentiments, and to enforce silence. Both its moral and physical character are inharmonic.'" S can be heard very distinctly 170 paces. Sch German, nearly equal to Sh English, is heard furthest of all consonants, because it possesses full and rich clang-tint, and is composed of three harmonic notes which predominate, while the inharmonic over-tones recede; this com- posite consonant can be heard 200 paces. M and X, unaccom- panied by vowels, are only meaningless blowing of air through the nostrils. Mama and Nana are understood 180 paces, but at a greater distance the sounds of M and N are lost, while the vowel A is still heard. ^ Helmholtz has also pointed out the very noticeable fact that if in calm weather an observer be placed on some elevation near a town — a tower or a hill-top — it will be found that words are no longer distinguishable, or at best only those composed of M and N with vowels. Vowels can be heard following one another in a curious interchange, and with remarkable cadences, because no consonants are heard, and the other vocal sounds cannot be joined into words. ^ It is thus shown that in the component sounds of speech a wide range of tests of different intensities and pitch is offered to the aurist. Such a numerous set of tests is needed in order to discover which sounds are heard best by an affected ear. One sound is not sufficient, because an ear may be unable to hear certain sounds, but be comparatively good for others. Hence, if oidy one or two sounds should be employed, as in the watch, just those sounds might not be heard as well as others. No sound-unit has ever been established, and, if it were, it would be useless, since, from the nature of the ear, such a unit would not be equally applicable in all cases. Therefore, speech becomes valuable as a test because of its composite sound-nature, and, also, because it is ever at the command of the examiner, whose 1 Wolf, op. cit.. )). 63. * Tonempt!ndiiiii;en, etc., p. 118 204 EXAMINATION OF PATIENTS. i! object in applying it as a test is comprehended by the patient without any preliminary instruction. Test-sentences and Test-words. — Test-sentences containing long vowel sounds are of great value in testing the hearing. Thus, arbitrary sentences, meaning nothing in themselves, may be chosen for tests.' The following are examples : " Pour oil on the waters of Lake Erie," and "He lies here in awe of these four large tigers."' Instead of sentences, most aurists use isolated test-words, for the sake of convenience. These may be chosen according to their logographic value. Blake^ demonstrates that a comparison of a large number of logographic tracings of the force-values of consonants shows that, while the force-value of the consonant sounds differs largely in different individuals, and differs also in the same individual at different times, the com- parative value of the consonant sounds one to another bears a fairly, though by no means absolutely, definite ratio. If, there- fore, we take the consonant sound which requires the greatest logographic value, and which would be most readily heard, expressing its value as 100, and that of other consonant sounds accordingly, we have a table from which to select materials for a list of test-words, based upon intensity rather than upon pitch of the voice-force producing them, and serving, as in case of chronic catarrh of the middle ear, as a measure of obstruction to the passage of sound. In compounding words from this table, it is better to use monosyllables, and it should be kept in mind that the logographic value of consonants formed at the back of the mouth is greater in combination with the lower- pitched, and of the fi-ont consonants in combination with the higher-pitched, vowel sounds. The tabular list is as follows : T 100, B 53, P 58, D 45, G 56, S 40, Z 53, C 62, F 35, K 31, L 21, X 11, M 9. Whispering and Loud Tones. — Very often whispers and words spoken in low tones are heard much more distinctly by the affected ear than loudly spoken words. This is due. to the damping of vowels, as shown by Wolf, whereby the consonants, which have been stated to be less sonorous than vowels, have a chance to be heard. This fact is of great importance, not only in estimating the hearing, but in addressing those hard of hear- ing. Members of a family very often pitch their voices too high, and hence confuse the afHicted one, thus gaining the idea that the individual is deafer than he really is. On the other hand, they are surprised that on some occasions he hears sounds 1 Dr. A. H. Buck, American Otol. Society, 1876. ^ Ti'ansactioiis of American Otol. Society, 1881. SOUND, HEARING, AND TESTS OF THE LATTER, 205 •aiul words spoken to others in comparatively U)\v tones. So marked is tliis in those hard of hearing, that it has l)een said a deaf person always hears when it is especially desired that he should not. This is due to the physiological acoustic fact men- tioned above, that in low-spoken tones the vowels are quelled, and the consonants, being allowed thereby a better utterance, are relatively streno:thened, and the whole w^ord is heard better than if roared out. This damping of vowels has both its good and bad side. Do not elevate the voice too high when you wish to make a deaf person hear, but do not lower it too much, unless to a whisper, if it is not desired that he should hear. Words may be heard even when the letters composing them, spoken separately, are not heard. This is especially so for the letters B, P, T, K, and R. The reason of this lies in the fact that letters pronounced alone are really words. Thus B is really composed of sounds of b and e, as in be; P, oi pea oy pee; K, of kaij, while R is equivalent to sounds of the word are. It may be said very truly that, in the latter instance, R, when pronounced alone, is altogether of a phonetic value different from that when standing at the beginning of a w^ord, as in Rab., or at the end of a word, as in Tar. Whispering. — Whispering has an advantage over loud words in testing, since the former cannot be as easily conveyed as the latter through the bones of the head to the auditory nerve. However, it must be borne in mind that in a case reported by Dr. Dennert,^ in which the cochlea had been lost by necrosis, the normal ear, though artificially stopped up as thoroughly as possible, could yet hear whispers six feet off. Sometimes, patients hear music better than speech, because the faintest music of an orchestra is more pow^erful than speech, as stated bv Wolf >■ Variable Hearing. — The hearing varies very greatly in cases ■of movable fluid in the tympanic cavity and in some forms of aural vertigo. When such peculiarities of hearing are fully established, they may aid greatly in diagnosis. The first kind s made manifest by changes of position of the patient's head ; the second form of variability of hearing comes and goes with the paroxysm of vertigo. It is probably due to alterations in the condition of the muscles in the tympanum, whereby altered tension in the sound-conducting apparatus is produced. Hearing Low Tones better than High Ones. — It is sometimes )bserved by [)atients that they hear low, bass notes much better ' Archiv f. Ohrenh., Bd. x. 206 EXAMINATION OF PATIENTS. than high ones; as, for example, in two instances, patients vol- unteered the information that they heard thunder much better than the chirping of crickets, and bass notes much better than high ones on the piano or organ. In testing with a watch, it was found that one giving out the deeper note was most easily heard by one of these patients ; the other was not thus tested. Ex- perimentally, I have shown that a deep note has the advantage of high notes in cases of increased lab3'rinthine pressure (p. 96). In an increase of such pressure, the stapes becomes more fixed, and it is on this small bone that the vibrations begin to grow less as the pressure within the labyrinth is increased. In such a case, it is manifest that, if vibrations from without are nor- mally conveyed to the stapes, there they must meet with hin- derance in their endeavor to reach the labyrinth. Only the more powerful sound-waves are able to overcome this obstacle and force the stapes into to-and-fro motions with the rest of the chain of ossicles. I have, therefore, thought it might be asked, Could not the inability to hear high notes in some cases, while low ones are heard nearly, if not quite normally, be construed into a sign that the stapes is impeded, either by undue pressure in the labyrinth, or by catarrhal fixation in the oval window ? That the cause of such a peculiar alteration in hearing probably does not lie in an undue tension in the membrana tympani, appears from the well-known phj'sical fact that the tense mem- brane is more susceptible to vibrations of high notes than to those of the low. The Position and Extent of Perforation in the Membrana Tym- pani may cause variation in the hearing power for certain sounds, especially consonants, as shown by Wolf.' Experiments with the consonant B upon defective drum-heads show that the perceptive power for this sound diminishes as the extent of the defect increases. The faintness of the consonant is most ob- servable when it stands at the end of the word. It may also be said that defects of the membrana flaccida are attended with great deafness for all sounds, which is probably due to an impli- cation of the malleo-incudal joint. Testing the Hearing in One-sided Deafness. — In measuring the hearing for sounds conveyed through the air in cases of one- sided deafness, or of hardness of hearing confined chiefly, if not entirelv, to one ear, care must be taken not to attribute to the worse ear that which is really heard by the better ear, though stopped and turned from the examiner. In any case where one ear is being tested, accuracy would demand the isolation of the ' Sprache und Ohr., 2d part. I» II SOUND, HEARING. AND TESTS OF THE LATTER. 207 Other. Usually, the ear not being tested is stopped and turned from the source of sound, the ear under examination being left open and turned towards the sound-source. This method will " usually give at least a proximate result as to the amount of hearing in the worse ear, but in order to exclude the fact that the better ear, though stopped and turned away, hears some of the test, it will be necessary to measure the hearing in the worse ear alternately open and stopped in order to see what effect this stoppage will have upon the amount of hearing it is supposed the worse ear still retains. In the method of Dennert and Luc?e,' the voice is relied upon chiefly for the test. The hetter ear is stopped, turned towards I« the source of sound, and tested, the deafer ear being alternately ■ opened and closed. The difference in the hearing, if there be any elicited by this method, is set down to the worse ear. A plan similar to the foregoing, and one which I have used for a long time in cases of one-sided deafness, is as follows: Place the patient so that the affected ear is towards the surgeon. Then with the finger stop the ear not to be tested. This may be done by the patient or by an assistant, preferably by the latter when great certainty is needed. Now, with the affected ear open and turned towards the surgeon, let tests of its hearing power be made. When the apparent limit of hearing on the I'Maffected side is obtained, let that ear be closed as the other ear I Bis, and then, with the affected ear still turned towards the ex- aminer, let tests be made again. If the closure of the deaf ear causes no difference in the hearing' distance already obtained, it is fair to conclude that whatever amount of hearing exists is not I ftdue to passage of sound through the external auditory canal of the worse ear turned towards the test. In such a case the con- clusion must therefore be, that sound either goes more easily through the bones of the head on the affected side than through I Bthe meatus, to the auditory nerve (which would be absurd), or I pthat sound has reached the brain by the other ear. Also, it may be concluded that the affected ear is practically, totally deaf. If, however, stopping the ear turned toward the examiner I l(the ear supposed to be the deafer) makes that ear still deafer, let the examiner approach the patient and repeat the tests until they are heard once more. The second hearing of the tests is evidently due to conduction of sound through the cranial bones and the finger in the meatus, and, therefore, must not be mis- takenly regarded as aerial conduction. The extent of the }»ower of the earto hear in this latter way will be expressed in the difference between the limit of hearing the first test and the ' Archiv f. Ohrenheilkunde, 1875. It ii08 EXAMINATION OF PATIENTS. limit of the second. Thus, a patient may hear speech as far as eight feet, with the good ear stopped and turned away, and the affected ear open. When the latter is stopped, but still turned toward the examiner, speech is no longer heard at eight feet, but it may be perceived by the patient at a distance of three feet, both ears still being kept firmly stopped. In such a case, not the former distance, but the difference between it and the latter distance, viz., jive feet, must be regarded as the limit of aerial conduction by the external auditory canal, for that repre- sents the amount of loss of hearing caused by stopping the meatus. Whatever is heard just as well with the deafer ear stopped as when open, the better ear remaining stopped throughout the testing, must still be heard by the better ear through the head ; but whatever is heard only with the worse ear open, the good ear being stopped, must be attributed to the worse ear. Another method of getting at the amount of hearing in a very deaf ear, or perhaps a totally deaf one for all that is known before the examination, is to begin the testing with both ears of the patient closed. Then, with the worse ear toward the sound-source, try to iind out how much is heard; after which let the artificial stoppage, usually accomplished either by the finger of the patient or of an assistant, be removed from the worse ear, the better one remaining stopped. The difference in the two results, if there is any, must be the true amount of hearing on the affected side. If there is no difference in the result, it is fair to conclude that sound con- ducted through the auditory canal to the deaf ear is not per- ceived by it. This being the case, if words repeated on the aft'ected side are still heard, it is not due to any remnant of hearing power in the deaf ear, but rather to the passage of sound through the head to the good ear. The question might be asked. Why cannot sound be conveyed to the deaf ear through the head, if it is conveyed to the better ear, which is stopped and turned away from the sound-source? The reply would be, that an ear which, either when stopped or open, perceives no difference in sound conveyed by the meatus, is not sensitive enough to hear sound conveyed to it through the head. TJiC Entotic Application of the Ear-trumpet. — In order to find out which parts of the chain of ossicles are most affected in cases of sclerosis and stiffening of these portions of the middle ear, it has been proposed by Dr. Albert Bing,^ of Vienna, to substitute the ordinary means of diagnosis found in the catheter, ' Die entotische Anwoiiduiig des Horrohrs. Monatsschr. f. Ohrenheilknnde,, Nos. 8, 9, and 10, 1870. \ I SOUND, HEARING, AND TESTS OF THE LATTER. 209 tlie auscultation-tube, and in tlie direct inspection of the mem- brana tynipani, by what he terms the entotic application of the ' hearing trumpet. ^ This is done by speaking through a collector of sound, one end of which is made to communicate directly with the tym- panic cavity, through a catheter iixed in the Eustachian tube. By such an apparatus, sound-waves may be brought directly into the tympanum and made to fall immediately upon the foot- plate of the stapes, from which they are carried over to the tiuid of the labyrinth and the auditory nerve. During the ex- amination by this method, the ears of the patient are to be stopped, in order to prevent sound from entering by the external 1 auditory canals, and, in order to prevent lip-reading, the eyes of the patient should be closed: he may then be required to repeat what he hears. According to the greater or less ability of the patient to hear by this method, Dr. Bing concludes that, 1, the stapes is entirely [^normal, or 2, that it is more easily movable than either of the other ossicles: o, that the obstacle to conduction lies onh' in the stapes or in it and the other ossicles at the same time, or 4, that the stapes has become anchylosed. In one instance in Avhich the patient heard much better by the entotic method, until a perforation in the drum-head was freed of tough exudation, when he heard better both with and without the trumpet, it was concluded that the chief obstacle to conduction of sound lay in the malleus and incus, while the stapes was easily moved. 14 SECTION II. AURICLE CHAPTER I. OEGANIC DEFECTS AND CUTANEOUS DISEASES. ORGANIC DEFECTS. Among organic defects in the auricle may be mentioned, ab- sence, plurality, abnormal position and shape, as well as partial and defective development. A partial or total want of the auricle may be congenital. This may be confined to one side, or it may occur on both sides and in conjunction with other defects of the head produced by alteration or imperfect development of the visceral arches. Such defects interfere more or less with the fineness of hearing. Traumatic loss of the auricle frequently occurs from accident, punishment, and disease. Plurality and Abnormal Position of Auricles. — A plurality of auricles has been found in lower animals' and in man, " Casse- bohm relates a case of a child with four ears, tMO naturally placed, and two lower down on the neck; there were in this instance two petrous portions in each tempoi-al bone."^ Birkett^ has reported the case of a young girl who, in addition to irregularities in her ears, had on each side above the middle of the sterno-cleido-mastoid muscle, a large growth resembling the lobule of an auricle, each supplied with an artery, and con- taining reticular cartilage like that of the pinna. Fig. 73 represents portions of a supernumerary auricle which I observed in a woman, forty years old, who presented herself at the Philadelphia Polyclinic. There appeared to be a rudi- ^ Especially in the pii^ ; Wilde, op. cit., 101. 2 Wilde, op. cit., p. 161. ' Transactions of Path. Soc, London, 1858, vol. ix. p. 448. ORGANIC DEFECTS AND CUTANEOUS DISEASES. 211 mentary and supernumerary tragus and lobule. Her auricles wore normal, and her hearing unatt'ected. Fig. 74 represents a supernumerary tragus in front of the auricle of a boy eleven years old. The hearing was perfect. Fii,'. 78. Fig. 74. ^he lad having applied for relief from an attack of herpes I* zoster on the helix and antihelix, the appendage was seen and • sketched. If 14 II Malformations of the Auricle. — Malformations of the auricle are generally found connected with defects or absence of the external auditory canal. The surgeon is usually consulted to know whether the malformation will interfere with the hearins: of infants thus deformed, and, if so, whether an operation will relieve the deafness and deformity. Mr. Toynbee,' in his excellent work, has given an account of a paper by Prof. Allen Thomson,^ treating of malformation of the external ear and the condition of the hearino; in such cases. It is there shown that in an incomplete development of the in- tegumental part of the apparatus, viz., the auricle and outer part of the meatus, there is usually absence of the tympanic ring, and consequently of the bony part of the meatus ; that there is also a defective state of the cavity of the tympanum and chain of small bones, and occasional irregularitj" or deticiency in the development of the malar, palatal, and maxillary portions of the face and mouth. Gruber^ has stated that in deformities of such a hic:h ii:rade he has never found a normal auditory canal. Usually there is , 1 Disease.s of the Ear, London, 1868, pp. 14, 15. ^ Edinburgh .Journal of Medical Science, April, 1847. * Lehrbuch der Ohrenheilkunde, p. 275. 212 AURICLE, not a trace of one present, or at best it is a narrow and short blind passage connected with the auricle. The latter usually does not occupy a position similar to that of a normal aui'icle, but is either nearer the cheek or pushed downwards toward the throat, and is movable in all directions with the neighboring skin. This is an important fact to bear in mind, if there is any inclination to make an artificial auditory canal. Of the two cases reported by Dr. C. J. Blake,' the following is considered by him as of great interest: It occurred in the right ear of a girl three years old; the long diameter of the auricle formed an angle of 45° with the vertical plane of the head; the position of the helix was barely indicated by a slight reduplication of the superior portion of the auricle, and the antihelix represented by a slight elevation above the superior border of the concha; the whole of this portion of the auricle resembled that of the chimpanzee, or of the cases of dementia given by Lay cock. " The perception for musical tones on this side of the head seemed to be good, and the integument covering the meatus" could easily be depressed with a probe, lender these circum- Fi"-. 70. stances, an exploratory operation was advised, but unfortunately the patient did not return at the appointed time. The family history of the patient gave no other case of malformation, and the little patient herself was otherwise normally developed.'' The accompanying figures represent the ears of a boy eight years old, the left auricle of whom is small and deformed. I ^ Statistical Keport, 1052 cases of Diseases of tiie Ear. Ma.~s. Charitable Eve Ji and Ear Intirmary, 1872. - |[ r I ii I! ORGANIC DEFECTS AXD CUTANEOUS DISEASES. 213 saw thi?; case wlien he was only three years old. The deformities are congenital. In January, 1884, when he was eight years old, I examined him again, and made the following notes. The hearing of the right ear is perfect. The tuning-fork vihrating on the vertex is best heard in the right ear. There is no meatus on the left side, hut there is a slight depression on the concha where usually the meatus is found. The auricle seems loosely attached to the side of the head, and the finger cannot detect anything like an osseous canal. The auricle seems to he attached to a cup-shaped depression lying between the mastoid and the root of the zygoma. The child is otherw^ise healthy, as are his parents and brothers and sisters. There are no supposed reasons given by the parents for the deformity in their child. With rudimentary auricles and absence of external auditory canal sometimes there nvdv be found a faulty development of the corresponding side of the face, as observed by von Troeltsch and Wagenhiiuser.^ Cases of microtia hav^e been reported by Blake and D. Hunt,^ and also by W. H. Robb.^ In connection with congenital macrostoma, in which a fissure-like prolonga- tion of one side of the mouth is found extending into the cheek backwards tow^ard the ear, and in which the lower jaw is mal- formed, malformations of the auricle and auricular appendages are observed.^ In these cases the hearing may not be much, if at all, afiected. Congenital Fistula of the Ear. — This is a rare form of malfor- mation or arrested development near the ear. Cases of it have been described by Schwartze, Heusinger, Schede, Schmitz,'' and Pfliiger.'' It consists in a dimple or a small fistulous opening close in front of the tragus, in the helix, or just in front of it, above the tragus, and in the concha, which nia}^ extend in some cases as far as the tympanic cavity. It may be symmetrical, as shown by Pfliiger, or in connection with defects in the throat, as shown by Schmitz. In the case given by Pfliiger a probe could be inserted 1^ cm. without difiiculty or pain. An interesting fact connected with the history of this case was that pus had been discharged a number of times from these openings, after attacks of earache. The cause of this anomaly is considered by Heusinger, Schmitz, and Pfliiger to be an arrest of development ' Archiv f. Olirenhcilk., Bd. xix. S. 55. '^ American Journal of Otology, vol. iii., 1881, p. 3. ' Ibid. p. 278. ♦ .lohn H. Morgan, British Med. .Journal, Nov. 12, 1881. ^ Ueber fistula auris congenita, etc., Halle, 1873. A. f. O., Bd. ii., N. F. 1874, S. 301. Abstract by Jacobv. " Monatsschr f. Ohrenlieilkunde, I^o. 11, 1874. 214 AURICLE. in the first visceral cleft, a view also held by A irchow, Urbaut- schitsch^ reports twelve cases of this defect occurring among 2000 cases of ear disease, observed by him in Vienna. It was bilateral in three instances. The same writer states that this defect is more common in the lower animals, like the sheep and the horse, than in man, as has been shown b}- Meckel and Geoflrey St. Hilaire. Kipp, Schwabach, and Paget have also published accounts of the observation of this defect. The author has seen six cases of it. CUTANEOUS DISEASES OF THE AURICLE. There are some cutaneous diseases of the auricle and of the parts adjacent to the ear which may fall to the care of an aural surgeon, and they shall be briefly considered. Simple Erythema. — This disease is usually caused by local irritation from bites of insects, badly fitting head-coverings, especially in infants, the action of the sun on the exposed ear, and the instillation of various nostra into the ear, or by irritating discharges from the organ itself. The membrana tympani may not be affected. Treatnient. — In mild cases of erythema of the auricle very little treatment is demanded. If the itchino; and hurnins; are great, it is best to use soothing dressings, such as cream, ung. aquse ros«, simple cerate, and the various mucilages, an excel- lent one being quince-seed mucilage. Erysipelas. — Erysipelas of the auricle may occur as a primary or idiopathic disease from local cold, or secondarily by extension of the disease to the auricle from parts adjacent to it. In the latter instance the prognosis will depend greatly upon the con- dition of the patient and the previous condition of the ear. While erysipelas of the face and head as a rule will render hearing in any case dull, most probably by an occlusion of the auditory canal, it does not necessarily leave the hearing perma- nently impaired. Even where erysipelas attacks an ear pre- viously diseased, the bad consequences are not permanent. In the case of a young lady, 18 years old, I have seen four or five attacks of erysipelas of the face in the course of a few years. On the right side she has a chronic purulent discharge from the ear, dating from early childhood. During the time she has been under my observation the erysipelas has always made the con- dition of the diseased ear temporarily worse, but notwithstanding ^ M. f. Ohrenheilkunde, No. 7, 1877. II li ORGANIC DEFECTS AND CUTANEOUS DISEASES. 215 the repeated hinderances to recovery, experienced by the ear, it has gradually assumed a more healthy condition. Treatment. — The treatment of erysipelas of the auricle is similar to that of the disease elsewhere, excepting that care must be exercised not to apply such cold dressings to the ear as would be justifiable in the disease on the face. It is prefer- able to apply light dressings to the erysipelatous ear, such as light gauze or linen sprinkled with flour or rice powder, and to avoid cold moisture. Intertrigo. — This disease may be found in children of all classes, and in the healthy as well as the unhealthy. It is . caused by mechanical irritation where the posterior surface of the auricle comes in contact with the mastoid surface. It is due primarily to a certain amount of maceration of these sur- faces, which favors excoriation and chafing. Hence dryness behind the auricle must be maintained. Cleanliness, of course, must be observed, but too much ^vashing is as bad as too little. The disease may also be caused by too much warmth about the i% head, tightly fitting caps, picking at the ear on the part of the children themselves, or by tossing or working the head about on the pillow, which, of course, causes the auricle to rub against the mastoid surface. The prognosis is favorable. The disease should be arrested as soon as possible in order to prevent it from passing into an eczematous condition. Treatment. — After the disease is fully established all washing of the parts behind the ear should cease, and the moist surfaces be dusted with a powder consisting of one part of oxide of zinc (Hubbuc's preferable) and from two to seven parts of pure starch. This wnll form a white crust, which should be let alone until it drops oif, wdien the surface underneath will be found to have entirely healed. I. . . . Frost-bite. — In very cold winters with us, and in cold climates every winter, frost-bitten ears are not uncommon. No special treatment is demanded in acute cases. Care must be taken to avoid too sudden a reaction, and this is done by the application of ice-water or snow at first, with the gradual application of warmer w^ater. If vesicles and subsequent excoriation occur, we must prevent the access of air as much as possible to the af- fected parts, by the application of emollient cerates or collodion.' I S In many cases, when nothing better can be procured, the ex- coriations, produced by the frost-bites, on the auricle may be _ covered bv linen smeared with ordinary glue.^ ISTew^ formations 1 Rail, op. cit., p. im. 2 j]^ic|_ 216 AURICLE. major portion of the pinna, as a result of frost-bite, and hard and sensitive nodules may be felt in the lobe. In such a case, seen recently by the author, the skin was purplish, covered with a slight amount of branny scales, and the nodules could be dis- tinctly seen as well as felt. The nodules in the auricle in this case did not resemble the gouty deposits described by Garrod.' They were so close together that the surface of the cartilage of the auricle had lost entirelv its smoothness. At the same time, the entire auricle, especially at the more elevated nodules, was quite sensitive to pressure. Tophi, as described by authors treating of gout, do not appear to be very common in this country. Lupus erythematosus, lupus vulgaris, psoriasis, ichthyosis, comedo, acne, keloid, molluscum librosum, with the disease elsewhere on the bodv, and ringworm, mav attack the auricle ; but beyond the mere mention of their occurrence, it is not neces- sary to enter into a discussion or description of them here. The reader is earnestly requested, however, to bear in mind the possibility of these diseases being found on the auricle and concha, and in the auditory canal, and to become acquainted with their nature and treatment as set forth in works on derma- tology. Pemphigus Gangrsenosus of the Auricle. — This disease was first described by Dr. Whitley Stokes, and mentioned by Wilde'- in the medical memoir attached to the census of Ireland in 1841. It is peculiar to Ireland, very apt to attack children on or about the ears, is very fatal, and prevails especially among the lower orders. It is said to have caused 17,799 deaths in ten years in Ireland, the truth of which, Wilde is inclined to believe. It is not known in this country, though the scars left by it have been seen bv the author, in an Irish woman. Phagedsena, or cancrum auris and gangrene from embolism, may be mentioned as of uncommon occurrence. Gangrene of the ears occurs in some low fevers ; it may be symmetrical and associated with gangrene of the nose. It has been observed after intermittent fever by H. Fischer,^ and after typhus by Estlander.* Gangrene of the auricle is similarly referred to by Patry,^ and by Barker and Cheyne.® It is usually, a very bad symptom, being the immediate precursor of death in most cases, though recovery has ensued after gangrene of the ' Treatment of Gout, London, 1859. - Diseases of the Ear, American ed., 1853, p. 174. •^ Langenbeck's Archiv, vol. xvii. pp. 335-339. •* Quoted by Fischer. " Archives Generales, 1863, i. p. 144. * Observations on Fevers, etc., p. 232, vol. i. See also Toner Lecture for 1877, by Wm. W. Keen, M.D. I t ORGANIC DEFECTS AND CUTANEOUS DISEASES. 217 auricles luul occurred in typhus fever, as shown by Estlajider, and by Barker and Cheyne. It is generally associated with livid and gangrenous spots elsewhere on the body. Eczema. — Eczema, both in the acute and chronic form, may be found in the auricle, and, as a disease modified by its sent in an organ of special sense, becomes of interest to the aurist. The acute form is more common than the chronic, attacks all ages and sexes, but is more frequent in children and in females. It is supposed to be connected with the phases of menstruation, and is considered by some, to be, with other symptoms, indica- tive of the menopause.' In children, acute eczema is often pro- duced artificially by iincleanliness, hy their own picking at the ear, and by head-coverings which fit too closely. In adults, acute eczema of the ear is frequently caused by the introduction into the organ of improper remedies for earache, toothache, etc. I • AciUe Eczema of the auricle or auricles may be idiopathic or an accompaniment of other diseases of the ear, or it may occur in the auricle from the contiguity of the latter to other parts of the head afiected by the disease. The idiopathic form may appear on bofh sides of the auricle, or it may be circumscribed on the anterior surface. The greatest interest this disease can have for the aurist, is when it attacks the auditory canal and invades the membrana tympani. Trentment. — The treatment of eczema of the auricle will be similar to that of eczema anywhere else on the general surface, with of course the modification rendered necessary by care not to apply any remedy which, by escaping into the auditory canal, would injure the drum-head. The treatment of the acute form of eczema of the auricle should always be very simple, and the dressings, when once applied, should not be changed more than twice daily. Most important is it that little or no washing, and absolutely no soap, should be applied to the auricle affected with acute or even subacute eczema. Both glycerine and cod-liver oil, applied on pledgets of charpie, and bound firmly to the eczematous auricle, are of great value in children.^ The following powdef will be found of great benefit in cases of acute eczema of the auricle: R. — Flor. /.inci, ^ij ; Alnminis, Anivli, aa 3J. :M. Fiat pulv. 1 firuber, op. cit , p. 288. 2 Gruber, Lehrbucb d. Ohrenh., 1870, p. 292. 218 AURICLE. Another, equally useful, is as follows: R. — Zinci ox., ^^j-iv; Ainyli, giv-vij. M. Fiat pul'v. These powders should be dusted carefully and thoroughly over the diseased auricle, and the latter should then remain un- disturbed as much as possible. The ointment of the oxide of zinc, benzoated, is also a very efficacious remedy in eczema of f< the auricle, acting as a protector, ii If the heat and burning become very great in acute eczema f of the auricle, cold must be applied, with caution, to the diseased f surface. This is best done with cloths steeped in cold water. Hebra' used, in acute eczema, a salve which he'called the Ung, Diachyli, which is made as follows: R. — 01. olivae, opt. fl3xv; Lithargyri, giij ^vj ; Aqun?, q. s. Coque. M. Fiat Ung.^ I This may be used in acute eczema of the auricle. The salve may be rubbed in with the finger two or three times daily, or \ it may be smeared on linen and the latter applied as a plaster. Subacute Eczema. — Should the eczema pass, as it is apt to do, h into a subacute form, characterized by great swelling, vesicles, and fissures in the skin, the auricle should be thoroughly rubbed twice daily, with sapo viridis, the Schmierseife of the Germans. Then the disease should be treated as an acute form. The subacute form of eczema of the auricle may be treated beneficially by the application of acetiun caiifharidis to the slug- gish parts, and then pencilling the latter with the following: R. — 01. cadini, fl_:^ij Alcohol, 115 j. t This will often prevent the disease ffom becoming chronic. Treatment. — In chronic eczema of the auricle, the aim must be to allay irritation, and at the same time to stimulate the parts into a healthy action. Attention must also be paid to the general condition of the patient, and the internal treatment by jj means of alterative tonics, among which arsenic will be found |1 ■ ^ See Gruber's Lehrbuch d. Ohrenlieilkunde, p. 29-1. ' This ointment is difficult to make, requiring more than ordinary pharma- • ceutical skill. That form prepared by McKelway, Borell, Cramer & Small, and J. P. Kemington, of Philadelphia, is recommended by Dr. Duhring, Diseases of the Skin, p. 188, which see. ^ i ORGANIC DEFECTS AND CUTANEOUS DISEASES. 219 highly efficacious, will play an important part in the manage- ment of the chronic forms of this disease. I I Various kinds of local treatment have been proposed for the chronic form of eczema of the auricle, among which, the best arc painting the diseased parts with acetum cantharidis, nitrate of silver (gr. x to iJ.^j aq.), and the application of emollients, the head being kept dry and cool. It has also been proposed' to coat the auricle with a solution of gutta-percha in chloroform, or to apply to it various forms of ointment of zinc and animo- niated mercury (U. S. L'harm.). The ointment made of the latter I have found most useful, as suggested to me by Dr. L. A. Duhring, of Philadelphia, in the following formula: R. — Hydnirgyri ammoniati, gr. x-xx ; M. Fiat unguentum. S. To be rubbed gently but thoroughly in. Dr. Duhring- places the preparations of tar amongst the most useful remedies, after the acute stages have passed away. The use of solutions of potassa, followed b}- stimulating ointments, is also highly recommended. Dr. Duhring's experience has been that eczema of the auricles is usually obstinate in its course. AVhen the eczematous disease has invaded the canal, and stimulation of the parts is needed, an ointment may be used, composed as follows : R. — Hydrarg. ammonio-cliloridi, 3J j Unguenti adipis, 5J. — M. S. Apply with a camel's-hair pencil to auditory canal once or twice daily. Another stimulating ointment is as follows : R . — Hydrarg. chlor. mitis, ^j ; : Ung. zinci oxidi, 3J. — M. S. Apply to the external ear thoroughly, twice or thrice daily. Or the followino;: R . — Hydrarg. ox. flav., gr. viij-xvj ; Vaselini, ^j. — M. S. Apply as above to the auricle or canal. Acute Phlegmon. — Wilde ^ has mentioned a form of simple phlegmon of the auricle caused by the sting of insects, which, however, does not appear to demand treatment. Rau* has de- scribed an idiopathic form of acute phlegmon of the auricle, ^ Wilde and Graves. See former, op. cit., p. 173. » Treatise on Di.seases of the Skin, pp. 207, 208, 1877. • 3 Diseases of the Ear, Phila., 1853, p. 1G9. * Obrenheilkunde, Berlin, 1856, p. 103. 11 220 AURICLE. which, running a severe course, with systemic derangement, rigors, etc., terminated in suppuration. Chronic Phleg-mon. — A chronic plegmon of the auricle has been described bv some writers as terminatins; in cancer. It is characterized by a circumscribed hardening at some part of the auricle, usually the tragus or lobule, which gradually spreads, producing hypertrophy and degeneration of the entire auricle, with thickening of the skin, lymphatic exudation, and after years of suppuration the auricle is at last destroyed. In some cases death has supervened as the result of exhaustion from this disease.' The auricle may become very large, as shown by Ivriigelstein,^ as quoted by Rau, who believes this disease is an insidious form of cellulitis, with secondary sclerosis of the skin, occurring in unhealthy subjects. The description suggests epithelioma. Treatment. — The treatment must be alterative, and if consid- erable hardening and hypertrophy of the auricle exist, it may be necessary to amputate, which has been performed success- fully by Fischer.^ Circumscribed Inflammation of the Cellular Tissue. — Circum- scribed inflammation of the cellular tissue of the auricle occurs in the form of boils. In the impoverished system they may be- come carbuncles, and produce permanent deformity of the pinna. A chronic attack of boils in the lobule has been noted by the author in a medical friend. These have occurred for years, but have rather decreased in frequency since an attack of typhoid fever. There has never been any deformity or loss of substance in the lobule, a rather curious fact when we remember the large amount of suppuration that has occurred from the small affected spot. The matter discharged from these boils, which usually dis- charged themselves on the posterior surface of the lobule, had a peculiar odor resembling that of valerian. Habermann* ob- served an abscess on the posterior surface of the auricle which discharged into the auditory canal. Cornu Cutaneum Auriculae. — Horny growths are occasionally found upon the human auricle. Dr. A. H, Buck^ observed a case of this nature in January, ' See Rau, op. cit., p. 104. AYepfe., Grundriss der Cliirurgie Operat, Num- ber}!;, 18'25, p. 118. Conradi, Surg. E.xperiences, Berlin, 1830. 2 IJeber den Krebs am Ohr. AUg. Med. Annalen des 19 Jahrbunderts, 1827, pp. 145, 152. ^ Rau, op. cit., p. 167. * Transactions of Amer. Otolog. Soc, 1871, pp. 18, 19. ■' Archiv f. Ohrenh., Bd. .xvii.^S. 29, 1881. ORGANIC DEFECTS AND CUTANEOUS DISEASES. 221 1871: it was a blunted, liorn-like protuberance, three-fourths of an ineli long, and nearly as broad at its base; it sprang from the upper and posterior part of the left helix. It was whitish in color at its base, but gradually grew quite brownish at its summit, which was moi-e or less jagged in appearance. It was distinctly striated, the markings running in a slightly divergent direction from the summit to the base. At the ex- tremity and in the middle portion it was hard like horn, but near the base it could be easily compressed, though yet com- paratively hard. The line of demarcation between the growth and the normal skin was very abrupt. It was not a source of pain to the patient, nor was there any tenderness on pressure. The growth was cut off by two incisions along either side of the base, the fresh edges approximated, and the wound dressed with lint. Union took place by granulation, and at the end of the third w^eek scarcely a trace of the operation was visible. I saw, some time since, in the Philadelphia Infirmary for Diseases of the Ear, a case of horny growth on the upper and outer portion of the helix of the left ear, in a large, strong man, forty-five years old, whose occupation obliged him to expose himself to all kinds of weather on the river. The growth was smaller than that described by Dr. Buck, and was not discolored on its outer edge. It caused no annoyance, but the patient had begun to pick it, and it was growing larger, when the man disappeared from observation. The middle ear on the same side was affected by a chronic purulent discharge, of slight amount. i f Secondary Syphilitic Eruptions. — In a monograph on syphilitic diseases of the ear, Gruber says he has never met with a primary sore in any part of the ear. He has, however, fre- quently seen secondary eruptions on the various parts of the ear, and has observed that particular portions of the external ear favor certain forms of eruption, as, for example, the point of insertion of the auricle and the lobule is most liable to a papular eruption, while the other parts of the auricle most fre- quently show an exanthematous eruption. Squamous eruptions, too, are found on the auricle, rather than in the meatus. These diseases of the auricle do not, however, interfere with the hear- ing to any marked extent, and belong rather to the province of dermatology. Syphilitic ulcers and warts on the auricle, I be- lieve, are rare. They are certainly not often recognized and described. ' ' Tubercular Syphiloderm. — An infiltration of the syphilitic ma- teries may be diffused throughout the skin of the auricle, or it may occur in the form of tubercles, varying in size from that of 222 AURICLE. a split pea to that of a cherry. The latter may coalesce, and thus form a general infiltration. The posterior part of the auricle is more likely to be attacked first than any other point, the spot most liable being the point of junction between the auricle and the head. This disease manifests itself any time after the first year of the inoculation has passed. It is most apt to occur in from two to ten years after the primary sore. I have recently observed a case of this disease of the auricle under the care of Dr. L. A. Duhring. In this instance, there first appeared a circumscribed, infiltrated lump on the posterior sur- face of the auricle, which gradually increased, until it has dif- fused itself throughout the tissues of the pinna. It was slightly elevated above the general surface of the auricle, of a deep reddish color, painless, and there was no itching in the growth; the latter was inclined to run a slow course. In the space of a month or six weeks, the infiltration had diffused itself through- out the greater part of the auricle, and somewhat over the mastoid portion. The thickening and deformity of the auricle had become considerable, the groove behind the auricle was obliterated, and the appendages assumed a firm, thick feeling. This condition lasts for some wrecks; then softening and ulcera- tion ensue, the latter beginning in some natural groove or de- pression. The ulcer varies in size, shape, and depth, its base is reddish, and covered with a yellowish or grayish puriform matter. The rate of ulceration varies according to the general condition of the patient; the auricle may be destroyed in the course of a few months. There is still no pain, the discharge is more or less offensive, usuall}' the latter to a marked degree. Dr. Samuel Sexton^ reports three cases of tubercular syphilide of the auricle. He regards this afifection as a tertiary lesion met with late in syphilis, and states that it is not liable to ulcerate, and that the loss of tissue when present is due to interstitial ab- sorption. His experience leads him to the conclusion that the dis- ease is disposed to confine itself to the anterior portion of the pinna. In an account of thirty cases of syphilitic disease of the organ of hearing. Dr. A. H. Buck' states that he found only two cases of syphilitic ulceration of the auricle. Both patients were men; the ulceration occurred within, or partly within, the fossa helicis. The ulceration in one case was deep ; in the other less so. The tragus was swollen in one instance. Syphilitic ulcerating gumma of the auricle has been described by Hessler^ as a tertiary ap- pearance. He reports a case cured by iodide of potash, which had resisted all forms of local treatment. 1 Journal of Cutaneous and Venereal Disease. New York, June, 1883. ^ American Journal of Otoloo;y, 1879, p. 76. » Archiv f. Ohrenheiliainde.'Bd. xx. S. 245, 1884. ORGANIC DEFECTS AND CUTANEOUS DISEASES. 223 Differential Diagitosis. — This disease of the auricle is to be dia<>-- nostieated by its history and l)y other manifestations of syphilis in the skin elsewhere, as alopecia, tubercles in the skin, scars, and a general syphilitic cachexia. It might be confused with epithelial cancer, from which, however, it may be known by its histor}', course, and objective symptoms. In the cancerous dis- ease there is ulceration at the outset, whereas, in syphilis, there is first the well-marked deposit and subsequent ulceration. In cancer, there are well-marked everted edges to the ulcer; in syphilis, there are none. The secretion will offer another point of differential diagnosis, since in cancer it is thin, watery, bloody, and scanty, wdiereas, in syphilis, it is thick, yellowish, and copious. In cancer, furthermore, there is pain, while there is none in the syphilitic ulceration. The odor in syphilis is more oft'ensive than in the cancerous disease. In the latter affection, the ulceration spreads peripherally from a single point; in syphilitic ulceration the breaking down is apt to occur at more than one point. It may always be known from eczema hy the presence of deeper ulceration. Syphilitic ulcera- tion might be confounded with lupus vulgaris, from which, however, it is to be distinguished by the history, lupus being more chronic, and the ulceration occurring at various points over the surface, but unattended by discharge. In lupus, a patch of varying size, from that of a pea to that of a small coin, first appears, being covered with small papules and tubercles from the size of a pin-head to that of a split-pea. These, in time, break down, and slowly ulcerate, are accompanied by a slight crusting and scaling of the epidermis, and characterized by marked cicatricial tissue. The treatment, of course, is indicated by the syphilitic nature of the disease. ■ T Idiopathic Herpes Zoster Auricularis. — In the course of inflam- matory processes in the deeper structures of the ear, groups of herpetic vesicles and pustules appear upon the auricle, or very close to it. In the same way, herpetic patches appear on the auricle in cases of widely diffused facial herpes. But an altogether different state of things is found in cases of idiopathic aural herpes, which is developed only on the structures of the ear.^ According to Gruber, this disease is one of the greatest rarities, for in 20,000 cases of diseases of the ear, he has observed only five instances of it. This disease attacks not only the parts of the organ of hearing supplied wnth true skin, but recently, Gruber has observed two cases in his clinic, in which, most 1 Die Blaschenflechte am Ohre., Monatsschr. f. 0., Mai, 1875. 224 AURICLE. I probably, the herpetic disease extended to the drum-head and the cavity of the middle ear. Herpes zoster auricukms, like herpes zoster in other parts of the body, manifests itself as an acute skin disease, accompanied by fever, and is characterized by the formation of vesicles and bullse, which appear in groups and are attended with severe pain. The pain in these cases of aural herpes exists usually many days, sometimes as long as two weeks, before the eruption occurs. In a case which came under my observation recently, the patient stated that he was liable to severe earache and pains about the ear, which always terminated in a week or ten days by "an eruption of blisters,"' which I fully verified during one of his attacks. In this case, the eruption was confined to the meatus and tragus. The pain is not always limited to the spot where at last the [ vesicles appear, but spreads out in different directions from the t eruptive spot. •'' Nerves Implicated. — According to the investigations of Gruber, the nerves affected are the auricularis magnus, from the anterior branch of the third cervical ; the auriculo-temporal, from the third branch of the trigeminus. He further states, that severe pain is usually complained of along the side of the neck and auricle, and the eruption appears much more frequently on the anterior surface of the auricle than on the posterior surface or in the auditory canal. Even in these favorite spots the vesicles and bulla? are more numerous in the tract supplied by filaments of the auricular branch of the pneumogastric nerve, and thus can be explained the fact that the eruption is more copious on the superior and anterior surface of the auricle than in any other part of it, and also why the posterior surface of the auricle remains almost entirely free. Perhaps the disease stands in close relation to fibres of the sj-mpathetic connected with the nerves already mentioned as implicated in this aftection. The cause of this disease of the external ear is most probably the same as that which produces the disease in other parts of the body, viz., impoverished blood and consequent depraved inner- vation. Syinptimis. — Fever precedes the eruption, and in the graver cases may continue after the eruption has made its appearance, for the latter may come on in crops, with intervals between them. In one case given by Gruber, the fever continued thus twenty days in spite of all that was done. The crops of vesicles may succeed one another at the same points on the auricle, and the latter set will prove the most painful, since they produce deeper ulcers. The skin of th« helix and of the fossa navicularis is ii p* ORGANIC DEFECTS AND CUTANEOUS DISEASES. 225 II most likely to be attacked with the severest eruption. "While herpes of the auricle does not present any features of dift'ereiice from that of the disease elsewhere on the surface of the body, it has decidedly peculiar features when found in the auditory canal, i P When herpes appears in the auditory canal, the hearing is diminished and subjective noises are heard. The hearing re- turns slowly after all the herpetic symptoms have disappeared. The membrana tympani is affected in some cases, according to Gruber, and then the deafness is great, and there is great sense |fe)f constriction in the head. After the vesicles rupture, the dis- ease amounts to superficial otitis externa diffusa. Gruber has Scarcely a doubt that herpes occurs in the mucous membrane of the middle ear, basing his supposition upon the views of I iBertholle^ on herpes of the soft palate. I I The prognosis of herpes zoster auricularis is favorable. While ' the ulcers left b}' it on the auricle may last for many weeks, the usual duration of the disease in its ordinary phases is from two to three weeks. Previous to the publication of Prof. Gruber's paper on herpes auricularis. Dr. J. Orne Green, in a paper on "Neuralgia in and about the Ear,"^ alludes to a case of herpes zoster of the small nerves supplying the helix, which he observed in a patient of ~ r. A. F. Damon. "There was a well-defined herpetic eruption over the anterior surface of the helix, which had been preceded for some days by considerable remittent pain in that part, which disappeared on the appearance of the eruption ; in a few days the vesicles dried up and the disease had subsided." He also alludes to herpes zoster of the nerves supplying the tragus and meatus, and quotes from the case of zoster of these parts published by Dr. Anstie :^ "The disease began with acute ipain in front of the tragus, recurring regularly four times in the twenty-four hours, and darting up into the meatus, the maxillary articulations, and on the side of the head ; there was no tenderness on pressure or abnormal appearance in the ear; a point doxlei/reux existed just in front of the tragus. On the ninth day the pain began to diminish, and on the thirteenth herpetic vesicles appeared on the auricle, which from irritation became ulcerated and very susceptible to cold, which set up the old euralgic pain ; on the twentieth day all symptoms had disap- eared.'"* Dr. J. O. Green^ has subsequently reported a well- marked case of herpes zoster, preceded by pain, on the posterior surface of the auricle of a lying-in woman. 1 Herpes guttural en general, etc. L'Union MdcL, 05, 68, 70, 1866. * Transactions American Otological Society, 1874. ^ Practitioner. * .J. O. Green, loc. cit., p. 569. ^ American Journal of Otology, vol. iii., 1881, p. 185. 16 II 226 AURICLE, Herpes Zoster of the Tragus. — I recently saw in a young lady, 18 years old, under treatment for slight pruritus of the external auditory canals, a very well-marked instance of herpes zoster of the right tragus. Sharp pain for several days, quite intense at times, preceded an eruption of vesicles, which finally became pustular, and then desiccated, without forming ulcers. The patient was pallid, though apparently strong and active. Treatment. — The treatment of this disease consists in the greatest attention to the general condition of the patient, and in local applications which will tend to prevent destruction of the deeper parts. Preservation of the vesicles is much more easily accomplished on the auricle than in the auditory canal. In the latter region, the tendency appears to be not to form crusts, but the vesicle soon bursts and a purulent discharge is ji then set up wdth considerable pain. In such a case, Gruber uses a solution of sulphate of zinc. In a second instance of this disease in the auditory canal, the fi same observer punctured the vesicle, leaving the epidermis as a i protective covering ; but even in this case the treatment had to be supplemented by the use of a solution of zinc. Artificial opening of the bullae on the auricle appeared to be followed by a much better result. The small, shallow ulcers which form in the latter case, are cured by the use of simple cerate. Where the pain is great, diachylon salve, to which tincture of opium is added, has been found of the greatest benefit ; the salve being smeared on linen and applied to the inflamed spots. The treatment recommended by Dr. Anstie in the case referred to above consisted in hypodermatic injections of one-sixth of a grain, twice daily, in the region of the auriculo-temporalis, pro- tecting the painful external parts from the air by coating them with collodion, and the painful parts of the auditory canal by means of a warm simple ointment of tallow, keeping the meatus closed by cotton. He also thinks counter-irritation, by means of mustard or cantharides over the occipital triangle, might prove beneficial by reflex stimulation. 1^ MORBID GROWTHS AND IX.TCJRIES. 227 CHAPTER II. MORBID GROWTHS AND INJURIES. MORBID GROWTHS. The auricle may be the seat of various morbid growths, such as cysts, angioma, lipoma, myxosarcoma, vascular iisevus, fibrous tumor, sarcoma, and epithelial cancer. , _ Xew formations of cartilage sometimes appear after frost-bite Pfbf the auricle, giving origin to numerous small, hard, and sensi- tive nodules, which may be both seen and felt throughout the cartilaginous structures of the pinna (p. 216). " " Cysts. — The simplest growth on the ear is a cyst. Tiiat form of primary cyst known as atheroma^ developed in the subcu- taneous tissues, may attain a very large size, in some instances reaching a diameter of several inches. Its growth is slow; in the concha there may be found the variety known as sebaceous tumor. In both forms, intlammation may occur, and a natural cure ensue. I ^ Treaiment. — These growths should be extirpated by the knife, and their sacs cauterized. Angioma. — Angioma or the formation of new vessels, espe- cially the cavernous variety, may be found in the auricle. The origin of such a growth may be in the auricle, or may spread to it from neighboring tissues. These growths may present re- markable as well as threatening appearances in some instances, as has been shown in a case related by Dr. Chimani.^ In this instance the tumor first showed itself, shortly after the birth of the patient, a strong, healthy boy. The new growth was at first 2 cm. in diameter, in front of the left ear, and of a soft consistence and bluish color. By the time the patient was five years old the tumor had become as large as a walnut, from which time until he was fourteen years old the growth increased rapidly in size, and one year later, when brought to Dr. Chimani, at the Military Medical School of Vienna, the Josephenum, the tumor included the greater portion of the left half of the scalp, II ' "Aneuri'sma cirsoideum." See Blake's Report: American Otological So- ciety, 1874. 228 AURICLE. was soft, elastic, slighth- fluctuating, painless, pulsated distinctly, and could be diminished in size by pressure. The skin covering it was bright red, and of a higher temperature than the sur- rounding parts. Angioma of the lobule only, has been observed and reported by Dr. Charles J, Kipp.^ In this instance the growth occupied the left lobe of a man fifty years old, and seemed to have been caused by a frost-bite of the ear, twelve years previous, at which time he noticed a bluish spot on the outer side of the lobule of the left ear. i Vascular Naevus Maternus. — That form of vascular growth known as "mother's mark" may involve the auricle, together ^ with parts of the adjacent cheek and neck. In a negress thus affected, the lobule and low^er half of the helix were especially large and liable to engorgement, while the general appearance of the auricle was elephantine and grotesque. All such vascular [-i growths are painless, but are liable to feel hot and heavy after exercise. The rest of the auricle ma}' be somewhat hypertro- phied, and if the grow'th invade the external auditory canal, the hearing will be impaired. Their vascular nature is very ap- parent by their color, their temperature, and compressibility, as well as by the pulsation which may be felt wdth more or less distinctness in all of them, and by the murmur which may be heard in some of the larger ones, as in the case reported b}'' Chimani. In the latter instance the subjective symptoms were aggravated by the fact that the auditory canal was greatly im- plicated in the growth. There were headache, hardness of hearing, tinnitus aurium, and sensations of heat and beating on the affected side. When neglected, nevoid growths may become aneurismal and necessitate amputation of the piima.^ Tre(d}iient. — The treatment of these vascular growths must always be modified by their position in or about the auricle, and by their size. The treatment of angioma of the lobule of the auricle is com- paratively simple, but treatment of larger growths involving the entire auricle and surrounding parts, and extending into the auditory canal, becomes of the greatest importance. It is even questionable whether heroic measures are ever justifiable in the latter instance. I In removing angioma of the lobule, the method followed by Dr. Kipp^ is probabl}- the best. I have used it with slight modifications, with entire satisfaction. It is to fasten the lobule in an ordinary entropion forceps, to control the hemorrhage, ^ Transactions American Otological Societv, 1875. « '^ Mr. F. Eve, Med. Times and Gazette, London, May 8, 1880. ' Loc. cit. \i M0R15ID GROWTHS AND INJURIES. 229 ud then make an incision parallel and close to the lower border :' the lobe. The skin should then be dissected oli' the tumor, and when the latter is fully exposed, the knife should be carried behind it, and its connection with the subcutaneous tissue evered. Healing by tirst intention usually ensues, and the obule heals without any deformity. For the cure of angioma, especially the larger forms, Gruber' has recommended various forms of cauterization, vaccination, the application of diachylon plaster and tartar emetic (^ij-gr. xviij),- the subcutaneous injection of liquor ferri sesquichlorati, and acupuncture. He gives the preference, however, over all these, to rapid extirpation of the new growth, and in order to prevent the necessarily copious hemorrhage, recommends liga- tion of the large vessels supplying the parts, or the use of the galvano-cautery. Subcutaneous injections of chloride of iron were used by Chimani, in the case referred to, with moderate success, but not enough to warrant the risks of inflammation and hemorrhage. The danger of the latter, as well as of sloughing, should deter the surgeon from adopting any form of treatment which would be likely to produce such results. II. Fibrous or Fibro-sarcomatous Tumors of the Lobule. — Tumors of arious sizes have been found on the lobule as the result of piercing this part of the ear for the purpose of wearing ear-rings. Deprcs reports having observed mucous patches at the perfora- tion of the lobule for ear-rings, in syphilitic patients.^ Gruber states that he has seen two cases in children, in wdiom small tumors, the size of a pea, appeared on both sides after the piercing of the ear several years before. In his opinion, these tumors had originated from granulations which, springing from the hole in the lobule, had developed skin on their free surface, and then become stationary. These tumors are composed, ac- cording to Billroth, of spindle-cells and connective tissue. A similar variety of tumor has been observed among negroes by several writers,* and is attributed invariably to wounds in- flicted by the piercing of the lobule, or the tearing consequent upon the enormous rings the lobule is obliged to support. Some years ago, I observed two large tumors of this variety in a 3'oung and very fat negress (mulatto). There was no his- tor}' of the lobules ever having been torn by the weight of her ear-rings, which were very large, nor of any wounding of the ])arts by the act of piercing. In this case it seemed that the II * Op. cit., pp. 409, 410. 2 Zeissl, quoted Ity (iniber. ^ American .Tourn. of Otolotjy, vol. ii., 1880, p. 61. * Langaard, Wiener Med. Wochenschrift, 1869. M. J. Bramley, Transactions of Medical Society of Calcutta, vol. vii., Saint- Vel, Gazette des Hopitaux, 1864. 230 AURICLE. growths had been brought about by the weight of the orna- ments.^ One tumor was as large as, and shaped like, an English wal- nut, with a large chestnut laid on it, and the other tumor was as large as the largest chestnut. I removed both tumors, and exhibited them at the Pathological Society of Philadelphia, where, in the remarks which followed from the members, it appeared that these tumors of the auricle, apparently produced by the improper wearing of ear-rings, had often been observed in this city, in negroes, and that they had usually grown again after removal ; but the subsequent growths were just as benig- [ nant as the first. Their microscopic character was similar to that given by Billroth to the tumors described by Gruber. This peculiar tendency to benignant recidives has also been noted by Dr. E. F. Weir, of ^^ew York City ; Dr. Bertolet, of Philadel- phia, and many others. Fibroma may be found in the concha in children, as reported by Biirkner.^ Myxo-fibroma of the auricle has been observed by C. R. Agnew.^ t Sarcoma of the Lobule. — M. Roudot* has described a case of sarcoma of the lobule, in a peasant woman, 42 years old. The tumor occupied the right lobule, was soft and ovoid, 5 mm. long, 3| mm. broad, and 8 mm. thick. It grew very slowly for twenty years; during the patient's fifth pregnancy, it developed ver}' rapidly, and included the entire lobule. The tumor appears to have been painless, for the most part, but sometimes during her menses the patient would complain of a burning pain in the auricle of the aifected side. In addition to the entire lobule, the tumor also included part of the tragus. The new^ growth was reddish and flat, with some eroded spots; on the hinder edge there was a pretty large ulcer; a second, smaller ulcer extended from the under part of the tragus out upon the skin of the cheek. The organ of hear- ing was otherwise normal, and there were no glandular enlarge- ments. The lobule, together with a small part of the tragus, was amputated, and the wound did well for several weeks, when the patient voluntarily left the hospital. Glandular Hypertrophy of the Lobule. — After inflammation of the skin of the lobule of the auricle, there may remain a chronic 1 Similar cases recently reported bv Buch, St. Petersbiirs]: ]Mecl. Weekly, 31, 1881; Habermann, Arch'iy f. Ohrenh , Bel. xyii. S. 29, 1881 ; E. E. Holt, Amer. Otol. Soc, 1888. 2 Archiv f. Ohrcnheilkiinde, Bd. xvi. S. 58, 1880. ' Amer. Otol. Soc, 1878. * Gazette Med. de Paris, 1875, Xo. 2G. li MORBID GROWTHS AND INJURIES. "231 'hvpertroitliy of the glandular structures, of a nature similar to those chronic enlargements met with in the cutaneous structures elsewhere in the body, after being invaded by inflammation. This is fully illustrated in the following case: Bridget G., aged 22 years, a seamstress, states that at thirteen ears of age she had an attack of erysipehis of the scalp, which nvolved the auricle to a marked extent. The auricle remained inflamed for six weeks, but then gradually lost all swelling, excepting at the lobule, which has remained about twice the natural size ever since. There has never been any return of the lerysipelas of the scalp. At the time of tirst examination, the lobule, besides its enlargement, presented a livid, reddish hue, was shiny, scaly, and slightly erectile when manipulated, l)ut not sensitive. Its surface usually presented a flaccid appearance, like a partialh' withered grape. Treatment — The under cutaneous edge of the lobule was dis- sected up for a cpiarter of an inch, and then a V-shaped incision was made, including the growth on the lobule. There was considerable bleeding from two or three spirting arterioles, which was finally controlled by ice. The edges of the cut were held together by a stitch; the wound healed by first intention, and without a trace of the incision. The tumor thus excised, I submitted to Dr. Morris Longstreth, Pathologist to the Pennsylvania Hospital, in Philadelphia, who ihas kindly made most skilful sections, and written the following descriptions of the microscopic appearances of the tumor: "The tumor shows varied histological and histioid elements; the preponderating constituent is an ill-developed epithelial cell, resembling the squamous variety and having a great diversity of outline. "First of all can be shown the elements of normal skin, the papillpe with the covering corneous layers, and the hair-bulbs. There can be seen, in the deeper parts, the subcutaneous con- nective tissue, in which in places the vessels are large and numerous; around these vessels the fibrous tissues are denser -■and more abundant than usually seen in these parts; this ■ ■fibrous tissue forms a sheath to, or a canal in which, the vessel 1 1 is distributed. In and around the sheaths of the vessels are I M seen, in many places, deposits of adipose tissue, arranged in "lines parallel to the main trunks and also following some of the smaller branches. So far, the appearances shown in the micro- scopic sections correspond to the normal histological elements of the skin, the papillary layer and the hair-bulbs seem normal, whilst the deeper layers are hypertrophied or hyperplastic; the connective-tissue parts appear overloaded or crowded with granular, (or cellular) elements. No distinct cells can be isolated It II It 232 AURICLE. here, and the structure altogether presents a very confused picture. " Between the dermic layers and parts further removed from the surface (viz., the parts which seem to constitute the tumor- mass proper) is a defining line ; the line is not constituted of a bounding or limiting membrane, such as to be described as a capsule or basement-membrane ; but there is to be seen a distinct ditferentiation of the one part from the other. This condition is well marked in some specimens. f. " The inner area shows the same confusion or want of distinct- j ness of arrangement. The cells approximate likewise to an epithelial type ; some appearing like ill-formed or undeveloped squamous epithelial cells ; others resembling young nuclear (embryonal formative) elements found in the lower strata of all membranous tissues; others again have the shape of columnar cells (perhaps this form may be due to close packing) ; still \ others appear of an elongated or fusiform character, or else as p rounded cells of small size with bipolar filiform appendages of ji great tenuity. In all this inner area there is no trace of blood- {i vessel structure, nor of a stroma or intercellular network. There >? is no appearance of stroma of any kind, save that of the filiform cell-appendages. " The nuclei of all these cells are of small size, and in a ma- jority of instances so obscured by granular or fatty elements as to be scarcely visible. In some instances the cell-shapes, but not the cell-arrangement, approximate to that of the small spindle-celled sarcoma. This character cannot be maintained as the nature of the growth. There is no one type presented in such a degree as to lead to the classification under any histioid group. " The only solution which presents itself, and that a proble- matic one, is that the new growth belongs in the main to the glandular structure, and with this has taken place a (sarco- matous ?) growth in the surrounding connective tissue ; that, under the erysipelatous irritation to which the lobe of the ear was subjected, in the first instance, some one or more of the glands became ectatic from the swelling and closure of the duct; and that, instead of its contents undergoing the accustomed de- generation, the consequence of the erysipelatoid hyperemia, started by the erysipelas and maintained, in part, by the ectasy of the gland, there ensued a hypertrophy or hyperplasia espe- cially of the underlying, more than of the superficial tissues. In other words, we have taking place an inflammatory new formation, in which especially participates the connective tissue, and this new-formed connective-tissue element has maintained, to a high degree, its hypervascular character (even to becoming somewhat erectile); and in this new growth, mixed elements IP MORBID GROWTHS AND INJURIES. 233 share in the oecupation of teiTit(MT ; on the one hand, cells which present a type tending to the epithelial character, on the other hand, coming out more conspicuously in the deeper parts, cells which in the fusiform character, verge toward the embryonal cells of a connective-tissue growth and give appearances calling to mind the sarcomatous new formation. ■ M " There is, however, another element or character present which T cannot wholly pass over, viz., the glandular element. Not only is there to be seen the passing by insensible gradations from the papillary layer in what we may regard as a part purely, or nearly so, of subcutaneous connective tissue (however much this may be changed by overcrowding of cells), but this again passes over into an area of cells in which there can be seen no stroma-cells, some of which are columnar in character that may well be held to have to do with the recess of a gland in the condition of ectasy. The only supposition under whicli the glandular participation in the new growth, as a whole, is ten- alile, is that the gland elements, and especially their secretion, under the influence of the permanently increased hypert^mia, did not tend, as is their wont, to retrograde metamorphosis, in spite of the gland becoming ectatic and thereby retaining its secreting contents. Also, it must be evident that the inflamma- tion-disturbances have something to do in producing a perma- nent alteration in the function of the atfected glands — not a very difficult supposition, and quite within the range of experience." Epithelial Cancer. — Epithelial cancer of the auricle has been described by Gruber,^ Wilde," Kramer,^ Toynbee,* Demarquay,^ J. Orne Green,^ Gustav Brunner,^ T. Bryant,^ W. W. Seely," and others. It is said by Gruber to be the only malignant disease which occurs in the auricle primarily. It generally appears as a small nodule or w^art in the skin of the auricle, which, being picked at in most cases, soon is found to be covered by yellowish scabs, the result of the hardening of a scanty discharge from the new^ growth. Beneath these crusts there is found an ulcer, with a not very rough base, somewhat disposed to bleed, and the edges of which are hard and uneven. After a rather slow destruction of the superficial tissues, the deeper structures of the ear may be invaded. The auricle may be destroyed in this way, and then ■^ 1 li ' Ohrenheilkunde, p. 416. ^ Diseases of the Ear, p. 208. ^ Op. cit., p. 204, quotes Fischer, 1S04, " Krebs am Ohre," and Kriigelstein, 1827, Ali<>;. Med Annalen des 19 Jahrhunderts. * Diseases of the Ear, p. 24. ^ Gazette des Hopitaux, Sept. :10, 18G9. * Transactions American Otolo2;ical Society, 1870. ^ Archiv f. Ohrenh., Bd. v. S. 28. * ;Med. Times and Gazette, London, .Jan. 0, 1872. ^ American Oto]oi;ical Society, 1883. 234 AURICLE. i the deeper parts of the ear become the seat of the cancerous disease. There is usually some pain, but it is not invariably severe; in some cases, however, it may be intense, as shown by . Brunner. f. Wilde alludes to chimney-sweep's mncer of the external ear, ^ which is, however, in no way peculiar, excepting as possessing large amounts of pigment. The chronic inflammation of the cellular tissue of the auricle, alluded to by Kramer, is in all probability a description of can- (4 cerous degeneration of the appendage. Epithelioma of the auricle may interfere greatly with the hearing, the interference being proportionate to the advance of |i the disease into the auditory meatus. I have seen two cases of ► this disease in the auricle, the first of which occurred in a negress, fifty years old. She stated, when I first saw her, that the growth on the ear was about six months old, and had been caused by a blow on p the auricle with a loaded cane. I found the meatus almost entirely occluded by the growth, which appeared to have started from the region of the tragus, and had progressed rapidly in- '* ward, on the superior wall of the auditorj- canal, producing also some induration outwards toward the zvffoma, its entire size being about that of a small English walnut. The discharge was bloody and purulent, several drachms daily in amount, not very offensive, but of a peculiar odor. The ulcerated surface of the tumor pointed inwards, filling up the auditorv canal. The hearino- was reduced to almost nothing. There had been no disease of the ear previous to this, according to the woman's statement, which appeared to be reliable in all respects. Excision of the growth was advised, as it had grown rapidly from a well-defined centre, but the patient refused, and soon after disappeared entirely from my notice. I have seen recently another case of epithelial cancer, begin- ning at the tragus and upper front edge of the helix of the auricle, in a man aged 40. He had been under observation and treatment for the disease for more than a year when I first saw him. Gradually the cancerous degeneration advanced inward on the front wall of the auditory canal, hiding the anterior part of the membrana tympani from view. The cancerous growth was scraped away from the tragus, meatus, and anterior wall of the auditorv canal, by means of a cutting spoon, January 30, 1884. Dr. Gustav Brunner,^ of Zurich, observed a case of primary I Arcliiv f. Ohrenh., Bd. v. S. 28, MORBID GROWTHS AND INJURIES. 235 epithelial eaneer of the oar, in a female 56 years old, which proved fatal in the course of the year. The health of the woman liad been good up to the time when a sliii'ht discharge came from the ear; previous to this there had been some itching in the ear, and she had scratched the orii'an with a hairpin, but there had been no deafness. For the slight discharge, she subjected herself to some kind of water- cure douche on the ear, and this was followed by intense earache and facial paralysis. Granulations in the meantime s[)rang up in the ear, wdiich upon manipulation bled freely; pain in tlie ear became intense and constant, and, as it was concluded that the morbid growth had already reached the inner wall of the tympanum, no operation was advised. The ear was kept care- fully cleansed, and the pain was eased by anodynes as far as it was possible. The auricle was at last dissected loose by the disease, and at several spots about the ear there was loss of sub- stance. There was no post-mortem examination permitted. In the early stage of this case, p^ain was the chief diagnostic diiference between it and one of polypus or granulations in the ear. Microscopic examination of a piece of the granulating mass in the meatus revealed the true malignant nature of the growth. Treatment. — The only beneficial treatment of epithelioma of the auricle is immediate excision of the growth, even if to do this it is necessary to amputate the entire pinna, as Avas done by Dr. Thaxter, in the case reported by Dr. J. Orne Green. ^ The hemorrhage which must naturally occur is to be controlled in the ordinary way by ligatures. '¥ Healing may be slow, and in those cases in which the entire auricle has been cut off close to the skull, the granulations must be closely watched and prevented from closing up the external auditory meatus. This is best done by keeping some form of .tent in the opening of the canal and by touching the granula- I Pions with caustics or by stimulating washes. The treatment will be eminently successful if the cancerous disease has not extended to the meatus and the drum ; in the latter instance the disease may have advanced too far to be controlled by surojical interference. II Wm Othaematoma. — Othfematoma, or blood-tumor of the ear, is I Icharacterized by congestion and heat in the auricle, and a rapid i "eftusion of blood between the cartilage of the auricle and the perichondrium. The tumor, in the course of a few hours or a day, attains the size of a bean or an Qgg[^, the color of the auricle may remain natural or become purplish, and though the tumor is somewhat hot and dense, fluctuation can be detected in it. ' Loc. cit. 236 AURICLE. There is some burning pain in the new growth, with a feeling of weight and distention. The earliest manifestations of the disease are rapid, but after the tumor is fully formed, it may remain apparently indolent for days or even weeks. At last it may rupture spontaneously, the most frequent mode of disap- pearance, or its contents may coagulate and absorption without rupture take place, causing considerable permanent deformity, but much less than when the tumor ruptures spontaneously or is punctured artiticially.' Its occurrence is more frequently unilateral than ambilateral, but an attack on one side may be Fii--. 77. ■'^ UuJ'U:[\.il ///,/|ii'i\'i;!AwW. * vl *.J OtH^MATO-VA 1, AND THE RESULTANT DEFORMITY 2. (Gfuber. followed by an attack on the other ;^ the lobule is never attacked in this disease of the ear. I have recently seen a case of this disease occurring simultaneously in both auricles of a young lawyer, forty years old, affected with paresis of the insane, August, 1883. In an account of twenty-four cases of this disease, by E. R. Hun,^ sixteen were unilateral, but in four cases the disease on one side was succeeded by the disease on the other, the first htematoma subsiding usually before the second ear was attacked. ' E. R. Hun, American .Journal of Insanity, p. 23, 1870. 2 Lavcock, case of Othivmatoma under care of Mr. J. Hutchinson, Med. Times and Gazette. Dec. 1862. p. fJ03. 3 Op. cit.,'p. 17. \ I Hf" MORBID GliOWTHS AND INJURIES. 237 The disease is more common in males than in females, only one of the above twenty-four cases being of the hitter sex. Tlie hite Dr. I. Hay informed me that he had never seen this disease in females, whereas he had constantlv met it in males. lie furthermore stated to me, that, when in charge of insane asy- lums, he had constantly iiad cases of otluiematoma on hand, two or three at a time in old cases of chronic dementia, a noticeable feature of whose malady is their entire harmlessness and docility. So great is this latter characteristic, tliat they are made kind of undcr-nurses in the asylum, which fact would tend to prove that the disease in them is caused neither by blows nor falls, as they are not likely to be struck by others, and are perfectly able to take care of themselves. ♦ Etiology. — This disease of the auricle has been the subject much discussion, as to its cause, nature, and significance. Formerly it was considered entirely the result of violence, but later writers have denied its purely traumatic origin, and have given to it an important significance, inasmuch as they have described an idiopathic variety occurring most frequently or only in the insane,^ asserting as its cause a disease of the brain, some authorities even localizing the exact seat of the cerebral (■disease in the restiform bodies.^ Others, while admitting its "" Tiiost frequent occurrence in the insane, still cling to the idea of its purely traumatic origin, being of the opinion that the weakened and often helpless condition of the insane renders them most liable to violence to the auricles.^ In all probability there are two* distinct forms, the purely traxmatic and the purely idiopathic ; the first seen in well-known cases of violence to the auricle, as in boxers, and the insane who have been beaten by their keepers, themselves, or each other; and the second, so frequently seen in the paralysis of the insane, and in diseases of the restiform bodies as proven by experimental irritation of them in rabbits. Even in cases of insanity where the latter variety is found, the first variety has been observed too, but the diflerence of the two forms is very apparent. It is also asserted that the purely idiopathic variety has been observed in the perfectly sane.^ Schwartze," Wendt, and P)lau'' have ob- served such cases. But even granting that at the time of the occurrence of the othsematoma in these cases the subjects w^ere II ^ E. E. Hun, American Jonrnal of Insanity, vol. xxvii., 1870. * Brown-Sequard, Lecture in Univ. of Penna., Oct. 10, 1872. ' Thurnam and Tovnbee ; Toynbee on the Ear, London, 1808, p. 21. Yon Troelt.sch, English Tninsl., 1869, p. 50. * Gruber, Lehrbuch der Ohrenheilkunde, Wicn, 1870, p. 281. ^ Koosa, Treatise on Diseases of the Ear, two cases by Koosa, and one case by Loring; also, a case by Gruber. Lehrbuch d. Ohrenhcilk., p. 283. I* Archiv furOhrenheills;unde, vol. ii. p. 213, and vol. iii. p. 29. ' Ibid., vol. xi.\. p. 203. The patient was fifteen vears old. I 238 A U R 1 U L E . sane, they certainly presented grave symptoms, for their malady \>. could but be regarded as indicative of disease of the brain, i; which had not yet, it is true, culminated in insanity/ but which would render their future sanity very problematical. " When we consider the intimate connection between the circulation in ji the ears and that of the rest of the head, we cannot but acknowl- edge that any disturbance in the circulation in the brain is prone to produce a corresponding alteration in the circulation of the ears, [Now, in all chronic cases of insanity, and especially I: in general paresis, we find a tendency to repeated congestions of f the head, and under such circumstances it is natural to suppose ^■ that the bloodvessels of the ears become gradually dilated, so as to favor the occurrence of an effusion of blood. It is idiopathic, depending upon a pathological condition of the brain, and is incapable of being produced by violence alone."'' Some of the earliest writers on this disease called it erysipelas of the auricle ; but, of course, that view was erroneous. This f disease may make its appearance on the posterior surface of the auricle, though rarely,^ and is called by Kramer* a perichondritis of the auricle. This author also asserted its frequent occurrence in the insane, but very rarely in others. He states, however, j that^Lano-enbeck had seen two cases in the sane, and Heyfelder ' one case in a healthy miller, in whom the tumor occurred with ^ pain after epistaxis for several days.^ Dr. Kirkbride, of the Pennsylvania Hospital for the Insane, i and Dr. Curvven, of the Pennsylvania State Lunatic Asylum at Harrisburg, are inclined to the opinion that othfematoma is ^ usually the result of violence, and almost invariably confined to males.'' Dr. J. H. Worthington,' chief physician to the Friends' Asylum for the Insane, at Frankford, Philadelphia, who has observed and treated a large number of cases of this disease of the auricle, has never seen a ease of this aftection in a sane person, nor in a case of curable insanity. He always considers this affection of the ear as an evidence of the incurable form of insanity, such as he has described as " congestive mania." From the observ^ations of Dr. Worthington, it appears that othematoma is always associated with a tendency to congestion of the membranes of the brain or the cerebral substance itself, f) in which opinion he is nearly in accord with Dr. Laycock,^ who thinks " that the states of the circulation, nutrition, and develop- ^ 1 IJrown-Sequard ; Roosa, Treatise on Diseases of the Ear, p. 112, 1873. ^ Hun, American Journal of Insanity, 1870, vol. xxvii p. 24. ^ Allgemeine Zeitschrift fiir P.«ychiatrie von Damcrow, 1848, vol. i ; Ran, Ohrenheili'iunde, p. 1()7. * Die Erkenntniss und Ileiluni;- d. Ohrenkranlvheiten, Berlin, 1849, p. 212. 5 Rust's Ma<,^azin, (3(5 Bd. 2 Heft, S. 297. « L. TurnbuU, Clinical Manual of Diseases of the Ear. 1872, pp. 138, 139. ' Ibid. 8 Med. Times and Gazette, March, 1862, p. 289. 11 MORBID GROWTHS AND INJURIES. 239 ment of the tissues which make up the ear, lobule, and cover the helix, ver\' commonly coincide with similar conditions of the encephalic tissues." I h That the origin of othematoma may be purely nervous, is proven by experimental irritation of the restiform bodies. Brown-Sequard' states that this variety of tumor is the result of disease at the base of the brain, and is usualh' found in the paralysis of the insane. It may be produced artificially in animals, and this he has done in less than one night, between the hours of ten in the evening and six o'clock in the morning. He has performed such experiments, and kept the animal under his own eye, until the artificially produced tumor made its ap- pearance. This he accomplished by an irritation applied to the restiform body, on the side corresponding to that of the tumor. The lecturer also drew attention to the fact that these tumors usually occur, in the insane, on that side corresponding to the aftected side of the brain, which proves that they cannot be, at least not alwavs, the result of violence on the part of the patient or his attendants; since violence of any kind would not be applied invarial>ly to the side of the head nor to the ear corre- sponding to the affected side of the brain. Dr. Yeats,- of the Coton Hill Institution for the Insane, Eng- land, believes that the cartilage is the seat of this affection, and that hence the lobule of the ear alwavs remains intact. He has not found othsematoma prejudicial to hearing; on the con- trary he has observed that the hearing became sharper in some instances during the disease. He has further observed that this affection of the ear is not confined to any particular form of insanity, although it is frequently found in dementia; that it never occurs in the sane, and that the prognosis of mental recovery in those affected with idiopathic othpematoma is ex- tremely unfavorable. In all his experience he knows of but one case of insanity in which recovery ensued after the appear- ance of this unfavorable symptom. The patient, a married female, thirty-three years old, was admitted to the aforesaid institution; thirteen months afterwards, in the midst of every variety of bad symptoms, otlipematoma appeared, and, after running its course, disappeared. Finally, the patient began to show sio;ns of mental recoverv, and was discharged from the asylum perfectly restored to reason, after three years of insanity. With the evidence thus gained it would seem that the inevit- able conclusion must be, that the occurrence of idiopathic othfematoma is found either in the hopelessly insane, or in those about to become so from cerebral disease which has induced the 1 Lecture in the Univensity of Pennsylvania, Oct. 10, 1872. 2 British Med. Journal, .June 21, 1873. 240 AURICLE. aft'ectiou on the auricle. The prognosis, therefore, in the case of one thus aftected, becomes extremely unfavorable. Treatment. — In the treatment of othsematoma the endeavor must be to alleviate pain, prevent as much as possible subse- quent deformity of the auricle, and to be guided in the treat- ment by the form of the disease, since it is manifest that surgical interference is, most usually, undesirable in the idiopathic form occurring in the insane, but it may be demanded in the traumatic form, or in the idiopathic form, should it occur in the sane. The pain in this disease of the auricle does not appear so urgent as to demand puncture of the tumor, at least not in the idiopathic form. It is evident, however, that if the pain caused by the distention of the parts in either form, especially in the traumatic variety, is great, it would be advisable to puncture the tumor. Deformity is not only less likely to occur if the auricle is let alone until spontaneous absorption is brought about, but in the insane is of so little moment that the fear of its occurrence should never induce the surgeon to operate. Dr. Hun has observed that, in those in whom spontaneous absorption or rupture has occurred, the deformity is very much less than when the tumor has been opened by the knife of the surgeon, the least deformity occurring when spontaneous absorp- ^ tion is induced. Of course, the form of the disease would have the greatest weight in deciding whether we should operate by incision or not; but, although the operation would not be contraindicated I in the traumatic form by the cerebral condition of the patient, 1 the most satisfactory results are said to be attained in those cases where spontaneous or induced absorption occurs. However, many prominent aural surgeons are in favor of j) early operation in all forms of othcematoma. Gruber^ gives the result of his observations, in connection \vith Drs. Joffe and Schlager, as favorable to an early evacuation of the effu- sion, and the application of pressure to insure union in the walls of the cavity which contained the blood. The instrument he uses is a trocar if the blood is still fluid; but if it is cogaulated, he incises the tumor and removes the clot. He is strongly opposed to the so-called antiphlogistic treatment by the use of "Goulard's solution ; " but recommends, for the thickening and deformity of the auricle, painting with tincture of iodine. Roosa^ and RockeeP incline to the above treatment, but Rau,* an author who appears perfectly conversant with all the literature ' Lehrbuch d. Uhrenheilkunde, Vienna 1870, p. 286. 2 Treatise on Diseases of the Ear, etc., New York, 1873, p. 111. '■^ Etude siir I'lleinatonio de I'Oreille. Paris, 1882. * Lelirbucli dor Olirenlioilkunde, Berlin, 1856, p. 170. '< %' MOKBII) GROWTHS A N D T N.T U HI ES. 241 pertiiining- to this subject up to the time of the publication of his book, is decidedly in tavor of using, at the commencement of the disease, cold lead-water dressings, which he advises to be used until the tumor begins to soften a little, then they are to be removed and warm fomentations of arnica used in order to favor resolution and absorption. He is of the opinion that incisions into the tumor are almost always injurious, yet they are preferable to the method of acupuncture as suggested by Spever, for the former operation removes more thoroughly the coagula. Saxe, according to Rau, recommended, after the incision and the removal of the coagula, the application of dressings of alum and water (2 drachms to fgiv), and to cover the entire ear with cotton- wadding. As we have already seen, Hun' dis- approves of incisions in any case of othsematoma, and Kramer' approves of general roborants and cool dressings at tirst, until the tumor begins to soften, then absorption may be promoted by the use of dressings of tincture of arnica. But he is opposed to all incisions and surgical operations in these cases. Dr. Kirkbride^ has found the application of ice and tincture of iodine most useful ; the latter may be applied twice daily. lie has not found the ear disposed in any case to resume its original shape. Dr. Worthington^ disapproves of incisions as useless. I ^ Kneading, or massage, has been recommended as aiding in absorption of the effusion. Massage and the pressure-bandage may be continued for some weeks, and in one case reported by Meyer,'^ the auricle, under this treatment, became absolutely perfect, excepting a slight thickening. If Othaematoma in the Sane. — Some writers have recorded instances of what they have termed spontaneous othaematoma in the sane; but in most instances, the cause of this disease in the sane can be traced to various traumatic influences, as boxing, and blows® on the auricle from many other causes,^ burns, scalds,^ and exposure to intense cold.^ The more clearly traumatic cases have also been termed spurious othaematoma, to distin- guish them from the truly symptomatic variety occurring in the ' Loc. cit., p. 23. ^ Die Erkenntniss and Heiluno; d. Ohrenkrankheiten, Berlin, 1849, p. 214. 3 See Turnbull, op. cit., pp. 138, 139. * See Turnbull, op. cit., pp. 132-140. ' Will. Meyer, Archiv f. Ohrenheilkunde, Bd. xvii. S. 2. C. J. Blake, American Journal of (ytoloyv, vol. iii., 1881, p. 193. « C. J. Blake, Statistical Eeport of 1652 Cases of Ear Disease, 1872. ' Trautmann, Cases of Ear Disease in Garrison, at Breslau, Prussia; Archiv f. Ohrenh., Bd. ix. S. 183. ^ C. J. Kipp, Transactions American Otol. Soc, 1873. 3 Gustav Brunner, Archiv f. Ohrenh., Bd. v. S. 26-28, 1870. 16 242 AURICLE. sane. It is most frequently observed among males, though the case reported by Dr. Blake was that of a woman thirty years old, who had been struck on the ear in falling. In this instance, an abscess ensued in the injured auricle, and after painful sup- puration, discharged an ounce of pus. As this disease has been noted among soldiers in a garrison, it is fair to presume that it is the result of rough sport in which they receive severe blows on the ear. IN^ot uncommonly the traumatic variety of othfematoma occurs among boys, receiving hard hits on the ear in playing foot-ball, as stated by the late Mr. Hinton, of London. One of the most remarkable accounts of the traumatic origin of this disease is that given by Dr. Brunner, of a man forty years old, who, in riding all night in a very cold railway car, fell asleep with the auricle against the window-pane, to which the auricle was frozen fast. The rarest instances of traumatic othpematoma are those resulting from burns or scalds, as in the , case related by Dr. Kipp. The prevalence of this form of injury [ among boxers is so common, that it is shown in ancient statues of noted athletes, as pointed out by Yirchow. Diagnosis. — The diagnosis will not be difficult, as the history [ and general condition of the patient will usually plainly indicate ■ the traumatic origin of this variety of blood-tumor of the ear. Most of the symptoms are sthenic, whereas the asthenic and indolent character of the tumor in the insane is verv marked, and hence distinctive. Treatment. — The treatment of traumatic othematoma should consist in opening the sac if suppuration has ensued. But if the latter process shall not have taken place, the symptoms of heat, congestion, swelling, and pain must be combated as in the idiopathic variety, viz., by application of ice and iodine. If it be necessary to open the sac to evacuate the pus which may have formed, the cavity should be gently stimulated by injections of weak solutions .of» carbolic or salicylic acid, and the walls kept in contact by gentle compresses. It will be found that with proper management the auricle can thus be kept from much deformity. INJURIES OF THE AURICLE. The general surgeon is often called upon to treat a variety of wounds of the auricle, but it is hardly in place to treat of them i here. Most of these are caused by quarrels, and are inflicted by weapons, blows, and bites. Those caused by weapons appear to be somewhat peculiar to the countries where they occur, as in the French soldiers, whose auricles were so frequently injured MORBID GROWTHS AND INJURIES. 243 II ir by tlie yatai;-haii in the battle of Coustantina ;' in Ireland, auricles luive been si)lit and bruised by the blackthorn stick;'- and in Germany, the student's " schniiss " is often obtained by a sword- thrnst or slash at the auricle. The treatment will consist in adjustiiii;- the wounded and displaced parts, keeping them in position by a stiff dressing, or by pins and ligatures coiled about fthera in shape of a figure 8,^ and attention to the general prin- iples of surgerj'. Fig. 78. Traumatic Cleft of the Lobule. — A not uncommon injury of the auricle is one caused by tearing out the ear-ring, and thus leaving a cleft of the lobule. This is produced most Irequently by children m play with their mothers, but it is also done in fights between women. I have [seen lately two sisters, both quarrelsome, in whom the lobules were cleft, one in three places, making four teat-like ap- pendages, or fringe, said to have been caused by her babes, but the other wo- I iman acknowledged that in a quarrel with a female acquaintance, the ear- ring had been intentionally torn from her ear by her adversary. In both of I these women the deformity had existed for several years. Treatment. — If such cases are treated as soon as they occur, union by first in- tention can usually be effected ; I have never seen any but chronic cases. Dr. Knapp, of New York, has lately sug- gested* a very neat and practicable a ^ operation for removing the deformity Hin such cases, without leaving the notch on the edge of the lobule, so common after operations on this part. This operation is a modification of the Alirault-Langenbeck operation for harelip, applied to the auricle, and consists in the following method : Thrust a narrow-bladed scalpel through the anterior part of the lobule near the lower end of the slit (at a, Fig. 78), sever a thin slice of skin along its edge, and when the _ -Other end of the slit is nearly reached (at r), make the slice a lllittle broader, leave its end (at b) in connection with the auricle, I Ithen go backward about two lines, and cut across the detached ' Wilde, op. cit., p. 164. '^ Ibid. * Darti^olles, .Journal de Medicine de Bordeaux, 28th Dec. 1878. yJour. of Otol, vol. i., 1879, p. 1.55. * Archives of Ophth. and Otol., vol. iii. No. 1. See Amer. 244 AURICLE. slice (at c), thus forming a small flap (c b). Xow seize the long portion of the slice with a pair of forceps, and divide with the knife its other end (at a) by a slightly curved section. Without waiting long for the cessation of the bleeding, the edges of the wound may be gently but securely united by three interrupted sutures. The first is applied to the middle of the edges on the anterior surface ; the second, about opposite the first, to the posterior edges. The curved needles need not penetrate more deeply into the substance of the lobule than about one-third of its thickness. By the third suture, the small flap (c b) left at the posterior part of the lobule, is made to bridge over the lower extremity of the gap. The needle, therefore, is first thrust through the free end (c) of the little flap, and then through the low^er edge of the wound in the anterior portion of the lobule, the suture tied, and the operation is finished. !N^o dressing is required. In three days the sutures are removed. Immediate union is usually obtained. I have frequently tried this method, and found it the only means of preventing the notch so often seen in the lobule after it has healed. SECTION III. EXTERNAL AUDITORY CANAL. CHAPTER I. CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. Otitis Externa Circumscripta consists in a circumsci'ibed Inflammation of the skin or snbcntaneous cellnlar and fibrous tissues of the auditory canal, terminating in a small abscess or boil, which, in discharging its contents, produces considerable destruction of the skin coverinc; it. Its seat is not confined to any particular portion of the auditory canal, but as it is most likel}' to occur in a region rich in glands, it is apt to be found in the outer part of the meatus. It may, however, arise in the deeper cellular tissues and in the periosteum of the bony portion of the auditory canal. Circumscribed inflammation of the ex- ternal auditory canal may arise sporadically or epidemically, and, in the latter instance, it is a striking fact that the abscesses are confined to a particular part of the auditory canal.' Bon- nafonf has recorded such an epidemic, occurring in Paris, in May and June, 1863, and Gruber^ reports the occurrence of a similar endemic attack of this disease in the summer of the same year in Vienna, at which time, the majority of the ab- scesses were found in the outer third of the auditory canal, near the tragus.* Lowenberg has suggested that furunculosis of the external ear may be caused by the presence in the blood of a peculiar microbe. He claims to have found it in the pus of a freshly lanced boil in the meatus.. SijDipfoms. — This disease is usually extremely painful, and is attended with fever and even considerable cerebral symptoms in some cases. The boils usually occur one at a time, but the * Gruber, Lehrbuch d. Obrenh., p. 297. 2 L' Union Medicalo, 1868. * Bericht Allg. Krankenhans, Vienna, 186^^. * Sec American Journal of Otology, vol. iv., 1882, ])p. 139-144. A review by . J. B Vernivne. 246 EXTERNAL AUDITORY CANAL. series may amount to a dozen. Sometimes they appear to merge so fast into one another, that the ease gained by the dis- charge of one is hardly enjoyed by the victim until the throb- bing and burning pain of a new one warns him that he must endure the torment of another. The auricle may become sensi- tive to the least touch and traction, especially if the abscesses are in the cartilaginous part of the canal, and the patient then cannot endure the ordinary pressure of the affected side of the head on the pillow. But such sensitiveness of the ear is not so likely to occur in this form of otitis externa as in the diffuse form. The severest pain and most distressing symptoms are found when the boil is seated in the unpliable parts of the bony portion of the canal ; intense distress, however, may be caused by a boil seated just within the opening of the auditory canal. Usually, the gravity^ of the pain and febrile symptoms will de- pend upon the deptli of the abscess in the tissues of the auditory canal, as well as upon its proximity to the drum-head. Small superficial abscesses do occur in the meatus without any pain, a sense of discomfort and dulness of hearing having been the only cause of the patient's seeking surgical relief. More than one such case has been seen where the abscess had run its full course and was on the point of discharging without having caused the patient any pain. But, of course, such cases are great exceptions, and are explained by the superficial seat of the in- flammation. Hardness of hearing and deafness are prominent symptoms of furuncles in the auditory canal. In some cases the deafness is almost absolute, and the congestion being so great, and extending consecutively even into the cavity of the tj'mpanum, the deafness is the last symptom to disappear. But the patient can be assured of the ultimate return of the hearing in such cases if there has been no organic lesion of the drum- cavity. As such a lesion is a very unlikely occurrence in this disease, there is every hope of the return of the hearing. Inspection of the auditor}- canal and membrana tympani is usually very difficult if the disease is advanced and the swelling of the meatus considerable. This difficultv is less likelv to . occur when the disease is in the cartilaginous part of the ear, j for with care it may be gradually stretched by the speculum. : When the disease is in the bony portion of the canal, one can ; usually obtain a view of the drum-head only in the earlier stages of the disease. In such cases, if the abscess is seated near the drum-head, it will be seen that the latter is more or less congested at that point nearest the abscess, and in many cases where the I boil is near the periphery of the membrana tympani in its !: upper half, considerable swelling will bo found in the region of ) the membrana flaccida and the folds of the drum-head. In such \ cases, at first sight, one may be inclined to diagnosticate the | CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 247 disease as myringitis, but the liistory of the case, and the com- paratively normal condition of the drum-head, excepting at the points of secondary congestion produced by the circumscribed intlammation of the canal, and the greater pain in the latter disease, will make the ti'ue diagnosis easy. When the abscess in the bony portion of the canal becomes fully developed, the view of the drum-head will be entirely cut oH) and the deafness and tinnitus become great. After the discharge has occurred, the drum-head may be seen as a red, and somewhat sodden membrane, which, however, in a few days, gradually assumes its normal color and outline, and the hearing will be found to be returning. Inspection of the auditory canal and drum-head by means of the ear-funnel, unless carefully done, becomes very painful to the patient with this disease of the ear; but it is very important to examine the canal well, in order to determine the seat, the quantity, and the stage of the disease, as well as to be assured of the absence or the presence of exostoses, cerumen, or other foreign bodies in the canal, which might interfere Avith the escape of the products of inflammation and greatly complicate the disease. Having established the presence of either or all of these complications, the surgeon must mitigate the effects of the exostoses, and remove, if possible, any other obstructions, such as cerumen, foreign bodies, etc., by the most gentle and thorough syringing, or by the most careful manipulation. I ^ If exostoses are in the auditory canal, care must be taken not to mistake such rounded prominences for the furuncles. This, in some cases, may prove to be no easy task, and, there- fore, as these growths, if congenital, are usually in both canals, if there be any suspicion that the affected ear contains such bony growths, the well ear should be examined, and if it con- tains them, caution should be observed in ascribing all the swelling in the diseased ear to the furuncles. However, as these prominent growths of bone are not very frequently seen in the ear, they will not often be found as complications in circumscribed external otitis, but it is well to bear in mind the possibility of their presence in the affected ear. Etiology. — Perhaps no disease of the ear has so many asserted causes, yet so few well-explained ones, as boils in the external ear. !N'o class or condition of men appears exempt from it, and in many instances the disease continues to recur for a long time, owing to the fact that the cause, which must be removed before permanent recovery can take place, has not been found after the most thorough search. According to some authorities, a particular article of rich food has been the cause of the disease, especially- in the more wealthy classes, while amemia and poverty 248 EXTERNAL AUDITORY CANAL. have most usually been considered fruitful causes of furuncles • in the external ear. Fatigue and consequent debility from any cause may produce them; and it is not uncommon to find furuncles in the auditory canal of young devotees to fashion, after a long and gay winter season with its round of parties and fatiguing attendants of late hours, bad air, indigestible food, and loss of sleep. I have never seen this disease in children. Treatinmt. — Of course, the best treatment for a boil or circum- scribed abscess is a poultice or some form of heat and moisture. But this is not easil}^ applicable to such inflammations in the auditory canal, on account of the narrowness of the passage and j the necessary blocking up of the canal which such a treatment might entail. It has, therefore, been deemed best to incise, as deeply as possible, a furuncle in the auditory canal as soon as the circumscribed swelling is detected, without waiting for pus \ to form in it. With the meatus lighted as well as possible by the aid of the forehead-mirror, though in some cases direct light will be suffi- cient if the furuncle is not too far down the auditor}' canal, and while the head of the patient is allow^ed to be entirely free, the surgeon may make a thorough and deep cut into the small abscess, taking care that the patient is allowed to jump away from the operator rather than tow^ards him, an end best gained by allowing the patient's head to be entirely unsupported, on the unaffected side, i. e., the side opposite to the operator. The knife is the quickest and surest way of escape from the pain of these furuncles in the auditory canal. It has also seemed that in those cases w^here the knife has been used promptly on the first boil that makes its appearance, others are less likely to come. If, however, they come, they are likely to be less severe. This may be due to the sudden relief given to the distended vessels of the skin of the canal by the free cut, at the outset of the inflammation. If the knife cannot be used, other means must be resorted to. Although poultices, in the strict sense of the term, cannot be applied to abscesses in the auditory canal, unless situated very near its mouth, and even then only in a } limited way, yet the constant or oft-repeated use of warm water by jj gentle instillation, the aural douche, or some of the varied forms of irrigation, will be found very grateful to the patient and favor- able to suppuration. Dr. A. H. Buck^ prefers hot water irriga- tion to all other means of allaying pain and terminating this disease in the canal. The simplest and perhaps the best way of applying warm w-ater as a dressing to any acute inflammation in the ear, and especially in the auditory canal, is to fill up the ear ^ American Journal of Otoloi^y, vol. ii. p. 34. I# ^« CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 249 with worm water and allow it to reniaiii there as lono; as pos- sible, while the patient, of course, lies down with the ait'ected ear uppermost. To the warm water thus used laudanum may be added. « . A snuill dossil of lint or cotton soaked in glycerine or equal ■parts of glycerine and water, and small conical poultices of flax- seed, will be found to act as excellent emollient dressings upon an abscess near the mouth of the auditory canal. ■ ■ The local abstraction of blood with two or three leeches, airectly under the ear in the depression behind the lobule, or in front of the tragus, close to the car, lias been recommended when the congestion and pain are intense, but it is not of much value. ■ i The removal of the discharge, which is not often very copious, le of great importance. Some form of alkaline wash will be found to act best as a cleanser while the contents of the abscess are being poured into the auditory canal. First of all stands warm water made slightly' opalescent with eastile soap, which should be applied by means of the syringe twice or thrice daily according to the amount of discharge. In the interval between the syringings, or just before them, a solution of bicarbonate of soda, gr. x-xx to f.5J, or of biborate of soda, gr. x to fsj, may be instilled into the meatus in quantities of from ten to fifteen drops warmed. These, by remaining in contact with the affected spot, will soften any hardened crusts of the discharged matters from the abscess and facilitate their removal by the syringe. As has already been said, the occurrence of a small abscess or hoil in the auditory canal, denotes that there is a tendency towards the occurrence of another or several in the same spot. Hence, the constitutional, as well as the local, treatment becomes of the greatest importance. Some observers have asserted that chronic furunculosis of the ear is a symptom of diabetes mellitus. I have observed one case of chronic furunculosis in the meatus, the middle ear being unaffected, in a diabetic woman. I Whatever is employed for the cure of boils, when occurring elsewhere in the body, should most surely be employed when they make their appearance in the auditory canal, for they are not only an evidence of the need of an alterative treatment, but they are intensely painful and interfere with hearing. At the head of the list of remedies stand iron and quinine, while in some cases iodide of potassium has been found most efficacious in breaking up a tendency to the formation of boils. But there is no specific in this malady, and if one form of treat- ment does not bring about the desired result, another must be tried, until the disease disappears. Most frequently the best results will be gained from those remedies which improve the N 250 EXTERXAL AUDITORY CANAL. general condition of the patient. Von Troeltsch strongly recom- mends the internal use of Fowler's solution in this disease.^ Dr. Samuel Sexton recommends the administration of the sulphide of calcium, as do others, in this disease of the ear. I have tried it in doses of one-tenth of a grain three or four times daily with undoubted success. This drug seems to induce reso- lution of the inflammation, and hence, in such cases, the neces- sity of an early incision into the swelling in the canal is done away with. Local Treatment. — Although local causes have very little to do wdth this disease of the auditorv canal, it will be found ad- vantao-eous to combine a local treatment w^ith the s^ivino: of- medicine internally. The use of some soothing or mildly stimu- lating salve, as the case seems to demand, has been found appa- rently to diminish the tendency to recurrence of the abscesses and to favor an early return to healthy action on the part of the various cutaneous structures. As a soothing application, nothing is better than a little cold cream smeared on a camel's-hair pencil and then painted round the walls of the meatus. In the early stages I have found the application of black wash soothing to the pain and smarting. The ice-bag carefully applied will ease the pain of a boil in the meatus. If a more stimulating ointment is needed, the following will be found to answer very well : R — Hydrargjn-i ammoniati, gr. i-ij. Ung. aq. ros;e, _^j. — M. Ft. ung. S. Apply to the ear with a camel's-hair pencil. A small portion of this ointment may be smeared on and around the affected spot, twice or thrice daily, by means of the hair-pencil, for several days, until the skin of the auditory canal appears to be free from the tendency to the formation of these small and painful abscesses. Painting with iodine around the auricle is claimed 'by Blau to prevent recurrence. If there is no return of the abscesses, the cons-estion soon o-oes from the drum-head, and the hearing will be restored. The granulations sometimes left by a furuncle in the ear are best treated by cauterization with a saturated solution of nitrate of silver, applied by means of a little cotton on the holder. As the granulations are distinctly marked centres of disease, touching them is much safer than instillations applied to them. Insufflations of boric acid are often sufficient to cause the granu- lations to disappear. A fuller consideration of the best treatment for polypoid granulations follownng external otitis will be found further on, where polypoid diseases are specially alluded to. ^ Diseases of the Ear, 2d American edition, p. 102. CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 251 Diffuse Inflammation of the External Auditory Canal. — This dis- ease attects tlie osseous part of the auditory canal usually, but it may at the same time invade the cartilaginous portion and even spread to parts of the auricle in some cases. The only essential difference between it and the disease treated of in the preceding passes, otitis externa circumscripta, consists in its tendency to diffuse distribution to the entire external ear. It does not always originate in the same layer of the lining of the auditory canal. " a" simple erythema of the cutis in the auditory canal may be considered the lightest form of the disease, and a periostitis of the canal may be called the severest form."^ Just as the circumscribed inflammation in the auditory canal shows the peculiar tendency to narrow itself down to a very minute and true abscess, the diffuse form of otitis externa shows the p)eculiarity to spread rapidly to all parts of the external auditory canal. A pure form of periostitis of the external auditory canal never occurs, for the disease is never confined to the periosteum, but from the outset, all the neighboring layers of the wall of the canal are attacked. This is due to the fact that the skin of the canal is more firmly united to the periosteum than the peri- osteum is to the bone. Hence, an inflammation of the cutis readily extends to the periosteum and the bone, this being most probably the usual course of the disease. There is also a con- secutive form of external otitis found in cases of acute otitis media. This always begins at the fundus of the canal. Sijmptoms. — The subjective symptoms of diffuse external otitis are more severe in the primar}' than in the consecutive form. In the former instance, pain, tinnitus, and deafness are the prominent and very distressing symptoms. Itching in the meatus is a constant, but frequently disregarded, symptom of the approach of this disease. In general the subjective symptoms do not differ greatly from those of the circumscribed external otitis. In the so-called diphtheritic form the pain is said to be intense, continuing without any interruption day and night until the inflammatory product has assumed another character. The deafness and tinnitus in diffuse external otitis are more marked and more obstinate than in the circumscribed otitis. The consecutive variety of diffuse inflammation of the external ear is, as a rule, less painful than the primary variety. This feature is most marked wdien the inflammation of the external ear is consecutive to purulent inflammation of the middle ear. The objective symptoms of diffuse external otitis vary with the position, cause, and grade of the inflammation, being more severe 1 Gruber, op. cit., p. 334. i 252 EXTERNAL AUDITORY CANAL, in the primary than in the consecutive form. When the inflam raation is situated in the bony portion of the canal, the disease j; assumes the nature of a periostitis with intense and continued i| pain, whereas the symptoms are not so severe when the disease )[ seems to be limited to the outer part of the auditory canal. At fj the beginning of the disease the skin of the auditory canal is more or less swollen and red, and, in some cases, portions of the cutaneous lining of the auditory canal may be excoriated or even exfoliated at certain points. Usually the redness and swelling are most marked in the bony * portion of the canal, with, of course, great narrowing of the * calibre of the canal, so that the latter appears to run to a point, thus assuming a conical shape. The skin of the fundus of the canal becomes puckered by the swelling, and one, perhaps more, of the ridges thus formed will shut off the drum-head from view. • The congestion and swelling, when the disease is at the fundus, are greatest in the region of the posterior periphery of the drum- membrane, and the vessels supplying the hammer and the mem- brana liaccida. The entire drum-head soon loses its gray color and its contour, so that the wall of the canal and the mem- brana tympani cannot be distinguished from each other by their ' appearances, and appear fused into each other, especially at the posterior border of the membrane. ^ All traces of the normal pyramid of light are lost, and the in- ^ filtration in many cases is so great that the consequent pucker- ing of the drum-head will cause several shining spots to appear on the prominent points thus produced by the swelling of its ('■ layers, M'hen light is thrown into the canal from the mirror The appearance of the inflamed parts is somewhat changed 1^ when the layers deeper tlian the skin of the canal are more dis- eased than the cutis itself. In such cases the swellino; of the structure beneath the cutis will push it so much out of place that the two sides of the canal 1; will be made to touch each other, and not even the narrowest 1^ speculum can then be pushed between them so as to gain a view '^ of the deeper part of the auditory canal and the drum-head. .,• Very often in such cases, since the superficial layer of the skin of ^ the passage is very little diseased and remains quite dry, it may ' be somewhat difiicult to say whether the disease is diffuse or circumscribed inflammation of the canal. However, in the former case we shall usually find more or less glandular swell- ing and tenderness about the ear, with pain on moving the jaw. Most important symptoms in some cases are the redness and ! swelling, with some aulema, of the mastoid process, because the surgeon may be misled into diagnosticating mastoid disease. The glandular tenderness under and in front of the auricle is, ;i II I-IKCUMSCRIBED AXD DIFFUSE INFLAMMATION. 253 however, a imicli more frequent attciulunt of this disease of tlie auditory canal, than the mastoid redness and tenderness. The discliarge of the products of inflammation in this disease mav occur from several points, but usually it comes from one onlv. In the former instance the tlisease manifests symptoms similar to those of circumscribed external otitis, whereas, in the latter instance, the symptoms are peculiar to a true diiiuse external otitis. In such a case, the discharge is remarkably copious, beginning as a discharge of colorless or bloody serum, and terminating in the course of a few days in a less copious purulent discharge. The amount of odorless bloody serum at the beginning of the discharge is so abundant in some cases, as to require the constant holding of a handkerchief to the ear, in order to protect the bedding or the clothing of the sutierer, and thus several handkerchiefs, in the course of the day, may be soaked with the discharge. The most marked instance of a tlow of this kind the author has ever seen, was from the ear of a Ja[>anese naval otficer, from whom the discharge was very red OS well as very copious, so red, indeed, 'that the patient con- sidered it blood. It continued three days, and was succeeded by a light-yellowish discharge of purulent matter, exfoliation of epidermis from the fundus of the auditory canal and drum- head, with perforation of the latter by external erosion in the postero-inferior quadrant on the eleventh day. The brief men- tion of this case leads naturally to the statement that many cases of this disease, when situate in the bony portion of the canal, are attended w^ith exfoliation of large pieces of epidermis and perforation of the drum-head from without inward. Per- foration of the drum-head does not occur frequently as a result of the ordinary course of the disease, but great caution in the use of the syringe should be observed at the stage of exfoliation, for fear of penetrating the drum-head by the force of the stream of water. Tlie swelling and exfoliation of the soft parts of the canal may be so great as to increase the pain and distress of the patient by a further distention of the canal, and the renewed irritation of the diseased part may reproduce considerable fever, which, however, subsides as soon as the exfoliated matter and discharge are removed. Where it is impossible to gain a view of the drum-head on account of the narrowing of the auditory canal, resort may be had to the catheter, the use of Politzer's bag, or Valsalva's method of inflation, in order to ascertain the condition of the Eustachian tube and middle ear. This is often of the greatest moment, not only in children in whom it is often difficult to make a perfect diagnosis in this disease, but also in adults, in order to determine wdiether or not the external otitis exists alone or is accompanied by deeper and more serious disease in 254 EXTERNAL AUDITORY CANAL. ^'\ the drum-cavity. All the objective symptoms in dift'use in- flammation of the external ear are modified by their causes and the diathesis of the patient. Hence, peculiar symptoms may be expected in that form of the disease produced b}' the presence of vegetable or animal parasites in the ear, in the diphtheritic form of the disease, and in any form in syphilitic or scrofulous individuals as well as in an}" traumatic case occurring in the more healthy, for in the latter instance the means by which the | disease has been produced must be taken into account, since ^ almost invariably it will complicate and alter the symptoms. ti The diphtheritic form of difl^use external otitis is vQvy rare, being unmentioned by many authorities. According to the best observers, it is never a primary affection, but rather an occurrence in the later stages of an inflammatory process. This form of the disease is usually found in scrofulous subjects in whom the original inflammation has been either neglected or improperly treated. In all such cases, after the usual purulent il discharge has lasted a longer or shorter time, there is a sudden increase of pain and fever, with the simultaneous appearance of a white diphtheritic membrane, which adheres most closely to the inflamed structure, and when even lightly touched causes ( intense pain and some bleeding of the parts beneath, as shown I by Gruber. Moos,^ and G. A. Callan,^ have each reported a '^ case of idiopathic diphtheria of the external auditory canal. Jacobson^ reports three cases of diphtheritic inflammation of the canal, observed in Lucre's clinic. Bezold,* of Munich, re- f ports three cases of fibrinous exudation from the walls of the if canal and the membrana tympani. '' In children there is often found, at the termination of an :^ attack of diphtheria, inflammation in the external ear. This (^ rapidly extends, in some cases, directly to the bone of the canal, I and baclcwards to the mastoid process. Pain is not a prominent -^ symptom in these inflammations following diphtheria, and this fact will readily distinguish them from the truly diphtheritic i form of external otitis in which the peculiar fiilse membrane is ^ found in the auditory canal. The form of the disease now referred to is one arising from the broken-down condition of the little patient, rather than a form of disease already described as the diphtheritic. In the former case the pain is not great, the swelling is considerable, and the tendenc}- to attack the bone is marked. Fluctuation is soon felt over the mastoid region, and, after the evacuation of the pus, the bone beneath is found denuded, and in some cases crumbling. Exuberant 1 Archives of Oph. and Otol., vol. i., No. 2, New York, 1870. ^ New York Med. Record, March 27, 1875. 