A Practical Treatise On The Diseases of

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A practical treatise
on the diseases of the ear
Daniel Bennett St. John Roosa

V
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LIBRARY
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1885
LEVI COOPER LANE 'FUND

TREATISE
ON THE
ANATOMY AND DISEASES OF THE EAR .

PRACTICAL TREATISE
ON THE
DISEASES OF THE EAR
THE ANATOMY OF THE ORGAN .

BY
D . B . ST. JOHN ROOSA, M .A ., M . D.,

Professor of Diseases of the Eye and Ear in the University of the City of New York ; Sur
geon to the Manhattan Eye and Ear Hospital ; Consulting Surgeon to the Brooklyn
Eye and Ear Hospital; President of the American Otological Society ;
Fellow of the New York Academyof Medicine ; Member of the Medi
cal Society of the County of New York, Etc., Etc.
E MEDICAL UD
THIRD EDITION .
16178
SAN FRANCISCO
Ilustrated by Wood Engravings and ('hromo-Lithographs.
NEW YORK :
WILLIAM WOOD & COMPANY,
27 GREAT JONES STREET
1876 .
ka
Entered according to Act of Congress, in the year 1873, by
D. B. ST. JOHN ROOSA,
In the Office of the Librarian of Congress, at Washington.
JOHN F . Trow & Son,

205-213 East 12th St.,
NEW YORK ..
Electrotyped by SMITH & MCDOUGAL, 82 Beekman Street.

RIZI
R78
1876
ADVERTISEMENT TO THE SECOND EDITION .
The present is a reprint of the first edition of this work, with the exception
that the new impression has afforded me the opportunity of correcting a few
typographical and other errors,which are almost unavoidable in a first edition.
No attempt has been made to rewrite any portion. Indeed , however much I
might have been disposed to thoroughly revise the book , the time since its
actual publication has been too short to make this necessary . The favor with
which the work has been received by the profession, is a cause of very great
satisfaction to me, and leads me to hope that it may continue for some time
to be adapted to the requirements of the practitioner.
20 EAST THIRTIETH STREET, April 4, 1874.

PREFACE .
THIS work is intended to be a guide to those who wish to treat

I the diseases of the ear. The portion that is devoted to a
description of these diseases, and the means for their relief and
cure, is founded upon my own experience in the observation and
treatment of more than thirty-eight hundred cases, in public and
private practice. I have, however, taken pains to give the experi
ence of other practitioners, both at home and abroad. I have
endeavored not only to give a comprehensive digest of the most
recent European researches, but also to present with entire impar
tiality, the views and experiences of American practitioners and
writers, so far as the plan of a practical treatise like this would
allow . To give a complete account of all that has been written on
Otology has not, however, been my aim .
Considerable space has been given to illustrative cases, with a
view of showing the actual symptoms of aural diseases and the
results of treatment. I have also added historicalsketches upon all
points of practice that are new or still under discussion , in order
that the successive steps by which our present position has been
reached might be distinctly traced, believing that thereby the
practitioner will often be saved needless labor in re-investigating
and re-experimenting. The nomenclature contained in this treatise
is that which I have found, after some years of experience in lec
turing upon diseases of the ear, most readily grasped by the stu
dent, and is, I believe, founded upon the real nature of the diseases.
The anatomical portion of the volume has been compiled from
the most recent authorities. The text-book of Professor J. Henle,
of Göttingen, a work which has not been translated into English ,
has been made the general basis of the descriptions of the various
parts of the ear, and of the arrangement of the subject.
In the preface to a translation of Von Tröltsch on the Ear,
PREFACE.
published a little more than nine years since, the translator had so
little faith in a general professional interest in the diagnosis and
treatment of diseases of the ear, that he quoted a proverb to indi
cate that an ordinary human life would not suffice to see the fruit
of the tree then being planted , in presenting to the English -speak
ing profession a work which has done much for the progress of
Otology.*
In view , however, of the active and permanent interest in this
subject, which has shown itself in the formation of societies, the
establishment of journals, improvements in methods of practice,
and a general appreciation of diseases of the ear, the author can
but felicitate himself that even in a short life he has seen some
fruit of a tree ,which , although he did not plant, he at least assisted
in cultivating.
The practice of Otology in this country was, a few years since,
almost exclusively confined to charlatans ; but it is now cultivated
by a class of men who are the equals of any in the profession . Ten
years ago, in most parts of the country, those who wished advice
upon a disease of the ear were forced to seek aid outside of the pro
fession. At the presenttime, there can be found those in the large
cities who are constantly and successfully treating aural diseases ;
and all over the land the old and familiar advice, “ Not to
meddle with the ear,” is growing far less frequent. The day will
soon arrive— if indeed it be not already upon us— when Otology will
take equal rank with Ophthalmology, to which department it has
so long been a mere appendage, and when some knowledge of the
diseases and treatment of the ear, will be required of every prac
titioner.
I have been assisted in various ways, in the preparation of this
work, by many who may rest assured that I have not been unmind
ful of their labors because their names are not here mentioned ;
but to Dr. Charles E. Rider, of Rochester, for assistance in compil.
ing the anatomy of the middle ear, and to Dr.George M . Beard ,
for critical suggestions in the literary execution of the work, of a
very valuable character, I am much indebted, and to both of these
gentlemen , I desire to present my cordial acknowledgments.
It is believed that in the foot-notes, the various authorities
whom I have consulted have been given proper credit, and they
* “ Arbores seret diligens agricola quarum adspiciet baccam ipse nun.

quam .”
PREFACE . V
are given in full at the close of the sketch of the progress of Oto
logy, and at the end of each anatomical section, in order that an
aural bibliography of works actually consulted by the author, and
accessible in this country, may be furnished to any who may desire
to pursue any special subjects further than would be fitting the
limits of a text-book.
Most of the engravings were made by Messrs. J. A . Cough
lan & Co. Those of instruments were furnished by Messrs. Shep
ard & Dudley, Otto & Reynders, and George Tiemann & Co., of
this city.
The chromo-lithographs were drawn by Dr. H . P. Quincy , of
Boston , from cases loaned meby Drs. Clarence J. Blake and Henry
L . Shaw , Surgeons to the Massachusetts Charitable Eye and Ear
Infirmary . Without the assistance of these gentlemen , I should
have found it very difficult to procure satisfactory representa
tions of the morbid membrana tympani. Dr. John L . Vander
voort, Librarian of the New York Hospital, has extended memany
courtesies in giving me free access to the valuable library of that
institution .
NEW YORK, May 29, 1873.

CONTENTS .
PART I .
INTRODUCTORY SKETCH AND EXTERNAL EAR .
CHAPTER I .
INTRODUCTION .
PAGE
A Sketch of the Progress of Otology, . . . . . . . . 52
CHAPTER II.
ANATOMY OF THE AURICLE AND EXTERNAL AUDITORY CANAL. 66
CHAPTER III.
THE EXAMINATION OF AURAL PATIENTS.
History — The Watch as a Test of Hearing - Register of Hearing Power
The Tuning-fork - Interference Otoscope - Von Conta 's Method - Aural
Specula — Method of Holding the Speculum - Von Tröltsch’s Otoscope
Binocular Otoscope - Prismatic Otoscope - Examination of the Pharynx
- -Rhinoscopy - Eustachian Catheter - Politzer's and Valsalva's Methods
- Bougies Diagnostic Tube, . . . . . . . . . 100
CHAPTER IV .
THE DISEASES OF THE AURICLE .
Shape of the Auricle - Its Functions — Malformations — Othæmatomata ,
Malignant Growths - Eczema, . . . . . . 118
CHAPTER V .
DIFFUSE AND CIRCUMSCRIBED INFLAMMATION OF THE EXTERNAL
AUDITORY CANAL.
Comparative Infrequency of these Affections – Diffuse Inflammation
Aural Douche - Method of Syringing - Furuncles, . . . . . 132
viii CONTENTS.
CHAPTER VI.
PARASITIC INFLAMMATION OF THE EXTERNAL AUDITORY CANAL.
PAGE
Aspergillus- Penicillium -Graphium Pencilloides — Trichothecium Ro-**
seum - Cases -- Syphilitic Ulcers - Condylomata. . . . . . 145
CHAPTER VII.
INSPISSATED CERUMEN .
Sudden Impairment of Hearing Power - Tinnitus Aurium - Vertigo
Pain in the Ear - Causes - Method of Removal - Cases Composition of
Cerumen - Buchanan on the Functions of Cerumen - Cerumen around
Foreign Bodies -- Mental Hallucinations relieved by removal of Har
dened Cerumen , . . . . . . . . . . 162
CHAPTER VIII.
FOREIGN BODIES IN THE EAR.
Insects - Living Larvæ - Other Foreign Bodies - Impression that the Pres
ence of a Foreign Body is in the Ear is very Dangerous — Proper Method
of Removal - Foreign Bodies in the Eustachian TubeCases Mental
Illusions as to the Presence of Foreign Bodies, . . . . . 178
PART II.
THE MIDDLE EAR .
CHAPTER IX .
ANATOMY OF THE MIDDLE EAR.
The Membrana Tympani — Shrapnell's Membrane - The Rivinian Fora
men — The Light Spot - Layers of Membrana Tympani- Blood vessels
- Nerves - Lymphatics — The Cavity of the Tympanum - Scheme for
Studying Walls of this Cavity - Ossicula Auditus — Blood -vessels
Nerves— The Mastoid Process - Mastoid Cells - Blood -vessels — The Eu
stachian Tube Muscles of the Tube Nerves - Historical Account of
Authorities, . . . . . . . . . . . 221
CHAPTER X .
INJURIES OF THE MEMBRANA TYMPANI.
No Independent Myringitis - Causes of Rupture of Drum head - Esplo
sion of Artillery - Gruber's Experiments to Determine Resisting Power
of Membrana Tympani - Effects of Compressed Air upon the Membrane
- The Investigations of A. H . Smith ,Green, and Magnus— Violence to
Membrane itself - Injury of Chorda Tympani Nerve - Functions of this
Nerve- Medico-legal Examinations - Evulsion of whole Membrane
Fracture of the Handle ofMalleus, . . . . . . 236
CONTENTS.
CHAPTER XI.
ACUTE CATARRHAL INFLAMMATION OF THE MIDDLE EAR.
PAGE
Nomenclature - Statistics of Acute Catarrh - Frequency of the Affection ,
although it is not often Reported — Symptoms— Diagnosis in Young
Children - Bulging of the Membrane - Causes— Treatment- Leeches
Paracentesis – Sub-acute Catarrh - Cases Otitis Media Hemorrhagica
- Cases - Aural Hemorrhage in the Course of Bright's Disease , . . 257
CHAPTER XII.
CHRONIC NON -SUPPURATIVE INFLAMMATION OF THE MIDDLE EAR .
Frequency of this Disease - Nomenclature - Catarrh - Otitis Media Hyper
plastica - Proliferous Inflammation - Subjective Symptoms of Catarrh
Vertigo - Insanity from Aural Disease– Tinnitus Aurium - Subjective
Symptoms of Proliferous Inflammation -- Objective Symptoms- Impair
ment of Hearing - Changes in the Membrana Tympani- Eustachian
Tube- Naso-pharyngeal Inflammation - Appearances with the Rhino
scope - Pathology - Causes, . . . . . . . . . 287
CHAPTER XIII.
CHRONIC NON -SUPPURATIVE INFLAMMATION OF THE MIDDLE EAR
- CONTINUED.
Treatment of the Catarrhal and Proliferous Forms, Constitutional and
Hygienic — Local Blood-letting — Applications to the Naso-pharyngeal
Space only applicable to the Catarrhal Form - Injections of Naso -pha
ryngeal Space -Gargling — Cauterizations- Nasal Douche- Cases of Oti
tisMedia from Use of the Douche - Gruber's Method of Cleansing Nares
- Nebulizers- Faucial Catheter - Treatment through the Eustachian
Tube- Air — Vapors — Fluids — Bougies Electricity - Cases of Death
from Use of Catheter - Length of Time Cases should be Treated , . 318
CHAPTER XIV .
THE TREATMENT OF CHRONIC NON -SUPPURATIVE INFLAMMATION
OF THE MIDDLE EAR - CONCLUDED .
History of the Operations upon the Membrana Tympani - Riolanus— Che
selden - Astley Cooper - Karl Himly - Supposed Cases of Death from
Perforation of Membrana Tympani - Schwartze's Revival of the Opera
tion - Politzer's Eyelet- Excision of the Malleus - Gruber's Myringo
dectomy- Weber's Division of the Tensor Tympani - Gruber's Knife
Lucae's and Politzer's Incision of Posterior Fold — Prout's Operation
Hinton 's Operation – The Effects of Condensed Air upon the Hearing
Power - Exhaustion of the Air from the External Auditory Canal- Re.
sults of Treatment, . . . . . . . . . . 349
CONTENTS .
CHAPTER XV.
ACUTE SUPPURATION OF THE MIDDLE EAR.
PAGE
Result of Acute Catarrh - Symptoms — Causes — Course — Treatment - Re
sults - Cases, . . . . . . . . . . . . 363
CHAPTER XVI.
CHRONIC SUPPURATION OF THE MIDDLE EAR.
Formerly known as Otorrhæa - Often confounded with Chronic Suppura
tion - Relative Frequency of Suppurative Affections of the External and
Middle Ear - Symptoms- Perforations of Membrana Tympani - Albu
minuria — Neglect of Chronic Suppuration - Hearing Power — Treatment
- Nitrate of Silver - Electricity — The Artificial Membrana Tympani
Prognosis - Cases, . . . . . . . . . . . 386
CHAPTER XVII.
THE CONSEQUENCES OF CHRONIC SUPPURATION OF THE MIDDLE
EAR .
Importance of the Subject - Life Insurance Companies decline to Insure
Patients suffering from these Consequences - Polypi- MalignantGrowths
- Middle Ear Mirror- Exostoses - Cases of Exostoses — Mastoid Disease
- Illustrative Cases- Caries and Necrosis of the Temporal Bone - Extrac
tion through the ExternalMeatus of the Whole Internal Ear – Progno
sis of Caries and Necrosis - Treatment- Cerebral Abscess – Pyæmia
Paralysis — Table showing the Course and Symptoms of Cases ofMenin
gitis , Cerebral Abscess, and Pyæmia resulting from Aural Disease, . 458
PART III.
THE INTERNAL EAR .
CHAPTER XVIII.
ANATOMY OF THE INTERNAL EAR.
Labyrinth - Division of Internal Ear - Vestibule - Semicircular Canals ,
mina Spiralis Membranacea - Terminal Auditory Apparatus- Auditory

Rods— Membrana Reticularis Auditory Cells — Blood -vessels - Authori
ties , . . . . . . . . . . . . . 484
CONTENTS.
CHAPTER XIX .
DISEASES OF THE INTERNAL EAR .
PAGE
Definition of Nervous Deafness - Most unfrequentof all Aural Diseases
Symptoms- Deafness to certain Tones - Double Hearing _ Ménière's
Cases - Electricity in the Diagnosis of Disease of the Auditory Nerve
Causes - Injuries — Hemorrhages and Effusions- Inflammation of the
Membranous Labyrinth - Quinine- Concussion - Remote Causes - Syph
ilis – Cerebro -spinal Meningitis– Fevers — The Exanthemata - Mumps
- Cerebral Tumors — Aneurism - Pathology - Treatment - Electricity
Otalgia, . . . . . . . . . . . . . 513
PART IV .
DEAF-MUTEISM AND HEARING TRUMPETS.
CHAPTER XX.
DEAF-MUTEISM .
Acquired and Congenital Cases — Causes - Appearances of Membrana Tym
pani and Pharynx - Treatment- Number of Deaf Mutes in the United
States — Hearing Trumpets, . . . . . . . . . 521
5
Description of Chromo-lithographs, . . . . . . . .
·
Index of Authors, . . . . . . . . . . . . 525

General Index, . . . . . . . . . . 520
·
LIST OF WOOD-CUTS.
TIG . PAGE
1. Normal Auricle, . .
2. Profile View of the Skull, with the Skeleton or Cartilage of the Auri.
cle,as well as that of the ExternalAuditory Canal,. .. .. .. 5754
3. Muscles of the External Ear, . . . .
4. View of the Cartilage and Muscles on the Posterior Surface of the
Auricle . . . . . . . . . . . .
5. Horizontal Section of the Head,through the External Auditory Canal,
6. Section through the External Meatus and the Ear at the Point of
Junction of the Cartilage of the Auricle with that of the Auditory
Canal, . . . . . . . . . . . . .
7. Vertical Section of the Osseous Meatus,Right Side, close to theMem
brana Tympani, . . . . no
8. Blake's Tuning-fork
ukolumno rk , .. . . . . . . . . .
9. Angular Forceps, . . . . . . . 80
10. Gruber's Speculum , . . . . . . . . . . 80
11. Method of Holding the Speculum in Position , . . . . . 82
12. Von Tröltsch's Otoscope, actual size, . . .
13. Method of Examining the Auditory Canal and Membrana Tympani,
14. Forehead -band, . . . . . .
15 . Blake's Operating Otoscope , . . . . . . . .
. . . . . . . .
16 . Hinge Speculum , . . .
17. Turck 's Speculum , .
18. Tobold 's Lamp, . .
19. Anterior Nares Speculum , · ·
·
20. Eustachian Catheters, actual size, . . . . . 94

21. Introduction of Eustachian Catheter, . .
22. Introduction of Eustachian Catheter (second
ou position
position )) . . .
23. Air-bag, . . . . . . . . . . . . . 96
24. Diagnostic Tube, . . . . . . . . . . . 97
25 . Method of using Politzer's Apparatus. (With Inhaler Attachment.) 99
26 . Othæmatoma. From a Photograph taken from a Plaster Cast when
the Tumefaction was greatest, . . . . . . . . 109
27. The same Ear, after Rupture and Contraction had taken place,. . 109
28. Othæmatoma; showing Amount ofContraction after Rupture of Cyst , 110
29. “ shows Separation ofPerichondrium from the Cartilage, 110
30. An Auricle Deformed by Inflammation , • 118
31. E . H . Clarke's Aural Douche, . . . . . . . . 123

32. Hard Rubber Syringe, . . . . . . . . . . 127
33. Method of Syringing the Ear, . . . . . . . . 128
34. Aspergillus Nigricans, . . . . . . . . . . 137
LIST OF WOOD -CUTS. xiii
FIG . PAGE
35. Aspergillus Flavescens, . 138
36. Specimen of the Spores ,and fully developed Growth of the Asper
gillus Flavescens, . . . . . . . 133
37. Penicillium , . . . . . . . . . 140
38. The Right Temporal Bone, without the Petrous Portion , in connec
tion with the Ossicula Auditus of a newly-born Child, seen from
within , . . . . . . . . . . . 182
39. Left Temporal Bone of the same Subject as preceding Figure, . . 182
40. The Right TemporalBone of a newly-born Child, with a Dried Mem
brana Tympani, . . . . . . . . . . 183
41, 42 . View of Membrana Tympani, showing Handle of Malleus and
Triangular Spot of Light, . . . . . . . . . 106
43 . Layers of Membrana Tympani, . . . . . 189
44. The Membrana Tympani, in connection with the Ossicula Auditus of
the Right Temporal Bone, . .. . . . . . . 194
45. The Right Temporal Bone, with the Membrana Tympani and Ossi
cula Auditus of an Adult, . . . . . . . . . 197
46 . Ossicula Auditus, . . . . . . . . 200
47. The Ossicula Auditus of the Left Cavity of the Tympanum ,seen from
within, . . . . . . . . . . . . 201
48. Section of theHead, showing the Divisions of the Ear and the Naso
pharyngeal Cavity , . . . . . . . . . . 208
49. Transverse Section of the Upper Part of the Eustachian Tube,. . 209
50. Transverse Section through the Lower End of the Eustachian Tube, 210
51. Transverse Section through the Lower End of the Eustachian Tube, 210
52. LateralWall of the Nasal Cavities,showing the PharyngealOrifice
Eustachian
of the Tube, . . . . . . . . 211
53. Transverse Section of Eustachian Tube and surrounding Parts, . 212
54. Section of the Upper Third of the Eustachian Tube, . . . 215
55. Section of theMiddle Third of the Eustachian Tube, . . . 216
56. Fracture of Handle of Malleus, . . . . . . . . 236
57. The same,showing the Fracture reduced, . . . 236
· · · · · · · ·
. .
58. Tuning -fork , . . . . . . . 269
59. Siegle's Speculum , . . 276
· · · · · · ·
. . . . . .
60. Pharyngitis granulosa, . . . . 277

61. Noyes' Eustachian Catheter, . 480
62. Posterior Nares Syringe, . . 290

63. Nebulizer for Pharynx, . .
64. Pomeroy's Faucial Catheter, 299
65. Apparatus for Steaming the Middle Ear, 303

66. Hackley 's Eustachian Nebulizer, . . 307
· ·
67. Apparatus for Injecting Vapors into the Nasal Passages, 309
68. Air-bag, with Inhaler Attachment, . . . . . 310
69. Weber's Knife for Dividing the Tensor TympaniMuscle, . . . 334
70. Gruber's Knife for Dividing the Tensor Tympani, . 337
71. Prout's Knife for Incising Adhesions, . . . . . . . 340
· ·
72. Vessel used in Syringing the Ear, . . . . . . . 373

73. Toynbee's ArtificialMembrana Tympani, . . . . . 376
XIV LIST OF WOOD -CUTS .
FIG . PAGE
74. Method of Inserting ArtificialMembrana Tympani, . . . . 380
75. Section of Aural Polypus, . . . . . . . . . 390
76 . Section of Aural Polypus, . . . . . . . . . 391
77. Section of Aural Polypus, . 392
78. Blake's Modification of Wilde's Snare, with Paracentesis Needle, · 395
79. Scissors for the Removal of Aural Polypi, . . . . 395
80 . Hinton 's Forceps, . . . . 396
81. Angular Glass Rod for Applying Acids to the Cavity of the Tym
panum , . . . . . . . . . . . . 397
82. Blake's Middle Ear Mirror, . . . . . . . 399
83,84. Two Views of Temporal Bone, Exfoliated in the Course of Chronic
Suppuration · · · · · · · · · · 436
85 . Left Temporal Bone, . . . . . . . . . . . 439
86. Inner Surface of the same specimen , . . . . . . . 439
87. Left Temporal Bone sawed through External Meatus,Middle Ear,
and Cochlea , . . . . . . . . . . . 440
88. Right Temporal Bone, showing the Cranial Surface of the Bone, . 441
89. Horizontal Section through the Lower Half of the Left Ear, . . 462
SO. The Left Vestibule, with the Semicircular Canals,from an Adult, . 463
91. The Vestibule, . . . . . . . . . . . 463
92. Osseous Cochlea and Semicircular Canals, with Stapes Bone. Left
Ear of an Adult, . . . . . . 465
93. Right Osseous Vestibule , Semicircular Canals, Cochlea , and Ossicular
Auditus of Newly -born , . .
94. The Right Osseous Labyrinth of a Newly-born Subject, opened on
its Posterior Surface, . . . 465
95. Section through the Apex of the Right Osseous Cochlea, parallel
with the Base, . . . . . . . . , , . 466
96. Section of the Temporal Bone, Verticalto its Long Axis. Posterior
Surface of the Section , . . . . . . . . . 467
97. Osseous Cochlea (Right) of the Newly -born , opened from the Outer
Surface, . . . . . . . . . . . . 468
98 . Right Osseous Cochlea opened anteriorly, , . . . . 469
Lamina Spiralis, . . . . . . . . . . 470
100. Expansion of the Right Cochlear Nerve, seen from the Base of the
Cochlea , . . . . . . . . .
101. Periosteum of the Labyrinth , . . . . . . . . 473
102. Periosteum of the Outer Wall ofthe Cochlea , . . . . 473
103. Utricle and Membranou s Semicircular Canals of the Left Side, . 473
s
104. Wall of Membranou Semicircular Canals , . . . .
105. A Piece of the Wall of the Utricle, with the Otoliths, .
106. Transverse Section of a Cochlea Spiral, . . . . . . 477
107. From the Terminal Auditory Apparatus of a Cat,
108. Profile View of Outer and Inner Rods , , · · · 480
109. Diagrammatic Representation of the Terminal Auditory Apparatus, . 482
110 . Hearing Trumpets, . . . . . . . . . . 520
PART I.
INTRODUCTORY SKETCH OF THE PROGRESS OF OTOLOGY.
THE EXTERNAL EAR.

INTRODUCTION .
CHAPTER I.
A SKETCH OF THE PROGRESS OF OTOLOGY.
THERE is perhaps no department of the art and science of

medicine in which there has been so much literature, with so
little exact, or as we say, scientific knowledge, as that which
was formerly known as aural medicine and surgery , but which
. is better designated by the term Otology .
460 –370 B. C.] Hundreds and perhaps thousands of volumes
have been written on the anatomy, physiology,
and diseases of the ear, from the time of Hippocrates until
our own day, and yet until the age of Valsalva, the seventeenth
century, the treatment of the affections of the organ of hear
ing was purely empirical, while the knowledge of its anatomy
and physiology was often incorrect and fragmentary. Even
after the investigations of the famous Italian , investigations
which consumed sixteen years of his life, and the subsequent
anatomical discoveries of the eighteenth century, it was re
served for our own day and generation to place the science of
otology, or the knowledge of the anatomy, physiology, and
diseases of the ear , on a level with that of other fields of labor
in medicine.
A singular apathy in regard to the maladies of one of the
most important organs of the body, an inexplicable ignorance
as to their results, a most irrational and empirical manner
of treatment, have been our heritage from the fathers. Prob
ably to -day, in the closing years of the nineteenth century ,
there are more practitioners of medicine who view aural med
icine and surgery from the stand-point of the errorists of the
18 A SKETCH OF THE
dark ages, than there are in any other field . It is to be feared

that even now many wise and skillfulmen do not know , that
to drop stimulating or even anodyne applications upon a
membrane which they have never examined, to probe an ear
for wax that they cannot see, are purely empirical practices
which every conscientious physician should hold in ab
horrence.
The great reformer of this science, Wilde,* wrote, as
late as 1853, that “ the affections of the ear, whether func
tional or organic, are spoken of, lectured on, written of, and
described (even in great part to the present day), not accord
ing to the laws of pathology which regulate other diseases,
but by a single symptom , that of deafness.”
It is with no desire to recount the details of the long and
painful story of the gropings in the dark , which have charac
terized the teachings on otology from the days of the philoso
pher of Cos, until the seventeenth century, that the author
attempts an historical sketch of our progress up to our present
position. He has neither the time nor the facilities for such
a task ; but he has simply aimed to sketch the outline history
of otology, from the sources to which he has been able to gain
access, in such a manner as to show the obstacles which, until
twenty years ago, have prevented the satisfactory progress of
the science.
The authorities which I have consulted in this introduction
will be found at the close of the chapter ; but I must first of
all make especial acknowledgment of my indebtedness for the
greater part of my material to that valuable compendium ,
Lincke's Handbuch der Ohrenheilkunde. I have, however,
consulted the original authorities as far as the best medical
library of New York, that of the New York Hospital, and my
own, would permit. Where no other authority is given in a
foot-note, Lincke is the one from which I quote, and often by
an exact translation .
The discoveries and teachings in the anatomy of the ear
will be first reviewed, after which the progress in the examin
ation and treatment of its diseases will be noted .
* Aural Surgery, English edition , p. 7.

PROGRESS OF OTOLOGY. 19
PROGRESS IN THE ANATOMY OF THE EAR .
Hippocrates probably knew very little of the anatomy of

the ear ,although it is supposed on doubtful grounds
570 B .C. ] that Alcmcon, a disciple of Pythagoras,was aware
of the passage that led from the cavity of the tym
panum to the throat, inasmuch as Aristotle quotes him as
saying that goats breathed through their ears.
384- 322 B .C.] The knowledge of Aristotle as to the ana
tomy of the ear did not go beyond the mem
brana tympani.
A . D . 98- 117] Rufus of Ephesus,who was the firstmedical lex
icographer, and who lived in the age of Pliny,*
used the names helix , lobe, tragus, and anti-tragus, which are
still employed to describe the different parts of the auricle .
Marinus, the preceptor of Galen, and whom Galen named
the restorer of anatomy, called the acoustic and facial nerve
one, under the name of the fifth pair.
A .D . 130] Galen does not seem to have made any great
advance in anatomical studies,and they were greatly
neglected down to the fifteenth century. The darkness of the
blind leading the blind is scarcely broken for thirteen hundred
years. What Galen wrote was authority , and naught else.
One valiant skeptic in medicine would have effected more
good during these centuries, than all the ponderous tomes that
were written by philosophers who reasoned upon premises
that had never been thoroughly established . So late as 1559
one Doctor Geynes was called before the College of Physicians
in London , for impugning the fallibility ofGalen . On his ac
knowledgment of his error, however, he was again received
into the college. t
The strong arm of the church , in the dark ages , prevented
anatomical investigations on the human cadaver, and for hun
dreds of years anatomical knowledge remained at a stand -still.
Galen , however, corrected the error of his preceptor in
thinking that the facial and acoustic nerves were one, and
showed that the latter entered the meatus auditorius internus,
* History of Medicine. Dunglison, p. 166 .
Chambers' Encyclopedia . American edition . Article, Galenus or Galen.
A SKETCH OF THE
a passage which his predecessors had regarded as impermea

ble. He gives no account of the anatomy of the internal ear,
although he compares it to a labyrinth , a name which Fallo
pius, fourteen hundred years later, fastened on it forever.
There is no record of the ossicula auditusuntil the fifteenth
century. Two Italian anatomists, Achilini and Beren
1480 ] gario, were the first to describe these bones, although
they were not the discoverers of them .
Berengario also first described the membrana tympani
“ with exactness.” The exactness of his knowledge may be
shown by the fact, that he was doubtfulwhether the origin of
themembrane was from the acoustic nerve, or themeninges of
the brain .
1542] Andreas Vesalius, who is said to have been the most
accurate anatomist of his day, * described the long pro
cess of the malleus, the Eustachian tube, the vestibule , and
the semicircular canals.
1604 ] The honor of the discovery of the stapes bone is
claimed by no less than three anatomists , viz., Ingrassia,
Columbo, and the renowned Bartolommeo Eustachius. The former
wrote commentaries upon Galen's works, that were published
long after his death . He claims to have shown it to his scholars
in 1546 , at Naples.
1523– 1562] Gabriel Fallopius, ofModena, died in the bloom
ofyouth, at theage of 39 ,+ buthe lived long enough
to accomplish much for anatomical science. He showed,among
other valuable points in the anatomy of the ear, that themas
toid cells communicated with the cavity of the tympanum .
He described the fenestræ rotunda and ovalis, and gave bis
name to the canal in which runs the facial nerve in its passage
through the cavity of the tympanum , acqucduct us Fallopii.
The great Cuvier regarded Vesalius, Eustachius, and Fallo
pius as the three anatomists of the sixteenth century to whom
belongs the honor of having restored the science of ana
tomy.
1500 – 1574 ] Bartolommeo Eustachius described the tensor
tympani as well as the stapedius muscle. He
* Dunglison . History of Medicine, p . 233 .
+ Chambers' Encyclopedia. Article, Fallopius.
PROGRESS OF OTOLOGY.
also gave a more exact account of the tube leading from

the pharynx to the middle ear, which is called the Eustachian
tube, although it was discovered by Vesalius. Eustachius also
gave a superficial description of the cochlea.
It is said that if poverty had not prevented Eustachius
from publishing his anatomical plates, anatomy would have
attained the perfection of the eighteenth century some two
hundred years earlier.*
1587 ] The first monograph on the anatomy of the ear was
from the pen of Volcher Koiter , a student of Fallopius.
It contained no original observations, however.
1543– 1573 ] Constant Varolius,t so well known from his de
scriptions of the brain , made the singular mistake
of supposing that themuscles of the cavity of the tympanum
were nerves which were torn by the sawing through of the
bone. Subsequently he admitted this error ; but he went so
far to the other side as to say that the tensor and laxator tym
parimuscles could be moved at will.
1537 - 1619 ) Linckef does not think that the famous Fabri
cius of Acquapendente, contributed very much to
our knowledge of the anatomy of the ear, while he led many
away into error as to some points . For example, he thought
that the chorda tympani nerve was a peculiar body, and not
a nerve. At any rate, Fabricius did good service by his
labors as a comparative anatomist, and it should be remem
bered that he was the instructor of the discoverer of the circu
lation of the blood .
1593- 1609 ] Julius Casserius, who was a professor in Venice
in 1609, a pupil and subsequently a rival of Fabri
cias, described the fissures that make the cartilaginous por
tion of the canal so flexible. He and Fabricius described the
laxator tympani minor in the same year, and both claim to
have discovered it first. Casserius also gave a better descrip
tion than had hitherto been done of the membrana tympani,
the ossicula auditus, and the labyrinth . Hewas the first to
* Chambers'Encyclopedia . Article , Eustachius.
+ Biographie Médicale . Paris, Pankoucki.
Handbuch , Bd . I., s. 14.
22 A SKETCH OF THE
describe the three and a half turns of the cochlea and the
membranous zone.
1665 ] The ceruminous glands, whose function and physio
logical action were first described by Nicolaus Stenon .
Lincke speaks of him as Stenson ; but this must be a mistake
in transcribing the name of the great Danish anatomist.
Passing on to the seventeenth century we find Antonine
Marie Valsalva rising up a head-and -shoulders above the ana
tomists of his age, and far exceeding his predecessors in the
amount and exactness of his knowledge.
He devoted more than sixteen years ofhis life to the study
of the anatomy of the ear, and for the purpose of its study
dissected more than a thousand heads. His master-work was
a treatise on the ear.* This work passed through five edi
tions in a short time. He described the attachment of the
tensor tympani to the Eustachian tube. He made the mis
take, however, of supposing that the ossicula auditus had no
periosteum , and that the cavity of the tympanum was con
nected by many openings to the cavity of the cranium . He
discovered the muscle that dilates the Eustachian tube and
moves the uvula . He also showed that the fenestra ovalis
was covered by membrane. His anatomical plates show a
good knowledge of the cochlea and semicircular canals.
Morgagni, himself an original investigator, a student and
friend of Valsalva , edited his master's work and made some
additions.
Of Valsalva's contributions to the treatment of the ear,
which were quite as important as his anatomical investiga
tions, we shall have occasion to speak in the second part of
this sketch .
1714 ] Valsalva had a rival, whose name the lapse of time
has well nigh effaced , Raymond Vieussens, who also
wrote a work on the ear. He gave new names to various
parts of the organ ; but his descriptions are said by Lincke
to be so mysterious that his contemporaries could not under
stand them .
1717 ] Rivinus, professor in Leipsic , observed an opening
* Tractatus de Aure Humana. Lugdunum Batavorum , 1742.
in themembrana tympani,which he believed to be a constant

anatomical condition . This supposed discovery excited the
warmest discussion among such anatomists as Walther , Ruysch ,
Morgagni, Cassebohm , and Valsalvo . Hyrtl, the present dis
tinguished anatomical teacher of Vienna, showed that it was
a rent in a macerated membrane ; but his predecessor, Berres,
believed in its existence and described it minutely .*
Quite recently Professor Bochdalek,of Prague, has revived
the question,t and has described the foramen of Rivinus as a
constant opening in the membrana tympani ; this author says
that there are sometimes two. It is, however, according to
Bochdalek , so small as not to be seen without the aid of a
magnifying glass.
In a discussion in one of themedical societies of Vienna,
Professors von Patruban, Gruber, and Politzer, unite in
affirming its existence, thus confirming Bochdalek's state
ment.
1718 ] The famous Ruysch (Frederick ), professor in Amster
dam , contributed to our knowledge of the distribution of
the vessels of the cavity of the tympanum , and corrected Val
salva's statement that the ossicula were not covered by peri
osteum .
1730 ] Cassebohm (Joan. Frid .), published a monograph upon
the ear, in six parts , which Lincke calls “ a monument
to the German industry and spirit of inquiry of the time.”
“ Ein Denkmal deutschen Fleisses und deutschen Beobach
tungsgeistes."
He disproved Valsalva's idea of the close connection
between the cavity of the tympanum and the cerebrum ; he
described the cochlea, and the development of the auditory
apparatus in the foetus.
1747– 1753] Brendel and Zinn, twoGöttingen anatomists, the
latter of whom is well known as thedescriber of the
suspensory ligament of the lens, known as the zonula of Zinn,
made further investigations as to the structure of the
cochlea.
1761 ] Dominic Cotugno,or Cotunni,the discoverer ofthe fluid
* Prager Viertel. Yahrschrift, 1866, I.
+ Tröltsch on the Ear, 2d American edition , p . 26 .
Monatsschrift für Ohrenheilkunde, Jahrgang III., No. I.
H
24 A SKETC OF THE
of the labyrinth, won such a reputation by his work upon

Naples. Hewas the first clearly to show that the labyrinth
was filled with fluid , and that this was one of the neces
sities for the perception of the undulations that we call
1747– 1832] Antonio Scarpa issued a work on the structure

of the ear, which brought the knowledge of its inner
arrangement to such a height that it seemed to his contem
poraries that there was little more to be done. The investi
gations of our own day have shown how premature was this
expression. Scarpa wrote upon the fenestra rotunda, which
connects the tympanic cavity with the lamina spiralis of the
cochlea. He described the osseous labyrinth with exactness ,
the membranous labyrinth , and the expansion of the acoustic
nerve .
Scarpa was secretary to the octogenarian Morgagni, when
the latter had lost his sight, and he wrote letters of advice
in Latin at the dictation of his blind preceptor.
1797] Alexander Monro,* “ Professor of Anatomy, Medicine
and Surgery,” in the University of Edinburgh , was the
author of a monograph on the organ of hearing in man and
other animals. It is a fine specimen of typography. In his
preface he states that Dr. Camper called in question his
description of the semicircular canal in whales, and that
Scarpa said that some of his teachings in regard to the
human ear were erroneous. Professor Monro claims to have
been the first anatomist to trace the auditory nerve within
the cochlea, vestibule, and semicircular canals. He quotes
from Valsalva, Winslow , Cassebohm , Haller, Cotunnius, Mec
kel, and others, to show that none of these anatomists had
traced nerves into the cochlea. Dr. Monro seems to make
out a good case for himself as against Scarpa, as far as I
have been able to determine, and to be entitled to the credit
of having traced the nerves into the cochlea before with
greater minuteness than Scarpa , and appears to have been
correct in his comparative anatomy.
* Three treatises on the Brain, the Eye and the Ear. Edinburgh and
London, 1797.
1800 ] Mr. Everard Home wrote an excellent, and, for its

time, exact account of themembrana tympani in a paper
for the Royal Society. * The measurements are accurately
given, but Mr. Home supposed that the fibrous layer was
muscular. He seems to have been a comparative anatomist
of great ability .
1806 ] Samuel Thomas Soemmering, a great name in anatom
ical science, contributed to otology by a series of plates
of the anatomy of the ear, which are almost as well worth
study to-day as they were seventy years ago.
1832 ] Henry Jones Shrapnell contributed a series of papers
to the London Medical Gazette . He described the
membrana flaccida of the drum -head , its nerves, with clear
ness and accuracy. His description of the former is available
for the student of the present time, and Shrapnell's membrane
is probably firmly fixed in the nomenclature of the anatomy
of the ear.
1832] Thomas Buchanan, of Hull, brought out a monograph
illustrative of the anatomy and diseases of the ear .
His ideas as to the importance of the cerumen produced
many errors in treatment, from which the profession has not
yet fully recovered . He published four works ; the title of
the last one illustrates what has just been said : “ Physio
logical Illustrations of the Organ of Hearing, more particularly
of the Secretion of Cerumen , and its effects in rendering
Auditory Perception acute and accurate .” #
1836 –39] The distinguished English surgeon , T . Wharton
Jones, Esq., contributed to a great cyclopædia an ar
ticle on the organ of hearing, which comprised all that was
known up to that time, and which is a very valuable mono
graph for reference.
1821-51] Weare now , in our review of the investigations of
the anatomy of the ear, down nearly to our own
time ; and we come to the familiar names of Huschke, Ar
* Philosophical Transactions, 1800 . The Croonian Lecture.
+ Vol. x., 1832.
Mr. Wilde on the early history of Aural Surgery . Dublin Medical
Journal, 1844 , p . 441.
S Cyclopædia of Anatomy and Physiology. Edited by Robert B . Todd. .
A SKETCH OF THE
nold , Schlemn, Johannes Müller, Breschet, Bonnafont, and

