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THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 PRESENTED BY 
 
 PROF. CHARLES A. KOFOID AND 
 
 MRS. PRUDENCE W. KOFOID 
 
PATHOLOGICAL 
 ANATOMY OF THE EAR. 
 
 BY 
 
 HERMANN SCHWARTZE, M. D., 
 
 PROFESSOR IN THE UMVERSITY OF HALLE a./S. 
 
 WITH THE AUTHOR'S RE VIS 10 XS AND ADDITIONS, AND 
 WITH THE ORIGINAL ILLUSTRATIONS. 
 
 TRANSLATED BY 
 
 J. ORNE GREEN, A. M., M. D., 
 
 BOSTON: 
 
 HOUGHTON, OSGOOD AND COMPANY. 
 
 GTbe Kibcrsitic Press, CambriUsc 
 
 1878. 
 
Copyright, 1878, 
 Br J. ORNE GREEN. 
 
 All rights reserved. 
 
 RIVERSIDE, CAMBRIDGE: 
 ELECTBOTTPED AND PRINTED 
 H. 0. HOOGHION AND COMPANY. 
 
■RFIQB 
 
 TRANSLATOR'S PREFACE. 
 
 Schwartze's " Pathological Anatomy of the Ear" 
 constitutes the sixth part of Kleb's " Handbook of 
 Pathological Anatomy." It is the only comprehen- 
 sive work strictly devoted to the pathological anat- 
 omy of this organ, and on account of the opportu- 
 nities and devotion of the author in this special 
 field, his well-known thoroughness and strict impar- 
 tiality in scientific researches, it is a most valuable 
 addition to the literature of otology. It is essen- 
 tially a hand-book on the subject of which it treats, 
 a small amount of space often sufficing to give the 
 results of researches, the laboriousness of which can 
 only be appreciated by those who have been engaged 
 in similar work. 
 
 The translation is issued, both to show what has 
 already been accomplished in this branch of otology, 
 and with the hope of directing still further attention 
 to pathological anatomy, the only solid foundation 
 for a still further advance in our knowledge of dis- 
 eases of the ear. It has been the object to repro- 
 
iv TRANSLATOR'S PREFACE. 
 
 cliice the work in the same concise language as the 
 original, together with the additions and corrections 
 which the author has made since the publication of 
 the German edition. The histology of the ear, to 
 which reference is often made, will be found fully 
 described in Strieker's " Manual of Histology " and 
 Koelliker's " Hand-book of Histology." 
 
 On account of the large number of references, 
 abbreviations are freely used. The first citation of 
 a work will be found with the full title ; in further 
 citations of the same work, abbreviations are often 
 used. Among the most frequent of these abbrevia- 
 tions are A. f. 0., for the Archiv fur Ohrenheilkunde, 
 M. f. 0., for the Monatschrift fur Ohrenheilkunde, 
 and A. f. A. und 0., for the Archives of Ophthalmol- 
 ogy and Otology. 
 
CONTENTS. 
 
 Page 
 
 Literature 1 
 
 ixtroductiox 2 
 
 Method of Dissection 5 
 
 The Temporal Boxe in general 8 
 
 Malformations ......... 8 
 
 Rarefaction 9 
 
 Hyperasmia . . . . . . . . .10 
 
 Atrophy 10 
 
 Osteoporosis . . . . . . . . .11 
 
 Hyperostosis . . . . . . . . . 11 
 
 Caries and Necrosis . . . . . . . .11 
 
 Fracture 19 
 
 New Growths ......... ilO 
 
 Exostoses 20 
 
 Tubercle 21 
 
 Cholesteatoma 21 
 
 Malignant Tumors ....... 26 
 
 The Auricle 28 
 
 INIalformations 28 
 
 Othoematoma . . . . . . . • - 35 
 
 Inflammations ......... 36 
 
 New Growths . . . . . . . . . 37 
 
 The External Meatus 38 
 
 ]\Ial formations ......... 38 
 
 Hyperemia and Hemorrhage ...... 40 
 
 Inflammations and their Results . . . . . 41 
 
 Erythema . . . . . . . . .42 
 
 Eczema ......... 42 
 
 Furuncle ......... 43 
 
 Ulceration ......... 46 
 
VI CONTENTS. 
 
 Collapse 47 
 
 Hyperostosis . . . . . . . , .47 
 
 Caries and Necrosis . . . . . . . . 47 
 
 Anomalies of Secretion 48 
 
 New Growths 50 
 
 Concretions ......... 50 
 
 Encysted Tumor . . » . . . . 50 
 
 Milium 50 
 
 AVarts 50 
 
 Polypi 50 
 
 Exostoses ......... 51 
 
 Epithelioma . . . . . . . . .52 
 
 Cholesteatoma . . <, . . . . . 52 
 
 Enchondroma ........ 53 
 
 Cylindroma . . « . . . . . 53 
 
 Injuries 54 
 
 Parasites ......... 54 
 
 The Drum-membrane 57 
 
 General Remarks 57 
 
 Malformations ......... 58 
 
 Hyperaemia ......... 61 
 
 Hemorrhage . . . . . . . . .02 
 
 Inflammation and its Residts ...... 63 
 
 (1.) Anomalies of Color and Transparency, Thickening, 
 
 Opacity, and Calcification 66 
 
 (2.) Anomalies of Curvature . . . . . 67 
 (3.) Perforation and Cicatricial Formation . . .76 
 
 (4.) Detachment of the Manubrium .... 82 
 
 (5.) Abscess 84 
 
 (6.) Ulceration 84 
 
 (7.) Anomalies of the Membrana Flaccida Shrapneli . 85 
 
 Atrophy (hernia and emphysema) ..... 85 
 
 New Growths 86 
 
 Epithelioma ....... 86 
 
 Cholesteatoma 87 
 
 Tubercle 88 
 
 Rupture 89 
 
 Fracture of the Manubrium 90 
 
 The Tympanum 90 
 
 General Remarks ........ 90 
 
 Malformations ......... 92 
 
 Hypercemia and Hemorrhage ...... 93 
 
CONTENTS. 
 
 Vll 
 
 Catarrhal Inflammation 
 
 (1.) Serous Catarrh ...... 
 
 (2.) Mucous Catarrh ...... 
 
 (3.) Purulent Catarrh 
 
 Croupous and Diphtheritic Inflammation 
 
 Caseous Inflammation ....... 
 
 Adhesive Inflammation ...... 
 
 Sclerosis 
 
 Caries of the Tympanum 
 
 Pathological Changes of the Ossicles and their Articulations 
 Pathological Changes of the Tympanic Muscles . 
 Injuries .......... 
 
 Foreign Bodies 
 
 New Growths ......... 
 
 Aural Polypi ....... 
 
 Cholesteatoma ........ 
 
 Exostoses ........ 
 
 Hyperostoses ........ 
 
 Cysts . ' 
 
 Epithelial Cancer ....... 
 
 Osteosarcoma ....... 
 
 Tubercle ......... 
 
 95 
 96 
 97 
 100 
 103 
 104 
 105 
 111 
 113 
 114 
 122 
 123 
 123 
 124 
 124 
 128 
 128 
 129 
 129 
 129 
 129 
 130 
 
 The Eustachian Tube 
 
 General Remarks .... 
 Malformations ..... 
 Hyperasmia and Hemorrhage . 
 Inflammation .... 
 
 Ulceration 
 
 Contraction and Enlargment 
 
 Adhesions 
 
 New Growths .... 
 
 Polypi 
 
 Exostoses .... 
 Foreign Bodies .... 
 
 Pathological Changes in the Tubal Muscles . 
 
 130 
 130 
 132 
 132 
 133 
 135 
 137 
 139 
 141 
 141 
 141 
 141 
 142 
 
 The Mastoid Process 142 
 
 General Remarks 142 
 
 Malformations ......... 143 
 
 HyperjEniia and Hemorrhage . . . . . .144 
 
 Catarrhal Inflammation of the Pneumatic Cells of the Bone . 144 
 Periostitis Externa ........ 145 
 
 Caries and Necrosis 146 
 
Vlll CONTENTS. 
 
 Eburnation (Sclerosis) ....... 149 
 
 P'raeture 149 
 
 New Growths . . . . . . . . .150 
 
 Polypi 150 
 
 Cholesteatoma . . . . . . . .150 
 
 Epithelial Cancer ....... 150 
 
 The Ixnkr Ear and Auditory Nerve . . . .151 
 
 General Keniarks 151 
 
 Malformations . . . . . . . . .154 
 
 Antemia .......... 155 
 
 Hypera^mia . . . . . . . . .156 
 
 Hemorrhage . . . . . . . . .157 
 
 Inflammation and its Results . . . . . .158 
 
 Caries and Necrosis ........ 1G2 
 
 New Growths . . . . . . . . . 1G5 
 
 Injuries . . . . . . . . 1G6 
 
 Diseases of the Auditory Nerve between its Central Origin 
 and its entrance into the Labyrinth . . . .167 
 
THE 
 
 PATHOLOGICAL AMTOMY OF THE EAR. 
 
 LITERATURE. 
 
 Duverney, Traite de I'Organe de I'Ouie. Paris, 1683. — Bauliinus, 
 Diss, de Auditus Lajsioiie. Basel, 1687. — Valsalra, De Aure Humana. 
 Bonn, 1704. — Rlviniis, De Auditus Yitiis. Leipzig, 1717. — Morffaf/ni, 
 De Sedibus et Causis Morborum. 1766. — Lieutaud, Historia Anatomi- 
 co-Med. 1767. (This contains in the fourth book, under Auris LfEsiones, 
 five very short clinical communications on the collection of mucus in the 
 inner ear cavities of children, on the collection of pus in the tympanum, 
 on thickening of the tympanic lining membrane, on thickening of the 
 drum-membrane, and on congenital absence of the incus in a deaf mute; 
 all collected from foreign authors, Fabricius ab Aquapendente, Mor- 
 gagni, etc. Also in the third book are two cases of caries ossis petrosi, 
 Xos. 108 and 4D6.) 
 
 KoJiIer, Beschreibung der Loderschen Sammlung. Leipzig, 1795 (con- 
 taining, on pages 146-160, only descriptions of normal preparations). — 
 Vuigtel, Handbuch der Pathologischen Anatomie. Halle, 1804. — Saun- 
 ders, J. C, The Anatomy of the Human Ear, illustrated by a series of 
 engravings of the natural size ; with a Treatise on the Diseases of that 
 Organ, etc. London, 1806. Second edition, London, 1817. Third edi- 
 tion, London, 1829. — Olio, Handbuch der Pathologischen Anatomie des 
 Menschen und der Thiere. Breslau, 1814. S. 39-41. S. 180-185.— 
 Meckel, J. F. Handbuch der Menschlichen Anatomie. Halle and Berlin, 
 1815. — i^/ewc/^maHn, Leichenoffnungen. Erlangen, 1815. S. 250. (Case 
 of osteo-sclerosis of the temporal bone in a deaf mute.) — Otto, Seltene 
 Beobachtungen zur Anatomie, Physiologic und Pathologic gehorig. I. 
 Heft. Breslau, 1816. S. Ill, 112. (Describes the closure of the Eusta- 
 chian tube by hardened mucus and the collection of a thick, clear, jelly- 
 like mass in the tympanum and in the labyrinth as the most common path- 
 ological conditions. Once he found adhesion of the ostium pharyngeum 
 
2 PATHOLOGY OF THE EAR. 
 
 tiibaa, and once he found the tympanutn filled with pseudo-membranes. — 
 lUird, Traite des Maladies de 1' Oreille. Paris, 1821. — 0/?o, Xeue sel- 
 tene Beobachtungen zur Anatomie, Physiologic und Pathologie gehorig. 
 Berlin, 1824. S. 4, 9G, 97. — Beck, Krankheiten des Gehororgans. Frei- 
 burg, 1827. — Saissy, Essai sur les Maladies de I'Oreille interne. Paris, 
 1827. — WitUjenstein, 'SoxinuW^. de Anatomia Auris Pathologica. Diss. 
 Inaug. Berlin, 1831. — Cruoeilhier, Anatomie Pathologique du Corps 
 Humain. 2 vols. Text and Atlas. Paris, 1^32-42. — Lincke, Handbuch 
 der Ohrenheilkunde. Leipzig, 1837. Bd. I. S. b'td-&bZ. — Hyrll, 
 Beitrage zur Pathologischen Anatomie des Gehororgans. Oesterr. Med. 
 Jahrb. XI. 1838, and in other places. — Ammon, Angeborene chirurg. 
 Krankheiten des Menschen. Mit Tafeln. Berlin, 1840. — PappenJieim, 
 Specielle Gewebelehre des Gehororgans. 1840. — Nuhn, Commentatio 
 de Yitiis, quaj Surdo-Mutitati subesse solent. Heidelberg, 1841. — 
 Bochdalek, Pathologisch-anatomische Untersuchungen der Gelior- und 
 Sprachwerkzeuge bei Taubstummen. OesteiT. Med. Jahrb. 1842, and 
 in other places. — Kuh, Klinische Beitrage zur Kenntniss der Entziin- 
 
 dung der inneren Abtheilungen des Gehororgans. Breslau, 1847 
 
 Guckelherger, Beitrage zur Pathologischen Anatomie der Entziindung des 
 Hcirorgans. Zeitschr. fiir Chir. und Geburtsh. VII. 3. 1854. — Rau, 
 Lehi'buch der Ohrenheilkunde. Berlin, 185G. — Stanley, £■(/?<?., Results 
 of Fifty-six Dissections of the Ear. Med. -Chirurg. Transactions, vol. 
 39. 1856. — Toynhee, Catalogue of Museum. 1857. — Von Troeltsch, 
 Anatomie des Ohres. 1860. 
 
 Also the text books of otology by Wilde (1853), Toynbee (1860), 
 Bonnafont (1860), Von Troeltsch (1st edition, 1862, 6th edhion, 1877), 
 Moos (1866), Gruber (1870), etc.; the special journals for ear-diseases, 
 viz., Archiv fiir Ohrenheilkunde, Monatschrift fiir Ohrenheilkunde, An- 
 nales des Maladies de I'Oreille et du Larynx, Archives of Ophthalmol- 
 ogy and Otology; Virchow's Archiv fiir Pathologische Anatomie, Archiv 
 fiir Phys. Heilkunde von Wagner, Med. Chirurg. Transactions, Guy's 
 Hosjiital Reports and articles distributed in innumerable other journals. 
 
 Joseph Toynbee (f 1866) is considered the founder 
 of the pathological anatomy of the ear. He was the 
 first who, in a thorough and systematic manner, de- 
 termined the principal pathological changes and es- 
 tablished the fact that the majority of these changes 
 were situated in the tympanum, or, as it is more com- 
 monly expressed, in the middle ear. 
 
 Toynbee published the results of his numerous dis- 
 
INTRODUCTION. 3 
 
 sections in the Medico-Cliirurgical Transactions (1841- 
 1855), and in the Transactions of the Pathological 
 Society of London (1849-1856). Somewhat later 
 (1857) they were given in an independent work with 
 the title " A Descriptive Catalogue of Preparations 
 Illustrative of the Diseases of the Ear in the Musenm 
 of Joseph Toynbee," and also in his work " Diseases 
 of the Ear, their Nature and Treatment," which ap- 
 peared in 1860'.^ 
 
 All that had been done towards the anatomical 
 foundation of aural pathology by the few physicians 
 and anatomists before Toynbee, is but little compared 
 with the mass of his material, and although the scat- 
 tered facts which have been made known by Val- 
 salva, Duverney, Morgagni, Itard, Hyrtl, and others, 
 are of value, still i\\Qy are separated, few in number, 
 and relate chiefly to such aural affections as are asso- 
 ciated with otorrhoea and lead to direct flital results. 
 
 In the further development of the pathological an- 
 atomy of the ear, after Toynbee, German physicians 
 have been principally active, not the anatomists, how- 
 ever, but practicing physicians (Von Troeltsch, Volto- 
 lini, Lucae, Politzer, Gruber, Magnus, Zaufal, Moos, 
 
 1 The Toynbee collection of pathological preparations of the ear con- 
 sists of more than eight hundred specimens, mostly dry, and is now in 
 Hunter's Museum of the College of Surgeons, London. In Germany, 
 except numerous private collections of individual teachers, there only 
 exists, so far as I know, a single large public collection, namely, in the 
 Pathological Institute of Leipzig, where it was formed by the late Wendt 
 and placed under the care of Prof. E. Wagner. For the beginner the 
 inspection of such large collections and of the best preparations is not of 
 so mucli value as personal dissection. The examination of ear prepara- 
 tions is of the most use for him who made them; for another observer 
 only of value when a number of preparations are placed together for 
 examination of some particular point. 
 
4 PATHOLOGY OF THE EAR. 
 
 Wendt (t 1875), Kessel, and many others). The 
 work of the anatomists is confined to some isolated 
 facts which have been communicated incidentally by 
 Yon Meckel, Otto, Bochdalek, Yirchow, A. Bottcher, 
 C. E. E. Hoffman, Klebs, Heller, and others. Among 
 the non-German authors, Bonnafont and Hinton 
 (t 1875) should be placed in the front rank. In path- 
 ological histology of the middle ear, Wendt had la- 
 ])ored with particularly good results of late years, 
 but has unfortunately been called from his work by 
 an unexpected early death. The pathological his- 
 tology of the labj'rinth of the ear is still in the first 
 stages of its development, and needs the services of 
 an extraordinary anatomist who must w^ork deeply 
 and thoroughly in this most difficult field for years 
 to bring forth any result. What has been done by 
 some in this field, of late years, with the most earnest 
 endeavors, is scarcely more than a sad dilettanteism, 
 and has no special value for science. 
 
 A systematic compilation and revision of the path- 
 ological anatomy of the ear has not been attempted 
 since the work by Lincke, who confined himself al- 
 most entirely to the history of malformations, and on 
 this account I must bee? indulg-ence for anv incom- 
 pleteness or defect in my work. I desire, however, 
 to lay special stress on the trustworthiness of all the 
 facts which are stated, and to the literary complete- 
 ness of all cited publications. Where the stated facts 
 are not derived from personal observation and in- 
 vestigation, the result of nearly twenty years' ex- 
 perience in the anatomical and practical study of 
 the human ear, the name of my authority is given 
 in brackets. 
 
DISSECTWX OF THE EAR. 5 
 
 A typically normal ear is comparatively seldom 
 found in dissection. In most cases abnormal condi- 
 tions of congestion and secretion, especially in the 
 middle ear, are met with which are certainly in the 
 majority of cases to be considered as phenomena 
 brought on during the agony, or else as having oc- 
 curred post-mortem. These changes are quite regu- 
 larly found in the bodies of those persons who have 
 died from heart and lung diseases and are the result 
 of venous congestion in the branches of the vena 
 cava superior. It is therefore necessary to avoid lay- 
 ing too great a clinical value on these insignificant 
 pathological alterations, especially if they are found 
 on both sides. 
 
 The diseases which most frequently affect the ear 
 are the acute exanthemata, typhus, acute and chronic 
 catarrh of the nose and naso-pharynx with their re- 
 sults, tuberculosis, diseases of the heart, syphilis, 
 puerperal fever, and chronic alcoholismus. 
 
 In dissecting the ear it is absolutely necessary for 
 the beginner to fix upon a regular method of prepa- 
 ration in order that important parts may not be for- 
 gotten, or destroyed during the dissection. 
 
 The following is the method of dissecting given by 
 Professor Lucae : — 
 
 I. Removed of the Temporal Bone with the tvhole Ear from the 
 Skull. A small chisel is driven downwards transversely through the 
 sella turcica between the processus clinoideus medior and anterior, 
 and again a second time through the centre of the eminence of 
 Blumenbach. Into the first openmg a small Langenbeck's resec- 
 tion-saw is inserted perpendicularly, and the bone is then sawn out- 
 wards through the body, and greater wing of the sphenoid to the 
 foramen rotundum of the sphenoid. The direction is then changed 
 slightly backwards and outwards, and the cut continued through the 
 
6 PATHOLOGY OF THE EAR. 
 
 bone, parallel with the crista ossis jje'-.rosi, to the point where the 
 squamous portion of the bone bends upwards. The saw is then to 
 be inserted in the opening already made with the chisel in the emi- 
 nence of Blumenbach and a cut made outwards and backwards, be- 
 hind and parallel with the crista ossis petrosi, through the condyloid 
 l^rocess of the occipital bone and for a part of the way in the lateral 
 sinus, the cut ending at the spot where the lateral sinus turns back- 
 wards. These two cuts are then to be united by a third cut wliich 
 should divide the crista ossis petrosi perpendicularly about one line 
 behind the point of union of the posterior and middle third of the 
 crista. 
 
 If it is desirable to remove both temporal bones the same proced- 
 ure is to be carried out on the other side. If only one petrous bone 
 is to be removed the two openings which were made with the chisel 
 at the beginning are united by a medial cut, the loosened bone 
 seized with forceps, raised up and dissected from the soft parts. 
 
 II. Dissection of the Ear. The anterior wall of the external 
 meatus should be removed with scissors and gouge-forceps up to 
 the membrana tympani. The osseous roof of the mastoid cells, of 
 the tympanum and of the osseous Eustachian tube should then be 
 chipped away with the gouge-forceps, or a small hook-shaped knife. 
 The cartilaginous, muscular Eustachian tube should be opened from 
 its pharyngeal orifice. For a thorough examination of the tym- 
 panum, including the ossicula, membrana tympani, tympanic mus- 
 cles and nervus facialis, the mode of procedure is as follows : the 
 tendon of the musculus tensor tympani and the articulation of the 
 incus and stapes should be divided by a delicate knife ; the pyramid 
 should then be separated from the osseous structures surrounding 
 the drum membrane and external meatus by sawing parallel with 
 the crista ossis petrosi nearly but not quite into the tympanum ; 
 this cut should begin behind the styloid process and run along the 
 anterior wall of the canalis caroticus. A light blow with a chisel 
 in the cut thus made with the saw will now separate the portions 
 of bone. The soft structures can then be dissected. 
 
 To examine the inner ear rapidly, saw along the whole length of 
 the pyramid parallel with the crista ossis petrosi through the vertex 
 of the upper semicircular canal ; this cut runs along the posterior* 
 wall of the canalis caroticus. Draw out from the porus acusticus in- 
 ternus the facial and auditory nerves and examine the exposed coch- 
 
DISSECTION OF THE EAR. 7 
 
 lea and vestibule. For a more accurate examiuation of the inner 
 ear remove the roof of the porus acusticus internus with the i^ouo-e- 
 forceps, then open the vestibule from above by a small hand-trephine. 
 After opening the osseous semicircular canals divide the membra- 
 nous canals with scissors and remove from the vestibule the mem- 
 branous utricle together with the membranous semicircular canals.^ 
 Expose the cochlea, which is bounded anteriorly and inwardly by 
 the fundus of the porus acusticus internus, by gradually chipping 
 away the bony mass surrounding it. 
 
 Besides the above method of Lucse minute directions 
 for dissection of the ear have been given by Toynbee,^ 
 Yon Troeltsch/ VoltoHni/ Wendt,^ and others which 
 can be recommended to the beginner as standard 
 procedures. The great difficulty of the dissection is 
 first met in the ipner ear, and can only be overcome 
 here by great patience and practice. The membra- 
 nous tissues of the labyrinth retain their structure 
 much longer than is usually supposed ; in the prepa- 
 ration of these tissues a light yellow solution of potass 
 chromate, or Mullers fluid, is recommended for their 
 preservation. I recommend the following method of 
 procedure as very well adapted to the examination 
 of the inner ear : — 
 
 Tlie trunk of the auditory nerve is followed to the point of sub- 
 division by breaking away the meatus auditorius internus above it. 
 In a microscopical examination of the nerve it is recommended that 
 it be compared with other nerve trunks (fticialis). The vestibule 
 and cochlea should be opened from above by gradually chipping 
 away the osseous roof with a chisel. The vestibule lies laterally 
 
 1 See the method described in Yirchow's ArcTdv, vol. xxix. 
 
 2 Toynbee, Diseases of the Ear, p. 6. 
 
 3 Von Troeltsch, Yirchow's Archiv, xiii., 513. Lelirhuch der Ohren- 
 heilkunde, 6 Aufl., S. 587. 
 
 * Yoltolini, Zerlegung und Unlersuchung des Gehororgans an der Leiche. 
 Habilliationsschrift, Breslau, 1862. 
 
 ^ Wendt, Archie fiir Heilkunde von E. Wagner, xiii., S 120. 
 
8 PATHOLOGY OF THE EAR. 
 
 from the facial nerve, that is, towards the squamous bone. Before 
 reaching the vestibule the upper semicircular canal will be opened 
 and the membranous canal should be cut through and drawn out. 
 After laying open the vestibule the membranous labyrinth is ex- 
 posed and should be removed with the other semicircular canals. 
 As soon as the osseous roof of the cochlea is chiselled away the base 
 of the modiolus, which lies towards the porus acusticus internus, 
 should be broken off, and the whole cochlea with the spiral lamina 
 lifted out. A careful dissection with needles is necessary for this. 
 The contents of the cochlea thus removed should now be placed in a 
 one per cent, solution of salt, aqueous humor, or perosmic acid, 0.1- 
 1 per cent., and laid aside for microscopical examination. 
 
 There remains now only to examine the plate of the stapes and 
 to expose the membrana tympani secundaria on its inner surface. 
 The sawing open of the whole pars petrosa should be avoided if it 
 is desirable to obtain a knowledge of the finer relations of the parts. 
 The use of the saw is only allowable for the removal of the petrous 
 bone from the skull, and should, as far as possible, be confined to 
 this. The fret-saw for the removal of the bone from the base of 
 the skull has the disadvantage that it is very easily broken, and its 
 use requires great practice. Compass-saws are better adapted for 
 the work, but the soft structures are too easily crushed by them. 
 The most useful instruments are chisel and hammer, Liier's gouge- 
 forceps, and, for the finer work on the bone, a graver. 
 
 THE TEMPORAL BONE. 
 
 Malformations. In the peculicarities of formation in 
 the temporal bone numerous individual differences 
 exist, some of which are unimportant, while on some 
 others it is possible that the fate of the individual 
 may depend. They may form the foundation for a 
 hereditary predisposition to certain diseases of the 
 ear itself,^ or also favor fatal secondary disease of the 
 brain. 
 
 1 From a hereditary unfavorable formation of the osseous middle ear, 
 (Von Trot'ltsi-h). A slight depth of the niches of the labyrinthine fone?i- 
 tra3 favors the retrogression of the swelling and duplicatures of the 
 
THE TEMPORAL BONE. 9 
 
 A complete absence of the whole temporal bone is 
 never found, but in some monsters a union of the two 
 ears is seen, and in double monsters with a single 
 head there may be a reduplication of the temporal 
 bones.^ 
 
 In hydrocephalus the temporal bone is turned 
 downwards and arched ; the meatus is directed down- 
 wards. 
 
 Defects of certain parts from arrest of development 
 are very common, on one or both sides. They may 
 embrace all or only certain portions of the ear (most 
 frequently the external and middle ear), while the 
 other portions are well developed. With a well- 
 formed external ear there may be arrest in the devel- 
 opment of the inner ear and nice versa? 
 
 Ossification Defects (rarefaction, opening) are among 
 the most common inherited irregularities. They are 
 especially frequent in the tegmen tympani ^ with a 
 perfectly normal dura mater, but are also found in 
 the canalis caroticus, in the canalis facialis, in the 
 floor of the tympanum, in the cortical substance of 
 the processus mastoideus, in the osseous roof of the 
 superior semicircular canal, and in the form of a 
 fissure of the squamous portion of the bone; in el- 
 derly persons they are also seen in the form of pits 
 
 mucous membrane, wlule a greater depth of these niches, particuhirly of 
 the fenestra oralis, is unfavorable for this healing process. 
 
 ^ Carl Langer, Zur Anatomie des Gehororgans doppelleihlger Missge- 
 hurten. Oesterr. Med. Wochenschrift, 1846, No. 21. 
 
 2 The earlier observations on malformations of the temporal bone, up 
 to the year 1837, are collected in Lincke's Handbuch der Ohrenlie'd- 
 kiinde, i., 582-611. For the later literature see p. 28, under "Au- 
 ricle." 
 
 3 Instead of absolute gaps in the bony tissue, the roof of the tym- 
 panum often contains cavities filled with reddish gelatinous tissue. 
 
10 
 
 PATHOLOGY OF THE EAR. 
 
 in the course of the fissura petroso-squamosaj and on 
 the inner snrfoce of the squamous bone, where they 
 
 reach the size of a bean, 
 and in their position cor- 
 respond to the Pacchio- 
 nian bodies. Aside from 
 the possibihty of mistak- 
 ing these defects in ossifi- 
 cation for carious destruc- 
 tion they have a great 
 practical importance be- 
 cause they favor the ex- 
 tension of inflammatory 
 processes from the ear to 
 the brain. 
 
 Pneumaticity of the pars 
 petrosa is understood to 
 be the existence of anom- 
 alous cavities in the bone. 
 
 Congenital Defect of the Bone on the ^^,|^-^1^ ^^.^ f^^lecl with air 
 upper surface of the pars petrosa near its 
 
 apex, and also in the sigmoid shius; otitis Or witll a gclatiuOUS red 
 
 media purulenta acuta without perforation x- ThpV SUrrOUnd the 
 
 of the drum membrane, resulting in fatal LlSSUC. 1 UCy SUrrOUnU lUe 
 
 basilar meningitis, a. Porus acusticus in- labvriuth OU all sidcS, CX- 
 
 ternus. b, c. Gaps in the upper surface , "t i ii 
 
 of the petrous bone. d. Gaps in the sulcus tcnduig CVCU tO thc UppCr 
 
 transversus. ^yr^\\ of the mcatus audi- 
 
 torius, and are in direct connection with the mastoid 
 cells. 
 
 Hypersemia of the petrous bone in which the tissue 
 of the bone is very rich in blood, and when looked 
 at through the dura mater often appears of a bluish 
 red color, is very common m typhus, and is also seen 
 in variola. 
 
 A general atrophy of the bone, in which it appears 
 
THE TEMPORAL BONE. 11 
 
 abnormally light in weight and fragile, occurs in old 
 age and with lues, tumors of the brain, and from other 
 unknown causes (for instance, in connection with an- 
 chylosis of the stapes). 
 
 Osteoporosis occurs in old age and produces open- 
 ings in the bone of the anterior wall of the meatus 
 (Von Troeltsch). 
 
 Hyperostosis, in which the temporal bone appears 
 very heavy and massive, its processes larger and 
 fuller, its openings and capillary canals smaller and 
 narrower than natural, is generally combined with a 
 universal hyperostosis of the skull (syphilis, old age), 
 but it may be confined to certain parts of the petrous 
 bone, as the meatus extern us, processus mastoideus, 
 tuba Eustachii, canalis caroticus, and it is then fre- 
 quently the result of continuous hypersemia and long 
 existing suppurative processes (with caries). 
 
 If the hyperostosis is the result of ossifying perios- 
 titis in foetal life or early childhood, it always leads to 
 great deafness and deafmutism. The labyrinthine 
 fenestrge are then found closed by ossification, the 
 ossicula anchylosed into one mass, the labyrinthine 
 cavities diminished in size, deposits of lime lie in 
 the meatus internus and on the saccule of the ves- 
 tibule, etc. 
 
 Friedreich ^ describes a hyperostosis of the petrous 
 bone in a case of congenital unilateral hypertrophy 
 of the head. 
 
 Caries and Necrosis. 
 
 Literature up to 1830 will be found in Lehrbuch der Pathologischen 
 Anatomic von Olto. S. 174. — Krukenherg, Jahrbiicher der Ambulator. 
 Klinik zu Halle. Bd. II. S. 203-252. Halle, 1824. —Wulzer, Schmidt's 
 
 1 VircJioio's Archiv, 28, Heft 5 and 6. 
 
12 
 
 PATHOLOGY OF THE EAR. 
 
 Jalirb. 1834. S. 344. — Bricheteau, Arch. Gen. 1834. December. — 
 WUlemier (resp. Scliroder van der Kolk), Diss. Inaiig. Utrecht, 1835. — 
 CruveiUiier, Anat. Patholog. du Corps Hiimain. 1835-1842. II. Vol. 33. 
 Livraison. Mahxdies du Cerveau. — Albers, Ueber Otorrhoe, Grafe's und 
 Walther's Journal. 1836. — Hamilton, Dublin Journ. 1841. — Hughes, 
 Lancet. 1841. — Smith, Dublin Journ. 1841. — Guckelherger, Zeitschi'. 
 f. Chir. und Geburtsk. VII. 3. l^bl. — Wolf, Preuss. Vereins-Ztg. 1857. 
 Nos. 35, 36. — Meniere, Article on Bony Sequestra observed in the differ- 
 ent Parts of the Ear. Gaz. Med. de Paris. 1857. No. 33. — Hutchinson, 
 Canstatts Jahresber. 1861. 3. S. 50. — /. 6>w&er, Wien. Med. Halle. 
 1863. — OJe?iiM.s, Medicinske Arch. III. 1. 1866. — Von Troeltsch, Anat. 
 Beitrage zur Lehre von der Ohreneiterung. Arch. f. O. IV. S. 97-142. 
 
 1869. — /. Gruher, Zur 
 
 Casuistik der Schliifen- 
 
 / "^-^"~-^ bein-Necrose. M. f. O. 
 
 1874. No. 9. (Case of 
 loss of the whole annulus 
 tympanicus and a portion 
 of the squama through the 
 external meatus, in a child 
 two years old.) — Boeters, 
 Necrose des Gehorlaby- 
 rinths. Diss. Inaug. Halle, 
 
 1875. — Also the already 
 quoted text books of otol- 
 og\' and the sjX'cial jour- 
 nals. 
 
 Caries, or ulcer- 
 ative ostitis, at- 
 tacks, of all the 
 bones of the skull. 
 Fig. 2. the temporal bone 
 
 Carious Perforation of the Anterior Wall of the mOSt frequently ; it 
 
 is very often bilat- 
 
 Pyraniid at the spot where the pars petrosa of the 
 temporal bone passes into the pars squamosa. Cor- 
 responding with this spot on the lower surface of the eral ancl aSSOciatCCl 
 dura mater were masses of granulations, the upper 
 surface of the dura mater being unchanged. Death 
 from pyemia. For history and dissection, see Archiv 
 fiir Ohrenheilk., II., S. 36. 
 
 with simultaneous 
 caries of other 
 bones of the skull. 
 The points of preference for caries are the mastoid pro- 
 cess, the median portion of the upper posterior wall 
 
THE TEMPORAL BONE. 
 
 13 
 
 of the meatus (floor of the antrum mastoideum), and 
 the walls of the tympanum, preferably its roof; less 
 frequently the pars petrosa is attacked and least fre- 
 quently the meatus auditorius internus. Exception- 
 ally extensive caries can exist in the petrous bone. 
 
 Caries Necrotica. In the carious cavity ff, is a loose sequestrum, consisting of 
 tlie greater part of tlie jn'ramid. b. Nervus acusticus. c. Processus conch'loideus 
 of the lower jaw. (/. Dura mater, with granulation-growths upon it, turned back. 
 
 tympanum, tuba, mastoid process, and even in the 
 external meatus, and yet the membrana tympani 
 remain entire, and the ossicles continue in their 
 position.^ Usually, however, the drum-membrane 
 shows a loss of substance or is wholly destroyed. 
 The dura mater covering the bone is generally thick- 
 
 . 1 Already proven by old observations: Lieutard, Hist. Anat. Med., vol. 
 ii., lib. iii., observ. 108. Kuh, Klinische Beitrdge, etc., Fall 2, S. 20. 
 
14 PATHOLOGY OF THE EAR. 
 
 enecl, is frequently but slightly attached to the bone 
 and discolored ; on removing it granulations are 
 found attached to its inner surface, which fill up 
 the carious openings in the osseous substance. 
 
 The caries is generally the secondary result of an 
 acute or chronic suppuration of the soft tissues of the 
 ear, which has extended to the surrounding bone ; 
 seldom is it the result of suppurative ostitis or pri- 
 mary periostitis. Usually the ulcerative process ex- 
 tends from the surface deeper and deeper into the 
 substance of the bone. Frequently on dissection pro- 
 cesses of demarcation are seen, osteosclerosis or osteo- 
 phytes. 
 
 Necrosis is less common than caries; it attacks 
 most frequently the mastoid process, the lower wall 
 of the external meatus, the ossicula and the pyramid. 
 Sometimes the squamous portion of the bone is alone 
 attacked by necrosis and may be thrown off in toto. 
 Cases have even been reported where almost the 
 whole temporal bone has been thrown off by necrosis 
 with retention of life. 
 
 The most common fjital results from these processes 
 are purulent meningitis,^ abscess of the brain,^ sinus- 
 phlebitis with p3^a3mia,^ or combinations of these dis- 
 
 1 Guckelberger, 1. c. Hinton, Med.-Chir. Transactions, xxxix., p. 101, 
 1856. Von Troeltsch, Virchoio's Arch'w, xvii., S. 14. Yoltolini, Ihid., 
 xviii., S. 2. Ulmer, Wiener Med. Halle, 1861, S. 40, 41. Ockel, 
 Petershurger Med. ZeitscJtrift, 1862. Wendt, Archiv. filr Phjs. Heil- 
 kunde von Wagner, 1870, etc. 
 
 2 Lebert, VircJioiu's ArcJiii\ x. Von Troeltsch, Ibid., xvii., S. 42. Gull, 
 Guy's Hospital Reports, 1858. Gruber, Zeitschr. der Wiener Aertze, 1860. 
 Schott, Wurzh. Med. Zeitschr., 1861, S. 462. R. Meyer, Pathologic des 
 Gehirnabscesses, Zurich, 1867; eighteen cases following caries of the pe- 
 trous bone, fourteen on the right, four on the left side. Wendt, 1. c, etc. 
 
 3 Lallemand, Lcttres, iv. § 36. Bruce, London Med. Gaz., vol. xxvii., 
 
THE TEMPORAL BONE. 
 
 15 
 
 eases. Much less common are fatal hemorrhages from 
 carious perforation of the canalis caroticus with ero- 
 sion of the carotis cerebralis/ of the arteria meningea 
 
 Fig. 4. 
 Necrosis of the Pyramid, a. Sinus transversus. i. Nervus acusticus. c. Se- 
 questrum slightly movable on firm pressure, d. Probe in an opening of the laby- 
 rinthine cavity, e. Apex of the pyramid. Death from abscess in the cerebellum. 
 
 p. 608 (an atlmirable article). Sedillot, De V Infection Purulente, 1S48. 
 Toynbee, Med.-Chir. Transactions, 1851, vol. xxxiv. Lebert, Ueher Ent- 
 zilndunf/ der Hirnsinus. Virchow's Arch.,\yL., 1855. Heussy, Ziiricb, 1855. 
 Weill, Strassburg, 1858. Von Duscb, Zeifschr.f. Rat. Med., 1859. Colin, 
 Klinik der Embolischen Gefdsskrankheiten, Berlin, 1860. Von Troeltsch, 
 VircJioto's Arch., xvii., 1, 2. Gruber, Wiener Wochenbl., 1862, Nos. 24, 
 25. Lancereaux, De la Thrombose et de VEmloUe Cerebrate, Paris, 1862. 
 Griesinger, Arch, fur Phys. Heilkunde, 1862. Schwartze, A. f 0., vi., 
 S. 219. Politzcr, Ibid., viii., S. 288. O. Heubner, Arch, fiir Phys. Heil- 
 kunde, ix., 1868. AVreden, Petersb. Med. Zeitschr., xvi., 5, S. 61-137. 
 Wendt, Arch, filr Heilkunde ron Wagner, xi., S. 562. 
 
 1 Kimmel, Observatio Anat. Patholog. de Cnnali Carotico Carie Syphi- 
 litica Exeso, Lipsiae, 1805, witb an illustration. Boinet, Arch, de Me'd., 
 1837. Lavacherie, Bulletin de I' Acad, de Med., 1848, vol. vii., p. 789. San- 
 
16 
 
 PATHOLOGY OF THE EAR. 
 
 media, of the large venous sinuses or of the bulbus 
 venae jugularis. 
 
 By which channels the extension of the purulent 
 inflammation takes place frequently remains uncertain 
 at the autopsy ; in many cases it probably takes place 
 along the course of the veins (aqua^cluctus vestibuli 
 and cochleae), along the folds of the dura mater which 
 _ extend into the fissura 
 
 p e t r o s o - s q u amosa, 
 along the neurilemma 
 of the acusticus or fa- 
 cialis, and also along 
 the connective tissue 
 of the capillary blood- 
 vessels which perfor- 
 ate the bone in all 
 directions (tegmen 
 tympani, hiatus sub- 
 arcuatus). 
 
 Sometimes death 
 results from severe 
 
 where it is impossible 
 
 Fig. 5. 
 