3 Archiv fiir Ohrenheilkunde, Bd. xix. S. 37, 1882. ^ Ibid., Bd. xiv. S. 6G, 1878. '■' CIRCUMSCRIBED AND DIFFUSE T N FT, A M M A TI ON . 255 irran Illations spring up around the opening nuide by the knife m the soft parts, and the peculiar depressed mi)uth of a sinus leading to dead bone soon begins to make its appearance. With a probe, a tract of bare bone corresponding to the region around the bony meatus ma}' be detected. For weeks, no portions of this diseased bone will come away, but at last the nearest edge of the dead tract will appear to rise up, so that a probe may be worked under it, and then gradually, day by day, the dead shell or scale of bone (for it is in many cases the outer wall of the mastoid cells) will be found to be coming out through the sinus. This process is attended wnth more or less discharge from the ear, but if the sinus behind the ear is kept freely open, the dis- charge from the auditory canal w^ill be very slight, and hence, granulations are not usually found in the canal in such a case, for the drainage is kept up from behind and away from the auditory meatus. During this process the patient has no pain, the discharge is not very copious, but there will be, from time to time, swelling of the glands in front of and under the ear, and down the tract of the sterno-cleido-mastoid muscle. These swellings are not painful nor very hard. The}' last for a few days and then usually disappear, though they may suppurate in the worst cases. Perhaps the form of inflammation over the mastoid, just sketched, may be due, primarily, to the inflamma- tion of a gland which has become diseased by the diphtheritic poison. In badly fed and delicate children the diphtheritic form of otitis externa may pass into the gangrenous variety. According to Gruber, otitis gangrsenosa is much more likely to occur in children than in adults. Although the external otitis occurring in diphtheritic children may lead to necrosis in and about the tympanum, with exfoliation of large pieces of the posterior wall of the auditory canal, I have never seen such cases assume a trulv gano-renous nature. I i Causes. — The causes of diffuse otitis may be purely idiopathic or local. The latter varietv wall be found the most usual, as cold air^nd cold water, wounds, injuries of all kinds, furuncles in the auditory canal, and various inflammatory processes both within and outside of the ear. The latter diseases attack the auditory canal from their nearness to it, as, for example, acute inflammation of the middle ear, some skin diseases, as eczema of the scalp and auricle, the acute exanthemata, and, in rare instances, pemphigus of the entire surface, may also attack the auditory canal and drum-head, as in a case seen by von Troeltsch. The improper use of all kinds of ear-picks, aurilaves, hair- pins, and tooth-picks, for scratching the ear or for the too zealous removal of cerumen, are constantly found to have been 256 EXTERNAL AUDITOBY CANAL. the exciting cause of this very painful disease of the auditory canal. ^ Some of the worst cases I have seen, especially among the patients in the infirmary, have been produced by the rough and persistent use of pins, which appear to have an especially bad influence on the glandular structures of the auditory canal. I have also observed that men very often make a verj^ im- proper use of a quill tooth-pick in scratching the meatus with it. This practice I have known to excite a series of obstinate ab- scesses which have at last passed into a chronic form of ditiiise external otitis. This latter form of the disease is not very painful, but the itching and discharge are very annoying. There are constantly found a few writers disposed to attri- bute some cases of diffuse inflammation of the external ear to syphilitic or gonorrhoea! causes. The disease in the former instance is attributed to papules, the secretion from which is irritating (Gruber) ; and other writers, among whom is Lincke, have endeavored to diagnosticate some forms of external otitis as syphilitic. The gonorrhoeal form appears very doubtful, from the fact that there is no mucous membrane in the external auditory canal. Dr. Ladreit de Lacharriere^ has described a form of acute syphilitic otitis which he considers purely a secondary accident, and to which he desires to call especial attention. These cases are said to be not uncommon, but the writer re- >- ferred to laments that no one but Triquet has devoted much i. attention to this or any forms of purely syphilitic disease of the { ear. It is certainly unknown in this country. Depres,^ in the course of six years at the Hopital de Lourcine, observed five cases of mucous patches, and one soft chancre in the auditory canal. He thinks he could have found other cases had he looked for them. The plaques were of the vegetant "' form, seated on the floor of the canal, and in one instance ex- tended to the menibrana tympani. In one case both auditory canals were invaded by these specific growths. The vegetations were treated by cauterization with a saturated solution o^chloride of zinc, from two to four applications being required, except in i- the case where both canals were the seats of the disease. In t that instance the treatment was protracted for six weeks. ' Jacobson^ observed, in Lucre's clinic, syphilitic ulceration in ij the external auditory canal of a man thirty years old. Exami- nation of the pharynx revealed it to be very red, and also that there was on the half arches of the palate an ulceration, covered ' Annales des Maladies dc I'Orcille et du Larynx, Mav, 1875. •-■ Ibid., Dec. 31, 1878. "' | ■' Archiv f. Olirenheilkuiido, Hd. xix. S. ?.6. i CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 257 with a gray tilm. In the meatus of the right aiulitory canal there was a circular ulcer with everted edges, which was covered by a dirty grayish-white and adherent pellicle. It was very sensitive to the least touch. I have seen in secondary syphilis, when an erythema was visible upon the forehead and face of the patient, a similar papular and furfuraceous condition of the auditory canal and membrana tympani. Under constitutional treatment the eruption disappeared simultaneously from all the afteetcd parts. I have also seen in several instances cicatrices after ulceration of the canal and membrana tympani in adults who had been the subjects of hereditary syphilis, but an ulcera- tion in the canal the direct result of S3'philis I have not seen. Tre((i)i\enf. — If we are able to begin the treatment of ditfuse intlammation of the external auditory canal in the early stages of congestion and pain, the first course to pursue will be to apply heat and moisture under restrictions yet to be laid down. Warm water, as hot as desired by the patient, should be con- stantly and gently applied to the affected auditory canal by irrigation or by instillation. When warm fluid applications are to be retained in the auditory canal, the best way to accomplish this is for the patient to lie down with the affected ear upper- most, as already stated w^hen discussing the subject of furuncles in the auditory canal, and the fluids should be kept in the ear as long as they are warm and grateful to the sufferer. To the water thus used may be added various anodynes, pre- feral)ly, however, laudanum or morphia. Magendie's solution undiluted Avill be found to be the best anodyne application, be- cause it is the cleanest and most pow^erful, and, although it should never be resorted to in the undiluted state, unless the pain is very severe, it can be endured in large quantities in the ear, without producing any unpleasant narcotism, even in young children. It may be used in instillations of five or ten drops, every half- hour, until relief from pain is obtained, in children as young as three years of age, with the best results. I have frequently used it thus, without observing the least narcotism. The best way to prescribe it is in small quantities, thus: R . — Morphia^ sulphatis, gr. iv ; Aquae/ fl.^ij. — M. S. Ten drops, warm, in the ear, as required. Or, five drops of a w^arm solution of atropia (gr. j-flSj- aq.) may be placed in the afifected ear, as suggested by Theobald, of Baltimore. Vokolini insists on the great benefit to be derived from using ' For water, cherry-laurel water may be substituted. 17 258 EXTERNAL AUDITORY CANAL. p absolute alcohol as an instillation in this disease, as recom- mended by Weber-Liel, It is claimed that it aborts the inflam- mation, and hence allays the pain.^ It has often seemed to the author that laudanum perhaps owes its anodyne and curative eftects to the abortive power of the alcohol in it. It is, perhaps, needless to say, that heat and moisture by all forms of solid poultices of carrots, onions, fat pork, oils, etc., will only tend to aggravate the present suflferings of the patient, and almost inevitably leave behind them portions of the poultice, j which, by undergoing decay, or becoming rancid, will lay the foun'dation of other evils, among which the aspergillus will be found playing a prominent part. In fact, most cases of difi'use inflammation of the canal are made worse, and the disease masked before the surgeon sees them, by the various domestic remedies applied in all cases of ear-pain. With the local treatment by heat and moisture as set forth, the surgeon must combine a constitutional treatment. He must see that the bowels are opened, if there is evidence of costive- ness or constipation, dyspeptic symptoms must be combated, and fever allayed. He may then administer a constitutional treatment specificall}' adapted to this disease in the auditory canal. Pain in this region may best be overcome by the ad- ministration of aconite, as this drug seems to have a happy eflfect in all painful implications of any branch of the fifth nerve. . The ext. aconiti may be given in the dose of one-tenth of a grain i every two hours, and with it may be given the sulphide of cal- cium in doses of one-tenth of a grain to adults, every four hours or oftener, if the inflammatory symptoms are severe.' Dr. . Theobald, of Baltimore, calls attention to the eflicacy of the pyrophosphate of soda, in just such cases as the sulphide of calcium is supposed to be useful. "It should be given in doses of ten to twenty grains every two, three, or four hours, accord- ing to the urgency of the symptoms."^ But whatever means we choose, the anodyne, the sudorific, and the alterative form of treatment, both local and constitutional, will render the greatest aid to the surgeon and comfort to the patient. If, however, in spite of the above treatment, carefully and conscientiously carried out, the swelling in the auditory canal t and the pain increase, an incision carried through the soft tissues • will be the next best and the promptest means of depletion and abortion of the dift'use inflammation. This, under no circum- stances, is to be done blindly or empirically without due illumi- nation and examination of the canal by means of the forehead- 1 Monatsschr. f. Ohronh., No. 7, 1877. ^ Sexton, American Otol. Soc, 1879. 3 Philada. Med. News, Feb, 1882. i CIRCUMSCKIJJED AND DIFFUSE IXFL A M M ATIOX . 259 mirror and ear-funnel. The eye of the surgeon must learn now to diagnosticate the best spot for the incision, by the elevation • and redness, and not by using a probe to find out the tenderest spot for cutting. In this form of inflammation of the external ear, leeching has been advised by some authorities. I have not derived much satisfaction, although two or three large leeches in front of the tragus may give temporary relief to the pain. But the external ear and the parts about it, in this affection, are usually so tender that the mechanical irritation of the leech is most distressing. Therefore this mode of depletion becomes of little value in this disease of the canal. An incision is far better, because more quickly done than leeching, and hence tar less painful in the end. And being applied directly to the afifected region, is much more etiicient. Xotwithstandins: all eftbrts at abortino- the inflamma- CD O tory process, suppuration may ensue, and a spontaneous dis- eharo-e from the ear set in. The secretion in the diffuse inflammation of the auditory canal may be very copious, and of a sanious nature. This must be carefully removed, and the ear kept as clean as possible by frequent and gentle syringing with warm water, to which a little castile soap, table salt, or bicarbonate of soda may be added. If the secretion should be tenacious and tend to accumulate in large quantities, and syringing fail to remove it, it should be carefully and gently wiped out with cotton on the cotton-holder. The cottou-holder should never be used by the inexperienced or inexpert hand, as in that case it will prove itself as unworthy an instrument as an aurilave, or sponge tied to a stick, which pushes in much more than it brings out and 7iever fails to do harm sooner or later. As the copious serous discharge, often tinged with blood, diminishes, the running from the ear may assume a yellow color and become thick, but much less in amount. This will be apt to assume a chronic tendency, and the deeper parts of the canal, may be found red, disposed to bleed, and roughened into little hillocks. The discharo:e is so much thicker that it is not easilv removed, and excites a tendency to the growth of granulations near the membrana tympani. It becomes, therefore, extremely important to cleanse the ear at this stage and keep down the granulations. I have found that the principle of aspiration applied to the tumid and sluggish parts will not only cleanse them, but stimu- late them into a healthy activity. After cleaning the ear as thoroughly as possible, by syringing and the cotton-holder, especially in those cases where the der- moid layer of the drum-head has been greatly inflamed, thrown into hillocks, and suppurates freely at several points, I have 260 EXTEKNAL AUDITORY CANAL. seen through the Siegle pneumatic speculum, as I have sucked upon the India-rubber tube attached to its side, large drops o( pus ooze from the openings in the dermoid layer in quantities sufficient to fill up the fundus of the auditory canal. By this means it is possible to cleanse the inflamed deeper parts much better than by any other means. It is surely the most rapid and perhaps the only immediate way of doing it when pus has accumulated under the dermoid layer of the drum-head or in deeper tissues of the skin of the canal, which enter into the structures of an abscess in the w^all of this passage. Whether an abscess be of the nature which forms in circumscribed otitis, or the more diffuse and sluggish kind found at the subsidence of the diffuse form of inflammation of the auditory canal, this method of cleaning out the diseased parts may be used. At the same time that the pus escapes from the sodden parts in such a case as already alluded to, in which aspiration is employed, I have observed that minute drops of blood start out from the excoriated parts everywhere in the canal. This acts as a stimu- lant to these parts, which do not bleed w^hen touched with the cotton-holder; but their bleeding upon gentle suction with the Fis. 79. \/^0"\ A I i f-^-^^ "Hi ■:" ■«'! Insufflation of Powders into the Ear under Illumination bv the Forehead Mirror. Siegle speculum reveals their true sluggish nature and will guide in the treatment. When secretion has been fully established nothing will be found as efficient in checking it, and in preventing the growth of granulations, as insufHation of boric acid, in fine powder, or If CIKCUMSCR115E]) AXD DIFFUSE INFLAMMATION. 261 boric acid in coinbiiuition with tincture of callendula officinalis (Sexton), or boric acid and oxide of zinc, in equal })arts (Theo- bald), boric acid and chinoline salicylate, one part of the former to sixteen parts of the latter, or boric acid and resorcin, eight parts of the former to one part of the latter. The manner of in- suttlation under illumination of the external auditory canal is shown in Fig. 79. The excellence which all the powders named possess as healers of aural inflammation and discharge, while parth' due to their drying and detergent qualities, is greatly augmented by their antiseptic and bactericide nature. All powders should be blown gently into the meatus and auditory canal by means of a very simple instrument, which the surgeon can make for himself. Thus, take a foot of good, black or red rubber-tubing, since this kind is more flexible and durable than white, and to one end attach a quill-cylinder made from a goose-quill tooth-pick. This serves to take up the powder and carry it to and into the ear- funnel as far as the inner end of the latter. The ear-funnel should be adjusted first, and the canal viewed bv the lio:ht reflected from the aurist's forehead-mirror (see p. 161.) Then under this good illumination the quill-end of the blow-tube, in which a little of the medicated powder (about one-third of a quill full) may have been taken up, may be inserted into the ear-funnel, or speculum, as it is generally called in this countr3^ The quill-end-piece must be held as one does a penholder, aim can then be readily taken at the diseased spot, and the gentlest pufl'from the surgeon's mouth, in which the proximal end of the rubber-tube is held, will send the pow^ler to the diseased surface. All other forms of powder-blo\vers have the disad- vantage of beino; too laro;e and thus interfering w^ith illumination of the ear during the insuiflation, and hence w^ith taking accurate aim and directing the powder just where it is most needed. The method of pouring the powder into the ear-funnel and then into the meatus is wdiolly inefficient, since most of the powder will cling to the speculum, and none of it can be accurately placed in the diseased ear. That portion of the powder which may get into the meatus by the method of pouring would require ramming to get it in its proper place, and this part of the manipu- lation becomes an additional labor for the surs-eon and disasrree- able and painful to the patient. Further, there is always the risk of bruisino; or abradine: the diseased surface in the canal by any form of ramming the powder into its place. It is, there- fore, a wholly inconvenient, inaccurate, and dangerous method of applying powders to the ear. It will generally be found that the insufflation of powder in external otitis diflJ'usa w^ill prevent the springing up of granulations, or induce their hasty disap- pearance. If, however, they should prove exuberant they may 262 EXTERNAL AUDITORY CAXAL. be touched with a saturated solution of nitrate of silver, carried to them on a tuft of cotton on the cotton-holder. If the instillation of a liquid remedy be desired for any good reason in these cases, instead of the dry treatment by insufflation of powders, the following will be found efficient: R — Liq. plumbi subacetatis, Tl^ xx. Acid, acetici diluti, ttl vj. Liq. opii sedativi, TT^ xx. Aq. destillat., q. s. t^j. — M. The tinctura opii may be substituted in the above prescription for the liq. opii sedativus. Or a one-grain solution of sulphate of zinc, in water, or a solution of borax, or a saturated solution of boric acid may be of value. Ten drops of either of these w^armed may be instilled into the ear once or twice daily. If the discharge is copious, the surgeon may syringe the ear once or twice daily. But syringing is, as a rule, never to be entrusted to the patient or his friends. As it tends to induce and pro- mote the growth of granulations, syringing, as well as all other fluid applications to the ear, must be used sparingly, and prefer- ably only by the surgeon. The indiscriminate advice to the patient to syringe his ear and put drops into it has done more to promote ear-disease than to cure it, and hence medical advisers must endeavor to overcome the tendency, growing for many years, to the excessive use of syringing and other modes of applying water to the ear. If polypi should spring up, with well-defined base or pedicle, they must be extracted by one of the various means described further on, and their attachment to the canal thoroughly touched for several days with a saturated solution of nitrate of silver, or a very minute quantity of chromic acid. In every case where polypi are pulled out, the patient should be told before the ex- traction that it will be necessary to touch the base of the growth with the acid, or some other caustic, in order to effect a cure. The treatment just described is that adapted to the ordinary form of otitis externa diffusa with no worse complication than polypoid granulations or polypi; there are, however, several other forms of this disease, as already stated, viz., the diphthe- ritic, the gangrenous, the syphilitic, and the parasitic. The treatment will be modifled in the first three, by the fact that they are much more painful than the fourth, which, how- ever, causes some pain. As the first three indicate a constitu- tional alteration and poisoning of the blood, their treatment must be largely of a supporting and alterative nature. Their names will indicate the kind of blood-poisoning they are due to, and their general treatment must be conducted on the principles followed in the same diseases when the}' manifest themselves elsewhere in the body. CIRCUMSCRIBED AXD DIFFUSE INFLAMMATION. 263 Epithelial Cancer of the Auditory Canal. — Epithelial cancer may attack the tissues in the meatus after tirst appearing at or near the tragus. The growth at this point may rapidly ulcerate, and advance inward along the canal, with great pain in the ear. The wall of the meatus becomes covered with small, wart-like excrescences, the tissues in the canal become infiltrated and dis- organized, and the membrana tympani invaded and perforated. Fistulte may appear between the mastoid and auricle, and the canal be destroyed, and in its place a large opening may be made by the disease. The articulation of the jaw now becomes ex- posed, the lymph-glands in the neighborhood infiltrated, and facial paralysis, with exophthalmus and blindness in the eye on the affected side, ensue. ^ Death occurs in the course of a few months from the time of the first ulceration. The treatment can be only palliative. Otomycosis. — Judging from the literature of the subject and my own experience, animal parasites are found in the external auditory canal much less frequently than fungi. ]^o special 'name has been suggested for that form of diffuse external otitis excited by the presence in the auditory canal of animal parasites, but for that kind of aural inflammation excited by the growth of fungi in the auditor}^ canal, the general term otomycosis has been suo^o-ested bv Virchow. The subject of animal parasites and insects accidentally lodged in the external ear will be considered under the head of foreign bodies in the ear, but I shall consider at this point that form of diffuse external otitis produced by vegetable parasites. The most common cause of this form of otitis externa diffusa is the grbw^th in the auditory canal of that kind of fungus called Aspergillus. Its two chief varieties are A. nigricans and n|A. ilavescens, the former of which is found in the ear much ■ more frequently than the latter. The ascomycete, i. e., the ■ highest form of development of the Aspergillus, is, as we shall ■ see further on, of very rare occurrence in the ear. Other kinds lof fungi have been found in the auditory canal of man, viz.: the " Graphb.nn jyeiiiciUoi'des, by Hassenstein and Hallier; the Ascophora elegans, by von Troeltsch; the Tricoihecium, by Schwartze and Steudener; and the Mucor mucedo seufuscus, by Boke. The Aspergillus is so very much more common in its occur- rence in the external ear than any other fungus, that the aural inflammation it produces is named by AVreden, of St. Peters- I pburg, Myririgoinycosis aspergillina, for it has been observed that this vegetable parasite has an especial proclivity to grow upon the membrana tympani. ^ Delstanche, fils, Archiv f. Ohrenheilkuude, Bd xv. il II II 264 EXTERNAL AUDITOEY CANAL. f Myringomycosis aspergillina has been most thoroughly de- scribed by Wredeii/ but before his works were published, Mayer^ and Pacini,^ Carl Cramer* and Schwartze, had described the occurrence of this form of parasitic disease in the external ear. Subsequent to the appearance of "Wreden's papers, various authors^ have given fully detailed accounts of this disease and its successful treatment. In seventy-four cases of the disease observed by Wreden, only two forms of fungi have been found, viz., the A. liavescens, or glaucus, and the A. nigricans, except- ing in one solitary case^ in which there was found a fungus richly supplied with capsular sporangia or asci, and which, on account of its intense purplish-red color, was called by Wreden the Otomyces j^urjMreus. This fungus was examined by Woronin, a distinguished mycologist of St. Petersburg, who pronounced it to be essentially different from the Ascophora of Schenk, which belongs to the Mucorini. Upon further investigation, this proved to be the ascomycete or utricular form of the Asper- gillus nigricans. Its fertile hyphens were seen to have a double outline under the microscope, and at ditferent places transverse septa, like the fructiferous hyphens in the varieties of Asper- gillus which had already been found in the ear. The wddth of the broadest of them was 0.00572 mm. to 0.00715 mm. in diameter. The double-outlined wall of the fungus was of a bright yellowash-red color, 0.00143 mm. thick. The fruit-end of the hyphen was composed of a comparatively very large, red, round, vesicular sporangium, which consisted of a thick-walled capsule and a number of round spores, which completely tilled its cavity. The diameter of the large sporangia was 0.0572 mm. to 0.00435; that of the smaller ones w^as 0.02145 mm. to 0.0429 mm. The thickness of the capsule wall was 0.00143 mm. to 0.00214 mm. Dr. J. Orne Green ^ has lately published an account of tinding in the ear a similar fungus, which he calls Aspergillus rubens. Still more recent!}' Dr. Swan M. Burnett,^ of Washington, has described the occurrence of the Otomyces purpureus. Two forms of Aspergillus have been found in the ear of man, viz. : the A. nigricans and A. glaucus. Some writers allude to 1 Die Myringomycosis aspergillina und ihre Bedeutung fiir das Gehororgan, 1868; and Myringomycosis aspergillina, 1869-73, according to personal and foreign observations, Archives of Oph. and Otol., iv. i., 1874. '•^ Beobachtimgen von Cvsten, mit Fadenpilzen aus dem iiussi'ren Gehorgange, Miiller's Archiv^ 1844, p. 401. ^ Supra una mufl'a parasitica nel condotto auditiv esterno, Florence, 1851. * Sterigmatocytis a\itacustica, a variety r)f Aspergillus, Vierteljahrschrift d. Naturforsch. Ge'sellschaft zu Zurich, 1859-60 ^ Schwartze, von Troeltsch, Bi)ke, Politzer, Gruber, Weber-Liel, J. Orne Green, C. J. Blake, lioosa, Bezold, Luca', Nolting, Bezold, Theobald, Swan M. Burnett, et al. « Proceedings of Boston Society of Med. Sciences, 1875. ' Archives of Otologv, vol. x.,'l880. II CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 265 ail A. tiavesceiis, but this is probably only a darker-colored A. glaucus. Clinically it would be much better to call the A. niavr the A. major, and A. glaucus the A. minor, since the fornicr is so much larger tlian the latter. This difference in size as well as in other ways, is easily seen under the microscope, Macroscopically, there is no distinct and guiding difference in appearance between these two forms of the fungus. The micro- scope alone can decide which of the two forms we are dealing with, in a diseased ear. The so-called A nigricans is by far the more common in its occurrence in the ear of man than the A. glaucus, which is rarely found in the ear. I have found it only on^e in twenty- eight cases. ' These forms are easily distinguished from each other by the shape of their fruit-heads and the arrangement of the sterigmata JJiereon, and on these differences I would like to base their nomenclature. So far as their color is concerned, it is wholly unreliable as a diagnostic difference; in no instance is their color either clearly green or black. In all cases of ordinary asper- gillus the color is yellowish or brownish. It has never been shown that one form excites an inflammation different from that produced by the other. For the sake of uniformity and order, I shall retain the names A. nigricans for the larger, and A. glaucus for the smaller species. Microscopic Features. — The microscopic features of the growth of this parasite in the human ear are varied and full of interest. If a small piece of a colony of Aspergillus nigricans, in the ear- liest stages of its development, be examined under the microscope with a power varying from 250 to 300 diameters, a ffeld similar to that in Fig. 80 will be observed. It is, in fact, the first formation of rootlets or the mycelial web, from which, at a later period, the fruit- stalks or fructiferous hyphens spring. It will also be seen that some of the filaments composing the web tend to become bulbous at one end, and that the latter, as the stem grows, becomes larger and dotted (Fig. 81), until finally there is standing out from the dense web of mycelial filaments a perfect fruit-stalk and a fructiferous head — the latter ^ Figs. 80, 81, and 82 are from original drawings by the author. 266 EXTERNAL AUDITORY CANAL. studded with short peg-like limbs, the sterigmata, on the free ends of which are the spores. (Fig. 82, b.) All of these stages of growth I have watched in specimens of the fungus removed from the human ear. In the fluid parts of the specimen, epithelium may usually be seen, in small quanti- ties, as the parasite develops, as in the upper part of Fig. 81. Very rapidly, in the course of a day or two at most, the perfect fruit-stalk is formed in large numbers and in all stages of development, and the mycelial iilaments can be seen to be coarser and septate. On one hand may be seen a well-formed though unripe fruit-stalk and head (Fig. 82, b), while in the Fis. 81. Fis. 82. Tt ?: centre of the field there mav be seen the ripe, aerial fruit, from which the fullv grown spores drop literally in myriads. (Fig. 82, c.) ^ ^ \ , The characteristic difl:erence between the two vapieties of aspergillus, the so-called yellow and hlaek, is seen in the shape and size of the receptacaluin, and the arrangement of the sterig- viaia upon it, these tw^o parts forming the so-called "-head" or sporangium. In the A. nigricans (Fig. 82, b) the sporangia or heads are distinguished from those of the A. glaucus (Fig. 82, a) by the fact that in the first the sterigmata cover the receptaculum, which is spherical, on all sides, while in the latter, the lower fifth or fourth of the receptaculum, which is ovoid in shape, is entirely free from sporangia. Macroscojric Features. — The macroscopic appearances of a mass of this fungus, as found in or washed from the ear, are worthy of attention. If an ear containing a mass of aspergillus be ex- amined by means of an ear-mirror and ear-funnel, it will present most usually an appearance which leads to the supposition that the ear is occluded not by wax, but by a foreign matter of an I 'i organic nature. CIRCUMSCRIBED AND DIFFUSE IX F LA M M AT I OX. 267 ■ I If the fungus has not been growing \oug in the ear, merely a patch of pale yellow, pollen-like niattei', of varying diameters, will be detected at the fundus of the auditory canal. This small colony of spores just developing into filaments is usually situate on the mendirana tympani, or very near it. In any case, whether the first deposition of spores occurs there or not, the tendenc}' of the aspergillus is to grow over the drum-head first, and from that point it spreads outward covering the wall of the meatus, until a hollow cast of the canal is formed by tlie vege- table parasite. The pollen-like appearance is seen only in the very earliest stages of a growth of that which is finally a so- called lardaceous-looking or false membrane, either partially or entirely filling the external auditory canal. In some cases the fungous mass looks like a ball or plug of wet newspaper, and in others the ear may seem to be plugged with a substance looking like wool. An inexperienced eye might conclude that the occluding plug thus formed is of ear- wax; but ear-wax looks more solid, shining, and drier, and it never excites pain and infiammation in the ear like the fungus .aspergillus. i Another important point in diflt'erential diagnosis is, that a mass of aspergillus does not lose its coherence when subjected to immersion in water or glycerine; but a lump of ordinary hardened ear-wax soon melts, and is dift'used through the water or glycerine. Finally, the microscope would reveal the true nature of any mass removed from the ear. Aspergillus is usually found growing at the fundus of the external auditory canal. It seems to seek the most secluded pa:-t of the canal, and hence is most likely to grow first upon the membrana tympani, from which it spreads outward over the entire auditory canal, forming a kind of false membrane in the shape of a glove-finger. This false membrane is composed chiefly of mycelial network, with all forms of aerial fructifica- tion of the plant, and some epithelium from the auditory canal. ilffhe sporangia are usually found on the surface of the false 'membrane turned toward the membrana tympani, and the wall of the auditory canal. Although the most perfect forms of growth of the fungus are usually found near the drum-mem- brane, I have seen specimens so flourishing at the mouth of the auditory canal, that the latter appeared to be sprinkled with bright yellow pollen. In such a case, recently observed, the membrana tympani was not seriously implicated. Usualh , how- ever, the membrana tympani and the skin of the canal near it are inflamed by the aspergillus. li^ An auditory canal which has been the seat of inflammation "is most liable to be invaded by the aspergillus. It seems that It 268 EXTERNAL AUDITORY CANAL. i the remnants of the inflammatory disease, such as pus, dried mucus, epithelial debris or blood, form excellent soil for the growth of the parasite. An active discharge from the ear, how- ever, is unfavorable to the growth of aspergillus in the canal. Aspergillus cannot be in an auditory canal for any length of time without causing the characteristic symptoms of its pres- \ ence; an exceptional case would seem to be one reported by I Moos.^ The growth of an aural fungus is usually confined to the f cutis of the membrana tympani, as shown by Wreden, but, in very rare instances, the parasite may invade the fibrous layer of the druni-head, and finally take root in the cavity of the tym- panum, as has been observed by Politzer^ and others. Symjptoms. — The symptoms of this disease are a sense of fulness, sliglit pain, burning, itching, tinnitus aurium, and hard- ness of hearing. The vessels of the malleus become congested, and in a day or two the membrana tympani becomes hidden by a thick, white, false membrane. The slight serous discharge which now sets in, marks the detachment of the false membrane, and the cessation of the pain. In some cases the cutis of the auditory canal becomes deeply inflamed, but not invariably. Tlie pain may become intense if the parasite is not removed. Men are more frequently attacked than women, according to Wreden, w^ho has seen fifty-one of the former, and twenty-three of the latter sex, aftected by fungi in the ear. In twenty-eight cases of this disease which have come under my notice in private, it occurred ten times in women, and , eighteen times in men. Both ears were aftected in six instances. So tar, this disease has never been found in very young children. The oldest patient I have observed with this disease of the ear was a man seventy-seven years old. | The following case, in which a perfect mycelial tube-cast of the auditory canal was removed hy the author, will supply all the typical features of an ordinary attack of the disease, and will be seen to agree in the main with the observations of others. The patient was under treatment for so-called chronic catarrh of the middle ears, complicated by ozfena. She stated that for more than a year she had had, from time to time, sudden attacks of pain in the left ear, which lasted for a day or two Avith more hardness of hearing, and then suddenly ceased, with a slight watery discharge from the aftected ear. The hearing then returned to its relatively normal state. When she told me this she was free from pain, and the drum-head and auditory canal were in the condition usually seen in a case of ordinary 1 Archiv f. Ohrenheilkunde, Bd. ii. p. 155. 2 Wiener Med. Wochenschrift, 28. 1870. • I I CIRCUMSCRIBED AND DIFFUSE IX FL A M M A TIO X . 269 ^progressive hardness of hearing, with intact but opaque drum- head. Within ten days from that time she came to me, stating that she had had, two days before, an attack of the pain ah'cady •described, and that there was still a little discharge from the ^ar. I examined the ear and found the inner portion of the osseous auditory meatus and the membrana tympani covered with a lalse membrane looking like wet newspaper. I instantly inferred the presence of a fungus, and removed the false mem- ^brane very easily by means of a pair of forceps. The removal f the false membrane caused no pain, nor were the parts eneath it very red and sensitive. There was a slight serous ischarge from the ear, a drop of which I examined immediately upon a carefully cleansed slide under the microscope, and found that it contained no pus, but myriads of brownish-yellow spores ■ iof the Aspergillus nigricans and vibriones.^ If The tube-cast into which the mycelial false membrane had ' been moulded, was composed chiefly of thalli, and upon its sur- t, face were free spores and tufts of aerial fructification of the A. %dgi'icans; throughout the false membrane thus formed were iBcattered epithelial scales. The hyphens, or fruit-stalks, w^ere not septate, and their large, ■ ^bulbous ends, from which the spores rise, were a beautiful 1 fgolden-yellow color, and resembled, in their general shape and appearance, an ordinary onion-top. In reference to the etiology of this case, it may be stated that the patient had lived for some time in a very damp house, the .cellar of which was " covered with mould," but before she had ^ fbome to live in that house she had never suffered from any fungus-disease in the ear, as far as she knew. The chronic disease of the ear may have predisposed the organ to a development of fungi, such a tendeacy having been found _iii other cases of chronic aural disease, by Wreden and various I iobservers. I I The hearing was impaired only from the onset of the pain "'until the false membrane w^as removed. An attempt to remove the false membrane in these cases is usually followed by pain, sometimes bleeding, Aspergillus not only spreads from the drum-head to the wall of the auditory canal and rice versa, but it perforates the drum- head sometimes, and finds its way into the drum-cavity, as in ^the case reported by Politzer.- jl i The following case is one of growth of aspergillus in the ■^ - ' Pouchet (comptes rendus, 1864, p. 148) has found bacteria and vibriones in a discharge from the ear, attended with itching. Hinton, Questions of Aural Surgery, London, 1874, p. 79. - Ueber pflanzliche Parasiten im Ohrc., Wiener Med. "VVochenschr. , 1870, 28. fi 270 EXTEEXAL AUDITORY CANAL. tympanic cavity : A young lady, 18 years old, applied in the autumn of 1872, to the author, for relief from a slight but con- stant discharge from the left ear. She stated that the discharge had never been attended by pain, that it was light colored and almost transparent. I found the external auditory canal free from disease of any kind, but- the drum-head was destroyed excepting in the region of the tympanic folds ; the malleus was still present. It was impossible to find out how long the fungus had been growing in the ear, for when it was first detected b}' the patient's bringing me a flake, dotted with blackish spots, which she had removed from her ear, there were no subjective symptoms difi'erent from those which had been connected with the case for years, according to her statements. In order to allay a little itching in the ear, the patient had thrust a hairpin into'^the tympanic cavity, through the largely perforated membrana tympani, and had pulled out the whitish scale, studded with black spots alluded to. That this specimen was pulled from the tympanic cavity was fully proven by the patient's using a hairpin again and bringing out in my presence more fungi on similar scales, which were instantly examined under the microscope. The auditory canal was, and had been for months pre\aous, free from all traces of anything of this nature or appearance, for she had been under constant treatment for the chronic dis- charge, which had obliged her to syringe the ear several times daily. By the use of instillations of absolute alcohol thrice daily, and syringing the ear with warm water, ail traces of the fungi and the discharge disappeared, and the ear remained free from itching and serous discharge for some weeks. Although the patient was living in afiiuence and perfect hygienic surrround- ings, the itching an^ discharge again returned, but all the symptoms were once more relieved by the use of alcohol-in- stillations in the ear with careful and thorough s^'ringing. This case I mention as a proof that otomycosis is not neces- sarily a disease of the external auditor}- canal, although as a rule it is. In the case just narrated, perhaps we have a very rare exception, unless it can be shown that in many cases a thin serous or sero-puruleut discharge from the middle ear, is kept up bv the presence of fungi. Perhaps this ease began as one ot myringomycosis in which the fungus, after destroying the drum- head, excepting in the region of its folds, penetrated into the drum-cavity and flourished there. Etiohgii. — Respecting the etiology it may be stated that, pre- vious disease of the ear, especially when limited to the canal, and the use of oleaginous remedies for difterent aural diseases are the most fruitful causes of this malady. RCUMSCRIBEl) AND DIFFUSE INFLAMMATION, 271 Otomycosis is said to be mucli more frequently met among the poor than in the richer classes of any country. My experience is just the reverse. As the climate, and consequently the dwellings, of northern continental Europe are damper and, on account of the cold, kept more closed than in this country, we can account for the fact that this disease appears to be more frequent there than here, and therefore attention has been called most thor- oughly to this form of aural disease by writers in Germany and JRussia. ^ y Mr. Hinton, of London, has rarely found aspergillus in the ear: but Dr. Cassells, of Glasgow, has met with it frequently in his experience. If search were made more frequently for it, aspergillus would be more frequently found. Previous diseases of the ear, especially those productive of exfoliation of epi- dermis, and those which have left behind them collections of dried pus or any of the products of inflammation, in the auditory canal, may induce a growth of vegetable saprophytes. It is now established beyond doubt, especially by the investi- gations of Bezold,^ that the use of oil in the ear for pain is one of the most fruitful causes of the grow^th of fungi in the auditory canal and on the drum-head. Oils and all forms of grease put into the ear are usually forgotten, when the pain is gone for which they were applied. They soon become rancid, and thus favor the growth of vegetable parasites, which finally produce all the well-marked symptoms of otomycosis. This fact furnishes the strono;est arajument against the com- mon and senseless use of sweet oil for all ear-diseases. It is entirely useless as a remedy for pain, and worthless as a solvent for inspissated w^ax; for a little reflection wall at once make it apparent that oil will not dissolve the semi-oleaginous ear-wax, but that to soften and detach it we need only a slightly alkaline wash. This is not onlv more efficient than oil, but cleaner and free from the danger of encouraging the growth of fungi. H It would also be w^ell for physicians to see that salves and ■ointments, which nmst be prescribed sometimes for aural maladies and applied to the auditory canal, are thoroughly washed out at last, when all further need of their presence in the canal has ceased. In some instances, though a pure' form of aspergillus may invade the fundus of the auditory canal, a bastard form of aspergillus and penicillium may spring up nearer the meatus. This has been observed by Hallier and Blake.^ Treatment. — The treatment of otomycosis of the fundus and ^alls of the external auditory canal, induced by the growth of I ' Die Entstehung von Pilzbildung im Ohr. Monatsschr. f. Ohrenh., Juli, 1873. ' Dr. C. J. Blake; Parasitic growths in the meatus auclitorius externus, Trans- actions American Otological Society, vol. i. p. 170, 1871. i V 272 EXTERNAL AUDITORY CANAL. aspergillns, consists first in destroying and removing the para- site, and, secondly, in allaying the inflammation which its growth in the ear-canal has caused. The destruction of the parasite is most easil}' and efliciently accomplished by thoroughly filling the fundus of the canal and all other parts of the external ear, aflected by the growth of the fungus, with powdered boric acid, borax, or boric acid in combination with chinoline sali- cylate (one of the latter to sixteen of the former). Thorough syringing, on the part of the surgeon, will accomplish the re- moval of all parts of the mycelial false membrane, which may have become detached from the wall of the auditory canal. 1 Those portions of the parasitic growth not spontaneously de- 4 tached, can generally be loosened or wiped from their seat by i means of the gentle use of the cotton-dossil on the cotton-holder, under thorough illumination of the affected parts by the fore- head-mirror. The method of application of these, or any powders, to the affected ear is by insufflation, as described on page 261. An ear affected with aspergillus should be seen every day by the surgeon, who alone should syringe it, and thus re- move the loosened portions of the membrane. After the ear is i thus cleansed, a fresh insufflation should be made of one of the I powders named above. This is by far the quickest method of v destroying aspergillus in the ear, and of allaying the inflamma- ^ tion it has produced. The substances named as useful powders, owe, doubtless, their ^ virtue to their antiseptic and germicide properties. I have i found it useful, after all signs of the growth of the parasitic if fungus and inflammation have disappeared, to allow^ the powder H to remain a little while in the ear — it may remain there indefi- j nitely without injury — in order to sterilize thoroughly the pre- - viously affected parts. j Until w^ithin a year or two, I had always employed as a germi- 1 cide in these cases alcohol, either pure or diluted with water, in J varying quantity, to suit the feelings of the patient. For in \ many instances, especially when the fungus had grown some \ time and the tissues had become broken, intense smarting i ensued upon applying alcohol, even diluted, to the inflamed ] skin of the auditory canal. Alcohol is undoubtedly an efficient 1 parasiticide, but it does not act as rapidly as the powders named, j it is not as easily applied, nor is its use in the ear free from dis- | comfort to the patient. In some cases, however, when the | surgeon cannot see the patient every day, the latter may apply i to his ear, once or twice daily, alcohol diluted to a point suf- i flcient to make its application painless. By allowing the alcohol I to remain in the ear for some minutes, the patient ma}' thus ^ apply an efficient parasiticide to his ear. This treatment, how- ever, is only supplemental to that by insufflation of one of the 6 FOREIGN BODIES. 273 germicide powders named. It must be repeated here that the patient is not to be entrusted with syringing his own ear. This is especially important because of the natural tendency of the ear thus affected with the growth of aspergillus, to develop an eczfnia of the meatus, concha, and pinna. This eczematous tendency is fostered by using the syringe freely, as patients to whom syringing is entrusted are most likely to do. Many other substances have been recommended as efficient parasiticide ap- plications to the ear when invaded by aspergillus. Until lately these have been applied in solution. One of the most soothing is said to be hypochlorite of lime, grs. ij, to water fsj. This certainly would come next in value to alcohol in the list of fluid applications. But the less dependence placed ui:)on fluid appli- cations to the ear in these cases, the better for the patient. Since the recommendation of Bezold, of Munich, to use pow- dered boric acid in cases of otorrhoea, this dry form of treatment has been found of greater aid than the fluid form. Theobald, of Baltimore, has used with advantage in these cases, a powder X)f equal parts of oxide of zinc and boric acid.^ Jl The masses of fungus which have collected in the ear — and these may be so great as to extend from the fundus of the audi- tory canal to the meatus externus — should be removed as quickly as possible. The detached masses are easily extracted from the ear by syringing; the adherent ones can usually be pulled away by gentle traction, or a safer plan would be to go on with the use of the parasiticide until the layers of the fungus are spontaneously detached, when they can be syringed out. tt CHAPTER II. FOEEIGN BODIES IX THE EXTEKNAL EAK. Animate as well as inanimate bodies are frequently found in the external ear. The former may become of great surgical importance from the annoyance, inflammation, pain, and deaf- ness which they are very apt to produce, as well as from the fact that they may find their way into the middle ear. M The source of foreign bodies may be either from within or without. Under the first class may be placed : abnormal col- 1 American Journal of Otology, vol. iii. p. 119, 1881. 18 274 EXTERNAL AUDITORY CANAL. J'j lections of ear-wax from the cerurainous glands ; masses of horny epithelial scales, forming the so-called Keratosis ohturans of "Wreden ; and collections of stiff hairs from the tragus and audi- tory canal; also clotted blood, inspissated aural discharges, scales of dead bone, and, in one sense, many of the new forma- tions in the external ear. But, of these varieties of foreign bodies, only the first three will be considered here ; the re- mainder are discussed elsewhere. Under the second head may be classed all animate or inani- mate things small enough to have gotten into the external ear from without. The manner in which they may get into the ear is extremely i varied. Foreign bodies of this class are most frequently found "■ in the ears of children, where they are placed usually in play, by the victim or his companions ; or foreign substances may be thrust into the ears of adults and of children by accidental or intentional violence. Animate bodies fly or crawl into the ear of man, FOREIGN BODIES ORIGINATING IN THE EAR. Collections of Cerumen in the Ear. — According to Petrequin, the cerumen consists mainly of fat and combinations of potash and fatty acids in the following proportions : In 100 parts of i cerumen are found 10 parts of water, 26 of fat, 38 of soapy 'f\ combination of potash soluble in alcohol, 14 of a similar com- bination insoluble in alcohol, and 12 of entirely insoluble organic f matter, with traces of chalk and soda. The name of cerumen is probably a corruption of a word com- pounded of cera and aurium, the wax of the ear. The word J cerumen, however, does not appear in modern Latin dictionaries. The appearances of an impacted plug of cerumen in the external auditory canal are not very varied. Usually, it is easily recognized, but now and then, especially when the impacted mass is due to slow accretion by the daily pushing in and smoothing down of its layers by the towel or fingers of the patient, it will not be "easy for the unpractised eye to recognize the mass at once as one of cerumen, for, in some cases, the im- paction has so completely adapted itself to the fundus of the meatus and the drum-head, as to resemble a dark and polished membrana tympani. In many cases such a polished mass of cerumen has been regarded as a somewhat abnormally colored drum-head, and treated as such, the deafness dependent upon the impaction of the wax being attributed to other causes,, and in some way connected with the " discolored membrana tym- pani." Such failures in diagnosis lead to curious results. It is, indeed, not uncommon to find patients suffering from i FOREIGN BODIES. 275 impaction of cerumen in the auditory canal, being treated for some other aural disease with which they are not attectod. Thus, the Eustachian catheter and instillation of nitrate of silver have been applied to relieve the deafness which a proper syringing would have speedily cured. ^ " The mere fact that the drum-head is hidden from sight should be suthcient proof that an abnormal obstruction has occurred in the auditory canal, and this alone ought to be considered as the probable cause of the unpleasant symptoms for which the patient -seeks relief. These unfortunate failures in diagnosis are but Ithe natural result of the unwillingness on the part of most medical men to devote any time to the study of diseases of the ear, but they are mistakes which might be prevented if the general medical eye were at all familiar with even the appear- ances of a normal drum-head and auditory canal. In fact, many an ear might be saved if the physician first consulted, could frankly state to the patient the nature and locality of his aural disease, although he might be unwilling to assume the treat- . ment of it. ^ The rapidity with which masses of cerumen accumulate in the external auditory canal varies greatly. In some indi- viduals, I have removed second and third obstructive plugs in the course of a few months. In other cases, judging from statements of the patients, the plug must have been accumu- lating, and giving some annoyance in the form of tinnitus and deafness, for years. As a rule, the deafness caused by a plug of cerumen in the auditory canal is of sudden approach, although the foundation of the offending mass may have been much an- terior to the hardness of hearing. In most cases the aggravated deafness comes on suddenly after a bath, or when the patient has a coryza, as in the latter instance the walls of the auditory canal may become a little swollen about the obstructing mass. In the former case, the patient thinks that water has gotten into his ear and is still there. In reality, the mass which has, up to the time of the bath, permitted the sound-waves to pass it, becomes swollen by the water which has gotten into the ear, . thus cutting off all approach to the drum-head. In vigorous 1 1 washing with a cloth, not only the water, but the patient's ■ I finger, "by pushing the plug further in, may contribute to the " onset of the hardness of hearing when a plug of cerumen has formed in the canal. Etiology of Rapid Formation of Cerumen. — There are many opinions respecting the cause of a rapid and abnormal secretion of cerumen, such as is seen in all grades of life. As the ceru- minous glands are really modified perspiratory glands, it is reasonable to suppose that a large amount of cerumen is in some way connected with the perspiration. Large amounts of ceru- I I) 276 EXTERNAL AUDITORY CANAL. I' men are found in the laboring classes, whose perspiratory system is, of course, very active, and I have observed that in persons leading a life of ease, in whom large and rapid masses of ear- wax are sometimes formed, the perspiratory glands in the axilla are unusually active. But I am not prepared to say that when- ever the axillary glands are unusually active we are sure to find large amounts of ear-wax in such cases. After certain acute processes in the ear, as, for example, furunculi in the canal, or an otitis media acuta, which has healed rapidly, I have ob- served a tendency to a rapid formation of normal wax in the ear. This is apparently due to the stimulation of the circula- tion of the meatus consequent upon the acute inflammatory aural disease. It is held by some that quinine, which affects the nervous structures of tlae inner ear, may also have great influence over the circulation of the external and middle ears, and that, there- fore, the secretion of cerumen is stimulated by this drug. The amount of cerumen is sometimes increased, after a tonic course of treatment for the general health, in certain cases of deafness, and also after local treatment tending to stimulate the circulation in the auditory canal. The repeated formation of obstructive masses of cerumen in the auditory can'al, which appears to be an idiosyncrasy in some cases, is probably, therefore, due to active circulation in the skin of the canal and its wax-glands. Great care must he taken to discriminate between impaction of cerumen and keratosis ohturans, a disease to be described hereafter. When the onset of hardness of hearing in cases of impacted cerumen is rapid, it will usually be found that the mass has formed without the knowledge of the patient, and is in no way due to his endeavors at cleansing the auditory canal. When the deafness due to impacted cerumen has been coming on slowly for months, sometimes for years, it will usually be found that the patient has been in the very bad habit of swab- bing out his ears, most commonly with the rolled-up corner of a towel, and sometimes with that most pernicious and repre- hensible implement, a piece of sponge fastened to a stick, and sold by druggists under the high-sounding name of an " aurilave." In these cases the plug will be found well packed in and moulded to the fundus of the auditory canal and drum- head. Such masses are not very hard to remove, considering the long period of their accumulation; they are usually found to contain large quantities of short libres of cotton or linen from the towel used in the efforts to cleanse the ear. Impaction of cerumen by attempts at cleansing the meatus not only occurs among adults, but is found among children. IP FOREIGN BODIES. 277 ■whose over-anxious attendants are constantly swabbin;-- out the meatus of their charges, with a corner of a towel, or with other means.' Such cases may sometimes result in a chronic ulcer of the bonv i)ortion of the auditory canal, or in the <2:i'0wth of a laro-e poly[Mis from an ulcerated spot on the wall of the bony canal very near the drum-head. In these cases of artificially impacted epidermis and cerumen, the foreign mass usually assumes the form of a hollow cast of the auditory canal, or a glove-iinger, with a cast of the drum- _ , head on the tip. These cases are usually stubborn, and in some 1 3 instances threaten the integrity of the bouy structure of the If auditory canal. In a case which I saw recently, not oidy a polypus sprang ™ . from the ulcer in the auditory canal, but the drum-head was I 9 ulcerated through, and water passed into the pharynx when sj'ringed into the external ear. ^ The patient, a boy eight years old, was carefully watched over by his nurse, who used daily the so-called aurilave, upon the little patient's ears. The impacted mass of epidermis and cerumen at last excited pain in the ear, and upon removal of the mass, which came out in the glove-finger shape, the skin of the auditory canal was found to have assumed almost the appearance of a mucous membrane. The most ulcerated por- tion was at the anterior wall near the drum-head, and the latter was perforated largely at the postero-inferior quadrant. The discharge was rather thick and dark-colored, not very copious, somewhat ofi^ensive, but the hearing was very little altered. A polypus sprang from the ulcerated spot on the anterior wall of the canal near its union with the membrana tynipani. Treatmerd. — The treatment of simple impaction of wax in the ear consists in the use of the syringe, as explained already (pp. 170,171). I II I I I J Cretaceous Bodies in the External Auditory Canal. — According to Ran- cretaceous masses in the auditory canal are the rarest kind of foreign bodies found in the ear. But accounts of such bodies being scattered throughout the works of other writers, they appear not to have been very uncommon. Du Verney and ' Similar conditions of the ear have been observed by Mr. Hinton, of London. See supplement to Toynbee on the Ear, London, 1868, p. 429. ' Ohrenhcilkunde, pp. -367, 868. The authorities i^iven are, Thom. Bartholini, acta medica et philosoph. Hafniensia : ann. 1671 et 1672, 4 T. I. p 82. L. C. F. Germanni, de miraculis mortuorum libritres. Dresd. et Lips., 1709, 4 Lib. 3, Tit. 3, Sect. 50, p. 1090. Du Vernev, p. 156. C. J. :Mvller miscell. nat. cur., Dec. 2, Ann. 6, Ubs. 262, p. 326. Collomb, (Euvres Med. Chirurg., Paris, 1790, p. 804. 278 EXTEENAL AUDITORY CANAL. Lesclievin^ appear to have had frequent examples of them in their experience, and in Williams's Treatise on the Ear- (Lon- don, 1840), the statement is found, on the authority of Auten- reith, of Tiibingen, that "in the bodies of almost all old people there is found, in the innermost part of the meatus auditorius externus, a firmly attached lump of indurated ear-wax, which, in old age, acquires a disposition to crystallize, partly in an earthy form," and also that "Morgagni has found the cerumen of the hardness of stony matter." But these bodies are not frequently met in the present day. I am not aware of any record of such a case in modern literature, nor have I ever met such cases in the many hundreds of ears of old people I have examined in various iniirmaries. But, since it is a well-known fact that mineral substances, such as potash, chalk, and soda, enter into the composition of the cerumen, it is not improbable that now and then stone-like bodies are found in the auditory canal, which owe their existence to the mineral elements of the cerumen. Treatment. — If such bodies should be found in the ear, the treatment of them may be eifected as detailed in the o-eneral summary at the end of this chapter. Laminated Epithelial Plug in the External Auditory Canal. — This obstructive disease of the external ear was first described by "Wreden,^ of St. Petersburg, and named by him keratosis ob- turans, in contradistinction to ceruminosis obturans, the im- pacted plug of ear-wax, with which it has often been confounded, though differing from it very widely. The latter disease, as its name implies, consists of a mass of inspissated cerumen, but it is easily removed by proper syringing, and the ceruminous nature of the mass removed from the ear is recognized, among other features, by the rapidity with which it dissolves in water. Keratosis obturans, however, recently described as a separate and special disease of the ear, is a collection of epithelial lamime, derived from the cutis of the external auditorv canal, of gradual accretion, causing great deafness, and very obstinate in its re- sistance to removal. Every one who has had any extended experience in removing from the ear impacted endogenous masses, usually of cerumen, must have noticed that now and then a peculiar mass is encountered, requiring a piecemeal re- moval by patient, and careful use of syringe and forceps, and which, after lying a long time in water, will not dissolve as ordinary ear-wax does. Wreden having investigated such exceptional masses, and, finding that their composition is not 1 Lincke's Samniluiii;-, I. No. 1, p. 29, 1835. ' Page 184. •'' Archives of Oph. and Otol., 1874. i I FOREIGN BODIES. 279 n of eeruinen but of the lioniy elements of the cutis, he has pro- ■ *posed for them the name of keratosis obturans. Beneath these masses, in a typical case, the membrana tympani will be found normal in appearance and usually unimpaired in function. The hearing, as a rule, is good after the removal of the mass of epi- thelium. Not so, however, in the so-called cholesteatomatous masses found in the canal and middle ear. These obstructive bodies are not confined to any age or sex. Upon inspection of an ear containing such a mass as has been described, a thin layer of ordinary cerumen may be seen covering the outer surface of the plug, and hence the impression is often A ^gained that the case is one of ordinary ceruminous impaction. ' But continued syringing, by its barren results, soon convinces the operator that he has encountered no such ordinary ob- struction. The first case of this disease I had the opportunity of ob- it serving occurred in July, 1874, since which time I have seen a number of cases in private as well as in the infirmary. The patient I. w^as a banker, sixty years old, sufi:ering from sudden and intense 'deafness in the occluded ear, with some tinnitus and vertigo. jThe auditory canal was almost entirely blocked up by the dense, ' horny mass, with the outer end covered by cerumen. The patient stated that ten years previous he had been liable to attacks of pain in the auricle, especially about the lobe, which were follow-ed by a crop of vesicles and pustules, probably a d I form of herpes zoster. Since then he has had no pain in or about the ear, but at times he has noticed, w^ithout any ap- parent previous cause, a thin and somewhat oflensive discharge. I f At first sight I thought the case one of impacted cerumen, mingled possibly with inspissated mucus and pus, but the utter failure of the attempts with the syringe to move the impacted mass at the first sittino- convinced me that the case was one of those described as keratosis obturans. H Owing to the fact that the auditory meatus w^as rendered abnormally tortuous by two large exostoses of the canal, one above, the other below, it required patient and careful picking and syringing for half an hour for eight days before all of the I I foreign body was removed, with, at last, a restitution to normal 1 1 hearing. From statements of the patient, it appeared probable ' that similar though smaller and less annoying plugs had been removed from the same ear before, by himself, but he could not give any idea as to the length of time the present one had been 1 1 forming, as the onset of deafness, the only symptom first at- tracting his attention to the ear, had been almost instantaneous. This patient had a slight return of the disease, one year after the above attack, but it was entirely removed by soaking the 280 EXTERNAL AUDITORY CANAL. | mass repeatedly for twenty-four hours with a sokition of bicar- bonate of soda, gr. xx, in glycerine and water, aa fgss. Usually in these cases of keratosis in the external ear, part of the mass comes away as a coherent plug, but most of it must be broken down and removed in small pieces. In the case narrated, about half of the mass was removed as a well-defined plug. When the horny and laminated mass is first washed out of the ear, it is perfectly white, and resembles a set of layers of wet tissue-paper slightly separated from one another by the buoyant efl:ect of the water. When pressed upon, it has the tough, leathery feel of a wad of wet paper, which peculiarity will always distinguish it from the ordinary cerumen-plug of soft and greasy consistence. As insolubility of such a mass is one of the distinctive features of this peculiar aural disease, a mass may remain as long as five months in glycerine and water without undergoing change. I exhibited such a mass at the Philadelphia Pathological Society, in December, 1874. This specimen, for several months longer, lay in the same preservative fluid, and still there was no disso- lution of the mass. Of course, had the mass been formed of ceruminous elements, it would have melted down almost in- . stantly, and distributed itself throughout the fluid. This resist- ance to solution will readily account for the ditficulty of its removal from the ear. The walls of the canal, from which a keratoid mass is removed, are usually ulcerated at some point, sometimes at several places. Granulations of a most sensitive nature may be found near such spots. Etiology. — Ko cause has been suggested for the occurrence ot this disease of the external ear, and, although among the laminse composing these masses Wreden has sometimes found vegetable spores, he is not inclined to ascribe the origin of the mass to the irritative presence of a fungus in the auditory canal. The chronic inflammation and desquamation in the skin ot the auditory canal* in these cases, may have been set up and favored by the undue efforts at cleansing by the use of a swab, which, unfortunately, some individuals expend upon themselves and upon those under their care. Excoriation is first brought about, and then a slow exudation of dermoid cells goes on, and these desquamated elements of the cells are packed in and mechanically retained in the canal. As the mass of hard epi- dermis increases in size, it presses on the skin of the canal, and tends to increase the local irritation. So great is the pressure and so sensitive is the inflamed skin, in many cases of this de- squamative aflection of the ear, that the presence of these lami- nated plugs is often attended with great and constant neuralgia in the auditory canal, and in front of and behind the auricle, and even over the temple. These plugs are so hard that they FOREIGN BODIES. 28 L retain any diseharg-c wliicli may emanate from the inflamed surface. In this way tliey further tend to keep up irritation and pain, and to complicate the disease, g ^ Treatment. — In cases showing a decided tendency to recurrence t)r renewal of these masses in the ear, care in preventing an accumulation of the horny lamime, by close watching and speedy removal of the slightest amount of scales, will greatly simitlity the disease and the treatment. The solution of soda already mentioned (p. 280) will he the simplest and the best loosener of the plug from the wall of the canal, but sooner or later recourse must be had to forceps and blunt probes. This disease seems to furnish the exception to the rule of treatment, never to use anything more forcible than the stream from the svrino;e for the removal of foreis-n bodies from the ear. Of course, the greatest care must be observed in the use of such instruments, and no one but the most experi- enced surgeon is justified in attempting to remove such a mass by instrumental means. It is with great caution that I advise their use, and still greater caution that I use them; but as I have resorted to them, and only by their use succeeded in removing the keratosis, I must, in these cases, give their due to such instruments. With perfect illumination of the meatus, proper instruments and cautious movements, added to a thorou2:h knowledo;e of the use of the implements and the part to be operated on, success must attend their emplovment. Fig. 83. Delicate Forceps for removal of Foreign BoniES from the Ear. The forceps, represented in Fig. 83, same size as original, is made to open and close very gently, and, being slender, cannot take a very firm hold upon the impacted mass of keratosis, but 282 EXTERNAL AUDITORY CANAL. 1 it is strong enough to pick off and lift away portions of the obstruction. The loss in strength caused by the narrowness of the branches of the instrument is fully compensated in the greater illumination gained by its slender shape, and it is also a i] much safer instrument than the stronger, thicker, and stiffer i forceps usually made for removing foreign bodies from the ear. l For removing objects more delicate than masses of keratosis I obturans, it is of the greatest value. It is just as necessary to i^ have such a delicate instrument as this to lift things from the •(, ear, as it is to work with delicate and very pliable forceps in ii( manipulating small objects undergoing preparation for micro- scopic use. In fact most aural instruments are too large. Illumination of the canal is thus too often sacrificed to the ^ strength and size of the instrument. I fully agree with those who earnestl}' deprecate the use of any other instrument than a syringe, for the removal of foreign bodies from the ear. The forceps, or any other instrument for removing objects from the ear, must never be tried until all other means have proved of no avail, and then only in the hands of the most experienced and under the most perfect illumination; for any manipulation of the ear resembling a blind grappling '}^ after the foreign body will most surely prove disastrous. Un- fortunately, the proper occasion for the use of the forceps is i almost invariably in an emergency, and is performed by the i most inexperienced hands. An examination into the facts of t the case, moreover, where they must finally be used, will usually "j reveal that originally they were not needed, and the simplest syringing at the outset would have rendered the use of any other instrument unnecessary. The only justifiable use of forceps at the outset may be in a li case of keratosis obturans, but even in such cases all instru- -f ments must be used with the greatest caution in conjunction i\ with repeated and thorough syringing. The accidents happen- ing to the ear from the ignorant use of instruments for the removal of foreign bodies, have been very numerous and are in- creasino; in number all the time. Seborrhcea of the External Auditory Canal. — This cutaneous disease is sometimes found in the auditory canal. It usually ^s affects both ears at the same time, and women are more apt to be the subjects of the disease than men. The patients complain of having felt some pain or itching in the ear or ears, which has led them to make various applications to the affected parts, and to scratch the ears with different implements, most usually a pin. This may lead to infiammation and still greater pain. They f^ generally find, sooner or later, that their ears are full of in- spissated matter, in crust-like pieces, which they consider dead FOREIGN BODIES. 283 skin. In consequence of this accumulation there are more or less hardness of hearing and tinnitus aurium. It is for these last-named symptoms that they seek relief. r[)on inspection the surgeon linds the auditory canal filled with grayish-white, thick sc-ales, more or less united into a pellicle, clinging to the wall of the canal and extending over the membrana tympani. The calibre of the canal may not be entirely tilled with this mass, but the drum-head is covered by it. This obstructive matter can generally be removed by forceps, and, owing to its tough coherence, it may be got from the ear in a rougli cast of the canal and the drum-membrane. The hollow of this cast is dry, but tlie surface, which has been lying against the cutaneous lining of the osseous part of the canal, will be humid. This humidity is not due to pus, but rather to a semi- fluid sebum. The wall of the canal against which this sebor- rhoeic mass has been lying is found to be red, tumid, and sen- sitive to the touch, and sometimes granulations, or even polypoid exuberances of the latter, are present. This disease is very frequently mistaken for eczema, but eczema rarely attacks the canal. If it is found in the canal, it will be seen that the auricle is also eczematous. In the disease under consideration, however, the auricle is entirely unaffected. These seborrhoeic masses form very rapidly, often in the space of a week, after the disease is fullv developed. ■ • Treatment. — The seborrhoeic masses must be carefully removed and the tumid and diseased surface of the skin of the canal treated. At the same time the general health, which is often found depraved, must be invigorated. The administration of Fowler's solution will 'greatly facilitate the cure of the skin disease in the ear. The local treatment should consist in the application to the diseased skin of an ointment containing the ammoniated mercury gr. x to vaseline 5J, or hydrarg. ox. rubri gr. x. to vaseline 5J. This may be put into the ear by means of a hair-pencil by the patient, or by a cotton-dossil on the cotton-holder, if applied bj' the surgeon. Insufflations of boric acid will be of use in this disease, applied by the surgeon from time to time, after the inspissated crusts have been removed, and the diseased surface fully exposed. This treatment must be kept up for several months in some cases, before the cure is effected. The prognosis is always favorable. Pruritus Auris. — Itciiing in the auditory meatus may be due to the retention of scales of hard cerumen, but that form is not considered here. A distinct disease, a true pruritus, is here alluded to. This is purely a nervous affection in the skin of the meatus, I have met it most frequentlj' in women at the menopause, or in tliose affected with asthma. An attack of the r 284 EXTERNAL AUDITORY CANAL. latter may be preceded bv, or attended with, pruritus in eacli f' canal. The itchino; is usually intense and irresistible. Scratch- ing is usually performed most vigorously bv the patients, and i' the skin abraded. It then becomes a ready growing place for i aspergillus. The pruritus, however, ma}^ continue to recur after the aspergillus has been entirely destroyed. Dr. Sexton^ has reported pruritus auris in a man suifering from nervous debility. Treatment. — I have always been able to allay the itching in these cases by the application of one of the following ointments: f R — Hydrarg. ox. rubri, gr. j. Vaseline, 3J. — M. Or R — Hydrarg. ox. flav., gr. ij. Vaseline, 3j. — M. " '■{ Apply a little of either to the aftected ear with hair-pencil. Ingrowing Hairs from the Tragus, resting on the Membrana Tympani. — Sometimes, though rarely, the growth of hair on the tragus may be so copious as to block up the external meatus or pass into the canal and rest upon the drum-head. Such cases have been observed and reported by Dr. Weir,^ of New York. In some instances the entire auricle, especially at the helix i and tragus, may be the seat of excessive and almost ludicrous !i pubescence. In such cases of excessive amounts of hair near ^ the auditory canal, loose liairs may get into the auditory passage, ^ or masses of them block it up so as to induce hardness of hearing, .f The symptom of single hairs on the drum-head will be a if scraping sound heard only by the patient, whenever the jaws If are moved. If cerumen aid in the matting of the hair about P the external meatus, considerable deafness may be the result. Treatment. — Epilation may be applied to the hairs on the tragus as a preventive means. If the hairs have led to obstruc- tion in the canal, the foreign mass must be removed on general principles. Solitary hairs resting upon the membrana tympani may be lifted away "by the delicate forceps (Fig. 83) under illumi- nation from the forehead-mirror (p. 161). FOREIGN BODIES FROM WITHOUT. Inanimate Objects. — From time immemorial children have pre- tended to place various kinds of seeds, beads, etc., in one ear and bring them out at the other, for the amusement of them- j selves ortheir younger and more ignorant companions. The 1 New York Med. llecord, Dec. 22, 1883. '■^ Transactions American Otological Society ,*1870, p. 30. FOREIGN BODIES. 285 latter are often victimized by utteuipting to imitate the deeds of the elder children, and succeed only as far as inserting the foreign body. Some time ago, I removed a honey-locust bean from the ear of a negro-boy. thirteen years old. There is every reason to believe the bean had been introduced two years before. The bean was in a perfect state of preservation, and had given uo trouble to the boy, who said he had been induced to "put it in his ear, because he had seen the big boys do the same thing, pretending to remove it again through the nose." He had tried the experiment and failed, but, as the inserted bean never gave him any pain, he had never told any one of it, " for fear of parental punishment." While examining the ear for purposes of comparison with another, I discovered the bean, whereupon the boy told the above tale. The bean was finally lifted out by forceps with the greatest ease. Children are very fond of stroking their faces and various parts of their body with beads or any similar object with a polished surface. It is while thus amusing themselves, by stroking their ears, that beads, etc., often slip into the auditory eaual. The variety of such bodies found in the ear is endless, being wads of paper, all kinds of seeds, and small beans, beads, round tips of pencils and penholders, pieces of slate-pencils, and little stones, buttons, etc. Usually the foreign body is placed in the ear by the victim; sometimes it is pushed in there slyly by his playmates. Sometimes during quarrels various long ob- jects, such as straws, pencils, penholders, bodkins, etc., are thrust into the ear maliciously, both among children and adults. I remember a case in which a woman having a grudge against a man, waited for a chance to box his ear, during the time he scratched his ear with a penholder, such being his custom. The opportunity oftered itself, the man received his box on the ear, and the pen-holder, being pushed suddenly into the canal, penetrated the drum-head. While this could hardly be called a foreign body which re- mained in the ear any length of time, it serves to show how the ear may be injured by pushing a foreign body into it, or by un- skilful endeavors at its removal, which may force it further inward. Foreign bodies often remain some time in the ear of little children without doing harm. If a foreign body is found by chance in the ear of an adult, it will often be found upon inquiry to have been put there during childhood, I have in my cabinet a specimen illustrative of such a case. Lt is a blue bead seven mm. in diameter, four mm. in thickness, and perforated at its centre, removed with a mass of inspissated cerumen from the right meatus auditorius externus of a woman sixty-eight years old. The patient was entirely unaware of its presence in her ear, and, of course, could give no account of its i 286 EXTERNAL AUDITORY CANAL. mode of getting there. It was in all probability placed there in her childhood and forgotten, as it produced neither pain nor deafness. Later, however, the accumulation of cerumen became so great as to cause deafness, and the removal of the obstructive mass to relieve the deafness led to the discovery of the blue bead. Upon closer inspection of the bead by the patient, she stated ( that she could recall having played with just such beads when she was about eight years old, and this being the case, it is fair to presume that the bead had quietly rested in her ear for sixty years, one of the longest periods of retention of a foreign body in the ear on record. Dr. Ludwig Mayer,^ in an article on foreign bodies in the ear,^ mentions four cases in which the foreign substances were in for four years, two for twenty years, one for forty-five, and one fori over sixty. ? Deleau states that he once removed a small snail-shell from ; the auditory canal of a woman, who knew nothing of its pres- ence in her ear.^ The same author relates having removed from the ear of a boy five years old another shell, after it had caused pain and distress by its presence in the ear for a year. i MarchaP extracted a coral bead, with a ragged surface, fromi the ear of a military ofiicer fifty years old, in whose ear the bead^ w^as placed when the patient was fifteen years old. j Some time since I removed, by a few gentle streams from the* syringe, a small pearl shirt-button from the ear of a little girl| six years old, after I had given her ether. Before she came toi me her ear had been very roughly handled by picks and probes,^ but not once syringed. As she had become very nervous aboutn the painful treatment of the ear, I gave her ether, and the eas€~ with which I syringed out the button only served as another proof of the folly of instrumental picking, probing, pulling, etc.,i] to remove a foreign body from the ear. The ear had commencedJ to discharge when I first saw her, and the canal was greatly^ swollen, yet the syringing brought away the ofl^ending body.j But we hardly dare call such a body offending; that term should] be applied to the heroic treatment with curettes, etc., to which:]^ the unfortunate little victim had been subjected. ^|. All kinds of corrosive and scalding fluids, melted metals, etc., 'J are not only exceedingly painful but threaten the life of theil suffx^rer if poured into the ear. Morrison* records a case of|j ( 1 Monatsschr. f. Ohrenheilkunde, Jahr. IV. No. 1. \ 2 Gazette M(?dicale de Paris, tome ii., 1834, No. 11, pp. 161-163. l 3 Kevue Med. Fianfaise et Etrangere, Jan. 1844. >. j * Wilde, page 878. \^\ Vi' t:' i FOKEIGX BODIES. 287 death following the instillation of nitric acid into the ear. ]{au^ states that melted lead poured into the ear of a drunken man produced deafness with purulent discharge and paralysis of the corresponding half of the face, and became so tirndy imbedded in the ear that as late as seventeen months after this accident the metal could not be removed. A case similar to that reported by Rau recently occurred in St. Mary's Hospital, Philadelphia, during the service of Dr. Schell. "Within a short time I have seen the evil effects of scalding tiuids upon the ear. The case was that of an Irish girl, 20 years old, who had been induced to pour boiling oil into her ear for some slight trouble in it. The agony which ensued was intense, and, although the acute symptoms had ceased entirely when I saw her, the drum-head was white and thick, like a piece of heavy paper, and the hearing was destroyed. I It would seem almost superfluous to mention such folly, but the general ignorance respecting the delicacy of the ear demands such recitals as warnings. A curious and self-inflicted irritation from a foreign body in the ear occurred in the case of a young printer, finally applying for relief at the author's clinic in the Philadelphia Dispensary in 1872. The young man stated that, two weeks previous to his call at the dispensary, he had placed the core of a roasted onion in his ear, for a slight earache. The pain soon ceased and the onion core was forgotten or " supposed to be absorbed " by the patient, until the secondary irritation, discharge, and hardness of hearing caused by its presence in the auditory canal, drew the patient's attention a second time to his ear. Without any further attempt at self-medication, he applied at the dispen- sary for relief, and, upon examination, I found the auditory canal entirely blocked up by the swollen and rotten remains of the onion core. The walls of the canal were irritated and excoriated, and a horribly stinking discharge poured from the ear, while the mechanical deafness was great. One good syringeful of warm w^ater removed the offending mass, restored the hearing, and revealed the fact that the drurn-head, though deeply macerated, w^as still intact. With the use of an astrin- gent wash for a few days the ear was entirely healed. Sometimes the foreign matter is entirely harmless of itself, and might remain in the ear indefinitely, without exerting an injurious eflPect. The efforts at its removal, made by the igno- rant, are the true cause of injury to the ear. This is illustrated in the following case : On the 30th of April, 1872, Mr. E. S., a machinist, 39 years old, consulted me for pain and deafness in the left ear. He 1 Ohrenheilkunde, I 319, and Med. Chirurg. Zeitung, 1852, No. 39. 288 EXTERNAL AUDITORY CANAL. stated that three da^'s previous, while crossing a street, a horse had splashed mud in his ear, which at that time was perfectly i sound. Upon returning to the shop where he was employed, his ear was examined by some of his comrades, who said they saw "something in the ear," and proceeded to extract the foreign matter with chijys and /mechanic's small tools. This, of course, caused the patient great suffering, for he said '^several little white jjehhles were taken out" (probably ossicles, as there was no trace of them in the ear when I examined him), and great deafness ensued in the thus roughly handled organ. The pain increased, and a large, red, hard tumefaction appeared under the left auricle and extended to the angle of the inferior maxilla. The patient, naturally a very strong and powerfully built man, was very pale, anxious, and bathed in cold sweat when I made the first examination. There was no discharge from the ear at the time he presented himself to me. My large testing- watch, audible at least forty feet, was heard by this man only about two and a half inches. He heard my voice only when I spoke very close to his ear, and this, probably, onW by bone-conduction. The tuning-fork, vibrating on the vertex, was heard by the patient very distinctly in the aftected ear. Upon inspection I found the meatus in this case uninjured. A small piece of black street-mud was adherent to the antero-superior quadrant of the periphery of the membrana tympani. The membrana tympani was found to have been entirely destroyed, excepting a very narrow peripheral band, and there was not a trace of an ossicle visible, all of these important structures havino;, without doubt, been torn out bv the io-norant endeavors of the man's friends to remove the mud which had been splashed into the ear. The inner wall of the tympanic cavity was fully exposed to view, revealing healthy, pale, shining mucous mem- brane, slightly abraded on the promontory. By the Valsalvan method of inflation, air passed through the perforation with the characteristic whistle. Twenty days later I saw the patient again at the dispensary. He had been hard at work ever since the injury, not excepting Sundays. He had entirely neglected to follow an}' of the simple directions I had given him, viz., to apply three large leeches to the swollen glands near the auricle, and to remain quiet. The pain and tumefaction had disappeared, however, and the patient was ruddy and cheerful once more. ]^o air passed through the perforated drum-head at this visit, and the hearing distance re- mained permanently unaltered. Upon inspection I found the edges of the perforated membrane adherent to the promontory and inner wall of the tympanum, the former appearing to pro- ject into the meatus in consequence of the excessive retraction of the small remnant of the membrana tympani around it. § FOEEIGN BODIES. 289 It is interestiiiiT to notice the sudden and c-i'cat loss of hcarins- in this case, as showing the comparatively greater importance of the destroyed ossicles than of the perforation and destruction of the drum-head, A simple accidental perforation of the mem- brana tympani or drumhead, rarely, if ever, causes such a deu"rcc of deafness as was found in this case, in which the evul- sion of the ossicles must be regarded as the real cause of the great deafness. m I The impaction and long retention of foreign bodies in the ears of children may lead to deaf-dumbness, w^iich may be cured by removal of the obstructions in the external auditory canals, as was showm in a ease observed by Dr. Sara E. Brown,^ of Boston. In this case, twenty-eight small gravel-stones which had lain in the external auditory canals for seven years were removed, and recovery of the hearing ensued. This child, a lad of sixteen years, was an inmate of a school for feeble-minded children, where he had been placed in consequence of his retarded mental development, following his deafness. After the pebbles were removed, the lad became more intelligent in ex- pression, and he regained the use of his speech, which he had begun to lose at the age of nine years, when he placed the gravel-stones in his ears. il Animate Objects in the Ear. — Usually, insects which are found in the ear have crawled or flown in during the sleeping hours of the patient. Of course, this is most likely to happen to those who sleep upon floors or on the ground. Bakers, who, working at night and becoming very tired, lie down on the floor of the l)akery, always infested with roaches, are very apt to be awakened by the presence of a roach in the ear. The peculiar elongated shape of this insect permits it to wedge itself in the auditory canal, which holds it tightly enough to prevent its escape but not to kill it. It, therefore, is apt to make most violent endeavors with its front feet to escape, and in so doing it scratches and scrapes upon the deeper parts of the auditory canal and drum-head. vSuch movements are productive of great annoyance and pain to the patient, and if the animal is not removed, severe inflammation will be set up. Fleas often find their way into the ear, and by their powerful leaps against the drum-head, which produce a noise said by the patients to re- semble thunder, cause intense discomfort to the sufterer. I examined, in the early part of the summer of 1875, an intelligent man's ear, and found large cicatrices in the mem- brana tympani, with greatly diminished hearing. The patient stated that in his boyhood, while playing in the fields, the so- 1 Archives of Oph. and OtoL, vol. iii. pp. 88-90, 1874. 19 290 EXTERNAL AUDITORY CAXAL. I called devil's darning-needle or dragon-fly had thrust itself, or its long pencil-like body, apparently accidentally, into his ear. Instantly, great inflammation and pain were set up in the organ, and the hearing-power was ultimately nearly lost. M. Guerin reported to the Societe de Chirurgie the case of a soldier, who had returned from Mexico, suifering from facial neuralgia and other afl:ections, which were relieved upon the escape of an Ixodes hominis from the suflerer's ear.' The so-called rose-bug may get into the ears of gardeners or ji others working among rose-bushes. I removed one such insect from the ear of a lady 80 years old, where it had flown while I; she was picking some roses. I syringed, not long since, from the ear of a little boy two years old, a dead fly, which was totally enveloped in a kind of epithelial cyst. The mother of the little patient informed me that a year previous, in the summer-time, the child had been attacked suddenly with pain, as she supposed, in the ear, and that his sufferings were so intense as to produce convulsions. The meatus was entirely occluded by the encysted fly; but upon removal of the foreign mass, the membrana tympani was revealed as perfect, and the hearing became normal. Dead flies are sometimes svringed from the ears of children afflicted with otorrhoea, to which they are attracted by the odor \ of the discharge, but in most instances produce no pain or sub- sequent trouble by their presence in the ear. In some instances, however, maggots grow in the ear after it has been invaded by flies. Heine' and Blake^ have published accounts of the growth of maggots in the ear, and the latter 1 authority has described minutely the apparatus by which these !' creatures maintain a hold in, and wound the canal and drum- -j head. The former writer describes a case of a little o;irl two i years old, the subject of a chronic otorrhcea, who had gone to i sleep in the hot sunlight with the diseased and ofiensive ear li* exposed to the incursion of the flies, and in consequence thereof i' maggots had sprung up in the ear. In the course of a few days, | fat, white maggots, with heads spotted black, were seen in the fundus of the auditory canal. Oil was poured into the ear, and as each maggot came to the surface of the oily bath, it was seized with forceps, and thus all trouble was removed from the ear. Heine states that he has never failed to remove maggots and all living creatures from the ear, b}' means of oil in a very few minutes. But the majority of surgeons have not been so fortunate in the removal of maggots by this means. g ^ Hinton, op. cit., p. 78. ^ Lincke's Sammlung, ii. p. 181. ' Living Larvae in the Human Ear. Archives of Oph. and Otol., vol. ii. No. 2. I l» FOREIGN BODIES, 291 The pain excited by the presence of maggots in the ear is intense, and drives the sutierer to frenzy and even into con- vulsions. They are usually found in ears previously afiected (with a more or less offensive otorrhoca, though in a case related by Dr. Kuntzmann/ the ear attacked by the larvfe was entirely -h'ealthv before invaded by the ily which deposited the noxious eii'ii;. The pain attending the presence of maggots in the ear is^easilv explained by the investigations of Kuntzmann and Blake.-'' The latter authority placed the larvje in a glass vessel con- taining a piece of raw meat soaked in warm water, and then l2<^bserved the movements and actions of the larvse under the I imicroscope. He found that the apparatus by which the maggot makes and retains his hold is composed of a delicate horny framework, armed with two hooks, of a stout horny nature, articulating with the aforesaid framework. By a repeated ex- tension and retraction of the hooks, the animal pierces and tears the softest and deepest tissues it can lay hold upon. Hence it is found always in the fundus of the auditory canal and sometimes in the tympanic cavity. Tiratment. — From the investigations of Blake and others it appears, that, since maggots retain such firm hold upon the I structures of the ear, after they once get in there, syringing and instillations of fluids which would not injure the ear are insuificient to kill and dislodge such creatures. Blake, Gruber, and others are of the opinion that nothing short of actually seizing the maggots with suitable forceps, and pulling them out, will satisfactorily remove them from the ear. Sometimes maggots do not appear willing to seize flesh "when placed in their way, but burrow immediately in the earth, as stated in Kuntzmanu's case, and I have observed that a mass of maggots which were just extruded from a fly showed no tendency to seize some meat which was given them, but, on the contrary, burrowed between it and the sides of a glass vessel containing it and them. As maggots are extremely hard to kill by any fluid not in- jurious to the ear, I obtained some for experiment, from a fly, by causing her to extrude her brood of fifty or sixty living creatures about two mm. long. These I placed in a glass vessel with the dead fly and nothing more, and after twenty-four hours found them still alive. T then placed a little piece of cold roast- beef, softened in water, into the glass for the maggots to live upon. Twenty-four hours later I found them active and grown to 1 Hufeland's Journal der praktischen Medicin, August, 1824, S. 108-11. Lincke's Sammlung ii. p. 178. ^ Archives of Oph. and OtoL, ii. No. 2. I *' II 292 EXTEENAL AUDITORY CANAL. be five mm. long, and their alimentary canals stained b_y the brown- juice of the roast meat. In order to try the eftects of some easily obtained fluids, innocuous to the ear, upon the maggots, I placed a maggot, No. 1, in a few drops of reiined kerosene oil. It crawled repeatedly from the oil and continued to live, though constantly thrust back and kept submerged in the oil. This maggot was finally killed in another way. Maggot No. 2 I placed in a saturated solution of salicylic acid (bleached, prepared by Hance Bros. & White, of Philadelphia). This one died in half an hour. No. 3 1 placed in alcohol, and it died in from five to ten minutes. No. 4 I placed in ether fortior (Squibb), and killed it by this means in two minutes. ' Nos. 5, 6, and 7 I placed in chloroform, and thej^ w^ere in- stantly killed. Dr. Roosa has found chloroform vapor, as well as Labarraque's solution of chlorinated soda, fatal to the life of these creatures.^ An eighth specimen I placed in hydrant w^ater, w^hich seems, as has. been observed by others, to make them more lively at first, and they continue to live and work their savage hooks for a long time, even in a glass vessel where they can gain no hold. "Water appears not to have the slightest efiect in arresting their work when they have once gained a hold in the soft, moist tissues of the ear. Even after they have been killed by various applications to the ear, the forceps may be required to detach them, so firm is their hold. Calomel sprinkled over them has been said to kill maggots in the ear; also solutions of tannin have effected their destruc- tion. Hydrocyanic acid, in the form of infusion made of cherry leaves, is said by Lucse to destroy maggots in the ear.^ Foreign Bodies in the Eustachian Tube and Middle Ear. — In Mayer's article ^ on foreign bodies in the organ of hearing, we learn that three were found in the Eustachian tube. One of these bodies, a barley-corn,* w^as found imbedded in the bony portion of the tube, but projected as far as the faucial end. The other two were lying in the wide faucial end of the Eustachian tube. The imbedded barley corn was found at a post-mortem, the cause of death not o-iven. Bouo^ies not uncommonlv break and leave portions behind them in the Eustachian tube. When the 1 Treatise on Diseases of the Ear, p. IGG. 2 Archiv f. Ohrenlieillvunde, Ed. xvii. p. 219, 1881. * Monatsschrift f. Ohrenhcilkunde, Jahrg. IV.., No. 1. * Prof. Fleischmann's Case. Hufeland's and Ossan's Journal, June, 1835, pp 25-28. I ^^^ FOREIGN BODIES. 293 houii'ies are armed with cotton, feathers,^ liairs, etc., this is more hkelv to occur. lu two cases, recited by Mayer, himinaria bouii'ies broke off, and remnants were left in the Eustachian tube. Urbantschitsch observed a case in which a piece of oak- leaf ]iassed from the mouth through the Eustachian tube and the middle ear, and finally passed through the membrana tym- pani into the external ear.^ In some instances a foreign body in the external ear is rudely pushed at last, by endeavors at its extraction, into the middle ear. One of the most interesting of such cases is given by Deleau, Jr.^ It is that of a little boy, who placed a small gravel-stone in his ear, in plaj^ with his comrades. The unskilful and painful Hjendeavors with a curette to remove the body, in conjunction Svith the struggles of the boy, ruptured the drum-head, pushed the gravel-stone into the tympanic cavity, produced hemorrhage and inflammation of the ear, temporary paralysis of the corre- tlBponding side of the face, and excessive photophobia in the eye |of the paralj'zed side. This happened while the boy was still in the provincial town where the accident occurred. He was brought to Paris, Pftwo weeks later, and Deleau examined the ear carefully, found the pebble seated in the cavity of the tympanum, with its only visible facet in the same plane with the drum-head. By gently touching the body it was found firmly grasped by the swollen mucous membrane of the middle ear, and being so near the chain of bones all traction upon the pebble was deemed highly improper, Deleau, therefore, introduced a firmly fitting catheter into the Eustachian tube. The third injection of water through this instrument threw the offending pebble into the concha. The otitis in this case soon disappeared, but there is no positive statement as to the condition of the hearing. Among the rare instances of this occurrence, is one observed by Moos.* In this case an unsuccessful endeavor had been made by a physician to remove a coffee-bean from the external auditory canal, under chloroform. After unskilful manipulation the bean disappeared from view. Purulent inflammation set in, perforation of the drum-head occurred, the incus exfoliated, and numerous polypi were developed. The latter were removed, and, b}' syringing, together with antiphlogistic treatment and the use of astringents in the ear, the bean came into view, though it had passed into the tympanum and could not be seen ' Heckslier of Hamburg. Mayer's Article, loc. cit. - Hospital Gazette, Oct. 4, 1879. ^ Lincke's .Sammluno;, i. pp. 1.53, 157. Gazette M^d. de Paris, 2d series, tome ii., 1834, Xo.' 11, pp. 161, 1G3. * Archives of Oph. and Otol., vol. iii. pp. 103-107, 1873. 294 EXTERNAL AUDITORY CANAL. at the first examination, immediately after the removal of the polypoid growths. IJpon the authority of Itard and Andry, Eaii mentions a case in which an ascaris wandered from the alimentary canal, through the pharynx, into the Eustachian tube. Sudden and powerful coughing in haemoptysis may force blood through the Eustachian tube into the tympanic cavity, where irritation and pain may be set up in consequence of the foreign matter thus brought in contact with the tympanic mucous membrane.^ Treatynent ; Bemoval of Foreign Bodies from, the Ear. — When a foreign body is said to be in the ear, the surgeon should first satisfy himself that such is really the case before he begins any operation for its removal. . Grave errors have occurred from the neglect of the surgeon to assure himself on this point., "When it is fully decided that the statement of the patient or his friends is correct, and that a foreign substance is really lodged in the ear, if the latter has not become irritated and swollen by the attempts of others at the removal of the foreign substance, usually a gentle syringing, the patient's head being inclined towards the affected side, that gravity may aid the sur- geon's efforts, will bring away the foreign body. In order to carry this out in very young children, already alarmed by the accidental entrance of the foreign body, we may have to resort to etherizing the patient. In any case, when syringing will not remove the foreign substance and the ear is at all inflamed and swollen, nothing more forcible than syringing should be at- tempted until the local irritation in the ear is allayed. Too often the attempts at removal of a foreign body from the ear are far more injurious than its presence in the ear. It may be said that all insoluble substances will do no harm to the ear if let alone. They should be removed in order to pre- vent mechanical obstruction and deafness. But there is nd need of haste. If an animate body, like an insect or maggot, be in the ear, the first effort should be to kill it. This is best accom- plished with insects by the instillation of oil, preferably sweet oil, into the ear. After all irritation is allayed, which can often be effected, though the foreign body is still in the ear, syringing may be resorted to, and usually with success, in removing the foreign substance. If this fails, and it appears that other means are demanded for the removal of the impacted foreign body, the greatest care and skill are now needed, in order to avoid injuring the ear. A dead insect can be removed from the ear by means 1 Eindringen von Elut, in die Paukenhohle bei Hivnaoptoe. Archiv f. Ohrenh., Bd. xi. S. 2\. Dr. Kiipper. If II FOREIGN BODIES. 295 of delicate forceps (p. 281) under good illumination, if syringing tiiils to remove it. A great many plans for removal of foreign bodies impacted in the ear, have been suggested. Voltolini^ recommends the use of the galvano-cautery for the removal of organic foreign bodies which, by unskilful manipula- tion, have been forced from the meatus into the tympanic cavity and have become imbedded there. By this means, he has cut up and removed piecemeal a bean which had been pushed through the membrana tympani and pressed into the drum-cavity, A bean cannot be properly cut up, however, until it has been softened by repeated injections of water. Then momentary glowings of the tinest silver wire cautery will char the bean, and the offending body can be gradually removed after several repetitions of the operation, on different days. But no one not extraordinarily familiar with diseases of the ear, as well as with the use of the galvano-cautery, should attempt such an operation. Voltolini has verj- justly said, the most that can be asked of the general practitioner is not that he shall remove a foreign body such as this from the ear, but that he shall recognize its presence and let it alone. It cannot be too often brought to mind that it is not the presence of a foreign body that causes ultimate harm to the patient, but the unskilful endeavors to get it out. Among the various ways of removing impacted bodies from the external ear, should be mentioned the agglutinative method. It has been recently revived by Dr. Lowenberg,- of Paris. This method was fully described by liiverius^ and Celsus,^ and is also given by Rau.^ It consists in smearing with glue or some equally tenacious substance, a piece of linen, cotton cloth, or the like, firmly attached to a handle, wdiich is brought into contact with the foreign body in the ear, and then allowed to remain until perfect adhesion takes place. Then, in most instances, the foreign substance can be lifted out with the above-named instrument. This method was employed in this country, some years ago, by a layman, Mr. Eli Whitney Blake,^ of Conn., for the purpose of removing a foreign body from the ear of a boy employed in his carriage factory. A somewhat similar method is to apply to the foreign body a piece of ad- hesive plaster fastened to a string, and then warm the miniature disk bv means of a burnins^-o-lass. When adhesion has taken place, traction on the string may remove the foreign body ^ Ueber fremde Korper in der Paukenhohle und deren Entfernunu;. M. f. O., :o. 5, 1876. - Berliner Klin. AVochenschr., Nos. 9, 10, 1872. 3 Opera Med., Franeofurti, M.DC.LXXIV., Cap de Surditate, p. 2C1. * Strasbourg edition, 180G, p. 342. ^ Op. cit., p. 375. * C. Hooker, Boston Journal, 1834. 296 EXTERXAL AUDITORY CANAL. attached to the adhesive plaster. This method was suggested by the late Dr. E. H. Clarke, of Boston. If syringing fail to remove a foreign body from the ear, and the surgeon is convinced of its impaction in the canal or the tympanic cavity, he may resort to efibrts at its removal by means of forceps specially adapted to such cases. For the removal of the laminated plugs of epithelium (p. 278), Dr. E. D. Spear, Jr.,^ of Boston, has devised a fine-toothed forceps re- sembling the fixation-forceps of the eyeball. For the removal of impacted foreign bodies, either organic or inorganic, Dr. Samuel Sexton,^ of New York, has devised an instrument, represented in Fig. 84. The instrument suggested itself to the mind of its inventor by his army experience in the use of bullet-forceps, with a tooth-like bite. JSTeedle points have been substituted for the teeth of the bullet-forceps, being set at such an angle that when closed against a presenting surface of whatever shape they seize it by the approximation of the two blades in the handle. This is done by pressure of them between the thumb and forefinger, which forces the sliding ring over the blades which are armed with the needle-point teeth. The latter sink into any substance of an organic nature, taking a profound hold on it, and permitting great traction. Fis. 84. Sexton's Foreign-body Forceps. (Two-thirjs natural size.) Removal of foreign bodies from the ear by incision through the Cdrtilaginous canal from without and behind the auricle was proposed by PauP of ^Egina. In the case of an impacted bone pencil- head in the tympanic cavity, Dr. Israel* separated the auricle 1 American Otological Society, 1880. - American Journal of Otologj', vol. ii. ' Leschevin ; Lincke's Sanimlinig, I. No. 1, p. 25. * Berliner Klin. "Wochenschr., No. 15, 1876, also M. f. O., No. 7, 1876. FOKEIGN BODIES. 297 from its posterior attuchnient to the osseous auditory canal after 11 gk cresceutic incision behind the ear had been made through the ' periosteum. The latter Avith the auricle was drawn forcibly forward, and the foreign body seized and removed through the opening thus formed in the canal. Before Dr. Israel saw this case, unskilful manipulation had driven the foreign body from the external auditory canal into tlie tympanum. The case then began to manifest very curious nervous phenomena. After the more acute inflammatory symptoms consequent upon the intro- duction of the foreign body and the endeavors at its extraction had subsided, the patient complained of great pain in both arms, the trunk, and the hips, while the head and ear were free from sufl'ering. Left pupil dilated ; fibrillar twitchings in the orbi- cularis of the left eye and the left levator alse nasi. Excessive hyperalgesia of the skin in the painful parts of the body, caused the patient to scream when touched. On the left side all the symptoms were more pronounced than on the right side. A day later, vomiting and irregular pulse ; contraction of the left hand forced the fingers upon the palm ; the latter was overcome only by painful and forciljle extension. Subcutaneous injections of atropia, ;l rngrm, relieved the con- traction, the hyperalgesia, pain, and inequality of the pupils. The hyperalgesia returned, however, and toothache set in. H'|A.fter the removal of the foreign body from the tympanum, all nervous phenomena vanished. Von Troeltsch' gives an account of four successful opera- tions of partial displacement of the auricle for the removal of impacted foreign bodies ; one by Langenbeck and three by Schwartze. Dr. J. Orne Green,- of Boston, has performed it recently, as have Moldenhauer^ and A. il. Buck,* with success. Green's operation was for the removal of a bullet from the ear of a man, a would-be suicide, forty years old; Moldenhauer's, ifipon a girl three and a half years old, for the removal of a pebble; and Buck's, upon a bo}' ten years old, for the removal of a bean. The usual mode of procedure is to make an incision above and behind the auricle in the mastoid region, down to the bone, and lay the auricle and cartilaginous canal forwards toward the cheek, until the insertion of the cartilaginous with the osseous canal is reached and plainly laid open to view. The posterior attachment of the cartilage to the bone is then ^cut _ through above and behind, and the foreign body grasped by idelicate forceps. Great care must be taken not to sever the jcartilage entirely from the bone. 1 Lehrbiich, 1881. 2 American Otol. Society, July 26, 1881. ' Archiv f Ohreiilieilkunde, Bd. xviii. S. 59, Nov. 1881. * Xew York Medical Eecord, Dec. Ifi, 1882. 298 EXTERNAL AUDITORY CANAL. vX. JSTicolaysen^ performed resection of the annnlus tympanicus, for the removal of a pebble from the tympanic cavity of a girl four years old. By means of a line saw, two cuts ■svere made in the anterior and lower portion of the annulus tympanicus 6 mm. apart. The intermediate piece of bone was loosened by a chisel. It was then found to be an easy matter to seize and remove the pebble. There was no inflammatory reaction. The discharge w^hich had been excited by the previous bad treatment ceased. The ossicles had been destroyed. CHAPTER III. EESULTS OF INFLAMMATION AND INJURY. Abscesses in the external auditory canal may lead to an evacuation of their contents through the duct of Steno,^ or through the cleft found in the posterior superior part of the cartilage of the auditory canal as described by Poorten, after the occurrence of otitis externa.^ ^ Caries of the meatus may follow inflammation of the middle ear; * in such a case, described by Blake, a portion of the mastoid wall of the osseous meatus, one inch long and half an inch wide, came away. I removed not long ago, an 'annular sequestrum from the auditory canal of a lady who had long suffered with otorrhoea. It acted like an irritating foreign body. Its removal was followed by recovery. Mr. Toynbee met with a case of chronic inflammation of the external auditory canal which extended to the bone and brain, producing death." But these are not the commonest results of inflammation in the auditory canal. Those more likely to be met are now about to be described. Chronic Circumscribed Ulceration in the External Auditory Canal. — Chronic diftuse inflammation of the external auditorv canal sometimes ends in the formation of distinct and circumscribed ulceration at one spot in the passage. 1 See a notice in Archiv f. Ohrenh., Bd. xx. S. 64, 1883. 2 Hribar; Wiener Med. Presse, No. 101, 1871. 3 Monatsschr. f. Obrenheilk., June, 1872. * C. J. Blake, Trans. Am. Otol. Soc, 1872. 5 Diseases of the Ear, 1868, p. 73 RESULTS OF INFLAMMATION AND I X J U K V . 299 From this diseasetl point an inflanmuitory process may be . omniunieated to the tympanic cavity, and hence ulceration in the external auditory canal becomes of importance, riceration on the wall of a patulous auditory canal must not be confounded with those cases of secondary inflammation of the skin of the canal, mentioned by Kramer,' "which result from caries of the meatus and of the tympanic cavity, or from destruction of the membrana tympani with disorganization of the investing mem- brane of the tympanum. In such instances the meatus tumefies, becomes indurated like cartilage, smooth, and dark red; the opening closes up till it will only admit the head of a pin; there is a thin acrid discharge, and on introducing a probe, bare, rough, and carious bone may be felt in the deeper part." The ulcers, especially alluded to here, are found in the unyielding skin of the bony portion of the auditory canal, and by their general features of chronicity and sluggishness remind one of the ordinary les; ulcer. Tliev throw off a scanty, dark-o-rav or greenish discharge, somewhat otfensive, which shows a tendency to form a dark crust around the mouth of the canal. Sometimes the discharge seems to have ceased, but in a few days it returns again, and, if allowed to run on, the disease will tend to form polypi and to attack the drum-head. The latter becomes congested, all its normal features are lost, and upon syringing the ear, water may pass into the nose and throat. The hearing up to this time may not be much impaired, for the middle ear has remained intact. Upon the occurrence of the perforation, however, the hearing is endangered. In any case, therefore, where there is found a discharge from the ear with an intact membrana tympani, the most careful search should be made for the cause, and, if an ulcer is found in the bony portion of the external auditory canal, to it the treat- ment should be directed. These ulcers, if situated in or near the membrana flaccida, may communicate with the upper part of the tympanic cavity. Itard,- when speaking of erysipelatous diseases of the external ear, consequent upon erysipelas of the head, alludes to vesicles which form in the auditory canal, and upon breaking, are con- verted into true ulcers, which suppurate for a long time. Others, including ^. R. Smith,* Williams,* AYilde,^ Rau,^ Toynbee," and Roosa,- allude with more or less distinctness to II ' Diseases of the Ear, Sydenham Soc, London, 1863. '-' Maladies de I'Oreille, Paris, 1821, p. 168. ^ Supplement to translation of Saissy on the Ear, Baltimore, 1829, p. 218. * Treatise on the Ear, London, 1840, p. 116. ^ Aural Surgery, American edition, Phila., 1853, p. 199. * Lehrliuch d. "Ohrenheilkunde, Berlin, 1856, p. 179. ■ Diseases of the Ear, 1868, pp. 79, 80. 300 EXTERNAL AUDITORY CANAL. an ulceration of the meatus, as a separate and chronic form of • aural disease. Etiology. — The causes of this disease are often obscure. But '> it will generally be found that a neglected inflammation in the 1 canal has run at last into the chronic disease here described, or that the ear has been unduly cleaned and abraded. ' TreaMient. — The treatment should consist in removal of any i^ irritant which keeps up the ulcer, and in stimulation of the ' inflamed spot. The latter is best accomplished by cauterization \ by means of strong solutions of nitrate of silver, conveyed to the ulcer by means of cotton on the cotton-holder. Insufllations of ' boric acid, borax, or borated chinoline (p. 261), or of borated j resorcin, will be found of great service in this affection. All discharges are to be most carefully cleaned out by mopping with absorbent cotton or by syringing, and the general health of the patient examined into and built up if necessary. As , scrofulous children are liable to be the subjects of this kind of ' local disease in the ear, iron and cod-liver oil will play a most im- portant part in the treatment of such ulcerations, when occurring ' in such subjects. The applications of the above local remedies should be effected by the surgeon daily at the outset. The patient's ear should be let alone at home, unless it runs greatly, when it xway be mopped out Avith absorbent cotton. The hearing is not usually affected in the early stages, but it will be, unless the disease is arrested. The prognosis is favorable if the ear is attended to in time. Reflex Ulceration in the External Auditory Canal. — Reflex neu- ralgia in the ear, from the irritation of diseased teeth and gums, has been alluded to and explained by the nervous connection ex- isting between the mouth and the ear (pp. 88, 89). It is possible to go a step further and explain reflex tissue-changes in the ear, induced in the same way. At this point only those changes ' . observed in the external auditory canal should be considered. Ulceration in the anterior wall of the auditory canal, near the membrana tympani, may be reflex in origin and maintenance. Such ulceration may be due to decayed molar teeth in the inferior or superior maxilla, on the same side. In these cases the ulceration may be healed by proper treatment, only to break out again and again' after intervals of varying lengths. At the outset there is usually some pain in the ear for a day, then a discharge is observed, the pain having ceased. Examination may reveal a well-marked ulcerated spot on the wall of the auditory canal. This is usually made to heal in a short time, but in the course of a few days, or, may be, even weeks, the same kind of an attack is again felt. In a case like this, a quick and permanent cure was effected after the removal of several RESULTS OF INFLAMMATION AND INJURY. 301 diseased molars in the lower jaw of the same side. Such reflex tissue-changes in the auditory canal are evoked in the following way: Let it iirst be borne in mind that irritation proceeding from any part of the body may excite waves of bloodvessel- (Ulatation in a correlated area. In the disease under considera- tion, the seat of irritation is in the teeth and gums, and the correlated area is the external auditory canaL The blood supply to the external auditory canal is derived from the external rarotid artery, by its branch, the posterior auricular, and the vaso-motor nerve controlling the calibre of these vessels is derived from the external carotid plexus of the sympatlietic. The diseased teeth in the case alluded to were supplied by the inferior dental nerve. Xow, the large sensory division of the inferior maxillary nerve, from which the inferior dental nerve comes, is connected on its inner side with the otic ganglion. This ganglion is connected with the plexus of the sympathetic, controlling the external carotid artery. As branches of this artery supply the external auditory canal, it is easily seen how this part of the ear becomes an area correlated to the seat of irritation in the diseased teeth, through the medium of the otic o-anglion. Since the result of irritation at one point in a vaso- mot'or tract is to suspend the inhibitory power of vaso-motor nerves in a correlated area, the vaso-motor branches of the carotid plexus, regulating the supply of blood" in the external ear, lose, for the time, their power of controlling the calibre of these vessels, on account of the irritation conveyed to them from the teeth through the otic ganglion. Therefore, the vessels in the external auditory canal become distended, and congestion, pain, and inflammation are the result. Cholesteatomatous-epithelial Impactions in the Auditory Canal. — These cholesteatomatous, epithelial masses are usually found in ears which have been the seat of chronic suppuration, but in which the latter process has apparently run its course. In such eases, the mucous membrane of the middle ear, as well as the cutaneous lining of the external auditory canal, seems to retain a tendency to the exfoliation of large masses of epithelial scales, which, accumulating in the ear, undergo a fatty degeneration and give rise to various symptoms, among which the more prominent are pain at times in the ear (but this is not a promi- nent characteristic of these formations), nausea and dizziness, with occasional vomiting. The hearing is, of course, impaired by the mechanical hinderance offered by these masses, which may be so large as to cause absorption of the bone of the audi- tory canal and a consequent widening of this passage. Even greater irritation than this may ensue as a consequence of the presence of such collections in the ear, and the bone structures 302 EXTERNAL AUDITORY CANAL. on which they press may become carious. The soft tissues thus- pressed upon ulcerate and become covered with granulations in some instances, and the membrana tympani and ossicles having undergone erosion, the entire tympanic cavity is occupied hyi the cholesteatomatous layers. The microscope reveals flattened!^ epithelial cells and crystals of cholestearine as the components of these lamellated masses. This process is very analogous to that( which produces the keratosis obturans (p. 280). Treatment. — The treatment of such accumulations should con- sist first in the complete removal of the obstructive mass. This may require some patience, for the removal of the more external layers often reveals the presence of deeper and fresher ones, and in some cases new ones seem to form during the treatment. The latter tendency is best combated by an alterative astrin- gent, as solutions of nitrate of silver, sulphate of copper, and zinc. I have found insufliations of boric acid and chinoline^ salicylate (p. 261) to cure these cases promptly. The softening i and removal of these masses is hastened by the use of solutions of bicarbonate of soda in glycerine and water. _ Sebaceous Tumors, Wens, in the Auditory Canal. — Sebaceous I tumors, or wens, are sometimes found in the skin of the cartila- ginous part of the external auditory canal. There is very good j reason to believe, however, that the surgeon is not usually called! upon for assistance in these cases until either the wen has under- gone changes in its structure either by erosion or by suppura- tion, or until it has produced, by pressure or inflammation, ^ organic changes in the cutaneous and osseous structures of the canal. When observed in the early stages of growth, i. e., before any breaking down of its component tissues has occurred, a sebaceous tumor may be seen extending from the anterior wall of the meatus, just within the tragus, entirely across the canal to the opposite wall, thus hiding the drum-head from view. The hearing is impaired in such a case by the mechanical obstruction, and the tinnitus and altered resonance of the pa- tient's voice are very annoying. It is this which first calls the patient's attention to his ear. "There is at this stage no pain and no discharge, and the growth may apparently undergo no im- portant change for many years. I have observed one now for six years, which seems to give no increased annoyance. These tumors are soft and compressible, and if a speculum is pushed carefully into the ear thus afl:ected, the tissues in the canal near the fundus will appear macerated and somewhat reddened. The sensibility of the skin of the canal becomes rather blunted than otherwise, at first in these cases. Their occurrence is rare, ' according to the testimony of Gruber, Eau, and others of large experience. They are analogous to wens of the scalp, and are ■ ^^K RESULTS OF INFLAMMATION AND INJURY. 