Toynbee.
1851] Toynbee * investigated anew the membrana tympani.
He especially added to our knowledge in regard to
the fibrous layer ,and described, for the first time, the dermoid
layer. This paper was published in the Philosophical Trans
actions. It was preceded by papers in the Medico-Chirur
gical Transactions, on the pathological anatomy of the ear,
papers which have given Toynbee lasting fame, because they
did very much to place otology upon as sound a basis in
pathology as they had been placed in anatomy by the labors
we have enumerated.
Toynbee's statement, that the Eustachian tube was usually
a closed canal, and that muscular action was required to open
it, led to Politzer's method of inflating the ear, of the value
of which procedure more will be said in our review of the pro
gress in therapeutics.
1856 ] Von Tröltsch began a series of anatomical investiga
tions, which , we may hope, have not yet ended . His
contributions relate to the structure of the membrana tympa
ni, the muscles of the Eustachian tube, and the pathological
anatomy of the middle ear. He also, in the course of some
investigations of the cavity of the tympanum of the foetus,
found that it was filled with a proliferation of themucous mem
brane of the labyrinth wall, which forms a mucous cushion ,
that rapidly lessens in size after birth . This anatomical fact
explained the frequency of inflammations of the middle ear
in young children.
1858 ] Gerlach followed Toynbee in the investigation of
the fibrous layer of the membrana tympani, and showed
that in the extreme periphery the circular fibers were
wanting.
1860] Magnus investigated anew the articulations of the
ossicula , and showed that there was no real joint be
tween the malleus and incus. He also denied the voluntary
or involuntary contraction of the tensor tympani muscle .
1862] Politzer and Lucre published the results of experi
* Diseases of the Ear. American edition.
+ Schwartze, Archiv für Ohrenheilkunde. Bd. I.
ments,which were supplementary to those of Müller, in show

ing that the origin of a certain crackling sound in the ear was
not in the tendon of the tensor tympani, but in the Eusta
chian tube.
1851] Corti,* an Italian anatomist, reviewed the work of his
countrymen of the former centuries who studied the
cochlea, and divided the lamina spiralis membranacea into
two different broad zones — an inner one, Zona denticulata ;
and an outer, Zona pectinata . He described some peculiar
bodies as teeth, which soon got the names of Corti's organ,
and which were subsequently found to be the termination of
nerves.
Claudius, Böttcher , and Deiter followed Corti in investiga
tions of this part, which will be fully noticed in discussing the
anatomy of the internal ear.t
1858] Hyrtl, an anatomist of great industry and reputation,
made an important discovery of the frequency of a thin
and porous bony covering to the roof of the cavity of the
tympanum , thus elucidating some cases of cerebral disease
arising from affections of the middle ear.
Our review now extends to the time of the publication of
the Archiv and the Monatsschrift für Ohrenheilkunde, as well
as to that of the American Journal ; the Archives of Oph
thalmology and Otology ; to familiar ground , in the knowledge
of which the subsequent pages are written .
PROGRESS IN AURAL THERAPEUTICS .
In the earlier ages the progress in the treatment of the ear

by no means kept pace with the advance in the knowledge of
its anatomy. While the structure of the organ was sufficiently
well understood to cause the investigation of its diseases to be
both interesting and profitable , the treatment was crude and
illogical, unworthy of the knowledge which should have been
its basis .
Herodotust says that there were specialists in Egypt, a par
* A Manual of Histology by Stricker, p. 1054 (Translation ).
For the material for the sketch of the preceding page, I am indebted to
Schwartze, Archiv für Ohrenheilkunde. Bd. I.
Herodotus, translated by Cary . Euterpe, p . 125.
28 A SKETCH OF THE
ticular physician for each disease, but no mention is made of

aurists . “ The art ofmedicine is thus divided amongst them :
each physician applies himself to one disease only, and not
more. All places abound in physicians ; some physicians are
for the eyes, others for the head, others for the teeth , others
for the parts about the belly, and others for internal discases."
Although Hippocrates knew very little about the anatomy
of the ear, he speaks at some length of the causes of aural
disease. For many of these he must have drawn upon his
imagination . They were very comprehensive, and may prop
erly be said to explain almost anything. They are such as
heat, cold , dryness, moisture, the blood, mucus, and the yel
low and black bile.
Hippocrates considered internal inflammation of the ear as
essentially an inflammation of the head. He described as a
very dangerous disease, pains in the ear, connected with high
fever , and if neither pus escaped from the ear nor blood from
the nose, the death of the patient usually occurred from the
ninth to the eleventh day.
This was probably the disease that we now name acute ca
tarrh of the middle ear, and the great medical philosopher
was certainly right in calling it a serious one.
Among all the improper remedies which Hippocrates recom
mends to be dropped into the ear, there is one good one, al
though it is very simple , which is often thought to be a sugges
tion of our own day ; that is , the instillation of warm water,
which the great physician advises to be done by means of a
sponge. If this simple , but often efficacious, treatment were
universally practised in cases of acute inflammations of the
outer and middle ear, it would alleviate a great deal of suf
fering .
Hippocrates seems to have had an eye to the effect upon
the patient's mind , to use no harsher term , if we may believe
that the following passage was not, as Lincke insinuates, in
terpolated * : “ If any person has a pain in his ear, the phy
sician should roll a bit of wool about his finger, and then pour
some warm oil into the ear, and then taking the wool in the
hollow of his hand, and hold it before the ear, in order to
* Lincke's Handbuch , Bd. II. p . 5.
make the patient believe it has come out of it. In order that
the deception may be complete, the wool should be at once
thrown into the fire.”
Asclepiades, a friend of Cicero, recommended instillations for
the ear, of oil, in which three or four cockroaches, or an Afri
can snail were cooked, while a piece of henbane in oil of roses,
or woman's milk , is to be afterwards added.
B . C. 44, A . D . 19] Celsus (Aulus Cornelius) also used a com
posite remedy which was said to be of service
in all kinds of diseases of the ear. It was made of cinnamon ,
cassia , blossoms of bulrushes, castoreum ,white pepper , am
monia ,myrrh , and saffron, as well as of various other agents.
These substances were all rubbed up with vinegar, and diluted
with the same agent when used.
Celsus, in his treatise De Medicina, spoke in some detail of
aural disease. He was perhaps the first to recommend vigor
ous injections of water in order to remove foreign bodies from
the ear, although this proper recommendation carries less
weight than it would have done had it not been mingled with
a great deal of bad advice, which shows that a disposition
to use the simplest means for a desired end, is not always
connected with great learning. Celsus recommends in obsti
nate cases of a foreign body in the ear, that the patient should
be laid upon a table, and upon the side of the affected ear,
when the surgeon strikes with a hammer upon the table , in
order to dislodge the foreign body by the concussion .
Among the mass of writers mentioned by Lincke as being
before Galen's time, Archigenes seems to have had some cor
rect notions. He practised venesection for severe pain in the
ear, and employed purgative enemas, warm baths to the ear,
especially by means of a sponge dipped in hot water. He
warns against the use of cold water. He also has his method
of removing a foreign body from the ear, and recommends a
vigorous shaking of the affected head. A child is to be seized
by the feet and well shaken , while adults are to be held
very much as Celsus proposed ; that is, they are to be laid
on a table , while the leaf of it nearest the head is to be
repeatedly opened and shut with a slam .
Archigenes, like other ancient authorities, however, thinks
30 A SKETCH OF THE
very much of instillations of various kinds for the relief of the

different forms of deafness. He recommends speaking- tubes
to the deaf.
Galen recognized the importance of the ear,
A . D , 130 –201]
inasmuch as it lies so closely to the head. Al
though his classifications of disease are very minute , we do
not seem to learn much from his writings, except the value of
agents that will excite the secretions of the nose and mouth ,
which he recommends in aural disease. He complains of the
empirical practices of his predecessors in ordering now cold
and now warm agents , now sweet and now sour ones.
He also tells of a poor patient of some less learned, or less
practical man than himself, who, in accordance with advice,
used black pepper as a local means of treatment for an in
flamed ear , and whose sufferings were so much augmented ,
that he came near hanging himself.
Galen objects to the common use of opium , which seemsto
have been employed very much in relieving the pain of aural
disease .
Tinnitus aurium , according to Galen , was due in some
cases to exhalations from the stomach, and in others to in
creased sensitiveness of the ears. Both of these causes cer
tainly leave much to be wished for, in the way of exact knowl
edge, as to the nature of this distressing symptom .
It would be tedious in the extreme to follow Galen through
his classification of diseases of the ear, and remedies for them .
Like his predecessors and contemporaries, he was not will
ing to admit that there were some diseases for which remedies
were useless, so far as their knowledge went. The aural pre
scriptions of the ancients may well be compared to the
mitrailleuse, dangerous far and wide.
Cælius Aurelianus, a successor of Galen , stands out prom
inently from the absurd theorizers of his time, in his clear
delineations of pain in the ear, and his sensible remedies for
it - leeches, cups, poultices, mustard -plasters, and so on.
Apollonius, quoted by Galen , took out foreign bodies with
ear-spoons, forceps, hooks, etc ., which were enveloped in wool
and dipped in turpentine. He softened ear-wax with saltpetre
in vinegar, and then removed it with lukewarm water or oil.
About this time we read of the materia medica of Marcel

lus, who gives us a glimpse of the popular remedies of the day.
Frogs ' fat is recommended for pain in the ear ; the urine of
pigs, of children and men , and the blood of young chickens,
for an ulcer in the ear ; for worms in the organ, the saliva
of a hungry man, and so on .
We see a great deal in the ancient literature, of worms
in the ear ; so that we must conclude that they were much
more commonly found in the olden time than with us. This
was probably due to the fact that cases of neglected suppura
tion were very frequent, and that living larvæ were thus often
developed.
600 A .D . ] The famous surgeon and obstetrician , Paulus
Æginita , who flourished in the seventh century,
should be remembered as a contributor to the surgery of
otology. He expended much energy on the subject of foreign
bodies in the ear, a field which has unfortunately always suf
fered from surgeons over-anxious for operations. He suggests
a method for their removal, which,when all other means fail,
is still to be thought of in our day. It is an incision behind
the ear, to detach the auricle from the canal. We are thus
enabled to get at the foreign body very readily. Hippocrates
is said to have also recommended this procedure.
According to Lincke, the Arabians got their knowledge of
otology, whatever it was, from the Greeks, of whom Galen
was the chief authority ; so that we can only add a few more
absurd remedies as their contribution to knowledge : for
deafness, the brain of a lion mixed with oil (the brain , not the
lion ,) is advised by Rhazes. Serapion advises instillation of
woman's milk for the cure of ear-ache in children ; and he
gives the important caution that if it be a boy who is affected ,
the milk must be that of a woman who is nursing a female
infant.
As we have seen , in noticing the progress in our knowledge
of the anatomy of the ear, the centuries from Galen to Val
salva were dark ages for our science. Lincke says : “ Otol
ogy remained at the same point at which the Grecian , Ro
man, and Arabian physicians had left it.” In Lincke' s own
list of the progress of these centuries we find traces of ignor
A SKETCH OF THE
ance and empiricism only. One author named Gadesden rec

ommends that, in cases of inflammation of the ear, one of the
lower classes be hired to suck out, by means of a tube placed
in the meatus externus, all the morbid material of the ear ;
and this is said to be a cure for all kinds of deafness, not even
excepting that from a purulent affection of the organ . Lincke
believes that Peter de la Cerlata was the first to use a specu
lum for widening the auditory canal for purposes of inspec
tion. * .
1560] Johannes Arcularius gave some sensible rules for
the management of aural disease . He declaimed, for
instance, against the indiscriminate practice of stuffing the
ear with cotton ; but he advised an extremely peculiar
means of extracting a foreign body from the ear. The
head of a lizard was to be cut off, placed in the affected ear,
and allowed to remain there for three hours. The animal is
then to be removed , when the foreign body will be found in
its mouth .
1560 ] Alexander Benedettirecommends,as a remedy for pain
in the ear, the semen of a boar, which is to be carefully
taken from the vagina of a sow , before she has dropped it upon
the ground . This, however, is the suggestion of a writer on
generalmedicine, and not on otology.
1523–1562] Gabriel Fallopius, in this century, seems to be
entitled to the honor of having first taught that a
discharge of pus from the ear of a child should not be meddled
with ; for as Fallopius gravely taught, and as has been gravely
repeated by his legitimate successors for two hundred and
seventy-three years, this discharge of pus is an effort of na
ture to throw morbid material out of the head through
the ear. The otorrhea of adults, according to Fallopius, is
also a discharge from the brain , and should not be treated by
astringents, but with mild , cleansing remedies. He used an
aural speculum , and employed sulphuric acid to remove
polypi.
1600 ] In the seventeenth century we hear of De Vigo, body
surgeon to Pope Julius II., curing his Holiness of a very
* The passage quoted to sustain this view is “ per inspectionem ad solen
trahendo aurem et ampliando cum speculo aut alio instrumento."
obstinate abscess of the right ear, by means of a mixture, or

liniment, of 3 ij of oil of eggs with 3 iij of oil of roses. What
kind of an abscess this was, or where it was situated , Lincke
does not tell us.
In the latter half of the sixteenth century a certain Capi
vacci seems to have deviated a little from the errors of his pre
decessors. He speaks with more precision of aural disease.
He describes thickening, ulcers, and cicatrices of the mem
brana tympani, and says that deafness which arises from an
affection of the nerve or labyrinth is incurable - a declaration
in which his successors, three hundred years after him , are
forced to unite. Capivaccialso describes a method of making
a differential diagnosis between the diseases of the peripheric
and of the centralparts of the organ of hearing. One end of
an iron rod , an ell in length , is put between the teeth of
the patient, while the other is placed upon a keyed musical
instrument. If he could distinguish the tones produced by
the vibrations of the keys of the instrument, his deafness
depended upon some lesion of themembrana tympani; if not,
it was an affection of the nerve. Here we see glimpses of de
duction from the anatomical knowledge of the time.
Peter Forest, who must have been an Englishman, judging
from his name, but who practised in Rome in this century,
to whose works Lincke gives no definite reference, collected fif
teen cases of aural disease that seem to have been carefully ob
served . One is a case of disease of the ear, ending in an af
fection of the brain and death . He speaks of pain in the ear
caused by the rays of the sun, and he tells a wonderful story
of a female deaf for seven years — so deaf that she could not
hear a clock strike — who, being advised by that character so
common in medical scenes, an old woman , to put some musk
in her ear, did so , and was cured . He also tells how his
teacher,Gisbert Horst, the director of a hospital in Rome,used
to heal deafness with water that was distilled over a young
mouse having no hair.
We trace one of the delusions that still lingers among us
namely, that the hearing is completely destroyed when the
membrana tympani is broken — to a writer named Hercules
Sassonia , who lived in this century. He also had the peculiar
34 A SKETCH OF THE
notion that patients always spoke in a low tone when the

disease of the ear was seated in the auditory nerve, because
the nerve supplying the tongue, a branch of the fifth, was at
the same time affected. In deafness arising from venereal
disease, blisters behind the ear, and a mixture of oil of guaia
cum and hydrochloric acid , as a local application, of which
the patient drank a little , were highly spoken of.
1510 – 1590 ] · The great Frenchman, the father of modern
surgery, Ambrosius Paré, figures in otological his
tory as the first one to employ a syringe for cleansing the
ear .
1597] Caspar Tagliacottzi,of Bologna, who did so much for

plastic surgery, did not neglect the ear, butattempted to
restore the auricle by taking integument from the adjacent
skin . He relates one case of a Benedictine Monk , where he
had done this with success.*
1690 ] Although the aural speculum had been used a hun
dred years before,we find a certain Johann Hartman very
unwilling to use it ; for he seems to advise the detection of
inspissated cerumen by the following simple method. He
placed a curved silver tube into the ear, and blew through it.
If the patient felt the breath to be cold , the deafness did not
proceed from impaction of wax. In our day the detail of
this method is sometimes simplified without altering the
principle ; that is to say, a probe is used to see if wax is in
the ear. Through all this century, the seventeenth , there
are numerous volumes on the treatment of the ear, but they
all tread through the barren waste of drops and decoctions,
theories, nomenclatures, and rank empiricism .
Lusitanus gives an amusing explanation of the practice of
cutting off the ears of thieves. He said that such treatment
rendered them incapable of propagating their kind, and hence
no more thieves could be born of them . He founded this
opinion on the statement of Hippocrates that the division of
the veins behind the ear rendered a man sterile, because the
* The efforts made to instruct and to cure the deaf and dumb, which were
first thoroughly incited in this half of the sixteenth century , we leave for a
fuller discussion in the chapter on deaf-muteism .
semen, which was generated in the brain , could no longer pass

down to the genitals .
Johann Baptista van Helmont, evidently a Belgian, casts
away the theory that had so long prevailed, of deafness being
caused by ascending exhalations, and clears up the whole
matter by ascribing it to the work of the devil, or other evil
spirits.
1610 ] Marcus Banze gives us the first idea of an artificial
membrana tympani, by proposing to place a tube of
ivory in the auditory canal, the end of which is covered by a
bit of pig 's bladder, as a protection to the exposed ear, when
the membrana tympani was lost by ulceration .
1646 ] The renowned surgeon, Fabricius of Hilden , or Fabri
cius Hildanus, so called to distinguish him from Fabri
cius of Acquapendente, contributed somewhat to the surgery of
the ear. He invented an instrument for extracting foreign
bodies from the ear, as, indeed, every surgeon of eminence
seems to have thought it his duty to do. He also wrote of
the removal of aural polypi. P .
In the latter half of the seventeenth century , Thomas Willis

attempted to prove, by experiments on animals, that total
deafness does not ensue when the membrana tympani is
destroyed . He also made some interesting observations on deaf
personswho only heard in the midst of a noise . Von Tröltsch
quotes one of these cases in his text-book,* that of a woman
who could only hear her husband when a servant was beating
a drum . The conversations in that family were probably not
very protracted. This kind of impairment of bearing, which
was called paracusis Willisiana,was referred by its describer
to a relaxation of the membrana tympani, the normal tension
being restored by the noise, 'or vibrations of the atmos
phere.
1683] Du Verney ,known by his labors in the anatomy of the
organ , and his work on the diseases of the ear, contributed
very little to sound knowledge, although he made an attempt
to arrange the diseases in accordance with the anatomy. He,
however, disputed the generally accepted opinion that a dis
* Diseases of the Ear, American translation, 2d edition, p.256 .

A SKETCH OF THE
charge of pus from the ear came from the brain , and showed
that the meatus auditorius internus was closed by the auditory
nerve, and that the pus must pass through the cochlea and
the fenestra ovalis rotunda, before it could get into the exter
nal auditory canal.
Du Verney modified Hippocrates' suggestion to get at a
foreign body not otherwise easily removed , by making an
opening behind the ear, and recommended that the incision
be made upon the upper side, because the vessels are smaller
in this position . He thus anticipates Von Tröltsch, who made
the samemodification of the original suggestion nearly two
hundred years later.*
In the works upon the ear that appear in this century, we
still continue to hear much of worms, or living larvæ , in the ear
- a state of things, however common among the ancients, that
is now very rare, because suppurating ears are usually cleansed.
The disgusting and magical ear-drops of the early and dark
ages are still used in this latter part of the seventeenth century.
Thus one writer records that a Capuchin monk mixed the urine
of a female donkey, that had brought forth but once, with that
of a male hare, of a wolf, or in case of the absence of the latter,
of an entirely white goat, warmed it, and adding a little oil of
caraway, used it as drops for the ear. Urine of the various
animals figures largely among the ear-drops of the period.
Paullini, one of the writers of the day, is in doubt, however,
whether it is proper that women should use the renal secretion
of dogs as a remedy for deafness .
Webegin to hearmore in the latter part of the seventeenth
century of the education of the deaf and dumb,but it is min
gled with much that is absurd in attempts at treatment. The
great error was then made, as it often is now , of supposing
that the diseases of the ear which produced deaf-muteism were
of a different nature from those which in the adult caused
deafness only .
John Wallis, an Englishman, was perhaps the first to in
struct a deaf-mute to speak — which he did , and that very well.
The case was one of acquired deaf-muteism , the patient having
* Diseases ofthe Ear. American translation, p. 488.

lost his hearing at eight years of age ; but he became able to

read the Bible aloud, and to converse with some fluency .
Lincke begins his account of the progress of otology in the
eighteenth century with the lament that it did not keep pace
with the anatomical investigations of the organ , which had
been brought to such a high point by the labors of Valsalva,
Cassebohm , Cotugno, and Scarpa, and he says thatOtology would
have advanced very much faster had Antoine Marie Valsalva
devoted himself more to its prosecution. But Valsalva did
much to give us correct notions in regard to the diseases of
the ear. He adduced cases where the membrana tympani
had been restored. He showed that the hearing power is
merely impaired , not lost, by a perforation of the membrana
tympani. He recognized anchylosis of the base of the stapes
as a cause of deafness. He gave us the Valsalvian experi
ment, the mode of forcing air through the Eustachian tube by
a forced expiration with the mouth and nostrils closed , and
be advises it as the best means of cleansing the middle ear
from pus. He proved that the cavity of the tympanum is
connected to the cells of the mastoid process, by a case in
which he injected the former through a fistulous opening in
the latter.* He also showed that stoppage of the Eustachian
tube is often a cause of deafness . This is certainly a re
freshing catalogue after we have been wading through the
disgusting empiricism of the centuries before.
Valsalva's century is, however , also cursed with theoretic
treatises on aural disease , such as that of one Frederich
Hoffmann, who goes on, in the good old way, with instillations
of wonderfully compounded ear-drops. Lincke mentions
numerous inaugural dissertations of this time, but they relate
chiefly to cases that were not properly understood by the re
porters of them ; and these authors, as well as their theses, are
deservedly forgotten .
1771] J. L. Petit in a work upon surgical diseases, reports
many interesting cases of caries of the temporal bone.
In one case of suppuration in the ear, with caries of themas
toid , he advised that this part should be cut down upon and
* As I have elsewhere shown, this case was for a long time supposed to
be oneof perforation of themastoid . Vide chapter on the disease of the mastoid .
38 A SKETCH OF THE
trepanned . His advice was not followed and the patient died .
He also relates cases where this operation was successfully
performed , and he must therefore be considered as the origi
nator of this valuable procedure .*
1735 ] We then come to the famouspostmaster of Versailles,
Guyot,who first injected the Eustachian tube. His own
hearing was impaired , and in order to relieve it he introduced
an angular tube of tin through the mouth , opposite (gegen ),not
into , the Eustachian tube. The distal extremity of this instru
ment was attached to a leathern tube. This was connected to
the reservoir of two small pumps, which were moved by two
cranks and a wheel fastened in machinery, by means of which
he forced fluid through a curved pewter tube, placed behind
the uvula, into, or about, the mouth of his Eustachian tube,
and removed the impairment of hearing.
1735 ] Beck ,t who quotes from the Hist. de l'Acad. des Sci
ences , thinks thatGuyot washed out the mouth of the Eus
tachian tube. We now know that the procedure alone is a
very valuable one. I regret very much that I cannot get
access to Guyot's original report to the French Academy.
About fifteen years later Archibald Cleland , an English
physician, revised the operation of catheterization of the Eus
tachian tube, and introduced a tube through the nose, which
was a much more practicable method than that of Guyot.
His contemporaries seem to have paid little attention to his
suggestions, for Van Swieten recommends catheterization of
the tube through the mouth as a possible operation . Wilde
attempts to claim the use of the catheter as a British dis
covery. He makes Guyot a mere suggester of the operation
of catheterization, but I think the evidence is in favor of the
French postmaster.
1755] Jonathan Wathan, an English author, reported cases
of restoration of hearing by means of catheterization of
the tube through the nose. His paper is in the Philosophical
Transactions of the Royal Society. He seems not to have
known of Cleland 's labors in the same direction .
* For a full account of the operations on the mastoid ,see the appropriate
chapter in this work .
Die Krankheiten des Gehoerorganes , 1827, p . 21.
Archibald Cleland still farther advanced the science of
otology by introducing a three-inch convex lens, with a han
dle , as a means of examining the ear. The ear was illumin
ated by a waxlight attached to the lens.
1748] Julian Busson proposed, in rather an undecided way,
to perforate the membrana tympani, in order to remove
collections of pus from behind it ; but, as this was a very dan
gerous operation , he advised the inhalation of vapors through
the mouth and nose, and then that they be forced into the
Eustachian tube by means of Valsalva's method , as he thought
that the pus might thus be driven out of the middle ear.
The surgeons, after the seemingly complete failure of phy
sicians to successfully treat diseases of the ear, animated by
the invention of the Eustachian catheter and Petit's operation
for perforation of the mastoid , seem to have been exceedingly
active in otology during the latter half of the eighteenth cen
tury. Antoine Petit,as wellas Cleland , recommended the use of
an instrument through the nose instead of through the mouth ,
as proposed by Guyot, and injections through the tube are
everywhere recommended in their writings.
The successful cases which were reported about this time
were usually among young persons. The reason that the
Eustachian catheter fell into such disrepute can be found in
the fact, that it was used in chronic cases, in which the prog
nosis should have been pronounced bad or hopeless from the
beginning, and a natural disappointment occurred from the
want of success.
One very careful soulwho seems to have been in great hor
ror of the operation , proposed that patients upon whom the
catheter was to be used should have the hairs of the nostrils
removed, and a day before the operation that lukewarm milk ,
or a linseed -mealmixture, or the like, should be drawn into
the nostrils, so as to make the parts more pliable .
1792] The operation of perforation or trephining the mas
toid process fell into great disrepute because a Danish
surgeon, Berger, caused it to be performed upon himself,
and very improperly, for “ deafness which had been years in
occurring, and which was accompanied by vertigo, headache,
and noise in both ears.” Meningitis resulted, and the pa
40 A SKETCH OF THE
tient died in a few days. This put a stop to the performance

of this very useful and necessary operation, until it was lately
revived, chiefly by German and American surgeons.
1800 ] Everard Home,* by his writings, suggested to Sir
Astley Cooper the operation of perforation of the mem
brana tympani, which the great English surgeon performed
successfully in four cases. The history of the rise and fall,
and revival of this operation will be found in the chapter on
chronic non -suppuration of the middle ear.
John Cunningham Saunderst wrote a work on the ear, its
anatomy and diseases, which went through several editions in
England, and one in America.
It is a brief, but scientific treatise , and far beyond its pre
decessors. It is characterized by simplicity, and is without
the absurdities of the older text-books. It is deficient in de
scriptions of the methods of examining the drum -head , and
teaches the erroneous doctrine that it is proper to probe a
membrana tympani to see if it be intact.
It should be remembered that Saunders advised paracen
tisis of the membrana tympani in cases of acute suppura
tion of the tympanumt- an operation that was revived by
Schwartze a few years ago.
He says : “ But let it be admitted that the tympanum has
suppurated , ought the membrana tympani to be abandoned
to a casual ulceration, or is itbetter to open it by art ? I am
inclined to prefer the latter, and if I can be assured , by
any symptom , that suppuration has taken place, I should
not hesitate to make a small perforation of the membrana
tympani, and to repeat it, if necessary, taking, at the same
time, every precaution to suppress the fresh collection of
matter.”
Saunders speaks wisely against the objections made to
checking a purulent discharge from the ears, and shows that
disease of the brain is very apt to follow a neglected chronic
suppuration, and he gives some interesting illustrative cases.
* Philosophical Transactions, 1800.
+ The Anatomy of the Human Ear, & c. Edited by Wm . Price, M .D .,
Philadelphia , 1827.
Ibid ., p . 59.
The book is very deficient in its treatment of the Eustachian

tube. Thus early do we find, in spite of Cleland's and Wa
In whithe
than 's teachings,
h
c English latelo he aagainst
has onlyprejudice gai tthenst
he us
usee of
of th
thee
catheter, which has only lately been overcome.
18 17 ]] J. H . Curtis also published a book on the ear, * but
1817
it added nothing to our knowledge,being a feeble imita
tion of the work of Saunders.
1819 ] J. A. Saissy , of Lyons, devoted the last twelve years
of his life to the study of aural disease. He published a
work on the ear, which attained the honor of a place in the
“ Dictionnaire des Sciences Médicales.” This work was trans
lated into English by Nathan R . Smith , the celebrated Ameri
can surgeon .t
1821] 1. M . G . Itard, Physician to the Royal Deaf and
Dumb Institution in Paris, also publishes a treatise,
which was translated into German , t and which did much in
the pioneer work of clearing up the undergrowth of centuries
of neglect.
Then followed Deleau, on the diseases of the middle ear
and on perforation of the membrana tympani, an operation
for which he claimed more than it deserved.
1827 ] Karl Joseph Beck , of Freiburg , published a Hand
book of the Diseases of the Ear. It is a succinct and
carefully written compendium of what was then known in this
department of science, and has a very good bibliography,
with the exception of the fact that the names of English au
thors are very often misspelled.
1833 ] Wilhelm Kramer, of Berlin , an author who still lives
in a vigorous old age, brought out a work which was
animated by the true scientific spirit, and which greatly sim
plified the practice of otology. He has since then published
a number of volumes .
He introduced a valvular handled speculum , that was an
improvement upon the very clumsy ones hitherto in use. He
* A Treatise on the Physiology and Diseases of the Ear, by John Harrison

Curtis, Esq . 3d Edition . London , 1823.
† An Essay on the Diseases of the Internal Ear. Baltimore , 1829.
Die Krankheiten des Obres und des Gehörs.
& Die Krankheiten des Gehoerorganes. Heidelberg und Leipzig.
42 A SKETCH OF THE
also gave us the air - press, by which air or vapors could be

introduced through the Eustachian tube into the middle ear.
In speaking of the practices of his predecessors, the in
tolerance of Kramer's spirit is seen an intolerance which is
painfully manifest in his later works.* In 1860 he speaks of
the writings of Hinton of London — a writer whom , I am sure,
all my readers will learn to respect, “ as in every respect
unimportant,” while Toynbee 's pathological investigations, to
which science is so much indebted , are actually treated with
sneers. In 1865, Kramer published a monograph,t which is
essentially a review in a very unfriendly spirit of the labors
of Toynbee, Wilde, Von Tröltsch, Erhard, Voltolini, and
others, of whose writings I shall soon speak. What good
work Dr. Kramer actually did for otology in his younger
days has been overshadowed by his subsequent writings.
In spite , of what I am almost inclined to call common sense,
he still persists in rejecting the modern method of investi
gation , as well as the results of examinations of ears re
moved from persons who have been deaf. He still con
tinues to use the handled bi-valved speculum , with sunlight
as the only source of illumination, and on cloudy days sends
away patients without examination ; and because Toynbee
made post-mortem examinations of many ears of persons whom
he had not seen during life, Kramer rejects all pathological
investigations, except experiments conducted upon a dead
body or a glass model. He speaks of Politzer's method of
inflating the middle ear, “ as a miserable resort in cases of
necessity , the employment of which , all pompous commenda
tions to the contrary notwithstanding, stamps him who uses
it with want of skill in the introduction of the catheter."
Again he calls Toynbee, in his work published in 1867, 4 and
this after Toynbee had lost his life in experiments as to the
effect of chloroform and hydrocyanic acid , “ a very poor aural
surgeon .” “ Ein miserabler Ohren -arzt."
These are fair specimens of Dr. Kramer's style in dealing
with an opponent, with any one who claims to have accom
* Ohrenheilkunde der Gegenwart, 1860. Berlin , 1861.
+ Ohrenkrankbeiten und Ohrenartze in England and Deutschland.
Handbuch der Ohrenheilkunde, p . 44 . Berlin , 1867.
plished anything for aural pathology and therapeutics in any

other way than by the employment of his catheters , his
bougies, and his valvular-handled speculum . ..
In this review of what has been done to bring otology up
to its present position , I have been compelled to notice the
difficulties with which the advance of the science has been
obliged to contend in the way of improper and unjust criticism ,
from one who , in this country and England , has acquired the
reputation of a safe guide and leader in this part of the field
ofmedicine.
1841) George Pilcher wrote an essay on the ear, which re
ceived the Fothergillian gold medal from the Medical
Society of London. It is a valuable compilation . The sec
tion on foreign bodies in the meatus is full of warning interest.
There is, however, very little of the author's own experience
in the volume.*
In 1841, a gentleman from New York, consulted Dr. James
Yearsley, of London, in regard to his deafness, who informed
Dr. Y. that he was enabled to improve his hearing power, so
that he could produce in his left ear a degree of hearing
quite sufficient for all ordinary purposes. This was done by
the introduction “ of a spill of paper previously moistened
with cotton to the bottom of the passage.” +
This was the real discovery of the artificial membrana tym
pani, although Dr. Martel Frank , in his cyclopædic text-book ,
refers to a means of preventing injury to the ear, but not of
improving the hearing when the membrana tympani is lost,
which is the use of a silver, gold , or lead tube, the inner end
of which is covered by a membrane. The fact that such a
means of protecting the ear was used in 1640 has been already
alluded to. It cannot be said , however, to be an artificial
membrana tympani in the sense of Yearsley's cotton wool,
which he soon substituted for the paper of the New York pa
tient, or of Toynbee's disk of rubber attached to a wire. The
artificial membrana tympani has proved itself a very valuable
* Treatise on the Structure, Economy, and Diseases of the Ear. American
edition, 1843.
+ On Deafness. Yearsley, p. 221.
44 A SKETCH OF THE
means of treatment, and is in constant use by many of those

who treat suppurations of the middle ear.*
Yearsley's book , as its title indicates, “ Deafness Prac
tically Illustrated ,” is not to be rated with the text-books of
Wilde, Toynbee, Kramer, or Frank.
The work of Dr. Frank,t already alluded to, will be found
a valuable work of reference , although it lacks individuality.
Hoffman 's (Tröltsch ’s) mode of examining the auditory canal
and membrana tympani is fully described by Frank on page
49 of his book ; but he attached no importance to it, not fore
seeing that it was to supersede all other methods, as it has
done, as improved and brought into general use by Von
Tröltsch .
1843] The work of William R . Wilde,# surgeon to St.Mark's
Hospital, which was republished in this country, where
it has had a large circulation, and which was translated into
German, probably did more to place our science upon a
sound basis than anything that has been done in otology since
the days of Valsalva. This work was founded on the obser
vations of a careful observer, who had acquired fine habits of
study as a skillful ophthalmologist. It was not, as the works
of Lincke and Frank , a cyclopædia of what had been written
on otology, nor was it full of absurd theories like that of Kra
mer , but it consisted in the application of thorough anatomi
cal, physiological, and therapeutical knowledge to the study
of an organ that had been hitherto treated as if it were sui
generis, and not subject to the same accidents and diseases,
and consequences of those diseases, as other parts made up ,
in like manner, of integument, of cartilage, mucous mem
brane, periosteum , and bone. In fact, Wilde — now Sir Wil
liam Wilde, in consequence of the well-earned recognition of
his Queen - brought otology, or aural surgery as he called
this department,down from the terra incognita of the ancients
to a point where it could be investigated by the average
practitioner, and where it was respected by all. He gave us
* Frank , p . 293.
+ Practische Anleitung zur Erkenntniss und Behandlung der Ohrenkrank
heiten. Erlanger, 1845.
Practical Observations on Aural Surgery . London.
the conical specula , reviving a suggestion of Dr. Newburg of

Brussels and Ignaz Gruber of Vienna, and drove the unbandy
ones of Fabricius and Kramer out of use. More than all, he
taught us that the most of aural disease was dependent upon
inflammation, and not upon that which was one of Kramer's
pet ideas at that time, “ nervous disease,” whatever that may
mean .
1860] Then came Toynbee's book,* which is mainly valua
ble for its anatomical and pathological investigations. It
can never take rank with Wilde's book as a useful treatise for
the practitioner , indispensable as were Toynbee's labors as an
anatomist and pathologist. Mr. James Hinton's supplement
has, however , materially improved Toynbee's treatise.
1861] Dr. Anton von Tröltsch , of Würzburg, published a
monograph t upon the anatomy of the ear, in 1861,which
he entitled a contribution to the scientific establishment of otol
ogy. It was certainly all that, and something more. While
it gave a very simple and complete account of the anatomy,
except that of the internal ear, there were many wise sugges
tions in the text with regard to the treatment of aural disease.
Von Tröltsch showed himself to be what in the eyes of Kra
mer is a reproach, but what is, in those of the profession at
large, an honorable position, a disciple of Wilde and Toynbee.
He built upon the foundations which the clinical skill of the
Irish, and the industrious labors of the English observer had
made, and brought otology in Germany into a position which
made it an inviting department of labor. His work upon the
anatomy contains the results of many original investigations,
which will be found in the anatomical descriptions of this
volume.
vou
1862] This work on the anatomy of the ear was soon fol
lowed by a text-book upon its diseases,I which had the
same scientific characteristics with the monograph upon the
anatomy. It has been translated into the English , French,
and Italian languages. In this country it met with great
* The Diseases of the Ear: their Nature, Diagnosis, and Treatment.
Reprint, Philadelphia .
+ Die Anatomie des Ohres. Würzburg, 1861.
Die Krankheiten des Ohres.
46 A SKETCH OF THE
favor, having passed through two editions, and it has given

tone to all the otological literature and investigations of its day.
Von Tröltsch improved and brought into general use the
method of illumination first proposed by Dr. Hoffman, of
Westphalia , and thus at one step advanced the science very
materially .
In 1862, the same year that Von Tröltsch issued his text
book , Dr. Adam Politzer , of Vienna, promulgated his method
of injecting the middle ear with air, or of inflating the middle
ear. It is hard to overestimate the value of this simple pro
cedure, and the benefit to our science and art that its invention
caused .
The writer can but quote the opinion of an eminent prac
titioner of this city , who in speaking of Politzer's method once
said to him : “ If a man were to take this air-bag, and travel
through the country, advertising himself as an aurist, and
blow up all the ears indiscriminately that were brought to
him , he would be a very successful quack .” Indeed , the
effects of this means of treatment, especially in the case of
children , or adults who have suffered but a short time from
impairment of the hearing, from disease of themiddle ear, are
often wonderful.
1863 ] Dr. Julius Erhard published a work upon the dis
eases of the ear, which is a peculiar mixture of truth
with error. The book is rather curious and interesting. *
In 1864, Dr. von Tröltsch , Dr. Politzer, and Dr. Herman
Schwartze , of Halle, issued the first number of the Archiv für
Ohrenheilkunde, a work which has been regularly continued
under their management, and which has formed a true guide
to the otological student and practitioner.
In 1865 Dr., now Professor, Politzer published a mono
graph upon the membrana tympani, which was translated into
English , and published in the United States, by my friends
and colleagues Drs . Arthur Mathewson and Homer P . New
ton , of Brooklyn . The frequent use which every recent
writer on otology is obliged to make of this valuable mono
graph , is sufficient evidence of its merit.
In October, 1867,the first number of the Monatsschrift für
* Klinische Otiatrie. Berlin .
Ohrenheilkunde was issued , under the direction of Dr. Volto

lini, of Breslau, Dr. Josef Gruber , of Vienna, Dr. F . E. Weber,
of Berlin, and Dr. N . Rüdlinger, of Munich. All of these edi
tors have contributed very much to the scientific advance of
otology ; while Dr. Rüdinger has probably done more than
any anatomist of his day to elucidate the anatomy of the
Eustachian tube. His photographic atlas of the ear is a work
of permanent value, and one of which the author has made
frequent use in illustrating some of the chapters of this
work.
1866 ] Dr. S. Moos,* of Heidelberg, issued a practical treatise
on aural disease in 1866 , and Dr. Gruber,t of Vienna,
one in 1870. Both of these volumes show much original re
search and are worthy of an English translation , which would
bring them before a much larger circle of readers.
The American Otological Society was established in 1868,
and has held annual meetings since, and has published four
volumes of Transactions. To these papers the author has
had frequent occasion to refer in the preparation of the fol
lowing chapters, and it is believed that they furnish evidence
of the high character of the work that has been done by
American otologists.
No outline of what has been done in the last twenty years
for otology would be complete withouta reference to the writ
ings of Professor Edward H , Clarke, of Harvard University.
Dr. Clarke published a paper on perforations of themembrana
tympani,f its causes and treatment, which was probably the
best that had been written on this subject. It received a full
recognition among foreign authorities. In this article is con
tained a very important sentence, quoted by Von Tröltsch in
his text-book, a passage full of meaning and warning : “ So
necessary is a careful attention to the ear, during the course of an
acute exanthema, that every physician who treats such a case with
out careful attention to the organ of hearing, must be denominated
an unscrupulous practitioner.”
Dr. Clarke has also published a monograph upon polypus
* Klinik der Ohrenkrankheiten .
| Lehrbuch der Ohrenheilkunde.
American Journal of the Medical Sciences, January, 1858 .
48 A SKETCH OF THE
of the ear, which contains very much of value as to the
nature and treatment of these products of inflammation.*
In 1869, Drs. H . Knapp, of New York , and S. Moos, of
Heidelberg, began the publication of the Archives of Ophthal
mology and Otology,which are issued simultaneously in Eng
lish and German, and which have added much to the scienti
fic interest in otology. The union of the two branches of sci
ence in so valuable a journal has certainly assisted to gain the
respect of the profession for the department of otology.
Dr. Lawrence Turnbull issued a treatise on the ear in 1872 ,
which more than any other book as yet published exhibits the
work done in otology on this side of the Atlantic.
Lincke, writing in 1840, regrets that in Germany no clinique
for the treatment of aural patients had as yet been organized.
Dr. Reiner , he says, had attempted to do so in Munich , but
had failed, as had Dr. Lincke in Leipsic ; and we know that
Saunders and Cooper had failed in establishing one in Lon
don ; for in 1804 , Saunders had an eye and ear infirmary in
London, under the name of the “ New London Dispensary for
Curing Diseases of the Eye and Ear.” But the aural part was
so unsuccessful, that it became necessary to close it to the au
ral practice. John Harrison Curtis, in 1816 , was more suc
cessful, and when Lincke wrote, his dispensary was still carried
on. In 1828, the New York Eye and Ear Infirmary,which had
been in existence eight years, treated 91 cases of diseases of
the ear, to 925 of diseases of the eye. That institution , ac
cording to its last published report, treated more than 2,000
aural cases,while every large city of Europe and America now
enjoys the benefits of institutions where aural diseases are
properly and specially treated .
The striking want of success in the treatment of aural dis
ease was due to the fact, that as yet no simple means had
been found for examining the membrana tympani and audi
tory canal. Besides this, the pharynx was not recognized as
the point of origin of the most of aural diseases, and there
was not a simple means of opening and treating the Eusta
chian tube. All these difficulties have been removed in the
· * Observations on the Nature and Treatment of Polypus of the Ear. Bos
ton , 1867.
AUTHORITIES. 49
nineteenth century, and in many details of treatment greatad

vances have been made,which render the care of aural disease
quite as satisfactory as that of any other of human ills. This
is not altogether due to the fact that so many new truths have
been discovered, but much of the gratifying change has re
sulted from the sweeping away of the webs of error.
In concluding this introductory chapter, the author begs
that the reader will bear in mind, that he has notattempted to
make itmore than an outline of what hasbeen done in otology
from the earliest times until our own day. I have attempted
to sketch only that which has left its traces upon the science,
and which has contributed materially to its progress. I
have merely desired to give such a historical account of the
work of the Fathers as would render any frequent references
to them unnecessary in the body of this work, and one which
may be a guide and encouragement for the workers of the
present and the future. The results of the investigations of a
more recent period ,so far as they pertain to the subjects treated
in this volume, will be found in the appropriate chapters.
AUTHORITIES
CONSULTED IN PREPARING THE PRECEDING HISTORICAL SKETCH .
Archiv für Ohrenheilkunde. Herausgegeben von A . Von Tröltsch , A . Polit

zer, und H . Schwartze. Würzburg. Bd. 1 — 6 .
Archives of Ophthalmology and Otology. Edited and published simultane
ously in English and German , by Prof. H . Knapp, M .D ., in New York,
and Prof. S. Moos, M .D ., in Heidelberg . Volumes I. to III. New York :
William Wood & Co. Carlsruhe : Chr. F . R . Müllersche Hof- Buch .
handlung, 1869 –1872.
Allen , Peter. Lectures on Aural Catarrh . J. & A. Churchill. London, 1871.
Beck , Karl Joseph. Die Krankheiten des Gehoerorganes. Heidelberg und
Leipzig , 1827.
NOTE. - For the convenience of the reader who may desire to consult the original
authorities, which the author has examined in preparing the preceding sketch , their com
plete titles are here given . The bibliography will, however, be seen to refer only to the
works actually examined , and not to those mentioned as quoted by the authorities.
50 AUTHORI
TIES
.
Biographie Médicale. Tom . I.-VII. Paris: C. L. F. Panckoucke.

Clarke, Edward H. American Journal of the Medical Sciences, Jan., 1858.
Clarke, Edward H . Observations on the Nature and Treatment of Polypus
of the Ear. Boston , 1867.
Curtis, John Harrison. A Treatise on the Physiology and Diseases of the
Ear. Third edition. London and Edinburgh , 1823 .
Cyclopædia of Anatomy and Physiology. London , 1839. Longman, Brown,
Green & Longmans. Article , “ The Organ of Hearing."
Dunglison , Robley. History of Medicine, from the earliest ages to the
commencement of the nineteenth century . Philadelphia : Lindsay and
Blakiston , 1872 .
Encyclopædia , Chambers'. J. B. Lippincott & Co. Philadelphia, 1872.
Erhard , Julius. Klinische Otiatrie. A . Hirschwald. Berlin, 1863.
Fabricius of Acquapendente. Opera Omnia Anatomica et Physiologica.
Lugduni Batavorum , 1738.
Frank, Martell. Practische Einleitung der Erkentniss und Behandlung der
Ohrenkrankheiten. Erlangen, 1845 .
Gruber, Josef. Lehrbuch der Ohrenheilkunde. Wien , 1870.
Henle, J. Handbuch der Menschen. Bd. II. Braunschweig , 1866 .
Herodotus. A new and literal version from the text of Baehr. By Henry
Cary , M .A . London : Henry G . Bohn, 1854.
Itard , J. M . G . Die Krankheiten des Ohres und des Gehörs. Aus dem
Fransösichen . Weimar, 1822.
Jones , T . Wharton . The Organ of Hearing, in Cyclopædia of Anatomy and
Physiology. London , 1839, vol. ii.
Lincke, CarlGustav. Handbuch der Theoretischen und Praktischen Ohren
heilkunde. Bd. I., II. Leipzig, 1837-1840.
Kramer, W . Die Ohrenheilkunde der Gegenwart (1860.) Berlin , 1861.
Kramer, W . The Aural Surgery of the Present Day. Translated by Henry
Power. New Sydenham Society. London , 1863.
Kramer, W . Handbuch der Ohrenheilkunde. Berlin, 1867.
Kramer, W . Ohrenkrankheiten und Ohrenaerzte in Deutschland und
England. Ein Nachtrag zur Ohrenheilkunde der Gegenwart. Berlin ,
1865.
Kramer, W . Die “ exakten ” deutschen Ohrenärzte . Berlin , 1871.
Monatsschrift für Ohrenheilkunde. Bd. I., vi.
Monro , Alexander . Three Treatises on the Brain , the Eye, and the Ear.
Edinburgh , 1797.
Moos, s. Klinik der Ohrenkrankheiten . Wien : W . Braumüller, 1866.
Politzer, Adam . Die Beleuchtungsbilder des Trommelfells in Gesunden
und Kranken Zustande. Wien , 1865 . Wilhelm Braumüller.
Politzer, Adam . The Membrana Tympanj in Health and Disease, & c.
With Supplement. Translated by A.Matthewson , M .D.,and H . G . New
ton , M .D . New York : William Wood & Co., 1869.
AUTHORITIES.
Saissy, J . A ., M . D . An Essay on the Diseases of the Internal Ear.

