NRLF
IllihllJIIili/IJIiiiiir;
mill
llllll IIHIJ
lllllllllllll
lljllll
|ljllllWII|ill
iililliiiiliiiliiii'liijiii
IJIjlllllllllllllJIIIIIMIIIlllllll
iniMJiiiiiiiiii
{;!!l!i
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.
RETURN TO the circulation desk of any
University of California Library
or to the
NORTHERN REGIONAL LIBRARY FACILITY
BIdg. 400, Richmond Field Station
University of California
Richmond, CA 94804-4698
DAYS
ALL BOOKS MAY BE RECALLED AFTER 7
2-month loans may be renewed by calling
(510)642-6753 .
1-year loans may be recharged by bringing books
toNRLF ^ ^ ,
Renewals and recharges may be made 4 days
prior to due date
DUE AS STAMPED BELOW
7!arc^Ti9^