 Caries of tlie Sulcus Transversus produced by b r a i U S y Ul p t O Ul S 
 a very extensive caries of the mastoid pi-ocess. 
 The sinus transversus was very much thinned, 
 but without ulceration. (From Toynbee, " Dis- tO fiud any tiling UlOre 
 eases of the Ear," p. 327.) ,i i • i • ,i 
 
 pathological in the 
 brain than oedema, the causal connection of which 
 with the ear-disease is perhaps very improbable. 
 
 tesson, Htjgiea, Bd. xiv., 1855. Cliassaignac, Trnite de la Suppuration, 
 vol. i., p. 529. Gaz. des Hop., 1857, p. 226. Marc See, Bullet, de la 
 Soc. Anal, de Paris, 1858, p. 6. Toynbee, Med.-Chir. Transactions, xliii., 
 p. 217 to 224, 1861. Baizeau, Gaz. des Hop., 1861, p. 350. Todlliche 
 Ohrhlulung hei Sypliil. Caries, Deutsche Klinik, 1863, No. 23. Boeke, 
 Pestli. Med. Chirwg. Presse, x., 28. A. Hermann, Wien. Med. Woclien- 
 schrift, xvii., 30-32. Pilz (Billroth), Diss. Iiuiitg., Berlin, 1865. Broea, 
 Gaz. des Hop., 1866, No. 53, p. 240. Hynes, The Lancet, 1870, No. 13. 
 Jollv, Arch. Ge'ner. de Mtd., 1870, March. 
 
THE TEMPORAL BONE. 17 
 
 Of late years the views of the relations of caries to 
 abscess of the brain have been decidedly modified. 
 Formerly it was generally thought that the brain- 
 abscess was the primary lesion, and that the pus 
 sought an exit for itself through the cavum tym- 
 pani ; ^ and it was considered to be the rule only in 
 very exceptional cases that the caries of the ear was 
 the primary, and the abscess of the brain the second- 
 ary lesion ; to-day, however, it is almost universally 
 considered that the facts are just the reverse. 
 
 The first who asserted this with confidence was 
 Morgagni.^ He declared, that in the majority of cases 
 the brain aftection was only the result of the caries 
 extending into the cavity of the skull. The opposite 
 process, a suppuration within the skull making an 
 outlet for itself through the ear, although it may per- 
 haps occur, is certainly very rare. 
 
 Only a few authors, as Odenius,^ now hold to the 
 correctness of the old theory for exceptional cases. 
 The possibility of an abscess in the cerebrum or cere- 
 bellum discharging itself through the temporal bone 
 (otorrhoea cerebralis, Itard), cannot certainly be de- 
 
 ^ Otto, Sellene Beohachtungen, etc., il, S. 97, savs: "The abscess, 
 ■which I liave always found only in the nii(hlle cerebral lobe and never in 
 the cerebellum, lies at the lowest point of the whole brain, and the pus 
 must therefore, from the law of gravity, sink and work its way through 
 the bone." 
 
 This theory of an opening of a brain abscess into the tympanic cavity 
 from destruction of its roof or of the mastoid cells, is found even in Rokit- 
 ansky, 3 Aufl., Band 1, 2, S. 460, 1855. 
 
 2 1. c, I., ep. xiv., art. 6. 
 
 ^ The case quoted by Odenius in support of his theory is as follows: 
 After injury to the head an abscess in the right cerebellum with pachy- 
 meningitis ; on the pars petrosa there was a superficial ulceration at the 
 external opening of the aqua;ductus vestibuli while the inner ear showed 
 only very slight signs of disease. Medicinske Archiv, iii., i., No. 4. 
 2 
 
18 PATHOLOGY OF THE EAR. 
 
 nied, since abscesses of the brain sometimes seek an 
 outlet for the pus in other parts of the skull through 
 natural or fistulous openings (ethnoid, frontal, sphe- 
 noid, and parietal). The assertion of Lallemand that 
 the pus of a brain-abscess never seeks an outlet at 
 any other spot than the ear, is incorrect. The facts 
 are that, as a rule, the abscess of the brain is second- 
 ary and the result of suppuration in the ear pro- 
 duced by an inflammation of the veins. It should not 
 be forgotten, however, that abscess of the brain and 
 disease of the ear may occur simultaneously from the 
 same cause (trauma), as has already been shown by 
 Albers. Abscesses of the brain from otitis are situated 
 in the temporal lobes of the cerebrum or in the cere- 
 bellum, more frequently on the right side. 
 
 Heusinger^ found in one case double abscess in 
 the posterior lobe of the cerebrum and in the cerebel- 
 lum with thrombus of the right lateral sinus, the 
 development of wdiich had been unsuspected. Ab- 
 scess of the brain frequently occurs without being in 
 direct connection with the carious mass. 
 
 Von Troeltsch and Magnus,^ each in one case, found 
 an abscess of the brain on the opposite side from the 
 affected ear. In such cases it has been supposed by 
 some that the abscess was caused by metastasis (em- 
 bolus) from the carious spot ; while by others all con- 
 nection between the abscess and the caries has been 
 denied, and tuberculosis of the lungs was regarded as 
 the cause of the brain-abscess (infection of the brain 
 from a gangrenous cavity). Finally, the possibility 
 of the accidental coincidence of the very frequent 
 
 1 Virchoto's Arch., xi., S. 92. 
 ^ A.f.O., .xi., S. 293. 
 
THE TEMPORAL BONE. 19 
 
 caries of the temporal bone with an idiopathic abscess 
 of the brain has been accepted by others, as was long- 
 since sucrs-ested by Abercrombie. 
 
 Exceptionally cases occur where instead of an ab- 
 scess a tumor of the brain ^ is found with chronic 
 otitis. 
 
 Both dissection and frequent clinical experience 
 show that caries of the temporal bone often heals. 
 If the labyrinth is exempt from the caries loss of the 
 hearing may not occur, but a very considerable de- 
 gree of the hearing may remain, depending on the 
 extent and location of the carious destruction. 
 
 Fractures of the base of the skull often reach the 
 temporal bone and allow a discharge of the liquor 
 cerebro-spinalis if they have extended into the laby- 
 rinth or the porus acusticus internus, into which the 
 subarachnoid cavity enters with the dura mater and 
 arachnoid. A rupture of the membrana tympani and 
 bleeding from the ear is usually associated with such 
 a fracture, but not always. In the latter case the 
 cerebro-spinal fluid may ooze out through a fissure of 
 the osseous canal. Sometimes the fissure extends 
 through both petrous bones, even when tlie injury 
 has taken place only on one side of the head.'^ The 
 injuries which are found on careful preparation of the 
 petrous bone are naturally very variable. Wendt, for 
 example, found in one case not only fracture of the 
 base of the stapes and the bridge of bone lying be- 
 tween the oval and round fenestra?, but also brain 
 substance in the vestibule and tympanum. It is 
 
 1 Bright, Giqi'x Hospital Reports, ii., 1857. p. 279, 2 cases. Fischer, 
 (case from Traube's Clinic), Charitc'-Annalen, 1863. 
 
 2 Case by Yoltolini, M. f. 0., 1869, S. 110. 
 
20 PATHOLOGY OF THE EAR. 
 
 well known that brain substance may be forced out 
 through the meatus. 
 
 The usual result of fractures of the petrous bones 
 is death from inflammation of the brain and its mem- 
 branes which may only develop several weeks after 
 the injury. If the reactive inflammation is not fatal 
 total deafness remains. If inflammation of the menin- 
 ges does not occur the fracture may heal, seldom by 
 osseous consolidation but more frequently by fibrous 
 union. This possibility has been confirmed by trust- 
 worthy dissections.^ 
 
 New Growths. Exostoses arising from the temporal 
 bone and projecting into the cavity of the skull have 
 been described by several authors, Petit, Cruveil- 
 hier,- Toynbee.^ 
 
 R. Yolkmann* has figured one of immense size 
 from the pathologico-anatomical museum in Halle ; 
 it existed simultaneously with sclerotic thickening of 
 the bones of the skull. 
 
 Smaller exostoses within the cavities of the ear are 
 common ; they are most frequent in the meatus ex- 
 
 1 See Langenbeck's Archiv, vi., S. 576. Deafness and facial paraly- 
 sis on the left from a fall on the left side of the occiput. Recovery. 
 Death from tuberculosis seven months afterwards. Anatomical appear- 
 ances: on the base of the skull, corresponding to a fissure at that spot, a 
 yellowish, rusty-brown discoloration; a new growth of connective tissue 
 in the brain; the origin of the nervus acusticus sinister in the fourth ven- 
 ticle less white than on the right side and infiltrated with numerous cor- 
 pora amylacea; the nerve fibres of the trunk of the acusticus normal. 
 The fissure of the skull passed through the pars tympanica, through the 
 porus acusticus externus, and separated the mastoid and squamous from 
 the petrous portion of the temporal bone. The fjap in the bone loas par- 
 tially filled hy fibrous tissue, partially by a mass of bone. 
 
 2 A7iat. Patholoq., ii. Livraison, xxvi. 
 8 Catalogue, No. 791. 
 
 * Knochenkrankheiten, S. 429. 
 
THE TEMPORAL BONE. 21 
 
 tenuis, where they may lead to complete closure of 
 the canal. 
 
 The condition which has been particularly described 
 by French authors as tubercle or tubercular infiltra- 
 tion ^ of the petrous bone, and has been assumed to be 
 a frequent cause of chronic otitis and caries in phthis- 
 ical persons, corresponds to our present idea of 
 ostitis caseosa. The masses which are described as 
 tubercles are carious cavities in the bone which are 
 filled with inspissated pus. Real tubercles in the pe- 
 trous bone are very rarely seen ; they do, however, 
 exist and have recently been described by Zaufal.^ 
 
 A tubercular mass of the size of a pigeon's egg, 
 which I once found on the porus acusticus internus, 
 did not arise from the petrous bone but from the dura 
 mater. 
 
 In pigs primary tuberculosis of the temporal bones 
 occurs not unfrequently.^ 
 
 Cholesteatoma. 
 
 VircJioio, Virch. Arch., VIII. S. 371. — Totjnbee, Lond. Med. Gaz. 
 1850. Nov. Med.-Chirur. Transactions. Vol. xlv. VII. Series. Diseases 
 of the Ear. 1860. — 6Vu/;e;-, Allgem. Wien. Med. Ztg. 1862. Nos. 31, 
 3.3. — iy. Fi'.'Jc/ier, Charite-Annalen. 1865. XIII. S. 262. —PraW, Diss. 
 Inauor. Berlin, 1865. — Bate maiui, On Cholesteatoma. Arch, of Med. 
 Vol.'lV. 1866.— Fon Trneltsch, A. f. O. IV. S. 99, 103, 106, 112, 118, 
 127, and Lehrbuch. 6 Aufl. S. AQl. — Buhl (Nobiling), Bayr. Aerztl. 
 Intelligenzblatt. 1869. No. 33. Fall 4. — Zwrce, Verhandl. der Berl. 
 Med. Gesellsch. I. (Sitzung vom 26 Febr. 1873) and Arch, fur O. VII. 
 S. Toi.— Wendt, Arch. f. Phvs. Ileilkunde von Wagner. XIV. 1873.— 
 Sitzungsprotocoll der Section fiir Ohrenheilkunde auf der Naturforscher- 
 Vers. in Leipzig. 1873. (Siehe Arch. f. O. VIII. S. 215.) 
 
 1 Rilliet and Barthez, Traite des Mnlnd. des Enfants, Bruxelles, ii., 
 p. 489. Nekton, Recherches sur V Affections Tuherc. des Os, Paris, 1837, 
 pp. 46, 70. Grisolle, Pres^e Med., 1837, No. 32. 
 
 2 A. f. 0., ii., S. 174. 
 
 3 Schiitz, Virchow'x Arch., Band 66, S. 93. 
 
22 
 
 PATHOLOGY OF THE EAR. 
 
 Cholesteatoma of the temporal bone (pearl tumor, 
 Yircliow ; molluscous or sebaceous tumor, Toynbee) is 
 a name often used for various pathological conditions. 
 In some of the least common cases it designates a 
 true new growth arising from the bone, or from parts 
 of the ear (skin of the meatus externus,^ membrana 
 tympani,"' or mucous membrane of the tympanum^) 
 
 Fig. 6. 
 Circumscribed Atrophy from a Cholesteatoma, a. A large opening in the posterior 
 wall of the meatus leading into a closed cavity, of the size of a walnut, in the 
 pars mastoidea, with perfectly smooth and solid walls, b. Entrance to the tym- 
 panum. At the sinus lateralis is a thin, transparent spot of bone. The corre- 
 sponding temporal bone on the right side was perfectly normal. 
 
 analogous to the cholesteatoma of other bones of the 
 skull (occiput, OS frontis), brain, or meninges. It 
 
 ^Toynbee, Sebaceous Tumora in the Ext. Auditory Meatus. Med.- 
 Chirur. Transact., vol. xliv. Schwartzo, A./. 0., vi., S. 294 ; Ibid., vii., 
 2.59, Note. 
 
 2Hinton, A. f. O., ii., S. 151. Wendt, A. f. Heilk,xix., Heft 6. 
 Kiipper, A. f. O., xi., p. 18. 
 
 3 J. Gruber (/. c). 
 
THE TEMPORAL BONE. 
 
 23 
 
 consists of a thin fibrous capsule, which contains a 
 substance resenibUno; stearine, and o-listenino- hke 
 mother-of-pearl, the morphological elements of which 
 are chiefly flat cells of polygonal shape (epidermal 
 cells), and also often, but not constantly, crystals of 
 cholesterine in small numbers. (According to Lucae, 
 they contain also nucleated giant cells.) ^ 
 
 In those cases in which a true new growth ex- 
 ists, all inflammatory irritation in the neighborhood is 
 wanting in the ear- 
 lier stages of its de- 
 velopment, and sup- 
 puration with a de- 
 structive tendency 
 is only shown later, 
 when we may luive 
 perforation of the 
 membrana tympani, 
 or the bone of the 
 upper wall of the 
 meatus, or of the sul- 
 cus transversus, wdth 
 opening into the 
 middle or posterior 
 fossa of the skull. 
 
 That cholesteato- 
 ma may appear as a true new growth in the middle 
 ear, has been lately fully established on dissection by 
 Lucae/ as he found with the growth neither inflamma- 
 tion of the tympanum nor perforation of the mem- 
 brana tympani. 
 
 ^ R. Volkmann, Knochenkrankheiten, S. 487, places the cholesteatoma 
 midway between cancroid and atheroma. 
 - l.'c. 
 
 Circumscribed Atrophy of the Sulcus Transver- 
 sus from cholesteotnma, with erosion of the sinus 
 (otorrhagia). Antrum mastoideum and tympanum 
 with smooth walls, and much enlarj^ed by atrophy 
 from pressure. The opening into the sulcus meas- 
 ures 11 mm. in length and 5-6 mm. in breadth, 
 and has perfectly smooth edges. 
 
24 
 
 PATHOLOGY OF THE EAR. 
 
 In the great majority of cases of so-called choles- 
 teatoma in the temporal bone, we are dealing with 
 nothing more than a retention of inflammatory 
 products, the result of suppurative processes (Von 
 Troeltsch). A collection of concentric layers of epi- 
 dermis cells and. occasional masses of cholesterine 
 crystals form around a nucleus of fatty and caseous 
 pus ; the connective tissue capsule is wholly wanting. 
 The cause of these collections is purulent catarrh of 
 the middle ear, with polypoid granulations and per- 
 foration of the membrana tympani. 
 
 Such collections are found in the natural cavities, 
 
 most frequent- 
 ly in the an- 
 trum mastoid- 
 d e u m ; but 
 they may ex- 
 ist in the tym- 
 panum, mea- 
 tus externus, 
 or in the cav- 
 ities of the 
 temporal bone 
 w hi c h have 
 been enlarged or freshly excavated by the pressure 
 of the ma&'s. In this way the whole temporal bone 
 may be infiltrated and destroyed. By pressure on 
 the neighljoring tissues, from the increase in the col- 
 lection and from its swelling by absorption of mois- 
 ture, or by the retention and resorption of the de- 
 generated products of secretion, serious diseases, and 
 even death may result (purulent sinus- thrombosis 
 wath pyoemia, meningitis, abscess of the brain). 
 
 Circumscribed Atrophy of the External Meatus, from clio- 
 lesteatoma. 
 
THE TEMPORAL BONE. 25 
 
 From time to time parts of the retention-tumor 
 may become loosened and be thrown off; this is usu- 
 ally preceded by severe pain caused by the swelling 
 of the mass. 
 
 The flat polygonal cells, which generally consti- 
 tute the chief part of these masses and of the whole 
 tumor, very much exceed in size the nornuil pave- 
 ment epithelium of the tympanic mucous membrane, 
 being three times and more larger (0.02-0.03 mm. 
 in diameter), and exactly resemble the cells of the 
 epidermis. Their apparent w\ant of nuclei is not real, 
 as the nuclei can be brought out clearly by treatment 
 with ammoniated solution of carmine (Lucae). Be- 
 tween the cells grains of fat are very frequently seen, 
 and sometimes threads of fungus. 
 
 The source of these large flat cells has been often 
 discussed. Lucae considers that the epidermis cells 
 have their origin on the granulations, the older layers 
 being continually thrown off and gradually collecting 
 in the cavity of the middle ear. On this account he 
 considers that the removal of the granulations is the 
 chief point of therapeutics. Von Troeltsch has some- 
 times found these gigantic flat cells in the normal 
 covering of the antrum mastoideum, most commonly, 
 however, with collections of pus in this cavity, and 
 he therefore thinks it very possible that under patho- 
 logical irritation and pressure this epithelial surface 
 develops in some special way.^ The fact is, that the 
 tympanic epithelium, under a chronic purulent in- 
 flammation with defect of the drum-membrane, often 
 assumes the characteristics of the skin, showing a rete 
 Malpighii and epidermis. 
 
 1 Lehrhuch, S. 425. 
 
26 PATHOLOGY OF THE EAR. 
 
 Wenclt considers that the development of the so- 
 called cholesteatoma of the temporal bone is due to 
 a form of desquamative inflammation of the mucous 
 membrane of the middle ear (with or without per- 
 foration of the membrana tympani), the epithelium 
 of this mucous membrane assuming an epidernjal 
 character, and developing a rete Malpighii during 
 or after a chronic inflammatory process. Chronic 
 inflammation of the walls of the meatus may lead 
 to the formation of a cholesteatoma, if the exfoliated 
 masses get into the middle ear, either through a 
 perforation of the drum-membrane, or through an 
 opening in the osseous walls of the meatus. 
 
 Malignant Tumors of the temporal bone are not com- 
 mon, if those cases are excluded in which tumors of 
 neighboring parts (parotid gland, base of the skull, 
 antrum of Highmore, etc.) have led to secondary 
 destruction in the ear. I myself have seen three 
 cases of primary epithelial cancer of the temporal 
 bone, of which two have been reported, and in all of 
 them the origin of the growth was the tympanic mu- 
 cous membrane.^ 
 
 Fig. 9 shows the extent of the destruction of the 
 bone in one of these cases, seen from the inside. 
 
 A list of all the malignant tumors known to me is confined tc 
 five cases described by Toynbee ^ (carcinoma), one by Gerliard ^ 
 (carcinoma of the left petrous bone), one by Billroth* (without au- 
 topsy), two by Wilde ^ (osteosarcoma), one by Travers '^ (without 
 
 1 Archiv f. Ohrenheilkunde, ix.. S. 208, 215, Note. 
 
 ^ Diseases of the Ear, cliap. xvii. 
 
 ^ Jenaer Zeitschi'., i., 4. 
 
 * Arc/i.f. Klin. Chir., x.. S G7. Compare also A. f. 0., v., S. 28. 
 
 ^ Pract. Berne rliincjeiu etc., S. 244. 
 
 6 Froriep's Nutizen, Bd. 25, No. 22, S. 352. 
 
THE TEMPORAL BONE. 
 
 27 
 
 autopsy), one by Boeke/ one by Wishart,^ one by Robertson ^ (sar- 
 coma). To these may be added three cases by Cruveilhier ; * two 
 of these, althougli described under the name " tumeurs fibreuses du 
 
 Fig. 9. 
 Destruction of the Temporal Bone by Epithelial Cancer, a. IMedian remnant of 
 the pars petrosa ; on the superior surface of its apex the bone is also destroyed 
 by the new growth, h. Porus acusticus internus. c. Foramen lacerum anterius. 
 d. Foramen ovale, enlarged by destruction of its edges to twice its natural circum- 
 ference, e. Foramen spinosum. f. Sphenoid articulation. 
 
 i-ocher," Rokitansky considers sliould probably be regarded as can- 
 cer, although in the first case, Avhich is the most fully described and 
 figured, Cruveilhier expressly adds, " ne presentait pas le moindre 
 
 1 Wiener Med. Halle, 1863, Nos. 45, 46. 
 
 2 Edinh. Med. and Surg. Journ., xviii., p. 393. 
 
 3 Transactions of the American Otological Societi/, 1870. 
 
 4 Anatonde Palliohgique du Corps Humain, ii., xxvi., planche 2. 
 
28 
 
 PATHOLOGY OF THE EAR. 
 
 vestige de degeneration cancereuse," From a remark of Cruveil- 
 hier's, it seems to be implied, that he had frequently found tumors 
 originating from the posterior and anterior surfaces of the petrous 
 bone. " Ces tumeurs sont tantot fibreuses, tantot osteo-fibreuses : 
 d'autres fois, elles presentent la degeneration cancereuse dans une 
 
 Destruction of the Petrous Bone by a Fibrous Tumor, from Cruveilhier. The 
 tumor originated apparently from the extension of the dura mater into the porus 
 acusticus internus. The openings in the bone involve the inner half of the posterior 
 surface of the pars petrosa. communicate extensively with the eanalis caroticus, and 
 unite the meatus auditorius internus, which cannot be recognized, with the foramen 
 lacerum posterius. 
 
 partie de leur etendue. La description des tumeurs du rocher me- 
 riterait de trouver place dans I'histoire des tumeurs developpees 
 dans le crane," etc. Death generall}' results from marasmus or 
 pressure on the brain, sometimes from basilar meningitis. 
 
 AURICLE. 
 Malformations. 
 
 Foiyc'/, Handbuch der Patholog. Anatomie. Halle. 1804. — MecM, 
 Handbuch der Patholog. Anatomie. I. S. 400-40G. — Beck, Krankheiten 
 des Gehororgans. Heidelberg und Leipzig:, 1827. S. 106. — Mich. Jdr/er, 
 Klin. Beobachtungen iiber Augen- und Oln-krankheiten (Von Amnion's 
 Zeitscbrift fUr Opbth. V. 1). — Hi/rtI, Boitriige zur Patholog. Anatomie 
 des Geliororgans. Oesterr. Med. Jahrb. XL 1838. (On Congenital Mal- 
 formations in Deaf-mutes and Monstrosities.) — Von Amman, Die Ange- 
 borenen Cbirurg. Krankheiten des Menscben. Berlin, 18.S9. S. 26. Taf. 
 Y. Fiir. 12-17. Taf. XXXHL Fi^. 16. — 5c/im«/c, Verkummerung 
 
A UPdCLE. 
 
 29 
 
 der Ohrmuschel mit Felilen des Gehorgangs. Beitriige, etc., Leipzig, 
 184G. S. 1 u. 2. — A. Thompson, Edinburgh Journ. of Med. Science, April, 
 1847. — Birnbaiun, Diss. Inaug. Giessen, 1848. — Wallmann, Ueber Miss- 
 bildungen des Knocbernen Gehororgans. Virch. Arch. 1857. YI. S. G03. 
 
 — StahL Einige Skizzen iiber Missstaltungen des ausseren Ohres. All- 
 gem. Zeitscbrift fur Psycliiatrie. XVI. S. 479. l^bd.— Toynbee, D'ls- 
 eases of the Ear. 1860. S. 15. — M. Schultze, Missbildungen im Bereiche 
 des ersten Kiemenbogens. Virch. Arch, XX. S. 3 78. — Heusin(ier,\Jfthev 
 Halskiemenfisteln von noeh nicht beobachteter Form. Virch. Arch. — 
 iJete, Ueber Fistula Auris Congenita, Meraorabilien. VIII. 24 June, 18G3. 
 
 — Bauer, Ueber die Fclsenbeine der Ilemicephalen. Diss. Inaug. Mar- 
 burg, 1863. — Claudius, Ueber den Schadel der Hemicephalen. Zcitschr. 
 f. Rat. jMed. XXI. 2. 18G4. — Kollmann, Beitriige znr Entwickelungsge- 
 schiehte des Menschen. Zeitschr. fiir Biologic. IV. S. 260 u. Taf. VII. — 
 Lucae, Virch. Arch. XXIX. S. C2 and A. f. O. X. S. 23S. — Heusinger, 
 Virch. Arch. XXIX. S. 3G1. — VircJwtv, Ibid. XXX. S. 221 and 
 XXXII. S. 518. — VoltoUnl, M. f. O. II. No. 1. 1866. Flechinger, All- 
 gem. Wiener Med. Ztg. 1866. Xo. 16. — Wreden, Petersb. Med. Zeitschr. 
 XIII. S. 204. 1867. — Heusinfjcr, Deutsche Zeitschrift fiir Thiermedicin 
 und Vergleichende Pathologic. II. 1870. — 6V!<fte'', Lehrbuch. 1870. S. 
 276. — Schmitz, Ueber Fistula Auris Congenita und andere Missbildungen 
 des Ohres. Diss. Inaug. 1873. Halle. 
 
 Fig. II. Fig. 12. 
 
 Bilateral Cats-ears with stenosis of the meatus and congenital deafness. Unilateral 
 atrophy of the face. 
 
 Malformations. Complete absence from arrest of de- 
 velopment may be fonnd on one or both sides. Ab- 
 sence of certain parts (lobule, helix, antihelix, car- 
 
30 
 
 PATHOLOGY OF THE EAR. 
 
 tilage), and imperfect development of the auricle 
 (microtia) of various kinds is much more common. 
 Sometimes the auricle appears pressed together from 
 
 Fig. 13. 
 
 Fig. 14. 
 
 Fig. 15. Fig. 16. 
 
 Cats-ear on the left dislocated downwards; on the right abnormal hypertrophy of 
 the auricle. Unilateral atrophy of the face. 
 
 Fig. 16. Bilateral Malformation of the Auricle with atresia of the meatus. Deaf- 
 mutism. 
 
 above downwards, the cats-ear as seen in the old 
 statues of Pan (Figs. 11, 12, 13, 14, 15) ; sometimes 
 spindle-shaped (Figs. 16, 17), and with deep indenta- 
 tions, or even with horizontal fissures. The tragus 
 
AURICLE. 
 
 31 
 
 may be so turned inwards as to close the meatus ; in 
 Fig. 18 only the fissured lobule was present, below 
 which was the entrance into a meatus extremely con- 
 
 Fig. 17. 
 
 Fig. 17. Unilateral Deformity of tiie Auricle with Atresia of the Meatus. 
 Fig. 18. Microtia with Stenosis of tlie Meatus. Only a fissured lobule remains. 
 Unilateral atropln' of the face. 
 
 tracted and directed upwards, the end of this meatus 
 being closed as in the normal ear by the membrana 
 tympani. Posteriorly from this rudimentary auricle 
 the dislocated cartilage could be felt under the skin. 
 
 The lobule is frequently adherent to the skin ; the 
 upper edge of the auricle is rarely so attached. 
 
 Usually with deformity of the auricle, such as is 
 represented in Figures 19, 20, 21, 22, further malfor- 
 mations exist in the deeper parts of the ear, atresia, 
 stenosis or complete absence of the meatus, or even 
 of the labyrinth. Exceptionally the other parts of 
 the ear may be normally formed. 
 
 Stenosis, or atresia of the meatus externus, is spe- 
 cially frequent. According to Virchow ^ congenital 
 anomalies in the external ear and its neighborhood 
 are to be referred to early disturbances in the closure 
 
 1 VircJww's Arcliio, Bd. 30, S. 2 21, and Bd. 32, S. 518. 
 
32 
 
 PATHOLOGY OF THE EAR. 
 
 of the first branchial cleft, and are often associated 
 with fistuliB of the other branchial clefts, cleft jD^late 
 and other forms of arrest of development in the facial 
 bones, as, for instance, with unilateral atrophy of the 
 face (Figures 12, 13, and 18). Stahl had already di- 
 
 Fig. 19. 
 
 Fi? 20 
 
 Fig. 19. Deformed Auricle with Absence of the Meatus. The cartilage undevel- 
 oped, onl}' seven lines long, and with three small illddincd dcijitJMons. Lobulus 
 as large as that of the health}' ear. Helix scarcely perceptible, tragus, antitragus, 
 antihelix, concha and fossa navicularis wanting. (From Michael Yaeger in Von 
 Amnion's " Zeitschr. f. Ophth.," Bd. V., H. I.) 
 
 Fig. 20. Deformitj' of the Auricle with Atresia of the Meatus. The ear is very 
 small ; the posterior edge of the helix is turned forwards (r/) ; only slight traces of 
 the antihelix (e) and its fossa ; the tragus (/) turned backwards and felt through the 
 skin as a cartilaginous point. From the tragus a cartilaginous half-ring could be 
 felt running downwards and forwards which, according to Yaeger, was a trace of the 
 cartilaginous meatus. Opposite the tragus was a point of the antitragus (f/) and be- 
 hind this two blind fossa. The cartilage proper is wanting; the lobule is united 
 with the skin at its posterior edge and lower end ; the helix the same; at the unat- 
 tached spot a pouch-like depression two lines long and the same broad existed. 
 (From Michael Yaeger.) 
 
 rected attention to the fact that deformity of the 
 auricular cartilag;e mio-ht be reg-arded as an indication 
 of imperfect development of the rest of the skull, and 
 that it bore a semeiotic relationship to the develop- 
 ment of the skull. 
 
A URICLE. 
 
 33 
 
 Rudimentary auricles are not usually inserted in 
 the normal position. It may, however, also happen 
 that well-formed auricles are dislocated on to the 
 cheek, neck, or shoulder. 
 
 A by no means rare form of arrest of development 
 is the fistula auris congenita, first described by Heu- 
 singer, which is to be regarded as a remnant of the 
 first branchial cleft. The fistulous opening generally 
 lies in front of the ear, usually one centimeter above 
 
 Fig. 21. 
 
 Congenital Deformity of the Auricle. 
 (From J. Griiber, " Lehrbuch," S. 275.) 
 
 Fig 22 
 
 Microtia (From J. Gruber, "Lehr- 
 bucli," S. 275.) 
 
 the tragus, but sometimes it is in the lobule (Betz). 
 A portion of the fistulous canal can sometimes be fol- 
 lowed with a very fine probe or bristle, or its callous 
 walls can be felt between the auricular cartilage and 
 the skin. From its opening a whitish yellow, cream- 
 like fluid exudes, which contains numerous pus cells. 
 By closure of the fistula small tumors produced by 
 the retention of the secretion may form in front of 
 the tragus. On the same spot in the skin in front 
 of the meatus very small cicatricial depressions are 
 
34 
 
 PATHOLOGY OF THE EAR. 
 
 often seen which are also to he referred to anomahes 
 m the closure of the first branchial cleft. These fis- 
 tulse exist with or without malformation of the auri- 
 cle ; sometimes they are associated with fistulas of 
 the neck. Communication with the middle ear or 
 pharynx could not be found in the cases which I have 
 observed. 
 
 Excessive development 
 
 seen as (1) abnormal en- 
 largement, complete or 
 partial (Figures 13 and 
 15, right ear) ; (2) auricu- 
 lar appendages (polyotia) 
 which may be said to du- 
 plicate certain parts of the 
 auricular cartilage. Un- 
 der the skin a misplaced 
 bit of cartilage can be felt. 
 These appendages, accord- 
 ing to Virchow, consist of 
 skin, subcutaneous cellu- 
 lar tissue, and reticular 
 cartilage ; they are seldom 
 numerous, are most com- 
 mon in front of the tragus, 
 but may be situated on the 
 lobule or side of the neck. 
 (3) Reduplication. Lan- 
 ger found four lobules in 
 two cases of monstrosities with double bodies.^ Wilde 
 describes a case from Cassebohm of a child with two 
 ears in the usual situation and two below on the 
 neck. 
 
 1 L c. 
 
 Fig. 23. 
 
 Auricular Appendages, Polyotia ; three 
 
 wart-like appendages in front of ♦he ear. 
 
 (From Von Amnion, Table xxxiii. Fig. 
 
 16.) 
 
AURICLE. 3t) 
 
 The form, size, position, and angle of insertion of 
 the auricle is subject to very great individual varia- 
 tions. Irregularities in the formation of the helix are 
 very common. Darwin assigns a so-called pointed 
 ear, i. e., an ear with a sharply defined indentation of 
 the helix, as is constantly seen in old statues of satyrs 
 and centaurs, to the earliest orders of human beings. 
 
 Othsematoma (blood-tumor, haematoma auriculgB, pe- 
 richondritis auricularis, erysipelas auriculie.^) 
 
 Bird, Journ. v. Grafe und Walther. 1833. XIX. S. 631. — Saxe, De 
 Othfematomate Yesanorum Commentatio. Diss. Inaug. Leipzig, 1853, 
 witli tlie literature up to 1852. — R. Hofmann, Oesterr. Zeitschr. fiir 
 pract. Heilkunde. 1862. No. 33. — G. i/rtase (Henle's und Pfeuifer's 
 Zeitscbr. III. Reilie. Bd. 24. S. 82. 1865). A complete catalogue of 
 the literature, 1833-1864. — Virchow, Gescliwlilste. 1. S. 135. — Z. Meyer, 
 Vircliow's ArcMv. XXXVII. Heft 4. — Gudden (Zeitsclar. fiir Psychia- 
 trie. XVIIL). — Grlednger. — Parreidt, Diss. Inaug. 1864. Halle. — 
 Haupt, Diss. Inaug. 1867. WUrzburg. 
 
 This is a fluctuating tumor on the concavity of the 
 auricle formed by a discharge of blood between the 
 perichondrium and cartilage. The perichondrium is 
 not only separated by the effusion from the cartilage, 
 but bits of the cartilage usually remain attached to 
 the membrane. In fresh cases it comes on with in- 
 flammatory symptoms, most frequently during de- 
 mentia paralytica, but it may occur in persons of 
 sound mind ; it is by no means always of a traumatic 
 nature. A predisposition to it is shown by a disease 
 of the cartilage which shows spots of softening and 
 spaces filled with fluid. 
 
 The hemorrhage is generally resorbed and the 
 thickened perichondrium is again attached to the 
 cartilage, but a permanent deformity is left from the 
 
 ^ Compare Kleb's Pathologiscke Anatomic, Bd. I., S. 98, 
 
36 
 
 PATHOLOGY OF THE EAR. 
 
 thickening and cicatricial shrinking of the auricle. 
 Suppuration and spontaneous rupture are very rare 
 and only occur in traumatic othasmatoma. Calcifica- 
 tion of the cartilage is common as a result of the ef- 
 fusion. 
 
 Inflammations and their Results. The usual diseases 
 of the skin may be located on the auricle. Erythema 
 (as intertrigo behind the ears), eczema, erysipelas, are 
 very common, phlegmonous inflammation, gangrene 
 
 Fig. 24. 
 Nrevus of the Auricle. Removed with the knife bj' Prof. R. Yolkman, .after 
 the application of a ligature. Recovery. 
 
 (in typhus, measles, erysipelas, or spontaneously in 
 nurslings), are less common. Lupus, pemphigus syph- 
 iliticus, and ichthyosis congenita, are also seen on the 
 auricle. Spontaneous perichondritis resulting in ab- 
 scess, has been in rare cases observed on the auricle 
 and heals usually without leaving a deformity. Par- 
 tial calcifications and very rarely ossifications,^ the 
 
 1 Bochdalek, Prag. VierteljahrsscJir., 1865, i., S. 33. 
 trdge. 
 
 Otolofjisclie Bei- 
 
A URICLE. 
 
 37 
 
 result of defective nutrition alone without a sign of 
 appreciable irritation, may be seen on the auricle ; 
 concretions of urate of soda are also found in ar- 
 thritic persons (Garrod). The auricle is almost com- 
 pletely exempt from syphilis, and fractures are very 
 rare on account of its elasticity. After burns and 
 skin eruptions synechiaB, or adhesions of the auricle 
 at its posterior surface to the skull, may occur. 
 
 New Growths. 
 
 de Cancro Auris Humanfe 
 Mitteldorpf, Galvanocaustik. 
 
 1804. 
 111. — 
 
 Fischer , Comment, 
 Habilitationsschrift. - 
 Wilde, Practical Obsei'vations, 
 etc. 1855.]). 193. — Von Bruns, 
 Handbucli der Pract. Cliirurg. 
 1859. Abth. II. S. 135, Abth. II. 
 S. IG7.— A. Wagner, Konigsh. 
 Med. Jahrb. 1859, IT. S. 115.— 
 Berend, Deutsche Klinik. 1864. 
 S. 483. — Velpeau, Cancroid of 
 the Auricular Cartilage. Gaz. 
 des Hop. 18G4. No. 27. — 0. 
 Saint- Vel, Ueber Fibrome. Gaz. 
 des Hop. 1864. No. 84. — F/r- 
 chow, Geschwiilste. III. S. 347. 
 1867. (Auriculare Angiome.) — 
 J'ungken, Berl. Klin. Wochen- 
 schrift. 1869. No. 8. (Gefass- 
 geschwiilste.) Knapp, Fibrome 
 des Lobulus. (A. f. A. u. O. 
 V. 1. S. 215.) 
 
 New Growths. Tumors 
 produced by the collec- 
 tion and retention of the Am icie 
 sebaceous secretion of 
 the skin (atheromata), are very frequent, possibly be- 
 cause there are no smooth muscular fibres on the 
 
 Fig. 25. 
 \tliei-oma on the Posterior Surface of the 
 natural size. (From J. Gruber, 
 Lehrbuch," S. 407.) 
 
38 PATHOLOGY OF THE EAR. 
 
 auricle, through the contraction of which the expul- 
 sion of the sebaceous matter is produced.-^ Fibroids 
 (cicatricial keloid) are often developed on the lobule 
 as the result of piercing the ear, and may grow to 
 the size of a hen's Qgg ; the}^ are most common in 
 negresses. Histologically, they show the exact struc- 
 ture of cicatrices in the skin, and frequently recur 
 when imperfectly removed. Angioma,- lipoma, cav- 
 ernous tumors, epithelial and chimney-sweeper's can- 
 cer,^ and cysts are also found. What Wilde* describes 
 and figures as a cyst, is probably a ha3matoma. 
 
 Epithelial cancer of the auricle is not unfrequent, 
 and may by extension lead to destruction of the mid- 
 dle and inner ears. 
 
 THE EXTERNAL MEATUS. 
 
 Malformations. Complete absence of the meatus is 
 found with a simultaneous absence or deformity of 
 the auricle, and also with congenital absence of the 
 membrana tympani (Michael Jaeger). In place of the 
 meatus, a compact wall of bone, several lines thick, is 
 then found. Sometimes at the seat of the entrance 
 to the meatus, only slight, single, double, or multiple 
 depressions exist, or the cartilaginous meatus may 
 
 1 Dr. Sappey, Gazette de Paris, 1863, 24. 
 
 2 Examples of congenital angioma of the auricle are given Ijy Jling- 
 ken (Berliner Klin. Wochenschrift, 1869, No. 8). They grew in the 
 meatus and in the depression between the mastoid process and the con- 
 dyloid process of the lower jaw. Jiingken ligated the common carotid 
 artery, as, from a rupture of the tumor, a nearly fatal hemorrliage oc- 
 curred. Seven years after the operation, there occurred a fresh hemor- 
 rhage from the tumor, and death. 
 
 3 Have been frequently described on the ear by English surgeons. 
 
 4 Practical Observations, p. 201. 
 
THE EXTERNAL MEATUS. 39 
 
 be present, and at the bottom of it, instead of the 
 osseous meatus, there may be a membranous ^ or firm 
 osseous closure (atresia congenita). If the deej^er 
 parts of the ear are well formed, this condition is not 
 inconsistent with fair hearing, as has been shown 
 by old observations."^ 
 
 Sometimes the funnel-shaped end of the narrow 
 cartilaginous portion passes into a very fine canal, 
 which extends farther inwards. In other cases the 
 meatus is narrowed equally throughout its extent, 
 or it may be contracted like an hour-glass near its 
 middle, or it may show a contraction close to the 
 membrana tympani produced by an abnormal projec- 
 tion of the anterior osseous wall. According to 
 Moos'^ band-like bridges of connective tissue be- 
 tween the walls of the meatus may occur as con- 
 genital malformations. The existence of congenital, 
 abnormal width of the meatus, which may be so pro- 
 nounced that the little finger can be inserted down to 
 the drum-membrane, is of little pathological interest. 
 