Translated from the French by Nathan R . Smith , M . D . With a Supple
ment on Diseases of the External Ear by the Translator. Baltimore,
1829 .
Saunders, John Cunningham . The Anatomy of the Human Ear,illustrated
by a series of Engravings of the natural size, with a treatise on the Dis
eases of that Organ, the causes of deafness and their proper treatment.
First American , from the second London edition. With notes and addi
tions by Wm. Price, M .D . Philadelphia : Benjamin Warner, 1821.
Schwartze, H . Die Wissenschaftliche Entwicklung der Ohrenheilkunde,
Archiv für Ohrenheilkunde, Bd. I.
Shrapnell , Henry Jones. On the Form and Structure of the Membrana
Tympani, p. 120 ; on the Function of the Membrana Tympani, p. 282 ;
on the Nerves of the Ear, p. 505 ; the London Medical Gazette, vol. x.
April 7, 1832, to September 29, 1832. London, 1832.
Soemmering , Sam . Thom . Icones organi-auditus-humani. Frankfort a. M .,
1806 .
Stricker, S. Handbuch der Lehre den Geweben, des Menschen und des
Thieres. Leipzig, 1869– 1871.
Stricker, S . A Manual of Histology. Translated by Henry Power and
others . American translation . Edited by Albert H . Buck . New York ,
1872.
Transactions, Philosophical, of the Royal Society of London . For the
years 1800, 1801.
Transactionsof the American Otological Society. New York . Vol. I.- III.
Toynbee, Joseph. A Descriptive Catalogue of Preparations illustrative of
the Diseases of the Ear, in the Museum of Joseph Toynbee, F . R .S.
London , 1857.
Toynbee, Joseph. The Diseases of the Ear, their Nature, Diagnosis, and
Treatment. (Reprint.) Philadelphia , 1860.
Toynbee, Joseph. The Same, with a Supplement by James Hinton . Lon
don, 1871.
Turnbull, Lawrence. A Clinical Manual of the Diseases of the Ear.
Philadelphia : J. B. Lippincott & Co., 1872.
von Troltsch, Anton. Die Anatomie des Ohres, in ihrer Anwendung auf
dem Praxis. Würzburg, 1861.
von Trollsch, Anton. Die Krankheiten des Obres. Ihre Erkentniss und
Behandlung. Würzburg, 1862.
The same, 4 Aufgabe.
Von Troltsch , Anton. The Diseases of the Ear, their Diagnosis and Treat
ment. Translated into English by D. B. St. John Roosa, M .D. New
York : William Wood & Co., 1864.
von Troltsch , Anton . Treatise on the Diseases of the Ear, including the
Anatomy of the Organ . Second edition , from the fourth German. Trans
lated and edited by D . B. St. John Roosa , M .D . New York : William
Wood & Co., 1869 .
S
RITIE
52 AUTHO .
Wilde, William R. Some Observations on the Early History of Aural

Surgery, and the Nosological Arrangement of Diseases of the Ear, by W .
R . Wilde, M .R .LA. The Dublin Journal of Medical Science. Vol. xxv.
Dublin, 1844.
Wilde, William R . Practical Observations on Aural Surgery, and the
Nature and Treatment of Diseases of the Ear, by William R . Wilde.
London : John Churchill, 1853.
rearsley, James. Deafness Practically Illustrated . Being an Exposition
of the Nature, Causes, and Treatment of Diseases of the Ear. Sixth edi.
tion. London : John Churchill & Sons, 1863.
CHAPTER II .
ANATOMY OF THE AURICLE AND THE EXTERNAL AUDITORY
CANAL
The beautiful appendage to the organ of hearing, which
is called the auricle, or little ear, has as its functions the recep
tion, reflection, and condensation of the waves of sound . Its
general shape is that of a funnel. Its framework , or basis, is
made up of flexible fibro-cartilage, and it is from one to two
millimetres in thickness. The cartilage is of the variety
known as reticular, and it is covered by perichondrium which
contains many elastic fibres. These fibres pass into the sub
stance of the cartilage, and form a network in the meshes of
Fig . 1.
The Auricle.
1. Felis . 2. Anti-helix . 3. Fossa helicis. 4. Concha . 5. Anti- tragus. 6. Tragus.
7. Lobe.
54 ANATOMY OF THE AURICLE.
which small cartilage cells are embedded. From the time of

Rufus of Ephesus (see page 19), the different parts of the auri
cle , which give it its beautiful and useful shape, have been
named as follows: FIG . 2 .
II A. h . F. t.
C. m . A . 30. h .
Profile View of the Skull,with the Skeleton or Cartilage of the Auricle, as well as that of the Ex
ternal Auditory Canal. The latter is exposed and drawn downwards, c.m . After Henie.
1. Meatus auditorius externus. 2. Tuberculum articulare of the temporal bone. 3. Mastoid
process. † Transverse section of the zygomatic process . H . Helix . A . h . Anti-helir.
F . t. Fossa triangularis. S. Scapha , or Fossa navicularis. F . c. Concha . C . h . Cauda
helicis . A. t. Anti-tragus. T. Tragus. * * *. Fissures in the cartilage of the external
auditory canal.
The edge that forms the outer border of the auricle is
called the helix , from a Greek word , enit, anything twisted,
Edloow , to turn around . This ridge varies in breadth , and is
more or less distinct in different individuals, according to the
care that has been taken to preserve the shape of the ear. It
begins at a point on the concave surface ofthe cartilage, called
the spine or crest of the helix , spina seu crista helicis. By fol
lowing down the posterior border with the finger, it will be
seen that its tissue does not pass into the lobe of the ear, but
that the latter is formed by the integument alone.
ANATOMY OF THE AURICLE .
ANATOMY OF THE AURICLE .
Just beneath the helix is a fossa — fossa navicularis, or
boat- like fossa — separating it from a second ridge -like bor
der, the anti-helix . Just in front of the opening into the audi
tory canal the cartilage becomes thickened, and forms a pro
jection or edge called the tragus, or goat, because hairs usu
ally grow upon this part, which were supposed by the ancients
to give it a certain kind of resemblance to the beard of that
animal. Just opposite to this, across the mouth , or meatus, of
the auditory canal, is a similar projection called the anti-tragus.
The greatest concavity of the auricle is called the concha, from
a Greek word meaning concave shell. This concavity passes
into the meatus auditorius externus, or outer opening of the ear.
Above the concha, and separated from it by a projection, is a
depression of a triangular shape, fossa triangularis.
Elastic fibrous bands, springing from the malar bone and
mastoid process , fasten the auricle in its position, and allow a
certain mobility to it. The auricle is completely covered by
the common integument of the body. This integument is
more firmly adherent to the anterior surface of the cartilage
than to the posterior, and from it, at the extremity of the ear,
a projection or tip, called the lobe, is formed. This portion
is poorly supplied with blood and nerves, and is consequently
not very sensitive. It is also very distensible, and when over
burdened by heavy ear-rings may become very much elongated ,
and thus its beauty be greatly marred .
In rare cases the cartilaginous structure extends to the lobe, when severe
reaction will follow the usually harmless operation of boring the ears for the
insertion of ear-rings.- Gruber.*
MUSCLES OF THE AURICLE .

There are three muscleswhich move the auricle, and which
are attached to the surrounding parts . They are
I. Levator or Attollens aurem ,
II. Attrahens aurem ,
III . Retrahens aurem .
They are placed immediately beneath the skin . In man
they are usually rudimentary ; but they are the analogues to
* Lehrbuch, p. 61.
56 ANATOMY OF THE AURICLE .
certain large and important muscles in some of the mam

malia .
Some persons, and especially those whose hearing has become impaired
from chronic aural disease , acquire considerable power in employing these
muscles, as well as the intrinsic ones. I have often observed their action when
patients were listening for the ticking of a watch ,which was being gradually
approached to the ear, and it may be observed when such personsare attempt
ing to hear distant sounds.
The levator is the largest of the three muscles. It is thin
and fan -shaped . It arises from theaponeurosis ofthe occipito
frontalis, and its fibres converge to be inserted into the upper
part of the auricle.
The attrahens aurem is the smallest of the three. It arises
from the lateral edge of the aponeurosis of the occipito-fron
talis muscle. Its fibres converge and are inserted in front of
the helix. This muscle is separated by the temporal fascia
from the temporal artery and vein .
The retrahens aurem consists of two or three bundles of
fibres, which arise from the mastoid process. They are in
serted into the lower part of the cranial surface of the concha.
The names of these muscles indicate their action : the
levator slightly lifts the auricle , the attrahens draws it forwards
and upwards, and the retrahens draws it backward .
Hyrtl states that no brute has a lobe as a part of the auricle, and that
none of the mammals living in water have this appendage. *
INTRINSIC MUSCLES.
The auricle has also a set of muscles which are contained
in its structure ; intrinsic muscles, as they are called by several
authors. With a single exception these muscles run between
different parts of the cartilage of the auricle and of the audi
tory canal.
They are all muscles of animal life , but they are very
slightly developed, and are therefore pale, and thin , and flat.
They lie closely upon the cartilage, and are inserted into its
fibrous covering by means of short tendinous fibres.
They are sometimes absent. It is possible, although not
* Lehrbuch der Anatomie des Menschen , Bd. II, p.617.
ANATOMY OF THE AURICLE. 57
certain, that they always exist1at0 birth, but that they subse
quently atrophy from want ofuse.
Two of these intrinsic muscles of the auricle belong to the
cartilage of the auditory canal, the remainder to the auricle.
The former occasionally run over into the latter.
1. Tragicus. — This muscle lies on the anterior surface of
the anteriorwall of the cartilage of the auditory canal,near
FIG . 3.
11
. . .
..
PROPRIE T
.
REA
RIO
104
de THE
re
ILA
M
Muscles of the External Ear. After Henle.
M . Meatus auditorius externus. H " , Spine of the helix. 1. Attollens, or Levator aurem . 2.
Helicismajor. 3. Helicisminor. 4. Tragicus. 5. Anti-tragicus.
the upperand the lateralborder. It is quadrangular in shape,
and nearly as long as it is broad. It is composed of parallel
fibres running nearly in a vertical direction. (See Fig. 3, 4.)
2. Anti-tragicus. This muscle lies on the posterior surface
of the posterior wall of the cartilage of the meatus. (See
Fig. 3.)
58 ANATOMY OF THE AURICLE.
3. Helicis Minor. Henle says that this is the most con
stant of the muscles of the auricle, and that it is often the
strongest of the intrinsic muscles. It is a fan -shaped muscle,
and is found on the lateral surface of the helix between its
root and spine. (Fig. 3, 3.)
4. Helicis Major.— This muscle runsover the anterior mar
gin of the helix, and is only loosely connected with it, and
passes over by a kind of tendinous termination into the levator
of the auricle. (Fig. 3, 2.)
5. Transversus Auriculæ . - Transverse Muscle of the Auricle.
– This muscle consists of fibres which are not very thickly
combined with loose connective tissue fibres, that run on the
FIG . 4 .
Et
Om
Ta
View of the Cartilage and Muscles on the Posterior Surface of the Auricle. After Henle.
E . t. Elevation made by fossa mangularis. E . c. Elevation formed by concha . 0 . m . Oblique
muscle. E. s. Eleration of scaphoid fossa. T. a. Transversus auricula . C. m . Carti
lage of the external auditory Canal. *. Attachment to the edge of the osseous canal.
C . c. Cartilage of the auricle. C. h . Cauda helicis.
posterior surface of the auricle from the scaphoid fossa to the
concha over the deep furrow corresponding to the anti-helix.
(Fig. 4.)
ANATOMY OF THE AURICLE . 59
6 . Oblique Muscle of the Auricle . — Obliquus Auriculæ . — This
muscle bridges over the furrow on the posterior surface of
the auricle , which corresponds to the prominence on the sur
face of the cartilage that forms the lower, sharp root of the
anti-helis . (See Fig . 4.)
7. Dilator of the Concha. ( Musculus incisurce majoris auri
culo Santorini.) Sometimes the above-named muscle is found
on the tragus.
Hyrtl* has found it arising from the anterior circumference
of the external meatus, whence it runs downwards and out
wards to the lower border of the tragus, which it draws for
ward, and thus enlarges the space of the concha .
The same author says that he knows of no instance of the
voluntary change in form of the auricle by the action of this
muscle.
“ The power of moving the auricle as a whole, is, however, by no means
very rare. Haller speaks of many such cases, and B . 8. Albin , the greatest
anatomist of the eighteenth century , used to take off his wig at his lectures, to
show his students how easily he could move the muscles of the auricle."
Duchenne and Ziemssen ,t by means of faradization , found that the muscles
of the cartilage of the meatus narrowed the incisura auris, and thus the canal
leading into the ear, preventing a portion of the sound undulations from reach
ing the membrana tympani, while, according to Duchenne, the helicis major
and minor lift up the helix , and thus favor the access of the sound waves.
BLOOD-VESSELS OF THE AURICLE .

Arteries :
1. Posterior auricular, from the external carotid .
2. Anterior auricular, from the temporal.
( The temporal is the smaller of the two terminal branches
of the carotid .)
3. An auricular branch of the occipital.
It will thus be seen that the blood supply of the auricle is entirely from the
external carotid artery.
The veins of the external ear empty in part into the tem
poral vein , as well as into the external jugular, or into the
posterior facial vein.
* Hyrt], 1. c., p. 518 . Henle, 1. c., p. 729 .
60 ANATOMY OF THE EXTERNAL AUDITORY CANAL .
NERVES OF THE AURICLE .
The nerves are the
1. Auricularis magnus, from the cervical plexus. The cer
vical plexus is formed by the anterior branches of the four
upper cervical nerves.
2. Posterior auricular, from the facial.
3. An auricular branch of the pneumogastric.
4. An auriculo -temporal branch of the inferior maxillary
nerve.
The branches of the cervical plexus are on the posterior
side of the auricle .
FIG . 5 .
1 4 5 6
Pothurn
larger le domai
8
Horizontal Section of the Head, through the External Auditory Canal. After Henle.
1. Cartilage of the External Auditory Canal. *. Fissurein the cartilage. 2. Cartilage of the
Auricle . 3. Tuberculum articulare of the lower jaw . 4. Fossa mandibularis. 5. Mem
brana tympani. 6. Cavity of the tympanum . 7. Vestibule. 8. Transverse sinus. 9.
Mastoid cells.
External Auditory Canal. (Meatus Auditorius Externus.)

- The canal leading from the auricle to the membrana tym
pani consists of two portions, an outer part, which is formed
of cartilage, and an inner, which is of bone.
Its external opening, which is formed by the cartilaginous
ANATOMY OF THE EXTERNAL AUDITORY CANAL.
portion , corresponds anteriorly and below with the margin of
the external ear. Behind, it is demarcated by the ridge which
connects the anterior border of the auricle with the margin of
the osseousmeatus ; above, it is bounded by the root of the
helix.
Inasmuch as the membrana tympani is not on a horizontal
plane, the walls of the canaldo not extend equally far inward.
The anterior and inferior wall is the longest.
It thus becomes impossible to give an exact measurement
of the canal which can be applied to all ears. The canalis also
curved, and its cartilaginous portion is very elastic.
FIG . 6
2 3
OM
NUN
AU
Section through the External Meatus and the Ear at the point of junction of the Cartilage of
the Auricle,cc, with that of the Auditory Canal. After Henle.
A small portion of the upper wall of the latter remains as a narrow band , CM '. CM ". Lower
wall of the cartilage of the external meatus. H ”. Spine of the helix. L. Lobe of the ear.
* . Fibrous lip of the border of the osseousmeatus. 1. Epicranius temporalis muscle. 2.
Levator auricularis. 3. Temporalmuscle. 4. Upper wall of the osseous canal. 5. Cav
ity of the tympanum . 6. Membrana tympani. 7. Stapes bone. 8. Vestibule . 9. Mea
tus auditorius internus and acoustic nerve. 10. Lower wall of the Osseousmeatus. 11.
Parotid gland .
The first curvature is described by Henle as zigzag in
62 ANATOMY OF THE EXTERNAL AUDITORY CANAL.
shape, and is well shown in the two preceding cuts. This cur
vature is constant.
These curvatures may be overcome, and the outer portion
of the canal rendered nearly if not quite straight, by drawing
the auricle upwards and backwards.
The cartilaginous portion of the canal is interrupted, espe
cially on its inferior wall, by gaps and fissures — the so-called
Incisurce Santorini. These gaps are filled up by fibrous tissue.
The osseous portion is an integral portion of the temporal
bone, and has a groove for the insertion of the membrana
tympani. (Sulcus pro membrana tympani.- Hyrtl.)
The length of the canal, according to Hyrtl, varies from
9 lines to one inch . The average length of the canal, accord
ing to Von Tröltsch,* is about 24 millimetres. The cartilagi
nous portion forms about one-third of this, or 8mm ., and the
osseous canal the remaining two -thirds, or 16mm .
The angle which the upper wall of the canal forms with
the membrana tympani, is an obtuse one ; but that between
the lower wall and the drum -head is acute ; it is one of about
45°.
The width of the canal varies as well as the length . It is
widest at the junction of the osseous with the cartilaginous
canal, and next to the membrana tympani.
According to Hyrtl, if the canal be filled with wax, the cast
is that of a spiral turning anteriorly , inwards and downwards.
The auditory canal is lined by integument, and not by
mucous membrane. Hence it is not correct to speak of a
catarrh of the external auditory canal. This integument is
merely a continuation of that of the general surface of the
body. The nearer it approaches the membrana tympani, the
thinner it becomes, and finally it covers the drum -head as a
very thin layer.
“ The integument of the cartilaginous portion of the canal
is 1 mm . thick, and contains soft hairs, with their sebaceous
glands, the ceruminous glands, and a little fat in its subcuta
neous tissue. In the osseous part of the canal, the integu
ment is only 0.1mm . in thickness, the soft hairs become very
* Treatise on the Ear, 2d American Edition , p . 18 .
ANATOMY OF THE EXTERNAL AUDITORY CANAL . 63
few , and the ceruminous glands are found only on the poste
rior upper wall,where they are generally seen , even close to
the membrana tympani. Small papillæ are found arranged in
rows under the cuticle, and also a corium with abundant elastic
fibres, of which the lower layers pass into the periosteum .” *
The ceruminous glands are like the sudoriparous or sweat
glands in their development and secretion . The only differ
ence between the secretion of the two kinds of glands, is that
the ceruminous glands contain some coloring matter. (Ceru
men is probably derived from cera aurium . — Hyrtl.)
The substance of the ceruminous glands is a yellowish
white , rather fluid material, which consists essentially of fat
globules, coloring matter and cells in which single globules of
fat and coloring matter are embedded ; there are also hairs
and scales of epidermis from the lining of themeatus. — (Kessel.)
When the cerumen has remained in the canal for a long time,
its watery contents are lost by evaporation , and it becomes a
hard mass .
Sometimes the hairs of the canal grow to such a length as
to obscure the view of the meatus and the drum -head. In
such cases I have been obliged to remove them with a pair of
curved scissors. By rubbing upon the surface of the mem
brana tympani, they may cause a tickling sensation in the ear
and become a source of annoyance. Dr. R . F . Weir relates
such a case. +
According to Buchanan, an author who laid too much stress
upon the part which the cerumen plays in the economy, there
are from one thousand to two thousand ceruminous glands.
The child at birth, and for some time after, has no osseous
meatus . The cartilaginous portion is at first attached to a
membranous part, just as it is afterwards to the osseous
portion.
Gruber | thinksthat there is a very narrow rim of osseous canal in the last
months of embryonal life.
In the newly -born this membranous portion constitutes
* The Organ of Hearing. J. Kessel, Stricker's Manual, p. 951. Translated
by J . OrneGreen .
+ Transactions American Otological Society, 3d year.
Monatsschrift für Ohrenheilkunde, Bl. II., p. 67.
ANATOMY OF THE EXTERNAL AUDITORY CANAL .
about one-half of the canal; but it gradually becomes shorter

as the bone grows outwardly . *
This ossification proceeds irregularly, and often leaves a
foramen , which, according to Von Tröltsch, has been mistaken
for a pathological condition, the result of caries.
An inflammation of the meatus in a young child , as shown
by the same author, might readily pass through this foramen
to themaxillary articulation or parotid gland.
The auditory canal of the dog and cat are closed at birth,
as are their eyelids. There is, perhaps, as Von Tröltsch sug
gests, an analogous condition in the closure of themeatus of
young children with vernix caseosa , and the approximation of
the walls of themeatus, near the membrana tympani.
Some birds have the power ofstopping their ears by a kind of valve. The
turkey bas a kind of erectile tissue projecting into the meatus, so that it can
close the ears more or less perfectly when angry. - ( Von Tröltsch .)
RELATIONS OF THE AUDITORY CANAL.

The cartilaginous portion is bounded anteriorly and inferi
orly by the parotid gland. Cases have been observed where
abscesses of the parotid have discharged into the auditory
canal, through the fissures of Santorini.
Enlargements of the parotid or lymphatic glands may con
tract the caliber of the canal by pressure .
The anterior wall is also in relation with the posterior wall
of the articular fossa of the inferior maxillary bone. Hence a
blow upon the chiu may produce a fracture of this plate , and
cause a hemorrhage from the ear. The thick articular car
tilage protects the auditory canal and temporal bone from the
full force of such a blow .
The posterior wall is made up by the mastoid process in
such a way that the canal is only separated from the trans
verse sinus by two thin plates of osseous tissue and the air
cells lying between them . The superior wall is covered on its
upper surface by the dura mater, and forms a portion of the
floor of themiddle fossa of the skull.— (Von Tröltsch .)
Thewall between the integumentof the canal and the dura
* Von Tröltsch, 1. c., p. 6.
ANATOMY OF THE EXTERNAL AUDITORY CANAL. 65
mater, as is shown by the instructive section that is given be

low , may be exceedingly thin , and inflammations of the meatus
may produce disease of the brain.
The auditory canal is bounded above and behind by por
tions of the mastoid cells, that are included in the “ middle
ear,” so that, strictly speaking, a portion of the mastoid part
of the middle ear is situated beyond the membrana tympani.
Inflammations of the mastoid , in not unfrequent cases, occur
with no perforation of the membrana tympani, and the pus
evacuates itself in the auditory canal.
The importance of these relations was first fully pointed out
by Von Tröltsch.
Fig . 7.
Sau .
CGLM . - --- -
MAE ---
Pr. M :
Vertical Section of the Osseous Meatus, right side, close to the Membrana Tympani. After
Von Trollsch .
M . A. E. Externalauditory canal. C ,gl, m . Articularfossa of lower jaw . Sq. Inner part of
the squamous portion of the temporal bone. The dura mater has been removed . F . S .
Fossa sigmoidea for the sinus transversus. Pr. M . Mastoid process.
BLOOD -VESSELS OF THE AUDITORY CANAL .

1. Posterior auricular artery, which also supplies the au
ricle.
2. Deep auricular, from the internal maxillary. It enters
ITIES
66 AUTHOR .
atthe articulation of the lower jaw, supplies the tragus, and

then gives off branches to the canal.
NERVES.
1. From third branch of the tri-facial or fifth nerve. These
enter through the anterior wall, between the cartilaginous and
osseous portions.
2. An auricular branch from the pneumogastric, which
enters the anterior wall of the bony canal.
This auricular branch was first described by Arnold in 1828.
The effect of irritation of this branch is often seen by the cough produced
when the aural speculum is pressed upon it, or when the part is touched by
a probe.
AUTHORITIES .
Gray, Henry . Anatomy, Descriptive and Surgical. Second American

Edition , 1862. (Reprint.) Philadelphia.
Gruber, J . Lehrbuch der Ohrenheilkunde. Wien , 1870 .
Henle, J. Anatomie des Menschen. Braunschweig , 1866.
Hyrti, J . Lehrbuch der Anatomie des Menschen. Wien , 1862.
Kessel, J. The External Ear in Stricker's Manual of Histology. Trans
lated by J. Orne Green . New York , 1872.
Von Troltsch . Treatise on the Diseases ofthe Ear, including theAnatomy
of the Organ. American Translation . New York , 1869.
CHAPTER III .
THE EXAMINATION OF AURAL PATIENTS.
It is a self-evident proposition, that in order to intelli

gently treat any disease, we must carefully and thoroughly
examine the parts involved. This is certainly as true of
the affections of the ear as it is of those of any other organ.
In making such an examination a definite plan should be
followed , even in the seemingly simple cases, until at last
a large experience enables the practitioner to omit or hurry
over some of the details which were necessary in the begin
ning of his practice.
In the examination of an aural patient, the following
method is the one that I have found very useful:- I usually
keep a record of the cases ; a plan which the young, and con
sequently not very busy, practitioner will find extremely valu
able. The name,age, and occupation of the patient are noted .
The history should then be given. This history should include
a pretty full statement of the general condition, the diseases
from which the patient has suffered, the number of times he
has had what is called “ ear-ache,” the medication to which
he has been subjected, and so on, from his earliest recollec
tions until the date of his coming under observation as an
aural patient.
By no other means than by eliciting such a history , can
the practitioner get the essential knowledge for a thorough
understanding of the subjective manifestations of the affec
tion of the ear. It is very important to ascertain when the
troublesome symptomswere first observed. Sometimes sev
eralminutes will be consumed in obtaining an answer to this
question. The first reply will be, perhaps, “ A few months
ago," or, “ A year or two." If this response be followed by
68 EXAMINATION OF AURAL PATIENTS.
the inquiry, " Before that time were your ears perfectly well ? ”
in many instances the patient will state, “ Well, no. I have
had a little dulness of hearing on one side, for ten or twelve
years, or for a good while " (which proves to be a number of
years ) ; or perhaps he says, “ There has been a little discharge
from that ear, which didn 't amount to much ,' ever since I
had the scarlet fever or the measles.” As illustrative of this
point, I may mention a case which lately came to my clinic ;
the patient, an old man , gave the following history : While
sitting quietly by the fire, blood began to run from his ears,
until he had lost quite an amount ; he stated positively that
this was the first time in all his long life that he had ever
had any kind of an affection of the ear, and that he could
imagine no cause for it. On close examination in the man
ner of questioning above indicated , he admitted that he had
suffered from a " slight running from the ears, which didn't sig
nify , ever since he was a child .” An inspection of the organs
showed that both membranæ tympani were removed by
ulceration, and that exuberant granulations existed, which ac
counted for this seemingly mysterious hemorrhage, to which
the patient could assign no cause.
It is well in obtaining the history to allow the patient to
tell his own story, occasionally interrupting him , as may be
necessary, in order to keep him to the matter in hand. After
having thus obtained as accurate an account as possible , the
next step is to test the amount of hearing. We have three
tests for the hearing power :
1. Ordinary conversation .
2. The tick of a watch .
· 3. The tuning - fork .
The first of these tests, the power of hearing conversa
tion, perhaps tells the most about a person 's practical hearing
power, and yet it is the one that is carried out with most diffi
culty . There are many persons who can hear the tick of an
ordinary watch but a short distance, say six inches, and yet
are able to hear ordinary conversation with some ease ; and
on the other hand , there are others who can hear the same
watch twice as far, but who are utterly unable to enjoy con
versation carried on in an ordinary tone. About the best test
THE WATCH AS A TEST OF HEARING . 69
of the hearing power that we have, is the one which shows the
patient's capability for hearing what is said in social inter
course, at the table, in the drawing -room , and so on. Inas
much , however, as practitioners, especially those who live in
large cities or towns, have not always, or even usually , the
opportunity of making such a test of their patient's hearing
capabilities, and since the amount of this power, although it
may be appreciated by the observer himself, cannot be made
clear to one who simply reads the case , we are obliged, in
recording the histories of patients , to be content with a state
ment as to how far an ordinary ticking watch may be heard ,
or at what distance words can be understood when they are
directed to the person observed , with his face so placed that
he cannot see the mouth of the speaker . This latter pre
caution is an essential one, since all persons with impaired
hearing soon learn to watch the lips of the speaker, in order
to compensate for their loss of hearing power.
In testing the hearing by means of the watch, it should
be first placed at a distance at which its ticking cannot
be heard by the patient, and then gradually approached
to a situation where the ticks can be accurately counted.
The latter may fairly be considered as the farthest point of
distinct hearing. The ear which is not being tested should
be closed during the examination by the hand . It is hard to
state the distance at which a watch should be heard by a
healthy ear, for the simple reason that different watches may
be heard at different distances, so varying is the distinctness
of the tick . It may be approximately stated, however, that
an ordinary ticking watch should be heard , by a person with
average hearing power, at least four feet. To this rule there
are, however, exceptions. For instance , I know a medical
gentleman in this city, who, as tested by the ordinary transac
tions of professional and social life, is not at all hard of hear
ing, who cannot hear a watch of common tone more than six
inches. Exact examination would undoubtedly show that this
gentleman 's hearing is defective with regard to all tones like
those of a watch.
In testing the hearing power by means of a watch, it is well
to remember, as Von Tröltsch suggests, that all watches are
70 REGI OF HEA
RIN POW .
STER G ER
heard better immediately after they are wound, and also that the
intensity of their sound is increased by holding them so that
the surgeon 's hand covers the back , or when they are held by
the patient's own hand. In the two latter instances the cause
of the increased clearness of the tick is, in the one case , the
retardation of the reflection of sonorous waves from the watch ,
and in the other, the conducting power of the patient's own
arm as it is stretched out.
The use of a tape or other measurer, to note the number
of inches at which the watch is heard, is indispensable for an
accurate record of a case. The measure should not be used ,
however, until the distance has been ascertained without it.
When the patient cannot hear the watch at any distance
from the ear, it should be laid or pressed upon the auricle ,
mastoid process, or forehead . Before using a watch for the
purpose of testing the hearing power of diseased ears we
should carefully ascertain how far itmay be heard by persons
whose hearing is unimpaired .
My friend Dr. J. S. Prout, Surgeon to the Brooklyn Eye
and Ear Hospital, has greatly facilitated our means of record
ing the hearing power, by a simple method, which is some
what analogous to that used in estimating the acuteness of
vision ; but, as Dr. Prout says,* “ the accuracy with which we
measure the visual power by Snellen 's test types, and record
the results obtained , cannot be arrived at by means of any of
the usual sound-makers (sonofactors ) ; nor will it be until an
instrument can be made which shall always produce uniform
tones.” Dr. Prout recommends a formula for registering the
hearing power, which he describes as follows: " For nearly
three years I have recorded the hearing power as a fraction ,
the numerator of which is the distance at which the particular
sound is heard , the denominator the distance at which it
should be heard by an ear of good average hearing power .
This denominator must vary according to the sonofactor used ,
and should generally be expressed in inches.
“ For still further simplification, and that the method may
be adapted to international use , I suggest the following abbre
viations : A . D ., auris dextra , instead of right ear, or R . E.;
* Boston Medical and Surgical Journal, Feb. 29, 1872.
REGISTER OF HEARING POWER. 71
A . S ., auris sinistra ; P . A ., P . aud., potentia auditûs, hearing
power ; V ., vox, the spoken voice ; V . S ., vox susurrata , whis
pered voice - or simply S., susurrus, a whisper ; H ., horolo
gium , the watch . ..
“ If this system should become general, then the formula
PA, A D , H , = }}, would to all otologists represent the fact
that a watch that should be heard at 36 inches was heard by
the right ear of the patient at a distance of 12 inches ; the
formula P A , AS, VS, = 36, would mean that the whispered
voice was heard by the left ear at 6 inches that should have
been heard at 36 inches."
I have employed Dr. Prout's method (more or less) for
some years. My own watch can be heard by a person with
good hearing power, at least 48 inches. It will be seen that
if I wish to express the hearing power of a person who hears
that watch one inch, I would use the fraction 3, and so on .
If the patient only hears the watch when brought in contact
with the ear , we may employ the formula ; if only on pres
sure, g ; if not at all, a's.
THE TUNING - FORK .

The tuning -fork is of value in determining if any disease
of the auditory nerve exists, and if so , whether its lesion pre
dominate over the affection of the outer parts of the ear.
As is well known, if we close our ears, and speak, the
sound of the voice seems to be confined to the head, as it
were ; its reflection being to a certain extent prevented by the
closure of the external auditory canal. If now the auditory
nerve be sound , and there be impacted wax in one auditory
canal, or a thickening of the mucous membrane lining the
cavity of the tympanum , the state of things will be similar to
that when the external meatus of a healthy ear is closed by
the finger, or by some similar means, and the vibration of
the tuning-fork will be heard more distinctly by an ear thus
affected than by the sound one. If the ears are equally
affected, it will be, of course ,more difficult to come to a con
clusion. If the nerve be seriously impaired , either primarily
or secondarily, by disease which has extended from the mid
72 VALUE OF THE TUNING -FORK .
dle ear, no such marked difference will be noticed when the

external meatus is closed .
Again , when the tick of a watch cannot be heard at all, if
the auditory nerve be not seriously impaired, the vibrations of
the tuning-fork, when its handle is placed on the teeth , fore
head , or mastoid process, will be distinctly heard ; while if
the nerve be the seat of serious lesion , so that absolute deaf
ness exists, these vibrations will not be at all perceived in
the head. Somedeaf-mutes, who were born deaf, and proba
bly with a disease of the central apparatus, have assured me
that they always felt the sound of the tuning-fork passing to
the region of the diaphragm or stomach, and they would in
voluntarily place their hand there when the vibration began .
The large tuning-forks of the note C are to be preferred to the
smaller ones.
There is one source of error in the use of the tuning -fork
that cannot be fully avoided . Patients who do not have fair
habits of observation will say that they near the tuning-fork
better from the better ear, because they think that they ought
to do so . A little care in urging such persons to notice the
sound carefully will usually cause a correct answer to be given.
Its chief value is, however, among persons who can be taught
to observe what they actually hear, and who will allow their
theoretical notions to remain in abeyance for a time. As Dr.
Prout intimates, the great desideratum is an instrument which
will give the same number of vibrations, of the same pitch
and tone under the same conditions. It should also be a
portable instrument, and which can be multiplied with accu
racy to any number that may be wanted by those who test
hearing power.
An interesting case occurred in my practice last spring,
which shows the value of the tuning-fork in cases of slight
impairment of hearing, and also exhibits the inadequacy of
the watch as a test of hearing power.
Dr. W .,æt. 33, consulted meMarch 12 , 1872, in regard to an uncomfortable,
“ stuffy " sensation in the right ear, attended by a slight impairment of hear
ing . His history was that he had had nasal catarrh for somemonths; for two
days be has observed the aural trouble . On testing the hearing power by the
watch , it was found to be normal, or 48 on both sides; but the tuning-fork was
heard better on the affected side, and the patient,a busy physician and an exact
VALUE OF THE TUNING - FORK . 73
observer, was sure that his hearing power was somewhat impaired upon the
right side, although the watch did not detect it. The membrana tympaniwas
slightly injected along the handle of the malleus.
I diagnosticated the affection as sub-acute inflammation of the middle ear
of the right side, and treated it by the use of the Eustachian catheter, Polit
zer's method , and a gargle, as well as by the application of a leech to the
tragus. After the first use of the catheter and Politzer's method, the tuning
fork was heard with equal distinctness on both sides, thus confirming the
diagnosis and illustrating the value of the test. The patient recovered per.
fectly in a few days ; but at each visit before the ear was inflated until his ear
was fully restored to the normal condition , the tuning -fork was heard more
distinctly on the affected side.
According to Politzer,* E . H . Weber was the first to show
the facts that have been stated with regard to the increase in
intensity of the sound of a tuning-fork, on the side of the
meatus that is closed by the finger. Mach, quoted by Politzer ,
explained this fact by the theory that the reflections of the
waves of sound from the ear was prevented by this closure
of the auditory canal. Politzer concludes, as the result of
experiments, which may be found in detail in the first vol
ume of the Archiv für Ohrenheilkunde, that the increased per
ception of sound that is felt in one ear depends upon two
causes :
1. The waves of sound that have been carried from the
bones of the skull to the air of the external auditory canal
are reflected back on the membrana tympani and ossicula
auditus.
2. In accordance with Mach's theory, the passing out of
the waves of sound which have reached the labyrinth and
cavity of the tympanum , through the bones of the head ,t is
prevented by the obstacle they meet in the closed ear.
It will thus be seen that Mach and Politzer explain the
phenomenon of increased perception of sounds conveyed
through the skull, in an ear whose peripheric portions are
obstructed by disease, or by some mechanical cause, entirely
by the theories that the loss of sound is prevented by the
obstruction to its reflection from the auditory canal, and that
back upon the nerve.

* Reprint from WienerMedizinischen Wochenschrift.
+ Archiv für Ohrenheilkunde, B . I., p. 321, 1868. Politzer, 1. c.
-74 VALUE OF THE TUNING -FORK .
Erhard* believes that the increased intensity of the sound

in an ear whose outer opening is closed , is due to the fact that
the force or impression of sounds that otherwise disturb and
distract the mind, is diminished by the closure of the meatus.
This reasoning seems to me plainly fallacious.
Cases of disease of the middle ear that are connected with
disease of the labyrinth , or cases in which the middle ear is
sound on one side, while the nerve is affected , and just the
opposite state of things exists on the other side —that is, the
middle ear is diseased and the nerve sound — will of course ren
der the value of the tuning - fork less positive, and a differen
tial diagnosis difficult.
Dr. Politzert attempted to make the tuning-fork test more
objective, that is to say, less dependent upon the statement of
the patient, by the use of a diagnostic tube with three arms.
The patient has one in each ear, while the surgeon alternately
interrupts the sound communicated by the vibrating tuning
fork through these arms to his own ear, by compressing one
of them with the finger.
If the sound of the tuning- fork be heard to pass more dis
tinctly through one branch or arm than the other, it is con
cluded that there is some obstruction in the middle ear of that
side, which intensifies the impression of sound produced on
the sensorium of the listener as well as that of the patient.
As I understand Politzer's objective test, the ear of the
examiner is placed in the same condition as that of the pa
tient. If it be applied to a person in whom we are positively
certain that the lesion is in the canal or middle ear, and when
the patient hears it more distinctly on that side, the sound
from the corresponding arm of the tube will usually be inten
sified to the listener.
I have placed a plug of cotton in one meatus of a person
whose ears were of equally good hearing power, and have then
used Dr. Politzer's triple -armed diagnostic tube, and thus far I
have heard the sound more intensely in the arm of the tube
that was in the plugged meatus. Other observers have at
times come to a different conclusion in the case of the person
* Klinische Otiatrie, p . 88 .
+ Archiv für Ohrenheilkunde, 1. c .
TUNING -FORK IN DIAGNOSIS.
whom I examined in this way, so that the test is not wholly

reliable .
It requires too many precautions to be generally available.
It is valuable as a physiological test, however.
The diagnosis of a slight impairment of the caliber of the
Eustachian , which is always, as I believe, attended by more
or less catarrh of the tympanic cavity, is rendered easier by
the use of the tuning-fork , as was illustrated by the case on
the preceding page.
If, however, in a decided case of catarrh of the middle ear,
the tuning-fork is heard better on the normal side, we must
conclude that there is some lesion of the labyrinth — perhaps as
Politzer * and Schwartze suggest, “ a fluxion towards the laby
rinth with serous exudation in the nerve structure.” In cases
of this kind, as the pressure upon the labyrinth is removed by
a decrease of the catarrh of the middle ear, the tuning-fork
will be heard better on the affected side.
Politzer + explains the fact that in some cases of perfora
tion of the membrana tympani, the tuning- fork is heard better
on the affected side by two reasons :
1. The mobility of the ossicula auditus, by which the pas
sage outward of the waves of sound that have once reached
the labyrinth is retarded, is lessened .
2 . By the perforation of the drum -head, the cavity of the
tympanum and auditory canal are converted into one space,
and a greater resonance from the larger air -chamber is pro
duced , which acts upon the fenestræ ovalis and rotunda , and
increases the intensity of the perceptive power of the labyrinth .
The tuning -fork used by Politzer in his experiments and
in his practice, corresponds to the second C in the base,
vibrating 512 times in the second. On striking it, we notice
particularly two distinct tones — one the ground tone or domi
. nant, the other the upper tone or musical fifth ; either one or
the other predominates, according to the density of the sub
stance against which the tuning - fork is struck . In employing
it for diagnosis, the predominance of the upper tone is often
very confusing to the patient, and the cause of error .
* L . c., p. 5 . + L. C., p . 12 .
BLAKE 'S TUNING - FORK .
In order to get the pure dominant, it is only necessary to

affix a pair of metal clamps to the ends of the branches ;
this is done by means of small screws. If the tuning-fork is
now struck even with a hard substance, only the dominant
is perceptible. Dr. Schaar, * of Vienna, diminishes the inten
sity of the upper tone by gentle pressure upon the lower por
tion of the branches.
Fig . 8. The value of the tuning- fork in testing the
perception of different musical tones has been
much increased by the discovery that, by fix
ing the clamps at different points upon the
branches, it is possible to obtain all the tones
and semitones up to an octave above the musi
cal fourth of the dominant tone of the tuning
fork . — ( Politzer.)
Dr. Blake , who has written a good digest
of this subject, says that “ Itard used a bell
which was struck by a pendulum , the force of
the blow being determined by the space through
which the pendulum passed before striking ; in
this way the difficulty as to control of the inten
sity of the sound was overcome, but the tone
remained the same.” Following this idea, Dr.
B. caused to be constructed the tuning- fork as
represented in the accompanying wood -cut
(one-third size), that is, the common instrument
with the clamps as used by Dr. Politzer, but
Blake's with the addition of a hammer, the head of
Tuning- Fork.
steel, one face being covered with soft rubber.
“ Lucæ proposed the use of a hammer faced with some elastic
material for striking the tuning -fork . The handle of the ham
mer is a steel spring, sliding in a bar affixed to the stem of
the fork,and fastened in place by a small set screw . By using
either the steel or rubber face of the hammer, either the upper
or lower tone will be rendered most prominent. By affixing
the clamps as Politzer directs, we obtain the variety of tone,
and by the distance to which the hammer is sprung can reg
* Blake, Reprint from Boston Medical and Surgical Journal, p. 3.
+ Blake, 1. c .
THE INTERFERENCE OTOSCOPE.
ulate their intensity. The adjustment is simple, and obvi

ates the necessity of employing any other musical instru
ment."
THE INTERFERENCE OTOSCOPE.
Dr. August Lucæ ,* of Berlin, proposes a new method of examining the
car for physiological and diagnostic purposes by means of what he terms the
interference otoscope interference apparatus would be, I think, a more appro
priate term .
Dr. Lucæ proves by experiment that the human membrana tympani does
not receive the complete intensity of the waves of sound, butthat it reflects a
portion of these waves ; also , that with the increase of the tension of themem
orana tympani, the reflection outward increases, and the reception of the
waves inward decreases. He then describes his apparatus, which is made
after that of G . Quincke, for explaining the reflection of sound waves.
It consists of a vertically placed glass tube, of about 10 inches in length , in
the centre of which is a joint of glass, for the app.ication of a horizontal tube
of gutta -percha, which is placed in the ear of the person to be examined. The
sounds are conveyed through the upper end of the vertically placed glass tube,
to the bottom , and thence through a second rubber tube to the ear of the
observer.
The lateral or horizontal tube passing into the auditory canal of the person
io be examined , should be one-quarter the wave length of the sounds that are
to be experimented with . The wave length from a tuning -fork of the note C '
is 48 Parisian inches.)
A cork with a handle is placed in the end of the lateral glass tube, which
can be pushed backward or drawn forward, and thus increase or decrease the
length of this tube according to the wave length of the sound employed .
As will be seen , the sounds divide in the middle of the tube into two parts .
One part passes directly down to the ear of the examiner ; the other, after it
has been reflected from the end of the lateral glass tube that is stopped by
a cork .
Lucæ 's apparatus is made for the tone C with 264 vibrations. Its wave
lengths are 48 Paris inches. The interference piece is therefore 12 Paris
inches in length .
By the aid of this apparatus, experiments were made on a glassmodel, the
ears of a dead subject, and those of living persons.
For the sake of convenience, Lucæ modified his apparatus. It now con
sists of a double otoscope, like the differential stethoscope of Scott Allison .
These arms are attached by a glass tube, shaped liked the letter X , to two
tubes: one for the ear of the examiner, the other for the resonator or sound
receiver into which the armsof the tuning-fork look . The fork is placed on a
stand and caused to vibrate by means of a hammer. The resonator should be
made of paste-board. The metal ones may injure the ear.
* Archiv für Ohrenheilkunde, Bd. III.
78 THE INTERFERENCE OTOSCOPE.
The interference arms are also made of gutta -percha . By alternately

pressing together one and the other tube of the double otoscope wemay decide
how much the sonorous waves are reflected from each ear. The practical
value of the interference diagnostic tube depends upon Lucæ 's conclusion that
there is a greater reflection of the waves of sound of the worse ear, if there
be disease of the peripheric parts of the organ of hearing . If, however, there
is a weaker reflection from the worse ear, it is concluded that there is disease
of the nerve. *
Lucæ 's theory ofthe increase in intensity of a sound when the meatus is
closed , or when there is peripheric disease, is that the intra -auricular pressure
is increased, which intensifies all sound, although it may prevent their being
distinctly perceived .
If this were so, it would seem that all persons whose hearing is impaired
from middle ear disease, which causes a secondary pressure upon the laby .
rinth - for example, in cases of anchylosis of the stapes-- should be disturbed by
the intensity as well as the indistinctness of sounds.
Lucæt in a subsequent article amplifies his views and does

not accept the theories ofMach and Politzer, that the closure
of the canal or of the cavity of the tympanum prevents the
passage of the waves of sound outward. Indeed he does not
believe that waves of sound that have reached the labyrinth
through the bones of the skull, return through the membrana
tympaniand ossicles. When we speak of the exit of sound
waves from the ear, we can only, according to Lucre, under
stand those undulations which are carried to the air of the
auditory canal from its walls and from the membrana tym
pani.
The conduction of sounds to the labyrinth is diminished
by increased tension of the membrana tympani. Still, when
this increased tension causes a slight but positive variation in
the pressure upon the labyrinth, the perception of deeper
sounds may be increased . The increased intensity of sound,
when the external auditory canal is closed, chiefly affects the
low tones , and is chiefly to be explained by the resonance of
the short column of air in the passage.
Lucæ admits the full diagnostic value of the tuning-fork
* Herr Schäfer, instrument maker, in Berlin , furnishes Lucæ 's inter
ference otoscope for 3 Prussian thalers ; the C tuning -fork for 5 thalers and
10 silver groschens ; the resonator or sound receiver for 2 thalers and 15
groschens. The whole apparatus would therefore cost about $10 in gold .
+ Archiv für Ohrenheilkunde, Bd. V ., p. 98.
VON CONTA'S METHOD .
for all cases of peripheric disease, such as impacted cerumen ,

affections of the cavity of the tympanum , if one side only be
affected , and he says that in all such cases, where the prognosis
is good, the tuning-forks C , C , C ', placed on any part of the
skull, will be heard better on the affected side ; but he does
not accept the theories of Mach and Politzer to explain this
phenomenon, and he limits the value of the tuning-fork in
diagnosis to acute and dangerous suppurative inflammations
of the middle ear, in which , if the tuning-fork be constantly
heard better on the affected side, the brain is not in danger .
VON CONTA 'S METHOD.
Von Conta, * of Weimar, some years since , recommended

that the tuning-fork be used to the exclusion of the watch , in
testing the hearing distance. In hismethod an elastic tube is
used through which the waves of sound are conducted , instead
of through the uninclosed air. The number of seconds or
minutes during which the gradually decreasing vibrations
of the tuning-fork are heard , becomes the measure of the
hearing power. The fork is struck upon the knee of the
examiner, and then immediately placed in the outer extremity
of the tube, which has been previously placed in the pa
tient's ear. The instant he ceases to hear the vibrations he
informs the surgeon by the word “ now ,” who has noted the
time with the watch in hand, when the fork was placed in
the tube.
This method is certainly not without value , but the desid
eratum , namely , a method by which the ability to hear sounds
resembling the human voice may be accurately estimated , is
In testing the visual power we have exact means which

indicate the practical loss of sightwhich the patient may have
suffered. It is to be hoped that the physiology of acoustics
may at no distant day present us one for the accurate estima
tion of a loss of hearing power.
* Archiv für Ohrenheilkunde, Bd. I.