303 encysted atheromatous tumors following hypertrophy of a seba- ceous gland, the excretory duct of which has become obliterated.^ Their chief seat being in the scalp may account for the fact that they are sometimes found in the skin of the auditory meatus. These tumors when seated in the scalp may so alter the nutri- tion of the subjacent parts as to produce destruction of the cellular tissue, depression of the external cranial table, and sub- sequently erosion of the inner table of the bone, so that the wen may become adherent to the dura mater. This tendency of a wen to cause erosion of the tissues beneath it, is seen in the ear as well as in the scalp, and, doubtless, is the cause of the so-called molluscous tumors in the ear, alluded to by Hinton, Toynbee, and Kirk-Duncanson.- Dr. J. Orne Green^ has ob- served this disease in the ear, which he terms cystic tumor. Exostoses of the Auditory Canal. — Exostoses, or bony growths of a rounded, hillock-like shape, are frequently found in the external auditory canal. They are covered by the skin of the canal, are entirely painless, and the only annoyance they give is due to their encroachment upon the calibre of the canal. Their size varies from that of a merely distinguishable elevation on the wall of the canal to that large enough to occlude the canal and produce deafness. The skin covering them is a little paler than that of the canal. Etiology. — These osseous growths may be congenital, or they may be the result of chronic inflammatory processes in the middle and external ear. They are frequently found in those who have been afflicted for a long time with discharges from the ear, though they are also very often found in those whose ears are otherwise normal. According to some authorities, exostoses of the meatus in some instances are plainly of a syphilitic origin. They may develop in the auditory canal at the same time with exostoses on other bones, as shown by Gruber, but he does not consider that all such bony growths in the canal have a specific origin. Contrary to the rule in other parts of the body, they are usually painless in the auditory canal. He has described several cases in which hyperplastic growths of the bone of the meatus were associated with a similar affection in the bony portion of the Eustachian tube, without, however, possessing any syphilitic origin.* Usually, the causes of exostoses in the auditory canal are obscure, although in many cases Toynbee's theory, that they are due to the rheumatic and gouty diatheses, may be satis- I' Misset ; Etude sur la Pathologie des Glandes Sebacees. Pai'is, 1872 '^ Edinburgh Med. .Journal, Nov. 1877. ^ American Journal of Otology, vol. iii., 1881. * Lehrbuch der Ohrenheilk., pp. 412, 576. V 304 EXTERNAL AUDITORY GAXAL. factory. As far as my experience goes, they have been met t more frequently in such diatheses than in any others. Mr. G. P. Field^ believes they could be produced by bathing every day in salt water, which would bring about a chronic inliammation of the walls of the canal. Dr. C. J. Blake- has described a peculiarity observed by Prof. Wyman, first in the crania of Hawaiian Islanders, and subse- quently in the crania of Peruvians, consisting of exostoses of the external auditory meatus occurring uniforml}- on the superior and inferior lips of the lamina forming the posterior wall of the passage, the same peculiar growth being described by AVelker { as occurring in the crania of American Indians. Out of three hundred and thirty-four Peruvian crania examined by Prof. Wyman, these growths were found in six, and in various de- grees, from a small pedunculated growth on the superior lip of the lamina to double growths on both lips nearly occluding the orifice of the passage. The supposition that aquatic habits might have to do with the presence of these growths, though applicable in the case of the Hawaiian Islanders, would not apply to the Peruvians, living, as they did, in a tract of country remote from the sea and remarkable for its aridity. That the occurrence of these growths is coincident with the development of the wall of the osseous meatus, as suggested by Dr. J. 0. Green, is further supported by the fact that the location of the growth was a constant one. Prof. Turner^ found exostoses in the auditory canal of a Peruvian skull and also in a Chenook Indian. The treatment of exostoses in the external auditory canal will be referred to further on. Osseous Closure of the Auditory Canal. — The consideration of exostoses in the auditory canal leads naturally to the considera- tion of osseous closure of the canal and the deafness which ensues. Such a closure of the auditory canal may be congenital or acquired. The acquired form appears to be commoner, and this fact should lead to a most careful treatment in those diseases of the ear attended with ulceration and granulations in the external auditory canal. If such growths are found in the auditory canal, great care on the part of the patient should be observed in not picking at or irritating them in any way. 1 The Lancet, January 8 and 15, 1881. - Report on the Progress of Otology, 1874. Dr. Bhike has since investigated the subject of the occurrence of exostoses in the osseous canal of prehistoric man. In 17 or 18 per cent, of the crania of mound-builders, exostoses were found {Ame7'ican Journal of Otol.,xo\. ii , 18801. 3 Journal of Anatomy and Physiology, vol. xii., part 2, p. 200; also American Journal of Otology, vol", i., 187!», p. 229. RESULTS OF INFLAMMATION AND INJURY. 305 Acquired bony closure of the canal has been observed and described by Bonnafont,' Dr. L. B.,- Mathewson,^ Jacobson,* Theobald,^ and others. In the cases named, operations for relief of the deafness were performed successfully. The only case of acquired bony occlusion of the auditory canal, which has come under my notice, presented itself in the right ear of a man fifty-eight years old. At eight years of age the patient was operated on in the Pennsylvania Hospital, for polypus of the left ear. After repeated attempts at ex- traction of the polypoid growth, which were followed by severe cauterization with solid sulphate of copper, great pain and total loss of hearing, he was removed by his parents from all further treatment. In 1874, about fifty years after the above-named operations, an examination of the ear re- vealed a shallow meatus, closed at the bottom by ordinary skin. Nothino; resembling a drum-head was visible. The skin at the fundus of the shallow auditory canal moved under the Siegle pneumatic speculum. The hearing was reduced to nothing for external sounds. Bone-conduction, however, very good on the occluded side. Tuning-fork on the vertex heard best in the occluded ear. The Eustachian tube was found to be pervious to air by Politzer's method, and the ordinary catheter. The patient, a man ot more than ordinary intelligence, was fully conscious of the entrance of air into his right tympanum, by artificial in- flation, as well as whenever he swallowed. As he was desirous of having an operation on the occluded ear for relief of his deafness, I made an exploratory incision with a paracentesis knife, but found that beneath the skin of the fundus of the canal, there was a bony partition cutting off the external from the middle ear. Considering the age of the patient and the good condition of his left ear, I was unwilling to perforate the bony septum in the auditory canal; but it is probable that such an operation might have been carried out with success in this case. The pathology of this case most probably consisted in acute inflammation, followed by suppuration, which was allowed to become chronic. Then there ensued a growth of polypi, for the extraction of which, several rough and painful operations were undertaken. Subsequently, the excessive granulation-tissue became organized into a bony septum, covered by a reflection of the normal cutis of the auditory canal. ' L'Uninn ^Nledicale, ^lav, 18G8 ; also Gazette des Hopitaux, No. 64, 1867. 2 Archiv f. Ohrenheilkuiide, Bd. x. S. 110 ^ Report of First Congress of International Otological Society, New York, Sept. 1876. * Archiv f. Ohrenh., Bd. xix. S. 34, 1882. ^ American Otological Society, 1882, p. 46. 20 306 EXTERXAL AUDITOEY CANAL. "A mass of granulations may become covered with skin or mucous membrane, and its central portions undergo a change into true osseous tissue."^ Respecting this form, Dr. Buck says "it would be difficult, \ particularly in this locality, to determine whether a real transi- tion from granulation-tissue to bone takes place, or whether simply the local irritation assumes a new phase, the cellular hyperplasia or formation of granulation-tissue ceasing and bone being formed." I am of the opinion that the closure of the canal I have just narrated was caused by a transformation of a mass of granulations into true bony tissue, at a point about i half-way down the auditory canal. Since the subcutaneous and • submucous tissues of the ear are, at the same time, periosteal coverings, it is reasonable to suppose that such acquired osseous occlusion as has been described cannot be very rare, but often escapes recognition. Treatment. — Exostoses in the external auditory canal demand ; no treatment, unless they occlude the canal and cause deafness by this obstruction. Then they may be bored through or cut away, as has been suggested and performed by several operators. Dr. Mathewson, in the case referred to (p. 305), used success- fully the dental lathe as the motive power to turn the drill. The skin is to be removed in these cases before the bone is operated on, and to do this. Dr. Mathewson employed the , instrument known among dentists as the scaler. The bony ; growth was then perforated at several points near its centre, ; with the smallest of the drills, about one and a half mm. in '|' diameter. This was easily done, and then larger drills, two and i a half to three mm. in diameter, were used to widen the open- ■ ing thus gained in the bony diaphragm. The hemorrhage was ^ not excessive, though there was enough to interfere slightly j with the operation. But the auditory canal was kept syringed j and swabbed out, so that in half an hour a complete canal to •; the drum-head was made. The granulations which arose sub- « sequently were combated with nitrate of silver, and, in the ^ course of a few weeks, the drum-head could be seen at the i, fundus of the canal. The discharge gradually ceased, and the sj hearing became normal. i Victor Bremer- prefers scissors to the dental lathe for the re- 1^ moval of exostoses in the auditory canal, and in some instances ij he has used chisels for their removal. Moos,^ in a case of ^ closure of the external auditory canal by exostoses, complicated by acute otitis media, and recurring granulations, employed for 1 A. H. Buck. " Ultimate forms of grauulation-tissue ill the ear." Transactions Ij of American Otological Society, 1874. 2 American Journal of Otology, vol. i. p. 228, 1878. 3 Archives of Otology, 1879. RESULTS OF INFLAMMATION AND INJURY. 307 I rrlie removal of the osseous growth tlie g-alvano-cautery, and sub- ■ ' sequeutly kept the canal open by laniinaria bougies. Gardiner- Brown ' employs the dental lathe, as does Mr. Field,'- for the H removal of these bony growths. As Dr. L. B., of Hamburg, gives an account of an exostosis in his own auditory canal, and the operation on it, by Dr. Xiiorre, of the same city, the case demands more than a passing notice. The first symptom of deafness occurred in the patient's forty- third year, in 1868, after a bath. On attempting to pick the Kear, to free it from water wdiich was supposed to have lodged there, an obstruction was felt by the patient, wdiich he seized and roughly pulled upon. This caused considerable pain and subsequently inflammation, with diminution of hearing. Upon consulting Dr. Knorre, the obstruction was pronounced by him an exostosis near the membrana t3'mpani. Mild astringent treat- I I ment was advised to allay the discharge and inflammation ex- ■ ■ cited by the patient; the hearing then gradually grew better, ■ Fand four years of undisturbed hearing were enjoyed. In 1873, ■ - the hearing began to grow w^orse, apparently without any ex- citing cause, but the bony tumor was found to be increasing in size; Dr. Knorre then proceeded to remove the bony obstruc- 14 tion by boring and chiselling. The obstruction was overcome I by successively removing parts of it with a drill and chisel, 1 touching the bony growth with hydrochloric and sulphuric f acid, burning it with a red-hot knitting needle, and filing down the free surface of it by means of delicate files, smooth on one side, such as are used by jewellers. Most of this treatment was attended with severe pain, so that intervals of rest were rendered necessary on account of the tenderness of the ear. The opera- tions for removal were commenced in June, and bv the followins^ January the free surface of the growth had been so much re- moved as to give a free space between it and the opposite wall of the auditory canal, and the hearing became once more normal. The patient attributed most of the success to the chiselling performed by Dr. Knorre; the other operations were performed by the patient himself. Other forms of acquired obstruction in the external auditory canal may be partial or total, and they may consist of cutaneous bands, diaphragms of skin or bone, and of horny growths. Dr. Engelmann, of St. Louis, has described a case in which a bridge-like band of skin stretched across the external auditory canal, from one wall to the other. This, he thought, was probably due to a union of two granular surfaces. Dr. A. H. 1 Lancet, March 13, 1880. ^ Lancet, 1881. If 308 EXTEEISTAL AUDITORY CANAL. Buck, of Xew York, has described a similar case.^ Dr. Roosa^ found, in a case of chronic suppuration of the middle ear, a car- tilaginous band stretched across the outer portion of the canal. Upon division of this band, it was found to contain " scales of bone which seemed to come from the posterior portion of the canal." Cutaneous Closure of the Auditory Canal. — Cutaneous closure of the canal at any point appears to be more frequent than bony closure. It may be congenital or acquired. This kind of ob- struction in the cana! is not always recognized at once, especi- ally if the diaphragm of skin is stretched across the canal near the fundus; in such a position, the obstruction may so closely resemble a thickened drum-head as to lead to some confusion in diagnosis. Dr. Morland^ has described a case of congenital imperforation of the auditory canal, caused by a cutaneous diaphragm in the cartilaginous portion of the canal, with hyperostosis of the bony portion. In this and in other cases the imperforation was not discovered until disease and deafness in the other ear drew at- tention to the imperfect hearing in the imperforate ear. In this case, the external ears were well formed. The oc- cluding cutaneous layer in the auditory canal appeared to be a "perfectly natural and smooth extension, or prolongation from the common covering of the auricle. It was not red nor uneven, nor as if thickened by previous or existing disease ; but white and uniform in appearance with the surrounding skin." After the patient was etherized, a crucial incision of the occluding cutaneous diaphragm was made, and the four result- ing flaps were removed with small curved scissors. An aperture, " about as large as a crow-quill," was made, through which a probe was cautiously passed, until it impinged against what was probably the drum- head. The lining of the meatus ap- peared normal, but there was considerable hyperostosis in the bony portion of the canal. !N"o view of the inner portion of the canal could be obtained. A piece of compressed sponge was then inserted, and subsequently sponge-tents, and the ear cleansed every few days, by the family physician of the patient. By Dr. Morland's advice, a gold tube was also worn in the meatus, and the ear healed in two months, with good hearing. Acquired Closure. — Dr. A. H. Buck* has recorded the case of a young woman, 26 years old, aftected with otorrhoea in the right ear in childhood, in whose right auditory canal he found 1 Trans. Amer. Otol. Soc, vol. i. p. 536. ^ \\,\(i_^ 1870, p. 90. s Ibid., 1879, pp. 31-34. * Ibid., vol. i. pp. 536, 537. « .^■i RESULTS OF INFLAMMATION AND INJURY. 309 " a smooth parchment-like memhrane of slight but uniform concavity, outwardly." It had a translucent appearance, with no evidence of beinc; provided with vascular supply, and it was tough and decidedly thicker than the menibrana tympani. AVhen this was pressed upon by a probe it yielded a crackling sound, audible even to the bystanders. This horn}' diaphragm was continuous with the skin of the canal at all points. A free crucial incision was made throuo:li this membrane, and it was found to lie about a line on the outer side of the normal plane of the niembrana tympani. Through the incision thus made, the red and succulent mucous membrane of the promon- tory was all that could be seen at first beyond the diaphragm. As an evidence of the vitality of the flilse membrane, it is stated that '' at the end of the examination a glistening border of bloody serum was noticed along the cut edges of the trian- gular flaps. At a subsequent visit it was ascertained that the malleus was still present, its tip being adherent to and covered by the tissues of the promontory. In some cases polypoid growths, invading the same transverse plane of the auditory canal, may grow together, and skin forming over them, a diaphragm is formed, which stubbornly occludes the canal at that point. Beyond the diaphragm the passage may be normal. Sometimes an orifice is found in the centre of this diaphragm, and by dilatation of this the diaphragm maybe reduced to a con- striction simply, and then the latter carefully widened.^ In such a case the constriction may be overcome by an appli- cation of nitric acid, made onlv once, as in the case of Dr. Buck referred to. I have often seen constriction and funnel-shaped narrowing of the auditory canal following chronic otorrhcea, espe- cially when the discharge had been due to ulceration of heredi- tarv svphilis. I have seen such alterations in the canal of both ears of adults, in whom the discharge had ceased years before. I have also observed granulation-tissue on the walls of the canal unite, and thus form a diaphragm across the canal. Dr. C. J. Blake- has met tumors of a horny nature in the audi- tory canal. These growths closely resemble the cornua humana. (See p. 220.) Acquired closure of the external auditory canal, either osseous or cutaneous, may arise from otorrhoea in child- hood,^ or from acute inflammation of the canal in childhood,^ or from the healino; of a wound of the auricle and cutaneous ex- ternal canal. ^ In an instance of the latter kind, Dr. Sexton successfully enlarged a slight sinuous opening in the occluding ^ See case by Dr. Buck, Transactions American Otolog. Soc, vol. i. p. 538. - Trans. Amer. Otoloej. Soc, voL i. p. 538. » Dr. S-. Theobald, American Otol. Society, 1882. * Dr. S. Sexton, American Journal of Otology, vol. iv., 1882. ^ Ibid. 310 EXTEKNAL AUDITORY CANAL. ■.'■1 diaphragm, and cut out a circular piece of the latter one-quarter of an inch in diameter. Then, by dilatation, kept up for some weeks, until healing in the skin of the meatus took place, the hearing was restored. Partial osseous closure of the canal occurs as the result of chronic purulent discharge from the ear, or from an ostitis set up by im- proper treatment, or other traumatic causes. In these the narrowing may be so great as to allow only the very fluid dis- charges to escape, while retaining the more inspissated portions of pus. In February, 1882, I was consulted by a lady 47 years old, regarding pain in her left ear and Eustachian region. She stated that twelve years previous her ear became somewhat diseased, but from the account she gave, its true nature could not be determined. She had been profoundly deaf in that ear ever since. Since the previous December her ear had discharged more, and it had been very ofl"ensive in odor. She had had pain in the left eye and left arm, and her neck and left submaxillary region had been stifle and the seat of pain. A'ertigo and nausea had been at times very great ; she was very pallid, and sufl:ered at times from psychical depression. Examination of the ear revealed a foreign substance, hard and dark, just within the meatus. This was inspissated pus, and upon its removal the osseous canal was found constricted to one-half its normal calibre. When ques- tioned, she stated that her left ear, i. e., her left auditory canal, had once been profoundly cauterized by a physician in the village where she lived with a solid stick of nitrate of silver. This caused great pain and inflammation, and doubtless induced the partial osseous closure of the canal. Syringing the ear by means of the tympanal syringe, the long slender nozzle of which entered easily through the constriction, brought away cheesy and fetid masses, and also caused water and pus to flow into her fauces. Syringing in this way for two days brought away all the cheesy collections in the tympanum, and relieved her entirely of the pain in various parts of her head, neck, and arm. The dizziness and nausea ceased, and her spirits improved. For a week the ear was cleansed daily by syringing and by carefully spooning out any inspissated debris which could be detected, by means of the platinum ring on the probe-like handle (Fig. 57). In the course of a week the red mucous membrane of the tympanic inner wall was seen. There was also a slight tendency to granulations and bleeding. Valsalva's inflation produced very easily- the charac- teristic whistle. The discharge became less, and was further lessened by the use of resorcin wash, ten grains to the fluidounce of water. Insutflation of powders could not be etiiciently carried out on account of tlie constriction of the osseous canal. How- ever, powdered boric acid was carefully conveyed on the cotton- RESULTS OF INFLAMMATION AND INJURY. 311 holder into the canal and to the inflamed mucous membrane, and the discharge reduced to a minimum. Epileptiform Symptoms from Irritation in the Auditory Canal. — It is well known that irritation set up in the auditory canal by the presence of a foreign body will produce epileptiform and even paralytic symptoms. This is amply confirmed by the ex- perience of Fabricius Hildanus, Toynbee, von Troeltsch, Wilde, Handiield Jones, Ilillairet, Moos, Urban Pritchard,^ Raymon- daud,- Kiipper,^ and others. It, therefore, becomes of the highest importance to examine the ear among other organs in a case of epileptiform disease of doubtful origin. The possi- bility that the ear or a foreign body in it may have something to do with the case in question should lead every physician to examine this organ or have it examined. It would be but safe to examine the ear as often as the pupil of the eye. Ear-cough. — Ear-cough, a peculiar reflex cough, excited by irritation of the external auditory canal, was known to medical men a long time ago. In the celebrated case, given by Fabricius Hildanus (1596), among the various reflex neuroses mentioned as the result of irritation of the external auditory canal by the presence of a glass bead, was a peculiar dry cough. Tissot* wrote of this peculiar cough as generally known in his time, and narrates an instance of it in " a French gentle- man who consulted him for total deafness, whose external audi- tory canal he could not touch, without occasioning a violent cough (toux tres forte), which was absolutely uncontrollable." He also states that Etmiiller (Francofurti, 1696-97) had ob- served, that, by touching the external auditory canal with a probe, one could produce a dry cough, which the latter at- tributed to the " sympathy between the nerves of the ear and those of the trachea." Pechlin^ regarded the peculiar cough (ear-cough) arising from rritation of the external auditory canal as a common occurrence, but mentions as a rarity a peculiar reflex sympathy (" consensus ") existing between the ear and the stomach (I'ouie et I'estomac), a striking example of which he observed in a military officer, who vomited considerably whenever his extremely sensitive 1^; II I! ' American .Journal of Otology, vol. ii. p. 9, 1880. ^ Archives Generales de Medicine, Sept. 1882. •■' Archiv f. Ohrenheillainde, Bd. xx. 107, 1883. * Traite des Nerfs et de leiirs Miladies. Paris et Londres, 1780, pp. 54-56. •' Observationum Physicomedicarum Tres libri, lo. Nicol. Pechlini, Hamburgi, anno M.DCXCI., Lib. 2, obs. 4-5 — quoted by Tissot, op. cit., p. 55. 312 EXTEENAL AUDITORY CANAL. '■ external auditory canal received the slightest touch even of the finger. With the object of ascertaining the percentage of those sub- ject to this sympathetic peculiarity, Dr. Fox, of Scarborough, England, carefully examined one hundred and eight persons : males, thirty-seven ; females, fort^^-live; sex not noted, twenty- six. He concluded that this hyperaesthetic state generally exists in both ears, sometimes, however, only in one, and occurs in about twenty per cent, of those examined. Ear-cousrh is due to the fact that the irritation of the auricular branch of the pneumogastric nerve, distributed to the auditory canal, is reflected to the motor fibres of the superior laryngeal nerve, also a branch of the pneumogastric. This induces con- traction of the crico-thyroid muscle, which manifests itself as coughing, and, in some instances, vomiting. Sometimes otitis externa diftusa will also produce the most obstinate ear-cough. The attacks may not be frequent, but they are severe and distressing, not uncommonly ending in vomiting. I have known most obstinate and distressing ear-cough to be excited by the presence in the auditory canals of inspissated cerumen. Fracture of the Tympanic Bone. — The tympanic bone, which enters largely into the formation of the posterior boundary of the glenoid cavity, as well as into the formation of the anterior wall of the osseous auditory canal, may be fractured by falls or blows upon the chin,^ or upon the cheek.^ The hemorrhage from the ear which usually occurs in these cases, has often misled the surgeon at the outset into diagnosticating fracture of the base of the skull. This mistake is all the more likely to be made if the patient is unconscious when first seen. Very often, how- ever, the patient is not unconscious, but complains of pain in his ear, especially upon moving his jaw. The latter symptom, to- gether with the swollen meatus, and the detection of a projection of bone from the anterior wall of the canal, into the calibre of the latter, will enable the surgeon to make the diagnosis of fracture of the tympanic plate. "These fractures of the tympanic bone are usually compound, and hence semi-detached parts of the skin of the auditory canal may be seen either projecting into the canal or floating in the blood. Treatment. — Excessive hemorrhage should be checked in a way not injurious to the drum-membrane. Hence, cold water should not be syringed into the ear. Any portion of bone projecting » r:uil Neis. These pour le Doctorat, Paris, 1879. Buchanan, of Glasgow, in American Journal of Otology, vol. iv. 215, 1882. « Biu-kner, Archiv f. Ohrenh., Bd. xviii. S. 300, 1882. RESULTS OF IXFL AM M A TION AXD INJURY. 313 into the canal, against or through the druni-niembrane, sliould he oarefully pushed back to its pLace, or, if loose, removed from the ear. Healing should* be conducted so as not to permit en- croachment upon the calibre of the canal. This can be eftected by the judicious use of bougies or tents in the canal, until heal- ing has taken place. Bleeding from the Meatus. — Hemorrhage from the ear occurs not uncommonly from traumatic causes which apparently pro- duce no further lesion. A physician informed me recently that, slipping suddenly, he struck his mastoid process violently on a projection of some kind in his office. The blow was followed by hemorrhage from the meatus, but by no further trouble. The hemorrhage in such cases comes from a so-called fissure in the skin of the external auditory canal, in its osseous portion. I have recently seen a case in a young woman, who fainted and fell on the floor. A slight hemorrhage came from the ear, and there was in the osseous part of the canal near the drum-mem- brane a red fissure. These must necessarily occur by contre- coup. Were the force of the blow greater, fracture of the bone underlying the fissure in the skin would probably ensue. Aneu- j-ismal tumor in the canal has been observed and described by Dr. C. A. Todd, of St. Louis.^ Hemorrhage from the meatus, connected with injuries to deeper parts of the ear, will be considered further on, when alluding to injuries of the internal ear. Treatmevt. — If the bleeding is due to an injury limited to the skin of the external canal, a mild styptic may be required. In any event the blood must not be allowed to form permanent clots or crusts in the meatus. Vicarious Menstruation from the Auditory Canal. — Bleeding from the ear has been observed in some instances of suppressed menstruation. It may be preceded by pain and a sense of ful- ness in the ear, which however is relieved by the hemorrhage.^ It may occur from a sebaceous tumor in the meatus, or from the mucous membrane of the middle ear, as in cases observed and fully described by -I. Orne Green.^ In the fii'st case, nose-bleed had once been the mode of vicarious menstruation. This at last gave place to bleeding from the meatus, sufficient at the monthly epoch to cover a handkerchief. The phenomenon was often preceded by severe headache, which Avas relieved when the bleeding came on. There were no other abnormal symptoms in the ear. Dr. Green made elliptical incisions about the base } American Journal of Otology, vol. iv. p. 187, 1882. * Hinton, Questions of Aural Surgery, p. 97. * American Journal of Otology, vol. iii , 1881. 314 EXTEKNAL AUDITORY CANAL. of the tumor and dissected out the entire mass. The cyst was nourished by a laro;e arterial branch. Five months after the operation there had been neither nasal nor aural vicarious bleed- ing. Mr. Field^ has described a case of vicarious menstruation from the right ear of a girl eighteen years old. She had had a purulent discharge from this ear since her sixth year. At about fourteen years of age, she had epistaxis and bleeding from the right ear. Since then she had lost blood from the ear every three weeks. Menstruation by the vagina had never been established. Her breasts were small, and no os uteri could be detected by digital examination. 1 Med. Press and Circular, London, Feb. 8, 1882. SECTION IV. MEMBRANA TYMPANI CHAPTER I. ACUTE AND CHKONIC INFLAMMATION, INJUEIES, AND MORBID GROWTHS. Acute Myringitis. — In many cases it is of great clinical con- venience to speak of an inflammation of the drum-head; but it is not easy to describe, anatomically, such a disease of the ear. Being so intimate in structural relation with the external auditory canal on one side, and with the tympanum on the other, disease in either of these parts may very easily extend to the drum-head ; but as the middle or fibrous layer is the only layer peculiar to the drum-head, and as it has no nervous and vascular supply of its own, it may indeed be said in safety that a true myringitis, implicating the middle layer of the membrane, rarely, if ever, occurs, JSTevertheless, it is often observed that an inflammation of the external auditory canal localizes itself in the outer layer of this important partition between the outer and middle ear. Also an inflammation of the mucous membrane of the middle ear may localize itself on the inner surface of the drum-head. Hence, clinically, myringitis may be classed among tlie diseases of the ear, for the fact is that an inflammation of the skin of the external canal, or of the mucous membrane on tlie inner surface of the membrana tympani, having culminated in the drum-head, will produce such modiflcations in that mem- brane as to demand attention somewhat diflferent from that obtained if the inflammation occurring in these constituent structures had localized itself elsewhere. As an idiopathic disease, myringitis is of rare occurrence; as a secondary event, very frequent.^ Symptoms. — A typical case of so-called myringitis is charac- terized by pain and tinnitus, but not intense hardness of hearing. ' Griiber, Monatsschr. fiir Ohrenheilkunie, Nos. U, 11, and 12, 1875. 316 MEMBEANA TYMPANI. Upon inspection it will be seen that the membrana tympani is congested, usually ver}' greatly if the disease has advanced, but that its position is not abnormal, and that the adjacent wall of the auditory canal is little or not at all cono-ested. At the same time the Eustachian tube may be found entirely free, and the membrana tympani will give no evidence by bulging that there is secretion in the tympanum. Hence, then, there may be an inflammation localized in the membrana tympani, the external auditory canal and the middle ear being free from inflammation. It would seem but just, therefore, to give the name of myrin- gitis to such a disease, and mark out for it a special treatment. By further watching such a case, it will be found that the ri membrana tympani becomes gradually thicker from infiltration, ■' and at last pus will be found on the outer surface, without the existence of a spontaneous opening in the membrane. By wiping away this product of inflammation, the outer surface of 'ii the membrane will be found very red, in some cases almost o;ranular, and it will bleed if touched rous-hlv. This condition of breaking down may go on until an ulcerated spot is at last formed on the outer surface of the drum-head. The latter may lead to a perforation of the membrana tympani, by erosion from without inward. The hearing in the meantime, however, does f\ not sufl-'er as it does when the tympanic cavity is primarily and chiefly affected by disease. As I have assured myself, by means ^j of the catheter and by incisions through the drum-head, that |j the tympanum is free from disease in all such cases as could be (^ termed mj-ringitis, which I have seen, I am disposed to consider so-called myringitis, an inflammation usually, if not always, of ^ the dermoid layer of the drum-head. If the mucous surface only of the membrana tympani is in- flamed, it is not easy to make such a delicate diagnosis, and, furthermore, there is no proof that inflammation would remain localized on the inner, as it does on the outer surface of the membrana tympani. Doubtless, localized inflammation does occur on the inner surface of the drum-head, but the symptoms it produces are not as distinctive as those produced b}' inflam- mation of the dermoid layer. The symptoms of acute myringitis may be learned from the following case, which will also show the clinical significance of )' the disease : ,' A gunsmith, a large, healthy man, 40 years old, complained V of some earache, considerable deafness, and marked tinnitus in his left ear, all of which he attributed to exposure to cold air i- on that side of the head for several hours, while at work. On inspection, the membrana tympani Avas found reddened, dry, scaly, and somewhat thickened, z. e., it looked more like a piece of thick sheepskin than the delicate normal drum-head. The i txfla:^[matiox, injuries, morbid GRowTirs. 817 Jiearing was found to be ^% in. for small watch. Tuning-fork, on vertex, heard best on affected side. The position of the membrane did not seem altered, but, as the latter looked thick, and as I suspected there might be retained secretion in the tympanum, the membrane was incised; nothing but air came whistling through the cut when Valsalva's inflation was per- formed. The hearing improved slightly. The perforation healed in a few hours, and the next day the hearing was reduced again to ^'V *"oi' the watch. The pain, though slight, continued; the membrane looked more swollen; the tinnitus was still annoying. In the course of two or three davs, the man presenting himself at the Infirmary, the membrana tympani was found to be covered with a film of pus, beneath which the membrane was quite red. The pain had now become less. Under instillations of zinc and opium, the secretion ceased, the drum-head healed, and the hearing returned, without there having been any symptom of disease, excepting in the dermoid layer of the membrana tympani. Differential Diagnosis between Acute Myringitis and Acute Otitis Media. — The disease most likely to be confounded wdth acute mvrino-itis is acute inflammation of the middle ear, but it will be found that there are some very characteristic features by which the one may be distinguished from the other. In acute otitis media there is found, early in the disease, an indrawing of the membrana tympani, without thickening, and the redness is limited to the manubrial plexus and the upper periphery. In acute myringitis, however, the membrane becomes first evenly red all over, rough from partial exfoliation of epithelium, and then thick and infiltrated, but not indrawn ; rather flattened than otherwise, or its position remains very nearly normal. The pain in otitis media is intense, while in acute myringitis it is not so terrific. In the former disease, the secretion forms within the tympanum, and there is consequently a marked tendency to perforation of the membrana tympani from within outward. In acute myringitis there is no special tendency to perforation, though there may be such an occurrence in the membrane, by erosion from without inward. Then, further, the secretion in otitis media is copious, and it may be either mucous or purulent. In acute myringitis, however, it is scanty and purulent. In the former, the febrile and constitutional symptoms are severe and often grave, while in acute myringitis such severe symptoms are wanting. These facts, added to others previously mentioned, would seem to warrant a conclu- sion that there may be, at least clinically, an independent disease, wdiich may be termed acute myringitis. Myringitis may occur in those affected with chronic tuberculosis of the lungs. 318 MEMBRANA TYMPANI. Etiology. — The most usual cause of myringitis is sudden ex- r posure of the drum-head to cold. This may occur either from blasts of cold air on the drum-head or from exposure of it to sudden cold in plunging or bathing in cold water. The latter exposure is most commonly incurred at the seaside. The disease may also be caused by instillations of irritating fluids into the auditory canal or by violence from any source. The membrane may be scalded, as in a case observed by Bezold.^ Treatment. — The treatment indicated in the acute stage is depletion of the congested membrane. Leeching near the ear will give relief, but a quicker way is scarification of the mem- brana tympani, as suggested b}' Dr. Blake. From two to four \, cuts may be made in each case, the points selected for incision being those of greatest prominence or congestion. Care must be taken not to cut through into the tympanic cavity. Relief is obtained, as a rule, b}' one scarification. I have practised this form of treatment, with success, in acute cases. Even in the acute stages relief to pain may be given by insuifiations of boric acid, or of borax, finely powdered. It has seemed to me that in some cases these insufflations tended to abort the disease. I have also ibund extremely serviceable the calendulated boric acid, as recommended by Dr. Samuel Sexton,'^ of New York. This powder is prepared by first triturating together equal parts by weight, of tincture of Calendula officinalis and finely powdered boric acid. Evaporate the calendula dowm in a water-bath at a temperature of about 150° F., to a pasty consistence, and then i mix with one-half the boric acid; evaporate to dryness, add the ' other half, and triturate. This strongly calendulated boric acid r should then be mixed with twice its weight of pure boric acid, and further triturated, when the surgeon has what is frequently alluded to in this work as calendulated boric acid. The J original strongl}' calendulated powder may be mixed with only j an equal weight of pure boracic acid, if so desired ; but I have I employed only that form made of one part of the original i strongly calendulated powder and two parts of pure boric acid, ^ which is equivalent to one part of calendula to three parts of » boric acid. If, however, secretion is established from the in- i(i flamed outer surface of the drum-membrane, the use of these same powders will almost invariably check the discharge, pro- tect the ulcerated surface of the membrane, and promote, by their detergent influence, a ready healing. If a fluid applica- tion is required or desired, the following may be used : K — Zinci sulphatis, gr. Tiiict. opii, f^j. Aqiuv, f^vij. J-iJ- ^ American Journ. Otol., vol. iv. 1882. ^ New York Med. Record, Dec. 31, 1881. INFLAMMATION, INJURIES, MORBID GROWTHS. 319 Of this ten drops, warmed, iiuiy be put into the ear, ouce or twice daily. The ear should be cleansed by absorbent cotton rather than by syringing, since the latter tends to promote granulations. If granulations form, they may be touched by strong solutions of nitrate of silver on the cotton-dossil on the cotton-holder. Abscess of the Membrana Tympani. — There may be a true abscess of the drum-membrane without perforation of the latter. Two cases are reported by Marian ;' in one the abscess occurred in the anterior lower quadrant of the membrane, and in the other, above the short process. I have seen two cases of abscess in or on the membrana tympani without perforation of the membrane ; once in the membrana flaccida, and once in the postero-superior quadrant implicating the adjacent wall of the auditory canal. In the cases I observed, there was pain. Spon- taneous rupture occurred in the first named, and in the latter instance I incised the abscess, with instant relief to the pain. Pain, autophony, and great tinnitus had been annoying the patient for a fortnight before the operation. The membrana tympani was thickened in this case, before the abscess formed, by the habit of excessive bathing and diving in cold sea-water, in which the patient had indulged for many years in summer. In winter-time he was in the habit of putting water into his ears in various ways. This unfortunate habit had produced a gradual thickening of the dermis of the membrana tympani. A myringitis ensuing upon exposure to cold, an abscess formed and was retained beneath the abnormally thick dermis, instead of rapidly ending in the formation and rupture of a vesicle, as is often seen in myringitis from exposure to cold. CHRONIC INFLAMMATION. If Ulcers in the Dermoid Layer. — As a consequence of acute ex- ternal otitis or of acute myringitis, ulcers may form on the membrana tympani. As has been stated when alluding to acute myringitis, erosion of the dermoid layer of the drum-head may occur in that disease. The first stage of such erosion would implicate the outer layer, while subsequent advances of the disease would involve the deeper layers. Hence, an ulcer on the drum-head may assume a terraced shape, the upper stratum being the dermoid, the middle the fibrous, and the inner the mucous layer of tlie membrana tympani. 1^ Most usually, however, the ulcerative process on the drum- ead does not pass beyond the two outer layers. That true 1 Archiv f. Ohrenh., Bd. xvii. S. 84, 1881. \ 320 MEMBRANA TYMPANI. ulcerative processes do occur here, has been fully shown by J. Orne Green. ^ Symftoms. — Such a process on the drum-head may be attended with some loss of hearing, and usually some tinnitus aurium, but pain is entirely absent. The attention of the patient is called to the ear partly by some hardness of hearing and the subjective noise, but chiefly by the scanty and slow discharge. The scantiness and slowness of the discharge lead to a hardening i of it about the meatus, and the ear, feeling dry and stift", the ^ patient is inclined to pick at it. By such manipulation, dry \ scales of dark matter are pulled from the meatus, and are usually another incentive to the patient to seek medical aid. Causes. — This ulceration of the dermoid and other layers of the membrana tympani, I have uniformly found in the poorly nourished classes of the Infirmary. A process in the external ear, especially on the outer surface of the membrana tympani, which otherwise would run an acute course and then disappear, tends to become chronic in the poor and the unclean. In addi- tion to poverty and uncleanliness, there must be added ignorant neglect or improper domestic treatment, the latter consisting chiefly of instilling oils which clog the ear and become rancid, or by the direct instillation of irritants of various kinds. It can be seen how readily all these circumstances tend to provoke, ) in the cachectic especially, a chronic ulceration in the external i ear. For it is a skin disease, a cutaneous ulcer, that is to be i contended with in such cases. Prognosis and Treatment. — The prognosis is favorable if the < proper treatment is carried out, but, like every other aural dis- ease, this tends to chronicity in the most favorable circumstances if not properly managed. Should the condition of the patient demand constitutional remedies (and it always will, according to my observation), some form of iron will be found of great benefit. The syrup of the iodide of iron, or some one of the numerous preparations of iron and cod-liver oil, will render good service in these cases. The local treatment is of the greatest importance in ulcera- tion of the membrana tympani. The auditory canal must be carefully cleansed by the surgeon by swabbing with absorbent cotton on the cotton-holder, or by syringing with warm water often enough to prevent accumulation of matter. But the se- cretion in these cases is not usually copious. It is, however, tenacious, and the patient is rarely able to remove it thoroughly by syringing. It is, therefore, of prime importance that the sur- geon should wipe off" the drum-head and inner end of the canal, > Ulceration of the dermoid layer of the membrana tympani. Transactions American Otol. Soc, vol. i.p. 431, 1873. INFLA M^l ATION, INJURIES, MORBID GROWTHS. 321 bv means of absorbent cotton on the cotton-bolder. This should be done very carefully and thorouglily, under good illumination of the canal, by means of the forehead-mirror. To attempt to cleanse an ear by swabbing it out, without such illumination, is worse tlian useless; it is always painful, and most usually injurious. The perfunctory custom of turning the sufi'erer's ear towards a window, and blindly forcing into the meatus a probe, armed or unarmed with a tuft of cotton, or a brush, is extremely hazardous. The canal varies enough in every patient to war- rant special illumination, by means of ear-funnel and forehead- mirror. By this means the curves in the canal are not struck and wounded, as they are when the canal is manipulated in a less scientific way. After the canal is properly lighted and the membrana tympani perfectly visible, let the latter be wiped off by means of a tuft of cotton on the flexible cotton-holder. AVhen the ulcerated membrane is thus cleansed, the local reme- dies may be applied. These may consist of insufliations as sug- gested for myringitis, p. 318, or, in the more chronic stages, of applications of nitrate of silver or of sulphate of copper. Dr. J. 0. Green has found the latter very beneficial in ulceration of the dermoid layer of the drum-head. Mtrate of silver is best employed in solution ; in these cases it should not be instilled into the ear and allowed to find its way to the fundus of the canal and the drum-head, but it should be applied, by means of cotton on the holder, directly to the diseased spot. Solutions of sulphate of copper may be applied by means of the cotton- holder, or the solid crystal may be used. Dr. Green prefers the latter to the nitrate of silver in any form, in these cases. Neither the cleansing, unless it be by very absorbent cotton, nor the treatment, as a rule, is to be entrusted to the patient in these forms of aural disease, for the reasons already given, that syringing tends to promote granulations, as indeed do instilla- tions of medicinal solutions, heretofore so largely prescribed for the patient's use at home. As insufflations of powders form the best mode of treatment, and as the patient cannot apply them to his ear, nor have it done at home, the treatment naturally falls into the hands of the surgeon. Perforation of the Membrana Flaccida. — Perforation of Shrap- nelTs membrane, or the membrana flaccida, appears to be an uncommon occurrence. It is usually found to be the result of chronic disease, either within the tympanic cavity or the external auditory canal, most usually the former, and is generally at- tended with great hardness of hearing. Most probably the ulcerative process attacking this part of the membrana tympani also greatly implicates the head and neck of the malleus and the 21 322 MEMBEANA TYMPANI. body of the incus, and the joint between these two ossicles. I have seen eleven casesof perforation of the membranaflaccida, all of them large, but unassociated with perforations elsewhere in the membrana tympani. The membrana liaccida, or the flaccid membrane of Shrap- nell, may be briefly described as a fan-shaped region, the lower borders "of which, or the imagined sticks of the fan, run back- ward and forward from the short process of the malleus above the upper edge of each so-called fold of the membrana tympani, forming a lower boundary about five mm. long. The upper edge of this important part of the membrana tympani corre- sponds to that peculiar part of the general periphery of the drum-head known as the segment of Rivinus. The latter is, perhaps, more accurately described as the margo tympanicus, or the inner edge of the upper bony wall of the external audi- tory canal, and may be looked upon as the osseous complement of the annulus tympanicus, to the innermost and free edge of M^hich the external ligament of the malleus is attached. The membrana flaccida thus outlined is about three mm. high, measuring from the short process up to the point of attachment of the membrane to the upper osseous wall of the auditory canal. This membrane is composed of only two layers, an outer skin layer from the auditory canal and an inner layer of mucous membrane reflected from the tympanic cavity and the inner surface of the margo tympanicus. Directly behind the central part of the membrana flaccida is the neck of the malleus, the head of which lies behind the margo tympanicus. The front part of this membrane is stretched over the anterior upper part of the tympanic cavity, entrance to which at this point is above the so-called anterior pocket of the drum-head. The back part of this membrane, behind the neck of the malleus, is stretched over the front end of a long and shallow groove yet to be de- scribed, and at this point the membrana flaccida is about two mm. from the lower part of the body of the incus. This pos- terior, groove-like cavity is wedge-shaped, bounded on its inner side by the upper part of the body of the incus and its short horizontal process, and on its outer side by the inner surface of the margo tympanicus. The edge of the wedge-shaped groove points downward, and its base opens upward toward the tegmen, while in its long diameter it widens and fades away backward into the tympanic cavity and mastoid antrum. At its anterior end and on its outer side this groove is covered in from the external auditory canal by the back part of the membrana flaccida. Hence, when the membrane gives way at this point, egress is given to matter from the upper and back part of the tympanic cavity, and from the mastoid antrum. Sometimes a perforation in the membrana flaccida is directly If INFLAMMATION, INJURIES, MORBID GROWTHS. 323 over the short process of the malleus, opening then into what is termed by Priissak and Gustav Briinner, a third pouch of the drum-head. This third pouch is said by the former writer, who first described it, to open into the tympanic cavity at one point only, viz., backward over the position of the posterior pouch of von Troeltsch. In perforations of the central part of the membrana flaccida, the neck of the malleus is exposed, and in anterior perforations, i. e., in those in front of the neck of the malleus, entrance is eflected directly to the large, upper space in the front part of the tympanic cavity, near the tympanic end of the Eustachian tube. Posterior perforations are usually attended with great dis- charge, and connected with mastoid symptoms; they are also the most obstinate and accompanied by profound deafness. Central perforations are most apt to be connected with disease in the external auditory canal, but are least obstinate to treat- ment, and are not usually attended with such profound hardness of hearing nor so great a discharge. Anterior perforations are most likel}' to be connected with pronounced disease in the nares. Eustachian tube, and the tym- panic cavity, and to give exit to a copious discharge. But they have seemed to me to be the most remediable. In cases of destruction of the entire membrana flaccida, attended with erosion of the margo tympanicus, there come into view, directly over the line of the folds of the membrana tympani, the neck and head of the malleus, and the junction of the latter with the incus, the body of the incus with the upper part of its descending crus, and the proximal part of its short, horizontal crus. In such cases of extensive destruction the entire dome of the tympanum under the roof can be viewed by turning the patient's head to the opposite side, and there may be seen as well the cavity of the upper and front part of the tympanum, and a dark cavity, in the back part of the space thus opened around the head of the malleus and body of the incus, which is the beginning of the mastoid antrum. When the perforation is in the anterior part of the membrana flaccida, the Valsalvan inflation is likely to produce a charac- teristic perforation-wdiistle, but when the perforation is else- where in the flaccid membrane, a perforation-whistle on inflation by any means is not likely to be produced, as can be readily understood upon reflecting, that, except in anterior perforations, the bod}' of the malleus and incus intervene between the cavity of the tympanum and the perforations. Another feature in these cases of perforation in the membrana flaccida, is the ab- sence of perforation in the membrana tympani below the folds. I have onl}' once observed a perforation here coexistent with 324 MEMBRANA TYMPANI. perforation in the membrana flaccida. Dr. C. J. Blake ^ has given an account of a case in which a small perforation in the flaccid membrane was associated with a large opening in the membrana tympani proper. Sometimes, especially in the pos- terior forms, denuded bone can be felt through these perfora- tions. My experience in this form of aural disease extends over twelve cases. Perhaps one of the rarest circumstances in these cases is to find a similar perforation, or, in fact, a perforation of any form, in both membranse flaccidse existing at the same time. An account of such a rare occurrence will be given in Case VII. IVeatment. — The existence of a perforation in the membrana flaccida, excepting, perhaps, the central variety, indicates great disease in the upper part of the tympanic cavity. As the bulk of the malleus and incus lies in the dome of the tympanum, directly behind the membrana flaccida, there is necessarily an impediment oftered by them to the escape of matter from the cavity of the drum, when the only perforation in the membrana tympani is in the flaccid part. The only eflicient treatment of tympanic disease, in these cases in which the perforation in the flaccid membrane is but a Fig. 85. '$■ '■■V LEACH St GREENE. BOSTON. Blake's Middle-ear Syringe. -■■^t ^ symptom of the position of the disease, is by means of the tym- panic syringe. The form I have used for some years is that described by Dr. C. J. Blake. It consists briefly in a dentist's syringe of hard ru])her, about 9 cm. long, and about 1.50 cm. in diameter. To this is added a short tube of glass, making a transparent " neck," in diameter 5 mm. to which curved nozzles 9 cm. in length, with diameters varying from ^ to IJ mm. may be fitted. The neck alluded to above maj^ be of 1 Transactions American Otological Society, vol. i. p. 546, 1875. INFLAMMATION, INJURIES, MORBID GROAVTHS, 325 glass or metal, and should be made to screw oft* and on. A metal " neck " has proved most satisfactory to the writer, because much more durable than o;lass. With such an instru- ment the surgeon can both cleanse and medicate direatly a diseased tympanum far better than in any other way. The experiences of J. Orne Green,' C, J. Blake,^ A. H. Buck,^ and H. G. Miller,* are of great interest and value in further elucida- tion of this important form of aural disease. Dr. C. J. Blake ^ writes me the following description of his new tympanic syringe. It is a sort of combination of the middle-ear syringe, and Hartmann's canula, and is useful in Fig. 86. I LEACH & GREENE, BOSTON. Blake's New Tympanic Syringe. washing out the middle ear. It consists of a brass tip with a small handle on it; over one end of this tip is slipped a rubber tube connecting with any form of rubber syringe — Davidson's or a bag-syringe, for instance — and to the other end screws any one of the slender canulfe, such as are used with the middle-ear syringe; it is, jper se, properly not a syringe, but the middle-ear nozzle for a syringe. Case I. Chronic discharge from the tymijmmm, with perforation of the memhrana flaccida posteriorhj. — John M., seventeen years old, came under my care in the Presbyterian Hospital of Phila- delphia, in July, 1872. He states that his first ear-trouble ' Boston Med. and Surgical .Journal, March 26, 1874. ^ Transactions American Otological Society, 1874, vol. i. p. 546. ^ Diagnosis and Treatment of Ear Diseases. New York : Wm. Wood & Co., 1880. * Transacfions American Otological Society, 1878, vol. ii. p. 257. '" March 31, 1884. 326 MEMBRANA TYMPANI. 1 occurred when he was four years old. He is a pale, intelligent lad, a hard student in a classical school. His father died insane, and he has a brother who is hopelessly insane. When the patient was twelve years old he began to have "gatherings in his ear" about twice each winter. A year before he became my patient, a constant and most copious discharge, preceded by pain, became established in the right ear. When I made my iirst examination of his ear, in July, 1872, the membrana tym- pani was found saturated with a yellowish-green pus. The only perforation in the membrana tympani was in the membrana flaccida, above and behind the short process of the malleus, but at no time was there a perforation-whistle obtained by an}- mode of inflation of the tympanic cavity. The hearing was reduced to , ^ ^ ' for the watch, and for the voice, nil. I passed a probe 50 ft. 'IF a short distance into the perforation. The cavity was sensitive, but there was no denuded bone. The treatment consisted of instillations of a solution of nitrate of silver (80 gr. to f.5J) once a week, at the hospital, and the patient was ordered to syringe his ear three times daily at home, and to instil a solution of zinc (gr. X to ff5J). For the latter solution were sometimes sub- stituted solutions of alum, and later a solution of nitrate of lead. In four months the discharge ceased, the nitrate of lead apparently having had the best etfect on the aural disease in this case. In November, five months from the beginning of treatment, the membrana tympani had assumed an almost normal appear- ance, except the cicatrix in the membrana flaccida. At no time were there any granulations, and the discharge remained, uniformly, of a light color, and of the consistence of cream. The hearino- improved to ~ for the watch, and the ^ ^ 50 ft. ' voice could be heard close to the aftected ear. The Eustachian tube was pervious. On the first of January, 1873, the patient was found com- plaining of pain and soreness in the mastoid process of the aftected ear, but he had no symptoms of fever. Perfect physical rest, with attention to general health, was ordered, and by the 10th of the month all mastoid symptoms had vanished. There was no return of the discharge as the pain subsided, but, as the patient was studying too much at his school, his health began to fail, and he was, therefore, ordered to quit school and take as much exercise in the open air as possible. By the 1st of December, 1873, the discharge returned, with pain in the ear and soreness when the auricle was pulled gently. The discharge continued for three months and a half, with" per- sistence of the old perforation in the membrana flaccida. I m H** I INFLAMMATION, INJURIES, MORBID GROWTHS. 327 could readily 8ce the discharge oozing slowly iVoiii the jiertbra- tion, after drying the orifice with the cotton-holder. At this second attack of discharge from the ear, the strength of the solution of nitrate of silver was increased to 480 gr. to f.^j. This caused intense pain for a few minutes; then the pain ceased entirely. In conjunction with ap[)lications of the strong solution of silver, the patient used a strong solution of the sul- phate of zinc (30 gr. to f.^J) at home, which seemed to exert a good etfect in the course of one month. The most careful syringing became necessary while using this strong solution of suli)hate of zinc, in order to remove the coagula produced by it. A few painful furunculi followed the cessation of the discharge. On the 22d March, 1874, the voice and the watch were heard five paces. There was a depressed cicatrix in the membrana flaccida, above and behind the short process. The membrana tympani, below the folds, was almost normal in color. This case came on with attacks of great pain, while the patient was a child ; there was no denuded bone ; the perforation in the membrane was just large enough to admit the small round head >of a silver probe, and there were from time to time attacks of 5 pain and throbbing in the affected ear, and finally the discharge ceased under the use of astringents, in stronger solutions after the relapse, than at first ; there was marked hardness of hearing, but no tinnitus at any time. It is of interest to note that the first cure was effected in the autumn of 1872, with no relapse until the Avinter of 1873-74. In the winter of 1872-73, there were simply ten days of mastoid sore- ness and pain, with no discharge. The patient has resumed his studies at school, and has gained in stature, strength, and hearing. Throughout the previous history of this case there is shown a tendency to recur ; but during the two years he was under treatment, he had only eight months of aural discharge, viz., the first four months, which were followed by one year of freedom from aural discharge, and then a recurrence of otorrhoea for three and a half monHis, which brings the history to March, 1874, after which date the patient went to reside in another city. The patient remained away, and did not give any report of himself until iNTovember 26, J 875, when it was found that the discharge had returned, and that a small polypus was protruding from the perforation in the membrana flaccida. The polypus was easily removed, but its precise point of attachment could not be determined. A small piece of cotton on the holder was moistened with chloroacetic acid and passed through the per- foration, and thus near to the attachment of the polyi)US._ The patient then passed from observation on account of his residence in a distant city. ' I have ceased to use this acid in the ear, on account of the pain it induces. 328 MEMBRAXA TTMPANI. On the 2cl of February, 1879, I found the external auditory canal tumid at the inner and upper end, where it joins the membrana tympani, and the latter in its posterior half seemed to bulge far forwards toward the anterior wall of the canal. It was pinkish, greatly macerated with pus, looked like ordinary skin, and the malleus was invisible. When the drum-head was pressed upon below, pus welled out from the perforation in the flaccid membrane. The condition of the ear at that time had been brought about apparently by unavoidable exposure to a storm of wind and sleet a short time previous. After the ex- posure, dull earache was soon felt, then a discharge set in for the first time for nearly four 3'ears, and the patient once more sought treatment. The mastoid process was not markedly in- volved at this time, though it had been some years previous the seat of great pain and tenderness. Denuded bone now could be felt by passing a probe directly through the perforation in the membrane, being in all probability a bare spot on the margo tympanicus, or on the incus. The hearing was greatly reduced, the pain had been very slight within the twenty-four hours just passed, the general health was good, but the right pupil was more dilatedthan the left. The ear was kept carefully cleansed by warm water syringing for a week, during which the patient was not seen, as he resided in another city, where he was in college. In "the course of ten days, when the patient was seen again, the drum-head had assumed a more normal position and appear- ance and the malleus was visible. The tympanic cavity was at this time cleansed by the tympanic syringe already described. After the cleansing, a few drops of a solution of nitrate of silver (80 gr. to fsj) were injected with the tympanic syringe, through the perforation into the cavity beyond. At home he was to keep the ear clean by syringing with castile soap and warm water. In four days the membrana tympani Avas seen to have assumed still further a more normal appearance and the discharge from the perforation was less. The same treatment with the tympanic syringe was gone through with and the patient was not seen "for a week. When he came again there was scarcely any discharge, and the membrana tympani looked nearly normal below the^folds. At this visit, a solution of only sixty grains of nitrate of silver to the fluidounce of water was applied to the tympanic cavity. By the use of the tympanic syringe some cheesy matter was washed out through the perfo- ration in the flaccid membrane, and the patient told to let his ear alone and not to syringe it; but he did not carry out these orders, and when he came again a small polypus was seen to liave sprung up over the perforation, very probably as the result of too mucii syringing. The polypus, which was quite vascular, INFLAMMATION, INJURIES, MORBID GROWTHS. ;329 was jiullod away with J51ake's snare, and a iew drops of a solu- tion of' nitrate of silver (480 gv. to f.^j) injected into the cavity through the perforation, without any discomfort or inflammatory reaction. In a week, when the patient was seen ao-aiu, thei-e was no discharge from the ear. In the course of a fortnight the patient took cold, and there was a slight return of discharge from the ear, accompanied by tumidity and soreness in the reii'ion of the perforation and the posterior wall of the inner end of" the auditory canal. All these symptoms, however, soon vanished under gentle syringing and the injection of an acid solution of acetate of lead and laudanum, by means of the tym- panic syringe. f The denuded surface of bone felt through the perforation, now seemed much less in extent, and gradually it appeared to be covered over with periosteum, as it no longer could be de- tected with a probe. The hearing became relativel}^ normal, the patient being able to hear the voice three or four feet, and a pocket watch ^ This improved condition continued for ^ 60 in- some months, after which, the patient was obliged by various duties to stay in another city. At no time in this case was there any perforation-whistle upon inflation of the tympanum ; there was evidently purulent matter in the cavity of the tympanum, as shown by the welling out of pus through the perforation in the flaccid membrane, when the membrana tympani below the folds was pressed upon. The hardness of hearing was at times profound, and the symp- toms of disease in the back part of the upper tympanum and mastoid region were marked. The unequal dilatation of the pupils is well worthy of note, for it was said by the patient that this haid been the case always since his ear had been affected, i.e., since he was twelve years old; it consisted in a partial paresis of the right iris, which, though dilatable, was sluggish under the same stimulus, in comparison with the left, and it would never open as widely as its fellow. In the treatment it is worthy of note that the tympanic syringe was the only means of cleansing and medicating the dise^ised cavity, and also that the very strong solutions of nitrate of silver were efficient in their action and caused no pain. Case II. Perforation of the membrana flaccida. — A second case of perforation of the membrana flaccida (Shrapnell's membrane) was observed in a man 22 years old. He stated that the first symptom in the affected ear, the left, was an attack of pain which had occurred seven months previous ; this was followed by a dis- charge, which had gradually become less. Becoming anxious to have it entirely checked, he had applied for treatment. 330 . MEMBRANA TYMPANI. The perforation was large, embracing most of the flaccid membrane and exposing the neck of the hammer. The dis- charge was very slight. Unfortunately for the further history of this case, like many others seen in public practice, it passed from notice after the second visit. The hearing in this case was greatly impaired. There was no perforation-whistle produced in this case at any time by any mode of tympanic inflation. Case III. Perforation of the membrana fiaccida; polypus pro- truding through the opening thus made. — A fourth case presents more clinical interest, as it had been long watched, from Sept. 7, 1875, to Sept. 1877. The patient, a German woman, 35 years old, stated that two years previously her left ear had troubled her for the first time. There was then some pain followed by an oflensive discharge ; the latter had continued, greatly to her 3 ft annoyance. The hearing was reduced to ^t^^ for the loudly ticking watch ; for the voice, similarly. The meatus was found smeared with a slight but ofifensive discharge which came from a large perforation in the flaccid part of the membrana tym- pani. The membrane was not perforated elsewhere, but it appeared abnormally thickened, as it always does, so far as my experience goes, when a perforation exists in the membrane of Shrapnell. A polypus as large as a small pea protruded through the perforation. The attachment of the polypus was inside tbe tympanum, posteriorly ; when it had been removed, which was easily done with a hook, it was found that the polypus attached posteriorly had grown forward between the membrana tympani, i. e., the region of the perforation, and the contents of the upper part of the tympanic cavity. Its inner surface was flattened; its outer surface, being free to grow out through the perforation, had assumed a convex shape, and this it was which was seen protruding through the opening in the membrane. There was no perforation-whistle at any time. The ear was kept carefully cleansed, and chloroacetic acid' was applied by means of the cotton-holder to the perforation and the t}- mpanic cavity adjacent to it. The patient syringed the ear two or three times dailv at home, and instilled a weak solution of zinc. The discharge diminished greatly, lost its fetor, and at last ceased entirely. The hearing was not materially improved, as indeed might be expected, M'hen it is remembered how near the articulations of the ossicles the brunt of the disease must have fallen. Indeed, I have yet to see a perforation of the membrana flaccida unattended with great deafness. ^ I have long since ceased to use this acid, on account of the great pain it induces. INFLAMMATION, INJURIES, MORBID GROWTHS. 331 Case IV. Perforation of the me)iibraii(( jhccida, probalilii from external causes; foreic/n body in the canal. — This case, besides presenting tlie eom{)arativel_v rurc occurrence, perforation of the membrana flaccida, also furnishes an example of the ftill rarer feature of being- probably caused bv external erosion. The patient, a Scotchman, o5 years old, complained of an in- tense pounding noise in the right ear, ^^■llich caused him much annoyance, and brought on frequent attacks of headache and dizziness. In the diseased ear the watch was heard only in contact with the auricle. His aural discomfort, which had ! become especially annoying to him within several years, had j led him to pick at his right ear, from which he had now and i then brouu'ht " small ijieces of somethino; which had an oiFensive * odor." He was entirely unsuspicious of the presence of a foreign body in the ear. The examination of the ear revealed an apparently free audi- i tory canal, but a very much thickened and irritated yet imper- forate membrana tympani. From the line of the folds of the latter and the short process, over the region of the membrana tiaccida and the inner portion of the upper wall of the auditory canal, i. •?., the segment of Rivinus, there seemed to be dark adherent wax. I^pon laying hold of this obstruction, it was easilv removed, and proved to be a grain of corn imbedded in cerumen. The place occupied by this mass was very much altered in appearance. From the line of the folds of the mem- brane to the segment of Rivinus, i. e.. the region of the mem- brana flaccida, appeared much more extensive and sunken than usual ; from the segment of Rivinus outward along the upper wall for one-eighth of an inch, the bony roof of the auditory canal seemed greatly hollowed out, into a dome-like space, and here the greater portion of the grain of corn was lodged. The membi ana flaccida appeared to be destroj'ed ; at the place usually occupied by it there was a whitish, roughened, cicatrized depression, bounded below by the distinct upper edge of the membrana tympani proper. Upon inflation the membrana tympani below the folds bulged, but no air escaped from the region of the flaccid portion. The membrana flaccida had been eroded apparently by external pressure in this case. The foreign body had been in this man's ear probably twenty- five years, as gleaned from the apparently trustworthy history of his life. Upon the removal of the foreign substance from the ear in this case, the subjective noise and the disagreeable head- symptoms ceased, but the hearing was not improved, which would seem to show that the impairment of this function was due to a process of disease in the tympanum, probably in its 332 MEMBRANA TYMPANI. I Upper i)art, in the region of the membrana flaccida, and not de- ■ pendent upon the presence of the foreign substance. Case V. Ulceratio7i of the membrana flaccida^ from external i irritatiou. — This case, without presenting a membrana flaccida I entirely perforated, ^^'as unmistakably one of ulceration of this part of the membrana tympani, due to pressure of a plug of ' hardened cerumen. The patient, a man forty years old, com- '■ plained of dull aching in the ear of several days' duration; the ' hearing was only slightly diminished. Upon inspection the canal was found to be tilled with cerumen, and the membrane consequently hidden from view. After removal of the obstruc- !' tive mass, the only change observed in the drum-head was an ' ulcerated spot in the membrana flaccida, immediately above the short process of the malleus. This ulcer was about 1.50 mm. iu diameter, and bled slightly on being touched ; it was tender on gentle pressure. The ear was let entirely alone for a week, at i the end of which time the ulcer had healed, and the ear had ,' resumed its entirely normal function. This case furnishes another example of the fact that the membrane of Shrapnell may be ulcerated from without. Case VI. Perforation in the anterior part of the membrana flaccida, right ear ; poli/pus attached to the perforation and occupying ' the entire membrana ftaccida. — On August 14, 1878, Frank C, aged '' twenty seven, a merchant, presented himself for treatment for a disagreeable aural discharge and deafness in the right ear. His statement was that three years previous he had suffered, for the flrst time, from earache and a running from this ear, since which time more or less dischars^e from the rio^ht ear had con- tinned. An examination of the case revealed almost total deafness on the right side, the voice being heard only when close to the ear; the other ear was normal. The tunino'-fork on the vertex was heard best in the diseased ear. There was no pharyngeal dis- ^ ease. Inspection of the membrana tympani revealed a normal drum-membrane, bathed slightly by pus, which seemed to flow over it from a bright polypus seated over the entire membrana flaccida. The folds of the membrana tympani were well marked, and above them the polypus lay. The polypus w^as extracted by means of a snare, with a narrow canula, as modifled by myself, for conveying the wire, and the attachment, which seemed broad, was touched with a saturated solution of nitrate of silver (480 gr. to f.5J), conveyed to it by means of a small roll of cotton on a cotton-holder. The attachment was treated the same way on the third day after, and when seen two days later the pedicle was no longer visible, thus leaving a free surface over the entire membrana flaccida, which appeared more hollowed than usual, IXFLAMM Al'IOX, INJURIES, MORBID GROWTHS. 333 iiiiil the folds of the membrana tympani were tlius thrown into greater protninonoe. More or less discbarge, however, continued to come into the auditory canal from a perforation in the anterior part of the membrana tiaecida, which perforation had been discovered after the removal of the polypus, which seemed to spring from its neighborhood. This discharge seemed to be diminished by the use of alum in and about the perforation, and finally, in less than a month and after a few applications, it ceased entirely for nearly a fortnight. On the 24tli of September, a little over a month from the time I the patient was iirst seen, a slight hemorrhage occurred from a [ small vessel running in the membrana flaccida, and a slight dis- j charge set in from the tympanic cavity through the opening in , the membrana flaccida. This was controlled by the use of pow- dered alum, and the ear became dry, no granulations were visi- I ble, and the swelling about the perforation went down. The , neck of the malleus could now be seen, and pressed upon and moved by a probe through the perforation in the membrana flaccida, showing that the opening had extended from the front , to the central part of the flaccid membrane. The probe could , be passed four mm. point-blank into a cavity, beyond the per- , foration. The discharge, however, returned again in slight quantity, and a new treatment was used in the form of the tym- 1 panic syringe. By this means in less than a month the case was permanently cured of the discharge, and the hearing was re- stored, as the rest of the notes will show. The first injections were made on October 1st. A nozzle, which is slightly curved, was used and turned toward the tegmen tympani. By this means a mixture of warm water and alcohol was first used, whereupon a little earache ensued, for a few minutes. The next day a little tenderness was complained of, and the pus seemed a little more copious, but laudable. The tympanic cavity was then cleansed with warm water by means of the tympanic syringe, and afterward a few drops of a solu- tion of nitrate of silver (gr, v to f.%j) were injected by the same means. On the next day the discharge seemed greater, and the patient complained of a feeling of soreness deep in his ear. I desisted, therefore, from the use of the tympanic syringe; but the true cause of the increased discharge and pain seemed to be a cold which was fully developed by the next day. The dis- charge seemed now to diminish, but it persisted, and in the course of two days the cleansing and medication by means of the tympanic syringe were resumed, and after some chees}' matter had been washed through the perforation, a few drops of a stronger solution of nitrate of silver (gr. Ix to f.^j) were injected into the cavity. No discomfort of any kind ensued, 334 MEMBRANA TYMPANI. but the patient expressed himself as feeling "comfortable in the ear," and in the course of three days, when he called again, a throbbing, which he had often felt in his ear had ceased. At this visit the tympanic syringe was used only for cleansing the cavity, and a little cheesy matter was washed out. On the next day, October 9th, a mere trace of creamy pus was seen around the perforation, the membrana tympani below the folds was dry and lustrous, the entire ear felt comfortable to the patient, and the hearing began to improve. At this time the cavity was cleansed with the tympanic syringe and a very little inspissated matter was washed out, after which, by the same syringe, a few drops of a stronger solution of nitrate of silver (gr. Ixxx to fSj) were similarly injected. No pain or dis- comfort of any kind ensued. In the course of two days when (| the patient was next seen, a little discharge was found coming from the perforation, though the patient was not conscious of any moisture in his ear. Nothing had been done to the ear by the patient in the interim of the visits at any time, as all the local treatment was applied entirely by the writer. The discharge seemed at this visit a little stained with the silver solution, but its entire amount was not more than a small drop. The cavity was syringed out by the tympanic syringe, and a few whitish flakes were thus removed; after which a few drops of a still stronger solution of nitrate of silver (gr. c to f.Sj) were injected | into the cavity with the tympanic syringe. 'No pain nor dis- comfort ensued, and the space beyond the perforation was dried out by means of absorbent cotton on the cotton-holder, after the auditory canal had been syringed, so as to leave no solution of ^ silver there. On the next day there was no discharge visible, the perforation was dri/, and the cotton on the cotton-holder, passed into the cavity through the perforation, brought out a little brownish matter. The cavity was then syringed with warm water by means of the tympanic syringe, but no flakes were thus removed, and no application of silver was made. In two daj's, during which nothing had been done to the ear, it was found to contain no discharge, and the membrana tym- pani was dry in all parts. The cavity was simply wiped by absorbent cotton, but no medication was applied to the ear. The next day the ear was found to be still entirely free from dis- charge, and the patient could hear with this ear a whisper at ten feet. A few brownish silver-stained flakes were at this visit washed from the cavity by means of the tympanic syringe. The patient was not seen again for a week, when it was found that the ear was entirely free from discharge, and again in a week later when he was seen, the ear was found to be entirely free from discharge, and the perforation was closed by a thin, brownish pellicle, varnished in appearance, and probably a fresh INFLAMMATION, INJURIES, MORBID GROWTHS. 335 orrowth of (lelicate cutis from the upper wall of the external auditory canal. It seems fair to conclude that this case was speedily cured by the use of the tympanic syringe. Case VII. Anterior perfondion in each riiembrana faccicla ; naso-phari/ngeal calarrh; jxirulod discharge J'roai each tympanic (•avitij. — Theodore M., aged 10 years, is said to have had dis- charge from his right ear when two years old, the only cause of which is said to have been cold in the head. Some vears later the left ear began to discharge from apparently the same cause, and both have run greatly ever since. Four years ago he had measles, since which the ears have been worse. The case came under my observation through the courtesy of Dr. H. X. Spencer, of St. Louis, Mo. Upon inspection I found each external auditory canal half tilled with offensive purulent matter, and a perforation, anterior to the neck of the malleus in each membrana flaccida ; the rest of each membrana tympani was intact. The nares were chronically intlamed, and the naso- pharynx clogged with a scanty, tenacious, yellowish mucus, all of which induced the child to breathe through his mouth. The alfe of the nose were hence weak, ill-developed, and the nose looked pinched and too small for his face. There was not, nor has there ever been, any bleeding from the nose, nor can blood be obtained on cotton on a probe, passed behind the velum into the naso-pharynx, as there would be were granula- tions there. His lips were usually parted and dry, and the fauces looked as those do which are exposed to respiration through the mouth. The hearing on the left side was for the voice two and one- half feet, and on the right side, four feet. Both ears were easily inflated either by Politzer's method or by Valsalva's, the per- foration-whistle being very loud, and pus was seen to issue from the perforations during the latter inflation. The general ap- pearance of the patient w^as strumous. Treatment. — Each day the ears were syringed, flrst with an ordinary syringe, and then each tympanic cavity was cleansed, through the perforation, by means of the tympanic syringe. After the ears were thus cleansed, there was syringed into each tympanic cavity a small quantity of absolute (anhydrous) alcohol. The naso-pharynx was touched each day, by passing behind the velum a tuft of cotton on an aluminium probe, soaked with the following mixture : R — Potassii iodidi, 0.50 ctgr. Tr. iodinii, 5 ctgr. Aq. destilL, 10 ctgr. This treatment was carefully carried out every week-day for a month, during which the nasal respiration improved, and 336 MEMBRAJS^A TYMPANl. there was much less hawking, especially in the mornings, on getting up. The aural symptoms did not improve under the alcohol treat- ment, the matter discharged was raarkedl}'^ purulent, and it might be said that the ears were exactlj' as they were before the^ month's local treatment. Sometimes the left ear seemed to discharge less, but I learned that this had always shown periods of less discharge under other forms of treatment. Therefore, on November 8, 1880, after one month of observa- tion of the case and the above treatment of the ears, the treat- ment was changed from the alcohol applications to the use of l| strong solutions of nitrate of silver. On that date, the tympana Avere cleansed as formerly with the tympanic syringe, and then a few drops of a solution of nitrate of silver, sixty grains to the iluidounce of water, were injected through the perforations into each tympanum by the tympanic syringe. This caused no sen- sation of any kind to the patient, and on the next day, after cleansing as usual, a few drops of an eighty-grain solution of nitrate of silver were injected into the tympanum with the tym- panic syringe. On the following day, L e., after two applications of nitrate of silver as above stated, the discharge seemed slightly less, and the tympana were cleansed simply, without receiving any treatment with a solution of nitrate of silver. The eighty- grain solution of silver was applied again on the 11th of Xo- vember, but nothing except cleansing was done to the ears on the 12th, when the discharge seemed lessening. The fauces were still touched every other day with the iodine solution above described. The ali© of the nose seemed stronger when felt during his movement of them, between my thumb and forefinger; his respiration became less b}^ the mouth, and he hawked and spat less from his tbroat and blew less from his nose. The case just narrated teaches very little, if anything, by its treatment, except perhaps the stubbornness of such forms of disease. The Valsalvan inflation caused pus to flow from the perforations and gave a loud perforation-whistle, which is in- teresting, as usually perforations in the membrana flaccida are not attended with a perforation-whistle on inflation. A perfora- tion, too, in each membrane is uotew^orthy, as well as the youth of the patient, these perforations, as a rule, not being observed in so young a subject. The case is given, therefore, on account of its history and description, rather than for the success of its treatment, which, by November 15, 1880, had not controlled the disease to any marked degree. Case VIII. Destruction of the entire left membrana flaccida; erosion of the margo tym-panicas; exposure of the head and neck of the malleus and of the body and proximal imrt of each crus of the IW INFLAMMATION, INJURIES, MORBID GROWTHS. 337 mens. — Miss H., aged thirty-five years, came nnder observation November 3, 1880, and stated that she was affected by pain and discharge in the left ear, in early childhood. The previous sum- mer, in August, she bathed freely in the surf at Cape May, and exposed herself to the full entrance of water into both ears. She finally, after two or three weeks of such exposure to cold salt- water, observed tinnitus and hardness of hearing, with some pain in the left ear. At this time some hardened secretion was washed from her ear, which relieved the tinnitus and hardness of hearing, the pain having already ceased. Dr H. S. Schell, who attended to the case for me, ordered her at that time to use a warm-water aural douche, but she could not employ it on account of the great dizziness caused by it. The membrana tynipani was found to be red, opaque, and flat, and the watch was not heard in this ear, but the tuning-fork, on the vertex, was heard best in this ear. Air entered the tympanum upon infla- tion, but no perforation- whistle was elicited. In the course of a day or two, the destruction of the flaccid membrane was diagnosticated, and from the cavity beyond, a cheesy mass was removed, and the hearing rose to six inches for the watch. On iN'ovember 3, 1880, when first observed by me, entire de- struction of the flaccid membrane was seen, with extensive erosion of the margo tympanicus, which exposed to view most distinctl}^ the head and neck of the malleus and the body of the incus, with the proximal parts of each crus. These ossicles, so far as could be seen, w^ere covered with their natural mucous- periosteal covering, and were white and shining. Entirely around and above them there was a semicircular opening, four mm. in diameter, which permitted a view into the upper part of the tympanic cavity, under the tegmen. This cavity was par- tiallj packed with cheesy debris, after removal of which the mucous membrane lining the cavity could be seen by careful illumination. This membrane was not very red, but looked puckered, and excreted a thick, offensive, dark,, and scanty matter, not sufficient, however, to bathe the membrana tympani below the folds. When first seen by me, there was also a slight hemorrhage, which continued for two days to trickle from the ^ack part of the cavity over the back part of the drum-head and out at the meatus. This had been observed at the meatus by the patient for a day previous to her coming to me. Her hearing at this time in the affected ear was three to four feet tor words spoken in a low tone. Cleansing the tympanic cavit}' by means of the tympanic syringe could not be carried out, because of the great dizziness 'irought on by a trial of it. Recourse was then had to absorbent ' otton on the cotton-holder, by which the cavity was very gently 22 338 MEMBRAXA TYMPANI. swabbed out. After the offensive matter had been removed iii this way, the cavity was further swabbed out by absorbent cotton, soaked in Condy's fluid (permanganate of potash) and warm water. After thus cleansing and disinfecting the cavity it was medicated by conveying to it, in the same manner, some of the following mixture : R. — Liq. pluinbi subacetatis, ttlxx. Aeidi acetici diluti, Tr\^vi. Liq. opii sedativi, Tt\^xx. Aqua?, q. s. ut ft. f^j. — M. Under this latter method of daily cleansing and medicating by cotton on the cotton-holder, the discharge ceased in twenty days, and all signs of otitis externa diffusa which had existed, during the first part of the observation of the case, disappeared. There had been pain at times, referred to the left eye and brow, and under the left ear; sometimes a pain had darted from the ( left ear backward toward the occiput. . The perforation became < much smaller and seemed likely to close entirely. Case IX. Chronic i)uruhnt otitis media on both sides; entire de- struction of the flaccid membrane on the right side. — On December 4, 1877, the Rev. Mr. Y., fort}^ years old, consulted me about a i discharge from both his ears, which had existed since scarlatina i in earlv childhood. He was of German origin, and had endured i a life of hardship as a bo}', when he had been beaten a good t deal about his head. The hearing in his left ear was nearly ji ofone, but the right ear, notwithstanding the destruction of the flaccid membrane, retained its function almost entirely. The destruction of the membrana flaccida had been accom- panied by a destruction of the head and neck of the malleus and the body of the incus; the manubrium of the malleus, how- •, ever, remained attached to the membrana tympani. All the membrana tympani proper behind a line marked by a prolonga- f tion of the long axis of the manubrium was also destro3'ed, and (| the red, velvety mucous membrane of the tympanic cavity could ( be seen beyond the remnant. The condition of the stapes could <- not be made out. The good hearing in this case, in spite of the great and | peculiar destruction in the sound-conducting parts, must, I think, 8 be accounted for by the free access the sound-waves had to the n tympanic cavity, and both fenestr£e. ! Case X. Chronic i^artdent discharge from the right ear, loith !f 2)oli/2:>>'s attached to the perforation in the back jmrt of the membrarm^^ flaccida. — Miss D., aged twent\--five years, came under observa-i tion January 25, 1880. A slight purulent discharge was coming i from the right ear. Upon inspection, a polypus was found ( attached to the posterior part of the membrana flaccida; theij I» INFLAMMATION, INJURIES, MORBID GROWTHS, 339 poly[)US being removed by Blake's siuire, a perforation in this membrane was detected. The point of attachment was touched with chromic acid, in five days a little powdered crude alum was blown into the fundus of the ear, over the perforation, and with one or two repetitions of this, in less than a month the discharge ceased, and the perforation in the flaccid membrane closed. An interesting feature in this case was that in /Ac left ear there was a cicatrized perforation in the central part of the flaccid membrane. The hearing in the right ear had not been afiected by the dis- ease, to any extent, which leads to the idea that the disease of the flaccid membrane in this case had arisen from without, and by erosion, as the patient had been in the habit of picking her auditor}' canal with pins and the like. Of the ten cases of perforation of the membrana flaccida, here presented, the following synopsis is given : Sex Ear Anterior 2 (in the double case, Case YII., the perforations were an- terior). ] Posterior, 3 I Central, 3 Eight, 5. t Entire destruction, 2. r Males, 7. t Females, 3. p^^^j^;^^^ Lett, 3. Unreco:__ .., Both sides, 1. '■ \ Internal (tyippanic), 7 Unrecorded, 1. p, f External (traumatic), 3. In four instances in which there was marked tympanic disease with discharge, a polypus was found growing from the perfora- ! tion. In the treatment of the tympanic disease, which is usually the cause of the perforation in the membrana flaccida, no means of cleansing and medication is so efficient as the tympanic syringe. The author has under observation, at the present time, two cases of perforation of the flaccid membrane: one anterior, in a man, 32 years old; the other, an anterior perforation, in a woman, 30 years old. Both have been attended with severe pain and discharge, at times, before coming under treatment. The cause in each seems to have been tympanic inflammation. Both have yielded greatly to treatment by antiseptic powders and solutions. INJURIES OF THE MEMBRANA TYMPANI. The membrana tympani is liable to a numl^er of injuries from without. These, while not directly interfering greatly with the function of hearing, unless at the same time thev aflect deeper parts of the organ of hearing, usually expose the mucous I lining of the tympanic cavity to the direct irritation of the ex- ' ternal air,_by perforating the membrane, and thus lead second- arily to inflammation and loss of hearing. 340 MEMBEAJSTA TYMPANI. Prominent among the causes which lead to traumatic rupture of the drum-head may be cited, boxing the ears, and receiving the force of a wave on the ear while bathing in the sea. The healthy membrane will usually resist these forces, but of course one which is any way diseased by fatty degeneration, atrophy, and by calcareous deposits, or one prevented from assuming proper equilibrium, by a closure of the Eustachian tube, is ex- tremely liable to yield to external violence above named. The drum-head may receive very injurious concussion from diving into the water, from the discharge of musketry or of a cannon, from falls, or from a gunshot wound near the ear, as, for example, in the upper maxilla and the horizontal plate of the ethmoid,^ and also from the kick of an animal on the mastoid process. The membrane is also often injured by the sudden introduction of long and slender instruments or implements into the auditory canal. In the case of a young man, 21 years old, killed by a fall from his horse, upon a pavement, the left membrana tympani was found to have been fissured in the posterior half. The length of the fissure was 2h mm.^ In some cases of traumatic rupture of the drum-head, the primary wound is followed by symptoms of aural vertigo, as has also been noted by others.^ The following case .shows such vertiginous symptoms : John M., Englishman, married, 30 years old ; the patient looked thin and somewhat anxious when he presented himself for treatment. The history given was that, the evening before, while sitting quietly reading, a companion playfully boxed him on the ear. Instantly he felt a roaring in the ear, but fortu- nately did nothing in the way of pouring in fluids with the view of relieving the noise and hardness of hearing. 'The following morning it was found, on inspecting the membrana tympani, that it was ruptured in the posterior and lower part; that the diameter of the perforation was about 2 mm,, and that there was little or no congestion in the drum-head. The patient had suffered greatly from heat of the previous night (it was July), and had been exhausted by nursing a sick infant. Upon his rising suddenly in my office, he grew very pale, said he was dizzy, and fainted. It was a long time, an hour or more, before he could go home, and then only in charge of an attendant. He 1 Casuistische Beitriige zu den traumatischen, Verletzungen des Trommelfells. Dr. E. Zaufiil Archiv f. Ohrenheilkunde, Bd. i., N. F., «. 188, 280, and Bd. ii. S. 31. 2 Trommelfellbefund nach Sturz init dem Pferde. Dr. Trautmann. A. f. 0., Bd. ii., N. F., S. 101. * Fall von trauniatischer Rupturdes Trommelfells mit Symptomen von Laby- rinthreizung. Dr Tarreidt. A. f. 0., Band ix. S. 179. Dr. Holmes; Trans. American International Otological Congress, 1876. INFLAMMATION, INJUKIES, MOliBIl) GROWTHS. 341 remiiined very dizz}^ all day, but, the perforation healing in the course of a few days, the hearing became good, but not entirely ^.nornuil, and the symptoms of dizziness disappeared. rrol)ably the perforation, by taking away some of the power the drum-head has of resisting the traction of the tensor tym- pani. bad allowed the latter to draw^ the chain of ossicles inward, producing temporary'pressure in the labyrinth, with consequent dizziness. * ♦ The membrana tympani has been found ruptured in those who have been executed by hanging. Dr. Ogston' has described such a case in which the tissure of the drum-head was ragged, and running from the tip of the manubrium downward towards the periphery of the membrane. The edges were everted, but there was neither blood nor any other fluid in the cavity of the drum. From the eversion of the edges in such a case, it might he supposed that the force which breaks the membrane acts from within the tympanic cavity, outward. The rupture of the mem- brane in such cases may be explained by supposing that the air in the tympanum, at the moment of the fall, is thrown into vio- lent concussion, and, not being able to escape by the Eustachian tube, owing to the constriction of that canal by tlie rope, it is forced violently outward, producing the tissure of the membrana tympani. The membrana tympani may be ruptured by an in- crease in the external atmospheric pressure, if the latter is very extraordinary, and if the Eustachian tube is more or less im- pervious.- The membrana tympani is probably able to endure sudden pressure from without, as in discharges of artillery, musketry, I etc., Avhether expected or not, only through the loose valve-like ' nature of the Eustachian tube. This seems fully shown by the I observations and experiments of Riidinger, Brunner, Lucas, and f the observations of John Green, referred to. Fracture of the Handle of the Malleus. — There are a few cases of fracture of the handle of the malleus on record. This rare accident has been described by Meniere,^ von Troeltsch,* and R. F. Weir f the first observed it in the ear of a gardener, who [ had thrust his ear against a twig, while working ; and the 1 second saw a fracture of this part of the malleus, resulting from j the accidental thrusting of a penholder into the auditory canal. \ In both cases the manubrium appeared to have united. Dr. ' Archiv f. Ohrenheilkunde, Band vi. '•* Dr. .John Green, " Condensed Air, GO lbs. to sqiuxre inch ; its Eft'ects on the Eustachian Tube." Tr. Amer. Otol. Soc, vol. i p. 129, 1870. ^ Gazette Med. de Paris, p. 50, 1856. * Treatise on the Ear, p. 151. ^ Ununited 'Fracture of Manubrium of Malleus, Tr. Amer. Otol. Soc, vol. i. p. 121, 1870. 342 MEMBRANA TYMPANI. "Weir's case presents the additional rarity of an ununited fracture of the manubrium. It occurred in an Irish laborer, in conse- quence of a fall from a height of fifteen feet, four months before Dr. Weir saw the case. The lower portion of the manubrium was seen to be distinctly movable upon the upper part, when- ever the tympanum was inflated. The fracture occurred just below the short process; inflation restored the parts to their normal position, but displacement occurred again in about fifteen minutes. Dr. C. S. TurnbulP observed a fracture in the manubrium mallei, near its lower part. Union finally occurred and was marked by distinct hyperostosis. I recently saw, in the Philadelphia Polyclinic, a malleus from which the lower two-thirds had been broken ofl:', by endeavors made to remove with instruments a foreign body, many years before. The mem- brane had grown around the short stump of the manubrium. Atrophy of the drum-head may occur in consequence ot pressure, long kept up, by a mass of hardened cerumen. This process is favored if the Eustachian tube is at the same time closed.^ It is not uncommon to find, in those suftering with chronic aural catarrh and deafness, hardened pieces of ear-wax in contact with the drum-head. Though such an obstruction may add nothing to the existing deafness, it may and often does produce sensations of fulness in the head, and, at times, vertigo. Such cases are apt to escape detection, simply because the patients have given up all treatment, considering their cases hopeless, and are no longer under examination. Although the deafness may remain unchanged after the removal of such masses of cerumen, the cerebral symptoms are greatly relieved. Reproduction of the Membrana Tympani. — The popular im- pression, that the membrana tympani once perforated can never be healed, is a wrong one. The drum-head, on the contrary, has great power of healing and restoration, as shown by Dr. H. N. Spencer^ and others. A simple slit in it will heal in a few hours if there is no inflammation in the drum-cavity. Larger, and even gaping, perforations, caused by disease, tend to heal, unless the disease in the tympanum keeps up and leads to a cica- trization of the edges of the opening in the membrana tympani. The tympanic disease behind the perforated drum-head should receive more attention than the simple perforation, which is but the vent for the hypersecretion resulting from the disease in the middle ear. It is, therefore, not only unwise, but harmful, to attempt to close, by stimulation of its edges, a hole in the 1 Phila. Med. and Surs^. Reporter, Feb. 22, 1879. 2 S. Moos, Archives of Oph. and Otol., vol. i. ]ip. 321, 324, 1869. 3 Case of Keproduction of the Membrana Tvnipani, Tran.sactions American Otol. Soc, vol. i. p. n9, 1871. INFLAMMATION, INJURIES, MORBID GROWTHS. 343 mcmbrana tj'mpani. If one should succeed in doing it, so long as the mucous menihnxne behind it is diseased, the closing of the })erforation would deprive the drum-cavity of a direct way of treatment of its diseased lining, and sooner or later the drum- head would give way again. It is not easy however, to cause a perforation in the head of the drum to heal while disease exists behind or about it. In endeavoring to do this, by stimulation of its edges, the hole is most usually made larger. In the Philadelphia 3Iedical Times for May 10, 1873, ]^o. 80, vol. iii., I reported a case of restitution of the membrana tympani after fifteen years of disease. The chief features of the case were as follows: On the last day of July, 1872, Chris- tian L., a German, 15 years old, consulted me respecting a chronic discharge from his right ear. The disease dated from infancy, without an}' history of a discharge from the left ear. All the statements of the boy were corroborated b}" his father, who ac- companied him. Examination revealed the presence of a co- pious, light-green discharge in the meatus. Upon removal of the obstruction in the canal, a large perforation was discovered in the upper posterior quadrant of the membrana tympani. Hear- 15 ft ing distance for watch ^^^r-n-- Eustachian tubes pervious to in- flation by Politzer's method. After cleansing the auditory canal and middle ear as thoroughly as possible, I instilled ten drops of a strong solution of nitrate of silver (5j-f Sj) into the ear. This was syringed out in a few moments, and the lad ordered to syringe his ear at home thrice daily, with ^varm water, and after each syringing to drop into the ear ten drops of a two-grain solution of sulphate of zinc warmed, and to allow the latter to remain in the ear five minutes. One week later I saw the boy; his ear was much better, and he was ordered to continue the treatment. By the middle of August, two weeks after he was first prescribed for, the discharge from the ear had ceased, and the hearing for the watch had increased to one-half the normal distance. A few days later, the perforation in the membrana tympani had closed, and the membrane, which at the time of the first examination was swollen and discolored, had assumed the normal lustre. The hearing had now become normal, and the drum-head was entirel}' restored. Sometimes the membrana is restored after entire destruction of the malleus, a thin mem- brane, chiefly dermoid, taking the place of the normal membrane. Even with no discernible malleus or parts of it, nor of the other ossicula, the hearing may be good. Usually, however, it is much impaired in those cases of reproduction of the membrane in which the ossicles are destroyed. '> I 344 MEMBRANA TYMPANI. Medico-legal Significance of Injuries to the Membrana Tympani. — After a blow has been received on the ear, either during a quarrel or in play, an action at law may be instituted to recover damages for supposed injury to the drum. The surgeon will be called on, in such cases, to decide, first, whether there has been an injury done the drum-head, and, if so, how far it will impair the hear- ing. In the first consideration he must bear in mind that the drum-head may have been perforated before the blow was received, though the patient or complainant may or may not know it. The chronic perforation can be readily distinguished from the acute. If it should be determined, however, that a ^ previously normal *drum-head has been ruptured by a blow on, | or a thrust in the ear, it then remains for the surgeon to deter- \ mine whether the hearing has been or will be impaired by the injury. The mere fissuring of a normal membrana tympani in the above way may not necessarily injure the hearing, nor oblige the patient to give up his daily work. If, however, there has been a severe blow on the ear, the hearing may be impaired from concussion of the nerve in the labyrinth, which, though associated with rupture of the drum-head, is not necessarily caused by it. If there has been no concussion of the inner ear and no inflammation set up in the drum-cavity, the ruptured drum-head will heal quickly if let alone, /. e., if nothing is dropped or poured into the ear. Ignorance on the latter score has led very often to the use of drops, the moment a fissure in the drum has been noticed. The matters thus poured into the canal, having entered the drum-cavity through the perforation, have set up inflammation in the delicate mucous membrane of the middle ear, and disease has been established where other- wise, by letting the ear intelligently alone, the perforation would have healed in a day or two. Thus it might appear that the blow had caused disease in reality produced by improper treat- ment of the ear. If, in a case of asserted traumatic violence to the drum-head, deafness should be immediately discovered by the surgeon, it must be determined wdiether it has been pro- duced b}' the same blow which has ruptured the drum, or whether it existed before. A temporary diminution of hearing is very likely to occur after a blow on the ear, hard enough to rupture the membrana tympani, but if great and sudden deaf- ness comes on after a blow on a previously healthy ear, and if it remains for several days without signs of improvement, it must then be adjudged permanent, and the claim for damages must be in accordance with the facts. Even if it should be de- cided that the injured ear was not in a state of health l)efore the blow, it would seem that all the greater claim could be made by the sufferer. In such a case, however, it must ever be borne in mind that it is not the fissure in the drum-head that r INFLAMMATION, INJURIES, MORBID GROWTHS. 345 ha^ clone the damage, l)ut a consequent inflannnation in the niit-Ulle ear, or the concussion of deeper and more delicate nervous parts of the organ of hearing. MORBID GROWTHS. Wart-like Bodies on the Membrana Tympani. — Wart-like ex- crescences on the membrana tympani, tirst described by Dr. Urbantschitsch,^ I have observed in but one case. There were in this case, that of a man 24 years old, two pale yellow warts about a millimetre in diameter, on the upper and posterior Isquadrant of the membrana tympani. There seemed to be no lexplanation for their occurrence, unless it could be found in the instillation of various fluids, which the patient had practised on his own responsibility, for some time, for the cure of deafness resulting from chronic catarrh of the middle ear. The constant irritation thus applied to the delicate dermoid layer of the drum- 1^ Jhead may have provoked the growth of some of its papillae into ™ 'the above-named wart-like bodies. Vascular Tumor, Moles, and Haematoma of the Membrana Tym- pani. — Vascular tumors are not often observed on the membrana tympani. Dr. A. H. Buck- observed a vascular tumor in each membrana tympani of a woman sixty-five years old. These were situate in the superior posterior quadrant of the membrana tympani, were soft, mole or tent-shaped, and one millimetre in diameter at their base. Four vears ao;o I observed in the left membrana tympani of a lady fifty-two years old, a brown, flat mole, extending from the membrana flaccida, the short process, and the folds, over the manubrium of the malleus to the umbo, the latter being barely distinguishable. At its upper part the mole was studded with a few short hairs. The hearing was un- aftected. Very recently I have seen this case again, and the mole was seen to be unchanged. Hcemntoma of the membrana tympani has been described by Biirkner^ as occurring in a pregnant woman. There was also an inflammation in the drum-cavity. Both processes were referred to the great congestion of the head which the pregnant condition induced in this woman. Moos* observed a traumatic hematoma in the posterior superior quadrant of the membrana tympani of a man forty-two years old, who had been struck on ^ Uebor eine eigenthiimliche Form von Epithelialauflagerung am Troinnielfell, und im aiisseren Gehoi-oang. A. f. O., Bd. x. S. 7. - American Journal of Otology, vol. iii. p. 282. 3 Archiv fiir Ohrenh., Bd. xv.'S. 220, 1879. * Ibid., Bd. XV. S. 68, 1879. 346 MEMBRANA TYMPANI. the cheek and helix by a bottle. The heematoma gradually moved away backwards toward the periphery. Endothelial Cholesteatoma of the Membrana Tympani. — As an antithesis of desquamative inflammation of the middle ear, Dr. Wendt^ described a new" growth, which he called genuine or endothelial cholesteatoma of the membrana tympani. The nature of this new growth is better understood when Dr. Wendt's investigations respecting the membrana propria of the drum-hfead are known. According to him, this membrane consists of coarse and line fasciculi ; both are inclosed in hyaline tunics, which are very resistant and contain cells of various forms (endothelia). Sometimes the nuclei are unaccompanied by protoplasm, but usually the latter, of round, oval, and stellate form, is present. These forms are subject to change according to the position of the cells. Lymphatics are found in the inter- stices. Endothelial cholesteatoma was found by Dr. Wendt in the right middle ear of a man who had died of typhus fever. The macroscopic examination revealed the following conditions : " In the anterior inferior part of the inner surface of the mem- brana tympani, there was found a slightly rough hemispherical mass IJ mm. in diameter; the transparent golden lustre was characteristic. The lower part of the tumor passed into the membrana tympani, the upper part, hemispherical in shape, projected into the tympanic cavity, and was united to the mem- brana tympani by a fold of mucous membrane. The growth, after displacing the rete Malpighii, extended outwardly at some points as far as the surface of the external auditor}^ canal ; at others it pressed upon the corium of the dermoid layer. "The mucous membrane of the tympanum was swollen and hyperaemic. The malleus at its anterior surface was detached from the membrana tympani, but still united to it posteriorly. The membrana tympani was flattened and somewhat thickened, it contained several small, round perforations, its layer of epi- dermis was discolored and broken down, and its mucous laj'er was swollen and intensely injected." The microscopic examination of this growth revealed the following: "The tumor is enveloped in a capsule of connective tissue ; the latter is loose at some points, stretched at others, runs ■parallel to the surface of the tumor, contains htematoidine, and is covered with cubical epithelium. The capsule covers the outer part of the tumor and that part of it which projects into the tympanum; the lower part passes over into the pathologi- cally altered substantia propria. The capsule is to be regarded 1 Arcliiv f. Heilkunde, 187;^, S. 551-5G2 ; also abstract bv Dr. Trautmann, Archiv f. Ohrenh., Ikl. ix. S. 281. ri INFLAMMATION, INJURIES, MORBID GROWTHS. 847 as emanating from the mucous layer of the membrana tvmpani."^ In the membrana propria numerous cavities tilled with parallel and concentrically arranged, nucleated pellicles were found. The trabeculiB were separated by these accumulations. These cavities became larger in the neighborhood of the tumor, in which the trabecular ran parallel to the surface of the membrana tympani ; they also ran in curves and at various angles. They consisted of extensive fibrils of connective tissue, arranged in fasciculi and inclosed in opaque, cylindrical, nucleated sheaths. These trabeculte were further united into coarser fasciculi. In the interstices the same pellicles were found as in the membrana propria. In the upper and older portion of the tumor, numerous crystals of cholestearine and drops of oil lay upon the pellicles, indicating retrograde metamorphosis. The pellicles were found to surround concentrically the coarser trabecul^e; some of the cells of the former were transparent, rhomboid, or crenated in form, and contained an oval nucleus. The above described changes in the membrana tympani are adduced by Dr. Wendt as proof of the endothelial origin of this new growth. Cholesteatoma of the Membrana Tympani. — Among recent ob- lervers Dr. Kiipper," of Elberfeld, Germany, has described a small mass which he calls a tumor, found on the membrana tympani of a man 30 3'ears old, who had died of consumption. This small object, Ih mm. in diameter, was situated below the umbo of the membrana tympani, and was easily removed by simply touching it with a needle. The little mass was pearl gray in color, and composed of several layers arranged like those of an onion. The microscopic examination showed that these were composed of layers of epithelium with here and there some crystals of cholestearine. This could not have been a true tumor. It was simply an aggregation of epithelium, which had undergone cholesteatomatous des-eneration. Its occurrence in this case on the membrana tympani was simply fortuitous, judging from the history of the case as given by the observer. The acute de- squamative inflammation of the membrana tympani described by some writers, seems to be a myringitis caused by the accu- mulation, retention, and pressure of- epidermis, brought about by the patient's undue efforts at cleansing the ear by picking or swabbing. ^ Review by Di'. Trautmann, loc. cit. ^ Cholesteatom des Trommelfelles. A. f. O., Ikl. xi. S. 18. SECTION Y. MIDDLE EAR. CHAPTER I. r, ACUTE CATARKHAL INFLAMMATIOlSr. Acute catarrhal inflammation of the middle ear is a process characterized by an increased formation of mucus, but which stops short of the production of pus. This increased amount of mucus in the middle ear usually escapes through the Eustachian tube, or by absorption ; it rarely causes a rupture of the mem- brana tympani, for the tendency of acute catarrh is rather towards a swelling and a thickening than to a breaking down of tissue. An acute catarrh of the middle ear, which advances to a per- foration of the membrana tympani, will most commonly be found to have led to purulent products, for pure mucus alone is rarely found escaping through a rupture in the drum-mem- brane. If, then, an acute catarrhal inflammation of the middle ear advances to the formation of pus, a more destructive form of inflammation, a purulent variety may be said to be present. While the latter condition must always be preceded in the middle ear by the former, catarrhal inflammation ma}^ have a distinct existence without the presence of pus. For the sake of clinical convenience, the endeavor is made to describe two forms of acute inflammation of the middle ear, but the fact must not be lost sight of that very often these so- called forms are but stages of the same disease, and that, there- fore, up to the point of succession, i. e., where the inucous symp- toms are succeeded by the purulent, the symptoms and treatment are the same for both forms. In fact all treatment in a case of acute catarrhal inflammation of the middle ear is based on the hope of preventing the formation of pus, which is known to be only too likely to follow the catarrhal or mucous stage. ACUTE CATARRHAL INFLAMMATION. 349 ^i/iiiptoms and Course. — The liglitest tbrni of iicutc catarrh of the middle ear comes on during an ordinary cohl in the head, or from any other cause which produces only a slight swelling and closure of the Eustachian tube, or congestion in the middle- ear cavity. In this form it is a congestion and slight swelling of the mucous lining of the Eustachian tube, and perhaps of that of the tympanum, accompanied by an unusual amount of mucus. It may thus atfect one or both ears. It causes no pain, in this mild character, and but little hardness of hearing; it brings about rather a stuffed feeling in the ears, with a slightly altered timbre of objective sounds. There is usually some tinnitus, tliough a slight chronic tinnitus may cease upon the occurrence of a mild tubal catarrh. The patient's voice may be subjec- tivel}' altered ; though this is rare in light cases of catarrh ot the ear. The membrana tympani may not even lose its lustre, though its vessels may appear slightly congested, and it may assume, if it is ordinarily transparent, a pinkish hue from the shining through of the congested tympanic vessels. * This form of catarrhal congestion of the middle ear rarely troubles the patient, and therefore receives very little attention. It may disappear as rapidly as it came, in the course of a day, without any treatment. That form, however, characterized chiefly by pain, hardness of hearing, autophony, and subjective noises in the ear, is not only more annoying to the patient, but demands prompt treat- ment. It comes on usually after exposure to cold; but it may be caused by various diseases involving the mucous membrane of the nose, mouth, throat, and nasopharynx, as syphilis, various continued fevers, and the exanthemata. Acute catarrh is more likely to affect one ear than both, and is apt to come on in an ear already affected by chronic catarrhal disease. Pain. — The pain is not as severe as that of purulent inflam- mation of the middle ear, and this is perhaps the chief early diagnostic point between the two diseases. The pain, usually darting only from throat to ear, may become sharp and boring and not limited to the ear. It is then very apt to follow the varied course of the fifth cranial nerve, and in this phase is not unfrequently mistaken for neuralgia both by patient and phy- sician. It intermits during the day, growing worse at night, but never becomes as intense and unendurable as the pain' of acute purulent otitis. It is often more a sensation of great fulness than true pain. Fever is rarely present, and the cerebral symp- toms are by no means grave; unless, of course, the aural disease accompanies or is caused by a febrile disease. 350 MIDDLE EAR. The pain is caused primarily b^' the inflammatioD of the mucous membrane, but it is aggravated and kept up by the results of the inflammation, /. e., by the swelling of the mucous membrane and by the increased amount of secretion. The lirst acts by diminishing the size of the cavit}- of the middle ear and closing the Eustachian tube, by which means the air is excluded from the tjmipanic cavity, and the products of inflammation cause pain by directly pressing on the inflamed mucous lining of the tympanum, tympanic plexus, and upon the membrana tympani. Vacuum ^formed in the Tym-panurn. — If the faucial mouth of the Eustachian tube becomes swollen and blocked up with mucus, the tympanic cavity is deprived of its proper ventilation, the air wdiich was in the cavitv at the beo-innino- of the tubal catarrh becomes absorbed, and, since no fresh supply of air can get through the swollen tube, a vacuum is formed in the cavity of the drum. This condition alone tends to produce pain; in children, it is often the only cause of pain in acute catarrh of the tube and tympanum, for, the external atmospheric pressure re- maining constant, the membrana tympani is forced inward, carrying wdth it the chain of ossicles. A continuance of the vacuum may lead not only to a great extravasation from the tympanic vessels, but even to their rupture. Hence, it is not uncommon to find true ecchymosis on the membrana tympani, after the Eustachian tube has been closed for some hours, in a case of acute aural catarrh. In some such waj- we may account for the rare cases of so-called otitis media hajmorrhagica, to be referred to hereafter. Pain increased by talking, coughing, sneezing, and eructation. — This is a prominent feature of acute aural catarrh, in which the faucial mouth of the Eustachian tube is always aftected. It is due, partly, to the muscular movements beneath the inflamed mucous membrane, and also to the direct efl'ects of the forcibly expired air upon the inflamed lining of the tube and tympanum, before secretion has taken place. According to investigations of Lucaj,^ it seems highly probable that, at each expiration, the air in the nasopharyngeal space is condensed, and hence pushed into the more or less normally patulous Eustachian tube. No one symptom in acute aural catarrh is so universally spoken of by patients, as the painful eflect of eructation. It is very common, indeed, for this to be complained of, as the only symptom in cases of congestion in either a previously perfectly healthy tube, or during an intercurrent acute congestion in a 1 Virchow's Arcliiv, Band Ixiv., Zur Function der tuba Eustachii und des Gaunienseirels. II ACUTE CATARRHAL INFLAMMATION, 351 chronic aural catarrh. Patients under treatment for the Litter will, upon changes in the weather, complain of the above gyniptoms. As those aiiected with chronic aural catarrh are also very apt to have a slight paresis of the velum, which prevents its being able perfectly to close the upper from the lower pharynx, it would seem that sudden eructations or any forcible expiration may be all the more likely to strike against the pharyngeal mouth of the Eustachian tube, and, in some cases, even penetrate into the tympanic cavity. Both Senac and Tissot^ observed difficulty in swallowing in cases of earache, which the former attributed to sympathy (con- sensus) between the pharynx and the ear, but which the latter observes " is connected with a slight inflammation of certain of tlie muscles of deglutition." I have observed in mj^ own case tliat when the faucial mouth of the Eustachian tube is slightly swollen, i. e., when, with a slight cold in the head, the tube does not become readily patulous on swallowing, a slight touch of the finger in the external auditory canal produces an intense tickling in the fauces high up behind the velum, and I am forced to cough. This peculiar sensibility does not exist in my ear when the Eustachian tube is unaffected, but probably every observer knows, as the author does, of many persons in whom the gentlest touch of the finger upon the mouth of the auditory canal will almost always bring about this peculiar dry cough, called ear-cough. (See p. oil.) I have observed that children whose ears are perfectl}^ healthy, as well as those whose ears are more or less diseased, are especially susceptible to this reflex cough. I have seen infants exhibit marked ear-cough upon their mothers most gently touching the concha or brushing some small object from the vicinity of the mouth of the ex- ternal auditor}' canal. But even those of any age in whom this reflex cough is found, are not always equally sensitive, for it iis more easily produced at one time than at another. It is, on the whole, most likely to attend some morbid condition of the ear, and I have seen it often in cases of acute catarrh of all grades. Hardness of Hearing. — The hardness of hearing is caused chiefly by the swelling of the raucous membrane and the collec- tion of mucus and extravasated serum in the tympanic cavity. These alterations in the tympanum interfere with the vibratory motions of the auditory ossicles, the former by a direct stifl:en- "ng of all their joints, and the latter by loading not only the ssicles but the fenestrte. Hence, hardness of hearing is most larked after secretion has taken place. At the onset of the ^ Traite des Nerfs et de leurs Maladies, Paris et Londres, 1780, p. 54, 352 MIDDLE EAR. inflammation the hearing may be morbidly acute. A secondary implication of the labyrinth by an extension of inflammation or congestion from the tympanum very probably often occurs, and tends further to impair the hearing. Throughout this dis- ease the resonance of the patient's voice is liable to annoying subjective alterations, most probably due to the altered condition of the Eustachian tube. Tinnitus Aurium. — This is one of the chief symptoms of acute aural catarrh. It is caused principally by the altered circulation in the tympanum, and seems to become more aggravated as the inflammation advances. It resembles, very often, painfully high musical notes, and is one of the most distressing symptoms, being complained of almost as much as the pain. Tinnitus is of the constant variety, i. e., unaflected by the pulsation, in simple catarrh ; when the inflammation becomes more severe, and purulent symptoms supervene, then, in some cases, the tinnitus becomes interrupted by the pulsations, and each heart- beat is felt in the ear most painfully. The tinnitus of acute catarrh is referred rather to the ear than the entire head; the latter variety seems to indicate severer inflammation. Sub- jective noises may be entirely unmusical in their sound, re- sembling merely a crackling of mucus or the bursting of bubbles of a tenacious substance. This kind of noise in the ear would seem to be not very diflicult of explanation, and should be re- ferred to the movements in the mucus in the middle ear. It is, of course, characteristic of a late stage. It may, therefore, be concluded that tinnitus aurium is due to what are best termed morbid vibrations originating in the various parts of the organ of hearing, /. e., they have truly an objective existence in the subject. That a morbid circulation of the blood, let us say a too rapid flow of it, through the temporal artery may cause tinnitus aurium, I know by personal experience, and I also am fully aware that such a form of tinnitus may be quelled by pressure over that artery just in front of the tragus. Tinnitus may be also relieved by gentle pressure over the carotids. Such facts would tend to show that the blood may throw the vessels of the ear into such morbid vibrations that the latter are interpreted by the ear as sounds. If sound is motion, what can be more reasonable than such an explanation? Tinnitus aurium, in general, may be explained by the " vas- cular theory" of Theobald.