 Some instances of a double meatus are known, 
 which are undoubtedly to be referred to arrest in the 
 closure of the first branchial cleft.* In one case by 
 Velpeau, one meatus led to the drum-membrane, 
 while the second ended in the mastoid process ; in 
 one case by Bernard, the two passages communicated 
 
 ^ This also occurs near the drum-membrane. Toynbee, London Med. 
 Gazette, 1850, p. 645. 
 
 2 Mussey in New York, 1838, American Journal. Schnidt's Jahrhueh. 
 1839, S. 320. 
 
 3 Klinik der OhrenJcrankheiten, S. 85. 
 
 * Voigtel, i., S. 295. Loder, i., S. 148, No. 583. Bernard, Journal de 
 PJiysiologle Experbnentale de Magendie, iv. Blandin. Lincke, Handbuch, 
 i., S. 623. 
 
40 PATHOLOGY OF THE EAR. 
 
 and were covered with a continuation of the external 
 skin. 
 
 In childhood, and up to the fourth year (accord- 
 ing to Huschke), an ossification gap, closed merely 
 by connective tissue, is found normally in the anterior 
 lower wall, to which Yon Troeltsch first directed at- 
 tention. The knowledge of this fact is of importance, 
 to avoid mistaking it for a carious opening. In adults, 
 remains of this opening are occasionally met with in 
 exceptional cases. During purulent inflammations of 
 the middle ear, ulcerative destruction of the skin 
 over this spot of deficient ossification may occur, and 
 through the opening an extension of the inflannna- 
 tory process of the meatus may reach the parotid 
 gland and the lower jaw. 
 
 Hypersemia and Hemorrhage. Hyper^emia of the skin 
 of the meatus, with or without swelling, is seen 
 in the beginning of a diffuse otitis externa ; in the 
 deeper parts of the osseous meatus during acute in- 
 flammations of the tympanum and on the posterior 
 upper wall during inflammations of the mastoid pro- 
 cess ; venous hypersemia is also found wdth disease of 
 the heart and emphysema of the lungs. 
 
 Hemorrhages, aside from those of traumatic origin, 
 Avhich are the result of direct or indirect injuries, 
 (fractures of the lower jaw, bruises, etc.), ma}^ occur 
 in the skin of the meatus, in the form of ecchymoses 
 and blood-blisters, i. e., hemorrhages between the ep- 
 idermis and cutis, accompan3'ing inflammations of the 
 middle ear. They are usually situated on the upper 
 wall of the meatus, and may extend directly into the 
 membrana tympani. In the severer forms of otitis 
 media purulenta, before rupture of the drum-mem- 
 
THE EXTERNAL MEATUS. 41 
 
 brane has taken place, I have frequently seen an 
 extensive vesicular separation of the epidermis on the 
 upper wall of the meatus produced by a sero-hemor- 
 rhagic exudation. 
 
 Inflammations and their Results. In addition to the dif- 
 ferent varieties of inflammation of the skin (ery- 
 thema, eczema, herpes, pemphigus, erysipelas) the 
 external portion of the meatus is subject to furuncles 
 and phlegmonous inflammation ; the inner portion of 
 the osseous meatus, where the cutis is very thin and 
 cannot be separated anatomically from the perios- 
 teum, i. e., where the soft tissues consist merely of a 
 periosteum covered with epidermis, is subject to j^eri- 
 ostltls. In the acute exanthemata, also, the skin of 
 the meatus is not always spared ; it is w^ell known 
 that the ^9?«s/?«/es of small-pox may show themselves 
 not only on the auricle, but also in the cartilaghious 
 portion of the osseous meatus. 
 
 In rare cases diffuse hypertrophy of the epidermis 
 of the papillary bodies {ichthyosis), leads to narrow- 
 ing and distortion of the canal, and to diffuse hyper- 
 trophies of the skin and the subcutaneous cellular 
 tissue (pachydermatitis) . 
 
 The common name, " catarrh of the external mea- 
 tus," formerly much abused, has anatomically no jus- 
 tification, except, perhaps, in those cases in which the 
 epidermis has been destroyed, as, for instance, in 
 acute, moist eczema ; it was used, however, as a gen- 
 eral designation of the various forms of inflammation 
 of the skin, which lead to suppuration, and which, in 
 their later stages, cannot, either during life or after 
 death, be sharply defined one from another. For 
 these different processes, the name otitis externa must 
 
42 PATHOLOGY OF THE EAR. 
 
 be used, but it must be distinctly understood that 
 such an otitis purulenta externa (in which the whole 
 surface of the meatus and drum-membrane is the seat 
 and source of the otorrhoea) is to be regarded as the 
 primary source of profuse suppurations only in very 
 few cases (most commonly in childhood, and with sup- 
 purative parotitis in typhus). In the great majority 
 of cases the source of the suppuration is in the mid- 
 dle ear, and the pus only flows into the meatus 
 through an opening in the drum-membrane. The 
 otitis externa purulenta without perforation of the 
 drum-memlirane which is met with in adults, is usu- 
 ally only an accompanying symptom, or the precursor 
 of acute inflammation of the drum-cavity (sympa- 
 thetic inflammation, Toynbee). 
 
 The otitis externa chronica due to fungous growths, 
 otomycosis, perhaps the most common form which is 
 found in adults/ is characterized by a slight and 
 chiefly serous secretion and a collection of macerated 
 epidermis cells between which the fungus grows. 
 With profuse suppuration the fungus does not meet 
 with a favorable resting-place. 
 
 Erythema (erythematous dermatitis) is a hyperse- 
 mia and serous infiltration of the papillary bodies. 
 The secretion of the glands is at first diminished, or 
 checked entirely. After the erythema the epidermis 
 scales off, and a profuse hypersecretion of a thin, 
 bright yellow cerumen may follow. 
 
 Eczema (acute or chronic) is often confined to the 
 external ear. The vesicles may be visible on the 
 meatus and membrana tynipani ; in most cases, how- 
 ever, only a red and moist skin, from which the epi- 
 
 1 Vide p. 56. 
 
THE EXTERNAL MEATUS. 43 
 
 dermis has been separated, is seen. According as pus- 
 tules or dry scales are formed with the vesicles the 
 disease is called eczema impetiginosum or squamosum. 
 In obstinate cases chronic eczema of the ear may cause 
 inflammatory hypertrophy of the corium, which can 
 produce stenosis of the meatus, deformity of the auri- 
 cle, and thickening of the cutis of the drum-membrane. 
 
 A not infrequent complication of eczema of the 
 meatus is mucous catarrh of the middle ear, without 
 perforation of the membrana tympani. 
 
 Furuncle, or perifollicular inflammation in the skin 
 of the meatus, offers no special peculiarities. In ac- 
 cordance with the anatomy of the parts it occurs only 
 in the external third of the canal, and according to 
 some authors (Verneuil, Roser) develops around the 
 ceruminous glands. The most common seat of the 
 furuncle is the anterior lower wall of the meatus. 
 
 Usually several follow, one after the other, and, in 
 some individuals, obstinately recur for many years. 
 Large furuncles may produce a temporary closure of 
 the meatus, so that, if the skin is thick and without 
 redness, they give the impression at first view that 
 union of the walls of the meatus has taken place. As 
 their results a slit-like narrowing of the meatus and 
 free desquamation of the epidermis may remain for 
 some time, by which the passage may be closed. 
 Granulations, growing on the edges of the ruptures 
 through which evacuation has taken place, may sim- 
 ulate a pol3q3us. 
 
 The diffuse inflcmimation of the skin is preceded by 
 hypera3mia and swelling, most marked in the vicinity 
 of the drum-membrane and in the meml^rane* itself; 
 it causes destruction and loss of the epidermis and su- 
 
44 PATHOLOGY OF THE EAR. 
 
 perficial suppuration. The fluid elements of the puru- 
 lent secretion consist in part of a transudation from 
 the greatly enlarged blood-vessels, in part originate in 
 the perspiratory and sebaceous glands. If the blood- 
 vessels are ruptured the pus will be temporarily 
 bloody. The inflammation can extend from the ele- 
 ments of the cutis and involve the subcutaneous cel- 
 lular tissue, producing there a new formation of round 
 cells (phlegmonous inflammation). If not relieved by 
 early and deep incisions the inflammation may go on 
 to gangrene, extensive destruction, disease of the 
 bone, or even to purulent thrombosis of the sinuses 
 and septica3mia. Also in periostitis of the meatus 
 death may result in exceptional cases from purulent 
 thrombus of the sinuses or meningitis (Toynbee), with- 
 out disease of the tynqmnitm and icithout 'perforation 
 of the me^nbrana tymj^ani} 
 
 As other residts of inflammation of the meatus 
 should be mentioned ; strictures, sometimes caused 
 merely by a thickening of the cutis, sometimes by 
 simultaneous hyperostosis. In the cartilaginous por- 
 tion, especially at the point where the cartilaginous 
 joins the osseous meatus, annular strictures may be 
 formed by a cicatricial circular thickening of the con- 
 nective tissue. Behind the stricture the osseous mea- 
 tus may be very much enlarged. Such strictures are 
 very dangerous complications of suppurations of the 
 
 1 The existence of a primary perichondritis has not been proven ana- 
 tomically. From observations during life there is a certain probability 
 that such occurs in some of the tedious inflammations where the swelling 
 is confined to the external half of the meatus and produces deep sinuous 
 abscesses and forms fistulas under the skin of the meatus; however, 
 neither from my own observation nor from the literature is any case 
 known to me where a necrosed cartilajre was thrown off. 
 
THE EXTERNAL MEATUS. 45 
 
 middle ear. Adhesion of the walls of the meatus, 
 noticed by Emmert ^ with a simultaneous union of the 
 tragus with the antitragus, results from burns, from 
 diphtheria of the middle ear (my own observation) 
 in connection with cicatricial adhesions of the palate, 
 and frequently in cases in which there is caries of the 
 middle ear. The meatus is closed either by a mem- 
 branous diaphragm which has one or more fine open- 
 ings in its centre, or else the osseous portion of the 
 meatus is completely filled by a new fibrous tissue 
 (my own observation). 
 
 A neiD growth of slight hands ^ uniting the walls of 
 the meatus with each other is sometimes found, but 
 much more frequent are granulations (polypoid ex- 
 crescences) from the cutis, which sometimes completely 
 fill the inner portion of the meatus, and may give the 
 surface of the membrana tympani the appearance of 
 a granulating wound. Thickening of the cutis, opac- 
 ity or perforation of the drum-membrane, is also 
 found. 
 
 FistidcG in the neighborhood of the meatus, and fis- 
 tulous perforation of its walls, are usually the result 
 of caries and necrosis (often of abscesses of the mid- 
 dle ear which break through the posterior upper wall 
 of the meatus, and which are frequently mistaken for 
 primary abscesses and furuncles of that passage); such 
 fistula3 may, however, result from suppuration of the 
 parotid ^ and the neighboring lymph glands without an 
 affection of the bone, and may also result from cancer. 
 Abscesses of the parotid usually rupture at the junc- 
 
 1 CMrurgie, III. Auflage, S. 173. 
 
 2 A./, d, ix., 237. 
 
 3 Virchow, Charite- Annalen, 1858, viii., 3. C. E. E. Hofinann, A.f. 
 0., iv., S. 283. 
 
46 PATHOLOGY OF THE EAR. 
 
 tion of the cartilaginous with the osseous meatus or 
 else through the incisurse Santorini. Vice versa in 
 childhood a suppuration of the meatus may extend to 
 the parotid gland and articulation of the jaw through 
 the ossification gaps already described (p. 40). Fis- 
 tulae under the skin of the cartilaginous meatus occur 
 from affections of the bone, from phlegmonous ab- 
 scesses in front of the tragus, and possibly, although 
 this is doubtful, from perichondritis.^ 
 
 Ulceration is rare. Simple erosion-ulcers at the en- 
 trance of the meatus may occur from inflammations, 
 attended by profuse and putrid suppuration ; ulcers 
 are also sometimes found with caries and necrosis, 
 with syphilis, and with epithelial cancer. Von 
 Troeltsch^ found an ulcer with sharply projecting 
 edges extending down to the bone on the posterior 
 wall, close to the membrana tympani, in a case of 
 miliary tubercular meningitis with simultaneous sup- 
 puration of the middle ear. The ulcers found with 
 constitutional syphilis are annular and covered with 
 a dirty grayish white exudation ; from their edges 
 being greatly swollen they cause contraction of the 
 meatus, and when they exist the lymph glands in the 
 vicinity of the ear are much swollen. 
 
 The skin of the meatus, if it has lost its epidermis 
 from moist eczema, or from any other cause, may, like 
 the skin of the auricle when affected by intertrigo, 
 assume the character of a diphtheritic ulcer, and this 
 has been called by Wreden ^ and by Moos ^ an inde- 
 pendent, primary diphtheritis of the skin of the mea- 
 tus. This dij)htheritic ulceration of the meatus may 
 
 1 Vide p. 45, remarks. ^ M.f. 0., 1868, No. 10, S. 154. 
 
 2 A.f. 0., iv., 130. 4 Moos, A./. 0., vi., S. 162. 
 
THE EXTERNAL MEATUS. 47 
 
 lead to cicatricial adhesion of the walls of the pas- 
 sage.^ 
 
 Collapse of the meatus means a slit-lilve contraction 
 of the passage in its cartihiginous portion, seen par- 
 ticularly in old age, and often produced (Von 
 Troeltsch) by a relaxation of the fibrous attachments 
 of the membranous posterior and upper portion of 
 the meatus to the squama. From this relaxation the 
 posterior wall of the cartilaginous meatus falls against 
 the anterior wall. 
 
 Hyperostosis with narrowing of the meatus is most 
 commonly found with caries of the middle and inner 
 ear, and is a cause of retention of pus ; it is found, 
 moreover, with non-purulent chronic inflammations of 
 the middle ear, associated with a growth of connective 
 tissue around the ossiculic, and also frequently exists 
 with osteo-sclerosis in the mastoid process and roof 
 of the tympanum. According to J. Gruber,^ not only 
 a thickening of the osseous portion of the meatus takes 
 place, but the ossification extends outwards along the 
 cartilaginous meatus so that the new growth of bone 
 may reach nearly to the orificium externum. 
 
 Caries and Necrosis. The spot of preference for 
 caries of the meatus is the posterior 
 upper wall near the membrana tym- 
 pani, corresponding either to the 
 floor of the antrum mastoideum, or 
 to the point where the antrum en- 
 ters the tympanum. Preceding the 
 rupture of the cutis the skin of the ^'^s- 26. 
 
 meatus on its upper and posterior 
 wall appears thickened and infil- of the upper waii of the 
 trated with pus ; later granulations 
 
 '^ Vide p. 45. 2 £ehrbuch der Ohrenheilkunde, S. 387. 
 
 The Head of the Har 
 mer exposed from caries 
 
48 PATHOLOGY OF THE EAR. 
 
 are seen projecting from the carious opening, or the 
 opening itself can be seen surrounded by extruding 
 edges of skin. If the carious destruction attacks the 
 upper wall of the passage near the drum-membrane, 
 the head of the hammer, either in articulation with 
 the body of the incus or separated, will be fully ex- 
 posed and can be readily seen on inspection. If both 
 of these ossicles have been lost the corresponding por- 
 tion of the tympanum is exposed. 
 
 Partial necrosis of the osseous meatus with the loss 
 of large portions of its walls results quite frequently 
 from long continued suppurations, especially in child- 
 hood. The OS tympanicum alone may also be at- 
 tacked by necrosis. 
 
 Anomalies of Secretion are noticed in the sebaceous 
 and perspiratory glands of the cartilaginous meatus. 
 The meatus of the new-born child contains vernix 
 caseosa, which completely covers the membrana tym- 
 pani. A h}- persecretion of the glands (seborrhoea) is 
 very common,^ and forms, from long retention and 
 thickening of the secretion due to the loss of its fluid 
 elements, obstructing masses which may by mechan- 
 ical irritation cause secondary inflammatory changes 
 in the skin. Whether changes in the glands them- 
 selves, such as hyperplasia or degeneration of the 
 glandular epithelium, is the cause of the frequent re- 
 currence of such masses, remains to be investigated. 
 
 These masses only produce a functional disturb- 
 ance when they hermetically close the meatus or lie 
 on the drum-membrane. They show a variable ana- 
 
 1 From the presence of foreign bodies the inflammatory irritation of 
 the skin very rapidly produces hypersecretion of the glands, by which the 
 foreio-n body may be in a few hours completely embedded and covered. 
 
THE EXTERXAL MEATUS. 49 
 
 tomical composition. Some consist almost entirely 
 of the secretion of the sebaceous and • sweat-glands, 
 others are chieily composed of masses of epidermis 
 arranged in lamellae (cul-de-sacs of epidermis resem- 
 bling the finger of a glove and filled with glandular 
 secretion). Hairs, round or oval bodies resembling 
 corpora amylacea but not giving the well-known 
 reaction to iodine, occasionally an acarus,^ and mould- 
 fungus, are also found in these masses. Their sur- 
 faces are sometimes glistening from cholesterine. 
 They are found at all ages, but are especially common 
 in old age. 
 
 If the mass completely fills the meatus down to the 
 membrana tympani, wdiich in most cases is not the 
 fact, a perfect impression of the drum-membrane with 
 all its characteristics is often found on the inner end 
 of the mass. In addition to secondary inflammatory 
 irritation of the skin these masses may produce atro- 
 phy or ulceration of the membrana tympani from 
 pressure, but still more commonly, by forcing the 
 drum-membrane inwards, they favor the adhesion of 
 that membrane to the inner wall of the tympanum ; 
 they may also cause a circumscribed atroph}^ of the 
 osseous meatus, and thus enormously enlarge that pas- 
 sage. Von Troeltsch ^ has described a case where one 
 of these masses was the cause of a fatal facial erysip- 
 elas. On the other hand such masses are not uncom- 
 monly complicated by other and wholly independent 
 
 1 First found by Berger in cerumen (Comptes Rendus, xx., S. 1506, 
 1845); previously seen by Henle in the sebaceous glands of the meatus 
 (Miiller's ArcMv, 1842, S. 237). 
 
 2 A.f. C»., vi., S. 48. 
 
50 PATHOLOGY OF THE EAR. 
 
 diseases of the middle ear, for instance, synostosis of 
 the stapes, of which Morgagni ^ gives an example. 
 
 New Growths. Concretions of carbonate and phos- 
 phate of lime, which have formed in the ear, have 
 been found in the meatus ; they are analogous to nasal 
 concretions. In horses similar concretions of an ivory 
 consistency frequently exist. 
 
 Encysted tumor has been seen once by Pappen- 
 heim.'^ It was attached by a small pedicle to the 
 skin and closed the meatus ; it consisted of a cavity 
 formed by the corium and epidermis, and was filled 
 with a white, slightly glistening contents consisting 
 of cholesterine, epithelial cells, fat globules, and crys- 
 tals of lime. 
 
 The tumors described by Toynbee under the name 
 " sebaceous tumors " are not to be considered as en- 
 cysted tumors but cholesteatomata. 
 
 3IiUum may occur in the meatus, as on the eyelid, 
 in the form of a white, round protuberance, of the 
 size of a millet-seed. It is formed from an obstructed 
 sebaceous gland. 
 
 Pedunculated warts covered with a normal cutis 
 containing hairs and sebaceous and sweat glands are 
 very rare. They w^ere found by Von Troeltsch ^ in 
 two cases originating from the upper wall ; in one 
 case the growth was quite near the drum-membrane. 
 
 Polypi, pedunculated tumors, may have their ori- 
 gin from any point of the meatus, usually, however, 
 they grow from the osseous meatus near the mem- 
 brana tympani, and should not be confounded with the 
 
 ^ De Sedibus et Causis Morhorum, lib. i., ep. xiv., art. 11. 
 
 2 Spec. Gewebelehre des Gelwrorgans, 1840. 
 
 3 Lehrbuch, 6 Aufl., S. 504. 
 
THE EXTERNAL MEATUS. 
 
 51 
 
 granulation-growths of the meatus ah-eady described 
 on p. 45. In one case described by Bihroth, the tu- 
 mor originated from the celkdar tissue between the 
 cartilage and the skin. In regard to their histolog- 
 ical structure it should be said, that they are always 
 covered with a pavement epithelium, and that they 
 contain neither glands nor cysts like the polypi of 
 the middle ear, although like these latter they may 
 have a papillary structure. Polypi of the meatus are 
 much more rare than polypi of the middle ear, but 
 do occur with an imperforate drum-membrane. Some- 
 times, however, they exist simultaneously with puru- 
 lent inflammation of the middle ear. 
 
 For a more minute account of aural polypi, com- 
 pare the chapter on the tympanum. 
 
 Exostoses,^ congenital or acquired, pedunculated or 
 w^ith a broad base, spongy or eburnated, are found. 
 The eburnated may be 
 developed from the 
 spongy variety, and per- 
 haps vice versa. Both 
 are only diiferent stages 
 of development of the 
 same process. Their 
 seat is generally at the 
 beginning of the osse- 
 ous meatus or close to 
 the membrana tympani, usually on the upper wall. 
 The calibre of the meatus may be almost or even 
 wholly destroyed by them, but as long as a slit even 
 remains open no disturbance of the hearing is no- 
 
 Fig. 27. 
 Exostoses of the Meatus. From Welcker, 
 A. f. O.," i., Table 2, Fig. 7. 
 
 ^ C. O. Weber, Die Exostosen und Enchondromen, Bonn, 1856. Welcker, 
 A.j: 0., l, S. 163, 1864. 
 
52 
 
 PATHOLOGY OF THE EAR. 
 
 ticed. It very easily occurs, however, under such 
 conditions, that the glandular secretion and the scales 
 of epidermis are collected and retained behind or be- 
 tween the exostoses, and thus hermetically close the 
 meatus. From the pressure of the exostoses against 
 the opposite wall, painful inflammation of the meatus 
 
 Fig. 28. 
 
 Exostoses on the Posterior Wall of Jleatus 
 
 near the drum-membrane. 
 
 Fig. 29. 
 Exostoses of the Meatus. 
 
 with the formation of granulations may take place, 
 and from the retention of the pus may lead very rap- 
 idly to perforation of the drum-membrane and sup- 
 puration of the tympanum. 
 
 Exostoses are much more frequent in men ; are 
 particularly common, according to Welcher, in the 
 skulls of transmarine races. Toynbee considered rheu- 
 matism and arthritis as their causes: I have often 
 seen them hereditary and unassociated with these 
 diseases. Syphilis is certainly to be excluded as a 
 cause. With chronic suppurations of the middle ear 
 exostoses and a tendency to hyperostosis often form 
 a dangerous complication, as they especially favor 
 the retention of the pus. 
 
 Epithelioma of the meatus, in the form of a rough 
 wart, is described by Kessel.^ 
 
 Cholesteatomata occurring primarily in the meatus 
 
 1 A.f. 0., iv., S. 1S4. 
 
THE EXTERNAL MEATUS. 53 
 
 are described in large numbers by Toynbee,^ as seba- 
 ceous tumors, although it is doubtful if he is not re- 
 ferring to the so-called cholesteatomata of the tympa- 
 num or antrum mastoideum,- which, after destruction 
 of the membrana tympani or of the posterior wall of 
 the meatus, are pressed forward into the meatus. 
 Toynbee certainly ascribes to these " sebaceous tu- 
 mors," a firm enveloping membrane of connective 
 tissue, which has its origin on the floor of the meatus, 
 near the drum-membrane, (?) and he considers that 
 the meatus may be considerably enlarged by the tu- 
 mor, and finally, that the bone may be perforated by 
 a gradual atrophy produced by the pressure of the 
 mass. According to him the membrana tympani may 
 often remain intact and pressed i^i against the lab}^- 
 rinthine wall ; in other cases, however, it may be per- 
 forated, and through the opening a portion of the 
 tumor may project into the tympanum. 
 • Enchondroma may arise from the cartilage of the 
 meatus and simulate a parotid tumor.'^ 
 
 Cylindroma is a name given by H. Meckel von 
 Hemsbach to a form of tumor, of Avhich he has de- 
 scribed one example.* According to the terminology 
 of the present day it would perhaps be called a my- 
 xoma cartilagineum. 
 
 In a man about forty years of age, a subcutaneous tumor gradu- 
 ally developed in the course of a half year in front of and below 
 the external meatus. It was extirpated by Von Barensprung. The 
 tumor originated from the cartilaghious wall of the meatus. "Within 
 the passage were merely small flat yellowish nodules ; on the outer 
 
 ^ Med.-Chirurg. Transactions, vol. xliv., p. 51. 
 
 2 Vide p. 22. 
 
 3 Launay, Gaz. des Hup., 1861, 46. 
 
 ^ Charite Annalen, Baud vii., S. 105, Fall 2. 
 
54 PATHOLOGY OF THE EAR. 
 
 surface of the meatus, however, was a yellowish, transparent en- 
 chonclromatous mass of the size of a walnut, consisting of numer- 
 ous sharply defiued lobules. Microscopically it showed in all parts 
 the uniform structure of a pure cylindroma. 
 
 Injuries of the meatus from sharp substances are 
 very common, but are destitute of imjiortant results 
 if the membrana tympani and the parts of the ear 
 behind it are untouched. From the intentional in- 
 fusion of melted metals and mineral acids into the 
 ear, and the thrusting of sharp substances as far as 
 the inner ear, severe inflammations with a fatal result 
 have been caused. 
 
 From the action of force on the under jaw (kick 
 of a horse) fractures of the anterior wall of the 
 meatus with fracture of the glenoid cavity but without 
 injury of the deeper parts, and especially without ex- 
 tension of the fracture to the base of the skull, and 
 without rupture of the drum-membrane, not infre- 
 quently occur. 
 
 Fractures of the base of the skull occasionally ex- 
 tend into the osseous meatus, and may even break off 
 and completely separate pieces of the bone. 
 
 Limited fractures, which do not extend to the base 
 of the skull, sometimes occur in the extremely thin 
 upper wall of the meatus from contusion of the head. 
 This may produce injury of the brain and evacuation 
 of brain substance from the ear, without death neces- 
 sarily resulting. 
 
 Parasites. 
 
 Animal : Huber, Yirchow's Archiv. Bd. 22. Gerlach, Allgcmeine 
 Therapie der Hausthiere. 2 Aufl. Berlin, 1868. Zilrn, Die thierischen 
 Parasiten auf und in dem Kcirper unserer Hauss'augethiere. 1872. Zilrn, 
 Die Ohrkrankheiten der Kaninchen. Deutsche Zeitschrift fiir Thier- 
 mediein uud vergl. Pathologie. 1 Bd. 1870. Von Trueltsch, A. f. O. 
 
THE EXTERNAL MEATUS. 55 
 
 IX. S. 198. 1875. Trautmann, Protocoll der Section fur Ohrenh. auf 
 del- Versammlung Deutscher Naturfoi'scher und Aerzte zu Hamburcr. 
 1876. A. f. O. XI. S. 272. 
 
 Vegetable: ^^alJer, Miiller's Arch. f. Anat. u. Phys. 1844. S. 404. 
 Pacini, Gaz. Mod. Ital. 1851. I. Ser. ]I. Grove, Quarterly Journal. 1857. 
 Vol. V. p. IGl. Cramer, Vierteljahrsschrift der naturforsch. Gesellsch. 
 zu Zurich. 1859,1860. Scliwartze, A. L O. II. S. 5. 18G5. Wreden, 
 A.f. O. in. 1, 1867. TFre(/e/i, Myringomycosis Aspergillina. Petersburg. 
 18G8. Sieudener, A.f. O. V. S. 163. 1870; and a large number of 
 later observations. 
 
 The existence of animal parasites (acari, gregari- 
 ulae), especially dermanyssus avium, symbiotes, derma- 
 tophagus, dermatodectes, has been known for a long 
 time to the veterinary pathologists as a common oc- 
 currence in the meatus of some animals (cow, horse, 
 dog, cat, rabbit, goat), where they may cause inflam- 
 mations or deep necrosis, even into the labyrinth ; 
 their transmission to the human ear, however, with 
 the exception of acarus folliculorum,^ has not yet been 
 observed, although from the close relations of many 
 persons with cats and rabbits it is very possible.^ On 
 the other hand vegetable ixirasites (aspergillus, asco- 
 phora elegans, trichothesium roseum, mucor mucedo) 
 are, according to recent observations, much more com- 
 mon than was formerly supposed, if one may judge 
 from the few references to them in the older Avritinsrs. 
 
 o 
 
 The attention of aural surgeons was first directed to 
 this point by a communication of the author in 1865 ; 
 and soon communications from all sides and from 
 every country were published, so that the fact is 
 now fully established that vegetable parasites, chiefly 
 mould-fungi (aspergillus niger), are developed and 
 
 ^ Compare p. 49. 
 
 2 Derniatodectes in the ear of the rabbit was first observed by Gerlach; 
 symbiotes cati in the ear of the cat by Huber. (Virchoic's Archiv, 
 Bd. xxii.) 
 
56 PATHOLOGY OF THE EAR. 
 
 find noiirisliment in the human meatus auditorius 
 and produce very obstinate and recurring inflamma- 
 tions of that passage and of the drum-membrane 
 (otomycosis of Virchow). On the healthy skin of 
 the meatus no fungus can live and fructify ; it is nec- 
 essary for the development of the growth that there 
 should exist an abnormal condition, possibly loosen- 
 ing of the epidermis, or a superficial inflammation of 
 the skin. In my opinion we have to deal not with a 
 parasitic inflammation, but the parasitic growth upon 
 and among the epidermal cells is an accidental but 
 important accident of the inflammation. A new irri- 
 tation is added by the fungus, hypera^mia and exu- 
 dation are increased, the increase in the vegetable 
 growth interferes with the removal of the secretion, 
 and of the loosened layers of epidermis, and may 
 finally close the median portion of the meatus. The 
 surface of the membrana tympani may be infiltrated 
 with the fungus,^ and if there is a perforation of that 
 membrane, the tympanic mucous membrane may be 
 afiected. 
 
 The diagnosis of otomycosis can frequently be made 
 with certainty Avith the naked eye. The fibres of 
 the fungus with their heads of fructification in insular 
 groups are recognized clearly in profile against the 
 wall of the meatus, or a peculiar white, felt-like de- 
 posit is seen on the membrana tympani. In many 
 cases, however, the diagnosis is doubtful without the 
 use of the microscope. Most frequently the otomy- 
 cosis is mistaken for a chronic eczema squamosum. 
 
 It should be added here that insects (musca, pulex, 
 
 1 From an observation of Politzer's it is established that the fungus 
 uiay even penetrate the tissue of the drum-membrane. 
 
THE DRUM-MEMBRANE. 57 
 
 myriapodes) and their larvas may get into the meatus, 
 and where destructive processes have ah-eady taken 
 place, may reach the middle and inner ears. It 
 should also be mentioned that pus in the meatus often 
 contains numerous bacteria and vibrios. Leyden ^ 
 found in the pus of a carious ear, " fine spirals of from 
 three to six turns which sometimes by wave-like mo- 
 tion beat the surrounding fluid and sometimes con- 
 tracted themselves together." They belong to the 
 lowest vegetable organisms (schizomj'cetes). 
 
 THE DRUM-MEMBRANE. 
 
 CasseboJnn, Tractatus IV. Aiiatomici de Aure Humana. Halje, 1734. 
 First describes the deposits of lime in the drnm-membrane. Plainer, 
 Diss, de Morbis Membranse Tympani. Leipzig, 1780. Gtudllsch, De 
 Morbis Membranas Tynip. Dissertatio. Leipzig, 1780. Von Troeltsch, 
 Virch. Arch. XVIL u. f. und Lehrbuch. Politzer, Beleuchtungsbilder 
 des Trommelfells. Wien, 18G5. Politzer, Zur Patholog. Anatomic der 
 Trommelfelltrubungcn. Oesterr. Zeitschr. fiir Prakt. Heilk. 18G2. VIII. 
 4.3, 4G, 51. Gniher, Lehrbuch, 1870. Wendt, in seinen Anatomischen 
 Beitriigen in Wagner's Archiv fiir Heilkunde. Hinton, Atlas of the 
 Membrana Tympani with descriptive text. London, 1874. 
 
 Pathological changes of the drum-membrane are extremely com- 
 mon, but are rarely the result of a primary aucl isolated disease of 
 that membrane. In most cases they are to be regarded as the sec- 
 ondary results of diseases of the middle ear, and of the external 
 meatus. Dissection alone cannot give us sufficient information in 
 regard to the changes observed during life, because we are dealing 
 with an organ which soon after death changes its color, polish, 
 transparency, and curvature. From the ease, however, with which 
 the membrana tympani can be examined during life, this defect 
 in anatomical investigation can be readily corrected. 
 
 For examining the histological changes, cross-sections of the 
 membrane are best adapted. The membrane should be laid for 
 some days in a weak solution of chromic acid, then in absolute 
 alcohol, and should then be embedded in gum or glycerine-glue. 
 1 Volkman, Klinisdie Vortrdge, i., No. 26. 
 
58 PATHOLOGY OF THE EAR. 
 
 Malformations. Congenital absence of the drum- 
 membrane, as an isolated malformation, without sim- 
 ultaneous absence of the osseous meatus, is doubtful. 
 Itard, Claude Bernard, Bonnafont,^ and Erhard,^ claim 
 to have seen cases where there was no dividing line 
 between the meatus and the tympanum, and the lining 
 membrane of both was of the same character and 
 color. Mistaking an acquired loss of the membrane 
 for congenital absence, is very easy, because in such 
 cases the epidermal covering of the meatus often ex- 
 tends over the mucous membrane of the tympanum. 
 It is certain that absence is often considered to be 
 congenital where it has clearly been caused by dis- 
 ease, as, for instance, in the case of Elsasser.^ Con- 
 genital absence of the membrane must certainly be 
 very rare. I myself have never seen an instance of 
 it. 
 
 The existence of congenital double membrana tym- 
 pani is also very doubtful. The examples of it given 
 by Duverney, Koehler, and Oberteuffer are in reality 
 membranous new growths in the meatus. 
 
 As the upper portion of membrana tympani in 
 the very young embryo is, according to Huschke, not 
 closed, it may happen, in very rare cases, that in 
 adults an arrest of development, in the shape of an 
 opening in the upper portion of the membrane, may 
 be seen. This corresponds in analogy with the colo- 
 boma iridis. It is produced by the flxilure of the true 
 membrana tympani to unite with the membrana flac- 
 cida. Such openings are sometimes found on both 
 
 1 Lehrhuch, 11. Auflage, S. 275. 
 
 2 Rauonelle Oliatrik, S. U. 
 
 3 Hufeland's /owrnaZ (Z. Pmct. Heilkunde, 1828, II. 7, S. 123, note. 
 
THE DRUM-MEMBRANE. 59 
 
 sides and associated with other forms of arrest in de- 
 velopment (cleft uvula, Von Troeltsch). The so- 
 called foramen Rivini, described in 1717 by Professor 
 Rivinus of Leipzig, and previously by Professor Mar- 
 chetti of Padua, in 1652, was for a long time the 
 source of active controversy.^ It was described as a 
 normal attribute of the drum-membrane, even very 
 recently by Professor Bochdalek, of Prague (1866^). 
 It was sometimes referred to the middle, sometimes 
 to the up2)er portion of the membrane. 
 
 A normal foramen Bivini does not exist. In most 
 cases where such an opening exists, and it is by no 
 means uncommon in the membrana flaccida Schrapneli 
 which is not involved in the functions of the ear, it 
 is the result of previous inflammation ; only in very 
 rare cases is it in man a congenital arrest of develop- 
 ment, although in the insect-eating animals it is more 
 common.'^ 
 
 Anomalies in form, size, and inclination of the 
 membrane are frequent, but of no importance. 
 Among the numerous varieties in form, the most note- 
 
 ^ The existence of the foramen Eivini is denied by liildehrandt, 
 Mayer, Meckel, Rudolphi, Cornelius, Cloquet, Linke, Engel; it is 
 doubted by Ruyscli, Pauli, Walther, Cassebohm, Haller ; it is main- 
 tained by Colle, Marchetti, Glaser, Rivinus, Munniks, Cheselden, Teich- 
 niayer, Scarpa, Berres. The opening is regarded as merely an excep- 
 tional arrest of development by Buschke, Hyrtl, Dursy. 
 
 2 Prager Vierteljahrssch:, 1866, Bd. I., S. 33-46. Bochdalek, Jun., 
 affirms the existence of Rivinian openings or canals (Oesterr. Zeitsclir. 
 fur Prakt. Heilkunde, 1866, Nos. 32, 33). He considers only the anterior 
 canal to be perfectly constant, and this opens into the anterior pouch 
 of the drum-membrane. The external opening in the drum-membrane 
 is surrounded by a projecting distinctly fibrous ring when examined mi- 
 croscopically. 
 
 ^ Bonnafont (Traite, etc., p. 273) has twice seen congenital openings 
 in the drum-membrane. 
 
60 PATHOLOGY OF THE EAR. 
 
 worthy is the triangdar form described by Koehler.^ 
 The size of the membrane depends on the variable, 
 individual width of the meatus. The normal di- 
 ameter of the elliptical membrane is 9-10 mm. in 
 its greatest length, and 8.7-9.4 mm. in its greatest 
 breadth. 
 
 Among the anomalies of inclination should be men- 
 tioned the very perpendicular position of the drum- 
 membrane as seen often in very musical people ; and 
 the nearly horizontal position of the membrane (nor- 
 mal in the new-born child) as seen in adults with 
 congenital deafmutism and with cretinismus. Von 
 Troeltsch^ thinks, that from the degree of inclination 
 •of the drum-membrane, it is perhaps possible to judge 
 of the higher or lower position of the sphenoid bone 
 and of the degree of perfection of the skull in gen- 
 eral ; in other words, that there seems to be a legiti- 
 mate connection between the anomalies of inclination 
 in the drum-membrane, and those of development 
 in the base of the skull. In the normal meatus of 
 adults, the averao;e normal ang-le of the drum-mem- 
 brane, i. e., the angle which the membrane forms 
 with the upper (or posterior) wall of the meatus, is 
 given by Von Troeltsch as 140°. 
 
 Congenital anomalies of inclination should not be 
 confounded with acquired anomalies of curvature, as 
 frequently happens in an examination by inexperi- 
 enced persons. 
 
 The manubrium may be inserted into the, mem- 
 brana propria in a false direction, for instance, it may 
 
 ^ Besclireibung der Loder^schen Sammlung, Leipzig, 1795, S. 188, 
 No. 582. 
 
 2 Lchrhuch, V. Auflaiie, S. 39. 
 
THE DRUM-MEMBRANE. 61 
 
 be directed forwards and downwards, or it may be 
 curved like a sabre throuo;hout its whole leng-th, or 
 merely at its lower end. 
 
 Hyperaemia. On the normal drnm-membrane and 
 along the manubrium no blood-vessels are visil)le ; 
 but temporary and slight irritation of the skin of the 
 meatus, or a touch on the membrana tympani, are 
 sufficient to produce momentary injection of the ves- 
 sels of the manubrium. Where these vessels appear 
 permanently congested and enlarged, in the form of 
 a bright or light red bundle of vessels along the pos- 
 terior edge of the manubrium, or wholly covering 
 that bone, it is either a sign of inflammatory irritation 
 in the drum-membrane or tympanum, or else a symp- 
 tom of habitual congestion of the head. 
 
 This hyperaemia in the vicinity of the hammer fre- 
 quently appears as a direct extension of a h^qoersemia 
 of the walls of the meatus. In its higher degrees it 
 is not confined to the immediate neighborhood of the 
 manubrium, but extends over a triangular portion of 
 the drum-membrane near that bone, the base of the 
 triangle being directed upwards. 
 
 Passive hyperemia in the venous ring on the pe- 
 riphery of the membrane is a common appearance 
 with hyperaemia of the tympanic mucous membrane. 
 When it is very marked, nmnerous radiating vessels 
 are seen in the cutis of the drum membrane anasto- 
 mosing with the vessels of the manubrium, becoming 
 wider as ih^y extend outwards, and finally joining 
 the venous ring on the periphery. In the highest 
 stage of hypera3mia of the cutis of the drum-mem- 
 brane the single capillaries are no longer seen, but 
 the membrane has a diffuse red color, the intensity of 
 
62 PATHOLOGY OF THE EAR. 
 
 which varies, according to the degree of hyperaemia, 
 from pink to blnish red, copper red, and scarlet. 
 Such hyperoemias of the skin are often seen without 
 hyperemia of the mucous membrane ; when they are 
 present the hammer is not visible. With normal or 
 increased transparency of the drum-membrane, a vio- 
 let appearance may be given to the membrane by 
 reflection from the hypercemia of the labyrinthine 
 wall of the tympanum, the drum-membrane itself not 
 participating in the hypercemia. With muco-puru- 
 lent catarrh of the tympanum without perforation, 
 the hyperemia of the drum-membrane is sometimes 
 confined to its mucous layer ; this is more especially 
 the case on the periphery or on certain isolated spots 
 of the membrane. In the majority of cases, however, 
 both the skin and the mucous layer of the membrane 
 are simultaneously hyperaemic. The lamina propria 
 is either entirely destitute of vessels, or is perforated 
 at its edge by single small capillaries. 
 