AURAL SPECULA.
EXAMINATION OF AUDITORY CANAL AND MEMBRANA TYMPANI.

The next step after noting the hearing power in the exam
ination of our imaginary patient, is the exploration of the
auditory canal and the membranæ tympani.
It is, of course, implied in this that an affection of the
auricle needs no special assistance for examination.
For the purpose of examining the external auditory canal
three instruments may be necessary : a pair of angular for
Fig . 9.
Angular Forceps.
ceps, an aural speculum , and a concave mirror or reflector.
The first is of use to remove any temporary obstructionswhich
may prevent a view ; the second dilates the canal; and the
third throws the light into it.
According to Wilde,* Dr. Newbourg, in a memoir pub
lished at Brussels in 1827, recommended an instrument which
is the origin of all the tubular ear specula now in use . It was
a slender horn tube, four inches long, with a bell-shaped outer
FIG . 10 .
DER
Gruber's Speculum .
orifice. Subsequently this instrument, which was much too
long,was improved by shortening it, by Dr. Ignaz Gruber, of
* Treatise on Diseases ofthe Ear, p . 60.
METHOD OF HOLDING THE SPECULUM .
Vienna, and generally introduced to the profession by Sir

William Wilde, in 1844. After a fair trial of the bi-valvular
instrument of Kramer, and the funnel-shaped one of Toynbee ,
I now use the conical speculum , either that of Wilde, Tröltsch ,
or Gruber. I do not think that any one of these has any
great advantage over the others. The practitioner will do very
well with any one of them . Too much stress is sometimes
laid on a little change in shape. I prefer that the interior sur
face of the speculum be brilliant, and not black, as those of
Gruber are sometimes made.
Those who consider that there is an advantage in a funnel
shaped instrument, will find the one here figured preferable
to Toynbee's, because the transition from the wide orifice,
which dilates the cartilaginous part of the canal to its fullest
extent, to the narrower, which exposes the osseous portion ,
is gradual, and thus prevents the reflection of many rays at
this point.
The speculum should be made of coin silver, for ordinary
use. For the purpose of applying acids or caustics, one of
hard rubber, porcelain , or glass is to be preferred .
The instrument is warmed by the hand before being used ,
and then inserted gently and slowly into the meatus with the
right hand , and held in position by the thumb and index fin
ger of the left, which will keep the speculum under complete
control, and enable the examiner to turn it so as to succes
sively view the different parts of the whole surface of the
membrana tympani, and at the same time to thoroughly
straighten the canal by pushing up the upper wall of the
canal.
It is very important that the speculum be held properly,
for I have seen many a student, for the want of knowledge of
this simple manipulation , labor for a long time without get
ting any view of themembrane,while the instrument was rest
ing on some portion of the projecting wall of the meatus.
Having thus dilated the canal, the light may be thrown
into it by means of the otoscope or reflector of Von Tröltsch ,
which is a concave mirror of about three inches in diameter ,
having a focal distance of about six inches. Ordinary day
light is the best source of illumination for thismirror,although
82 VON TROLTSCH ' S OTOSCOPE .
sun light, lamp light, gas light, that of a candle, or the reflec
tion from a light-colored wall, may each be made available in
this method of examining the outer parts of the ear. This is
a very simple process , although many make a difficult one of
it. If we but use the skill we acquired in our juvenile days in
throwing a dazzling light upon a desired object by means of
a bit of broken mirror, it will serve us in good stead here.
The mirror is held very lightly in the hand, and the light is
condensed upon any desired part by a very slight movement.
Fig . 11.
Method of holding the Speculum in Position .

It is now almost universally conceded by the profession ,
that this method is altogether the best that has yet been sug
gested for the examination of the membrana tympani. It has
the unequivocal endorsement of such otologists as James
Hinton of London, Schwartze of Halle, Politzer and Joseph
Gruber of Vienna. It was first introduced to the profession
at large by Professor Anton Von Tröltsch, in 1855,without pre
Fig. 12. 85
REYNDERS
OTTO-
Von Tröltsch's Otoscope, actual size.

84 METHOD OF EXAMINING MEMBRANA TYMPANI.
vious knowledge that it had been suggested by others, al

though Dr. Hoffman , of Westphalia , had previously, in 1841,
used an ordinary shaving mirror with a central opening for the
examination of the ear. Professor Edward Jaeger, in his work
on Cataract and Cataract Operations, published in 1853, sug
gests that his ophthalmoscope may be used with the concave
mirror of four inches focal distance, for the examination of the
FIG . 13.
Method of Examining the Auditory Canal and Membrana Tympani.
external auditory canal. I have also been informed by nu

merous practitioners that they have often used the ophthalmu
METHOD OF EXAMINING MEMBRANA TYMPANI. 85
scopic mirror for examining the ear ; but in spite of all these
statements , and the fact that Frank, * in his work on the Ear,
gives a sketch of Hoffman 's otoscope, the credit of the introduc
tion into general use of the concave mirror for the examination
of the ear as certainly belongs to Von Tröltsch , as the inven
tion of the ophthalmoscope to Heinrich Helmholtz. It is
somewhat surprising, however, that after the description which
Frank gives in his text-book of Hoffman 's method, and the
drawing which he furnishes of the mirror, no attention was
paid to the subject until Von Tröltsch revived it, without
knowing of Hoffman's apparatus.
I introduced the use of the aural mirror, or otoscope as it
should be called , into the practice of the New York Eye and
Ear Infirmary, in 1863, where it soon superseded all other
methods, and whence it has been very generally adopted in
the United States.
It may be safely said that the adoption of this simple
method of examination has done more for the scientific and
practical study of aural disease, than any previous suggestion
in this department. It has placed within the hands of every
practitioner a method by which he may, in a few minutes,
learn to examine a membrane which not a few physicians
have never seen on the living subject.
I deem it unnecessary to describe the numerousmethods
which preceded that of Von Tröltsch, since they are fast be
coming obsolete, and their description belongs rather to the
history of otology than to a practical treatise . Even the
method of examination bymeans of the direct rays of the sun ,
which held out so long in the hands of some practitioners, has
at last given way to the use of the mirror and ordinary day
light.
It is sometimes convenient for the examiner and the pa
tient to sit during the examination of the membrana tympani,
and sometimes both may stand , or, as I usually examine, the
patientmay sit in a revolving chair, while the surgeon stands.
The position of the patient will not be an importantmatter ,
so long as a good illumination is thrown into the canal. A
* Practische Anleitung, zur Erkentniss der Ohrenheilkunde, p. 49.

86 BINOCULAR OTOSCOPE .
forehead band is essential in making applications to the ear,

and it is often convenient at other times. I cannot see any
FIG. 14.
Forehead Band.
great advantage in the various complicated and expensive
bands with ball-and- socket joints, but I use a simple screw
attachment by which the mirror is fastened to the head -band .
The head -band should be of elastic material, such as india
rubber webbed cloth .
Dr. Di Rossi,* in a very recent paper on binocular otoscopy , proposes the
use of a microscopic object- glass set at an angle of 70° in a spectacle frame, as
a simple and efficient binocular otoscope. This suggestion has just met my
eye as this volume is passing through the press, and I am inclined to think
that it is a very useful one.t
Dr. Di Rossi's first instrument consisted of an arrange
mentof prisms behind a concave mirror. The prisms are plane,
one of 90°, the other of 10°. The diameter of the concave
mirror is 7 centimetres. Its focaldistance is 16 centimetres.
The central opening in themirror is of an elliptical shape.
The instrument differs from the binocular ophthalmoscope of
Dr. Giraud Teulon in the following respects :
1. The mirror is much larger, inasmuch as ordinary day
light is used as the source of illumination.
2. The focal distance is less.
3. The prisms are of a higher degree.
I think the advantages of binocular vision in examining
the ear are not sufficient to atone for the loss of simplicity and
* Monatsschrift für Ohrenheilkunde, Jahrgang VI, No. 7.
+ Mr. H . W . Hunter, optician , will furnish the apparatus.
Monatsschrift für Ohrenheilkunde, No. 12, 1869.
BLAKE'S PRISMATIC OTOSCOPE . 87 .
cheapness in the instrument used for examination that occurs

when the binocular otoscope is substituted for Von Tröltsch 's
monocular concave mirror. A little practice enables the sur
geon to judge with sufficient accuracy as to the depth of objects
in the canal or upon the drum -head , or beyond it, upon which
he is operating ; for it is only in operating, for example , in
puncturing the membrana tympani, that I have ever felt any
difficulty in judging of the depth of the surface which it was
desired to touch .
Mr. Edward S . Ritchie , of Boston , at the suggestion of
Dr. Clarence J. Blake,* has made an instrument which is
designed to overcome the disadvantages attending the exclu
sion of one eye from the visual act in operating upon the
membrana tympani :
“ It consists of a hand rubber speculum (Politzer's ) of the
largest size, fitted with a metallic rim , to which is attached a
revolving prism and an arm , bearing at its outer end a lens
of about an inch focus ; this arm is movable , but sufficiently
firm to remain fixed at any angle at which it is placed. The
prism is just within the focal dis FIG . 15 .
tance of the lens, and its incident
face is armed with a small metal
shield , having an opening in the cen
tre corresponding in its short diam
eter to the diameter of the pencil of
light falling upon it from the lens.
" The advantage of the prism
over a mirror or other reflecting sur
face is, that we have almost total
reflection ; and but little of the light
concentrated upon the prism by the
lens is lost. Blake's Operating Otoscope.
“ In operating, an assistant is required to draw the auricle
upward and backward , and keep the speculum in position,
with the pencil of light upon the opening in the shield of the
prism . It is not claimed for this instrument that it at all
supersedes the head mirror of Von Tröltsch, but it is certainly
of great advantage in themore complicated operations,where
* Late Contributions to Aural Surgery . Boston , 1870.
88 EXAMINATION OF PHARYNX .
a steady and uniform illumination is indispensable. The

instrument, as a whole, weighs only about one hundred and
fifty grains, and can be made much lighter ; so that when
once firmly inserted in the meatus, it remains in position , and
there is no necessity for holding it nor fear of its slipping out
of place during the operation.”
The practitioner will often be obliged to examine the ear
and pharynx of a patient who is too ill to get up from the bed.
The light from a candle then becomes a very convenient and
ample means of illumination . The finest changes on a mem
brana tympani and in the auditory canal may be observed by
the aid of the otoscope and such a light.
EXAMINATION OF THE PHARYNX AND EUSTACHIAN TUBES.

After having heard the patient's history, and having ascer
tained the amount of hearing, we may proceed to the exami
nation of the pharynx and nares, and mouths of the Eusta
chian tubes. Although the profession has been a long time
in coming to an appreciation of the fact, it is now generally
conceded that the starting-pointof a large percentage of aural
cases is in these parts.
The pharynx is best examined by turning the patient's face
to an open window , and holding the tongue by means of a
Fig . 16 .
Turck's or a simple hinge specu
lum . Turck 's instrument is to be
preferred to others, because the
hand of the examiner does not
obscure the view in its use. I
often, however, use a reflector
and ordinary daylight for an in
spection of the pharynx, and it
Hinge Speculum . has some advantages over a direct
illumination .
Some surgeons prefer to use artificial light in examining
the pharynx as well as other parts of the body, but I much
prefer ordinary daylight for all examinations, when it is pos
sible to use it, to that from any artificial source, or to the
direct rays of the sun, since it seems to me that the natural
RHINOSCOPY.
hues are thus best observed . In the evening, of course, arti

ficial light must be used. A reflector should then be em .
Fig. 17.
113
Turck's Speculum .
ployed . It is well to have the reflector attached to a forehead

band, as in the practice of rhinoscopy or pharyngoscopy,
which will be immediately described ; but I may defer any
description of what to observe on examining the fauces and
pharynx until we come to speak of pharyngeal disease.
RHINOSCOPY.
Rhinoscopy, as a practical method of examining the pos
terior nares, was suggested by Sir William Wilde in his treatise
on aural surgery, having previously been spoken of by Boz
zini, as a possible method of examining the parts behind the
hanging palate , in a book published in Weimar in 1807.*
Professor Czermak, of Prague, following up Turck's inves
tigations on the larynx, was the first to actually introduce
rhinoscopy into anything like general use ; while Dr. Semel
eder , Surgeon to the Gumpendorf Hospital in Vienna, and
afterwards Surgeon to the Archduke Maximilian, while in
Mexico , gave us the first full account of what was to be ob
T. Caswell, 1866.
90 RHINOSCOPY.
served by this means, with some interesting cases. Voltolini,

of Breslau, has also added much to our knowledge of the
value of this means of diagnosis.
It is by no means necessary that every aural patient should
be examined with the so-called rhinoscope, nor will the most
accomplished manipulator be able to see the mouth of the
Eustachian tubes in every case ; but every one who attempts
to treat the disease of the organ of hearing will find his diag
nosis very often facilitated by an inspection of these parts ; for
example, when any unusual difficulty is experienced in enter
ing themouth of the Eustachian tube.
For the practice of rhinoscopy we need a lamp, or other
source of artificial illumination , a small mirror, a tongue spa
tula , and a concave mirror thatmay be attached to a forehead
band or placed on Semeleder's spectacle frame. Any brightly
burning lamp, or a good Argand gas-burner, will answer as a
source of illumination .
Various kinds of costly apparatus for the purpose of con
Fig . 18 .
Todald's Lamp. After Tobold.

densing the light have been suggested and employed. If the
surgeon be not satisfied with an ordinary lamp, perhaps the
RHINOSCOPY. 91
apparatus of Tobold will be found the best. In some in

stances, although not always, an instrument for holding back
the uvula is required . Variousappliances have been suggested
for this purpose, nooses, hooks, spatulas, and so on, for any
of which a surgeon of ordinary tact will find or provide a sub
stitute when wanted .
It is above all things requisite that the patient should be
tractable , and this tractability is perhaps more common than
many surgeons imagine. Those who precede all their mani
pulations by an appeal to their patients to be very quiet,to be
sure not to stir, not to mind a little pain , etc., and who at the
same time make a great show of instruments, will generally
have intractable and timid patients ; but he who goes quietly
to work , will find few patients that will not submit with more
or less patience to all such manipulations as are required in
rhinoscopy, the use of the Eustachian catheter, and the like.
The patient being seated in front of the examiner, with a
good light at one side, the mouth is well opened , and the
tongue held by means of the depressor mentioned above.
The surgeon should be careful in placing the tongue depres
sor, so that he may not cause undue pressure, which will pro
duce gagging, and prevent all further manipulations. The
light is then turned upon the pharynx by the head mirror, so
that it is accurately focused , when the parts will be well
illuminated .
Having secured a good view of the pharynx, uvula , and
tonsils, the throat mirror is to be intro Fig . 19 .
duced. This instrument is first warmed
by holding it for an instant over the
flame of the lamp ; its heat is then S
tested by placing it on the back of the

hand , after which it is gently and quick
ly introduced, with its reflecting face
upwards, into the space between the
soft palate and cavity of the posterior
pharyngeal wall. There are some pa - Anterior Nares Speculum .
tients, however, in whom it will be impossible to make a rhi
noscopic examination , on account of the small space between
the uvula and posterior wall of the pharynx. A very few , also ,
OPY
92 RHINOSC .
have such irritable throats as also to render such an examina

tion impracticable.
The examination of thenostrils anteriorly — anterior rhinos
copy, as it is called by Cohen* — is often an important part of
the examination of a case of aural disease.
It is very often sufficient to place the patient in front of a
good light, and open the nares by pressing upon the tip of the
nose. If an instrument be necessary, I find that the one fig
ured on the preceding page serves a very useful purpose. I am
sorry that I do not know the name of the inventor of this little
instrument.
EXAMINATION OF EUSTACHIAN TUBE .
We may now turn , as the next step in our examination of

a case of supposed aural disease, to the investigation of the
condition of the Eustachian tube and cavity of the tympanum .
The means of this examination may be classified as follows :
I. The Eustachian catheter.
II. Politzer's method .
III. Valsalva 's method .
IV . Eustachian bougies.
From the date of the promulgation of the use of the Eus
tachian catheter by the postmaster of Versailles, Guyot, until
Toynbee 's time, the views of the profession as regards the use
of this instrument have varied exceedingly . At one time it
was almost utterly rejected by the greater number of respect
able practitioners, and at another time has been considered
by them as a panacea in the treatment of aural disease. The
text-books of Wilde and Toynbee, which attached very little
importance to the use of the Eustachian catheter, and which
bear intrinsic evidence that the authors did not choose to be
very familiar with the details of the proper employment of the
instrument, probably did more than anything else to cause the
profession in our own country to settle down , until a few years
since, into the belief that the Eustachian catheter was always
a useless and sometimes a dangerous instrument. I well re
member the discouraging response of a prominent American
* Diseases of the Throat, p . 75 .
INTRODUCTION OF EUSTACHIAN CATHETER . 93
practitioner, who had then had large experience in aural dis

ease , to my statement, at the beginning of my active profes
sional life , that I proposed to use the Eustachian catheter in
the treatment of diseases of the ear, that he was glad to say
that he never had used the instrument, and this was the com
mon sentimentamong our respectable practitioners until a very
recent date . In regard to the change in sentiment in this
regard, I only need to say,that nearly every American surgeon
who now treats auraldisease, attaches much importance to the
use of this instrument.
We have now to speak of the Eustachian catheter as a
means of diagnosis.
The material ofwhich the instrument should be made may
be either alloyed silver or hard rubber. For diagnosis the
silver catheter is to be preferred ; for the injection of warm
vapors , the hard rubber instrument is the only one to be used ,
because the heat will very soon make it impossible for a
patient to bear the metal instrument in the nostril.
In the method of introduction, we proceed as did Archi
bald Cleland, an English surgeon, who, after Guyot, did the
most to demonstrate the utility of entering the mouth of the
Eustachian tube with an instrument, and we pass the catheter
through the nostril. It is very difficult to imagine how the
Versailles layman succeeded in introducing an instrument into
the tube, through the mouth . He certainly did not use a
catheter such as we now employ, and which is sketched on
the next page. This instrument is a delicate tube of about six
inches in length, with a slight curve at its extremity . A long
and flexible catheter might, it is true, be passed behind the soft
palate into or opposite the mouth of the tube, and this is the
operation which Guyot demonstrated to the Paris Academicians,
and which , by removingmucus from about the trumpet-shaped
pharyngeal extremity of the canal, relieved his impairment of
hearing.*
The various steps in the operation of introducing the Eus
tachian catheter are as follows:
1. Let the patient be seated on a chair,with a little higher
back than usual, so that the head may be supported. If the
* For a fuller account of Guyot's operation , see Introductory Chapter.
94 INTRODUCTION OF EUSTACHIAN CATHETER .
FIG . 20 . patient be a child , it can rest its head

against a table or wall, or what is better,
be supported by an adult.
I seldom use the Eustachian catheter in young
children ; for them I prefer Politzer 's method of in
flating the middle ear.
2 . Let the patient blow his nose, so as
to moisten the passage and remove any
collections of mucus, while the surgeon
takes the catheter thoroughly cleansed
and warmed , and forces air through it in
order to be sure that it is permeable.
3. The operator, standing a little to
one side, draws down the upper lip with
the left hand , and with the thumb and
finger of his right hand lightly holds the
catheter close to the funnel-shaped end ,
nearly in a vertical position, with the ring
looking towards the median line of the
body, until it has entered the meatus,
when it is quickly turned to an approach
to the horizontal position , so that the
beak rests on the floor of the nasal mea
tus, close to the septum , with its convexity
upwards.
4 . The catheter is then to be slid or in
sinuated backwards with a gentle motion ,
keeping it as close as possible to the floor
of themeatus, gradually elevating the han
dle until the instrument becomes perfectly
horizontal and the beak rests upon the
posterior wall of the pharynx.
5 . At this point the funnel-shaped end
of the catheter in the hand of the operator
is to be raised a little above the horizontal
line and at the same time withdrawn a
little.
Eustachian Catheters, 6. Turn the catheter about a quarter on
actual size. its axis, from within outwards. This mo
INTRODUCTION OF EUSTACHIAN CATHETER . 95
tion lifts the beak of the instrument into the mouth of the
Eustachian tube. This latter movement is aided somewhat
Fig . 21.
Awit
Introduction of Eustachiun Catheter.

by the contraction of the soft palate, which performs a swal
lowing movement, raises itself,and lifts the beak of the instru
ment into the tube. Once in position the catheter should not
cause the patient any inconvenience in speaking or swallowing.
The difficulties that are found in introducing the catheter,
simple manipulation as it is, arise from two causes :
First, the surgeon does not always hold the instrument in
a vertical position (see Fig. 21) until he has got the beak well
into the meatus. A failure to do this willoften cause the instru
ment to pass between the inferior and middle turbinated bones,
instead of along the floor of themeatus, which must be hugged
in order that the instrument may get to the mouth of the tube.
96 INTRODUC OF EUSTACHI CATHETER .
TION AN
Second , the patient is apt to shut his eyes spasmodically

and contract his facial muscles, and thus prevent the relaxa
FIG . 22.
The Eustachian Catheter in Position .

tion of the parts that is necessary during the manipulation.
This difficulty is only to be overcome by persuading the pa
Fig . 23. tient to open his eyes and look about the room ,
which can be done if the surgeon have a quiet,
assuring manner. This difficulty usually passes
away with the second or third use of the instru
ment, and sometimes it does not arise.
Having introduced the catheter we may
force air through it into the cavity of the tym
panum , by means of an air-bag whose nozzle
should fit accurately into the funnel- shaped ex
tremity of the nasal instrument. Air may also
be blown in from the lungs of the examiner
Air -Bag. through a slender bit of rubber tubing, the tips
DIAGNOSTIC TUBE . 97
of which are placed in the opening of the catheter and the
mouth of the examiner respectively. The use of the rubber
bag or syringe is to be preferred to this method as being a
more cleanly and delicate one.
After air has been forced into the middle ear in this man
ner, the membrana tympani should again be examined by the
surgeon, to determine if it has become injected, or if it has
undergone any change in position ; that is to say, he should
see whether the current has actually reached the cavity of the
tympanum or not.
Most authorities recommend the use of an instrument like
the stethoscope, which is placed in the ear of the patient
while the air is being driven through the tube, and they claim
to be generally able to decide as to whether the air enters by
the sound communicated through the tube. I am constrained
to think that it is very difficult to distinguish sounds proceed
ing from the pharyngeal mouth of the tube from those pro
duced in the cavity of the tympanum , and I do not, therefore,
attach that importance to the use of the stethoscope in this
manner, that has been usually ascribed to it ; but I rely more
upon the appearances of the membrane of the tympanum after
Fig . 24 .
Diagnostic Tube.
the air has been forced in , with some attention also to the
sensations of the patient, as to where the air is felt, than upon
the use of the so -called otoscope - although I would be very
98 DIAGNOSTIC TUBE .
far from wholly rejecting its employment, or from denying

its value.
The otoscope consists essentially of a piece of elastic
tubing with a tip on each end , designed for the ear of the
patient and that of the examiner respectively. It should not
be called an otoscope, but rather, as Kramer suggests, the
diagnostic tube. The mirror for examining the ear should be
called the otoscope, just as that for examining the fundus of
the eye is named the ophthalmoscope ; that for the throat, the
laryngoscope, and so on.
POLITZER'S METHOD OF INFLATING THE EAR.

The next means of examining the condition of the Eusta
chian tube and cavity of the tympanum is named , from the
gentleman who suggested it, Politzer's method . It is a means
of diagnosis and treatment of very great value, and we owe
very much to Dr. Adam Politzer, of Vienna, for this method
ofsending air into the middle ear.
As is very well known, in the action of swallowing, the
uvula rests upon the pharyngeal wall so as to shut off the
upper from the lower pharyngeal space ; so that persons
affected with cleft palate , who cannot thus separate these
spaces, are greatly inconvenienced by the passage of solids
and fluids upwards to the posterior nares. It was long ago
shown that the pharyngeal orifice of the Eustachian tube
opened during the swallowing process. Politzer's method
takes advantage of these physiological facts in the following
way : the person to be examined takes a little water in the
mouth , while the surgeon places the nozzle of an air -bag into
one of the nostrils, closes the other with his finger, and causes
the patient to swallow the water at a given signal previously
agreed upon , when he forces in the air by compressing the
india -rubber bag. I usually say “ now ” ; upon which the
patient swallows.
In examining children, I use, as suggested by Mr. Hinton ,
a piece of rubber tubing, and force the air from my own lungs,
on giving a signalby raising the hand.
The effect of the air thus forced in upon the membrana
POLITZER 'S METHOD. 99
tympani is often almost wonderful. A person who has be

come deaf to ordinary conversation sometimes in an instant
again hears the familiar tones of human conversation, and
feels himself in a new world . In such a case, mucus has usu
ally obstructed the calibre of the tube, and is driven away by
the current of air, which must of necessity go against the
FIG . 25.
Method of Using Politzer's Apparatus. (With Inhaler Attachment.)
mouths of the tube, and will usually pass on into the middle
ear. The patient's own testimony will usually, although not
always, be conclusive as to whether the air entered the ear.
The exceptional cases are those in which the Eustachian tube
and the cavity of the tympanum have become so narrowed by
a hypertrophy and sclerosis of the lining mucous membrane
that only a very narrow , feeble current can enter. We shall
have need to dwell upon the uses of Politzer's method when
100 VALSALVA' S METHOD .
we are discussing the affections of the middle ear, and I there

fore content myself with this description of it, while we pass
on to Valsalva 's method of inflating the ear.
VALSALVA'S METHOD .
The distinguished anatomist Valsalva, who is well known

to the profession by his treatise on the ear, suggested a means
of inflating the membrana tympani, which has become so
popular as to be used by nearly two-thirds of all the patients
who come to physicians on account of their ears. It has been
recommended by generations of medical men as a means of
curing affections of the ear,or of determining if the Eustachian
tube be open, or the drum -head broken. Universal as is its
use , I regard it as almost a useless and not an entirely safe
method. It consists essentially in forcing air into the ear,
after a vigorous inspiration, the mouth and nostrils being
closed. It will be observed that when the ear is inflated by
this method , a very great use of the muscles of the chest
is made ; and just in this lies the danger to the ear. This
vigorous expansion of the chest causes a congestion of the
ear which is sometimes more or less permanent, and materially
harms the part by increasing the flow of blood to it. There
is another objection to the frequent employment of the Val
salvian method , or experiment, as it is sometimes styled . It
soon ceases to have its momentary effect of increasing the
hearing distance, which it does by rendering the membrane of
the drum tenser, and then the membrane becomes relaxed and
flaccid , so that I have sometimes seen the membrana tympani
of patients who have been in the daily and perhaps hourly
habit of forcing air into the ears, flap to and fro like a valve
on the slightest movements of the nostrils.
This latter objection, of course , applies to Politzer'smethod
if it be very frequently practised ; but as it must be done by
means of an apparatus, patients are not so apt to take it into
their own hands.
I do not now advise the use of the Valsalvian method in
the treatment of aural disease , and as a means of diagnosis it
BOUGIES. 101
is, in most cases, vastly inferior to the use of the catheter or

Politzer's method .
Imay add a word about the last-named means of examining
the Eustachian tube, namely , bougies. Filiform catgut bougies
may sometimes be employed with advantage in determining if
the non -entrance of air by the catheter or Politzer's method be
due to a stricture ; but the need for their employment occurs
only in a very limited number of cases , and when they are
used great care and judgment are necessary . This subject
will be fully discussed in the chapter on Chronic Non-suppu
rative Inflammation of the Middle Ear.
It will be understood by the reader that very many cases
of aural disease - for example, those of the external auditory
canal— will not require the exhaustive examination that has
just been detailed ,yet many cases will require a systematic and
complete observation, such as I have attempted to delineate ,
in order to a diagnosis which shall be exact and consequently
valuable. The time thus consumed is sometimes considerable ,
but not as great in amount as those who simply read these
descriptions will perhaps imagine. The details occupy more
in description than in execution ; and their strict performance
will of themselves in timemake those who carry them out good
observers of the phenomena of disease.
CHAPTER IV .
THE DISEASES OF THE AURICLE .
A FINELY formed auricle is justly esteemed one of the marks

of personal beauty. The celebrated physiognomist, Lavater ,
also attached considerable importance to this part in deter
mining character. A humorousGerman critic , quoted by Vol
tolini, in speaking of Lavater's ideas of physiognomy, says :
“ It would be very queer of Dame Nature, if she had hung every
one's character on the nose, so that any one who was a mas
ter in physiognomycould read it. Perhaps fearing this, some
people shut their eyes and are ashamed to look one in the
face.” A French author, Dr. Amédée Joux, quoted by Von
Tröltsch, goes much farther than Lavater in his estimation of
the signification of the auricle ; and besides the part which it
plays in indicating human character, he claims that, more
than any other organ of the body, it descends with its par
ticular form from father to child, and that by the shape of
the auricle we may be assisted in determining the legitimacy
of children , and the conjugal fidelity of a mother. He says ,
“ Montre-moi ton oreille, je te dirai qui,tu es, d 'où tu viens, et où tu
vas,” or, as we should say in English, “ Let me see your ear,
and I will tell you who you are, where you came from , and
where you are going.”
I am inclined to think that this view of the importance of
the auricle is Gallic, rather than truly physiological. Recent
authorities, such as Gruber of Vienna, believe that the grace
and beauty of the auricle have little influence upon the func
tions, whatever may be the physiognomic or other significance
of the part. It makes very little difference as regards the
* Diseases of the Ear. 20 American Edition , p. 14.
FUNCTIONS OF THE AURICLE . 103
hearing power, however much it may affect personal beauty,

whether the auricle lies exactly at a proper and graceful angle
on the head , or whether it be closely adherent, and thus sim
ply form an ugly appendage ; and yet the auricle has func
tions, although, like the muscles which move it, these functions
in man are comparatively unimportant and rudimentary. We
all know , however, that there is some importance attached to
this part by persons with impaired hearing ; for all of us have
seen such persons place the hand behind the auricle when lis
tening intently , in order to facilitate the conduction of sound
into the auditory canal.
Voltolini * considers the auricle to be a reflector, con
denser, and conductor of the waves of sound. As a reflector,
the fossa of the concha throws the sound-waves against the
tragus, whence they pass into the auditory canal. This author
is inclined to the belief that when the auricle is small
the concha is deeper, in order to compensate for the loss.
The auricle is a condenser of sound , just as is every other
firm and elastic body. Its chief function, however, accord
ing to Voltolini, is that of a conductor of sound. If it were
merely a reflector and condenser, it would have done its
work better if formed of bone. It is to be considered as an
external membrana tympani. This outer membrane is placed
in different degrees of tension by reflex action, just as is the
true membrana tympani by the tensor tympani muscle. This
may be illustrated by observing the operation of syringing the
ear. At the entrance of each stream of water, the auricle
moves, and at times this motion is sufficient to cause a back
ward current of thewater from the ear . Again ,many persons
with impaired hearing can hear the watch, if it touch but the
outermost tip of the auricle, while it cannot be heard if held
but a line removed from the part.
Voltolini sums up his consideration of the auricle, by say
ing that “ the auricle may be considered as the outer orifice
of a hearing or speaking-tube, of which the external auditory
canal is the tube proper — and since the sound receiver is so
large in proportion to the calibre and length of the tube we
* Monatsschrift für Ohrenheilkende, Jabrgang II, No. I.
104 MALFORMATIONS .
may see what nonsense it is to recommend the so -called invisi

ble ear-trumpets, which are simply short aural specula .”
A full consideration of the affections of the auricle belongs
rather to general than to special surgery, inasmuch as dis
eases of the auricle rarely cause marked impairment of the
hearing ; and yet, for the sake of completeness in thiswork , I
may call attention to the principal symptoms, with the general
pathology and treatment of malformations and acquired affec
tions of this part. We may conveniently classify them as
follows :
I. - Malformations.
II.-- Tumors .
III. - Malignant disease.
IV . - Injuries.
V . - Eczema.
MALFORMATIONS.
Many of the so-called malformations are the simple results
of ill treatment of the auricle. Many women cover their ears
so tightly with their hair, cap, and hood, as finally , by the
excessive pressure , to obliterate the natural ridges and depres
sions which go to make up a finely shaped ear. Boys often
get into the bad habit of pressing their caps down upon their
ears. They thus cause them to lap over, and give them the
unsightly appearance known as “ dog ears.”
All the attention which we as medical advisers may give
to such acquired malformations, is to warn those who thus
improperly treat this appendage of the risk they are running
of becoming deformed .
There is a class of malformations of the auricle which has
the same pathological interest with other forms of arrested de
velopment, such as spina bifida, coloboma iridis, etc., butunfor
tunately they are also cases for which our art can do nothing.
I refer to those cases in which the auricle is congenitally
absent, or where it exists only in a rudimentary form . In
such instances the middle and internal ear are usually also in
a deficient condition, and the auditory canal closed . Cases
MALFORMATIONS. 105
have been seen , however, where the auricle was absent, while
the other parts of the ear were in a normal condition , and in
which there was a good hearing power. The description of a
case recently reported by Dr. Knapp, of New York , will serve
as a description for the whole class:*
“ In a healthy child of three months, the left auricle con
sisted of a slightly tortuous ridge, two lines in height and
three-quarters of an inch in length . It felt tough to the touch,
like a healthy auricle, being undoubtedly composed of carti
lage and skin . Its shape represented the rudiments of the
helix and lobule ; the other parts of the auricle were not
visible. Immediately in front of the middle of the rudimen
tary auricle, there was a small round depression, indicating
the situation of the external meatus.” An incision through
this point showed that the auditory canal was filled up by
bone, or rather that there was no canal.
The experience of the profession is against the attempt to
open a canal to an organ which will probably be found so im
perfect that sound cannot be perceived by it. By means of
the tuning - fork we may always determine in the case of any
persons of sufficient age whether the central apparatus be or
be not unimpaired. If the canal be closed , while the laby
rinth is intact, the vibrations of a tuning-fork whose handle is
placed on the teeth or forehead will be heard more distinctly
in the affected than in the sound ear. The reflection of the
sound waves is diminished by the stoppage of the auditory
passage, just as in cases of inspissated cerumen and thicken
ing of the mucus membrane of the carity of the tympanum
and the Eustachian tube, or perhaps there is no nervous appa
ratus on that side to receive the sound waves.
Superfluous auricles sometimes occur, just as do supernume
rary toes and fingers. They are objects ofanatomical curiosity
rather than of therapeutical interest. Beck + details a num
ber of cases in which , by freaks of Nature, the auricle was
placed on the back , the shoulder, and near the angle of the
mouth .
* Transactions American Otological Society , p . 14 . 3d Year.

+ Krankheiten des Gehörorgans, p. 108.
106 TUMORS OF THE AURICLE.
The tumors found in the auricle may be divided into the

following classes :
I. - Fibro- cartilaginous.
II.— Sebaceous.
III. — Vascular.
FIBRO-CARTILAGINOUS TUMORS.
The first-named form is a simple hypertrophy of the nor
mal structure of the auricle .
According to Billroth ,* these tumors consist chiefly of fusi
form cells and connective tissue, and are nothing more than
hypertrophy of a cicatrix such as occurs on other parts of the
body after injuries.
They seem to occur much more frequently among the
African than the Caucasian race. I have removed several of
these growths from the auricles of negro women , while I have
but rarely seen them among whites. I am also informed that
they occur very frequently among the Africans of the East
and West Indies, where they grow to an enormous size.
The etiology of these growths is very simple, if my own
experience may be trusted on this point. They occur as the
result of the irritation of the lobes produced by the truly
barbarous custom of piercing the ears in order that ear-rings
may be worn . They are much more apt to be found in the
lower classes, because these use brass ear- rings much more
commonly than wealthier persons, although the growths may
occur even if gold ear-rings are used . They sometimes reach
an enormous size, and become a very serious deformity. If
these ornaments are considered indispensable , as no doubt
they are, ladies should wear them by causing them to be
clasped around the auricle by means of a suitable contrivance
now sold by the jewellers and very much used.
One of the older authors, Frank, gives illustrations of the
proper instruments with which to pierce the ears, with a de
tailed account of the operation ; but the efforts of the medical
adviser should be towards the prevention of the barbarous
custom rather than increasing the facilities for retaining it.
* General Surgical Pathology and Therapeutics, p. 551. Translated by
C . E . Hackley, M . D.
OTHÆMATOMATA . 107
Fibro -cartilaginous tumors should be removed if they

attain such a size as to be at all troublesome. The removal
is readily effected by a V -shaped incision made with strong
scissors. The edges of the wound are then brought together
by sutures. The resulting deformity is usually very slight,
and is much less than that from the tumor.
Sebaceous tumors should be removed by enucleation .
Erectile tumors occurring on the auricle are, perhaps, best
treated by means of the galvano-caustic apparatus, of which
more will be said when we come to the subject of aural polypi.
OTHÆMATOMATA, OR VASCULAR TUMOR OF THE EAR.