^ At the outset in this theory a subjective sensation is to be regarded as having no imaginary but a real existence, and, therefore, tinnitus aurium has a real 1 Tinnitus Auriiuii, a consideration of the causes upon which it depends and an attempt to exjilain its production in accordance with physical principle? : Samuel Theobald, M.D., Baltimore, 1875. ACUTE CATARRHAL INFLAMMATION. 353 existence, being due to morbid vibrations produced in the vessels of the internal ear and tlien comnuuiicated to the nerve. Two modes wherebv vibrations of the vessels of the labyrinth may be enabled to produce a sensible impression upon the auditory nerve are suggested by Dr. Theobald, viz. : 1. The amplitude of the vibrations maj' be increased ; 2. The vibrations renuiining unaltered, their efiect upon the nerve may be magnitied, either by retiection and concentration, or by resonance. The tirst condition may be said to exist whenever an undue amount of friction attends the movements of the blood. " This will happen when the normal rehitionship between the intra- vascular and the intra-labyrinthine pressure is disturbed, or when, in any other way, the natural and easy flow of the blood is perturbed, as, for instance, in hypereemia or anfemia of the labyrinth vessels, increased or diminished intra-labyrinthine tension, partial compression or obstruction of the trunks of the vessels by inflammatory or other causes, and Anally, when the constitution of the blood itself is altered, as in span?emia or chlorosis. The tinnitus which is known to occur in increased labyrinthine pressure is attributed " to the accompanying vas- cular disturbance, rather than regarded as the expression of an irritation of the nerve, the immediate result of compression." Tinnitus aurium occurrino- in diseases of the middle and external ear, unaccompanied by pressure in the labyrinth, may be referred to the defect in the sound-conducting apparatus. Whenever waves of sound cannot, from without, obtain normal admission to the percipient parts of the ear, tinnitus aurium may also be referred to the same kind of obstruction, since con- litions of the sound-conducting apparatus which prohibit the entrance of sounds from without will also prevent their escape from within, and this will piagnify their eftect upon the nerve, or increase their loudness. The well-known fact that tinnitus aurium is not often complained of when a perforation in the membrana tympani exists, is explained by Theobald as due to the ready escape thus oflered to the vibrations occurring in the ear. The probability of the origin of tinnitus in this way is in- creased by the fact that just the notes of high pitch which these delicate vascular vibrations would make, would correspond to the generally high quality of subjective noises in the ear. Dr. Blako' has sliown that notes of tuning-forks which give an extremely high number of vibrations per second are heard iiuich more easily when the membrana tympani is perforated,, that is, they gain access to the auditory nerve more readily. This being undoubtedly the case, as shown by Blake's experi- ments, Theobald is apparently tully justified in his theory as to 1 Transactions American Otological Society, vol. i. p. 438. 23 (J 354 MIDDLE EAR. I the ready escape of hig-li tones originating in the vascular i movements of the labyrinth, which might be interpreted by the ear as tinnitus, did they not readily escape through the perfora- '. tion in the membrana tympani. ! The ordinary normal vascular movements in the labyrinth are not productive of tinnitus aurium, because a normal ear permits the 'escape of all vibrations produced by ordinary vas- cular movements in the ear, without perceiving them as sound. That motions sufficient to produce sound are constantly going on in the ear, which, however, the latter fails to hear, in the , normal correlation of forces obtaining in the healthy organ, is ', proven by gently stopping a normal ear, whereupon tinnitus of' varied pitch may be perceived. This, as has already been said, is due to the altered resonance and reflection brought about in the ear by the stoppage of the meatus wjth the linger; for that which prevents sounds, f. e., ' vibrations, from entering the ear will also prevent the escape of those originating in the ear, and thus the ear hears the so- called subjective sounds. Autophony. — The subjects of acute aural catarrh often com- plain of hearing their own voices disagreeably or even painfully ' in the affected organ. The}- liken this sensation to that experi- enced by one speaking in a closet, or with one's head in a barrel. This altered resonance of one's voice is termed autophony. It : is not a symptom entirely of disease of the middle ear, as it may be experienced in a disease of the external ear. It is due to the obstruction offered by the swollen aural tissues to the ready egress of vocal sounds from the ear, which in a state of healtli permits a normal, and hence unconscious, transmission of sounds both to and from it. Disease of the middle ear especially in- terferes with the ready normal transmission of the vocal sounds^ of the patient, and autophony is the result. Autophony can be? produced artificially by the introduction of the finger into the( external auditory meatus. Sexton"^ explains autopiiony as duef to the fiict that the vocal sounds instead of being heard from the! mouth through the external air and then by the drum, are, ina some cases of aural disease, made to gain access to the nerve off hearing by traversing the tissues between the mouth and the earC in a more or less direct line, thus being heard /c/^.^^e in comparison]' with normal hearing. Altered resonance in the ear, especialljj in the musically educated, may be characterized by a variety of hyper;\?sthetic and varied phenomena of subjective sounds. Altered resonance is experienced by musicians, not only ini their own voices, but also in the instruments on which theyt' perform. The latter seem to give forth incorrect notes. 1 New York Med. Kecord, Jan. 22, 1881. It ACUTE CATARRHAL INFLAMMATION. 355 'Double Hearing or Subjective Echo-like Sensation; Paracusis DupUcata ; Suhjerfire Alteration in Pitch. — Double heariii!^-, or a subjective ecbo-likc perception of tones or words spoken I)}' or to the patient, may be connected with acute catarrh of the middle ear. Generally the latter part of the word is thus perceived ; it seems to be higher in pitch, as I can testify by observation of tins phenomenon in my right ear. During a slight catai-rliul closure of the Eustachian tube without pain, I have heard a dis- agreeable echo of the last syllables of words in my right ear. The tones of the syllables thus perceived were certainly higher in pitch than the word as spoken to me. How great this "harping was, I cannot state. The notes of the piano did not eem to me to be thus sharped, nor were they subjectively echoed in their true pitch. In some cases both words and musical notes are perceived in this peculiar echo-like way, without alteration in pitch; this is more likely to be the case with words than with musical tones. The latter are usually sharped a halftone or more. Some of the earliest accounts of this phenomenon are those of Sauvages, Itard, and von Gumpert;^ the same symptom has been noted by von Troeltsch and Politzer. The cases of Sauvages and Itard were observed in patients suffering with catarrh of the middle ear. Von Gurnpert observed the pheno- menon on himself. The subjective difference in the note varied between the third, the fourth, and the octave. He also per- ceived the echo-like ending of words. The peculiarity lasted for a week. , Yon Wittich,- too, observed most carefully a similar alteration in his own hearing, four weeks after an inflammation in his ear. " The notes of a tuning-fork appeared exactly a halftone higher in the diseased ear than in the well one. The same was perceived respecting notes of the iiiiddle scale, either when whistled or struck on the piano. They were heard double, the difference between the two ears being a halftone." "This [ihenomenon remained unaltered, both when the ex- ternal auditory canal on the affected side was filled with water or cotton-wool, and when by inflation the membrana tympani was made to change its tension. Apparently, a somewhat different phenomenon presented itself when a vibrating tuning- fork was placed on the teeth, for the natural tone was heard gradually to die away into the next half tone higher." In the latter instance there was ap})arently a double hearing, or an after-hearing of the true note sharped, in the diseased ear. ' Quoted bv Bressler : Die Krankheiten des Kopfes und der Sinnesorgane, Berlin, 1840, Bd. ii. S. 875. See Moos and Gniber. - Konigsberg Med. Jahrbiicher. Bd. iii., 1861. 356 MIDDLE EAR. When the fork was placed on the vertex, the tone appeared higher the nearer it was to the aft'ected ear. Two forks, one of which was a half a tone higher than the other, were heard as the same note, when the higher was held before the well ear and the lower before the diseased ear. Sir Everard Home^ has related the case of an eminent music teacher, who, after taking cold, perceived, in addition to confu- sion of sounds in his ears, that the pitch of one ear was half a note lower than that of the other; and also that the perception of a simple sound did not reach both ears at the same time, but seemed as two distinct sounds following each other in quick succession, the latter being the lower and weaker. This phenomenon was considered by Home to be due to de- fective action in the muscular structures governing the tension of the membrana tympani, although it is evident he was entirely unacquainted with the structure of the membrane, since he described as he thought a radiate muscle lying in the drum- head, whereas no such structure exists as part of its layers. But that he has accurately described a case of double hearing and subjective alterations in pitch, is beyond doubt. Moos^ relates two cases: one, that of a tenor singer who, for fourteen days after a severe coryza, heard simultaneously the treble of all the notes he sang. This was found to be due to catarrh of the middle ear and some hardness of hearing on both sides. The same author gives an account of double hearing in a case of chronic catarrh of the middle ear. In this instance the phenomenon of double hearing came on after the patient used chloroform for relief from an attack of asthma. Immediately after the narcosis the hearing was worse, subjective noises of various descriptions were perceived, and the patient noticed that all notes from a' up were heard double in both ears. Later the notes thus doubled were q" and all notes from that point up the scale. These subjective phenomena of hearing can be ascribed to the exacerbation of catarrh produced by the breathing of the chloroform. Gruber^ has noted the phenomenon in two cases: in one case, that of a musician, a musical note was heard a third higher. In some instances the after-sound may be of the same pitch as i the original note. Perhaps this phenomenon, double hearing, would be noted ? more frequently if the patients were generally educated iu i* music, for it is worthy of note that in the cases recorded the ( sulterers were musical. 1 Philosophical Transactions, Koyal Society of London, Part I., 1800. 2 Klinik d. Ohrenheilkunde, pp. 319, 320, 1866. » (.p. cit., p. 626. ACUTE CATARRHAL INFLAMMATION, 357 Case L Tlie first instance of double hearinci;, or, as I prefer to call it, subjective alteration of pitcli, wbicli I observed, was in a young Austrian officer of good musical education, an amateur performer on tbe violin. During an acute otitis media on the left side, he noticed that in tuning his violin the note appeared a third higher in the affected than in the normal ear. This condition lasted for several days, but disappeared with the cessa- tion of the acute disease of the ear. In this case the hearing could be called double in the sense that the normal ear heard the true note and the diseased ear another, viz., one apparently higher than the original note, producing subjective confusion. Case II. In this case the subjective alteration in pitch oc- curred in both ears. During a successful treatment for chronic purulent disease of both ears, the patient, a young woman of 23, music teacher, suffered from a slight intercurrent acute otitis media on both sides. All sounds became disagreeable, and she especially noted and complained of a sharping of all musical tones of the voice of others in sine-ing and of the notes on the piano. This, however, disappeared in a week, and the purulent disease was finally cured. The hearing in this case became almost normal after the disappearance of the suppurative disease of the middle ears. In this second case it could hardly be said the patient suffered from double hearing, for she heard a similar subjective sharping of piano-notes in both ears. This she knew to be the case, not by discord, but by her knowledge of music, for she knew, when she struck a given note on the piano, that the note her ears perceived in their diseased state was sharper than the note she heard when the same key was struck by her in health. Intra-tym'panic Pressure during Phonaiion. — Under normal conditions, phonation produces variations in pressure both in" the mouth and nasopharyngeal space. It is greatest with some consonant sounds. Experiments of Dr. C. J. Blake^ show that this presRure is sufficient to be communicated to the tympanic cavity through the Eustachian tube. This pressure may be- come pain^^ul in some cases of disease of the middle ear. In such instances the patient may voluntarily avoid pronouncing the nasal consonant sounds m, n, and ng, since the pressure in the tympanum, brought about by their phonation, is painful. The sensations produced by their pronunciation has been de- scribed as a disao-reeable crackino; and burstino- sound, least so with m ; most so with ng. In a case of this kind observed by Dr. Blake, a cicatrix in the membrana tympani was seen to ^ Intra-tvmpanic Pressure during Phonation, Trans. Amer. Otol. Soc, vol ii. p. 75, 1875" 35S MIDDLE EAR. make vibrations with each of the above consonant sounds ; least with m, a larger one with n, and " with ng a double excursion was observed, the membrane only partially resuming its original position between the two movements." All of these unpleasant symptoms were relieved by excision of a portion of the flaccid cicatrix. A round opening was thus made, the symptoms above named disappeared, and the patient articulated normally. Dr. Blake also found that a manometric column of water (diara. 1 mm.) connected with the meatus, when m was pronounced, rose and fell ^ mm. ; with n, nearly 1 mm. ; and with ng, a double rise and fall of nearly the same degree was observed. Recurrence, every year for fourteen years, of a Peculiar Suhjective Noise and Altered Resonance of Voice, in the Left Ear ; Tempo- rarily relieved by Pressure on the Auricle and 3Ieatus. — Sep- tember 9, 1873, Mrs. C, 35 years old, living in affluence, states that for fourteen years she has experienced an altered resonance of her voice and some buzzing noise in fhe left ear, which come on together in June, with the warm weather, and last until September. She also makes the strange statement that these subjective alterations become apparent to her toward midday and last until about bedtime. She can always gain relief for a few moments by pressing and pushing the auricle and meatus on the atfected side, but as soon thereafter as she swallows, the altered resonance returns. The hearing remains unaltered and certainly appears perfect on testing. The voices of others are never changed in quality as her own is. She says she has, in winter, catarrh of the throat, at which time there is more or less soreness confined to the Eustachian region on the side where these peculiar alterations occur in the summer season. In winter, however, these subjective alterations have never occurred. Examination revealed a follicular pharyngitis with- *out hypersecretion. The membrana tympani was normal in every respect, except iu its being a little more indrawn than its fellow. The tuning- fork placed on the top of the head was heard equally well in both ears. The Eustachian tubes were readily pervious to air from Politzer's bag. As the statements concerning these peculiar subjective symptoms in the leit ear are to be credited, there are several points of great interest which earnestly de- mand some explanation. 1. The occurrence of these pecuhar symptoms in summer-time only. 2. Their coming on towards niidday and passing off towards bedtime, i. e., about 0-10 p.m. 3. The temporary relief gained by pressing on the auricle and in the meatus. 4. Their instantaneous return on swallowing. Naturally the mind connects their causation with summer and its heat, which idea is only strengthened by the statement that ACUTE CATARRHAL INFLAMMATION. 359 they grew worse as the day grew warmer, and disappeared as the sun went down and the temperature fell. The chief cause of this subjective alteration in the ear must be sought in the condition of the Eustacliian tube. It is not uncommon to tind the nasal mucous membrane sub- ject to an irritability from the heat of summer; it, therefore, seems fair to presume that the same irritability — a kind of erectility — may exist around the faucial end of the Eustachian tube. Let us suppose then that the heat of summer caused in this case a swelling in the tube in the manner suggested above; at the same time, it expanded the air locked up in the tym- panum by the closure of the mouth of the Eustachian tube. The expansion of the air contained in the tympanum forced the membrana tympani outward, and unlocked the malleo- incudal joint. This disturbed the equilibrium of these parts and brought about very much such an altered resonance as any one experiences after blowing the nose during an ordinary nasal and faucial catarrh. This pushing outward of the membrana tympani was sus- tained by the expanded air of the tympanum until the patient pushed the auricle and pressed the tinger-end into the meatus. Then the column of air in the external auditorv canal, being condensed by the pressure from the tinger-tip, forced the mem- brana tympani inward. The latter, in turn, pushed some of the expanded air of the drum-cavity out through the slightly swollen Eustachian tube, and resumed, with the ossicula, a posi- tion of equilibrium, and then vibrated normally until an act of swallowing occurred. Then the altered resonance returned. The return of the peculiar subjective resonance after the act of swallowing can be explained thus : The first effect of swal- lowing is to open the Eustachian tube, and to force air into the drum-cavity. But in the normal, loosely closing, or closed tube, more than the requisite amount of air recoils, and the equilibrium is maintained in the tympanum. In this case the tube was enough swollen to interfere with the recoil of a surplus of air which it was obliged to permit to enter the drum-cavity at the relatively powerful act of swallowing. According to Lucpe, so powerful is this act, and so great is the amount of air forced into the tympanum by it, that the first effect in the latter cavity is one of condensation. In this case the tube was not so much swollen as not to permit the usual large amount of air to enter the tympanum at swallowing, but it was enough irritated and narrowed by the effects of heat to interfere with the ready recoil of the surplus of air forced into the drum-cavitv bv swallowing; hence too much air remained in the tympanum, the equilibrium remained disturbed, and the peculiar resonance 360 MIDDLE EAR. became once more apparent, until the finger forced the mem- brana tjmpani back to a normal position. Acute Aural Catarrh in Infants and Young Children. — Since this disease constitutes much of the so-called earache in little children, it will be well to bestow more than ordinary comment on its occurrence in them. Unfortunately it is a disease too commonly overlooked in them, partly oil account of their in- ability to locate their pain and communicate their feelings to others, and also on account of the difficulty of examining young and sufiering infants. Hence the disease may escape proper treatment, and lead finally to permanent injury of hearing, and even to results fatal to life if allowed to pass into the purulent form of tympanic inflammation. This disease of the ear is apt to come on with catarrh of the air-passages, teething, whooping- cough, and the exanthemata. Its most common occurrence is during a cold. If it occur in an infant, the little victim will suddenly cry out most piteously, at first only with every severer twinge of the increasing pain, but at last it will utter a quick succession of piteous and peculiar shrieks. This cry has been said to resemble that occurring in acute bowel-disease, and has often been mistaken for that in infants. But the continuance of the pain, despite the treatment directed to the bowels, will soon show the careful observer that the disease is not in the intestines. The infant will refuse all nourishment, the breast or the bottle is pushed away, and if the nurse now endeavors to dandle the little sufferer, each movement will cause it to shriek more loudly, and convulsions may supervene. In an older child the cries may be so dreadful that isolation of the patient in a remote part of the house becomes necessary in order not to alarm its relatives and neighbors. Such severe forms usually terminate in suppuration. Very frequently, attacks of earache from acute aural catarrh come on only at night, for several nights in succession, but in the intervening daytime the little patient plays about as usual. If the ear is examined in such cases, the membrana tympani will be found greatly drawn in and lustreless, looking like ground glass, or a polished steel surface just breathed upon. The manubrium of the malleus in such cases is so much re- tracted and foreshortened, that it will appear far up and behind in the posterior superior quadrant of the drum-head. The mend)rane may appear congested about the malleus and its folds. It must be remembeped that in infants, and very young children under six years of age, the membrana tympani occu- pies, normalh% a position much more horizontal than in older children and adults (see p. 50). These cases are primarily and emphatically tubal catarrh^ with ACUTE CATARRHAL INFLAMMATION. 361 more or less liypera^niic swelling of the lining mucous mem- brane of the tympanic cavity. The pain is aggravated at night, especially by the recumbent position, which, of course, increases the congestion and swelling, both in the tube and tympanum. Thus, the vacuum already alluded to is made greater, and the external air presses with greater force on the outer surface of the membra na tympani, forcing the latter inward, and with it the chain of ossicles. The freedom from pain in the daytime is due to a partial subsi- dence of swelling in the tube and tympanun, and consequently to less of a forcing inward of the membrana tympani and the ossicles. A want of air in the tympanic cavity is, therefore, one the chief causes of pain in these cases of acute catarrh of the ear ; and hence, sneezing, blowing the nose, or an artiticial infla- tion of the tympanum will usuall}- cause a cessation of the pain, by overcoming the vacuum in the tympanic cavity and thus re- lieving the undue tension of the drum-membrane. In very young children, a high degree of deafness may be present from merely a persistent simple catarrhal process in the Eustachian tube. If the latter is opened, usually by one good inflation with Politzer's air-bag, the hearing is instantly greatly improved, and a few repetitions, everv other day, of this manipu- lation will eti'ect an entire cure of the case. But such cases, I believe, are rarely recognized soon enough for beneficial treat- ment. Yet, I have seen enough of them to lead me to conclude that many cases of chronic deafness, in those just arriving at the age of puberty, are attributable solely to neglect of simple catarrh of the tube four or five years previously. In such cases the closure of the Eustachian tube, especially if it be on only- one side, is either not noticed by the patient or his friends, or, if noticed, is neglected, in the hope that the child will outgrow the trouble : audit appears that sometimes it does, by a spontaneous opening of the tube. Usually, however, the tube being closed for a long time and the tympanum deprived of air, the latter loses, often irretrievably, its function of permeability, just as an air-sac in the lung would, beyond a stopped-up bronchial tubule. Acute aural catarrh in larger children is usually the result of undue exposure to dampness and cold. Although these attacks of acute catarrhal inflammation of the middle ear, from impru- dent exposure to cold, are both comnion and painful, they are not usually as likely to become chronic, and thus permanently ; injure the hearing, as those forms of aural inflammation brought il on by the exanthemata. The latter usually lead to purulent in- flammation and spontaneous rupture of the membrana tympani, . but acute catarrh may run a painful course, without producing ' spontaneous rupture of the drum-membrane. In fact, this tendency to produce a spontaneous rupture of the drum-head, 862 MIDDLE EAK. or not, is one of the distinguishing marks between acute puru- lent and acute catarrhal inflammation of the middle ear. The large majority of all cases of chronic purulent inflamma- tion of the middle ear, are unhesitatingly attributed by the patients to the exanthemata or to some of the continued fevers. If the purulent discharge is said to be the result of earache from cold, it is usually found to date back to earliest infancy. Another equally striking fact is that chronic aural catarrh, i. e,, oft-returning and slowly increasing hardness of hearing, is almost invariably attributed to, or at least said to be aggravated by, cold in the head. It may be that inflammation of the middle ear, caused by cold in the head or acute inflammation of the air- passages, is of a sthenic type, while that produced by blood- poisoning of any kind, like the exanthemata, continued fevers, syphilis, etc., is of a decidedly asthenic type, tending to destruc- tion of tissue. Objective Symptoms in Acute Catarrh of the Middle Ear. — If the membrana tympani can be examined in the first stages of this disease, there will be noted, first, a slight congestion about the periphery of the membrane, with a somewhat greater amount in the membrana flaccida and in the vessels lying over the handle of the malleus. The color of the membrana tympani, in general, will not be much altered at first, but its lustre may be slightly dimmed, and the pyramid of light will become faint or fade entirely. In many cases, even in those w^ith considerable accumulation of mucus in the tympanum, the membrana tym- pani will not lose its contour, as it does in the purulent form of otitis media. A marked objective symptom, however, is the retraction of the membrana tympani. Retraction of the 3Iembrana Tympani. — The retraction of the membrana tympani may be so great in these cases, on account of the exhaustion of air from the tympanic cavity, that mucus in quite large quantities may be present without causing any bulging of the drum-head. In such cases, however, unless the drum-head is very thick, the mucus can be seen through the delicate membrane ; the color of the latter will then be in- fluenced by that of the mucus in the tympanic cavity, and the surface of the membrana tympani may finally be made to bulge, either in spots, by lumps of mucus, or regularly at some one segment, mostl}^ the hinder, by a more homogeneous kind of mucus. If the fluid in the drum-cavity is serous, bubbles can be easily seen in it through the membrana tympani. Spontaneous Rupture of the Membrana Tympani. — Spontaneous rupture of the membrana t^anpani is rare in simple acute catarrhal inflammation of the middle ear. I consider this the chief diagnostic point between this disease and acute purulent inflammation of the middle ear, to which, I grant, the acute ACUTE CATARRHAL INFLAMMATION. 363 ■ iitarrli is only too likely to lead. But since, as a matter of liict, Ave rarely find purely mucous products breaking down the incmbrana tynipani and discharging themselves througli the opening thus made, while we constantly find pus escaping in this manner, I am forced to conclude that acute catarrhal intlammation leads rather to a thickening of tissue than to I lie more destructive disease — acute purulent inflamnuition of the mucous lining of the middle ear. In the latter instance we invariabl}' find purulent discharge escaping from one or more spontaneous ruptures in the membrana tymjtani. The same new was entertained by Kau,^ who states that the results of inflammation, comprehended " under perforation of the mem- brana tympani, destruction of the ossicles of hearing, caries of the mastoid,'" etc., do not follow acute catarrhal intlammation of the ear, but are results of the acute pui-ulent form of aural disease. I observed, not long since, in a medical man, 60 years old, just recovering from pneuuionia, an apparent exception to what seems the rule, that pure mucus is never found escaping through a spontaneous opening in the membrana tympani. A little pain, with considerable dulness of hearing, were the first symptoms. These were noted by the patient some days before the membrana tynipani was examined. I found the membrana tympani uni- formly pinkish and thick in appearance, lustreless, and bulging in its entire posterior half; the position of the malleus plainly visible. Paracentesis of the drum-membrane was proposed, but not performed at request of patient; and that night and the next morning jelly-like, transparent mucus, resembling thick white of egg, came from the tympanum through a sponta- neous opening in the drum-membrane. This perforation healed in a day. Although this case was complicated finally by a deep- seated abscess of the cellular tissue over the mastoid portion, the hearing was fully restored. The membrana tympani now shows a small, grayish spot in the posterior segment w^here the open- ing occurred. In addition to the chief symptoms, fulness and pain in the ear, with hardness of hearing and tinnitus aurium, we shall find, usually, in acute catarrh of the ear, general catarrhal symptoms of sore throat, cold in the head, cough and hoarse- ness, and some headache ; but vertigo and fever are not common attendants of this disease. The latter symptoms are usually proportioned to the severity of the pain. As a rule, all the symptoms of acute aural catarrh will be found abating with the cessation of the general catarrhal symptoms, excepting, perhaps, the deafness, which may increase with the general 1 Ohrenheilkunde, sec. 195. 364 MIDDLE EAR. increase of local secretion from the various parts of the mucous ■ tract implicated in the general catarrh. This increase in the deafness is, of course, due to the mechanical obstruction in the 1 Eustachian tube and tympanic cavity, brought about by the j large amount of thick mucus retained in the middle ear, by the , swelling of its mucous lining. The latter may be kept up by ' additional attacks of slight catarrhal swelling. I Course. — This affection may lead rapidly to purulent inflam- mation of the middle ear. It is not, however, the more violent form, either in children or adults, which leads to permanent ! deafness. The oft-recurring, slight attacks of fulness in the ears, ■' with every cold in the head, are most likely to lead to a chronic catarrhal swelling and deafness. Such cases finally cause an . accumulation of inspissated mucus in the tympanic cavity, according to some observers (Hinton). My experience would i lead me to believe that such accumulations are not as common i' in this country as they appear to be in England, if we may judge from the writings of the late Mr. Hinton. Be this as it may, respecting the slow and chronic accumulations of inspis- sated mucus, it is very certain that the oft-recurring stuffed feeling in the ears, with every cold in the head, usually leads to permanent changes in the hearing unless relieved by proper treatment. Etiology. — Acute catarrh of the middle ear is most apt to occur in the spring and autumn, or in changeable weather in midwinter, and is usually found whenever catarrh of the air- passages is prevalent. It is also caused by teething, whooping- cough, continued fevers, the exanthemata, and syphilis. In summer-time there are two great causes for its occurrence, viz., cold bathing and diving, and sitting in a draught of air to cool the heated body. In the first instance, the exposure of the ear to breakers or to the cold water in diving, is the cause of the in- flammation. This is easily understood when one reflects that the membrana tympani is so thin that its mucous surface is practically brought into direct contact with the cold water whenever the latter enters the external auditorv canal, as in diving, or by any other incautious means of submerging the head. It would seem that in such cases the inflammation of the tympanic cavity is secondary to a myringitis produced by the cold water. Strangling, often induced in diving, may lead to the introduction of cold water through the Eustachian tube into the middle ear, and thus produce inflammation of the tympanic mucous membrane. In the second instance, when inflammation of the middle ear comes on after cooling ofi' in a draught of air, it seems to be the result of a general constitutional disturbance ACUTE CATARRHAL INFLAMMATION. 365 due to the exposure of the heated cutaneous surface to cold air, and the result is similar to a chilling of the surface of the hody ia winter, when, as is well known, the aural disease is often joined to sore throat and coryza, all of which are due to the "same atmospheric or telluric cause, Many cases of catarrhal inflammation of the tympanic cavity may be said to be to a great extent mechanical in their origin. The catarrh of the Eustachian tube closes up that important communication between the tympanum and the fauces, causing a vacuum and a retention of mucus in the drum-cavity. Conse- quently an irritation is set up there, both by the want of air in the drum and a slow decomposition of the retained tympanic excretions. Hence many an acute catarrhal process in the tym- panic cavity, accompanied even b^^ pain, may be cut short by one or two good inflations by means of Pulitzer's air-bag. A great many cases of acute catarrh of the middle ear are produced by sudden exposure to the air after all forms of vapor baths. The heroic Turkish and Kussian baths, so largely advertised, are constantly producing acute catarrh of the ear. The same evil result is often due to " cold packing " in water-cure estab- lishments. Earache from Teething. — Earache occurs very often in teething; 30 frequently is it an attendant of this period of childhood that I have known mothers to prophesy with accuracy the coming through of a new tooth, from the sudden attack of earache. The vast majority of these cases never pass beyond the simple catarrhal form. This peculiar connection between teething and earache was also noted by Rau.^ In some instances we may find that the catarrhal inflamma- tion has passed into the acute purulent form of tympanic inflam- mation, attended by perforation of the membrana tympani and discharge of puriform matter. The tendency to inflammation of the ear in teething is favored by the nervous connection between the teeth and the vascular supply of the ear. The middle-ear cavity is supplied by the tympanic branch of the internal carotid artery, which anasto- moses with the tympanic branch of the internal maxillary and stylo-mastoid arteries, branches from the external carotid. The tympanic branch of the internal carotid artery passes directly from the latter to the tympanic cavity. Hence, any congestive etfect on this vessel must be quickly and largely felt in the ear. Dilatation of this branch is brought about rapidly by any inhibitory force brought to bear upon its vaso-motor nerves. Such a force is supplied in the irritation from in- 1 Ohrenheilkunde, sec. 168. 366 MIDDLE EAR. flamed gums in infants. For, since the carotid plexus and the inferior dental nerve are both supplied by branches of the otic ganglion, irritation communicated to the ganglion from the teeth must be felt in the vaso-motor nerves originating from it The eflect of such an irritation is to inhibit the vaso-motor nerves governing the calibre of the tympanic artery alluded to. It then becomes dihited, and the parts of the ear it supplies en- gorged. Congestion, inflammation, and suppuration may then ensue. This inflammatory action maybe communicated quickly from the middle ear, in young children, through the petro- squamosal fissure to the brain. It is thus shown how convul- sions, meningitis, and death occur in infants in connection with 11 teething. Earache in Whoopivg-cough. — Whooping-cough is not an un- common cause of acute catarrh of the middle car; the perfora- tion of the membrana tympani occurring in these cases may be due to the mechanical force of the cough, and not merely to spontaneous results from the catarrhal disease. Without doubt, the inflammation in the tympanum weakens the lining of the cavity and favors its easy rupture by the force of coughing. The M intimate relation between the ear and the pneumogastric nerve ' must not be forgotten as a causal element in ear disease occur- ring in pertussis. ,,, Diagnosis. — The diagnosis of acute catarrh of the middle ear will be aided, chiefly, by the comparatively slight pain, the marked hardness of hearing, and the annoying hissing tinnitus, and, in a minor degree, by the presence of other catarrhal symptoms, such as sore throat, cough, etc., with little or no fever, nor any marked constitutional disturbance. It will also be noted that the pain is more easily overcome than the hard- ness of hearing, and that there is no tendency to a spontaneous l-upture of the membrana tympani. When the patient inflates his ear, or when it is inflated artificially by the surgeon, loud mucous rales will be heard in it. These are audible in a marked degree to the patient, and easily heard by the surgeon's ear, when assisted by the ausculting tube. Objectively, the diagnosis will be aided by careful inspection of the membrana tympani. The latter will be found to present the varying appearances already described, according to the stage of the disease. At times it may be noted, with surprise, that the membrana tympani has not undergone great objective changes, notwithstanding the marked subjective symptoms iu acute catarrh. If the secretion of mucus has been large, and consequently the deafness of a high degree, usually it will be seen that the membrana tympani is forced to bulge from the pressure of the ACUTE CATARRHAL INFLAMMATION. 367 I retained mucus in tlie tvnipanic cavity. Another iniportant aid I in diaii'nosi.s is tlie freedom of the auricle and auditory catial 1 from inlhimmation. These may be handled without pain to the patient in acute aural catarrh, but if there is inflammation of P4,ny part of the external ear, ordinary examination with the speculum, which necessitates some traction on the auricle and meatus, will cause pain. This is often a partial means of tindiui;' i out, in a case of asserted pain in the ear, where the seat of the disease is, or at least what division of the ear is probably most affected. Prognosis. — The prognosis of acute catarrh of the middle ear is, on the whole, favorable. By careful observance of all the symptoms and prompt ap})lication of the treatment about to be detailed, usually the disease will termiiuite favorably. It should never be neglected, even in its mildest forms, since repeated slight attacks are very likely to lead at last to permanent hard- ness of li earing. Treatment. — The milder forms of congestion are to be treated by relieving the general catarrhal symptoms, and a thorough inflation of the tympanum. The first object is to be gained by opening the bowels, if necessary, and restoring the function of the skin, which is usually more or less disturbed. A mild diet nmst 1)6 observed, and spirituous drinks, smoking, chewing, and sufHng tobacco are to be sedulously avoided. The patient must be housed, and a sudorific and anodyne regimen observed. The second object, inflating the tympanic cavity, is to be gained by using Politzer's air-bag, the Eustachian catheter, or Valsalva's method'of inflation. The latter mode of inflation consists in the patient's holding his nose and forcing air, by powerful expira- tion, into the tympanum while his mouth is closed. By thus inflating the tympanum, the formation of a vacuum is pre- vented and the secretions are forced away from the ossicles and allowed to escape through the artificially opened Eustachian tube, or they become rapidly absorbed. Air blown by the air-bag into the nostrils of children, will force open the Eustachian tube without any cooperation on the part of the patients; in fact, crying on their part will l[ft itp the palate, shut ofl:*the lower from the upper pharynx, and facilitate the passage of air into the tympanum. If the child is tractable,' puffing out the cheeks with closed lips, according to the suggestion of E. E. Holt, prolonged pho- nation of the vowel a, or of the words hick, hack, hock, etc., accordincr to the sut^-o-estions of Luctxi^ and Gruber,- will aid ^ Yirchow's Archiv, vol. xliv. 2 Monatsschr. f. U., Nos. 10 and 11, 1875. 368 MIDDLE EAR. in lifting the soft palate and in closing the nasopharynx from the cavity of the mouth and throat. At the moment of, or during the distention of the cheeks, or of the prolonged phona- tion, air may be forced into the tympana by Politzer's bag; if only one tympanum needs inflation, the one opposite to it may be firmly stopped with the finger during the operation of infla- tion, and thus, in some cases, it seems that more air is forced into the ear to be ventilated, because of the greater resistance oliered, by the voluntarily stopped ear, to the column of air pressed into the nasopharynx. The treatment need not be actively antiphlogistic unless the pain and fever become severe. Should the pain grow intense, leeches must be applied in front of the tragus, as near as possible to the ear, directl}- in front of the tragus or under the auricle. This tends to prevent suppuration. Before leeches are applied, the mouth of the auditory canal should be stopped with cotton to prevent their crawling into the meatus. Such a mishap would cause the patient not only intense pain but most probably a severe external otitis. Hence, the advice sometimes given to deliberately apply the leech to the meatus is to be rejected. Even in the most favorable spot, a leech-bite not unfrequently produces a circumscribed abscess. Anodynes. — Anodynes should be given in doses sufficient to allay pain and produce sleep at night. Aconite, in doses pro- portioned to age, is of great value in acute otitis. A hop pillow, or any form of dry heat, will often prove very grateful in this malady. In addition to the above means, warm and soothing gargles, and warm applications with the sj'ringe or aural douche, to the Fig. 87. Aural Douchk. ear, together with rest in bed or in the room, will be found to hasten restoration to health and hearing. Sprayivfi the Nasopharynx. — In cases of acute aural catarrh, in which the fauces, nasopharynx, and Eustachian tube are espe- cially inflamed, spraying of these parts by warm fluids will be found grateful to the patient and very useful in the treatment of the disease. ACUTE G A T A R K H A L i:SFL A .M IM A T I O N , 369 "Warm water, slightly impregnated with salt (lifty-six grains to the pint) is often employed, and in acute cases is of some value. r>ut warm water containing chlorate of potash (3-5 gr. to f.Tj), four or live-grain solutions of borax or of boracic acid, or bicarbonate of soda, four or five grains to the fluidounce of water, will prove more useful in all cases than solutions of salt. The most convenient form of application of warm spray to the nasopharynx is by means of a hand atomizer; the steam atomizer may be used, l)ut it is not nearly as convenient as the hand-apparatus. It can but be repeated here that all forms of oils and fats are to be kept most carefully out of the ear, in this as in all other acute aural diseases. Sw^eet oil and other fats not only clog the ear and mask the disease, but they load the drum-mem- brane, increase the pain, and, as they are usually forgotten and left in the ear after the pain ceases, they become rancid and tiavor the growth of fungi. These, in turn, produce a painful and troublesome acute disease of the external, and even of the middle ear (p. 263). It would he well if it were remembered that most of the so-called remedies for earache would make a well ear painful if they were put into it. Paracentesis of the 3Iembraiui TympanL — , If the collection of mucus in the tym- panum becomes great, the membrane bulge, and the pain continue, it will gen- erally be best to incise the membrana tympani. , This should be done by means of the i specially devised knife shown in Fig. 88, I at the posterior inferior quadrant, unless ^ome other point protrudes ver}' greatly. This operation is to be performed under perfect illumination and inspection of the auditory canal and membrana tympani, by means of the forehead- mirror and a speculum. The latter should be as wide as can be admitted comfortably into the meatus. The incision may be in the form of a stab or slit. Usually some of the retained mucus, or muco-pus, will issue from the wound instantly. It may be further aided in its escape from the tympanic cavity by 24 Paracentesis Knife. 370 MIDDLE EAE. ; some form of inflation, preferably by Valsalva's method. But i' the latter aid, which is quite sufficient, should be gently effected, r The svrino-e need not be employed at all to remove mucus or ' any matter from the tympanic cavity immediately after para- centesis of the drum-membrane. It often is not even necessary to resort to inflation at first, since the elastic force in the retained matter is quite sufficient to favor its escape after the incision in f:| the membrana tympani. This operation is simple enough, but • a very important one. It leaves none but good results behind ■ it when properly done, but it is not to be undertaken without careful consideration, and never simply for the relief of paiu. ! Its chief indication is to permit the escape from the drum-cavity of retained products of inflammation, accompanied by pain and - deafness. Unless the surgeon can recognize the presence of • matter in the drum-cavity, and is convinced that such retention is provocative of continued pain or deafness, and is also threaten- ing to produce a large destruction of tissue in the drum-mem- brane, by an ultimate perforative ulceration, he cannot be justified in resorting to the operation of paracentesis of the membrane in any form of acute otitis media. CHAPTER II. CHEONIC CATAKRHAL INFLAMMATION. The onset of this disease is usually insidious. It may be preceded by numerous painful attacks of acute aural catarrh, but ver}" frequently there is no history of precedent acute catarrh of the ear. Chronic catarrh of the middle ear is seen under two chief forms : (a) the secretory or moist, and (6) the asecretory or dry form. To these aspects of the chronic disease, diflferent names, and in some cases vastlv different natures have been assigned. But in both of these chief forms it is usually found, on close examination, that a markedly catarrhal condi- ■ tion of adjacent and related mucous tissues, either has preceded I or attends the chronic aural disease. Even in those cases of t chronic aural disease in which the nervous features are promi- i nent, the latter usually are seen to be due to nutrient dis- •; turbances in the nerves of the middle ear, and possibly of the ) internal ear, induced by the antecedent aural catarrh. Inded, , it seems that many cases of aural vertigo, under its numerous s CHRONIC CATAKEIIAL I N FL A M .M ATION. 371 es, niig-lit be traced buck to a chronic catarrhal disease of he middle ear. Chronic aural catarrh, therefore, Avith its multitude of symp- ^tonis, has given rise to many ditferent opinions as to its real I |hature and also to a very diverse nomenclature. This is due to the fact that the observation of the disease has usually begun at a more or less advanced stage of the affection, and but rarely continued until terminated by a careful study of the diseased tissues after death. Hence the number of names applied to this malady, as, " nervous deafness," " hypertrophic " and " pro- liferous inilammation," " sclerosis," and " chronic thickening of ■the mucous membrane of the tympanum," " anchylosis of the iTBtapes," and " progressive hardness of hearing." They all possess the merit of designating at least marked characteristics of the malad}' to which they are applied. To the inquiring and observant student of aural disease, each of these terms will offer itself in many cases as the best descriptive name of the tedious complaint he finds before him. But no single one of them admits of universal application. " Chronic catarrh " seems to me to be indeed the only universally applicable name. It is comprehensive, and surely serves to denominate the essential nature of the disease. SUBJECTIVE SYMPTOMS. The earliest subjective symptoms of this disease are tinnitus aurium and a gradual diminution of the hearing. These symp- toms appear usually only in one ear at a time, most commonly the left, and a varying period may elapse before the other ear is attacked. The onset of the subjective noise in the ear may be quite sudden ; the time of its first occurrence can usually be stated accurately l)y the patient. This subjective buzzing, chirping, or hissing may appear on rising in the morning, during or after a severe cold in the head or after a depressing illness. The noise is not intense at first, but gradually becomes louder and more annovino;, the hearing usuallv diminishing at the same rate. The statements of patients as to the quality and character of the subjective aural noise are extremely varying. The ob- jective sounds to which they are likened are commonly taken from the sounds to which the patient is most exposed ; the mechanic seems to hear noises of machinery, the student the hissing or buzzing of a lamp, while the simmering of the tea- kettle is a universal similitude used to explain the quality of tinnitus aurium. In many cases a hyperjiesthesia to objective sound seems to come on with tiie annoying subjective noises. I have known patients suffering with distressing subjective 872 MIDDLE EAR. hissing in the ear and greatly reduced hearing, to complain bitterly of the intensely disagreeable eifect on the diseased ear of the noises of the street, and even of the blowing of the wind across the auricle while walking. This sensitiveness may persist for months. Sometimes patients seem to get used to the noise in the ear. When their attention is specially drawn to it they will sometimes state that they are aware of a singing in the ear but it is of no great moment to them. The singing in the ears is not very severe, nor does it grow louder in these cases. All subjective noises of the ear in this disease may be increased by fatigue, drinking spirits, smoking, and prolonged conversation. In some cases, after each meal the noise seems much louder. Some authorities' state that abnormal conditions of the genito- urinary apparatus tend to aggravate the tinnitus of chronic aural catarrh. It is very certain that gastric and intestinal de- rangements tend to make tinnitus aurium more intense. But in some cases, tinnitus aurium either never appears in the disease or only at a later stage, long after the hearing is much reduced. These cases, being deprived of the warning as to the threatened failure of the function of the ear found in tinnitus aurium, are rarely made aware of the loss in hearing until it becomes very great. This is especially the case when one ear remains perfect. A failure of hearing in it, temporary or otherwise, is often the first occasion for noticing the defect in the other ear. A patient may come with the statement that while lying on the good ear in bed, accidentally it was discovered that some ordinary sound, such as the voice of a friend, the crying of a child, or the bell on the street-car, was not perceived by the free ear. This has led to domestic testing with a watch or a clock, and these are found to be not perceived, or but imperfectly, in the ear which now for the first time is discovered to be faulty. The coming on of this kind of deafness is so insidious that, in many cases, even among the most intelligent, there is no reliable history of the origin of the disease. I have known children of physicians to be thus affected, but their fathers were not able to state when and how the disease probably began. These cases, with no definite account of the beginning of deafness, seem, in nw experience, to belong to a class with hereditary tendencies to chronic catarrh of the ear. In the case of a physician's child, I found the father affected in one ear; in a young lawyer's, the father and uncles were similarly troubled. A young gentleman, growing markedly deaf in both ears, lately aggravated, as he thought, % shooting, ^ Weber-Liel, Progressive Schwerhorigkeit, p. 19. CHRONIC CATARRHAL INFLAMMATION. 373 stated that his family in some branches grew deaf, but he could not tell when the disease began to appear in him ; he thought perhaps after undue exposure in the army ten years before. And such cases might be cited by scores. Darts of pain are felt in some cases, every day or two ; but this is not a very frequent symptom. If it occur, it is only in the earlier stages. Most patients complain of a sense of fulness and discomfort in the ear, as the disease advances. If the secre- tion of mucus is considerable, more or less cracking is heard in the ear In' the patient. After the ear cracks, it seems open for a little while, and the patient may hear better. But in a short time the sense of stoppage in the ear returns, and the hardness of hearing is again present. But the pain and the sense of fulness are increased by changes in the weather during the winter season. In summer all such symptoms are very much less prominent. A great sensitiveness of the ear may coexist with great deafness. Sounds which cannot be fully understood, i e., words which are perceived only as sound, uttered very near an ear rendered entirely deaf by catarrh, will often produce pain in the ear. AVith the tinnitus aurium, loss of hearing, and darting pain in some cases, disagreeable sensations are felt in the fauces, throat, and larynx. The character of these subjective conditions is variously described by the sufferers. Most of them complain, however, of constriction, tickling, sensation of fulness, and burning in the throat. All of these are aggravated by cold, any depressed state of health, or often by stimulating food, and by dyspepsia with constipation. In some instances after an ordinarv heartv meal, the throat will feel more or less burning, which is aggravated if the patient is obliged to talk in any prolonged way. Very often the disagreeable feeling in the throat is described as that of a hair or foreign substance l^'ing in the fauces, but which still clings there notwithstanding all efforts at swallowing. According to Weber-Liel,^ this symptom is specially apt to be complained of by females. In a state of health all acts of swallowing can be felt, or heard, in the Eustachian tube and middle ear. But in these cases of chronic aural disease attended with pharyngeal symptoms, swallowing cannot be perceived in the affected ear by the patient ; not even when the attention is drawn to the normal process by the physician. Very few persons are aware that at each act of swallowing, they can perceive, if the Eustachian tube is in a normal state, a sensation of opening and crackling in the ear. This peculiar thud felt in the ears, at swallowing, is but the normal process 1 Op. cit., p. 23. 374 MIDDLE EAR. of ventilation of the tympanic cavity. When the attention of one possessing good ears is drawn to this fact, it is then recog- nized, usually for the first time, so accustomed do all become to normal physiological processes. Consequently any symptomatic change in this respect must be inquired for by the physician ; for the patients never volunteer any information on this point, being, as already stated, ignorant of what a normal ear might perceive in swallowing. Vertigo is sometimes felt in the later stages of this disease, but it cannot be considered a very common symptom, according to m}^ experience. When it is present as a symptom of chronic aural catarrh, it is paroxysmal in character. This characteristic alone would help to diagnosticate it from vertigo caused by cerebral disease. In the latter instance, the vertigo, if it occurs, is either constant or invariably produced by some particular act, like walking, and there is more or less permanent alteration in the gait. Vertigo caused by chronic aural disease is usually connected with an increase in the subjective noises and an aggravation of the deafness. In such cases, any force which increases the pressure in the tympanic cavity is apt to bring on an attack of giddiness, as, for example, sudden swallowing, pro- longed acts of deglutition, and powerful inflations of the tym- panic cavity, either by natural or artificial means. Changes in the weather, and consequent increases in the catarrhal symp- toms, will often lend their aid in producing a greater tendency to aural vertigo. In most cases, by abatement of the catarrhal congestion, the vertigo will be lessened. In all such cases the Eustachian tube will be found to be at least temporarily narrowed, and the tympanum consequently imperfectly ventilated. The vertigo produced by inflation of a middle ear already diseased by chronic catarrh, and in which the membrana tympani is in- drawn and moi'e or less unvieldino; to forces intended to push it outward, is due to pressure on the foot-plate of the stirrup-boue and upon the membrane of the round window. The latter mem- brane is highly susceptible to changes of atmospheric pressure in the tympanum, as recently shown by Weber-Liel.^ Since, in the catarrhal ear, the drum-head is both stiffened and held inward by the retraction of the tensor tympani muscle, air forced into the drum-cavity, instead of equalizing the pressure by carrying ahead of it the membrana tympani, which forms so large a part of the outer wall of the drum-cavity, is suddenly spent upon the more delicate coverings of the fenestrae in the inner wall of the tympanum. Pressure thus exerted on the labyrinth-fluid must produce not only a morbid oscillation and compression of the terminal filaments of the nerve of hearing, 1 Centralblatt flir die 3Ied. Wissenscbaften, No. 2, 1876. CHRONIC CATARRHAL INFLAMMATION. 375 but also an alteration in the pressure of the cerebro-spinal fluitl, for the hxbyrinthine fluid has been shown' to be in direct com- munication with the cerebro-spinal fluid. The auditory nerve has motor as well as sensory fibres. A portion of the fibres of origin of the auditory nerve are closely connected with a mass of motor cells in the hulb.- These fibres pass into, and are continued in, the inferior peduncles of the cerebellum. Further, it is known that the motor filaments of the auditory nerve are distributed to the ampullae of the semi- circular camils, the sensory fibres passing to other parts of the labvrinth. By excitation of the ampullar nerves, reflex motor excitation is conveyed to the cerebellum, the phenomena of which will be considered more fully under aural vertigo. Therefore it can be seen how undue pressure in the laby- rinth can be conveyed to the brain, and produce cerebro-aural symptoms. Hearing Better in a Noise. — Hearing better in a noise is very often a marked symptom of the later stages of chronic aural catarrrh, when the condition of the tympanum has become dry and sclerotic, or wdien the thickening of the mucous membrane has become great in the moist form of the disease. This condi- tion of the hearing, once supposed to be a mere fancy on the part of the patients, or at least due to the general elevation of the voice all are obliged to assume in a noise, has been shown to be real. Those presenting this symptom, Paracusis Wil- lisiana, are found upon examination to hear the ticking of a watch somewhat better in a noise, for instance, in a mill or a railway train, than in a quieter place. ISTo entirely satisfactory explanation has ever yet been given for this. Dr. A, H. Buck mentions,^ but does not claim as an original idea, the following explanation for this peculiarity in hearing. "The pathological condition in the cases here under considera- tion is assumed to be one of rigidity, either of the annular membrane or ligament which holds the foot-plate of the stirrup in the fenestra ovalis, or of the secondary tympanic membrane covering the fenestra rotunda. Ordinary waves of sound, such, for instance, as are produced in ordinary conversation, are not of sufficient strength to overcome the rigidity of the annular ligament or of the secondary tympanic membrane ; consequently the patient fails to hear the conversation. In the midst of loud noise, however, waves of sound are produced of sufficient strength to set the stirrup in motion in spite of the existing pathological obstacles. Once in vibration, this little ossicle, 1 WeLor-Liel, Monatssclir. f. Ohrenli., Berlin, August, 1870, and Prof. Hasse, Anat. Studien, No. xix. p. 768. ■•' Duval : See Gelle, De I'Orcille, p. 323, Paris, 1881. ' Report on the Progress of Otology, N. Y. Record, June 5, 1875. 376 MIDDLE EAR. .§!: which might very properly be called the key to the auditory chamber, can perform with a certain degree of freedom the sub- ordinate vibrations called into existence by the conversation which is being carried on near by, vibrations which are neces- sary to the act of hearing it. The louder tones open the door for the entrance of the feebler ones." This can be most safely considered a sign of great rigidity in the sound-conducting parts of the tympanic cavity, and also a very unfavorable omen. Hereditary Tendency. — The tendency to this disease is markedly hereditary. Recently I have been consulted by a woman and her seven children for chronic aural catarrh. The woman was about 40 years old; the oldest child was about 18 years old. . The disease manifested itself early in life in the children, the [ worst of whom was a boy about 11 years old. The family were in the hard-workino^ class, and but moderatelv nourished. The boy, the worst case, was at school. Odor. — A symptom of this disease is a peculiar odor which I have noted, pervading the vast majority of those in the mature stages of chronic aural catarrh. It is not at all like the odor of ozoena ; it is more like that of saliva. By simply passing one's tongue over one's linger, and allowing the saliva to evapo- rate slowly, this odor may be simulated. It cannot be called offensive, and it is not perceived at any distance from the patient. It seems to emanate through the nose, and is more noticeable in females than in males, because in the latter it is usually disguised by tobacco. This odor, I think, is due to a disordered condition of the follicles of the mucous membrane of the fauces, mouth, nasopharynx, and nose. OBJECTIVE SYMPTOMS, Appearances in the Externcd Auditory Omal. — It may be said that in chronic aural catarrh characteristic changes occur in the external auditor3^ canal. Chief among these is the diminished i or suspended secretion of cerumen. The ear-wax not only be- comes smaller in amount, but often assumes a brittle quality; later it often ceases to be formed at all. This points to a great alteration in the nutrition ot the organ of hearino;. This im- portant excretion ceasing to be poured into the auditory canal, there set in a dryness and scaly condition of the skin of the meatus. This latter state favors the growth of aspergillus. 3Iernhrana Tympani ; Changes in Color. — The membrana tyra- pani usually loses its lustre and transparency in chronic aural Ij catarrh. But as these changes are not always indicative of such a disease in the tympanum, they must never be regarded as of positive value. In some cases of chronic catarrh of the middle CHRONIC CATARRHAL INFLAMMATION", 377 ear, the iiiembrana, tyiii})aiii WMiy be thinnor tlian usual, and cases are met with in which the lustre remains unchanged. In the latter instance, the chronic alterations in the mucous mem- brane of the middle ear have most probably occurred elsewhere than on the inner surface of the drum-head. The membrana tympani may appear uniformly pink from the transmission of the redness of the congested mucous membrane on the pro- montory. Another important fact to bear in mind respecting color- changes in the drum-head is that, even in those with normal hearing, especially in children, the membrana tympani is not unfrequently rather dull in appearance for longer or shorter periods. The lustre of the membrane is most easily lost; alterations in tenuity are more indicative of a deeper change in structure. Calcareous Deposits. — Chalky spots may be found in the drum- head of an ear affected b}^ chronic catarrh ; but they cannot be considered characteristic of the disease. They are usually traceable to a previous purulent disease in the ear, all other traces of which have gone, for it is not uncommon to find these b^eposits entirely unaccompanied by hardness of hearing. Cal- ' "careous spots may arise in the course of a chronic aural catarrh. After an experience of fourteen years, in the daily examina- tion of the drum-head, both in Europe and America, I am struck by the general rarity of chalky spots in the membrana tympani of those born in the latter country. It seems that these deposits are much more frequent in those born and reared in Xorthern Europe. Perhaps the milder climate of the latitude of this city may account for their rarity in the drum-heads of those born here. Changes in Position of the Membrana TymjxivJ — A much surer objective symptom of chronic aural catarrh, especially when joined to opacity and loss of lustre, is a retraction of the mem- brana tympani. The drum-head then appears drawn in, and the manubrium of the malleus foreshortened, the short process of the latter projects more sharply than usual, and the folds of the membrana tympani (see p. 52) are ver}' prominent. The manu- brium is not only indrawn, but is pulled backwards and upwards, and the entire concavity and curves of the drum-head being thus altered, the pyramid of light, normally found in the antero- inferior quadrant, is very much changed in position, or it may disappear altogether (see p. 53). As the latter reflection depends on the lustre as well as the curve and position of the drum-head, and as more or less opacity is found in chronic aural catarrh, the normal pyramid of light is usually one of the first features to vanish from the diseas'ed membrane. The numubrium not only appears indrawn, but rotated about its long vertical axis 378 MIDDLE EAR. SO as to pull the posterior half of the drum-head into greater prominence, and to drag the anterior half into a greater de- . pression. The causes of this retraction of the membrana tympani and malleus have been variously assigned by several distinguished observers. Politzer is of the opinion that the swollen and chronically diseased condition of the Eustachian tube interferes so much with the normal ventilation of the tympanic cavity as to cause a constant want of air, if not an entire vacuum, in it. This want causes a disturbance in equi- librium in the atmospheric pressure on each side of the drum- head, and the preponderance of the external air forces the drum- head in and relaxes the tendon of the tensor tympani muscle. This in turn may, by fatty degeneration or adhesion, or both, or by contraction from want of use, fix the drum-head in its indrawn position. In such a condition, the want of air in the tympanic cavity is the prime factor in the retraction of the drum-head. Weber-Liel ascribes the drawing in of the membrana t^mipani chiefly to the retraction of the tensor tympani muscle. This muscle is described by him as a part of the palatal and tubal muscles (see p. 109). The latter, becoming diseased and under- going fatty degeneration, are no longer able to preserve their proper amount of tension, and hence occur disturbances in the equilibrium of the muscular structures of the middle ear. In this process (defective motility of the faucio-tubal muscle), the paralysis of the tensor veli sive dilator tubfe plays very probably the chief part, not only because of the resultant persistent and ever-increasing hinderance to the ventilation of the tympanic cavity, but also because this muscle, which stands in the rela- tion of antagonist to the tensor ti/mpard, when paralyzed, is the chief causative power of the antagonistic contraction of the tensor tympani.^ Implication of the Sympathetic and other Nerves ; Flushing of the Cutaneous Surface adjacent to the Ear. — Among the objective symptoms of chronic aural catarrh may be mentioned implica- tions, more or less frequent, of the sympathetic nerve. It is not uncommon to find " complex disturbances in the correlated tracts of the vagus, glosso-pharyngeus, facial, auricularis magnus, and the accessorius nerves, standing in close connection with aural maladies of this nature. It is also not at all uncommon to find in deaf women, suffering from spinal irritation, muscular weakness, and rheumatic pains in the muscles of the throat and neck, sensitive spots on the side of the neck, behind the sterno- cleido-mastoid muscle, where the auricularis magnus and acces- sorius arise. Pressure on these spots causes not only pain run- ^ TVebcr-Liel, op. cit., p. 14. CHRONIC CATARRHAL INFLAMMATION. 379 iiing clown to the shoulder, but also occasions, in the ear on the corresponding side, a feeling of fulness and more or less tinnitus [ aarium."^ In some cases of chronic aural catarrh, especially in the dry form, called by some writers progressive hardness of hearing, a i tlushiuff of the skin near the ear is observed. I have seen but 1 three cases in which distinct, deep-tinted, and circumscribed I Hushing of tlie surface of the skin near the ear, was connected ; with tinnitus aurium and progressive hardness of hearing.^ t The historv in these cases was such as to lead to the conclusion I that this peculiar vascular congestion in the skin may be, in I Bome instances, a symptom of aural disease. Weber-LieP has described a case which presented, in one car, symptoms resem- ; hling those observed by Bernard, after section of the cervical • sympathetic. In some cases it must be admitted that the distinctly catarrhal symptoms are nmch less prominent than the nervous features of the disease, and such cases have given rise to the tlieorv of ■ nervous deafness. But my conviction is that upon ordinary ': search all such cases, no matter how^ prominent the nervous symptoms may be, wdien the case presents itself for treatment, can be traced back to a causative catarrhal trouble in the fauces, Eustachian tube, and middle ear. But it must be admitted that there are many good reasons for assigning to some cases a I nervous nature, as may be seen by the following cases": i Case I. I was asked by Dr. T. Hollingsworth Andrews, in ' May, 1874, to see with him a young lad}^ 26 years old, unmar- ried, of large, robust frame, a resident of the v^^estern part of ] Pennsylvania. Six years previous to the time I saw her, she had suffered from an attack of probably rheumatic facial paral- vsis on the rie^lit side. Within two or three vears she had noticed a diminution in hearing, accompanied by an uninter- rupted and distressing singing in her ears. The hearing on the right side was reduced to -q\; on the left, to -§% for the w-atch. The tuning-fork, placed on the vertex, was heard better in the better ear. The membrana tympani on the right side was more retracted than on the left. The lustre of both was good. The Kustachian tubes were pervious. There was, in this case, a constant quivering of the buccal Jind labial muscles, wdiich dated back for a year or more. I'here vas also a distinct jyiirplish-redjiash over the cheeks and neck as far as the clavicle, with an increase in the tinnitus lohenever the patient was ' Weber-Liel, op. cit., p. 3. ^ Three cases of tinnitus aurium and deafness, accompanied by very distinct flushing of the cutaneous surface adjacent to the ear, by the author, in Archives (fOphTand Otol., vol. iv. ' Op. cit., p. '2. 380 MIDDLE EAR. even ordinarily excited or fatigued. The application of the constani electric current from a Brenner apparatus, at the time of the exi amination, did not afford even temporary relief to the tinnitusi I saw the case but once. Case II. Mrs. Van C, 56 years old, patient in the Presbyteriar( Hospital, in Philadelphia; a farmer's wife, small and thin. Sh( stated that at the menopausis she experienced a sudden and exi cessive tinnitus aurium, which, however, had diminished it severity since then, but, though it had become quite endurable- it had never entirely ceased even temporarily. The hearing!' did not appear to be aiiected in this case. There was, howeveri a peculiar vascular congestion or flushing, deep carmine in color.1 which came on with any considerable fatigue or excitementi and was attended with an increase in the tinnitus aurium. This flush extended from both ears, where it seemed to startj over each sterno-cleido-mastoid muscle, forwards toward thq thyroid gland, where the blushes of each side coalesced and extended over the chest and mammfe. At the same time, a similarly tinted blush extended over the nucha and upper part ol the back and shoulders, so that the woman appeared covered byl a carmine-colored cape with the limits already designated. The rest of the skin-surface was sallow. There were, at this time^ some linear blushes running from the ears forwards over the temples, uniting across the forehead. This truly objectivev flushing was probably analogous to the subjective flushes soi often felt hy women at the menopausis. Case III. Mrs. McA., of Delaware, a very large, strong; woman, aged 45 years, living in a malarial district, and then in! her eleventh pregnancy. The patient stated that she had had ani increasing hardness of hearing, with tinnitus on both sides, fori some years. The drum-heads were opaque. In her case there wast a peculiar flash on the left cheek, corresponding to the worse ear, which became apparent on exertion or exposure to heat or cold, and was coincident with an increase of tinnitus aurium. This case grew much better while taking -^ gr. of strychnia thrice dailv and usins; the constant electric current. The history of these cases adds something to the knowledges^ of a form of aural disease in which the nervous symptoms pre-|, dominate. Since similar flushing has occurred from well-known direct% lesion of the sympathetic, it is fair to assume that the fliishingj. in the cases I have just narrated must also have been due to an^ irritation of the sympathetic. In two of the cases, as there werev^ other symptoms of chronic alterations in the organ of hearing,] it would seem probable that in them, at least, the flushings werei directly traceable to the aural malady. In the second case, it may have been but the precursor of deafness. I CHRONIC CATARRHAL INFLAMMATION. 881 Cirenmscribcd tiusliing of the cutaneous surface in any [)art of the body, whether from external violence or internal causes, is rare and in many respects unsolved. In a ease' of direct mechanical violence to the sympathetic nerve, the oidy known case at that time on record, " the face presented, after walking in the heat, a distinct Hush on the right side, and was pale on the left. The right half of the face was very red. The ilush extended to the middle line, but was less definite as to its limit on the chin and lips than above these points." Dr. Wm. Ogle^ has reported a case of probable destruction of the right cervical sympathetic by abscesses. In this case " the eyeball was retracted, the palpebral lissure narrowed, the pupil contracted, the right side of the face redder and hotter than the left during repose, but after violent exercise or fever, colder. The left side of the face alone sweated, and the right side of the mouth and tongue was complained of as being dry." In a case* under the care of M. Trelat, at the St. Louis, in Paris, in which the sympathetic nerve had been destroyed by an operation for removal of a deep-seated tumor of the neck, " on the day following the operation, the face was deeply congested, especially on the right side, which displayed well-defined patches of violet and red color." These cases are cited because they present instances of flushing of the face and parts of the head from known and direct lesions of the sympathetic nerve. In the three cases I observed and have related above, there was well-defined flushing without historj' of external violence to the sympathetic nerve. There- fore it seems fair to conclude that the nerve was afiected from within, and to it treatment would be well directed. JVares. — The changes in thenares, often attending, and appar- ently in many cases promotive of, chronic aural catarrh, may be very great. There is what in brief may be termed hyper- trophic catarrh of the nares in these cases. The hypertrophy is usually found on the inferior turbinated bones, though it may invade all the membranous structures of the nostrils, either on the turbinated bones or upon the septum. Posterior nasal hypertrophies are the most important, on account of their proximity to the faucial end of the Eustachian tube. There are often found enchondromatous enlargements on the septum, de- viations of the septum, and other forms of obstruction in the nares in the subjects of chronic aural catarrh. These obstruc- tions, as may be supposed, interfere with normal nasal respira- ' " Gunshot and Other Injuries of the Nerves." Mitchell, Morehouse and Keen. Philadelphia, IH14. ' Medico-Chirurgical Transactions, vol. lii. p. 154. _ _' yee Abstract in Med. Press and Circular, p. 78, Jan. 1869 382 MIDDLE EAE. tion, and lead to moutli-breathing. Thus the throat becomes affected by the irritation of direct respiration, and the nares and nasopharynx become further affected by being deprived of the normal stimulus of nasal respiration. The Eustachian tube, deprived of the natural stimulus of nasal respiration fails to become patulous as often as it should, and may remain closed for long periods, and the drum-cavity is thus deprived of its normal quantity of ventilation. This condition, in turn, fixes the ossicles, retracts the membrana tympani, and tends to the production of anchylosis in the sound-conducting apparatus of the middle ear. The Condition of the Pharynx and Throat. — The pharynx, ton- 'j* sils, and velum will be found to present varying appearances according to the form of the disease. In the moist form the secretion of mucus will be markedly increased, and the glandular structures of the mucous lining of ^\ the fauces will appear enlarged and inflamed, their function being of course stimulated by the disease. The tonsils are usually very much enlarged in this form of the disease, and the velum appears swollen. But this is only an accompaniment of the general catarrh, not the cause of it in the ear nor of the hardness of hearing. It will very often be found that the most swollen tonsil is on the side of the better ear. The secretion of the nose is also very apt to be abnormally great. This form of the disease really deserves the name of i< catarrh in its strict meanins; of " flowinsr " or " runnins:." But many cases of chronic aural catarrh do not continue to i show this abnormal amount of secretion in the pharynx. In these cases the mucous membrane has either rapidly ceased to f throw off large amounts of mucus, or it has slipped at once into an atonic and dry state. In such cases the mucous membrane of the entire pharynx, especially on the posterior wall, is pale and, at spots, apparently cicatrized. It may even somewhat resemble granular pharyngitis without marked secretion. The velum appears rather thinner than natural, as though its muscular structures were atrophied, as indeed they are; and the raphe is no longer directW in the median line, nor are the halves symmetrical in shape and position. A paresis has appar- ently affected one half more than the other, and the uvula and the weaker half will be drawn toward the stronger side, which will usually be found to agree with the better ear. All of these changes in the action of the muscles of the fauces must be attributed to the ettects of the catarrh. Loss of Function in the Velum. — The loss of normal mobility in the velum is further seen when the patient is told to phouate the vowel a broad. Then, the velum and uvula, instead of rising quickly to shut off the lower from the upper pharynx, I CHRONIC CATARRHAL INFLAMMATION. 383 will tail more or less to fultil this function. The uvula either hang-s loose and downward, (^uite relaxed, or it clings to one or the other side, on the edge of the velum. As the patient pho- nates, the uvula may slip from this position on the veluni and hang loosely downward, or it may curve forward or backward against the posterior wall of tlie })harynx. In such conditions, sudden eructation, coughing, or sneezing may at times produce pain in the ear. It is also very noticeable that the act of swal- lowing- cannot be performed rapidly by persons thus affected in the faucial muscles. Changes in the Voice. — With these alterations in the ear and throat, the vocal functions usually become weaker. The timbre of the voice is altered, and, if the patient has been a singer, the voice is found to be rapidly losing musical power. A kind of hoarseness sets in, when singing or prolonged conversation is attempted. The voice "breaks" or "cracks," and a general sense of fatigue in the throat becomes a prominent and distress- ing symptom. My observation leads me to conclude that all of these alterations in the throat usually begin to appear before the early morbid changes in the ear. The latter seems to become affected by a passing inward and upward of the nasal and throat-disease, through the tube into the tympanic cavity. When once there, a long series of nutrient changes begin, which, with varying symptoms, usually terminate in total deaf- ness; though in some cases chronic aural catarrh seems to stand still after having diminished, but not destroyed, the func- tion of the ear. A marked characteristic of chronic aural catarrh is not only to advance slowly and surely in one ear, but to pass to the other, sooner or later. The changing of the voice, i. e., the gradual assumption by the patient of a high and peculiar pitch in the voice in talking, will often aid in diagnosticating a chronic catarrhal alFection of the middle ear, even when the patient is sure that the aural malady is of sudden advent. "An explanation of the numerous symptoms of affections of the vocal organs, so often associated with aural disease, may be sought in the direct connection between the acoustic nucleus (b}' means of the acoustic trunk) and the probable centre of speech in the cortex of the island of Riel. On the other hand, it is important to bear in mind the anastomosis between the vagus and the petrosal ganglion of the glosso-pharyngeal nerve (tympanic plexus, tubal nerves) and the auricular branch of the pneumogastric nerve, which, in this instance, plays the part of a communicating link. During the insertion of a probe into the Eustachian tube of one possessed of good ears, pain is felt in the larynx when the probe reaches the isthmus. This is felt before the person operated on is aware of the presence of the 384 MIDDLE EAR. probe in the ear. In pericliondritis crico-arytenoidea there is always pain in the ear."^ Saissy relates that in the records of the Parisian Academy of Sciences for the year 1705, a singular case is accredited: "A young man, 20 years old, lost both hearing and speech after his larynx had been squeezed by a strong man, in a fight. All means tried for the restoration of hearing failed in this case."^ Objective Changes in the Eustachian Tube. — As may be inferred, from what has been already said in the preceding pages, the Eustachian tube, being lined with mucous membrane continuous with that of the fauces and of the tympanic cavity, and forming such an important part of the middle ear, undergoes serious and most important changes in chronic aural catarrh. These changes are due primarily to thickening of the lining of the tube, or to obstruction of its calibre by mucus. Hence arise very striking objective symptoms, which become apparent to the surgeon upon using the Valsalvan method of inflation, the Eustachian catheter, Politzer's inflation-bag, or bougies for dila- tation of the tube. To all of the processes of inflating the drum, and to the probe, the tube will offer more or less resist- ance ; in some rare instances the inflammatory process may have been so great as to cause an entire closure of the tube at the isthmus. Upon auscultation of a catarrhal ear, into which some air enters from the catheter, the sound perceived by the auscultator will reveal the presence of mucus in the Eustachian tube, or a narrowing of the same with perhaps a diminution of secretion. The first condition is found in the moist form; the latter sound, that of air rushing through a narrow and dry tube, is of course found in those cases in which the secretion is not in large amount, and in which the catarrh has led to a hypertrophic process throughout the mucous and submucous tract of the tube. These symptoms of obstruction, usually ascribed to the changes just named, are accounted for somewhat dififerently by Weber-Liel. This observer states that in many cases of asecre- tory catarrh of the middle ear, or, as he calls it, progressive hardness of hearing, the Eustachian tube is easily permeable to a bougie, but not to air by any ordinary means of inflation. The cause assigned for this obstruction to the entrance of air, is the relaxed condition of the muscular walls of the tube. So great is this relaxation, that the flaccid walls cannot be forced apart by any of the ordinary means of inflation. Be this as it ma}-, the cause of this muscular weakness, atrophy, or paresis, is, in my opinion, to be considered secondary 1 Weber-Liel, op. cit., p. 35. ^ Quoted by Weber-Liel, loc. cit. f CHRONIC CATARRHAL INFLAMMATION. 385 to the catarrhal inflammation. This is analogous to processes in other muscular structures underlying mucous membrane elsewhere in the body. Thus in the alimentary tract, muscular derangements are constantly found following close upon catar- rhal disease of its mucous lining; the same may be said of the bladder and of the lung. In all of these, a prominent symp- tomatic change, . following close upon inflammation of their mucous layer, is the want of proper contractility in the sub- jacent muscular structures. It would, therefore, seem much simpler to account for the symptoms of muscular derangement in the middle ear, afl:ected by chronic catarrh, in the same way as muscular alterations occurring in a chronically inflamed bronchus are explained. The mucous membrane of the nose, pharynx, and Eustachian tube may be not only greatly congested and swollen, but ex- tremely irritable, assuming almost an erectile nature. In such cases, merely smelling an irritating substance has been known to produce an instantaneous closure of the Eustachian tube, altered pressure in the tympanic cavity, deafness, and sudden , unconsciousness. i| Erhard^ mentions the case of a boy, whose nasal and Eusta- ehian mucous membrane possessed such peculiar irritability that upon applying his nose for an instant to a bottle containing sulphuric ether, all of the above sjmiptoms ensued, not only once, but repeatedly for many days in succession, whenever Erhard desired to demonstrate the case to his pupils. Upon inflating the tympana in this case, consciousness instantly re- turned. This case points unmistakably to a sudden closing of the tubes, a disturbed equilibrium in the membrana tympani, forcing inward of the chain of ossicles, pressure by this means on the lab vri nth-fluid, and thence to the cerebro-spinal fluid (pp. 138, 139). Adenoid Growths and Granulations in the Nasopharynx. — In a number of cases of chronic aural catarrh, there are found adenoid growths and granulations in the nasopharyngeal space. Their nature and the symptoms the}^ produce have been very carefully studied and described by Czermak, Tiirck, Semeleder, Voltolini, Lowenberg, and W. Meyer.^ These growths are described as benignant in nature, and more or less leaf-like or conical in their shape. They are usually situate quite high in the nasopharynx, are extremely delicate, and hence bleed on being touched. Their height or length rarely exceeds three cm., and their breadth or thickness varies from a few lines in the smallest to one or two centimetres in the ^ Outlines of Physical Otiatrics. Translation in Phila. Med. Times, Jan. 4, 1873. . » Archiv fiir Ohrenh., Bd. ii., N. F., S. 129 and 241. 25 386 MIDDLE EAR. ' largest. As might be supposed, such growths interfere not only with respiration and enunciation, but also with the normal l| ventilation of the Eustachian tubes and the tympana. The symptoms are a tendency to bleed whether touched or not, alteration in the pronunciation of certain vocal sounds, as i m, n, and ng, and a great change in the facial expression, from the falling in of the alse of the nose, and the respiration through the mouth, necessitated by the obstruction in the posterior part of the nares. The hearing, too, will in time become greatly lessened from the chronic stoppage in the Eustachian tubes, and the interference to the normal ventilation of the middle ears. The proportion of aural disease in persons thus affected in the nasopharynx has been placed by Meyer at 130 in 175. Although not uncommonly I find this condition of the naso- pharynx, the proportion is by no means similar to the above, a fact to be accounted for, very probably, by the milder climate of Philadelphia, Dr. Meyer having made his observations in the ^ high latitude of Copenhagen. A nasopharynx thus affected is apt to secrete large amounts of tough greenish mucus, the velum may be swollen, and the lower pharynx chronically inflamed. On the other hand, these growths may be present in the naso- pharynx without any marked accompanying changes in the f pharynx and velum. Not uncommonly, the altered enunciation, respiration, and facial expression arouse a suspicion of their presence, which is subsequently confirmed by rhinoscopic ex- amination, and manipulation with a probe or the finger, the latter causing the growths to bleed. Symptoms in the Eustachian Tube and Tympanum revealed by In- flation and Auscultation. — Unless there is total occlusion of the Eustachian tube, some air can be forced through it into the tympanic cavity in every case of chronic aural catarrh. To accomplish this, the methods employed ma}- be those known as Valsalva's and Politzer's, or that more direct one, with the catheter and hand-balloon. The sounds produced by forcing air jt into the drum-cavity are easily heard by means of the ausculta- tion-tube. These sounds, however, are greatly modified hy the means used to inflate the drum and by the condition of the Eustachian tube, and, very probably, of the tympanic cavity. In using the catheter it will be found that its calibre and the column of air forced through it, influence the pitch and quality of the sound heard on auscultation. For, the air passed through the catheter, like every column of air passing rapidly through a pipe, will produce in the latter its fundamental tone, dependent upon the length and diameter of the pipe. Hence, in a wide catheter, a fuller and deeper sound is heard ; in a narrower one, a whistling noise. Unless this is borne in mind, the quality of CHRONIC CATARRHAL INFLAMMATION. 387 the sound thus produced might be referred to the condition of the Eustachian tube. Having, therefore, found out, before the catheter is inserted, the general quality and pitch of the sound produced by forcing air' through it from the hand-balloon, the surgeon can, with advantage, study the sounds resulting from intlation of the tube and tymi)anic cavity by the catheter. These sounds will be found to be very different from those obtained even in the same ear by Valsalva's or Politzer's inflation. In the former, there is no instrument employed, which, of course, excludes any sounds from such a source ; in the latter, the instrument being so re- mote from the fauces, no sound produced in the hand-bag is j I conveyed into the middle ear and thence to the ear of the aus- cultator. In both of these latter methods of inflation, only the movements of the natural parts concerned and the thud of the entering air are perceived. In that respect they are certainly superior to the Eustachian catheter, since, by their use, the con- dition of the tube can often be determined without confusing sounds originating in the instrument. The catheter, however, is of the greatest aid and usefulness, if it be but remembered that the quality of the sound made by the air forced into the tube, is influenced by the calibre of the instrument. Air forced into the normal Eustachian tube and middle ear by artiticial means, conveys to the auscultator the impression of air passing with freedom through an unimpeded tube. When the methods of Valsalva or Politzer are used, the air enters with a thud, the ear seems to have been filled by the air sent in, and the impulse thus conveyed upon the membrana tympani reveals itself most distinctly to the ear of the auscultator, joined to the ear of the one operated on, by means of a rubber tube. Auscultation by the same means, applied to an ear the Eusta- chian tube of which is narrowed or clogged by the products of chronic inflammation, reveals a diflerent physical condition of the ventilating apparatus of the tympanic cavity. If mucus is present, bubbling sounds will be heard ; if the tube is dry, then, of course, a dry sound. At the same time the tube seems nar- rowed, for the quality of the sound made by the air inflated is that of air passing through a narrow tube. Air inflated through a normal Eustachian tube enters inde- pendently of the act of swallowing ; in the tube narrowed or altered by chronic catarrhal inflammation, this act on the patient's part aids greatly in the artiticial ventilation of the drum-cavity. So resisting is the diseased Eustachian tube to ventilation, that in some cases air can be forced through only during swallowing. This latter condition is highly character- istic of alteration in the tube. 388 MIDDLE EAR. The Objective Effects of Ivflatwn upon the 3Iembrana Tj/mpani. — The efl'ects of iutiatioii upon the membraiia tympani are among the most important objective sjmiptoms. In some respects they have been duly considered, but there are some signs which are deserving of special notice. During Valsalva's inflation the surgeon can inspect the drum-head and the eflects produced on it by the motions of the contents of the tympanic cavity. He can also inspect the membrana during Politzer's inflation, if he stand beside the patient and illuminate the previously well- placed speculum, by the forehead-mirror. More or less bulging of the drum-head will be caused by inflation. If the handle of the malleus is held retracted, by alteration in the mobility of the tendon of the tensor tympani, this bulging of the membrane will occur behind and before the manubrium ; but if the manu- brium is not held in, as above suggested, then it and the mem- brane will be moved more or less as a whole. At the same time, if there is movable fluid in the cavity of the drum, it will be forced against the membrana tympani and modify the picture presented to the observer. Bubbles may be seen then distinctly through the membrane, or inspissated secretion may be found to change position in the drum. A most interesting and instructive change, produced by in- flation, in the appearance of the drum-head, is the forcing out- ward of depressed spots or cicatrices. Unless this symptom is sought for, and promptly noted after the air is forced into the tympanum, it may escape notice. Very often depressed cicatrices are considered retractions adherent to the inner tympanic wall, but on inflation these de- pressions may not only return to the plane of the rest of the drum-head, but not uncommonly they project beyond it, into the auditory canal, forming thus bladder- or blister-like spots. In some cases these are filled only with air ; in other cases, in fact often, the}' are tilled with brownish fluid, which will give them an amber tint. IN^ot only will these appearances come out on the drum-head by inflation, but they can be produced very easily under suction by Siegle's speculum. This latter method of examination of the drum-head is of the greatest value, for, when the tube is stopped up and absolutely impervious to air, the pneumatic speculum or its equivalent becomes the only means of producing movements in the drum- head, and secondarily of the contents of the drum-cavity. Not uncommonly inflation of the tympanic cavity, especially by Valsalva's or Politzer's method, produces objective sounds, readily audible without the aid of the auscultation-tube. Es- pecially is this observable when the entire drum-head is flaccid and easily moved to and fro, or when, in a comparatively nor- mally tense membrane, flaccid scars are found. CHItONIC CATARRHAL INFLAMMATION. 389 The sound [jroduccd in either instance is that of a loose crack- ling and tlapping of the Haceid tissue. In a case recently ob- served, so loud was this flapping-sound that it was heard across ' ' a .large room, not only during Valsalva's method of inflation, but also during rapid breathing through the congested nares, the mouth being kept closed. Causes of Chronic Catarrh of the Middle Ear. — Very few patients can assign a satisfactory cause for their disease. In fact, it is not an eas}' task for the physician to discover the positive I cause for chronic aural catarrh in the majority of cases. It does seem that very often chronic catarrh of the middle ear is caused by chronic coryza. It would be safer, in most cases, to say that f chronic aural catarrh is found associated with, rather than pro- duced by, certain diseases; though the latter may have much to do in its ao-o-ravation and chronicitv. Thus, chronic catarrh of the ear is frequently observed joined with chronic catarrhal disease of the mucous membrane elsewhere; phthisis; grief and weeping; nursing the sick, especially by night, with loss of sleep ; progressive locomotor ataxia; sciatica; general neu- ralgia, but especially neuralgia of the fifth nerve; insanity; intemperance and debauchery. It may also be found following close upon pregnancy, the menopause, uterine diseases, continued fevers, any of the eruptive fevers, mumps, great shock after frac- ture of limbs, sedentary life, rheumatism, gout, and, perhaps, secondary syphilis. Syphilitic Disease in the Middle Ear. — In some instances syphilis apparently causes well-marked changes in the middle ear, which alterations have been very erroneously referred to the nerve- structures of the internal ear, especially to the cochlea. There are many more reasons for placing these apparently sy[)hilitic chano;es in the tissues of the middle ear, the conductive tunc- tions of which we are acquainted with, than in the labyrinthine and nervous structures, of the mechanism of which physiologists know noi-hing positive. These cases of syphilitic deafness, due to change in the middle ear, are characterized by the sudden- ness and profundity of the hardness of hearing, as shown by the following case : (3n November 16, 1880, Mr. F., 28 years old, a barkeeper in AVilliamsport, Pa., consulted me at the suggestion of Dr. Nutt, of that city. The patient stated that about four months pre- vious, after going to bed as usual, with perfect hearing in both ears, he got up the next morning deaf in his right ear, which " had roared like a sea-shell," and been deaf ever since. lie was a large, fine-looking man, with light hair, fair, rosy com|)lexion, and apparently in perfect health. He admitted having had syphilis and gonorrhoea some years previous. He denied having ever had any cutaneous eruptions or sore eyes. He had been married 390 MIDDLE EAE. 4. five years to a healthy woman, but she had never borne children. His phj^sician wrote me that on account of syphilis in this man he had given him iodide of potash and bichloride of mercury, which he was still takino; when he consulted the w^riter. But the hearing had not improved under its use. Further examination of this case showed that the tuning-fork, vibrating on the vertex, was said to be heard equally well in both ears ; that the voice was heard normally in the left ear, but only in close proximity to the right ear, and probably through the bones of the head. The Eustachian catheter, however, re- vealed on the right side a perfectly and easily inflatable Eus- tachian tube. An examination of the mouth and fauces re- vealed no abnormal condition, excepting two siispidous red warts on the velum, to the left of the uvula. The examination of the right ear revealed a very red fundus of the auditory canal and a deeply congested flaccid membrane and manubrium. While this con- gestion may have been due to the presence of a firmly wedged plug of cotton which the patient had long worn in the afiected ear, it should be borne in mind that both Bumstead and Sexton^ have noted such congestion as a symptom in syphilitic ear disease. In addition, the history of syphilis, with the presence of spe- cific warts on the velum, and the sterility of the patient and his wife, together with the sudden, profound, and permanent deaf- ness, without any very definite reasons purely aural, would tend to place this case among those of syphilitic deafness. The two great questions in such a case are: Where is the lesion ? and, What is its form ? As the Eustachian tube was perfectly and very easily inflatable by the catheter, and showed no signs of having ever been mor- bidly closed, we are forced to look elsewhere for the cause of deafness. As the tuning-fork on the vertex was heard in the afiected ear, we cannot place the lesion in the labyrinth ; we are forced to locate it in the middle ear. In endeavoring to determine its nature, we must recall the tendency to the formation, in this man, of papilloma or granu- loma as shown by the peculiar warts on the velum. In fact, in this case one is strongly reminded of the explanation of similar afiections given by Dr, Sexton in the paper quoted, " that it may be surmised that granuloma, or circumscribed, small, round- cell-inflltration takes place within the tympanum, that the invasion is rapid, and that it prevents by fixation the conductive appa- ratus from its normal movements." This case seems so well marked in its peculiar features as to warrant its being placed among the syphilitic diseases of the ^ See paper by Dr. Sexton: Ainer. Journal of Otology, vol. ii. p. 301, 1880. II CHRONIC CATAKKHAL INFL A M M ATIOX . 391 middle ear, a class which Dr. Albert II. Buck proposes to place as class first, in his categ'ory of specific cases.' In this country, within the last few years, I have observed a number of cases of chronic aural catarrh traceable to exposure by sleeping on the ground, while in the field as soldiers during the recent war. Anglo-Saxons born in tropical countries, as well as those whose parents are, one an Anglo-Saxon, the other a native of a tropical region, seem specially liable to chronic aural catarrh. This has been remarked by Hinton, of London, who had large opportunity of seeing such cases among the English with con- nections in India. In our country I have observed such a ten- dency in children born of Anglo-Saxons and Mexicans in Mexico and South America. In these cases Hinton has observed a thinning of the mem- brana tympani in its posterior segment. In a few cases I have seen, a similar condition of the drum-head was noted. I have observed a number of eases of chronic catarrhal deafness in young women from eighteen to thirty years of age, associated with, and apparently caused by, ozaena and menstrual irregu- larities ; according to my experience, ozasna is more frequent in girls and women than in men. Hunting, which often brings with it a wetting, and especially duck-shooting, seems to be a cause of chronic aural catarrh in men. Also, diving and ducking the head in cold water most surely produce a thickening of the drum-head and lead at last to a chronic catarrhal state of the tympanic cavity. Mill-hands of both sexes are specially liable to chronic catarrh of the middle ear; as also are carpenters, boiler-makers, and female domestics. In the first class, the noise, the confinement of the work, and the dust certainly tend to produce catarrh of the air-passages, general dcbilitv, and aural disease. Carpenters are constantly exposed to the varying temperatures around a new building; the latter cause, added to their liability to perspire and the fact that they are generally insufl[iciently clad, makes them very often the victims of aural disease. Boilermakers' and telegraph operators' deafness may be partly due to nervous exhaustion from continuous shock, but chiefiy it is dependent upon catarrhal disease. Female domestics, and women forced to do their own house- work, are constantly exposed to great changes in temperature, because their labor takes them one moment to the hot kitchen and the next moment to the cold court or roof to hang up wet clothes, or from cooking in the house to scrubbing in the open air. To these facts may be added that such women are usually 1 American Journal of Otology, vol. i. p. 29, 1879. CHAPTEE III. TREATMENT OF GHROXIC CATARRHAL INFLAMMATION. In treating chronic catarrh of the middle ear, the particular form presenting itself, either the moist or the dry, must be kept sharply in mind. It is very evident that grave mistakes have been made in applying empirically one form of treatment, steam, for example, to every case of hardness of hearing which could be attributed in any way to chronic catarrh. A moment's re- 892 MIDDLE EAR. found in damp skirts, and when they rest for a moment it is usually without any covering for the head, at the front door or at a window, in a draught. These are some of the more manifest causes ; there are other i causes assigned by patients, but these are mostly fanciful. Since, however, some of these causes have been given by really intelli- gent people, it may be well to cite a few : thus, a lady informed me that her deafness, markedly catarrhal, was ushered in by a hasty journey to Europe and back again to America. Two persons of intelligence have assured me that they became deaf in Switzerland, as the}" thought, from the chilly air, and the damp rooms of hotels. Others attribute their hardness of hearing to blows on or about the ear, excessive night study, editorial work, and sudden noises near the ear, as of firing guns, etc. The latter cause very frequently produces an injury of the labyrinth, but it, like many of the causes given by patients, has only served to call attention to an ear already diseased by chronic catarrh. In some cases vo reason. is given; it seems that the patients in such cases have been growing deaf so long that they have become used to it. This is specially noticeable in children who have become deaf, or in adults who became chronically deaf while children. One might suppose that deafness for which no cause is as- signed, would be found in neglected children of the poor. But I have been surprised to find that children of the rich and educated — children well cared for — are frequenth' plg-ced under treatment for hardness of hearing for which no reason is given by the parents, nor can the latter be assisted by the surgeon in recalling any probable cause. These cases are almost invariably found in families having, apparently, an hereditary tendency to deafness. TREATMENT OF CHRONIC CATARRH. 393 tieetion would surely show the folly of usino- such a remedy in ii case of moist catarrh. On the other hand, some such relaxiuij; or softenino- means may be of value in the dry and sclerotic forms of catarrhal deafness. The treatment of any case of chronic catarrh of the ear re- solves itself very quickly into the question, What will restore the middle ear to its normal condition of containino; air and conducting sound? The answer to this will depend upon the power to decide, whether the interference to hearing is due to an excess of secretion in any part of the mucous lining of the middle ear, or to an absence of such a secretion combined with the thickening, stiffening, or drying of any or all the parts concerned in conducting sound. With this divergence in form, or in these different stages if you will, comes a vast diver- gence in treatment. And, at the outset, it must be confessed that treatment applied to the moist, secretory forms is far more satisfactory to patient and physician than that applied to the so-called dry, ascretory, "proliferous," "chronically thickened," or " anchylosed " forms. Doubtless, many cases have been placed in the latter category, that of the dry form, which really should have been placed in the former class. Among recent authors, Mr. James Hinton, of London, has shown, that a large number of cases formerly diagnosticated as purely dry chronic catarrh of the middle ear, are really cases of inspissated accumulations in the tympanic cavity, and by their removal hearing is restored. Of course, those cases in which masses of fluid behind the drum- head cause the latter to bulge, have long been recognized by aurists, but Hinton, Schwartze, and Weber-Liel claim that man}- cases of what was once called hopeless thickening and hardening of the drum and its contents, are really very remediable ex- amples of simply hardened old secretions in the drum. With- out doubt such is sometimes but not often the case ; the great obstacle in the way of their successful treatment is the impossi- bility of always diagnosticating them. The more fluid these "old accumulations are, the more readily are they recognized; the older and harder they are, the more difficult they are of recognition through the drum-head. Omsfjtidional Remedies and H^iqkne. — Constitutional remedies are of the greatest value in the treatment of chronic aural catarrh. They are most efficient when chosen from 'the list of so-called alterative medicines or alterative tonics. The prefer- able drugs are, perhaps, iodide of iron, iodide of potassium, and bichloride of mercurj^ These are especially adapted to the cases presenting strumous features, glandular enlargements, and the decidedl}- secretory characteristics. In the dry form, I have obtained the best effects by using iron and strychnia, and the combination found most desirable is wine of iron Avith strychnia 394 MIDDLE EAR. . (gr. ss-j to f5iv). The dose of such a mixture should be a tea- spoonful thrice daily. For some time past, internal remedies have fallen into disuse in the treatment of chronic aural diseases; but lately, it has seemed best to return to them, fully aware that they are not to be relied on for all the aid needed, but as admirable adjuvants to the local treatment. Mr. Hinton has advised^ the giving of perehloride of mercury ; this he has given in doses of -^ or ^l gr. two or three times a day, with the perehloride of iron, and lie believes this combination is often useful in the dry or pro- liferous form. Applications to the Nares, Nasopharynx, and Throat. — Medicated applications to the nares, nasopharjnix, and fauces are of great importance in the treatment of chronic aural catarrh. From what has been said elsewhere, it will be seen that from the nature of the origin of this disease in many instances, treat- ment of the parts just named would be indicated. In b}' far the vast majority of cases of chronic catarrh, more benelit is derived from the proper treatment of the nares and pharynx than from direct medication of the tympanum. The latter is probably not as often reached by injections aimed at it as is supposed, and, if reached by such substances, is probably more frequently injured than not. In ever}^ case of chronic aural catarrh, the lesion in the tympanum either has been, or still is due to want of air in the cavity. This, of course, has been due chiefly to the occlusion, either temporary or permanent, of the Eustachian tube. Such being the case, the treatment must aim either at the removal of this obstruction to ventilation of the tympanum, or to its effects. The latter may have obtained so long as to be irremediable, but the first aim in the treatment should be to restore the tube to its physical function as conveyer of air to the tympanum, and endeavor to check the advance of the disease. There are, however, some cases of chronic catarrh of the middle ear, in which the Eustachiau tube is found to be per- vious, both to natural and artificial inflation, and yet the hear- ing is much impaired. In these cases it will be found that the lining membrane of the tympanum has undergone a change, mostly a thickening, or that the conductors of sound in the tympanic cavity have become stiffened by the chronic disease in the mucous membrane. Although the tube is found pervious in these cases when ex- amined by the surgeon for the first time, there must have been a period in the history of the process when the tube was stopped up and thus aided in bringing about the condition of the drum- cavity just mentioned. 1 Op. cit., p. 243. TREATMENT. OF CHRONIC CATARRH. 395 Tt may be said, therefore, that these two chief forms, viz., {a) a cUisecl tube with an empty tym[)anum, and {/>) the pervious tube with a sclerotic tympanum, are classes into which chronic aural catarrh may be placed. A third class (c) ma}' also be found in which inspissated matter is retained in the tymi)anum, because the tube is closed. If iluids ever can be or shouhl be thrown into the tympanic cavity, the class c would aftbrd the proper occasion. Direct Mcdicafion of the Nares and Nasopharynx. — Direct medi- cation of the nares and nasopharynx ma\' be best accomplished by instillations, by applications conveyed into these parts, on cotton twisted fast to the end of a cotton-holder, and by sprays. Instillations into the nares may be entrusted to the patient, and form a valuable adjuvant to the local treatment by other means, carried out by the surgeon. In this manner from three to five drops once or twice daily may be dropped into the patient's nostrils by himself or an assistant. All aqueous solutions must be warmed before they are instilled into the nose. If only one nostril, and the tube and ear on that side are affected, the treat- ment may be limited to that side. The solutions best adapted for instillation are Dobell's solution,^ chlorate of potash (gr. iv to foj water), solution of sulphate of zinc (one grain), or sulpho- carbolate of zinc (gr. v to f .^j water), and weak solutions of nitrate of silver (one-half to one grain to the ounce of water). Fluid cosmoline, alone or combined with boric acid (four grains to the ounce), is also an efficient and agreeable preparation for instillation. It need not be warmed. The hypertrophied mucous membrane of the turbinated bones, especially that of the inferior turbinated bone, may be touched with a mixture of iodine and glycerine in equal parts, or with the compound iodine mixture, composed of potass, iodidi 0.50 grammes, tinct. iodinii 5.00 grammes, aq. destill. 10.00 grammes. These aflected parts may also be touched with solutions of nitrate of silver, 1 to 5 grains to the fluidounce of water. When the anterior hypertrophies of the turbinated bones are to be touched, the nostrils must be dilated either by Kramer's speculum, or by a short hard-rubber nasal-speculum very similar to a W'ide, short aural-speculum. The latter remains in position by itself; the former must be held by the surgeon. The illumi- nation should be by the forehead-mirror. The medication to be applied is then conveyed to the anterior hypertrophy, or it may be carried along the entire length of the inferior turbinated bone to the posterior part of it, or to the posterior pharyngeal wall. Care should be taken not to touch the under ^ Dobell's solution consists of so(1;l' bibor. unci soclaj bicarb., aa gr. ij ; acid carbol. S^- J ) glycerinae f ^j ; and aquae f .^j. 396 MIDDLE EAR. I edge of the turbinated bone, nor the floor of the nose, as these!' parts are very sensitive. Hence the cotton-dossil must not bef dripping, nor too Uirge. Neither must it be soaked, for in that! case, if it is squeezed, excess of fluid will fall from it upon these !. sensitive parts, as it is passed or pressed upon the less sensitive side of the turbinated bone. In all forms of medication of the ' nares, nasopharynx, Eustachian tubes, and fauces the prime; consideration is not to irritate. If the surgeon cannot cure, he: must, at least, be careful to make no worse. Arrest disease, benefit the hearing if possible, but be careful not to retard nor to make worse chronic catarrhal processes in the nose and ear. '' I must refer to purely rhinological sources for directions forj treatment of posterior hypertrophies of the turbinated bones, -, adenoid growths, polypi of the nose, and major operations on '^ the nasopharynx. Hand-atomizer. — One of the most convenient, efficient, agree- i able, and, at the same time, one of the safest ways of applying' medication to the nares and nasopharynx is b}- means of the ' hand-atomizer. With this instrument the surgeon may convey into the diseased cavities of the nose and pharynx in the simple , rhinitis, which so often accompanies and promotes chronic aural catarrh, the spray of the following mixtures: ^^ R. — Zinci sulphocarbolat., gr. v. > Listerine (Lambert's), f^ij. Aqiuv. fgvj. — M. Or, R. — Zinci iodidi, gr. v. , Listerine (Lambert's), fgij. Aqua?, f jvj. — M. If there is any accumulation of mucus which the patient is not able to remove by blowing his nose, the nares may be sprayed with the following: R. — Sodfe bicarb., Sodffi bibor., aii ,^ss. Listerine (Lambert's), f3J. Aquae, f ^iij. — M. The spray of the distillate of hamamelis will be found agree- able and efficient in acute rhinitis, as well as the spray of, Dobell's solution. In the more chronic and hypertrophic forms of rhinitis, the spray of the following mixture will be found very efficient: iR. — lodinii cryst., gr. iv. Potass, iodidi, gr. x. Zinci iodidi, Zinci sulpbocarbol., aii 9,]- Listerine, t\^j. Aqua\ f .oiii- 1 Dr. Letterts, Phila. Med. News, May 3, 1884. TREATMENT OF CHRONIC CATARRH. 397 The local applications, as here set forth, may be made bv the ( surgeon two or three times a week. They should be followed bv inflations of the tympana by Politzer's method, or by tlie Kustachian catheter. These applications may be supplemented by instillations into the nose, by the patient at home. When iodine preparations are applied to the nares, by means of the cotton-holder, the sprays should be thrown into the nose thereafter. Irrigation of the Nasophar)/)ix by means of the Nasal Douche. — Any form of irrigation applied to the nasopharyx may be called a nasal douche. But this name is specially applied to an instru- ; nient devised by E. H. Weber, during his physiological studies on the velum and pharynx. I It consists of a bottle to the lower part of the side of which a I hose is attached. The latter has a nose-piece, best made of glass, olive-shaped,^which fits snugly into one nostril. In this country and in England, such an instrument is usually called Thudicum's nasal douche, after him who introduced it to the notice of the profession in the latter country. It is, without doubt, the best means surgery possesses of irrigating the nares and nasopharynx. Accidents to the ear have happened by improper use of the nasal douche. When it is carefully and correctly applied, however, I do not know that water has ever been forced by it into the middle ear. The use of the nasal douche should be limited, however, to the treatment of ozaena, or fetid nasal catarrh, and to irrigation of these parts after operations on them. The following rules will be found to give the greatest assur- ance of safety, if most strictly adhered to. And, so far as I have observed, no accident has ever happened where they have been fully observed: 1. The vessel containing the fluid to be injected must not be higher than the forehead of the patient. 2. The forehead must not be inclined forward too greatly, for if it be, the fluid enters the frontal sinuses; nor must the head be thrown backward. The upright position is the only safe one. If 8. The fluid used in each case must be tepid, and in bad weather the patient should not leave the room for a quarter of an hour after the use of the douche. The discovery of the nasal douche is attributed to E. H. Weber, while he was making his experiments on the organs of smell. According to Dr. Seyfert,^ Theodore Weber, of Halle, was the first to utilize the fact that a stream of water passed through one nostril will escape through the other, after passing ^ Ueber die vielfaclie Anwendung des Irrigationsapparats. Wiener Med. Presse, Nos. 33, 34, 36, 1872. 