 Hemorrhage. Spontaneous and traumatic hemor- 
 rhage in the substance of the membrana tympani is 
 seen as minute ecchymoses, superficial extravasations, 
 haematomata and hemorrhagic infiltrations, and may 
 occur either in the layer of skin or of mucous mem- 
 brane, sometimes in both simultaneously. It is found 
 with simultaneous hyperaemia of the tympanic mucous 
 membrane during measles, small-pox, typhus, scurvy, 
 from compression of the lungs by pleuritic exudation, 
 and from other causes which produce congestion of 
 the vena cava superior, from endocarditis and also 
 from primary inflammations of the drum-membrane. 
 The hemorrhages may occur just in front of or be- 
 hind the manubrium, in the posterior upper part of 
 
THE DRUM-MEMBRANE. G3 
 
 the membrane, and also at other spots. Hemor- 
 rhagic infiltration is sometimes found on the edges 
 of perforations, and appears as an ill-defined bluish- 
 black thickening of the edges. Ha3matoma in the 
 mucous layer appears as a bluish-red, sharply defined, 
 round or oval prominence above the plane of the 
 mucous membrane. It was first described by Wendt,^ 
 who found it in the dissection of small-pox cases. The 
 remains of extravasations I have often seen as gray- 
 ish-black pigmentations of the mucous layer, like the 
 pigmentation in the intestinal mucous membrane after 
 cholera infantum. The ecchymoses which occur un- 
 der the epidermis change their position and wander 
 in the course of a few weeks towards the periphery 
 of the membrana tympani, generally towards the 
 posterior upper wall, and from there pass on to the 
 skin of the meatus. This very peculiar locomotion 
 was first described by Von Troeltsch,^ and has since 
 been noticed in various ways. It has been thought 
 that its cause was an eccentric growth of the epider- 
 mal covering, while Zaufiil endeavors to explain it by 
 capillary action, and Kessel thinks that the extrava- 
 sation is within the lymph-vessels, and its motion 
 dependent on the movement in these vessels. 
 
 Inflammation of the Drum-Membrane (myringitis) and 
 its results. An independent primary inflammation 
 of the drum-membrane is relatively rare, and is usu- 
 ally found only on one side. In most cases, inflam- 
 mation of the tympanum or of the meatus is also 
 present, and the inflammation of the drum-membrane 
 mak«s its appearance as a secondary affection. 
 
 ^ Arch. f. Heilkunde von Wagner, xiii., S. 128. 
 2 Lehrbuch, V. Aufl., S. 131, note. 
 
64 PATHOLOGY OF THE EAR. 
 
 In the acute form of myringitis, the membrane 
 appears flattened and the manubrium indistinct from 
 hypera^mia and serous infiltration of the layer of cutis. 
 The position of the manubrium is only recognized by 
 a red line of blood-vessels. The epidermis is macer- 
 ated, becomes loose and is destroyed ; owing to this 
 the corium is exposed, and appears red, loosened, and 
 swollen. The swelling is the result of serous and cel- 
 lular infiltration. In the mucosa immense numbers 
 of cells are found in the connective tissue stroma, 
 and the blood-vessels are enlarged. The substantia 
 propria shows a peculiar swelling and softening of 
 the fibres from which the drum-membrane assumes a 
 soft relaxed condition, and is very easily torn. The 
 meatus near the membrana tympani, if not originally 
 affected, participates secondarily in the inflammation, 
 the sharp boundary between the meatus and drum- 
 membrane disappears, and the membrane itself looks 
 smaller than natural on account of the swelling of the 
 meatus. 
 
 Sometimes ecchymoses and interlamellar abscesses 
 occur in the membrane. In very 
 rare cases perforating ulcers are 
 found. (Fig. 30.) 
 
 Acute diseases of the skin of 
 the meatus sometimes extend on 
 to the skin of the drum-mem- 
 brane, and the vesicles of eczema 
 ■"'2 ^° and pemphigus have been seen on 
 
 An Ulcer perfovatinsr from • , -r ^ xl ^ 1,1, ,„ 
 
 without inward, in the central it- I haVC UCVCr SCCH the plllyC- 
 portion of tlie drum membrane, teuular foHU of myringitis OCCUr- 
 
 ring with scrofula as it is described by Triquet.^ Pos- 
 
 1 Presse Med., 1863, 18. 
 
THE DRUM-MEMBRANE. 65 
 
 sibly this is owing to its being confounded with vesic- 
 ular prominences of the skin or with the vesicles of 
 eczema. 
 
 The chronic inflammation of the membrana tym- 
 pani, which comes under observation frequently, is 
 also seldom an isolated disease, but is usually only an 
 accompaniment of simultaneous inflammation of the 
 tympanum. The membrane is covered with pus, is 
 thickened, flattened, of a yellowish gray color, with 
 radiating varicose blood-vessels, and occasionall}'' with 
 polypoid excrescences. No part of the hammer, 
 except perhaps the processus brevis, can be recog- 
 nized. In the substantia propria there are deposits 
 of fat and lime, in the mucous membrane infiltration 
 with round cells ; cysts also are sometimes formed. 
 
 The walls of the meatus are, in their external half, 
 of nearly normal appearance, in their inner half, near 
 the drum-membrane, usually covered with black crusts, 
 but nowhere with fresh pus. 
 
 The myringitis parasitica (myringomycosis asper- 
 gillina, Wreden's), described by Wreden as an inde- 
 pendent disease, is only one of the appearances of 
 otomycosis.^ 
 
 Nassiloff ^ has given the name myringitis villosa to 
 a form of chronic inflammation, in which ijairillary 
 outgrowths or villi from 0.06 — 0.25 mm. in length 
 are developed on the external surface of the mem- 
 brane with an increase of vascularity ; at the same 
 time the fibres of the drum-membrane may be sup- 
 planted by a new growth of a vascular connective 
 tissue in the cutis and membrana propria. 
 
 1 Vide p. 56, 
 
 ^Med. Centralblatt, 1SG7, No. 11. 
 5 
 
66 PATHOLOGY OF THE EAR. 
 
 According to Nassiloff, these villi are covered with 
 several layers of pavement epithelium ; according to 
 Kessel, by a single layer of cylinder epithelium, with 
 peculiar variations in form. Both are apparently 
 only different stages of development of the same new 
 growths,^ and are analogous to the polypoid inflam- 
 mations of the mucous membrane. 
 
 As results of inflannnation of the membrana tym- 
 pani should be mentioned : — 
 
 1. Anomalies of color and trajisjxirenci/. Aside 
 from individual variations in color and transparency 
 which the healthy drum-membrane may offer, ojKici- 
 ties and thickenings are often found as the result of 
 inflammatorj' processes. The smoky-gray or pearl- 
 gray color of the normal membrane may become deep 
 gray, whitish gra}^, yellow, or yellowish red. All 
 these variations of color are seen much more pro- 
 nounced on examining living subjects than they are 
 on the dead body, where they are indistinct if the 
 preparation is not perfectly fresh, and have often 
 wholly disappeared if the preparation has been in 
 spirit. 
 
 The transmission of color from the contents of the 
 tympanum, whether due to abnormal conditions of 
 its mucous membrane or to the collection of secre- 
 tion in the cavity, have an important influence on 
 the changes of color. The infantile drum-membrane, 
 on account of the greater thickness of its cutis and 
 mucous layers, always appears a thicker whitish gray 
 than does the membrane of adults, and it is possible 
 that this variation from the normal color sometimes 
 continues till adult life as an anomaly of development. 
 
 1 S. Kessel, Zur Myringitis Villosa. A. f. 0., v., S. 250. 
 
THE DRUM-MEMBRANE. 67 
 
 In old age a whitish discoloration of the membrane 
 is by no means to be referred to the physiological 
 changes due to age.^ 
 
 Opacities do not always correspond with thicken- 
 ings of the membrane, but are also found with atro- 
 phic processes. According to their extent, position, 
 and form, we distinguish partial and total opacities, 
 peripheral and intermediar, crescentic, speckled, stri- 
 ated, etc. 
 
 The histological substratum of opacities is variable ; 
 most frequently it is a new growth of connective 
 tissue together with changes in the superficial layer 
 of epithelium, such as deposition of fat and lime, albu- 
 minous infiltration, or else a new growth of connec- 
 tive tissue in the lamina propria. It is rare that a 
 single layer of the drum-membrane is the seat of an 
 opacity ; usually all three layers, on account of their 
 intimate relations, are simultaneously affected by the 
 pathological processes. Thickenings generally occur 
 from an increase in the thickness of the superficial 
 layers of the membrane, rarely of the fibrous middle 
 layer. (The normal thickness of the membrane is 
 0.1 mm.) 
 
 Partial opacities most commonly begin in the sub- 
 stantia propria, but, with very few exceptions, ex- 
 tend from that into both the superficial layers. They 
 appear as irregular yellowish-white or white specks 
 and lines, at first with indistinct, later wdth sharply 
 defined edges. They are caused by fatty degenera- 
 tion of the membrana propria itself, or by a new 
 
 ^ Gruber describes, as a frequent appearance in old age, a periphei-al 
 yellowish or milky opacity, winch is usually due to fatty degeneration 
 of the substantia propria. — Lehrbuch, p. 398. 
 
68 PATHOLOGY OF THE EAR. 
 
 growth of connective tissue between the fibres of 
 that membrane, thus crowding these fibres together. 
 
 A crescentic intermedlar opacity behind the manu- 
 brium, the convexity directed towards the periph- 
 ery, is a frequently recurring variety. It often 
 exists with simultaneous hypertrophy and adhesive 
 inflammation of the mucous membrane (synechiae 
 within the tympanum). Some intermediar opacities, 
 it should be stated, are only optical appearances on 
 the membrana tympani, and disappear whenever the 
 drum-membrane can be examined perpendicularly to 
 its surface. In other cases partial opacities in the 
 form of irregular specks and striaa (tendinous opaci- 
 ties) are seen, which inclose atrophic spots in the 
 membrane. These are found more especially with 
 rigidity and anchylosis of the ossicles. 
 
 The so-called j)eri2)heral ojKiclties are peripheral, 
 whitish-gray opacities, varying very much in the in- 
 tensity of their color ; they are produced by a depo- 
 sition of fat-globules between the circular fibres of 
 the lamina propria, which fibres are, in the normal 
 condition, closely crow^led together on the periphery 
 of the membrane ; or else they are caused by a thick- 
 ening of the mucous layer of the membrane, which 
 in this region possesses in the normal condition, villi 
 or papillae, as was first described by Gerlach. 
 
 When these peripheral opacities are very well 
 marked there always exists a simultaneous patholog- 
 ical thickening of the tympanic mucous membrane, 
 and it will be noticed that the central portion of the 
 membrana tvmpani appears darker and more trans- 
 parent than usual, and apparently or in reality is 
 curved deeper inwards than is natural. 
 
THE DRUM-MEMBRANE. 
 
 G9 
 
 Calcifications in the membrana tympani are very 
 common. They may occur as isolated affections with- 
 out pathological changes in the deeper parts of the 
 ear and with a normal hearing ; more commonly they 
 are the remains of previous suppurative processes in 
 the ear, but they are also found in deaf persons with 
 non-suppurative inflammations of the middle ear. 
 
 Ffg. 3 
 
 Fig. 32. 
 
 Fig. 33. Fig 34. 
 
 Fig. 31. Calcification.^ in the Drum-membrane. 
 
 Figs. 32 and 33. Calcitications and Cicatrices. 
 
 Fig. 34. Calcitication of the whole Drum-membrane seen from within, with a cic- 
 atricial formation in the posterior upper quadrant. The calcified membrane projects 
 sharply into the tympanum and is as hard as bone. 
 
 The most common form of calcification is a crescent 
 before or behind the manubrium ; the horse-shoe vari- 
 ety is less common. In the highest degrees of calcifi- 
 cation the deposit extends over the whole memlsrane, 
 but this occurs only after suppurative processes. The 
 drum-membrane is then transformed into a perfectly 
 rigid stony plate, sometimes of considerable thick- 
 ness (2-3 mm.). 
 
70 PATHOLOGY OF THE EAR. 
 
 Besides the crescentic form the deposits of lime oc- 
 cur as irregular and radiating striations from the end 
 of the manubrium towards the periphery of the 
 drum-membrane , 
 
 A central calcification surrounding the manubrium 
 is very rare. Beginners in otoscopy can easily mis- 
 take the yellow appearance of the end of the manu- 
 brium, which is visible under normal conditions, for a 
 calcification. 
 
 The seat of calcification is either the lamina propria 
 alone, in which case the superficial layers of the 
 drum-membrane are easily separated under water by 
 means of needles from the calcification, or else all 
 three layers of the drum-membrane are calcified ; in 
 this latter case the deposit often projects above the 
 surface of the mucous membrane, rarely above that 
 of the skin. 
 
 The thickened epidermis of the membrana iym- 
 pani appears to be very rarely indeed the sole seat 
 of lime deposits (Lucae). 
 
 The deposition of amorphous lime-particles takes 
 place in the membrana propria, partially between and 
 in its fibres, partially in the drum-membrane corpus- 
 cles ; with the lime there is usually much fat, seldom 
 any pigment. According to Wendt, the deposition 
 occurs in the endothelial sheaths wdiich surround, like 
 a tube, the processes of the fibrous framework of the 
 membrane. The histolocrical chanojes near the calci- 
 fied spots extend further than would be supposed 
 from the clearly defined edges of the deposit. Ex- 
 ceptionally crystallized lime is found, as was first 
 described by Von Troeltsch.^ Bauer - found crystals 
 
 ^ Virchow's Archiv, xvii., S. 16. 
 ^ Diss. Inauf/., 1863, Marburg. 
 
THE DRUM-MEMBRANE. 71 
 
 of phosphate of lime in the membrana tympani of 
 hemicephali. with deposits of the same salt in the 
 tympanum and laljyrinth, and the stapes was com- 
 pletely imbedded in a solid crystalline mass of lime. 
 Liicae^ found crystals of carbonate of lime (aragonite) 
 in the peripheral portion of the thickened epidermis 
 of the membrana tympani in a case of chronic catarrh 
 of the middle ear. 
 
 The existence of a 7iew growth of hone near cal- 
 cified portions of the membrana tympani in man 
 was first proved by the histological investigations of 
 Politzer, and was later confirmed by Wendt from his 
 own dissections. Microscopically large and numer- 
 ous bone corpuscles with short processes are seen. 
 
 Partial opacities may, finally, be produced accord- 
 ing to Gruber,^ by a duplicature of the drum-mem- 
 brane and the union of the mucous surfiices by con- 
 nective tissue. They result from long continued 
 closure of the Eustachian tube, are usually situated 
 in the posterior segment of the membrane, pass back- 
 wards in a curve from the processus brevis and re- 
 semble a strongly developed, so called posterior fold. 
 The affected segment of the membrana tympani ap- 
 pears diminished in size and is opaque. Partial opac- 
 ities produced in the same way may, according to 
 Gruber, also occur on the anterior seo'ment and as- 
 sume a circular shape. 
 
 Similar opacities can be produced by a growth on 
 the mucous membrane or by a union of the pouches 
 of the membrana tympani. 
 
 Total ojmcities of the drum-membrane are most 
 
 ^ Virchow's ArcJiiv, xxxvi., June. 
 2 Lekrbuch, S. 402. 
 
72 PATHOLOGY OF THE EAR. 
 
 frequently produced by a thickening of the mucous 
 membrane, one of the results of the general thicken- 
 ing of the whole tympanic mucous membrane which 
 occurs from chronic catarrhs. The thickening of the 
 mucous layer of the drum-membrane may be so ex- 
 treme as to be five times the normal thickness (0.1 
 mm.) of all the layers together. The thickening is 
 caused by enlargement of the blood-vessels and the 
 presence of large numbers of cells in the connective 
 tissue stroma. The epithelium remains intact. Ex- 
 amined externally during life the membrana tympani 
 appears in such cases bluish-white or fibrous, resem- 
 bling a slightly-ground glass (Politzer). The manu- 
 brium remains visible or its contour is even more dis- 
 tinct than on the normal membrane, so long as the 
 external layers are unaffected. In most cases such 
 thickening of the mucous layer is complicated by cir- 
 cumscribed or diffiise secondary opacities of the lam- 
 ina propria or of the skin. 
 
 Total opacities may also occur from a loosening 
 and thickening of the epidermis, from swelling of 
 the cutis layer, by which the hammer is rendered in- 
 visible, and from untransparency of the lamina pro- 
 pria alone. Thickenings of the epidermal layer are 
 usually the result of the different forms of otitis ex- 
 terna, but are also produced by suppuration of the 
 tympanum with perforation of the drum-membrane. 
 From the serous infiltration and thickening of the 
 epidermis, the membrana tympani appears grayish- 
 white, without lustre, flattened and rough. In the 
 highest stages of the disease the epidermis is com- 
 pletely macerated. Diffiise swelling of the dermis is 
 produced by the enlargement of the blood-vessels and 
 
THE DRUM-MEMBRANE. 73 
 
 the deposition of pus cells between the meshes of con- 
 nective tissue ; diffuse opacity of the lamina propria 
 by translucent swelling, albuminous infiltration or 
 fatty degeneration of the fibres of the drum-mem- 
 brane, and by the deposition of calcareous molecules. 
 Exceptionally, Politzer found an unusual number of 
 the normal fibres constituting the histological sub- 
 stratum of opacities in the lamina propria. 
 
 2. Anomalies of Curvature 
 May appear as convex projections, as flattening or as 
 increased concavity (drawing inwards) of the drum- 
 membrane. 
 
 Convex j^'^ojectlons, the result of inflammatory 
 swelling with acute catarrh of the tympanum, seldom 
 involve the wdiole extent of the membrane. The 
 membrana tympani projects in the shape of a hemi- 
 sphere, is bluish-red, moist and glis- 
 tening, resembling the surface of a 
 smooth polypus. With this condi- 
 tion of the drum-membrane, the 
 position of the manubrium may be 
 indicated by a groove between the 
 anterior and posterior segments of p's 35. 
 
 the projection. Bladder-Uke Piotnision 
 
 . . . pi "" ^^^ Posterior Upper 
 
 Jrartial IWOjectlOnS of the mem- Quadrant; from collection 
 
 brane are very common from collec- f '""'^"''°" '" ^^'^ '^^^"'^ 
 
 •'^ tympani. 
 
 tion of exudation in the tympanum, 
 and also during acute myringitis ; they are most com- 
 mon near the periphery and on the upper half of the 
 membrane, often appearing as bladder-like projections 
 on the periphery of the posterior upper quadrant. 
 They are also produced by granulations, infiltrations. 
 
74 PATHOLOGY OF THE EAR. 
 
 and abscesses in the clrmn-memlDrane. by the collection 
 of pus, mucus, caseous and epidermal masses behind 
 the membrane, and by polypi within the tympanum. 
 
 The granulations of the membrana tympani are. 
 papillary connective-tissue growths of the cutis layer, 
 and certain portions or even the whole membrane 
 may be thus affected. They are more common during 
 otitis media purulenta with perforation than during 
 chronic otitis externa, without perforation. 
 
 The partial projections of the drum-membrane, 
 which are sometimes produced by collections of air 
 under its skin, and by hernial openings in the mem- 
 brane, will be considered with atrophy of the mem- 
 brane. 
 
 Flattening, by which the drum-membrane loses its 
 normal concavity around the umbo, and appears as a 
 flat disk, results, 1. From swelling of its layer of 
 skin, which often occurs with swelling of the layer 
 of mucous membrane ; 2. From collections of exuda- 
 tion behind the membrane ; 3. From inaction of the 
 tensor tympani, as in fatty degeneration, atrophy, 
 etc., of that muscle. 
 
 Increased concavity (abnormal drawing inwards, 
 collapse, depression). A normal membrana tympani 
 shows on dissection an increased concavity so long as 
 the rigor mortis of the tensor tympani continues. 
 
 Pathological concavity is produced by every long 
 continued closure of the Eustachian tube ; also by 
 synechise of the membrana tympani or of the manu- 
 brium with the labyrinthine wall, or with the floor 
 of the tympanum ; ^ by peripheral thickening of the 
 
 ^ By synechia between the drum-membvane and the labyrinthine 
 wall, the tympanum may be divided into two parts, the anterior comniu- 
 
THE DRUM-MEMBRANE. 75 
 
 layer of mucous membrane and by shortening of the 
 tendon of the tensor tympani muscle, resulting from 
 retraction of the thickened mucous membrane which 
 covers it. 
 
 With a pathological increased concavity, the color 
 of the drum-membrane may remain unchanged, or it 
 may be modified by the transmitted color of the tym- 
 panic mucous membrane, or it may be dark gray, 
 from opacity of the drum-membrane itself. The lus- 
 tre is often increased ; the triangular light reflex is 
 widened and pushed towards the periphery, and often 
 there is a striated light reflex on the anterior lower 
 portion of the periphery of the membrane. 
 
 The characteristics of increased concavity of the 
 whole membrane when examined from the meatus, 
 are perspective foreshortening of the manubrium, ab- 
 normal prominence of the short process and the axis- 
 ligaments, more especially the posterior ligament, 
 ligamentum mallei posticum (Helmholtz). Seen from 
 within the central portion of the drum-membrane is 
 funnel-shaped, and lies close to the labyrinthine wall 
 of tlie tympanum. 
 
 The so-called posterior fold of the membrana tympani, which, 
 when very pronounced, has been considered as diagnostic, of in- 
 creased concavity, is not a true fold, but a slight angular promi- 
 nence of the membrane, as the result of which a curved projecting 
 ridge of membrane is found running from the short process back- 
 wards, as Von Troeltsch rightly described it in the first edition of 
 his work (1862, S. 148). 
 
 In the natural position of the membrane, the hammer always ap- 
 pears, on inspection, during life, shorter and smaller than it really 
 is. This is shown very clearly on dissection, if the membrana tym- 
 
 iiicating with the Eustachian tube, the posterior with the mastoid pro- 
 cess. 
 
76 PATHOLOGY OF THE EAR. 
 
 pani is examined before and after removal of the meatus. In a 
 pathological sense, perspective foreshortening is only used when 
 there is a pathological increase in the concavity of the membi-ane. 
 The perspective foreshortening is seen in its highest degree with 
 the maximum concavity of the membrane, that is, in those cases in 
 which the membrane lies against the labyrintli wall. With the 
 lesser degrees of foreshortening, there is very often also a perspec- 
 tive diminution in the size of the manubrium, because the anterior 
 half of the membrane is more strongly drawn inwards than the 
 posterior half. When there is large destruction of the drum-mem- 
 brane in the neighborhood of the hammer, the manubrium may lie 
 so nearly horizontal that only tlie short process, with its point di- 
 rected downwards, is visible externally. 
 
 For an account of partial concavities, see Cicatrices 
 (p. 80), and Atrophy of the Memhrana Tympani, 
 
 (p. 85). 
 
 3. Perforations and Cicatricial Formations. 
 
 Perforations occur in all parts of the inembrana 
 tympani ; are most common on the anterior lower 
 quadrant of the membrane in the intermediar zone 
 between the manubrium and the tendinous tympanic 
 ring; are most rare immediately at the manubrium or 
 periphery because at these spots the lamina propria 
 is most strongly developed and offers the greatest re- 
 sistance to destructive processes (Politzer). Perfora- 
 tions in the extreme upper portion of the membrane, 
 in the so-called membrana flaccid a Shrapneli, where 
 there is no lamina propria, are by no means rare. 
 
 The size of perforations vary from that of a fine 
 needle to a loss of the whole membrane. Most com- 
 monly a Y shaped portion of the membrane remains 
 above and around the manubrium and a falciform 
 remnant on the periphery. 
 
 The most common shape of perforations is round, 
 
THE DRUM-MEMBRANE. 
 
 77 
 
 oval, elliptical, or kidney-shaped. With a central per- 
 foration the exposed manubrium is drawn inwards by 
 the tension of the tendon of the tensor tympani mus- 
 cle, and lies near or directly against the promon- 
 tory ; in many cases it is even drawn so far inwards 
 
 Fig. 36. 
 
 Fig. 37. 
 
 Fig. 38. 
 
 Fig. 36. 
 edges. 
 Fig. .37. 
 Fig. 38. 
 
 Fig. 39. Fig. 40. 
 
 An old Circular Perforation of the Drum-membrane with thickened 
 
 Kidney-shaped Perforation. 
 
 Large Kidney-shaped Loss of the Membrane, the manubrium exposed 
 and a deposit of lime in the remnants of the drum-membrane. 
 
 Fig. 39. Loss of the whole Drum-membrane ; retention of the exposed manu- 
 brium and of the tendinous ring. 
 
 Fig. 40. Loss of the Drum-membrane, the manubrium exposed and necrosed. 
 Tlie head of the stapes visible. In the membrana Shrapneli is a deeply sunken cica- 
 
 and upwards that on inspection from the meatus it 
 appears to have entirely disappeared. In other cases 
 the lower end nppears to be shortened from absorp- 
 tion, or the whole manubrium up to the head of the 
 hammer is wantinar. 
 
78 PATHOLOGY OF THE EAR. 
 
 In by far the greater number of cases the perfora- 
 tion takes place from within outwards during otitis 
 media purulenta, but occasionally from without in- 
 wards by perforating ulcer, or as the result of an ab- 
 scess of the membrane during myringitis. Various 
 conditions unite in producing these perforations, in- 
 flammatory softening of the tissues of the drum-mem- 
 brane, pressure of the exudation behind the drum- 
 membrane, and movement caused by expiration. At 
 first only a rupture occurs ; the edges of this then 
 ulcerate and the loss of substance is produced. The 
 extent of this loss of substance depends very much on 
 constitutional conditions. The largest and most rapid 
 destructions occur in scrofula, tuberculosis, and espe- 
 cially in scarlet fever. 
 
 Spontaneous atrophy, or atrophy^ of the mem- 
 brana tympani from any pressure upon it, without 
 the existence of suppurative inflammation, is a very 
 rare cause of perforation. When it does occur the 
 whole drum-membrane appears extremely delicate 
 and transparent, and the walls of the perforation are 
 very thin. According to Beck^ there is a predisposi- 
 tion to atrophic perforation of the drum-membrane in 
 old age. 
 
 Fresh perforations show irregular, rough, ragged 
 edges, old ones smooth, thinned or thickened, or occa- 
 sionally calcified edges, the thickening being caused 
 by development of blood vessels and infiltration of 
 cells. The edges of the perforations may be partially 
 or completely united with the mucous membrane of 
 
 1 Sfhwartze, A.f. 0., ii., S. 291. 
 
 2 Beck, Krankhciten des Gehoroi-gans, Heidelberg and Leipzig. 1827, 
 S. 187. 
 
THE DRUM-MEMBRANE. 79 
 
 the labyrinthine wall, either directly or by bands of 
 connective tissue. 
 
 Duplicate perforations of the drum-membrane were 
 formerly considered very rare (for instance by Polit- 
 zer, " Beleuchtungsbilder," S. 135), 
 but from what I have seen during life, 
 and also on dissection, double and 
 triple perforations, separated from 
 each other by a bridge of membrane, 
 are by no means uncommon. For a 
 long time I doubted the existence of ""'g ^i. 
 
 the cribriform condition of the mem- Double Perforation of 
 
 the Drum-membrane. 
 
 brana tympani such as was first de- 
 scribed by Bonnofont, but from my own experience 
 I am convinced that, not only in tuberculosis pulmo- 
 num and miliary tuberculosis, but also in scarlatina 
 Avith pharyngeal diphtheritis and pytemic conditions, 
 the membrana tympani may be simultaneously per- 
 forated at different points. These multiple perfora- 
 tions are at first vQvy minute, but rapidly enlarge and 
 finally coalesce into a large opening (perhaps from 
 emboli).^ 
 
 With the very marked regenerative power pos- 
 sessed by the drum-membrane ^ healing of perfora- 
 tions is very frequently observed. Destruction of 
 more than two thirds of the whole membrane may 
 be restored. In recent perforations, and in those 
 without much loss of substance, the healing takes 
 
 1 On multiple perforation of the drum-membrane compare C. E. E. 
 Hoffmann, A.f. 0., iv., S, 277. 
 
 ^ I once saw a wonderful instance of this in a case in which I had ex- 
 cised more than two thirds of the drum-membrane and had also removed 
 the entire hammer. After some weeks the whole opening was closed by 
 a newly formed membrane. 
 
80 PATHOLOGY OF THE EAR. 
 
 place without leaving any visible pathological change 
 on the membrane ; in older and larger perforations a 
 persistent cicatrix results. The drum-membrane be- 
 comes at first pale and dry, the edges of the perfora- 
 tion become thin, and with strong illumination ap- 
 pear to be translucent, and closure occurs from the 
 growth of connective tissue from the edges. 
 
 Not infrequently broad bands of blood-vessels are 
 seen running from the edges of the perforation to- 
 wards the periphery of the drum-membrane, but 
 after the closure of the opening these gradually dis- 
 appear, although they may remain visible on the 
 
 Fig. 42. Fig. 43. 
 
 Fig. 42. Oval cicatrix in the drum-membrane. 
 
 Fig. 43. Large cicatrix in the posterior half of the drum-membrane; in the an- 
 terior half is a round perforation with calcified edges and two calcified spots. (From 
 Politzer, " Beleuchtungsbilder," etc., Taf. II., Fig. 4.) 
 
 newly formed cicatrix for a long time. The fully de- 
 veloped cicatrix consists of a thin stratum of connec- 
 tive tissue containing capillary vessels, and each side 
 of this is covered by a very thin layer of epithelium. 
 The lamina j^roj^ria is not rejjrochiced, but is seen on 
 the edges of the cicatrix sharply defined and passing 
 directly into concentric fibrillary connective tissue 
 running parallel to the edges of the cicatrix. Some- 
 times, in certain spots, the fibres of the lamina pro- 
 pria pass into the cicatricial tissue and undergo a 
 change of form. 
 
THE DRUM-MEMBRANE. 81 
 
 The cicatrix, on account of its want of lamina pro- 
 pria, always appears to lie below the plane of the 
 rest of the drum membrane, i. e., sunken inwards 
 nearer the wall of the labyrinth. 
 
 The size and shape of cicatrices vary according to 
 the original loss of substance. The most usual form 
 is oval, round, or kidney-shaped. 
 
 By inspection from the meatus they appear sharply 
 defined, darker than the surrounding tissue and 
 sunken inwards. On the inflation of air into the 
 middle ear the cicatrix is pressed outwards and be- 
 comes wrinkled. Large cicatrices may lie against 
 the long process of the incus or against the labyrinth- 
 wall and the stapes ; they may be attached to these 
 parts either directly or by bands and membranes of 
 connective tissue. 
 
 Fig. 44. Fig. 45. 
 
 Fig. 44. Two very large Cicatrices in the Drum-membrane before and behind the 
 Manubrium, throughout most of their extent adherent to the labyrinth-wall of the 
 tympanum. 
 
 Fig. 45. Funnel-shaped retracted Cicatrix of the Drum-membrane adherent to the 
 Labyrinth- Wall. (A diagrammatic section through the meatus, drum-membrane, and 
 tympanum; from Pol itzer, " Beleuchtungebilder," etc., S. 109.) 
 
 When the cicatrix adheres directly to the labyrinth- 
 wall a cross-section through it sometimes shows a 
 cavity resembling a cyst or glandular involution of 
 the surface. The origin of these apparent changes 
 will be considered in the chapter on the tympanum. 
 
82 PATHOLOGY OF THE EAR. 
 
 The external surface of those cicatrices which are 
 attached to the wall of the labyrinth are generally 
 moist and occasionally secrete pus, owing to an insuf- 
 ficient hardening of the epithelium.^ 
 
 In very many cases this desired closure of the per- 
 foration by cicatrix, does not take place, but the ex- 
 ternal and internal surfaces of the edges of the per- 
 foration unite and the opening of the membrane 
 becomes permanent. In such cases there may be a 
 thickening of the edges of the perforation, by a new 
 growth of connective tissue (Fig. 36), and this may 
 undergo calcification (Fig. 43). 
 
 An apparent, but unreal cicatrization sometimes oc- 
 curs from the swollen mucous membrane entirely 
 filling the tympanum, so that the edges of the perfo- 
 ration lie in contact with and become adherent to 
 this tympanic mucous membrane. In such a case is 
 seen a deeply sunken spot on the membrana tympani 
 covered with thickened epidermis. 
 
 4. Detachment of the Manuhrium 
 From its insertion into the drum-membrane gener- 
 ally takes place only at its lower end, seldom through- 
 out its whole length ; it then projects into the tym- 
 panum, and approaches, or even touches the prom- 
 ontory ; this occurs frequently during inflammatory 
 softening (hyperasmia and swelling) of the membrana 
 tympani from the tension of the tendon of the tensor 
 tympani, and is found, both with and without per- 
 foration of the membrane in the vicinity of the 
 manubrium. In one case I saw such a detachment 
 with a double perforation (Fig. 47). On the mucous 
 
 1 Politzer, I.e., S. 111. 
 
THE DRUM-MEMBRANE. 83 
 
 membrane opposite the detached bone, a shallow 
 groove or a slight eminence is sometimes seen. In 
 other cases the detached manubrium appears to lie in 
 its usual position on the drum-membrane, but can be 
 very easily raised from it. Wendt once found a de- 
 tached and separated manubrium embedded in a tu- 
 bular covering of bright red, soft, smooth tissue, in 
 which the bone was readily movable. After detach- 
 
 Fig. 46. Fig. 47. 
 
 Fig. 46. Diagrammatic Section through Meatus, Drum-membrane, and Tympa- 
 num, to demonstrate the separation of the manubrium from the drum-membrane. 
 (From Politzer, '"Beleuchtungsbilder," S. 118.) 
 
 Fig. 47. Double Perforation of the Membrane with a Manubrium detached, and 
 at its lower end atrophied. Seen from the tympanum. 
 
 ment, the manubrium may again be united to the 
 drum-membrane by a bridge of connective tissue. 
 No constant change in the curvature of the mem- 
 brana tympani is produced by a detachment of the 
 manubrium ; the membrane may be flattened ex- 
 ternally, or it may appear abnormally concave, or 
 show partial projections, especially on its posterior 
 upper part. On inspection, detachment can some- 
 times be diagnosticated from the fact that the manu- 
 brium suddenly disappears, perhaps just below the 
 short process, and yet no abnormal concavity of the 
 membrane exists. 
 
 According to Gruber the cartilaginous covering of 
 the manubrium may be separated from the bone by 
 
84 PATHOLOGY OF THE EAR. 
 
 a collection of fluid between the two, but this is 
 doubtful. 
 
 5. Abscess. 
 Interlamellar abscesses of the membrana tympani 
 may occur with acute myringitis and acute catarrh 
 of the tympanum, but are rare ; 
 when present they are generally 
 multiple, and appear as slight prom- 
 inences of a yellow color, and of a 
 dull, waxy lustre. On pressure with 
 a probe, a depression can be made 
 in them as seen in the centre of 
 Interlamellar Abscess in Fig. 48. The drum-mcmbrane is hy- 
 
 the Drum-membrane. pgr^Emic and SWOllcU. They should 
 
 not be confounded with the much more common par- 
 tial projections of the membrane, produced by collec- 
 tions of secretion within the tympanum. 
 
 6. Ulceration 
 
 Seldom comes under observation on account of the 
 slight thickness of the drum-membrane (0.1 mm.). 
 It may be confined to the layer of the cutis in myrin- 
 gitis with hypersemia and swelling, or to the mucous 
 meml3rane in suppurative inflammation of the tym- 
 panum, as the precursor of perforation, or it may oc- 
 cur associated with perforations. 
 
 When in the cutis it ajDpears as a shallow depression, 
 w4th an uneven, rough, villous, dirty-red base which is 
 covered with discolored detritus or crusts of dried pus.^ 
 The rest of the drum-membrane is softened and thick- 
 ened by the inflammation. 
 
 1 On ulcerations of the drum-membrane, compare Toynbee, Diseases 
 of the Ear, p. 145. Wilde, Practical Observations, p. 271. Politzer, 
 Beleuchtumjshilder, S. 66. Von Troeltscb, Lelirhuch, 4 Aufl. S. 119. 
 
THE DRUM-MEMBRANE. 85 
 
 7. Anomalies of the 3Iemhrana Flaccida ShrapnelL 
 Retraction of Shrapnel's membrane may occur with 
 or without adhesion to the neck of the hammer, the 
 curvature of the drum-membrane remaining normal, 
 or showing increased concavity : it is also common 
 with a wrinkled condition or with perforation of the 
 drum-membrane (Fig. 40). Since Shrapnel's mem- 
 brane is an accessory part of the membrana tym- 
 pani of no importance for the functions of the ear, 
 its pathological changes possess but little interest. It 
 was formerly erroneously thought by Zaufal that a 
 funnel-shaped retraction of this membrane w^as path- 
 ognomonic of partial anchylosis of the hammer-incus 
 articulation, but this appearance is often found with 
 a perfectly normal condition of the middle ear. 
 
 Atrophy of the Drum-membrane, partial or total, is 
 very common. The Partial Atroj^hy is caused by 
 disappearance of the lamina propria from circum- 
 scribed affections of the mucous membrane during 
 chronic tympanic catarrh without perforation. In 
 appearance it is sometimes difSficult to distinguish it 
 from cicatrices, but it generally shows less distinctly 
 defined edges than these latter. 
 
 Total Atro2-)hy, generally of the membrana pro- 
 pria, is very common from long-continued closure of 
 the Eustachian tube, which causes increased tension, 
 and so a tension-atrophy ; it is sometimes caused by 
 masses of cerumen lying against the membrane (a 
 pressure-atrophy). The formation of numerous ra- 
 diating, straight or curved folds, with striated reflec- 
 tions of light, after inflation of the tympanum, are 
 characteristic of total atrophy, as is also abnormal 
 
86 PATHOLOGY OF THE EAR. 
 
 mobility of the membrane under variations of the air- 
 pressure. 
 
 With very marked atrophy, the membrana tym- 
 pani sinks into the tympanum (collapse of Wilde), and 
 the contour of the labyrinthine wall, promontory, 
 niche of the fenestra rotunda, incus, and stapes, may 
 be visible, together with the chorda tympani and the 
 pouches of Troeltsch. If hypergemia of the labyrinth- 
 wall exists, this is readily recognized by the trans- 
 mission of a violet-red color through the atrophied 
 membrane. With the higher degrees of atrophy per- 
 forations of the drum-membrane may occur without 
 a preceding suppuration (p. 78). 
 
 With partial atrophy of the lamina propria there 
 are occasionally hernial protrusions of the mucosa 
 between the separated fibres of the membrane, form- 
 ing hladdei' or p^«rse-?^^e j^i^^oininences on the mem- 
 brana tympani which contain air or secretion. With 
 a partial loss of substance in the mucosa and lamina 
 propria during chronic inflammation of the tjan- 
 panum, it may happen that an exten- 
 sive emphysema of the membrana 
 tympani is produced by a collection 
 of air beneath its cutis ; this is par- 
 ticularly likely to occur from infla- 
 tion of the middle ear. AVith this 
 emphysema the membrana tympani 
 
 Purse-like Projection on prCSCUtS a TOUgh SUrfaCC, and tllC 
 
 the Drum-membrane. manubrium is couccalcd. Usually 
 it disappears rapidly when the air pressure ceases. 
 
 New Growths. The common granulation-groioths 
 have been described already (p. 74). 
 
 Upithelial growths occur both on the skin and the 
 
 Fig. 49. 
 
THE DRUM-MEMBRANE. 87 
 
 mucosa of the drum-membrane. They are seen ex- 
 ceptionally on the skm in the form of circumscribed, 
 hard, glistening white, pearl-like bodies, varying in 
 size from a millet seed to the head of a pin, and are 
 sometimes found in large numbers. They are of car- 
 tilaginous consistence, and contain a yellowish thick 
 mass (epithelium) inclosed in a firm investing mem- 
 brane ; they are subject to an excentric change of po- 
 sition with the growth of the epithe- 
 lial layer of the drum-membrane^ 
 just as extravasations are. Since 
 glandular elements are wanting in 
 the membrana tympani, these small 
 tumors cannot be regarded as mil- 
 ium, which they externally very Fig. so. 
 closely resemble, but may be possi- J^^'^^ ^™^^"'^ ""/^^ 
 
 ^ ' J L Drum -membrane. Irom 
 
 bly very small cholesteatomata. Urbantsciutsch. 
 
 The epithelial new growths on the mucous mem- 
 brane are flat, round, white protuberances, only vis- 
 ible from within the tympanum. 
 
 Membranous, papillary, and polypoid new growths 
 are very common on the mucosa. All the transition 
 forms are seen, from the polypi of microscopic size 
 attached to the mucosa by a small pedicle to com- 
 plete polypoid degeneration of the whole drum-mem- 
 brane. Von Troeltsch^ first discovered that sometimes 
 the fibres of the membrana propria were to be found 
 in large numbers in polypi originating from the 
 membrana tympani. 
 