The peculiar effusion of blood which quite often occurs in
the auricle , and especially among the insane, and which is
known as othæmatoma, hæmatoma auris, or vascular tumor
of the auricle , has caused quite an amount of discussion
among scientific observers. Virchow * and E . R . Hunt of
Albany, N . Y., are the authors who seem to me to have
given us the clearest and best accounts of this interesting
affection, and , in what I am about to say, I shall avail myself
of their labors , together with some experience of my own on
this subject.
The so-called othæmatomata may be divided into those of
idiopathic and traumatic origin. The idiopathic form occurs
chiefly , though not exclusively , among the insane. I have
seen two cases occurring in people of sound mind, which cor
responded very well with the descriptions of those occurring in
the insane as given by Dr. Hun, whose observations seem
to have been confined to this class. My friend, Dr. E . G .
Loring, has also seen one idiopathic case in a sane person .
The symptoms of the idiopathic form of the affection are as
follows : Before the tumor appears we find the ear or ears, as
the case may be, red and swollen , and the face and eyes give
evidence of a strong determination of blood ; occasionally,
however, there is no redness of the skin , and there is merely
some adema of the auricle ; among the insane there is no
* Die Krankhaften Geschwulsten , Bd. I, p. 135.
† American Journal of Insanity, July, 1870.
108 ОТНЕМАТОМАТА .
manifestation of general ill health . In a few hours, or itmay

be days, an effusion of blood takes place. The tumor occu
pies the concha in the main , but it extends over the auricle so
as to obliterate its ridges and cause the usually beautiful part
to appear like a roundish reddened tumor, varying in size
from a bean to a hen 's egg. This tumor is evidently of an
inflammatory nature, being hot and painful. The swelling is
usually quite firm , but a careful examination will detect
fluctuation.
The vascular tumor of the auricle , judging from Dr. Hun's
statistics, is much more common among men than women .
He reports twenty -four cases, ofwhich twenty -three occurred
in males. The form of insanity was general paresis in eight
cases , melancholia in six , acute mania in four, chronic mania
in four, and dementia in two. These statements accord with
the views of other authors, so that we may conclude that
hæmatoma auris , when occurring in the insane, is a symptom
which is highly unfavorable , and which points to an incurable
form of disease of the brain .
The tumor either ruptures spontaneously, sometimes with
such violence as to spirt the blood to a distance of several
feet, or, unless interfered with, is gradually absorbed. Spon
taneous rupture is more common than absorption .
Dr. Hun 's observations show that the traumatic and idio
pathic othæmatomata are not alike ; for in one case which he
details , an insane person, already suffering from hæmatoma of
one auricle , received a blow from a broom -handle on the other,
which produced swelling and ecchymosis, but no hæmatoma. We
must, therefore , I think, strictly distinguish the idiopathic
from the traumatic form .
The etiology of hæmatoma is deemed by Hun to be two
fold, viz., cerebral congestion and centripetal irritation of the
system by the emotions ; and he considers either of these
causes sufficient to produce the effusion . In general paresis
there is, according to all authors, a tendency to repeated con
gestions of the head , and it is supposed that the blood-vessels
of the ears become so dilated as to favor the effusion . The
second factor in producing hæmatoma auris, centripetal irri
tation of the sympathetic from strong emotions, is especially
OTHÆMATOMATA . 109
active among the insane, because their emotions are not

under the control of the will.
Virchow has made the pathology of othæmatomata very
plain , both by his descriptions and the excellent illustrations
which he furnishes in his great treatise on tumors. He says that
“ the older authors described the affection as erysipelas of the
auricle occurring in the insane. It was supposed that in the
hyperæmia and general change in the system a hemorrhage
occurred , which caused a separation of the perichondrium from
the cartilage ; but in true othæmatomata, pieces of the carti
lage become attached to the perichondrium .”
FIG. 26. FIG . 27
Othaematoma The sameEar after rupture and con

From a Photograph taken from a plaster traction had taken place. After
cast, when the tumefaction was great Hun .
est. After Hun .
CASE I.– J. A. C., æt.34. General Paresis. Admitted January , 1857. In .
sanity hereditary in his family . Discharged June, 1858. Re-admitted May,
1859. July 24, a simple sanguineous cyst was observed in each ear. Effusion
rapidly took place until the outlines of the auricle were obliterated . Sept. 30 ,
the tumors have gradually subsided . Patient died May 10, 1860.
According to the Berlin pathologist, the morbid process
seems to be primarily a softening or deliquescing one, induced
by general disturbances of nutrition, or possibly — although
TA
110 OTHÆMATOMA .
this class of cases seems to belong to itself — by local injuries

of the cartilage. The tumor disappears either by gradual
absorption, spontaneous rupture, or by the puncture of the
surgeon. Coagula often form , which make a delicate coating
over the separated portions, and these afterwards serve as
means of adhesion . When suppuration does not take place,
great deformity is apt to occur from the thickening and retrac
tion of the soft parts, especially of the perichondrium .
Fig . 28. Fig. 29.
Showing amount of contraction after Shows separation of perichonarium

rupture of cyst. After Hun . from the cartilage. After Hun .
CASE II.— D. M ., æt. — . Melancholia . Second attack . Hæmatoma began

May 18, 1869. On July 3, had hæmatoma on both ears. Aug. 1, the left auricle
burstat upper portion of concha,and the contents, consisting of fluid and clotted
blood, were thrown to the ceiling a distance of 12 feet. Died Sept. 9 , 1869. A
section of auricles showed that the perichondrium was much thickened, and
separated from the auricular cartilage on its outer aspect, so as to leave a large,
smooth cavity, lined with a smooth, shining membrane, and containing a few
drops of serous fluid .
The authorities differ as to the proper method of treating
idiopathic othæmatomata. Dr. Hun says that puncturing or
laying open the sac does more harm than good. He believes
that the least amount of deformity is obtained when the effu
sion is gradually absorbed. Dr. Gray, of the Utica Insane
OTHEMATOMATA. 111
Asylum , proposes to ligate the posterior auricular artery.
Gruber advises the evacuation of the fluid and the coagula ,
and the use of a compressive bandage. My own limited expe
rience inclines me to Gruber's method of treatment.
Vascular tumors caused by violence should not be con
founded with those occurring idiopathically .
Gudden , a German writer and physician for the insane,
quoted by Virchow , has shown that the auricles of ancient
statues are very frequently ornamented by tumors resembling
the vascular effusions seen among the insane. In the gallery
at Munich the head of Hercules has such ears. These mis
shapen auricles are the typical marks of the ancient boxers or
pugilists. Such fighters wrapped their hands in leather, and,
thus armed , struck the ears of their antagonists ; consequently
in the figures of Hercules, Pollux, and other classical fighters,
a deformed auricle is a regular appearance. Other historical
personages — the Trojan Hector for example - are represented
as having othæmatomata .
To conclude from these observations that the othæmatom
ata are always the result of traumatic influences , that they
are more frequent among the insane because they are very apt
to injure themselves or be injured by their attendants, seems
to me to be manifestly incorrect, judging both from Dr. Hun 's
observations and from the fact that these tumors are very
uncommon. Even the English writers, living in the land pre
eminent for pugilists, scarcelymention them . Wilde* describes
and gives an illustration of one case, however, which seems to
have been a hæmatoma, but was not recognized as such by
the author. It was idiopathic in origin. It occurred in a
male, aged twenty-four, and was about the size of a small
pear. It occupied the upper portion of the left auricle, be
tween the helix and the concha. It was treated by incisions,
and considerable deformity resulted .
Toynbee + describes these cases under the head of cysts ,
and seems inclined to ascribe a traumatic origin to them , and
he states that it is the opinion of Dr. Thurnam , physician to
one of the County Insane Asylums of England , that they are
* Aural Surgery , English edition , p. 164.
+ Diseases of the Ear, American edition , p . 53 .
112 OTHÆMATOMATA .
less frequent than formerly , on account of the fact that vio

lence is not so much employed in the management of the
insane. Dr. Thurnam evacuated the contents of the tumors,
and used setons, and thus claims to have prevented the
deformity to some extent. Toynbee mentions but one case,
that of a boxer, that he has himself seen ; but his description
is not detailed enough to allow us to judge whether it was
identical with those observed in the insane.
Dr. Hun is so strongly of the opinion that the idiopathic
othæmatoma are symptoms of insanity , that he would con
sider any person having such tumor upon the auricle , even if
sane, as a person to be carefully observed as to cerebral
symptoms. This is an opinion of Dr. Hun's which the
author gained in a recent conversation with him upon this
subject.
I have also recently had a very interesting and instructive
interview with Dr. Brown- Séquard , now of this city , on the
subject of the etiology of vascular tumors of the auricle.
Dr. Séquard has found that sections of the restiform bodies,
or largest column of themedulla oblongata, in animals (Guinea
pigs), will produce a hemorrhage beneath the skin of the auri
cle in from 12 to 24 hours. This hemorrhage is soon followed
by gangrene of the part. I had, through Dr. Séquard's cour
tesy, the opportunity of examining such ears , and of verifying
the fact of the subsequent gangrene. The hemorrhage usually
occurs in the fossa navicularis of the auricle. This hemor
rhage usually takes place on the same side with that of the
section .
Dr. Séquard also stated that sections of the sciatic nerve,
by reflex action upon the medulla , would produce the same
result, and that he had produced in his own person flushing
of the auricle by pinching the sciatic nerve.
Dr. Séquard believes that disease of the base of the brain ,
which is, however, not always attended by insanity , is the
cause of hæmatoma auris. In the human animal, gangrene is
not apt to result from the hemorrhage ; probably because the
thicker tissue of the human auricle has a greater resisting
power.
It will thus be seen that Dr. Séquard's views confirm those
OTHÆMATOMATA . 113
of Dr. Hun ,while they shed a new light upon the valuable
clinical observations of the latter.
Any inflammation of the integument, connective tissue, and
cartilage of the auricle, leading to effusion of serum , blood, or
the formation of pus, will be apt to cause a deformity of
the part ; but such a case should be distinguished from an
othæmatoma.
FIG . 30 .
Auricle Deformed by Inflammation .

The sketch from a photograph,which is here given , shows
the result of what was at first an inflammation of the cartila
ginous portion of the auditory canal. A polypus formed from
the prolonged use of poultices , the inflammation extended to
the tissue of the auricle, and after a long period of suffering,
during which small abscesses were formed,which were evac
uated , after pursuing a sinuous course in the integument, the
auricle attained the shape which is here shown. The hearing
power is unimpaired when the very small meatus is kept
open .
From all that has been written of vascular tumors of the
114 MALIGNANT DISEASE .
ear, and from my own experience, I think we may safely

affirm —
First. That there are two distinct varieties of othæma
tomata : Traumatic and Idiopathic.
Second. That the idiopathic is much more common among
the insane than among others, but that identically or nearly
the same affection does occur among the sane. It is proba
ble, however, from Brown-Séquard 's experiments, that the
affection is caused by some lesion of the base of the brain , so
that although persons suffering from vascular tumor of the
ear may not always be insane, they generally have brain
disease .
Third. The traumatic form differs from the idiopathic in
being a simple extravasation of blood from vessels ruptured
by violence. In such cases the deformity resulting from the
spontaneous effusions does not occur, unless among profes
sional pugilists ,where the violence is frequently repeated , and
the auricle, from repeated hemorrhages, assumes a shape like
that resulting from a true othæmatoma.
MALIGNANT DISEASE.
Epithelioma.— The auricle is sometimes, although not fre
quently, the seat of malignant disease. I have observed one
case of epithelioma of this part, in which the whole auricle
was destroyed , and the disease had invaded the auditory canal.
I lost sight of the patient after some weeks, and I can give no
account of the subsequent course of the disease, which was
unchecked by the treatment adopted — the application of
fuming nitric acid . Dr. J. Orne Green , of Boston ,* also re
ports a case, and quotes one from Velpeau.
Epithelioma of the auricle usually begins as a small papule ,
which finally develops into an open ulcer. This spreads very
rapidly, involving finally the auditory canal and, unless ar
rested , the deeper parts .
Excision or amputation of the parts is the only proper
treatment. When the auricle alone is involved, this is very
* Transactions American Otological Society, third year.

ECZEMA OF THE AURICLE . 115
easily accomplished . In the healing process care should be

taken , as suggested by Dr. Green, to prevent the closure of
the meatus by the cicatrix , a result which followed in the case
reported by him , in consequence of the refusal of the patient
to remain under observation until the wound was healed.
Sarcoma. — Sarcomatous tumors may occur on the auricle
as well as in the auditory canal, where they arise from the
cartilaginous portion . They grow very slowly, but they may
extend to the auditory canal, causing external otitis, to the
middle ear, and even to the labyrinth and meninges of the
brain . Early removal is the only safe means of treatment,
and even then the growth may return .
Vascular Neoplasia . - Angioma, a form of vascular tumor
which , at first sight, according to Gruber, resembles an othæ
matoma, may occur on the auricle . The treatment that has
been attempted in angioma is, in general terms, cauterization
with various substances, or inoculation with vaccine lymph,
the application of tartar emetic ointment, or subcutaneous
injection of dilute tincture of the sesquichloride of iron ; but
the simplest and only effectual remedy is the amputation of
the affected portion.
ECZEMA.
Eczema of the auricle is not one of the most frequent

affections of the ear, as shown by the statistics of eye and
ear hospitals and writers on otology ; but a large number of
cases never come under the attention of special observers , and
are, consequently , not found in their statistics. Inasmuch as
eczema of the auricle is usually attended by the same disease
in the auditory canal, it will be more convenient to speak of
them both at this time.
Eczema of the ear seems to occur more frequently among
females than males ; but it is found in both sexes. The symp
toms are the same as those of eczema in other parts of the body,
with some symptomspeculiar to the ear. The symptomspecu
liar to the ear,are redness, swelling,and the formation ofvesicles
which become pustular, and which finally cover the whole re
gion with unsightly crusts, from which a discharge occurs. The
116 ECZEMA OF THE AURICLE .
auricle becomes a misshapen mass, while the swelling and in .

crustation of the integument lining the auditory passage and
membrana tympani impair the hearing to a serious extent.
Fulness and noise in the ears are then added to the patient's
other symptoms, and the condition is unpleasant in the high
est degree. The disease, when left to itself, is apt to have a
very chronic course, and yet it is very amenable to proper
treatment. The causes of eczema are not very clear. I have
usually observed it in persons of weak constitutions, and not
among the strong and vigorous. It rarely occurs upon the
auricle alone ; but it is usually found in conjunction with the
same disease on other parts of the body, most frequently in
conjunction with eczema of the face and head, although it
sometimes occurs on the auricle and in the meatus alone.
According to Ausspitz,* formerly an assistant to Hebra , the
great dermatologist of Vienna, eczema of the ear differs from
the same disease as it appears in other parts of the body, in
occurring with a greater amount of swelling and secretion of
a serous fluid than is usual, together with the more frequent
appearance of fissures in the tissue.
Treatment. — The treatment of eczema is simple, and I have
usually found the results very good . The advice of Ausspitz ,
to do as little as possible in the acute form , is excellent. The
auricle should be kept from the air. This may be accom
plished by the use of oils, powders, or even by a plaster- of
Paris bandage . A good application is the formula of Aus
spitz :
R Flor. Zinci .. . .. . . .. .. . . . .. .. . . . . 3 ij
Pulv , Alum
Amyli Pulv. Š āā .. . .. .. .. ...... ... 3j
M . Ft. pulv .
This powder is dusted over the affected portion with a
camel's-hair brush . If theauricle be excoriated and sensitive,
astringent solutions of sulphate of zinc may be used .
At the same time with this local treatment, as in all other
diseases, the physician should carefully consider the general
* Archiv für Ohrenheilkunde, Bd. I., p. 124.
ECZEMA OF THE AURICLE. 117
state of the patient, since in this, a cause for the eczema may
often be found ,which being removed by appropriate manage
ment, will prevent a relapse of the affection .
Eczema of the auricle and auditory canal is not often
brought to the notice of the surgeon until it has become
chronic. Its treatment then may require the greatest patience
and care The treatment which I have found usually success
ful is the following : The auricle is carefully poulticed with
flax -seed meal until all the crusts can be removed , and is then
anointed with an ointment of the sulphate of iron and simple
cerate, in the proportions of from one to two grains of the
former to a drachm of the latter. This ointment is applied as
often as may be necessary to keep the part constantly anointed ,
until the vesicles have ceased to form .
The local treatment of the auditory canal is often unsuc
cessful from the want of the personal attention of the physi
cian . No one who is unable to examine the external opening
of the ear down to the membrana tympani, can tell when it is
or is not clean . Without a thorough removal of the material
thrown off in an eczema, there can be no cure. An eczema
tous auricle may perhaps recover spontaneously , an eczema
tous auditory canal will, probably , never thus return to a
normal condition . The material thrown off from the inflamed
integument collects in the narrow passage, and by mechan
ical irritation increases the swelling, and produces the most
troublesome symptom of the disease — deafness. The audi
tory canal should be therefore carefully cleansed every day
with the syringe and angular forceps or cotton -holder, under
a good illumination with the otoscope, and then an appro
priate liquid application be made. A liquid preparation is to
be preferred to an unctuous one, for the simple reason that
an ointment will again block up the passage, and thus pre
vent the patient from securing the full benefit to his hearing
power which the removalof the epidermis, crusts , and pus has
produced. Wemay fail to cure many a case of disease of the
integument lining this part, if we do not carry out our own
advice ; we should never give over the treatment into the
hands of the parents or attendants of the patient, for they
will be incompetent assistants.
118 ECZEMA OF THE AURICLE .
The warm douche is very valuable in the treatment of

chronic eczema of the canal. It allays itching sensations,
and is usually very grateful to the patient. The use of the
douche may be entrusted to the patient himself. It is well to
use it very often in the early periods of treatment, say once an
hour. The warm water is a direct antiphlogistic ; I have seen
its use alone, curemost obstinate cases of inflammation of the
canal, that have existed for years.
The only specific remedy for internal use in chronic eczema
of the auricle, as well as that of the same disease in other
parts of the body, is arsenic . In very chronic cases I usually
give Fowler's solution in connection with the local treatment,
and it is usually of great avail.
I am aware of various other modes of treating eczema,
and of the almost innumerable applications which are recom
mended ; but I feel confident that that which I have sketched
will serve its purpose so well, when modified by individual
judgment in practice, as to fulfill all reasonable requirements.
Calcareous formations are often found in the auricle , in
persons of a gouty habit, as in other parts of the body.
These symptoms of gout often cause a great deal of local pain,
which is sometimes relieved by an unctuous application to the
hardened and tender parts . Dr. Garrod, * of London , first
called attention to these formations, which he found to be
urate of soda. They were most frequently found by Garrod
on the upper border of the helix , and were supposed not to
exist on the lower part of the auricle ; but I found what seemed
to be such a formation , in the concha of a gentleman who suf
fered from gout. Unlike those cases reported by Dr. Garrod,
this spot was very painful.
* Von Tröltsch, Diseases of the Ear, p. 56.
CHAPTER V .
DIFFUSE AND CIRCUMSCRIBED INFLAMMATION OF THE
EXTERNAL AUDITORY CANAL .
The affections of the external auditory canal may be con .

veniently arranged as follows:
1.— Diffuse inflammation.
II. — Circumscribed inflammation .
III. – Vegetable fungous growths.
IV. - Inspissated cerumen.
V. - Eczema.
VI. — Foreign bodies .
VII. – Polypi.
VIII. — Exostoses and hyperostoses .
IX . - Syphilitic condylomata and ulcers.
To avoid any misconception , I would remark that while
bony growths (exostoses and hyperostoses) are classed under
the affections of the external auditory canal, they are actually
consequences of inflammations of the middle ear. It will
therefore be more appropriate to consider this rather impor
tant subject under the head of diseases of the cavity of the
tympanum . An account of their pathology and treatment
will be found in the chapter devoted to the Consequences of
Chronic Suppuration of the Middle Ear. The subject of Aural
Polypi will also be deferred until a subsequent chapter, for
they are also much more frequently the result of inflammation
of the middle ear, than of disease of the external auditory
canal.
Otitis externa is the generic term for all the various forms
of inflammation of the external auditory passage, but it is not
specific enough for any exact study of these affections.
120 DIFFUSE INFLAMMATION .
Inflammations of the external auditory canal are much

more rare than those of the middle ear ; of 1000 cases of the
different varieties of aural disease observed by myself in pri
vate practice, but 132 were cases of affections of the outer ear.
This proportion is about the same in the statistics of other
authors and those of public institutions.
Some writers speak of the inflammations of the external
auditory passage as being catarrhal in its nature ; but as Von
Tröltsch strongly insists, and as has already been said in the
description of the anatomy of the auditory canal, there cannot
be catarrhal inflammation where there is no mucousmembrane.
The lining of this passage is integument, and in no proper
sense can we speak of a catarrh of the integument.
DIFFUSE INFLAMMATION.
I will first give an account of the diffuse form of inflam
mation of the auditory canal.
Symptoms. — The subjective symptoms of diffuse inflamma
tion of the external auditory canal are itching sensations in
the canal, pain , and a sense of fulness.
I speak of these symptoms in the order in which, on care
ful examination of the history of the cases, I have found they
usually appear. It is true that patients often give a period
later than the one in which the itching sensations occurred, as
the one in which their ears first troubled them , but ears in a
normal state have, so to speak, no sensations ; that is to say,
they are not thought of, and need no especial care. When an
ear begins to require something to relieve itching sensations,
it is already diseased .
The objective symptoms are impairment of hearing, red
ness of the canal and of the membrana tympani, swelling, and,
at a subsequent period , suppuration of the epidermis and
integument. In the lower part of the canal, dealing as we do
with periosteum , the pain will be intense, like that from a
paronychia . An inflammation of integument that is so tightly
bound down to the bone as is this portion of the integumen
tary lining of the auditory canal, can but be essentially a
periostitis.
DIFFUSE INFLAMMATION. 121
Prolonged suppuration of the integument, or even suppu

rative action that has been of short duration , but violent, may
produce polypi, or, as I prefer to call them , granulations, in
the external auditory canal. I have the notes of four such
cases. One, that of a lady, was complicated by a precedent
inflammation of the cavity of the tympanum ; but the inflam
mation of the external auditory canal was an independent one.
Very large granulations, or polypi, sprang up in a few days
after a poultice had been applied. This poultice was ordered
by the attending physician to relieve the initial pain of an in
flammation of the canal, such as sometimes occurs from the
continued instillation of astringents. It was applied for some
days through a misunderstanding of the damage that might
ensue, and very large granulations formed.
The second case occurred in an Irish laborer , whom I saw
at my clinic in the University Medical College. I removed a
large polypus from the meatus, which the patient stated posi
tively had occurred in a few days, and that he had never pre
viously suffered from disease of the ear. After the treatment
had progressed for some time, I found that the inflammation
was confined to the canal and the outer layer of the drum
head , and that his statement as to the existence of previous
disease was probably correct. I could find no cause for the
rapid course of the inflammation .
The third case I saw at the Brooklyn Eye and Ear Hos
pital. The trouble in the ear had lasted seven days, and here
also there was a large polypus.
The fourth case was that of a lady whom I saw in pri
vate practice . She suffered from what she supposes to have
been an abscess or furuncle of the external meatus. It was
lanced, and then poultices were applied . I saw her six days
after. She had used the poultices nearly the whole of the six
days. I found the canal blocked up by a polypus as large as
a filbert, growing from the anterior wall of the canal. The
final result of this case in deformity of the auricle , is seen in
the engraving on page 113.
The microscopic appearances of the growths are identical
with those of polypi springing from the mucous membrane of
122 DIFFUSE INFLAMMATION - CAUSES.
the cavity of the tympanum , which will be fully discussed in

a subsequent chapter.
Although it is anticipating somewhat of what should be
said under the head of treatment, I will here state that the un
doubted cause of these growths, in two of the cases just given ,
was the prolonged use of the poultices. Von Tröltsch called
attention to the fact that poultices produced tedious suppura
tion ; but I believe this is the first intimation that they cause
the sprouting up of exuberant granulations in the canal.
Causes.— The causes of the diffuse form of inflammation are
various. Irritation of the ear by means of ear-picks, by hair
pins, favorite instruments with women ; the instillation of such
agents as Harlem oil, Cologne water, camphorated oil, and so
on, are frequent causes of an inflammation of this part. There
is probably some antecedent inflammation of the integument
which causes a resort to those agents, to relieve the trouble
some itching sensations. Cold draughts of air are often
spoken of as causes of inflammation of the outer canal ; but
such influences are more apt to produce an inflammation of
the naso-pharyngeal space ,and through that of the middle ear.
In fact, the causes of external otitis diffusa seem to be chiefly
local, if I may so speak ; that is, the disease is caused by me
chanical causes acting locally . There may, however, be an
antecedent eczematous inflammation before the diffuse , non
eruptive form begins.
Of late an apparatus, consisting of a very small sponge
attached to an appropriate handle, and called an aurilave, has
been devised , and is sold largely by apothecaries as an instru
ment for cleansing the ear. It does a great dealof harm . By
its use the secretions are packed in the ear, and inflammation
of the integument or inspissation of the cerumen is very often
caused.
Physicians are often asked if the outer ear should be pro
tected from the cold air by a plug of cotton, ear muffs, or
similar means. The beginning of aural inflammation is rarely
from the auditory canal, although the auricle is sometimes
frozen from exposure to cold . If, however, a person sit in a
railway carriage which is going very fast, with the ear next
DIFFUSE INFLAMMATION — TREATMENT. 123
to an open window , or if the auditory canal and membrana

tympani be exposed in any similar manner to a draught of air ,
an inflammation of the canal and of the tympanic cavity may
ensue. But when there is no such draught upon the ear, as,
for instance, when a person is walking or driving in the open
air, there is no need, unless there is danger that the auricle
will be frost-bitten , of using a covering to the meatus audito
rius any more than to the nostrils . The natural curvatures
of the canal will prevent a current of air from reaching the
drum -head. This is, however, only true as respects healthy
ears. In cases of chronic aural catarrh , and in the other
kinds of middle ear troubles, the canals sometimes become
very sensitive to the cold, and require protection when healthy
ears do not. When no inconvenience is felt from allowing the
ears to remain uncovered , it is better to leave them without
protection. The habit of plugging the auditory canals with
cotton on every slight pretext is a bad one, because it is apt
to cause the ears to become over -sensitive. As I have said ,
we do not usually get an inflammation of the ear from an
exposure of the auditory canal, but from such causes as
wet feet, an exposure of the whole surface of the body, and
so on.
There is altogether too much solicitude on the part of
mothers and other persons as to the cleanliness of their chil
dren 's or their own ears. The auricle and the edges of the
opening into the canal, which are about all that the little fin
ger will reach , are the only parts of the organ that require
cleansing when the ears are in a state of health . Any further
manipulations with towels, ear-spoons, and so on , are med
dlesome, and may become dangerous to the health of the
canal.
Treatment. - An attack of otitis externa diffusa in an adult

may be usually cut short by the use of leeches. They should
be applied, as Wilde long ago pointed out, not on the mastoid
process but on the tragus, for the reason which Von Tröltsch
gives, that in this place the vessels which supply the canal
and outer layer of membrana tympani are most conveniently
and surely reached . Leeches in this form of disease are not
124 AURAL DOUCHE .
as certain in their effects ,however, as when used for an inflam

mation of the middle ear ; when, as we shall see, they exert an
almost magical influence, so rapid is their effect. In the early
stages of the disease , when the pain is severe, and suppura
tion has not yet occurred, but the canal is red, swelled, and
sensitive, greatbenefit will be produced by scarifications of the
cartilaginous wall. This scarification is made with a tenotomy
knife. The incisions should be from three-fourths to an inch
long on the walls of the canal, as recommended by Gruber, of
Vienna . Warm water should also be allowed to run into the
ear , by means of Clarke's aural douche, or any similar means.
FIG . 31.
E . H . Clarke's Aural Douche.
When patients are told to apply warm water to the ear,unless

they are particularly instructed, they will almost invariably
use the syringe, thinking that is the way in which the water is
to be applied ; but what is required is the steady flow of warm
water upon the part,and this is best attained bymeans of the
douche. Patients should be instructed in its use, and espe
cially should they be told that, unless the auricle is kept on
the stretch , so that the walls of the canal are apart, the water
will not enter the ear. The douche is the same as the so
called nasal douche of Weber, and is very valuable in cases
of aural inflammation . As has been seen in the first chap
ter, Hippocrates advised the use of warm water to the ear for
DIFFUSE INFLAMMATION — TREATMENT. 125
the relief of pain , but it fell into undeserved disuse until the
value of its application was reinforced upon the minds of a
profession filled with the idea of the virtues of composite " ear
drops."
Of late the cup has been made of soft rubber, and it thus
becomes much more convenient to carry about. In the ab
sence of the cup, a bit of rubber tubing and an ordinary bowl,
by the application of the principle of the syphon, will make an
efficient and simple douche.
The value of the auraldouche is by no means limited to
cases of inflammation of the outer portions of the ear. In
acute inflammations and chronic suppurations of the middle
ear, it becomes a very valuable means of alleviating pain and
of cleansing the ear. For the latter purpose it is especially
valuable among children .
If the use of the leeches, the employment of scarification ,
is quite unlikely — a small flax-seed poultice may be applied in

the canal ; but the ear should not be covered by a large poul
tice, as is often done ; such poultices relax the tissue to so
great an extent that granulations or polypi are apt to spring
up from the softened and loosened tissue, as we have seen in
the cases that I have detailed. A poultice should never be
applied to or on the ear for more than a few hours. They are
almost as dangerous a remedy in aural as in ophthalmic
practice , where they have caused the loss of many eyes.
At night the ear should be kept warm by wrapping it in
from beneath , by means of a rubber bag filled with hot water,

or some similar contrivance. By attention to these details
much suffering will be spared the patient, and the course of
the affection will be shortened . In addition to the local treat
ment it will sometimes be necessary, although not often, to
give one of the preparations of morphine, or a dose of chloral
internally. I have not found much advantage from the addi
tion of narcotics to the warm water instillations, although
there may be some benefit from their use. Magendie' s solu
tion of morphia is the agent I usually employ in the ear, using
about one part to eight of water, dropped when warm into the
126 DIFFUSE INFLAMMATION — TREATMENT .
canal. The popular remedies for ear-ache, dependent upon

whatever cause , are usually sweet -oil and laudanum , molasses,
Harlem oil, glycerine, and a roasted onion. The oil, lauda
num , and molasses are tolerably efficient ; but although they
are useful in their property of stilling pain , they are far infe
rior to the leeches, scarification , and warm water. I have
seen children , who had been suffering from severe pain in the
ear, drop off to sleep in a few moments after a tablespoonful
of warm water was poured into the ear ; and yet I am very
sorry to say that there are some rare cases where warm water
seems to aggravate the pain ; but the leeches scarcely ever
fail us.
The onion acts just as the conical flax-seed poultice, and
may be resorted to if the warm water fails, and leeches are
not to be had. Harlem oil, and all similar stimulating appli
cations, do nothing but harm , and increase the sufferings of
use hey Theainlaityn resort
apatient.
octorbecfor
thetdistressed
ha dsubmit
tand t toh ppain iin tthe
days a, to without
he eear, such applications,
going to a
physician, because they have been taught by sad experience
that doctors pay very little attention to an ear-ache— and yet
what pain is worse ? Warm vapor of any kind, the smoke
from a cigar, for example, is very grateful to an inflamed audi
tory canal or membrana tympani ; and a steam nebulizer be
comes at some times a very useful adjuvant in treatment of
acute aural inflammations. Sometimes, children , who awake
auditory canal.
Some practitioners are in the habit of indiscriminately
advising blisters behind the ear in all forms of aural disease,
whether acute or chronic. Whatever may be their virtue in
chronic disease , they are only an aggravation in the acute
forms of aural inflammation, and must give a patient an unfa
vorable idea of the benefits of counter -irritation. Speedy
relief from the severe pain of otitis is as imperative as in peri
tonitis or iritis , and I have dwelt on the various remedies at
some length , in order that the practitioner may be at no loss
for some agent that will cut short the inflammatory action.
I will tabulate the remedies in the order that I consider them
valuable : 1. Leeches ; 2. Scarifications ; 3 . Warm douche ; 4.
SYRINGING THE EAR. 127
Conical poultice in the canal; 5 . Steam or warm vapor ; 6.
Opium or chloral.
Dr. A. D .Williams, of St Louis, has recommended the use
of a solution of a sulphate ofatropia , two grains to the ounce,
which is dropped into the auditory canal as a remedy for the
relief of the pain from aural inflammation. I have not as yet
had sufficient experience in its use to give an opinion as to
the value of the remedy in this class of cases. A suggestion
from such a competent observer is well worthy of attention.
Most adult patients go about while suffering from external
diffuse otitis. During the more acute stages it would be bet
ter to keep them in -doors and in bed . If this can be accom
plished, the use of diaphoretics will aid the local treatment.
If, in spite of our efforts, suppuration is once fairly estab
lished, or if the disease has advanced to this point when first
seen by the practitioner, we must endeavor to limit the suppu
ration . To this end thorough cleansing of the ears is neces
sary. This is best accomplished by syringing — a simple pro
cedure, but one which many physicians are unable to carry
out efficiently and with neatness. The appliances necessary
for a thorough syringing of the ear are, first, a good syringe.
I think the small hard -rubber syringe is the best, although a
Davidson's syringe does very well. The glass syringes are of
no use whatever.
Fig . 32.
Hard Rubber Syringe.

Then we need a bowl- a small one, not a large wash -bowl,
but one such as is used as a finger-bowl - being thin and easily
in the syringing process. No towels or napkins are needed

about the neck , to prevent spilling the water ; no assistant be
side the patient is required, if he be an adult, and if the proce
128 SYRINGING THE EAR .
dure be carried out as will be described. The patient being

seated, holds the bowl well under the auricle, in the hollow
just under the lobe, keeping the head perfectly straight, and
using both hands to steady the vessel. The surgeon should
thoroughly straighten the auditory canal with the left hand,
and placing the nozzle of the syringe well into the meatus,
direct the stream with the right, down to the membrana tym
pani. It is well to prepare the patient for the shock of the
water, by allowing a part of the first syringeful to pass into
the concha, and not into the canal.
FIG . 33.
Method of Syringing the Ear.

It will be seen , that no patient is capable of thoroughly
syringing his own ear, and that no person who has not been
taught the simple process will be able to accomplish the object
for which syringing is undertaken, that is, the cleansing
of the auditory canal and the outer surface of the membrana
SYRINGING THE EAR. 129
tympani. Notwithstanding these facts , patients suffering from

an ulcerative process in the ear, and who require the daily
removal of the pus as an essential to recovery, are often sent
away without other instruction than the advice to syringe the
ear. It is almost as difficult for a person to properly syringe
his own ear, as to cauterize his own palpebral conjunctiva.
We certainly should never think of leaving the latter manipu
lation to any but a person who had been taught to manage it
properly .
The ear affected with chronic external otitis should be
cleansed from one to three times daily , while the secretion is
at its height. This cleansing should always be done under a
good illumination by means of the otoscope attached to a
forehead band . The parts should be then dried by means of
cotton twisted about a thin bit of wood , or a steel cotton
holder .
The agents which may be used in checking ulceration are
numerous. I prefer solutions of nitrate of silver , of alum , and
of the sulphates of zinc and copper,to the others. The nitrate
of silver I use in strong solutions, from 20 to 40 grains to
the ounce, pencilled over the parts ; the sulphates and the
alum in solutions of from 1 to 4 grains to the ounce , instilled
into the ear. The choice of the astringent is, however, much
less important than the thorough removal of the pus, which
should be done at least three times a week , and , if possible ,
daily , by the physician himself.
What may be done for a neglected suppuration of the
auditory canal, by the mere daily removal of the pus and the
application of a caustic or astringent, however many altera
tives and other constitutional remedies may have been taken
in vain , is sometimes marvellous.
The practitioner should always be on his guard, lest he
mistake a chronic suppuration in the middle ear for one of the
auditory canal, with an intact membrana tympani. It will be
seen by the statistics in the chapter on the former disease,that
a long-continued suppuration in the ear usually has its origin ,
not in the canal, or outer layer of the drum -head, but in the
cavity of the tympanum whence it advances and perforates the
membrana tympani. Chronic suppuration from the external
130 FURUNCLES IN THE AUDITORY CANAL.
auditory canal, contrary to what has often been written upon

this subject, and contrary to the opinion of most practitioners
with whom I have conversed on this subject, is, judging from my
experience, a rare disease. When it does exist, it is, if properly
treated , by the free use of warm water astringents ,and leeches,
if need be, exceedingly tractable , and almost always curable .
CIRCUMSCRIBED INFLAMMATION OF THE EXTERNAL AUDITORY

CANAL, OR FURUNCLES OF THE CANAL.
By circumscribed inflammation occurring in this part we
simply mean furuncles . They generally arise in connection
with the existence of furuncles in other parts of the body, and
are, like them , very painful. They also produce deafness by
mechanically closing the auditory canal. Tinnitus aurium
noise in the ears— a symptom which is apt to be very trouble
some in almost all other aural affections, is not generally
present when furuncular inflammation exists. It may be, how
ever, after the pus from the boil has been evacuated, and some
of it, perhaps, remains in the canal and presses upon themem
brana tympani, and through it upon the ossicula auditus and
auditory nerve. The tinnitus is absent in the early stages,
because there is no pressure exerted upon the drum -head by
a circumscribed swelling of the canal.
There will be no difficulty in the diagnosis , if the ear be
examined by means of the mirror, or otoscope, and reflected
daylight or sunlight. One or more circumscribed swellings
are found in the caliber of the canal. Their usual situation is
a point near the tragus, on the anterior wall, and we may have
two or more at a time.
The proper treatment is to make an incision at as early a
period as possible, and then to continuously apply warm water ,
giving the ear an uninterrupted warm bath , as it were.
It makes no difference whether pus or blood be evacuated
by the incision . The relief following is generally immediate in
either case . The incision is best made with a sharp-pointed
curved bistoury, cutting from below upwards, and not with
a scalpel down upon it, as the books usually advise. It can
thus be made more quickly , and does not cause as much pain
FURUNCLES IN THE AUDITORY CANAL. 131
as when done with the scalpel. The ear should be syringed
with warm water after the hemorrhage has ceased , and care
fully dried with the cotton -holder, or the impairment of hear
ing and sensations of fulness will be greater than before the
opening was made.
After the furuncle is opened , and the pain caused by it has
disappeared , it is well to smear the passage with some oint
ment, in order to hasten the softening of the indurated tissue
surrounding the furuncle, but as long as pain continues the
use of warm water should be persisted in by means of the
aural douche. The thorough cleansing will usually relieve
the impairment of hearing caused by the swelling and closure
of the canal, while the incision and douche will cut short the
pain . Each new furuncle is of course to be treated in the
same way. Steam may also be allowed to pass into the ear
from any sort of a vessel.
Leeches do not seem to do the same amount of good in
furuncular inflammation as in the diffuse form .
The vapor of chloroform passed into the auditory canal
has been highly spoken of, but I do not know much of it by
esperience , having been generally satisfied with the method
of treatment above indicated.
We shall probably not be done with the case when one
furuncle has been evacuated, and has healed ; for here just as
in other parts of the body, one boil is apt to follow another
in rapid succession.
Causes. This brings us to consider the cause of this affec

tion. I do not think I ever saw a furuncular inflammation of
the external auditory canal in a patient who was in other
respects in a physiological condition. It seems to be the
evidence of a wrong state of the system of some kind .
Furuncles are very apt to occur in anæmic persons. I
have seen several cases where they were troublesome after
parturition, during which the system had been much ex
hausted, and perhaps the patient had not been under the
most judicious management as regards the diet. When iron
was administered, and nourishing diet substituted for slops,
the boils ceased to recur.
132 FURUNCLES IN THE AUDITORY CANAL.
Every spring I see cases of furuncular inflammation in

young ladies who were zealous attendants upon the German,
and who spent large portions of the night in the ball- room ,
for quite long periods. They were not particularly anæmic,
but they had no proper appetite, and were evidently suffering
from the effects of an improper mode of life. Regular hours,
regular times for eating, exercise in the open air, soon relieved
these cases, but those who would persist in their dissipations,
did not recover until the season was over. In one case there
were also hordeoli or styes, which are generally regarded as
evidences of mal-nutrition .
It will be seen from this, thatthe local treatment is by far
the lesser part of our labor in these cases of circumscribed
inflammation of the auditory canal. We should be very care
ful to inquire as to the appetite, exercise, mode of life , and
specifically correct anything which may be out of the way. It
will not be enough to give general directions, such as, “ You
must take exercise and live well,” but the amount and kind of
exercise , the time of eating, variety of food, and so on, should
be plainly indicated ; at the same time some one of the prepa
rations of iron will generally be required.
The ear should be kept from the influence of cold air,when
the patient is out of doors, by cotton, or an ear-lap ; but the
habit of thus protecting the ears in the open clear air, where
there is no draught, should be abandoned when the furuncles
have ceased to recur.
I have lately found, after the suggestion of Dr. L . Fisher, that the use of
a small cotton plug saturated with glycerine, is a valuable means of relieving
the pain from a furuncular inflammation of the canal. The plug should be
changed twice a day .
CHAPTER VI.
PARASITIC INFLAMMATION OF THE EXTERNAL AUDITORY CANAL .
SYPHILITIC ULCERS AND CONDYLOMATA.
It is not more than six years since the profession became

generally aware of the fact, that vegetable fungi were germi
nated in the auditory canal,and that they caused or aggravated
inflammations of this part and of the surface of the membrana
tympani. By the publications of Professor Schwartze of Halle ,
Dr. Wreden of St. Petersburg, and many others whose names
will be quoted in this chap' er , this fact has now become well
known, and has enabled us to more clearly understand and
more successfully treat certain cases of otitis externa.
The history of the growth of the aspergillus fungus, as
well as that of the other vegetable parasites that have been
found in the ear, is so recent, that an account of it seems to
be necessary as an introduction to the study of the diseases
caused by it.
In 1867, Schwartze * reported a case of inflammation of
the auditory canal, in which the aspergillus fungus was found .
Prof. J. Vogel made the microscopic examination that settled
the fact, and he called Schwartze's attention to two cases
which had been previously reported ; one by Mayer in Mul
ler's Archiv , 1844, p . 401, and one by Pacini, quoted by
Kuchenmeister in his work on Parasites, published in Leipzig
in 1855. In both these cases the fungus was a species of
aspergillus.
Mayer's case was peculiar . The fungus occurred in the
ear of a child , having what he called scrofulous otorrhoea, and
* Archiv für Ohrenheilkunde, Bd. II, p. 7.
134 OTITIS PARASITICA .
the parasite was contained in round and oval cysts, of the size
of a cherry. The walls of the cysts were fibrous, filamentous,
white in color externally, while within they were hollow ,
greenish and granular.
Pacini's case was like those that have since been observed :
A boy of fourteen years came from a sea -bath , and complained that water
remained in his ear. Itching and painful sensations ensued ,and at last nearly
complete deafness . In the auditory canal small transparent vesicles were seen .
Two weeks after a whitish membrane was found on the walls. It was removed
by syringing with warm water ; but it soon returned . The microscopic exam
ination revealed the presence of a fungus. The parasite was removed by the
injection of a solution of acetate of lead , of the strength of two grains to the
ounce of water.
Dr. Robert Wreden * reported six cases of the growth of
the aspergillus fungus the year after Schwartze's case was
published . He gave the name of myringomykosis to the dis
ease caused by the fungus. He subsequently added eight to
these, and published the whole, with a very complete account
of the appearance of the fungus, in a monograph.t
Since the publication of Schwartze's and Wreden's cases
others have been reported by Orne Green,t of Boston, C . J.
Blake, Knapp , and bymyself and others. Indeed, the occur
rence of such a fungus in an inflamed ear is now a well recog
nized fact, for which we are indebted to Schwartze.
Causes. In order thatwe may correctly understand the na

ture of parasitic otitis , it should be remembered that it is not a
primary disease, but a consequence of a diffuse otitis , which
may have been of such a mild character as scarcely to have
attracted the attention of a patient, especially if it occur in
one who is taught to believe, as most patients are, that an
aural disease will “ wear away ” of itself, or, at any rate , that
medical assistance will be of no avail for it.
The disease which usually precedes the formation of a
vegetable fungus in the ear, is, as I believe, an eczema.
The etiology of the affection is not, however, quite clear,
* Archiv, für Ohrenheilkunde, B. III., p. 1.
Die Myringomykosis aspergillina . St. Petersburg.
| Transactions of the American Otological Society, 1869.
§ American Journal of the Medical Sciences, Jan., 1870.
OTITIS PARASITICA. 135
but I feel quite certain that I have not seen a case of the
growth of the vegetable fungus in which the ear was sound
before the growth occurred . Some kind of an inflammation
which loosens the epidermis, has first occurred.
The fungus is actually a mould , such as clings to damp
walls and adheres to bread that is not kept thoroughly
dry . As we should expect, the habits of the Russians, living,
as they are almost compelled to , in badly ventilated rooms
during the long winter, are very favorable to the production
of aspergillus.
There is hardly a doubt that these cases of vegetable fun
gous growths in the ear, were formerly mistaken for impacted
cerumen , and otitis externa diffusa . Since my attention has
been called to the subject, I recall two cases of very obstinate
inflammation of the auditory canal, which I now believe were
cases of the growth of vegetable parasites in the part. It is
an interesting fact, that they both recovered from the affec
tion without any use of the specific parasiticides.
Symptoms. — The subjective symptoms of the growth of a

vegetable fungus in the ear, are very similar to those from
inspissated cerumen. There is a sensation of fulness in the ear,
with tinnitus aurium , vertigo, impairment of hearing , and pain .
As is well known, pain is not a common symptom of inspis
sated cerumen, although it does occur. Pain is, however,
usually one of the symptoms of otitis parasitica. It is not,
however , the severe pain of a furuncle , or of acute catarrh
of the middle ear, but it is a dull, heavy sensation in the ear.
The objective symptoms consist in the adherence to the
walls of the canal and to the outer surface of the membrana
tympani of whitish or blackish flakes, that may be readily
mistaken for simple epidermis or hard wax. Sometimes these
flakes or casts block up the whole passage. They cannot be
removed by a syringe ; but the angular forceps,which should
only be used under a good illumination by means of the oto
scope, are required to detach them . When the casts are
removed the tissue beneath is found to be reddened and ten
der, and in a very few hours the growth will be found to be
reproduced.
The microscope must be called in to make the diagnosis

certain . The appearance of the growth , as seen by the aid
of this instrument, will soon be detailed.
The practitioner who has once carefully observed the
objective evidences of a vegetable fungus will, however, not
be apt to fail to recognize it in a subsequent case.
The varieties of vegetable parasites that may be found in
the ear, and which there cause inflammation , are
( flavus,
I. - Aspergillus glaucus,
( nigricans.
II. — Penicillium glaucum .
III. — Graphium pencilloides .
IV. - Trichothecium roseum .
The aspergillus fungus, which, in one of its varieties , is the
parasitemost commonly found in the ear, seems to have a pecu
liar affinity for a diseased auditory canal and membrana tym
pani, and to be found almost exclusively on this part of the
body. Dr. William H . Draper, of this city, has, however ,
observed one case of the growth of the aspergillus fungus on
the inner side of the thigh, and it afterwards appeared in
the auditory canal.
· Wreden was not able to find any penicillium fungus in his
cases, but Blake * reports a case in which on the second attack
ofotitis parasitica , specimensof bastard penicillium were found.
Dr. Hassenstein , t ofGotha, has observed one case in which
a patient suffering from the usual symptoms of aural catarrh
was found to have a yellowish green secretion upon the mem
brana tympani. This secretion continued for some ten days,
in spite of treatment, and there was considerable redness,
swelling, and pain in the auditory canal and drum -head.
This secretion was found to contain three varieties of
vegetable fungi, as an examination by Professor Hallier, of
Jena, showed : 1. Aspergillus glaucus. 2. Stemphylium , which
was very like stemphylium polomorphum belonging to the
* Transactions American Otological Society, fourth year, 1871.
+ Archiv für Ohrenheilkunde, Bd. IV ., p. 164 .
OTITIS PARASITICA . 137
aspergillus. 3. Graphium pencilloides. Dr. Hallier was un

able to say whether the second variety sprang directly from
the aspergillus or not. The graphium pencilloides , of which
an accurate botanical description is given in the article from
which I am quoting, occurs in nature on wood, especially on
elder-wood .
Dr. F . Steudener,* of Halle, describes another form of
fungus which occurs in the ear, Trichothecium roseum . The
evidence on this point is not quite conclusive, however, for
Professor de Barry, to whom Dr. S. showed the specimen ,
said it resembled this fungus, although it could not be tho
roughly examined, the specimen having been injured . Dr.
Steudener then cultivated the actual trichothecium fungus
FIG . 34 .
W . 9.2
Aspergillus nigricans. 220 Diameters.

a. Mycelium fibre. b . Fruit-bearing fibre. C. Naked sporangium . d . Sporangium covered
with basidia only. e. More mature sporangium . i. Spores in a state of germination .
upon some epidermis , and inasmuch as the spores and myce

lium resembled those in the fungus removed from the ear, he
thoughthimself justified in assuming that the latter were actu
ally those of the trichothecium roseum . The evidence is there
fore not quite positive as to the nature of the fungus.
• Archiv für Ohrenheilkunde, B . V ., p . 163.
The different varieties of the aspergillus fungus are by far

the common kinds of vegetable parasites that have been found
in the ear, although it is probable , now that attention has
been turned to this subject, that others will be found.
The first two of the accompanying drawings of the asper
gillus were made by my friend, Dr. William B . Lewis,* from
specimensof cases occurring in my practice. The third engrav
ing (Fig . 36 )represents another specimen from the samesource ,
which was drawn by my colleague, Dr. Charles S. Bull. Dr.
Lewis describes the fungus as of three essential parts :
1st, the mycelium , a dense network or pseudo-membrane
of delicate fibres ,which form the groundwork or roots, as it
were, from which the 2d part, or fructifying portion (fertile
hyphen), arises perpendicularly ; and 3d , the free spores,
which lie thickly strewn upon and in the mycelium .
FIG. 35 .
W .B.L
Aspergillus flavescens. 220 Diameters.
8. Mycelium fibre. b. Fruit-bearing fibre. c. Sporangium -bearing spores upon the basidra.
g , Basidia , showing constriction preparatory to the separation of spores. k . Epithelium .
The physiological relation of the fruitful fibres to the mycelium is not

shown in the accompanying cuts, but may be at once made clear by examining
a portion of common mould with low power.
The fibres of the pseudo-membrane are unfruitful, branched , straight, or
curved, and frequently somewhat swollen at the joints. In the broader fibres
transverse cell-walls are distinguished , and all, broad and narrow , contain
faintly granular plasma. The breadth of the mycelium fibres was from 0 .00015
to 0 .0002 of an inch (0 .0038 to 0.005 of a millimetre).
In the fruit-bearing portion are found the changes in form which establish
* American Journal of the Medical Sciences, vol. lix., 1870, p. 105.