398 MIDDLE EAE. I through the nasopharyngeal space. This is due to the well- ' known reflex action of the velum palati, which causes it to ' retract and shut off the nasopharynx from the pharynx. ! A universal mistake of physicians and patients is to place the L vessel holding the fluid at a verj^ great height above the head. '' The surface of the fluid in the douche-bottle must have only i" that elevation above the nose sufficient to carry the irrigation into the nasopharynx. If the vessel is held or placed higher ' than this, it is plain that the fluid used may be forced too high, ' •even into the frontal sinuses and tympana. Before the nasal douche is used by the patient, the surgeon i' should satisfy himself that there are no obstructions to the ; passage of the water through either nostril. An obstacle to the '■ return current of the irrigating stream would be just as danger- ' OU8 as too high a position of the source. Patients often ask how much fluid they ,are to use in the ■ douche, and how long the current should be allowed to flow ' through the nares without being interrupted ? To the first ques- ' tion, it may be said that half a pint is enough to begin the use of the douche with; the amount can be increased gradually as • the patient becomes better practised in the use of the instru- ' ment. The second question is more important, and to it the reply may be given that at first the current must run but a short i time through the nares wrthout interruption, say during the short holding of the breath. Gradually the patient learns to ' breathe comfortably through the mouth, while the current of water runs through the nares. When proficiency in this respect has been attained, perhaps an entire pint or even more may be run through the nostrils and nasopharynx without interruption. But at the outset of the emploj^ment of this apparatus, the patient must be told of the importance to him of not gasping or gulping during the operation. The latter, danger is most easily ;' avoided by allowing the current of fluid to run through the nares only as long as the patient can quite comfortably hold his breath. In the warm water used in the douche, all that will be most ' usually necessary at first will be common table-salt, in the pro- portion of 56 grains to the pint of fluid. In many instances I have found it very beneflcial to use a preparation of salt known , as "sea-salt." This is said to be the result of evaporation of sea-water; it surely is stronger to the taste than common table- salt, and doubtless contains more haloid elements. In ozsena, in addition to the common salt, a few drops of a strong solution of permanganate of potash may be thrown into the water, until the latter becomes impregnated with it. A thirty-grain solution of this drug may be written for, and the r patient instructed to use about 10 to 20 drops to the pint of II TREATMENT OF CHRONIC CATARRH, 399 water. The use of a nasal synnge is entirely reprehensible, from the uuccr- taintv of its pressure, even in the sur- geon's hand. Applica/ions to the Eastnchkin Tube. — In most cases of swelling and narrowing of the Eustachian tube, the use of intiation simply will be quite sufficient to over- come the obstacle. If, however, after the catheter is known to be properly placed in the mouth of the tube, no air is forced into the tympanum, the tube may be con- sidered occluded, and resort may be had to the careful use of a probe of catgut, lami- uaria, or whalebone. Perhaps the most desirable form of bougie for this purpose is the small catheter-bougie of Weber- Liel; it is best emplo3'ed with a gradu- ated catheter devised to go with it. All bougies or probes, for use in the Eusta- chian catheter and tube, should first be fitted into the catheter, and marked at two points, on that end nearest the sur- geon. The first point should correspond to the exact length of the catheter used, which will indicate when the distal end of the probe is about to leave the beak of the catheter and enter the tube; the second point should be as distant from the first as the length of the amount of probe it is desired to push into the tube. This may vary from one to one and a half inches. Inflation should be done as thoroughly as possible before the probe is inserted, never afterwards, for fear of emphysema. Even the most gentle ma- nipulation may al)rade a diseased mucous membrane, and then an inflation might produce the above-named complication. Various applications have been advised and made to the mucous lining of the Eustachian tube, in order to allay chronic inflammation. In most cases they do more harm than good; beyond weak so- lutions of bicarbonate of soda (gr. v-f.5J), and sulphate of zinc (gr. ,i-f.lj), all injec- tions into the Eustachian tube are of risk. Steam is not to be considered anything more than useless; it is not harmful, un- less carelessly applied, when the j)atient may be scalded. Fig. 89. Weber-Liel's graduated metallic Eus catheter A., for passage of the small catheter of gummed silk B. 400 MIDDLE EAR. In all cases, the fluid injected either into the mouth, or^ further into the calibre of the tube, should be warmed. Great benefit may result from making various applications to the mouth of the tube, but no further inward, in chronic catarrh of the middle ear. In this way, applications to the nares and nasopharynx act in this disease. Much good may be thus done by touching the faucial region of the tube with nitrate of silver in solution, or the various solutions named on p. 395. In order to accomplish this, the medication may be applied along the inferior turbinated bone until the posterior pharyngeal wall is touched, or an aluminium cotton-holder, such as is found in all surgical instrument-makers' shops, may be made to gently and cautiously carry up behind the velum the fluid to be applied. The point of the probe in the latter method may be directed toward either tube, or, if both tubal mouths are to be touched, the probe may be held in the median line, behind the velum. Then the natural reflex action of the pharyngeal and palatal muscles will tend to bring the mouths of the tubes toward each other and the probe, lying in the median line. Such a mode of application is especially necessary when granulations or ulcers exist in the nasopharyngeal space. Such a condition may exist without any marked disease in the pharynx below the velum. Sometimes the first real indication of its existence is obtained by the blood found on the cotton-tuffc at the end of the probe when it is withdrawn from the nasophar3'nx. The treatment of adenoid and polypoid growths should con- sist in their evulsion or cauterization, and in subsequent appli- cations of astringents to the nasopharyngeal space. The mechanical destruction of these formations, however, is painful and inconvenient, while their cauterization is simple, and in most cases all that is needed. It has been proposed by Dr. Meyer,^ to crush and tear these adenoid bodies by means of an instrument, somewhat like a lithotrite, to be introduced through the nares. An index-finger of the surgeon is to be inserted at the same time through the mouth and behind the velum, so as to direct these growths between the prongs of the crushing implement. But in many cases it will be necessary only to wound these growths with the finger, or a probe armed with a large tuft of cotton, and then apply a solution of nitrate of silver to the nasopharynx, by means of the last-named instrument. After the application of silver, which may be in strength varying from 10-20-30 gr. to fSj of water, astringent, demulcent, or detergent solutions may be employed by means of the atomizer or nasal douche. Salt and water, in the proportion of fifty-six grains of the former to a ' Archiv f. Ohrcnh., Bd. ix. TREATMENT OF CHRONIC CATARRH. 401 pint of the latter, will usiuillv be all that is required utter the use of nitrate of silver, but if a stronger tiuitl appears to be demanded, sulphate of zine, in the strength of gr. i-ij to f.T,j of water, may be used, and, if there is an offensive odor to the dis- charge from the nares, solutions of permanganate of potash may be employed as already directed (p. 398). Politzer' finds that in cases of adenoid growths in the naso- pharynx, which bring about swelling and closure of the mouth of the Eustachian tube and hardness of hearing, touching the afl'ected parts with nitrate of silver is more effectual than cutting or dragging away the new growths. Excision of the Toisils. — This operation I consider rarely, if ever, necessary for the relief of hardness of hearing or deafness, simr)lv because the altered function of hearing is in no wav de- pendent on the tonsillar enlargement. The larger tonsil is often on the side of the better ear; some- times on the side of a perfectly normal ear, and very often enlarged tonsils are found in those with perfect hearing. When enlargement of the tonsils is associated with deafness, they are to be regarded simply as symptoms of a catarrhal con- dition which has also brought about alteration in the glandular structures of the nasopharynx. Eustachian tube, and in the middle ear. Their violent excision (and excision is always nolent) is worse than useless — it is positively harmful and always alarming. I am furthermore convinced of the futility of excision of the tonsils for hardness of hearing, because the largest tonsils I have seen were the successors of excised ones. Thev might almost be re2:arded as recidives of a morbid growth, like those succeed- ing fibrous tumors of the lobule. The remedies for the other catarrhal symptoms are usually beneficial to the enlarged tonsils. Clipping the Uvula. — In some instances an elongated uvula keeps up a constant irritation of the fauces and posterior wall of the pharynx, thus contributing to an aggravation of an aural catarrh. AH that is required in such cases is to clip off the re- dundant mucous membrane, carefully avoiding an ablation of the muscular part of this important appendage to the velum. A removal of such a fold of mucous membrane is generally stimulation sufficient to excite the rest of the uvula to contrac- tion. The entire removal of the uvula is as reprehensible as it is common. Gargles alone will often contract the uvula. Gargles. — One of the simplest and best gargles in the pharyn- gitis which usually attends chronic aural catarrh, is a saturated solution of chlorate of potash. Another highly useful and ' Zur Therapie der mit adenoiden Yegetationen im Rachenraum complicirten 26 Erkrankungen'des Mittelohrs. Archiv f. 0., Band x. S 402 MIDDLE EAR. more astringent one, is the rhus glabrum gargle, as prepared ! by H. C. Blair's Sons, of Philadelphia. Its formula is: R. — Potass, chloratis, ^ij. Ext. fl. rheos glabri, Glycerinse, aa f^j. Aqua?, f^^vj. — M. Another very elegant gargle is prepared by Saj-re, of Phila- delphia, as follows : B . — Glycerite of sumach, Tinct. pomegranate bark, aa f3iv. Infus. rosa." comp., q. s. f. Oj. The usefulness of gargling consists, not only in healing the mucous surfaces, but also in the gymnastic elfect on the velum and muscular structures of the Eustachian tube, which it brings about. A'pplications to the Cavity of the Drum. — That which was said against applications to the cavity of the Eustachian tube maybe repeated here. Few applications which are aimed at the tym- panic cavity ever reach it. If they did, they would probably do more harm than good. To render the Eustachian tube pervious to air, and hence to ventilate the drum-cavity, is more important than to inject tluids into it, unless, the membrana tympani being perforated by disease, a means of escape of medicated fluids is afforded. Vapors of iodine, ether, or chloroform may be of assistance in stimulating a delicate but diseased mucous lining, but it would be just as wise to fill, with a fluid, an air-vesicle in the lung by the way of a bronchial tube, as to till up the tympanum, if one could, by injecting fluids through the Eustachian tube, iu chronic aural catarrh, unless there is evidence of inspissation of mucus in the drum-cavity. In such cases, weak and warm solutions of bicarbonate of soda (3-5 gr. to f.Sj) are of service. But even with these, great caution must be observed. In all cases in which injections thus directed have apparently produced good results, I have felt inclined to ascribe the benetit to the gentle stimulation and ventilation of the Eustachian tube, rather than to the direct contact of the injected fluid with the cavity of the drum. The latter is an air cavity, and resents the pres- ence of medicating fluid. Operations with tfie Knife on the Drum-head. — AVhen it has been found impossible to send into the tympanum as much air as seemed demanded, resort has been had to the knife. And the mere incision, with the subsequent admission of air to the drum, has had much more to do with the good result than the choice of the particular spot of the operation. This is proven- by the It TREATMENT OF CHRONIC CATARRH. 403 well-known fact, that, no matter where the perforation is made, the hearing, which at first has been increased, has diminished as soon as the opening in the drum healed. And this, as every surgeon knows, occurs sometimes even in a few hours. Space forbids my entering upon the history of cutting opera- tions on and through the drum-head. The proposal of the operation of cutting through the mem- brana tympani is supposed to have originated with Johannes Eiolanus, of Paris, in 1650 ; Sir Astley Cooper, one hundred and lifty years later, performed the operation in several cases, with apparent success, but subsequent]}' abandoned it on account of his want of encouragement. About sevcnty-tive years before Sir Astley Cooper's operations on the drum-head of man, Cheselden perforated the drum-heads of dogs, and believed that the latter were not only not made deaf by it, but that they he- came more sensitive to some sounds. In the latter part oi" the eighteenth centurj', the operation appears to have fallen into the hands of quacks, and to have been disregarded by the regular practitioners : a reaction too often found when the latter, in ™ their enthusiasm, make use of an operation in a multitude of !§^ cases, whether suitable or not. The indications for the operation had been very vaguely given up to 1800, when Himly in Germany, and Sir Astley Cooper in England, proposed to make use of the operation of perforation of the drum-head in closure of the Eustachian tube. Cooper operated in a number of cases, with a variable success; but as he operated rather empirically, simply for deafness arising from closure of the Eustachian tube, a condition he does not seem to have been fully able to diagnosticate, he soon ceased to obtain results as good as those he first appeared to have ob- tained, and he then abandoned the operation entirely. Again, the unfortunate reaction in the minds of the regular profession, and naturally enough, again the operation is found almost en- tirely in the hands of quacks, with not only no good results, but apparently most disastrous ones. Himly showed that the opera- ■i^tion, when it had proven of benefit, was in exceptional cases of deafness due to hermetical closure of the Eustachian tube. But the operation ceased to be regarded with favor, because it had been widely and ignorantly applied; and Wilde is found obliged to speak in defence of the operation, since some had condemned it as dangerous to life — which, however, they could not prove. It at last became fully established by the operations of Cooper, Itard, Saunders, Schwartze, Hinton, Politzer, and others, that it is highly necessary and entirely safe, to perforate the membrane of the drum, in order to remove from the drum-cavity any fluid or semi-solid accumulation, which cannot escape or be forced out in any other way. 404 MIDDLE EAR. But, as a great demand has ever been, and still is, made on the aurist for relief from chronic, neglected catarrh of the middle ear, without fluid accumulations in the latter, but with every symptom of sclerosis and retraction of the membrana tympani and even of deeper parts of the sound-conducting appa- ratus, assistance has been sought in various forms of incision and excision of the membrana tympani ; in the maintenance of permanent perforations in it; and in tenotomy of the tensor tympani muscle. Various forms of incision and excision of the membrana tympani for the relief of hardness of hearing not dependent on accumulations of ftidd in the tympanum, but upon chronic thicken- ing, hardenino' stiff'enino; and retraction of the membrana tvm- pani and other parts of the sound-conducting apparatus of the middle ear, have been proposed by several authorities. The operations about to be named have been undertaken with no empirical intent, but with a knowledge of a clearly diagnosticated condition of the auditory apparatus. This must be said of them as preeminently distinguishing them from previous operations on the drum-head ; though the best results of paracentesis membranse tympani are obtained when fluid has collected in the drum-cavity. When the membrana tympani is indrawn, LucEe and Politzer have proposed to incise the folds of the mem- brane. Gruber has advocated repeated prickings or incisions, and even excision of parts of the drum-head (myringectomy). Excision of the handle of the malleus, the chief object being to retain a permanent opening in the membrana tympani, must be deprecated. Repeated incisions through cicatrices, or an incision through the posterior fold of the membrana tympani, most surely lead to good results in many cases of progressive hardness of hearing. In "the former instance the benefit is due to the tightening of the previously flaccid part of the drum-head, which ensues with the healing of the cuts ; in the second instance the drum-head, already too tightly stretched, is freed, and very often it and the chain of ossicles will swing more freely in consequence of this simple operation. With the head of the patient gently sup- ported, and the canal properly illuminated, by light reflected from the forehead-mirror, the incisions may be made best with a spear-headed knife, the shaft of which should be six cm. long, and curved at an angle of 45° from the hard-rubber handle.' Similar procedures are recommended by Gruber* for the cor- rection of anomalies in tension of the membrana tympani. The same authority has also suggested the excision of a piece of the ^ Politzer, Wiener Med. Wochensch., 1871, Nos. 1 and 2. ■' Lehrbuch, pp. 581, 582. TREATMENT OF CHEONIC CATARRH, 405 (Iruin-liead l)_v means of an instrument arran_ii;c(l esiiecially for the operation. The great aim of otologists, from the time of I'aroisse to the present moment, has been, and still is, to make and retain a perforation in the membrana tympani, in a manner at once simple and free from danger. If such a i)erforation could be obtained, it has been supposed that the hearing, in many cases of chronic aural catarrh, would be improved. " To attain this end, numerous suggestions have been made: as, to keep the per- foration 0})en by means of a triangular-shaped sound (Paroisse); to insert into it a bougie (Saissy), or, small solid or hollow bodies (Philippeaux and Frank); but as they have proven of no value, it will be better to con- fine the attention to the few ^1^. 90. exceptional forms which have seemed to offer a reasonable hope of aid. Sometimes an artificial perfo- ration in the drum-head is re- tained by means of a small, hard rubber eyelet, as suggested by Politzer.' The eyelet, with a furrow on its outer surface — its general shape being that of a miniature barrel — is fastened to a piece of fine silk or cotton thread, and then inserted into a small cut in the membrane, at any chosen point, by means of special forceps (Fig. 90), or by those represented in Fig. 83. The thread attached to the eyelet provides a means of pulling it from the ear, when such a pro- cedure becomes necessary. If the eyelet becomes clogged with dried mucus, Politzer has found that a drop of glycerine, placed in it by means of a l*ravaz syringe, will soften such an obstacle and permit its being removed by means of a stift" bristle. Politzer has found that in many cases the eyelet is borne without anv inflammatory reaction in the drum-head or tvm- panic cavity; yet in some instances, the good result of the opera- tion has been nullified by the irritation in the ear consequent upon the introduction of the eyelet. Since, in several cases in which the eyelet set up inflammation, sharp projections were found on it, the necessity of making the eyelet perfectly smooth before it is put into use becomes apparent. I have performed this operation with entire success, with temporary improvement in hearing. But the ]^erforation in the membrane healed in a few weeks and pushed the eyelet out into the canal, and the hearing receded. Polit/.er's Eyelet and Eyklet Forceps. Wiener Mod. Wochenschrift, 1868 and 18G9. 406 MIDDLE EAR. Another method of retaining a permanent opening in the membrana tympani has been suggested by Voltolini,^ of Breslau. It consists in making a long incision both in front of and behind the manubrium, and then encircling the latter with a tubular ring of fine gold. The latter is about 2^ mm, in diameter, and is so constructed that when its two free ends are brought together on the inner side of the drum-head behind the malleus, they do not tit closely together but permit of a passage of air into the tympanum, which is further insured by an opening in the canule on the outer side. The latter opening marks the hinge-like division in the canule, and is opposite the point of junction of the free ends. Into the calibre of each half of the tube at this hinge- or joint-like point, Voltolini passes the delicate and flaring pointed-ends of specially devised forceps, by which the canule is pressed into its circular shape after its free ends are brought behind the manubrium. But necrosis of the manubrium having resulted from this manipulation, it would seem that this procedure could not be of universal application when a permanent opening in the drum-head is to be obtained. Aluminium, being of specific gravity lighter than that of gold, has been substituted by Voltolini in the manufacture of the tubular ring.- It has been proposed, by Weber-Liel,^ to make a cicatrix in the membrana tympani, at its inferior posterior quadrant, by means of the galvano-cauterj', and in the spot thus deprived of its regenerative power, to make an opening, with the hope that such a perforation would persist. By this method, a perforation has been maintained for three and a half years, with the greatest improvement in the hearing. In a number of cases of chronic otitis catarrhalis, with little or no opacity of the membrana tympani and with a pervious Eustachian tube, Simrock has resorted to puncturing the drum- head by the application of sulphuric acid, usuallj- to a spot on the posterior half of the membrane. The method is said, by its proposer, to be not at all hazardous, as a very little acid will produce all the desired eflect, and be entirely under control. The acid is applied to the desired spot by means of a tuft of cotton on the end of a probe, and an opening is effected almost instantly by gentle pressure of the probe point, or by smearing the acid carefully over the membrane at a circumscribed point; the tissue is rapidly destroyed, and the hole is cleared by lifting away the dead substance. The asserted advantages of this method are the rapidity and permanence of its effects. Of 1 Monatsschrift f. Ohrenh., No. 3, 1874. 2 See Wober-Liel, M. f. 0., No. 4, 1875. 3 Eine persistcnte ffiffnung im Trommelfelle. Dr. "Weber-Liel, M. f. O., No. 2, 1871, and JSTo. 4, 1875. Also " Progressive Schwerhorigkeit," p. 185, 1873. I TREATMENT OF CHKOXIC CAT A RE IT. 40? seventeen oritiees thus made, tliree remained open for four months. In three cases slight inflammation of the middle and external ear occurred, but without serious complications. Hear- ing for conversation improved nuirkedly in six; less so in four; no improvement for hearing in seven. Of seventeen cases the tinnitus disappeared in live ; in nine it was much diminished; in three unimproved. "After the perforation has thus been made, the ear should not be syringed even if slight discharge occur. "^ I have never employed either of these two last-named methods, nor, in fact, any method, excepting by Politzer's eyelet, to retain a pennanent opening in the membrana tympani. The latter structure is emphatically a protection to the mucous lining of the drum-cavity, and rather than incur the probability of a sup- puration in the middle ear by exposure, I have refrained from that which w^ould be unlikely to prove of great help to the hearing, but wdiich might be very apt to excite inflammation in the drum-cavitv. Tenotomy of the Tensor Tympani. — In 1868, Dr. Weber-Liel,^ of Berlin, acting upon a suggestion of Hyrtl, invented the ope- . ration of tenotomy of the tensor tympani, for which he devised a special instrument, his so-called " hook-knife.^ At various times since then Dr. Weber-Liel has published articles on this subject, setting forth the indications for, and the manner of this operation, together with the results of it, which he claims are in the main advantageous. His views have met watli w^arm support by some, but with entire opposition by others, on the other side of the Atlantic. In America the operation has been regarded with caution ; a few have performed it and published their results ; but on the whole, the operation has not aftbrded here the aid, in treatment of progressive hardness of hearing, which it appears to have done in the land of its origin. Carl Frank, the late Dr. R. M. Bertolet, Gruber, J. 0. Green, 0. D. Pomeroy, Schwartze, A. Hartman, and others, have performed the operation, but at . the present time the operation has fallen into disuse. ' Removal of Fluid and Inspissated 3Iatter from the Cavity of the Dnim, and JEustachian Tube. — Before inflation of the tympanum provided the surgeon with an efiicient and harmless method of clearing the Eustachian tube, it was customary to inject bland fluids into the tube. The stream thus forced into the middle 1 Xew York Med. Keoord, March 27, 1875. 2 Monatsschrift f. Ohrenh. ■S'o. 4, 1868; No. 12, 1868; No. 10, 1870; No. 11, 1871 ; No. 12, 1871 ; No. 1, 1872; No. 3, 1872. Vortrag : Berliner Medicinische Gesellschaft, 8 Juli, 1874. See Yirchow's Archiv, Bd. 62. ^ Hakenmesserchen. 408 MIDDLE EAR. ear was found to be most efficient when it could escape by the external auditory canal.^ Mr. James Hinton, of London, believed that mucus often became hardened in the tympanic cavity, behind an intact drum-head, and, giving to the latter a white, opaque appear- ance, led to a diagnosis of thickening of the membrana tympani. To obviate the deafness in such cases, he made an incision 2-3 lines long in the drum-head, behind the malleus, and then forcibly injected, from the external auditory canal, a warm solu- tion of bicarbonate of soda. He laid great stress on the herme- tical fitting of the nozzle of the syringe into the meatus. I have never found this procedure necessary in this country, where I believe inspissation of mucus is less likely to occur than in more humid and colder climates. It is not uncommon in syringing an ear afifected with chronic discharge, to find that the water passes into the nares. This is no disadvantage if it is produced by gentle syringing, but forcible syringing in any case in which there is an opening in the membrana tympani, must be regarded with caution, since a force thus applied with a view of carrying matter through the Eustachian tube into the pharynx might throw some of the injected fluid into the mastoid cavities and set up irritation there. Accumulation of fluid in the tympanic cavity and the best means for its removal are illlustrated in the following cases : Case I. Broivnish Transparent Fluid in the TympaniG Cavity^ visible only through a thin depressed Cicatrix; Incision and total Relief. — Dec. 1, 1875, Dr. A., 80 years old, a hale, hearty man, single, of an extraordinarily well-preserved constitution. Patient stated that for a month, since a cold in his head, he had noted a failure of hearino- in the ris^ht ear. He was liable to ac- cumulations of ear-wax, according to his statement, and had had his ear syringed, on the supposition that the deafness was due to inspissated cerumen. But no relief was thus obtained. On examination of the ear, the membrana tympani appeared rather opaque, excepting at the upper and hinder quadrant, where it was thin and depressed, and through which the incudo-stapedial joint was plainly visible. This thin, depressed quadrant was markedly of a dark, brownish-yellow color ; the rest of the membrane was opaque and gray. Under Siegle's pneumatic speculum, it swelled out into a bladder-like protuberance, ard seemed to be filled from behind with a dark, yellowish-brown fluid, as the air was exhausted by the speculum from the auditory canal. The hearing was about a foot for the voice and -^ for the watch. The tympanum could not be inflated by an}- method, as ' Ran, op. cit., section 210. TREATMENT OF CHRONIC CATAKRIf. 409 the Eustachian tube was markedly occluded by the remnants of the catarrh. The patient also stated that the Kustachian tubes ■\veie never easily inflated by Valsalva's method ; in tact, he doubted wliethcr they were of the average width. No form of in- flati(^n caused any alteration in the appearance of the depressed spot, which moved so easily under the Siegle speculum. Incision of this spot gave instant escape to some brownish transparent serum or mucus, and suction with the Siegle speculum brought out a good deal more, in all al)out twenty to thirty drops. The hearing immediately rose to about the normal grade. Voice and watch were heard easily thirty feet. In the course of a week, as was to be expected from the swollen state of the Eus- tachian tube, the tympanic cavit}' filled again. Paracentesis of the same tJiin spot gave vent to about the same quantity of fluid, and the hearing again went up. In the course of another week, a slight return of " muffled feeling " in the ear, which was relieved by incision and escape of a small amount of fluid. At this visit the Politzer bag forced the Eustachian tube open, and there Avas no further return of deafness. On March rSO, following, I examined the membrana tympani, and found that the thicker part was more shining, and the thin spot, though depressed, was not discolored by any brownish fluid in the drum-cavity. Hearing normal. Case II. Re-accumulation of Mucus in the Tpnpanum. — July 1, 1874, Jacob Y., aged 55 years, single, American, furnace-maker, a healthy, spare man. Not very strong. Seemed to be a man of more than ordinary intelligence for one in his position. He stated that for a 3'ear or more past, he had noted a gradual dimi- nution of hearing on the left side. The right meatus auditorius Avas occluded as described on page 305, on which side the tuning- fork, Avhen vibrating on his vertex, was best perceived. The case had been treated by several physicians as one of ordinary chronic catarrh of the middle ear. The drum-head had been said to be thickened, the catheter had been used to inflate the tympanic cavity and to convey various fluids into the Eustachian tube. This treatment, he said, always produced a temporary improve- ment in the hearing. When I examined the ear, the membrana tympani appeared thickened, and resembled in general, the opaque lustreless drum- head of chronic catarrh. The hearina; for the watch was about 4 111 KK-^^. I also inflated the middle ear by means of the catheter, 60 m. -^ several times a week for a month. Each inflation improved the hearing a little, but in a few hours it sank back again to its low point. ^ The inflations were repeated from time to time for a few weeks, longer, with ahvays some improvement in hearing. On the 12th of September, the patient came with the state- 410 MIDDLE EAR. ment that the benefit of the catheter, though marked, was only temporary: that he constantly felt something like a drop of fluid moving in his ear whenever his head was moved, and that whenever he lay down he heard better. He had told me this before, but I paid no, heed to it. But it was now discovered that when he reclined, the hearing really became better, as was shown by testing with a watch. This seemed to point to movable fluid in the drum-cavity, and consequently it Avas proposed to the patient that the drum-head should be incised. This being acceded to by the patient, a puncture was made in the posterior inferior quadrant of the mem bran a tympani, and there instantly escaped, on inflating by Valsalva's method, about twenty drops of a brownish, transparent, serous fluid, with some streaks of opaque mucus. But its presence had been in no way, as far as I could discover, indicated by any appearance of the membrana tympani. The hearing rose from one inch, to five feet, for a watch. The membrana tympani became more concave, and of a bluer hue ; before the incision it was flat and steel-gray. The hearing, thus regained, remained unimpaired until March, 1875, when, after taking a cold, the symptoms returned in the ear. In this instance there was rather a sense of fulness than of movable fluid. A paracentesis in the same spot restored the hearing, giving vent again to a similar thinnish fluid, nearly transparent, and tinged with brown. By the 23d of the same month the ear filled up again. The membrane was again perforated, as it resembled the membrana tympani in the previous conditions ; though I do not pretend to say that a dark-grayish color of the drum-head indicates mucus or serum in the tympanic cavity. The perforation gave vent to the same kind of brownish fluid, strongly suggestive of extrava- sated serum from the capillaries of the tympanum. The hearing instantly rose to its relatively normal point. By the loth of April following, the same symptoms of muffled hearing returned, and the membrana tympani seemed flattened somewhat, but not enough to attract the attention of one entirely unacquainted with the case, and not on the lookout for changes in the membrane. The color of the drum-head might be said to be dark gra}'. After the incision it always assumed a light bluish-gray color. Again the paracentesis of the drum-head was resorted to, and after the itsual brovrnish-red fluid escaped, the hearing returned. Again, on May 8, the same note was made, and again on June 8. Then perfect immunity from aural trouble until Sept. 8, when the symptoms returned, but relief was obtained as above. Aorain, on October 26 and iSTovember 24, the membrana tyin- pani was punctured, which completed the history for 1875. On January 3, 187G, the hearing had become again dulled, the con- TREATMENT OF CHRONIC CATARRH. 411 liitioii being soon recognized by the patient, who came to have his ear operated on again. The incision was made with Just the same results as above, and then again on February 19, and on March 28. Only once, February 19, were bubbles in the tympanum visible behind the membrane. On A'alsalva's inflation they moved very markedly. The quantity discharged in this in- stance was less than on previous occasions. In every other in- stance there was nothing to call special attention to the presence of fluid in the drum; and this circumstance leads one to believe that many such cases are treated as chronic catarrh, and re- garded as gradual sclerosis of the tympanum, because there is uo special change on the drum-head indicative of fluid in the tympanic cavity. As the fluid gradually gets harder, the case is abandoned as hopeless. This would seem to be avoidable in some cases, judging from this and others, by incising the mem- brane, at least as a last resort, even when the case resembles t those of so-called dry catarrh, with thickening of the tissues of the tympanum. The operation never caused the slightest pain, the perforation always healed within twenty-four hours, and the relief gained by the evacuation of the fluid contents of the tympanum lasted, in each instance, for a month, at least, and sometimes longer. In only one instance could bubbles be seen in the tympanum before the membrana tympani was incised, viz., on the 19th Februarv, 1876. The case never presented, on any other occasion, the ordinary signs of mucus in the tympanum. In fact, the paracentesis, in the first instance, was performed solely on the strength of the subjective feelings of moving fluid in the drum-cavity. This operation gave relief until March 28. On this occasion the membrana tympani showed a bro^^■nish-purple color. The bearing had become dull, and the ear felt "stopped up." No form of inflation relieved the symptoms. A tivelfth perforation of the membrana tympani, at the same place, the lower posterior \ quadrant, gave vent to the usual kind of fluid, and effected a i return of hearing. After the perforation and inflation, the membrane became more of a normal bluish-pearl color. April 8. There was a reaccumulation of fluid in the tympanic oavity. The patient felt at this time the movable drop of fluid , in his ear. The thirteenth paracentesis was performed, followed by \ the escape of the same kind of fluid, and the usual relief to his hardness of hearing. 24th. A similar condition of the ear, the fourteenth paracentesis, and relief of symptoms. ^ May 17. A similar note, with ix fifteenth paracentesis, and the -ame dischairge and relief. 412 MIDDLE EAR. ( / June 20. The same note, with a sixteenth operation. ' Ave/. 23. Similar note, with a seventeenth paracentesis. It should be stated that the patient was obliged to be out at night., and in all weathers, as policeman at the Centennial Grounds, i Oct. 2H. Same notes, with the eighteenth paracentesis, in the same spot, lower posterior quadrant of the drum-head. Dec. 27. A similar note, and the nineteenth paracentesis. Feb. 6, 1877. A similar note, and the twentieth paracentesis. There were no pharyngeal nor nasal symptoms to account for the reaccumulation. 3Iarch 27. The same condition of the ear, and the twenty-jirshi operation for relief was performed. May 11. A similar note, and the twenty-second paracentesis was performed. The patient was not seen for a long interval — not uutilJanuary 25, 1878. He stated that for four months past, his ear had beeir growing duller or "filling up," as he said, and that the sensation; of distention had at last become painful. The membrana tyra- ■ pani revealed symptoms in no way ditferent from those usually seen when the patient had presented himself for operation. The hearing was very much reduced ; the voice being heard only a foot. I performed paracentesis, the twenty-third time, at the- lower posterior quadrant; the same kind of brownish, tea-colored - transparent fluid escaped from the perforation thus made, and the relief to hearing was as great as ever — the voice being im- mediately heard normally. This shows that no organic change can have taken place in the conducting apparatus of the middle ear, though the origin of the fluid in the drum-cavity, remained yet obscure. Feb. 25. Another "filling up" in the ear had occurred again, and a paracentesis, the twenty-fourth, gave the similar results of discharge and relief. July 26. A similar note, and the twenty-fifth operation, with relief. Nov. 29. A similar condition of the ear, and a twenty-sixth paracentesis, with the usual results. Jane 5, 1879. An interval of six months elapsed. The patient i came again with the ear "filled up." The twenty-seventh para- centesis Avas performed with the usual favorable results. Sept. 26. IJpon this occasion, bubbles were distinctly seen ■ behind the lower half of the membrana tympani. These moved when the patient inflated by Valsalva's method, but his hearing was in nc^ way relieved by the inflation. At this visit, the twenty- ■ eighth paracentesis was performed; not so much fluid as usual escaped, but the hearing returned. June 15, 1880. A similar note, the twenty-ninth operation, and the same results. II TREATMENT OF CHRONIC CATARRH. 413 Sept. 3. A siuiilar note, with tbu tluvticth paracentesis. None of the operations have ever been more than simple I'lmctures in the membrane, and lia^'e never given any pain. Sept. 5, 1881. Only one recurrence of the symptoms, and (>nlv one paracentesis in this year. This made the thirty-Jirst (>peration. Nov. 6, 1882. The patient stated at this time that his left eye liad become dimmed in vision, and that his left ear was again stopped up. Paracentesis, the thirfi/seco/id, in the lower hinder ([uadrant, tailed to give relief, because, as I found out later, the tinid this time required for an exit a perforation in the upper posterior quadrant (see note of March 27, 1883). Upon this occasion, I sent him to Dr. Charles A. Oliver for ophthalmic examination, whose notes may be consulted for the results he obtained. Dee. 14. The hearing was found to be three feet for isolated words. The ear felt stopped up, but the membrana tympani looked smooth and fairly normal in color. The thirtii-tliird para- centesis was made, a rather opaque, yellowish fluid escaped, and the hearing thereafter was six feet for same tests as above named. The membrana tympani became very much retracted and thrown into rugae, and bluish-white in color, as on March 14, 1875. Jan. 21, 1883. Patient again felt his ear stopped up. He t seemed rather feeble at this time. The thirty-fourth paracentesis was made, and a slightly opaque, yellowish, thin fluid escaped, after which the hearing became relatively normal. 30//l a similar condition of the ear again noted. The thirty- ffth paracentesis was performed, and a thin yellowish fluid i escaped. The hearing was made better thereby, but it did not seem to reach the same liigh point after the operations as some years previous. The paracentesis left no scar on the membrane. ; The latter healed in a few hours. March 27. Patient complained that his ear was again "filled up." 'Ho bubbles were seen behind membrane before paracentesis. The thirty-sixth operation was then performed. The membrane 1 seemed tougher than usual. Valsalva's inflation forced out a J little frothy^ brownish fluid, as in previous instances. By this inflation, bubbles were seen moving in the upper and hinder quadrant, but they did not escape through the perforation in . the lower posterior quadrant. A second paracentesis was then : made in the upper posterior quadrant, and considerable pale, i yellow, thin, transparent fluid escaped. Patient said his eye and j ear felt better. Hearing for words before the operation, eight ;, inches; after operation, five feet. I In the operation of oS'ovember 6th, and in that of March 27th, ! the paracentesis in the lower posterior quadrant did not seem to 414 MIDDLE EAE be adequate for the perfect drainage of the tympanic cavity. ,' Hence in the operation of March 27th, a second puncture was made in the upper posterior quadrant where the bubbles were ; seen, which could not escape from the first and lower opening, j and more fluid escaped from this second upper opening than from the first and lower one. ' 31ay 1. The patient complained of a stufted feeling in his ear, and for the thirty-seventh time, the membrana tympani w^as per- forated at the lower posterior quarter; but not a drop of fluid escaped, nor could the patient inflate the drum-cavity by Val- salva's method. ' M. The patient still complained of the stufted feeling in his : ear, and he said he could not inflate by Valsalva's method. Paracentesis for the thirty-eighth time was performed, and a drop of grayish opaque fluid was forced out by Valsalva's method. The case seemed to be changing in type, appearing to be more i like an ordinary case of hypertrophic catarrh of the drum- ' cavity. On June 6th, the symptoms of deafness being the same, without any evidence of fluid in the drum-cavity, the catheter was used for inflating the left Eustachian tube, since the patient was unable to inflate as he once could by Valsalva's method; but this gave no relief to his deafness nor the sensation of fulness in the ear. The patient was evidently weaker ; was dizzy when he stooped, and when he walked. The scar made by the per- foi'ation of May 3d was still very plainly visible, demonstrating the want of the quick reparative powder always heretofore seen in this case. Aug. 10. The hearing for voice was six inches, only in the left ear. Inflation by Politzer's method increased the hearing to several feet. The tuning-fork vibrating on the vertex was heard best in the right ear, and the voice in the left ear, wdien w^ords were uttered close to it. 20th. The patient could again easily inflate his ears by Valsalva's method. His hearing w^as nearly relatively normal, /. e., three or four feet for vocal sounds, and he had no further sensations of filling up of his ear with fluid, the occurrence of which he had learned to recognize. He was just as dizzy as ever, especially when he turned around suddenly. The direction of the turning made no difference; he would stas-o-er toward either side. The scar of the last paracentesis was still plainly visible, as a red, scab- like line on the manubrium, near the short process, where it had moved from the lower posterior quadrant of the drum-membrane. The membrana tympani moved easil}' and plainly under Val- i salva's inflation. Dr. Chas. A. Oliver, who has made, in this man, extensive and skilful ophthalmological examinations, has come to the fol- 1 i TREATMENT OF CHRONIC CATARRH, 415 lowing- eoncliisions, which tend to exphiin the vertigo and altered gait in this ease: "J.. A chronic pachymeningitis, limited to the anterior two- thirds of the left base, involving a few of the nerve-sheaths at their foramina; causing subvaginal oedema, with consecutive neuritis and partial atrophy, "^. A new growth, very chronic in its development and course, situated in anj^ part of the brain not directly interfering with any motor or sensory nerve-structure. The neoplasm causing, pressure in all directions, with accidental passage of arachnoidal tiuid through a few of the weaker foramina into the outgoing nerve-sheaths; this serous exudation producing incom- plete choking of the nerve, followed by inflammation and atrophic degeneration. " C. Sclerosis of the posterior columns of the spinal cord; the disease having advanced as far as the beginning of the stage of full development, without complication or extension of morbid process." The point the case just narrated illustrates is, the great prob- ability that many a case of chronic deafness is only due to retained mucus in the cavity of the drum, the symptoms of which have not been, and cannot always be, clearly defined, for they ma}^ not be at all sharply expressed on the drum-head. It also shows that repeated paracentesis may be performed with great benefit. Where this fluid came from, and what caused its constant recurrence, are not easily answered. The Eustachian tube was always pervious to Yalsalvan inflation, and to the air of the catheter, Politzer's bag, etc. The difliculty of diagnosticating the presence of fluid or even inspissated mucus in the tympanum, in such cases of chronic catarrh, depends on several causes. The chief obstacle is, of course, tlie more or less altered condition of the membrana tympani. This may be so uniformly thick as to prevent seeing the delicate outlines of bits of mucus or bubbles lying against its inner surface. If it is cicatrized et any point, the retained fluid will cause a bulging at the cicatrix almost invariably, especially after inflation; but, if the membrane is uniformly thick, the mucus cannot make it bulge at any one point. Recent accumulations are most likely to cause in general bulging of the membrana tympani, but chronic accumulations cause a retrac- tion. In the latter instance, there is a vacuum of air in the drum-cavity. This is a very prominent symptom of chronic re- i tentiou of fluid in the tympanum. If only one ear is aftected, the examiner will be aided in his diagnosis by comparing the , two ears. lie will be guided l)y the ditterence in position be- I tween the two membrante, and also by the color. The mem- 416 MIDDLE EAE. brana behind which there is retained fluid will bulge more than its fellow, if the drum-cavitj be full of recent exudation ; less so, if the matter in the drum be an old and fluid accumulation. The color of the membrane is aftected by the matter retained behind it. Instead of being bluish-steel in color, it becomes a tint of gray-amber in color. These are guiding-points in favor of paracentesis, even if bubbles in the fluid cannot be discerned behind the drum-head. ELECTRICITY IN AURAL DISEASES. In 1868, Dr. Rudolph Brenner, of St. Petersburg, published his renowned work on Electro-otiatrics. His book consisted of a series of investigations and observations respecting the opera- tion of electric currents upon the organ of hearing, both in health and in disease. It was avowedly an endeavor to found a rational electro-otology. For seventy years previous to this time, i. e., from the time of Yolta, and his zealous pupil Ritter, numerous experiments had been made to find out whether and how the auditory nerve reacted under electric stimulation; but, as Brenner says, this period closed without any definite knowledge on this point. In the historical sketch which precedes the account of Brenner's labors, the reader is informed that the flrst experiments were performed in 1800-1802 by Yolta and Ritter; afterwards by Grapengiesser, who apparently was the first to produce sensation of sound by means of a simple current. From this time the entire subject remained untouched until Erman, in 1812, revived it. A long pause in this kind of work then ensued, until once more the subject was resumed by R. "Wagner, in 1843, who stated that it was extremely difiicult to produce sound-sensations in the ear by means of galvanism. Then followed the testi- monies of E. H. Weber, 1846, E. Harless, 1853, and Longet, 1850, that sound-sensations could be produced in the ear by means of the electric current. Schift", 1858, Ludwig, 1858, and Fick, 1860, appear to be in doubt whether the nerve is really electrically excited in those cases in which sound-sensation appears to be produced; they in- cline to the view that it is due to purely mechanical excitation of the sound-conducting parts, as did E. H. "Weber. Dr. Brenner has usually employed in his experiments a zinc- copper battery, but he has also used zinc-carbon batteries. The first, especially the Siemen's modification of Daniel's battery, is preferable on account of its more constant stream and slow exhaustion. Twenty of the above-named cells will be suflicient for all purposes connected with the application of electricity to the ear. TREATMENT OF CHRONIC CATARRH. 417 3Iode of Application of Elertrii-iti/ to the Organ of Hcarinq ; In- stninients employee/. — The electrodes are connected to the oar hy means of wires inclosed in rubhertubins^. They shonld l)e from six to ten feet long, in order to allow of perfect freedom in movement, change of position, and varying distances between battery and patient. The electrodes may vary in pattern : small ball-shaped ones, covered with thick muslin, which can be wet with salt and water, are preferable when the electrode is to be simply placed in the meatus, untilled with water. The form of electrode for the ear, used chictl}' by Brenner, consists of an ordinary hard-rubber ear-funnel, to which is fastened copper wire extending down the long axis of the funnel. This form is to be used in the auditory canal filled with tepid water. The number of elements to be inserted into the current is decided by means of what is called a polarity chooser (Strom- wiihler), the current is turned by a polarity changer (Strom- wender), and its rapidity, i. e., intensity, is lessened by a rheostat or resister. Inserted into the current may be a magnetic needle, which will alwaj's give information to the surgeon, respecting the activity of the current. After ten years of most careful observation, Dr. Brenner has become convinced that the audi- tor}' nerve can be excited by the electric fluid, and he has an- nounced the following formula for describing the phenomena which occur during such galvanic excitation. Brenner's Normal Forinulaof the Reaction of the Auditory Nerve. — The signs used in this formula are : G (Glerausch, noise), to designate the acoustic sensation excited by the galvanic current ; the degrees of intensity, by G' and g ; closing the current by S (Schliessung) ; duration of the current, D (Bauer) ; and the opening of the same by (Oeflhung). The direction is indi- cated by the name of the electrode in the ear at each moment of separate excitation, /. e., the kathode by Ka, and anode by A. Then the phenomena occurring by galvanic excitation of the auditory nerve may be expressed thus : Ka S G' : means that a marked sensation of sound occurs at each closure of the current, while the organ of hearing is under the influence of the kathode and the anode is placed upon a spot of the body at a distance from the ear. Ka D G > : means that a sound is heard, which rapidly diminishes and finally ceases, while the current runs in the same direction. Ka — : When the current is opened no sound sensation is perceived. A S — : If, now, the current be turned, so that the organ of hearing come under the influence of the anode, there occurs no sensation of sound by closing the current. 27 418 MIDDLE EAR. ti A D — : Nor does such occur during the continuance of the current. A O G : But by opening the current, sound sensation occurs, which corresponds qualitatively with that which was perceived when the current was closed while running in the opposite direction. But this sensation is much slighter and only of momentary duration.^ There may be several deviations from this normal formula in certain pathological conditions of the auditory nerve. Dr. Brenner gives the following: 1. Simple hj-peraesthesia : An auditory nerve thus aftected, reacts under electric currents very much weaker than those required to produce a corresponding excitation in the normal auditory nerve. Thus the duration (D) of the reaction during the moments Ka D and A O is much longer, and during a moderate current the Ka D-sensation does not terminate before the opening of the current.^ 2. Hypersesthesia with qualitative alteration of the formula : In this state the reaction of the auditory nerve under the electric excitation manifests not only an easy excitability, but also a change in its mode of occurrence. Thus, with Ka S, Ka D, and A there is a subjective ringing, and with A S, A D, and Ka there is hissing.^ 3. Inversion of the formula for simple hypersethesia : In some cases the disappearance of the normal formula in presence of the pathological, can be very striking. The former may be characterized by the lower notes of the scale, and distinguished from the pathological reactions by shortness of duration. With weak currents this condition does not manifest itself. 4. Hypersesthesia of the auditory nerve with the parodoxical formula in the unarmed ear. This form of hyperpesthesia is very curious and very frequent, and has been observed by Brenner only in old and deep disease of the ear. This form is characterized by the circumstance that during the application of electricity to one ear, not only the auditory nerve of that side but also that of the other ear responds, but in an inverted manner, so that in the ear not under treatment the perceptions of sound occur at those moments of excitation, during which the nerve of the ear immediately under treatment is silent; the ear not treated reacts exactly as if it were under the influence of the other electrode.* The observations and formula of Brenner have been fully ^ Brenner, Electro-Otiatrik, p. 91. 2 Op. cit , p. 183. 3 Op. cit., p. 195. * Brenner, op. cit., p. 201. TREATMENT OF CHRONIC CATARRH. 419 verified by Erb,' Moos," and Ilagen,^ in Germany, and by Blake and otliers in this country. Schwartze,* Shulz,^ and Benedikt," have been the principal ' opponents of the views of Brenner. The present status of the question may be said to be as follows: r>renner and his co- laborers believe that they have demonstrated that the subjective sound-sensations occurring during a galvanic examination of the ear, are produced by direct stimulation of the auditory nerve. The opponents above named admit the sensations, but believe that these sensations depend upon retiex irritation of the trige- minus and the sympathetic nerve. A somewhat new field of therapeutic application of the con- stant electric current has been opened by Dr. Weber-Liel, of Berlin. This observer introduces the current through the Eustachian tube by means of a silver wire conveyed through a catheter." Bj' this method he claims to bring the muscular structures of the tube and perhaps those of the middle ear (tensor tympani and stapedius) under the direct influence of the galvanic current. It will be seen that in such an a})plication of electricity, the direct irritation of the auditory nerve is left out of consideration. The treatment is really applied to the middle ear, and probably marks a new era in the use of electricity in some forms of aural disease, as, for example, in cases of atrophy, flaccidity, or degeneration of the muscles. In such cases per- haps the muscular structures of the middle ear derive a benefit from the gymnastic, as w^ell as from the dynamic effect of the electric current. It is claimed bv Weber-Liel that this kind of intra-tubal electrization will relieve the symptoms of paralysis in the tubal muscles, cause the subjective noises to cease, and bring the hear- ing almost to the normal standard, if the treatment is begun before secondary changes have occurred in the tympanum, and if no other complication exists. He also states that after the tubal muscles have been thus galvanized, the air from the cathe- ter can be forced into the tympanum more readily, without the aid of swallowing, the latter is more easily performed and in- flation by Valsalva's method succeeds where before it failed, all of which he adduces as proof that the paralysis of the muscles ' W. Erb, Die galvanische Reaction des nervos^en Gehorapparates, etc. Archiv f. Aue;. und Ohrenheilk., Band i. iS. l.')7, and Band ii. iS. 1-51. '•^ Klinik der Ohrenkrankheiten, 1806, p. 882, and elsewliere. ^ Elcctro-otiatrische Studien. Wiener Med. Wochenschrift, 1866. * Archiv f. Ohrenh., Band 1. ^ Sitzung der k. k. Gesellschaft d. Aertze, 2 July, 1865 ; also Wiener Med, Zeitnno;, 1865. No. 23. « Wiener Med. Presse. 1870. Nos. 37, 39, 42, 43, 47, 48, 50, 51, and 52. ' Progressive Schwerhorigkeit, p. 36. 420 MIDDLE EAR. concerned in these acts has disappeared, and that the disappear- ance is due to the use of electricity.^ But the latter part of the proposition cannot be so easily admitted, since exactly the same improvement in these parts does occur after a careful catheterization, and the use of a bougie, the latter being passed up into and even past the isthmus tub?e. ISTot only in recent but in chronic cases of catarrhal disease, and closure of the tube, in which neither by the catheter, Val- salva's method, nor by the act of swallowing, the tube could be opened, a bougie passed into the tube on two or three successive days, has appeared to stimulate the tubal muscles to proper action, without the aid of electricity. To illustrate this, let me bring forward the following case : Mr. T., 40 years old, of Maine, consulted me with his physician, for deafness in the right ear, following a copious and chronic nasopharyngeal catarrh. The active catarrhal symptoms had been checked, and the mucous membrane of the nares and pharynx was abnormally dry. The right membrane was thin ; promontory and incudo-stapedial joint visible through the mem- ibrane ; lustre good. Great tinnitus ; hearing for watch -^ in. At the first visit, air could not be forced into the tympanum by the catheter nor by the Politzer bag. A silver catheter was then introduced, and through it one of Weber-Liel's admirable tym- panic catheters (delicate flexible bougie-catheters of gummed silk) was pushed through the silver instrument and into the tympanum. This produced an immediate though slight im- provement in hearing; the operation was repeated on three consecutive days, and by the fifth day after the first operation the patient volunteered the statement that " his ear opened whenever he swallowed, a sensation he had not noticed for nearly a year." Air could now be forced into the tympanum both by the catheter and Politzer's method. The hearing rose to ^ 111 — -^ for the watch, but the tinnitus was not materially altered. 60 m. ' "^ The patient, being obliged to leave the city, passed from under my treatment. The case is quoted chiefly to prove that the signs of muscular paralysis may be made to disappear without the aid of elec- tricity. Since in this case, and in many similar ones, the physical manipulation of the diseased parts is almost identical with that adopted by Weber-Liel in his intra-tubal electrization, excepting that the latter factor, the passage of the electric current, is left out, and since the result is about the same in both instances, it would really seem that the benefit in such cases depends upon a i| 1 Op. cit., p. 165. I OBJECTIVE NOISES IN THE EAR. 421 thorough opening of an occluded Eustachian tuhe,and the con- sequent restoration of tlie tyni[)anuni to a proper degree of ventihition, and 7ioi upon cleetricifij. Dr. Ilitzig^ prefers the so-called external application of elec- tricity for therapeutical purposes. But he thinks that the electrization of the muscles in the tympanum, by means of the electrode (wire) introduced into the Eustachian tube, may in the future be shown to be of value, but for the direct excitation of the acoustic nerve this method has but a limited supplemental ■worth. CHAPTER IV DISEASES OF THE MIDDLE EAR {Continued). It is proposed to devote this chapter to the consideration of several rare and interesting pathological processes, in the middle ear. Some of these about to be described have been observed in close connection with catarrhal processes in the tympanum, and some of them may have had their origin in such a process in the tympanic cavity. They are certainly full of interest to the aurist, and not without interest to the general practitioner. As these diseases are rare, and some of them malignant, it must be accepted beforehand tliat the treatment is an open question in some,. and unsatisfactory in others. One of the rarest and most interestino* is that first described. Objective Snapping- Noises in the Ear. — Sometimes there occurs a snapping or cracking noise in the ear, which is audible not only to the sufterer but to others. This noise has been likened to the snapping of the finger-nails, or to the sudden drawing apart of the finger-ends when slightly moistened with saliva or a tenacious fluid. The first simile is the more striking. Some persons possess the power of voluntarily producing such a sound in the ear. It is knoAvn that Fabricius ab Aquapendente and Johannes Muller,^ were able to produce such a sound; the former only on both sides at the same time, but the latter in either ear according to his desire. It was ascribed by him to a 1 Bempi-kuno-en iiljcr die Auf<,ml)en der " Eloctro-otiatrik " und den Weg zu deren Losuiii;-.' E. Ilitzio-. A. f. O., N. F., Bd. 2, S. 70. 2 Manual of Physiology, London, 1838-1842. Translated by Wm. Baly, :\I.D., p. 1262, vol. ii. 422 MIDDLE EAR. voluntary contraction of the tensor tjmpani muscle. Muller^ was disposed to regard this voluntary power as not uncommon, and mentions the fact that Meyer had known a gentleman who possessed it. Lucse^ has observ^ed this power to voluntarily produce a snap- ping noise in the ear, or to contract the tensor tympani, as he believes, in three friends, all of them scientific men. Politzer^ observed both the voluntary and involuntary production of this snapping noise, in the ear of a young physician, and Schwartze* alludes to the voluntary ability to make this peculiar noise, as do Schrapinger,^Delstanche, tils,^ S. M, Burnett,'' and Brenner.* I have observed on several occasions this power in certain indi- viduals, all of them affected with an aural disease. Two of them were physicians, and with the noise, which was rather a creak- ing or a whizzing than a snapping, visible motion occurred in the membrana t^'rapani. In one it was heard on both sides, and cicatrices in the membranes were seen to move most distinctl}', and also seemed to contribute to the noise by a kind of crack- ling sound. In the second case the noise was not very loud, but the membrana tympani moved visibly. The third instance was in a patient, a young man, twenty-three years old. The hearing was normal in the ear in which the noise was made. Instances of the involuntary occurrence of a snapping sound in and from the ear have been observed by Schwartze,^ Boeck,^" Politzer,^^ Leudet,^^ Kiipper,^^ and myself.^* Since the publication of the first edition of this treatise, Holmes,^^ of Chicago, has reported the occurrence of involuntary, objective snapping sounds in both ears of a 3'oung woman, eighteen years old, accompanied by involuntary spasms of the pharyngeal muscles, forty times a minute. Biirkner^^ reports the occurrence of this phenomenon in the ear of a man, twenty- seven years old, induced by a blow. Chas. A. Todd^'' reports its 1 Manual of Physiology, London, 1838-1842. Translated by Wm. Baly, M.D., p. 1262, vol. ii. 2 Archiv f OhrenheiUv., Bd. iii. S. 201, 1867. 3 Ibid., Bd. iv. S. 19-29, 1868. * Ibid., Bd. vi. S. 228, 1870. ^ Transactions of the Austrian Acad, of Sciences, vol. 62, sec. 2, 1870. • ^ Etude sur le Bourdonnenient de I'Oreille ; Paris et Bruxelles, 1872, p. 47. '' Archives of Otologv, vol. viii. p. 357, 1879. >j 8 Monatsschrift f. Ohrenh., No. 10, 1879. "*" » Archiv f. Ohrenheillvunde, Bd. ii. B. 5, 1867 ; also Ibid , Bd. vi. S. 228, 1870. i» Ibid., Bd. ii. S. 203, 1867. | " Ibid., Bd. iv. S. 19-29, 1868 ; also Wiener Med. Presse, 1871. | 12 Gazette Medicale de Paris, Nos. 32, 35, 1869 ; Comptes rendus de I'Academie i, de Science de Paris, Mav 10, 1869. ' 13 Archiv fur Ohrenheilkunde, Bd. i. N P., 1873, S. 296. ! " Philadelphia ]Mcdical Times, Nos. 172 and 181, 1875. i 1^ Chicago Med. Journal, Mav, 1879. j 16 Archiv f. Ohrenh., Hd. xv."^S. 219, 1 87 9. ' i 1' St. Louis Courier of Med., July, 1880. . "' ; H OBJECTIVE NOISES IN THE EAR. 423 occurrence in the ear of a man, the noises being accompanied by simultaneous spasm in the velum and sterno-cleido-mastoid muscle; and K. C. Brandeis^ gives an account of observing this peculiar noise in both ears of a girl, twelve years old. In this case there were synchronous spasms in the soft palate, uvula, accompanied l)y simultaneous movements in the membrana tym- pani. The muscular contractions also extended to the digastric muscles on both sides, as well as to the mylo-hyoid and thyro- hyoid muscles, but no movements in the larynx, either as a whole or a part. H, N. Spencer^ and Wagenhiiuser^ have reported the occur- ence of an objective aneurismal-like bruit, emanating from the ear, the first in a man, the second in a woman. It was un- doubtedly vascular in its origin in both instances. jSIurmurs of systolic origin are occasionally heard, both objectively and subjectively. These have been described'' as objective and subjective murmurs, and are classed under brain- murmurs. They may be independent of aural disease, and usually occur in the young. They are probably due to the fact that the internal carotid artery develops more rapidly than the ^osseous canal in the petrous bone, through which it passes in its way to the brain. The stenosis thus brought about in the blood- vessel, induces, by the pressure of the blood from behind, a gradual and sufficient enlargement in the canal. The systolic murmur heard in such cases is purely physiological. An objective whizzing sound may come from the ear during mastication, as observed by Moos, but this is not to be classed with the distinct, involuntary, spasmodic, snapping sounds in the ear, which may be heard objectively in some rare instances. There are, how^ever, several cases on record in which a peculiar objective noise in the ear has occurred without any act of volition on the part of the patients. The noise is often very frequent, loud, and distressing in its occurrence, and presents interesting and varied features enough to warrant it a separate mention here. Since the time of Miiller's observations on himself, this peculiar snapping noise in the ear has been variously ascribed to either voluntary or involuntary contraction of the tensor tym- pani, to clonic spasm in the stapedius muscle, in a single case, by Wreden, or to spasm in the palatal muscles whereby the anterior wall of the mouth of the Eustachian tube is suddenly drawn away from the posterior wall and the noise is thus pro- duced. The latter view is that of Politzer and Lushka and is 1 Archives of Otol., vol. xii., 1883, p. 14. * Amer. Journal Otol , vol. iii., 1881. - » Arohiv f. Ohrenh., Bd. xix. S. G2, 1882. * J. O. Green, American Otological Society, 1878. 424 MIDDLE EAR. now received as sufficiently explanatory of the majority of the cases which have been observed. According to this theory the noise is really produced in the nasopharynx, but is conveyed to the ear of the subject through the Eustachian tube. The ear of an observer also perceives the noise as coming from the ear of the person in whom the peculiar sound originates. The noise is also heard equally well at the nostril of the patient in many cases. The case of spasm of the stapedius muscle described by "Wreden is, so far as I know, unique, unless a very low and gentle tapping sound which I once heard in the ear of a patient, by placing my ear close to his, was to be explained by an in- voluntary twitching of the stapedius. There was nothing but its faintness that led me to this conclusion. There was no dizzi- ness nor deafness. The cases of Leudet and Delstanche are considered by them as examples of an objective snapping noise in the ear, due to spasm of the tensor tympani muscle. That of the former was involuntary, while that of the latter was volun- tary. But the account of Leudet is evidently one of this pecu- liar noise produced by the spasmodic opening of the mouth of the Eustachian tube; as indeed was that of Delstanche, for in both there is history of simultaneous movement in the palate. The following is a short account of the above-named curious affection, occurring in a Japanese lad eighteen years old. The patient came under my care for treatment of a chronic suppura- tive inflammation of the left middle ear, with perforation of the membrana tympani, the result of acute inflammation incurred in July, 1874, by diving in cold salt water. The nasopharynx and the pharynx were catarrhal, for which he was treated by applica- tions to the pharynx and nares. The patient complained only of the left ear. He did not draw my attention to the right ear, affected by the spasm about to be described, but while inspecting the right ear for purposes of comparison, I heard distinctly a noise resembling the snapping of the • tinger-nails, emanating from it. The snapping was most audible when the ear of the listener was placed close to the right ear of the patient, but it could be distinctly heard ten feet from the ear from which it came. It was also heard very distinctly when tlie ear was placed near the right nostril of the patient. It was not, how- ever, audible in the left ear of the patient, neither by placing my ear on his ear, nor by the use of the auscultation-tube. In- spection revealed a thickened and reddened condition of the right membrana tympani; and the patient stated that he had had, some years previous, discharges from the right ear, and it was found that the hearing was defective in it. The snapping sounds began in it in the previous summer, one week after the acute inflammation in the left ear. At the first examination, by simple inspection, no motion was detected in OBJECTIVE NOISES IN THE EAE 425 Politzer's Manomkteh. the membrana tynipani at each stiap])iiio-, but in the course of a month, the thickening of the drum-head becoming less, a vcr}' sHght retraction of the drum-head at its antero-superior quadrant was seen. Before any motion in the drum-head was observed by simple insjx^ction, to occur with each of these peculiar objective noises, I placed a small glass mano- meter devised by Politzer, with its cajtillary calibre, one millimetre in diameter, tilled with colored water, into the meatus of the right ear, also tilled with water, the two columns of fluid being hermetically joined by an India-rubber stopper on the manometer. The column of water thus brought into contact with the membrana tym- pani, showed a negative fluctuation of one-half millimetre at each snapping sound, thus demonstratino- a retraction of the membrana tvm- pani too small to be seen at that time by inspection, but later, apparent upon close and attentive inspection. The drum-head moved readily under the Siegle pneumatic speculum. The examination of the fauces revealed an elevation and retraction of the velum palati, chiefly on the right side, with each snapping sound in the ear and each manometric depression. The negative fluctuation — i. e., depression in the manometric column — amounting to one-half millimetre, occurring at each objective sound in the ear, was entirely distinct from a very slight positive oscillation in the same column at each cardiac impulse. The latter could not always be discerned. Deglutition, respiration, and speech exercised a marked influ- ence over the spasmodic condition already described. The patient stated that deglutition and rapid respiration increased the frequency of the sn^lpping noise in the ear, but that when he held his breath, the spasms in the velum palati and the snapping noise in the ear, ceased entirely, to begin again with renewed respiratory acts. I found, indeed, that so long as the patient held his breath neither he nor I could hear any snapping, nor could I detect any spasmodic movement of the velum ; but they all recurred as soon as the patient resumed his breatliing. During ordinary respiration I counted twenty spasms in a minute, which appeared to be the average numl)er; but with a voluntarily increased number of respirations, the number of snappings and spasms of the velum rose to thirty in a minute. During continued speech no snappings occurred. The^e peculiar snappings were not in regular succession, iior synchronous with the respirations. Two or three snappings usually occurred in quick succession, were followed by a pause, 426 MIDDLE EAR. then there were several more, thus completing twenty in a minute. These noises interfered so much with the hearing in the ear in which they occurred, that the patient, when specially desirous to increase his hearing, held his breath, wdiich, as already stated, would control the spasms. It was found by testing with a watch, audible normally sixty inches, that the hearing was indeed influenced by the spasms and their tempo- i| rary cessation as the patient had stated ; for the watch, audible to him onl}^ on contact during the spasms, was heard two inches when the noises w^ere arrested by holding his breath. Tuning-forks held before the ear, appeared to the patient to rise in pitch at each spasm. The rise in the note was well imitated by the patient. This altered pitch was to be expected, tj because at each spasm the drum-head was retracted, and ren- i dered, by this increased tension, more sensitive to high than to i low notes, and hence the ear perceived the higher, to the exclu- i sion of the lower partial tones of the tuning-forks. The snapping sounds, but not the spasmodic elevations in the velum, could be arrested in two other ways. By throwing the patient's head back as far as he could get it, although the spasms in the velum palati went on with the usual intervals, the objec- tive noises in the ear were arrested. I could also stop the noise by pressing my linger firmly against the velum, and pushing it upward towards the pharyngeal opening of the right Eustachian tube. Although a powerful twitching, with the usual intervals of repose of the muscular structures thus pressed upon, could be felt, all snapping noises ceased. Pressure upon the left half of the velum palati and mediately upon the pharyngeal opening of the left Eustachian tube revealed no twitching in that region, nor did it influence in any way the spasms and noises on the opposite side of the pharynx and in the right ear. As the patient expressed no desire for relief from this objec- tive noise in the ear, seventy-two days went by, with a number of opportunities of observing all the phenomena just detailed. On the seventy-second da}- after I had first heard the snappings from the ear, the patient informed me that, within a few days, a perforation had occurred in the drum-head of the ear from which the noises emanated, and that the latter had greatly de- creased in loudness and frequency. Inspection then revealed, indeed, a perfectly well-defined dry perforation in the antero- superior quadrant of the membrana tympani, where previously the slight but spasmodic indrawing of the membrane had been observed ; but there was no explanation of the perforation so far as could then be discerned, nor could the patient give any solution of its occurrence. In a few days, the snappings, which had become very infrequent and nearly inaudible, ceased entirely. Although a little mucous discharge ensued in about a week after OBJECTIVE NOISES IN THE EAR. 4'27 the perforation, probably from exposure of the mucous lining of the tympanic cavity to the winter atmosphere, it was easily checked, and the membrana tympani closed. Since then there lias been no rcdirn of the snapping noises, nor any spasmodic amotion in the cehnn palati, Eastaehian lube, middle ear, nor nieiidtrana tym- pani. The young gentleman remained under observation until his return to Ja[»an in the autumn of 1876. Kecently I have observed two other cases of objective aural noises, both of which were evidently connected with catarrhal disease in the nares and nasopharynx. The first case was that of a young physician, twenty-eight years old, who consulted me, on October 5, 1888. lie stated that for twentv months he had felt a " clickino;" in his left ear, produced by both objective and subjective sounds: as, for ex- ample, the clicking of a card in the fingers, or the blowing of a shrill toy whistle near his ear, or by his own coughing, speaking, or singing. It was found that when he said m, n, or o, rather loudlv but with no other vowel sound, this clickino; in his ear was produced. 1 thought I could detect a slight change in the pyramid of light, i. e., a slight motion of the membrana tympani, when he produced the "clicking" in his ear by uttering these consonant and the vowel sounds. I also faintlv heard, bv means of the auscultation-tube, the " clicking" in his ear, when he pro- duced it as described above. There was no difference in the sound, when induced by sub- jective or objective causes ; it was more likely to be produced at night or the end of the day when fatigued, than in the early part of the day. Up to this time it had never occurred auto- matically, i. e., without an objective or a subjecto-objective ex- citant. Subsequently, when the patient was run down by the winter's work, this " clicking sound " did occur automatically when he was entirely quiet. The membrana tympani displayed a good lustre and the pyramid of light was fair ; the membrana w'as retracted and the incus was visible. The membrana moved fairly under the pneumatic speculum. The right membrana manifested an iden- tical condition. The Eustachian tubes were entirely pervious to inflations ; the anterior and posterior nares were hypertrophic, the left markedly more so than the right; the pharynx was red, and manifested tobacco-smokers' pharyngitis. The patient had smoked cisrarettes to excess, but had not done so recentlv. There was at no time any discernible muscular spasm in anj' part of the pharynx nor velum palati, nor w^as the patient con- scious of an}' spasmodic motion or twitching in any part of the nasopharyngo-aural tract. Treatment. — The anterior, hypertrophied portions of both in- ferior turbinated bones were touched several times w-ith Lugol's 428 MIDDLE EAR. solution of iodine. Upon one occasion this mixture was pushed along the left inferior turbinated bone to the posterior pharyn- geal wall. This caused pain and brought on an attack of the " clicking" in the left ear. The pain and the " clicking " were quickly allayed, however, by spraying the nostrils with fluid cosmoline (Petroleol). In a short time, /. e., after four or five applications of the iodine to the inferior turbinated bone, and the use of the cosmoline spray, the hypertrophy became much less, and the noise in the ear occurred less readily and not so frequentl}'. The patient then dropped all treatment until last spring, when the " clicking " became very annoying, occurring easily when the patient was exposed to noises, or when he sang, talked, or whistled. Finally the noise occurred automatically, even when the patient and his surroundings were perfectly quiet. The patient was somewhat debilitated, and about this time, after running up stairs one evening- after supper, fainted upon reaching his room. The nasal hypertrophies, both anterior and posterior, espe- cially on the left side, seemed larger, and the nasal catarrh gen- erally worse. He was advised to undergo nasal treatment at the hands of Dr. Seller. The latter applied iodine and glyc- erine, equal parts, to the hypertrophies, sprayed the nares with Dobell's solution, and once scarified the hypertrophied tissues at the back of the septum on the left side, by means of the gal- vanic wire-cautery. This treatment produced very good results, the " clicking" practically ceased to annoy, as it occurred very rarely, and only very faintly. The improvement has been maintained to the present time. Etiology. — There was in this case an undoubted spasmodic action in muscular tissue near the Eustachian tube, but entirely invisible to the examiner and not felt by the patient. I am dis- posed to locate the muscular spasm, in this case, in the upper fibres of the superior constrictor of the pharynx. This muscle arises from the lower third of the margin of the internal ptery- goid plate, and its hamular process, from the contiguous portion of the palate bone and the reflected tendons of the tensor palati muscle, from the pterygo-maxillary ligament, from the alveolar process above the posterior extremity of the mylo-hyoid ridge, and by a few fibres from the side of the tongue in connection with the genio-hyo-glossus. Its superior fibres of insertion arch beneath the levator palati and the Eustachian tube. The mucous membrane of this muscular tract was, as has been stated, markedly catarrhal, the inferior turbinated bones and the nares were hypertrophied, and the fauces were aftected by smokers' pharjMigitis. In these conditions in the mucous mem- brane, there is found sufficient cause of irritation of the sensitive nerves in these parts, this irritation is reflected to the under- II OBJECTIVE NOISES IX TIIK EAR. 429 lying muscular structures through motor nerves, and there ensue spasmodic twitcliings near tlie Eustachian tuhe which are perceived as suhjective and objective noises. That the origin of these "clickings" lay in the catarrhal condition of the upper pharynx and the nares is fully shown by the cessation of the noises upon the amelioration of the catarrhal symptoms. The easy excitation of the spasms by talking, is explained by 1 the fact that a few fibres of origin of the superior constrictor of the pharynx arise from the genio-liyo-glossus, and hence lingual motions would tend to excite the aforesaid sounds in the ear. It may also depend upon the motions of the jaw, as the con- strictor has a partial origin from the posterior part of the alveo- lar process, and upon the uiovements of the buccinator, which has a common origin with the superior constrictor of the phar- ynx, in the pterygo-raaxillary ligament. The annoying audi- bility of these muscular spasms is due to the insertion of the superior constrictor near the Eustachian tube. Another case of objective snapping noises in the ear came under my observation within a short time, and is now under treatment. Miss McG., aged twenty years, stated on June 2, 1884, that about six months previous she had first noticed a clicking sound in her right ear, and that her family noticed that they too could hear it. She is not disturbed by the noise at night, though it appears to be almost ceaseless. Its occurrence is paroxysmal, with short intervals. It is heard objectively quite as well — perhaps better — at the nostrils than at the meatus of the right ear. It is ver^^ well heard at the latter point by means of the ear-trumpet. The number of " clicks " is about eighteen or twenty per minute. With each clicking sound the lower max- illa is both felt and seen to move, chiefly towards the right side ; the latter symptom is very annoying to the patient. A mano- metric column, attached to the right ear, rises and falls with each "click," due, very probably,* however, to the motion of the lower maxilla and not to movements in the membrana tym- pani. The patient stated that she had of late begun to hear the noise in the left ear. Objectively, it is not very pronounced on this side; it can be heard however at this point. Pressure upon tlie muscles over the carotid on the right side, behind the angle of the jaw, arrests the motion of the latter and the objective noise. Opening the mouth very widely stops the noise almost entirely, only a faint " click" being heard now and then. I The patient is a pale blonde, somewhat neurasthenic ; the right membrana tympani is opaque and retracted, and on this side the hearing is reduced to a few inches. The nares, naso- pharynx, and fauces are catarrhal, and she often feels the drop- •430 MIDDLE EAR. ping of mucus from her nasopharynx into the throat. Her spirits are not depressed by these peculiar aural phenomena, and she sleeps well. The motion of the lower maxilla, observed in this case in connection with each clicking sound, is due to a clonic spasm of the pterygoid muscles of both sides, but chiefly of the left side, as denoted in the greater tendency of the maxilla to move towards the opposite side, /. e., towards the right, since when the external pterygoid muscle of one side acts either alone, or chiefly, the corresponding side of the jaw re- mains fixed, and the symphysis deviates to the opposite side. The distinct, objective audibility of the spasms at the nares and auditory meatus, is due to the fact that the internal ptery- goid arises from the pterygoid fossa, its fibres being attached to the inner surface of the external pterygoid plate, and to the grooved surface of the tuberosity of the palate bone. Its in- ternal surface is in close relation to the tensor palati, while the external pterygoid arises from the pterygoid ridge on the wing of the sphenoid, and the portion of the bone included between it and the base of the pterygoid process, from the outer surface of the external pterygoid plate, and from the tuberosity of the palate and superior maxillary bones. Hence any vibrations occurring in the muscular structures near their points of origin, would be easily communicated by the Eustachian tube to the tympanic cavity and the external ear, and also directly through the nares to the external air. So that a snapping sound occur- ring in the region of these muscles would be at once a subjec- tive and an objective noise, in and from the nasopharynx and ear. These sounds may have been augmented by a simulta- neous spasm in the fibres of the superior constrictor of the pharynx, which has a small tract of insertion on the inferior maxilla, above the inner end of the mylo-hyoid ridge. The spasms in the muscles in this case are to be accounted for, as in the previous instance, by the catarrhal irritation conveyed to the sensitive nerves of the mucous membrane in the vicinity of the muscles affected. The irritation is thus conveyed to the motor nerves of the muscles in the catarrhal tract, and the latter, in an endeavor to eject the irritant, are thrown into a series of clonic spasms. Simultaneous Spasm in the Soft Palate. — In the vast majority of all the cases on record, this noise, whether voluntary or not, has been accompanied by a spasmodic elevation and retraction of the soft palate, and sometimes of other muscles of deglutition. In the case observed by Klipper, there was, in addition to the movements in the velum, a simultaneous elevation of the larynx, the floor of the mouth, and the root of the tongue. Simultaneous movements, i. e., retractions of the membrana tympani, have been observed less frequently than the above- OBJECTIVE NOISES IN THE EAR, 431 mimed motions in the velum. The ind rawing of the membrane, when observed, has not always been at the same s[)Ot, It has varied from being at the point of the manubrium, to being at various other portions of the membrane. This would seem to militate against the theory that tlie noise, and consequently the retraction of the drum-iiead, is due to spasm of the tensor tym- pani muscle. For were it due to the latter, the indrawing of the membrane would be likely to occur in a line with the handle of the malleus, and not in one of the quadrants of the membrane, at some distance from the malleus, as it did in the case I have observed. Simultaneous Twitchhigs Elsewhere. — In some instances the in- voluntary objective noise in the ear has been accompanied by simultaneous twitchings of the muscles of the brow, nose, and face, as in Kiipper's case, which was am bilateral, or with simul- taneous spasms of the mylo-hyoid muscle, of the anterior belly of the digastric, of the pterygoids, and in the brow on the same side, as was noted by Leudct, Todd, Brandeis, and myself. In the case by Brandeis there was neuralgia in tlie brow and amy- osthenia of the lingers, on the side corresponding with the ear in which the noise was heard. The age of those thus atfected varies from five to fifty years, as shown in the cases reported by Schwartze. Of all those alluded to here in whom such an objective aural noise, either voluntary or involuntary, has been observed, six were females; four of whom were adults, the cases of Moos, Leudet, Holmes, and mj-self; while two were little girls, five and twelve years old, respectively, one observed by Schwartze and the other by Brandeis, Involuntary objective noises in the ear, and the attendant symptoms already described, rarely occur on more than one side at a time ; in six instances, however, they w^ere observed to be in both ears, twice by Schwartze, once by Kiipper, Holmes, Brandeis, and myself. The mode of the occurrence of the involuntary snappings in the ear varies greatl}'. It may be too rapid to be counted (Schwartze), or isochronous with the pulse, and so loud as to waken the patient at night (Boeck), or it maj' resemble the ticking of a watch, w^ith pauses (Schwartze). In the case ob- served by Leudet, the noises occurred in pairs, the one being a " kind of echo" of the other, and in the case cited by Kiip[)er, they occurred irregularly, and as often as 140 times in a minute. The state of the hearing in an ear thus affected varies with the cases, being in some normal ; in others, noises occur in an ear already somewhat hard of licaring, while in some the hear- ing is momentarily affected, apparently by the altered tension 482 MIDDLE EAR. which ensues in the tympanum, with each spasmodic occurrence of the noise. Causes. — The causes of the occurrence of involuntar}- objec- tive noises in the ear, have been souglit for in several ways, as in neuralgia of the superior maxillary branch of the fifth pair, with tic of the seventh, and of the branch which the inferior maxillary sends to the tensor tympani by means of the otic ganglion (Leudet), or in a reflex spasm, conveyed from the sensor}^ nerves of the diseased mucous membrane to the corre- sponding motor nerves, in cases connected with catarrh of the pharynx (Klipper). As an analogue to this peculiar affection of the ear. Dr. Klipper cites spasms of the orbicularis palpebrarum in connection with diseases of the conjunctiva. As shown in the cases I have observed and narrated above, the clonic spasms causing these objective noises are the reflex result of the irrita- tion from the catarrhal inflammation of the mucous membrane in the nasopharynx. Doubtless the retraction of the membrana tympani in some instances of objective noise in the ear, may have been due to a contraction of the tensor tympani muscle, but in the case of the Japanese, already given, the retraction of the drum-head was due, most probably, to the formation of a vacuum in the tympanum, produced by the sudden drawing apart of the walls of the faucial mouth of the Eustachian tube. This I consider all the more probable since the retraction ceased, as did the spasm of the velum and the noise, as soon as the membrana tympani ruptured. Ti^eafment. — The whole number of these cases is comparatively small, and the individual experience in regard to them limited, so that our knowledge respecting the therapeutics of this variety of aural disease has been very meagre. So far as we can glean an opinion from what has been written by others concerning the treatment of these cases of clonic spasms, the induced current has eftected the only apparent relief and cure (Schwartze, Politzer, and Boeck). This was tried without any good effect in the case of the Japanese, narrated as occurring in my own experience. Since spontaneous perforation of the membrana tympani in this case was soon followed by entire cessation of the clonic spasm in the velum, and elsewhere in the ear, and of the peculiar noises in the ear, I would recommend artificial perfora- tion in any similar case, if speedy relief from the symptoms should be urgently required, or if they should not 3deld to treatment of the catarrh of the nasopharynx which so evidently underlies them as the true cause. The treatment the author has found beneficial in these spasms is set forth in the account given above of the cases he has observed. It must be directed to the inflamed nares and nasopharynx. TUBERCULAR DISEASE OF THE EAR. 433 Extravasation of Blood into the Tympanum in Bright's Disease of the Kidneys. — An extravasation of blood into the tyniiianum in Bright's disease has been observed by Schwartze,' Buck,- P. McBride,^ Eajnaud,* and others. It has likewise been obscrve(P that deafness is a symptom of Bright's disease not directly traceable to uneniia, and that pain and suppuration may occur in the later stages of this malady.^ In the latter instance the tympanic disease may originate in an extravasation of blood into the drum-cavity. It is not diliicult to comprehend how, in the atheromatous and weakened condition of the vascular system in this form of renal disease, an extravasation may occur in the ear as it does in the eye and elsewhere. However, evidences in favor of either frequent or well-marked aural lesions, dependent upon renal diseases, are extremely meagre. Those lesions in the ear, which have been found in connection with Bright's disease and diabetes mellitus, and wdnch may have been dependent upon the dyscrasia induced by these renal disorders, are in the form of sero-sanguiiiolent and hemorrhagic eifusions into the drum- cavity. But the latter must not be mistaken for a sthenic form of otitis media hemorrhagica. From the serous nature of the membranous structures of the labyrinth, organic changes might reasonably be expected in that part of the ear in Bright's dis- ease, but positive proof of the occurrence of such lesions, based on ante- and post-mortem history, is wanting. Otitis Media Hemorrhagica. — Some observers claim to have detected a sthenic form of hemorrhagic otitis media. Its occur- rence is certainly very rare. It has been observed by Roosa, Mathewson, Hackley, and 0. D. Pomeroy. It is an acute and painful process, terminating in perforation of the membrana tympani and the escape of blood, but none of the ordinary re- sults of inflanmiation. The pain is relieved by the escape of blood from the drum-cavity. Tubercular Disease of the Ear. — Dr. Schlitz^ has made a study of tuberculosis of the inner and middle ear, with special refer- ence to the etiology of this process and the manner of its further dissemination thi-oughout the body. His investigations show ' Archiv f. Ohrenheilkunde, Bd. iv. S. 12. ' Diagnosis and Treatment of Diseases of the Ear, 1880, p. 164. ' Edinburgh Med. Journal, February and March, 1882. * Annales des Maladies de I'Oreille, March, 1881. * G. M. Smith, Transact. N. Y. Academy of Medicine, vol. iii. ^ Roosa, op. cit., p. 257. ' Die Tuberculose des inneren und mittleren Ohrs beim Schweine nebst, etc. Virchow's Archiv, Ixvi. p. 93. See review by Steudener, A. f. 0., Bd. ix. S. 130-132. 28 t 434 MIDDLE EAR. that the disease is usually ushered in by a catarrh of the pharynx, accompanied by a pulpy swelling and subsequent cheesy degen- eration of the neighboring lymphatic glands (13'mphatic catarrh), and finally passes into the tympanic cavity through the Eus- tachian tube. The disease then attacks the bony tissue of the pars tympanica, which soon passes into a state of proliferation, and in the inflamed and swollen tissue the first small gray tuber- culous nodules make their appearance (tuberculous osteomyelitis of the pars tympanica). At the same time small miliary nodules arise in the inflamed mucous lining of the cavum tympani. The tuberculous new formations finally till completely the drum- cavity, dislocating the auditory ossicles, which become necrosed. The entire pars tympanica is changed into new growth, and the disease advances in a peculiar manner along the tracts of the nerves which touch the tympanic cavity. At an early period the tuberculous growth penetrates into the Fallopian canal and attacks the facial nerve, which by this de- posit of tuberculous nodules in its interstitial connective tissue, is entirely separated into its individual fasciculi. Finally the internal ear is attacked, the semicircular canals and the cochlea are tilled with an exuberant tuberculous mass, which by the way of the aquaeductus vestibuli et cochleae passes into the T3ranial cavity. In the same manner the process advances in the connective tissue of the acoustic nerve and into the internal auditory canal, from which at last a tumor as large as a walnut may extend into the cavity of the cranium. It is worthy of re- mark that the dura mater is never invaded by the new growth ; it is only pushed ahead of it towards the brain. From the tympanic cavity the new growth, after it has em- braced the membrana tympani, passes into the external auditory canal and extends as a nodulated polypoid excrescence over the sulcus tympanicus and outward beyond it. At a later period, caseous as well as tibrous and calcareous transformation, takes place in the morbid growth. Secondarily, tuberculous processes may occur in any other of the organs of the body. Desquamative Inflammation of the Middle Ear ; So-called Chole- steatoma of the Petrous Bone. — Dr. Wendt has given a new ex- planation of the greatly discussed question concerning the true ^ nature of the so-called cholesteatoma of the petrous bone. He believes that in these cases there is present a special kind of in- flammation which he terms desquamative. This disease is ^ regarded as a collection of epithelium which is thrown off by jif the mucous membrane of the middle ear, in altered form and f increased quantity, and which, tinding no way of escape, is t ^'i 1 «.•■ DESQUAMATIVE INFLAMMATION OF MIDDLE EAR. 435 aceuinulated in the cavities of the middle ear, until it gnidiuilly fills them. Eleven cases of this disease were observed in the living, one of which was examined 'post mortem. In every case the collec- tions were composed of cells resembling scales of epidermis. The cells were arranged in lamelhv, through which were various, but never large, quantities of oil and cholestearin. In six in- stances the point of origin of these masses was undoubtedly the tympanum. In the other cases, simply their presence but not tiieir origin in the tympanum could be shown. Dr. Weudt has based upon his clinical and anatomical studies the following conclusions : "1. In some cases collections of a peculiar matter, resembling greatly the cerumen, are found in the external auditory canal and in the osseous middle ear. "2. These masses originate in a desquamative inflammation, characterized b}- a prolitic growth and exfoliation of epidermis- scales entirely like the cells of the mucous membrane of the osseous middle ear, the epithelial lining of which, during or after a chronic inflammatory process, may, by exposure to ex- ternal irritation, through the perforated membrana tympani, assume a cutaneous nature with the formation of a rete Mal- pighii and external layers, which, on account of the clogging up of the ear and the consequent shutting off" of the air, may undergo partial fatty degeneration. "3. They produce hardness of hearing of a moderate degree when they are dry and loosely placed, and when no greater changes in the sound-conducting apparatus are present. When the opposite conditions prevail, the deafness is of high degree, and pain wiM be produced if these masses swell, either under the influence of spontaneous suppuration in the middle ear, or of moisture from without. "4. They can produce important changes in the ear, the petrous bone, and even in the contents of the cranium, by means of the pressure they exert in their vicinity when they soften and swell, and also by their growth; perhaps too their size may in- crease by absorption of the broken-down fluid elements of them- selves or of neighboring pathological formations. "5. Their removal, though usually attended with pain and tediousness, is absolutely imperative. "6. It is not improbable that similar masses originating in a chronic inflammation of the walls of the external auditory canal, may pass into the tympanic cavity through perforations in the membrana tympani and produce there the same symp- toms (see p. 301). " 7. The collections of epidermis-cells, described in the litera- ture as cholesteatoma of the petrous bone, are likewise to be 436 MIDDLE EAR. regarded as products of a desquamative process in the middl ear, until it shall be proven, by a comprehensive study of th masses, that they originate in some other way." New-formed Membranes and Bands in the Middle Ear. — Morbidi membranes and bands occur very often in this cavity, and are very delicate in consistence and of a whitish or graj- tint. In the membranes there are deficiencies Avhich can be detected macroscopically; in the synechial bands these deticiencies are seen only under the microscope. All of the above-named new formations (membranes, bands, and cords) may be found in thei same ear. Their situation is very varied, they may connect the' various walls of the tympanum with one another and with the ossicula, they may be found in the mastoid cells, in connection with the membrana tympani, spread over the round window and the niche of the oval window, the rami of the incus, the; stapes, and over the tympanic mouth of the Eustachian tube,«j and the tendon of the tensor tympani. ii| Calcareous and osseous deposits may occur in these growths;'^ the functional derangements depend upon the consistence and situation of the latter. The diagnosis of these structures is possible during life if the membrana is thin enough, and Siegle's pneumatic speculum is used to aid in the examination. Respect-»f| ing the treatment, Wendt laid greatest stress on prevention: ■ the perfectly visible ones may, in some instances, be relieved by operations, which must consist in excision of a part, and not : simply incision.^ M Treatment. — Respecting the treatment. Dr. Trautmann very justly says: " After the pathological process has set in, constant ^ use of the catheter, by stretching and positive atmospheric pressure, will do more in producing atrophy and complete de struction, perhaps entire cure, than an operation in which ai piece of the morbid deposit must be cut out in order to preven fresh adhesion. Such an excision becomes very unsatisfactory, since the remote point of attachment of the morbid ligamenij cannot be seen." The Corpuscles of Politzer and Kessel; Wendt's Examination. "VVendt subjected these structures to a careful examination, andi^ concluded that too much importance had been attached to thera|| by their discoverers. He found these thickenings on the cor and bands in the tympanum and mastoid cells in thirty-three^ per cent, of all cases examined, both in the healthy and in the^ diseased ear. The form of these bodies is very varied, and byj I 1 Prof. Wendt, Archiv f. Heilkunde, 1874, pp. 97-100; also review by Dr4 Trautmann, in Archiv f. Ohrenh., Bd. ix. S. 279-281. MALIGNANT GROWTHS IN THE NASOPHARYNX. 437 no means as typical as held by rolitzer and Kosscl. Both "VVendt and Trautniann believe that the majority of these bodies are foetal remnants, though a few of them may be of recent date and of pathological origin. Dr. Trautmann considers them en- tirely insigniticant, unless, on account of their situation and rigidity, they should become mechanical hinderances to the function of the middle ear.^ Embolism in the Mucous Membrane of the Tympanic Cavity, — In some instances of general embolism and pyaemia, it has been supposed that embolism may occur in the mucous lining of the tympanum.^ In such a case observed by Wendt, there were found, besides nasopharyngeal catarrh, grea't alterations in the drum-cavity. The latter consisted in excessive swelling, macera- tion, and friability of the mucous membrane, which appeared to be stained with the coloring matter of the blood, and filled in its interstices with blood-corpuscles. The stapedes were buried in the swollen membrane, which fact probably helps to explain the great and sudden deafness which preceded death. The changes in this case were referred by Dr. Wendt to embolism of the tympanic artery, but the embolism could not be found post mortem. Malignant Growths in the Nasopharynx, involving the Ear. — Malignant neoplasms in the nasophar3'nx may involve the ear at an early period of their growth, as shown by the history of the following case of small-celled sarcoma in the vault of the j)harynx : On February 26, 1881, Dr. X , forty-five years of age, a practitioner of medicine in Philadelphia, consulted me respecting an increasing dulness of hearing in both ears, but chiefly in the left, with autophony, and also an altered objective pitch in his voice. His statements were, briefly, that in 1878 he had suft'ered from sciatica, and had taken Turkish baths freely as a cure; that he had then experienced what he considered a nasal catarrh, and some hardness of hearing in the left ear, without tinnitus aurium, but with more or less catarrhal resonance in his voice, with autophony. All of these symptoms increased latterly, as he supposed, in consequence of great exposure in his day and night work during the past rigorous winter, and at last he found he could not auscult with either ear. At the same time there was a sensation of moving fluid in his ears when he blew his nose. Examination of the hearing revealed that the watch was heard, left, ^% in.; right, -^-^ in. The tuning-fork on the vertex 1 See review ofWendt's paper, by Dr. Trautmann, Archiv f. 0., Bd. ix. S. 281. 2 Wendt;' A. f. 0., Bd. ix. S. 121. Abstract by von Troeltsch. 438 MIDDLE EAR. was heard better in the left ear. The voice was heard much better than the watch-sounds. The Eustachian tubes were in- flatable by Valsalva's method ; the pharynx and anterior nares were only very slightly congested. The left membrana tympaui was greatly retracted, and thrown into radiate folds ; behind it bubbles were seen distinctly. The right membrane was less re- tracted, without radiate folds, and bubbles were also seen behind it. Both membranes were therefore punctured, and the tym- pana evacuated, by Valsalva's method of inflation, of several | drops of yellowish, transparent fluid. Both the objective and subjective alteration in the vocal resonance disappeared instantly, and the hearing rose to the normal condition in the right ear, and to nearly a normal point in the left. This relief was main- tained until March 8th, nearly two weeks, when the right ear began to grow dull again, and the vocal resonance to return, both apparently caused by a filling up of the tympana, with fluid, as before. Bubbles were seen again, and paracentesis of the right membrane let out a large quantity of yellowish, muco- purulent matter, with the same relief as before. The patient was using at this time a weak solution of sulphate of zinc, 1 gr. to f §j — five drops, warmed, in each nostril once daily. On March 22d the right membrane had to be again punctured for the relief of the previous symptoms ; but the left ear showed ' no bubbles behind the membrane, and hence did not seem to i require puncturing. Not so, however, on April 8th, when both membranes required puncturing, which was followed by the same kind of discharge, and consequent relief. The nares, especially the left nostril, now seemed to be growing more stopped, nasal respiration began to grow ditficult, and at night painful, the pain being referred to the nucha and occiput. The ' patient now began to lose flesh and sleep, and became markedly weak in his muscles, and the nasal douche, which he had used once or twice, gave no further relief; in fact, the obstruction in the left nostril became almost total, Valsalva's inflation became more and more difficult, and both taste and smell failed. By ; April 27th, two months after he was first seen by the writer, Valsalva's inflation had become impossible, and the fluid was drawn from the left tympanum, after paracentesis, by means of suction with Siegle's speculum. The Eustachian catheter caused pain, and its use was not persevered in. The almost constant | and great pain in the nucha was probably due to congestion ■ of the vertebral veins. The aural symptoms may be considered due largely, if not entirely, to the mechanical obstruction of the pharyngeal mouth of the Eustachian tubes. j On July 10, 1881, Doctor X died. His decline was very J rapid from the date of the consultation, notes of which follow. ^ The tumor did not grow downward to any great extent, as it ' MALIGNANT GROWTHS IN THE NASOPHARYNX. 439 never appeui-ed below the velum. It eularg-ed sufHeiently, how- ever, in that direction to interfere seriouslv with deii'lutition and speech, so that toward the end it was necessary to feed him almost entirelj bv the rectum, and for him to communicate with his friends by writing. About two weeks before his death he took to his bed, and at the same time there were evidences I of pressure at the base of the brain. He had marked converging strabismus, dilatation of the pupils, dimness of vision, and ptosis. He also became very dull and drowsy, sleeping most of the time. His death was comparatively an easy one, and was caused immediately by [ exhaustion. There was no post-mortem examination. Dr. Harrison Allen, with whom I consulted in this case writes the following sketch of the case from his nasopharyngeal exami- nations : "Dr. X was seen by me in consultation with my friend, i Dr. Burnett, about April 15, 1881. At that time the soft palate was intenselv reddened and covered on its anterior surface with a number of nodular elevations, wdiich probably answered to the enlarged and engorged orifices of the glands there situated. The oropharynx was much congested and exceedingly irritable. The nasal chambers were both perfectly normal, the left being the larger. The voice of the patient had a decidedly nasal intonation. "It appears that about a year ago several attacks of epistaxis had occurred at short intervals, and the nasal intonation became from that time noticeable. At or near the same time a dull pain was experienced in the nape of the neck. The attacks of bleeding have long ceased, but the nasal voice and the nasal pain have persisted and caused Dr. X to suspect that he was suf- fering from his old enemy, rheumatic neuralgia, with a compli- cation of nasal catarrh. At the time of the above examination, nasal respiration w^as almost impossible. Examination was much interfered with by the almost incessant efforts of the patient to clear the pharynx of tenacious mucus. "The rhinal mirror detected a swelling on the left side of the vault of the nasopharynx. The Eustachian fossiB were con- ested, but in other respects appeared to be normal. The nger, being introduced into the nasopharynx, defined the swelling to be of the size of a chestnut, having a broad base and almost entirely occluding the left posterior naris. Con- siderable bleeding ensued upon the manipulation, and the patient acknowledged more distress than usually follows this rather disagreeable test. "April 22d, I saw the patient again, and succeeded in detaching portion, of the pharyngeal mass with the finger. This frag- ent, when submitted to Dr. Carl Seiler for microscopical ex- amination, was found to be a portion of a small-celled sarcoma. \i 440 MIDDLE EAR. " I saw Dr. X on three other occasions, but had no reason to change the opinion previously formed, that the patient was suffering from a vascular malignant growth at the pharyngeal vault, sessile in form and occluding the posterior naris of the left side. "The treatment was simply palliative, though the doctor was informed that an operation was, in my judgment, justifiable. The operation I proposed was a removal of the projecting mass in the pharynx, with the object of increasing the degree of nasal breathing. But the idea of an operation was so repugnant to the patient's feelings that the proposition was not urged. It was well that nothing of the kind was attempted, for, in the light of subsequent events, such a procedure would most likely have simply precipitated the fatal issue. " I saw the case for the last time in consultation with Prof. D. H. Agnew, who confirmed the views entertained by Dr. Burnett and myself, as to the nature of the case. The mass had by this time extended across the vault, and the degree of pharyn- geal congestion had greatly increased. "A word of explanation is demanded respecting the nasal respiration. The mass, while lying on the left side, is described as occluding the left naris only; yet the arrest of the nasal respiration was absolute. It has already been seen that the left side of the nose was the larger. There is no doubt that nasal breathing was carried on almost entirely on the left side, and when this side was filled by the growth, the general congestion of the pharynx was sufiicient to occlude the already narrowed rio-ht chamber." *o Primary Cancer of the Middle Ear. — Cancerous disease often passes from neighboring tissues to the middle ear, as, for ex- ample, in cancer of the auricle,^ cancer at the base of the skull,^ malignant disease of the parotid gland,^ and of the antrum of Highmore,* but cases in which it can be shown that the primary seat of the cancer has been in the middle ear are extremely rare. Instances of primary cancer of the middle ear have, however, been recorded by Toy nbee,^ Billroth,*^ Wilde," Travers,® "Wishart,® Boke,^°llobertson," and Schwartze,^- as referred to by the latter. 1 Gruber, Lehrbuch, p. 596. 2 Tiirck, Zeitschr. der K. K. Gesellschaft der Aerzte zu "Wien, 1855. 3 Schwartze, Archiv f. Ohrenh., Bd. ix. S. 215. * Schwartze, Ibid. ^ Diseases of the Ear, chap. xvii. ♦* Archiv f. Ivlin. Chirurgie, x. 67. ■^ Quoted bv Schwartze, loc. cit. Osteo-sarcoma. 8 Froriep'sNotizen, Bd. 25, No. 22, S. 352. ^ Edinburo-h Med. and Surg. Journal, vol. xviii. p. 393. 10 Wiener Med. Halle, 1863, Nos. 45 and 46. " Transact. American Otol. Soc, 1870. 12 Archiv fiir Ohrenh., Bd. ix. S. 208, 1875. PRIMARY CANCER OF THE MIDDLE EAR. 441 Jlisfor//, Coifi'sc, a))d Sipiq^fows. — In most cases there is a history of i)revious chronic purulent discharge, from the ear, Avliich tinally becomes the seat of the primary cancerous disease. The purulent affection may continue for a long time before the sym})tonis of the malignant disease appear. These are usually more or less sudden hemorrhages, with a more acrid and fetid discharge from the ear, and, at the same time, the ear becomes the seat of constant and increasing pain. Sensitive and ex- uberant granulations till the canal. The parts al)out the ear may become swollen and infiltrated, at last breaking down into ulceration. Death ma}' ensue before the disease breaks through the cutaneous tissues about the ear; but all the osseous parts to ■svhich the external ear is attached may be destroyed. An abscess not uncommonly forms over the mastoid portion, and in a short time sequestra may escape from the sinus left by the circumscribed inflammation. The hemorrhages may now become less frequent, but a discharge more or less copious and of a sanious nature still continues from the ear. The hearing is, of course, greatly impaird, and if the tuning-fork is not heard on the vertex, it may be concluded that the disease has invaded the labyrinth. Facial paralysis may ensue, and the glands near the ear usually become infiltrated and may suppurate. As the tissues about the ear break down, forming ulcers "with eroded edges, the hemorrhages from the ear increase in amount and frequency, the pain is terrific, and the fetor intolerable. In the case re- ported by Schwartze, the palate became paralyzed on the affected side. Finally the patient dies from exhaustion. Etiology. — Malignant disease of the ear most usually originates in the mucous lining of the tympanum.^ Malignant disease in an ear previously affected with chronic and neglected otorrhoea, may have its origin in the latter process.^ Some of the cases of death supposed to be due to the removal of aural polypi, should have been referred to an extension of a malignant disease, rather than to the excision of a tumor.^ Malignant growths in the middle ear are usually the result of extension thither from neighboring parts, as, epithelial cancer from the external ear, and fibrous" and medullary carcinoma from the pharynx or from the dura mater.* This seems to be confirmed by observations of cases by Moos,^ O. D. Pomeroy,^ Sune y Molist,^ Assaky, Polaillon,^ and others. » Toynbee, op. cit., p. 386. ^ Schwartze, op. cit., p. 218. » Eoosa, Treatise, p. 3!i4. * (imber, Lehrbuch, p. 59G. * American .Journal of Utoloa;v, vol. i. p. 209, 1879. « Ibid., vol. iii. p. 98, 18,Sl. ' Ibid.,, vol. iv., 1882. From Gaceta Medica Catalana, 3Iay 15, 1882. 8 Aunales des Maladies de I'Oreille, Nov. 1879. 442 MIDDLE EAR. Treatment. — It has generally been supposed that treatment is futile in these cases, but Schwartze claims to have obtained beneficial results from perforation of the mastoid process, when the disease has seemed to be extending inward, or to be pent up in the tympanum and mastoid cavity. Cancer of the Mastoid Portion. — The mastoid process may be- come the seat of cancer, as shown by Rondot.^ Its history and symptoms are similar to those given as characteristic of primary cancer of the middle ear, inasmuch as it seems to be a conse- quence of neglected chronic otorrhcea. The earliest symptoms, besides the chronic aural discharge, are hemorrhages from the ear, soon followed by intense pain and swelling of the mastoid and the parts about the seat of the disease, great deafness, and tinnitus aurium. As the disease advances, facial paralysis may ensue, the mastoid portion be- comes more swollen and painful, the extreme point of the pro- cess may be most tender, giddiness and vomiting are apt to be joined to the other symptoms, and the entire mastoid region is covered with suppurating and fungoid nodules. Emphysematous Tumor over the Mastoid Portion. — Xatural de- hiscences in the mastoid portion of the temporal bone some- times persist, and favor the escape of air from the middle ear and mastoid cavity to the skin l.ying over the latter, as has been observed in a case reported by Prof. Wernher,^ of Giessen. This curious affection may show itself suddenly after Sin ordinary act of sneezing,, in the form of a tumor, the size of a pigeon's egg, over the mastoid. There is no pain attending its formation, and the patient may be entirely unconscious of its occurrence. So perfect may the connection be between the mastoid cavity and the emphysematous tumor, that gentle pressure will force the air from the latter into the middle ear and fauces ; but renewed expiratory eflbrts will reproduce the tumor. Gradually such a formation over the mastoid may extend, until the entire corresponding half of the scalp is in- volved, and the latter is lifted at some points 1^" to 2" above the skull, as was observed in the case referred to. The middle ear and membrana tympani may be normal, but a large dehiscence, the remnant of the natural openings in the infantile bone, may be found running across the entire mastoid portion, as in the case reported by Wernher. Compression long kept up, having failed, in the case reported, to produce a cure, a successful endeavor was made to set up adhesive inflammation 1 Ibid., p. 227, 1875. * Deutsche Zeitschrift fiir Chirurgie, Bd. iii. ; also Arcliiv fiir Ohrenh., Bd. ix. J J if TRAUMATISM OF THE MASTOID. 443 between the edges of the dehiscence and the superjacent soft tissues. This was accomplished by means of subcutaneous in- jections of tincture of iodine at various points in the tumor. Hairs in the Mastoid Cells. — Another curious condition of the mastoid cavity is the followinii-, rehited bv the late Mr. Tovnbee. He showed' a specimen of hairs in the mastoid cells, and said that according to his experience the case was unique. The hairs were firmly embedded in the mastoid cells, and surrounded by masses of epidermis. Dr. Tilbury Fox, who examined them, agreed that the hairs could not have been introduced from without, but were nourished in the cells. Traumatism of the Mastoid. — Serious wounds^ and fractures' occur in the mastoid portion of the temporal bone. The follow- ing case of injur}' of the mastoid is of great interest, as it shows how great a perforating wound of the osseous substance this part of the bone can sustain without fatal results, and furnishes a strong argument in favor of the impunity of careful surgical operations on this part of the ear. Firicture of the Mastoid Portion, Followed by Faded Paredijsis. — On November 3, 1881, John McMurray, twenty-four years old, a brakeman, was admitted to the surgical ward of the Presby- terian Hospital, Philadelphia, during the service of Dr. Thomas B. Reed. At the time of his admission he was insensible, and remained out of his mind for two w^eeks thereafter. There was a wound running horizontally backward from the meatus, en- tirely through fhe auricle, and communicating with a deeper wound which extended into the mastoid portion and the posterior bony wall of the auditory canal, so as to throw these two cavities into one. Upon returning to consciousness his statement was, that on the 3d of Xovember, while on duty as brakeman on a freight train, he was struck behind the left ear. He could not say how or by what he was struck. He was found insensible and bleed- ing on top of his car, where he had fallen while putting on the brake. The sterno-cleido-mastoid muscle was cut from its insertion, there were marked facial paralysis and hardness of hearing on the injured side, and there had"^ been considerable hemorrhage, both before and after admission to the hospital. The writer examined the case, for the first time, November 29tlj, in the Ear Department of the Dispensary connected with 1 From the report of the Patholoo-ical Society of London, in the Medical Times and Gazette, March 3, 1866, p. 238. 2 Biirkner,' Archiv fiir Ohrenheilkunde, Bd. xvi. S. 59, 1880. 5 Kirchner, Ibid., Bd. xix. S. 257, 1883. 444 MIDDLE EAR. the Hospital, and found the patient very weak, with the left side of his face greatly paralyzed, and a disposition to lose his vision for a few moments upon turning in bed, or rising suddenly. The wound in the auricle had already healed. The auditory canal was somewhat obstructed with granulations in its deeper parts, but at the point of junction between the bony and car- tilaginous parts, on the posterior wall, the canal communicated with the Avound cavity in the mastoid. A movable piece of bone, spongj^-looking behind, but rather smooth in front, that is, towards the auditory canal, lay in this wound and was easily pushed backwards and forwards, both from the auditory canal and mastoid wound. This piece of bone was pushed so far forwards into the calibre of the canal, as to hide the drum-head from view, except at its upper and anterior quadrant. The patient could not hear words on this side, nor the tuning- fork by aerial conduction, but the fork vibrating on his vertex was most distinctly heard in the wounded ear. As no perfora- tion-whistle was ever produced, either by Valsalva's or Politzer's inflation, the diagnosis limited the disease to the outer ear and the mastoid portion. On December 16, 1881, the aforesaid movable piece of bone became detached from the soft parts and was removed. The ' drum-head now became more visible, only about one-third being ' hidden from view by a granulation on the posterior wall of the auditor}^ canal; but no perforation in it could be detected. The | hearing also improved, words being heard a foot off". The piece > of removed bone was about one-half an inch in length and breadth, and three-eighths of an inch thick, rather smooth on the surface towards the auditory canal, but evidently composed of ' mastoid cells, traversed by a distinct canal which resembled in calibre the facial canal. Upon holding this piece of bone in | such a position as to correspond with a similar part of a normal I temporal bone of the left side, the canal running through it was found to correspond with a part of the facial canal, not far from the stylo-mastoid foramen. Hence the facial paralysis must be explained by the assumption that the facial canal and its nerve were severed by the blow which had penetrated the mastoid ^ portion of temporal bone. j An ophthalmoscopic examination revealed on the right side a .; quite prominent, choked disk; the veins decidedly swollen, disk : very red; the arteries diminished in size, their coats white and . glistening; an especially white patch on nasal side of disk; the i right pupil considerably larger than its fellow. On the left side ',' the same condition was found, but it had been of longer duration. ,] The patient's condition continued to improve, however, in ij every respect, excepting in the paralyzed state of his face. The if hearing improved, he ceased to lose his sight upon sudden J f! ACUTE PURULENT INFLAMMATION. 445 motion, and lie was finally dismissed January 2, 18S2, at his own request, the wound in the mastoid having closed, and the calibre of the auditory canal being nearly perfect. lie was seen a few months later, appeared in very good health, the hearing was very good, but the facial paralysis remained. \f CHAPTER V. ACUTE PUKULENT INFLAMMATIOX. The disease previously treated of, catarrhal inflammation of the middle ear, is characterized by its tendency to harden and stifl:en the original tissues of the ear, and in some cases to de- velop hypertrophy of the same. But purulent inflammation of the middle ear, which it is now proposed to consider, is charac- terized, both in its acute and chronic form, by its tendency to break down and to destroy the tissues of the ear invaded. These two distinctions cannot be too constantly kept in mind, when endeavoring to study diseases of the middle ear, for it will be found upon careful examination that every inflammation invading the mucous membrane of the middle ear, in the vast majority of instances, must be placed in one of these two general divisions. Already it has been shown that catarrhal inflamma- tion of the middle ear is conservative of tissue, and limits itself strictly to the ear. But there is a large number of cases of in- flammation of the mucous lining of the middle ear, which tend at the outset to the formation of pus. This form of inflamma- tion of the middle ear, not only' breaks down and destroys the tissues of the ear, but it is characterized by its tendency to in- vade other parts of the head, especially the cranial cavity. In this virulent form it not unfrequently produces pyfe,niia, embolic diseases in the abdominal and thoracic viscera, cerebral abscess, and death. SUBJECTIVE SYMPTOMS. The subjective symptoms of acute purulent infla,mraation of the middle ear are usually very rapid and violent in their suc- cession. They are chiefly itching and tickling, referred to the Eustachian region and the car; a sense of fulness and uninter- mittent pain deep in the ear, which is greatly increased by coughing, sneezing, talking, or eating; tenderness of the ad- 446 MIDDLE EAR. f jacent maxillarj^ articulation (though the hitter symptom is not as marked in this disease as it is in inflammation of the external auditory canal); vertigo; tinnitus aurium; and hardness of hearing. To these distressing symptoms in the ear, is added pain in the side of the head corresponding with the affected ear, running forward to the eye, temple, and frontal sinus, and backward to the occiput. The condition of the sufferer becomes at last most pitiable; every movement of the head and body causes intense agony, the eyes roll about in a frenzy of pain, no comfortable position can be obtained either in sitting or in lying down, and even the strongest man may be forced to shriek, so dreadful is the suffer- ing from acute purulent otitis media. If the victim is an infant or young child, all these symptoms may be mistaken for another disease, very often for incipient brain-disease, and this erroneous opinion is all the more confirmed by the not uncommon con- vulsion, into which the child may be thrown by its frightful sufferings. Usually these symptoms are relieved by a spon- taneous rupture of the drum-head and escape of purulent matter. But this result will be more fully discussed under the considera- tion of the objective symptoms of the disease. It becomes, indeed, one of the prime duties of a physician to be on the lookout for the acute occurrence of this disease in children, for upon its timely recognition may depend the life of the little patient. Certainly much suffering would be avoided, perhaps many lives saved, if the ear were even once thought of as the possible cause of an apparently obscure disease, in those too young to tell where the seat of their pain is. Not only in children, but in adults, this disease is one of the most important the physician meets. The importance of treat- ing it properly in its acute stage cannot be too highly estimated. Yet it is lamentable to state, that it is usually entirely disre- garded. Itching in Throat and Ear. — The itching and tickling of this disease are felt running from the throat, along the Eustachian tube, and to the depths of the ear, or vice versa. This is due to a direct passage of the inflammation from the throat to the ear, in some cases; in others, it is purely reflex, like ear-cough. Very often this sense of itching is the first symptom which calls the attention of the patient to his ear. It may, however, be entirely overlooked, and the ear is disregarded, until sharp pain in it arrests the attention of the sufferer. Pain. — In the pain of acute purulent inflammation of the ear, we have perhaps the earliest diagnostic symptom of this disease. It will be found that, as a rule, the severity and continuance of ACUTE PURULENT INFLAMMATION. 