 The cholesteatoma of the drum-membrane, several 
 cases of which have been described, was once exam- 
 
 ^ First described by Urbantschitscb, A.f. O., x., S. 7. 
 2 Virchoiv^s Archiv, xvii., S. 44. 
 
88 PATHOLOGY OF THE EAR. 
 
 ined histologically by Wendt, and found to have been 
 developed from the endothelial sheaths of the pro- 
 cesses of the lamina propria. The tumor was situated 
 on the inner surface of a perforated drum-membrane, 
 was hemispherical, bright-red, slightly knobbed, and 
 with a bright metallic or golden lustre. It was sur- 
 rounded by an investing membrane of connective 
 tissue, a continuation of the mucous membrane ; and 
 was composed of '• alternating hypertrophied pro- 
 cesses and sheaths of the lamina propria arranged con- 
 centrically, the latter containing a deposit of choles- 
 terine." 
 
 In the case described by Hinton^ (sebaceous tu- 
 mor), a brownish tumor, the size of a pea, consisting 
 of a thin sack of connective tissue (possibly from the 
 membrana tympani), and containing laminae of epi- 
 thelium, was situated on the inner surface of the drum- 
 membrane, above the processus brevis ; the tumor 
 was directly adherent to the drum-membrane ; there 
 had been no preceding otorrhoea ; the tympanum con- 
 tained numerous pseudo-membranous bands. 
 
 Tubercle of the membrana tympani appears in chil- 
 dren with miliary tuberculosis as yellowish-red spots, 
 as large or larger than the head of a pin, situated in 
 the intermediar zones of the membrane ; the remain- 
 ing portions of the membrane are without injection, 
 and of a yellowish-gray opacity, from the transmission 
 of color from the muco-purulent exudation within the 
 tympanum. Examined from the tympanum these 
 spots appear flat, slightly projecting above the plane 
 of the mucous membrane, and clearly defined. In 
 chronic tuberculosis of the lungs in adults, I have fre- 
 
 ^ Compare A. f. 0., ii., S. 151. 
 
THE DRUM-MEMBRANE. 
 
 89 
 
 qiiently seen during life yellowish, slightly prominent 
 hard spots, which were followed by a rapid ulcerative 
 destruction of the niembrana tympani, and which 
 were apparently tubercles of that membrane. The 
 histological confirmation of this opinion is at present 
 wanting. 
 
 Rupture of the Drum-membrane frequently occurs di- 
 rectly from injury (entrance of a foreign body), or 
 
 Fig. 53. 
 
 Fig. 51. Rupture of the Drum-membrane, from a blow on the ear. From Toyn- 
 bee, "Diseases of the Ear," p. 182. 
 
 Fig. 52. Rupture of an atrophied Drum-membrane, from violent inflation by 
 Yalsal-a's method. From Toynbee, Ibid., p. ]83. 
 
 Fig. 53. Rupture of the Drum-membrane, from a person who was hanged. Seen 
 from the tympanum. 
 
 indirectly from air pressure (explosion, box on the 
 ear, diving, and from whooping cough) ; also, from 
 fractures of the skull, and from violent concus- 
 sions of the petrous bone. The edges of a rupture 
 from a direct wound are generally irregular, jagged, 
 and suffused with blood ; those of a rupture from in- 
 direct force almost always show a clean fissure parallel 
 
90 PATHOLOGY OF THE EAR. 
 
 to the radial fibres of the membrane. The ruptures 
 which are seen in artillerists often run parallel to and 
 behind the manubrium. When ruptures occur from 
 a moderate air-pressure, it will usually be found that 
 the anatomical condition of the drum-membrane pre- 
 disposed thereto, atrophy or calcification having ex- 
 isted previously. 
 
 Simple ruptures, without deeper injury of the ear, 
 usually heal in healthy individuals and under proper 
 care in from a few days to a few weeks, sometimes 
 leaving a cicatrix and sometimes not. 
 
 Simultaneously with rupture of 
 
 EHHJI the drum-membrane, in rare cases, 
 * !■ ^^^^^^^ dislocation of the hammer and 
 !( Il incus, and in still more rare cases 
 H fractures of the manubrium. These 
 ^hH fractures of the bone may heal, leav- 
 ^^^ ing very marked changes in its form, 
 '^ '^' such as abnormally oblique position. 
 
 Fractured Manubrium, contortiou of itS loUS^ axis, Or aUgU- 
 From Roosa, "Diseases , . p i i p 
 
 of the Ear," 1873, p. 236. lar positiou of the lowcr fragment. 
 
 THE TYMPANUM. 
 
 According to our present pathologico-anatomical knowledge, the 
 tympanum is the most frequently involved in pathological processes 
 of all the parts of the ear. The mucous-periosteal covering of this 
 cavity is, in its normal condition, extremely thin and delicate, being 
 only 0.75 mm. thick ; it is perfectly translucent, colorless, and glis- 
 tening fi'om slight moisture ; it covers, in addition to the walls of 
 the cavity, all the ossicles, and the tendons of the musculus tensor 
 tympani and musculus stapedius. The air cavity, inclosed by this 
 mucous membrane, has the physiological function of furnishing a 
 free space for the vibrations of the membrana tympani and the ossi- 
 cles, and for the distention of the membrane of the fenestra rotunda. 
 
THE TYMPANUM. Ql 
 
 Any changes within this space, which can produce any obstruction 
 to the free vibration of these parts must be the cause of disturbances 
 of hearing. The most common of these changes are large collec- 
 tions of secretion,^ swelling and rigidity of the mucous membrane 
 with the consequent diminished mobility of the conducting appara- 
 tus, destructive processes from ulceration, abnormal adhesions of 
 parts of the conducting apparatus with each other, or with the walls 
 of the cavity, and tumors. 
 
 Pathologically, the mucous periosteal covering of the tympanum 
 has many of the properties of the serous membranes, although, 
 according to its histological structure and its development, it must 
 be considered a mucous rather than a serous membrane. Its arterial 
 blood is obtained from several sources : the arteria meningea media, 
 a branch of the maxillaris internus ; arteria stylomastoidea and pha- 
 ryugea ascendens, branches of the carotis externa ; arteria auricularis 
 posterior ; arteria tympanica ; and arteria carotis interna ; all of 
 which anastomose with each other. 
 
 The veins pass internally through fine openings of the fissura 
 petroso-squamosa to the veins of the dura mater, and thence into 
 the sinus petrosus superior, and also externally to the venous ring 
 surrounding the drum-membrane, and to the meatus. According to 
 Kessel, the lymph-vessels form here and there a tubular system in 
 the periosteum, which is provided with oval expansions or lateral 
 projections. Under the tegmen tympani, where the periosteum sep- 
 arates from the mucous membrane, are funnel-shaped or round 
 lymph spaces communicating with each other and with a fine net- 
 work of vessels. From the variation of air-pressure in the tympa- 
 num, the movement of the lymph in these lymph-spaces, and the 
 system of tubes is caused (Kessel). 
 
 The connective tissue of the tympanic mucous membrane can be 
 divided into a subepithelial and a periosteal layer. The latter gives 
 off fibres to the tunica adventitia of the blood-vessels of the bone, 
 and to the sheaths of the nerves which pass along the grooves of 
 the bone, and on this account and on account of the arrangement 
 of the blood-vessels, it can be designated as the periosteum (Prus- 
 sak). 
 
 Peculiar bodies, with the structure of the Pacinian tactile-cor- 
 puscles, were simultaneously described by Kessel and Politzer as 
 
 1 A few drops of serous fluid are very often found in the tympanum, 
 ■with an otherwise normal condition of the ear. 
 
92 PATHOLOGY OF THE EAR. 
 
 normal attributes of the mucous membrane of the tympanum and 
 mastoid process ; by the former they were regarded as organs of 
 special physiological imiDortance ; but later, Wendt^ showed that 
 they were artificial products, atrophic remains of pseudo-membranes. 
 Von Troeltsch' found similar bodies in 1859,^ and described them as 
 pathological formations ; and some observers still consider them as 
 such ; for instance, Zaufal, who considers them psaumomata. 
 
 For microscopical investigation, the tympanic mucous membrane 
 must be separated from the bone, which can be most easily done on 
 the labyrinthine wall. It must then, for the preparation of cross 
 sections, be hardened for some days in dilute chromic acid, then em- 
 bedded in liver which has been hardened in alcohol, or in supporting 
 liquids, as mucilage, or glue and glycerine. 
 
 Malformations. The tympanum may be replaced 
 by a solid mass of bone. Sometimes it is onl}- rudi- 
 mentary, sometimes, on the contrary, it is enormously 
 large. Again, the labyrinthine fenestr^e may be want- 
 ing, entirely or partially. Slight changes from the 
 normal formation of the walls are common ; namely, 
 absence of the eminentia pyramidalis, osseous nar- 
 rowing of the labyrinthine fenestra3, protrusion of the 
 lower wall with obliteration of the fenestra rotunda 
 (Odenius). 
 
 The ossicles, all ^ or any of them, may be congen- 
 itally wanting. A fusing of the three ossicles into one 
 (columella) has been found.^ Michael Jaeger found 
 a stapes with only one crus fused Avith the incus. 
 Sometimes superfluous ossicles are present. A long 
 cylindrical sesamoid bone between the malleus and 
 
 1 According to W. Krause, they consist of concentric layers of connec- 
 tive tissue, ■without nerve-fibres and -witliout interstitial fluid. 
 
 - Virchow^s Archil; xvii.. S. 60. 
 
 3 Otto, Lehrhuch der Patholorj. Anatomic, Berlin, 1830, Bd. i.. S. 172. 
 Bernard. Treviranus, Itard. 
 
 ■* Constatts' JaJiresbericht, 184 7, Heidenreich, S. 111. 
 
THE TYMPANUM. 93 
 
 incus was found in the case of Rose ^ with atresia of 
 the meatus, also in the case of Otto.^ 
 
 Malformations in the shape of the ossicles, espe- 
 cially of the stapes, where they are abnormally small 
 or large, are more common. In 
 the stapes we may have an un- ^^ ^^^==^ 
 equal leno^th of its crura, or only ^""^ 
 
 i ° , .^ "^ ""ig- ". Fig. 56. 
 
 one crus may be present (Com- 
 
 . 1 , rr,. 1 ^^^- 55- T'^*^ Stapes (s) has 
 
 parettl, CaSSebohrn, Tiedemann, its normal base, but only one 
 
 MichaelJaeger),oronecrusmay T"'' '''"'"' ^Th '"'" ''1 
 
 CI /' 'J long process of the normal 
 
 not reach the base, or both crura i"cus (i\ one bone, on the 
 
 1 -ill 1-1 r- Hammer [m], the manubrium 
 
 may be united by a bridge of and short process are wanting. 
 
 bone, this latter malformation, '^''^'^ drum-membrane was also 
 
 . wanting. (From M. Jaeger.) 
 
 aCCOrdmg to Bonnafont, bemg Fig. 56. Malformation of 
 
 quite common. The loner arm *'^^^'T^' ""^^' '^"^^T 
 
 ^ ^ O reach the base. (From \V elck- 
 
 Of the incus may be more or less er, " Archiv flir Ohrenheilk.," 
 
 bent. Ba.i.,™.,i.,ri«.3, 
 
 The rarest congenital malformations of shape are 
 in the malleus, Bonnafont^ quotes one observation 
 of congenital absence of the manubrium in a calf. 
 Michael Jaes-er found in one case of cono:enital ab- 
 sence of the membrana tympani and meatus that the 
 head and neck of the malleus were of regular shape 
 and in normal connection with the incus, but that the 
 manubrium and processus brevis were wanting. 
 
 Hypersemia and Hemorrhage. Hyperemia of the 
 tympanic mucous membrane in its different degrees 
 is among the most common occurrences. Especially 
 in childhood it may easily occur with every cold in 
 the head, bronchitis, stomatitis aphthosa, or angina, 
 
 1 Rose, vide A. f. 0., iii., S. 251. 
 
 2 Otto, L c, S. 174, note 21. 
 
 3 l. c, p. 538. 
 
94 PATHOLOGY OF THE EAR. 
 
 and may disappear again in a short time without 
 leaving any anatomical or functional disturbances. 
 Yenous congestion may take place with disease of 
 the heart or lungs, or with tumors of the neck, which 
 exert a pressure on the veins of the neck. It may 
 also occur secondarily from suppuration of the inner 
 ear, and from meningitis by extension along the pro- 
 cesses of the dura mater which pass into the tj'm- 
 panum. 
 
 The hyperemia affects by preference the venous 
 vessels, which become not only enlarged but tortu- 
 ous and with occasional expansions.^ 
 
 Isolated small ecchymoses are often found with re- 
 cent hypersemia of the mucous membrane. 
 
 Extravasations of blood into the tympanum (h^em- 
 ato-tympanum) occur through injury from severe 
 concussion of the skull (blow, fall on the head) with 
 or without fracture of the temporal bone ; ^ through 
 direct injury of the ear by the entrance of sharp 
 substances with simultaneous rupture of the drum- 
 membrane ; through strangulation, violent vomiting 
 and whooping cough. They may also occur spon- 
 taneously with acute inflammations, with morbus 
 Brightii, cynanche diphtheritica, and, according to 
 Trautmann, with endocarditis verrucosa recens and 
 ulcerosa. The extravasation which appears through 
 the drum-membrane of bluish-red or bluish-black 
 color, may be resorbed or may lead to suppurative 
 inflammation. 
 
 1 Politzer, A. f. 0., vii., S. 13. 
 
 2 A case of haeniatotympanum without injury of the drum-membrane, 
 meatus or pars petrosa, from a fatal blow with an axe, is desci'ibed by 
 Casper, Handbuch der Gerichtlichen Medecin, Thanatalog. TheiL, S. 209, 
 Fall 66. 
 
THE TYMPANUM. 95 
 
 Hemorrhagic infiltrations of the mucous membrane 
 occur with congestive catarrhs of the middle ear. 
 
 Catarrhal inflammation is characterized by hypera^mia, 
 swelling, and exudation. Although in most cases the 
 exudation is of a mixed character, still from anatom- 
 ical investigation we are justified in distinguishing 
 (1) serous catarrh, (2) mucous catarrh, (3) purulent 
 catarrh. 
 
 These three forms, pure and clearly defined, may 
 occur in the tympanum, but the transition forms are 
 much more common. To distinguish them, however, 
 by special names, according to the character of the 
 exudation, would be scarcely possible and practically 
 valueless, for it would be necessary to make a large 
 number of subdivisions, as sero-mucous, sero-hemor- 
 rhagic, muco-purulent, muco-hemorrhagic, etc. 
 
 The division into catarrhal and purulent otitis me- 
 dia, favored by the older authors^ and. still very com- 
 monly used, is not defensible because the first variety 
 can pass into the second and no distinct boundary ex- 
 ists between the two. Perforation of the membrana 
 tympani even is not an infallible mark of distinc- 
 tion. 
 
 The very highest degrees of catarrhal swelling of 
 the tympanic mucous membrane are capable of com- 
 plete retrogression, the membrane resuming its cob- 
 web-like delicacy, and moulding itself accurately to 
 the osseous Avails and contents of the tympanic cav- 
 ity. The cellular infiltration of the subepithelial con- 
 nective tissue disappears by fatty degeneration and 
 decay, and possibly, in part, by being absorbed into 
 the lymph-vessels. For this process weeks are nec- 
 
 1 Schlegtendal, De Otitide. Diss. Inaug., Halle, 1821. 
 
96 PATHOLOGY .OF THE EAR. 
 
 essary. In many cases, however, retrogression is in- 
 complete, and there remain projections and duphca- 
 tures of the mucous membrane in the form of pseudo- 
 membranes or synechice, by which different parts of 
 the ear are abnormally adherent or the tympanic 
 cavity is permanently affected in its size and form. 
 
 The serous catarrh^ (otitis media serosa, inflam- 
 matory dropsy of the tympanum) is the least com- 
 mon of the three varieties and should not be mis- 
 taken for the very common simple transudation (hy- 
 drops ex-vacuo), which results from closure of the 
 Eustachian tube. In its acute form the membrana 
 tympani at first appears reddened by a fine injection 
 of its cutis layer, the tympanic mucous memljrane 
 throughout, even to the covering of the ossicles, is 
 finely injected, and the cavity is in part, seldom 
 wholly, filled Avith a clear, yellowish serous fluid 
 which may become yellowish red from the intermix- 
 ture of blood (sero-hemorrhagic). A slight swelling 
 of the mucous membrane is sometimes caused by a 
 watery infiltration, oedema, of the subepithelial con- 
 nective tissue. The Eustachian tube may retain its 
 normal permeability. 
 
 If the membrana tympani has not been rendered 
 untranslucent from old opacities, it is possible both 
 during life and after death to recognize the boundary 
 line of the serous exudation, and its movement on a 
 change of position of the tympanum. Sometimes, 
 also, bubbles are distinctly visible. 
 
 In the chronic form of serous catarrh all hypene- 
 
 1 Scliwartze, Paracentese des Trommel fells, Halle, 1808. Politzer, 
 A. f. 0., iii., 328. Zaufal, .1. /. 0., v., S. 38. Wendt, Archiv. fur 
 Heilkunde von E. Wagner, xiii., S. 158-161. 
 
THE TYMPANUM. 97 
 
 mia is wanting, but hypertrophic processes are com- 
 mon in the mucous membrane, in which the ossicles 
 may be embedded or a new growth of membranes or 
 bands (synechiaB) be produced. 
 
 The serous catarrh is found especially common in 
 old age in persons otherwise 
 • healthy ; it is also found with 
 syphilis, heart diseases, pneumo- 
 nia, pleuritic exudations, Bright's 
 disease, naso-pharyngeal catarrh, 
 and apparently may be sometimes 
 dependent on disturbances of vaso- ^. ^^ 
 
 motor innervation. Serous Exudation in the 
 
 The mucous catarrh ^ (otitis Tympanum, the nearly hor- 
 
 izontal boundary line of the 
 
 media catarrhahs). The acute liquid appearing through the 
 form shows a universal hypergemia •^"""-"lembrane. 
 of varia])le degree, sometimes with hemorrhages in 
 the subepithelial connective tissue, and swelling of 
 the mucous membrane. This swelling may affect the 
 whole membrane equally, or it may be more strongly 
 marked at certain spots, the tegmen and promontory ; 
 it is produced by enlargement of the blood-vessels 
 and hemorrhages, which press the fibres of connec- 
 tive tissue apart, and by a serous and cellular infil- 
 tration of the layer of loose connective tissue beneath 
 the epithelium, numerous cells like lymph corpuscles 
 being deposited between the fibres. 
 
 All of these changes are confined to the subepithe- 
 
 1 Otto, Seltene Beohachtimgen zur Anatomie, etc., I. Heft, Breslau, 1816, 
 S. 111. Duverney, Traite de FOrgane de VOuie, Paris, 1683, Partiii., 
 S. 184. Ulricli, Ueber den Catarrh des Mittleren Ohres (Oesterreich. Jahr- 
 hlicher, 1847, October, November, and December). LehrbiicJier Von 
 Ptau, Yon Troeltsch, Gruber, etc. Histologically the most important are 
 the articles by Wendt in Wagner's Archiv. 
 
98 PATHOLOGY OF THE EAR. 
 
 lial layer of connective tissue. The epithelium itself 
 is retained. The cavity is partially or wholly filled 
 with thick adhesive mucus mingled with a few cell 
 elements, epithelium, mucous or pus corpuscles, red 
 blood-corpuscles, nucleated cells and collections of 
 nuclei ; not infrequentl}^ in the dead body crystals, 
 triiDle-phosphate and others, are found. Gruber^ 
 claims to have also found goblet-cells in the exuda- 
 tion accompanying mucous catarrh of the middle ear. 
 The consistence of the mucus may be such as to 
 require a regular dissection with forceps and knife in 
 order to free the walls and the ossicles. It may be 
 either transparent or opaque (white-gray, bloody). 
 If the whole cavity is not filled, the mucus adheres 
 by preference to the floor and to the niches of the 
 labj'rinthine fenestra?, to the roof of the cavity on 
 and above the hammer-anvil articulation, and on the 
 inner surface of the membrana tympani. In the lat- 
 ter case the curved boundary lines of the exudation 
 may be visible externally through the drum-mem- 
 brane. 
 
 The source of the mucus is a hypersecretion of 
 the tubular and racemose glands existing in the iyvn- 
 panic mucous membrane, which are found enlarged 
 and widened into cysts near their orifices ; ^ a part 
 of the mucus also comes from the surfiice of the 
 wdiole mucous membrane. 
 
 The chronic variety of mucous catarrh leads to 
 thickening of the mucous membrane, which then as- 
 
 1 Lehrhuch, S. 436. 
 
 2 The round (jlandular cysts, ascribed by C. Krause to tlie normal mu- 
 cous membrane, are really joatliological enlargements of the normal tubu- 
 lar slands. 
 
THE TYMPANUM. 99 
 
 Slimes a darker, bluish-gray or white appearance, and 
 seems firmer, stronger, and more vascular than nor- 
 mal ; the blood-vessels also become varicose. Some- 
 times villous prolongations and slight elevations are 
 seen on the surface of the membrane. The thicken- 
 ing may be confined to certain spots, the mucosa of 
 the drum-membrane, malleo-incal articulation, laby- 
 rinthine fenestrge, or it may be equally distributed 
 over all portions of the membrane, and may even 
 completely obliterate the whole tympanic cavity. 
 With the thickening of the mucous membrane the 
 membrana tympani appears thickened, leather}^, and 
 but slightly yielding to the touch. 
 
 In its clinical history the mucous, like the serous 
 catarrh, is distinguished from the purulent catarrh in 
 that it does not usually lead to ulcerative destruction 
 of the drum-membrane. Occasionally, to be sure, it 
 leads to slight ruptures of a drum-membrane some- 
 what softened by inflammation, but after the evacua- 
 tion of some mucus from the tympanum, these rup- 
 tures soon heal and have no influence on the further 
 course of the disease. Where ulcerative destruction 
 occurs we are no longer dealing with a simple mucous 
 catarrh, but with a combination of the mucous with 
 the purulent catarrh. 
 
 Marked thickening from a new growth of connec- 
 tive tissue on the fenestra of the labyrinth, and 
 around the articulation of the malleus and incus are 
 specially injurious to the conduction of sound. The 
 niche of the fenestra rotunda may be completely 
 closed and the ossicles may be wholly embedded in 
 the hypertrophied mucous membrane, so that careful 
 preparation is necessary to render them visible. 
 
100 PATHOLOGY OF THE EAR. 
 
 The acute mucous catarrh, loithout i^erforation of 
 the drum-7nemhrane, may unexpectedly and rapidly 
 lead, in extremely rare cases, to sopor, convulsions, 
 and death, from meningitis (two cases of my own,, 
 two of Wendt's).^ In one of the cases described by 
 Wendt, the autopsy showed extensive meningitis 
 with abundant adherent exudation over the whole 
 surfiice of the brain. 
 
 The 2^urulent catarrh (otitis media purulenta) usu- 
 ally leads to rupture, ulceration, and loss of substance 
 in the drum-membrane, and the discharge of the pus 
 externally. 
 
 An exception to this rule is only found in the forms 
 of the disease seen in nursing children, and in those 
 cases in which there is thickening of the membrana 
 tj^mpani.^ 
 
 A discharge of the pus towards the pharynx through 
 the Eustachian tube is unusual. 
 
 The acute variety is very common with the acute 
 exanthemata, typhus, tuberculosis of the lungs, and 
 scrofula. 
 
 The exudation may be pure pus, of a yellowish or 
 3^ellowish green color and creamy consistency, or it 
 
 1 ArcJtio fur Heilkunde von Wagner, xi., Fall 12 u. 13. 
 
 2 Literature of Otitis Int. Purulenta Infantum : Duverney, Tractatus 
 de Organo Auditus, NUrnberg, 1684, S, 36. Koppen, Diss. Inaug., 1857, 
 Marburg. Von Troeltsch, Verhandlu7igen der Physihal. Geselhclwji in 
 Wurzburg, ix., 1859. See also LeJirbuch, 6 Aufl., S. 404. Schwartze, A. 
 
 f. 0., i., S. 202-205, 1864. Wreden, M. f. O., 1868, No. 7, et seq. 
 Brunner, Beitrdge zur Anatomie des Mitderen Ohres, Leipzig, 1870, S. 31. 
 Zaufal, Sectionen des Gehororgans von Neugeiorenen und Sduglingen, 
 Oesterr. Jahrh. f. Padiatrik, 1870, 1., S. 118 et seq. Wendt, Ueber das 
 VerJialten der PaukenlwMe beim Fotus und Neugeborenen, Arch, der Heil- 
 kunde, xiv., 1873. Kutscbarianz, A. f. 0., x., S. 118-127, 1874, Ed. 
 Hofmann, vide^. /. 0., xi., S. 81, 1875. 
 
THE TYMPANUM. 101 
 
 may contain, in addition to innumerable pus cells, 
 granular corpuscles, and granules, a small amount of 
 epithelium and detritus, with some mucus or blood 
 (muco-purulent catarrh). Beneath the layer of pus 
 the mucous membrane is bright red, deprived of its 
 epithelium, and more or less swollen, even to a thick- 
 ness of one to two millimeters or more. The greatest 
 swelling usually appears on the roof of the cavity and 
 on the promontory. 
 
 The swelling is due to enlargement of the blood- 
 vessels, cellular and serous infiltration of the connec- 
 tive-tissue stroma, and sometimes to hemorrhagic 
 infiltration. 
 
 In chronic cases, the disease leads to hyperplastic 
 processes in the mucous membrane, to the formation 
 of nodules, villous projections, papillary growths, 
 knobbed swellings, or polypoid tumors. Only rarely 
 does the hyperplasia of the mucous membrane fill the 
 entire cavity. The minute granulations on the surface 
 of the mucosa, which are composed of lymph-cells, 
 generally contain loops of blood-vessels. In the mid- 
 dle layer of the mucosa there is a thick infiltration 
 of round cells gradually disappearing towards the 
 deeper tissues. In the periosteal connective tissue, 
 which is the most rarely affected of all the tissues, 
 Politzer ^ found an enlargement of the lymph- vessels, 
 and near by round or oval microscopic cysts, with a 
 connective tissue capsule and cellular contents. The 
 cysts varied in size from oV to \ mm., and he consid- 
 ered them to be loops of an enlarged and varicose 
 lymph-vessel. 
 
 Secondary ulceration in this disease is relatively 
 1 A. f. 0., xi. 
 
102 PATHOLOGY OF THE EAR. 
 
 rare. However, from a deep loss of substance in the 
 mucous membrane, during putrid purulent inflamma- 
 tion, caries may occur on the ossicula or the walls of 
 the tympanum. If the pus is stagnant for a long 
 time, fatty pus cells, fatty detritus and cholesterine 
 are found ; the latter particularly under the tegmen 
 tympani, where it collects in large adherent layers ; 
 in addition to these, sometimes epithelial cells, in 
 white laminated crusts, one half mm. or more thick, 
 are seen. From the stagnation, drying and degener- 
 ation of the purulent masses in the antrum mastoi- 
 deum, fatal resorption and infection may take place 
 (acute miliary tuberculosis, tuberculous self-infec- 
 tion). 
 
 With chronic suppuration of the tympanum, the 
 dura mater over the tegmen tympani is frequently 
 diseased, being either thickened by the inflammation 
 and abnormally adherent, or else loosened and occa- 
 sionally dotted with small masses of pus. 
 
 After the healing of a chronic suppuration of the 
 tympanum, the perforation of the drum-membrane 
 remaining open, it will frequently be seen that the 
 epidermis of the meatus has extended into the tym- 
 panum, sometimes even into the mastoid cells. This 
 dermoid transformation of the tympanic mucous mem- 
 brane which would without such a change be exposed 
 to many injurious influences, affords the surest pro- 
 tection against a recurrence of the suppuration, and 
 is therefore especially desirable in all cases where the 
 defect of the drum-membrane is such that its closure 
 by cicatricial tissue cannot be expected. 
 
 Partial calcification of the mucous membrane, affect- 
 ing all of its layers and projecting above the normal 
 
THE TYMPANUM. 103 
 
 plane of the membrane, is an occasional result of 
 clironic tympanic suppuration. Such calcifications 
 of the mucous membrane are sometimes seen during 
 life on the promontory, if there is a favorably situated 
 perforation of the drum-membrane. Fine blood-ves- 
 sels sometimes run over the spots of calcification, 
 showing that a thin layer of connective tissue remains 
 upon them. 
 
 Purulent tympanic catarrh may be fatal, even in 
 adults, without there being an externally appreciahle 
 disease of the hone, by purulent meningitis,^ or phle- 
 bitis of the sinuses and pyemia ;^ this may occur 
 without perforation of the drum-membrane.^ It is 
 less common in the acute than in the chronic form of 
 the disease. As a rule it only occurs when the drum- 
 membrane has been increased in thickness and power 
 of resistance by previous inflammatory processes. 
 
 Croupous and Diphtheritic Inflammation. The exist- 
 ence of croupous tympanic inflammation was unknown 
 till it was very recently described by Wendt. In 
 most cases of pharyngeal and lar3aigeal croup there 
 is only a collateral hyperemia or catarrh, either mu- 
 cous or purulent, in the ear ; but in several cases 
 Wendt* found a firm croup-membrane on the tym- 
 panic mucous membrane, which was swollen, much 
 infiltrated with cells and hyperiemic.^ The croup- 
 membrane also covered the ossicula. 
 
 1 Schwartze, A. f. 0., i., S. 200; iv., S. 235, Fall 1. 
 
 2 Gruber, Wiener WochenUatt, 1862, 24, 25. 
 
 3 Von Troeltsch, Anatomk cles Ohres, S. 70. Schwartze, A. f. O., 
 i., S. 200, ii., S. 287, iv., S. 235. ]\Iayer, Ihkl, i., S. 226. Pagenstecber, 
 Arch. f. KUn. Chir., iv., S. 531. 
 
 ^ Archiv filr Heilkunde, x'ni., S. 157. 
 
 ^ Illustrated in A'Ins der Patholog. Histologie von A. Tliiei-felder, i. Lie- 
 feriin2j. Table i., Figs. 5-7. 
 
104 PATHOLOGY OF THE EAR. 
 
 With diphtheritic inflammation of the mucous mem- 
 brane of the nose and pharynx, Schwartze ^ and 
 Wendt^ found only purulent and putrid catarrh in 
 the middle ear; Wreden,^ on the contrary, reports 
 that, in St. Petersburg, he has frequently observed, 
 during life, a diphtheritic inflammation of the middle 
 ear in the course of scarlet fever with diphtheritis 
 of the nose and pharynx, occurring in children from 
 four to fourteen years of age. From the anatomical 
 description of the two dissections of Wreden's, it is, 
 however, not certain that an extension of the diph- 
 theritic process from the pharynx to the mucous 
 membrane of the middle ear had taken place, a fact 
 which has already been emphasized by Wendt.^ 
 
 Klipper^ found with diphtheritis of the pharynx 
 a croupous inflammation in the Eustachian tub;^ and 
 tj-mpanum. 
 
 Caseous Inflammation of the tj-mpanic mucous mem- 
 brane scarcely ever exists, except in chronic tubercu- 
 losis^ with simultaneous miliary tuberculosis, and is 
 never found without defect of the membrana tym- 
 pani. It may also possibly occur in congenital syphi- 
 lis. The purulent exudation which is mixed with 
 desquamated epithelium loses its fluid constituents by 
 resorption of its serum, and forms grayish-yellow or 
 yellowish-white masses, which are generally firmly 
 imbedded in the tissue of the swollen mucous mem- 
 
 1 A. f. 0., I, S. 203. 
 
 2 Arch. f. Hellkunde, xi., S. 260. 
 3ili. / O., 1868, Xo. 10. 
 
 4 /. c, S. 259. 
 ^ A. f. 0., xi., S. 20. 
 
 ® Joseph Hamernjk;, Ueher Taubheit und Halbseitige Gesichtdahmung im 
 Verlaufe der Tuberculose, 1844. Zeitsch: d. Wiener Aertze, Sept. 
 
THE TYMPANUM. 105 
 
 brane, and infiltrate this tissue with fatty pus-cells 
 and detritus. Rapid ulceration follows with loss of 
 the mucous membrane, and with apparent polypoid 
 degeneration of its tissue, and sometimes carious de- 
 struction of the neio;hborino: bone occurs. 
 
 This caseous inflammation should not be confounded 
 with inspissation or caseous metamorphosis of pus, 
 which is extremely frequent in the tympanum and 
 antrum mastoideum. 
 
 Adhesive Inflammation and Sclerosis. The t^^ipanic 
 mucous membrane, like the serous membranes, shows 
 a marked tendency to adhesive inflammation,^ with a 
 new growth of vascular connective tissue in the form 
 of membranes, bands, strings, and threads. Every 
 form of catarrhal inflammation, serous, mucous, or 
 purulent, may lead to these growths, but they appear 
 to be especially common with the serous exudation. 
 Strictly speaking, this is not a special, separate spe- 
 cies of inflammation, but only a variety. All investi- 
 gators agree on the great frequency with which these 
 bands are found in the tympanum. Even to the older 
 physicians their existence w^as not unknown (Mor- 
 gagni). In 1,013 diseased ears, Toynbee found them 
 in 202, or twenty per cent. Of the direct adhesion 
 of the niembrana tympani with the medial wall of the 
 tympanum (promontorium), with the long process of 
 the incus, and with the stapes we have already spoken 
 in the chapter on the drum-membrane.^ This adhe- 
 
 1 Morgagni, De Sedibus et Causis Morborian, i., Epist. xiv., S. 15. 
 Toynbee, Diseases of the Ear, 18G0, pp. 272-275. Von Troeltsch, Lehr- 
 buch. Politzer, Beleuchtunf/shilder, etc., S 109. Gi'uber, Lehrhucli, S. 438 
 and 557. Wendt, Arcliio f. He'dkunde von Wagner, xv., S. 98. Zaufal, 
 A. f. O., v., S. 38. 
 
 2 Pas-e 74. 
 
106 PATHOLOGY OF THE EAR. 
 
 sion is produced by the two epithelial surfaces of the 
 mucous membrane which lie in contact being de- 
 stroyed by pressure, and then the tissue of the mu- 
 cous membrane becomes changed into a vascular 
 granulation tissue, which is sul)ject to the usual cica- 
 tricial contraction. The union of the mucous sur- 
 faces may also take place directly by proliferation 
 from the contiguous conical and dendriform protu- 
 berances of the membrane, and thus the apparent 
 cysts, spoken of in the chapter on the drum-mem- 
 brane, are formed.^ These cavities are nothing more 
 than gaps between the adherent protuberances of 
 the two mucous surfices (Wendt). Specially narrow 
 tympana are particularly predisposed to such adhe- 
 sive processes, as are also, in the normal cavity, those 
 spots the least widely separated from each other (Von 
 Troeltsch). Closure of the Eustachian tube, by caus- 
 ing the membrana tympani to approach the laby- 
 rinthine wall, and depression of that membrane from 
 an external mass of cerumen lying against it, also 
 favor these adhesive processes by narrowing the tym- 
 panic cavity. 
 
 Still more common than this direct union, with the 
 consequent diminution in the size of the tympanum, 
 are the so-called pseudo-membranous growths. They 
 occur simultaneously in various forms in the same 
 ear, and may be so numerous that the whole cavity 
 appears to be filled with an irregular net-work. They 
 are so common that they are found in about every 
 fifth ear (Wendt). When recent they appear of a 
 red or grayish-red color, soft and succulent from 
 serous infiltration ; when old, whitish-gray, or white 
 
 1 Pao-e 81. 
 
THE TYMPANUM. 107 
 
 and firm. Confounding them with simple stringy 
 mucus, which is often found in similar shapes, is only 
 possible from a very superficial observation. Open- 
 ings can be seen in the pseudo-membranes, even with 
 the naked eye ; in the thread-like synechiie they are, 
 however, visible only under the microscope. Their 
 situation is extremely variable ; they may unite the 
 ossicula with each other or with the walls of the 
 t^'mpanum ; the drum-membrane with the tympanic 
 walls, the stapes, or the long process of the incus ; 
 the tendon of the tensor tj'mpani muscle with the 
 roof of the cavity or the ossicula ; very frequently 
 an arm of the stapes with the walls of the fenestra 
 ovalis. The fenestra rotunda and the ostium tym- 
 panicum tubje may also be completely or partially 
 covered by them, thus causing complete or partial 
 closure of those openings. 
 
 When these adhesive processes are extensive, the 
 tendon of the tensor tympani is almost always in- 
 volved. By large membranes the tympanum may 
 be divided into separate cavities. 
 
 An influence on the sound-conduction of the tym- 
 panic apparatus can only be ascribed to those bands 
 which are tense and rigid, and which also bind down 
 or touch the separate parts of this conducting ap- 
 paratus, or else when they are situated on parts of 
 special acoustic importance. On the ossicula, for 
 instance, tense synechia) of the stapes would be much 
 more injurious than the same would be on the incus 
 or malleus, on account of the minuteness of the nor- 
 mal vibrations of the stapes. Small synechise on the 
 stapes are sufficient to reduce the hearing as much as 
 extensive membranes between the drum-membrane 
 and labyrinthine wall would do. 
 
108 PATHOLOGY OF THE EAR. 
 
 Many of these membranous bridges are not pro- 
 duced by pathological processes, but are the remains 
 of the mucous tissue which fills the tympanum of the 
 foetus and new-born child ; they are the result of in- 
 complete retrogression of this tissue, a sort of arrest 
 of development.-^ The occasional duplicatures of the 
 mucous membrane between the long process of the 
 incus and the manubrium or the inner tympanic 
 wall, and between the tendon of the tensor tympani 
 muscle and the tympanic roof are referable to this 
 cause. 
 
 The pathological connecting-bands are produced 
 (1) by the contact and union of portions of the mu- 
 cous membrane, when in a condition of swelling and 
 proliferation; (2) by the formation of granulations 
 during suppurative processes, as in ulceration of the 
 mucous membrane or of the bone. If adhesion has 
 taken place on one or many minute spots, the retro- 
 gression of the swelling of the mucous membrane 
 leaves string or thread-like synechige, due to the draw- 
 ing out and shriveling of the conical protuberances 
 on the mucous surfaces, which have become united 
 together. If, instead of adhesion in minute spots, an 
 extensive surface has become adherent, membranes, 
 instead of thread-like synechiae, are formed. In either 
 case, a simple duplicature of the mucous membrane 
 is formed covered with a cubic or pavement epithe- 
 lium, very deficient in cellular elements and blood- 
 vessels, and consisting entirely of connective tissue 
 with elastic fibres. In this connective tissue, a thin 
 envelope of loose, wide-meshed, pliable tissue can be 
 
 1 Hinton, Guy's Hospital Reports, 1863, vol. ix., pp. 264-268. Politzer, 
 Beleuchtungsbilder, 1865, S. 109. 
 
THE TYMPANUM. 109 
 
 distinguished, in which a fine, slender net-work of 
 capilkiries is distributed ; this is the subepitliehal 
 layer of the mucous membrane. Surrounded by this 
 envelope are bundles of parallel, firm, tense fibres, in 
 the form of a frame-work which incloses the coarser 
 capillaries, and the few minute arteries and veins 
 wdiich nourish the tissue ; this is the periosteal layer 
 of the mucous membrane. By atrophy, and by 
 mechanical irritation, produced by variations in the 
 air-pressure, as by sneezing, blowing the nose, etc., 
 membranes may become simple thread-like sjnechiae, 
 and the openings, which are frequently found in the 
 membranes, are referable also to these same causes. 
 
 The synechias produced by the union of true gran- 
 ulations are, when recent, distinguished by the char- 
 acter of their tissue and by the absence of an epithe- 
 lial coverino;. 
 
 In fully developed membranes and synechia? of an 
 old date, it is impossible to distinguish, either from 
 the histological examination, or from their situation, 
 wdiether they are the remains of the foetal mucous 
 cushion, or of a pathological swelling. The latter 
 may completely disappear without leaving any ana- 
 tomical changes. If marked atrophy of the adhesions 
 has taken place, it may be said with certainty that 
 they date from a swelling which has long since passed 
 away, and often that they date from the foetal tissue 
 (Wendt). 
 
 These connecting-bands, even if quite old, share in 
 new diseases of the ear (hypersemia, interstitial ex- 
 travasations), and suffer further changes of a regres- 
 sive or progressive kind. In addition to the already 
 described atrophy, they are subject to the deposition 
 
110 PATHOLOGY OF THE EAR. 
 
 of fat ill the cells of the connective-tissue stroma, to 
 sclerosis, to cicatricial contraction, to calcification, 
 and to ossification. From all of these processes their 
 physical characteristics may be altered so that they 
 interfere with the conduction of sound. 
 
 (1.) AirojjJiy may cause partial or comjolete disap- 
 pearance of the new-growths, perhaps favored by the 
 positive air-pressure in the tympanum, which occurs 
 spontaneously in sneezing, blowing the nose, etc., or 
 artificially from the air-douche. 
 