OTITIS PARASITICA . 139
the varieties. It consists of a filament, which , especially in the aspergillus
nigricans, is stouter than those of the mycelium , bearing upon its summit an
enlargement, the receptacle or sporangium .
Those who are interested in a fuller botanical description of the fungus will
find it in the journal from which I have quoted , as given by Dr. Lewis, in an
article furnished by Dr. L . and myself, and in Wreden's monograph.
FIG . 36 .
Specimen of the Spores and fully developed Growth of the Aspergillus flavescens. Case III.
In Dr. Blake's case, which has been alluded to, a portion
of the specimen was planted upon lemon -peel, placed in a
closed glass vessel, at a constant temperature of 80° F.,when
it gave, at the end of the third day, a well-developed growth
of the Leptothrix form of Penicillium .
The specimen represented in the accompanying wood -cut

exhibited a mycelium and fully developed sporangia (a ). The
Fig. 37. spores, of which a collection is re
presented at b, were of a brown color
and oval outline, of about the same
size as the spores of Aspergillus ni
gricans. Under a magnifying power
of 300, some of these spores showed
Penicillium . After Blake.
a double outline. Mingled with this
growth there was a close network of
very fine mycelium .
Treatment. — The treatment of otitis parasitica is exceed

ingly simple , but it is often very tedious, and the practitioner
must not expect that all the aural symptoms will be relieved
when the vegetable fungus has ceased to appear. If the
theory which I have adopted, that the parasitic affection is a
secondary disease, be correct, wemay only expect to relieve the
most troublesome symptoms, pain , vertigo and impairment of
hearing , by the destruction of the parasite. The inflammation
will continue, in some cases, long after the microscope has
failed to find any traces of aspergillus in the auditory canal.
But the loosened epidermis and the flakes of mould should
be carefully removed every day by means of the forceps and
syringe, the ear being well illuminated while the former is
used, and the canal frequently douched with warm water by
means of Clarke's douche. I am in the habit of pencilling
the canal with nitrate of silver in strong solutions, after the
cleansing process is over, not for the purpose of destroying
the fungus, but to subdue the inflammation of the integument.
At the same time, I treat any affection of the middle ear, that
may co-exist with that of the canal, by the appropriate means.
Dr. Wreden gives a long list of agents which he believes
to be useful as parasiticides. He mentions, among others,
alcohol, bichloride of mercury , acetate of lead, tincture of
iodine and carbolic acid . He prefers the hypochlorate of
lime, which he recommends to be used in the strength of one
to two grains to the ounce of water. The salt must be freshly
dissolved in water at each application. Fowler 's solution
OTITIS PARASITICA 141
ranks next to the lime as a parasiticide, according to Wreden.
Solutions of tannic acid , gr. x ad 3j, are used by some author
ities.
Drs. Orne Green of Boston, and Knapp of this city, concur
with me in believing that a thorough use of warm water is the
only parasiticide necessary.
Dr. Eugene Peugnet,* of this city, believes from experience
in one very obstinate case, that the following formula is very
useful.
R . Veratria ..... ... gr. ij
Acid . Acet . . . . . . m . X
Aq. Rosa ļ āā . . . 3 ss.
Glycerine
M.
This is to be pencilled on the ear after the canal is thor
oughly cleansed . I have used this formula but in one case.
The following cases will furnish a commentary on whathas
been said , and perhaps illustrate the nature of the affection
better than any more extended remarks. The first two have
already been published , but the third has never before been
printed .
CASES OF ASPERGILLUS.
CASE I. - I was consulted, June 30, 1869, by J. F. B., a gentleman æt. 24, in
regard to pain and impairment of hearing in the left ear. He stated that
about a year before he had experienced a sense of fulness in the ear, as if it
were “ stopped up," and that, at the same time, there was considerable tinnitus
aurium . He consulted a physician , who diagnosticated inspissated cerumen ,
and removed a large quantity of what seemed to be ear-wax from the canal.
The relief afforden was of short duration , for the ear soon filled up . From
that time to the present the patient has been in the habit of syringing the ear,
and at times masses of some foreign substance were removed by this process.
Of late he has noticed black particles strewn in the substance removed, which
he thinks are due to the entrance of dust from the smoke-pipe of a steamer
during a recent voyage from Europe. The patient now experiences very con
siderable pain in the ear, and it is the occurrence of this new symptom which
has led him to consult me. The other symptoms — the sensation of fulness ,
tinnitus aurium , and impaired hearing, continue. Patient's general health is
good ,though he is very subject to naso -pharyngeal catarrh.
* American Journal of Syphilography and Dermatology, vol. iii, p. 209.
+ American Journal of the Medical Sciences, 1. c.
142 CASES OF ASPERGILLUS .
On examination, a watch which is usually heard at least thirty inches

from the auricle is only heard one and a half inches, and the auditory canal
is filled with a lardaceous mass , punctated by minute black spots. This
mass was very adherent to the walls of the canal, and could not be thor
oughly removed by syringing, but required the use of the angular forceps ,
under a good illumination by means of Tröltsch 's otoscope and ordinary
daylight. The surface beneath this mass,which peeled off from the canal,was
red and very sensitive. After the removal of the foreign substance, a minute
perforation of the membrana tympani was found situated in the anterior and
inferior quadrant. There was no true suppuration, but mucus alone bubbled
out from the opening during the inflation of the Eustachian tube. The Eusta
chian tube was shown to be permeable by Politzer's method , but there was
very little sensation experienced in the ear when the air was forced in .
On the removal of the collection , the patient experienced immediate relief
from the pain and tinnitus aurium , but the hearing was not very much im
proved. The diagnosis catarrh of the middle ear was made, while an exact
definition of the state of things in the canal was delayed . Portions of the
lardaceous, flaky substance removed from the canal were placed in glycerine.
He was ordered to use injections of warm water, by means of Clarke's aural
douche, several times daily, and to drop in a solution of zinc. sulph ., gr. ij ad
aqua 3 j, twice a day. The Eustachian catheter was used , and air injected
through it into the cavity of the tympanum .
It was some days before the entire collection was fully removed , and in
spots where it had been separated and taken out,it was renewed very rapidly,
and each time reproduced the symptomsof pain and fulness. A weak solution
of carbolic acid was then used ; but it caused very great irritation , and inflam
mation was set up, which lasted many days. This was treated by the use of
warm water, through the douche. When it had subsided , the lardaceous
masses were removed by the forceps, and in some instances casts of the mem
brana tympani came away , although the walls of the canal showed the most
disposition to a reproduction of the growth .
July 27, the opening in the membrana tympani had healed , and the hear
ing so much improved that the watch was heard six inches, and the symptoms
completely relieved . There was still a slight tendency to the growth of the
fungus, as it proved to be, on the posterior wall of the canal. The membrana
tympani was lustreless and rigid ,the handle of the malleus distinct, but there
was no light spot. From the 1st of August I did not again see my patient
until October 18th. Meanwhile he had used the aural douche daily, and the
growth had not returned ; but the catarrhal inflammation of the middle ear
had not been materially benefited, as shown by the rigidity of the membrana
tympani and the impairment of hearing. The membrane is now (November
19 ) somewhat translucent,and the patient is being treated , with benefit, by
means of the injection of air, the use of a gargle , etc., for the middle ear
affection.
The flakes, preserved in glycerine, were examined by my friend Dr. C. E .
Hackley and myself under the microscope,and Dr. Hackley believed them to
exhibit specimens of Aspergillus nigricans. At a later date, Dr. Wm. B. Lewis
very kindly made a thorough examination, and confirmed Dr. Hackley's opin
CASES OF ASPERGILLUS . 143
ion . In this case it is clearly evident that the growth of the fungus was
secondary to the inflammation of the middle ear, for the patient never fully
recovered his hearing power.
CASE II.— Sept. 28, 1869, I was consulted by Mr. S.,æt. 51, on account of
impaired hearing, vertigo, pain in the ears, and tinnitus aurium . Vertigo was
the symptom upon which the patient laid the most stress, and of which he
was most anxious to be relieved . He said that he was so dizzy whenever he
attempted to walk about, as to be unable to attend to his ordinary business. His
condition in other respects was excellent. The patientalso stated he had heard
perfectly well until two months since, when he was attacked with the aural
symptoms narrated above, which had been aggravated since their inception ,
He had been treated by the instillation of oils, and so on . He could hear my
watch about one inch on the right side, and not at all on the other. Both
auditory canals were found filled with a tenaceous material, which could only
be removed by the forceps. It was several days before I could completely
remove the firmly adherent coating of the canal and membrana tympani.
The morbid product was immediately examined by Dr. Lewis, and found
to be a specimen of the Aspergillus flavescens. Its removal gave the patient
great relief; but on the reappearance of the growth, which was in two or three
days after its thorough removal, the vertigo and tinnitus returned . The mem
brana tympani was intact, but lustreless and rigid . The Eustachian tubes
opened sluggishly, and there was all the evidence of aural catarrh , beside the
affection of the canal and of the outer layer of themembrane of the tympanum .
The free use of warm water, with an astringent, finally subdued the morbid
process in the canal, so that the patient was able to make a journey to the
South. When he left my care, Oct. 18, the auditory canals were entirely free
from abnormal secretion , the hearing was improved, so that the watch was
heard from five to six inches on the right side, and from one to two on the
Jeft. The dizziness was entirely gone, and the tinnitus ceased to be annoying .
The catarrh of the inside ear, as shown by rigidity of the membrana tympani,
sluggish action of the tubes, and impairment of hearing, still continued. I
saw this patient about a year afterward, and he was entirely well, his ears
baving returned to a normal condition .
CASE III. - Lt. L.,æt. 30, U . S. N .- Dec. 2, 1872.- Since a child ,has been
more or less deaf in right ear, owing to a series of abscesses. This impairment
of hearing was increased by his service near the frequent explosion of cannon.
About a year ago he had an abscess in left ear (probably in auditory canal),
with considerable purulent discharge having an offensive odor. For about
two weeks he has had a series of abscesses in the left ear, with considerable
discharge of black material.
Hearing distance, R . 2 ., L . .
The tuning-fork was heard more distinctly in the right earwhen the han
dle was placed on the forehead or teeth . The pharynx is granular.
The rightmembrana tympani is very much sunken and is opaque.
The auditory canal of that side contains numerous scales of epidermis
strewn with black spots.
144 SYPHILITIC ULCERS AND CONDYLOMATA .
The left canal is full of pus, and the membrana tympani is perforated.
Themicroscopic examination showed the presence of the aspergillus nigri
cans in both auditory canals.
The patient's general condition was excellent, except,as is the case with most
aural patients , he was somewhat despondent on account of the loss of hearing.
The diagnosis of chronic suppurative inflammation of the middle ear,with
aspergillus growth , wasmade as regards the left ear. In the right, there was
chronic non-suppurative inflammation with the same fungus growth in the
auditory canal.
The patient was seen nearly every day until December 24, and treated by
the use of leeches, the syringe and warm water, with the subsequent applica
tion of nitrate of silver, gr. 40 ad 3j, brushed over the canal and drum -head.
tion of sulphate of zinc, two grains to the ounce , into the ears. The Eusta
chian catheter and Politzer's method were used to force air into the middle
ears, and the patient used a gargle of chlorate of potash .
The aspergillus fungus disappeared in a few days, but the affection of the
middle ear and canal lasted much longer .
On the 24th of December, however, just 22 days after he came under
13
treatment, Lt. L . was discharged ,with hearing distance for watch , 48 48
At 16 feet distance he could hear and carry on a conversation in the ordinary
tone, with his face away from the speaker. The left canal still continued to
swell, and the epidermis to scale off. The patient had eczema of the scalp and
auricle. Someweeks after he was said to be still improved .
SYPHILITIC ULCERS. CONDYLOMATA .

I have not seen affections of the auditory canal which
could be said to be the result of the poison of syphilis ; but
trustworthy authors* speak of secondary syphilitic ulcerations
of the auditory canal, and of condylomata + occurring in the
same part. Schwartze believes that polypoid growths in the
canal are sometimes a local manifestation of syphilis. Inas
much, however, as granulations exactly like those occurring
in syphilitic cases are also found in the auditory canals of
persons not affected with syphilis, it becomes very difficult to
say that such growths are ever pathognomonic of the disease.
This much is certain , syphilitic affections of the auditory canal
are extremely rare , while it cannot be denied that the poison
of syphilis once in the system will modify any affection that
may occur in any of the organs of the body.
* Schwartze , Archiv für Ohrenheilkunde, Bd. IV, p. 262.
+ Steudener, I. c., Bd. IV , p. 20 .
SYPHILITIC ULCERS AND CONDYLOMATA. 145
I will, however , reserve the discussion of the effects of
syphilis upon the ear, for a fuller treatment in a later chapter.
I need only further say, at this point, that whether ulcera
tions or growths in the auditory canal be or be not caused or
modified by syphilis , the necessity for local treatment at the
basis of which is local cleanliness — remains as urgent as if
there were no constitutional disease .
The most appropriate constitutional treatment can never
do away with the necessity for local care.
CHAPTER VII.
INSPISSATED CERUMEN.
AMONG the laity, and even in the profession, hardening of

the ear -wax is generally regarded as a very harmless affection.
It is also considered by many as the most common of all the
diseases of the ear. The first treatment that many aural
patients receive at the hands of their medical advisers, is a
vigorous syringing, or worse still, probing, in order to see if
the wax be not hardened .
Now the facts are, that inspissation of cerumen is, com
paratively, not one of the common affections of the ear, and
that when it does actually occur, it is by no means the simple
and harmless disease that it is often supposed to be. Of four
teen hundred and forty- eight aural cases observed by myself
in private practice, only one hundred and one were what might
fairly be said to be cases of inspissated cerumen ; that is to
say, cases in which the impaction of ear-wax was the chief
cause of the aural symptoms.
It would be manifestly incorrect to class cases of chronic
ulceration of the middle ear, or cases of chronic non-suppura
tive inflammation of the same part, in which impacted ceru
men was also found, as cases of the last named disease.
My classification is founded on the principle that, the
hardening of the secretion is not in any fair sense a primary
or independent disease, where there is no positive relief either
from the tinnitus aurium or impairment of hearing by the re
moval of the cerumen. It is possible that we shall some day
come to believe that inspissated cerumen is very rarely, if
ever, an independent affection , but rather a symptom of some
disturbance of the nutrition of other parts of the organ of
hearing than the auditory canal. It is possible that the hard
ening and collection are caused by an abnormal heat of the
canal, in inflammatory swelling, which produces an evaporation
of the water of the cerumen. When the inflammation passes
away, the cerumen in its hardened state would not readily be
INSPISSATED CERUMEN . 147
cast out by the motions of the jaw . This is a theory of the

etiology of inspissated cerumen , that clinical experience in
clines me to adopt, for the history of some cases plainly
shows the occurrence of inflammatory swelling of the canal
before the symptoms of inspissated cerumen have occurred.
Admitting, however, that inspissated cerumen is a primary
affection , the cases which have been alluded to, should be
omitted from any table prepared to show its etiology.
Toynbee tabulated 200 cases of inspissated cerumen ; but if
the above ideas be correct, many of his cases should not have
been classified as cases of hardening of the ear wax. For the
same reason the tables of many Eye and Ear Hospitals are
open to criticism .
Symptoms. — The prominent symptoms of true cases of in

spissated cerumen are : 1. Sudden impairment of hearing. 2 .
Tinnitus aurium . 3 . Vertigo. 4. Pain in the ear.
The practitioner will not need to spend much time in
determining the cause of such symptoms. If they be produced
by impaction of the cerumen, a glance at the auditory canal
by means of the speculum and otoscope will determine the
matter, or at least it will give us positive evidence as to the
presence of the inspissated substance. Itneed hardly be said
that the practice of probing the ear to determine if the wax
be hardened, is an extremely unphilosophical procedure, while
it is not without danger to the membrana tympani. I am
obliged to say, however, that I have seen several cases in
which this probing has been undertaken without ocular
examination ; and where inflammation of the lining of the
canal, of the drum -head , and in one case even perforation
of the membrane, had resulted from the manipulations in
the dark.
The appearance of inspissated cerumen is very character
istic. Wax which presses upon the walls of the canal and
upon the membrana tympani, in adults , is of a dark brown or
black color, and usually fills the canal. The presence of even
quite an amount of soft yellow cerumen , which still leaves an
opening, however narrow , down to the drum -head, can hardly
cause any unpleasant symptoms.
The diagnosis of inspissated cerumen is sometimes ob
148 INSPISSATED CERUMEN .
scured , by the useless habit indulged in by so many of the

laity and of the profession also, of pouring sweet or other oils
into the auditory canal on the appearance of any aural symp
toms. A lady once came from St. Louis to consult a New
York physician in regard to a loss of hearing. She had been
seen by no less than six medical men , all of whom had pre
scribed applications to be dropped into the ear, and none of
whom had made an examination . She had suffered for six
years from the great impairment of hearing, and came to New
York as a last resort. Having arrived here, she was sent to
me. I found the ears filled with oils, but beneath all this,
hardened cerumen , which was easily removed ; and, although
her hearing had been impaired for so long a time, the removal
of the wax restored it to the normal power, so that she heard
ordinary conversation with ease, and a watch several feet.
In this case, I did not imagine, until the ears were cleansed by
the syringe, that impacted cerumen was the cause of the loss of
hearing. I could scarcely believe that oils would be persis
tently dropped in an ear by so many different advisers before
the membrana tympani had been examined.
The tuning-fork will be of use, if the inspissated cerumen
be confined to one side in determining the prognosis ; but
practically the better plan is to defer any statement as to the
prognosis until the cerumen is removed .
The loss of hearing from hardening of the cerumen , as has
been intimated, is apt to occur very suddenly. I have seen
several cases where patients could tell the very instant when
the ear “ closed up," as they often say. The jolting of a ride
in a New York stage often displaces the hardened material,
and presses it into the canal, causing troublesome symptoms
in an instant ; and, as I have said , these symptoms do not
occur, no matter how much cerumen may be in the ear, until
the impaction takes place, when the loss of hearing, the tinni
tus aurium , and the increased resonance of the patient's own
voice , calls his attention to the ear.
Pain of the most distressing nature sometimes occurs from
the impaction of cerumen. I remember one case where ano
dynes had been used for ten days to relieve a pain in the ear ,
which an examination showed was the result of the affection
INSPISSATED CERUMEN - CAUSES. 149
now under consideration. In another case, that of a young

lady, suppuration of the drum -head resulted from the long
continued impaction of cerumen. This suppuration was pre
ceded by very severe pain , from which no relief was expe
rienced until the mass of cerumen was evacuated sponta
neously, like a cork from a bottle of champagne, and, as the
patient stated, with a report like thatof a pistol. The removal
of a plug of cerumen from the auditory canal of the other
side, a plug that was very tightly wedged in , saved the patient
from a similar experience on that side.
Among the cases that are appended to this chapter , will be
found another where excruciating pain was one of the promi
nent symptoms of a case of inspissated cerumen . Yet neither
pain nor vertigo are the ordinary symptoms of this disease ;
impairment of hearing and tinnitus are the usual ones.
Causes. I do not think the causes of inspissated cerumen
are as plainly recognized as we could wish . It was once my
opinion that it was usually a local affection , and while I still
believe that there are some cases where the inspissation
of the cerumen is the only disease which affected many
ears that are found filled with hardened wax, I am persuaded
that in the majority of cases, even after we have excluded
such ones as those in which the cerumen hardens upon the
remains of an ulcerating drum -head, or in an ear that has for
a long time been affected by chronic catarrh of themiddle ear,
inspissated cerumen is a symptom of an inflammatory affec
tion of the lining membrane of the canal.
In some cases it is possible to believe that this inflamma
tory affection may have passed away before the hardened
cerumen is removed ; so that after syringing, the hearing dis
tance becomes normal, and the tinnitus is relieved . What
this process is, I cannot say ; but I look with suspicion upon
any ear in which the cerumen hardens and becomes fre
quently impacted .
I have seen several cases in which impaction of the ceru
men has occurred more than a dozen times in a few years, and
I have found that some of these persons were beginning to
suffer from disease of the middle ear. I have been unable to
150 INSPISSATED CERUMEN - CAUSES.
see that increased activity of the other sudoriparous or sweat

glands of the body, or, in other words,excessive perspiration ,
was at all a necessary accompaniment of these cases. Some
times the patients with inspissated cerumen say that they
perspire excessively ; and again , they are not at all aware of
any such peculiarity. Often , indeed , they state positively that
they donot perspire any more than is natural. I think, there
fore, we must reject this from among the causes of this disease .
I have no doubt but that the bad habit of cleansing the
auditory canal with the end of a towel, or with an aurilave
a bit of sponge fastened on a handle — or the like, has a ten
dency to pack the cerumen in the canal ; but after all, a cause
must, I think, be sought for behind this, and this is possibly
to be found in an inflammation of the middle ear, which has
extended to the auditory canal, or in an inflammation of the
canal itself.
I have observed that almost all patients suffering from
inspissated cerumen ascribe the attack to “ cold ” which they
have taken . In many of these cases no evidence is found to
substantiate the theory, for, as all my readers know , patients
are very apt to ascribe all kinds of diseases to cold , even when
they cannot positively remember that they have suffered from
a cold in the head , throat, or chest.
Yet many cases have come to me, in which there was a
naso -pharyngeal catarrh co-incident with the impaction of
cerumen, or with the aural symptoms.
I suppose a very slight swelling of the auditory canal
would prevent the free removal of the cerumen, which natu
rally takes place from the motion of the lower jaw ,as it presses
upon the lower part of the wall of the meatus. When the wax
has once collected , partial evaporation of its watery contents
occurs, and we get the characteristic black color, and the mass
becomes, on its surface at least, as hard as soft wood, and in
rare cases as hard as some kinds of stone.
Cases enough have been seen to show , that inflammation
of the canal does favor inspissation of the cerumen ; the only
question upon which any doubt may be thrown is , whether
impaction of cerumen does ever occur without an antecedent
inflammation , and from purely mechanical causes, such as
packing of the secretion by improper attempts to cleanse the

canal, or from a peculiar tendency to excessive action of these
numerous glands.
Certain it is, thatmany cases require only local treatment,
and that whatever inflammation preceded the evaporation of
the fluid of the cerumen, was fully removed when the patients
came under treatment.
Many patients suffering from chronic non -suppurative in
flammation complain that their ears secrete no wax. This
state of things is due to two facts :
One is, that such patients are very apt to syringe their ears
very frequently, and thus remove all the cerumen as fast as it
forms. The other is, that the chronic catarrhal, or proliferat
ing process, probably extends to the auditory canal, and inter
feres with the functions of the ceruminous glands.
Under the guidance of Mr. T . Wakely ,who published an
account of the wonderful virtues of glycerine in the London
Lancet, * the profession were at one time very much in the
habit of recommending the use of this agent to re-establish
the secretion of cerumen . Mr. Wakeley even published a
work entitled “ Clinical Reports on the Use of Glycerine in
the Treatment of certain Forms of Deafness.” Mr. Wilde
showed that the reporter of these cases was not “ conversant.
with either the normal or pathological appearances of the ear,”
and glycerine, after a fair trial, which is still kept up by some
physicians, proved to be of no avail in relieving impairment of
hearing.
Its use for the restoration of the secretion of cerumen was
about as rationalas the other instillations, ofwhich an account
has been given in the introductory chapter. Yet in our own
century, a surgeon to a London hospital gravely recommended ,
as a portion of a new cure for deafness, “ the finest curled wool
on the sheep's head, carefully cut with scissors, and washed
in hot water,” and added “ thatthe best wool is that procured
from a small German sheep ;" + while in the samecity , Wakely 's
book was gravely noticed as a contribution to clinical medi
cine.
* Wilde's Aural Surgery , p . 38.
# Wilde, 1. c., p. 43.
152 INSPISSATED CERUMEN
INSPISSATED
CERUMEN - - TREATMENT.
TREATMENT.
Treatment. The treatment of inspissated cerumen is ex
ceedingly simple. The hardened materialshould be removed by
theuse of the syringe and warm water. The syringing should be
performed in the manner that has been depicted on page 128.
In the majority of cases but a few minutes are necessary
to remove the mass. In some cases, however, we are com
pelled to use a solvent for a few hours prior to the syringing
process. I usually use a saturated solution of the bicarbon
ate of soda for this purpose.
The cerumen is sometimes so hard, and so tightly wedged
into the auditory canal, that a daily sitting for a week is neces
sary to its removal. I have notes of two such cases . In one
of them I finally softened the mass by the use of fuming nitric
acid , after having completely failed to make any impression
upon it by alkaline solutions or oils.
Professor S . D . Gross recommends a pick and curette for
the removal of inspissated cerumen. He says, “ Ear-wax,
however hard , or however firmly impacted, is more readily
removed with such an instrument than with any other contri
vance of which I have any knowledge." * I am constrained
to say, that I consider such advice from so eminent a source
as the distinguished Professor in the Jefferson Medical Col
lege , calculated to give a dangerous and false impression as
to the propermethod of removing ear-wax. The syringe and
warm water will be found to be the only means that are neces
sary in ninety-nine cases out of a hundred. The use of the
“ pick and curette,” or of any pointed instrument, is a danger
ous means of removing inspissated cerumen , except in the
hands of men of very large surgical experience, who have
learned to treat ears as if they were soap -bubbles. It is only
in the rare cases in which the syringe fails that the use of an
instrument, employed under a good illumination by means of
themirror and forehead band , should be resorted to. In such
cases I have found a Bowman's probe a very good means of
breaking up the hard surface of the mass, after which the
syringe will easily finish the work . I am indebted to Dr.
Isaac Hays ,of Philadelphia , for this suggestion of the use of
the probe in lifting up the hard cover of the mass.
* American Journal ofthe Medical Sciences , October, 1864.
The auditory canal may contain a surprisingly large quan
tity of hardened cerumen, and it is necessary to examine the
ear quite often during the syringing process , in order to see
how much remains, lest we continue the injections after the
wax is removed , and thus injure the drum -head. All the wax
should be removed. The thinnest scale or flake left upon the
drum -head, is sometimes sufficient to keep up the disturbing
symptoms. I have seen two cases where the diagnosis was
correctly made, and the syringing undertaken , and yet the
symptoms were not relieved , because a small flake of wax was
left upon the drum -head.
The membrana tympani is usually found very much red
dened after the removal of the wax ; but this is probably due
to the injections of warm water. It is also sometimes pressed
inward. This may be due to the mechanical pressure which
has been exerted upon it by the cerumen , or to the catarrh of
the tympanic cavity which so often accompanies this disease.
If the hearing is very much improved after the removal of
the wax, the ear should be protected from the shock of sounds
by a little pledget of cotton placed lightly in the meatus. If
the drum -head be sunken inward , Politzer 's method of inflat
ing the middle ear, or the Eustachian catheter, should be
employed to restore it to a normal position .
Since some persons are disposed to frequent attacks of
inspissated cerumen, it is well to advise them to have the ear
syringed with warm water once in two or three months. It is
probable that it requires a longer time than this, for cerumen
to become so hard or so tightly packed in the canal, that it
cannot be readily removed by the patient or a non -medical
friend.
It is always well to examine both ears, even when only one
is complained of. I have often found the ear in which the
hearing was still unimpaired, quite as full of wax as the other,
although it had not yet become pressed upon the drum -head ,
and thus had given no trouble.
I append a few cases, which illustrate what has been said ,
and which will, perhaps, contribute to a knowledge of the eti
ology of the disease.
The first was one of the last upon my case-book when this
154 INSPISSATED CERUMEN - CASES.
chapter was finished, but it happens to be of interest, inas
much as sudden and acute pain was one of the symptoms.
It is inserted,however, not for its peculiarity, but as an
illustration of the ordinary type of these cases.
CASE I.– March 5, 1873,Mr. De. S.,æt. 28, consulted me about a pain in
his ear. Two days since he experienced a “ buzzingnoise" in the ear, and last
night he had severe pain in it,wbich was relieved by some liquid application .
The buzzing noise still continues, and he cannot hear well from the left side.
The hearing distance is - Right ear normal ; Left ear, Pe, or the watch is
heard when pressed upon the auricle.
Tuning .fork is heard much better on the left side.
Diagnosis - Inspissated cerumen in left ear.
Themass was removed by syringing,and the hearing distance became
in a few moments.
CASE II. - A , B ., coachman , at N . Y . Eye and Ear Infirmary , in 1864 . The
patient complained of head symptoms for somemonths. He ascribes them to
a sunstroke. On cross -examination it was found that he had never actually
suffered from sunstroke; but that since his head symptoms- chiefly buzzing
in the ear and deafness - had begun , he imagined that they were caused by a
fancied sunstroke.
He stated that he had been treated in a New York hospital for some weeks,
but without benefit. His ears had never been examined , and he had concluded
to have their condition investigated , as many of the symptoms which made
him " bad in the head " were referred to his ears.
An examination showed inspissated cerumen in both ears. I have mislaid
the record which gave an account of his hearing power ; but all the trouble
some symptoms were at once relieved by the removal of the mass, which was
done by the use ofthe syringe.
This case is almost as striking as that related by Von Tröltsch , in which a
poor fellow was blistered and cupped to the verge of severe depression , for
a supposed concussion of the brain, which proved to be a case of inspissated
cerumen .
CASE III. - The following case shows, I think, that a swelling of the canal
may prevent the normal exit of the cerumen , and thus favor its impaction :
Miss Johnson , æt. 29, consulted me,March 23, 1873, on account of her ears,
and gave the following history : For fourteen or fifteen years she had suffered
at intervals from abscesses in both ears. The hearing has been seriously im .
paired on the right side from an ulcer resulting from scarlet fever, since she
was five years old . For the past two or three months the hearing has been
impaired in the left ear, and she has suffered from abscesses near the external
meatus, which have caused great swelling and tenderness of the parts. The
impairmentof hearing was most marked in the morning. For the last four
weeks she has been constantly deaf, although for a few moments a few days
ago she heard very well ; she then felt as if something had broken in the ear.
INSPISSATED CERUMEN - CASES. 155
Hearing distance, tested by the watch — Right ear,it; L.,
Diagnosis. - Right ear, chronic suppuration in tympanic cavity. Left ear,
inspissated cerumen . A small furuncle was found in the outer part of the
canal, which was a very narrow one.
The mass of cerumen was removed in about 20 minutes by syringing,
when the hearing distance became P5.
Politzer's method of inflating the ear was then employed .
March 6, H . D . 14 .
After the use ofPolitzer'smethod,the hearing distance became is.
The above case illustrates the theory of the preceding chapter, that inspis
sated cerumen is in reality but one of the symptoms of certain forms of
inflammatory affection . In this case the inflammation had not fully run its
course, for the canal was red and swelled. Perhaps, indeed , this was an
habitual condition of the part .
The following case, which may be considered a remark

able one, illustrates not only the etiology of inspissated ceru
men, but also the effect of quinine upon the ear ; and I insert
it as much to show the influence of this agent upon the audi
tory apparatus, as for its bearing upon the subject now under
discussion.
It has already been published,* but I think it worthy a
wider circulation than it has hitherto obtained .
CASE IV . - On the 3d of May, 1870, I was consulted by Dr. N ., æt. 34, on
account of his throat and ears . Hestated that he had had acute pharyngeal and
laryngeal disease some ten years before. He also informed me that neither he
nor his parents have any recollection of any serious difficulty with his ears prior
to the date of the attack , from whose consequences he is now suffering. The
laryngeal inflammation was followed by chronic naso -pharyngeal catarrh , and
in 1863 he was obliged to take five-grain doses of quinine for some weeks on
account of nervous prostration from malarial fever contracted in the Southern
States. These doses were increased to ten grains, and cinchonism was pro
duced. The symptoms of cinchonism were , ringing in the ears and dizziness.
In 1864, the doctor again took quinine uutil the constitutional effects were
produced , the dose finally reached being twenty to twenty-five grains, which
was taken every other day. While employing the quinine in this manner a
severe attack of otitis occurred . The patient states in a written history taken
from his diary that he recovered from the otitis under antiphlogistic treatment.
After recovery from the aural disease, Dr. N . was obliged to resort to the
use of the quinine on account of the constitutional disease, - a severe malarial
neuralgia . He took one dose of fifteen grains, which was followed by pain in
the ears. Several efforts were made to return to the use of the quinine, but
pain in the ear supervened on each dose. “ From this period,February, 1865,"
* Transactions of the American Otological Society, 1873.
to quote the exact words of the patient, “ my ears began to give me constant
trouble . I was incessantly annoyed by unnatural noises, which would fre
quently reach such a pitch , for a few moments,as to exclude all other sounds."
The naso-pharyngeal disease also increased , and in March, 1865, he was seen .
on account of the state of his ears,by a distinguished practitioner. The throat
was considered the origin of the aural affection ,and it was accordingly treated ,
and was improved ; but the ears remained in the same condition , that is, they
were sensitive and affected by tinnitus, and there was some impairment of
hearing .
After the pharynx had been treated ,until July of this year (1865), and while
undergoing treatment, another attack of otitis media occurred , which was pre
ceded by five weeks of facial neuralgia . The use of quinine for the relief of
these attacks had been avoided ; but at last, the patient, worn out by pain ,
took a fifteen -grain dose of the sulphate, upon which the ear disease imme
diately supervened . The quinine was taken on July 30th, and the attack of
otitis media occurred on the next day. The otitis was of so severe a character
as to place the doctor in a very depressed condition, and when he recovered
from this and the neuralgia, which he did simultaneously, to use the patient's
own language, he was “ a perfect wreck ."
He then sailed for Europe, and in the Scotch Highlands recovered from the
malarial disease, never having suffered from it since up to the present time.
The ears, however, became very sensitive to the air, and cotton plugs were
resorted to, and Dr. N . has never from this time been able to leave the meatus
open , even while in -doors, until the past week . The hearing power was also
greatly impaired while in Scotland ; the patient therefore went to the south
of France, where his ears were still troublesome. The aural symptoms were
tinnitus, a sense of pressure in the auditory canal,and frequent attacks of neu
ralgia of the fifth pair. The intellect also became somewhat obscured. After
a year's stay abroad, Dr. N . returned home, when the naso-pharyngeal catarrh
returned . He then, under the advice of a physician , began the use of the
nasal douche for its relief, taking all the precautions that are enjoined, using
a warm solution of common salt in water. It was observed , however, that in
an hour or two after using the douche, there was an uncomfortable sensation in
the ears which becamemore prominent after each application . The physician
then advised “ less pressure " in the use of the douche ; but the next applica
tion was followed by severe pain , and this method of treatment was abandoned .
The patient was then suffering from what was called an inflammation of the
auditory canal ; all treatment was given up until September of this year, when
another attack of otitis media and of facial neuralgia occurred . The next two
years were spent in Italy.
The general health of the patient was then excellent, but the hearing did
not improve, and the patient was obliged to use the cotton plugs. Returning
to America in the spring, the naso-pharyngeal catarrh ,which had not appeared
while in Italy, returned , and in April, pain occurred in both ears, for which he
was treated by leeches, diaphoretics, and hot fomentations ; after this attack
the patient describes himself as totally deaf, - unable to distinguish the loud .
est sounds. “ There was a feeling of spasmodic constriction , and fulness
invading the cavity of the tympanum , and a sensation of pressure upon the
INSPISSATED CERUMEN — CASES. 157
drum -head.” On the third day the patient became able to hear what was
said to him , if the words were spoken very loudly and with the mouth applied
close to the ear ; as time passed he became still more improved, so that he
could hear conversation addressed specially to him at a short distance, and a
watch usually heard at four feet,ata distance of two inches on each side, H .= .
This was his condition when be first came under the writer's observation,
on May 3, 1870. I found that the general nervous system of Dr. N .,from his
years of suffering, was in a highly sensitive condition. His pharynx was
highly congested ,the uvula very long ,and both auditory capals were extremely
sensitive and plugged with hard wax. For two weeks the patient was under
my care , during which time I cut off the uvula , and made many attempts to
remove the impacted wax by syringing, and the use of the forceps ; but in all
these attempts I failed , in consequence of the hardness of the cerumen and the
tightness with which it was held by the auditory canal, and also because the
ear was extremely tender to the slightest touch .
At the end of this time, the patient was suddenly called to Minnesota, and
I did not see him again until June 26 , 1872, when he presented bimself and
gave the following history of the time that had elapsed . The very small
quantity of wax removed , and the cutting off of the uvula, had relieved the
pharynx and ears to some slight extent, and , the climate being adapted to his
condition , he did very well , except that the hearing was impaired .
On June 18 , 1871, another attack of otitis occurred , which caused some
considerable discomfort, although it was a less severe attack than those which
had preceded it. The otitis again occurring, the patient came to me, on the
date above mentioned ; more than two years from the first visit. I found him
suffering severe pain , for which he was taking anodynes ; the ears were
about in the same state as when I last saw him . The hearing distance was
about i , the canals were plugged with hardened wax ; the patient appeared
in fair physical condition , but mentally he was excited and slightly irritable
and depressed.
I proceeded to remove the impacted wax, and that from the right ear came
away on the second day. It was so tightly wedged in that the removal, which
was effected by the syringe and forceps, caused severe pain,although the walls
of the canal were not touched . On the fifth day, after the use of various agents
to soften the mass of cerumen in the left ear, I burned it with nitric acid, and
then succeeded in removing it. This removal also caused great pain . The
membranæ tympani were suppurating, that is , the outer layers, and they were
somewhat sunken , especially along the handle of the malleus. The use of a
solution , nitrate of silver 40 gr. ad 3 j, and inflation by Politzer's method, soon
restored them to a normal appearance, except that the curvature remained
altered . The sensitiveness of the ears was removed , so that they could be
touched , applications made to the drum -head, and so on,without producing any
unpleasant sensations. The hearing distance became on the right side, and
was improved on the left, but to whatextent Ido notknow ,not having seen the
patient for some time. He became able to sleep without an anodyne. The
cotton plugs which had been worn for years were now removed ,and he became
altogether a different person , as regards his mental condition .
I think we must regard the otitis in this case, although to a certain extent
dependent upon the naso -pharyngeal catarrh , as chiefly caused by the use of
quinine. By looking at the history and observing how promptly and invaria .
bly the pain in the ears occurred in several instances after the use of the agent,
we are forced to the conclusion that quinine was the exciting cause of the
aural inflammation . At what date the impaction of wax occurred, we cannot
positively determine. I am disposed to believe that it was at the time the
patient awoke profoundly deaf, in April, 1870, or more than two years before
it was removed. The wax was certainly there one month after, in May, 1870,
when I first saw him .
Tbe condition of the patient'smind is illustrated by the fact that he should
allow two years to pass away with no attempt to remove a foreign body, from
whose partial removal he had obtained some relief, and which he believed to
be one of the causes of his impaired hearing . I can only partially account for
this delay, by supposing that my efforts at softening and removing the mass
had so far succeeded as to lift the cerumen from the drum -head , and thus give
partial relief. Indeed , the plug, which I took out on the second day , was on
its way out, and would, I think, have soon escaped spontaneously, with one of
the loud reports with which hardened wax sometimes shoots from the auditory
canal. The structure of the plugs was that usually found, that is, cerumen in
layers ; but there was some epidermis exfoliated, and also some pus between
the mass of wax and the canal.
The case seems to me to be one of those which have been reported, where
inflammation of the integument lining the canal was one of the causes of
impaction of wax , and it may be a contribution to the etiology of that dis
ease. The earlier history also illustrates the effect of quinine upon the ear,
which I am inclined to suspect is sometimes an inflammation of the conduct
ing portions, as well as of the acoustic nerve or labyrinth . We have long
known of the latter effect,but the former has not been often observed.
The following case occurred in my clinic at the Brooklyn
Eye and Ear Hospital, and was reported by Dr. David Web
ster,* who was then House Surgeon.
It illustrates the serious inflammatory trouble that may be
caused by inspissated cerumen, a fact which has been already
alluded to in this chapter.
CASE V .— “ D . H .,aged 28, laborer, presented himself at Dr. Roosa 's clinic,at
this hospital, Nov. 1st, 1870. Five days previously his right ear was attacked
with pain , tinnitus, and deafness, which symptoms had gradually increased up
to date. He had slept but little for the last two nights, in consequence of the
severity of the pain . He could hear the ticking of an ordinary watch at the
distance of only one inch .
Upon examination we observed a little puffiness ofmastoid process, and some
swelling back of the angle of the lower jaw and of the walls of the meatus.
* Medical Record, vol. v., p. 536 .
INSPISSATED CERUMEN. 159
There was also some pharyngitis . Through the auralspeculum the external
meatus was seen to be plugged with hard wax. This was removed by care
fully syringing the ear with warm water. Some pus was found in the canal,
and at first the membrana tympani was thought to be perforated , but upon
more careful examination it was found to be intact, though a complete exam
ination of it was rendered in possible by the narrowing of themeatus conse
quent upon the swelling.
Politzer's method for inflating the middle ear was practised, and the patient
was directed to fill his ear frequently with warm water.
Nov. 2. - He said that the pain was so relieved that he rested well lastnight,
and complained more of a sensation of soreness than of pain . The tinnitus
and swelling were undiminished , but the hearing distance had risen to ten
inches. On using Politzer's method , the patient felt the air enter neither ear,
and when this was done again, with the addition of the vapor of chloroform ,
the air was felt only in the left. He was directed to continue the use of warm
water.
Nov. 3. - The swollen walls of the meatus had becomemore sensitive to the
touch , and the pain had returned. He was treated by means of the warm
aural douche, Politzer's method again used , and the entrance to the meatus
stuffed with cotton in order to exclude the cold air .
Nov. 5 .— The swelling had increased . Dr. Prout,who saw the patient for
Dr. Roosa ,made two incisions in the walls of themeatus - one backwards, the
other upwards. Pus followed the knife in the latter. The pain caused by
the incisions was immediately relieved by the warm douche (Clarke's aural
douche ).
Nov. 8. - He was again seen by Dr. Roosa. There was an abscess in the
anterior wall of the meatus, just behind the tra us. This was opened , and a
considerable quantity of thick pus evacuated . The meatus was as thoroughly
as possible cleansed by syringing, and the use of pledgets of cotton.
Nov. 15. - The swelling had so far diminished that the drum -head could be
properly examined. It was covered with bits of wax and epidermis, which
were removed by gentle syringing. The hearing distance was twelve inches.
A week later Dr. Roosa pronounced the patient cured , so far as the ear was
concerned,all signs of irritation having disappeared , no tinnitus remaining,
and the hearing function being restored to its normal condition . A gargle of
alum and chlorate of potassa was used for his pharyngeal trouble.
A point of especial interest in this case is its causation . As the membrana
tympani remained intact throughout, and inasmuch as, even after the swell
ing had subsided , small particles of wax still adhered tenaciously to the surface
of the drum -head and of the walls of themeatus, we could not avoid the con
clusion that it was due to the impacted cerumen acting as a foreign body.
This is the only case of the kind that has occurred in this hospital during
the two and a half years of its existence,during which timeabout eleven hun
dred and fifty ear cases have been treated.”
Dr. O . D . Pomeroy,* one of my colleagues at the Man
hattan Eye and Ear Hospital, has tabulated , from the

records of that institution, 200 ears in which the diagnosis of
inspissated cerumen was made. The cases were found to be
accompanied or caused by middle ear disease in a very large
proportion of cases, for the hearing was found to be normal
after removal of the cerumen in but 27 ears. It must be
remembered, however, that the diagnosis was evidently set
down in this table, as in Toynbee's cases, as inspissated ceru
men , when the predominant affection - for example , disease
of the labyrinth , chronic suppuration in the tympanic cavity,
and so on - should have been given as the true diagnosis.
Again , if a patient got nearly perfect relief from the
removal of the cerumen ,but the hearing distance was not quite
normal, the case did not appear among those with perfect
hearing, while it is possible that the normal hearing power
was restored in a few days, when the mechanical effects of
the packing of the cerumen had passed away.
Pain worthy of note was caused by the cerumen in 12 ears
of the 200.
COMPOSITION AND FUNCTIONS OF CERUMEN.