447 pain is niucli more iiuirked than in the eatarrhal I'orni of in- tiammation of the middle ear. As has been stated, the pain in that disease is never so intense as in acute purulent inflammation of the ear, and it very often remits during the daytime; but the pain in the acute purulent disease often leaps at once to an unendurable severity, and, if left to itself, is eased only by the escape of puriform matter from the tympanic cavity. AVhile the pain of the former is often not severe enough to keep the patient from his daily avocation, the pain of the disease under consideration is usually so intense as to excite secondary symptoms of fever, and in some cases de- lirium. Alteration in Hearing. — At the beginning of this disease the hearing may become abnormally sensitive, and ordinary sounds will cause increase of pain in the ear. The patient's own voice may also give him pain. As the inflammation advances and its results are more full}' established, the hearing will grow dull, and by the time secretion is fully established, the deafness may be great. The subjective noises are usually very annoying, and in many cases very distressing. Concerning tinnitus aurium and all kinds of so-called subjective aural sounds, the reader is referred to page 352. Vertigo, Fever, and Deliriwn. — Vertigo may be a symptom in this, as in manv other aural diseases. It seems most marked after secretion is established, and before the membrana tympani is ruptued. It is, therefore, apparently due to pressure com- municated to the labyrinth. It often continues, however, after rupture in the membrana tympani. Fever and delirium, excited by the intense acute inflamma- tion, must be treated on general principles, with this exception, that cold applications to the head, near the afl:ected ear, should be avoided. While cold may allay inflammation elsewhere, no good results can come from its application to an acutely in- flamed middle ear. This is due to the specially bad effects of cold in any form npon the ear. OBJECTIVE SYMPTOMS. L„„.„ .,..^„„. early stages of this disease, it will be found congested at its periphery, and markedh^ about the membrana flaccida and the malleus. Gradually this congestion spreads inward from the periphery and outward, i. e., backward and forward from the manubrium of the malleus, until the entire drum-head is de- cidedly pinkish, with especially deep shades in its upper half 448 MIDDLE EAR. When so much congestion has occurred, the usual contour of the membrane will be less marked, the handle of the hammer will be less distinct, and the lustre of the dermoid layer, and the pyramid of light will disappear. Vesicles may form on the membrana tympani at this point of the disease, but they are not common. The normal features of the drum-head are thus made to vanish, but in the lighter cases they may not become more distorted than above described, while in the severer cases the congestion and swelling of the membrane become so great that, at the fundus of the canal, there is only an undefined and sodden red diaphragm in the place of the normal drum-head. Spontaneous Rapture of the Memtjrana Tympani. — This event is to be regarded as a chief symptom of purulent inflammation of the middle ear. Whatever may have been the nature of the inflammatory action in the tympanum at the outset, it will be found that when the disease has advanced so far as to produce spontaneous rupture of the membrana tympani, the matter discharged through such a ruptured spot will be of a Y)urulent nature. This is in keeping with the tendency of the disease to break down tissue. Mucus in large amount may accumulate behind the membrana tympani, and, after clogging the tj'm- panum for a time, be absorbed. It cannot be shown that if pus forms in the tympanum it is ever absorbed, or, if let alone, it escapes in any other way than by spontaneousl}^ rupturing the membrana tympani. Nor does nature long delay the rupturing of the membrana tympani after pus has formed in the tympanic cavity. But mucus may lie in the tympanum long after all acute symptoms have subsided, and is usually the cause of the continued deafness after a comparatively slight attack of catar- rhal congestion and inflammation. In acute purulent inflammation of the tympanum, the mem- brana tympani will be found to be bulging very soon after the onset of the acute symptoms, unless the membrana tympani is broken down early in the inflammatory process. The bulging is usually confined to the posterior half of the membrana tym- pani, because all the efforts of blowing the nose, sneezing, and the like, force the products of inflammation backwards toward the hinder part of the tympanic cavity. I COURSE. The course of acute purulent inflammation may, therefore, be said to tend to a greater or less destructive process in the mucous lining of the cavity of the tympanum, and to rupture of the membrana tympani. The latter event is usually the first destructive result of the disease, and is very likely to give relief ) i ACUTE PURULENT INFLAMMATION. 449 to pain. In some of the more violent cases, pain may not only continue, but increase after the rupture of the membrane. In such cases, a well-grounded suspicion may be aroused that the disease has invaded parts deeper than the mucous lining of the drum-cavity, and that it is likely that either the mastoid cells, or the cranial cavity, or both, may have become affected. Authentic accounts of death resulting directly from acute purulent intlammation of the ear are rare — though doubtless death has occurred from this disease in its early stages, but has been set down to other causes. Death from the chronic form is a common occurrence. Fossihle Fatalify of ihe Acute Form of Furulent InfanrrnaU'ov of the 3F«ldle Ear. — It is a great misfortune, but one to be attributed to the hitherto imperlect means of examining the ear, and the consequent ignorance concerning the processes which go on there, that so few positive and accurate facts can be found as to the number of deaths occurring from acute purulent inflamma- tion in a previously healthy ear. Most writers mention its occurrence, but few give details of cases. Toynbee' found that the dura mater partook in the tympanic inflammation of typhus fever, which fact would seem to indicate that the tympanic disease shared largely in the fatal result. Bezold- has found that the tympanum is attacked by purulent in- flammation in four per cent, of all cases of typhoid fever. Itard, quoted by Toynbee, gives an authentic account of death in a sliort time after the onset of acute tympanic disease, the latter being undoubtedly the cause of death. Wilde^ says death occurs frequently from acute inflammation of the ear, among the lower classes in Ireland; but he gives no account of these cases, probably because he considered them so well known as to need no illustration. Dr. Edward LI. Clarke,* of Boston, has narrated a case occur- ring in his practice, of a boy, in whom the acute inflammation of the middle ear proved fatal in fourteen weeks after its onset, by producing an abscess in the brain. In this case the inflam- mation of the middle ear passed through the tegmen tympani and thence to the brain. "The moisture and redness of the petrous bone at that point served to mark the track of the disease." Tins case was of three weeks' standing when Dr. Clarke first had the opportunity of treating it, and he very justly ob- serves: "If it had been possible to arrest the disease when it first attacked the ear, and before the bone, or rather the peri- 1 Op. cit., p. 320. 2 Archiv fiir Ohrenheilkunde. Bd. xxi., 1884. ^ iJiseascs, of the Ear, p. 24L * Archives of Scientitic and Practical Medicine, Jan. 1873, No. 1. 29 450 MIDDLE EAR. osteum, was invaded, the life of the patient would probably -have been saved."^ I saw, not long since, in the Philadelphia Infirmary for Dis- eases of the Ear, a case of acute inflammation of the tympanic cavity, in a woman thirty years old, which proved fatal in less than a month, by an extension to the mastoid cells and brain. The patient rejected the treatment proposed to her, viz., trephin- [ ing tlie outer wall of the mastoid portion, and did not return to the Infirmary; but I learned from her friends that she at last succumbed, with every symptom of most violent intiammation of the brain. Though these cases show the course acute inflammation of the drum-cavity may take, it usually pursues a more favorable course. But they show the importance of early and intelligent treatment. Darolles- has given an account of acute otitis media puruleuta \ of the right side, followed b^' facial paralysis on the same side on the tenth day; acute meningitis was caused in this case by [ irruption of the pus into the aqueduct of Fallopius. On the sixteenth day profuse sweating, involuntary dischargee of urine and feces, paralysis of the left arm, dilated pupils, reacting sluggishly, thready pulse, temperature 40.6° C., were noted. Death occurred the same evening. The post-mortem examina- tion revealed: Veins of the pia and dura mater greatly con- gested; copious purulent infiltration into the subarachnoid cellular tissue, confined chiefly to the base, and the convexity of •the right hemisphere; on the leftside only those portions of the brain overlying the sphenoid bone were aftected. Small in- sulated purulent foci were found along the bloodvessels of the . convexity of the brain. The pia mater adhered at several points M to the gray substance. '^| The outer surface of the petrous bone presented no abnormal feature, but the tympanic cavity was filled with pus, in which ■ the ossicles floated about free. A small perforation the size of *l a pin-head was found in the upper segment of the drum-head; the mastoid cells were also filled with pus. The facial nerve was exposed as fiir as its second turn, at the Fallopian hiatus, and was covered throughout its course with thick pus. The other walls of the tympanum were normal. Dr. Giihde^ has related a case of death resulting from an acute purulent inflammation of the middle ear. The patient was a young private soldier, under Dr. Giihde's observation in Magde- burg," Germany. The acute symptoms occurred on the 27th of 1 Loc. cil., p. 47. 2 Bulletin de la Societe Anatoiniquc de Paris, 1 fasc, 1875. See review by Kiihn, Archiv f. Ohrenheillc, Bd. x. S. '253. s Archiv f. Ohrenheilk., N. F., Bd. ii. S. 98. ACUTE PURULENT INFLAMMATION. 451 ■August, but appeared to subside after a slight discliarge had occurred from the alfected ear, the right. By the 12th of Septem- ber, however, the discharge from the ear and tlie pain having in the meantime ceased, the patient comphiined once more of pain in the ear, and his mastoid portion was found to be very sensitive to pressure. Notwithstanding rest in bed and free leeching behind the affected ear, cerebral symptoms set in, and on the second day after the appearance of the symptoms the man died. The post-mortem examination revealed that the pus had ac- cumulated in the tympanic cavity in large amount, l)ut instead of bursting through the membrana tym[)ani a second time, and thus saving the life of the patient, it had forced its way into the mastoid cavity, and thence through a defective spot in its posterior wall, until the products of inflammation were brought in contact with the dura mater. This, of course, set up an irritation in the covering of the brain, and fatal meningitis soon followed. A free opening in the membrana tympani might have saved this man's life. I have observed, not infrequently, that a perforation in the membrana tympani will heal up after giving vent to some of the products of inflammation in the tympanum, but before the cavity is entirely drained. If the case is watched now for several days, it will be found that there is a return of pain, and the drum-head will be seen to be bulging again. Disease may have already thickened it so much that it will not give way as Cjuickly as it did before, and therefore it becomes imperative to open it artificially, and allow whatever may have accumulated behind it to escape. In some cases, before the acute process had entirely disappeared, I have found it necessary to puncture the membrana tympani a second time. ETIOLOGY. The most usual causes of acute purulent inflammation of the middle ear are the exanthemata, local cold in various forms, and direct violence to the ear. The first two are well known as the most fruitful sources of this severe malady. Whooping-cough also very often produces acute purulent disease of the tympanum. When acute purulent inflammation arises in these diseases it is always a serious complication, chiefly because it is either un- recognized or neglected for the supposed sake of more attention to the general disease. The latter, however, can receive every possible attention, while the ear-disease gets its share too. Even if the attention is not drawn to the ear by symptoms pf aural disease, the knowledge that the latter is likely to occur in 452 MIDDLE EAR. the already named maladies, should prompt an early and careful examination of the ears in evei^i/ case of exanthematous disease. If the treatment of the ear were made an important part of the general treatment, the latter would certainly be more effectual in the exanthemata, for not onl}' would the general disease run a more favorable course in its acute stages, because relieved of a most painful complication, but there would be less chronic purulent disease of the ear with its dreadful results, following in the track of the above-named affections. Mr. Ilinton,' of London, was of the opinion that the mortality from scarlatina might be diminished by bestowing care upon the ears when affected by that disease. Cold Bathmg ; its Effect on the Middle Ear. — The effect of cold bathing on the ear has received of late a good amount of the attention due it. The exposure of the ear to cold water, in diving, sea-bathing, and the like, seems to be a very common , cause of acute inflammation in the middle ear. While it cannot be denied that sea-bathing applied to the general cutaneous surface may be very benelicial in certain forms of ear-disease, the contact of cold water with the membrana tympani is always fraught with danger to the ear. Therefore all forms of cold-water bathing must be so con- ducted as to preclude this dangerous contact of cold water with the drum-membrane. This can be done only by keeping the head above water, or by stopping up the external ears, if the head is to go under the surface of the water. This may seem an extreme view, and it may be said that thousands bathe with- out incurring acute inflammation in the ear. Such may be the case, but while acute processes may be avoided, it is equally certain that the frequent contact of cold water with the mem- brana tympani, lays the foundation of chronic deafness of a catarrhal variety. In the latter case the conservative force of nature thickens the drum-membrane in order to resist the frequent assaults of the cold water, which is allowed to enter the external auditory canal. The frequent entrance of cold water into the externxil auditory canal induces a tendency to a chronic dermatitis and periostitis of that part of the ear. It is noteworth}^ that no mammal but man goes voluntarily under water, without being provided with a means of prevent- ing the water from running into the ears. It is a fact well known to many that hunting dogs taught to dive, become deaf. Acute Infiammation of the Tympanic Cavity produced by Concus- sion. — Now and then an acute inflammation in the drum-cavity is set up by a fall, a blow upon the auricle, or an explosion near the ear. In such a case the traumatic force seems to be the ' Questions of Aural Surgery, p. 133. J f ■^1 ■.ff! ACUTE PURULENT INFLAMMATION. 453 powerful compression of the air in the external auditory canal and tympanic cavity, brought about by the sudden concussion. These cases are entirely distinct from cases of deafness result- ing from concussion of the nervous api^aratus of the ear. Tn the latter we find deafness, unattended by any signs of acute intianimation of the middle ear, the only symptom. When ail acute inflammation in the middle ear is caused by a fall, an explanation may be sought for in the peculiar way in which the force of the fall is spent upon the air of the tympanic cavity. The concussion of the air in this cavity may be so powerful as really to wound the mucous membrane. As no direct violence is offered to the middle ear in these cases, the intiammation must be due to the effect of the violent oscillation of the air in the tympanic cavity. I have seen but one case of acute inflammation of the middle ear resulting from a fall, and that was in Politzer's clinic, in Vienna, in 1872. Prof. Politzer stated, at that time, that "he had seen a few cases of what he termed traumatic catarrh^ of the middle ear, a disease entirelv distinct from those forms of disease resulting from concussion of the cochlea." Acute Purulent InJIammation of the Tymjoanic Cavity^ from a Blow on the Auricle. — I have observed acute inflammation in the tympanic cavity, following a blow on the auricle, in a boy thirteen years old, who was struck on the ear by a ball. There was, in this case, very little external otitis, the auditory canal remained unswollen, though rather more tender than usual, there was pain deep in the ear, with tinnitus and deaf- ness, great redness and swelling of the membrana tympani, perforation of the same, and a discharge of blood, mucus, and pus from the tympanum. Mastication was painful to the affected ear, and the boy lost appetite and strength. Inflation of the tympanum was easily done by the method of Valsalva and by that of Politzer, showing no obstruction in the Eustachian tube. The ear was syringed regularly each day with warm water, and mild astringents were instilled into it, tonics were given, and in six weeks the boy began to recover his health and hearing, both of which were finally restored. Concussion plainly caused this case of tympanal inflammation. Its mode of action was by a sudden compression of the column of air in the auditory canal, as the ball struck the auricle, and by a consequent forcing in^^ard of the membrana tympani, and a violent shaking of the delicate structures in the middle ear. Very interesting -cases of this kind of acute inflammation of the middle ear produced by concussion, are four reported by • Saissy alludes to a similar form of disease, English translation by N. R. Smith, Baltimore, 1829, p. 109. 454 MIDDLE EAR, Dr. J. Orne Green. ^ Two of these cases of acute tympanal dis- ease were caused bj an explosion^ of a bag of gas, one b}' a blow on the ear from a policeman's club, and a fourth by a fall thirty feet, upon the head. In all of these cases the drum-membrane was ruptured by the traumatic force, and in the first three purulent, and in the last-named simple, catarrhal inflammation ensued. These cases are examples of accidental injury to the sound-conducting apparatus of the ear, and should be carefully diagnosticated from cases of partial or total loss of hearing, from accidental injury to the brain or nervous structures of the ear. Such cases become of the greatest importance in legal medicine on account of the accuracy of diagnosis demanded by their occurrence. Not long since, an intelligent man presented himself for treatment of deafness and tinnitus resulting, as he said, from a blow on the ear, from a policeman's club, a few days before. He stoutly asserted the integrity of his ear before the blow, but after removal of dried blood from the auditory- canal I found an unmistakably chronically diseased drum-head, and, on examin- ing the fauces, a markedly granular pharynx. On the next day, after the drum-head had become dry from the water syringed into the ear, it was found to be lustreless and retracted, the handle of the malleus prominent and twisted on its long vertical diameter, and the lower segment of the drum-head contained calcareous spots. The Eustachian tube was pervious to the air of the catheter. With all these features of chronically diseased throat and a more or less atrophied drum-head, an opinion as to the cause of deafness should be given guardedly. It is well known that a progressive hardness of hearing may advance very far, before the attention of the patient is drawn to it. In the case just mentioned, it appears probable, to one familiar with aural dis- ease, that the blow from the policeman's club was not the sole cause of the deafness, yet, at the first recital of such a case, one naturally thinks immediately of an acute injury to the nervous structures of the ear. DIAGNOSIS. In the diagnosis of this disease there are several prominent subjective and objective symptoms for guidance. In the first instance, the severity of the pain will be so much greater and persistent than that of acute catarrh, that it alone will aid in ^ Transactions American Otolos;ical Society, 1872. '^ One of the two cases caused by explosion was under the care of Dr. Shaw, to ■whom Dr. Green acknowledges liimself indebted for the notes of the case (loc. cit.). ACUTE PURULENT INFLAMMATION. 455 forniing- a true diagnosis, and the general systemic disturbance which also accompanies it, will be an additional evidence as to the real nature of this disease. With all this intense pain in the car, we may be surprised to find the auricle and meatus not sensitive to gentle traction. This latter feature of the disease should at once free our minds from the idea that the })ain is caused bv anv form of external otitis. In either the circumscribed or diffuse variety of external otitis, the slightest numipulation of the auricle and auditory canal is usually attended with pain. The objective symptoms, too, in external otitis, enable us to form a diagnosis between it and acute inflammation in the middle ear. The diflercntial diagnosis becomes more difficult when there is a diffuse external otitis consecutive to the tympanic inflammation, especially if the former should close the auditory canal. This closure, how- ever, is not so likely to occur in the consecutive as in the idio- paihic form of external otitis. Another aid in diagnosis is the fact that diffuse external otitis, consecutive to an acute inflam- mation of the middle ear, is comparatively rare, and not very rapid in its onset. Before it appears, an opportunity is gen- erallv afforded to examine the membrana tvmpani and establish a diagnosis of the original tympanic disease. If doubt is still present, as to the condition of the drum-cavity, its state must be further determined by the use of the Eustachian catheter, inspection of the fauces and nares, and a careful noting of all the general symptoms. Earache from Decayed and otherwise Diseased Teeth. — The pain of acute inflammation of the tympanic cavity may be confounded with that caused by diseased teeth, and other dental irritation. Von Troeltsch has already noticed that it is often difHcult to dis- tinguish pain in the molar teeth from pain in the middle ear. Many cases of earache occur, not only in those with neglected carious teeth, but in the more fortunate whose teeth are fllled with gold. In the latter, otalgia is often produced by inflam- mation and caries beneath the fllling. I see constantly nuxny cases in the former class, in the Inflrmary, and now and then cases of the latter variety present themselves in private. Al- though, in such cases, the objective aural symptoms would remove all doubt from the mind of one familiar with the ap- pearances of a normal ear, still, the possible cause of pain in the ear, arising from diseased teeth, should be borne in mind until the diagnosis of a different cause is fully established. Whenever we tind earache without sufficient objective symp- toms of its cause, it is never amiss to inquire after the condition of the teeth. liau^ says that, in young children, dentition is always attended 1 Ohrenlioilkunde, p. 158, Berlin, 1856. 456 MIDDLE EAR. with irritation in, and sometimes discharge from, the skin lining the external auditory canal. (See p. 89.) The fact that an unchanging pain is usually the oiihj symptom present in otalgia due to a diseased tooth, will aid the diagnosis. Upon reviewing the records of lifteen hundred cases of ear- disease observed by him. Sexton^ found that the teeth are the seat of disease more frequently than was at first suspected, and of these cases, fully one-third owed the origin and continuance of their aural malady to the dental disease, to a greater or less degree. This excitation of disease in the ear by diseased teeth, gums, and buccal surfaces in the mouth, is succinctly explained by the continuity of nerve-fibre — not simply a continuity of sensori-motor nerve-fibres, but in the relation of the vaso-motor nerves and their functions (Woakes). Sexton further states that the ear begins to suffer from sym- pathetic dental irritation from the time of the appearance of the two central incisors of the lower jaw; that during second denti- tion the mouth has but little rest, and hence there may be re- flected from it an irritation in the form of engorgement, to the middle ear, and hypertrophy of the gums and epulis may be regarded as probable causes of aural disease in later years. He also draws attention to possible detrimental action on the mouth, and thence upon the ear, from bad plates holding artifi- cial teeth, and from poisonous substances entering into fillings for cavities (especially amalgams containing mercury). Appearances of the Membirina Tympani. — The general alteration of the membrana tympani is more intense in acute purulent otitis media than in the catarrhal form. The membrane will be found passing from a stage of congestion around its periphery and malleus, to successive ones of greater intensity, until all its contours are lost, and either a bulging or a misshapen diaphragm is seen at the fundus of the auditory canal. But we cannot point out any specific symptom in the membrana tjmipani as peculiar to this disease; it is rather the general and severe im- plication of the whole membrane that would seem to distinc- tively mark its condition in this disease. Whenever any matter collects behind the membrana tympani in quantities large enough to force the latter to bulge, such pro- trusion is almost invariably in the posterior half of the mem- brane. If the membrane has not been thickened by previous catarrhal disease, it is more apt to give way spontaneously in the acute purulent form than in the acute catarrhal form of otitis. Bulging is hence more common in the latter than in the former disease. 'Whenever the membrane appears to be in hillocks, or puck- * American Journal of the Medical Sciences, Jan. 1880. ACUTE PURULENT INFLAMMATION. 457 cred, there is most probably exceptional iniplieatioii of its dermoid layer, in all likelihood due to a consecutive diffuse external otitis. The latter may not advance further outward than the immediate reu'ion of the membrana tympani; or it may, unfortunately, invade the entire external ear. PROGNOSIS AND TllEATMENT. The prognosis in properly treated acute purulent inflamma- tion of the middle ear, though usually favorable, must always be moditied by the cause of the disease and the general condition and age of the patient. The cases arising in acute exanthemata are the least favorable, because usually neglected. Those occur- ring in an ear previously diseased, or in one occluded to an extent likely to prevent the escape of the ])roducts of inflam- mation, must be considered as gravely complicated, not only as to the hearing, but as to the life of the sufferer. An ordinary uncomplicated case of acute inflammation of the middle ear, arising from cold or from traumatic violence, is rarely fatal to life. This disease usually causes, however, some permanent alteration in the hearing, though the amount is small in the properly treated cases. The treatment of acute tympanic inflammation must be em- phatically antiphlogistic. The endeavor must be to reduce the congestion and pain, and to prevent suppuration. The patient should be housed if the weather is cold or inclement in any way, and in most cases it will be best to confine the patient to a warm room. If the sufferer can be kept quiet and comfort- able in bed, the sudorific treatment will be enhanced. The bowels should be opened b}' a saline cathartic if they are at all confined, and the perspiratory action of the skin promoted by the administration of sweet spirits of nitre, Dover's powder, neutral mixture, and the like. The pain should be controlled, if possible, by aconite — this drug having especial effect on the fifth and, perhaps, other cranial nerves. The one-tenth of a grain of the alcoholic extract of aconite (U. S. P.) may be administered every half hour or hour, according to the age and susceptibility of the patient. The sulphide of calcium, in doses of one-tenth of a grain every half hour or hour, has seemed in many instances to abort an acute inflammatory process in the ear, in adults. But care must be taken not to give too large doses, nor doses too long continued, as doses as high as two to four grains in twenty-four hours have deranged the bowels and kidneys, pro- ducing diarrhoea and strangury. The bromides in many cases will have a calming effect upon the nerves, and opium and morphia will aid greatly in easing the intense pain of acute in- 458 MIDDLE EAR. flammation of the middle ear. Combined with the constitu- tional treatment just detailed, local dry warmth may be em- ployed. A hot-water rubber bag, or a flat six-ounce bottle, may be tilled with hot w^ater and kept against or in front of the auricle on the aftected side. In many instances a sad-iron, a stone, or a brick, may be heated and wrapped in a piece of blanket and then kept close against the painful ear. These forms of dry heat should be tried before resorting to warm irrigations. If, however, in spite of all efforts made by the aforesaid methods for relief the pain increases, warm irrigations may be tried, either by the syringe or some form of aural douche, or by means of a piece of rubber tubing and a basin or pitcher of hot water, the two latter being arranged to work together by means of the siphon principle. A very simple and efficient way of applying hot water to the ear is by means of a spoon, dipping the water from a cup and filling the painful ear wath hot water every few minutes, according to the temperature of the water and the feelings of the patient. If the inflammatory symp- toms, however, increase, and the pain become more intense, the disease and the tendency to suppuration may be further com- bated by leeching. This is best accomplished by placing the leeches close to the ear. The points to which they sliould be made to attach themselves, are close in front of the tragus and along the limits of the auricle where it fades into the cheek. If the pain and tenderness are marked in the region of the mastoid portion of the temporal bone, some of the leeches should be placed in the hollow close under the auricle, and over the mastoid. The so-called European or Swedish leeches will be found the best, because the largest and strongest. From three to six of such leeches will usually relieve the pain and check the advance of inflammation, if they are put on in time. From three to six ounces of blood should be drawn in the earliest stages of the disease. If any of the products of inflammation have appeared, deple- tion by this means is most positively contraindicated ; if blood is to be drawn, it must be done near the outset of the inflamma- tion. Of course, this is a mode of treatment more easily carried out in a city and upon adults ; but even children will submit rather than suffer. Paracentesis of the Drum-head. — The drum-head should be fre- quently and carefull}' examined, and if the slightest bulging appears in it, or if the products of inflammation become visible through it, and it appears likely to be ruptured, it will be better for the surgeon to choose the place of opening than to leave it to nature. The best point for paracentesis of the drum-head has been found to be the postero-inferior quadrant, for from that point the tympanic cavity is most easily drained. Nature may A CHRONIC TLMIULEXT INFLAMMATION, 459 rupture the drum-head at any point, hut since perforations in the posterior parts of the membrana tjnipani heal more rai)idly than those clsewliere in the memhrano, and as perfect drainiige of the (h-um-cavity is very important and most easily accom- plished from below, it is best to select the point named, for in- cising- the membrana tympani. But paracentesis is never to be resorted to simply to relieve pain. It should be performed only to permit the escape of the products of intiammation from the drum-cavity (p. 369). All forms of continued poulticing should be most carefully and especially avoided in acute inflammation of the drum-cavity. In the first place, they cannot be brought into very close proximity with the diseased spot ; and, secondly, in any event, the}' favor too great a maceration, and consequent formation of granula- tions in the ear. They are, therefore, especially evil in aural diseases, for the formation of granulations, brought about by a poultice to the ear, mechanically interferes with the escape of matter from the ear and inspection of the membrana tympani, and they may leave the organ chronically diseased, or destroy its functions altogether. This is the experience of every aurist, and is amply testified to in every modern work on Otology. A kind of compromise may be made with the old prejudice I in favor of poultices over the ear, by allowing the patient to [wear a fold of cotton-wadding over the auricle and side of head, or to hold a warm hop-pillow to the painful ear. After secre- tion is established, a poultice of any kind would only increase [the suppuration. Simplicity of treatment added to a careful and thorough diagnosis, is the best means with which to combat acute disease in the ear, as well as elsewhere. CHAPTEK YI, CHKONIC PURULENT INFLAMMATION. When alluding to acute inflammation of the middle ear, the greatest stress was laid on preventing suppuration. If, in spite I of all efforts, suppuration does occur, or if before the patient consults any one concerning his aural disease, suppuration shall [have become established in the ear, then every endeavor must 460 MIDDLE EAR. be made to check the discharge. There should be no fear to do this as promptly as possible, for so long as a chronic purulent discharge comes from an ear, the patient's life and hearing are in danger. There need be no anxiety therefore about " drying up" the running from the ear; "of driving it in on the brain," etc. Unhesitatingly it can be said that unless the otorrhoea is cured, the disease surely tends to extend to the brain. If it does not reach the brain, it may be because the patient will die of pypemia and metastatic abscesses, before the central organ in the skull is reached. Look at it then as one may, chronic discharge from the ear demands earnest consideration, careful and prompt treatment, and thorough cure, if it can be attained. So grave, in fact, is this disease that some insurance companies in Great Britain are advised by their medical examiners to refuse to take a risk on the life of one thus diseased.^ Often the hearing is gone, beyond hope of recovery, before any treatment of the purulent disease in the ear. At last the ofiensiveness of the running usually leads the patient to seek medical aid. The surgeon too often, after finding the hearing gone, advises the patient to let the discharge alone, "that it will dry up," etc. This is a mistake as fatal as it is common. Just because the hearing is destroyed, and the disease will advance from the middle ear to the internal ear, the mastoid cells, and the brain, the patient should be made aware of his condition and urged to undergo prompt treatment. His doctor should teach him that a disease which has destroyed the hearing can destroy the life; that cerebral abscess is but the logical sequence of such a corroding disease in the tympanum. Treatment therefore should be instituted, not simply with a view of regaining the hearing, though often much is regained, but with the hope of freeing the patient from an ofi:ensive, annoying, and dangerous disease. ETIOLOGY. Eespecting the causes of chronic purulent otitis media, it is almost enough to say that they are the same as those productive of acute otitis media, and that the latter is the forerunner of the chronic form. Brietly, they are exposure to cold, traumatic in- fluences, diphtheria, and the exanthemata. The latter, especially measles and scarlatina, are notoriously assigned as causes of a large number of the cases of chronic purulent discharge from the ear, which the surgeon is called upon to treat. Most common of all assigned causes, is scarlet fever. The question naturally arises, 1 Dalby, Diseases and Injuries of the Ear, p. 176. CHRONIC PURULENT INFLAMMATION. 401 Is this necessarily the case; is there somcthinp; in the scarlati- nous poison Avhicli tends to eliminate itself through the mucous memhrane of the middle ears? Can it ibr a moment be sup- posed that, just as the kidney is likely to become congested and intiamed in scarlet fever, so is the mucous lining ot" the ear? Since the throat and nasopharynx are very apt to be diseased in scarlatina, and since an aural disease is prompt to follow close upon a disease of the nares, the acute process in the middle ears, in scarlet fever, may be accounted for. But is there a specific tendency in the aural disease of scarlet fever, to become chronic? Upon close examination of these cases, it will be found that, though the suft'erer has passed through a disease which has made him weak and liable to aft'ections of the mucous tract, neglect of the acute inflammation in the ear has done the real mischief. Were this not true, then prompt attention to the in- flamed ear in scarlatina would not be fraught with the good result it always is. Diphtheria as a Cause. — Diphtheria is very often followed by a virulent form of chronic purulent inflammation of the ear, in children. There seems to be a tendency in this disease for the purulent otitis to fall at once into a chronic form. Pain is not always present and the acute stage is not well marked, but granulations spring up in a few days, the bone becomes necrotic, and sequestra are thrown off from various parts of the temporal bone. In a child sixteen months old, without any previous symptoms of pain or acute inflammation in the ear, a large cold abscess formed behind the auricle, pus ran from the meatus, the abscess was opened by the family's medical adviser, and denuded bone was found extending along the posterior wall of the external auditory canal and over the outer wall of the mas- toid portion. In another instance, a little girl four years old was attacked by diphtheria; without any severe symptoms of acute otitis media, the child complained of discomfort in her right ear; then suddenly facial paralysis set in and continued for many days. This disappeared after a copious and fetid dis- charge from the meatus of the affected ear, Kapidl}-, without pain, an abscess formed over the mastoid and was opened, dead bone was found in the auditory canal and over the mastoid; the ear was blocked with large granulations, and the major portion of the mastoid was thrown off as a sequestrum, from the opening behind the auricle. Tlie rayiidity with which the chronic form of purulent otitis is established in these cases is worthy of note. It is, therefore, advisable, in order to prevent destruction of the ear, to examine the organ in every case of diphtheria, espe- cially if the patient's attention is called to the ear by the least discomfort, and, if it bulge, to make a free vent in the rnera- brana tympani. This would permit the escape of matter from 462 MIDDLE EAR. the drum, and prevent a burrowing to deeper parts. Such a procedure forms at least the best and perhaps the only means of preventing the rapid, almost gangrenous destruction of the ear, so likely to follow diphtheria in children. But ignorance of this fact, or unw^illingness and inability to carry out the necessary manipulation in the examination and operation on the mem- brana tympani, have led the majorit}- of physicians to under- estimate the importance of doing that which is necessarj- to ^ save the hearing and prevent necrosis of the temporal bone. Consequently the patient is said to have recovered from the diphtheritic disease, in cases in which he survives, but his hear-- ing is lost, and he is spared only to undergo a tedious and exhausting suppuration in his ear, and finally to die from an extension of the aural inflammation to the brain, or to other organs of the body, or from general pyaemia. In order to convince one's self of the fearful ravages of chronic purulent inflammation of the middle ear, it is only requisite to take a casual glance at the literature pertaining to otology in Europe and America. But, though many cases of these evil consequences are recorded, every one whose attention is spe- cially drawn to the point, will state that numerous cases of death, from aural disease, are put down to other causes. Age and sex have nothing to do with the causation of chronic purulent disease of the middle ear in children. The desire on the part of parents to have their girls free from the necessarily disgusting feature of an oflensive aural discharge, leads them to bring their daughters sooner perhaps than their sons for treat- ment. Girls are more closely observed than bo3'S, which ac- counts for the fact that among 3'oung patients the girls are in the majority. Boys, with a chronic aural discharge, are more likely to escape notice from the simple fact that they are absent from home more than the girls are. When, however, the boys begin to lag in their studies, on account of hardness of hearing, the aurist is consulted. Such circumstances may have more or less influence in causing an apparent preponderance in the number of young girl patients, over that of the 3'oung men, but one sex is just as liable as another to chronic purulent inflam- mation of the middle ear, in childhood. Of adult patients afflicted with chronic purulent otitis media, the men seem to be in the majority. This is accounted for in part by the above- | mentioned want of care bestowed on them in boyhood, and subsequently by their more exposed life. Among the patients met with in infirmary practice, w^omen, whose lives are exposed, as servants, are just as liable as men to contract chronic puru- lent disease of the middle ear. CHRONIC PURULENT INFLAMMATION. 463 SYMPTOMS. Tlie chief symptoms of chronic uncomplicated purulent otitis media, are either hardness of hearing-, or profound deafness, and a purulent discharge from the ear. The defect in hearing may vary from but slight hardness of hearing to absolute deafness. The vibrating tuning-fork on the vertex may be heard quite well in the affected ear if the laby- rinth has not been invaded by the inflammation. If the latter has advanced inward toward the labyrinth, then the auditory nerve will have been more or less affected, and the failure to hear the tuning-fork, by bone-conduction, can be easily ac- counted for. While the deafness mav be thus demonstrated to be absolute and irremediable, this fact is not sufficient to induce the physician to dissuade his patient from treatment, but rather to encourage him to undergo treatment, to prevent the advance of the disease. The Discharge. — The discharge is usually much more copious in children than in adults. In the latter, the discharge is more likely to be copious the less chronic the disease, a feature due, in all probability, to the more active condition of the inflamed mucous membrane. As the disease advances, the mucous mem- brane is either destroyed, or so greatly altered in structure as to cease to throw off much secretion, and the discharge in such cases becomes thinner, more offensive, irritating, and suggestive of necrosed bone. In children the discharge is copious because of the activity of the mucous membrane of the nasopharynx, Eustachian tube, and middle ear. Hence, in these young pa- tients the purulent discharge is mixed with ropes of mucus, more or less transparent, from the Eustachian tube and the tympanum. The color of the discharge varies from a light- yellow to a dark-yellow or green, but there is no rule about this. I have observed that the more copious discharges from children are lighter in color than the scanty, which are usually darker. The slighter discharges of adults, afflicted with chronic purulent disease of the middle ear, are dark and more likely to form crusts or scabs in the meatus. In some rare instances the Icolor of an otorrhoea may be bluish, as mentioned by Dr. Zaufal.' Such a discharge was found to contain the bacterium ternio; and the blue coloring matter gave a reaction characteristic of litmus. In most cases there seems to be a peculiar butyric odor to the discharges of chronic suppuration from the ear. This is mainly on account of the want of cleanliness. There will be very little 1 Archiv f. Ohrenh., Bd. vi. S. 206. 464 MIDDLE EAK. odor in an ear thus affected if it is kept clean and there is no necrosed bone retained. But if the latter provisions are not met, then of course all the peculiarly disagreeable and butyric odors of putrid pus and decaying bone will be emitted. Appearances of the External Auditory Canal. — Inspection of the ear by means of the ear-mirror and the funnel will reveal maceration of the skin of the auditory canal, more or less destruction of the drum-head, and inflammation of the mucous membrane of the tympanic cavity. This is the view in an ordinary uncomplicated case; if there are complications arising from the purulent disease or from any other source, in the ex- ternal or middle ear, they will now become apparent. But all such features of chronic purulent inflammation of the ear will be considered under the consequences of the unchecked disease. In order to obtain a good view of the external ear and membrana tympani, the auditory canal must be syringed out, and usually it will be found necessary to wipe off the drum-head with a little tuft of cotton-wool on the cotton-holder. This is demanded if the pus is tenacious or hardened on the remnant of '] the membrane. Syringing without the latter manipulation has often led to error, since the red and inflamed parts beneath the film of tenacious muco-pus have not been seen. Inspection of the external auditory canal in the simplest form of chronic purulent inflammation of the middle ear, reveals maceration of the cutaneous lining of the passage, and some- times one or more exostoses. The latter are the more likelj^ to be found the more chronic the case. They rarely exceed two in number. If the chronic discharge is not copious, the macera- tion of the skin in the canal is not great. Instead of that, there are found scales and crusts of hardened pus, mucus, and epi- dermis in the inner part of the auditory canal and on the outer surface of the upper part of the drum-head. In cases of copious discharge, the delicate skin lining the inner part of the bony auditory canal, becomes more like mucous membrane than skin. This has led to the erroneous idea that the inner part of the auditory canal is normally lined with mucous membrane. It never is, but only assumes somewhat the appearance and nature of diseased mucous membrane, when subjected to con- stant irritation. This condition of the lining of the external auditory canal, is apt to be most marked in those individuals who have resorted to the injurious sponge-swab for cleansing their ears. Appearances of the Drum-head and the Tympanic Cavity. — Chronic purulent discharge from the tympanum presupposes a perfora- tion in the membrana tympani. Such a perforation may be at any [)oint in the membrane, least frequenth', however, in the flaccid part or the membrane of Shrapnell. A perforation iu CHRONIC PURULENT INFLAMMATION. 465 the membrana tympani may vary from the size of a pin's point to that which embraces the entire drurn-hcad. Usually, even in the worst cases, a rim about the annulus is left, from which, ^ if the purulent process is stayed, a new membrane nuiy grow to . a greater or less extent. ■ f Multiple perforations are rare, sometimes two may be found T close together in the under part of the membrane, separated by a thin band, and, in very rare instances, throe perforations may be found in the same membrana tynipani. The handle of the hammer may remain intact, notwithstanding large destruction I in the drum-head. In other instances, the manubrium may be more or less eroded as the perforation extends. If the mem- brane is destroyed, or if the perforation in it is in the upper and hinder part, the lower portion of the long process of the incus, the incudo-stapedial joint, and the rami of the stapes, as well as the niche of the round window, may come into sight after the ear has been well cleansed of pus and then dried out with cotton on the holder. Nevertheless, a large perforation may exist in the upper and hinder part of the membrana tympani, and the aforesaid ossicles may be intact, yet invisible, for they are apparently a little higher in the tympanum in some individuals than in others. The mere fact that they cannot be detected in cases generally favorable to their exposure, does not prove that they are de- stroved. In some cases, the mucous membrane about them is too swollen to permit of their ready recognition. When a large perforation is about on the same plane with them, their lower ends may become visible by inclining the patient's head as far as possible towards the opposite shoulder, and looking up and behind the curtain-like rim of the membrana tympani, between them and the observer. In order to obtain a good view of the relations of these bones to one another, and of the separate rami of the stapes when they are to be seen, the patient's head will always have to be moved about gently from one position to another, till the desired view is obtained. The eye of the ob- server must always be directed towards the roof of the tympanum rather than towards the plane of the membrana tympani or inner wall of the tympanic cavity. The api)earance of the membrana tympani or its remnant, will vary fro'.u one of great opacity and grayness, with red and cica- trized edges of tlie perforation, to that of uniform redness and thickness. The manubrium of the malleus may be buried in the thick and swollen membrane, or, if the latter is gray and thickened, the position of the manubrium is marked often b}' only a tracery of congested vessels. In other cases, the handle of the hammer is seen as a ridge in the membrane of the same color, be that either red or gray : or, the handle of the malleus 30 466 MIDDLE EAR. may project alone in the plane of the former membrana tym- pani. In such cases, the so-called folds of the membrane may still remain, extending from the short process of the malleus, one backward, the other forward towards the periphery. It is usually the posterior one which interferes with a good view of the deeper-lying ossicles. A perforated membrane is always retracted. TREATMENT. Two fundamental rules of treatment must be observed in every form of chronic purulent inflammation in the middle ear, viz., cleanliness and perseverance. In some cases it seems highly probable that careful and thorough syringing of the running ear, several times a day, persevered in, would have cured the disease without the aid of astringents. It would certainl}" be far better to rely on the use of tepid water and the syringe, with a good hope of success, than to do absolutely nothing for the inflamed and oftensive ear, since, in the latter course, the condition of the ear and of the patient will almost surely go from bad to worse. Especially at the beginning of the scientific treatment should the ear be made clean by the surgeon, in order that its real condition should be seen, and then it should be kept clean in order that the remedies applied to the mucous membrane may have an efl:ect. So important is this cleansing that it would be well to leave it entirely to the surgeon. I have never found it necessary or desirable to employ any of the heroic methods of forcing water either through the meatus, the middle ear, and Eustachian tube, or vice versa. Saissy, Millingen, and Hinton have advocated this procedure for clean- ing the middle ear of inspissated contents arising in chronic purulent inflammation. If, in syringing the ear, some water escapes into the Eustachian tube and throat, it is of no moment. It may, indeed, be a sign of more thorough cleansing of the middle ear; but it is not desirable to force water to take this course, for, at the same time, some of it might be injected into the mastoid cells and there set up acute inflammation. In any event, forcible syringing of the ear is very liable to make the patient dizzy. Moderate syringing will not thus attect the pa- tient; it is usually borne perfectly. It is very unusual to observe a case in which no form or manner of syringing can be tolerated, on account of vertigo. Cleansing the ear in such an instance may be efl'ected by using absorbent cotton on the cotton-holder. Sometimes, however, the most complete syringing will not re- move all that should be washed out from the ear, especially the more tenacious variety of muco-purulent matter which collects like a film over the membrana tj^nipani and the mucous mem- brane of the middle ear. In such cases, Castile soap may be CHRONIC PURULENT INFLAMMATION. 467 added to the water, in sutiieient umount to make tlie latter a little opaleseent; or, before each re_i>:ular .syriui>-iiii;, a solution of bicarbonate of soda (10-20 gr. to f5j) niay be instilled into the ear and allowed to soak there from three to five minutes. Then, the matter thus softened may be more easily washed out. Still, in these cases, the surg-eon must use his judgment as to whether the inspissated matter is to be removed or not. If the discharge is still active, then such masses should be removed; but if the running shows signs of stopping, it has seemed better in some cases not to w^ash these adherent films or crusts away. They do not invariably form, most discharges tending not to harden, but to come away if the ear is properh- cleansed. Not uncommonly, however, perforations in the drum-head close, first, by the formation of a kind of scab over the opening, then by true cicatricial tissue. The former finally falls ofi", leaving the latter as a permanent closure. But what I specially wish to call attention to h, first, the importance of favoring the formation of this scab-like closure in the perforated membrane of an ear affected with a chronic discharge from the tympanic cavity; and, secondly, the importance of letting such formations alone when they have once closed the perforation in the mem- brana tympani. Such formations must be regarded as an effort of Xature to protect the lining mucous membrane of the tym- panum. The normal drum-head must be regarded, to a very great extent, as a barrier between a mucous surface and the direct effects of the external air. It is often observed that as a discharge from the tympanum ceases, the matter now being poured out in small quantities from the hole in the membrana tympani begins to stick to the edges of the vent ISTature provided it, until, at last, a small scab or plug fills the perforation and the discharge stops. The appli- cation of remedies, now, must be timed so as not to prevent this formation of a natural plug for the hole in the drum-head. When a discharge begins to diminish, it is decidedly better to lessen the quantity of remedial applications to the ear; for they will not only prevent the healing or scabbing over of the perforation, but they will enter the tympanum, where they have ceased to be needed, and act as irritants. Doubtless, many dis- charges are kept up by continuing to syringe the ear and to put in drops. But no positive law on this point can be laid down. Each case must be studied pretty much for itself. It will, however, never be amiss to pause in the instillations in order to find out whether there is really any further need for them, and to discover that which is still more important, viz., whether they are so far irritants as to keep up the slight dis- charge which still lingers. Cessation of treatment is not unfrequently followed by 468 MIDDLE EAR. formation of the above-named covering over the perforation, and the healing of the ear. That this covering of yellow in- spissated muco-purulent matter over the hole in the drum-head is of greatest value, is seen in those cases in which it has been unfortunately removed. In several instances where such a covering had formed, before the cases came under my notice, and before I was aware of the real meaning and value of this natural patch to the wounded drum-head, in my zeal to remove what in one sense was a for- eign body, from the membrana tympani, I softened the scab and removed it. In two instances a clean-cut perforation be- came visible, and through it the healthy mucous lining of the tympanic cavity could be seen. But in a few days the mucous lining of the drum became congested, because the air had too free access to it, and an otorrhcea, which had subsided, returned. After a longer or shorter period these dry coverings will peel o& and escape as tough or hard shells, as the parts beneath heal and can dispense with them. This fact naturally drew my atten- tion to the value of a dry local treatment in chronic otorrhcea. The Adcantages of a Dry Local Treatment. — One of the greatest hinderances to cure in an ear disease accompanied by otorrhcea, whether the disease be due to inflammation in the auditory canal or middle ear, is the presence of granulations and poly- poid growths. Yet one of the oldest forms of treatment of otorrhoeal disease has been by copious syringing and instilla- tion of various fluid medicines. Hence, in such treatment of this class of aural diseases, moisture has been repeatedly applied to, and kept in the ear, a naturally heated localit}'. ISTow as heat and moisture tend to promote granulations and keep up a discharge, it has become very apparent to aurists that a moist treatment of otorrhcea in many instances has a tendency to keep up rather than to check the morbid discharge from the ear. Cleanliness in a running ear must, of course, be maintained by judicious syringing with tepid water in copious discharges, and in cases of slight otorrhcea the ear can be kept clean with- out syringing by the use of a swab of absorbent cotton on the cotton-holder, or by absorbent cotton rolled into a long slender dossil, and gently inserted into the ear. A copious discharge may be defined as one which overflows the auditory canal, fills the concha, and runs on the cheek. A slight one just fills the canal as far as the meatus at most, or at least only keeps the membrana tympani moist. In the worst cases of otorrhcea I have long since ceased to let the patient or his friends syringe the running ear, if he can be seen every day or two by his physician, and let the latter perform this important operation. After syringing, the surgeon should dry the ear with absorbent cotton on tiie cotton-holder, applied under illumination of the CHRONIC rURULENT INFLAMMATION. 409 ear by the forohoad-mirror. If the patient must he entrusted witli cleansing his oar at home, it sliould he done hy ahsorhent cotton and not with the syriuge. J>y following these general rules, it will be seen that a great deal of moisture once entering into the cleansing part of the treatment of aural discharge may be eliminated. Perhaps in one case in a hundred the jtatient's ear must be syringed at home, but not in a greater ratio of cases will the necessity arise. Respecting the local medication of the diseased ear much may be said. Formerly a patient with otorrhoca, regardless of its cause, was directed, in addition to usino; the svrinlastic processes, and to the formation of rugous elevations ami tirm projections. By continued growth and constant enlargement these formations may entirely" till up the tympanum, and, after perforation of the membrana tym- pani, till the entire auditory canal. They may also cause Hat, bridge-like adhesions to form between the membrana tympani, auditory ossicles, and the walls of the tympanic cavity. Cystic cavities may be formed by the union of*^ several elevations with one another. By degeneration and exfoliation these polypoid growths may disappear. Spontaneous degeneration is brought about in these cases by deposition of fat,"or by homorrhag-es ; the vascularity of these growths greatly predisposes to the latter mode. The pathological alterations in the veins and lymphatics of the mucous membrane of the tympanum, in cases of chronic purulent discharge with perforation of the membrana tympani, have been described by Politzer.^ These changes chiefly con- sist in dilatation. In some instances the veins, especially on the inner surface of the mucous membrane, covering the promon- tory, are greatly widened, ver}- tortuous, with here and there large dilatations. He concludes that in chronic inflammation of the lining of the drum-cavitj', large numbers of new vessels are formed. The walls of the bloodvessels are often opaque and thickened, being infiltrated with a granular exudation, and pig- mented ; or, in other cases, the vessels may be tilled with blood- globules, while the walls are thinned at some points, and con- sequently dilated here and there. The changes in the lymphatics of the mucous membrane of the tympanum are much less common than the alterations in the bloodvessels. Altered lymphatics have been found by Politzer in new connective-tissue growths in the cavit}' of the drum, when affected by chronic purulent inflammation. Treatment of Granulations. — Since granulations are very often the result of poulticing in the acute stage of an inflammation in the ear, it should be said again that all such treatment as contains any of the elements of heated moisture, must be avoided in the endeavors to cure granulations in any part of the ear. The ear should be kept scrupulously clean b}- syringing, to be repeated as often as is necessary to gain this object. Then some form of astringent or caustic should be applied. An en- deavor may also be made to remove, by evulsion, the large 1 Studien iiber Gefiissveranderung in der erkrankten Mittelohrauskleidung, A. f. 0., N. F., Bd. i. S. 11. 496 MIDDLE EAR. granulations, if thej can be gotten hold of with convenience to the surgeon and without pain to the patient. But it is not absohitely necessary thus to remove granulations from the ear. They may be pencilled with solutions of nitrate of silver (60- 480 gr. to f5j) or with chromic acid. These applications are best made by means of a small tuft of cotton on the cotton- holder ; great care should be taken to have not too much of these fluids on the cotton, but just enough to paint the growths without causing any surplus of fluid to be squeezed out and run upon other parts of the ear, as soon as the cotton-tuft is brought into contact with the granulations.. Aural Polypi. — The term polypus is a relic of the older no- menclature, which classed new growths according to their form or general appearance, rather than their structure. The name polypus was first applied to all tumors which, originating by means of a distinct pedicle from the inner surface of any cavity of the body, projected at last as an independent growth into the same, or into the passages leading to it. AUEAL POLYPI. Aural polypi vary in size from one millimetre to three or four centimetres in length, and may completely block the ex- ternal auditory canal, and project beyond the meatus. They have generally a more or less club- or pear-like shape, and their surface is usually papillated, giving a mulberry-like appearance, particularly to the basal portions of the growths. With few e.Kceptions their consistence is soft, but elastic, and their color may be any shade of grayish-pink or red. Aural polypi are frequently multiple, several of them being found in the same ear. One or more of the auditory ossicles may become embedded within the substance of one of these growths, and the tumor may also by its pressure markedly en- large the osseous part of the auditory canal. These aural tumors may originate from the mucous membrane or periosteum of any portion of the tympanic cavity, or, much more rarely, from the dermoid layer of the membrana tympani, or the skin of the external auditory canal. By far their most frequent seats are on the upper and inner walls of the tympanic cavity. Polypi are most frequently found in males, and before thirty years of age. The vast majority occur in cases of suppurative disease of the middle ear, and when they are situated on the wall of the external canal, it will be generally found that the suppurative process has been a very prolonged one. In fact, all these growths may be considered as inflammation-tumors, distinctly illustrating the now widely accepted doctrine of the inflanmiatory origin of all neoplasms. .^1 CHRONIC PURULENT INFLAMMATION. 497 By far the larger number of aural polypi are covered with epithelium, the character of which always agrees with that of the cells covering the mucous membrane from which tlioy liave originated: thus if from the floor of the tympanum or the lower portion of its walls, the epithelium will be columnar or columnar- ciliated; while if from the promontory or the roof, it will l)e found to be of the tessellated variety. The transition from tiie former to the latter of these forms in the tympanum is gradual, and thus it is that several varieties are, in rare instances, found upon the same polypus. In systematic treatises upon diseases of the ear, aural polypi have long been classed into mucous polypi, fil)ronuita, and myxomata; angiomata having lately been added to the list by A. H. Buck, The term mucous polyp has only a clinical meaning, every form of tumor of soft consistence found in the ear having been described by difterent authors under this head. The statements of Schwartze^ and others that this form of growth exactly resembles the mucous polyp of the nasal and other cavities, is absolutely incorrect, the mucous polypus of rhinologists being simpl}' a hyperplasia of the normal mucous membrane, and no such growth has yet been accurately de- scribed as occurring in the ear. The name, therefore, should be permanently dropped from otological literature, or used only in a clinical sense, to denote any tumor of soft consistence. Moos and Steinbriigge,- in their very valuable pa[)er on this subject, call most aural polypi "granulation-tumors," and the name is a most satisfactory one, but they seem to overlook marked differences in the structure of the neoplasms classed under that heading, and to ignore the similarity or identity of many of them, to soft or mucous papillomata. Aural polypi should be classified as follows: 1. Granulation-tumors; 2. ^oft Papillomata; 3. Fibromata; 4. 31yxomata. In the rearrange- ment of the section on aural polypi, and the classification he- has now adopted, the author has been greatly aided by the iur vestigations of Drs. R. W. Seiss and Walter Chrystie, of Philadelphia. Granulation-tumors (see Fig. 93) are usually of small size, very dark in color, of soft consistence, and bleed easily and freely, when touched. They comprise about one-half the entire num- ber of aural polypi, and are usually found in cases where the suppurative process has been rapid and intense. Their structure is that of a simple granulation, from which they markedly differ, however, in being covered either by a layer of columnar 1 Pathological Anatomy of tlie Ear, p. 125.. ^ Archives of Otology, vol. xi. p. 328. '32 498 MIDDLE EAR or squamous epithelial cells, the latter of which may form a dense, horny coating to the growth. The}' consist of spherical embryonal cells, some of which present ver^^ distinct nuclei, others having several very small nuclei. Among these elements are numerous capillaries in an embryonal condition. Some of the embryonal cells send out prolongations, which unite by anastomosis with others, and Fio;. m. Section of a Granulation-tumor-polvpus, from MicRO-PHOTOGTsAPn of Specimen Prepared by Drs. R. W. Seiss and Walter Chrystie for the Author. thus a network of plasmatic cells is formed, the meshes of which are filled with an amorphous, fundamental substance, sometimes fibrillar, in Mdiich are held the spherical embry- onal cells. These pol3'pi are frequently deepl}' stained with blood, or large clots may be found, from ruptured bloodvessels in their substance. The epithelial covering may occur in single or in multiple layers, and may, as already stated, consist of columnar or of squamous cells. It adheres firmly to the stroma of the growth, following all the convolutions of the lobulated surface. Soft or silicons Pap'dlomafa (see Fig. 94) occur as large, club- shaped tumors, of light color, elastic, and not readily bleeding under the touch. They are usually found in cases where the irritation has been very prolonged, but not of a high grade of intensity. They comprise about ninety per cent, of all aural polypi other than granulation-tumors. Their surface is generally much lobulated, giving frequently a mulberry-like appearance to the growth. CHEONIC PURULENT INFLAMMATION 400 A description of the specimen from whic-li the acconipanviiii,' micro-photograph was taken will perfcctlv illustrate the tvi-ical Fiir. 01 / Section op a Soft Papilloma-polypus, from Micuo-photograph of a Specimen Pre- pared BY Drs. R. W. Seiss and Walter Ciirystie for the Author. structure of these neoplasms. The stroma is composed of dense, somewhat imperfectly developed connective tissue, which sends out numerous papilhuy projections, each containing a capillary loop. Each projection is covered by a layer of cuhoidal epi- thelium, which is so great in amount as to till up the sulci be- tween the pillars. Many of the pillars send out secondary branching papill?e. Near the surface of the growth the epi- thelium becomes squamous; in some examples of this neoplasm this covering is hard and bony in character. Spots of myxo- matous degeneration frequently occur in these polypi, especially when they have long persisted. Very vascular, or even cavern- ous examples of this class are occasionally met. Fibromata, in the true meaning of the term, are exceedinglv rare; the so-called "fibrous tumor" of clinical otology beiiigrin the majority of instances, exami)les of soft papillomata. They are developed from the periosteal lining of the tympanic cavity,' and are large, dense, pale-colored polypi, usually covered by a multiple layer of pavement epithelium. These structures ex- hibit a more or less fibrillated, tirm connective tissue, in which are found numerous connective-tissue corpuscles. They are sometimes vascular or cavernous. The intracellular substance 1 Schwartze, rath. Anat. of the Ear, p. ll'ij. 500 MIDDLE EAR. is said, by Sclivvartze, to be "sometimes perfectly homogeneous, sometimes grossly fibrillary."^ Patches of myxomatous degen- eration are especially frequent in these growths, and the epi- thelial investment may become hard and skin-like. They also show a marked tendency to undergo cavernous change. Myxomata occurring in the ear are yet rarer than polypoid fibromata, not half a dozen instances having yet been satisfac- torily described. They are exceedingly soft, gelatinous tumors, springing from a broad base, and are mostly covered by mul- tiple layers of pavement-epithelium. Their stroma consists of a homogeneous, gelatinous tissue crossed by a network of spindle- and star-shaped cells, and in which are embedded a few round, granular cells; occasionally these tumors are rich in bloodvessels, and may contain organized blood-clots. To account for these growths, according to the now^ rarely received theory of Cohnheim, by the fact that the foetal tym- panum contains mucous tissue, seems altogether erroneous, especially as myxomata frequently occur in parts of the l)ody where no mucous embryonal tissue is to be found. The Ano-ioma of Buck^ is described as follows: "The entire mass" (of the tumor) "consisted of bloodvessels, radiating from an irregularly shaped central cavity, and separated by a network of fibrous connective tissue, holding blood corpuscles in its meshes." It appears to have been a true independent neoplasm, but as this is the only reliable instance on record of its occur- rence, so far as we are aware, it can as yet only be regarded as a pathological curiosity. " Cysts/' " organized blood-clots," "venous blood sacs," and a few other formations growing within the ear, have been more or less vaguely described by difterent authors. It is impossible to give to any of them definite pathological significance. J. Orne Green^ speaks of "polypoid growths," "which are undoubtedly hypertrophies" of "the papiltte on the dermoid layer of the membrana tympani; " but Dr. Green gives no detailed account of their structure. They seem to be very rare in their occurrence. Any of the four classes of aural polypi just described may present examples of cystic, cheesy, and teleangiectatic changes having taken place within the structure of the neoplasm. Ex- tensive fatty degeneration may also be present; which may spontaneously amputate the growth by destruction of its pedicle. Osseous and cholesteatomatous masses have also been de- scribed as occurring in the substance of aural polypi. Epithe- lioma, osteosarcoma, and gummata have been delineated by ^ Op. cit., p. 127. ^ Transactions American Otological Society, 1870. ^ llnd. Report on Progress of Otology. . It CHRONIC PURULENT INFLAMMATION. 501 various writers as arisino- from tlio middle ear; all are exceed- iiigh' rare, and have been but imperfeetly described. All aural tumors belonging to any of the four classes of our schedule — possibly with the exception of the fibromata — are entirely benigmmt, showing no propensity whatever to involve surrounding healthy tissue, nor tendency towards recidivity after thorough removal and proper after-treatment. Fibroids nuiy, pos- sibly, at times exhibit the rapid growth and semi-malignant character of some of those found in the nasal fossae. An Organized Vesicular Polypus, containing the Necrosed Long Process of the Incus. — After the removal of a soft polypus as large as a pea from the left ear of a boy seven years old, an inmate of the surgical ward of the Presbyterian Hospital in Philadelphia, a bright red body was discovered, which, at first sight, was supposed to be a clot of blood. It was gently pulled out, and found to be an organized vesicular body, containing, apparently, fluid blood, and a small, hard substance embedded in it. This proved to be a portion of one of the auditory ossicles, and upon its being subjected to examination by Prof. H. Allen, of the University of Pennsylvania, it was [ironounced by him to be the long process of the incus. The vesicle-like poly- pus, when placed in a mixture of equal parts of water and glyc- erine, gave up its blood, but retained a membranous, sac-like appearance, though pale and flaccid. Sgmjyfonis. — It cannot be said that there is any special train of symptoms which betray the presence of an aural polypus. Wherever a chronic purulent discharge from the ear has existed a long time, the presence of a polypus may be suspected, espe- cially if from time to time there has been hemorrhage from the ear, but the usual symptoms are only those of chronic otorrhea. In rare instances, aural polypi may be productive of hemiplegia, as shown by Schwartze.^ In such instances it is supposed that retention of pus, inducing a severer inflammation in the tym- panum, causes a hyperemia of the meninges of the brain. In the case given by Schwartze, there was incomplete hemiplegia on the corresponding side, together with anesthesia and ptosis, without facial paralysis. Removal of the polypi caused the symptoms to vanish. Hemicrania, sensations of fulness, vertigo, retention of pus, nausea, and vomiting have been observed as results of the pres- ence of a large, obstructive polypus in the auditory canal ; but they are not to be regarded as characteristic of the presence of polypi generally. The vast majority of aural polypi are first discovered by the s.urgeon when the patient applies for relief from an aural discharge, the latter being the only symptom. 1 Archiv f. Ohrenh., Bd. iv. S. 147. 502 MIDDLE EAE, Spontaneous Detachment of Polypi, — Polypi sometimes become detached without any .greater application of force than syrinojing. In some instances they undergo what is termed spontaneous detachment. Schwartze^ observed two such cases: one, the de- tachment of a so-called mucous pol3'pus; another, that of a sarcomatous growth. He also quotes Saissy, Toynbee, and Kramer as having observed similar occurrences. In three instances I have observed the detachment of small polypi by syringing: one, from the wall of the meatus; another, from a small opening in the posterior-superior quadrant of the drum-head. In the former case, a discharge had lasted for a long time, much to the annoyance of the patient, a lady twenty j-ears old. The discharge ceased, and the perforation closed as soon as the pol3'pus was washed out. In the second case there was no perforation of the drum-head. Treatment of Aural Polypus. — The treatment of an aural polyp begins with its removal. The after-treatment of the ear, and especially of the point to which the growth was attached, is as important as removing the polypus. The patient should be told this and enjoined to persevere, after the evulsion of the growth, with the subsequent local treatment of the ear at the hands of the surgeon. Unless this is properly and thoroughly done, it is almost useless to remove the polypus, for the patient will at least have undergone some annoyance and pain by the extraction of the growth, and, after a short freedom from it, a new one Avill spring up. Many patients are deterred from undergoing the removal of an aural polyp because of their fear of a renewal of the growth. This will, indeed, happen if, after the polypus is removed, the point of attachment is not treated ; but if the after- treatment is properly gone through with, no fresh polypus will grow from the point of previous attachment, and, furthermore, the tendency to their formation anywhere in the ear will be re- moved. The best instrument for the removal of an aural polyp is Wilde's^ snare, or Blake's^ modification of it. Wilde's instru- ment consists of a fine steel stem five inches long, and bent in the middle (Fig. 95). It is provided with a movable bar which slides on the square portion of the shaft near the handle, whidi latter part fits over the thumb. At the distal end there is a button-like projection perforated by holes running parallel to the stem, one on each side of it. There are also two small rings at the angle. Through these a fine wire of silver, platinum, or iron, or a strand of Jack-line or fishing-gimp (Hinton) may 1 Archiv f. Ohrenh., Bd ii. S. 0. 1867. 2 Diseases of the Ear, Phila., 1853, p. 897. 3 Arch, of Ojih. and OtoL, vol. i. p. 435, 1870. CHRONIC PURULENT INFLAMMATION 503 be drawn to form a small loop or noose at the point, while the ends of the wire, or whatever is used to form the snare, are coiled about the crossbar at the handle. When the instrument is in order, the crossbar may be at any Fig. 95. ^r^-?\#^'- M .<^^^ ti. -f Wilde's Acral Polypus Snare. point on its part of the shaft, most convenient to the su rgeon By traction on the crossbar, the loop at the end is narrowed and the polypus or its pedicle constricted, Blake's modification of the valuable instrument of Wilde, consists chiefly in causing the wire, left bare between the point and the angle in the shaft, to run in a miniature barrel slightly [widened at the end and perforated by two holes through which a wire passes to form the loop. Instead of fastening the free ends of the wire to a crossbar, they are wound in opposite Pio;. 96. Blake's Wilde's Snare, with adjustable Paracentesis-needle. directions around a button on top of a short, square canule, 1 cm. long, wdiich is made to slide smoothly on the square portion of the shaft. To the under surface of the canule there is attached a ring in the plane of the long axis of the instru- ment, by which traction is made and the loop narrowed. The handle or thumb-piece of the instrument is formed of a ring placed at an angle of 45°, transversely to the shaft. The aforesaid barrel is made to fit into a socket at the angle of the instrument and held in place by a set-screw. Dr. Blake has also planned a paracentesis-needle to go with this instru- ment, and which is made to fit into the socket at the angle where it is held in place by means of the set-screw. The whole 504 MIDDLE EAR, afiords an admirable improvement on the original Wilde's snare. The author, some years ago, made the end of the canula Fig. 97. Aural Polypus Snare, with Fenestrated Canula. fenestrated, so as to prevent drawing the loop into the barrel, and thus delaying an operation. The canula was made to con- sist of steel, and to be from 1 to 1.50 mm. in diameter. In this instrument the author has used brass piano-wire, or tine brass CHRONIC PURULENT INFLAMMATION, 505 wire used by saddlers for sewiiio-. The instrument is kIiowm in its natural size, with utii;-u)v of the leiiestra at its end, in Kiu". !I7. Dr. Samuel Sexton/ of New "S'ork, has fmiher iniprovcMl this form of polypus snare, by givin«^- the wire "three abrupt turns Sexton's Polypus Snare, with Notched Slide for Fastening the Ends op the Wire. through notches cut rather deeply in the slide for its reception." (Fig. 98.) Before the snare or any other means is employed for the re- moval of a polypus, the latter should be carefully examined by a curved probe, in order to determine if possible the point of attachment of the base or pedicle of the growth. I have gained great aid in this search by means of a very simple instrument, consisting of a platinum wire ring 4 mm. in diameter, soldered very neatly to a cotton-holder. This is as large a ring as will prove useful; smaller ones may be used with advantage. By passing this instrument down the well-lighted canal, the polyp may be very much more easily and thoroughly moved about on its attachment by means of this ring-end, than if the growth were touched by a smooth and blunt probe. By observing on which side the ring glides most easily, or where it meets with a resist- ance, a fair,"if not a positive idea of the point of attachment of the polypus may be obtained. This instrument is also an ex- 1 American Journal of Otology, vol. ii. p. 2W, 18S0. 506 MIDDLE EAR. Fitr. 99. FiiT. 100. r cellent means of scraping oiF the slough from a cauterized pedicle. An ordinary silver probe may also be used for manipu- lation of the polyp. The Use of the iSnare. — With the canal well lighted by means of the forehead-mirror, let the snare be passed over the polyp and brought as near the point of attachment as possible. There is no sensibility in the growth, but the walls of the canal which must be touched in this manipulation are extremely sensitive, and un- less great skill be used, the pa- tient will suifer pain. As a rule, the snare should be used without an ear-funnel or speculum in the external meatus. When the snare has disappeared over the polyp, let gentle constriction and trac- tion be made, and then, if the in- strument has been well adjusted, the growth, or the major portion of it, will be removed. Some hemorrhage will usually ensue, and all further operative endeavor should be postponed until a clear view of the external canal and the fundus can be obtained. Itard^ observed a rapid hemorrhage of four ounces of blood after the re- moval of a polyp from each ear, and Moos^ records an "alarming hemorrhao-e from the ear after the extraction of a small polypus from the short process of the malleus, necessitating a tampon." But these are rare occurrences, and are not to be cited to deter from the removal of an aural polyp as soon as it is discovered. Polypus Hook. — AVhen polypi are quite small, not more than half the diameter of the auditory have found it very convenient to use a small steel I have caused to be fitted to an adjustable holder. Silver Probe FOR Manipula- tion OF Polypi. Permanent Pla- tinum AViRE Loop ON Fexible Shaft. canal, I hook, which 1 Maladies de I'Oreille, tome ii. p. 124, 182L ^ Arch, of Oph. and Otol., voL iii. p. 107, 1873. CHRONIC PURULENT INFLAMMATION. 507 Bv this means, wliicli is quite simple and attended with less darkening of the canal than the use of the more cunilu-ous ^vi^e-snare, a small polypus can be lifted from its stem without Fit;-. 101. PoLYPLS Hook. i 508 MIDDLE EAR, touching the wall of the canal, and, consequently, without any pain to the patient. Dr. Jacoby,^ of Breslau, has applied the galvano-caustic method to the removal and treatment of granulations and polypi in the ear, with asserted success. But it is a means no surer nor more rapid than the more usual and less complicated methods just detailed, and certainly no less, but perhaps more, painful. Mr. Toynbee proposed to destroy polypi by applying to them potassa cum calce, an unmanageable, slow,' and dangerous pro- cedure, and one not at all in practice now-a-days. In the latter part of his career, Mr. Toynbee succeeded in destroying polypi by gentle and continued pressure by means of small pieces of sponge or wool.^ The late Dr. Edward H. Clarke^ succeeded in causing aural polypi to disappear by injecting into their structure, by means of a hypodermic syringe, a few drops of the solution of per- chloride of iron, or of persulphate of iron. Treatment after the removal of the Aural Polyp. — A number of suggestions have been made respecting the applications to be made to the diseased ear after the polyp is removed by evulsion. Both the matter and the mode of its application are deserving of the greatest consideration. The best applications are nitrate of silver and chromic acid, both of which are to be used in con- centrated solution. Nitrate of silver in the solid state may be applied by means of a porte-caustique, as recommended by Wilde. But he enjoined the greatest care in getting to the seat of the polypus, and only there, lest the auditory canal be cauterized and inilamed. But at best the " solid stick " is a dangerous application about the ear, and should, therefore, be kept out. A saturated aqueous solution of nitrate of silver (480 gr. to f.Sj) may be advantage- ously applied to the seat of the polypus and any surrounding granular surface, by means of a tuft of cotton on the cotton- holder. This will cause no pain so long as it is not brought in contact with the skin of the auditory canal. The remnant of the polyp and the more or less granular mucous tissues in the drum-cavity are not sensitive to it. But even the saturated solution of nitrate, of silver may act too slowly, on account of the superficial slough which it forms. Chromic acid, an escharotic more powerful than the preceding one, may be used with great and rapid aid in removing granu- lations, or the remnants of a polypus, as has been shown by ' Archiv f. Ohrenh., Bd. v. S. 1, and Bd. vi. S. 235. * See " Diseases of the Ear," siippleinent by Mr. Hinton, p. 438. '^ Observations on the Nature and Treatment of Polypus of the Ear, Boston, 18G7, p 71. I' CHRONIC PURULENT INFLAMMATION. 509 Dr. W. W. Seely/ of Cincinnati. I liave employed tliis for the destruction of the broad attachment of tlie hiri;e mucous, and fibroid polypi, but not very often for the destruction of smaller polypoid growths or their attachments. Its ai)[)lication may cause })ain, '.vhich comes on an hour or more alter the root of the polypus is touched, and continues as a dull aching for some time. This gradually wears otf, if tlie acid has not been a{»}>lied too freely, and every possible precaution must -be observed to avoid this, and when the patient is next seen it will he found that a large eschar has formed at the points touched by the acid. Under no other application does the remnant of the ])edicle of a polypus disappear so surely and so rapidly. It should be applied in tlie same manner as the solution of silver. A few crvstals should be crushed and slio-litlv moistened with water, and into this concentrated mixture the tuft, prepared as described above, when alluding to the use of nitrate of silver, should be dipped and then conveyed to the diseased spot. The latter may be gently brushed or pressed upon by the tuft of cotton thus prepared. The cotton tuft must not contain much acid, nor should that which it carries be too fluid — it should be ^pasty — for otherwise when the cotton is pressed on the granula- tion, or the cut surface of a pedicle, an excess of acid would be squeezed out, and run upon the healthy tissues. But care will prevent any such mishap, and enable any one to command the rapid and thoroughly curative action of chromic acid. The consideration of the results named under the fourth head (p. -ITS) v^ill be reserved for the following chapter. CHAPTEK VIII. COURSE AND CONSEQUENCES OF CHRONIC PURULENT INFLAMMATION {Continued). Chronic suppuration of the tympanum, after a longer or a shorter duration, may extend inward toward the labyiinth and the auditory nerve, upward through the tegmen tym})ani, di- rectly toward the middle lobe of the brain, backward throu.gli the mastoid antrum to the mastoid portion, its cells, and the lateral sinus, or outward to the bony auditory canal. The close anatomical relation between the tympanic cavity and 1 Transactions American Otol. Soc , vol. i. p. 160, 1871. i 510 MIDDLE EAK. the above-named reo-ions, has already been pointed out when con- sidering the anatomy of the middle ear. But it will be necessary to recall that relation at this time in order to obtain a juster idea of the mode and extent of the ravages made by chronic suppu- ration in the various parts of the temporal bone, and even in the bones adjoining it. Chronic suppuration of the middle ear advances by the suc- cessive stages of ulceration of the mucous membrane, periostitis, ostitis, caries, and necrosis of subjacent bones. The interval between the acute stage and these successive chronic stages, varies greatly in length. In some instances the acute stage is rapidly succeeded by all the others, even the necrotic exfoliation of some of the most important parts of the internal ear, while in others, a generation, or an ordinary lifetime, may elapse before the chronic process in the mucous membrane seems to leap at a bound to caries and necrosis of the bone beneath. And this is true, whether the advance of the tympanic disease is inward, backward, upward, or outward. The least common result of such a process is necrosis and exfoliation of the cochlea, either alone or in conjunction with the rest, or parts of the labyrinth, and other portions of the temporal bone. After a chronic suppuration has been in process for a period varying from a year or two to thirty or forty years, during which time the patient has suffered from nothing but the discharge, quite suddenly a new train of symptoms may be presented. These consist chietiy in an attack of severe pain in the ear, without any apparent cause so far as the patient can assign, swelling about the auricle, and bulging of the latter from the side of the head, chill, fever, constipation, intense vertigo, nausea, vomiting, and sometimes a peculiarly distressing and intense tinnitus in the affected ear. The hardness of hearing is increased to total deafness. To these sym[)toms may be added those consisting of paralysis of the facial muscles, and of the extremities on the side corresponding to the diseased ear, delirium, coma, and death. Thougli not infrequently, after the paralysis of the face and the exLrciHities has been fully established, it, with the })ain, tinnitus, nausea, vertigo, and vomiting, is quite suddenly relieved by a copious discharge of pus from the ear. The patient then re- covers; with, however, the absolute deafuess characteristic of destruction of the labyrinth, and with some continued discharge from the ear. Upon examining the external ear in such cases, not only bare bone may be felt, but loose sequestra are found at, or near the external auditory canal, or protruding from the opening of a sinus behind the auricle. In those cases in which the cochlea has been thrown off as a separate sequestrum, it has been found in the auditory canal, from which it has been lifted CHRONIC PURULENT INFLAMMATION. f)!! \vitli ease. When joined to other bony tissncs, lornniii;- a hirgo sequestrum, the whole has been worked from the meatus, or from the aforesaid opening behind the auricle. Exfoliation of the Cochlea. — Exfoliation of the cochlea, as a sequestrum separate from the rest of the labyrinth, has been observed and descrilied by Meniere,* Grul)er,-llinton,^ Toynbee,' Cassells,^ Parreidt,^ Boeck," Dennert,^ and Lucfe." In the vast majority of these cases the cochlea was taken out, or came out during life, the patient, of course, remainiiiif totally deaf in the affected ear, but free from facial jiaralysis. Only ill two cases, that of Boeck, and in one of the three of Meniere, was the necrosed cochlea found after death as a free sequestrum in the external ear. The case of Boeck was further exception- ally characterized by facial paralysis. The patient, a child under two years of age, succuml)ed during the ])rogres8 of the necrotic disease of the internal ear, from acute hydrocephalus. In all of these cases the cochlea was removed through the ex- ternal auditory meatus; not uncommonly, before "the acute symptoms of the detachment of the sequestrum, the external ear and mastoid portion are free from pain or tenderness on press- ure, a very marked, though not an invariable diagnostic ditfer- ence between deep-seated inflanmiation of the laln-rinth and mastoid disease. Sometimes detachment of pieces of the bony auditor}' canal precede the exfoliation of the cochlea. Facial paralysis is rarely observed, and never permanent, when the cochlea alone is thrown off. From recorded accounts it appears that only Toynbee has observed this symptom in con- nection with exfoliation, during life, of the separate cochlea. ISTecrosis and exfoliation of both cochleae have been observed only by Gruber."- The patient, a lad twelve years old, who had suffered from otorrhceafor several years after scarlatina, showed no signs of facial paralj-sis, but remained totally deaf. Exfoliation of the Cochlea, Vestibule, Semicircular Canals, and Deeper Farts. — Larger sequestra, composed of not only the cochlea, but the rest of the labyrinth, the porus acusticus in- ternus, and even the major portion of the temporal bone, have 1 Gazette Med. cle Paris, No. 50, 1857. ■' Wiener Allg. Med. Zt-itung, 1864; also "Lehrbuch," p. 542, 1870. » See Toynbee, Archiv f. Ohrenh., Bd. i. S. 114, 18(54. * Ibid. ^ " (Juestions of Aural Surgery," bv James Hinton, London, 1874, p. 206. e See Scbwartze, Arehiv f." Ohrenh\ Hd. ix. S. 238, 1875. ' Ibid. 8 Arcbiv f. Ohrenh., Ed. x. S. 231, 1876. 3 Ibid., Bd. X. S. 230, 1876. 10 Wiener Allg. Med. Zeitung, 1864. I 512 MIDDLE EAR. been removed during life and described, by Wilde/ Shaw,^ Toynbeej^* C. R. Agnew,* Voltolini/ O. D/Pomeroy,^ C. J, Blake," and Samuel Sexton.^ In the two cases of Toynbee the sequestra were not removed until after death, which occurred in consequence of the severe and previously neglected aural disease. In the other cases the large sequestra were removed through the external meatus, excepting in the case under the care of Dr. Pomeroy, in which the sequestrum, the major part of the temporal bone, came out by a natural process from the opening of a sinus behind the auricle. The implication in the necrosis of so much of the temporal bone as ensues when the entire labyrinth, the porus acusticus internus, and other parts of the petrous bone are thus thrown oft" as sequestra, is naturally attended with facial paralysis as a markedly characteristic symptom, besides the intense deafness. Besides the invariably' ensuing facial paralysis, which may be permanent, there may occur, as in the case reported by "Wilde, temporary paralysis of the arm and leg on the side of the diseased ear. The latter paralysis, however, vanishes upon the cessation of the acute symptoms, and may be considered as due to pressure from the retained pus in the ear. All the symptoms observed in connection with necrosis and exfoliation of the cochlea, are intensified when the necrosis involves other parts of the labyrinth and the neighboring petrous bone. jS^Ot only are the deep-seated pains, tinnitus aurium, deaf- ness, vertigo, nausea, and vomiting urgent symptoms, but the external ear is tumefied and more sensitive to pressure; the mastoid portion is more apt to become tender and painful ; an abscess may form there, and opening, leave a sinus which leads to dead bone; the discharge is excessively fetid; the cerebral symptoms often threatening ; the gait may be altered for long periods, as in a case reported by Sexton ; convulsions and coma may supervene, and death occur, as shown in two cases recorded b}'' Toyubee. In one of these an opening was found leading from the sequestrum in the posterior part of the petrous bone to the jugular fossa. In -necrosis originating in the inner wall of the tympanum, there seems to be a tendency on the part of the disease to enucleate the hard and resistant labyrinth from 1 Treatise on Diseases of the Ear, Pliila , 1853, p. 358. Sir Philip Crampton's case. ' Seventh Vol. Trans. Path. Soc. London. See Toynbee, Archiv f. Ohrenh., Bd. i., 18(54. •* Two cases: Archiv f. Ohrenh., Bd. i., 1864. * Amer. Med. Times, vol. vi. p. 183 ; also v. Troeltsch on the Ear, 2d Am. ed., p. 471, 1809. s Monatsschr. f. Ohrenh., 1870, No. 6. " Trans. Amer. Otol. Soc, 1872. ' Ibid., 1880, vol. ii. p. 417. 8 Illustrated Quarterly of Medicine and Surgery, N. Y., Jan. 1882. CHRONIC PURULEXT 1 X FL A M ^r ATTON . 513 the surrounding, more porous part of the petrous l)one in which it lies embedded. Treatment. — It is usually found that up to the time the patient applies for relief from the acute and painful symptoms which have been suddenly added to the chronic aural disease, there has been almost total neglect of the ear, and that the external auditory canal is blocked by one or more polyi)i, which has caused a retention and consecpient burrowing of pus. It, there- fore, becomes necessar}-, as the tirst step in the treatment, to free the external auditorj- canal and permit the escape of the products of inflammation ; after which, if dead bone be recognized, the escape of the sequestra should be favored, either by hygienic or direct surgical means. It not uncommonly happens that, before the sequestra of the deeper parts are removed, pieces of the more superficial parts of the external auditory canal escape or have to be pulled either from the meatus or a sinus near the auricle. If such an opening behind the ear leads to dead bone, a poultice kept constantly over the mouth of the sinus — not oeer the auditory meatus — will be found to favor greatly the process of nature in throwing off the sequestra. Traction upon the latter should never be made until they are entirely loose. Then, the sooner they are removed the better. Polypi and polypoid granulations are not indicative of dead bone, yet the presence of carious bone in the ear is always attended by the growth of granulati()ns. They are in such cases hard, sensitive to the touch, and bleed easily. These are very apt to be seated near the inner opening of a sinus, and are not un- commonly found attached to the auditory canal, thus forming an exception to the general rule in respect to the point of attach- ment of such growths. They are, in fact, to be regarded as exuberant granulations rather than polypi. They should be extracted if they interfere with drainage of the ear, but they will almost surely recur until the dead bone is removed. Then they will be found to disappear in the general improvement which takes place in the ear. So long as they do not interfere with the thorough cleansing of the ear, while the dead bone is still present, then- presence need not be combated, beyond keep- ing them down to a point which permits the escape of pus and the entrance of cleansing fluids and medications. The general constitutional treatment should be of the most supporting kind: meat, vegetables, farinaceous foods, milk, and eggs; iron, quinia, and cod-liver oil. In the more virulent cases, resembling in many respects a typhoid condition, alcoholic stimulants mav be g-iven if the failure in strength of the patient indicates such administration. A result of neglected purulent inflammation of the tympanum, more common than caries of the cochlea and labyrinth, is inflam- 33 514 MIDDLE EAR. mation, caries, and necrosis of the mastoid cells and of the entire mastoid portion of the temporal bone. ]S"o only is this a common event, but it is also a very fatal one. But this fact is not a new one to otologists; more or less distinct records of this disease can be found throughout the history of medicine and surgery. A greater want is felt in the paucitj' of accounts of how to prevent it ; or, if it is fully established, how to recog- nize and cure it. Prevention becomes of greatest importance; no part of the body tolerates neglect or improper treatment so poorly as the middle ear, when attacked by chronic suppuration. Caries of the mastoid is rarely a necessary result of the latter disease; it is almost invariably traceable to neglect of the puru- lent tympanic disorder. It must be remembered that the mastoid portion of the tem- poral bone is covered by periosteum, a continuation of that of the external auditory canal, and that its cavity consists of inter- communicating air-cells lined with mucous membrane connected with the middle ear. These cells, moreover, may extend over the upper wall of the external auditory canal, upward toward the parietal bone and inward toward the petrous part of the temporal bone ; in some instances, however, even in the adult the mastoid portion is small, and its cells rudimentary. In the normal bone, veins pass from the upper part of the mastoid cavit}' to the lateral, or to the superior petrosal sinus. This highly important cavity has but one outlet, viz., by means of the mastoid antrum into the tympanum. But this outlet is both small, and, so far as drainage is concerned, badly placed, since it is at the top of the cavity. Only the siphon action could empty the lower cells at the tip of the process, and it is probable that sometimes the cells are thus naturally drained when the discharge is excessive. It seems probable that the mastoid portion and its cells resist for a long time, in some cases, the chronic ulceration in the tympanum, for in very chronic cases the remnants of the cfells, or the shell of the mastoid cavity, are found choked with a cheesy mass, consisting of epithelial debris, pus, etc., forming a so-called cholesteatomatous mass. This at last, choking up every avenue of escape for the products of inflammation, be- comes a distending, irritating, and poisonous mass, which, if not removed, will either induce purulent absorption, so-called pyemia, or an irruption into the lateral sinus, or both of these events. Mastoid Disease; Symptoms and Course. — For clinical conve- nience mastoid inflammation consecutive to purulent disease in the tympanum, may be divided into : 1. Periostitis of its outer surface. CHROXIC rrRri.HNT INFLAMMATION. ^Ai) 2. Congestion and iiitiammiition of the mucous menibnine lining the uir-cells of the mastoid cavity. 3. Caries and necrosis; followed by meningitis, thrombus in the lateral and other sinuses of the brain, enil)olism, i)yaMnia, and cerebral abscess. 1. The Jirst is not uncommonly observed as an attendant of acute inflammation of the middle ear, with consecutive inflam- mation in the external auditory canal. It may also a})i)ear during chronic suppuration in the tympanum. An abscess may form over the mastoid as a result of this periostitis, and, in some broken-down and scrofulous diatheses, caries of the outer table may be thus induced. The latter, asthenic form is characterized by its painlessness; the former, the sthenic type, by the reverse. The asthenic process may occur as a sequel of diphtheria in children, as shown by the following cases: Case I. Frank H., 16 months old, born in Philadelphia, Avas attacked by diphtheria in March, 1875. I saw the case six weeks after the onset of the diphtheria. The mother of the child stated that, on the fourth day after the initial symptoms of diphtheria, she noticed a red swelling behind the right auricle over the mastoid. This swelling increased rapidl}^ in size, but is said to have caused the child no pain, nor was it markedly tender on pressure. There w^as no history of any previous aural disease, nor of any diphtheritic deposit in or about the external ear. The mastoid abscess was poulticed, and in a few days it was opened by the family physician, with a free discharge of pus. From that time until I saw the patient a constant and otFensive discharge continued from the mastoid incision and from the ear. I examined the case for the first time on the 22d of April, 1875, about six weeks after the onset of the diphtheritic disease, and found by the probe dead but adherent bone on the mastoid portion near the external auditory canal. The auditory passage was blocked by granulations. There was also considerable swelling about the ear, and the pus tended to burrow in the direction of the sterno-cleido-mastoid muscle. There was a sinus running from the mastoid abscess into the external audi- tory canal, which will, I think, account for the discharge from the ear and the granulations alluded to above, as well as lend probability to the statement of the mother that the mastoicl disease preceded any kind of discharge from the external audi- tory canal. On the 27th of April, 1875, I made an incision, an inch long, over the mastoid portion, which gave free exit to the pus, and diminished the discharge from the ear, as well as the tendency on the part of the pus to burrow downward into the neck. Throuo-h this incision the denuded bone could be felt. 516 MIDDLE EAK. In a mouth, on the 28th of May, there was a detached piece of bone at the opening I had made over the mastoid, and, on June 1, 1 extracted the sequestrum represented in Figs. 102 and 103. The general sweHing around the ear had gone down. The local treatment up to this time had been simple cleansing of the ear and keeping the mastoid incision free enough for drainage, and to permit the escape of dead bone. Fio-. 102. Yin-. 103. Outer Surface. (Natural size.) Inner Surface. (Natural size.) The child was considerably run down by his blood-disease, but, with tonics and the good effects of a summer in the country, rapidly grew better. The ear was kept carefully cleansed, as w^as the opening of the sinus behind the auricle, and a weak solution of sulphate of copper (gr. iij to fSj) was used for instilla- tion and injection. In two hundred and ninety-five days after the free incision over the mastoid, the sinus behind the auricle finally closed; a slight discharge — a few drops — still came from the external ear every day or two. So far as could be ascertained in so young a patient, then about twenty-six months old, there was no impairment of hear- ing as the result of the mastoid disease. In this child some of the chain of glands situated over the mastoid portion of the temporal bone and along the tract of the sterno-cleido-mastoid muscle, successively enlarged and slug- gishly suppurated, without pain, wdiich would seem to indicate that the inflammation over the mastoid portion, and of its outer table, in this case, was due to an inflammation of such a gland, the first in the chain to be diseased by the diphtheritic poison. Such a disease as this, occurring over the outer wall of the mastoid portion m a child, becomes of moment not only to the hearing, but even to the life of the patient. The latter is due to the fact that in children there is much greater probability of an extension inward of such a disease as I have just described, than there is of its successful outward termination, for the dense tissues over the mastoid in voung children are much more re- sistant than the thin and somewhat cribriform or dehiscent outer table of the mastoid portion of the temporal bone. Hence, in just such a sluggish form of abscess over the mastoid as was CHRONIC PURULENT INFLAMMATION. 517 found in this child, there may be danger of a burrowing imvard of the disease, deep intlaniination of the mastoid eells, caries ox- tending into the cranial cavity, }»yiemia, and death. That this disease originatetl outside of the mastoid portion of the temporal bone, is further shown l)y the first aural symptom, if it may be called such, viz., the mastoid swelling, unaccom- panied by pain in the ear. Had the disease started in the middle ear or in the mastoid cells, there would surely have been symptoms of great suffering in the child at the outset, and subsequently, it is highly probable, we should liave found an impairment of hearing; whereas that functi(.)n did not ap- pear to be affected at any time during the disease. The following case is one resulting from scarlatina and diph- theria combined ; but in it, too, I am inclined to regard the carious erosion as starting on the outer side of the mastoid : Case II. Mary Coogan was attacked in April, 187G, when three and a half years old, with diphtheria and scarlatina. The throat symptoms were very bad. In about three weeks after the beginning of the fever, which was soon followed by a running from the right ear without pain, facial paralysis was observed on the right side, and in three weeks an abscess formed over the mastoid and spontaneously opened. There was no pain at any time. The facial paralysis now began to disappear, and was only very slightly visible in October, 1876, when I lirst saw her; in a few weeks it vanished entirely. The external auditory canal w^as blocked wnth granu- lations springing from the posterior wall ; there was a large sinus close to and behind the auricle leading to the external auditory canal ; offensive pus was discharged from the meatus and the sinus; denuded bone was felt with the probe passed into the sinus and external auditory meatus. The child was given cod- liver oil and some other tonics; a poultice was kept constantly over the opening of the sinus hehwd the auricle; and by Decem- ber, 1876, a sequestrum could be distinguished, one end of which began to protrude by January, 1877, from the sinus. The sequestrum appeared "to consist of the major part of the outer wall of the mastoid and that part of the latter which goes to form the posterior wall of the bony auditory canal. And this was verified by the extraction of the sequestrum through the sinus on February 12, 1877. As shown in the accompanying woodcuts (Figs. 104 and 105), the sequestrum consisted of a large number of the air-cells of the mastoid cavity as well as of a large part of its anterior and outer wall. The ear was syringed with warm water for a few days ; the dis- charge from the ear'ceased entirely ; the granulations shrivelled and disappeared ; the opening behind the auricle closed. 518 MIDDLE EAR, The sthenic variety of mastoid periostitis is characterized by pain and tenderness in the mastoid portion, with some redness of the skin. It may mislead the observer into the idea that it is inflammation of the mastoid cells. But the less deep-seated Fio;. 104. Fio-. lOo. Outer Surface. (Natural size.) IxsER Surface. (Natural size.) pain in the ear and head, and the readiness with which the periostitis yields to leeching or a deep incision (Wildej, will serve as diagnostic points. It must be borne in mind, however, that inflammation of the external periosteum may be associated with deeper inflammation in the mastoid cavity. 2. Congestion and Inflammation of the 3Iucous Membrane of the Mastoid Cells. — A simple congestion of the mastoid cells may coexist with a tympanic inflammation. The pain may not be referred to the mastoid in all cases, though usually the pain is thus referred, and there is noted some swelling over the mastoid. This congestive process may readily yield to treatment or even undergo resolution. If not, there may ensue a deposition of a reddish, pulpy material, as shown by A. H. Buck,^ followed by suppuration, caries, and necrosis in and about the mastoid cavity. In some instances, after the congestive stage has been full}' established, instead of an active inflammation, there ensues a subacute process in the mastoid cells, analogous to the chronic catarrh supervening upon a severe congestion of the middle ear. It was noted, when alluding to inflammatory processes in the middle ear, that although a congestion, in some instances, was followed by destructive suppuration, in others it "was succeeded by the more conservative sclerotic process known as chronic catarrhal thickening or proliferation. An analogous process may succeed the congestive stage in an inflammatory process in the mastoid cavity, and lead to thicken- ing of the mucous membrane covering the bony septa between the mastoid cells, and to an hyperostosis of the latter. That ^ Archives of Opli. and Otul., vol. iii., 1873. CHROXIC PURULENT IXFL A M M A T 1 o X . 519 such 11 slow and insidious process may occur in tlic middle ear and mastoid cavity seems probable from tbe cheesy accumula- tions almost invariably found in the worst cases oi' necrosis of the mastoid cells and temporal bone. 3. Om'ous lujiammation of (he Mastoid Cells. — Leaving out of consideration those extraordinary cases of acute inflammation of the mastoid cells, in a previously entirely healthy ear, it may be stated that after a purulent inflammation has existed for a longer or shorter time in the middle ear, an acute and virulent intlammatory process seems to be superadded to the chronic process alreadv fastened on the oro-an of hearins:. This acute stage in the disease already existing in the mucous membrane of the middle ear and mastoid cells, is analogous to a similar process in a diseased mucous membrane anywhere else in the body. Hence an early symptom of the acute engorgement of the vessels in the mucous lining of the ear, is a diminution or an entire cessation of the discharge which may have been existing for a long time. And just because fatal cases have been, for the above reasons, preceded by a cessation of discharge, there may have arisen the prejudice against stopping an aural dis- charge. But the same argument might be used against stop- ping a chronic discharge from the bowels or the lungs. After an unusual exposure to cold, after a blow on the dis- eased ear, or in the natural course of the purulent tympanic disease, severe and increasing pain is felt in the organ, which bids defiance to all ordinary remedies for relief; or, if a tempo- rary relief be experienced by fomentations, leeching, and opium, the pain returns very quickl}^ and perhaps with greater intensity. The discharge, which, as stated, had at first ceased, may be renewed, though altered in appearance and usually offensive in odor. The mastoid region becomes very sensitive to pressure, the skin over it oecomes slightly bogg}' and reddened, the deep-seated pain in the ear is found to be shooting forwards toward the brow% and upwards to the vertex, and backwards toward the occiput, and the auricle may, during the more acute paroxysms of pain, stand out farther from the head than its fellow; but this symptom may disappear in a few hours, to be observed when another paroxysm of pain comes on. This varia- bility in the position of the auricle, is a marked diagnostic symptom of mastoid affections, and should obtain earnest atten- tion from the surgeon. In some instances it is very striking, and, as after abstraction of blood it subsides, it may be due to the intense eno-oro-ement of the dense tissues about the ear. It surely is not due to the formation of pus, for it appears too soon in the disease. It may be analogous to the swellings lower down in the. neck, in the sterno cleido-mastoid muscle, which have been observed by some (Voltolini and others) as an accompani- 520 MIDDLE EAR. ment of mastoid periostitis. These swellino's, though large, reel, tender, and painful, usually disappear without suppuration. The te^idency of mastoid pain to exacerbations, chiefly at night, is worthy of note. As the mastoid symptoms increase in severity, the general appearance and condition of the patient are most striking and pitiable. Kot uncommonly the sulferer con- tinues to go about his daily duties, especially when unaware of the true nature of his disease. The pain deep in the ear and head is most intense, the pulse — often slow and weak at lirst — becomes very rapid, sleep is out of the question, the appetite fails, nausea and vomiting ensue, the tongue becomes dry and rough, and the face becomes peculiarly haggard and bathed in cold sweat. Though very weak, the patient may still continue to walk about, not unfrequently coming regularly to his physi- cian. But, gradually, unless relief is obtained by evacuation of the products of inflammation which have accumulated in the mastoid, it is observed that the answers of the patient are becom- ing incorrect respecting even his name and place of residence, that his intellect is confused, and that his strength is failing. Rigors and irregular fever set in, every movement of the body now causes almost indescribable agony in the head; stupor and coma, with alteration in the size of the pupil on the afJ'ected side of the head, are noted in rapid succession, and, unless speedy relief is given, death supervenes. This train of symptoms is not obscure, but points most posi- tively to the true nature of the terrible disease of which it might be said to be eminently characteristic. And yet a true diagnosis is rarely made until too late, the disease being vaguely called cerebral. But in most cases its cerebral character is in no way a necessary one, and would either never show itself, or be obliterated entirely, if prompt and proper treatment were ap- plied to the disease while confined to the mastoid. As it is easier for pus to find its way through the inner wall of the mastoid cavity and transverse sinus than it is to force its way through the outer mastoid table in adults, it is not likely to choose the latter way; and hence the direful accidents follow- ing pent-up pus in the mastoid cells. And yet patients have been allowed to die witli no better effort for their rescue than a poultice bound over the bony cavity in which lay the cause of their dissolution. The best that nature can do in inflammation within the mas- toid cavity, is to break down by necrosis the outer mastoid table, or to force the pus through a natural dehiscence which might happen to exist in a given case. And in some instances, it would seem that nature thus gave a vent to the products of in- flammation in the mastoid cells. But, in the vast majority of cases, such relief cannot be reasonably hoped for, and the CHROXIC PURULENT INFLAMMATION. 521 natural result then is an erosion of the thin wall of tlie lateral sinus, or a passage of the intlannnatory process to tlie nu'iiiiii^es and the sinuses of the hrain, hy the vaseular conununieation existing hetween the mastoid cavity and the former structures. Thrombi may entirely till the lateral sinus on the side of the affected ear and extend into the correspondino; petrosal sinus. These may undergo suppuration and gangrene, and give rise to embolism and blood-poisoning. A deep-seated abscess not un- frequently forms in the muscles of the neck near the affected mastoid cavity. Cerebral abscess is not an uncommon result of mastoid disease, as well as of chronic purulent disease in the tympanum. Its origin from purulent absorption would seem to be rendered all the more positive from the fact observed by von Troeltsch, that it may occur in the brain on the side opposite to the diseased ear. The tympanic cavity, though the starting-point of these ravas:es, mav be found in a measure intact, as tliouo-h the force of the chronic suppuration had been spent on the nuistoid and its vicinity. Hence, even in fatal cases of mastoid disease, the ossicles are sometimes found in situ, and the membrana tympani perforated but not destroyed. In very rare instances, mastoid disease may run its full course without an accompanying per- foration in the drum-head. Treatment of Mastoid Disease. — Inflammation of the perios- teum will usuallv vield to the local abstraction of blood, which is best accomplished by thorough leeching, or by a deep inci- sion down to the bone. The latter procedure, Wilde's incision, will not only relieve by depletion of the congested vessels, but will also have the happiest results in relieving the tension of the dense tissues over the mastoid. Without doubt, such an incision, besides giving immediate relief to the patient's pain, in manv instances cuts short a process which mio^ht extend to deeper parts and produce caries of the mastoid portion. This incision should be made about one-fourth of an inch behind the attachment of the auricle, and extend for about an inch, or even an inch and s half, across the mastoid in the line of the course of the sterno-cleido-mastoid muscle. Sometimes a branch of the posterior auricular artery is severed in this operation, but the hemorrhage is of service rather than otherwise. It is to be controlled" on general surgical principles. A poultice maybe applied to the Incision, and the latter kept open, if necessary, by means of a tent. The bone beneath the thus incised peri- osteum may be found entirely healthy, though inflammation may be going on in the mastoid cavity. If the mastoid cells are deeply congested or inflamed, the incision of the periosteum will be but palliative, and the renewal or increase of the pain will indicate the probability of the existence of tlie second con- 522 MIDDLE EAR. dition of mastoid disease, viz. : Congestion and inflammation of the war-ous membrane of the mastoid cells. If, after the above-named treatment, local depletion and the incision of the periosteum over the mastoid, the pain, which may have been further com- bated by anodynes, should still persist, grow worse, and be accompanied by symptoms of general constitutional derange- ment, the outer mastoid wall should be perforated. Artificial Perforation of the Mastoid Portion of the Temporal Bone. — So far as the statements of the past concern this opera- tion, they do not demand an extended reference here. Any reliable book on diseases of the ear will give details respecting the unchecked ravages of chronic otorrhoea truly appalling. It is claimed now, and Avith reason, that mastoid disease and its fatal results can be prevented in many, if not in most cases; or if intlammation is set up in the mastoid cells, a safe means of relief is afforded in the operation of perforating the outer table of the mastoid portion. Excepting to allude briefly to a few of the prominent historical facts connected with this operation, it will not be necessary to recall the past; I shall base ni}' statements mainly on the writ- ings published within the last ten or twelve years by men, most of whom are yet living and working. The history of perforation of the mastoid portion begins with the writings and operations of Jean Louis Petit,^ and of Jasser,- a Prussian military surgeon. Petit died in 1750, and, as the accounts of his operations were posthumous, Jasser, who ope- rated on the mastoid not until 1776, may have been entirely io-norant of the labors of the distino-uished suro-eon of France. Although both of these men operated most successfully in their first cases, the indications for the operation were evidently not clearly comprehended by their contemporaries and immediate successors. The operation w^as most mistakenly resorted to for the relief of deafness, and even Jasser seems to have lost sight of the real worth of the operation, viz., the evacuation of the products of inflammation from the cavity of the mastoid portion. As the real worth and applicability of the operation were entirely misconceived; as it was resorted to empiricall}-, on all sides, to relieve deafness, and not to keep pus from burrowing to the brain, reports of failure and of death, consequent upon it, soon followed, and the operation was rejected without one word of justice. No fact of history points more conclusively to the total mis- conception of the true intent of the operation than the fatal 1 See Schwiirtze and Eysell, Archiv f. Ohrenh., Bd. i., X. F., 1873 ; also, Saissy, op. cit., p. ](J4. ^ See writings of Roosa, Buck, and others. CHRONIC PURULENT INFLAMMATION. 523 result of it in the case' of Baron von Berorer, jiliysician to the Ivin«: of Denmark. Dr. I)Cro;er, liavinn" suflbrcd for a lont(S lafnp'influca. It is probably a local meningitis involving chiefly the auditory nerve. Thus, a girl, five years old, with perfect hearing, speech, and health, is suddenly attacked with violent vomiting, which lasts, with intermissions, for several days; there are also'chill and fever. N'o cause can be assigned 532 DISEASES OF THE INTERNAL EAR. for the illness. On the first day of the disease the child still hears; on the second da}' the hearing is found to be entirely gone, but the intellect is, and has been from the first, clear. Signs are well understood. From the first appearance of the dis- ease the hearing seems to he annihilated. There have been no spasms nor paralysis, and no opisthotonos. The urine and the feces present nothing abnormal. The child may cry out that the noises in the head are distressing. By the fourth day the appetite returns, and the child is found playing in bed. Upon attempting to walk, in the course of two or three weeks, the gait is unsteady, and the child must be led about. An exami- nation of the ear reveals nothing in the sound-conducting ap- paratus to account for these distressing symptoms. Such cases, in the opinion of Yoltolini, "speak for them- selves." "They cannot be either meningitis or cerebro-spinal meningitis, but must be regarded as a specific disease of child- hood — as specific as croup."" Many aurists are inclined to adopt this view. The mere fact of the rare occurrence of death in the above-described disease, and the absence of important sj-mp- toms of meningitis, as well as the permanent deafness resulting, should call attention to the probability that many such cases have been erroneously called meningitis instead of idiopathic inflammation of the internal ear or labyrinth. But, in estab- lishing the presence of such a primary inflammation in the labyrinth, great care must be taken to exclude the existence of a previous disease in the middle ear; for, doubtless, many a so- called primary labyrinth-disease is in reality secondary to a tympanic disease, as held by von Troeltsch,- Politzer,^ and many others. But on this aspect of labyrinthine vertigo more will be said hereafter. It is extremely ditiicult to be sure, that in every case of sup- posed primary lesion in the labyrinth, there has been no pre- existing tj'mpanic disease. Until the latter can be excluded positively, it is not easy to determine that a labyrinth-disease which has manifested itself, is primary in origin. This dividing line in the diagnosis, makes these cases of so-called Meniere's disease, or aural vertigo, of greatest interest to the physician. According to some observers, there is a hemorrhagic process, sudden and acute, occurring as a primary disease of the laby- rinth. While such a disease may occur in the very robust and florid, as a primary labyrinth-aflection, pathological evidence is so far wanting as to excite caution in making a positive diag- nosis. Doubtless many cases of apparently hemorrhagic disease of the internal ear occur, as shown by Moos ;* but he is disposed 1 Monatsschrift. f. Ohrenh., 187*2, No. 8. -' Treatise, Loot. l>8, p. 516. » Archiv f. Olireiiljoilkunde, Bd. ii. S. HI. * Archives of Oph. and OtoL, vol. iii. part 1, p. 118. PRIMARY AND SECONliAin' I X K I, A M M \ r lu N . 