 (2.) Sclerosis. The fibres of connective tissue 
 become tense, and assume a parallel arrangement, 
 become apparently thicker, and look rigid, fragile, 
 and opaque. Here and there long spaces are formed 
 between them, filled with a finely granular contents, 
 which is but little altered by the addition of acids. 
 These spaces occasionally show encapsuled cells. The 
 fibres resemble somewhat the processes of the lamina 
 propria. 
 
 (3.) Cicatricial contraction shows thickly crowded, 
 tense fibrillae, generally parallel, but occasionally in- 
 terwoven with each other. The tissue is very firm, 
 and with difficulty picked to pieces. The fragility 
 and marked opacity seen in the sclerotic fibres is 
 wanting. The fixed cells are more numerous than in 
 sclerosis. Cicatricial thickening is found not only in 
 the synechiae produced from granulations, but also 
 in the common duplicatures of the mucous membrane. 
 
 (4.) Calcifications occur only on the inner zone of 
 the connective tissue, which corresponds with the per- 
 iosteal layer of the mucous membrane. The lime is 
 found deposited in molecules in slit-like spaces be- 
 tween the separate fibrillar, or between bundles of 
 
THE TYMPANUM. Ill 
 
 fibrillre. These spaces sometimes appear to have a 
 fusiform arrangement, and may be wholly filled by 
 the lime. 
 
 (5.) Ossification may occur within calcified mem- 
 branes in the form of separate islets or of large 
 lamellae. Bone corpuscles, with their processes, are 
 seen in a homogeneous, hard, glistening stroma, which, 
 on the addition of muriatic acid, shows no striation. 
 
 Sclerosis of the tympanic mucous membrane (indu- 
 ration, dry catarrh, rigidity of the tympanic mucous 
 membrane (Toynbee), chronic periostitis of the iym- 
 panum) is a clinical designation, used by aural sur- 
 geons, which only partially describes the histological 
 condition. \o\\ Troeltsch, who first introduced this 
 name into the otological terminology, wished to des- 
 ignate thereby only the gross appearances and the ma- 
 croscopic condition of the mucous mendjrane, which 
 appears thicker, stiffer, and less elastic than in the 
 normal condition. The result of this change is rig- 
 idity of the articulations of the ossicles, and conse- 
 quent increased resistance to the conduction of sound 
 through the tympanic apparatus. The most frequent 
 ultimate result is anchylosis of the stapes. 
 
 The histolou-ical chang-es which are the foundation 
 of the so-called sclerosis are of various kinds. Only 
 in a small proportion of the cases is there really a 
 connective-tissue sclerosis of the deep periosteal layer 
 of the mucous membrane, with cellular infiltration of 
 the subepithelial layer ; but when this does exist, the 
 connective tissue of the deeper layer, normally ar- 
 ranged in fibrilla?, shows tendinous bundles, like the 
 tendinous processes of the membrana propria. These 
 bundles appear homogeneous, brittle, opaque, with 
 
112 PATHOLOGY OF THE EAR. 
 
 parallel or slightly waving fibres, and spaces between 
 these fibres filled Avith a few encapsuled cells, or with 
 a finely granular and crumbling mass (Wendt). In 
 this condition the vessels are only few in number, 
 and the ej^lthelium and subeintheUal connective-tissue 
 may remain perfectly normal, or the latter may like- 
 wise undergo thickening. 
 
 More commonly, however, this deep periosteal layer 
 is richly impregnated Avith finely granular lime-salts, 
 with here and there spindle-shaped spaces free from 
 the deposit, or with spots of osseous new growth, ossi- 
 fying periostitis. In still other cases, according to 
 Von Troeltsch, there is a cicatricial contraction, with 
 thickening of a previously swollen, infiltrated, and 
 hypersemic tissue. 
 
 As the results of sclerosis, should be mentioned 
 the changes which take place on the membrane of 
 the fenestra rotunda; namely, thickenings, deposits 
 of lime and of large round cells in its connective- 
 tissue stroma (Wendt). 
 
 All these changes are the secondary results of 
 chronic inflammation, and ma}^ occur after a serous, 
 mucous, or purulent exudation, or may exist with 
 any of these exudations. Only when this fact is 
 borne in mind is the term sclerosis, which originated 
 from clinical necessity, justifiable. Whether, in fact, 
 cases of circumscribed sclerosis of the tympanic mu- 
 cous membrane occur, in which the disease is wholly 
 confined to certain limited portions of membrane, as, 
 for instance, the fenestra ovalis, and thus producing 
 anchylosis of the stapes, remains to be investigated 
 histologically. From macroscopic examination such 
 a condition can scarcely be doubted. The only ques- 
 
THE TYMPANUM, 113 
 
 tion is, whether in such cases an extensive disease of 
 the periosteal layer of the mucous membrane, pro- 
 ducing only at certain points gross, macroscojoic 
 chani»:es, is not at the bottom of the trouble. 
 
 Caries of the Tympanum. Purulent catarrh of the 
 tympanum may lead to ulceration of the mucous peri- 
 osteal lining of the cavity by which the bone is 
 exposed, and very soon attacked by the ulcerative 
 process. In this way circumscribed caries in the tym- 
 panum occurs on the roof, labyrinth wall, and other 
 places, but especially often on the thin osseous lam- 
 ella, which separates the cavity Avhere the head of the 
 malleus lies from the external meatus. I have, how- 
 ever, seen circumscribed caries on the labyrinth wall, 
 with simultaneous thickening of the lining membrane 
 of the tympanum without ulceration. Carious de- 
 struction of the tympanic walls and of the ossicula is 
 exceptional, with an imperforate drum-membrane. If 
 the carious spot is on the wall of the labyrinth it can 
 frequently be recognized through the perforation of 
 the membrana tympani by the yellowish discolora- 
 tion, roughness, and irregular margin of the ulcerated 
 mucous membrane. 
 
 By perforation of the Fallopian canal, facial paraly- 
 sis may be produced from the pressure of the exu- 
 dation on the trunk of the nerve, or from neuritis.^ 
 Yet in cases where dissection shows a carious destruc- 
 tion of the canal, the facial paralysis during life is 
 sometimes absent (Gruber). 
 
 Both labyrinthine fenestrae may, by caries, be fused 
 into a single large opening in the labyrinth wall. By 
 
 1 Tillmanns, Ueher FaciaUslalimung hei Ohrkranklieiten. Diss. Inaug., 
 Halle, 1869. 
 
114 PATHOLOGY OF THE EAR. 
 
 Still greater destruction the tympanic and labyrinth- 
 ine cavities may form a common cavity communicat- 
 ing with the posterior fossa of the skull. 
 
 After the healing of a caries of the tympanum, the 
 perforation of the drum-membrane may close by cica- 
 tricial formation, but usually an injury of the hearing 
 remains, the cause of which may be adhesive inflam- 
 mation within the cavity ; numerous cicatricial bands 
 may unite and bind down the ossicula with each 
 other, and with the drum-membrane and the tym- 
 panic walls. 
 
 Pathological Changes of the Ossicula and their Attach- 
 ments. Carious destruction of the ossicles^ is very com- 
 mon, and may occur at all ages. There may be loss 
 of certain parts of the bones, or the bones themselves 
 may be completely freed from their attachments, 
 change their natural positions, form new and abnormal 
 attachments, or be wholly expelled. The most com- 
 mon cause of these changes are the acute suppurative 
 processes of the mucous membrane covering the ossi- 
 cles, which occur during scarlet and typhus fevers, or 
 else the chronic suppurations in scrofula and tubercu- 
 losis. The existence oi primary ostitis of the ossicles 
 is also not to be denied.^ 
 
 On the hammer, with extensive loss of the drum- 
 membrane,^ there is frequently a destruction of the 
 lower end of the manubrium.^ 
 
 1 Schwai'tze, SitzunfjsprotocoU der Section fiir Ohrenlteilkunde auf der 
 Naturforscher-Versammlung in Wiesbaden, 1873, A.f. 0., viii., S. 226. 
 
 2 Vide Von Troeltsch, A- /■ 0., vi. S. 55. 
 8 Vide Fig. 40. 
 
 * Carious loss in the middle of the manubrium, by which that bone is 
 separated into two parts, occurs very rarely. Wendt found, in one case, 
 the separated ends .of the bone united by a soft, red band of tissue. 
 
THE TYMPANUM. 115 
 
 Circumscribed destructive processes on the head of 
 the hammer, without an affection of the manubrium, 
 are by no means rare, even without an extensive 
 defect in the membrana tympani (Fig. 59). Circum- 
 scribed granulations on the upper portion of the 
 drum-membrane, around the short process, would 
 arouse suspicion that there existed such an isolated 
 caries on the head of the hammer. The manubrium 
 may remain in the drum-membrane, even if the head 
 of the hammer is separated by caries and expelled 
 (Fig. 58). ^ 
 
 On the incus the processes may be lost, the long 
 one first of all, and the corpus incudis then falls 
 away from its connection with the head 
 of the hammer; more rarely the pro- ^p 
 cesses remain and only the body of the 
 bone shows carious roughness. Some- 
 times the incus, even with an imperfo- 
 
 ' A Figs. 58, 59. 
 
 rate drum-membrane, is loosened from pic. 53. carious 
 its connections and destroyed by caries. Head of the Manu- 
 
 0. 1 , . 1 , , • • brium thrown off 
 
 n tne stapes carious destruction is during iife. 
 
 chiefly confined to the head and the ^^g-^^- cadous 
 
 111 Excavation on the 
 
 crura. Not unfrequently both crura Head of the Ham- 
 are lost, but the base usually remains ™"' 
 in its attachments covered by a hypertrophied mu- 
 cous membrane, or by a growth of connective tissue. 
 The marked resistance of the base of the stapes to 
 the destructive inflammatory processes of the tym- 
 panum is apparently explained by the fact that it 
 receives part of its nutrition from the vessels of the 
 labyrinth. I found partial destruction of the base 
 once in a child, which died from miliary tuberculosis. 
 While malleus and incus are frequently throw^n off 
 
 */ 
 
116 PATHOLOGY OF THE EAR. 
 
 during life in a state of necrosis from suppurative 
 processes, as in scarlet fever, this is very rarely the 
 case with the stapes. Up to the year 1873, I myself 
 had never observed it; since then such a case has 
 been observed by Dr. Boeck, of Magdeburg, and a 
 short time afterwards two cases occurred in my own 
 practice. 
 
 The case of Boeck, observed in 1867, is for other 
 reasons remarkable, and I therefore give it : — 
 
 Wittling, a manufacturer, forty-five years old, previously healthy, 
 and of strong constitution, as the result of exjiosure to a draft of 
 air suffered, in the summer of 1866, from the usual symptoms of an 
 acute otitis media purulenta sinistra. Disease of the bone was not 
 suspected. On the 30th of December, he suddenly had two epileptic 
 attacks, at an interval of half an hour. Dr. Boeck saw the second 
 attack and describes it in the following language : " The patient 
 was seized in the midst of a sentence, repeated the last word si^oken 
 at first slowly, then more and more rapidly for thirty or forty times ; 
 the gaze was fixed and the right hand raised ; these symptoms were 
 followed by loss of consciousness and a regular epileptic attack 
 lasting from ten to fifteen minutes. Such attacks were repeated 
 twice at short intervals, and never recurred afterwards. From that 
 time the patient suffered continuously from dizziness and uncer- 
 tainty of gait, so that he was unable to walk without being led. 
 Polypoid granulations were developed in the meatus, which rapidly 
 grew again after removal, and there was a very copious otorrhoea. 
 On the 8th of March, 1867, while the ear was being syringed, the 
 stapes in a perfect state was removed. Its base appeared somewhat 
 roughened on its vestibular side when examined by a magnifying 
 glass. The patient died from rapid consumption of the lungs on 
 May 4, 1867. There was no autopsy. 
 
 On the malleus and incus, Von Troeltsch^ has found 
 a flattening due to atrophy from pressure, when the 
 drum-membrane was strongly drawn inwards and 
 pressed against the labyrinth wall. 
 
 ^ A. f. O., viii., S. 230. 
 
THE TYMPANUM. 117 
 
 Softening of the ossicula in osteomalacica has been 
 described by Morand.^ 
 
 In general osteosclerosis of the skull, as in syphilis, 
 the ossicula are found very heavy and full. 
 
 In injuries from penetration of the ear, fractures 
 of the ossicles occur, particularly in the manubrium 
 (Fig. 54). 
 
 Loosening and separation of the articulations. The 
 articulating capsule between the incus and stapes 
 may become so relaxed that a sort of subluxation 
 may occur. When tiie membrana tympani is strongly 
 drawn inwards it is quite common to see the little 
 depression on the head of the stapes lying against 
 that membrane, giving an appearance as though the 
 stapes was wholly separated from its articulation with 
 the incus. The fact however is, that the incus is only 
 pushed aside within the distended and relaxed cap- 
 sule. This relaxation of the capsular band is some- 
 times found particularly marked with synostosis of 
 the stapes in the fenestra ovalis (Magnus). 
 
 Complete separation of the articulations, diastasis 
 of the ossicula, occurs most easily between the incus 
 and stapes, as the result of purulent inflammation, 
 which destroys and throws off the os Sylvii lying be- 
 tween them. The artificial diastases, produced by a 
 careless dissection, are readily distinguished from the 
 pathological by the healthy condition of the articu- 
 lating surfaces of the ossicles, and by the fact that 
 the OS Sylvii usually remains attached to the long 
 process of the incus. Relaxation of the firm articu- 
 lating capsule between the malleus and incus seldom 
 occurs with inflammations. I have described one such 
 
 1 Quoted by Bonnafont, p. 539. 
 
118 PATHOLOGY OF THE EAR. 
 
 case, associated with superficial caries of the articu- 
 lating surface of the body of the incus, and atrophy 
 of the musculus tensor tympani and musculus sta- 
 pedius.^ I saw a similar case with Professor Zaufal, 
 which was associated with innnobility of the incus. 
 
 From injuries of the skull with fissure of the pe- 
 trous bone diastasis of the ossicula may take place. 
 In one case I saw this condition associated with a 
 paralysis of all the muscles of the eye on the same 
 side. 
 
 Blumenbach ^ asserts that hydrocephalus may be the cause of dias- 
 tasis, the pars petrosa and squamosa being so separated from each 
 other that the incus is completely separated from the stapes, and the 
 malleus and incus remain connected with the squamous portion of 
 the bone and are drawn downwards. In one case he asserts that he 
 saw the stapes lifted out of the foramen ovale. I give this on the 
 authority of Blumenbach, having had no experience of my own with 
 this condition. 
 
 Rigidity and immohillty , anchylosis, is very com- 
 mon in the annular ligament of the stapes and in the 
 malleo-incus articulation . 
 
 The normal movement of the base of the stapes is 
 very small. Helmholtz found that the excursions of 
 the stapes were from iV to tV mm. ; from this it is 
 evident that the appreciation of the pathological im- 
 pairment of mobility is extremely difficult, and the 
 diagnosis of rigidity is often quite arbitrary. On this 
 account Politzer has proposed to measure accurately 
 the degree of mobility by inserting a fine manometer 
 tube filled with a solution of carmine, air-tight, into the 
 superior semicircular canal, and then measuring the 
 
 1 ArcMv fur OhrenlieiUcunde, ii., S. 290. 
 
 ^ GeschicJde und Besclireibung der Knochen, 2 Auflage, S. 151, note 1. 
 
THE TYMPANUM. 119 
 
 variations of the fluid in the tube during changes of 
 air pressure hi the meatus.^ 
 
 The recognition of complete anchylosis of the stapes 
 is very easy and can, if doubtful, be determined with 
 certainty from the fact that no change occurs in the 
 lio-ht-reflex on the membrane of the fenestra rotunda 
 
 o 
 
 when the stapes is pressed upon, or if this light-reflex 
 is obscyred by swelling of the mucous membrane, a 
 drop of fluid, placed in an opening made into the ex- 
 ternal semicircular canal, w^ill answer the same pur- 
 pose. 
 
 The capability of vibration in the ossicula is dimin- 
 ished by thickening or rigidity of the mucous mem- 
 brane which covers these bones (sclerosis, calcification 
 or ossification of the periosteal connective tissue with 
 cellular and serous infiltration of the subepithelial 
 layer), by synechia3 and by the imbedding of the 
 bones in hypertrophied connective tissue (membra- 
 nous anchylosis). A very common cause of rigidity 
 of the stapes is stifliiess of its annular ligament, pro- 
 duced by a deposition of lime in the membrane, which 
 is often associated with similar depositions in the mu- 
 cous membrane of the stapes itself and of the promon- 
 tory. If the whole annular ligament, or even only 
 the periosteal layer of the mucosa which covers it, is 
 changed into a mass of lime, absolute immobility, an- 
 chylosis of the stapes, results. The same result is 
 produced by a new growth of bone, hyperostosis, on 
 the base of the stapes, on the promontory, and on the 
 foramen ovale ; by osseous bridges between the crura 
 and the walls of the niches and by the direct pinching 
 of the crura in a foramen ovale much narrowed by 
 
 1 Wiener Med. Wochensclir., 1862, S. 214. 
 
120 PATHOLOGY OF THE EAR. 
 
 hyperostosis. A predisposition to such synostosis of 
 the stapes with the foramen ovale is produced by ad- 
 vanced age, possibly because at this time the cartilage 
 covering the periphery of the base of the stapes and 
 the edges of the foramen ovale suffers a physiological 
 degeneration. 
 
 The existence of anchylosis of the stapes is how- 
 ever by no means confined to old age ; but^ay be 
 found at all ages, and is even sometimes congenital, 
 the result of intrauterine inflammation.^ T have met 
 w^ith it very frequently in dementia paralytica. Ac- 
 cording to Toynbee, arthritis and rheumatism are the 
 most important factors in its aatiology. It remains to 
 be investigated whether primary diseases, calcification 
 and ossification, of the cartilaginous coverings of the 
 ossicula do not, more commonly than is supposed, 
 predispose to rigidity and synostosis. 
 
 Anchylosis of the stapes is found only exceptionally 
 without gross pathological changes of the whole lin- 
 ing membrane of the tympanum. As a rule liyperiB- 
 mia, thickening, and synechijB are found together with 
 whitish opacities on the membrana tympani. 
 
 After complete immobility of the base of the stapes 
 has existed for a long time the crura become atro- 
 phied from inactivity, so that they break at a slight 
 touch. This atrophy of the crura is then in marked 
 contrast with the often clearly defined hyperostosis of 
 the base of the bone, which may project into the ves- 
 tibule, sometimes producing within that cavity a bony 
 tumor with a convex surface. 
 
 Another secondary result, dependent on the defi- 
 
 1 According to Gegenbauer anchylosis of the stapes is perhaps in some 
 animals a normal condition. 
 
THE TYMPANUM. 121 
 
 cient mobility of the base of the stapes, is a new 
 growth of cartilage in the annular ligament ; this pro- 
 ceeds from the cartilage of the foramen ovale and is 
 analogous to the new growths of cartilage in anchy- 
 losed joints.^ A synostosis between malleus and incus, 
 following a previous diastasis of the bones, was de- 
 scribed by me.^ 
 
 Malleus and incus may become ossified with the 
 upper wall of the tympanmn. 
 
 Exostoses ^ on the ossicula, the result of ossifying 
 periostitis, without suppuration of the tympanum and 
 without perforation of the drum-membrane, are com- 
 mon on the incus, where the point of preference is on 
 the lab^'rinth-side of the end of the short process ; 
 they are less common on the malleus and least com- 
 mon on the stapes. The space between the long and 
 short processes of the incus was found by Wendt 
 filled with a new growth of bone, in a woman sixty- 
 five years of age, who had suffered from arthritis. 
 On the end of the manubrium of a child, after sup- 
 puration of the tympanum which had left a persistent 
 kidney-shaped opening in the membrana tympani, I 
 once saw an exostosis the size of a small pea, possibly 
 an ossified enchondroma. Toynbee also describes an 
 exostosis on the manubrium.^ Enchondromata ap- 
 parently are developed quite often on the sharply 
 projecting processus brevis, such as is seen with a 
 retracted drum-membrane. 
 
 1 Compare Wendt, Archiv der Heilkunde von E. Wagner, xiv., S. 
 286. 
 
 ■^A.f. 0., ix. 
 
 3 Ilesselbacli, Beschreibung der Patholog., Prdparate zu Wiirzburg, 
 Giessen, 1824, S. 126. Toynbee, Medical Times and Gazette, 1859, De- 
 cember, p. 589. 
 .•* Catalogue, No. 628. 
 
122 PATHOLOGY OF THE EAR. 
 
 Pathological Changes of the Tympanic Muscles. Idio- 
 pathic primary diseases of these muscles are unknown ; 
 secondary changes, on the contrar}^, have been fre- 
 quently observed with chronic inflammations of the 
 tympanum. From long impairment of their functions 
 as, for instance, from synechiiB between the drum- 
 membrane and the promontory, they may undei'go 
 fatty or fibrous degeneration, or may become atro- 
 phied. True, hyperplasia of the muscles has been less 
 commonly observed ; it has, however, been found in 
 chronic suppuration of the tympanum with perfora- 
 tion of the drum-memlDrane, polypus and caries of the 
 ossicula (Wendt). Extravasations of blood within the 
 muscles and h^ematomata on the tendon of the tensor 
 tympani muscle may occur during congestive catarrh. 
 
 Shortening of the tendon of the tonsor tympani 
 may result, (1.) From connective-tissue adhesions be- 
 tween the tendon and its sheath, the mucous mem- 
 brane covering it. This is so common that it has 
 been described as normal by some anatomists, as 
 Henle, but without doubt the normal condition is 
 such that the tendon shall move freeh^ within its 
 sheath. (2.) From retraction of the thickened mu- 
 cous membrane covering the tendon, during chronic 
 thickening of the general tympanic mucous mem- 
 brane, first described b}^ Politzer ^ as a common result 
 from long closure of the Eustachian tube. (3.) From 
 membranous or thread-like synechia© connecting the 
 sheath of the tendon with the roof of the tympanum 
 or with other parts of that cavity, especially the long 
 process of the incus and the stapes. These membra- 
 nous new-growths may contain osteoid deposits. 
 
 1 Beleuchtungshilder des Trommelfelh , S. 132. 
 
THE TYMPANUM. 123 
 
 Destruction of the tendon of the tensor tympani is 
 very common during suppurative processes. 
 
 Hinton found fibromata oil the tendon of the tensor 
 tympani. 
 
 Often when there is an extreme drawing; inwards 
 of the drum-membrane and partial obliteration of the 
 tympanum the tendon is completely imbedded in the 
 swollen and thickened mucous membrane w^hich lines 
 the tegmen tympani. 
 
 At the insertion of the stapedius muscle Hyrtl oc- 
 casionally saw a small bony process which sometimes 
 even projected into the body of that muscle. 
 
 Injuries. - Fractures of the base of the skull often 
 extend through the tympanic walls, and may thus 
 afford communication between the tympanum and 
 the labyrinth or cranial cavity. 
 
 From the entrance of sharp substances through the 
 membrana tympani separation and dislocation of the 
 ossicula may take place. 
 
 Foreign bodies sometimes, when the drum-membrane 
 is uninjured, reach the tympanum through the Eusta- 
 chian tube. The most common of these are minute 
 particles of coal-soot, which under a superficial ex- 
 amination could be mistaken for a grayish-black pig- 
 mentation of the mucous membrane : the constituent 
 parts of plants and hairs have also been found. 
 
 During expulsion of blood, either in hremoptysis 
 or h^ematemesis, blood may pass into the tj^mpanum. 
 Bits of food and bile may also reach the cavity dur- 
 ino; vomitino"- 
 
 Foreign bodies entering the tympanum from the 
 external meatus, after injury of the drum-membrane, 
 may give rise to multifold nervous symptoms, and 
 
124 PATHOLOGY OF THE EAR. 
 
 have frequently procliicecl fatal disease of the brain, 
 as purulent basilar meningitis and abscess of the 
 brain. 
 
 New Growths. 
 
 AURAL POLYPI. 
 
 Th. Wallstein, De quibusdam Otitidis Ext. Formis. Grypbiae, 1846. 
 (Asserting tlie fact, first proven by Professor Baum, that ciliated epithe- 
 lium is found on aural polypi). Meissner, Zeitschrift f. Rat. Medicin 
 1853. S. 350. (With a complete index of the literature.) Wedl, Grund- 
 ziige der Patholog. Histologic. Wien, 1854. S. 467. Billroth, Ueber den 
 Bau der Schleimpolypen. Berlin, 1855. S. 27. Fors^er, Atlas der Patho- 
 logischen Histologic. S. 73. 1859. Von Troeltsch, Yirchovf's Arch. XVH. 
 S. 40, 41. 1859. A. f. O. IV. S. 99 and 104 and Lehrbucb. Kessel, 
 A. f. O. IV. S. 167. 1868. Steudener, K.i.O. IV. S. 199. 1868. 
 Lucae, Virchow's Arch. XXIX. S. 39. 
 
 Contrary to earlier opinions, by far the greater 
 number of aural polypi arise without doubt from the 
 mucous membrane of the tympanum. Even in cases 
 where they appear to have their origin in the skin of 
 the meatus anatomical investigation shows that in 
 reality they arise from the cavities lying above the 
 meatus, which are a part of the 
 middle ear, and lined with mucous 
 membrane (Yon Troeltsch). Pol- 
 ypi vary from a microscopic size 
 to large tumors, three or four 
 centimeters long, which produce 
 ulceration of the drum-mem- 
 '''^' ^°' '^' '■ brane, fill and project out of the 
 
 Fig. 60. Smooth Aural Pol v- rr^, • i i i 
 
 pus, the base covered with lucatus. ihcy may imbed and 
 smooth papiii^. surround the hammer,^ and in 
 
 Fig. 61. Papillary Aural ^ 
 
 Polypus resembling 'condyle- rare cascs caii enlarge the osse- 
 '"'''**■ ous meatus by pressure. If the 
 
 polypus projects out of the meatus the secretion quite 
 
 1 Case by Borberg, A./. 0., vii., S. 55. 
 
THE TYMPANUM. 125 
 
 frequently produces ulceration on its club-shaped end. 
 Often several polypi are in the same ear ; it is less 
 common to find polypi simultaneously in both ears. 
 Spontaneous expulsion of large polypi several cen- 
 timeters in length has occurred in several cases ; I 
 myself have observed one such case. 
 
 The external form of polypi is variable. We find 
 them perfectly smooth and club-shaped on their ex- 
 ternal portions, but most of these show a papillary 
 structure near their bases ; the color of the parts of 
 the tumor exposed to the air is whitish or grayish 
 yellow-pink. Others again are knobbed on their sur- 
 faces from a universal papillary structure, and the 
 color is bright red. The papilla are either situated 
 on a compact base of tissue, or the whole tumor 'con- 
 sists only of branching papillae of all sizes and forms, 
 producing sometimes an appearance like condylomata. 
 
 The consistency of most polypi is soft ; only rarely 
 is one seen of fibromatous hardness. 
 
 All aural polypi are covered by epithelium, either 
 by a single or multiple layer of cylinder epithelium, 
 the upper layer of which possesses cilice, or by a "mul- 
 tiple layer of pavement epithelium, or by a mixed 
 epithelium. In the latter case the base of the tumor 
 is covered by a ciliated cylinder epithelium and its 
 external end by a multiple layer of pavement epitheli- 
 um, arranged as in the epidermis. The transition from 
 the cylinder to the pavement epithelium is gradual. 
 
 According to their histological structure three spe- 
 cies of polypi can be distinguished: mucous polypi, 
 fibromata, and myxomata. 
 
 The mucous polyjn are the most common and are 
 exactly similar to mucous polypi of other cavities, 
 
126 PATHOLOGY OF THE EAR. 
 
 being produced by a hyperplasia of the tympanic 
 mucous membrane. 
 
 The glands which exist in them are tubular inver- 
 sions of the epithelium into the tissue of the polypus: 
 they are hyperplastic formations of the glands of the 
 tympanic mucous membrane, which have been de- 
 scribed by Von Troeltsch and Wendt. With these tu- 
 bular glands the cystic cavities described by Meissner 
 are almost always found ; the cysts being lined with 
 an imperfect epithelium, and filled with a mucous 
 fluid in which loose epithelial cells and mucous cor- 
 puscles are suspended. According to Steudener they 
 are to be regarded as retention-cysts, produced from 
 the tubular glands. It is possible, however, that 
 they are produced by the union of the interpapillary 
 spaces in the same manner that they were observed 
 to be produced on a papillary polypus of the portio 
 vaginalis uteri by Rindfleisch.^ 
 
 Fibromata are developed from the periosteal layer 
 of the tympanic mucous membrane, and are similar 
 to the fibromata which develop as naso-pharyngeal 
 polypi from the periosteum of the base of the skull. 
 They are dense and fixed, of a pale color on account 
 of the paucity of developed blood-vessels, are always 
 covered by a multiple layer of pavement epithelium, 
 and are never very markedly papillary. Into their 
 epithelial covering small papillae, generally single but 
 occasionally double, project, like the papilla of the 
 cutis. Tubular glands and cysts are not found in 
 these fibromata. Their structure consists of a firm 
 connective tissue with numerous spindle or star- 
 shaped connective-tissue corpuscles, the processes of 
 
 1 Patholog. Histologic, S. 62. 
 
THE TYMPANUM. 127 
 
 which anastomose with each other. The intercellu- 
 lar substance is sometimes perfectly homogeneous, 
 sometimes grossly fibrillary. In the latter case the 
 fibrillar are generally arranged in bundles interlacing 
 with each other. 
 
 The existence of the very rare polypoid myxomata 
 of the tympanic mucous membrane was first con- 
 firmed by Steudener, in a polj-pus arising by a broad 
 base from the tympanum of a boy seventeen years 
 old. It had been extirpated by me, and from its ex- 
 ternal appearance seemed to be perfectly gelatinous. 
 Its epithelial covering consisted of a multiple layer 
 of pavement epithelium into which flat papilla?, like 
 those of the cutis, projected. 
 
 " The stroma consisted of a perfectly homogeneous 
 gelatinous tissue crossed by an anastomosing net- 
 work of spindle and star-shaped cells ; very fine 
 fibrillin were also found, which in some parts ac- 
 companied the rows of cells, in other parts formed a 
 wide-meshed network through the gelatinous tissue. 
 On the surfice of the tumor, and also in the neio-h- 
 borhood of the blood-vessels, these fibrilloe were es- 
 pecially numerous, in the former case in layers 
 parallel to the surface of the tumor, in the latter 
 case in layers concentric to the blood-vessels." 
 
 In the gelatinous tissue, in the meshes of the net- 
 work formed by the cells and fibrilla?, a moderate 
 number of round, granular cells with a simple round 
 nucleus, of the size and appearance of lymph-cor- 
 puscles, were found ; in certain spots, these were col- 
 lected together in small groups.^ 
 
 To explain the existence of this form of tumor it 
 
 1 Steudener, I. c. 
 
128 PATHOLOGY OF THE EAR. 
 
 should be remembered that the foetal tympanum con- 
 tahis mucous tissue, which gradually undergoes a 
 retrograde metamorphosis after birth. Residues of 
 this tissue may, on the occurrence of purulent catarrh 
 of the middle ear, which is extremely common in 
 new-born children, become irritated and increase in 
 size, thus producing a polypoid tumor. 
 
 It should be noticed here that a polypus arising 
 from the promontory and projecting into the meatus, 
 may be entirely shut off from the tympanum by a cica- 
 tricial adhesion of the edges of the perforation of the 
 membrana tympani with the labyrinth-wall around 
 the insertion of the polypus. 
 
 Hinton found a small fibroma arising from the 
 chorda tympani and Professor Koeppe informs me 
 that he has seen a gumma on the same spot. 
 
 Cholesteatoma, pearl-tumor, has already been fully 
 described on page 22. 
 
 Exostoses occur on the tympanic walls and on the 
 ossicles. On the floor of the cavity and on the lower 
 edge of the promontory, they occur as normal forma- 
 tions, like osteophytes, in the form of sharp points 
 and osseous bridges ; but they are also found in these 
 shapes as pathological formations 
 on other parts, as the promontory, 
 the neighborhood of the fenestra 
 rotunda and eminentia pyramid- 
 alis, where they are the results of 
 chronic periostitis. If the drum- 
 Fig. 62. membrane has been partially de- 
 Exostoses of the Laby- stroyed, tlicy may be visible on 
 
 rinth-wall, visible tlirough . . „ , . ■, 
 
 a perforation of the Drum- mspectlOn. OsSCOUS bridgCS are 
 
 membrane. souietimcs fouud bctwceu the 
 
 eminentia pyramidalis and fenestra ovalis. 
 
THE TYMPANUM. 120 
 
 Zaufal describes and figures an extensive, com- 
 pact exostosis, arising from the posterior wall of the 
 tympanum and the wall of the fossa jugularis, which 
 had closed the fenestra rotunda and produced partial 
 absorption of the sulcus pro membrana tjnnpani.^ 
 
 Hyperostosis of the fenestra rotunda produces a 
 slit-like narrowing and, in its highest degrees, com- 
 plete closure of this opening, as was well known to 
 the older observers.^ If the hyperostosis of the tym- 
 panic walls is equally distributed a marked narrowing 
 of the tympanum results. 
 
 Cysts. A retention-cyst lined with epithelium and 
 filled with rhombic tables of fat-crystals has been de- 
 scribed by me ; ^ it was apparently developed from a 
 tubular mucous gland of the tympanic mucous mem- 
 brane. Politzer'^ has seen cyst-like formations aris- 
 ing from the mucosa of the drum-membrane, " con- 
 sisting of a sack with thick fluid contents." Toynbee 
 and Hinton have described cases of sebaceous tumors 
 or dermoid cysts,^ containing hairs. 
 
 Epitlielial cancer, arising primarily from the tym- 
 panum, is extremely rare.^ 
 
 Osteosarcoma of the tympanum reaching into the 
 meatus has been observed by Wilde," Toynbee,^ and 
 
 1 A.f. O.. ii., S. 48. 
 
 2 Cassebohm, De Aiire Humana, Halae, 1734, S. 39. Cotunni, De 
 Aquretluctu, Viennse, 1774, S. 132. 
 
 ^ A.f. 0., i., S. 205. 
 4 Ykle A.f. 0., v., S. 216. 
 
 ^ Transactions of the Patliolog. Society, xvii., pp. 274, 275. 
 ® Vide page 26. 
 
 ' Pract. Bemerkungen ilber Ohrenheilkunde, Uebersetzung, S. 244, 
 433. 
 
 8 Diseases of the Ear, p. 386. 
 
 9 Wiener Med. Halle, 1863, No. 54. 
 
130 PATHOLOGY OF THE EAR. 
 
 Tubercle. The existence of miliary tubercle in the 
 tympanic mucous membrane of man has not been 
 proven anatomically with certainty. I have fre- 
 quently observed during life small, gray, miliary nod- 
 ules on the inflamed and swollen mucous membrane 
 of the inner tympanic Avail during the purulent otitis 
 of tuberculous children ; these I was inclined to re- 
 gard from their gross appearances as tubercles. In 
 my anatomical investigations I have as yet sought 
 them in vain. 
 
 In the pig the frequent occurrence of tuberculosis 
 of the middle ear has been confirmed by Sclmtz.^ 
 
 EUSTACHIAN TUBE. 
 
 Wendl, Kranklieiten der Nasenrachenhohle und des Racliens. (Ziems- 
 se/t'.s- Handbucli der Spec. Pathologie und Therapie, Band vii., S. 235-323, 
 1874. Moos, Beitrage zur Normalen und Patliologischen Anatomie und 
 zur Pliysiologie der Eustacliischen Rohre. Mit 18 Abbildungen. Wies- 
 baden, 1874. Lebrbiicher von Toi/nbee, Von TroeUsch, Gruber. 
 
 General Remarks. 
 
 The Eustachian tube in man is closed, when at rest, by the slight 
 contact of its walls. It is, however, a condition of normal hearing 
 that the canal should be from time to time opened in order that the 
 differences of air-pressure between the tympanum and the atmos- 
 phere may be equalized by the so-called ventilation of the tym- 
 panum. Every long-continued closure of the tube at any point 
 of its course by swelling, collection of secretion, or insufficiency of 
 the musculus dilatator tubie sive tensor veli palatini results, Avhen 
 the drum-membrane is imperforate, in a gradual absorption of the 
 air within the tympanum ; the drum-membrane, with its appendages, 
 then sinks inwards, owing to the over-pressure of the atmosphere, 
 its tension is increased, and a hypertemia ex vacuo occurs in the 
 tympanic mucous membrane. As the result of this hyperamiia, a 
 transudation or serous exudation next takes place, and this is fre- 
 
 1 Virdwics Archlv, Band GG, S 93. 
 
EUSTACHIAN TUBE. 131 
 
 quently followed by swelling of the tympanic mucous membrane and 
 abnormal adhesions between the drum-membrane, its appendages, 
 and the tympanic walls. As the Eustachian tube in children is ab- 
 solutely wider and shorter than in adults, it would in childhood less 
 commonly and easily become closed were it not that the form of 
 the pharyngeal orifice in children is slit-like, while in adults it is 
 widely open ; and this foi'm of the pharyngeal orifice furnishes a 
 predisposition to closure of the tube whenever the mucous membrane 
 of the naso-pharynx is swollen. The shape of the pharyngeal 
 orifice is subject to individual variations ; it is in adults by no means 
 always funnel-shaped, but often a triangular or crescentic open fis- 
 sure ; its average distance from the postei-ior end of the lower nasal 
 cartilage is, according to Luschka, 7 mm. The width of the canal 
 is, in adults, subject to very great individual differences : the aver- 
 age diameter is, for the isthmus, 2 mm. high and 1 mm. wide ; for 
 tlie pharyngeal orifice, 8 mm. high and 5 mm. wide ; for the tym- 
 panic orifice, 5 mm. high and 3 mm. wide. 
 
 The mucous membrane of the canal is somewhat projecting at 
 the pharyngeal orifice, but at other points is, in the normal condi- 
 tion, smooth, firmly adherent to the tissues beneath, not easily torn, 
 and of a light yellow color. The valve of the tube, a valve-like 
 duplicature of the mucous membrane, which was described as a nor- 
 mal formation at the pharyngeal end of the canal, by Koellner ^ and 
 the older anatomists, is pathological, and due to a relaxation or 
 wrinkled swelling of the mucous membrane. Recently the same 
 thing has been described by Moos " "as a prominence, a true valve, 
 which, although varying in different individuals, is never absent in 
 the normal condition." 
 
 The mucous membrane in the osseous portion of the tube cor- 
 responds in its pathological changes veith the tympanic mucous 
 membrane, except that membranous new growths are less common 
 in the tube than in the tympanum ; the membrane in the cartilagi- 
 nous tube, however, conforms, as a rule, with the condition of the 
 mucous membrane of the naso-pharynx. And also just as there 
 exists a cystogenous, adenoid tissiae, with numerous scattered lymph- 
 follicles directly beneath the mucous membrane on the roof of the 
 
 1 Reil's Archiv, ii., S. 18. 
 
 2 Bei/rdge zur Anatomie unci Pliysiologie der Eustaclmchen Rohre, 
 Wiesbaden, 1874, S. 29. 
 
132 PATHOLOGY OF THE EAR. 
 
 naso-pliavvngeal cavity, passing transversely from one tubal orifice 
 to the other, and also ou the tubal prominence and in the cavity of 
 Eosenmiiller, so also there is in direct continuity with this tissue at 
 the pharyngeal orifice of the Eustacliiau tube a layer of cystogenous 
 substance, of variable thickness, beneath the ciliated cylinder epithe- 
 lium. This adenoid tissue is subject, especially in childhood, to great 
 hyperplasia, causing narrowing and closure of the orifice of the 
 tube. In old age this same tissue is subject to atrophy. The mu- 
 cous membrane, between the tubal prominence and the choanjB, is 
 normally of a rather paler, more j-ellowish color than the rest of 
 the mucous membrane. 
 
 Malformations. Congenital absence of the Eustachian 
 tube was observed by J. Gruber,^ in one case associ- 
 ated with absence of the meatus, ossicula, and a ru- 
 dimentary development of the tympanum and laby- 
 rinth. Cases of congenital obliteration and stenosis 
 are also very rare ; one case is recently described by 
 J. Gruber,^ which was associated with cleft palate. 
 Congenital widening of the tube to three or four times 
 its normal calibre is described by Cock.^ Congenital 
 anomalies of the tube, in the form of angular bends ^ 
 in its osseous portion, of ossification-gaps in the wall 
 of the canalis caroticus, of unsj'tnmetrical position of 
 the pharyngeal orifices, are more common. 
 