According to J. E . Petrequin,* cerumen is of a smeary con
sistency, on account of the soapy material made by the potash
which it contains. A part of it is soluble in water, another in
water and alcohol. It also contains, according to the same
authority, about one-tenth per cent of water, a mixture of oil
and stearine, and a dry material not soluble in water, alcohol,
and ether, in which chalk , and traces of chalk and soda are
found. As age advances, the parts of the cerumen that are
soluble in water and soluble substances increase, but those
soluble in alcohol diminish ; so that in older persons the ceru
men becomes dry and brittle .
Kessel's account of the cerumen has already been given
on page 63 ; but it may be well to repeat his statements at
this point. The contents of the ceruminous glands only dif
• Archiv für Ohrenheilkunde, Bd. V ., p . 230, from Comptes Rend, de
l'Acad. des Sciences, 1869, xvi., pp. 940, 941.
7 Stricker's Manual, The External Ear, by Kessel, translated by J. Orne
Green , p. 951.
INSPISSATED CERUMEN. 161
fer from those of the sweat glands in the fact that the former
contain masses of very fine coloring matter. The substance
secreted by the ceruminous and sebaceous glands together, is a
yellowish -white , rather fluid material,which consists essentially
of small and large fat globules, corpuscles of coloring matter in
masses, and cells in which single globules of fat and coloring
matter are embedded ; hairs, and scales of epidermis from the
lining of the canal are also found in the canal.
Those who are curious in regard to the opinions of the last
century and the early part of the present one, on the subject
of the functions of the cerumen and the affections of the ear
caused by the suppression of the secretion, will find the book
of Thomas Buchanan ,* of Hull, interesting reading.
Mr. Buchanan ascribed most of the diseases of the ear to
impaction of cerumen or stoppage of its secretion. He be
lieved that it had a very important function in relieving the
harshness of the waves of sound. If it were not for the lining
of cerumen which is in the meatus, the waves of sound would
fall irregularly upon the drum membrane and cause it to
vibrate unevenly.
Mr. Buchanan also explained Mr. Everard Home's case of
double hearing by his theory of deficient secretion of the ceru
men. It was that of a music teacher, who found that after a
cold the pitch of one ear was half a note deeper than the other,
and that a simple tone was not recognized as one by both ears.
This is a specimen of the author's fanciful notions about
the important functions of this lubricating and protecting
secretion.
He makes a disease - Tubulus Hirsutus — of the growth of
hairs in the canal, saying that no one with acute hearing has
hairs growing over the surface of the membrana tympani.
от
He also tells a singular story of a man who became very
deaf, in his opinion from years of loud talking to a deaf wife.
* Physiological Illustrations of the Organ of Hearing,more particularly of
the Secretion of Cerumen, and its effects in rendering auditory perception accu
rate and acute , with further remarks on the treatment of diminution of hear
ing, arising from imperfect secretion , etc. Being a sequel to the Guide and to
the Illustrations of Acoustic Surgery , London , 1828.
11
He imagined that the continued screaming at last lessened

the sensibility of the portio mollis.*
The function of the ceruminous glands is probably that
of the sudoriparous glands. They keep the parts in which
they secrete pliable, and also prevent the ready admission of
insects. There is no evidence that the cerumen has anything
to do with the regulations of the intensity with which the
waves of sound reach the ear.
Children are very rarely affected with inspissated cerumen .
I have notes of but three such cases. Yet when children suf
fer from chronic suppuration in the tympanic cavity , it is
not an uncommon occurrence to find hardened wax on the
remains of themembrana tympani.
Foreign bodies , such as raisins, inserted to relieve pain ,
sometimes form a nucleus about which the cerumen hardens.
Dr. Agnew , of this city, related such a case at one of the meet
ings of the New York Ophthalmological Society, where a mass
of cerumen was removed, in which a raisin was found, which
the patient, a person in middle life, remembered to have been
inserted some thirty years before. I have removed masses
of wax in several instances , in which insects were found em
bedded .
Mental hallucinations have been in rare instances relieved
by the removal of inspissated cerumen . Prof. Mayer, form
erly directorof the Insane Asylum at Hamburg, is the author
ity for this statement.fi
I once saw a lady who, though not regarded as a person
of unsound mind, seemed to be such , and who complained
greatly of tinnitus aurium in all its varieties. I found the
ears full of impacted cerumen ; but she utterly refused to
allow me to remove it, and I never saw her but once. It
would have been very interesting to know the effect of the
relief of the tinnitus upon the mental hallucinations of which
she seemed to be a victim .
* A good synopsis of Buchanan's book will be found in Lincke's Sammlung
auserlesener Abhandlungen und Beobachtungen aus dem Gebiete der Ohren
heilkunde, Bd. III. Leipzig, 1836 .
+ Von Tröltsch on the Ear, 2d edition, p . 531 .
CHAPTER VIII .
FOREIGN BODIES IN THE EAR .
The usual point of entrance of foreign bodies into the ear

is through the external auditory canal, although they very
often pass beyond this part and become lodged in the cavity
of the tympanum , or Eustachian tube, while in some rare
instances a foreign body has entered the ear, through the
Eustachian tube. I have therefore entitled this chapter,
Foreign Bodies in the Ear, so that I might properly include
all such cases in the descriptions that are aboutto be given.
The foreign bodies that are found in the auditory canal
are very naturally placed under three heads: insects , or the
like which creep into the passage ; their larvæ which are gene
rated there, and various articles, such as beads, buttons, peas,
beans, and so on , which are pushed into the ear by children
or silly adults.
INSECTS IN THE EAR .

When a live insect gets into an ear, the pain produced is
usually intense and agonizing. Insects are more apt to get
into the ears of sportsmen while hunting in thicket and under
brush, and of farmers laboring in the field, than of dwellers
in cities and towns. Yet, on the hot days of summer when
insect life is very active, the city practitioner will sometimes
be called to remove a bug from the ear, if the agony induced
by the foreign body do not stimulate some of the family to a
successful attempt at its removal.
There is an insect, which lives on the leaves of fruits and
flowers, and which , like others, sometimes flies into the ear,
164 INSECTS IN THE EAR.
which is called an ear-wig, and there was an ancient super

stition that it crept into the brain through the ear. The for
ficula auricularis, or so - called ear-wig , has probably no more
propensity to fly into the ear, than any other insect ; any of
the ordinary flies may do so.
The most efficient and the speediest means of removing an
insect from the ear is the use of a syringe and warm water.
As little animals usually get into the ear when the patient is
in the fields or forests, where physicians are not always at
hand, laymen should be taught, in the case of the occurrence
of such an accident, to immediately pour water in the meatus.
This will disturb the animal and either drown it or cause it
to run out.
Some writers advise the use of an oil dropped into the ear
before the water is used , but Wilde and Von Tröltsch agree
that this is an unnecessary waste of time. I have treated but
two of such cases, and in both of these the insect was promptly
dislodged by the use of the syringe, and I have no doubt that
the simple filling of the auditory canal with water, will cause
insects to come out at once.
LIVING LARVÆ IN THE EAR .

Insects sometimes deposit their eggs upon the pus of a
suppurating ear. According to Wood , who is quoted by
Blake, * insects have a very acute sense of smell. “ No flock
of vultures can be directed more unerringly to their revolting
prey by scenting its odors from afar.”
The odor of an otitis media purulenta thus brings the insect
to deposit its eggs in the auditory canal and cavity of the
tympanum , where they soon become grubs or larvæ .
These larvæ always excite considerable, and sometimes very
severe pain , but in the cases which I have seen , the patients
complain much more of the wriggling movements of the grubs
in the ear, than of the pain.
The ancient works on aural diseases speak very much of
worms in the ear and of the proper means of removing them .
* Living Larvæ in the Human Ear. Archives of Ophthalmology and
Otology, Vol. II., No. 2 .
LIVING LARVE IN THE EAR . 165
It is probable that these so -called worms were the larvæ of

insects which germinated from eggs deposited in the pus of a
chronic suppurative process. Certain it is, that since the
habit of cleansing an ear from pus has become a well-recog
nized duty , the practitioner of the present time sees very little
of worms in the ears.
The pain from the presence of these grubs, which ac
tually fasten themselves, when hatched, into the tissue of
the canal, and bite upon it, as it were, is apt to occur sud
denly.
An Austrian physician, Dr. Scheibenzuber, * reports a case
of a peasant ploughing in the field , who was seized in an
instant, with a severe pain in the ear, which he ascribed to
the flying in of a bug, but the surgeon found the ear full of
well developed larvæ .
I have several times observed dead insects in the pus that
was washed out from an external auditory canal, and it is
undoubtedly true, as I have already suggested, that we should ,
equally with the ancients, have many cases of living larvæ in
the ear, were it not that suppurating ears are usually now
a -days regularly cleansed.
The larvæ that have thus far been found in the ear are
those of themuscida sarcophaga ( Blake, Gruber), and of the
muscida lucilia (Blake).
Dr. Blake t hasmade a study of the nature and habits of
these grubs, by taking them from the ear at a very early
period of development ; as near as could be ascertained within
twelve hours of the time of their deposit. He placed a speci
men on the bottom of a thin glass vessel and covered it with
a piece of raw beef, soaked in warm water, in such a manner
that by inverting the glass the movements of the larvæ could
be easily studied under the microscope.
Dr. Blake found that the apparatus by which the larva
attaches itself, and which pierces and tears the tissue, is made
up of a strong but delicate framework of horny consistency and
of two hooks also of a stout horny structure , articulating with
this frame-work . The larva burrows its way into the tissue
* Monatsschrift für Ohrenheilkunde, Jahrgang III., No. 3.
† Archives of Ophthalmology and Otology, 1. c.
166 LIVING LARVE IN THE EAR.
on which it feeds by repeated extension and contraction of the

hooks, alternately piercing and tearing.
These movements explain the agonizing pain which pa
tients experience when the larvæ appear from the eggs.
These hooks are very large in proportion to the size of the
body of the larvæ .
Dr. Blake says that the instincts of the animal lead it to
bury itself beneath the surface, and to seek warmth and mois
ture and a soft , yielding tissue for its work . Hence, they
are always found at the end of the canal or in the cavity of
the tympanum .
As yet, they have always been found in connection with
suppuration of the middle ear, with its consequent perforation
of the membrana tympani.
The examination of the auditory canal infested by living
larvæ , shows small white worm -like animals moving rapidly
about, very much as a mass of common earth-worms. As I
write, I have before me a number of specimens of the dead
grubs. They are about a half an inch in length, and of the
diameter of a large knitting needle.
Treatment. — I have found it impossible to remove living

larvæ by means of the syringe. The more they are syringed
the more lively they become. Before the syringing is at
tempted, some agent should be instilled into the ear which
will kill them , when the syringe will usually remove them .
Sometimes, however , even after death , their hooks penetrate
so deeply into the tissue that they can only be removed with
the forceps. The forceps should not be needlessly used, how
ever , for even with the most careful manipulation, and with
tractable patients, they often abrade the integument of the
canal, and thus cause pain . I have used Labarraque's solu
tion of chlorinated soda to kill these grubs, but simply because
it was at hand when I saw the cases.
The larvæ have also been killed by forcing the vapor of
chloroform into the cavity of the tympanum through the
Eustachian tube. I believe, however , that it will be sufficient
to force the vapor into the external ear,or to instill some such
fluid as I have mentioned into the canal.
FOREIGN BODIES IN THE EAR . 167
It need hardly be said, that the disease which allowed of

the deposition of the eggs, and the hatching of the grubs,
should be treated after they have been removed. Even those
who are advocates of allowing a discharge from the ear to
remain unchecked, will hardly defend such a neglect when
the ear has become a disgusting receptacle in which larvæ are
formed.
FOREIGN BODIES IN THE EAR .
The foreign bodies that are placed in the ears of children

by themselves or their playmates , have, from the time of the
first writers on otology, formed a fertile field for the labors of
surgeons. The importance of the subject has been unduly
magnified . From some source or other, the laity have got the
impression that a foreign body in the ear, like a wild beast
accidentally let loose upon a civilized community, is to be
hunted down at all hazards. The presence of a foreign body
in the canal is, after all, however, not a very serious matter.
Children do not usually push them in far enough to do any
harm . It is the meddlesomeinterference of nurses and friends,
and sometimes of unwise practitioners, that forces them into
dangerous positions. There was a notion prevalent in Eng
land , in Shakspeare's times,* that poison poured into the ears
was as dangerous as if taken into the stomach ; and from this,
in some manner or other, has come the idea that a foreign
body in the ear becomes at once a very dangerous thing.
It would be well, if this fear of foreign bodies in the ear,
were transferred to cases where they have entered the eye
ball, where the most serious results do occur from the neglect
to promptly remove a foreign substance. Unskillful or indis
creet attempts to remove a foreign body are often more dan
gerous than the foreign body itself. In the case of a foreign
body in the eye, it is the loss of sight that is threatened , and
it is usually the worst that can happen ; but it is not a very
rare experience that improper attempts to remove a foreign
body from the ear have cost the life of the patient.
* Play of Hamlet.
168 FOREIGN BODIES IN THE EAR.
When, therefore , a child is brought to the practitioner, in

whose ear there is, or there is supposed to be, a foreign body,
let him first, by ocular examination , be sure that the diagno
sis is correct, and then let him attempt to remove it by a safe
means.
“ First catch your hare,” is the quaint and familiar begin
ning of the receipt for cooking this animal; and in imitation
of this sage advice, the writer, taught by experience that the
diagnosis of mothers and nurses is not always to be trusted ,
would urge upon his readers the wisdom of not attempting to
remove a foreign body which he cannot see. There is nothing
more deceptive than the tactile examination . Again and
again have I seen physicians click what they supposed to be
a foreign body, by means of a probe, when they were simply
striking the bony wall of the canal.
The surgeon should not take the testimony of the most
intelligentnurse in the world , as to the presence of a foreign
body in the ear, unless he sees it himself. Such testimony is
only valuable to prove that a foreign body was once in the
ear. Any attempt to remove a foreign body that is not seen ,
but which is supposed to be in the ear, will lead to a danger
ous and mortifying failure.
Even when it is seen, a forcible or violentattempt is always
a dangerous procedure.
Voltolini,* in writing on this subject, says, “ that even the
point of a dagger, if allowed to quietly remain in the ear, will
not do as much harm as forcible attempts to remove it."
The danger to be apprehended from attempts to remove a
foreign body by the use of force is, that it will be pushed
downwards in the ear, and through the membrana tympani
into the cavity of the tympanum , and even into the labyrinth .
Unfortunately for the fair fame of surgical science, such cases
are on record .
Treatment. If the physician see a case in which a foreign

body has really got into the auditory canal— a fact which he
should determine by the use of thespeculum and the otoscope
* Monatsschrift für Ohrenheilkunde, Jahrgang II., No. xi.
REMOVAL OF FOREIGN BODIES. 169
- before it has been meddled with , he will almost always be
able to remove it by the process of syringing the ear with
warm water. Children , however young , will readily submit to
this operation , and it is almost always successful, if, as I have
said, there have been no previous manipulations with instru
ments.
Unfortunately, however, the cases are not usually seen by
a physician until the friends of the little patient, having found
by the child 's own statement that a bead, or a pea, or a shoe
button, or the like, is in the meatus, and having been able to
see it, have pushed it well in , in their misguided zeal to re
move that which in itself, is not dangerous to the ear or its
functions.
Many cases are on record where foreign bodies, which had
not occluded the auditory passage, have remained in it for
years without doing harm . Thus Wreden * reports a case in
which he removed a button from the outer ear, which had re
mained at the junction of the osseous and cartilaginous canal
of a boy of seventeen, for twelve years, and without doing any
harm .
If, however, the foreign body has become impacted by the
attempts to remove it, and if serious inflammatory symptoms
have arisen , it is better to wait until the latter has subsided
before any further attempts at removal are made.
Then, if instruments are to be used , the child should be
placed under the influence of ether, and by means of a pair
of delicate forceps, or a probe, it should , if possible, be dis
lodged from its wedged position, and then removed by the
syringe. No manipulation of this kind should be attempted ,
however, unless the foreign body is well illuminated , so that
the surgeon can see exactly what he is doing during the whole
of his manipulations.
In cases where injections made while the patient is in an
upright position , do not remove the foreign body, Voltolini
hasadopted the following method with success :
The child is laid upon a table , so that its head may hang
a little over the end of it. The membrana tympani then forms
* Monatsschrift für Ohrenheilkunde, Jahrgang III., No. 12 .

170 REMOVAL OF FOREIGN BODIES .
a plane with the upper wall of the auditory canal, that runs
obliquely downward . The syringing is then performed as
usual. In two cases Voltolini has succeeded in removing the
foreign body by this manoeuvre,when the ordinary method did
not succeed .
Voltolini has also used the galvano-caustic in breaking
ap the so-called Johannis brod or carob bean. The bean
having become so firmly wedged into the ear that it was im
possible to move it one way or the other, he inserted the
needle “ with lightning -like rapidity ” into the body, and when
it cooled , the bean broke with a snap audible to the patient
and to those about. When sufficiently broken up , it was
removed by syringing.
Foreign bodies, such as peas, beans, and the like, are
harder to remove after they have been in the ear for some
time, than metallic bodies , because they swell, and thus be
come wedged firmly in the canal, and if they have been pushed
into the cavity of the tympanum they excite still more trouble
and become still more unmanageable .
I have seen quite a number of foreign bodies in the ear,
and I have never but in one case failed to remove them , and
then I saw the patient but once for a few moments. The
syringing did not succeed, and I asked the mother to bring
the patient to my clinic at the Hospital, where she might be
placed under the influence of an anæsthetic , but she was not
brought.
In one case, when the child first came under my observa
tion, a button was lodged in the cavity of the tympanum by
efforts to remove it. I syringed it in vain on several occa
sions. I then proceeded carefully with instruments, the pa
tient being anæsthetized . This attempt also failed. I then
ordered the mother to syringe the ear three times a day, which
was necessary on account of the purulent otitis media which
had been set up by the presence of the button in the cavity of
the tympanum , and I also advised the careful use of poul
tices . To my delight, in about four weeks I had the satisfac
tion of removing the button from the canal, where it had been
brought by the syringing and the use of the poultices.
I have now under my care a little child of four years of
REMOVAL OF FOREIGN BODIES. 171
age, who, according to her own statement to ber nurse, put an

ordinary shoe-button,madeof papier -mache, in her ear. As soon
as the nurse's attention was called to the case, she reported it
to the family , who sent for a physician, who saw the button,
and attempted to remove it, under chloroform , using for this
purpose a small elevator. It is stated that half thebutton was
removed in this way ; but the other half could not be dislodged.
In a few days, the child having become very weak from the
operation and theanæsthetic, from the chloroform , I was called
in consultation . A careful examination was made. Themem
brana tympani was found to be gone, there was considerable
swelling of the canal, but the button was not to be seen either
by the physician or myself, although he thought he detected
it with the probe.
Another surgeon was called in , and he was not able to find
a foreign body, and the child has been under treatment ever
since for a chronic suppuration of the middle ear, the mem
brana tympani and the ossicula being gone, and the hearing
irretrievably injured .
I recite such cases in order to show what harmful conse
quences may result from the most conscientious attempts to
remove a foreign body with instruments.
No engravings are given in this volume of the numerous
hooks, forceps, perforators, drills, picks, et id genus omne, that
have been devised by surgeons, with more ingenuity than wis
dom , for the removal of foreign bodies from the ear, because I
firmly believe that the vast majority of such instruments are
very dangerous weapons ; while they are usually greatly infe
rior in efficiency to the use of the warm water and syringe.
Cases will occur, however, in which syringing will not be suf
ficient; but I should not hasten unduly , unless the body had
become impacted in the tympanic cavity , or was causing
unpleasant or serious symptoms. In such cases the ordi
nary armamentarium of the surgeon will contain instruments
adapted for the individual cases as they occur. Let him
remember, however, that once beyond the membrana tympani,
he is dealing with parts whose injury becomes dangerous not
only to hearing but to life.
The ancient suggestion of Hippocrates and Du Verney (see
172 REMOVAL OF FOREIGN BODIES.
page 36 ), to detach the auricle from the ear, will be found

worthy of consideration when it is found impossible to remove
a foreign body through the canal. It certainly cannot be a
dangerous operation , and it is much to be preferred to any
risk of serious injury to the cavity of the tympanum or the
labyrinth .
Dr. Lowenberg* reports an ingeniousmethod by which he
removed a small ivory ball, from the tip of a quill penholder,
which had been forced into the ear of a boy nine years of
age. Various attempts at removal, by other hands, wounded
the canal, perforated the membrana tympani, and excited
severe inflammation. After the inflammation had subsided ,
Dr. Lowenberg attempted to remove the body by syringing,
by Valsalva 's and Politzer's methods of inflating the ears ;
but he failed . He then extracted the ball by bringing the
point of a small brush , dipped in joiners' glue, in contact
with its outer surface, allowing the glue to harden , and then
extracting brush and ball together.
Dr. E . H . Clarke, who is quoted by Blake in the same
report from which I have taken the description of Dr. Lowen
berg's method, once adopted a similar procedure with success.
The foreign body was a hard, smooth ball, and it was ex
tracted by passing a thread through a small square of adhe
sive plaster, and bringing the latter , by means of a fine tube,
into contact with the surface of the ball, when sunlight was
concentrated upon it by means of a lens, until it softened and
adhered, when it was easily extracted .
These two methods are certainly to be commended as both
ingenious and safe .
It is possible that the reader is ready to believe, that I am
attaching too much importance to this subject of the removal
of foreign bodies from the ear : but I am sure that any one
who has taken the pains to look over the literature of this
subject, or who has seen many cases, will feel that too much
stress cannot well be laid upon the necessity for skill and wis
dom in the management of these cases.
I will, however, close the chapter by some statistics which
* Report on the Progress of Otology , by C . J. Blake, Transactions Ameri
can Otological Society , 1872.
FOREIGN BODIES IN THE EUSTACHIAN TUBE. 173
have been carefully prepared by Dr. Mayer, of Munich ,which
illustrate this subject, and with the insertion of a painful case,
from Mr. Pilcher's book on the ear,which is one I have been in
the habit of repeating to my class, as a warning to those who
try to extract from an ear what they have never seen.
My distinguished countryman, Dr. J. Marion Sims, of this city, published
an article, illustrated by three cases, in the American Journal for Medical Sci
ences, vol. ix ., 1845, that very warmly and ably advocated the use of the
syringe for the removal of foreign bodies from the ear, but which did not
receive the attention it deserved .
FOREIGN BODIES IN THE EUSTACHIAN TUBE.

Among the cases whose statistics will be given as reported by Dr. Mayer,
two will be noticed where laminaria bougies were broken off in the Eustachian
tube. Dr. Hecksher,* of Hamburg, relates an interesting case that belongs to
this class. The patient was a principal of a college, who had been accus
tomed to treat his own ears — which were affected with chronic catarrh - by the
use of the Eustachian catheter.
Dr. Hecksher received a telegram one day from the patient, for whom he
had occasionally prescribed, stating that he had got a foreign body in one of
his Eustachian tubes. When Dr. Hecksher reached the patient,he gave the
following history :
He had introduced through a metallic catheter a whalebone probe into the
tube . On the end of this probe was fastened with a silk thread a raven 's
feather, which he used for the purpose of washing away mucus from the tube.
One evening as he was using the apparatus, he drew back the probe with
out the feather, and he found that he had left it in the tube . It caused so
much pain that he could not sleep. Attempts were made by a physician to
remove the foreign body , but they failed . Dr. Hecksher then attempted to
remove the body , but the parts were so swollen that he could not practice
rhinoscopy , and see the feather, and he failed with various kinds of forceps to
remove it .
So much inflammation ensued that he was obliged to desist, and use anti
phlogistic treatment; but the patient finally removed the feather himself by
the aid of the catheter introduced in the usual way, and his finger passed
behind the uvula.
CASES.
Dr. Ludwig Mayer t has collected the cases of foreign
bodies in the ear that he has been able to find in the litera
* Monatsschrift für Ohrenheilkunde, 1870 , No. 1.
+ Monatsschrift für Ohrenheilkunde, Jahrgang IV , No. 1
174 STATISTICS OF FOREIGN BODIES IN THE EAR .
ture of the fifty years preceding 1870. The whole number is

77. Of these persons
16 were between 1 and 10 years of age.
10 " " 10 " 20 "
10 " " 20 " 50 "
1 was over 50 6 6
The age of the remainder is unstated .
In 66 cases the foreign body was in the auditory canal,
8 were in the cavity of the tympanum , and 3 in the Eustachian
tube. Of the three cases in the Eustachian tube, two were at
the pharyngeal orifice. In the third case, a barley -corn pro
jected from the pharyngeal orifice, and at the post-mortem
section — it is not stated of what disease the patient died — the
foreign body was found to reach into the osseous tube.
In two of the cases the foreign body was in the ear but
twelvehours before seen by the surgeon who reported them . In
only 12 of the cases was the foreign body in but a short time,
varying from days to weeks. In the remainder, they were in
for years. Four were in for four years, two for twenty years,
one for forty-five, and one for more than sixty years.
The substances found were — a needle, carob beans (6 ),
beans (3), cherry pits (6 ), living larvæ (4), peas (1 ), a wisdom
tooth of the upper jaw , a grain of coffee, a snail, pearls (2) ,
point of a glass syringe, a glass ball, wads of cotton (6), a
carious tooth , a piece of hard coal, a wad of paper , a gun cap,
a piece of bone, a piece of bread , a bit of lead , laminaria
bougies in the tube (2 ), a millet seed , a piece of coral, a
barley-corn in the tube, and an agate stone.
Dr. Mayer finds, on an analysis of these cases , that the
attempts to remove the foreign bodies had usually caused
much more trouble in the ear than their presence.
In 48 of the 77 cases, functional and pathological changes
are said to have occured as a result of the presence of the
foreign bodies. In 11 of the cases it is reported , that the
attempt at removal caused these disturbances.
Pain in the ear was generally the disturbing symptom in
those cases in which the foreign body caused any trouble.
This was chiefly due to the irritation of the lining membrane
CASES OF FOREIGN BODIES IN THE EAR . 175
of the canal, which is so closely allied to periosteum in its

nature as to be subject to intense pain . Besides, as shown by
F . E . Weber, the pain in the cartilaginous portion of the canal
is severe on account of the fact, that the fibrous tissue of the
cartilaginous canal is fastened to the squamous portion of the
temporal bone, above and behind , by tense fibres. As has
been shown , the canal is very richly supplied in nerves, and
this serves to explain the severe pain experienced when a
rough body is in the ear, or when the canal is abraded by
attempts at the removal of a smooth and harmless one.
Polypi arose five times in consequence of the inflammation
of the ear. Severe hemorrhage occurred five times, and
always in consequence of attempts to remove the foreign
bodies.
In one case there was delirium , and in three cases suppu
rative meningitis, and once a cerebral abscess, with , of course ,
a fatal result.
The membrana tympani was perforated, and the cavity of
the tympanum inflamed , from the efforts at extraction in the
ta
three cases in which meningitis resultedd .
In one case the patient, a child , attempted to push the
foreign body - a piece of flint-stone - out through the other ear.
Suppurative meningitis occurred , and death resulted in a few
days. The stone was so firmly fixed in the mastoid cells that
trouble was experienced •in removing it, even at the post
mortem examination .
In one case on the section , a wad of paper was found in a
cerebral abscess which communicated with a collection of pus
in the tympanic cavity . It had probably been forced there by
the attempts to remove it!
The disturbances of the nervous system were considerable
in some cases, and they throw light upon the influence of
chronic aural suppuration upon this part of the organism . In
three cases therewere generalconvulsions; there was paralysis
of one side of the face in five cases , atrophy of the arm in two
cases , twice there was anesthesia of the whole of one side
of the body. There were two cases of epilepsy. The facial
paralysis was caused by a continuation of the inflammation
to the Fallopian canal and the facial nerve.
176 CASES OF FOREIGN BODIES IN THE EAR .
The convulsions and the epilepsy were probably caused
by reflex action through the medulla oblongata , due to peri
pheric irritation of the fifth pair of nerves.
The cases of atrophy of the arm and anesthesia of the
body are so imperfectly reported, that Mayer does not attempt
any explanation of them .
Our limits do not allow of a complete transcription of the
cases which Dr. Mayer has collected with such care; only a
few of themore curious or important ones, can receive a fur
ther allusion.
In one case a horse coughed some oats into the ear of a
man as he was going by the animal.
Deleau , Junior, removed a foreign body from the cavity of
the tympanum , an agate stone, by an injection of water
through the Eustachian tube. The reader will find this case
fully reported in Lincke's collection of Monographs on the
Ear.*
The case of atrophy of one arm , epilepsy, anesthesia of
one-half of the body, is the famous one of Fabricius Hildanus,
quoted by Von Tröltsch. t The patient, a young woman of
18 years, is said to have been cured of all these symptomsby
the removal of the foreign body, a glass ball, eight years after
it was inserted.
Handfield Jones I saw a case in which hemiplegia with
convulsions arose from the presence of insects in the ear.
Wederstrandt g reports a case in which molten lead was
poured into the right ear of a drunken man. The pain was
not severe ; the hearing power was gone. The patient was
able to leave the hospital in eight days. The lead was
not removed, and severe suppuration occurred . Seventeen
months after he was in the same condition , with paralysis
of the right orbicularis palpebrarum muscle ; a polypus had
grown over the lead .
In three of the cases death occurred, and in all of them it
may properly be said to have been caused by attempts to
* Lincke's Sammlung, Bd. I, p. 154. .
+ Text-book , American translation, p . 490.
| Sydenham Society Year-book , 1861.
$ American Journal of the Medical Sciences, vol. ix.
FATAL ATTEMPT TO REMOVE A FOREIGN BODY.
FATAL ATTEMPT ]TO REMOVE A FOREIGN BODY .
177
remove foreign bodies, which, whatever disturbances of the
system they might have produced, would not probably have
led to death .
Mr. Pilcher, in his work on the ear, * reports a very in
structive case in full in which surgeons of a London hospital
attempted to remove from the ear of a child of seven years of
age, the head of a nail, which they never saw , but which they
felt with a probe.
The first surgeon to whom the child was brought said he
saw the head of the nail, but he did not attempt to remove it
because four men could not hold the boy's head still. A
director, dressing forceps, which were both bent in the forci
ble efforts, forceps with hooks were used , and they were also
bent straight, but the nail could not be removed . An incision
was then made behind the auricle, and the meatus was ex
posed . A search was then made for the nail, with forceps
and an elevator. Tooth forceps were then used ; three pieces
of metal, which appeared to be pieces of the nail, were
removed by these delicate instruments . The malleus bone was
then removed by the forceps.
The patient was now so exhausted that “ his pulse could
scarcely be felt, and his skin was bedewed with cold per
spiration .”
The operator then stated that he had used “ more force
than was warrantable.” He thought, however, there was now
a large opening (sic) through which pus might escape, and
yet he feared that a portion of the petrous bone might exfo
liate , and that meningitis and abscess of the brain might
occur. He stated that he had seen three or four cases which
had terminated in this manner.
Of course the little victim died, and that too on the third
day after these operative attempts .
The post-mortem examination revealed softening of the
base of the brain , and of the anterior part of the hemispheres.
Not a vestige of the bony part of the external auditory
canal remained, it having been removed during the operation,
* Treatise on the Ear, American edition,by George Pilcher. Philadelphia ,
1843. Reprint.
12
178 FATAL ATTEMPT TO REMOVE A FOREIGN BODY.
and the floor of the tympanum was also wanting. There was
considerable pus in the tympanic cavity.
“ The nail not being in the tympanum , sections were made
through the cochlea, vestibule, semicircular canals, and mastoid
cells ; but there was no nail to be found.”
The fact has already been alluded to in this chapter, that

persons sometimes suppose there is a foreign body in the ear,
when there is actually none in it, and when there probably
never has been one there .
At times mental delusions occur on this subject. I have
seen several cases of the kind which are quite remarkable.
Two cases I saw at the New York Eye and Ear Infirmary ,
where the patients, who were women of the lower class in life,
supposed that pins were in the auditory canal. No amount
of reasoning, nor the subterfuge of pretending to remove a
pin from the ear, by syringing, could satisfy these females.
In another case a woman brought her son to my clinic in
the University of New York, and stated that he was passing
pieces of anthracite coal from the external meatus. She had
quite a quantity of coal in a handkerchief, which she said had
been passed from the ear. Some of these pieces of coal were
larger than the auricle . The boy agreed with his mother in
her insane statements. I am sorry that they passed from my
observation before I could fully investigate the cause or mo
tive for the delusion .
In another part of this work * allusion will be again made to
the cases , not uncommon , in which patients with chronic dis
ease of the middle ear, and persons who perhaps were of sound
mind, firmly believed, in spite of the negative result of my
examinations, that there was inspissated cerumen in the audi
tory canal. Indeed, the sensation of fulness of the canal in
chronic cases of disease of themiddle ear, is often so decided
as to render such a belief pardonable, in a person who has not
full confidence in the surgeon who examines the ear.
It has been mentioned , in the second chapter, that the hairs
ofthe auditory canal sometimes lie on the drum -head, and thus
become irritating foreign bodies.
• Chapter on Chronic Non -suppurative Inflammation .
PART II.
THE MIDDLE EAR .

CHAPTER IX .
ANATOMY OF THE MIDDLE EAR .
By far the greater number of aural diseases affectwhat is

known as the middle ear. Of one thousand cases occurring
in the private practice of the author, eight hundred and nine
were diseases that involved these parts chiefly . The ana
tomy of this region, therefore, demands a careful and exact
study.
By the term middle ear, we comprehend, strictly speaking ,
only the cavity of the tympanum , the mastoid cells, and the
Eustachian tube ; but since the structure of the membrana
tympani is in part identical with that of the cavity of the tym
panum , and since it is always involved in any considerable
affection of the middle ear, I have thought it wise to consider
its anatomy in the same chapter, with that of the other parts
with which it is so intimately connected.
THE MEMBRANA TYMPANI.
The membrana tympani, or drum -head, forms the bound

ary between the external and middle ear. It partakes of the
characteristics of these two parts, in being composed of integ
ument and mucous membrane, while it has one structure the
middle or fibrous layer _ that is peculiar to itself.
The upper border of this membrane lies 7mm . nearer to
the entrance of the external auditory canal than the lower.
The posterior border is about 5mm . nearer this entrance, or
meatus, than the anterior . The angle that the membrana
tympani makes with the axis of the auditory canal, is one of
about 55°. The inclination of the twomembranes to an angle
opening upwards is one varying from 130° to 135°. In the
182 ANATOMY OF MEMBRANA TYMPANI.
newly bom , the membrana tympani is more in a horizontal
position than in the adult, and lies almost in the same line
with the upper wall of the external auditory canal.
FIG. 38.
The Right Temporal Bone, without the Petrous Portion, in connection with the Ossicula
Auditus of a newly born Child, seen from within . After Rüdinger.*
4, is above the incus,whose short process is directed nearly horizontally backward . 6. The
long arm of the incus, which extends freely into the cavity of the tympanum . 6. The
malleus, in articulation with the incus. 7. Long process of the malleus, which runs
under the crista tympanica , in a furrow , to the fissura petroso-tympanica . 8. The
stapes, in articulation with the incus.
The peculiar manner in which the membrana tympani is

placed in the canal causes it to form an acute angle with the
Fig . 39.
Left Temporal Bone of the same Subject as preceding Mgure.
* Atlas des Menschlichen Gehörorganes. München, 1867.

ANATOMY OF MEMBRANA TYMPANI. 183
lower and anterior wall of the auditory canal, but an obtuse
one with the upper and posterior wall. 11 .
The general shape of the membrane is elliptical ; but the

regularity of the ellipse is broken in upon by the incomplete
ness of the bony ring surrounding the membrane. In the
upper part of this bony ring an oral section is wanting : this
space is known as the segment of Rivini.
Fig . 40.
1. The righttemporalbone of a newly born child , with a dried membrana tympani. ( After a pha
tograph . Rüdinger .) 2. The malleus bone, its apex reaching to the centre of the mem
brane. 3 . The long process of the incus, seen through the transparentmembrane. It is
also sometimes observed on the living subject in cases of atrophy of the membrane.
The long axis of this ellipsoid runs downwards and for

wards, the shorter backwards and downwards. If the diam
eters of the membrane are measured in the direction of the
axes of the ellipsoid , that of the long axis is 9.5 - 10mm ., and
the horizontal is 8m . Measured in the usual manner , the
horizontal diameter is 8 -8 .5, and the vertical 8.5- 9mm .
The Rivinian segment is filled by the tissue of the cutis
and the mucous membrane of the tympanic cavity. The
greater part of the fibres of the tendinous ring of the mem
brana tympani bend from their former course, and at this
point turns toward the short process of the malleus,which lies
more deeply where it is inserted. The remainder of the ten
dinous fibres of the ring pass upward , and are lost in the con
nective tissue of the periosteum .
This causes an irregular triangular space to be formed ,

bounded above by the Rivinian segment, and on each side by
two bands, which attach the apex of the small process of the
malleus to the anterior and posterior corners of the osseous
groove.
This space, and the tissue filling it,was first described by
Mr. Henry Jones Shrapnell,* and named by him the membrana
flaccida. It is often called Shrapnell's membrane. Mr.
Shrapnell considered that the function of this flaccid mem
brane was to protect the more tense fibres during the effects
of sudden and loud sounds, or the actions of coughing and
sneezing, when by yielding it saves the tense fibres from being
ruptured . In the hare and the sheep , that would be otherwise
defenceless animals, were it not for the great power of their
ears to warn them of approaching dangers, this structure is
remarkably developed .
The tissue composing Shrapnell's membrane is less tense
than the remainder of the membrana tympani, and sometimes
falls in like a pouch towards the tympanic cavity. It consists
of a very thin layer of cutis and ofmucous membrane. The
mucous membrane extends to the osseous edge of the Rivin
ian segment, and from here passes over to the projecting neck
of themalleus bone,which lies opposite .
The existence of a minute opening in the membrane - the so -called Rivin
ian foramen - has been warmly disputed from the timeof its discovery, 1717, by
Rivinus, a professor in Leipsic , until the present day. Professor Patruban ,
of Vienna , found such an opening in 300 membranes, part of which were
healthy , part diseased. He allowed a fine stream of quicksilver to pass into
the so-called canal, and it always appeared on the other side of the membrana
flaccida,
Professor Joseph Grubers has also found the foramen in many specimens.
Inasmuch as he oftener found it in pathological specimens, he thinks that its
* London MedicalGazette, vol. 10, p. 120. Several German authors speak

of Shrapnell as Odo Shrapnell ; but his name,as it appears in the original of
his articles, is as I have given it.
+ According to Von Tröltsch, the so-called foramen of Rivinus was first
discovered by Glaser, in 1680, who was then professor in Basle. Bochdalek ,
however, claims the discovery for Colle.
| Monatsschrift für Ohrenheilkunde, Jahrgang III., No. 1.
$ L . C.
RIVINIAN FORAMEN . 185
size is at least increased by disease. Gruber does not believe that it is an
opening always to be found ; but that it is one frequently observed , and thatit
would be an interesting inquiry as to how far it is the result of disease.
Dr. Politzer* thinks that the Rivinian foramen is a constant appearance,not
an anomaly or result of disease.
Hyrtlt denies the existence of themembrane, and says that he has never
found it, either on the adult or infantile cadaver. The ability to blow tobacco
smoke from the ears is the result, he thinks, of a want of development in the
upper part of themembrane.
Professor Bochdalek , of Prague, rediscovered the opening at the upper
margin of the membrana tympani, one-third to three-fourth lines from the
edge, and reopened the discussion which Hyrtl seemed to have closed.
If the Rivinian foramen , or canal, does exist in the membrana flaccida, it is
so small that only a fine bristle, or hair, will pass in it, and the anatomist
must sometimes persevere for hours with a magnifying-glass, in order to find
it. Bochdalekt describes his discovery of the opening as follows : “ To my
great astonishment I saw , by means of a magnifying-glass, on the posterior
portion of a small depression on the membrana tympani, and a little behind
the malleus, a very small canal, in which was perceived , although very
indistinctly , a punctiform opening. By means of a very fine bristle I suc
ceeded in entering a narrow groove, not more than one-third of a line long,
which ran in an oblique direction from above downward, and somewhat ante
riorly , into the cavity of the tympanum , so that the bristle passed immediately
beneath the handle of themalleus,and just as closely beneath the chorda tym .
pani. On pushing the bristle still farther, it passed under the tendon of the
inner muscle of the malleus,and struck on the inner wall of the cavity of the
tympanum ."
Dr. Bochdalek also found the foramen in the opposite membrane of the
same subject, as well as in sixty-three other preparations of the membrana
tympani. Forty of them were from fresh subjects, the remainder had been
preserved in alcohol. In two cases only the opening was not found. In both
these cases morbid changes (thickening ?) had occurred in the drum -head .
Kessels believes that the foramen is the result of inflammation . He says
that he has convinced himself of the correctness of this view , by dissections
and by examination of the living subject at Gruber's clinic.
The author believes in the existence of the foramen of Rivinus, from the
clinical fact that be has heard a whistling sound , seemingly through themem
brana tympani, in several cases, when the Valsalvian experiment was made,
when neither he nor other observers could detect the slightest opening with
the eye. I have also been startled , in one or two instances, on blowing my
nostrils violently, by hearing the air whistle through the drum -head , as it
seemed . On one occasion , I immediately consulted a friend who has large
experience in examining the membrana tympani, and he decided that it was
* L . c.
+ Anatomie des Menschen, p.520.
Prag. Viertel. Jahrschrift , January, 1866.
& Stricker's Hand-book of Histology, p. 953.
not perforate, as did several others who soon examined the ear. Indeed, I
have never suffered from any disease of the ear that led me to suppose the
drum -head could be perforate.
I cannot escape the subjective conviction , however, that the foramen of
Rivinus exists, and that air may be occasionally heard to whistle through it,
although the opening itself cannot be seen.
Mr. Wharton Jones* described the circular and radiating

fibres of the membrana tympani in his article on the organ of
hearing
Sir Everard Home + supposed that these fibres were muscular, and he
thought that by this muscle " accurate perceptions of soundswere conveyed to
the internal organ." Mr. Home admitted that the muscles of the malleus
stretched and relaxed the membrana tympani, but only in order to bring the
radiated muscle into a state capable of acting .
Mr. Home reports a case of double hearing, and he explains it by a defective
action of the radiated muscle, which was not exerted with the same quicknesg
and force in one ear as in the other, so that the sound was half a note too low ,
as well as later in being impressed upon the organ. It is interesting to note that
nearly all the cases of double hearing are observed as occurring in musicians.
The patient, judging from the history, evidently had a catarrh of the tym
panic cavity, and the double hearing probably arose from unequal pressure on
the labyrinths.
The objects in the membrana tympaniwhich first strike

the attention of the observer are the handle, or long process
of the malleus bone, and the triangular spot of light. I am
now speaking of the membrane, when viewed through the
auditory canal. When this is detached, the reflection called
the light spot, is not seen , because one of the conditions
for its formation is removed , as is also true, to a certain
extent, of a membrane seen after death , when the tissues are
macerated .
The long process of the malleus, also called the handle or
manubrium of the malleus, divides the membrane into two
parts. The anterior part is larger than the posterior. The
attachment of the malleus between the layers of the drum
head will be described in the description of these parts .
At the extremity of the handle of the malleus is situated
the apex of the light spot. This point is also the place of
* Cyclopædia of Anatomy and Physiology, vol. ii.
+ Philosophical Transactions of the Royal Society of London, 1800 . Part I.
THE TRIANGULAR LIGHT SPOT. 187
greatest concavity of the outer surface of the drum -head,

and is called the umbo (boss of a shield ), or navel of the
membrane.
The light spot, as will be seen in the chapter on chronic
non -suppurative disease of the middle ear , is one of the im
portant standpoints for the diagnosis of certain affections of
the middle ear. The study of the conditions necessary to its
formation is therefore of importance.
FIG . 41. Fe. 42.
View of Membrana Tympani, showing Handle of Malleus and Triangular Spot of Light.
An account of the normal color of the membrana tympani

will be found in the chapter on Chronic Non -suppurative In
flammation. Until the investigations of Von Tröltsch and
Politzer, this was described as seen in the dead subject ; but
the post-mortem appearances of this membrane are no guide
to its appearance on the living subject. The ordinary breadth
of the light spot, at its base, is from one and a half to two
millimetres. — ( Politzer.) It is sometimes interrupted in its
continuity .
The chief causes of the existence of the light spot, accord
ing to Politzer,* are the inclination of the membrane to the
axis of the external auditory canal, and the concavity pro
duced by the traction of the handle of the malleus.
If light be thrown upon a dried preparation of the human
ear, as in the examination of the living subject, through the
auditory canal, the light spot will be found in the same posi
tion as it is seen in life. It is also displaced very little bymov
ing the eye in different directions, because the axis of vision
• The Membrana Tympani, p. 26 . Mathewson and Newton 's translation .
188 THE TRIANGULAR LIGHT SPOT.
corresponds so nearly to the axis of the meatus, that the light

spot can change very little with respect to the inclination to
the membrana tympani.
No light would be reflected to the eye if the membrane
were a plane surface ; for, with its inclination to the auditory
canal, all rays thrown upon it would be reflected against the
anterior and lower wall of the canal. In consequence, how
ever, of the inward curvature from the traction of the handle
of the malleus, its parts undergo such a change of inclination
that the anterior portion stands directly at right angles to the
axis of vision of the observer, and the light thrown upon it is
reflected back to the eye.
Politzer proved the correctness of this opinion by stretch
ing an animal membrane over a large ring, and giving it the
inclination of the membrana tympani. No reflection will be
perceived until the central portion is pressed inward , or made
concave by traction from behind it.
Helmholtz * also states that the triangular spot of light is
due to reflection. Voltolinit claims that the light spot may
be seen when no auditory canal is present ; indeed, even when
the membrane is completely removed. This seemsto me to
be a mistake ; for while there is a reflex from any generally
convex brilliant membrane, such as the drum -head, although
it has a central concavity , there is no such triangular and
fixed one, as when the auditory canal is present, and this is
the whole point ofthe theory of Politzer.
Voltolini is correct, however, in calling attention to other
modifications of the light spot, than its inclination in the audi
tory canal. If it become thickened, inflamed or infiltrated ;
in other words, if from mechanical or chemical causes it cease
to be a brilliant membrane, and it does not reflect light as
well as formerly , the light spot will no longer be triangular in
shape, and perhaps not exist at all ; but neither the concavity
nor polish of the membrane have all to do with the existence
of the light spot, as Voltolini asserts . Any person can prove
this for himself by a few simple experiments , with a membrano
stretched over the end of a tube.
# Monatsschrift für Ohrenheilkunde, Jahrgang VI., No. 8.
+ L . C.
LAYERS OF THE MEMBRANA TYMPANI. 189
The light spot depends upon three factors, viz. :