533 to regard even the best detiiiecl cases as seamdan/ to disease of the middle ear. If, therotbre, any trace of prel-xistiiig disease of the tympanum, or of any part of the mi(Ulle ear or external auditory canal, is found in connection with very manifest symptoms of hd)yrinthine vertigo, the latter cannot be adjudged as primary. But, if an individual in full possession of positively normal hearing, be sudtlenly attacked with tinnitus aurium, dis- tressing vertigo, nausea, vomiting, and faintness, the forehead and entire cutaneous surface being at the same time bathed in clammy sweat, but the mind entirely clear, and if the gait be unsteady, or the ability to walk entirely gone, with more or less hardness of hearing at the outset, rapidly passing into total deafness, then a diagnosis of acute, primary intlammation of the internal ear, serous or hemorrhao-ic, mav be made. O'xses. — If the diagnosis of a primary inflammatory disease of the labyrinth is hard to establish, the assigning of a cause for it is perhaps still more ditiicult. Iti some instances it is evi- dent, as in cases of violence, that the origin of the disease in the labyrinth is traumatic. Perhaps, in some cases, it is due to hemorrhage from atheromatous vessels, rendered Aveak by gen- eral atheroma in the circulatory system. Treatment. — If the diagnosis of a primary intlammation, of a serous or purulent nature, can be established, the treatment should be conducted on general principles. Calomel and iodide of potassium will, perhaps, render the best aid. If the disease appear to be of a hemorrhagic nature, and the subject of it apoplectic in diathesis, then the form of treatment known as depletory should be used. Local bloodletting would be of prime importance. This might be followed by iodide of potas- sium or the bichloride of mercury, or by both. Here, too, in either form of the disease, is one of the few instances in which a blister over the mastoid, or in front, or about the auricle, may be of advantage. But vesication must be kept up if it is to be of service in tliese cases. A small, solitary blister is of no avail; it is, indeed, a positive annoyance to the patient, wdio should be made as comfortable as possible. But a small vesicated spot behind the auricle may be kept up for several weeks. Digitalis and nitrate of silver— but both with great caution — may be given, a[)parently with advantage. Injuries. — Fractures of the base of the skull often implicate the temporal bone. The fissure may extend through the petrous portion, and involve the bony labyrinth, with its delicate and important soft contents. I examined, not long ago, the skull' of a young man, who in sliding on the ice fell, and, striking ' Specimen C. 21 : >riis('uiii of the College of Pliysicians of Pliiladelpliiu. 534 DISEASES OF THE INTERNAL EAR. his occiput, fractured his skull. The line of fracture ran sym- metrically through the temporal bones as follows : Rigid Side, viewed externally. — The fracture began in the squamous portion, at a point one-half inch in front of the posterior inferior angle of the parietal bone, ran across the lower part of the squama, then downward, forward, and inward, form- ing a curve with its concavity downward, across the upper and anterior wall of the external auditory canal, and was lost in the glenoid iissure. Internally, the line of fracture began at a point on the upper edge of the temporal bone where the squama fades into the anterior surface of the petrous portion, followed the anterior edge of the tegmen tympani, and ran through the Eustachian tube, in the long axis of the latter. The fracture had thus separated the anterior half of the osseous Eustachian tube from the posterior, and a portion of the anterior wall of the external auditory canal from the rest of the meatus. The two canals were thus thrown into one. The delicate septum of bone between the carotid canal and the Eustachian tube was intact. Left Side, viewed externally. — The fracture began at a point similar to that on the opposite side, ran directly forward toward, and in a line with the zygoma, till it reached the point where the latter fades into the junction of the squama and mastoid: here the fracture ran abruptly downward and across the external auditory meatus, dividing the canal equally into an upper and lower part, and instead of losing itself in the glenoid iissure, it ran through the tympanic bone. Internally, the fracture started at a point similar to that on the opposite side, but ran much closer to the ridge of the petrous portion; it ran down through the middle of the tegmen tympani, bisecting the mastoid antrum, tympanic cavity, and the Eustachian tube, and met the line of fracture of the opposite side at the spheno-occipital suture. The horizontal semicircular canal was laid bare, but not fractured ; it could be seen like an ivory coil lying in the spongy tissue of the temporal bone exposed by the fracture of the mastoid antrum. The internal ear was not fractured on either side. There had evidently been great hemorrhage, as the mastoid cells and sig- moid sinus were filled with hard and dried blood. The ante- mortem notes are wanting. Politzer^ has given the details of a case of fracture of the temporal bones, observed by him in a man, who suddenly fell, striking his occiput on the pavement. Unconsciousness lasted several hours; upon the return of consciousness it was found that the man could not hear nor speak. On the next day, however, the power of speech returned. In the seventh week 1 Arcliiv f. Olnenh., Bd. ii. S. 88, 1865. I I PRIMARY AND SECONDARY 1 X F L A M M A TI U N . 535 moningitis set in, and death oeeurred. The post-tnortcni exanii- uatiou revealed a tissure at the ])ase of the oeciput, exteiidiiii; through hoth temporal hones, across the vestil»ule to flu- inn('7- wall of the tympanum. ^ The soft parts of each lahvrinth were disorganized; <.n the right side, the eoagulum resulting from the iK-morrhagv was found nearly unaltered; on the left side, purulent metamor- phosis had occurred, and from this point, ])us had forced its way through the fracture to the haseof the skull, and there produced a hasilar meningitis, which had caused death. Symmetrical fracture of the bas^ of the skull, similar to this case, has been described by Voltolini:' A soldier was struck on tlie left temple by a billet of wood, lie fell stunned; upon regaining consciousness in a few minutes, he vomited, com- plained of noises in his head, and deafness. There was no hemorrhage from the ear, nor paralysis. Cerebral symptoms supervened, and death occurred on the eleventh day after the injury. The post-mortem examination revealed a fracture ex- tending through both petrous bones, between the round window and the cochlea. It is said that the base of the skull may be fractured; the membrana tympani ruptured; hemorrhage from the ear may take place; there may be facial paralysis on the correspondiirg side, and yet total recovery ensue, as shown in a case given by Dr. A. Eysell,-' of Ilalle. Si/iiipfo)i)s. — In all works of surgery it will be found that one of the symptoms, and a very unfavorable one, too, in fracture of the base of the skull, is a discharge of serum, sometimes tino-ed with blood, from the external auditorv meatus. The serous discharge is generally supposed to be the cerebro-spinal fluid. It is a much graver symptom than pure hemorrhage from the ear. If the fracture has implicated the bony labyrinth, it can very readily be understood how an escape of serous fluid nuiy occur from the external meatus. Let it be supposed that such a frac- ture has not only placed the internal ear in communication with the tympanum, but that the membrana tympani, or the upper wall of the auditory canal, or both, ha^'e also been Assured. Then the fluid contents of the internal ear, shown by Ilasse to be part of the cerebro-spinal fluid (see pp. 138, 139) will naturally escape, and the internal ear be destroyed. Injuries thus afl'ecting the interiuil ear may be produced by penetrating violence from without, through the external auditorv canal, or by blows and falls. That force known as contre-coup, often produces fracture at the base of the skull. When the force ' M. f. uiiffiih., is(;;). 2 Archiv f. Ohrenh., Bd. vii. S. 208, 1873. 536 DISEASES OF THE INTERNAL EAR. comes from below upward, as in a fall, the force of which is communicated through the legs and spinal column to the base of the sknll, a fracture may occur only at the latter point, a circumscribed disk of bone being driven upward, as it were, without an extension of the fissure outward to the membrana tympani. In such cases great difiiculty will be met in making an accurate diagnosis. Even when the fracture has extended to the membrana tympani and the external auditory canal, thus placing the latter potentially in communication with the in- ternal "ear, blood-clots may, for days, occlude the fissure; but sooner or later the cerebrf)-spinal fluid will make its appearance, in such cases, at the outer auditory meatus. Although it appears that fractures at the base of the skull, involving the petrous bone, may not prove fatal in every in- stance, the hearing is permanently destroyed by such an injurj'. Mr. J. Hutchinson^ has reported a case of fracture of the petrous and squamous portions of the right temporal bone, without laceration of the dura mater. Acute arachnitis occurred over both sides of the brain. On the day following the fall which produced this injury, there was found a watery discharge from the right ear. This observer states that inflammation of the subarachnoid space is more likely to occur than arach- nitis, after injuries to the head, in which' a drainage from one ear has ensued. Another case from this observer is as follows : A boy fell down stairs, was stunned, and bled from the right ear, and was deaf on that side. On the 2d day he was conscious but stupid; still deaf on right side. 3d day: Pulse 80, irregu- lar; feverish; peevish and restless; tongue coated; serous dis- charge from ear. 4th. day: Worse; very restless; no paralysis; pupils dilated and fixed. IsTear midnight violent convulsion, in which he died. At the autopsy, fracture of the petrous bone was found. Lymph in the subarachnoid spaces at the base of the brain and around the pons and medulla. SECONDARY INFLAMMATION OF THE INTERNAL EAR. Disease of the internal ear has been, for a long time, con- sidered a result consequent upon other diseases. Itard names five causes of secondary changes in the auditory nerve, in all probability meaning by the latter the entire internal ear. These causes are thus given by him:^ Concussion of the nerve, convulsions, apoplexy, fevers, and sympathetic influence of some other diseased orqan. ' Liincot, London, 1875, voL i. - Maladies de I'Oreille, Paris, 1821, p. oil. t> PRIMARY AND SECONDARY INFLAMMATION. oBT Deafness from Concussion. — Deafness from coticiis.'^ioii is no uii- coniinoii oecMUTenee. The followino- eases will illustrate the 2;eiieral features of such aecidents. Case L Mr. R., banker, lu^ed thirty-eiglit, single, stated that eiglit years previous he was thrown from his horse, lie was made senseless for some time: upon recovering consciousness lu' found that he was absolutely deaf in the left ear, and he has remained so ever since. Taste and smell Avcre greatly imi)aired; l)ut they gradually returned, taste first, and then the sense of smell. Tlie latter, however, has never been as sharp as it was before the accident. The inspection of the left external ear and membrana tympani presented nothing abnormal. Tlie deafness was ab- solute. Case II. A young man, nineteen years old, standing on a moving raihvay-train, was struck on the head as the train passed under a bridge. He was picked up and carried home in un- consciousness. Upon the recovery of consciousness, it was ob- served that he was deaf in both ears. Ilis family think he could hear a little when he lirst became conscious, but in a few days he was certainly absolutely deaf. His voice assumed a most pe- culiar and unnatural clang. Upon inspection of the drum-heads, it was found that they presented nothing to explain the deaf- ness. The diagnosis in such cases is paralysis of the auditory nerve, from concussion of the labyrinth. Case III. A boy was struck on the external ear by a liard snow-ball. He became totally and permanently deaf on that side. The drum-head appeared normal. Case IV. Ayouno^druo-oristwas standiuijwith some friends near a party of men firing salutes on the fourth of July ; while his back was turned to the guns, the discharge occurred, and he instantly observed a buzzina; and deafness in one ear. This continued for some days ; rest and some general tonic treatment seemed to do good, for gradually the subjective noises in the ear ceased and the hearing grew sharper and finally was restored. But these cases do not usually terminate so favorably. Whatever is done for them must be done promptly. Case V. An Irishman, forty years old, states that he became deaf in his left ear from an accident which hap|)ened to him while helping to lay cobble-stones in a street. He stated that that in lifting the long, heavy pounder these men use to drive the stonee down, he lost his balance, and the force of the blow seemed to spend itself on the left side of his body and head. He noticed immediately that he was deaf, and he has remained so. The drum-heads presented nothing to explain the deafness, and the case was apparently one of deafness from concussion. Dr. Brunner' has recorded the case of a man thirty-six years 1 Archiv f. Ohrenlieilkunde, Bd. vi. S. 32. 538 DISEASES OF THE INTERNAL EAR. old, who fell and struck the left temple : the man lay for some time insensible ; he was picked up and carried into his house, where he lay in unconsciousness all night. There was some bleeding from the nose and left ear. Upon regaining his con- sciousness he was unable to speak or to write, and there was paralysis of taste on the left side, the latter attributable, accord- ing to Dr. Brunner, to an injury of the chorda tympani. The power to speak and write returned in the course of three weeks. The sense of taste returned gradually in the course of four months. The hearing, at that length of time after the fall, was '— for the watch. 150 cm. Itard states that convulsions are a rare cause of deafness in the adult, but a frequent one in infancy. When the hearing is lost in the first three or four years of life, it is generally in consequence of convulsions. A number of infants, referred to by him, had become deaf at the period of dentition, having, for the most part, ceased to hear immediately after a light con- vulsion. I have seen a number of mute children who were sup- posed to have becoiije deaf in consequence of convulsions. Upon closer investigation, there was no history of cerebro-spinal men- ingitis, and I am inclined to believe that the cause assigned by the parents, " fits," was the true explanation of the destruction of hearing. Most writers are in accord that the following dis- eases produce secondary results in the labyrinth, i.e., secondary morbid processes in the tympanic cavity : cerebro-spinal menin- gitis, mumps, and syphilis ; typhoid, intermittent, and other continued fevers ; the exanthemata, and some skin diseases about the head, as erysipelas ; and the puerperal state, and its diseases. Hardness of Hearing, and Total Deafness after Cerebro-spinal Meningitis. — Hardness of hearing and total deafness frequently occur as sequelse of cerebro-spinal meningitis, a fact noted by all writers on the nature and course of this fever. In an epidemic in the Philadelphia Hospital,^ occurring in 1866-67, deafness existed to a greater or less extent in sixteen cases. In twenty-four cases observed by Fassett, referred to by Stille, one-half recovered; but three of them with entire loss of hearing, and one with partial deafness as well as strabismus. Dr. Knap])^ had an opportunity of seeing seventy-one cases of deafness, and fourteen of blindness, mostly in children under ten years of age, the result of epidemic cerebro-spinal menin- ' See " Epidemic ]\reninc;itis, (ir Cerebro-spinal Meningitis,'" In- Prnf. Alfred Stille. Philu., 1867, p 61. ^ '^ "Deafness from Epidemic Cerebro-spinal ^leningiti-." Trans. Amer. Otol. Soc, vol. i. p. 448, 1878 I PRIMARY AND SECONDARY INFLAMMATION. 539 gitis ill New York, in 187:^-73. He stat(";< tliat "the donfiiCHS or blindness was, in most cases, tirst noticed during tiie tirst or second week of the fever; in rare cases the deafness set in during the mostly protracted period of convalescence, and, ex- ceptionally, even so late as six niotifhs after the heginning of the cerebro-spinal inthuuniation. In these latter cases, however, some hardness of hearing was observed when the patients had so for recovered that tlieir hearing could be tested. The hard- ness of hearing then increased slowly, and terminated in com- plete deafness within some weeks or months." Both meningitis and cerebro-spinal meningitis may lead to disease of the labyrinth by direct transmission of tlie inflam- matory action. Disease of the middle ear also results from those aftections, and in many cases these two parts of the ear mav be simultaneouslv afiected. But accordin. St. 540 DISEASES OF THE INTERNAL EAR. In a case observed by Moos, the hearins: failed on the third day; the other symptoms ceased on the ninth day, and four days Later the hearing began to improve. It is stated by Moos,^ that, in the cases, terminating favorably, reported by Ziemsseu and Hess,^ the hardness of hearing began mostly on the third day. After a careful dissection and microscopical examination of the internal ears in a case of cerebro-spinal meningitis, which proved fatal thirty-six hours from its inception, Lucas^ found the hemispheres, base of the brain, pons, and medulla aifected by a purulent inflammation of the pia mater. The microscopic ex- amination traced the purulent inflammation along the auditory nerve to the cochlete. Purulent inflammation of the sacculi, ampullae, and canals of the membranous labj-rinth was also found; along their vessels were masses of pus-cells and free blood-corpuscles; the vessels were intensely congested and much thickened; the semicircular canals also showed occasional ecchv- moses. The tympanic cavities, except a slight injection, were normal. The. fibres of the facial nerve were subjected to micro- scopical examination, and were found to be normal. In the ampullae and sacculi were here and there deposits of fat and chalk. Lucfe concluded that it was probable the disease began first in the brain and then passed to the ear. In the same article it is stated that Heller^ found, in a case presenting similar disorganization in the labyrinth, purulent inflammation of the middle ears. In some cases of deafness after cerebro-spinal meningitis there appear to be lacunae in the hearing :^ thus, speech is heard very imperfectly, while the patent's own step and loud noises in the street are heard com[)aratively well. The low notes on the piano are not heard in some of these cases. This seems to indi- cate that parts of the terminal nerve-filaments have been im- paired, while others have escaped. When some hearing still remains, hope of further recovery may be entertained if the treatment be applied promptly. This has seemed most effica- cious, according to some observers, when consisting in the ap- plication of the constant electric current, according to Bren- ner's method. The tone lacunte, or gaps in the hearing, were very marked in a young man seventeen years old, whom I examined several years after his recovery from an attack of epidemic cerebro- 1 Archives of Oph. and Otol., vol. i. - Deutsche^ Archiv fur Klin. Med., 1865. ^ Archiv f. Olirenheilk., Bd. v. * Archiv f. Klin. Med., Bd. i!i. S. 482. * S. Moos, Peculiar Dis'urbances of Hearing; after Cerebro-spinal ^leningitis ; considerable Improvement by the Galvanic CiuTcnt. Archives of Oph. and Otol., vol. i. pp. 332-340, 1869. riUMAKY AND SECONDAKV 1 N F I, A M M A T K « X . .")41 spinal meningitis. He could not hear the voice of others, but he heard his own. lie could easily perceive some sounds, as the cracking of a whip, the rolling of lu-avy carts past his door, etc. His voice was peculiar, and wauVmg in tind)re, Hke that of the deaf-mute. His intellect was good, and his capacity for business well known. Electricity, applied in Jiren- ner's way, ettected no improvement ; very probably, because ap- phed too late. The staggering gait is usually noted, only at lirst, in those who have been made deaf by cerebro-spinal meningitis. This sequel howiever may be still marl*3d six weeks after convales- cence. In walking, the gait is sailor-like, and the peculiar atti- tude of those on shipboard is assumed in order to steady the body. The staggering gait does not remain, however, as the absolute deafness does. Prognosis and Treainient. — The prognosis is always highly unfavorable. The treatment, certainly in the early stages of the deafness, would naturally be the treatment carried out for the cure of the primary disease. After convalescence from the A meningitis, electricity in the form of the constant current, and " the administration of strychnia, either internally or hypoder- matically, have been thought to be of value, if there is any rem- nant of hearing. But they are not usually attended with satis- factory results, and if the hearing be entirely gone, they are powerless to restore it. Disease of the Internal Ear from Syphilis. — Although the majority of w^riters upon 83'philis, agree that the ear is often affected in the constitutional form of that disease, aurists have not felt warranted in making such assertions, nor is it probable that the internal ear is the seat of the disease. It is far more rational to suppose that the syphilitic taint is felt first and chiefly in the mucous membrane of the middle ear. Schwartze^ states very justly that " the ([uestion to be decided is whether the aural diseases which occur in the course of con- stitutional syphilis, possess distinctly characteristic and ever- recurring anatomical and clinical peculiarities. Only by proving that such is the case can it be positively shown that a given ear- disease is of a specific nature." lie further regards the recovery of an aural affection, in consequence of an anti-syphilitic treat- ment, as inadequate proof of the origin of the ear-disease. After considering syphilitic affections of the external and middle ear, he alludes to"^ syphilitic disease of the nervous apparatus of the ear. Six cases are given, four of which were affections of one side only. The characters of these were, intracranial paralysis » Ardiiv f. Ohronhfilkundc, Ikl. iv. S. '2")3. 542 DISEASES OF THE INTERNAL EAR. of the acoustic nerve, anaesthesia of the left acoustic nerve, in consequence of otitis interna sj'philitica, and paral3'sis of both acustici, from double otitis interna syphilitica. Some of these cases were benelited in their hearing, by anti-syphilitic treat- ment, but this cannot be assumed as establishing the existence of a disease of the internal ear. In many instances of deafness occurring in syphilitic patients, an endeavor has been made to establish the diagnosis of syphi- litic inflammation of the cochlea. The existence of such a dis- ease and recovery from it, cannot be proven by the acoustic phenomena presenting themselves. These may be accounted for much more easily by the supposition of altered conduction of sound, by reason of changes in the mucous membrane of the middle ear so well known to occur in SN'philis, than by the difhcult and entirely untenable view that changes in audi- tion are due to alteration in the nerve, and hence are yjhe- nomena of altered perception. The fact that sudden deafness in a syphilitic patient may be cured by an anti-syphilitic remedy, is by no means a proof that the disease lay in the cochlea or in any other part of the nerve-structures in the internal ear. It would be just as much a proof, perhaps more potent evidence, that the disease had been in the mucous mem- brane of the drum-cavity or in that of its contents, and, by inter- fering with sound-conduction, had caused deafness, and that the latter had been removed by the anti-syphilitic action of the drug upon the mucous membrane. Furthenjiore, if in these cases an inflammation of nerve-tissue has been imagined, it is by no means clear on any ground, that the disease could be easily cured by any remedy, nor, if the disease were removed, that the hearing would return either quickly or so completely as has been asserted in the cases of so-called " cochlitis." Symptoms, Prognosis, ami Treatment. — The chief symptoms of asserted sj-philitic disease of the internal ear are said to be sudden deafness, accompanied sometimes by paralysis of other parts of the body, and by vertigo, nausea, and unsteadiness of gait. Tinnitus aurium is more or less constant, and may, with sensations of fulness and beating in the ear, precede the deafness. Headache is generally complained of, the scalp being very often, in such cases, the seat of a cutaneous eruption of a more or less markedl}' specific nature. The prognosis is not favorable; if the syphilitic nature of the disease can be established, the treat- ment, of course, should be an anti-syphilitic one. Disease of the Internal Ear from Typhoid Fever. — 1\\ some in- stances it would seem that the internal ear had been aft'ected by typhoid fever. But the vast majority of cases thus diagnosticated appear, on closer investigation, to be diseases of the tympanum. PRIMARY AND SECONDARY INFLAMMATION. fi4Z A labyrinth-attectiou must be considered, so far as it follows typhoid fever, as at most secondary to a tympanic disorder. As I have observed a numl)er of nei::lected cases of tympanic inflam- mation following tyi)hoid fever, I am led to conclude that it is in the middle ear, rather than in the labyrinth, that an aural disease after typhoid beg-ins. A chronic aural catarrh having such an origin is as likely to be incorrectly diagnosticated as a nervous or labyrinthine disease, as it is when arising from other causes. By neglect of the tympanic disease, a labyrinthine dis- order may be established. Hence, the erroneous impression that the labyrinth has been the seat of the prinuiry affection. Treatment is of no avail in these cases. Aural Disease in Rachitic Affections. — It is not uncommon to find rachitic subjects suffering from purulent disease in the tympanum, from symptoms of catarrhal disease in the middle ear, and from total deafness, with dumbness. The filamentous cones found by Virchow in rachitic bones have been found in the labyrinth of rachitic patients who had been deaf and dumb, and in the recessus hemiellipticus.' The scah^? of the cochlea in such cases mav be abnormallv and irreii'ularlv curved and in- clined to be angular at the turns. Entrance to the round window may be narrowed to 0.5 mm., one-half the normal size. The niche for the oval Avindow ma}' be rendered deep by super- posed bone tissue, and, the plate of the stapes disappearing, its place may be occupied by bone tissue. The entrance to the porus acusticus may be narrowed and misshapen ; fibrinous coagula may be found in the cochlea, and in the acoustic nerve; the ganglion cells may be full of pigment, and exhibit the so- called knots of nerves of Ranvier. These alterations, according to Moos, may be congenital or acquired. Under the first head may be found imperfect ossification of the stapes, absence of its foot-plate, while the original club-shape of the whole undeveloped bone is maintained. In such cases there is also found imper- fect ossification of the facial canal. Under acquired alterations, the same observers have placed hyperostosis of the tympanic walls with consequent deepening of the fenestral niches, and impairment of the hearing Also contraction of the internal porus acusticus, and transformation of the annular ligament of the stapedial foot-plate into bone, thus demonstrating the occurrence of rachitic processes in the tem- poral bone. ' Moos and Steinbriigge, Archives nf Otology, vol. xi., 1882. 544 DISEASES OF THE INTERNAL EAR. AURAL VERTIGO. Aural or auditory vertigo, as its name would indicate, is a vertiginous condition due to an irritation of the auditorj^ ap- paratus. This irritation, usually in the form of pressure, may be situated either in the external, the middle, or the internal ear, or in or upon the auditory nerve, within the cranial cavity. Though originating in the different parts of the organ of hear- ing, this irritation, in order to produce vertigo, must be exerted ultimately in the form of pressure upon the terminal filaments of the auditory nerve in the semicircular canals, and thence conveyed to the cerebellum, as will be shown hereafter. Some observers hold that all disturbances in e(][uilibration, as mani- fested in giddiness, are due either to a temporary or a perma- nent lesion in the labyrinth. In fact, some hold that the semi- circular canals are vertiginous centres. While I am not prepared to accept this theory, it is plain to my mind that in the semi- circular canals there is found a very sensitive medium of com- munication of impressions to the cerebellum, and hence that these canals may be considered as in many respects presiding over the equilibrium of the body. Although many instances of vertigo can be shown to be due to irritation of these canals, by virtue of the vaso-motor connection between them and remote parts of the body, it is my object to limit the scope of this paper to a consideration of vertigo arising from irritation in the various parts of the auditory apparatus, and communicated to the semi- circular canals, and thence to the cerebellum. The whole matter of aural vertigo will be most easily understood by a considera- tion, first, of the structure and distribution of the auditor}- nerve. Structure of the Auditory Nerve. — M. Duval has shown' that a portion of the fibres of origin of the auditory nerve are closely connected with a mass of motor-cells in the bulb, and that these fibres pass into, and are continued in, the inferior peduncles of the cerebellum. The inferior peduncles of the cerebellum connect it with the medulla oblongata, pass on downwards to the back of the medulla, forming part of the restiform bodies, and are then connected below with the corre- sponding half of the cord, excepting the posterior median columns. It is well known that injuries of these peduncles cause dis- turbances in motion similar to those observed after lesions of the semicircular canals. It seems, therefore, that there is a sort of special function resident in these canals, that exaltation of ' Gelle, de I'Oreille, etc. p. 323. Paris, 1881. PRIMARY AND SECONDARY INFLAMMATION. 545 their function evokes peculiar movements of the head and mediately of the trunk and limbs, and that the anatomical ex- planation of this is found in their cerebellar connection. It further appears that there are two kinds of fibres in the auditory nerve, viz., the motor libres, distributed to the ami)ullie df the semicircular canals and connected with the bulb and the inferior peduncles of the brain, and another set distributed to the utrie- ulus, the sacculus, and the cochlea, which are accepted as purely sensory. It is to the motor set of fibres in the acoustic nerve that our attention must be directed in considering the subject of aural vertii!:o. The question naturally arises. Are not these inferior peduncles wounded in experiments on the semicircular canals? The reply is that in the pigeon, used for these investigations, the semicir- cular canals stand away from surrounding tissues in the cranium, as the cochlea does in the bulla of the guinea-pig, so that the mutilation of any parts but the semicircular canals is avoided. That the phenomena attributed to mutilation of the semicircular canals in these experiments are justified seems further confirmed by recent experiments by Gelle, of Paris, upon the cochlea alone, by which he shows that in the guinea-pig mutilation and extir- pation of the cochlea, easily accomplished in this animal without opening the true cranial cavity, is unattended by the slightest disturbance in equilibration. It must be further borne in mind that the auditory nerve originates from numerous white strife — the linea' transverste — which emerge from the floor of the fourth ventricle, and that it is also connected with the gray matter of the medulla. Now, the fibres of the pneumogastric nerve may be traced deeply through the fasciculi of iho. medulla, to terminate in a gray nucleus near the fioor of the fourth ventricle; so that, anatomi- cally, the auditory nerve and the pneumogastric are thus shown to be at least contiguous at their origin — a fact entirely satisfac- tory in the "overfiow" theory, as will be shown. As has been said already, authors speak of a "vertiginous centre,'"^ and of vertigo as "undoubtedly a sensation." The latter may be evoked by an overflow of nerve-impulse from some one centre of the encephalon, to the so-called vertiginous centre; and, from what we know of the physiology of the semi- circular canals, we may assume that the central termination of the ampullar nerves is in very close connection with a spot in the brain, irritation of which will produce the sensation of gid- diness. This, as we now know through the labors of Duval, is 1 P. ilcBride, of Edinburgh, Medical Times and Gazette, vol. i., 1881 ; also J. A. Irwin, M.A. Cantab., M.'D. Edin., Pathology of Sea-sick nes?, Lancet, Nov. 25, 1881. 35 546 DISEASES OF THE INTERNAL EAR. in the cerebellum, and owes its great influence most probably to its connection, by means of its inferior peduncles, with the spinal cord. To this connection we owe the greater or less impulse con- veyed over the portion of the auditory nerve supplying the semicircular canals in every turn of the head or movement of the body. When this impulse is slight, or let us say normal, it does not produce vertigo, but informs us, or aids in the infor- mation, of our position in space. Thus there is established the so-called "sense of equilibrium." The disturbance of this sense constitutes vertigo. If such an "overflow" of irritation can take place between the central termination of the ampullar nerves — i. e., the nerves of the semicircular canals — and the vertiginous centre in the cerebellum, it is fair to assume that a similar "overflow" may take place between this ampullar centre and the pneumogastric centre, simply because the two latter are more contiguous to each other than the ampullar centre and the vertiginous centre in the cerebellum. In this contiguity is found an easy expla- nation of the nausea, vomiting, pallor, and faintness, the slow breathing and weak pulse, which occur in aural vertigo; for we are entitled to assume that the irritation in the auditory appa- ratus and auditory nerve-centre overflows to the respiratory, the cardiac, and the vomiting centre. Symptoms. — The symptoms of aural vertigo may be briefly stated as follows. The patient more or less suddenly' experi- ences in one or both ears, tinnitus and more or less hardness of hearing. This is quickly followed by dizziness passing rapidly into a pronounced vertigo, with reeling and falling, accompanied by nausea, vomiting, and fliintness, but rarel}' with loss of con- sciousness. When the latter ensues, it is simply complete syn- cope from the nausea and vomiting. Usually the patient almost instinctively associates his vertigo and attendant malaise with derangement in the ear, which ma}' or may not have been pre- viously diseased. These symptoms, which are here given in the order of their onset and sequence, are subject to modifications according to the part of the ear aflected. Thus, when the irri- tation is in the external ear, neither the tinnitus nor the deafness may be excessive; but both are permanent from the onset to the cure, and the tinnitus is acoustically of the uninterrupted quality. When the irritation lies in the middle ear, the symp- toms are likely to be paroxysmal, as though the physical condi- tions upon which the altered and morbid pressure or tension depends, varied with the state of the atmosphere or with the health of the patient. In cases dependent upon irritation in the internal ear or labyrinth, all the symptoms are usuall}' more pro- nounced, though the attacks of tinnitus and dizziness are parox- PRIMARY AND SECON])AKV INFLAMMATION. o47 ysmal, Avliile the deafness is most protound and jtermanent, wbethei- it conies on siuldenly with the tirst attack of vertigo or not. The latter passes otf, but the deafness remains. Vertigo dependent ui)on a tumor in or u[)on the auditory nerve, and which may be denominated a central form of audi- tory vertigo, is usually not paroxysmal, the })atient experiencing a constant and increasing tendency to alterations in gait, with a disposition to fall towards the affected side in walking. Here the permanency of the symptoms should lead us to suspect disease in the cranial cavity. Differential Diagnosis. — AH the forms of aural vertigo are not onlv confounded in diagnosis with one another — and in some cases there may be a comminirlins; of forms in the same sub- ject — but they are constantly mistaken for stomachic vertigo, so-called biliousness, epilepsy, and even apoplexy. The confu- sion among the various forms is hardl}^ to be wondered at, but the aural symptoms and the usually retained consciousness should make the ditferential diagnosis between this disease and others just mentioned ver}' easy. Then, too, the absence of spasm, and the marked pallor in the patient should lead away from the diagnosis of either fits or apoplexy. This defective diagnosis has led to a faulty nomenclature, so that the term Meniere's disease, which, if it means anything, means a disease of the semicircular canals only — /. e., a disease of the internal ear — has been very erroneously used to designate aural vertigo in general, instead of being limited to the form of aural vertigo dependent upon disease in the aforesaid canals. That this term, "Meniere's disease," should be thus restricted will, I think, be evident after a closer examination of all the forms of aural vertigo, of which Meniere's disease is clearly only one. That form of aural vertigo due to irritation in the external ear, may be considered the simplest form of the disease, so tar as concerns its production and cure; but the mode of its action is the same as in other and graver forms; i. e., the pressure and irritation are at last conveyed to the cerebellum, and then the vertigo is evoked. lltastration. — Doubtless all are familiar with the celebrated case of external ear-vertigo and other reflex phenomena asso- ciated with it, recorded by Fabricius Ilildanus. In this instance, a young girl, 18 years old, is said to have exhibited, besides the ear-vertigo, atrophy of one arm, epileptiform symptoms, and even anaesthesia of one-half of the body, all of which were cured by the removal of a glass bead or ball from the external auditory canal, where it had lain for eight years. This case is not only classical but highly instructive, but in this latter respect no more so than "numerous cases of tinnitus aurium, vertigo, and nausea due to the presence of foreign bodies as 548 DISEASES OF THE INTERNAL EAR, simple as masses of hardened ear-wax in the auditory canal, and occurring in the experience of most physicians. Vertigo due to irritation in, or applied to, the external ear and outer surface of the drum-head is also constantly seen in syringing the ear, sometimes when done ever so gently. Here the mode of irrita- tion in most cases is by pressure upon the drum-head, and mediately by means of the ossicles and the labyrinth-fluid upon the filaments of the auditory nerve in the ampullae of the semi- circular canals, the anatomical reasons for which have already been presented. The giddiness, however, induced by suddenly injecting cold water into the external auditory canal cannot be altogether ex- plained by the pressure it exerts on the drum-head and medi- ately upon the ossicles of hearing, the labyrinth-fluid, and the cerebellar branches of the auditory nerve found in the ampullae of the semicircular canals. Here an explanation must be sought for in the nervous connection between the external ear, the seat of the irritation, and the vertebral artery wdiich supplies the circulation in the labyrinth. We must bear in mind that the eft'ect of irritation in a vaso-motor nerve-tract is to excite vessel- dilatation in a correlated area, through diminished inhibitory nerve power. In this instance the irritation is the sudden pres- ence of cold water in the external auditory canal, the diminished inhibitory nerve power is felt in the vertebral plexus, and the correlated area is the labyrinth and especially the semicircular canals. The morbid impression caused by the cold water is conveyed by the auricular branch of the pneumogastric nerve, found in this part of the ear, to the inferior cervical ganglion, to which the vagus sends a branch. From this ganglion the irri- tation is deflected to the vertebral plexus, into the formation of wdiich, fibres from this lower cervical ganglion enter largely; the inhibitory power of the plexus is overcome, and vessel-dila- tation ensues in the vertebral artery. This causes an increase in the blood-supply to the labyrinth, and the latter is in a measure engorged, and the labyrinth-fluid, having no adequate means of rapid escape, is compressed within its bony cavity. This compression is, of course, quickly felt by the nerve-fila- ments in the ampullae of the semicircular canals, they are com- promised, and vertigo ensues, for anatomical reasons already given. Thus it is shown that external ear-vertigo is produced in two ways, viz., either mechanically by direct pressure on the drum- head and the chain of ossicles, or reflectively through the nervous system. Middle Ear-vertigo. — When w^e come to consider aural vertigo caused by disease in the middle ear, we approach a much more complicated subject. Here the pressure and consequent me- PRIMARY AND SECONDARY INFLAMMATION. 549 cliaiiioal irritation may be eonveyod in various ways to tlie labvrintli-fluid and the terminal filaments of the auditory nerve in the setnieircular canals, and thenee by tlie motor fibres to the cerebellum. Tlie most frequent mode of irritative pressure is exerted by an accumulation of fluid, mucus, pus, or serum \n the tympanic cavity. The pressure is conveyed tlirou^;)! the foot-plate of the stirrup-bone or through the mend)rane of the round window, or through both, to the labyrinth-fluid, and through the latter medium to the auditory nerve, which, as I have stated, contains motor filaments, and thus to the cerel)ellum. In fact, this process of conduction of irritation is but an exag- geration of the mode of the mechanism of hearing; and we can very easily understand how a o-reat noise, or any noise at times, may produce dizziness and other cerebral disturbance. Again, morbid pressure may be exerted from the middle ear upon the deeper parts of the auditory apparatus concerned in the production of 6ar- vertigo, by closure of the Eustachian tube, in throat- and nose-disease. After this closure of the tube, the air shut in the tympanic cavity is soon absorbed, a vacuum is then formed in the drum-cavity, and the external air [)resses the membrana tympani inward, carrying with it the malleus and the rest of the chain of bonelets. Thus the labyrinth-fluid is unduly compressed, and, as in the previous case, the auditory filame'iits in the semicircular canals are also compressed and the cerebellum irritated. In some rare instances there seems to be reason to suppose that a tonic contraction of the tensor tympani muscle occurs,^ and that retraction of the membrana tympani and the chain of ossicles ensues. In this way the foot-plate of the stapes is forced inward through the oval window, upon tlie labyrinth-fluid, and cerebellar irritation is produced, as hereto- fore described. The attacks of aural vertigo of this latter form are paroxysmal, and are accompanied by so-called "variable hearing,"- the hearing growing worse as the tinnitus, which is the prodrome, increases, and flnally ushers in the vertigo. In fact, any undue loading of one or of all of the ossicles, or any abnormal pressure upo'n them, or even excessive swelling of the mucous membrane covering them, by forcing them inward, or by carrying only the stirrup abnormally inward, would tend to compress unduly the labyrinth-fluid, especially if at the same time the swelling of the mucous membrane extends to the round window and prevents the compensatory yielding of its membrane to the inward pressure of the stirru[i. In this way the vertigo so often present in acute otitis media may be explained. 1 See article on " Viuiahle Hearing," by the autlior, in report of Section of Otology, International Medical Congre.-^s, Philadelphia, 1876. 2 The late Mr. James Hinlon, of London, in " Questions of Aural Surgery.'' I 550 DISEASES OF THE INTERNAL EAR. Middle ear-vertigo from chronic disease in the tympanum is very common. This source of vertigo is to be expected when we reflect that there is a direct communication between the cir- culation of blood in the middle ear and that in the labyrinth. Politzer has shown that the capillary bloodvessels of the tym- panum pass directly through the inner or labyrinth wall of the tympanic cavity to the vestibule and other parts of the internal ear. Hence it is easily seen how disturbed circulation, which must ensue in chronic disease in the walls of the tjmipanic cavit}', may be felt in the internal ear; and as disturbances in circulation, by altering the pressure in the labyrinth, especially in the semicircular canals, produce vertigo, it can be shown how chronic middle-ear disease may thus induce aural vertigo. In middle ear-vertigo, it maj^ also be assumed that the pressure in the labyrinth may at times be brought about by altered cir- culation due to reflex influences, as was shown in external ear- vertigo. The path of the irritation in this ca^e, however, lies probably between the vertebral artery, the vertebral plexus, and the inferior cervical ganglion on one side, and the otic ganglion on the other.^ Internal Ear-vertigo. — In considering ear-vertigo due to disease in the internal ear, we approach at once the most difficult and the most interesting form of the disease under consideration. It may be produced by disease in the auditory nerve or in any part of the labyrinth except the cochlea. From recent experi- ments of Gelle, of Paris, it is conclusively shown that laceration and destruction of the cochlea in mammals (especially in rodents) has no eflect whatever upon equilibration. This renders it more probable that the semicircular canals are the seat of the organ of equilibration. Up to this point we have considered the effect on these canals of irritation originating elsewhere and communicated to them. IS'ow we shall consider the phenomena of disturbed equilibra- tion due to disease arising in them and the irritation it conveys to the cerebellum ; and under this head we shall also consider the phenomena of disturbed equilibration due to irritation in or upon the auditory nerve before it reaches the labyrinth, as is sometimes found in tumors, either in the nerve or lying upon it. The phenomena in the latter case appear to be contirmatory of the existence of intimate connection between the auditory nerve- fibres and the cerebellum, by means of the inferior peduncles of the latter. ^ The iympamc nerve communicixtcs with the small peirosal, a branch from the otic ganglion. The otic ganglion communicates with the superior cervical gan- glion, and this with the m'iddle cervical ganglion, if present ; if not, with the in- ferior cervical ganglion. The inferior cervical ganglion supplies largely the vertebral plexus, regulating the supply of blood in the labyrinth. PRIMARY AND SECONOAUY I N F L A M M A 1' 1 ON , 551 Clinical Histo)')/ ami Siimpionis. — In internal car-viTtiiro, tlio ear liavini;- been previi)usly liealthy, or considered so, the patient is suddenly attacked by tinnitus, vertigo, nausea, reeling, and falling, but liis consciousness is retained. After these symptoms abate and the alarm of the patient subsides, the hearing is dis- covered to begone in the affected ear. This form of ear-vertigo the writer has seen in adults of various ages, usually in men over thirty, and in all grades and avocations — in the iuird- worked physician as well as in the over-worked mechanic. Upon examination, the drum-head will present no great (thange, or it will look like one belonging to an ear previously the seat of chronic catarrh; and generally, upon close inquiry, it will be elicited that there is history of exposure, in camp or in daily labor, to inclement weather, and that the ear now attacked so severely has already, at times, felt stufied and deaf, but that it got better and remained a good and serviceable organ. The general health will be found to have recently foiled, or to have been greatly taxed by some sudden stress of work, and it will also be found that the ear has " buzzed a little of late," l)ut not con- stantly, and that this had been forgotten, until the attack of ear-vertigo brought it back to the memory. The hearing will be found to be "profoundly impaired, and to remain so, while the tinnitus may or may not remain, and the vertigo will be found to have temporarily vanished. Sometimes, with care and proper management, no further attacks of vertigo are felt; but the hearing remains permanently atfected. On the other hand, the tinnitus may be always present to some extent, may increase suddenly at times, and form, as it were, a forerunner of subse- quent attacks of vertigo. As I have rarely seen a case of internal ear-vertigo without conclusive evidence of a previous chronic catarrhal (lisease in the middle ear, with necessarily great changes in nutrition and circulation, and as it is fully "established that the circulation between the middle and internal ears is most closely connected, therefore, I am forced to conclude that internal ear-vertigo, or " labvrinthine vertigo," is usually preceded by pathological changes in the circulation of the middle ear, which induce changes in the vessels of the internal ear, culminating in the sudden and grand attack just described. Whether these changes and their results are of an apoplectiform nature cannot be discussed here. The diagnosis, however, will be aided by the suddenness of the tinnitus, vertigo, and deafness, and especially by the fact that the tinnitus and vertigo are more or less evanescent, while the deafness is profound and permanent from the first. Tins form of aural vertigo, and no other, may justly be termed "Meniere's disease." 552 DISEASES OF THE INTERISTAL EAR. Central Ear-vertigo. — There is a form of ear-vertigo which is due to a tumor of the auditory nerve (p. 536). When the vertiginous symptoms dependent on the presence of such a tumor, usually fibrous or sarcomatous in nature, first show themselves, it is not easy to distinguish between this form of ear-vertigo and that due to chronic changes in the middle and internal ear combined. There are, however, some points of difference so constant in their occurrence as to constitute truly pathognomonic symptoms. To begin with, central ear-vertigo dependent upon morbid growths in the auditory nerve, is never sudden, but slow in its onset. The deafness and tinnitus, as Avell as the vertigo, are comparatively slight at first, but then steadily increase, and are always permanent from the time they first show themselves until the end. The gait is permanently altered, though it may be only slightly changed at first, and the tendency is to fall towards the affected side. Not so, however, in true internal ear-vertigo, in which the initial lesion is in the labyrinth, in or very near the semicircular canals. In this form of disease the deafness is sudden, profound, and permanent, but the giddiness and falling are paroxysmal. In middle ear-vertigo, in which the deafness and tinnitus are great, the deafness is not sudden nor profound, the vertigo comes in attacks, and there is no per- manent alteration in gait. Apparent Motion during the Vertigo. — During the vertigo, objects may appear to revolve in an antero-posterior direction, in a ver- tical plane. There may be total loss of equilibrium, but perfect consciousness. The attacks may come and go suddenly, and be followed by a cold sweat. It is very interesting to note the various planes of the ap- parent motion experienced by a patient during attacks of vertigo, and the length and character of the arcs of the apparent meri- dians described, both by the patient's body and surrounding objects. The attacks of vertigo, always accompanied by perfect consciousness, may be characterized by an apparent motion in a vertical plane from in front, backwards, i. e., in the plane of the superior semicircular canal. Or, the apparent motion may be in the plane of the horizontal or inferior semicircular canal. The apparent motion may be felt even when the patient closes his eyes, a clinical fact entirely in harmony with the experi- mental observations of Mach (p. 149). At the time of the attacks of vertigo, the apparent or subjective motions of the patient's body may cease when he lies upon his back, although the apparent motion of surrounding objects may continue. The paroxysmal nature of the vertigo, with temporary increase of the tinnitus, in an already diseased ear, would seem to indicate that whatever the cause of the irritation is, it is not constant nor totally destructive of the part chiefl}' attacked. Such cases pre- I I PRIMARY AND SECONDARY INFLAMMATION. 553 sent a collection of clinical phenomena, i)artly of a suhjet-tive nature, most strikingly in accord with the recent investigations of Mach, Breuer, Cyon, and Curschnum, all of which liave added facts tending toward the conclusion that, although the semicir- cular canals may not be devoid of acoustic functions, they seem to possess well-marked features of presiding over the pose of the head, and mediately over that of the entire body (pp. 149 and l;')!). Those Avho sufler as described above may tinally recover from the liabilitv to be attacked bv vertigo, but thev remain totallv deaf in the affected ear. Treatment of Aural Vertigo. — If it has been shown that aural vertigo is due to pressure in some form, either directly or medi- ately, upon the auditory nerve, and reflexively thence to the cerebellum, the indication in treating such cases is to remove, or at least diminish, this pressure; and this can be done surgi- cally or medicinally. Great confusion arises when these cases of aural vertio;o are treated as cases of biliousness — a much too frequent error. If the irritative pressure is due to a foreign sub- stance of any kind in the auditory- canal, it is to be relieved by the removal of the foreign substance, best accomplished by syringing with warm water. If the irritation is due to pressure from matter accumulated and retained in the drum-cavitv, it must be allayed bv removal of the retained mass. This can be accomplished by paracentesis of the drum-head, by inflation of the tympanic cavity with Politzer's air-bag, and by catheterization. Even when matter is inspissated in the drum-cavity, one or all of these methods com- bined must effect its removal. The ossicles are thus allowed to swing freely, the stirrup comes back to its normal position, the membrane of the round window is relieved, and the pressure is taken from the labyrinth-fluid and the ampullar nerves in the semicircular canals. If the pressure is due to a vacuum in the drum-cavity, and a consequent indrawing of the drum-head and the ossicles from closure of the Eustachian tube at its foucial end, the introduc- tion of air by one or both of the above means will usually restore the drum-head to its proper place and unlock the pressed-in chain of bonelets, thus relieving the compression in the labyrinth and semicircular canals. In cases of tonic spasm of the tensor tympani muscle, the attacks may be relieved by inflation of the drum-cavity, which forces outward the drum-membrane and the malleus and an- tagonizes the indrawing efl:ects of the spasm in the tensor muscle. The disease in this form is also to be combated by anti- spasmodics, preferably bromide of potash in large and frequent doses, as much as ten to fifteen grains every fifteen minutes 554 DISEASES OF THE INTERNAL EAR. being given, with most excellent effect, as the attacks are com- ing on, or during them. When the vertigo is due to chronic aural catarrh, i. e., chronic change in the mucous membrane of the middle ear, the field of treatment becomes indeed a wide one. The catarrh of the mucous membrane of fauces, nasopharynx, and nares will usu- ally require treatment, as well as the mucous membrane of the cavity of the drum; but in these cases the greatest benefit may accrue from the use of tonics and bromide of potash as above advised. The morbid circulation which very probably underlies these cases, may be connected with anaemia or plethora, and the diag- nostician must bear this in mind in the treatment of the case. Local treatment in the external auditory canal, in this form of the disease will usually increase the dizziness by overloading, physically, the membrana tympani. Blisters, leeches, etc., about the external ear and mastoid portion of the temporal bone are useless ; they may be so bothersome as to increase the malady. Rest in bed is absolutely essential when tbe vertigo is frequent and severe. It is always a relief during an attack of dizziness. The vertiginous centre may be said thus to recover itself, and the immediate attack is found to pass oft" more quickly than if the patient continues to walk about, and the liability to subsequent attacks is diminished. This is not the case, however, if the vertigo is constant and apparently due to a cerebral tumor in or about the auditory nerve or labyrinth. Respecting the treatment of internal ear-vertigo, it may be said that a typical case of this form of the disease presents deaf- ness which is irremediable. The attacks of tinnitus and dizzi- ness may be lessened in number by attention to the general health, preference among drugs being given to quinia, strychnia, and iron, separate or combined. For immediate relief of the tinnitus nothing has been found by the writer equal to bromide of potash, and, in fact, no internal remedy is equal to this in relieving tinnitus generally. Finalij', the tinnitus and dizziness may cease, never to be felt again, but the deafness remains, being probably due to an organization of an exudation or extravasation thrown into the labvrinth at the time of the first o-rand attack. But, unfortu- nately, the pathological processes in such cases are not well known, as the researches have been meagre. If the case is seen at the beginning of the disease, and there is reason to surmise the existence of an exudation, an extravasation, or a hemorrhage into the labyrinth, the administration of the iodide of potash or of mercury, or both, would certainly be indicated; but, given late in the disease, these are valueless. The greatest care should MORBIP GROWTHS OF THE AUDlTuHY NERVE. r)55 be taken to build up rather than luvak down tissue; for tliero is generally in these eases of supposed exudative disease ample ground for the belief that, in overwork, a minute vessel in the labvrintli lias ruptured or that a passive exudation has oecurrcil from the walls of several vessels. In conclusion, the following facts should be recalled to mind : 1. That there are two sets of fibres in the auditory nerve, viz., the sensory and the motor. 2. That the motor filaments are connected on one side with the cerebellum by means of the inferior peduncles, and on the other side with the nerve-filaments sent to the ampulla) of the semicircular canals. 3. That irritation of these ampullar nerves may be conveyed from either of the three parts of the auditory apparatus, or from the auditory nerve itself, in the mechanical form of pressure, and that this irritation may be further conveyed to the cerebellum and cause vertigo: so that it logically follows that this reflex cerebellar phenomenon as produced by aural irritation should receive the general denomination of aural raiigo, and that Meniere's disease is only a form of aural vertigo. Hence the latter name, unless used after accurate diagnosis of a disease originating in the labyrinth, i.e., in the semicircular canals, will create confusion. But it should be said, in justice to Meniere, that, so far as the writer knows, he has never claimed a general application of his name to all forms of aural vertigo. It has been so applied only by well-meaning but inaccurate diagnosti- cians. CHArTEK II. MORBID GROWTHS OF THE AUDITORY NERVE. The auditory nerve is more frequently the seat of morbid growths than any other cerebral nerve, as shown by Virchow. Such formations are usually of a fibrous or sarcomatous nature; the nerve may also undergo amyloid degeneration. Fibrous Tumors. — Fibrous tumors of the auditory nerve may be idiopathic in origin, but more usually they are found in con- nection with caries of the temporal bone (Gruber). Such 656 DISEASES OF THE INTERXAL EAR. growths have also been described by Landiforth and Leveque- Lasource, as stated bj Moos.^ Bojer^ describes a case of what was termed by him " cancer of the occipital fossa." In this instance the morbid growth invaded and destroyed the auditory nerve, as it did most of the nerves distributed to the right side of the head. The subject was a man, 33 years old. Carre^ observed a case of what he termed cancer of the an- nular protuberance (pons Varolii) in a man 29 years old; the hearing was diminished. At the post-mortem examination, the auditory nerve was found pressed upon, but not destroyed. Sarcoma. — Cases of sarcoma of the auditory nerve have been observed b}' Voltolini and Forster.^ In the case given by the former, a sarcoma tilled the entire left internal auditory canal, and the auditory nerve was destroyed. In the case observed by Forster, a sarcoma as large as a goose's egg had sent off a peg- like process into the left internal auditory canal, which was enlarged. Other cases presenting more or less striking symptoms of sarcomatous growths in the auditory nerve, have been recorded by Cruveilhier,-' Moos,^ and Boettcher.^ The latter denomi- nated the growth observed by him, libro-sarcoma. Symptoms. — It would appear from the published accounts of the occurrence of this form of cerebral tumor that it is found most frequently in females. The ages of those affected vary from seventeen to forty-nine years. The duration of the dis- ease, counting from the earliest S3uiiptoms, may extend over seven or eight years; though it ma}^ run its full course in a year, as shown in a case recorded by Moos. The cause of this disease of the auditory nerve has been supposed to be due, in some cases, to exposure to cold; but the most frequent causes, as stated by Yirchow, are mechanical injuries to the head and syphilis. The earliest and most striking symptoms are tinnitus auriura and failure in hearing, with more or less dizziness; these are followed bv o-reater deafness, increased noise and distress in the head, and dizziness on motion, with consequent uncertainty ot gait. Then there may come a period of relief and apparent re- ^ Archives of Oph. and OtoL, vol. iv., 187-i. - Bulletin dc la Societe Anatomique, 9 serie, 1834, p. 273. ^ Ibid., p. 115. * AVurzburger iled. Zeitschr., 1862; .see Moos, Archives of Oph. and Otol., p. -484, vol. iv. ^ Anatomic Path., livraison 26 ; see Kramer, " Die Erkenntniss, etc. derOhrenh.," 1849, p. 858. " Loc. cit. " Archives of Oph. and Otol., vol. iii. pp. 134-171, 1873. MORBID GROWTHS OF THE AUDITORY NERVE. 557 covery from most of these syini)toins, i'.\rL'i>tiiig- ihr luinluess of heiinng. But, sooner or later, all \\\v above syini>toin.s rrtmii and become aggravated; the power of eontrolliiig the HmbH, both upper and lower, fails; pain in the head is' intense and' lasting; the dizziness grows worse; the patient walks with legs apart, inclining to one side in walking; and nausea and voinft- ing may occur. In some cases, facial paralysis occurs quite early in the disease, and there may be ansesthesia of the mucous membrane of the nose, as noted by Moos. Not uncommonly there are symptoms of chronic aural catarrh in the ear corre- sponding to the side on which the auditory nerve is invaded; and this has often misled in making a diagnosis. Finallv, the general nutrition of the patient begins to fail; the strength goes; diarrhoea may supervene; or the patient nuiy sink into coina, and die with or without convulsions. Through the kindness of Dr. Morris Longstreth, Pathologist to the Pennsylvania Hospital, I have had the opportunity" of consulting the ante-mortem notes, and of aiding in the post- mortem examination, of the following case o^ tumor of each audi- tory nerve: Catharine C, admitted to the medical wards of the Pennsyl- vania Hospital on October 12, 1874. An American by birth, but of Irish parentage; forty-two years old; single, and a seam- stress. Has always been well until within a year of her admis- sion to the hospital, when she took a severe cold in the head. She also began to have at this time pain in her forehead and vertex. In the previous June her hearing began to fail rapidly, until she became very deaf. Then there supervened tinnitus aurium, unsteadiness in gait, pain in her limbs, impairment of sensation in the legs, vertigo, and occasional nausea. There had never been any loss of power in the limbs, nor muscular trembling. On Nov. 1st, when Dr. James H. Hutchinson' took charge of the ward, it was noticed by him that there was a tendency on the part of the patient, when walking, to fall forward and to the right, and that on some occasions she had fallen. Attacks of vertigo could be induced in the erect position, by closing her eyes; but she was free from them when lying in bed. There was great pain in the head, generally referred to the vertex and to the forehead over her eyes. The tinnitus aurium continued very intense and annoying; it was, however, paroxysmal, being worse in the morning. There w^as nausea, but ho vomiting. There was no loss of power in the limbs, nor paralysis of any of the cranial nerves, and no disturbance of sensibility at that time, as noted by Dr. Hutchinson. She was deaf, but not ab- 1 See Phihi. .Aled. Times, May 8, 1875. 558 DISEASES OF THE INTEKNAL EAR. solutely so. There was no history or suspicion of syphihtic taint. The physical condition of the Eustachian tubes and tym- pana was found, by Dr. R. M. Bertolet, to be normah The ophthalmoscope revealed, in the right eye^ " indistinct outline of disk; left eye, chang-es more marked, viz., outline of disk obliterated, veins much enlarged and curved at margin of disk, which is redder than normal, vessels not usually seen being distinctly visible toward its outer side." The subsequent history of tliis woman shows that she was deafer at some times than at others; the right ear was better than the left (post-mortem examination revealed on the left auditor}' nerve the larger tumor); there were headache, falling, with inability to rise, loss of power to assist herself, and, finally, confinement to bed. There then ensued loss of power over legs, failure of intellect, and difficulty in swallowing. Muscles of eye- ball prolapsed; pulse and respiration increased in frequency; cyanosis of face; involuntary evacuation of urine. Disks of both eyes became indistinct in outline: there was impaired sen- sation of extremities; unconsciousness and death supervened. Temperature, a few hours before death, 106° F. Two hours after death, an examination was made by Dr. Morris Longstreth, to whom I am indebted for the following notes: The thoracic and abdominal viscera were normal, in general; the only point to be noted was marked congestion of lung, with a small area of pneumonia in left lower lobe. Only one kidney was found, the right one, weighing nine and a half ounces. The cranium was normal, except the conditions noted below in relation to the internal auditory meatus and jugular foramina. Dura mater was normal, excepting two small spiculie of bone in the neighborhood of the falx cerebri. Arachnoid membrane normal. Pia congested. Cerebral convolutions were flattened, especially at convexity. At the base, the floor of the third ventricle was bulging downwards and fluctuating. 0)1 the left side, behind the petrous bone, below the tentorium, was a large tumor, pressing on the left hemisphere of the cere- bellum, left half of pons, and left crus cerebri. The nerves springing from the left side of the medulla oblongata, passed on the under surface of this tumor, were flattened bv it and some- what adherent to it. The seventh nerve (auditory and facial) wound inward, forward, and then downward around the tumor, to which it was tightlj'^ adherent, and by which it was flattened into a ribbon-like band, appearing transparent. The two divi- sions of this nerve could not be separated without destroying them, as their consistence was so much reduced. This tumor measured two inches transversely ; one and three-quarter inches « I I MORBID GROWTHS OF THE AmiTOKV NKRVK. 559 antero-posteriorly. It was lobiilatcd, ami luailc ui) ol' cvsts with solid intervening structure-like partition. Some portions were reddish or pinkish (cystic); other parts white, tirni, and opaque. This tumor extended with the eighth nerve into the left in- ternal auditory meatus, which was consideral)ly widened, 'J'he nerve ran along the forward and inner part of the canal, whilst the projection from the tumor-mass was on the outer and hack part of this passage. In the removal of the hrain the left nerve with the tumor was cut through at the surface of the petrous bone, thus separating part of the tumor and leaving it within the internal auditory canah After removal of the brain, there was quite unexjtectedly found a second tumor, resting on and adherent to the posterior surface of the right petrous bone. It was oval in shape; live-eighths of an inch long, extending along the bone; seven-sixteenths of an inch in its vertical diameter, and of doughy consistence. It was attached by a sort of pedicle, which was found to extend into the right internal auditory canal. Its consistence was considerably greater than the larger tumor, on the left side, and the eighth nerve was more intimately united to it. As its presence was not known until after the removal of the brain and the division of the nerves was made, it is not known positively what relation it sustained to the eighth nerve; but, apparently, the nerve-trunk ran under it to reach the in- ternal auditory meatus. The tumor had, as on the other side, considerably enlarged the porus acusticus internus. The bone was not uncovered, the dura mater being still adherent, but thinned. The right eighth nerve, from its origin, seemed of normal size and consistence. Microscojy'tcal Examination of Left Cochlea. — The tumor on the left petrous bone, as already described in the post-mortem record, had pressed Hat the nerves entering the porus acusticus on this side. The new growth had, by pressure, enlarged the opening and forced itself into it for some distance, making the internal auditory canal funnel-shaped. There was no evidence that the growth'^extended in the nerve-trunk itself, or that it had reached the fundus of the canal. The canal was occupied by an increase of connective-tissue substance toward the base of the cochlea. The \\alls of the internal auditory canal were covered by a thin periosteum; the bone was everywhere covered, and presented no roughness nor erosion. The shape of the modiolus was normal. The spaces in its substance, which normally are occupied by (livisions of the cochlear nerves, showed no trace of nerve-fibril ho or ganglia. At one point was seen some exceedingly delicate fibrous tissue arranged in a regular, wavy manner. Many of the spaces con- 560 DISEASES OF THE INTERNAL EAR. tained granular and fatty detritus, showing in its midst a few fine fibres, by which the material was held in place in connection with the walls of the spaces; these fibres took somewhat the form of a network. Others of the Spaces were nearly free of contents, showing sometimes a scant fibrous network; sometimes the space was crossed by a delicate bony trabecula. A number of vascular lumina were here visible, often recognizable by their corpuscular contents; their size was small and their number not great. The lamina spiralis ossea was normal in shape; the space be- tween the lamellae of bone contained no trace of nervous tissue, but was occupied by a very fine fibrous material, containing in it much less granular matter than similar tissue in the spaces of the modiolus, with which it was continuous. The membrana basilaris was not suificiently well preserved in any of the sections to admit of a particular description. The pieces of it that were examined, however, showed no marked changes. Nothing was seen of Corti's organ. The ligamentum spirale externum of Henle was normal in appearance. The lining cubical epithelium of both scalse was very distinct, and presented a smooth, even surface. The bone at all parts pre- sented, microscopically, perfectly normal conditions. Microscojnc Examination of Right Cochlea. — The tumor had grown deeply into the internal auditory meatus, which was di- lated from atrophy of its wall by pressure. This atrophy ex- tended markedly toward the base of the cochlea, reaching close up to or into the modiolus, where parts of the tumor in mass could be seen. In consequence, the bony parts between the scalse and the fundus of the internal auditory canal were rendered thin. The modiolus did not present the characteristic form, and difiered in shape also from that shown in similar sections taken from the opposite cochlea. The alteration was more noticeable in parts nearer the summit, and was partly due to new material extending within the scalse, and partly to a change within the bone itself; whether this was from ail extension of the tumor, or from other changes in the bone, was not determined. The bloodvessels were not a conspicuous feature in the modi- olus; they certainly were not increased in number, nor were their lumina exaggerated. A number of them contained corpus- cular elements. The bone-tissue at this portion was normal in appearance. The ganglionic spaces in the modiolus presented a markedly difterent picture from those on the opposite side; the}^ contained a granular, amorphous material or cell-structure. No appearance of new fibres, nor indeed of fibrous material, was made out. Near the junction of the lamina spiralis ossea f MORBID GROWTHS OF THE AUDITORY NERVE. 561 with the modiolus these spaces heounie larL;x'r, ami the celhilar nature ot their contents was more distinctly to be seen. In some sections this cellular material seemed directly continuous with the material deposited within the scahie. The lamina spiralis ossea presented about the same aj)i>earance in all the sections, and was unchanged in form. Tlie sjiace between the bony lamelliB of the lamina spiralis showed no nervous structure, but contained granular material quite dense in character. The demarcation between the osseous lamellaj and the space itself was very distinct; the lamelUe themselves, except in their rigidity, gave no characteristic bony appearance. They took the staining of chromic acid quite deeply, whilst the granular material between was nearly cleared of color by wash- ing and soaking in oil of cloves. In one or two places only, in all of the sections, was seen, between the lamellte, a trace of fibrous tissue. At the habenula perforata there were no nerve-fibres to be recognized. The membrana basilaris, in sections equally delicate with those taken from the opposite side, was much better pre- served in the right cochlea than in the left. It showed sometimes in cross-section, sometimes in mass, giving a profile view of some extent of its surface; sometimes it was in connection with the ligamentum spirale, sometimes it was torn loose from this connec- tion, and was lying free in the scala; again, it was crumpled up by the separation of the ligamentum spirale from the outer bony wall. In none of the sections did it appear to have any of Corti's organ in relation with it. In some of the specimens there seemed to be a thickening or a growth developed upon this membrane, as will be spoken of below. Corti's organ, except in one doubtful instance, was ikot to be seen, even in a frag- mentary condition, in the preparations. I do not mean to im])ly that Corti's organ was destroyed or wasted, but simply state the fact that, in carefully treated specimens, no certain trace of it was discovered. The membrane of Eeissner was, of course, not preserved ; only its ends of attachment at the outer wall and at the lamina ossea were represented by a trace of tissue. The membrana tectoria was seen in a more or less fragmentary condition in all the specimens, attached to the extremity of the labium vestibulare, while the other end of it was not in connec- tion with any tissue, but floated freely in the ductus cochlearis. In the sulcus spiralis was seen in some specimens a small collec- tion of material, mostly of a granular nature, although some- times it presented distinct cell-elements, not unlike in appear- ance those seen at other parts, whose origin from the new grcnvth was undoubted. ConOerning the scalee, it was noted that, when the cochlea 30 562 DISEASES OF THE INTEENAL EAR. was first laid open, a material was seen by the naked eye within them, placed at the junction of the lamina spiralis ossea with the modiolus, and both above and below the lamina, i. e., in both the scala vestibuli and the scala tympani. With the micro- scope, this material was very conspicuous in all of the sections examined, and it was more abundant in the scala tympani. In places there Avas seen a connection or continuity between the new growth within the spaces of the modiolus and that of the scalse. This material showed an extension of itself along the fibrous covering of the lamina spiralis ossea. In no instance did it extend,^however, to the membrana basilaris, although in some specimens there could be seen an unevenness of the epithelial lining of the scalse. At" the outer wall of the cochlea, especially at the ligamentum spirale and its stria vascularis, there was more material of nearly the same appearance; it was never seen in masses, projecting into the cleared spaces, but showed as a roughness and irregu- larity of the lining membrane. This change was chiefly in the ductus cochlearis on its outer wall. The change was not limited merely to the surface, but showed itself in the deeper- parts, and the condition was more apparent in instances where the liga- mentum spirale had been dragged and separated from the outer bony wall. The eifect of this new material was to give an appearance of greater thickness to the ligamentum spirale, especially near its union with the membrana basilaris. In some specimens it appeared as though this material extended along the membrana basilaris; in no instance was it seen in continuity with similar changes on the lamina spiralis ossea, but was co- existent with such a condition. As far as the membrana basi- laris itself was concerned, the change appeared limited to the upper (ductus cochlearis) surface; although the limitation of the material to this surface could not be affirmed positively in cross- sections, other specimens seen in profile from below showed no material to be present on the under (scala tympani) surface. No good nor distinct profile view of the floor of the ductus coch- learis was obtained, No examination with gold solution was made for the presence of nerve-fibres, as this test, as is universally conceded, is value- less, except when carried out in perfectly fresh tissues. Innum- erable pigment-masses were seen at the periphery of the sections, and in the modiolus, such as have been seen on other occasions in bone treated with chromic solution and acid for the purpose of decalcification. May not this be the origin of the " brownish pigment, mostly deposited in multipolar cells," described by Boettcher as occurring in a similar position ? This case, as well as the one about to be given, will furnish many points of guidance in establishing a differential diagnosis MORBID GROWTHS OF THE AUDITORY NERVE. 563 between Meniere's disease, or labyrintliiiie vertigo, and tlie ver- tigo associated with permanent nlterati(in in the gait, very often observed in eases of cerebral tnnior, February 1, 1876, James L., aged 35, laborer. Irishman, was admitted to the wards of Prof. J. M. Da Costa, in the l*ennsyl- vania Hospital. The patient admits having had a ciiancroid ten years previous, but denies all seconda'ry symptoms, and none can be found. Six years previous to admission to the wards he had suffered from malarial fever, for which he had taken large doses of quinia without poisonous effects, but he had been salivated, llis health had been good up to seven weeks before entering the hospital, when he took cold from exposure, had a severe coryza, and in less than a week he had noticed buzzing in his ears, vertigo, staggering in his gait, but 710 alteration in hearing. "When he would sit or lie down, his vertiginous symptoms would vanish. Headache was complained of, and nausea and vomiting had occurred at times. On admission to the hospital, it was found that there was a depression in the skull at the junction of the sagittal and coronal sutures, but no other evidence of violence to the head; he could give no account of the origin of the depression in the skull. Pupils were normal; tongue extended straight; voice high- pitched; patient cheerful; the hearing was found to be for the watch, on the right side, "^ ^ ' ; on tlie leftside, -r-^- There ® ' 4 ft. ' 4 ft. was decided loss of sensation and power on the left side, in arm and leg. Electro-muscular contractility was not impaired; slight loss of coordination; he could walk with eyes shut as well as open; stands poorly on one leg, but picks up small objects well. He walks with his legs far apart, tending to the left side, towards which side he easily falls. Stands with legs widely separated, for when erect he soon leans towards the left; the least push would then throw him towards the left side, whereas he was quite firm when pushed in an}- other direction. Dimness of vision had been noted by patient; the ophthalmic examina- tion made by Dr. W. F. Norris showed slight haziness, and striation of the retina in each eye. The urine was high-colored and slightly turbid: sp. gr. 1021; acid; no albumen; no sugar; there were traces of urates. Occa- sionally severe pain in back of head, relieved by bromide of potassium; vertigo felt only in the upright ]>osture; feels a subjective, not an objective, uncertainty in walking. No mur- mur in temporal or mastoid region. Such were the general notes on the ward-book. Aural Notes. — Both drum-membranes were normal in lustre, color, and tenuity ; not the slightest congestion in them anywhere. 564 DISEASES OF THE INTERNAL EAR. Inclination of membranes nearly normal; left (deafer side) a little more retracted than right. The former, therefore, shows less of a pyramid of light than the latter. Under the pneumatic speculum the left moves more readily than the right membrane. Hearing for watch, L. = y^; R. = ^. Speech is heard relatively much better than the watch. Patient said he heard a vibrating tuning-fork placed on his vertex in both ears. Eustachian tubes perfectly pervious, as shown by the Eustachian catheter. Hear- ing was not altered by inflation of tympanum. UnusuaUi/ severe sneezing^ icas caused hy the introduction of the catheter ; he thought his ears buzzed a little more after exami- nation. Vertigo and gait were in no way changed by manipu- lation and examination. He says he is dizzy whenever, and only whenever he attempts to walk, and relief is always obtained by sitting down. There was considerable nasopharyngeal catarrh, but the Eustachian tubes were pervious, as stated. There was no evi- dence of accumulation of mucus in the tympanum, and the external auditory canal was entirely normal. JSTothing, there- fore, was found in either of these parts of the ear to account for the peculiar symptoms in this case. If the man's statement be true, that his hardness of hearing, peculiar vertigo, and altered gait came on at the same time, this would look like a case of aural vertigo, but every well-marked case of vertigo from aural irritation is j^aroxi/smal as to the onset of dizziness, reeling, fall- ing, etc. Some tinnitus, and usually considerable alteration in hearing remain, but the gait is wqvqv permanently changed. Pathological Changes. — In a case recorded by Moos,- the post- mortem examination revealed a tumor of the left auditorv nerve, which had caused compression of the pons cerebelli, and of the left oculo-motor, the fifth, and the facial nerves; there was also gray degeneration of the spinal cord. The condition of the organ of Corti was one of fatty change, and partial destruction. In the case of Cruveilhier referred to, there was found under the tentorium cerebelli on the left side, a hard nodulated tumor, which pressed upon the left half of the pons, the medulla, the peduncles of the cerebellum, and upon the cerebellum itself. The tumor hung by a stout pedicle over the posterior surface of the petrous bone. The seventh nerve was destroyed at the porus acusticus internus. Fibro-sarcoma. — Dr. Boettcher,^ of Dorpat, writes of fibro- sarcoma of the auditory nerve as of no uncommon occurrence. ^ Great susceptibility to sneezing has been observed in cases of tumor of the brain involving the auditory nerve. '■^ Arcliives of Oph. and (Jtol., vol. iv. p. 484. 3 On Changes in the Ketina and Labyrinth in a case of Fibro-sarcoma of the Auditory Nerve. Archives of Oph. and OtoL, vol. iii. pp. 134-171, 1873. MORBID GROWTHS OF THE AUDITORY NERVK. 5Go But lie believes, that the microscopic chjiii<,a-s in the lahvriiith in such cases have usually escaped attention. Fortnnatolv for otolotrj, the article on the case referred to is offered hv its dis- tinguished writer as the beginning of a [)athological histology of the cochlea. In the case of a young woman, 21 years old, who died in consequence of the cerebral tumor, the niorbid growth was tbund connected with the common truidc of the facial and the auditory nerves. The latter appeared like a white cord, 2 em. long, and 1 mm. thick, showing, under the microscope, medullary nerve- fibres in all its fasciculi, but the medullary sheath was nowhere complete. The great denudation of entire fasciculi of axis-cylinders, noted in this case, was considered very extraordinary. " All the fibres were colored by chloride of gold, intensely violet. Fatty degeneration was not discoverable in the specimen mounted in alcohol. Part of the tumor extended into the porus acusticus internus. This canal was found dilated in all directions by the morbid growth. This was deemed simply tlie result of atrophy from pressure. At the bottom of the internal auditory canal, where the tumor was found in contact with the base of the cochlea, the growth bulo-ed toward the modiolus. rsot a trace of nervous elements remained in the modiolus. An absence of the nerve-fibres was also demonstrable in the spiral canal of the modiolus. The lacunse once occupied by the spiral ganglion were empty. Changes in the Vestibule and Semicircular Canals. — "Here the epithelium and connective tissue-envelope of the sacculi, and membranous canals were well preserved; large and numerous vessels were observed in the envelope. The macula and the crist?e acusticfe were unaltered in form, but no nervous fibres were seen to enter these structures." The facial nerve was present from the angle of, and filled the bonv canal. The s'ano-lion e:eniculatuni was found to be atro- phied. There was facial paralysis on the corresponding side. The tumor was classed by Dr. Boettcher among the fibro-sarco- mata. Glioma. — Briickner' has described a cerebral tumor, which occurred in his wife, in whom the suspected cause was a fall on the back of her head on the ice, in her thirteenth year. The first symptoms of the disease were noted about three years later, in the form of uncertainty in the use of her upper and lower limbs. Four years before her death, which occurred when she was twenty-eight years old, a diminution of hearing upon the left side was accidentally noticed, with giddiness and catarrh 1 Berliner Klin. Wochenschr., No. 29, 1867. 566 DISEASES OF THE II^TEKNAL EAR. of the middle ear; and, finally, complete deafness. A singular phenomenon in this case was that, three or four months before death, a whirring, like the placental murmur, could be heard by applying the ear directly to the patient's left temple ; once, very feebly on the right temple; the sound ceased to be heard by herself or others after she had taken large doses of iodide of potassium. The left auditory nerve was found to be entirely obliterated, and in its place there was a large glioma. The Labyrinth in Ileo-typhus. — By post-mortem examination. Moos' found in the labyrinth of a soldier who had died of ileo- typhus or typhoid fever, a large quantity of lymphoid corpuscles on the lamina spiralis membranacea, on the sacculi and the am- pullfe. Some of these had undergone fatty degeneration. They were most numerous in the region of the point of entrance of the cochlear branch of the auditory nerve, into the labyrinth. Fattij metamorphosis of the organ of Corti, closely resembling that found in sarcoma of the auditory nerve, may also be the result of hemorrhages into the cochlea, as shown by Moos.- Amyloid degmeration of the auditory nerve has been fully described by Forster^ and Voltolini,* and its occurrence cor- roborated by Luc?e and Politzer. It appears to be of common occurrence, as stated by Gruber. Hallucinations of Hearing in the Insane. — Hallucinations of hearino- are common in the insane. Thev are very often not dependent upon any aural disease; though in many instances they seem to have been induced by a disease in the ear. In some instances, after the removal of a plug of cerumen or other morbid cause of the hallucinations, the latter have been dimin- ished, but not entirely removed. They have been noted in women afflicted with nymphomania. In such, the hallucination has been the supposed hearing of a man's voice, which, as Dr. O. D. Pomeroy^ has observed, indicates rather a disease of the nervous sj'stem than of the ear. Still, whenever insane patients complain of subjective hearing, their ears should be examined, for a removal of the aural irritation, if one should exist, may relieve, if it does not entirely banish the hallucinations. Moos^ found an enlargement of the bulb of the jugular vein ^ Ueber die Anatomischen Veriinderungendes H;xutigen Ohrlabyrinths bei Ileo- Typhus. Verhandl. d. Naturwiss. Med. Yereins zu Heidelberg, v. 199 ; also M. f.'O., No. 2, 1872. 2 Archives of Oph. and Otol., vol. iv. pp. 497-502, 1875. ' Atlas of Pathological Anatomy, p. 8G, 1854. * Virchow's Arohiv, vol. 22, p. 114, 18G1. 5 Hallucinations of Hearing in the Insane, Transactions American Otol. Soc, vol. i. p. 184, 1871. ^ Archives of Oph. and Otol., vol. iv. pp. 479-482, 1875. MOllBID GROWTHS OF THE AUDITORY NERVE. 567 in the right petrous bone of an insane man, wlio had snfK'red with the most intense and distrcssin(]j noises in the ear, and to escape which he finally committed suicide. _ It ^yas supposed that when blood passed from the lateral sinus into the enlaro-ed bulb of the Juirular vein, vortices must have been formed in the current, and in consequence thereof a blood murmur must have been produced, which on account ot its nearness to the labyrinth must have been heard as a loud subjective noise. In this account, allusion is made to the theories of Oppolzer, Friedreich, and lioudet. They explain the tinnitus of chlorotic patients as a subjective percej)ti()n of the bruit de diable, because it disappears usually on compression of the carotid, Friedreich has not found this rule invariable. I have known an insane woman to be distressed and made worse by the imagined hearing of an infant's cry. As she could not stop the imagined cry of pain, that of her own child, whose death had caused the insanity, the brain symptoms became markedly worse. The ear was not examined in this case. An insane man, with normal ears, once or twice presented him- self to me for treatment to gain relief from sounds of a peculiar kind, " spirit voices,'' which he seemed to hear in the air above his head. These sounds were not always disagreeable to him, but were annoying by their long continuance, and by their preventing sleep. The ears were carefully examined in this case, but nothing whatever abnormal was found in them. The tinnitus of the insane is referred either to the interior of the head or to a point outside, but not remote. It might be termed cerebral and not aural tinnitus. Nervous Deafness. — Strictly nervous deafness must be regarded as among the greatest rarities. Among the peculiar nervous symptoms which sometimes attend acute articular rheumatism, may be found a form of acute deafness, which might be called nervous. At the same time hysterical symptoms may manifest themselves. Dr. S. Weir Mitchell has called mv attention to what he terms hysterical deafness. In the case of a young woman he observed a deafness, which would apparently come and go during conversation. At other times, the patient would fail to hear under circumstances in which she had but a short time before appeared to hear well. I have never observed such a case, but I doubt not that such should be classed under hys- terical phenomena. ]Moos^ observed a case of intracranial disease after acute rheumatism, with peculiar nervous phenomena, combined with 1 Archives of Oph. and Otol., vol. i. p. 4f;4. 568 DISEASES OF THE INTERNAL EAR. complete deafness for noises, musical tones, and speech. The patient was communicated with by writing, for several weeks. Under the use of the constant electric current, the patient en- tirely recovered. When it is remembered that there is a close connection be- tween acute articular rheumatism, chorea,^ and meningitis, it can be understood how the hearing might be either temporarily or permanently aifected by the rheumatic poison. Total deafness may be the result of a fall brought on by diz- ziness from causes other than aural. This fact must be carefull}' borne in mind in estimating the part the ear may have had in the production of the primary disease, as is shown in a case given by Moos,-* as follows: A soldier suddenly fainted and fell, without any previous warning. Upon the return of conscious- ness, he was found to be entirely deaf to all sounds. Subjective noises were noticed at first, but they gradually ceased. It was believed that, in consequence of the fall, an extravasation of blood took place at the origin of both auditory nerves; in no other way could the total and sudden deafness be accounted for. Fracture of the bone would in all probability have pro- duced death. The precise seat of the extravasation was sup- posed to have been in the medulla oblongata, at the point of origin of the deep root of the auditor}^ nerve. If a repeatedly applied galvanic current of such intensity as will cause twitching of the muscles of the face and the extremi- ties, fail to produce sensations of hearing, we ma}- infer the existence of complete paralysis of the auditory nerve, and form an unfavorable prognosis. The Effects of Quinine upon the Ear. — The question is often asked, Does quinine cause ear-disease — Does it make one per- manently deaf? And the answer, so far as I am able to give it, is always in the negative. I say this with all reserve, and with the full knowledge that many high authorities^ have taken an opposite view, and have, as they believe, adduced proof of its correctness. Wherever quinine has been supposed to be a cause of deafness, usually it can be shown that the disease for which the drug has been given is the underlying cause of the failure in hearing. It is most positively known that malarial diseases — chills and fever — for which large doses of quinine are usually given, are frequently followed by hardness of hearing and deaf- ness, whether quinine be given or not. But yet malarial disease 1 Germain Sec; De la Choree, Paris, 1850. 2 Archives of Oph. and Otol., vol. ii. pp. 199-203, 1871. * Dr. Roosa, Trans. Amer. Otol. Soc, vol. i. p. 276; also vol. ii. p. 0:3; also M. Molier, INIemoiros de I'Academie Eoyale de 3Iedicine, p. 722, quoted by Drs. Koosa and Hammond. MORlUn (i now Ills OF THE AUDITORY XERVE. i)C)9 often runs its most virulent course, and (luinine is also ji;ivc'n in large doses, \Yitliout the production ofdealiiess. A great many patients tliiid<: they arc deaf in consequence of taking quinine; but in all such cases which I have observed, there was most evident cause for the deafness, in catarrhal disease of the nasopharynx and throat, which antedated the administration of quinine. In many cases, the diseases for which the quinine had been given, as puerperal maladies, con- tinued fevers, chest-aiFections, etc., were an amply sufficient cause of deafness, and not the taking of the drug in (piestion. It is admitted that quinine will cause ringing in the head and ears as well as temporary hardness of hearing, ])rol)ably by con- gestion of the middle ear. But were quinine injurious to the ear, its ill-elFects could be plainly seen when given to those affected with aural disease. On the contrary, a partially deaf person may be made temporarily deafer, but when the quinine is no longer taken, the hearing returns to its relatively normal point. Furthermore, some kinds of tinnitus aurium, viz., from anremia and debility, are stopped b}' taking quinine. Of I'ourse, poisonous doses of quinine, like any other morbific element in- troduced into the blood, might have a bad effect on the nerve of hearing, and on the sound-conducting parts too. But, so far as my experience goes, all necessary doses of this useful drug can be given in any case with impunity, whether the ears are affected or not. It would appear that sometimes congestion of the external ear occurs as the result of the administration of large doses of this drug.^ H. K. Spencer^ has observed that quinine congests the mem- brana tympani in a few minutes. But he finds no evidence that the hearing is permanently affected by the drug. Kirchner,^ however, claims that quinine may produce permanent changes in the ear by vaso-motor disturbances, the congestion apparently beginning in the tympanic cavity, and extending to the laby- rinth. Weber-LieP maintains that both salicylic acid and qui- nine produce hardness of hearing, that induced by the former being greater and lasting longer than that caused by quinine. It is'claimed that both d'rugs "lower the temperature of the ex- ternal auditory canal. ' Eoosa, Transactions American Otolog. Soc, vol. ii. p. Oo. ■■2 American .Journal of Otology, vol. iii. 168, 1881. 3 Berliner Klin. Wt>cliensclinft. 49, 1881. * Monatsschrift fur Ohrcnheili Archives of Oph. and Otol., vol. ii. p. 138, 1871. * Contributions a I'etucle de lesions intracerebrales de la surdi-mutite, Ann. des maladies de I'oreille, 1875, pp. 813-322. See A. f. 0., Bd. xi. S. 179; abstract by Ivnlin. ^ Transactions of Medico-Chirurg. Soc, London, 1825. METHODS OF UELIEF AND EDUCATION. 571 The congenital form of {leaf-dmnhness has generally been considered as the coninioner occurronce. In coniparatively few instances its existence has been proven by post-mortem exami- nation to have been due to malformation of tlie internal eiir or of parts of the brain. Knowledge as to its true nature and cause would be greatly enlKuuxHrby more thorough records, in deaf and dumb institutions, of the condition of tlie ear during life and a complete description of its state, as revealed by post- mortem investigation. Beard and Roosa^ placed the average of congenital deaf- muteness at about sixty-one per cent, of all cases of mutes; Wilde placed it at fifty per cent. By a reference to the reports of the last three years, of the Pennsylvania Institution for the Deaf and Dumb, Philadelphia, it will be found that one hundred and thirty-seven children were admitted within that time, who lost their hearing from fever and other causes, and had in consequence become dumb. They constituted two-thirds of the entire number of admissions, thus showing that, in this institution at least, congenital deaf- muteness is considerably less frequent than the acquired form. It is held by von Troeltsch that an hereditary tendency to deaf-dumbness exists in some families. AVithin a very short time I have seen a family in which four children were deaf mutes. But it appears from the investigations of modern times that the acquired form of deaf-muteness is by far more common than was once supposed. In many instances the history of a case points to a destructive disease of the sound-conducting parts in the tympanum and also in the labyrinth, at a very early period of extra-uterine life. But even in these lamentable cases, to state that the sufferer came into the world endowed with the power to hear, is often a grain of comfort to parents who cannot bear to regard a child as congeni tally defective. Every physician may be called upon to decide whether a child is deaf and dumb, and if it be, to suggest, if not a cure for the deafness, at least a plan for the proper education of the little patient. In very young children it cannot be readily decided whether total deafness exists or not. But whether a child is totally deaf or not, it may be too deaf to learn to talk by hearing others speak. It is not unusual to find pupils in deaf and dumb insti- tutions who can hear loud sounds, and even the human voice when shouted into their ears. Without deciding, therefore, that the child is entirely devoid of hearing, a physician may find, on examination, that it is too 1 Op. cit., p. 515. 572 DEAF-ilUTES AND PARTIALLY DEAF CHILDREN. deaf to learn to talk in the ordinary way, in which case he should advise its parents to arrange for its proper education in another manner. Advice is rarely sought respecting the aural condition of a child until, having come to an age when most children begin to use words intelligently, it arouses suspicion as to its peculiar defect, by showing no evidence of learning to talk. It may be stated by the parents that they believe the child was, at one time, able to talk, because it has spoken such words as "mama or papa;" but the mere utterance of these elemen- tary sounds of speech, which may occur entirely involuntarih' in extremely young infants, is no evidence that the child hears. If there is reason to believe that the fears of the parents respect- ing the deficiency in the child are w^ell grounded, a thorough examination of the ear should be made. If nothing abnormal can be discovered in the external or middle ear by inspection, or b}^ inflation, and if the child has reached an age when it ought to talk, it may be concluded that it is too deaf to learn to talk by hearing others, and that, in all probability, its deafness cannot be relieved. If, however, on inspection an obstruction or deficiency in the sound-conducting parts is found, or if a suppuration exists in the ear, all such interferences to hearing should be combated in the ways already named in a previous part of this work. Without doubt some cases of deaf-muteness might be prevented by an early treatment of the local symptoms. There is every reason to believe that very young children may be the subjects of chronic aural catarrh, which comes on insidiously, producing in them progressive hardness of hearing. While the same grade of hardness of hearing which has resulted in them would not seriously impede an adult who had already learned to talk, a child thus aifected is too deaf to learn to talk by hearing others speak. I have found that mute children, in whom the membrana tympani showed signs of chronic aural catarrh, at the age of four and a half y«ars, could hear the voice probably well enough to be taught to speak, when addressed V)y means of an ear-trumpet, if it were possible for any one in their fiimily to undertake so laborious a method of instructing them. Beyond combating a disease already firmly seated in the sound-conducting parts of the ear of a deaf-mute, the surgeon can do nothino-. If the changes in these parts have not been of a deeply organic nature, the hearing may be partially restored. But if tliese changes have been of a structural nature, or have extended to the internal ear, litttle, if an}-, benefit to hearing can be hoped for. The on!}' plea for treating a suppurative disease, which is not uncommon in deaf-mutes, would be to prevent the fatal results of neo-lected otorrhoea. MKTHODS OF RELIEF AND EDUCATION. 573 While it is l)y no moans the jtroviiice of ihis hook to describe or atlvoeate any particuhir nietliod of instructiiii; deaf-mutes, a word may be said respecting the methods which are usually em- ployed. In all civilized communities there arc provisions for the proper corporeal, moral, and intellectual trainini:; of the deaf and dumb. Deaf-mutes naturally communicate with one another by means of a sign-language, which, in most respects, is common to all nations. This method, scientifically elaborated, is termed dactylology or finger-talking. Tntil within a few years it lias been the only mode of instructing deaf-mutes in England and the United States. The German system of educating mutes by teaching tliem to understand and use language, bv observinc; and imitatinir the articulate speech of others, in which mctliod the pupils are most positively forbidden to use the sign-language, has been emplo^-ed for a long time in most of the countries of Continental Europe. An accurate and succinct account of this so-called German method may be found in a most interesting brochure on the subject, by Mr. AV. B. Dalby.^ Instances of mutes learnino; to understand what was said to them, by watching the lips of the speaker, are on record from the beginning of the eighth century, when John De Beverley, Archbishop of York, thus instructed an adult mute in the Christian religion, to the middle of the seventeenth century, when the book of John Bulwer induced John Wallis, of the University of Oxford, and William Holden, Canon of Ely and St. Paul's, to devote themselves to the education of the deaf and dumb by means of lip-reading. It has also been practised in Spain and Italy between these two periods above alluded to, England, however, appearing to have been the pioneer in this mode of instruction, though among the last to give it an extended trial. Hemiche, of Germany ^in the middle of the eighteenth century, seems to have been the next notable advocate of instructing deaf- mutes by lip-reading and articulation. It is now universally emplo^'ed in that country. In order to accomplish education by this means, the child must possess ordinary intelligence, normal vocal organs, and it must begin its studies in this direction at not later than seven years of age. The average length of time which must be given this course of education "before the pupil can understand and communicate with any one he may meet, is about eight years. But orreat attainments are thus made. It is a well-known fact I " Education of the Deaf and Dumb by means of Lip-reading and Articula- tion." By W. B. Dalby, F.K.C.S., M.D. (Cantab.), London, 1872. 574 DEAF-MUTES AND PARTIALLY DEAF CHILDREN. that English mutes thus instructed have learned to talk not only their own language, but French and German, and have become brilliant ornaments to society. In Vienna, I have frequentl}' conversed in their own lan- guage with German deaf-mutes who had attained such accuracy of observation of the lips of the speaker that they immediately perceived my foreign accent. BelVs System of Visible Speech. — There is another means of teaching deaf-mutes articulation, and that is by the system of visible speech, or phonetic writing, of A. Melville Bell. It is based on the physiological action and position of the vocal organs during speech, and is practically an alphabet of sounds, in which the symbols inform the child how to place its lips, tongue, and palate, and thus produce a vocal sound. It was successfully" employed in England in 1869, since which time it has been introduced in several institutions in this country. Lip-reading and visible speech may be of great value in the education of children who have become deaf after having learned to talk in the first four or five years of their life. Children of this age, who become entirely deaf in consequence of scarlatina, cerebro-spinal meningitis, or of any disease, will often volun- tarily cease to talk, and thus, forgetting how to use speech, become mutes. I recall the case of an intelligent boy, six years old, who, becoming entirely deaf after cerebro-spinal meningitis, showed the greatest reluctance to talk, and relapsed at once into making signs, with the result of becoming mute. No matter how deaf a child may have become after it has learned to talk, it should be coerced to continue the use of speech, and discour- aged in the use of signs. His conception of wdiat speech is and his ability to use it are invaluable aids in his further education by means of lip-reading and articulation, or by visible speech. Partially Deaf Children, — There is a large class of children, who are by no means deaf-mutes, yet who hear so badly as to be under constant disadvantages at ordinary schools. Such children, on account of their poor hearing, are often imposed upon, both by their companions and their instructors; the former deceiving them, the latter misunderstanding them, and consequently losing patience with them. Do as they may, such pupils must fall behind. It is not desirable for many reasons that children who have learned to talk, but who have become quite dull of hearing, should be isolated into separate classes; it is much better they should continue their studies with those among whom their lives are to be spent. But allowance should be made for their defective hearing. This can only be accomplished by first ascer- taining it. Many a child is hard of hearing without knowing METHODS OF RELIEF AND EDUCATION. 575 its defect; it is, therefore, tlie place of Its eMers to find out and determine the amount of its deficient hearing. That some special provision must he made for such children is fully justified hy the statistics compiled hy Dr. C. J. JJlake, who has shown that out of 8715 cases of ear-disease, accom- panied by impairment of hearing, 2175, or 25 per cent., were children under tourteen years of "age, all of them pujiils in the public schools. In order that proper allowance be made for their defective hearing, he has suggested that a careful examination " should be made in each case, to determine the degree of deafness as tested by the distance at which the voice of the teacher can be heard in ordinary conversation tone, and again by the pronun- ciation of consonant tones." These tests "could be made by the teacher, and the following directions for making tliem are given : The teacher should always occupy, in testing tlie ditierent cases, the same position, preferably the rostrum or seat usually occupied by him in school-hours. He should speak in the same tone of voice used in the school-room exercises. The child to be tested should be placed in front of the teacher, and at the extreme limit of the farthest line of seats, and 'graduall}- ad- vanced toward the teacher at certain intervals, the tests being repeated until a point is reached at which the child can hear distinctly. This point should determine the place the child should occupy in the school-room. The ears should be tested separately, the ear to be tested being turned toward the teacher, while the other is artificially closed. The child should be required to repeat distinctly the words as he hears them. The use of the voice in making tests of this kind is preferable to the use of watch, musical instruments, and the like, as being more applicable to the child's needs. The tests should be re- peated when the child passes from one room to another, as the deo;ree of deafness often varies at ditierent ages. The examina- tion of pupils by a medical expert is reconmiended as prefer- able, since an opinion of the nature of the aural disease and the mode of treatment could thereby be afforded the pupil. Dr. Blake strongly recommended the establishment of a medical supervisor of schools ; the post to be occupied by a competent physician, who had made the matter of school hygiene a study, and his whole time to be devoted to the duties of his position. Such a careful and scientific examination would reveal that some of the children are suffering from a disease of the ear, entirely amenable to treatment if given at that time. They would, by thus being taken care of, not only regain hearing, and make more rapid advances in their studies, but they would often be enabled to get rid of a disease which would otherwise gradu- ally grow worse, because unrecognized, and finally, becoming 576 DEAF-MUTES AKD PARTIALLY DEAF CHILDREN, irremediable, render them permanently deaf. There is no greater fallacy in hygiene than that a child " will outgrow deafness." Dr. Samuel Sexton^ makes the very important sug- gestion that teachers do not enjoy greater immunity from hard- ness of hearing than others in the same social position, and that, therefore, those preparing or offering themselves as teachers, should be examined regarding their hearing-power. This might be very satisfactorily tested if the examinations for admission to the ranks of teachers were oral instead of written. Ear-trumpets. — It has been proposed that the hopelessly hard of hearing use ear-trumpets. Such instruments are of most service when the defective hearing is due to a chronic catarrhal process in the middle ear, in which the ossicles and the mem- brana tympani are present. By a concentration of sound upon the conducting parts, the latter are in many instances made to perform their function better. If, however, the nerve is dis- eased, the concentration of sound by means of ear-trumpets will not be of much aid. It has also been observed that, in cases of chronic suppuration with perforation and destruction of the drum-head, the use of the ear-trumpet is more apt to produce confusion and dizziness, than better hearing, No one form of ear-trumpet can be con- sidered the best; each patient must be tried by a series of in- struments, until one is found which proves of service to him. It may be said most positively that all small, and so-called " invisible " ear-trumpets, or instruments to assist the hearing, no matter under what name they are vended, are useless, because they neither concentrate more sound upon the drum-head, nor increase the resonance of the external ear. In everj" instance all such instruments, which, lie in the auditory canal, interfere with what little hearing may still exist. There is one excep- tion, viz,, in cases of hardnes of hearing due to a collapse of the cartilaginous auditory canal, if such cases exist. Here, relief may be gained by holding the walls of the meatus apart by means of a small tube of some kind. Although I have never seen such a case, I am able to conceive that some instances of impaired hearing in old people may be due to such causes, after the loss of teeth, and the consequent alteration in the position of the under jaw, and the encroachment of its condyle upon the tissues of the external meatus of the ear. I have heard of a case of hardness of hearing which was relieved by wearing a com- plete set of artificial teeth. This, of course, would render the position of the under jaw normal, and thus relieve what has been called collapse of the auditory canal, 1 Circular No. 5, 1881, Bureau of Education, Washington, D. C. I N 1) K X . A COU^LETEK. 104 xl Adenoid growths in nasopharynx, 400 Ampulla', 13G Ampullar bruuclie.-^, autlitory nerve, 132 enlargement, 125 nK)utiis, semicircular canals, 121 Annulus tendinosus, .37 tympanicus, 42 Anomalies of taste and salivary secre- tion, 492 Anvil, see Incus. Aqua?ductus cochle:o, 40, 139 Arachnoid sac and lympii of labyrinth. 138, 139 Arborescent fibrous structure, meni- brana tympani, 59 Arteria stapcdia, 90 Articulation, deaf-mute?, 573, 574 Artificial membrana tympani, 480-485 action, 482 cotton pellets, 480 paper disks, .484 protective function, 484 Aspergillus in the ear, 2G3-273 etiology, 270 forms of, 204 macroscopic features, 2G6 microscopic features, 265 symptoms, 268 treatment, 271 Atomizer, the hand, 39G Audition, 140-144 Axial ligament, malleus, 70 Auditory canal, 37 anatomy, 37 annulus tympanicus, 42 aspergillus in, 263-278 boils, 245, 250 cerumen collections, 274 ceruminous glands, 45 development, 41 diseases, 245-314 cholesteatomatous impactions, • 301 closure, cutaneous, 308 Aiiilitory caiuil — closure, osscou.-;, 304 partial os.scous, 310 collapse, 576 cretaceous bodies, 277 diffuse inllammation, 251 diphtheritic inllammation, 254 ear-cough, 311 embryology of, 37 epileptiform symptoms from irritation, 311 epithelial cancer, 2G3 exostoses, 303 foreign bodies in, 273-298 fracture of tympanic bone, 312 gangrenous inflammation, 255 general deserif)tion, 43-45 gonorriifual, 256 hairs from tragus on membrana tympani, 284 iiemorrhagc, 313 inllamnuition, 298 injury. ^98 insufllation of powders, 260-262 keratosis obturans, 278 laminated epithelial plug, 278 maggots in, 290-292 otitis externa circumscripta, 245-250 diffusa, 251 outward growth of cutis, 46, 47 physiology, 46 pruritus, 283 sebaceous tumors, 302 seborrhica, 282 segment of Ilivinus, 43 spina tympanica anlica, major, 42 minor, 42 postica, 42 syphilitic and gonorrhieal liammalion, 256 temperature, 36, 569 treatment of disoa^o, 257 ulceration, chronic circum- scribed, 298, 299 42 in- 87 578 INDEX. Auditory canal — ulceration, reflex, 300 vessels and nerves, 46 vicarious menstruation, 313 Auditory nerve, 181, 544 ampullar branches, 132 amyloid degeneration, 566 cochlear branches, 132 distribution, 131 electric reaction, 417 fatty metamorphosis, 566 tibro-sarcoma, 564, 565 glioma, 565, 566 morbid growths, 555 origin, 131 sarcoma, 556 tumors, fibrous, 555 on both nerves, 557-562 vestibular branches, 132 Aural vertigo, 531, 544-555 Auricle, 19 abnormal ]iosition, 210 anatomy, 19 angioma, 227 bloodvessels, 22 cancer, 233-235 cartilage of, 19 cleft of lobule, 243, 244 comparative functions, 28,29 congenital fistula, 213 cornu cutaneum, 220 cutaneous diseases, 214 cysts, 227 Darwin on, 26 diseases of, 210 divisions, 19 eczema, 217 subacute, 218 embryo, 19 epithelial cancer, 233-235 erysipelas, 214 erythema, simjile, 214 fibrous tumors, 229, 230 frostbite, 215 gangrene, 216 glandular hypertrophy, lobule, 230 hair on, 23 herpes zoster, idiopathic, 223-225 inflammation of cellular tissue, cir- cumscribed, 220 injuries, 242 in aquatic mammals, 29 in architecture of the skull, 26 in cranium progenicum, 25 in Egyptians, 25 in Giotto's "Envy,"' 25 in lower animals, 28 integument, 22 intertrigo, 215 ligaments, 21 lymphatics, 22 malformations, 211 Auricle — morbid growths, 227 movements of, 24 muscles, 19 naevus maternus, 228 nerves, 22 organic defects, 210-214 othtematoma in the insane, 235 in the sane, 241 pemphigus gangrasnosus, 216 phlegmon, acute, 219 chronic, 220 plurality, 210 points on, 26 jihysiognomy, 25 physiology, 23 resonant functions of human, 30-36 shape, size, and position, 25 sudoriferous glands, 22 syphilis, secondary, 221 syphiloderm, tubercular, 221-223 tophi, 216 tragus, herpes zoster of, 226 tumors of lobule, 229, 230 Auscultation-tube, 177 three-limbed, see Tests. Autophony, 354, 358 Axial ligament, 70 BANDS in tympanum, 92 Bathing, etfect on ear, 452 Blake's "Wilde's snare, 503 Bloodvessels, tympanic cavity, 89, 90 Boils, in external auditory canal, 245- 250 Bony closure of auditory canal, 304 Bright's disease, extravasation of blood into tympanum, 433 Bruit de diable, subjective, 567 CANAL of cochlea, 122 Canals, semicircular, 124 Cancer, epithelial, auditory canal, 263 auricle, 233-235 mastoid portion, 442 middle ear, primary, 440 Cartilage, auricular, 19 Cartilaginous groove for malleus, 57 Catarrhal inflammation middle ear, acute, 348-370 alteration in pitch, subjective, 355 anodynes, 368 autophony, 354, 358 course, 349, 364 diagnosis, 366 double hearing, 355 earache from teething, 365 infants and young chil- dren, 360 INDEX. 57J) Cntiirrlml itiflniuniation iiiidiUc oar, acute — etiology, 3(54 forms', 348 hardness of hearing, 351 intrutynipanic prossiiro diirinu; jihoiuUion, o')7 nienibrana tvnijiani, ajijioar- ances, 34'.>, oG2, 8(J9 retraction, 362 spontaneous rupture, 302 pain, 349 from muscular motion, 350 paracentesis, 309 paracusis dujilicata, 355 paresis of velum, 351 jirognosis, 3G7 retraction of niembrana tym- pani, 362 sprays in nasopharynx, 368 symptoms, 349 objective, 362 teething-, 365 tinnitus aurium, 352 treatment, 367 vacuum in tympanum, 350 whooping-cough, 366 Catarrhal inflammation middle ear, chronic, 370-421 applications to cavity of drum, 402 to Eustachian tube, 399 to nares, nasopharynx, and throat, 394 auscultation of Eustachian tube and tympanum, 386 causes, 389 changes in Eustachian tube, 384 changes in voice, 383 constitutional remedies and hy- giene, 393 eyeletof Politzer and othei-s,405 gargles, 401 hand atomizer, 396 membrana tympani, operations with knife, 402 nares in, 381 nasopharynx, adenoid growths in, 385' paracusis Willisiana, 375 pharynx and throat in, 382 removal of fluid from tympanic cavity, 407-416 sympathetic nerves, changes, 378 symptoms, objective, 370 subjective, 371 tenotomy of tensor tympani, 407 tonsils, excision, 401 treatment, 393-421 Catarrhal innammatinn middle onr, clironic — uvula, clipping, 401 velum, loss of function, 382 vertigo, 374 Caliicterization, Kustachian tube, 179 Catheters, Kustachian, 174 Cernminous glands, auditory cainil, 45 Cerebro-spinal meningitis, ear in, 538- 541 Chorda tympani nerve, 85-87 irritation of, 491 Chinoline sali(;ylate, in otorrhcra, 470 Chorea, ear in, 5'iS Ciliated cells, cochlea, 130 Clang-tint, see Sound. Cochlea, 122 arches of Corti, 130 branches, auditory nerve, 132 canal of, 122 ciliated cells, 130 Corti's organ, 129, 130 crista spiralis, 127 ductus cochlearis, 128 exfoliation, necrotic, 511 habenula perforata, 128 membrana reticularis, 130 tectoria, 131 modiolus and lamina spiralis ossea, 123 nerve-ends, inner and outer, 132 pillars of Corti, 130 physiology, 140-144 lieissner's membrane, 127 scala?, 123 soft parts, 125 stria vascularis, 128 vas prominens, 128 zona.', 128 Cold bathing, etfects on middle ear, 452 Color-hearing, 189 Comparative^functions, auricle, 28, 29 distribution of bloodvessels, mem- brana tympani, 02-65 Concavo-convexity of membrana tym- pani 51 Concussion, deafness from, 537, 538 effects on middle ear, 452-454 Consonants, see Tests. Corpuscles of Politzer and Kessel, 436 Corti, arches of, 130 Corti's organ, 129, 130 in brain tumor, 561 Corti, pillars of, 130 Cotton-holder, 168, 169 Cretin, membrana tympani of, 50 Crista acustica, 136 spiralis, 127 1) EAF-DUMBNESS, 570-570 accpiircd, 571 580 INDEX. Deaf-dumbncps, congenital, 571 Deaf and dumb, articulation of, 574 instructions, 573 lip-reading, 573 visible speech, 574 Deaf points in ear, see Hearing. Deafness, nervous, 567 hysterical, 567 Descending fibres, membrana tympani, 59 Dermis of membrana tympani in chil- dren, 49 Diphtheritic diseases of ear, 254, 461, 462 Double hearing, 355 Ductus cochlearis, 128 EAR, external, see Auricle, Auditory Canal, and Membrana Tympani. Ear, Middle, see Tympanum, Tympanic Cavity, Eustachian Tube, and Mas- toid. Ear, internal, see Internal Ear, Laby- rinth, Cochlea, and Semicircular Canals. Earache, from diseased teeth, 455 from teething, 365 in children, 360-362 in whooping-cough, 366 Ear-cough, 311 Ear, examination of, 159-209 forehead-mirror, 161 foreign bodies, in external, 273-298 Ear-mirror, 160 Ear-syringe, 169 Ear-trumpet, application of entotic, 208 Ear-trumpets, 576 Electricity in aural diseases, 416 Brenner's formula of the reaction of auditory nerve, 417 mode of application to the car, 417 Embryo, auricle in, 19 Embryology, auditory canal, 37 Eminentia stapedii, 81 Emphysematous tumor, mastoid, 442 Endolymph, 138, 139 Epileptiform manifestations, 485 irritation in auditory canal, 311 Eustachian catheters, 174 air-bag for inflation, 178 auscultation-tube, 177 Bonnafont's nose-clamp, 176 fixation, 181, 182 insertion, 179 Re.xton's flexible, 176 lube, 101-108 anatomy, 101-108 applications to, 399 at rest, 114 auscultation and inflation, 386 bony portion, 101 Eustachian tube — bloodvessels and nerves, 108 cartilaginous portion, 101 catheterization, 179-183 foreign bodies in, 292-294 inflation, 183 inner pterygoid muscle, 105 intratubal electrization, 419 islands of cartilage, 114 ligamenta salpingo-pharvngea, 105 mucous membrane, 107 muscles closing, 115 motions during phonation, 113 physiology, 112 conjoint, of tympanic cav- ity and mastoid cells, 118, 119 plica salpingo-palatina, 106 rhinoscopic examination, 174 safet\-tube, 114 size and shape of mouth, 108 tensor palati muscle, 103 tonsilla pharyngea, 107 Evelet of Politzer, membrana tvmpani, 405 Examination of ear, 159-209 author's forceps for removal of foreign objects, 168 polarized light, 159 position of surgeon, 167 removal of obstructions, 168 sound, hearing, and tests, 186 Examination of nares, fauces, throat, and Eustachian tube, 171-179 of throat, etc., Tobold's apparatus, 172 Exosto-ses, in the auditory canal, 303 in Hawaiian Islanders, 304 in mound-builders, 304 in Peruvians, 304 FACIAL angle and the position of the auricle, 26 Facial canal, 84 lymphatic cavity in, 85 nerve, course, 84 paralysis, 488 Fauces, examination of, 171 in chronic aural catarrh, 397-401 Faun's ear, 26 Fenestra?, 80 Fistula, congenital, of auricle, 213 Fixator baseos stapedis, 81 Floor, of tympanum, 77 Flushing of cutaneous surface, 878-381 Folds of membrana tympani, 52 of mucous membrane of cliorda tympani, 01 Folius, process of, 66, 67 Forehead ear-mirror, 161 INDEX. .'iSl Foreign bodies in oxternul oar, 'J7:>-'J!IS in Kustaeliinn lube, 'J'.l'J-294 in middle ear, L".i'J-U;H trcaliuent, 12'.)4-'_'",IS Fracture of base of sUull, car in, 533. 