 Hypersemia and Hemorrhage. Hyperasmia in the tu- 
 bal mucous membrane occurs of all degrees, from a 
 slight net-like injection to a uniform scarlet or brown- 
 red color. With simultaneous hyperasmia of the pha- 
 rynx, it is most marked in the cartilaginous portion 
 
 1 Vi.le A./. 0., ii., S. 154. 
 
 2 LeJtrbuch der Ohrenheilkunde, S. 573, with an illustration. 
 ^ Med. Cliirurg. Transactions, London, vol. xix., p. ICl. 
 
 * The median wall of the os^eoiis tube may show depressions two mm. 
 or more in depth, and, as the lateral wall does not follow this cui'vature, 
 a sudden dilation of the tube at these points is then produced. 
 
EUSTACHIAN TUBE. 133 
 
 of the tube, gradually diminishing in intensity towards 
 the tympanic orifice. Just the opposite is the case 
 with simultaneous hyperaemia of the tympanum. If 
 the hypenemia of the pharynx extends into the car- 
 tilaginous tube, rhinoscopic examination during life, 
 and also the autopsy, often show the ostium pharyn- 
 geum tuboB surrounded by a tissue of enlarged veins, 
 which can be followed into the tube. Dissection, in 
 such cases, shows also a decided injection, with in- 
 creased secretion, higher up the tube. Not infre- 
 quently a decided hyperasmia of the pharynx will be 
 found to cease just at the edge of the tube. 
 
 Hemorrhages are found in the form of ecchymoses 
 in the tissue of the mucous membrane and as large 
 Hat extravasations. If the exudation is situated at 
 the ostium pharyngeum the opening may be closed 
 as with a plug. Gray and grayish-black pigmenta- 
 tions of the pharyngeal mucous membrane ai'e some- 
 times seen to extend into the cartilao-inous tube. 
 Large amounts of coagulated blood are sometimes 
 seen in the tube after fracture of the base of the skull 
 and after haemoptysis and hasmatemesis. 
 
 Inflammation. The catarrhal inflammation of the 
 Eustachian tube is characterized by hyperaemia, in- 
 creased secretion and swelling of the mucous mem- 
 brane. An abundant collection of mucous secretion 
 is found very often on dissection, not unfrequently 
 so much that it appears to fill the whole calibre of 
 the tube. In this mucus many loose ciliated epithe- 
 lial cells are mixed. If the mucus is thick and ad- 
 hesive it may form distinct masses which project from 
 the pharyngeal orifice as the mucous masses do from 
 the OS uteri j such masses may also firmly close the 
 
134 PATHOLOGY OF THE EAR. 
 
 osseous tube when the cartilaghious tube is empty. 
 These masses are of a jelly-like consistency and may 
 be connected with similar masses in the tympanum. 
 
 The cause of the swelling in the mucous membrane 
 is hyperoemia and serous infiltration, and also an in- 
 crease in the lymph-like elements of the subepithelial 
 tissue (cellular infiltration) which are most numerous 
 at the pharyngeal end of the canal. By a specially 
 large collection of these cells at certain spots, hyper- 
 plasia of the gland follicles, a granular appearance of 
 the mucous membrane, is produced. There is also in 
 chronic cases a marked projection and wrinkling of 
 the mucous membrane perpendicular to the axis of 
 the canal, with hypertrophy of the glandular layer 
 and thickeninor- of the submucous connective-tissue. 
 
 o 
 
 Great swelling is found most commonly at the ostium 
 pharyngeum, which is then changed to a mere slit ; 
 higher up the tube it is more rare and is leas-t com- 
 mon in the osseous tube. In the latter situation, 
 however, a granular appearance of the mucous mem- 
 brane caused by the formation of small cells may oc- 
 cur, with simultaneous analogous changes in the tym- 
 panic mucous membrane, or the layer of submucous 
 connective tissue may be hypertrophied. 
 
 The existence of a genuine croupous inflammation 
 in the mucous membrane of the tube during croup of 
 the larynx and pharynx has been certainly proved 
 by Wcndt.i 
 
 In variola, according to the same author, peculiar 
 changes of the epithelium with the formation of cavi- 
 ties of variable size and form and filled with pus cells, 
 take place very commonly at the pharyngeal orifice 
 
 1 Archiv der Heilkunde, xi., S. 2(31. 
 
EUSTACHIAN TUBE. 135 
 
 and less commonly higher up, along the lower third 
 of the tube. 
 
 Traumatic inflammations of the Eustachian tube 
 sometimes occur after surgical operations in the naso- 
 pharynx, from incisions into the tubal orifice during 
 resection of the upper jaw, etc. 
 
 Secondary changes of the tubal cartilage, in the 
 form of small spots of ossification, have been described 
 by Moos.^ 
 
 Calcifications of the tubal cartilage also occur with 
 chronic inflammation of the middle ear. 
 
 Ulceration at the ostium pharyngeum and extend- 
 ing from here into the lower end of the cartilaginous 
 tube is found in syphilis, tuberculosis, scrofula, diph- 
 theritis, and variola.'^ I have frequently observed with 
 the rhinoscope on the tubal prominence and at the 
 entrance of the pharjaigeal orifice small, round, super- 
 ficial /o?/icw?«r ulcerations, the result of purulent fol- 
 licular catarrh of the naso-pharynx. In caries of the 
 temporal bone with destruction of the osseous tube 
 ulcers from erosion are seen on the ostium pharyn- 
 geum if the foetid pus flows into the pharynx in large 
 quantities. The ulcers in variola are always super- 
 ficial, usually of a round form, more common on the 
 sides than on the floor and medial surface of the 
 pharyngeal orifice, but they may, however, change 
 the whole ostium pharyngeum into a flat ulcerated 
 surface. They rarely extend to the lower third of 
 the cartilaginous tube. 
 
 1 I. c, p. 49. 
 
 2 According to Seidl the ulcerations of typlius may occur in the tube. 
 Wiener Med. Wochenschrift, 1852, Nos. 2, 5, 6. Ueber den Einjluss des 
 Catheterismus der Eusl. Rohre. 
 
136 PATHOLOGY OF THE EAR. 
 
 The ulcers in S3'phili.s and tuberculosis which ex- 
 tend from the pharyngeal mucous membrane are 
 much deeper, reaching the cartilage itself and even 
 penetrating its substance. On the edges and in the 
 neighborhood of tuberculous ulcerations of the tubal 
 prominences Wendt^ has found formations of fresh 
 miliary tubercles. 
 
 An extensive tuberculous ulceration which I have 
 preserved in my collection, taken from a man thirty- 
 three years old, extends to the middle line of the 
 fornix and the posterior pharyngeal wall, involves 
 the cavity of Rosenmiiller, which is changed into a 
 large excavation twice as deep as the cavity on the 
 opposite side, and has destroyed the greater part of 
 the tubal prominence. The mucous membrane of 
 the lower portions of the tube was hypera^mic and 
 swollen, but without ulceration. In addition there 
 was double perforation and purulent infiltration of 
 the drum-membrane, and the tympanic mucous mem- 
 brane was greatly swollen, and infiltrated with pus. 
 The articulating connections of the ossicles were 
 loosened. 
 
 Syphilitic ulcerations on the tubal prominence and 
 at the entrance of the pharyngeal orifice, with ulcera- 
 tions on other parts of the naso-pharynx as the sep- 
 tum narium, choanee, fornix, posterior wall of the 
 uvula, can often be recognized by rhinoscopic exami- 
 nation, where the usual inspection of the pharynx 
 without a mirror would raise no suspicion that an 
 ulcerative process existed. 
 
 Higher up in the tube, ulcerative processes only 
 occur with caries and tumors (epithelial cancer), 
 
 1 I. c, p. 297. 
 
EUSTACHIAN TUBE. 137 
 
 which may partially or wholly destroy the osseous 
 tube. 
 
 Contraction and Enlargement. Contraction or stenosis 
 of the Eustachian tube, even to complete closure, 
 takes place from swelling of the mucous membrane 
 or thickening of the submucous connective-tissue in 
 catarrh, from hyperplasia of the cystogenous tissue 
 at the pharyngeal orifice, from oedema of the tubal 
 prominence during congestion of the vena cava supe- 
 rior, from cicatricial formations in the naso-pharynx, 
 and at the ostium pharyngeum, from hypertrophic 
 thickening of the soft palate, by which the anterior 
 lip of the tube may be pressed against the posterior 
 lip,^ from insufficiency of the palato-tubal muscles 
 in congenital or acquired fissure of the palate and 
 in cleft palate, from closure of the ostium pharyn- 
 geum by new growths in the naso-pharynx, such as 
 naso-pharyngeal polypi, large cysts, cicatricial bands, 
 hyperplastic pharyngeal tonsils,^ great swelling of the 
 lower nasal-cartilage," or great hypertrophy of the 
 
 1 Von Trooltsch, A.f. 0., iv., S. 136. 
 
 2 The pharyngeal tonsils (glandulae pharyngeae) undergo, especially 
 in childhood, and more rarely between the ages of twenty and thirty, a 
 hyperplasia so that they assume a ragged, almost polypoid appearance. 
 In the higher degrees of this hyperplasia they may reach more tlian a 
 centimeter above the upper part of the vomer and directly cover the ori- 
 fice of the tube. By compression this orifice may be narrowed to a mere 
 slit. If, at the same time, there is hyperplasia of the cystogenous tissue 
 of the tubal proniinence, this prominence appears as a soft fold l cm. 
 thick, and with a ragged edge projecting into the naso-pharynx. Adhe- 
 sions of the hyperplastic glandula pharyngea with the tubal prominence 
 may also exist. 
 
 2 The posterior edge of the lower nasal cartilage is often enormously 
 thickened and lengthened posteriorly; it then appears ragged, notched, 
 or fringed. It may then reach the orifice of the tube, and project over 
 and partially lie upon this orifice. The irritation resulting from this 
 produces hyperasmia and hypersecretion which extends usually as far as 
 
138 PATHOLOGY OF THE EAR. 
 
 palatine tonsils.-^ Stenosis from hyperostoses and 
 exostoses, with or without osteosclerosis of the skull, 
 or from new connective-tissue growths at the tym- 
 panic orifice, as in caries or hyperplastic catarrh of 
 the tympanum, is much less common. 
 
 Stenosis in the middle portion of the canal appears 
 to be extremely rare. It is in practice, from inexact 
 observation, thought to be much more common than 
 it is in reality. Not infrequently an angular bend in 
 the course of the tube or a projection of the carotid 
 canal into the osseous tube is mistaken for stenosis, 
 on attempting to pass a bougie. Real strictures, in 
 the sense in which urethral strictures are formed by 
 thickening and atrophic shortening of the tissues, ap- 
 pear not to occur in the Eustachian tube. In the 
 osseous tube, however, contractions from hypertrophy 
 of the connective-tissue layer of the mucosa, some- 
 times with deposits of lime, occur. 
 
 Contractions at the ostium tympanicum are fre- 
 quent in otitis media, produced by hypertrophic mu- 
 cous membrane which forms a fold or valve-like elon- 
 gation of the tissue, or else by a new growtli of con- 
 nective-tissue, which also fills the anterior part of the 
 tympanum ; this new tissue, when of recent growth, 
 is succulent and red, when old is grayish white and 
 firm. Thread-like bridges of tissue also occur across 
 the ostium tympanicum (Von Troeltsch,^ Magnus^), 
 
 the osseous tube (Von Trocltsch, A.f. O., iv., S. 139). Cystogenous 
 tissue exists nornially in the nuieous membrane, whicli projects from the 
 lower nasal cartilage. 
 
 1 In extreme hypertrophy of the palatine tonsils the arcus pharyngo- 
 palatinus, or even the whole palate, may be pressed against the ostium 
 pharyngeum. (This is denied by Wendt.) 
 
 2 A. f. 0., iv., S. 111. 
 
 3 A.'/. O., vi., S. 258. 
 
EUSTACHIAN TUBE. 139 
 
 An osseous stricture of the tube, three mm. long, 
 and one cm. below the ostium tympanicum, was seen 
 and figured by Toynbee.^ A bristle could scarcely be 
 passed through it. 
 
 The canalis caroticus may project so far into the 
 osseous tube as to almost close its calibre. I have 
 also frequently seen the carotid artery separated from 
 the tube merely by a thin, transparent lamella of 
 bone. 
 
 In atrophy of the mucous membrane of the naso- 
 pharynx, the ostium pharyngeum appears unusually 
 wide open and deep. The tubal prominence then 
 projects very much, and from the thinning of its mu- 
 cous covering appears almost bare. 
 
 Acquired enlarcjement of the canal throughout its 
 whole extent is frequent in connection with sclerosis 
 of the tympanic mucous membrane. The canal may 
 be enlarged to three or four times its normal calibre. 
 Partial enlargement in the osseous portion, due to 
 atrophy of the osseous walls, is found after chronic 
 suppurations of the tympanum. 
 
 According to Riidinger^ in the bodies of old per- 
 sons, an abnormal gaping of the tube throiirjhout its 
 whole length, with an atrophy of the musculus dilata- 
 tor tubge, is frequently seen. 
 
 Adhesions, from adhesive inflammation or hyper- 
 ostosis, may occur at both orifices of the tube, but 
 are rare in the canal itself Cicatricial adhesions of 
 the ostium pharyngeum occur from syphilitic ulcer- 
 ations in the naso-pharynx. The cicatricial tissue 
 
 1 Montldfi Journal, August, 1850 ; Medical Times, February, 1850, 
 p. 143. 
 
 2 MonatsscJirift fur Ohrcnheilkunde, 1868, No. 9. 
 
140 PATHOLOGY OF THE EAR. 
 
 closes the orifice, usually after destruction of the 
 whole limb lis cartilagineus and adhesion of the palate 
 to the posterior wall of the pharynx. The number 
 of these cases as yet described is not large.-^ After 
 diphtheria, variola,- and scrofula, cicatricial closure of 
 the pharyngeal orifice has been observed. A case of 
 the latter form occurred in Halle in January, 18To;^ 
 
 A bo}' twelve years old died from stenosis of the trachea caused 
 by a cicatrized ulceration, directly above its bifurcation. The lungs 
 were free from tubercles. The naso-pharynx was reduced to the size 
 of a small hazel-nut. The firm cicatricial tissue which closed this 
 cavity from the mouth, by the adhesion of the soft palate to the pos- 
 terior wall of the pharynx was enormously thick, reaching, close to 
 the vertebral column, a thickness of two centimeters. On the edge 
 of the hard palate in the median line was a very minute opening 
 surrounded by white cicatricial edges. The choante w^ere of normal 
 width, the mucous membrane slightly thickened, the cavernous tissue 
 on the posterior portion of the lower nasal cartilage very much 
 hypertrophied ; the ostium pharyngeum of the right tube completely 
 obliterated by cicatricial tissue ; that of the left tube narrowed to 
 one millimeter; both drum-membranes very much drawn inwards; 
 tympana and mastoid cells on both sides completely filled with a 
 sero-mucous, perfectly clear exudation. During life such a degree 
 of deafness existed that it was necessary to shout directly into the 
 ear. 
 
 Adhesions from growths of conective tissue at i\\e 
 ostium tympanicum are frequent with caries of the 
 temporal bone, and after the cessation of suppura- 
 tion of the tj'mpanic mucous membrane. Bridges of 
 
 1 Otto, Patholog. Anatomie, Breslau, 1814, S. 184. Sellene Beohach- 
 tungen zur Anatomie, etc., Breslau, 1816, S. 3. Virchow in Virchow's 
 Archiv, xv., S. 313. J. Gruher, StatistiscJier Berichf von ISeS. 
 
 2 Lindenbaum, ^./. O., i., S. 295. According to Wend t, deep de- 
 Ptructive processes and adhesions are not found in variola. (Krankhci- 
 ten des Nasenrachenraums, S. 285.) 
 
 3 Already published in Volkman's Beilriige zur Chintrgie, Leipzig, 
 1875, S. 305. 
 
EUSTACHIAN TUBE. 141 
 
 connective tissue within the tube itself are found in 
 great variety; they were found three times in the 
 cartilaginous tube by Wendt, and had already been 
 described in three cases by Toynbee.^ 
 
 Wever ^ describes an adhesion throughout the whole 
 length of the tube produced " by a fibrous substance, 
 which w^as firmly united with the mucous mem- 
 brane." 
 
 New Growths. Polypi within the tube have been 
 described in a few cases. The most noteworthy case 
 is that of Voltolini/ where the polypus filled the 
 whole tube like an earth-worm and had produced an 
 enlargement of its calibre. 
 
 Large tympanic polypi, fibromata, often have one of 
 their attachments in the ostium tympanicum. Cases 
 are also known where their only insertion was in 
 this orifice. Smaller polypoid tumors frequently oc- 
 cur in the osseous tube. 
 
 In syphilis excrescences like the pointed condylo- 
 mata are sometimes seen at the ostium pharj^igeum ; 
 in miliary tuberculosis caseous nodules are sometimes 
 seen at the same spot. 
 
 Exostoses, in the form of osteophytes, are fre- 
 quently found in the Eustachian tube with similar 
 growths in the tympanum. 
 
 Foreign Bodies. During the act of vomiting parti- 
 cles of food sometimes pass into the tube. Other for- 
 eign bodies scarcely ever get into this canal, except 
 those introduced for surgical purposes and accidentally 
 left in, such as broken bougies, etc. The case of 
 
 ^ Translation by Moos, p. 221. 
 
 2 Dbs. Inaug., Freiburg, 1835, S. 13. 
 
 8 Virchow's Arch., xxxi., S. 220. 
 
142 PATHOLOGY OF THE EAR. 
 
 Fleischmann ^ is well known, where he found, during 
 dissection, a grain of barley deep in the tube. An- 
 dry ^ once found an ascaris in the canal. 
 
 Pathological Changes in the Tubal Muscles. Fatty degen- 
 eration and atrophy of the tubal palatine muscles are 
 the frequent results of chronic retro-nasal and tubal 
 catarrhs. In trichinosis the tubal muscles are con- 
 stantly very abundantly infiltrated with the parasite, 
 while the two tympanic muscles appear to always re- 
 main free from them. 
 
 A muscular hypertrophy of the musculus tensor 
 veli palatini vel dilatator tubse has been described by- 
 Moos '^ as the result of chronic tubal catarrh. 
 
 Extensive hemorrhagic infarcts also occur in the 
 tubal muscles (Zaufal). 
 
 MASTOID PROCESS. 
 
 Z'tya, Processus Mastoideus und (lessen Zellen. Ann. Univers. 188. S. 
 241. Maggio, 18G4. (Auszug von jT/zeiVe in AS'c/i»?/(/^'s Jahrbiichern. Bd. 
 125. Heft i. S. 33.) ScJucarIze and Et/sell, Ueber die kiinstliche Eroff- 
 nung des Warzenfortsatzes. A. f. O. YII. S. 157. 1873 et seq. 
 Buck, Diseases of the Mastoid Process. Arcliiv fiir Augen- und Ohren- 
 heilkunde, HI. 1. 1873. 2. 1874. Wendt, Archiv fiir Heilkunde von 
 Wagner. Xlll. S. 424-427. 
 
 The lining membrane of the air-cells of the processus mastoideus, 
 the communication of which with the tympanum Valsalsa first dem- 
 onstrated,'* and Sappey afterwards named the canalis petromas- 
 toideus, is a direct continuation of the mucous membrane of the 
 tympanum, and is subject to the same pathological changes as the 
 tympanic mucous membrane. It possesses, however, no ciliated epi- 
 
 1 Linkers Sammhnu/. Band ii., S. 183. 
 
 2 Itard, Krankheiten des Ohres, ^^'eimar, 1822, S. 94. 
 ^ I.e., p. 47. 
 
 * De Aure Humana, 1707, p. 17. According to Buck the passage from 
 the tympanum to the antrum mastoideum is sometimes double (/. c). 
 
MASTOID PROCESS. 143 
 
 theliiira. In the antrum mastoideum, exactly the same pathological 
 condition is almost always found as in the tympanum, while the rest 
 of the mastoid cells may remain free from disease or, at least, the 
 changes in them are not of the same intensity and form as in the 
 tympanum. From the unequal development, and variable relation of 
 the solid to the spongy osseous substance in the mastoid process, it 
 is sometimes difficult to decide in a given case whether we are 
 dealing with a pathological or physiological appearance. 
 
 Primary and isolated disease of the mastoid occurs but very rarely ; 
 secondary disease is common from diseases of the tympanum and me- 
 atus. In childhood caries and necrosis is generally confined to the 
 mastoid process, while in the tympanum only purulent catarrh occurs. 
 
 Malformations. Complete absence of the process is 
 found together with other malformations deeper in 
 the temporal bone, in congenital deafmutism. 
 
 The external form and size of the mastoid process 
 is extremely variable. Wildberg^ found its point 
 curved like a beak, resembling in appearance the 
 processus coracoideus of the scapula. 
 
 The size and form of the mastoid cells are subject 
 to great variations ; even in the two processes of the 
 same individual, they seldom correspond. In six 
 hundred skulls, HyrtP found that in three the occiput 
 helped form the cells. The antrum mastoideum is 
 the only large cavity, which is constantly present ; 
 in a child this lies very superficially, directly behind 
 and above the external meatus. 
 
 In the cortical substance of the bone, which is 
 normally from two to six millimeters thick, thin spots 
 or congenital ossification gaps may exist, sometimes 
 of such a size that the point of the little finger can 
 
 1 Versuch einer Annt. Physiol. PatJwl. Ahliandl. iiber die Gelwrwerkzeuge 
 des Menschcn. S. 14, note h. 
 
 2 Wiener Med. Wochenschrift, 1860. 
 
144: PATHOLOGY OF THE EAR. 
 
 be passed into them. The openings may be the 
 cause of an emphysema of the skin behind the ear. 
 
 Separation of the mastoid from the rest of the tem- 
 poral bone, was seen several times by Meckel. 
 
 Hypersemia and Hemorrhage. Diffuse hypercemia of 
 the mucous liuing of the mastoid is common with sim- 
 ultaneous hypera3mia of the tympanum, and may be 
 of au}^ degree, from a yellowish red to a bluish black 
 color. 
 
 Hemorrhatres are found in the form of hemorrhao-ic 
 infiltration of the mucous membrane, and of effusions 
 of blood on the surface of the mucous membrane, 
 especially during typhus, and after injury, such as a 
 blow on the head or fracture of the skull. 
 
 Catarrhal Inflammation of the Pneumatic Cells of the Bone. 
 The swelling and thickening of the mucous-periosteal 
 lining of the antrum and mastoid cells may comiDletely 
 fill these cavities, if they are of small size. The mu- 
 cous membrane then assumes from serous infiltration a 
 succulent, gelatinous appearance, and the osseous cav- 
 ities, which in their normal condition should contain 
 air, appear to be filled with a red pulpy mass. The 
 communication of the antrum mastoid eum with the 
 tympanum may thus be completely obliterated or 
 only be retained through a narrow slit. Where the 
 swelling is of a lesser degree the unoccupied space 
 may be wholly or partially filled with exudation, 
 either serum, mucus, or pus. In most cases the 
 tympanum is at the same time inflamed, but an in- 
 dependent inflammation may occur in the cells with- 
 out extending to the tympanum and without perfora- 
 tion of the drum-membrane. From an oral com- 
 munication I have learned of a dissection of a case of 
 
MASTOID PROCESS. 145 
 
 Professor Zaufal's in which an isolated suppuration in 
 the mastoid cells took place without caries, and with- 
 out extending to the tympanum, and led to phlebitis 
 of the sinuses and death. 
 
 Wendt found, in a case of croup of the whole mid- 
 dle ear, which came on during variola, true croupous 
 membrane also in the mastoid cells, together with 
 abundant cellular infiltration of the connective-tissue 
 vstroma of the mucous membrane. 
 
 As the result of chronic catarrhal inflammation 
 within the cells, pseudo-membranes are often formed 
 by which the communication with the tympanum is 
 closed. These pseudo-membranes, by shutting in a 
 number of the osseous cells, may produce large cystic 
 cavities filled with a serous or mucous contents. In 
 these new formed membranes calcifications and ossifi- 
 cations may take place just as in the membranes 
 within the tympanum. From the retention of pus in 
 the mastoid cells crystals of cholesterine may be 
 formed, often in large masses, together with granu- 
 lar corpuscles, fluid fat, and detritus. 
 
 Periostitis Externa. The external periosteum of the 
 mastoid is sometimes attacked by primary inflamma- 
 tion without the cavities of the middle ear being dis- 
 eased. In these cases pus may collect between the 
 periosteum and the bone, superficial necrosis of the 
 cortical substance may follow, the periosteum after 
 being loosened may rupture and a subcutaneous ab- 
 scess result. The periostitis may extend to the pos- 
 terior upper wall of the meatus,^ which then always 
 shows during life redness and swelling. 
 
 Such a primary periostitis externa is rare compared 
 
 ^ Preparation in the Collection of Professor Zaufal. 
 
146 PATHOLOGY OF THE EAR. 
 
 with the great frequency of secondary periostitis as- 
 sociated with caries and necrosis of the mastoid cells. 
 
 The separation of the periosteum from the bone by 
 a collection of pus, unless extensive, does not always 
 lead to necrosis. 
 
 Suppurating Ij^mph-glands over the mastoid pro- 
 cess, glandulse subauriculares, with fistula beneath 
 the skin, should not be confounded with periostitic 
 abscesses. Suppuration of the parotid may produce 
 fistuloe, which may extend even to the mastoid region, 
 without the bone becoming affected by the suppura- 
 tive process. 
 
 Caries and Necrosis is more common in the mastoid 
 than in any other part of the temporal bone. It is 
 most frequent in childhood, on account of the ana- 
 tomical relations of the bone, which are highly favor- 
 able to the retention and consequent inspissation and 
 putreftiction of the pus formed in suppurative inflam- 
 mation of the mucous-periosteal lining of the mastoid 
 cells. If during the inflammation ulceration takes 
 place, the bone, deprived of its periosteum, is very 
 soon involved in the molecular necrosis of the tissues, 
 producing caries. 
 
 With caries of the mastoid process the posterior 
 wall of the meatus is almost always deprived of its 
 periosteum and perforated. 
 
 Not unfrequently, if large portions of bone have 
 become gangrenous from interference with their nu- 
 trition, large perfectly loose sequestra are found within 
 a carious cavity of the mastoid which is nearly filled 
 by granulations ; the cortical substance of the bone 
 remains firm. In such cases of central necrosis of 
 the mastoid the disease of the mucous periosteal lin- 
 
MASTOID PROCESS. 
 
 147 
 
 ing of the cells, and not a periostitis externa, is the 
 cause of the necrosis. If the putrid pus does not find 
 a sufficient exit into the tympanum a fistulous open- 
 ing; throusrh the 
 osseous walls is 
 formed, and thus 
 a drainage-canal 
 produced. Such 
 a fistula in the 
 cortical substance 
 may exist with- 
 out the skin over 
 the mastoid show- 
 ing any percepti- 
 ble change. Oc- 
 casionally such 
 an opening be- ^.^ ^3 
 
 comes filled with Central CariesNecrotica of the Mastoid Process. Loose 
 fr in Illations s^Q"^^^''""! within the cavlt}'. The cortlcalis perfect. 
 
 which will simulate fluctuation, and yet an incision 
 will show that there is no pus. 
 
 These fistulae generally open through the skin on 
 the external surface of the mastoid, or througli the 
 posterior upper wall of the external meatus, less com- 
 monly through the lower portion of the mastoid, when 
 the pus may gravitate into the neck and lie quite 
 deep ; they may, however, also open into the pos- 
 terior or middle fossa of the skull, and thus produce 
 fiital secondary disease, as meningitis or phlebitis of 
 the sinuses with pysemia. The dangerous proximity 
 of the sinus lateralis, whose osseous wall is often per- 
 forated by caries, is of special importance in this con- 
 nection. 
 
148 
 
 PATHOLOGY OF THE EAR. 
 
 Before the fistulsB break through the skin, abscesses 
 form behind or below the auricle or in the meatus. 
 These may extend even to the middle line of the 
 occiput, or following the course of the deep fascia of 
 
 the neck may 
 f l^f'/^ even r e a c h 
 
 the p 1 e u r a. 
 Minute se- 
 questrse may 
 disappear 
 very slowly 
 by resorption 
 through the 
 granulations. 
 The presence 
 of sutures on 
 the sequestra 
 often deter- 
 mine exactly 
 the locality 
 from w h i c h 
 the bone has 
 been thrown 
 off. After the expulsion of a sequestrum through 
 the fistulce, or after its removal artificially, the natural 
 healing often takes place wonderfully rapidly if the 
 individual is free from dyscrasioB, the whole cavity 
 in the mastoid filling with granulations which are 
 gradually transformed into ossified connective tissue 
 (eburnation), and a deeply sunken osseous cicatrix is 
 left behind. In other cases the walls of the patho- 
 logical cavity and of the fistulous canal become cov- 
 ered with perfectly smooth, yellowish-white mem- 
 
 Fig. 64. 
 
 Loose Sequestrum in the Mastoid Process seen through a 
 large carious opening (h) in the Corticalis. At (a) is a cari- 
 ous opening in the posterior wall of the meatus communicat- 
 ing with the cavity of the mastoid. At (c) is a carious open- 
 ing on the lower side of the pars mastoidea. (From Kuh, 
 " Klinische Beitrage," etc., Breslau, 1847.) 
 
MASTOID PROCESS. 149 
 
 brane resembling mucous membrane, which prevents 
 the complete obliteration of the cavity. The open- 
 ing in the skin in such a case becomes closed by a 
 black hard mass, not unlike cerumen, which furnishes 
 a natural protection against external injuries. Micro- 
 scopic examination shows these black masses to con- 
 sist of epithelium, tables of cholesterine, and de- 
 tritus. 
 
 If exfoliation of a large piece of bone does not take 
 place the disease is very much prolonged, and the 
 mastoid process may be by degrees completely or 
 partially lost. Krukenberg ^ first called attention to 
 the fact that the bone may be replaced sometimes by 
 a soft, uniform, caseous mass, which can be easily cut 
 by the knife (caseous degeneration). At the same 
 time the mastoid process may appear swollen exter- 
 nally owing to an oedema of the skin. 
 
 Eburnation or sclerosis is a common result of chronic 
 inflammations of the middle ear, especially of the 
 purulent variety ; it occurs at all ages, even in the 
 earliest childhood. The osseous air-cells become 
 gradually narrower and narrower, and finally disap- 
 pear entirely ; the diploe between the tabula externa 
 and interna becomes filled with a mass of bone, and 
 the cortical substance is thickened by a deposit of 
 bone on its external surface. 
 
 Sclerosis of the mastoid is also found without any 
 indications of previous inflammation of the middle 
 ear. This is seen especially often in extreme old age 
 and after constitutional syphilis. 
 
 Fracture. In fractures of the skull the fissure may 
 pass through the mastoid process and the posterior 
 
 1 Jahrbiicher der Ambulatorischen Klinik zu Halle, Bd. ii., S. 214. 
 
150 PATHOLOGY OF THE EAR. 
 
 upper wall of the meatus, without injuring the drum- 
 membrane. 
 
 New Growths. The lymph glands lying over the 
 mastoid process may become inflamed, increase in 
 size, and form a well-marked lymphomatous tumor. 
 The inflammation of these glands may occur Avith or 
 after acute exanthemata and is sometimes very acute, 
 accompanied by fever and very severe pain. The 
 tumor may reach a large size — I have seen one as 
 large as the fist, — is hard and extremely sensitive to 
 the slightest touch. The skin covering it may be at 
 the same time inflamed and infiltrated. 
 
 Arnemann reports that he has frequently seen con- 
 cretions of a chalk-like consistency in the mastoid 
 cells during syphilis. 
 
 Polypi often arise from the point where the tympa- 
 num passes into the mastoid cells. In the cells them- 
 selves polypoid growths of the mucous membrane are 
 also found, usually of small size but sometimes in large 
 numbers. 
 
 That fibrous poljqw originating in the mastoid cells 
 '• sometimes appear externally behind the auricle 
 through openings formed by exfoliation of carious 
 bone," as Josef Gruber asserts,^ I have never yet 
 satisfied myself Possibly such were confounded with 
 malignant tumors. 
 
 Cholesteatoma has its most common origin in the 
 antrum mastoideum.^ 
 
 Epithelial cancer can occur primarily in the mastoid 
 process, beginning with darting pains and a red, ex- 
 tremely hard swelling of the mastoid. After incision 
 or spontaneous rupture a foul ulcer is formed which 
 
 1 Lehrhuch, S. 593. ^ pr^v/e p. 23. 
 
THE INNER EAR. — AUDITORY NERVE. 151 
 
 rapidly becomes deep and gives rise to frequently 
 recurring hemorrhages. After some months the hard 
 infiltration of the neighboring lymph-glands extends 
 to the lymph glands in the parotid which lie in front 
 of the auricle. 
 
 THE INNER EAR. — AUDITORY NERVE. 
 
 T. C. Miirer, De Causis Cophoseos Surdo-Mutorum Indagata Difficili- 
 bus. Comment, brevis Sectionibus Cadaverum ut Plurimum Illustrata. 
 C. tab. lithogr. HaffnisE, 1825. Saissy, Essai surles Maladies de I'Oreille 
 Interne, 1827. Translated by FiVs/er. Ilmenau, 1829. (Deals chiefly with 
 Diseases of the Middle Ear.) Plainer, De Auribus Defectivis. Diss. 
 Inaug. Anat. Pathol. Marburg, 1838 (with illustrations). Bochdaleck, 
 Einige Patholog. Anatomische Untersuehungen der Gehbr. and Sprach- 
 werkzeuge von Taubstummen, als Beitrag zur Pathologie des Gehbrsinns, 
 1839. (Abdruck in S'cAma/z, Beitrage. Heft 2. S. 124-156.) Toijnbee, De- 
 scriptive Catalogue, etc. London, 1857. p. 75. Meniere, Gazette Med- 
 icale de Paris. 1861. p. 598. VoUolini, Virchow's Archiv. XXII. 1, 
 2. Die Krankheiten des Labyrinths und des Gehbrnerven. (Abhand- 
 hingen der Schlesischen Gesellschaft. Naturw.-nied. Abth. 1862. Heft 
 1.) Michel, Memoires sur les Anomalies Congenitales de I'Oreille 
 Interne. Gaz. Med. de Strassbourg, 1863. No. 4. Samuel Moos, 
 Plbtzliche Taubheit. Wiener Med. Wochenschrift, 1863. Nos. 41-43. 
 Politzer, A. i. O. H. S. 86. Ueber Liision des Labyrinthes. 1867. Hin- 
 ton. Observations on some of the Affections classed as Nervous Deaf- 
 ness. Guy's Hosp. Reports, XIIL p. 152. 1868. Voholini, Kopfver- 
 letzung; vollstiindige Taubheit. Autopsie. M. f. O. 1869. S. 109. 
 Gruber, Lehrbuch der Ohrenheilkunde 1870. S. 613-621. A. BiHtcher, 
 tJeber die Veranderungen des Labyrinths, etc., in einem Fall von 
 Fibrosarcom des Nerv. Acusticus. Archiv. f. A. u. O. Bd. 11. 2 Abth. 
 See also A. f. O. VL S. 279. 1871. S. Moos, Archiv. f. A. u. O. XL 
 S. 24 ; in. S. 84 ; Y. S. 245. Yirchow's Archiv. Bd. 69. Heft. 2, S. 
 313, 1877. 
 
 Primary diseases of the ultimate structures of the acoustic nerve, 
 and of the osseous capsule of the labyrinth, appear to be very much 
 less common than diseases of the middle ear. "Whether this is in 
 reality the fact, or whether this iufrequency is only specious on ac- 
 count of the concealed position and difficulty of examination of 
 these structures, must remain for further investigation.^ 
 
 1 Deiters (JJntersuchungen iiber die Lamina Spiralis Memhranacca, 
 
152 PATHOLOGY OF THE EAR. 
 
 Secondary disturbances in tlie circulation and nutrition of the 
 labyrintli during disease of tlie middle ear, and of the brain, have 
 been often recognized. The theory that the nutrition of the laby- 
 rinth is supported only by the exclusive vascular system of the 
 arteria auditiva interna,-^ a theory which was used to explain the ap- 
 parent infrequency of pathological changes in the labyrinth, has been 
 rendered doubtful by the recent discovery of a direct connection 
 between the vascular system of the middle ear, and that of the laby- 
 rinth through the inner wall of the tympanum. From the exami- 
 nation of cross-sections through the jaromontory, Politzer ^ claims to 
 have satisfied himself of such a direct vascular connection between 
 the tympanum and labyrinth. Further confirmation of this fact, so 
 far as it relates to a connection between the vascular systems other 
 than through the capillaries, is yet wanting. 
 
 lienle classifies the labyrinth of the ear under the pseudo-lymph 
 spaces. According to Hasse, the endolymphatic cavity is in con- 
 nection through the aqujeductus vestibuli (ductus endolymphaticus), 
 with the liquor cerebralis, while the perilymphatic cavity is appar- 
 entlv in connection through the aquteductus cochleae (ductus peri- 
 lymphaticus), with the jugular lymph-system. Schwalbe,^ on the 
 coutrarv, saw the space between the osseous and membranous laby- 
 rinth fill itself fi-om the subarachnoid cavity through the porus acus- 
 ticus internus. 
 
 The vena? auditivce interme, which pass through the porus acus- 
 ticus internus with the arteria auditiva interna, and the nervus 
 acusticus, empties its blood into the lower end of the sinus petrosus 
 inferior or of the sinus lateralis. The vein contained in the aquce- 
 ductus vestibuli, which is composed of branches from the semicir- 
 cular canals, empties into the sinus petrosus superior, either directly 
 or through the interposition of a vena meningea media (Henle). 
 
 Bonn, 1860) says, p. 11 : "That he very often found changes in the 
 lamina spiralis membranacea, namely, fatty degeneration, in individuals 
 otherwise healthy, and that in man it is only exceptionally that a per- 
 fectly normal specimen comes under observation." 
 
 1 Hyrtl found on injection of the arteria auditiva interna and menin- 
 gea media with different colored waters, that the labyrinth only assumed 
 the color used in the arteria auditiva, and tliat the rest of the temporal 
 bone assumed the color used in the arteria meningea media {Vide 
 Henle, Geffisslelire. Brnunschweig, 1876, S. 217). 
 
 2 A. F.O., xi., S. 237. ^ Med. Centralblatt, 1869, No. 30. 
 
THE INNER EAR.— AUDITORY NERVE. 153 
 
 The nervus acusticus arises in the medulla oblongata by two 
 roots, one of which comes from ganglion cells on the floor of the 
 fourth ventricle (the central acoustic nucleus, Stieda), the other 
 arises with very thick fibres from the large-celled ganglion nucleus 
 in the crus cerebelli ad medullam oblongatam (the lateral acoustic 
 nucleus). This latter root just beyond its exit from the medulla has 
 a small ganglion. The two roots unite soon into a common trunk. 
 The course of the acoustic fibres in the cerebellum is not known ; 
 according to Meyuert the fibres of the roots of the acusticus cross 
 each other. 
 
 The membranous tissues of the labyrinth retain their forms longer 
 and better after death than is generally supposed.^ For their preser- 
 vation, or for preparing them for microscopic examination, the follow- 
 ing methods are used : — 
 
 (1.) Immersion in absolute alcohol after previous softening of the 
 bone in dilute muriatic acid (Henle). 
 
 (2.) Immersion in chromic acid and potass chromate, Midler's 
 fluid. 
 
 (3.) Immersion in a solution of a substance which itself becomes 
 hard ; according to Boettcher glue, according to Loewenberg con- 
 centrated solution of gum arabie, according to Klebs glue and glyc- 
 erine in equal parts. 
 
 For the anatomical recognition of atrophy of the nerve fibres in 
 the ultimate nervous apparatus the reaction with gold chloride is 
 used. 
 
 For the examination of the cochlea, Waldeyer - gives the follow- 
 ing method of preparation : '' After opening the osseous covering at 
 several spots the cochlea should be laid for twenty-four hours in a 
 large quantity of a solution of palladium chloride (0.001 per cent.) 
 or of perosmic acid (0.2-1 per cent.). It should then be placed in 
 absolute alcohol for twenty hours ; then decalcified by a mixture of 
 a solution of palladium chloride (0.001 per cent.) with one tenth 
 part of a solution of muriatic or chromic acid (^ - 1 per cent.). After 
 decalcification the preparation should be again laid in absolute alco- 
 hol." 
 
 CochleiB which have been hardened in Miiller's fluid can also be 
 decalcified with advantage after the manner of Waldeyer (Steud- 
 ener.) 
 
 1 Boettcher, A. f. A. und 0. - Strieker's Handbuck, ii., S. 958. 
 
154 PATHOLOGY OF THE EAR. 
 
 Malformations. In aclclition to the literature of this 
 subject, mentioned under malformations of the ear in 
 general, the following works treat speciallj^ of mal- 
 formations of the inner ear. 
 