58G malleus, 341 GAIT, alteration of, in brain tumor, 503, 504 (ianglion, otic, 8U (iargles, 401 Geometrical divisions, membrana tym- pani, 50 Glaserian fissure, 38, 42 Granulations, 494 treatment, 495 II ABENULA perforata, 128 Hajmatoma, of membrana tympani, 345 Hair, on auricle, 23 Hairs in mastoid cells, 443 Hallucinations of bearing, 5GG Hearing, 190 better in noise, 375 " deaf points " of ear, 188 effect of jierforation of membrana tympani on, 200 low notes better than high ones, 205 record, 191 sound and color, 189 testing in one-sided deafness, 20G- 208 tests, 190 normal, 190 variable, see Tests. Hemorrhage from meatus, 313 Hypertrophy, glandular, of lobule, 230- Hysterical deafness, 5G7 TNCUS, 71 i dimensions, 72 Inflation methods, 185 Politzer's method, 183 Insane, hallucinations of hearing, 5GG otbR'matotna, 235-241 Insufflation of powders into ear, 2G0-2C2 otorrhcea, 47G Intensity, see Sound. Internal ear, 120 ann?mia, 528 anomalies of formation, 527 articular rheumatism, 5G8 cerebro-spinal meningitis, 538- 541 ' chorea, 5G8 cochlea, 122 i ntt'rnai car — crista veslibiili, 121 deafness from concussion, 537, 538 • diseases, 527 falls, 6G8 hemorrhagic process, 532 hyper:ciiiia, 52S in drunkciine.ss, 529 inflammation, 528 injuries, 533 macuhc cribros:c, 122 Meniere's disease, 530 meningitis, 508 morbid growtiis of the auditory nerve, 555 otitis labyrinthica, 531 physiology, 140-144 primary inflammation, 527-53G rachitic affections, 543 reccssus coehlearis, 121 spha?ricus, 121 relation with middle car, 153- 150 sacculus rotundus, 121 secondary inliammalion, 530- 544 semicircular canals, 124 ami>ullar mouths, 121 sinus sulciformis, 121 syphilitic disease, 541, 542 topograi)Ly, 137, 138 typhoid fever, 542 vestibule, 120 Intratvmpanic pressure, in phonation, 357' TAC'OBSON'S nerve, sec Tvmpanic fj Nerve, 89 K ERATOSIS obturans, 278 TAnYinXTIl and auditory nerve, ! L 120 j Labyrinth, exfoliation, 511 hypencmia, 529 in brain tumor, 5G1 in tumor of auditory nerve, 501 in tj'jihuid fever, 500 membranous, 1:?3 Lamina s})iralis ossea, 123, 125 Laryngeal, forehead-mirror, 173 mirrors, 172 Ligamenta canaliculorum, 134 saipingo-jiliaryngea, 1()5 Ligaments, malleus, 09 Ligament of .stapes, 73 jjip-reading, 573 582 INDEX. Lobule, cleft, 243, 244 glandular hypertrophy, 230-233 sarcoma, 230 tumors of, 229 Lustre of membrana tympani, 49 Lymphatic cavitj* in facial canal, 85 MACULA acustica, 186 Maculaj cribrosfv, 122 Malleus, see Middle Ear, 60-68 axial ligament, 70 dimensions, 69 fixation, 69 fracture of, 341 head and neck, 68 Malleo-incudal joint, 72, 70 Malleus, ligaments, 69 manubrium, 50 processes, 66, 07 Manubrium mallei, 50 Mastoid, 109, 110 antrum, 84, 111 cancer, 442 cells, 109-111 diseases, 514-526 emphysematous tumor, 442 hairs in cells, 443 traumatism, 443 treatment of mastoid disease, 521- 526 trephining, 524-520 Membrana flaccida, 52 diseases, 321-339 foramen of Kivini, 52 opening in, 52 perforations, 321-339 treatment of diseases of, 324 reticularis, 130 tectoria, 131 tympani, 47 abscess, 319 anatomy, 47 annulus tendinosus, 57 arborescent fibrous structure, 59 artificial, 480-485 cartilaginous groove for mal- leus, 57 cholesteatoma, 340, 347 color, 48 comparative distribution of bloodvessels, 02-05 concavo-convexity, 51 dermoid layer, 47 descending fibres, 59 dimensions, 48 diseases, 315-358 dermis in children, 49 elements of membrana propria, 00 eyelet of Politzer, 405 Membrana tympani — fibrous layer, 58 folds, 48, 52 of mucous membrane for chorda tympani, 01 fracture of malleus, 341 geometrical divisions, 50 hfematoma, 345 head and neck of malleus, 68 inclinations, 50 injuries, 339-342 internal or mucous layer, 60 in the cretin, 50 lustre, 49 manubrium of malleus, 50 medico-legal significance of in- juries, 344 membrana flaccida, 52 propria, 58, 60 middle layer, 58 moles, 345 morbid growths, 345-347 motions in respiration, 113 mucous layer, 60 myringitis, acute, 315-319 objective effects of inflation, 388 operations with knife on, 402 outer surface, 47 paracentesis, 369, 458, 459 permanent perforation, mainte- nence of, 405, 400 physiological variations in in- clination, 50 pouches of, 61 pyramid of light, 53-56 reproduction, 342 shape, 48 short process, 66 Shrapnell's membrane, 48, 52 two short processes of malleus, 58 ulcers in dermis, 319 vascular supply, 61 tumor, 345 villi on mucous surface, 01 wart-like bodies, 345 j'ellow spot at end of manu- brium, 52 Membranous labj^rinth, 133 semicircular canals, 133 Meniere's disease, 530 Meningitis, internal ear in, 508 Menstruation, vicarious, from ear, 313 j Middle ear, 00 ' acute catarrhal inflammation, 848-370 purulent inllainmation, 445-449 bands in, nature of, 92 cancer, primar\^, 440 chronic catarrhal inflamma- tion, 370 I N 1 » E X 583 Middle oar — chronic ]>uriiloiit iiiUamiua- tion, 45!) corpuscles of I'olit/.er and Kossol, 436 desquamative iiithiMinuilion, 485 cfl'eots of cold balliing, 452 facial canal, S4 incus, 71 inllaniinatiun from concussion, 452-454 malleo-incudal joint, 72 malleus, GG new-formed membranes and bands, 43G ossicles of hearing, GG physiology, 00-92 pouches of membrana tvmpani, 78, 7-:t ])rocessus cochleariformis, 82 relation between internal ear and, 153-156 septum tuba?, 82 stapes, 72 syphilitic diseases, 389 tympanum, 7G Mirror, ear, IGO forehead, for ear, IGl laryngeal, 172 middle ear, Blake's, 166 Modiolus, 123 Moles, membrana tympani, 345 Movements of auricle, 24 of membrana tympani, 113 Muscular accommodation, 99 Music, perception of high notes, see Tests. Mutes, deaf, 570-576 Myringitis, 315-319 N AKES, treatment of in catarrh, 394- 399 Nasal douche, 397 Nasopharynx, adenoid growths, 400 applications, 394 granulatioms, 385 malignant growths involving ear, 437 sprays, 368 treatment of adenoid growths, 400 Nervous deafness, 5G7 phenomena in otitis media puru- lenta, 487 Noises, aural, objective, causes, 421-433 treatment, 432, 433 subject! ve, see Tinnitus Aurium. BJEGTIVE noises, in ear, 421-433 Ossicles of hearing, middle ear, 66 Ossicles of hearing — deductions from experiments on, 97 dimensions, 74 Ossicles, experiments on, 97, 9S mechanism of, 93-90 Osteophytes in tymjianic cavity, 93 Olhu'matoMia, auricle, 235-241 Otic ganglion, S9 Otitis labyrintliica, 531 Otitis media calarrhalis acuta, .scrCalai- rhal Inflammation of the Middle Kar, Acute. Otitis media calarrhalis cluonii'a, see Catarrhal liitlammmatiun of the Mid- dle Ear, Chronic. Otitis media ha'morrhagica, 433 Otoliths, 137 I Otomycosis, 263-273 i Otorrluea, fluid remedies, 474-47G I insutllations, 476 i tables of treatment, 472, 473 Otoscopes, 162 Otoscope, interference, see Tests. Outward growth of cutis, auditory canal, 46, 47 Oval window (base of stapes), 74 PARACENTESIS, membrana tvm- . . pani, 369, 407-416, 459 ^'aracusis duplicata, 355 !'aresis of velum palati, 351 ^'artial deafness in children, 574, 575 or overtones, see Sound. Petrous bone, see Temporal Bone. Perilymph, 139 Pbonation, efl'ects on Eustachian tube, 113 intratympanic pressure from, 357 Physiognomy of auricle, 25 Pillars of Corti, 130 Planes of semicircular canals, 125 Planum semilunare, 137 Plica salpingo-palatina, 106 salpingo-pharyiigea, 106 Polarized light, examination of ear, 159 Polypi, aural, V.IC-'AY.* angioma, 500 classilication, 497 fibromata, 499 granulation • tumors, 497 myxomata, 500 pajiillomata, soft, 19S snares, 503-5O.S spontaneous detachment, 502 symptoms, 501 treatment, 502-509 Pouches of membrana tympani, 61, 78, 79 Processes of nuiUeus, 66, 67 Processus cochleariformis, 82 584 INDEX. Psychoses, reflex, in chronic purulent otitis media, 493 Purulent inflammation of mitldle ear, acute, 445-459 course, 448 diagnosis, 454-457 etiology, 451 prognosis and treatment, 457- 459 symptoms, objective, 447 subjective, 445 Puiulent inflammation of middle ear, chronic, 459-526 alterations in gait, 490 anomalies of taste and salivary secretion, 492 course and consequences, 478 diphtheria, 461, 462 epileptiform manifestations, 485 etiology, 460 facial paralysis, 488 granulations and polypi, 494 irritation of chorda tympani, 491 nervous phe-nomena, 485 polypi, treatment of, 502-509 reflex psychoses in, 493 sj-niptoms, 463-466 treatment, 466-478 dry, by insufllation of powders, 468-475 vertigo in, 493 Pyramid of light, of merabrana tym- pani, 53 QUALITY, see Sound. (Quinine, effect on ear, 568, 569 )ACIIITIC diseases, internal car in, \ 543 ^eissner's membrane, see Cochlea, icsonant functions of human auricle, 30-36 Ecsorcin, in otorrhcca, 470 Rheumatism, internal ear in, 568 Rhinoscopy, 174 Rhinoscopic examination, Eustachian tube, 174 llivini, foramen of, 52 segment of, 43 Rosenmiiller's fossa, 103 Round window and ossicles, mechanism of, 93-96 O A.CCULT, 183, 136 U .Safety-tube, Eustachian tube, 114 Salicylic acid, effects on the ear, 569 Sarcoma, auditory nerve, 556 of lobule, 230 Scalaj of cochlea, 123 Sebaceous tumors in the external ear, 302 Seborrhcea of external auditory canal, 282 Segment of Rivinus, auditory canal, 43 Semicircular canals, 124 ampulla^, 136 ampullar enlargement, 125 crista acustica, 136 dimensions, 124 in fibro-sarcoma, 565 ligamenta canaliculorum, 134 macula acustica, 136 membranous, 133 papilliform prominences, 135 physiology, 144-153 planes, 125 planum semilunare, 137 sacculi, 136 Septum tub», 82 Short process, malleus, 51 processes, malleus, 58 Shrapnell's membrane, 48, 52 perforations, 321-339 Snares, polvpus, 503-508 Sound, 186- clang-tint, 186 color, see Hearing, 189 intensity, 186 musical annotation, 187 partial or overtones, 187 pitch, 186 qualit}', 186 Specula, aural, 162 Speculum, pneumatic, of Siegle, 163 S[)eech, see Tests. Spina tympanica antica, 42 major, 42 minor, 42 postica, 42 Sprays, for nares, 368 Stapes or stirrup, 73 base of, and oval window, 74 dimensions, 73 ligaments, 73 Stapedius muscle and facial nerve, 81 function, 81 Stirrup, see Stapes. Stop-watch, 192 Stria vascularis, see Cochlea. Syphilis, external car, 221-223, 256 internal ear, 541, 542 middle car, 389-391- Syringing ear, 171 TEETH, earache from diseased, 455 Teething, earache, 365 Tegmen tympani, 76 INI) i-: X 585 TciM|)eriitiiro of mulitory ciuial, Mi, 5ti'.( Tumjioral bono, jumtouiy of", oS— 11 eliolesteatoiiiu, 435 devolopinoiit, o^i, 8',) Tensor jmlati muscle, 108 tyinpixiii muscle, 82, 83 physiology, 90, 01 tenotomy, -107 Tests, applications of entotic ear-trum- pet, -208 high musical notes, 200 interference-otoscope, I'Jd speech, 198 stop-watch, 192 tiiroc-limbetl auscultation-tuhe, 195 tuning-fork, 192-195 in diagnosis, 194 in normal cas(^ 197 variable hearing, 205 vowels and consonants, 202-204 watch, 190 whispering and loud tones, 204, 205 Tinnitus aurium, 352-354, 5G7 Tonsils, excision, 401 ToMsilla pharyngea, 107 Tubercular disease of ear, 433 Tumor of auditory nerve, labyrinth in, 5(11, 562 of brain, labyrinth in, 561, 562 of nasopharynx involving the ear, 437 Tuning-fork, see Tests. in diagnosis, 194 Tympanic cavity, 66 anatomy, 66 anterior and posterior walls, 83 bloodvessels, 89, 90 bon\' canals about, 84 chorda tympani nerve, 85 development of canals, 84 embolism of mucous mem- brane, 437 eminentia stapedii, 81 extravasation of blood in Bright's disease, 433 facial nerve, course, 84 Hxator baseos stapedis, 81 floor, 77 function of staj)edius, 81 inflation methods, 185 inner wall, SO mastoid antrum, 84 mechanism of round window, 93-96 nerves of mucous membrane, 87, 89 Tympanic cavity — ossicles, deductions from ex- periments on, 97 osteophytes in, 93 outer wall, 77 power of muscular mi mm- dation,9!t pressure in plionalion, ;!57 round wiiHh>w, function, 93-96 tensor tympani nnisclc, 82, 8;> "Weber-Iiiel's ex|)eriments on ossicles, 98 bone, fracture, 312 syringe, Hlake's, 324, 325 Tympanum, see Tymiumic Cavity. Typhoid fever, ear in, 542, 566 ULCERATION, chronic circuin- .«cribed, in canal, 298, 299 Ulceration, reflex, in canal, :iOO Utriculus, 133 Uvula, clipping, 4i)l deviation of, ;!51 VACUUM in tympanum, 350 Vascular -upply of inemlirana tympani, 61 Vas prominens, see Cochlea. Vertigo, aural, 531, 544-555 in brain tumor, 563, 564 in chronic purulent otitis media, 493 Vessels and nerves of auditory canal, 46 Vestibule, 120 in flbro-sarcoiiia, 5<)5 Vestibular l)raiuhe>, auditory nerve, 132 ' , Villi, on mucous surface membruna tympani, 61 \'isible speech, 574 Vowels, see Tests. WALLS of tympanic cavitv, 83 Watch, see Tests. Whispering, see Tests. Whooping-cough, earache, 3ital, London, etc. Kourlli American from the iliiid London edition. Tliorougldy revised, with copious additions, by CliARI.ES S. Bui.i., ^LD., Surgeon and Pathologist to the New York Eye and Kar Inlirmary. 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While all enlightened physicians will agree that : No man in America was belter fltletl than Dr. a knowledge of physics is desinible for the medi- Draper for the task he undertook, and he hat pro- cal student, only those actually engaged m the I vided the student and practitioner of medicine teaching of the primary subjt., Professor of Chemistry and Toxicology in the College of Physicians and Surgeons, Baltimore, and Professor of Chemistry in the Maryland College of Pharmacy. Manual of Chemistry. A Guide to Lectures and Laboratory work for Beginners in Chemistry. A Text-book, specially adapted for Students of Pharmacy and Medicine. New (second) edition. In one 8vo. vol. of 478 pp., with 44 woodcuts and 7 colored plates illustrating 56 of the most important chemical tests. Cloth, $3.25. In this book the author has endeavored to meet the wants of the student of medicine or pharmacy in regard to his chemical studies, and he has suc- ceeded in presenting his subject so clearly that no one who really wishes to acquire a fair knowledge of chemistry can fail to do so with the help of thi.s work. The largest section of the book is naturally that devoted to the consideration of the carbon compounds, or erganic chemistry. An excellent feature is the introduction of a number of plates showing the various colors of the most important chemical reactions of the metallic salts, of some of the alkaloids, and of the urinary tests. In the part treati ng of physiological chemistry the section on analysis of the urine will be found very practi- cal, and well suited to the needs of the practitioner of medicine.— TAe Medical Record, May 25, 1889. Wohler's Outlines of Organic Chemistry. Edited by Fittig. Translated by Ira Eemsen, M. D., Ph. D. In one 12mo. volume of 550 pages. Cloth, $3. LEHMANN'S MANUAL OF CHEMICAL PHYS- IOLOGY. In one octavo volume of 327 pages, with 41 illustrations. Cloth. 82.2.5. CARPENTER'S HUMAN PHYSIOLOGY. Edited by Henbt Poweb. In one octavo volume. CARPENTER'SPRIZE ESSAY ONTHEUSEAND Abuse of Alcoholic Liquors in Health and Dis- ease. With explanations of scientific words. Small 12mo. 178 pages. Cloth, 60 cents. Lea Brothers & Co.'s Publications — Clioiui8try. 9 FItANKLANn,E.,iy. C.L.,F.li.S.,&JAPI\ I\ It., I\ /. C., Professor of Cliemistn/ in the Nonnal School Aisuit. l\of. of ChrviiMry in Iht Normal of Science, London. School of Science, London. Inorganic Chemistry. In one handsome octavo volume of 677 pages with 61 woodcuts and 2 plates. Cloth, $.3.75 ; leather, $4.75. riiis excellent treHllNe will not fall to Uko IIh plnro RH one of tlie very best on tlie Huhjecl vt which it trealH. We Imve been much pleaneft with tlie comprohenHlve ami luciil tiiHiinor in This work should supersede other works of its class in the medical colleges. It is certainly hotter adapted than any work upon ehumistry.witli which we are acquainted, to impart that clear and full knowledge of the science which students of med- I wliich the ditricullies of <'ht«mii'»l ncitali.m and icine should have. Physicians who feel that their nomenclature have been cleared up hy the wrilerx chemical knowledge is behind the times, would i It shows on every page inat the problem of do well to devote some of their leisure time to the rendorin,'? the obscurities of this science eacy study of this work. The descriptions and demon- of comprehension has long and HUcoeHsfully strations are made -so plain that there is no difti- engaged the attention of the authors.— J/e,, Professor of Chemistry in the Johns Hopkins University, Baltimore- Principles of Theoretical Chemistry, with special reference to the Constitu- tion of Chemical Compounds. New (third) and thoroughly revised edition. In one hand- some royal 12mo. volume of 316 pages. Cloth, $2.00 This work of Dr. Remsen is the very text-book needed, and the medical student who has it at his fingers' ends, so to speak, can, if he chooses, make himself familiar with any branch of chem- istry which he may desire to pursue. It would be difficult indeed to find a more lucid, full, and at the same time compact explication of the philos- ophy of chemistry, than the book before us, and we recommend it to the careful and impartial examination of college faculties ast^ie text-book of chemical instruction. — St. Louis Medical and Sur- gical Journal, January, 1888. It is a healthful sign when we see a demand for a third edition of such a book as this. This edi- tion is larger than the last by about seventy-five pages, and much of it has been rewritten, thus bringing it fully abreast of the latest investiga- tions.— iV. Y. Medical Journal, Dec. 31, 1887. CHARLES, T. CBANSTOVJST, 31. D., F. C. S., M, S., Formerly Asst. Prof, and Demonst. of Chemistry and Chemical Physics, Queen's College, Belfast. The Elements of Physiological and Pathological Chemistry. A Handbook for Medical Students and Practitioners. Containing a general account of Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and Excretions of the Body in Health and in Disease. Together with the methods for pre- paring or separating their chief constituents, as also for their examination in detail, and an outline syllabus of a practical course of instruction for students. In one handsome octavo volume of 463 pages, with 38 woodcuts and 1 colored plate. Cloth, $3.50. nowadays. Dr. Charles has devoted much space to the elucidation of urinary mysteries. He does this with much detail, and yet in a practical and intelligible manner. In fact, the author has filled his book with many practical hints. — Medical Rec- ord, December 20, 1884. Dr. Charles is fully impressed with the impor- tance and practical reach of his subject, and he has treated it in a competent and instructive man- ner. We cannot recommend a better book than the present. In fact, it fills a gap in medical text- books, and that is a thing which can rarely be said HOFFMAJVJ^, F,, A,3£,f I*h.I>,, & FOWFM, F,B,, Fh.J),, Public Analyst to the State of New York. Prof, of Anal. Chem. in the Phil. Coll. of Pharmacy. A Manual of Chemical Analysis, as applied to the Examination of Medicinal Chemicals and their Preparations. Being a Guide for the Determination of their Identity and Quality, and for the Detection of Impurities and Adulterations. For the use of Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceutical and Medical Students. Third edition, entirely rewritten and much enlarged. In one very handsome octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. tion of them singularly explicit. Moreover, it is exceptionally free from typographical errors. We have no hesitation in recommending it to those We congratulate the author on the appearance of the third edition of this work, published for the first time in this country also. It is admirable and the information it undertakes to supply is both extensive and trustworthy. The selection of pro- cesses for determining the purity of the substan- ces of which it treats is excellent and the descrip- who are engaged either in the manufacture or the testing of medicinal chemicals. — Lcmdon Pharma- ceutical Jowmal and Transactions, 1883. CLOWFS, FRAN:Kf D, Sc, London, Senior Science- Master at the High School, Neivcastle-under-Lyme, etc. An Elementary Treatise on Practical Chemistry and Qualitative Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and Colleges and by Beginners. Third American from the fourth and revised English edition. In one very handsome royal 12mo. volume of 387 pages, with 55 illustrations. Cloth, $2.50. This work has long been a favorite with labora- tory instructors on account of its systematic plan, carrying the student step by step from the simplest questions of chemical analysis, to the more recon- dite problems. Features quite as commendable are the regularity and system demanded of the student in the performance of each analysis. These characteristics are preserved in the present edition, which we can heartily recommend as a sat- isfactory guide for the student of inorganic chem- ical analysis. — Neiv York Medical Journal, Oct. 9, 1886. BAJLFF, CMAMLES M,, M, D., F. It. C. F., Assistant Physician at the London Hospital. Clinical Chemistry. In one pocket-dze 12mo. volume of 314 pages, with 16 illustrations. Limp cloth, red edges, $1.50. This is one of the most instructive little works that we have met with in a long time. The author is a physician and physiologist, as well as a chem- ist, consequently the book is unqualifiedly prac- tical, telling the physician just what he ought to know, of the apjJfications of chemistry in medi- See Students' Series of Manuals, page 31. cine. Dr. Ralfe is thoroughly acquainted with the latest contributions to his science, and it is quite refreshing to find the subject dealt with so clearly and simply, yet in such evident harmony with the modern scientific methods and spirit. — Medical Record, February 2, 1884. CLASSEN, ALEXAWnEB, Professor in the Royal Polytechnic School, Aix-la-Chapelle. Elementary Quantitative Analysis. Translated, with notes and additions, by Edgar F. Smith, Ph. D., Assistant Professor of Chemistry in the Towne Scientific School, University of Penna. In one 12mo. volume of 324 pages, with 36 illus. Cloth, $2.00. It Is probably the best manual of an elementary and then advancing to the analysis of minerals and nature extant, insomuch as its methods are the such products as are met with in applied chemls- best. It leaches by examples, commencing with try. It is an indispensable book for students in single determinations, followed by separations, chemistry.— Boston Journal of Chemistry, Oct. 1878, I Lea Brothers & Co.'s Publications— Phjinii., Mat. Metl.,Tlieriip. 11 HARB, HOBART AMORY, B. Se„ M. D., Cliniea!. Professor of Dhen-fei of CfnM'xn an.i D'.,nn,ntrtilor of Thxmpoulir* in th» VnivartUy nj PennsylcntiKx; Hecrelar;/ of the Conutntioit forthelievmiunoflhe Uitit»i Ulalm Pharmaeopaiui ot 1890. r J A Text-Book of Practical Therapeutics; With Kspociiil Reference to tho Application of lu'iiu'dial Measures to Disease ami their iMiiiiloyrnent upon a Kiuioiiiil Basis. With spoeial ehaplers by Diis. (}. E. i>|.; S.ii \vi:iNt I'z, Kdwauk .Maimin, J. Howard Rki:vks antl Barton C. Hikst. In one handsome octavo vohinic of t]'22 pages. CUith, $3.75; leather, $4.75. Just ready. This vohnuc is at once a woik on TlierapcMitica and on Treatment, hoth written for stndents and practitioners. Considerahle e.Kperience in teaching; and in elini<:il work lixs convinced the autiior that if the iinderi!;radiiate or Kradnate studonl of medicine is to Ikj equipped with a real working knowiedfj;e of tiie main 8ni>jcels of liis profession, lie must be furnished with a closely interwoven statement of iiis resources and of the eonditicms calling for their employment. Further, this material must he so presented as to show clearly the reasons underlying the choice of remedies in any given citse. Valuai>le empirical facts, as yet unexplained, must he included for completeness. These conditiona are all fulfilled by this work. Tiie various parts are written to lit each other and are am- ply cross-referenced to enable the reailer to obtain a connected grasp of the science. The signs of the diflerent stages of each disease are clearly stated, the most appropriate drugs named and the best mode of application shown by prescri[)tions. The work includes remedial measures, other than drugs, except electricity. The alphabetical arrangement is used throughout for ease of reference. In addition to a general index there is an inilex of diseases and remedies, which being copious and explanatory will be of great assistance in rapidly suggesting the best means of treatment in any given disease. BRVNTON, T. LAUnBR, M.D., D.Sc, F.R.S., F.R.CP., Lecturer on Materia Medica and Therapeutics at St. Bartholomew's Hospital, lA»uioii, etc. A Text-Book of Pharmacology, Therapeutics and Materia Medica; Including the Pharmacy, the Physiological Actiim and the Therapeutical Uses of Drugs. Third edition. Octavo, 1305 pages, 230 illustrations. Cloth, $5".50 ; leather, $(5.50. No words of praise are needed for this work, for it has already spoken for itself in former editions. It was by unanimous consent placed among the foremost oooks on the subject ever published in made in various directions in the art of therapeu- tics, and it now stands unrivalled in its thoroughly scientific presentation of the modes of drug action. No one who wishes to be fully up to the times in any language, and the better it is known and studied I this science can afford to neglect the study of Dr the more highly it is appreciated. The present edition contains much new matter, the insertion of which has been necessitated by the advances Brunton's work. The indexes are excellent, and add not a little to the practical value of the book. —Af»Jical Record, May 25, 1889. MAISCH, JOHW3I., Bhar, J)., Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. A Manual of Organic Materia Medica; Being a Guide to Materia Medica of the Vegetable and Animal Kingdoms. For the use of Students, Druggists, Pharmai-ists and Physicians. New (4th) edition, thoroughly revised. In one handsome royal r2mo. volume of 529 pages, with 258 illustrations. Cloth, $3. Jml ready. For everyone interested in materia medica, Maisch's Manual, first published in 188-2, and now in its fourth edition, is an indispensable book. For the American pharmaceutical student it is the work which will give him the necessary knowl- edge in the easiest way, partly because the text is brief, concise, and free from unnecessary matter, and partly because of the numerous illustrations, whicn bring facts worth knowing immediately be- fore his eyes. That it answers its purposes in this respect the rapid succession of edition.s is the best evidence. It is the favorite book of the American student even outside of Maisch's several hundred personal students. The arrangement of its con- tents shows the practical temlency of the book. Maisch's system of cla.ssification is ea-sy and com- prehensive.— PAam»accu., LL. !>., Professor of Theory and Practice of Mrd. and of Clinical Med. in the Univ. of Penna, Therapeutics and Materia Medica. A Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History. Fourth edition, revised and enlarged. In two large and handsome ocUvo volumes, containing 19db pages. r,, Professor Emeritus of the Theory and Prac- tice of Medicine and of Clinical Medicine in the University of Pennsylvania. Prof, of Mat. Med. and Botany in Phila. College of Pharmacy, Sec^y to the Ameri- can Pharmaceutical Association. The National Dispensatory. CONTAINING THE NATURAL HISTORY. CHEMISTRY, PHARMACY, ACTIONS AND USES OF MEDICINES, INCLUDING THOSE RECOGNIZED IN THE PHARMACOPCEIAS OF THE UNITED STATES, GREAT BRITAIN AND GERMANY, WITH NUMEROUS REFERENCES TO THE FRENCH CODEX. Fourth edition revised, and covering the new British Pharmacopoeia. In one mag- nificent imperial octavo volume of 1794 pages, with 311 elaborate engravings. Price in cloth, $7.25 ; leather, raised bands, |8.00. *^*This work will be furnished with Patent Ready Reference Thumb-letter Index for $1.00 in addition to the price in any style of binding. In this new edition of The National Dispensatory, all important changes in the recent British Pharmacopoeia have been incorporated throughout the volume, while in the Addenda will be found, grouped in a convenient section of 24 pages, all therapeutical novelties which have been established in professional favor since the publication of the third edition two years ago. Since its first publication, The National Dispensatory has been the most accurate work of its kind, and in this edition, as always before, it may be said to be the representative of the most recent state of American, English, German and French Pharmacology, Therapeutics and Materia Medica. It is with much pleasure that the fourth edition I discovery have received due attention. — Kansas of this magnificent work is received. The authors and publishers have reason to feel proud of this, the most comprehensive, elaborate and accurate work of the kind ever printed in this country. It is no wonder that it has become the standard au- thority for both the medical and pharmaceutical profession, and that four editions have been re- quired to supply the constant and increasing, demand since its first appearance in 1879. The entire field has been gone over and the various articles revised in accordance with the latest developments regarding the attributes and thera- peutical action of drugs. The remedies of recent* City Menieal Index, Nov. 1887. We think it a matter for congratulation that the profession of medicine and that of pharmacy have shown such appreciation of this great work as to call for four editions within the comparatively brief period of eight years. The matters with which it deals are of so practical a nature that neither the physician nor the pharmacist can do without the latest text-books on them, especially those that are so accurate and comprehensive as this one. The book is in every way creditable both to the authors and to the publishers. — New York Medical Journal, May 21, 1887. FAMQUSABSOJSr, ROBERT, M, JD., F. B, C. B,, LL, J>., Lecturer on Materia Medica at St. Mary's Hospital Medical School, London. A Guide to Therapeutics and Materia Medica. New (fourth) American, from the fourth English edition. Enlarged and adapted to the U. S. Pharmacopoeia. By Frank Woodbury, M. D., Professor of Materia Medica and Therapeutics and Clinical Medicine in the Medico-Chirurgical College of Philadelphia. In one handsome 12mo, volume of 581 pages. Cloth, $2.50. It may correctly be regarded as the most modern work of its kind. It is concise, yet complete. Containing an account of all remedies that have a place in the British and United States Pharma- copoeias, as well as considering all non-official but important new drugs, it becomes in fact a miniature dispensatory. — Pacific Medical Journal, June, 1889. An especially attractive feature is an arrange ment by which the physiological and therapeutical actions of various remedies are shown in parallel columns. This aids greatly in fixing attention and facilitates study. The American editor has en- larged the work so as to make it include all the remedies and preparations in the U. S. Pharma- copoeia. The book is a most valuable addition to the list of treatises on this most imnortant subject. — American Practitioner and News, Nov. 9th, 1889. EBBS, BOBEBT T., M. 2)., Jackson Professor of Clinical Medicine in Harvard University, Medical Department. A Text-Book of Therapeutics and Materia Medica. Intended for the Use of Students and Practitioners. Octavo The present work seems destined to take a promi- nent place as a text-book on the subjects of which it treats. It possesses all the essentials which we expect in a book of its kind, such as conciseness, clearness, a judicious classification, and a reason- able degree of dogmatism. All the newest drugs of promise are treated ol. The clinical index at the end will be found very useful. We heartily 544 pages. Cloth, $3.50 ; leather, $4.50. commend the book and congratulate the author on having produced so good a one.— iV. Y. Medical Jou'i nal, Feb. 18, 1888. Dr. Edes' book represents better than any older book the practical therapeutics of the present day. The book is a thoroughly practical one. The classification of remedies has reference to their therapeutic action. — Pharmaceutical Era, Jan. 1888. BBUCE, J, 31ITCUELL, M. 2>., F, B, C. B., Physician and Lecturer on Materia Medica and Therapeutics at Charing Cross Hospital, London. Materia Medica and Therapeutics. An Introduction to Rational Treatment, Fourth edition. 12mo., 591 pages. Cloth, $1.50. See Students' Series of Manuals, page 31. GBIFFITH, BOBEBT EGLESFIELB, M, B. A Universal Formulary, containing the Methods of Preparing and Adminis- tering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceut- ists. Third edition, thoroughly revised, with numerous additions, by John M. Maisch, Pilar. D., Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. In one octavo volume of 775 pages, with 38 illustrations Cloth, $4.50 ; leather, $5.50. Lea Brothers & Co.'s Publioations — Pathol., Histol. 13 GBEBN, T, HENRY, M. !>., Lecturer on rainuloijiiaiul Morbiii Auntomu at Oinring- Cross Hospilnt Medical School, lAmdon. Pathology and Morbid Anatomy. New (sixtli) Anioriian from the Hevenlh revised Englisli edition, (k-tavo, 589 pp., with Ki? eiiKniviiiKs. (.Moth, $2.75. Ju*( ready. The Pathology and Morbid Anatomy of IT. , trun.-latiMl into Kngllwli, gre too nhnlnmo for the Green is too well known by members of the medi- cal profession to need any commendation. There is scarcely an intelligent physician anywhere who has not the work in his library, for it is almost an essential. In fact it is better adapted to the wants of general practitioners than any work rf the kind Willi which we are acquainted. The works of German authors upon pathology, which have been physician. Dr. fireen's work i>r<'fiHoly in«'etii liln wishes. The cuts exhibit the uiip«'araM<-pN of pathological structures Just as llicy are seen through the microsoope. Tlio fact that It In no generally employed ns a t«xl-boiik by nieiliiiil stu- dents is eviilencp that we have not si.i ki-ii too much In ito favor. — Vxncinnati Medical iS'tun, Oct. 1889. PAYNE, JOSEPH F., 31, D., F. Ji. C. P., Senior AssistniU Phi/sicinn ami Lecturer mi Patholofficnl Anatiimii, St. Thnman' llonpitnl Lumlim. A Manual of General Pathology, Designed as an Intrrductiun to liie I'rac- tice of Medicine. Octavo of 524 pages, with 152 illtis. and a colored plate. Cloth, |.'?.50. Knowing, as a teacher and examiner, the exact cal factors in those diseases now with reasonable needs of medical students, the author has in the work before us prepared for their especial use what we do not hesitate to say is the best introduc- tion to general pathology that we have yet ex- amined. A departure which our author has taken is the greater attention paid to the causa- tion of disease, and more especially to the etiologi- cerlainty ascribed to patliogcnctii" microtifs. In this department he has been very full and explicit, not only in a descriptive manner, but In the tech- nique of investigaliim. The Appendix, giving methods of resear«: * c'J'^P'f.'* Kl"'''''*'-y^Vavi si added, withthe helpof which the structureof each Provincial MedicalJoumal, May 1, 1889. tissue becomes clear to the reader. A copious I PEPPEB, A. J., M. B., M. S., F. B. C. S,, Surgeon and Lecturer at St. Mary's Hospital, London. Surgical Pathologv. In one ijocket-size 12mo. yoliime of 511 pages, with 81 illustrations Limp cloth, red edges, $2.00. See Sliulent.<^ Serie.'i of Mnntial.., Prof, of the Principles and Practice of Med. and of Clin. Mtd. in Bellevue Hospital Medical College, N. Y. A Treatise on the Principles and Practice of Medicine. Designed for the use of Students and Practitioners of Medicine. New (sixth) edition, thoroughly re- vised and rewritten by the Author, assisted by William H. Welch, M. D., Professor of Pathology, Johns Hopkins University, Baltimore, and Austin Flint, Jr., M. D., LL. D., Professor of Physiology, Bellevue Hospital Medical College, N. Y. In one very handsome octavo volume of 1160 pages, with illustrations. Cloth, $5.50 ; leather, $6.50. No text-book on the principles and practice of medicine hias ever met in this country with such general approval by medical students and practi- tioners as the work of Professor Flint. In all the medical colleges of the United States it is the fa- vorite work upon Practice; and, as we have stated before in alluding to it, there is no other medical work that can be so generally found in the libra- ries of physicians. In every state and territory of this vastcountry the book that will be most likely to be found in the office of a medical man, whether I in city, town, village, or at some cross-roads, is Flint's Practice. We make this statement to a ; considerable extent from personal observation, and it is the testimony also of others. An examina- tion shows that very considerable changes have been made in the sixth edition. The work may un- doubtedly be regarded as fairly representing the present state of the science of medicine, and as reflecting the views of those who exemplify in their practice the present stage of progress of med- ical art. — Cincinnati Medical Newt, Oct. 1886. BRISTOWB, JOHN SYEB, M. J>., LL, 2)., jP. B, S., Senior Physician to aiid Lecturer on Medicine at St. Thomas^ Ho'-pilal, London. A Treatise on the Science and Practice of Medicine. Seventh edi- tion. In one large octavo volume of 1325 pages. Cloth, $6.50 ; leather, $7.50. Just ready. always met. For it is a work that is built on a stable foundation, systematic, scientific and prac- tical, containing the matured experience of a physician who has every claim to be considered an authority, and composed inastjle which at- tracts the practitioner as much as the student. No one can say that this book has obtained a success which was undeserved, and we trust that its author will long continue to supervise the production of fresh editions for the advantage of the coming generation of medical students. — The Lancet, 3 n\y 12, 1890. The remarkable regularity with which new edi- tions of this text-book make their appearance is striking testimony to its excellence and value. This, too, in spite of the numerous rivals for the favor of the student which have been put forth within the sixteen years since Bristowe's" Medi- cine " first appeared. Nor can it be said that the author himself has failed to keep his manual abreast of advancing knowledge, arduous as that task must prove. So long as there is shown such care and circumspection in the inclusion of all new matter that has stood the. test of criticism, so long will this work retain the favor which it has HABTSHOBNBf HBNBY, M, !>., LL, I>,, Lately Professor of Hygiene in the University of Pennsylvania. Essentials of the Principles and Practice of Medicine. A Handbook for Students and Practitioners. Fifth edition, thoroughly revised and rewritten. In one royal 12mo. volume of 669 pages, with 144 illustrations. Cloth, $2,75; half bound, $3.00. Within the compass of 600 pages it treats of the history of medicine, general pathology, general symptomatology, and physical diagnosis (including laryngoscope, ophthalmoscope, etc.), general ther- apeutics, nosology, and special pathology and prac- tice. There is a wonderful amount of information contained in this work, and it is one of the best of its kind that we have seen.— Glasgow Medical Journal, Nov. 1882. An indispensable book. No work ever exhibited a better average of actual practical treatment than this one; and probably not one writer in our day had a better opportunity than Dr. Hartshorne for condensing all the views of eminent {iraetitionera into a 12mo. The numerous illustrations will be very useful to students especially. These essen- tials, as the name suggests, are not intended to supersede the text-books of Flint and Bartholow, but they are the most valuable in affording the means to see at a glance the whole literature of any disease, and the most valuable treatment. — Chicago Medical Journal and Examiner, April, 1882. BBYNOLDS, J, BVSSBLL, M, D,, Professor of the Principles and Practice of Medicine in University College, London. A System of Medicine. With notes and additions by Henry Hartshorne, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. In three large and handsome octavo volumes, containing 3056 double-columned pages, with 317 illustra- tions. Price per volume, cloth, $5.00 ; sheep, $6.00 ; very handsome half Russia, raised bands, $6.50. Per set, cloth, $15; leather, $18, Sold only by subscription. STILLB, ALFBBD, M, X)., LL, D,, Professor Emeritus of the Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna. Cholera: Its Origin, History, Causation, Symptoms, Lesions, Prevention and Treat- ment. In one handsome 12mo. volume of 163 pages, with a chart. Cloth, $1,25. WATSON, SIB THOMAS, M, D,, Late Physician in Ordinaiy to the Queen. Lectures on the Principles and Practice of Physic. A new American from the hCth English edition. Edited, with additions, and 190 illustrations, by Henry Hartshorne, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. In two large octavo volumes of 1840 pages. Cloth, $9.00 ; leather, $11.00, LECTURES ON THE STUDY OP FEVER. By A. Hudson, M. D., M. R. I. A. In one octavo volume of 308 pages. Cloth, S2.50. A TREATISE ON FEVER. By Robert D. Lyons, K. C. C. In one 8vo. vol. of 354 pp. Cloth, $2.25. LA ROCHE ON YELLOW FEVER, considered in its Historical, Pathological, Etiological and Therapeutical Relations. In two large and hand- some octavo volumes of 1468 pp. Cloth, $7.00. Lea Brothers & Co.'s PuuLiOATiONfl — SyNtein of Motl. 15 For Sale by StibscripHon Only. A System of Practical Medicine. BY AMERICAN AUTHOllS. Edited by WILLIAM PEPPER, M. D., LL. D., PROVOST AND PROFESSOR OF THE THEORY AND PRArmCK OF MKDKMNE AND OF CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA, Assisted hj Lotus Starr, M. D., Clinical Professor of the Diseases of Cliildrcn in the Hospital of the University of Pennsylvania. The complete work, in five volumes, containing 5573 pages, with 198 Ulmlrations, is now ready. Price per volume, cloth, $5; leather, $0 ; half Russia, raised bamls and open back, $7. In this great work American medicine is for the first time reflected hy its worthiest teachers, and presented in the full development of the practical utility whicli is its pre- eminent characteristic. The most able men — from the East and the West, from the North and the South, from all the prominent centres of education, and from all liie hospitals which afford special opportunities for study and practice — have united in generous rivalry to bring together this vast aggregate of specialized experience. The distinguished editor has so apj)ortioned the work thai to each author has been assigned the subject which he is peculiarly fitted to discuss, and in whicli his views will be accepted as the latest expression of scientific and practical knowledj;e. Thf practitioner will therefore find these volumes a complete, authoritative and unfailing work of reference, to which he may at all times turn with full certainty oi finding what he needs in its most recent aspect, whether he seeks information on the general principles of medi- cine, or minute guidance in the treatment of special disease. So wide is the scope of the work that, with the exception of midwifery and matters strictly surgical, it embraces the whole domain of medicine, including the departments for which the physician is accustomed to rely on special treatises, such as diseases of women and children, of the genito-urinary organs, of the skin, of the nerves, hygiene and sanitary science, and medical ophthalmology and Otology. Moreover, authors have inserted the formulas which they have found most efficient in the treatment of the various affections. It may thus be truly regarded as a Complete Library op Practical Medicine, and the general practitioner possessing it may feel secure that he will require little else in the daily round of professional duties. In spite of every effort to condense the vast amount of practical information fur- nished, it has been impossible to present it in less than 5 large octavo volumes, containing about 5600 beautifully printed pages, and embodying the matter of about 15 ordinary octavos. Illustrations are introduced wherever requisite to elucidate the text. A detailed prospectus will be sent to any address on application to the publishers. These two volumes bring this admirable work physicians who are acquainted with all the vnrie to a close, and fully sustain the high standard ties of climate in the IJnited States, the character reached by the earlier volumes; we have only of the soil, the manners and customs of the peo- therefore to echo the eulogium pronounced upon pie, etc., it is peculiarly adapted to the wants them. We would warmly congratulate the editor of American practitioners of medicine, and it and his collaborators at the conclusion of their ! seems to us that every one of them would desire laborious task on the admirable manner in which, i to have it. It has been truly called a "Complete from first to last, they have performed their several Library of Practical Medicine," and the general duties. They have succeeded in producing a practitioner will require little else in his round work which will long remain a standard work of of professional duties.— Cincinnati Medical Neta, reference, to which practitioners will look for i March, 1880. guidance, and authors will resort for facts. Each of the volumes Is provided with a most From a literary point of view, the work is without I copious index, and the work altogether promise- any serious blemish, and in respect of production, to be one which will add much to the medic. il it has the beautiful finish that Americans always '• literature of the pre.sent century, and reflect gic;it give their works.— £di«6ur(7/> MedicalJournal, Jan. ' credit upon the scholarship and practical acumen 1887. of its authors.— r/ie London Lnnret, Oct. 3, 1885. • • The greatest distinctively American work on The feeling of proud satisfaction with which the the practice of medicine, and, indeed, the super- I American profession sees this, its representative lative adjective would not be inappropriate were system of practical medicine issued to the mt'dl- even all other productions placed in comparison, cal world, is fully justified by the character of the An examination of the five volumes is sufficient work. 'Ihe entire caste of the system Is In keep- to convince one of the magnitude of the enter- ing with the best thoughts of the leaders and fol- pri.se, and of the success which has attended its lowers of our home school of medicine, and the fulfilment.— 7'/^e Medical Age, July 26, 1886. combination of the scientific study of disea-xe jind This huge volume forms a fitting close to the the practical application of e.\act and experimen- great system of medicine which in so short a time tal knowledge to the treatment of human m:il- has won so high a place in medical literature, and adies, makes every one of us share in the pride has done 'such credit to the profession in this that has welcomed Dr. Pepper's lahors. Sheared country. Among the twenty-three contributors of the prolixity that wearies the readers of the are the names of the leading neurologists in German school, the articles glean these same America, and mo.st of the work in the volume is of fields for all that is valuable. It Is the outcome the highest oTder.— Boston Medical and Surgical i of American brains, and Is marked throughout Journal, July 21, 1887. ! by much of the sturdy In.iependence of thought We consider it one of the grandest works on ' and originality that is a national characteristic. Practical Medicine in the English language. It is 1 Yet nowhere is there lack of study of the most a work of which the profession of this country can i advanced views of the da.y.— North Carolina Medi- feel proud. Written exclusively by American I eai Jotirna/, Sept. 1886. 16 Lea Brothers &, Co.'s Publications — Clinical Med., etc. FOTSBRGILLf J. Jf., M, D., Bdin., M, It, C. -P., Zond., Physician to the City of London Hospital for Diseases of the Chest. The Practitioner's Handbook c f Treatment ; Or, The Principles of Thera- peutics. New (third) edition. In one 8vo. vol. of 661 pages. Cloth, $3.75 ; leather, $4.75. To have a description of the normal physiologi- cal processes of an organ and of the methods of treatment of its morbid conditions brought together in a single chapter, and the relations between the two clearly stated, cannot fail to prove a great convenience to many thoughtful but busy physicians. The practical value of the volume is greatly increased by the introduction of many prescriptions. That the profession appreciates that the author has undertaken an important work and has- accomplished it is shown by the demand for this third edition. — N. Y. Med. Jour., June 11,'87. This is a wonderful book. If there be such a thing as "medicine made easy," this is the work to accomplish this result. — Va. Med. Month., June,'87. It is an excellent, practical work on therapeutics, well arranged and clearly expressed, useful to the student and young practitioner, perhaps even to the old. — Dublin Journal of Medical Science, March, 1888. We do not know a more readable, practical and useful work on the treatment of disease than the one we have now before us. — Pacific Medical and Surgical Journal, October, 1887. VATJGMAN, VICTOR C, I*h. D., Jf. !>., Prof, of Phys. and Path. Chem. and Assoc. Prof, of Therap. and Mat. Med. in the Univ. of Mich. and NOVY, FREDEBICK G., M, D, Instructor in Hygiene and Phys. Chem. in the Univ. of Mich. Ptomaines and Leucomaines, or Putrefactive and Physiological Alkaloids. In one handsome 12mo. volume of 311 pages. Cloth, $1.75. This book is what has been wanted for some ' observers and experimenters on micro-organisms. years by the medical profession. The subject of ptomaines and leucomaines, so far as their disease- producing relations are concerned, has been under special study scarcely more than a decade, but within that period facts have been discovered upon which theories of permanent standing have been built, until now the practitioner is far be- i hind the times if he does not appreciate the j importance of ptomaines. This is the first attempt made to collect into book form the results of 1 and to trace the relationship of cause and effect of the putrefactive alkaloids. We congratulate the autliors upon the successful presentation of the current views on the subject in such manner as to make them easily comprehensible, while to the practitioner, after he has carefully read the book, it will serve, also, as a frequent reference work, because of the technical information it gives. — Va. Medical Monthly, Sept. 1888. FINLAYSON, JAMES, 31, J>., Editor, Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc Clinical Manual for the Study of Medical Cases. With Chapters by Prof. Gairdner on the Physiognomy of Disease; Prof. Stephenson on Diseases of the Female Organs; Dr. Robertson on Insanity; Dr. Gemmell on Physical Diagnosis Dr. Coats on Laryngoscopy and Post-Mortem Examinations, and by the Editor on Case taking. Family History and Symptoms cf Disorder in the Various Systems. New edition- In one 12mo. volume of 682 pages, with 158 illustrations. Cloth, $2.50. The profession cannot but welcome the second edition of this very valuable work of Finlayson and his collaborators. The size of the book has been increased and the number of illustrations nearly doubled. The manner in which the subject is treated is a most practical one. Symptoms alone and their diagnostic indications form the basis of discussion. The text explains clearly and fully the methods of examinations and the con- clusions to be drawn from the physical signs. — The Medical News, April 23, 1887. We are pleased to see a second edition of this admirable book. It is essentially a practical treatise on medical diagnosis, in which every sign and symptom of disease is carefully analyzed, and their relative significance in the different affec- tions in which they occur pointed out. From their synthesis the student can accurately determine the disease with which he has to deal. The book has no competitor, nor is it likely to have as long as future editions maintain its present standard of excellence. The general practitioner will find many practical hints in its pages, while a careful study of the work will save him from many pitfalls in diagnosis. — Liverpool Medico- Chirurgical Jour- nal, January, 1887. Just ready. See BROADBEKT, W, H,, M, D,, F, H, C, F., Physician to and Lecturer on Medicine at St. Mary's Hospital, London. The Pulse. In one 12mo. volume of 312 pages. Cloth, $1.75. Series of Clinical Manuals, page 31 MABEBSJETOJV, S. O., 31, D,, Senior Physician to and late Lect. on Principles and Practice of Med. at Chiy's Hospital, London. On the Diseases of the Abdomen ; Comprising those of the Stomach, and other parts of the Alimentary Canal, (Esophagus, Caecum, Intestines and Peritoneum. Second American from third enlarged and revised English edition. In one handsome octavo volume of 554 pages, with illustrations. Cloth, $3.50. This valuable treatise on diseases of the htomach | to the times, and making it a volume of interest to and abdomen will be found a cyclopadia of infor' mation, systematically arranged, on all diseases of the alimentary tract, from the mouth .to the rectum. A fair proportion of each chapter is devoted to symptoms, pathology, and therapeutics. The present ediiion is fuller than former ones in many particulars, and has been thoroughly revised and amended by the author. Several new chap- ters have been added, bringing the work fully up the practitioner in every field of medicine and surgery. Perverted nutrition is in some form associated with all diseases we have to combat, and we need all the light that can be obtained on a subject so broad ana general. Dr. Habershon's work is one that every practitioner should read and study for himself. — N. ¥. Medical Journal, April, 1879. TANNEB, TH03IAS HAWKES, 31. D. A Manual of CUnical Medicine and Physical Diagnosis. Third American from the second London edition. Revised and enlarged by Tilbury Fox, M. D. In one small 12mo. volume of 362 pages, with illustrations. Cloth, $1.50. Lea Brothers & Co.'s Publioations— Uytfieue, lllectr., Israel. 17 BABTHOLOW, ROBERTS, A. M., M. />., LL. />., Piof. of Materia iJedica and General Tlieiajieuliai in the Jtffeison Mul. Coll. of I'htla., ete. Medical Electricity. A I'r:uti«il Treatise on the ApplicaliciiH of Kle.tricil/ to Medicine and Sur<;eiy. New (tliini) edition. In one very liandsoine orUivo volume ol" 308 pages, with 110 illustrations. Clotii, $2.50, The fact that this work has readied its tliini edi- tion in six years, and that it has been kept fully abreast with the increasing; use and kn(>wledj{e of electricity.demonstrates its claim to be considered a practical treatise of tried value to the profession. The matter added to the present edition embraces the most recent advances in electrical treatment. The illustrations are abumlant and clear, anci the work constitutes a full, clear and concise manual well adapted to the needs of both student and practitioner. — The Medical iVeios May 14, 1887. This "practical treatise on tiie applications of electricity to medicine and surgery lias grown to be so important a work that every practitioner should read it, eHppoially when It In reoaltod what po.Msibilities lie in the path of Ih.- further study of the therapeutics of electricity. Iir. Hartholow han hero nresenled the profession with a ii>1h<. work that, beKiiiniiiK with eli'inciitary deHcrlpiinnH and principles, Krailuiilly ^rows, pax" by iiage, into ,» magnificently practical treatise, describiiiK opera- tioua in detail, and giving records of succi-iiHoa that prove electricity to be marvellous as a curatiTB agent in many forms of disease. The doctor can- niH now do l)etlcr than to ])ossohs himself of Dr. Hartholow's treatise, just as it is. — \'tr(jinia Medu cal Monthly, June, 1887. TEO, I, BURNEY, M, !>., F. R. C. P., Professor of Clinical Therapeutics in King's College, London, and Physician to King's College Hospital. Pood in Health and Disease. In one 12mo, volume of 590 pages. Cloth, $2. Just ready. See Series of Clinical jl/a/i »«/.<, page 31. Dr. Yeo is fully master of his subject and he supplies in a compact form nearly all that the practitioner requires to know on the subject of diet. The work is divided into two parts— food in health and food in disease. Dr. Yeo has gathered together from all quarters an immense amount of useful information within a comparatively smalt compass, and he has arranged and digested his materials with skill for the use of the practitioner. We have seldom seen a book which more thor- oughly realizes the object for which it was written than this little work of Dr. Yeo.— British Medical Journal, Feb. 8, 1890. RICHARDSON, B. TF., 31. D., LL, I),, F.R.S,, Fellow of the Royal College of Physicians, Ijondon. Preventive Medicine. In one octavo volume of 729 pages. Cloth, $4; leather, $5. Dr. Richardson has succeeded in producing a work which is elevated in conception, comprehen- sive in scope, scientific in character, systematic in arrangement, and which is written in a clear, con- cise and pleasant manner. He evinces the happy faculty of extracting the pith of what is known on the subject, and of presenting it in a most simple, intelligent and practical form. There is perhaps no similar work written for the general public thatcontains such acomplete, reliable and instruc- tive collection of data upon the diseases common to the race, their origins, causes, and the measures for their prevention. The descriptions of diseases are clear, chaste and scholarly; the discussion ol the question of disease is comprehensive, masterly and fully abreast with the latest and best knowl- edge on the subject, and the preventive measures advised are accurate, explicit and reliable. — The Amei'ican Journal of the Medical Sciences, April, 1884. This is a book that will surely find a place on the table of every progressive physician. To the medi- cal profession, whose duly is quite as much to prevent as to cure disease, the book will be a boon. — Boston Medical and Surgical Journal, March 0, '84. The treatise contains a vast amount of solid, val- uable hygienic information. — Medical and Surgical Reporter, Feb. 23, 1884. THE YEAR-BOOK OF TREATMENT FOR 1800, A Comprehensive and Critical Review for Practitioners of Medi- cine. In one 12mo. volume of 329 pages. Cloth, $1.25. J«.s( read;/. ^f.*^ For special commutations with periodicals see pages 1 and 2. In the present issue of the YearBook of Treat- ment we find the usual clear, concise, complete and accurate epitome of the chief advances made in the treatment of disease during a year. The different sutijects are arranged in sections under the heads of the principal systems of the body. The serial medical literature of England, Amer- ica and of the Continent has been laid under contribution, with the result that a large mass of information, valuable to the practitioner, is pre- sented for his immediate reference. Hrief notices of the most important new books on ciich subject add greatly to the value of the annual retrospect. Sucli a book, produced as it is in an elegant and convenient form and at a very low price, ought to be in the hands of every member oi the profes- sion.— ^/le Practitioner, Feb. 1890. THE YEAR-BOOKS of TREATMENT for 1880 and 87, Similar to above. 12mo., 320-341 pages. Limp cloth, $1.25 each. SCHREIBER, JOSEPH, 31. D, A Manual of Treatment by Massage and Methodical Muscle Ex- ercise. Transl.qted bv Walter Mkndelson. .M. D., of New York. In one handsome octavo volume Translated by Walter Mendelson, .M. D., of New Y()^rk. ime of 274 pages, with 117 tine engravings. Cloth, $2.75. STURGES' INTRODUCTION TO THE STUDY OF CLINICAL MEDICINE. Being a Guide to the Investigation of Disease. In one handsome l2mo. voluhie of 127 pages. Cloth, 81.26. DAVIS' CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES. By N. S. Davis M. D. Edited by Frank H. Davis, M. D. Second edition. 12mo. 287 pages. Cloth, $1.75. TODD'S CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In one octavo volume of 320 pages. Cioth, $2.50. PAVY'S TREATISE ON TIIE FUNCTION OF DI- GESTION; its Disorders and their Treatment From the second Lomion edition. In one octavo volume of 2:w pages. Cloth, 82.(K). BARLOW'S MANUAL OF THE PRACTICE OP MEDICINE. With additions by I). F. Condiic, M. D. 1 vol. 8vo., pp. 60.1. Cloth, $2.50. CHAMBERS'MANIULOFDIET AND REGIMEN IN HEAi.,TU AND HICKNhXS. In one hand- some octavo volume of 302 pp. Cloth, $2.76. HOLLAND'S MEDICAL NOTES AND REFLEC- TIONS. 1 vol. 8vo.. pp. 493. Cloth. $3,60. 18 Lea Brothers & Co.'s Publications — Tliroat, liungs, Heart, Nerves. FLINT, AVSTIN, M. D., iX. !>., Profeisor of the Principles and Practice of Medicine in Bellevue Hospital Medical College, N. 7. A. Manual of Auscultation and Percussion ; Of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. New (fifth) edition. Edited by James C. Wilson, M. D., Jefferson Medical College, Philadelphia. In one handsome royal 12mo. volume of about 300 pages, with 14 illustrations. Shortly. B7 THE SAME AUTHOR. A Practical Treatise on the Physical Exploration of the Chest and the Diagnosis of Diseases Affecting the Respiratory Organs. Second and revised edition. In one handsome octavo volume of 591 pages. Cloth, $4.50. Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and Complications, Fatality and Prognosis, Treatment and Physical Diag- nosis ; In a series of Clinical Studies. In one octavo volume of 442 pages. Cloth, $3.50. A Practical Treatise on the Diagnosis, Pathology and Treatment of Diseases of the Heart. Second revised and enlarged edition. In one octavo volume of 550 pages, with a plate. Cloth, $4. Essays on Conservative Medicine and Kindred Topics. In one very hand- some royal 12mo. volume of 210 pages. Cloth, $1.38. BBOWNE, LENNOX, F. R, C. 5., F,, Senior Physician to the Central London Throat and Ear Hospital. A Practical Guide to Diseases of the Throat and Nose, including Associated Affections of the Ear. New (third) and enlarged edition. In one imperial octavo volume of 734 pages, with 120 illustrations in color, and 235 engravings on wood. Cloth, $6.60. Just ready. The third edition of Mr. Lennox Browne's in- structive and artistic work on " The Throat and Its Diseases" appears under the title of "The Throat and Nose aad Their Diseases." This change has been rendered desirable by the ad- vances made during the last decade in rhinology. The nasal sections, which extend to upwards of 100 pages, give in a short space the best account of the present position of rhinology with which we are acquainted. The engravings in this hand- some volume are of the same high order as here- tofore, and more numerous than ever; they can- not fail to be of the greatest assistance to senior stu- dents and practitioners. The instruments, either figured or described, are those which, as the result of experience, Mr. Browne has found to be of the greatestutilityindiagnosisandtreatment; they are most simple, inexpensive and easily kept aseptic- points of much importance. We have on a former occasion eulogised the beautiful and typical col- ored plates drawn on stone by the author-artist himself, and forming in themselves a valuable and instructive atlas, the equal of which is not to iDe found in any modern work, treating of these subjects. Mr. Lennox Browne is to congratulated on having produced the best practical text-book on diseases of the throat and nose extant. We are glad to learn that it is being translated into French and German. — The Provincial Medical Journal, August 1, 1890. SFILFB, CAUL, M. !>., Lecturer on Laryngoscopy in the University of Pennsylvania. A Handbook of Diagnosis and Treatment of Diseases of the Throat, Nose and Naso-Pharynx. New (third) edition. In one handsome royal 12mo. volume of 373 pages, with 101 illustrations and 2 colored plates. Cloth, $2.25. Few medical writers surpass this author in | of topics and methods. The book deserves a larg« ability to make his meaning perfectly clear in a sale, especially among general practitioners— CAt- few words, and in discrimination in selection, both | cago Medical Journal and Examiner, April, 1889. COMFN, J. SOLIS, M, D., Lecturer on Laryngoscopy and Diseases of the Throat and Chest in the Jefferson Medical College. Diseases of the Throat and Nasal Passages. A Guide to the Diagnosis and Treatment of Affections of the Pharynx, (Esophagus, Trachea, Larynx and Nares. Third edition, thoroughly revised and rewritten, with a large number of new illustrations. In one very handsome octavo volume. Preparing. GBOSS, S. n,f 3I.D,, LL.n.f n.C.L, Oxon., LL.n. Cantab. A Practical Treatise on Foreign Bodies in the Air-passages. In one octavo volume of 452 pages, with 59 illustrations. Cloth, $2.75. FULLER ON DISEASES OF THE LUN.GS AND AIR-PASSAGES. Their Pathology, Physical Di- agnosis, Symptoms and Treatment. From the second and revised English edition. In one octavo volume of 476 pages. Cloth, fiS.50. WALSHE ON THE DISEASES OF THE HEART AND GREAT VESSELS. Third American edi- tion. In 1 vol. 8vo., 41fi pp. Cloth. Sli.OO. SLADE ON DIPHTHERIA; its Nature and Treat- ment, with an account of the History of its Pre- valence in various Countries. Second and revised edition. In one 12mo. vol., 158 pp. Cloth, 81.25. SMITH ON CONSUMPTION ; its Early and Reme- diable Stages. 1 vol. 8vo., 253 pp. Cloth, $2.26. LA ROCHE ON PNEUMONIA, pages. Cloth,83.00. 1 vol. 8vo. of 490 WILLIAMS ON PULMONARY CONSUMPTION ; its Nature, Varieties and Treatment. With an analysis of one thousand cases to exemplify its duration. In one 8vo. vol. of 303 pp. Cloth. S2 50. BLA^DPORD ON INSANITY AND ITS TREAT- MKNT. Lectures on the Treatment, Medical and Leg.al, of Insane Patients. In one very hand- so rne octavo v 'lumf. ,,,„ JONES' CLINICAL OBSERVATIONS ON FUNC- TIONAL NERVOUS DISORDERS. Second American Edition. In one handsome octavo volume of 34i) pages. Cloth, $3.25. Lea Brothers & Co.'s Pdblications — Nerv.aiul IVIoiit. I>Ih., etc. 19 MOSS, JAMES, M.n., F.ll.CP., LL, />., Senior AssMa:it Physirimt to the AVanchcjiler Rnt/nl /iirtrmai-i/. A Handbook on Diseases of tho Nervous System. In one otiiivD volume of 725 jiages, witli ISt ilhistriitions. C'IdIIi, ifl.'jO; loiitlier, ;ji')..'>0. This admirable work is intenJed for students of ' tlio dopartment of modicliiP of which It treaU. medicine and for suelimedioalnu'ii lis have no time I>r. Uoss holds such a hi»;h scionlKlc |M)sltl«n that for lengthy treatises. In the present instance the any writii\t;'< which hoar his iinine «ri« nHiiirally duty of arranging the vast store of material al the expectecl to have ihK impress of a powertiil Intef- disjjosal of the author, and of abridging the de- lect. In every part this hnnd)M>i>k merits tho scnption of the different aspects of nervous dis- hinhosi praise,' and will no douht tio found of tho eases, has been performed with singular skill, and greatest value to the student a<< well a-s to the proc- the result is a concise and philosopliical guide to | tilioner.— ^iinburi;/! MediealJoumal, Jan. 1887. MITCHELL, S, WEIIi^MVjy., Physician to Orthoiuedic Hospilal and the Infirman/ f(rr Di.seniies of the Nervotu Syitem, Phila., ele. Lectures on Diseases of the Nervous System; Especiiilly in Women. Second edition. In one 12mo. volume of 2.SS pages. Clotli, $I.7o. No work in our language develops or displays more features of tliat many-sided affection, hys- teria, or gives clearer directions for its differen- tiation, or sounder suggestions relative to its general management and treatment. The Isook is particularly valuable in that it represents in the main the author's own clinical studies, which have been so extensive and fruitful as to give his teachings the stamp of authority all over tho realm of medicine. The work, although writtea by a specialist, has no exclusive character, and the general practitioner above all others will tind its perusal profitable, since it deals with diseases which he frequently encounters and must essay to treat. — American Practitivner, August, 1885. HAMILTON, ALLAJ^ McLANB, M. !>., Attending Physician at the Hospital for Epileptics and Paralytics, BlaekwdCa Island, N. 7. Nervous Diseases ; Their Description and Treatment. Second edition, thoroughly revised and rewritten. In one octavo volume of 598 pages, with 72 illustrations. Cloth, $4. When thefirstedition of this good book appeared characterized this book as the best of its kind in we gave it our emphatic endorsement, and the any language, which is a handsome endorsement present edition enhances our appreciation of the from an exalted source. The improvements in the book and its author as a safe guide to students of new edition, and the additions to it, will justify its clinical neurology. One of the best and most i purchase even by those who possess the old. — critical of English neurological journals. Brain, has Alienist and Neurologist, April, 1882. TZTKE, DAJSIEL HACK, M, H,, Joint Author of The Manual of Psychological Medicine, etc. Illustrations of the Influence of the Mind upon the Body in Health and Disease. Designed to elucidate the Action of the Imagination. New edition. Thoroughly revised and rewritten. In one 8vo. vol. of 467 pp., with 2 col. plates. Cloth, $3. It is impossible to peruse these interesting chap- method of interpretation. Guided by an enlight- ters without being convinced of the author's per- ened deduction, the author has reclaimed for feet sincerity, impartiality, and thorough mental science a most interesting domain in psychology, grasp. Dr. Tuke has exhibited the requisite previously abandoned to charlatans and empirics, amount of scientific address on all occasions, and I This book, well conceived and well written, mu.st the more intricate the phenomena the more firmly 1 commend itself to every thoughtful understand- has he adhered to a physiological and rational |ing.—jVeic For* ifedica/ yournn^ September 6, 1884. GBAY, LAJ^DON CARTEB, M.IX^ Professor of D'senses of the Mind and Xcrvous System in the Xew York Polyclinic. A Practical Treatise on Diseases of the Nervous System. Frrparing. CLOUSTON, THOMAS S., M, D., E, B. C, P., L. B. C, S., Lecturer on Mental Diseases in the University of Edinburgh. Clinical Lectures on Mental Diseases. With an Appendix, containing an Abstract of the Statutes of tlie United States and of the Several States and Territories re- lating to the Custody of the Insane. By Charles F. Foi^o.m, M. D., Assistant Professor of Mental Diseases, Med. Dep. of Harvard Univ. In one handsome octavo volume of 541 pages, with eight lithographic plates, four of which are beautifully colored. Cloth, $4. The 'practitioner as well as the student will ac- the general practitioner in guiding him to a dla^- cept the plain, practical teaching of the author as a uosis and indicatmg the treatment especially in forward step in the literature of insanity. It is many obscure and doubtful ca-es of mental dis- refre^hing to find a physician of Dr. Clouston's ease. To the American reader Dr. Folsom s Ap- experience and high reputation giving the bed- < pendix adds greatly to the value of the work, and sicfe notes upon wKich his experience has been , will m ke it a desirable a.idition to every library, founded and his mature judgment esie-hUi^heA. —American PsychologicalJou'~nal,J\x\y,liiH. Such clinical observations cannot but be useful to 8^' Dr. Folsom's Abstract may also be obtained separately in one octavo volume of 108 pages. Cloth, $1.50, SAVAGE, GEOBGE H, M. D., Lecturer on Mental Diseases at Ouy's Hospital, London. Insanity and Allied Neuroses, Practical and Clinical. In one 12mo. vol. of 551 pages, with 18 illus. Cloth, $2.00. See Series of Clinical ManuaU, page 31. PLATFAIB, W. S, 31. O., E. B. C. P. The Systematic Treatment of Nerve Prostration and Hysteria. In one handsome small 12mo. volume of 97 pages. Cloth, |;l.00. 20 Lea Brothers & Co.'s Publications — Surgery. ROBBBTS, JO aif B., M. !>., Prop.ssor of Anatomy and Surgery in the Philadelphia Polyclinic. Professor of the Principles and Practice of Surgery in the Woman^s Medical College of Pennsylvania. Lecturer in Anatomy in the Univer- sity of Pennsylvania. The Principles and Practice of Modern Surgery. For the use of Students and Practitioners of Medicine and Surgery. In one very handsome octavo volume of 780 pages, with 501 illustrations. Cloth, $4.50; leather, §5.50. Just ready. In this volume, as its title indicates, the author has endeavored to give a thorough exposition of the best surgical practice of the present time. Not relying exclusively on his own large experience, he has consulted the latest literature of all kinds bearing on his specialty, and has gleaned therefrom the opinions of the best authorities, and the methods of the most practical surgeons. The well-established facts of the science are clearly stated, but history, theories and untried innovations are rigidly excluded. The work is richly illustrated. In the selection of matter and in the consideration of the vast number of questions involved, the author has used his most critical judgment in the endeavor to render the work of the greatest practical advantage to both practitioners and students. ASMBJJBST, JOSN, Jr., M. J>., Barton Prof, of Surgery and Clin. Surgery in Univ. of Penna., Surgeon to the Penna. Hosp., etc. The Principles and Practice of Surgery. New (fifth) edition, enlarged and thoroughly revised. In one large and handsome octavo volume of 1144 pages, with 642 illustrations. Cloth, $6 ; leather, $7. A complete and most excellent work on surgery.) It is only necessary to examine it to see at once' its excellence and real merit either as text-book for the student or a guide for the general practi- tioner. It fully considers in detail every surgical injury and disease to which the body is liable, and every advance in surgery worth noting is to be found ia its proper place. It is unquestionably the best and most complete single volume on surgery, in the English language, and cannot but receive that continued appreciation which its merits justly demand. — Southern Practitioner, Feb. 1890. This is one of the most popular and useful of the many well-known treatises on general surgery. It furnishes in a concise manner a clear and comprehensive description of the modes of prac- tice now generally employed in the treatment of surgical affections, with a plain exposition of the principles on which those modes of practice are based. The entire work has been carefully revised, and a number of new illustrations introduced that greatly enhance the value of the book. — Cincinnati Lancet -Clinic, Dec. 14, 1889. DBUITT, BOBBBT, M. B, C. S., etc. Manual of Modern Surgery. Twelfth edition, thoroughly revised by Stan- ley Boyd, M. B., B. S., F. K. C. S. In one 8vo. volume of 965 pages, with 373 illustra- tions. Cloth, $4 ; leather, $5. It is essentially a new book, rewritten from be- ginning to end. The editor has brought his work up to the latest date, and nearly every subject on which the student and practitioner would desire to consult a surgical volume, has found its place here. The volume closes with about twenty pages of formulae covering a broad range of practical therapeutics. The student will find that the new Druitt is to this generation what the old one was to the former, and no higher praise need be accorded to any volume. — North Carolina Medical Journal, October, 1887. Druitt's Surgery has been an exceedingly popu- lar work in the profession. It is stated that 50,000 copies have been sold in England, while in the United States, ever since its first issue, it has been used as a text-book to a very large extent. Dur- ing the late war in this country it was so highly appreciated that a copy was issued by the Govern- ment to each surgeon. The present edition, while it has the same features peculiar to the work at first, embodies all recent discoveries in surgery, and is fully up to the times. — Cincinnati Medical News, September, 1887. GANT, FBEDBBICK JAMES, F. B. C. S., Senior Surgeon to the Royal Free Hospital. The Student's Surgery. A Multum in Parvo. In one square octavo volume of 848 pages, with 159 engravings. Cloth, $3.75. subjects. The volume is a condensation of the author's well-known larger works on surgery, notably his "Science and Practice of Surgery". Students requiring the essentials of surgery The claims of this volume to be a multum in parvo are certainly substantiated. The author covers the whole field of clinical and operative surgery in about eight hundred pages of very com- pactly printed matter. For a student's manual it appears to us in every way excellent, containing almost everything necessary to equip the student with sound, matter-of-fact knowledge on surgical in a handy and condensed form, and those who cannot devote time to theoretical or speculative pathology will find this volume exceedingly ser- vlcea,b\e.— The Physician and Surgeon, April, 1890. GBOSS, S. J>., M. J)., LL. !>., jD. C. L. Oxon., LL. n. Cantab., Emeritus Professor of Surgery in the Jefferson Medical College of Philadelphia, A System of Surgery : Pathological, Diagnostic, Therapeutic and Operative. Sixth edition, thoroughly revised and greatly improved. In two large and beautifully printed imperial octavo volumes containing 2382 pages, illustrated by 1623 engravings. Strongly bound in leather, raised bands, $15. BALL, CMABLBS B., M. Ch., Bub., F. B. C. S., E., Surgeon and Teacher at Sir P. Dun's Hospital, Dublin. Diseases of the Rectum and Anus. In one 12mo. volume of 417 pages, with 54 engravings and 4 colored plates. Cloth, $2.25. See Series of Clinical Manuals, page 31. GIBNEY, r. JP., M. J>., Surgeon to the Orthopcedic Hospital, New York, etc. ^f\tr.nr.a ar,A Htnrlonta In one hand- Lea Brothers & Co.'s Publications — Surpcry. 21 ERICHSEW, JOHN E„ F. R. S,, F. R, C. 8., Professor of Swgerfi in University College, lA>ndon, ele. The Science and Art of Surgery eases and Operations. From the eiglitli and enlarged P^nglisli edition. page.>< beautiful octavo volumes of 2oU) Cloth, $9; leather, raised bands, $11 We have always regarded "The Science and Art of Surgery" as one of the be.st surgioal text- books in the English language, and this eighth edition only confirms our previous opinion. We take great pleasure in cordially commending it to our readers.— T/ie3/e., LL, 2)., Surgeon to Bellevue Hospital, New York. A Practical Treatise on Fractures and Dislocations. Seventh edition thoroughly revised and much improved. In one very handsome octavo volume of 998 pages, with 379 illustrations. Cloth, $5.50 ; leather, $6.50. This book is without a rival in any language It is essentially a practical treatise, and it gathers within its covers almost everything valuable that has been written about fractures and dislocations. "The principles and methods of treatment are very fully given. The book is so well known that it does not require any lengthened review. We can only say that it is still unapproached as a treatise. — The Dublin Journal of Medical Science, Feb. 1886. PICK, T, PICKERING, F, R. C, S., Surgeon to and Lecturer on Surgery at St. George's Hospital, Loruion. Fractures and Dislocations. In one 12mo. volume of 530 pages, illustrations. Limp cloth, $2,00. See Series of Clinical ManiMls, page 31. with 93 Lea Brothers & Co.'s Publications — Otol., Ophtliul. 23 BVBNBTT, CHARLBS Jl,, A. M., M. D., Professor of Otology in the PInladelphia rolyclinie; President of the American Otologieal Society. The Ear, Its Anatomy, Physiology and Disoasos, A Practical TreatiHo for the use of Medical Stiulents and I'lactitidiicrs. Second cditinn. In one liandsomc octavo volume of 580 pages, with 107 illustrations, ("loth, ii4.0() ; leather, }!").(»(). We note with pleasure the appearnnoe of a Hecond onrriod out, nnil miidi new matter aiMed I>r edition of this valual)le work. When it first came Burnett's work must Ik. rcKanlrd a.s a v.tv vahin- out it was accepted by the profession as one of l)le oontrihiition to aural surKery imt only on the standard works on modern aural surgery in i account of its comprehensiveness I'.ut liecause it the English language; and ni his second edition I contains tlie results of tlie careful personal ohservn- Dr. Burnett has fully mauitained his reputation, tion and experience of thiseminenlanrBJ Hurneou for the book is replete with valuable information ! —Lomion Lancet, Feb. 21, 1885. and suggestions. The revision has been carefully | POLITZEB, ADAM, Imperial- Royal Prof, of Aural Therap. in the Univ. of Vienna. A Text-Book of the Ear and its Diseases. Translated, at the Author's re- quest, by James Patterson Cas.sei.i,s, M. I)., M. li. C. S. In one handsome octavo vol- ame of 800 pages, with 257 original illustrations. Cloth, $5.50. The whole work can be recommended as a reli- I the practitioner in his treatment.— fios/on Medical able guide to the student, and an etticient aid to | and Huryical Journal, June 7, 1883. BEBBY, GEOBGE A., 31. B., F, B. C. S., Ed., Ophthalmic Surgeon, Edinburgh Royal Infirmary. Diseases of the Eye. A Practical Treatise for Students of Ophthalmology. In one octavo volume of 683 pages, with 144 illustrations, 62 of which are bcautifidlv colored. Cloth, $7.50. This newest candidate for favor among ophthal- | novice — with a mass of details with no key to their mological students is designed to be purely clinical unravelling. It is apparent that the literature of in character and the plan is well adhered to. We j each subject has been gone over in a very thor- have been forcibly struck by the rare good taste , ough manner. The fact that he was writing a in the selection of what is essential which per- clinical treatise for beginners and not an cncyclo- vades the book. The author seems to have the psedia has always been present with the author, uncommon faculty of viewing his subject as a The number and excellence of the colored ilhis- whole and seizing the salient points and not con- trations in the text deserve more than a passing fusing his reader — presumably a student and a notice. — Archives of Ophthalmology, Sept. 1S80. JJJLEB, HENBT E., F. B. C. S., Senior Ass't Surgeon, Royal Westininster Ophthalmic Hasp. ; late Clinical Ass't, Moorfields, London. A Handbook of Ophthalmic Science and Practice. Handsome Svro. vol- ume of 460 pages, with 125 woodcuts, 27 colored plates, selections from Test-types of Jaeger and Snellen, and Holmgren's Color-blindness Test. Cloth, $4.50 ; leather, $5.50. It presents to the student concise descriptions illustrations are nearly all original. We have ex- and typical illustrations of all important eye affec- amined this entire work with great care, and it tions, placed in juxtaposition, so as to be grasped represents the commonly accepted views of ad- at a glance. Beyond a doubt it is the best illus- vanced ophthalmologists. We can most heartily trated handbook of ophthalmic science which has commend this book to all medical students, prac- ever appeared. Then, what is still better, these i titioners and specialists.— i)etroi< Lajteet, Jan. '86. NETTLESMIB, EDWABJD, F. B. C. S., Ophthalmic Surg, and Led. on Ophth. Surg, at St. Thovias' Hospital, London. The Student's Guide to Diseases of the Eye. New (fourth) American from the fifth English edition, thoroughly revised. With a Supplement on the Detection of Color Blindness, by William Thomson, M. D., Professor of Ophthalmology in the Jefferson Medical College. In one 12mo. volume of about 500 pages, with 164 illus- trations, selections from Snellen's test-types and formula?, and a colored plate. Shortly. NOBBIS, W3I. F., M. X>., and OLIVEB, CHAS. A., M. D. Clin. Prof, of Ophthalmology in Univ. of Pa. A Text-Book of Ophthalmology. In one octavo volume of about 500 pages, with illustrations. Freparing. CABTEB, B. BBVDENELL, & FBOST, W. ADAMS, F. B. C. S., F. B. C. S., Ophthalmic Surgeon to and Leet. on Ophthal- Ass't Ophthalmic Surgeon and Joint Lett, mic Surgery at St. George's Hospital, London. on Oph. Sur., St. George's Hasp., London. Ophthalmic Surgery. In one 12mo. volume of 559 pages, with 91 woodcuts, color-blindness test, test-types and dots and appendix of formulte. Cloth, $2.25. See Series of Clinical Manuals, imge 31. WELLS ON THE EYE. In one^ctavo volume, i LAWSON ON INJURIES TO THE EYE, ORBIT LAURENCE AiNU MuON'S HANDY BOOK OF [ AND EYELIDS: Their Immediate and Remote qPHTHALM IC SURGERY, for the use of Prac- , ^^^^^^ ^„,„^^ ^j ^^ ^jtb titioners. Second edition. In one octavo vol- ^ ^, ,u «or« ume of 227 pages, with 65 illus. Cloth, ifi.lb. , 92 illustrations. Cloth, $3.60. 24 Lea Brothers & Co.'s Publications — Urin. Dis., Dentistry, etc. ROBBBTS, WILLIAM, 31, !>., Lecturer on Medicine in the Manchester School of Medicine, etc. A Practical Treatise on Urinary and Benal Diseases, including Uri- nary Deposits. Fourth American from the fourth London edition. In one hand- some octavo volume of 609 pages, with 81 illustrations. Cloth, $3.50. It may be said to be the best_book in print on the i guage in its account of the diflPerent affections.— subject of which it treats. — The American Journal of the Medical Sciences, Jan. 1886. The peculiar value and finish of the book are in a measure derived from its resolute maintenance of a clinical and practical character. It is an un- rivalled exposition of everything which relates directly or indirectly to the diagnosis, prognosis and treatment of urinary diseases, and possesses a completeness not found elsewhere in our lan- 'he Manchester Medical Chronicle, July, 1885. The value of this treatise as a guide boofc'to the physician in daily practice can hardly be over- estimated. That it is fully up to the level of our present knowledge is a fact reflecting great credit upon Dr. Roberts, who has a wide reputation as a busy practitioner. — The Medical Record, July 31, 1886. BUBDT, CSABLES W., M, />., Chicago, Bright's Disease and Allied Affections of the Kidneys. In one octavo volume of 288 pages, with illustrations. Cloth, $2. ~" ----- . - short space the theories, facts and treatments, and going more fully into their later developments. On treatment the writer is particularly strong, steering clear of generalities, and seldom omit- ting, what text-books usually do, the unimportant items which are all important to the general prac- titioner.— TAe Manchester Medical Chronicle, Oct 1886. The object of this work is to "furnish a system- atic, practical and concise description of the pathology and treatment of the chief organic diseases of the kidney associated with albuminu- ria, which shall represent the most recent ad- vances in our knowledge on these subjects ;" and this definition of the object is a fair description of the book. The work is a useful one, giving in a MOBMIS, SBJVBY, M. B., F, B, C, S,, Surgeon to and Lecturer on Surgery at Middlesex Hospital, London. Surgical Diseases of the Kidney. In one 12mo. volume of 554 pages, with 40 woodcuts, and 6 colored plates. Limp cloth, $2.25. See Series of Clinical Manuals, page 31. In this manual we have a distinct addition to surgical literature, which gives information not elsewhere to be met with in a single work. Such a book was distinctly required, and Mr. Morris has very diligently and ably performed the task he took in hand. It is a full and trustworthy book of reference, both for students and prac- titioners in search of guidance. The illustrations in the text and the chromo-lithographs are beau- tifully executed. — The London Lancet, Feb. 26, 1886. See Series LUCAS, CLBMBWT, M, B,, B, S,, B, B, C, S., Senior Assistant Surgeon to Chty's Hospital, London. Diseases of the Urethra. In one 12mo. volume. Preparing, of Clinical Manuals, page 4. TSOMBSQ]^, SIB SBNBY, Surgeon and Professor of Clinical Surgery to University College Hospital, London. Lectures on Diseases of the Urinary Organs. Second American from the third English edition. In one 8vo. volume of 203 pp., with 25 illustrations. Cloth, $2.25. By the Same Author. On the Pathology and Treatment of Stricture of the Urethra and Urinary Fistulse. From the third English edition. In one octavo volume of 359 pages, with 47 cuts and 3 plates. Cloth, $3.50. TSB AMBBICAN SYSTBM OB DBJ^TISTBT, In Treatises by Various Authors. Edited by Wilbur F. Litch, M, D,, D. D. S., Professor of Prosthetic Dentistry, Materia Medica and Therapeutics in the Pennsylvania College of Dental Surgery. In three very handsome octavo volumes con- taining 3160 pages, with 1863 illustrations and 9 full-page plates. Per volume, cloth, $6 ; leather, $7 ; half Morocco, gilt top, $8. The complete work is now ready. For sale by subscription only. As an encyclopsedia of Dentistry it has no su- j doubtless it is), to mark an epoch in the history of dentistry. Dentists will be satisfied with it and perior. It should form a part of every dentist's library, as the information it contains is of the freatest value to all engaged in the practice of entistry. — American Jour. Dent. Sci., Sept. 1886. A grand system, big enough and good enough and handsome enough for a monument (which proud of it — they must. It is sure to be precisely what the student needs to put him and keep him in the right track, while the profession at large will receive incalculable benefit from it. — Odonto- graphic Journal, Jan. 1887. COLBMAN, A,, L, B, C, B,, B, B, C, S,, Bxam, L, 2). S,, Senior Dent, Surg, and Led. on Dent. Surg, at St. Bartholomew's Hosp. and the Dent. Hosp., London. A Manual of Dental Surgery and Pathology. Thoroughly revised and adapted to the use of American Students, by Thomas C. Stellwagen, M. A., M. D., D. D. S., Prof, of Physiology in the Philadelphia Dental College. In one handsome octavo volume of 412 pages, with 331 illustrations. Cloth, $3.25. It should be in the possession of every practi- tioner in this country. The part devoted to first and second dentition and irregularities in the per- manent teeth is fully worth the price. In fact, price should not be considered in purchasing such a work. If the money put into some of our so- called standard text-books could be converted into such publications as this, much good would result. — Southern Dental Journal, May, 1882. The author brings to his task a large experience acquired under the most favorable circumstances. There have been added to the volume a hundred pages by the American editor, embodying the views of the leading home teachers in dental sur- gery. The work, therefore, may be regarded as strictly abreast of the times, and as a very high authority on the subjects of which it treats. — American Practitioner, July, 1882. BASHAM ON RENAL DISEASES: A Clinical Guide to their Diagnosis and Treatment. In one 12mo. vol. of 304 pages, with 21 Illustrations. Cloth, 82.00. Lea Brothers & Co.'s Publications — VeuerciU, Iinpoteiu'c. 25 GBOSS, SA3rUBL TF., A, M., M. />., LL. 7>., Professor of the Principles of i^urgery/ and of Clinical Snryeri/ in the Jejfcrsan Mniunl Collffir of I'hiln. A Practical Treatise on Impotence, Sterility, and Allied ioisordors of the Male Sexual Organs. Now (4th) eilition, tliorDUKlily rfvised by F. K. Sturgis, M. D., Prof, of Diseases of tlie (lenito-l'riiiary Organs and of N'enereal Oiseasei*, N. Y. Post Grad. Med. Sdiool. In one very handsome octavo volume of alxnit 175 pages, with about 20 illustrations. Sliorth/. A few notices of the previous edition are appended. It must be gratifying to both author and pub- | Tills now classical work on tlio subject of Impo- lishers that large first and second editions of this tence and sterility iti the male needs no extended little worlv were so soon exhausted, while the fact review, for it is already well known to the j)r<>- that it has been translated into Russian may indi- fession. Dr. (iross has tiy his tireless lnl)or done Cite that it filled a void even in foreign literature, i more towards clearing upthe diagnosis and treut- His is a careful and physiological study of the mentof these obscure cases than any other Ameri sexual act, so far as concerns the male, and all his conclusions are scientifically reached. The book has a place by itself in our literature, and furnishes a large fund ofMnformation concerning important matters that are too often passed over in silence. — TTie iWedica; Press, June, 1887. can physician. 'I'he fact tlialtti is book has rapidly r\in through two large editions, and that the author is now forced to issue a third, is good and suttlcient evidence of its excellence. — Atlanta Multcat ., 31. JD,f LL. D., D. C. i., etc. A Practical Treatise on the Diseases, Injuries and Malformations of the Urinary Bladder, the Prostate Gland and the Urethra. Ihird edition, thoroughly revised by Samuel W. Gros-s M. D. In one octavo volume of 5/4 pages, with 170 illustrations. Cloth, $4.50. CULLFBIFB, A.,& BV3ISTEAJ), F. J., 31. n., LL.D., Surgeon to the Hdpital du Midi. Late Professor of Venereal Diseases in the College of Physinan.<, a7id Surgeons, New York. An Atlas of Venereal Diseases, Translated and edited by Freeman J. Briw- STEAD M D. In one imjierial 4to. volume of 328 pages, double-colinnns, with 26 plates, containing about 150 figures, beautifully colored, many of them the size of life. Stronply bound in cloth, $17.00. A spec imen of the plates a nd text sent by mail, on receipt of Lo cts. HILL ON SYPHILIS AND LOCAL CONTAGIOUS I FORMr OF LOCAL IJ/S^^ASE AFKKCTINC4 DISORDERS. Inone8vovol.of479p.Cloth.$3.2.5. PRINCIPALLY THE ORGANS OF GENERA- LEE'S LECTURES ON SYPHILIS AND SuMEiTION. In one 8vo. vol. of 246 pages. Cloth, ^J.^.. 26 Lea Brothers & Co.'s Publications — Venereal, Skin. TATLOB, nOBEnT W,, A.M., M.D., Clinical Professor of Qeni'o Urinary Diseases in the College of Physicians and Surgeons, New York ; Surgeon io the Department of Venereal and Skin Diseases of the New Fork Hospital; Presi- dent of the American Dermatological Association. A Clinical Atlas of Venereal and Skin Diseases: Including Diagnosis, Prognosis and Treatment. In eight large folio parts, measuring 14 x 18 inches, and comprising 58 beautifully-colored plates with 213 figures, and 431 pages of text with 85 engravings. Complete work just ready. Price per part, $2.50. Bound in one volume, half Russia, $27 ; half Turkey Morocco, $28. For sale by subscription only. Specimen plates sent on receipt of 10 cents. A full prospectus sent to any address on application. The completion of this monumental work is a subject of congratulation, not only to the author and publishers, but to the profession at large ; indeed it is to the latter that it directly appeals as a wonderfully clear exposition of a confessedly difficult branch of medicine Good literature has joined haads with good art with highly satisfac- tory results for both. There are altogether 213 figures, many of which are life size, and represent the highest perfection of the" chromo-litho- graphic art, and scattered throughout the text are innumerable engravings. Quite a proportion of these illustrations are from the author's own collection, while on the other hand the best atlases of the world have been drawn upon for the most typical and successful pictures of the many different types of venereal and skin dis ease. We think we may say without undue exaggeration that the reproductions, both in color and in black and white, are almost invariably successful. The text is practical, full of thera- peutical suggestions, and the clinical accounts of disease are clear and incisive. Dr. Taylor is, happily, an eminent authority in both departments, »nd we find as a consequence that the two divis- ions of this work possess an equal scientific and literary merit. We have already passed the limits allotted to a notice of this kind, and while we have nothing but praise for this admirable atlas, it must be said in justification that it is more than warranted by the merits of the work itself. — The Medical News, Dec. 14, 1889. It would be hard to use words which would per- spicuously enough convey to the reader the great value of this Clinical Atlas. This Atlas is more complete even than an ordinary course of clinical lectures, for in no one college or hospital course is it at all probable that all of the diseases herein represented would be seen. It is also more ser- viceable to the majority of students than attend- ance upon clinical lectures, for most of the students who sit on remote seats in the lecture hall cannot see the subject as well as the office studentcan examine these true to-life chromo-lith- ographs. Comparing the text to a lecturer, it is more satisfactory in exactness and fulness than he would be likely to be in lecturing over a single case. Indeed, this Atlas is invaluable to the gen- eral practitioner, for it enables the eye of the physician to make diagnosis of a given case of skin manifestation by comparing the case with the picture in the .4i/as, where will be found also the text of diagnosis, pathology, and full sections on treatment. — Virginia Medical Monthly, Dec. 1889. STDE, J. NEVINS, A. M., M. !>., professor of Dermatology and Venereal Diseases in Bush Medical College, Chicago. A Practical Treatise on Diseases of the Skin. For the use of Students and Practitioners. New (second) edition. In one handsome octavo volume of 676 pages, with 2 colored plates and 85 beautiful and elaborate illustrations. Cloth, $4.50; leather, $5.50. We can heartily commend it, not only as an admirable text-book for teacher and student, but in its clear and comprehensive rules for diagnosis, its sound and independent doctrines in pathology, and its minute and judicious directions for the treatment of disease, as a most satis'factory and complete practical guide for the physician. — Ameri- can Journal of the Medical Sciences, July, 1888. A useful glossary descriptive of terms is given. The descriptive portions of this work are plain and easily understood, and above all are very accurate. The therapeutical part is abundantly supplied with excellent recommendations. The picture part is well done. The value of the work to practitioners is great because of the excellence of the descriptions, the suggestiveness of the advice, and the correctness of the details and the principles of therapeutics impressed upon the Tea,deT.~Virginia Med. Monthly, May, 1888. The second edition of his treatise is like his clinical instruction, admirably arranged, attractive in diction, and strikingly practical throughout. The chapter on general symptomatology is a model in its way ; no clearer description of the various primary and consecutive lesions of the skin is to be met with anywhere. Those on general diagno- sis and therapeutics are also worthy of careful study. Dr. Hyde has shown himself a compre- hensive reader of the latest literature, and has in- corporated into his book all the best of that which the past years have brought forth. The prescrip- tions and formulae are given in both common and metric sy.stems. Text and illustrations are good, and colored plates of rare cases lend additional attractions. Altogether it is a work exactly fitted to the needs of a general practitioner, and no one will make a mistake in purchasing it.— Medical Press of Western New York, June, 1888. FOX, T., M. D., F.B. C. JP., and FOX, T. C, B.A., M.B. C.S., Physician to the Department for Skin Diseases, Physician for Diseases of the Skin to the University College Hospital, London. Westminster Hospital, London. An Epitome of Skin Diseases. With Formulae. For Students and Prac- titioners. Third edition, revised and enlarged. In one very handsome 12mo. volume of 238 pages. Cloth, $1.25. The third edition of this convenient handbook calls for notice owing to the revision and expansion which it has undergone. The arrangement of skin diseases in alphabetical order, which is the method of classification adopted in this work, becomes a positive advantage to the student. The book is one which we can strongly recommend, not only to students but also to practitioners who require a compendious summary of the present state of dermatology. — British Medical Journal, July 2, 1883. We cordially recommend Fox's Epitome to those whose time is limited and who wish a handy manual to lie upon the table for Instant reference. Its alphabetical arrangement is suited to this use, for all one has to know is the name of the disease, and here are its description and the appropriate treatment at hand and ready for instant applica- tion. The present edition has been very carefully revised and a number of new diseases are de- scribed, while most of the recent additions to dermal therapeutics find mention, and the formu- lary at the end of the book has been considerably augmented.— TAe Medical News, December, 1883. WILSON, EBAS3IUS, F. B. S. The Student's Book of Cutaneous Medicine and Diseases of the Skin. In one handsome small octavo volume of 535 pages. Cloth, $3.50. HILLIER'S HANDBOOK OF SKIN DISE.\SES; for Students and Practitioners. Second Ameri- can edition. In one 12mo. volume of 353 pages, wall plates. Cloth, $^.25. Lea Brothers & Co.'s Publications— Dim. of VVomeu. 27 The American Systems of Gynecology and Obstetrics. University of Pennsylvania, Pliiladelpliia. In four vcrv liandsonie octavo voliiniex, con- taining 3612 pages, 1092 engravings and 8 plates. C'oni'plete work }u.'., .1. IIKNDIUK LI,(tYi>, M. H, MATIUKW I). MANN, A. M., M. D., H. ^'E^VEI,L MARTIN, F. R. 8., M. P., I'.Sr., M.A., RlCHAUii H. MAURY, M. D.. C. D. PALMER, M. Ii., RO.SWELI, PARK, M. I)., THEOPHIU'S PAKVIN, M. D., LL. D., R. A. F. PENRO.SE, M. !>., LL. P., THAPPEUS A. REAMY, A. M., M. P., J. C. REEVE, M. P., A. P. ROCKWEIvL, A. M., M. P., ALEXAN1)ER .1. C. SKENE, M. P., J. LEWIS SMITH, M. P., STEPHEN SMITH, M. P., R. STANSBURY SUTTON, A. M., M. P., LL. P., T. GAILLARP THOMAS, M. P., LL. P., ELY VAN PE WARKER, M. P., W. GILL WYLIE, M. P. WILLIAM H. BAKER, M. P., ROBERT BATTEY, M. P., SAMUEL C. BUSEY, M. P., JAMES C. CAMERON, M. P., HENRY 0. COE, A. M., M. P., EPWARD P. PAVIS, M. P., G. E. Pe SCHWEINITZ, M. P., E. C. PUPLEY, A. B., M. P., B. McE. EMMET, M. P., GEORGE J. ENGELMANN, M. P., HENRY J. GARRIGUES, A. M., M. P., WILLIAM GOOPELL, A. M., M. P., EGBERT H. GRANPIN, A. M., M. P., SAMUEL W. GROSS, M. P., ROBERT P. HARRIS, M. P., GEORGE T. HARRISON, M. P., BARTON 0. HIRST, M. P. STEPHEN Y. HOWELL, M. P., A. REEVES JACKSON, A. M., M. P., W. W. JAGGARP, M. P., EPWARP W. JENKS, M. P., LL. P., HOWARD A. KELLY, M. P., This is volume two of The American System of j tor may be congrfttulated for having made suoh « Obstetrics, completing the wonderfully full series issued from the house of Lea Brotners & Co. dur- ing the past two years. Two magnificent volumes devoted to gynecology, and now two like volumes embracing everything pertaining to obstetrics. These volumes are the contributions of the most eminent gentlemen of this country in these de wise selection of his contributors. — Jonrnnl of tht American Metiieal Astorialion, Sept. R, 18R8. In our notice of the "Sy.stem of Practical Medi- cine by American Authors," we made the follow- ing statement: — "It is a work of which the pro- fession in this country can feel proud. Written exclusively by American physicians who are ac- partments of the profession. Each contributor j quainted with all the varieties of climate in the presents a monograph upon his special topic, j United States, the character of the soil, the man- apparently without restriction in space, so tnat i ners and customs of the people, etc., it is pecui- everything in the way of history, theory, methods, | iarly adapted to the wants of American practition- and results is presented to our fullest need. The i ers of medicine, and it seems to us that every one work will long remain as a monument of great in- I of them would desire to have it" Every word dustry and good judgment. As a work of general 1 thus expressed in regard to the "American Sys- reference, it will be found remarkably full and in- tem of Practical Medicine" is applicable to the structive in every direction of inquiry. — The Ob- \ "System of Gynecology by American Authors," stetric Gazette, September, 1889. There can be but little doubt that this work will find the same favor with the profession that has been accorded to the " System of Medicine by American Authors," and the "System of Gynecol- ogy byAmerican Authors." One is at a loss to know wliat to say of this volume, for fear that just and merited praise may be mistaken for flattery. The subjects of some of the papers are discussed in various works on obstetrics, though not to the full which we desire now to bring to the attention of our readers. It, like the other, has been written exclusively Vjy American physicians who are acquainted with all the characteristics of American people, who are well informed in regard to the peculiarities of American women, their manners, customs, modes of living, etc. As every practis- ing physician is called upon to treat diseases of females, and as they constitute a class to which the family physician must give attention, and extent that is found in this volume. The papers } cannot pass over to a specialist, we do not know of of Prs. Engelmann, Martin, Hirst, Jaggard and j a work in any department of medicine that we Reeve are incomparably beyond anything that can should so strongly recommend medical men gen- be found in obstetrical works. Certainly the Edi- ! erally purchasing.— OirwjimiaM J/e,, Surgeon to the Womari's Hospital, New York, etc. The Principles and Practice of Gynaecology ; For the use of Students and Practitioners of Medicine. New (third) edition, thoroughly revised. In one large and very handsome octavo volume of 880 pages, with 150 illustrations. Cloth, |5 ; leather, $6 ; very handsome half Russia, raised bands, $6.50, We are in doubt whether to congratulate the author more than the profession upon the appear- ance of the third edition of this well-known work. Embodying, as it does, the life-long experience of one who has conspicuously distinguished himself as a bold and successful operator, and who has devoted so much attention to the specialty, we feel sure the profession will not fail to appreciate the privilege thus offered them of perusing the views and practice of the author. His earnestness of purpose and conscientiousness are manifest. He gives not only his individual experience but endeavors to represent the actual state of gynse- eologioal science and art. — British Medical Jour- nal, May 16, 1885. TAIT, LAWSON, F,B. C, S., Professor of Oyncecology in Queen's College, Birmingham; late President of the British Cfyne- coloqical Society ; Fellow American Gynecological Society. Diseases of Women and Abdominal Surgery. In two very handsome octavo volumes. Volume I., 554 pages, 62 engravings and 3 plates. Cloth, $3. Just ready. Volume II., preparing. The plan of the work does not indicate the regu- lar system of a text book, and yet nearly every- thing of disease pertaining to the various organs receives a fair consideration. The description of diseased conditions is exceedingly clear, and the treatment, medical or surgical, is very satisfactory. Much of the text is abundantly illustrated with cases, which add value in showing the results of the suggested plans of treatment. We feel con- fident that few gynecologists of the country will fail to place the work in their libraries. — The Obstetric Gazette, March, 1890. nAVENPOUT, F. H., M. J)., Assistant in Gynaecology in the Medical Department of Harvard University, Boston. Diseases of Women, a Manual of Non-Surgical Gynaecology. De- signed especially for the Use of Students and General Practitioners. In one handsome 12mo. volume of 317 pages, with 105 illustrations. Cloth, $1.50. Just ready. We agree with the many reviewers whose no- tices we have read in other journals congratulating Dr. Davenport on the success which he has attained. He has tried to write a book for the student and general practitioner which would tell them just what they ought to know without distracting their attention with a lot of compila- tions for which they could have no possible use. In this he has been eminently successful. There is not even a paragraph of useless matter. Everything is of the newest, freshest and most practical, so much so that we have recommended it to our class of gynecology students. What the author advises in the way of treatment has all been practically tested by himself, and each method receives only so much commendation as he has found that it deserves. We aie sure that these good qualities will command for it a large sale. — Canada Medical Record, Dec. 1889. MAY, CHAJRLES H,, M. X)., Late House Surgeon to Mount Sinai Hospital, New York. A Manual of theDiseases of Women. Being a concise and systematic expo- sition of the theory and practice of gynecology. New (2d) edition, edited by L. S. Eau, M. D., Attending Gynecologist at the Harlem Hospital, N. Y. In one 12mo. volume of 360 pages, with 31 illustrations. Cloth, $1.75. Just ready. This is a manual of gynecology in a very con- densed form, and the fact that a second edition has been called for indicates that it has met with a favorable reception. It is intended, the author tells us, to aid the student who after having care- fully perused larger works desires to review the subject, and he adds that it may be useful to the practitioner who wishes to refresh his memory rapidly but has not the time to consult larger works. We are much struck with the readiness and convenience with which one can refer to any subject contained in this volume. Carefully com- piled indexes and ample illustrations also enrich the work. This manual will be found to fulfil its purposes very satisfactorily. — The Physician and Surgeon, June, 1890. DVNCAN, J. MATTHEWS, M,JD,, LL, D., F. B, S. E., etc. Clinical Lectures on the Diseases of Women ; Delivered in Saint Bar- tholomew's Hospital. In one handsome octavo volume of 175 pages. Cloth, $1.50. rule, adequately handled in the text-books; others They are in every way worthy of their author ; indeed, we look upon them as among the most valuable of his contributions. They are all upon matters of great interest to the general practitioner. Some of them deal with subjects that are not, as a of them, while Bearing upon topics that are usually treated of at length in such works, yet bear such a stamp of individuality that they deserve to be widely le&d.—N. Y. Medical Journal, March, 1880. HODGE ON DISEASES PECULIAR TO WOMEN. Including Displacements of the Uterus. Second edition, revised and enlarged. In one beauti- fully printed octavo volume of 519 pages, with original illustrations. Cloth, Sl.50. RAMSBOTHAM'S PRINCIPLES AND PRAC- TICE OP OBSTETRIC MEDICINE AND SURGERY. In reference to the Process of Parturition. A new and enlarged edition, thor- oughly revised by the Author. With additions by W. V. Keating, M. D., Professor of Obstetrics, etc., in the Jefferson Medical College of Phila- delphia. In one large and handsome imperial octayo volume of (UO pages, with Ci full page plates and 43 woodcuts in the text, containing in all nearly 200 beautiful figures. Strongly bound in leather, with raised bands, $7. WEST'S LECTURES ON THE DISEASES OF WOMEN Third American from the third Lon- don edition. In one octavo volume of 543 pages. Cloth, $3.75; leather, S4. 75. Lea Brothers & Co.'s Publications — Mi., and FANCOUBT, M, B., Phys. to the General Lying-in Hasp., Land. Obstetric Phys. to St. Thomas' Hosp., Land. A System of Obstetric Medicine and Surgery, Theoretical and Clin- ical. For the Student and the Practitioner. The Section on Embryology by Prof. Milnes Marshall. In one 8vo. volume of 872 pp., with 231 illustrations. Cloth, $5; leather, $6. The immediate purpose of the work is to furnish a handbook of obstetric medicine and surgery for the use of the student and practitioner. It is not an exaggeration to sav of the bonk that it is the best treatise in the English language yet published, and this will not be a surprise to those who are acquainted with the work of the elder Barnes. Every practitioner who desires to have the best obstetrical opinions of the time in a readily accessible and condensed form, ought to own a copy of th» book. — Journal of the American Meiiical Association, June 12, 188t'>. The Authors have made a text-book which is In every way quite worthy to take a place beside the best treatises of the period.— A'eio York Medital Journal, July 2, 1887. BABKEB, FOBBYCF, A. M., M. !>., LL, J>., FliUn,, Clinical Professor of Midwifery and the Di.'iensesof Women in the Bellevue Hospital Medical CoUege, New York Honorary Fellow of the Obstetrical Societies of London and Eiiinburgh, etc., etc. Obstetrical and Clinical Essays. 12mo., about 300 pages. Preparing. PABBYj JOHN S,, M, B., ,„,,.,. Obstetrician to the Philadelphia Hospital, Vice-President of the Obstet. Society of Philadelphia. Extra - Uterine Pregnancy: Its Clinical History, Diagnosis, Prognosis and Treatment. In one handsome octavo volume of 272 pages. Cloth, $2.50. WINCKEL.F. .^ . . ^n^.■^AUA A Complete Treatise on the Pathology and Treatment of Childbed, For Students and Practitioners. Translated, with the consent of the Awtlior, Inun tlie second German edition, bv J. R. Chadwick, M. I). Octavo 484 pages. Cloth, $4.00. ASHWELL'S PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. Third American from the third and revised London edition. In one 8vo. vol., pp. 520. Cloth, 83.50. TANNER ON PREGNANCY. Octavo, 490 pages, colored plates, 16 cuts. Cloth. S4.i5 CHURCHILL ON THE PUERPERAL FEVER AND OTHER DISEASES PEOITLIAR TO WO- MEN. In oneSvo. vol. of 4fi4 pages. Cloth, r^.SO. MEIGS ON THE NATITRE, SIGNS AND TREAT- MENT OF CHILDBED FEVER. In one 8to. volume of 346 psKes. Cloth, 12.00. 30 Lea Brothers & Co.'s Publications — Mldwfy., Dis. Ghildn. LJEISHMAN, WILLIAM, 31. D., Regius Professor of Midwifery in the University of Glasgow, etc. A System of Midwifery, Including the Diseases of Pregnancy and the Puerperal State. Third American edition, revised by the Author, with additions hj John S. Pakry, M. D., Obstetrician to the Pliiladelphia Hospital, etc. In one large and very handsome octavo voliune of 740 pages, with 205 illustrations. Cloth, $4.50 ; leather, $5.50. The author is broad in his teachings, and dis- cusses briefly the comparative anatomy of the pel- vis and the mobility of the pelvic articulations. The second chapter is devoted especially to the study of the pelvis, while in the third the female organs or generation are introduced. The structure and development of the ovum are admirably described. Then follow chapters upon the various subjects embraced in the study of mid- wifery. The descriptions throughout the work are plain and pleasing. It is sufficient to state that in this, the last edition of this well-known work, every recent advancement in this field has been brought forward. — Physician and Surgeon, Jan. 1880. To the American student the work before us must prove admirably adapted. Complete in all its parts, essentially modern in its teachings, and with demonstrations noted for clearness and precision, it will gain in favor and be recognized as a work of standard merit. The work cannot fail to be popular and is cordially recommended. — N. 0. Med. and Surg. Journ., March, 1880. It has been well and carefully written. The views of the author are broad and liberal, and in- dicate a well-balanced judgment and matured mind. We observe no spirit of dogmatism, but the earnest teaching of the thoughtful observer and lover of true science. Take the volume as a whole, and it has few equals. — Maryland Medical Journal, Feb. 1880. LANDIS, HBNUY G,, A, M,, M, 2>., Professor of Obstetrics and the Diseases of Women in Starling Medical College, Columbus, O. The Management of Labor, and of the Lying-in Period. In handsome 12mo. volume of 334 pages, with 28 illustrations. Cloth, $1.75. The author has designed to place in the hands of the young practitioner a book in which he can find necessary information in an instant. As far as we can see, nothing is omitted. The advice is sound, and the proceedures are safe and practical. Oentralblatt fiir Oynakologie, December 4, 1886. This is a book we can heartily recommend, the author goes much more practically into the details of the management of labor than most text-books, and is so readable throughout as to one tempt any one who should happen to commence the book to read it through. The author pre- supposes a theoretical knowledge of obstetrics, and has consistently excluded from this little work everything that is not of practical use in the lying-in room. We think that if it is as widely read as it deserves, it will do much to improve obstetric practice in general. — iVeio Orleans Medi- cal and Surgical Journal, Mar. 1886. SMITH, J, LEWIS, M, D., Clinical Professor of Diseases of Children in the Bellevue Hospital Medical College, N. T, A Treatise on the Diseases of Infancy and Childhood. New (sixth) edition, thoroughly revised and rewritten. In one handsome octavo volume of 867 pages, with 40 illustrations. Cloth, $4.50 ; leather, $5.50. For years it has stood high in the confidence of the profession, and with the additions and alter- ations now made it may be said to be the best book in the language on the subject of which it treats. An examination of the text fully sus- tains the claims made in the preface, that "in preparing the sixth edition the author has revised the text to such an extent that a considerable part of the book may be considered new." If the young practitioner proposes to place in his library but one book on the diseases of children, we would unhesitatingly say, let that book be the one which is the subject of this notice. — The American Journal of the Medical Sciences, April, 1886. No better work on children's diseases could be placed in the hands of the student, containing, as it does, a very complete account of the symptoms and pathology of the diseases of early life, and possessing the further advantage, in which it stands alone amongst other works on its subject, of recommending treatment in accordance with the most recent therapeutical views. — British and Foreign Medico-Chirurgical Review. Those familiar with former editions of the work will readily recognize the painstaking with which this revision has been made. Many of the articles have been entirely rewritten. The whole work is enriched with a research and reasoning which plainly show that the author has spared neither time nor labor in bringing it to its present ap- proach towards perfection. The extended table of contents and the well-prepared index will enable the busy practitioner to reach readily and quickly for reference the various subjects treated of in the body of the work, and even those who are familiar with former editions will find the improvements in the present richly worth the cost of the work. — Atlanta Medical and Sur<^ical Journal, Dec. 1886. Dr. Smith's work hasjustly become the standard all over the world as the book on children's dis- eases The whole book is admirable, both for the practitioner and the student. Dr. Smith writes from a large experience and a close observation of cases at the bedside. He is extremely prac- tical, and these facts make the work what it is — the best of all works on the diseases of children. — Virginia Medical Monthly, June, 1886. OWUW, EDMUWn, M. B., F. JR. C S,, Surgeon to the Children's Hospital, Ch-eat Ormond St., London. Surgical Diseases of Children. In one 12mo. volume of 625 pages, with 4 chromo-lithographic plates and 85 woodcuts. Clotli, $2. See Series of Clinical Manuals, page 31. One is immediately struck on reading this book with its agreeable style and the evidence it every- where presents of the practical familiarity of its author with his subject. The book may be honestly recommended to both students and practitioners. It is full of sound information, pleasantly given. — Annals of Surgery, May, 1886. WEST, CHABLES, M. D., Physician to the Hospital for Sick CMliren, London, etc.. On Some Disorders of the Nervous System in Childhood. 12mo. volume of 127 pages. Cloth, $1.00. In one small CONDIE'S PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Sixth edition, re- vised and augmented. In one octavo volume of 779 pages. Cloth, $5.25; leather, $6.26. Lea Brothers & Co.'s Publications— Med. Juriu.» AlLicol. 31 TIDY, CHARLES MEYMOTT, M. B„ F. C. S., Profess r > TAYLOB, ALFBEJD S., M. D., Lecturer on Medical Jurisprudence and VhemiMrxi in (?»;/'« Hospital, London. Poisons in Relation to Medical Jurisprudence and Medicine, Tliird American, from the third and revised English edition. In one large octavo volume of 788 pages. Cloth, $5.50; leather, $6.50. By the Same Author. A Manual of Medical Jurisprudence. Eighth American from the tenth Lon- don edition, thoroughly revised and rewritten. Edited by John J. Keese, M. D. In one large octavo volume. PEPPER, AUGUSTUS J., M. S., M. B., F. R. C. S., Examiner in Forensic Medicine at the University of Ijondon. Forensic Medicine. In one pocket-size 12mo. volume. Preparing. See Students' Series of Manuals, below. STUDENTS' SERIES OF MANUALS. A Series of Fifteen Manuals, for the use of Students and Practitioners of Medicine and Surgery, written by eminent Teachers or Examiners, and issued in pocket-size 12mo volumes of 300-540 pages, richly illustrated and at a low price. The following volumes are now ready: Tbevf.s' Manual of isur- gery, by various writers, in Ihree volumes, each, $2; Bei.i.'s Comparative Phvsio ogy and Anatomy, 82; Gould's Surgical Diagnosis. 82; Robertson's Physiological Physics. 82; Bruce's Materia Medica and Thern- peutics (4th edition), $1.50; Power's Human Physiology (2'd edition), $1.50; Clarke and Lockwuod's Diisectors' Manual, 81-50; Ralfe's Clinical Chemistry, 81-50; Treves' Surgical Applied Anatomy, $2; Pepper's Surgical Pathology, $2 ; and Klein's Elements of Histology (4th edition), $1.75. The following is in press : Pepper's Forensic Medicine. For separate notices see index on last page. SERIES OF CLINICAL MANUALS, In arranging for this Series it has been the design of the publishers to provide the profession with a colleciion of authoritative monographs on important clinical subjects in a cheap and portable form. The volumes will contain about 550 pages and will be freely illustrated by chromo-lithographs and wood- cuts. The following volumes are now ready: Yeo on Food in Health and Disease, $2; Broadiiknt on the Pulse, $1.15; Carter & Frost's Ophthalmic Surgery, 8'-2 25; Hutchinson on Si//jAi/i«, $2.25; Ball on the Rectum and Anus, 82.25; Marsh on the Joints, 82; Owen on Surgical Diseases of Children, $2; Morris on Surgical Disinses of the Kidney, $2.25 ; Pick on FVaetures and Dislocations, $2; Butlin on the Tungue, $i.50; TuEyzs on Intestinal Obstruction, $2; tiud Swage on Insanity and Allied Neuroses,^. The following is in active preparation: Lucas on IHseases of the Urethra. For separate notices see index on last page. LEA, HENRY C, Chapters from the Religious History of Spain.— Censorship of the Press. — Mystics and Illuminati. — The Endemoniadas of Queretaro.— El Santo Nino de la Guardia.— Brianda de Bardaxi. In one 12mo. volume of 522 pages. Cloth, $2.50. Juxt nxuly. In making researches for a History of the Spanish Inquisition the author has been led to investigate various subjects deserving of treatment more elaborate than ctMild be accorded to them in a continuous narrative. These he has worked out in the present vol- ume in the hope that beside the intrinsic interest of the themes themselves, they may serve to explain some of the causes which reduced to impotence a nation that in the sixteenth century aspired to univer.sal monarchy. By the same Author. Superstition and Force : Essays on The Wager of Law. The Wager of Battle, The Ordeal and Torture. Third revised and enlarged edition. In one handsome royal 12mo. volume of 552 pages. Clotli, $2.50. By the Same Author. Studies in Church History. The Rise of the Temporal Power— Ben- efit of Clergy— Excommunication. New edition. In one very handsome roval octavo volume of 605 pages. Cloth, $2.50. ▲Hen's Anatomy ..... 6 American Journal of the Medical Sciences . 3 American Systems of Gynecology and Obstetrics 27 American System of Practical Medicine . . 15 American System of Dentistry - . .24 Ashhurst's Surgery ..... 20 Ashwell on Diseases of Women . . .29 Attfleld's Chemistry ... 9 Ball on the Rectum and Anus . . . 20, 31 Barker's Obstetrical and Clinical Essays, . 29 Barlow's Practice of Medicine . . .17 Barnes' System of Obstetric Medicine . . 29 Bartholow on Electricity .... 17 Basham on Renal Diseases .... 24 Bell's Comparative Physiology and Anatomy . 7, 31 Bellamj-'s Surgical Anatomy ... 6 Berry on the Eye ..... 23 Billings' National Medical Dictionary . . 4 Blandford on Insanity . . . .18 Bloxam's Chemistry . .... 9 Bristowe's Practice of Medicine ... 14 Broadbent on the Pulse . . . . 16, 31 Browne on the Throat, Nose and Ear . . 18 Bruce's Materia Medica and Therapeutics . 12 Brunton's Materia Medica and Therapeutics . 11 Bryant's Practice of Surgery . . . .21 Bumstead and Taylor on Venereal. See Taylor. 2.5 Burnett on the Ear . . . 23 Butlin on the Tongue . . .21,31 Carpenter on the Use and Abuse of Alcohol . 8 Carpenter's Human Physiology ... 8 Carter & Frost's Ophthalmic Surgery . .23,31 Chambers on Diet and Regimen . . . 17 Chapman's Human Physiology ... 8 Charles' Physiological and Pathological Chem. 10 Churchill on Puerperal Fever . . .29 Clarke and Lockwood's Dissectors' Manual . 6, 31 Classen's Quantitative Analysis . . . 10 Cleland's Dissector . .... 6 Clouston on Insanity . ... 19 Clowes' Practical Chemistry ... 10 Coats' Pathology 13 Cohen on the "Throat 18 Coleman's Dental Surgery . . . .24 Condie on Diseases of Children . . .30 Cornil on Sj-philis ..... 25 Dalton on the Circulation .... 7 Dalton's HumanPhysiology ... 8 Davenport on Diseases of Women . . . 28 Davis' Clinical Lectures ... 17 Draper's Medical Physics .... 7 Druitt's Modern Surgery .... 20 Duncan on Diseases of Women . . .28 Dungllson's Medical Dictionary ... 5 Edes' Materia Medica and Therapeutics . 12 £dis on Diseases of Women .... 27 Ellis' Demonstrations of Anatomy . . 7 Emmet's Gynaecology . . . 28 Erichsen's System of Surgery ... 21 Farquharson's Therapeutics and Mat. Med. . 12 Flnlayson's Clinical Diagnosis . . .16 Flint on Auscultation and Percuasion . . 18 Flint on Phthisis 18 Flint on Respiratorj' Organs ... 18 Flint on the Heart 18 Flint's Essaj-s 18 Flint's Practice of Medicine ... 14 Folsom's Laws of TJ. S. on Custody of Insane . 19 Foster's Physiology ..... 8 Fothergill's Handbook of Treatment • . 16 Fownes' Elementary Chemistry ... 9 Fox on Diseases of the Skin . ... 26 Frankland and Japp's Inorganic Chemistry . 9 Fuller on the Lungs and Air Passages . . 18 Gant's Student's Surgery ... .20 Gibney's Orthopaedic Surgery . 20 Gould s Surgical Diagnosis . . . .21,31 Gray's Anatomy . . . . . .5 Greene's Medical Chemistry .... 9 Green's Pathology and Morbid Anatomy . 13 Griffith's Universal Formulary ... 12 Gross on Foreign Bodies in Air- Passages . 18 Gross on Impotence and Sterility . . . 25 Gross on Urinary Organs . . . 25 Gross System otSurgerj' . . . 20 Habershon on the Abdomen . . . 16 Hamilton on Fractures and Dislocations . 22 Hamilton on Nervous Diseases ... 19 Hare's Practical Therapeutics . . .11 Hartshorne's Anatomy and Physiology . . 6 Hartshorne's Conspectus of the Med. Sciences . 3 Hartshorne's Es.sentials of Medicine . . 14 Hermann's Experimental Pharmacology . 11 Hill on Syphilis 25 Hillier's Handbook of Skin Diseases . . 26 Hoblyn's Medical Dictionary ... 3 Hodge on Women .... 28 Hoffmann and Power's Chemical Analysis . 10 Holden's Landmarks ..... 5 Holland's Medical Notes and Reflections . 17 Holmes' Principles and Practice of Surgery . 22 Holmes' System of Surgery . . . 'a Horner's Anatomy and Histology . . 6 Hudson on Fever . ... 4 Hutchinson on Syphilis . . . .25,31 Hyde on the Diseases of the Skin . . .26 Jones (C. Handlield) on Nervous Disorders . 18 Juler's Ophthalmic Science and Practice . 23 King's Manual of Obstetrics . ... 29 Klein's Histology .... .13,31 Landis on Labor ..... 30 La Roche on Pneumonia, Malaria, etc. . La Roche on Yellow Fever . Laurence and Moon's Ophthalmic Surgery Lawson on the Eye, Orbit and Eyelid Lea's Chapters from Religious History of Spain Lea's Studies in Church History Lea's Superstition and Force Lee on Syphilis Lehmann s Chemical Physiology . Leishman's Midwiferj' Lucas on Diseases of the Urethra . Ludlow's Manual of Examinations Lyons on Fe\ er . Maisch's Organic Materia Medica . Marsh on the Joints May on Diseases of Women . Medical News . . , Medical News Visiting List . Medical News Phj^sicians' Ledger . Meigs on Childbed Fever Miller's Practice of Surgery . . . Miller's Principles of Surgery Mitchell's Nervous Diseases of Women . Morris on Diseases of the Kidney . National Dispensatory National Medical Dictionary Neill and Smith's Compendium of Med. Scl. Nettleship on Diseases of the Eye . . Norris and Oliver on the Eye Owen on Diseases of Children Parrish's Practical Pharmacy . . Parry on Extra-Uterine Pregnancy Parvin's Midwifery Pavy on Digestion and its Disorders PajTie's General Pathology . Pepper's System of Medicine Pepper's Forensic Medicine . Pepper's Surgical Pathology Pick on Fractures and Dislocations Pirrie's System of Surgery . Playfair on Nerve Prostration and Hysteria Playfair's Midwifery .... Politzer on the Ear and its Diseases Power's Human Physiology . Purdy on Bright's Disease and Allied Affections Ralfe's Clinical Chemistry Ramsbotham on Parturition Remsen's Theoretical Chemistry . Reynolds' System of Medicine Richardson's Preventive Medicine Roberts on Uriuary Diseases . . Roberts' Compend of Anatomy Roberts' Surgery .... Robertson's Physiological Physics Ross on Nervous Diseases Savage on Insanity, including Hysteria . Schafer's Essentials of Histology, Schreiber on Massage . Seller on the Throat. Nose and Naso-Pharynx Senn's Surgical Bacteriology Series ol Clinical Manuals Simon's Manual of Chemistry Slade on Diphtheria .... Smith (Edward) on Consumption . Smith (J. Lewis) on Children Smith's Operative Surgery Stille on Cholera .... Stilli5