 ]\Iundbn, Anatomia Surdinati. S. 422. De Labyrinth! Auris Content. 
 P\,oeilerer, Descript. Foetus Paras., in Comment. Societ. Goetting. IV. 
 Meckel, Handbuch der Patholog. Anatomie. Bd. I. /. G. Midler, An- 
 nalen fiir Ges. Heilkunde. 1832. (Dissections of the ears of some deaf- 
 mutes.) Ed. Cock, Med.-chir. Transactions. Vol. XIX. 1837. Thur- 
 nam, Ibid. Nuhn, Dissert, de Vitiis, quae Surdo-mutitati subesse solerit. 
 Heidelbei-g, 1841. Michel, Mittheilung an die Franzosische Akademie. 
 1855. Helie (Nantes), Archiv. Gener. de Med. XII. 485. BuM and 
 Hohrich, Beitrag zur Entwicklungsgeschichte des Inneren Obres, ent- 
 nommen aus Missbildungen desselben. Zeitschrift fur Biologie. 1867. 
 Schwartze, A. f. O. V. S. 296. 1870. VoltoUni, Monatschrift f. O. 
 1870. No. 9. Section des Gehororgans eines Hemiccphalus. 
 
 The whole laljjrinth may be wanting^ or it may be 
 imperfectly developed. In the latter case certain parts 
 may be wanting, as the semicircular canals^ or the 
 cochlea ; or certain parts may be rudimentary ^ only ; 
 or again the whole labyrinth may form a single cav- 
 ity or curved canal without communication with the 
 tympanum .* 
 
 Dissimilarity in the size and shape of separate por- 
 tions of the labyrinths of different individuals is very 
 
 1 Saissy, Uebersetzung, S. 173. External ear, drum-membrane and 
 Eustachian tube normally formed ; tympanum full of mucus. Ossicula, 
 labyrinthine fenestra and all parts of the labyrinth were wanting. 
 
 - Miirer, /. c. Tympanum, vestibule and cochlea normal ; only the 
 first portions of the semi-circular canals present ; at the position where 
 they should have been was spongy bone. Several cases by Bochdalek, 
 (1. c. Fall 3, 4, 6). Voltolini (Virchoic'.f Archiv, xxvii.), and others. 
 My own observation in 1867, in a child with rachitis and premature 
 synostosis of the skull. 
 
 3 Cochlea with 1^-2 spirals, without modiolus or lamina spiralis ; the 
 semi-circular canals widened or narrowed, in their middle portions im- 
 passable or ending in a blind cul de sac. 
 
 * Roederer, Saissy. 
 
THE INNER EAR. — AUDITORY NERVE. 155 
 
 common, but the sliajDe on the two sides of the same 
 individual is always the same, as was asserted by 
 Meckel and confirmed by Claudius. 
 
 In one case in which there was a normal develop- 
 ment of the external and middle ears I found an ab- 
 sence of the osseous and membranous labyrinths on 
 both sides, that is, the cochleae, vestibules, and semi- 
 circular canals w^ere all wanting. The trunk of the 
 nervus acusticus ended just beyond its subdivision in 
 a neuroma-like swellino; within the bone and was in 
 part adherent to the base of the normally movable 
 stapes. Microscopic examination of these neurama- 
 tous swellings showed small nerve fibres crossing each 
 other in different directions and betw^een these fibres 
 a small amount of loose connective tissue. The pos- 
 sibility of a malformation being confined to the laby- 
 rinth is recognized from a consideration of the devel- 
 opment of this organ, for the labyrinth is developed 
 from the lal)yrinthine-vesicle in the region of the cer- 
 ebellum while the middle ear and external meatus are 
 formed from the first branchial cleft and the ossicula 
 from the first and second branchial plates. The au- 
 ditory nerve which eventually unites the brain and 
 the labyrinthine vesicle is developed independently. 
 
 Congenital Absence of the auditory nerve is ex- 
 tremely rare and is never found except with absence 
 of the labyrinth. The earlier the arrest of develop- 
 ment takes place the smaller is the meatus auditorius 
 internus found to be. 
 
 Anaemia of the labyrinth, the anatomical recognition 
 of which is very difficult, has been assumed to be the 
 cause of disturbances of function in the ear which fol- 
 low very depleting diseases and which are also seen 
 
156 PATHOLOGY OF THE EAR. 
 
 in general anemia without other pathological changes ; 
 but it is still doubtful whether these aural symptoms 
 cannot be referred w^ith equal justice to changes in the 
 intracranial circulation and a consequent imperfect 
 perceptive power in the central organ, the brain. 
 Anaemia certainly results from contraction (endarte- 
 ritis chronica^) and embolus of the arteria auditiva in- 
 terna, a branch of the arteria basilaris, and also from 
 aneurism of the arteria basilaris and carotis. An em- 
 bolus of the basilaris was found on dissection by Prof. 
 Friedreich of Heidelberg to be the cause of a sudden 
 deafness in one case. 
 
 Hypersemia in the labyrinth, of various degrees of 
 intensity, from a net-like injection to a diffuse red- 
 ness, confined to certain parts, as the vestibule ^ and 
 cochlea,^ or equally distributed in all parts occurs, — 
 
 (1.) In some febrile general diseases, as typhus, 
 puerperal fever, acute tuberculosis, and also with 
 poisoning from carbonic oxide gas. 
 
 (2.) With acute and chronic inflammations of the 
 tympanum. 
 
 (3.) With intracranial hyperoemias and conges- 
 tions (meningitis), and with fractures of the skull. 
 
 (4.) As a passive hyperaemia in disturbances of the 
 circulation, with disease of the heart and emphysema 
 of the lungs, from pressure on the veins of the neck 
 by tumors, especially those arising from scrofula, and 
 from the lymph-glands, from pressure by tumors on 
 the brain-sinuses which receive the venous blood of 
 
 1 Whether the endarteritis luetica of the arteries of the brain, described 
 by Heubner, also occurs on the arteria auditiva interna, I do not know. 
 
 - Hinton, Supplement to Toi/nbee^s Diseases of the Ear, p. 4G1 (in 
 hereditary Syphilis). 
 
 3 Toynbee, Catalogue, No. 512 (in constitutional Syphilis). 
 
THE INNER EAR. — AUDITORY NERVE. 157 
 
 the labyrinth, from thrombus and phlebitis of the 
 sinus petrosus superior. 
 
 (5.) As the result of disturbances in the vaso-motor 
 innervation in hysterical persons. 
 
 Hyperasmia of the labyrinth is most commonly de- 
 scribed in connection with inflammatory affections of 
 the tympanum.^ From my own anatomical inves- 
 tigations, I must add, however, that even with the 
 most acute inflammations of the tymjDanum, a simul- 
 taneous hyperoemia of the labyrinth was met with 
 only exceptionally. 
 
 Hemorrhage. Eccliymoses in the membranous tis- 
 sues of the labyrinth are found with hypergemias 
 in typhus, acute tuberculosis, and variola. Hemor- 
 rhages'^ into the labyrinthine cavity and the mem- 
 branous labyrinth occur with fractures of the petrous 
 bone, with severe contusions of the skull without 
 fracture,^ with atheroma of the arteries, with heart 
 and kidney affections, with acute tuberculosis, typhus, 
 scarlet-fever, measles, and, according to Toynbee, with 
 mumps and arthritis. The extravasations produced 
 by fractures may become jDurulent, and from the 
 evacuation of the pus through the porus acusticus 
 internus may set up a basilar meningitis.* Deposits 
 of pigment can be regarded as pathological only when 
 very marked. In adults, a slight amount of pigment 
 
 ^ Hinton alone, I. c, found it foi'ty-one times. 
 
 2 Toynbee, Catalogue, cases 711, 738, 752. 
 
 8 Moos {A. f. A. and 0., Bd. ii., S. 24) found in a gun-shot fracture 
 of the mastoid and external meatus, together with purulent catarrh of 
 the middle ear, and perforation and synechiaj of the drum-membrane, 
 an effusion of blood in the membranous labyrinth, and a hemorrhagic 
 infiltration of the perineurilemma of the nerves which lie in the lamina 
 spiralis ossea. There was total deafness. 
 
 4 Politzer, A. f. 0., ii., S. 88. 
 
158 PATHOLOGY OF THE EAR. 
 
 is SO often seen on the different parts of the laby- 
 rinthine tissues/ especially in the cochlea, in cases in 
 Avhich it was well known there were no disturbances 
 of function, that it is possibl}' a normal condition. 
 
 Inflammation and its Results. The existence of an in- 
 dependent and primary, non-traumatic inflammation 
 of the membranous labyrinth had not yet been demon- 
 strated anatomically wdth certainty.^ In regard to the 
 case of Meniere, described as a primary inflammation, 
 '• exsudation sanguine," in the semicircular canals and 
 vestibule, it is doubtful whether it was anything more 
 than a simple hemorrhage. Death is very rare dur- 
 ing recent inflammations of the labyrinth, and from 
 an accident only is it possible to clear up this doubt 
 anatomically. 
 
 The following case was under my observation dur- 
 ing the summer of 1877, and afterwards came to dis- 
 section. It places the existence of a 'priraary acute 
 'purulent inflammation of the labyrinth without sup- 
 puration of the middle ear beyond all doubt. 
 
 A woman, tliirtj-tbree years old, of delicate constitution, had 
 aborted on account of constitutional syphilis, passed through a 
 course of inunction, and remained anaemic afterwards. For some 
 weeks she complained of headache on the right side, then of pain 
 in the ear, dizziness, staggering gait, violent subjective noises, and 
 frequent vomiting. Objectively there was hyperfemia of the right 
 drum-membrane. On account of increasing pain in the ear para- 
 centesis of the right drum-membrane was performed without evacu- 
 
 1 Koelliker, Gewehelehre (1852), §§ 234, 235. Lucae, Virchow's Archiv, 
 Bd. 29, S. 10. 
 
 2 According to Heidenreicli (Canstatt's JahresbericJit , 1846), the ex- 
 istence of an independent acute inflammation of the labyrinth was found 
 on dissection by Biechy and Batissier (Revue des Special, etc., Me'd.- 
 chiriirg. Juillet. Revue Med., S. 587). The original article was not at my 
 command. 
 
THE INNER EAR. — AUDITORY NERVE. 159 
 
 ating any pus. For some clays there was improvement, then an 
 increase in the pain in the head came on with a rapid rise in the 
 temperature to 40.5 Centigrade, and the usual symptoms of acute 
 meningitis purulenta. 
 
 The autopsy showed diffuse purulent meningitis of the base and 
 convexity ; no caries of the temporal bone, no purulent deposit on 
 the nerve trunks in the porus acusticus internus. The drum-mem- 
 brane was not perforated, the puncture having healed ; the tympanic 
 mucous membrane was a little thickened, the tympanum free from 
 pus and of normal appearance. In the labyrinth — cochlea, vesti- 
 bule, and semicircular canals — was a sero-purulent fluid, of milky 
 appearance, which, under the microscope, showed nothing but ftitty 
 pus cells. The vessels of the semicircular canals were tensely filled 
 and tortuous, those of the ampullns showed the same conditions in a 
 more marked degree, and in certain spots small extravasations were 
 seen. The utriculus and sacculus were much swollen and infiltrated 
 by blood and pus. The course of the labyrinthine suppuration into 
 the cranium could not be recognized. Aside from moderate enlarge- 
 ment of the spleen, all the organs, both of the chest and abdomen, 
 were free from changes which could have any bearing on the fatal 
 disease. 
 
 From clinical observation it is probable that an 
 acute primary and independent inflammation of the 
 inner ear occurs not infrequently, and Voltolini ^ con- 
 siders that in childhood there is a special predisposi- 
 tion to this inflammation. 
 
 Secondary imflammations of the labyrinth are found 
 with diseases of the middle ear, preferably purulent 
 catarrhs and caries, and with diseases of the brain. 
 The most common iivQimrulent inflammation, the whole 
 labyrinthine cavity being filled with pus and the 
 membranous structures destroyed, while at the same 
 time purulent inflammation or hypero^mia of the tym- 
 panum exists.^ The extension of a purulent process 
 
 1 M. f. 0., 1867, S. 9-14 ; 1868, S. 91 ; 1870, S. 91, 103. 
 
 2 Saissy, 1. c, Uebersetzung, S. 175. Lucae, A./. O., v., S. 190. 
 
160 PATHOLOGY OF THE EAR. 
 
 from the middle ear to the labyrinth takes place most 
 easily through the labyrinthine fenestras, the mem- 
 branes of which often become perforated, or through 
 a fistula in the labj'rinthine wall of the tympanum. 
 The labyrinth cavity has, however, been found filled 
 with pus, without the existence of this direct commu- 
 nication with the tympanum, by Viricel,^ Heller,^ and 
 Lucae,'^ in cases of cerebro-spinal meningitis. Heller 
 is inclined to consider the inflammation of the laby- 
 rinth as an extension of the meningitis (neuritis de- 
 scendens) along the course of the neurilemma of the 
 acoustic nerve on account of the hj^oergeraia, and 
 ecchymoses in that tissue, and the pus cells between 
 the nerve fibres. An extension of the suppuration in 
 the opposite direction, that is, towards the base of the 
 skull along the neurilemma of the acusticus, does not 
 always result from suppuration of the labyrinth, as 
 the pus may become inspissated, caseous, and remain 
 a long time in the labyrinth without injury. This is 
 shown by many cases of caries, and also by old obser- 
 vations in deaf-mutes.* In other cases the suppura- 
 tion of the labyrinth produces necrosis of that organ. 
 In a case of caries of the labyrinth-wall in a tubercu- 
 lous subject, which had healed, Wendt° found not only 
 detritus in the labyrinth, but a closure of the inner 
 meatus by connective tissue, which afforded a natural 
 protection against the extension of the suppuration 
 towards the base of the brain. The nerve trunks in 
 the inner meatus were not destroyed. 
 
 1 Quoted by Saissy, S. 175. 
 
 2 HeWer, Deittsches Archiv fur KtiniscJie Medicin, 1867, Band iii., S. 
 482. 
 
 3 A./. 0., v., S. 188. 
 
 * Memoirs of the Medi'-nl Society of London j vol. iii., S. 1. 
 5 Case 34-4 a, of his collection of anatomical preparations. 
 
THE INNER EAR. — AUDITORY NERVE. 161 
 
 In its lighter forms the inflammation of the laby- 
 rinth does not go on to suppuration, but onh' produces 
 a small cell infiltration, that is, an infiltration of lym- 
 phoid corpuscles, in the membranous labyrinth, such 
 as Moos ^ has described in cases of caries of the tem- 
 poral bone, and of typhus, variola, and scarlet fever 
 associated with inflanmiation of the tympanum. 
 
 That disturbances of nutrition in the ultimate nerve- 
 apparatus of the labyrinth, takes place from the con- 
 tinuous intralabyrinthine pressure which must neces- 
 sarily result from many diseases of the middle ear, is 
 highly probable. The anatomical proofs of this are 
 however as yet very few. 
 
 As the results and remains of chronic inflammation, 
 the following changes have been seen and described : 
 swelling, thickening and atrophy of the membranous 
 labyrinth, fatty degeneration of Corti's organ,^ con- 
 nective-tissue growths on the saccule and utricle of 
 the vestibule," growths of connective tissue from the 
 osseous to the membranous labyrinth, filling of the 
 labyrinthine cavity with a thick, yellowish- white mass 
 resembling detritus or with a reddish soft mass of 
 tissue, calcifications, ossifications,* and hyperostoses, 
 collections of pigment and cholesterine, and changes 
 in the labyrinth water which is found hemorrhagic,^ 
 jelly-like,^ opaque, diminished and increased. Also 
 
 1 Moos, A./. A. und 0.. iii., 1, S. 84; Ibid., v., S. 245 and 246. 
 
 2 Moos, vide A./. O., ix., S. 298, 299. 
 
 3 Schwartze, A./. 0., iv., S. 245. 
 
 * Hinton describes an ossification of the saccule. Moos (Af. 0., ix., 
 S. 276, Fall 8,) found with anchylosis of the ossicula in secondary syph- 
 ilis a deposition of lime concretions on the saccules of the vestibule and 
 on the semicircular canals. 
 
 5 Gruber, Lehrluch, S. 617, note. 
 
 6 Otto, /. c. 
 
 11 
 
162 PATHOLOGY OF THE EAR. 
 
 the abnormal increase or diminution of the Hme crys- 
 tals, otoliths, in the semicircular canals and the sacs 
 of the vestibule, have been referred to inflammatory 
 processes.^ 
 
 The use of these lime-crystals and the corpora amylacea, which 
 are often present in large numbers, is unexplained, and at least they 
 should not be used to account for marked disturbances of function. 
 Lucae ^ found masses of fat and lime in the ampuUsE and vestibular 
 sacs in a case of acute purulent inflammation of the inner ear with 
 meningitis epidemica, where good hearing existed before the fiital 
 disease. In another case Lucae ^ found the membranous semicircu- 
 lar canals completely filled with lime-crystals where there had been 
 no inflammation in the ear. 
 
 Voltolini ^ is of the opinion that not only the increase of the oto- 
 liths may be the result of a "perverted nervous influence" (namely, 
 in inflammatory conditions of the inner ear, as caries) but that abnor- 
 mal forms of these crystals may also be produced by these same in- 
 fluences. Usually these crystals are hexagonal columns truncated at 
 the ends, but Krause ^ has seen them octohedral, and Voltolini pris- 
 matic in form. 
 
 Caries and Necrosis. 
 
 Literature, of Necrosis of the Labyrinth. Wilde, Pract. Bomerkiingen, 
 etc., Uebersetzung. S. 432. Meniere, Gaz. Med. de Paris, 1857, No. 50. 
 Fon rroe//sc/i,Virch. Arch. XVII. S. 47. Toynbee, k. i. O. L S. 112, 
 with a supplement at S. 158. Gruber, AUgem. Wiener Med. Ztg. IX. 
 41-45. Voltolini, M.i.O. IV. S. 85. Sclucartze, A. i. O. IX. S. 238. 
 Boeters, Inaugural-Dissertation, Halle, 1875. Dennert, A. f. O. X. S. 
 231. Lucae, Ibid. S. 236. 
 
 In very exceptional cases a caries, confined to the 
 labyrinth without the other portions of the temporal 
 bone showing any sign of the disease, is found. An 
 
 ^ Papponheiin and Voltolini. 
 
 2 A.f. O., v., S. 189. 
 
 8 Virchotv's Archiv, xxix., S. 44. 
 
 * Ibid., xxii., S. 126. 
 
 s Bock's Anatomie, 2 Aufl., ii., S. 217. 
 
THE INNER EAR. — AUDITORY NERVE. 163 
 
 old observation of this disease with a figure is given 
 by Platner,^ who found a carious opening in the wall 
 of the posterior semicircular canal in an ear otherwise 
 healthy. From carious destruction of the osseous 
 capsule of the labyrinth at any spot an incurable deaf- 
 ness results, owing to the loss of the labyrinth water 
 and destruction of the ultimate nervous apparatus. 
 
 Necrosis confined to the labyrinth is more common, 
 and is seen in different stages from the line of begin- 
 ning demarcation to the complete separation and dis- 
 charge of the diseased bone. Childhood seems to be 
 specially predisposed to this. 
 
 Cases of necrotic separation of the cochlea, either 
 alone or wath the contiguous parts of the semi-circu- 
 lar canals, have been described most frequently. In 
 other less common cases, the necrosis affects the 
 whole labyrinth, so that the entire pyramid including 
 the cochlea, vestibule, and semicircular canals, is sep- 
 arated from its attachments, and its removal is not 
 inconsistent w^ith life, provided that the process of 
 demarcation has not already produced a fatal disease 
 of the meninges of the brain. The first case of this 
 kind was published by Wilde. 
 
 The usual course which a sequestrum of this kind 
 takes, is through the labyrinth wall of the tympanum, 
 into that cavity, and from there into the meatus. 
 
 Niemetschek, in Prague, has observed one case 
 where the necrotic labyrinth was throwai off through 
 the nose. 
 
 A beginning necrosis of the labyrinth can be rec- 
 ognized by the very decided white color of the bone 
 at the affected spot, and by the line of demarcation 
 
 1 Given in Schmalz, Beitrage, i., S. 175. 
 
164 
 
 PATHOLOGY OF THE EAR. 
 
 surrounding this ^pot. Along this line of demarca- 
 tion the bone is softened, or already at certain spots 
 separated. Later on in the process, a new growth 
 of bone is seen near this line. The relative frequency 
 
 Fig. 65. 
 
 Necrosed Cochlea discharged during life. 
 
 Fig. a shows a completely separated sequestrum including the cochlea, from the 
 pyramid of a child two and one half year's old, which died from tubercular menin- 
 gitis. It is magnified three times, and shows the sequestrum when looked at from 
 the upper surface. The upper half of the illustration shows the first spiral of the 
 cochlea, which on the right passes into the second spiral. On the left of the illus- 
 tration a remnant of compact osseous substance is recognized, which belonged to the 
 anterior wall of the petrous bone above the canalis caroticus. On the edge of tlie 
 posterior side of the preparation, a trace of the meatus auditorius internus remains. 
 The carotid artery and jugular vein were uninjured. 
 
 Fig. b shows the necrosed cochlea of a man thirty -eight years old. The modio- 
 lus with its base turned towards the meatus auditorius internus can be seen; from 
 this a layer of bone projects which corresponds to the inner wall of the first and the 
 outer wall of the second spiral of the cochlea. The lamina spiralis ossea can be 
 traced in tlie preparation for nearly one and a half spirals. In this case complete 
 recovery took place, leaving total deafness of this ear, and dizziness on violent 
 movement. There was no facial paralysis. 
 
 Fig. c shows two views of a necrosed cochlea with the whole modiolus, thrown 
 off during life by a young woman; one view is taken from the apex, ami the other 
 from the side. The formation of the lamina spiralis ossea, is perfectly retained. 
 Magnified three times. 
 
 of circumscribed necrosis of the labyrinth is ex- 
 plained b}^ the separate development, separate nutri- 
 tion, and very early ossification of this part. It is, 
 in most cases, caused by a caries of the spongy por- 
 
THE INNER EAR. — AUDITORY NERVE. 165 
 
 tion of the pyramid which surrounds the compact 
 bone of the labyrinth, or else it is caused by the peri- 
 ostitis purulenta within the labyrinth which, as we 
 have seen, results from suppuration of the tympanum. 
 In the very rare cases which run an acute course, 
 and are not preceded by a long otorrhoea, the cause of 
 the necrosis is perhaps an embolus of the arteria au- 
 dit! va interna. 
 
 New Growths in the Labyrinth. New growths of con- 
 nective tissue have been already described under 
 inflammation. Exostoses have been several times 
 found in the vestibule, three times by Toynbee, and 
 an old case of this kind is described by Platner.^ In 
 the cupola of the cochlea, Voltolini ^ found a " fibro- 
 muscular " tumor. A doubtful granulation-like sar- 
 coma in the vestibule was described by me.^ 
 
 In the vestibule, and almost filling that cavity, lay a mass of tis- 
 sue of a dark-red color ; this could be picked to pieces with the 
 greatest difficulty, and showed under the microscope very numerous 
 blood-vessels laying in a tissue composed, for the most part, of small, 
 generally round or oval cells, and a small amount of fibrous inter- 
 mediate substance. There was no pus in the vestibule ; its osseous 
 walls were healthy, except a spot of caries the size of a pea, on the 
 lower wall in the centre of the otherwise healthy pars petrosa. 
 
 Whether cholesteatoma occurs primarily in the laby- 
 rinth, is doubtful. Boettcher suspects it may arise 
 from the epithelium of the aquasductus vestibuli. A 
 cholesteatoma arising from the tympanum can extend 
 to the labyrinth secondarily. 
 
 In the membranous semicircular canals, small elevations, papilla, 
 of the pavement epithelium on the basal membrane, occur, which 
 
 1 De Auribus Defectivis, Diss. Inaug., Marbui'g, 1838, with an illustration. 
 
 2 Virchow's ArcJiiv, xxii., 1, 2. 
 
 3 yl. /. 0, ii., S. 285. 
 
166 PATHOLOGY OF THE EAR. 
 
 are considered by Lucae ^ to be pathological formations, but by Ru- 
 dinger,^ are described as normal villi of these canals. Recently 
 they have been considered normal by Utz^ also, on account of their 
 constant existence and their regular arrangement and development. 
 In new-born children these prominences do not exist. 
 
 Tuberculosis of the inner ear (cochlea and semi- 
 circular canals), an extension of the same disease 
 from the tympanum, occurs frequently in pigs, ac- 
 cording to Schlitz.* The growth may extend from 
 the labyrinth into the connective tissue of the nervus 
 acusticus, and thus reach the meatus internus and the 
 cranial cavity. 
 
 Injuries. The labyrinth is so protected by its sit- 
 uation and its osseous capsule, that direct injuries 
 reach it only in very rare cases ; indirect injuries, on 
 the contrary, are common in fractures of the skull, 
 which extend through the petrous bone, producing 
 effusion of blood and laceration of the membranous 
 labyrinth. Direct injuries from the penetration of 
 needles or other sharp substances into the inner ear, 
 with penetration of the labyrinth wall, fracture of 
 the stapes, and laceration of the soft parts of the ves- 
 tibule, have been reported in very small numbers. A 
 case of this kind will be found in the " Gazette des 
 Hopitaux," 1857, No. 130 with the autopsy, which 
 showed an extravasation of blood on the petrous 
 bone, and purulent meningitis. In a dog a spike of 
 grass was once found which, entering the meatus 
 and tympanum, penetrated to the cochlea. Lesions of 
 
 1 Virchotv's Arcliiv, xxvii., S. 169. 
 
 2 A. f. 0., ii., 1867. 
 
 * Beitrage zur Histologie der Hdutigen Bogengdnge, etc., Miinchen, 
 1875. 
 « Virchotv's Archiv, Bd. 66, S. 93. 
 
THE INNER EAR. — AUDITORY NERVE. 167 
 
 the inner ear, with fatal result, are more commonly 
 caused by the pouring into the meatus of concentrated 
 mineral acids, or of molten metal, with a criminal 
 intent.^ 
 
 With fissures in the pars petrosa which pass through 
 the inner ear, there is a discharge of serous fluid from 
 the meatus if the membrana tympani has been in- 
 jured, or if the fissure has extended to the walls of 
 the meatus. It has already been remarked, on page 
 20, that this injury is not necessarily fiital. In all 
 cases, however, absolute deafness results, and if the 
 fissure extends through both petrous bones, as some- 
 times occurs, the deafness is bilateral. 
 
 Diseasesof the Auditory Nerve. Congenital absence of 
 the auditory nerve beginning at its point of entrance 
 into the petrous bone has only been noticed with 
 simultaneous absence of the labyrinth. Acquired 
 loss of the branches of the auditory nerve may result 
 from inflammation and from new growths. 
 
 Hypercumia of the neurdemma is seen as a post- 
 mortem change, but it also occurs with neuritis.^ 
 
 Old and recent apoplexies in and around the trunk 
 of the nerve have been observed after injuries, and 
 also in connection with fatty degeneration of Corti's 
 organ (Moos). 
 
 Atro'pliy as a secondary process in the nerve trunk 
 or its branches is only known to take place from dis- 
 ease of the parts of the brain from which the nerve 
 originates, cerebellum, fourth ventricle, medulla ob- 
 
 ^ Osiander, XJeber den Selbxtmord, S. 395, narrates the case of an 
 Englishwoman who killed six husbands, one after another, by i)ouring 
 molten lead into the ears when, they were asleep. 
 
 2 Compare p. 168. 
 
168 PATHOLOGY OF THE EAR. 
 
 loiigata ; from hydrocephalus internus, from apoplexy 
 and softening of the brain, or from atrophy of those 
 parts to which it is distributed, i. e. the ultimate nerv- 
 ous apparatus.^ Atrophy from this latter cause ap- 
 pears to be developed often from the loss of function 
 of the peripheral conducting apparatus. It is also 
 caused by the pressure of tumors at the base of the 
 skull, by tumors of the brain, by extravasations of 
 blood in the porus acusticus internus, by periostitis 
 of the porus acusticus,^ and by neuritis. 
 
 According to Erb ^ atrophy of the acusticus now 
 and then occurs with tabes. I myself have never seen 
 such a case. Whether the disturbances in the nervus 
 acusticus,*^ which were observed by Duchenne and 
 Bourdon, were dependent on the extension of the 
 pathological process to the base of the skull, was not 
 decided. Lucae, who alone has reported accurate dis- 
 sections of the ear in cases of gray degeneration of 
 the spinal cord with deafness, says that he found no 
 disease in the acusticus.^ 
 
 From long-continued loss of function in the periph- 
 eral apparatus, especially from anchylosis of the stapes 
 
 1 According to O. Weber (Pitha ami Billroth, i., S. 344), when the 
 inner ear has been destroyed the acusticus does not show atrophy, but, 
 as a rule, fatty degeneration, which may extend even into the parts of 
 the nerve within the brain. 
 
 2 According to Beck (Krankheiien des Gehororgona, S. 120, 124), this 
 was observed by Soemmering. Toynbee, Catalogue, 791, 792. Zeissl, 
 Constitutionelle Syphilis, Erlangen, 1864, S. 297. A case of paralysis 
 due to compression, and of atrophy, produced by an osseous constriction 
 of the meatus auditorius internus from periostitis ossificans syphilitica. 
 Hinton, Gwfs Hospital Reports, 1867 : two cases. 
 
 3 Kranlheiten des Rilclemnarks in Ziemsscns Handhuch, xi., 2, 1 Ab- 
 theilung, S. 142. 
 
 ^ Friedreich, Degeneratice Atropine der Spinalen Hinterstrdnge, 
 6 Compare A./. 0., ii., S. 305. 
 
THE INNER EAR. — AUDITORY NERVE. 169 
 
 associated with immobility of the membrane of the 
 fenestra rotunda, is often developed a centripetal 
 progressive atrophy ; this, however, is by no means 
 a constant result. Haighton found atrophy of the 
 nerve associated with inspissated pus in the laby- 
 rinthine cavities. 
 
 Tumors may force themselves into the porus acusti- 
 cus, produce atrophy of the nerve trunk, and, in addi- 
 tion, as Boettcher^ found, may produce atrophy in the 
 nerve-fibres and ganglion cells of the ultimate nerv- 
 ous apparatus of the labyrinth, and also complete dis- 
 appearance of the inner and outer hair-cells, while all 
 the other parts of the ultimate acoustic apparatus of 
 the cochlea remain intact. Tumors may also produce 
 a very decided enlargement of the osseous canal and 
 extensive destruction in the petrous bone.'^ 
 
 Neuritis of the acusticus has been proved to exist 
 only with fissure of the petrous bone, with caries and 
 with cerebro-spinal meningitis. The nerve trunk is 
 reddened and swollen, surrounded with and infiltrated 
 by pus, and in the more advanced stages of the dis- 
 ease is softened and destroyed. 
 
 The presence of a large amount of corpora amy- 
 lacea between the nerve-fibres of the trunk of the 
 acusticus, which has been falsely designated'^ "amy- 
 loid degeneration of the acusticus," is generally to 
 be regarded as an accompaniment of atrophy of the 
 nerves.* The corpora amylacea are seen associated 
 
 1 Vide A.f. 0., vi., S. 279. 
 
 '■^ An instance of this is seen in Figure 10. 
 
 2 Voltolini, Virchotv's ArcJiiv, xviii., xx., xxii. 
 
 ^ G. Meissner, Zeitschrift fiir Rat. Med. N. F., iii., 3, 1853. Foerster, 
 Atlas (ler Path. Hlstolor/ie, 1856, Taf. xviii. The liistological details are 
 most accurately given by Schweigger-Seidel. (Virch. Arch., Bd. xxii., 
 S. 114.) 
 
170 PATHOLOGY OF THE EAR. 
 
 with nucleated cells lying in the hypertrophied in- 
 termediate-substance of the nerves, which is formed 
 of connective tissue (nucleated connective tissue, pro- 
 cesses of spindle-cells) ; the nerve fibres themselves 
 appear to have undergone fatty degeneration and to 
 have disappeared. It should be added that these cor- 
 puscles are found in variable quantities in the trunk 
 of every normal nerve. 
 
 The supposition of Hyrtl ^ that atrophy of the 
 acusticus is found in all deaf-mutes is incorrect. 
 
 Fibrous degeneration may lead to hardening of the 
 nerve so that it becomes firmer than the facialis. 
 
 New growths in the trunk of the acusticus, or its 
 branches, ramus cochleae et vestibuli, are reported as 
 follows : — 
 
 Fibromata were found by Gruber,^ especially wdth 
 caries of the temporal bone. The ganglion-like swel- 
 lings on the ramus cochlea, which were found by 
 Fleischmann ^ probably also belong to this category. 
 In a case by Leveque-Lasource,* a fibroma fourteen 
 lines in diameter occupied the meatus internus of 
 an old woman who had become gradually deaf and 
 blind. 
 
 Sarcomata are quite common on the acusticus, ac- 
 cording to Foerster.^ A case is given by Voltolini,^ 
 and by Moos.' 
 
 Neuromata. Cases are given by Virchow,^ and 
 
 1 Topogr. Anatomic, 1857, i., S. 228. 
 ^ LeJirbuch, S. 545. 
 3 Hufeland's Journal, 1840, Heft 1. 
 * Lincke, Handhuch der Ohrenh., i., S. 651. 
 5 Witrzb. Med. Zeitschrift, iii., S. 199 
 ^ Virchow's ArcJiiv, xxii., S. 125. 
 
 ■^ Compare A.f. O., ix., S. 298, with fatty metainorpliosis and partial 
 loss of Corti's organ. 
 
 s Geschwiilste, ii., S. 151, iii., S. 295. 
 
THE INNER EAR. — AUDITORY NERVE. 171 
 
 by Klebs.^ A number of the so-called neuromata of 
 the acusticus arise in reality from the neuroglia, and 
 are therefore to be referred to the gliomata.^ 
 
 Gummata of the brain or base of the skull may 
 affect the trunk of the acusticus.^ 
 
 Concretions of carbonate of lime were found by 
 Boettcher ^ on the periosteum of the porus acusticus 
 internus and also in the neurilemma, particularly in 
 persons of middle age. 
 
 Tumors of the petrous bone, which arise from the 
 dura mater, may produce compression, consequent 
 atrophy, and complete destruction of the trunk of 
 the nerve. In a child aged two years, I found a mass 
 of tubercle, the size of a pigeon's Qgg, arising from 
 the dura mater, and lying at the entrance of the 
 meatus auditorius internus, which had produced pa- 
 ralysis of the facialis and acusticus by compression : 
 there was no caries.^ 
 
 Virchow ^ figures a psammoma of the dura mater 
 as large as a mulberry, which was attached by a 
 broad base at the entrance of the meatus internus, 
 extended a short distance into the osseous canal, and 
 had produced paralysis of the facialis and acusticus 
 by compression. 
 
 Rayer' describes a case of unilateral deafness ap- 
 parently due to a syphilitic tumor as large as a pig- 
 eon's egg in the fossa of the petrous bone. 
 
 ^ Prager Vierteljahresschrift, 1877, S. 65. The tumor filled the inner 
 meatus. The facialis had completely disappeared in the tumor; the acus- 
 ticus remained distinct. 
 
 2 Virchow's Geschivulste, ii., S. 151. 3 Ibid., S. 463. 
 
 * Virchow'' s Archiv, Bd. xvii., S. 104. 
 6 A.f. 0., v., S. 296. 
 
 * Geschwiilste, ii., S. 116. 
 
 ' Gross and Lanccreaux, Ajfect. Nervi Syphil., Paris, 1861, S. 381. 
 
172 PATHOLOGY OF THE EAR. 
 
 Other iniracratiial processes, both basilar and cere- 
 bral, which may produce disease of the acusticus, are : 
 basilar meningitis,, by pressure of its exudation on the 
 oedematous, softened nerve trunk, or by cicatricial 
 contraction of the arachnoid membrane; aneurism of 
 the arteria basilaris ; ^ hydrocephalus internus ; tu- 
 mors of the brain.^ 
 
 According to Calmeil, disturbances of hearing occur 
 in one ninth of all cases of tumors of the brain. Ac- 
 cording to the tables of Ladame,^ in seventy-seven 
 cases of tumor of the cerebellum, disturbances of hear- 
 ing occurred seven times ; in twenty-six cases of tu- 
 mors of the pons they occurred seven times; in twen- 
 ty-seven cases of tumors of the middle lobes, three 
 times; on the other hand, no disturbances of hearing 
 occurred in twenty-seven cases of tumors of the ante- 
 rior lobes, in fourteen of the posterior lobes, and in 
 four of the fourth ventricle. In a number of tumors 
 of the brain unilateral disturbances of hearing were 
 the first symptoms of the disease, as has been shown 
 by Cruveilhier. Tumors of the cerebellum not infre- 
 quently produce bilateral total deafness, beginning 
 first on the side corresponding to the tumor ; and this 
 bilateral deafness may occur even in cases where a di- 
 rect pressure of the tumor on the nerve trunk of the 
 second ear or on its nucleus in the medulla oblon- 
 gata is utterly impossible, and where other symptoms 
 of paralysis of other nerves of the brain or spinal 
 cord on the second side are also wanting. Per- 
 
 ^ Toynboe, Catologue, No. 772. Griesingor, Archie fur Heilkunde, 
 1862, 6 Heft. Lebert, Berliner Kiln. Wochenschrift, 1866. 
 
 ^ An old case by Lincke, Han.dhnch der Ohrenheilkunde, i., S. G50-653. 
 
 ^ Symjitomatologie und Diagnostik der Gehingeschwiilste, Wurzburg, 
 1865. 
 
THE INNER EAR. — AUDITORY NERVE. 173 
 
 haps in such cases there exists a neuritis of the ulti- 
 mate nervous apparatus in the labyrinth, or possibly 
 only an interference of function due to fluxionary 
 oedema. 
 
 Bruckner ^ describes a case of tumor within the 
 skull where the auditory nerve trunk was completely 
 torn across by the dragging of the mass. As the re- 
 sults of fractures of the skull, a similar tearing of the 
 nervous acusticus with an intact facialis has been 
 found. 
 
 As a cause of deafness, in addition to the direct 
 compression of the nerve trunk by a tumor and com- 
 pression of the parts of the brain from which the 
 nerve arises, should be mentioned softening of the 
 brain-substance in the neighborhood of the tumor at 
 its point of insertion in the brain. It should also be 
 remembered that simultaneously with the brain dis- 
 ease, peripheral disease in the conducting apparatus 
 may occur which alone may be sufficient to account 
 for the disturbances of function. Especially, often I 
 have found anchylosis of the stapes associated with 
 atrophy of the brain (dementia paralytica), and also 
 with tumors of the brain.^ 
 
 Pathological changes in the fourth ventricle appear 
 to have much less influence in producing disturbances 
 of hearing than was formerly supposed. Thickening 
 of the ependyma, which has been spoken of as some- 
 thing of importance'^ in the dissection of deaf-mutes, 
 is very commonly found in various diseases of the 
 
 ^ Berliner Kim. Wochenschrift, 18(57, No. 29. 
 
 2 Vide A.f. 0., ii., S. 289, Fall 8. 
 
 3 H.Meyer, Zur Analomie fJer Taiibstummheit, VircTi. Arch., xiv., 5, 
 6, p. 551, 1858. Voltolini, Ibid., xxvi., S. 171, 1863. Falk, Zur Sta- 
 tistik der Taubstummen, Arcluf. Psychiatrie, iii., S. 418. 
 
174 PATHOLOGY OF THE EAR. 
 
 brain, especially in insane persons, where not the 
 slightest disturbance of hearing existed : when found 
 in deaf-mutism it can be considered only as an inci- 
 dental appearance. Tumors in the fourth ventricle 
 have been found several times without any disturb- 
 ance of the hearing having existed.^ Even complete 
 absence of the striae acusticse is not, according to 
 Engel, accompanied by deafness.^ 
 
 Disturbances of the ear are but rarely the result of 
 hemorrhages in the brain, or of encephalic collections ; 
 according to Moos they are most common with uni- 
 lateral apoplexy in the pons. Whether they may 
 also be produced temporarily by simple liypera3mia 
 of the brain and its membranes (arterial fluxion with 
 oedema or venous congestion) is, to judge from clini- 
 cal observations, certainly probable, but has, however, 
 never been recognized anatomically. As Bottcher ^ 
 has already said, very continuous and laborious work 
 is still needed in order to throw more light anatomi- 
 cally on cerebral deafness. After previous hardening 
 of the brain the whole region wdiere the central gan- 
 glia lie, from which the fibres of the acusticus arise, 
 must be successively dissected. 
 
 1 Ladame, S//mpiomatoloffie unci DkifinoMik der Himgescliwiihtc, Wiirz- 
 burg, 1865. In four tumors of the fourth ventricle no disturbance of 
 hearing. Foerster, Wiirzb. Med. Zeilschr., Bd. iii., Heft 3. Cjsticercus 
 in the fourth ventricle. Hydrocephalus intornus. 
 
 2 Wicnei- Wochensclirift, 1862, No. 60. 
 
 3 Bocttcher, Archiv f. A. u. 0., ii., 2. 
 
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