I. — The inclination of the membrana tympani to the
auditory canal.
II. — The traction of themalleus,which renders it concave
at the center .
III. Its polish or brilliancy.
THE LAYERS OF THE MEMBRANA TYMPANI.
The membrana tympani is not quite 0.1 millimetre in thick

ness (Henle) — about as thick as very fine letter -paper or gold
beater's skin (Von Tröltsch). This thickness varies within
small limits.
FIG . 48 .
There are three layers in the structure of 302
the membrana tympani.
1. A thin layer of integument.
2 . A fibrous layer. This layer forms the
principal thickness of the membrane.
3. A mucous layer continuous with that
of the tympanic cavity.
The first or integumentary layer of the
membrana tympani has none of the hairs or
glands of the lining of the canal, of which
it is a direct continuation. The papillæ are
found as far as the short process of the mal
leus.
The epidermal cells, the cuticle and corium
diminish gradually in thickness from the peri Vertical Section of Fi
phery towards the handle of the malleus ; they Brous Layer of the
then increase and are thickest on the outer Membrana Tympani.
After Henle.
edge of this bone.
The fibrous layer consists of lamellæ , each one of which
forms a mesh -work of smooth fibres with narrow , almost
fissure-shaped apertures. The fibres have an average breadth
of 0 .01 millimeters.
The majority of the fibres run to the malleus in a radiating
or circular direction . A small number of them , however, run
in different directions between these two sets of fibres. The
190 LAYERS OF THE MEMBRANA TYMPANI.
radiating fibres are external, beneath the cutis, the circular

next to the mucous membrane.
The fibres of the membrana tympani are sharply outlined
and opaque, flattened on the sides, swelling out in the middle.
They are from 0.0036 to 0.0108 millimeters in thickness.
Sometimes they appear to be homogeneous, but they are
actually fibrillated. Chromic acid , chloride of gold , and osmic
acid bring out the fibrillated structure. — (Kessel.)
The fibrous layer might be well described , according to
Kessel, “ as a deep layer of the corium changed and adapted
for physiological purposes.” The slits or apertures which
have been spoken of are usually empty and appear to glisten,
or on their edges they are covered by a finely granular
mass.
Cells are sometimes found which fill them exactly . Von
Tröltsch called these cells the corpuscles of the membrana
tympani. The larger spaces contain encapsulated nuclei, and
are frequently filled with amaboid cells.
On the periphery the thin layers of the membrana tym
pani interweave, leaving large and small spaces between the
fibres for the passage of vessels, and form , by union with the
outer and internal layers, the “ tendinous ring ,” which is
attached by means of a thin periosteum to the osseous ring,
or annulus tympanicus. ( See engraving on page 201.)
All the layers of the fibrous layers are united to the osseous
ring. Kessel confirms Gruber's observation that the circular
fibres may be followed into the tendinous ring ; but he adds,
“ these fibres singly , and at some distance from each other,
pass off again from the ring at very acute angles, collect
together and reach nearly as great thickness as that which
results from the union of the fibres, coming from the epider
mis, cutis and mucous membrane." The tension of these
fibres causes a convexity of the radii of its surface towards
themeatus externus, giving themembrane a general convexity .
The circular fibres do not exist on the lower third of the
handle of the malleus and the adjacent parts.
The handle of the malleus is attached to the fibrous layer
between the radiating and circular fibres. According to Gru
ber, there is a cartilaginous formation,which begins over the
STRUCTURE OF MEMBRANA TYMPANI. 191
short process of the malleus, and extends imm . below the
handle. This is firmly united below ; but above, at the short
process, there is a kind of a joint, the cavity of which is filled
with synovial fluid .
Prussak, Moos and Kessel,* say that while this cartilage
exists — that is to say, that a third of the shortprocess is of car
tilage — it passes into the osseous portion without interruption .
There is also , according to Prussak and Moos, a thin layer
of cartilage cells under the periosteum of the handle of the
malleus not only in infants, but also in adults.
Kessel found on sections of the ossicles in embryos from
three to nine months, that the malleus is surrounded by an
independent periosteum distinct from the elements of the
fibrous layer, and only united with the mucous layer by a
duplicature of the mucous membrane. In place of the short
process there is a quantity of glistening nucleated cells under
the periosteum and in the tissue duplicature. These elements
remain through life as cartilage cells, and form a a solid mass
with the osseous portion of the small process.
At birth the malleus is only closely united to the mem
brana tympani at two points — at the short process, and at the
lower third of the handle. The fibrous layer is united with
the periosteum of the upper portion of the handle of the
malleus only by loose connective tissue, so that a slight
motion of the bone is possible at this point without an arti
culation
Themucous layer consists of an epithelium and a fibrous

frame-work beneath it. On the inner side of the membrane,
at the upper part of its posterior half, is found an irregu
larly triangular fold , 3 to 4mm . high and 4m . broad, which
arises close behind the annulus tympanicus, and extends to
the handle of the malleus. A cavity is thus formed which
opens below ,which is called by Von Tröltsch,t who described
it, “ the posterior pouch ” of the membrana tympani.
The best view of this duplicature is seen by viewing the
* Stricker's Hand -Book , p. 955.
+ Von Tröltsch, Lebrbuch der Ohrenheilkunde Vierte Aufgabe, 1868 ,
p . 38.
192 BLOOD -VESSELS OF MEMBRANA TYMPANI.
membrana tympani from the inside, while it is still in position,

after the roof of the tympanic cavity has been removed, and
the incus detached from the malleus ; but it may even be
seen from the outer surface, by a good illumination, in the
living subject. The tissue of the pocket is the same as that
of the fibrous layer. — ( Von Tröltsch.)
A similar space is found in front of the malleus, but this
is not formed by a duplicature of the fibrous layer , but by a
small long process turned towards the neck of the malleus,
by the mucous membrane that lines the tympanic cavity, and
by all the parts that enter and leave the Glaserian fissure , by
the bony process of the malleus, by the anterior ligament of
the malleus, the chorda tympani nerve, and the inferior tym
panic artery.
Villous processes are found on the edge of the mucous
membrane, especially in children. These processes are also
found on the pouch of Von Tröltsch and on the malleus. They
are covered by flattened epithelium , and are composed of con
nective tissue in which there are capillary loops.
BLOOD - VESSELS.
According to the recent investigations of Kessel, there are

blood -vessels, nerves, and lymphatics in all the layers of the
membrana tympani. It had been previously taught by nearly
all the writers, that there were no blood-vessels or nerves in
the fibrous layer of the drum -head, although according to
Gerlach , there was a capillary anastomosis between the mu
cous membrane and the cutis on the periphery of the middle
or fibrous layer. Kessel* also claims to have first described
the lymph vessels.
According to Kessel, there is a direct passage of blood
vessels from the outer layer of the membrana tympani to the
cavity of the tympanum ; a complete capillary net-work in the
fibrous layer communicates with the cutis and the mucous
membrane .
The blood-vessels that pass from the auditory canal down
* L . c., p . 958.
NERVES OF MEMBRANA TYMPANI. 193
upon the membrana tympani, come from the deep auricular

artery , which is a branch of the internal maxillary.
Those on the mucous membrane arise from the vessels of
the tympanic cavity .
The blood supply of the outer layer of the membrane may
be very readily traced in many cases of inflammation, or after
injecting the canal with warm water. The whole circumfer
ence of the membrane is usually found injected in connection
with redness of the lower part of the canal. Larger vessels
run immediately behind the handle of the malleus to the
umbo, where they pass off in radii to the edge.
NERVES OF THE MEMBRANA TYMPANI.
Nerves are found in each layer of the membrana tympani.

The larger nerve -trunks accompany the chief vessels. They
divide as these do, and frequently unite together like the
capillaries. They form thick networks under the epithelium
of the cutis , and also under thatofthe mucousmembrane. A
fundamental plexus, a capillary plexus near the vessels, and a
sub -epithelial plexus may be distinguished.
The chief nerve-trunk consists of medullated fibres,which is
provided with a sheath of Schwann , and lies on the boundary
between the cutis and the fibrous layer. It passes on to the
membrane at the upper part of the posterior segment. Be
sides this chief trunk, several small branches enter the mem
brane at different parts of the periphery.
In addition to the openings in the fibrous layers, with their
contents, Kessel found a large number of nucleated swellings,
provided with two or more processes, that unite with the
nerve -fibres, and which lie above and between the single
fibrous layers.
The greater part of the cell elements found between the
fibres of the fibrous layer, must be considered , according to
Kessel, as belonging to the blood and lymph vessels, and to
the nervous system .*
* Kessel, in Stricker's Handbook, p . 962.

194 NERVES OF MEMBRANA TYMPANI.
The nerves of the mucous membrane of the membrana
tympani are also more numerous, according to the author
from whom I have just quoted, than has been hitherto sup
posed. There is a plexus near the vessels, and a sub-epith
FIG . 44.
LIE
21
W
.
SEE
T
S
The Membrana Tympani, Bone.

in connection with the Ossicula Auditus of the Right Temporal
From a Photograph . Rüdinger.
1. Transverse section of the fossa sigmoidea, in which is the transverse sinus. 2. Lower sec
tion of the transverse sinus. 3. Inner side of the transverse wall thrown back, which
causes, 4, the emissariusmastoideus to be opened . 5. Carotid canal. 6. Themembrana
tympani connected to themucous membrane of the cavity of the tympanum . 7. Themal
leus on the anterior and upper portion of the handle ; the pockets of themembrana tym
pani are seen . 8. The divided tendon of the tensor tympani muscle. 9. The incus.
10. Stapes lying by the stapediusmuscle, on the pyramid, which is opened . 11. Stape
diusmuscle. 12. Section of facial nerve. 13. Chorda tympaninerve.
lial plexus. The former accompanies the lymph rather than
the blood -vessels. It receives its fibres, in part, from threads
of the tympanic plexus, which pass on to the membrane,
with the mucous membrane, from different parts of the peri
LYMPH VESSELS OF MEMBRANA TYMPANI. 195
phery, and partly from the nerves of the cutis, passing

through the fibrous layer. The sub -epithelial plexus is a
fine network directly under the epithelium , which it supplies
with threads.*
The outer nerve supply of the membrana tympani is from
the fifth pair. The main trunk is a branch of the superficial
temporal nerve, from the third branch of the trifacial or fifth
nerve .
The chorda tympani nerve runs along the inner surface of
the membrana tympani, but gives no branches to it.
LYMPH VESSELS.
They are arranged in three layers, like those of the blood
vessels. The first layer belongs to the cutis, the second to
the fibrous layer, and the third to the mucous membrane. In
the cutis they form a very fine network, immediately under
the rete Malpighii. This network passes over the capillaries at
many points . They gradually pass into large capillaries,
which often interlace with the blood capillaries, and finally
unite in independent and larger trunks. These run either
posteriorly and above, or, exactly like the blood -vessels, pass
at various points to the periphery and to the auditory canal.
In the mucous membrane, also , there. is, although not in
large number , a sub-epithelial network, lying near the tendin
ous ring. These vessels are distinguished from the blood capil
laries of the same width by their manifold dilatations.
THE CAVITY OF THE TYMPANUM .

The tympanum (drum ), cavity of the tympanum , or drum
of the ear, is the irregular, air-containing space lying beyond
the membrana tympani. The mastoid cells, also containing
air, and lying in the mastoid portion of the temporal bone,
are connected with the tympanum at its upper and posterior
part ; while the Eustachian tube permits the entrance of air
into the cavity through the upper part of its anterior wall.
* Kessel, p . 963.
+ Kessel, Handbuch der Lehre von dem Geweben , p . 851.
196 THE CAVITY OF THE TYMPANUM .
The points to be noted in the description of the tympanic

cavity are indicated in the following scheme:
I 1. DIMENSIONS.
( the Anterior.
the Posterior.
2 . WALLS
the Outer.
the Inner.
the Upper .
the Lower.
| Malleus.
3. OSSICLES. { Incus.
Stapes.
THE | Malleus — Incus.
TYMPANUM ( Ligaments of mov Incus— Tympanum .
presents for ex able joints | Incus— Stapes.
amination its 4 . LIGAMENTS .
Obturator Stapedis.
Ligaments of im . Mallei Superior .
movable joints. Mallei Anterior.
| Incudis Superior.
Tensor !
5.MUSCLES. Stapedius.
6 . Mucous MEMBRANE .
7. VESSELS.
| 8. NERVES.
1. The dimensions of the tympanum , like those of the exter
nal auditory meatus, vary much in different individuals. The
following table shows about the average diameters, as given
by Von Tröltsch :*
Antero-posterior diameter . . . . . . 13mm .
Vertical • at anterior part, 5 to 8mm ,
• at posterior “ 15mm .
Transverse • at anterior “ 3 to 4 .5mm .
. opposite the drum -head, 2mm .
2. The anterior wall presents, at its upper part, an opening
of considerable size — the tympanic orifice of the Eustachian
tube. Below this is a strong bony plate.
* Text-book, American translation, p. 171 .
CAVITY OF THE TYMPANUM . 197
The posterior wall separates the cavity of the tympanum
from the mastoid cells. The opening into the cells is at its
upper part, close under the roof, and considerably higher than
the orifice of the Eustachian tube.
FIG. 45.
$1992
13
The Right Temporal Bone,with the Membrana Tympani and Ossicula Auditus of an Adult.
1. Squamous portion - under figure 1 the sulcus of the transverse sinus runs downward . 2. A
bristle passes through the mastoid foramen . 3. Mastoid cells. 4. Antrum of themastoid ,
communicating both with the mastoid cells and with the tympanic cavity. 5. Styloid
process. 6. Membrana tympani ; a point of mucous membrane of the tympanic cav
ity is seen under the number 6. 7. The malleus. Under the chorda tympani we see
the divided lendon of the tensor tympanimuscle. 8. The incus. 9. The short process. 10.
The chorda tympaninerve. 11. The stapes. 12. Stapediusmuscle. 13. Facialnerve. 14.
Stapedius nerde, branch of facial. The relations of themastoid cells to the cavity of the
tympanum and the relations of the former to the transverse sinus are well shown. After
Rudinger .
The outer wall of the tympanic cavity is composed, for the

most part, of the membrana tympani; but it extends much
further backwards than the membrane, and contains three
small openings : the aperture of the iter chordæ posterius, the
198 CAVITY OF THE TYMPANUM .
Glaserian fissure, and the aperture of the iter chordæ ante

rius.
The opening of the iter chordoe posterius is on a level with
the centre of themembrana tympani, and close to the margin
of the membrane, and gives entrance to the chorda tympani
nerve. The nerve then runs upwards under the long process
of the incus, on the free margin of the posterior pocket of the
membrana, then forwards across the neck of the malleus, and
finally enters the iter chordce anterius, or canal of Huguier .
The Glaserian fissure opens above, and in front of, the mem
brana tympani; while just above it is seen the aperture of the
iter chordæ anterius.
The inner wall of the tympanum is the outer boundary of
the labyrinth , and consists of bone. It has two small aper
tures closed by membranes. The upper and larger opening is
called the fenestra ovalis, or oval window , and leads into the
vestibule ; while the lower and smaller one is called the fenes
tra rotunda, or round window , and communicates with the
cochlea. The former is closed by the periosteum of the vesti
bule , to which the base of the stapes is attached . The fenes
tra rotunda lies below the fenestra ovalis, and is closed by the
membrana tympani secundaria . Both these openings may per
haps more properly be called canals, since they have consid
erable depth , the membranes which close them lying at their
inner extremities.
In front of the fenestræ , and partly between them , lies the
promontory, a projection of the outermost turn of the cochlea.
Upon it may be seen three shallow grooves for branches of
the tympanic plexus. In front of the promontory the inner
wall of the tympanum consists of a very thin plate of bone
separating this cavity from the carotid artery. This plate is
pierced by many minute openings for vessels and nerves, and
has, besides, many irregularities on its tympanic surface.
Just above and behind the fenestra ovalis, is a slight
rounded ridge, corresponding to the aqueductus Fallopii, which
gives passage to the facial nerve. This canal is covered by
an extremely thin plate of bone. Behind and below the fen
estra ovalis is the pyramid , a hollow , bony projection contain
ing the stapedius muscle. The bottom of this cavity of the
CAVITY OF THE TYMPANUM . 199
pyramid is in communication with the aquæductus Fallopii by
means of a minute canal. Just behind the ridge of the Fallo
pian canal, and about on a level with the fenestra ovalis, is
seen a hard , smooth, bony surface, which corresponds to the
external or horizontal semicircular canal of the labyrinth .
The upper wall, or roof of the tympanum , is the partition
between this cavity and that of the cranium . Its thickness
and density vary considerably in different subjects. It is
sometimes very thin and porous, or entirely wanting, so that
the tympanum forms a part of the cranial cavity.
The lower wall, or floor of the tympanum , separates this
cavity from the jugular vein . Like the roof, it varies greatly
in thickness, being sometimes wholly membranous. It is very
irregular on its upper or tympanic surface ; and lying much
below some points in the floor of the external auditory mea
tus, and below the orifices of the Eustachian tube and mastoid
cells , it is usually covered , in cases of purulent affections of
the middle ear , by a large quantity of pus. It is perforated
by the glosso -pharyngeal nerve and a minute vessel.
Studied with an eye to pathological conditions, some of
these walls present very important relations. Thus the roof
of the tympanum lies in contact with the meninges of the
brain , so that in caries of this wall the patient may die of
purulent meningitis or cerebritis . Again , caries of the lower
wall may be followed by phlebitis of the jugular vein ; while
caries of the inner wall has sometimes caused destruction
of the coats of the carotid artery and fatal hemorrhage,
also a suppurative inflammation of the labyrinth , with exten
sion into the cavity of the skull. It is easy to see, too, how
even a non -suppurative inflammation of the tympanum may
affect the facial nerve, since, during a part of its course, the
nerve is separated from the mucous membrane by only a thin
plate of bone, which may even be deficient in many places.
Indeed , swelling of this nerve, causing temporal facial paraly
sis, or destruction of it, producing permanent paralysis, is
not uncommon in connection with a suppuration in the
middle ear.
200 OSSICULA AUDITUS .
OSSICULA AUDITUS.
3. The three small bones of the ear, the ossicula auditus,
which serve for the conduction of the sonorous undulations
through the tympanum to the labyrinth , are the malleus, or
hammer ; the incus, or anvil ; and the stapes, or stirrup.
FIG . 46 .
The malleus may be described as consisting of the head,

neck, short process, manubrium or handle, and the long pro
cess or processus gracilis.* The head is the larger, upper
pression , twice or thrice as long as it is broad, and of con
siderable depth for articulation with the incus. Below the
head is a constricted portion called the neck , and just below
this, and on the upper end of the manubrium , is a promi
nence to which the processes are attached. The manu
brium extends downward and inward , being inserted into the
drum -membrane between the circular and radiating fibres of
the middle layer. The processus gracilis passes from the
eminence below the neck forward and outward to the Glaserian
fissure . The short process lies at the base of the manubrium
opposite where it gives attachment to the tensor tympani.
The incus lies just back of the malleus, and may be de
scribed as having a body and two processes. On the anterior
and inner surface of the head is seen the surface for articula
tion with the malleus. The short process projects backward
and articulates with the posterior wall of the tympanum .
The long process,much more slender than the other, descends
at a right angle with the short process, and parallel with and
behind the manubrium ,to end in the processus lenticularis which
articulates with the head of the stapes. This articulation lies
a little higher than the tip of the manubrium .
The stapes consists of the head , neck, crura and base, and
* Somewriters call the handle of the malleus the long process.
OSSICULA AUDITUS. 201
is the innermost and smallest of the bones of the ear, and
indeed of the body. The head presents on its outer part a
surface for articulation with the lenticular process of the long
process of the incus. Just internally to the head is the con
stricted portion called the neck, into which is inserted the
stapediusmuscle. From the neck the crura diverge horizon
tally, the one forward and inward, the other backward and
FIG . 47 .
The Ossicula Auditus of the Left Cavity of the Tympanum , seen from within .
1. Themalleus, with the handle running downwards, and the processus gracilis running to the
right. 2. The incus,with its short process running to the left, and its long process in
articulation with the stapes. 8. The stapes.
The Ossicula Auditus of the Right Cavity of the Tympanum , seen from within .
1. The head of the malleus. 2. The processus gracilis. 3. The long process, or handle. 4 .
Long process of the incus. 5 . The short process of the incus. 6 . The stapes.
The Right Annulus Tympanicus, or Long Ring, of the Newly Born , seen from without.
1. The anterior thicker part, in the newly born , lies next to the Glaserian fissure, which is
quite wide, and just behind the condyloid fossa unites with the squamous portion of the
temporal bone. 2. A process on the posterior half of the ring, about the middle, which is
always present in varying degrees of development. ( From Rüdinger's Photographic
Atlas des Menschlichen Gehörorganes.)
inward, to be inserted into a thin plate constituting the base,
which lies upon the membrane of the fenestra ovalis. On the
outer side of the base is a delicate ridge running from the
extremities of the crura and into which is inserted the obtu
rator stapedis.
4. Ofthe ligaments of the ossicles we have two classes : the
ligaments of the movable joints and those of the immovable
joints .
The malleo-incus joint may be classed with the gynglimus
202 OSSICULA AUDITUS.
articulations on account of the character of the articulating

surfaces. These surfaces are covered by cartilage about
0.04mm . in thickness. The capsule is tense . This joint is
provided with synovial membrane.
The articulation between the short process of the incus
and the posterior tympanic wall is an amphiarthrosis, and is
surrounded by a tolerably thick and tense capsule. The mo
tion is quite restricted .
The joint between the processus lenticularis of the incus
and the head of the stapes is an arthrosis, the processus len
ticularis corresponding to the ball and the head of the stapes
to the socket. Both surfaces are covered with cartilage.
The cartilage is much more delicate than those of the other
joints , and is characterized by being rich in elastic fibres.
The ligamentum obturatorium stapedis is a thin membrane
inserted into the ridge on the outer side of the base of the
stapes and into the inner edges of the crura, closing the open
ing formed by these parts.
The head of the malleus lies sometimes in contact with the
roof of the tympanic cavity. More frequently it is connected
with the roof by the cylindrical lig . mallei superius ( Sæmmering).
The neck of the malleus is held in place by the cartilage which
sometimes takes the place of the long process, and by the
lig. mallei anterius ( Arnold ), which goes from the spina angularis
of the sphenoid parallel with the fissura petro -tympanica to
be inserted upon the head of the malleus.
The incus, when not in immediate contact with the roof of
the tympanum , is attached to the roof by means of the lig .
incudis superius ( Arnold ), and is inserted into the posterior
border of the body of the bone.
5 . The tensor tympani muscle arises in front of the anterior
opening of the canalis musculo -tubarius from the pyramid of
the temporal bone, from the upper wall of the tubal cartilage
and from the neighboring border of the sphenoid . It passes
over the septum tubæ into and through the canal of the tensor
tympani. Just before leaving the canal it becomes tendinous.
The tendon at the extremity of the canal turns outward and
runs nearly at a right angle with the muscular part to the
base of the manubrium mallei.
BLOOD- VESSELS OF THE TYMPANUM . 203
The stapedius muscle arises from the bottom of the pyra

mid , or eminentia stapedii, the hollow of which it fills. At the
orifice of the canal it becomes tendinous, and thence runs, at
an obtuse angle with the rest of the muscle, to the neck of the
stapes. This is the smallest distinct muscle of the human
body.
6 . The mucous membrane of the tympanum is a continuation
of that of the Eustachian tube and naso-pharyngeal space.
It is extremely delicate and consists chiefly of an epithelium
and a layer of connective tissue underneath. On the lower,
the anterior portion of the inner , and the posterior walls, the
epithelium consists mainly of columnar cells ; while on the
promontory, roof, membrana tympani and ossicles , pavement
cells predominate. The thinness of the connective tissue is such
that Von Tröltsch asserts that the mucous membrane cannot
be separated from the periosteum , and that every catarrh is
a periostitis. But, according to Kessel, the connective tissue
of the mucous membrane in some places forms a fibrous
frame-work which separates from the periosteum , and passes
from one projection of bone to another through the free space
of the cavity. One such bridge has frequently been observed
to pass from the eminentia pyramidalis to the processus
cochleariformis, while many are seen on the floor of the
tympanum .
BLOOD- VESSELS.
The tympanum receives its nutrition from five sources :
1. The tympanic branch of the internal maxillary which
supplies the membrana tympani.
2. The stylo -mastoid branch of the posterior auricular
which supplies the back part of the tympanum and mastoid
cells.
3. The petrosal branch of the middle meningeal and
branches of the ascending pharyngeal and internal carotid .
The veins of the tympanum empty into the middle menin
geal and pharyngeal.
NERVES.
The tensor tympani muscle is supplied by a branch from
204 NERVES OF THE TYMPANUM .
the otic ganglion , and from the internal pterygoid, a branch of

the third division of the trifacial.
The stapedius is supplied by a filament from the facial
nerve.
The nerves of the mucous membrane are derived from the
tympanic plexus, consisting of a combination of the great sym
pathetic, the trifacial, and the glosso -pharyngeal.
The nerves thatmake up the tympanic plexus, according
to Von Tröltsch ,* are
1. Several carotico -tympanic nerves, branches from the
plexus of the sympathetic in the carotid canal, which enter
the cavity of the tympanum through special foramina. "
2 . A twig of the superficial petrosal nerve, entering the
cavity from above. It is regarded by some as a connection
between the otic ganglion and bend of the facial. Others
consider it a continuation of the tympanic nerve (Jacobson 's )
to the otic ganglion.
3. The ramifications of the tympanic nerve, arising from
the glosso-pharyngens.
The otic ganglion is situated near the foramen ovale of the
greater wing of the sphenoid bone, in front of the middle
meningeal artery , on the outer side of the cartilage of the
Eustachian tube, and the point of origin of the tensor palati
muscle .
It is made up of motor fibres from the third division of the
fifth nerve, of sensory fibres from the glosso-pharyngeal, and
of fibres from the great sympathetic.
Its branches of distribution are to the tensor tympani and
the tensor palate muscles. It sends a twig to the external
pterygoid branch of the fifth nerve, and several communicating
branches to the auricular nerve of the third branch of the fifth
nerve.
By this ganglion the soft palate, the drum -head and tensor
tympani, and the integument of the external ear are put in
relation with each other and with the general nervous system .
- (Von Tröltsch.)
The chorda tympani nerve seems to pass through the tym
* Treatise on the Ear, American translation, p. 97.
MASTOID PROCESS . 205
panic cavity without being in any physiological relation to it.

Division of this nerve in operations upon the tensor tympani
muscle usually has no effect upon the functions of the ear.*
THE MASTOID PROCESS.
The mastoid portion of the temporal bone (uaotós, a nipple

or teat) is situated at the posterior part of the temporal bone.
Its external surface is rough, and perforated by numerous
foramina. One of these, of large size , situated at the poste
rior border of the bone, is called the mastoid foramen .
Through it passes a vein to the transverse sinus and a small
artery .
This roughened appearance of the mastoid is sometimes
so marked that it resembles the inner cellular structure of the
bone. In some rare cases there is even complete absence of
the outer layer of bone, so that the air cavities open exter
nally, as well as into the cavity of the tympanum and the
external auditory canal.
Gruber t has seen emphysema of the neck and of the occi
pital region result from the inflation of the cavity of the tym
panum in cases where such external openings existed under
the skin.
This foramen does not always exist in themastoid process ,
but is sometimes found in the occipitalbone, or in the suture
between the temporal and the occipital.
The mastoid portion is continued below into a conical pro
jection, which is the true mastoid process. To this process
are attached the sterno-mastoid , the splenius capitis , and
trachelo -mastoid muscles.
On the inner side of the mastoid process is a deep groove,
called the fossa sigmoidea ( see cut on page 197). In this
groove is a part of the lateral sinus, and themastoid foramen
opens into it. The mastoid process is hollowed out into a
number of spaces of various size, which are called the mastoid
cells.
· * See Chapter X . for an account of the functions of the chorda tympani.
+ Lehrbuch, p . 32.
206 THE MASTOD CELLS .
THE MASTOID CELLS.

The upper or horizontal part of the process, called also the
antrum mastoideum , is in communication with the tympanum
by means of one or more openings in the posterior tympanic
wall ; and since it exists even in the infant,before the develop
ment of the mastoid process, it has been suggested that the
name of “ upper cavity of the tympanum ” would be more
appropriate . The second part of these cells, lying in the mas
toid process of the temporal bone, are below the horizontal
part. The whole consistof a great number of irregular spaces
of varying sizes — sizes that also vary much in different indivi
duals. The whole are enclosed by a dense cortical layer of
bone, separating them from the cavity of the skull, and limit
ing them externally . This cortical layer also is of different
thicknesses in different individuals, a fact of some practical
importance in cases of suppurative inflammation of the mid
dle ear implicating these cells. Several small foramina are
seen in the mastoid portion of the temporal bone - openings
for branches of the middle meningeal artery and the vasa
emissaria Santorini.
The cells are lined by a mucous membrane similar to that
of the membrana tympani, but it is more delicate.
The epithelium consists of smooth cells of the same con
sistency and arrangement as those of the membrana tympani.
Under this we find two layers of connective tissue, correspond
ing to the periosteum . The latter layer contains numerous
nerves, and blood and lymph vessels . The upper layer very
frequently separates itself at the free edge of the cells , like a
membrane, and becomes attached to more closely lying tips
or projections of bone. By this means the cavities of two
cells lying next each other become separated. In the larger
cells these membranes are stretched horizontally, like cur
tains, by means of processes which arise from them .
(Kessel.)*
At birth the mastoid process is but the rudiment of what it
is afterwards to be. It is a small tuberosity, and contains but
* Handbuch der Lehre von den Geweben . Vierte Lieferung, p. 864.
THE MASTOID CELLS. 207
one cell of any considerable size, which afterwards becomes

the mastoid antrum .
Dr. Giovanni Zoja ,* of Pavia , examined sixty -eight fresh
preparations, and one hundred dry ones, in order to get the
average size of the mastoid process and its cavities. The
result of his investigations is, that the breadth of the mastoid
is 19 millimetres, its thickness 13mm ., and its length 12mm .
About one millimetre should be deducted from these measure
ments in the bone of the female subject. Zoja does not con
firm Velpeau's view , that the mastoid process is more devel
oped in advanced life. The cortical layer, according to these
examinations, has an average thickness of from one to two
millimetres.
In two of the sixty -eight specimens belonging to one subject
the cells were united into one large cavity , so that they formed,
as it were, a mastoid cavity. This was also found in another
case on one side only. The cells in the centre of the process are
usually the larger, and communicate with one another, if they
are not separated by the membane that has been described .
In several cases there were cells only in thebase of the process.
Occasionally these cells extended to the side of the skull, or
even to the middle of the petrous part of the temporal bone.
Dr. Zoja thinks that the development of the cellular struc
ture goes on in a kind of system . They become gradually
larger , they are lined with a peculiar membrane, in the spaces
a gelatinous mass is found , which becomes gradually serous,
and is either taken up by the vessels of the cavities or passes
into the cavity of the tympanum , where it is absorbed .
In five of the sixty- eight specimens the antrum was found
to be separated from the other cellular spaces by a membran
ous partition. t
BLOOD - VESSELS OF THE MASTOID PROCESS.

The blood supply of the mastoid cells is furnished by the
stylo -mastoid branch of the posterior auricular artery, while
their nerves come from the tympanic plexus.
* Gruber's Lehrbuch, p. 33.
| Henle, Lehrbuch, p. 751.
208 EUSTACHIAN TUBE.
THE EUSTACHIAN TUBE .
The Eustachian tube, like the external auditory meatu
consists of an osseous and a cartilaginous part. The formers,
FIG. 48.
15
LIMIT
3
TELE
M
Y
A
A
N
Section of the Head, showingAfter

the Divisions of the- Rüdinger.
a Photograph Ear and the Naso-pharyngeal Cavity.
1. Cartilage of external auditory canal. 2. Osseous auditory canal. 3, 4, Membranæ Tym
panorum . 5. Cavity of the tympanum . 6. Dilator muscle of the Eustachian tube. 7.
Levator palati muscle. 8. Mucous membrane of the pharyngeal orifice of the tube. 9.
Leftmembrana tympani. 10. Handleof themalleusand short process. 11. Tensor tym
panimuscle. 12. Mucousmembrane of themembranous portion of the tube,perforated by
a needle. 13. Levator veli palati muscle. 14 . Mucous membrane of the posterior sur
face of the pharynx. 15. Mucous membrane of the pharynx,attached to the lower surface
of the body of the sphenoid bone. 16. Sphenoidal sinus. 17. Hypophysis cerebri and its
relations to the cerebral arteries and the cavernous sinus.
EUSTACHIAN TUBE . 209
measures 11mm ., the latter 24mm ., so that the whole length

of the tube, from its opening into the tympanic cavity to its
pharyngeal orifice, measures 35mm . The tube, from its tym
panic end, runs forward , inward, and downward. Its axis
makes an angle of 135º with the axis of the external auditory
canal, and an angle of 40° with the horizontal plane.
The diameter of the osseous portion of the tube is about
2mm . The walls are smooth , and covered by a mucous mem
brane, which , like that of the tympanum , is closely adherent
to the periosteum . The lateral wall belongs to the pars tym
panica ; the median wall separates the tube from the carotid
canal ; the upper wall is formed by the septum tubæ , the floor
of the canal for the tensor tympanimuscle.
Fig . 49.
Transverse Section of the Upper Part of the Eustachian Tube. After Henle.
* Fibres of the spheno-staphylinus muscle.
The shape of the anterior extremity of the osseous tube is

very irregular, the inner wall extending forward much further
than the lateral wall. This part, “ the isthmus,” is the
narrowest portion of the tube. Here the tube gradually
widens, and ends anteriorly in a trumpet-shaped orifice 9mm .
high and 5mm . broad, which projects slightly into the post
14
nasal space, and lies a little above the level of the floor of the
nostril.
The cartilage of the tube is made up of two plates — a me
dian and a lateral. The median plate, which is much the
larger, is triangular, and into its upper and outer part is
inserted the hook -shaped and smaller lateral cartilage. But
most of the lateral wall and all of the lower is formed of
membrane instead of cartilage, the membrane forming nearly
a half of the circumference of the tube.
FIG. 50.
FIG . 51,
Transverse Section through the Lorder

End of the Eustachian Tube. After
Transverse Section through the Lower End of Henle .
the Eustachian Tube. After Henle. * Mucous glands. * * Transverse sec
* Mucous glands. * * Fibres of petrostaphyli tion of the petrostaphylinusmuscle.
nus muscle
Themedian wall of the cartilage of the tube is below 1mm .

in thickness on its posterior extremity, but increases in size
gradually to 21 to 3m ., and on its free anterior border may
even reach 7mm . The tissue of the cartilage is chiefly hya
line, but it has a fibrous base substance at various spots ;
sometimes on the surface, sometimes on the interior, and
especially near the edges.
The mucousmembrane which fills up the concavity of the
cartilage, and which changes the caliber up to the vicinity of
the pharyngeal orifice to a plane surface, is 0.6mm . thick at
its densest portion. It is connected to the perichondrium by
loose connective tissue. It is made smooth by numerous aci
nose glands of about 0.6mm . in diameter and 0.15mm. in
thickness. These glands form a continuous layer backwards
from the pharyngeal orifice for some distance. Toward the
cavity of the tympanum they are less numerous, yet, accord
ing to Von Tröltsch , they are found on the tym panic orifice.
Toward the pharyngeal orifice large mucous glands appear
lying on the outer side of the cartilage.
FIG. 62.
FS 1. 8 1 Mm
Lateral Wall of the Nasal Cavities, showing the Pharyngeal Orifice of the Eustachian Tube.
After Henle . The Middle Turbinated Bone is removed .
Mm . Border of attachment of the middle turbinated bone. The upper membrane is split by a
vertical section , and turned back on two sides, in order to show the openings of the upper
ethmoidal cells. F . S. Frontal sinus. S. S. Sphenoidal sinus. 1. Openings of the lower
ethmoidal cells. 2. Probe entering into themiddle nasal space from the frontal sinus. S.
Constant opening between the antrum of the upper jaw and the nasal cavity. 4. Occa
sional opening between the sameparts. 6. Pharyngeal orifice of the Eustachian tube.
The lateral wall of the tube, which, with its upper border,
bounds the convex surface of the enveloping ridge of the car
tilage, has about the same thickness as the median wall, and
the same covering of mucous membrane. The tissue in the
upper half is quite firm , in the lower more relaxed and spongy.
Fat is its chief structure.
A portion of the tendinous origin of the spheno-staphyli
nus muscle unites with the firmer portion of the wall, and for
some distance this origin rups in a thin layer between the
upper border of the soft wall of the tube, and unites with the
convex surface of the latter.
Fig . 58.
Transverse Section of Eustachian Tube and Surrounding Parts. After Rüdinger.

1. Median cartilaginous plate. 2. Lateral cartilaginous hook . 3. Dilator of the tube. 4. La
vator of the softpalate. 5. Basilar Abro-cartilage. 6 and 7. Acinous glands. 8. Fat in
the lateral wall. 9. Safety tube. 10. Accessory flosure. 11. Fold of mucous membrane.
12. Adjacent tissues.
The spheno-staphylinus muscle being thus attached to the
tube has the power of rolling over the upper inverted border
of the cartilage, and of enlarging the angle which the lateral
wall forms with the median.
The opening or gaping of the tube depends upon this
action , which occurs with the act of swallowing.
At the point where the lateral wall of the nasal cavity

passes into the pharynx, at the same heightwith the posterior
point of the inferior turbinated bone, lies the pharyngeal ori
fice of the tube. (Fig . 52.)
Since the inner wall of this canal projects into the caliber
of the naso -pharyngeal space,the mouth of the tube lies more
in a frontal than sagittal plane. Ithas a puffy median border,
while the lateral wall passes without any distinct line of sep
aration into the nasal cavity. The width of the mouth of the
tube varies in different persons, and has the general shape of
a funnel.
According to Rüdinger, * the minute differences in form of
the Eustachian tube in animals is so characteristic, that from
a section of the Eustachian tube, the animal from which it has
been taken can be designated .
The known functions are to conduct away the secretions
of the cavity of the tympanum , and to act as a ventilator of
this part. What part it has to do with the conduction of
sound to the ear, or what connection it has with the voice, has
not as yet been determined. Rüdinger has observed fatty
degeneration of the tubal cartilage of man, and it may be
conceived that fatty degeneration of its muscles may occur
in some subjects and become a serious impediment to the per
formance of its functions.
The mucous membrane of the tube is at its lower part
quite thick , like that of the pharynx, of which it is an imme
diate continuation . Its epithelium is ciliated , the motion
being in the direction of the pharynx. This anatomical fact
explains the intolerance which this membrane displays towards
the injection of fluids from the pharyngeal orifice. The tube
of the infant differs much from that of the adult. It is shorter,
wider, and more nearly horizontal.
Rüdinger divides the fissure of the tube into two portions.
There is a semi-cylindrical space under the hook of the carti
lage which he calls the safety tube, and the fissure connecting
with it the accessory fissure .
Both divisions are produced by the shape of the cartilage,
* Stricker's Hand-book , p . 973.

214 EUSTACHIAN TUBE .
and are separated from each other by projections of mucous

membrane. The mucous membrane is firmly attached to the
tissues about it on the concavity of the hook ; but at that point
where the accessory fissures begin , fold -like projections are
produced between this fissure and the safety tube. The pro
jection of these folds prevents the safety tube from being closed .
The closure is first possible at the point where the bend of
the cartilage becomes narrower, and the mucous membrane is
not closely united with it. This point is at about the middle
of the tube, where the mucous membrane has a slightly undu
lating surface, as seen in Fig . 55.
The question whether the tube is normally open — that is,
when the muscles of deglutition are at rest — is one which has
been much debated . Throughout the narrowest part of the
tube the larger part of the outer and inner walls are in con
tact, but at the upper part is a small chink which , as some
authors claim , remains patent,while others deny this. How
ever, any observer with normal tubes will be able to notice
that the tube opens, or at least widens, at every act of swal
lowing. If the nostrils are tightly held , air will be pumped
out of the tympanum by the act of swallowing, and this air
will be restored again to the ear-drum by swallowing with the
nostrils free.
MUSCLES OF THE TUBE .
The muscular apparatus of the Eustachian tube also be

longs to the pharynx. Indeed, these parts are so closely con
nected in all their structures, that an affection of one part
independent of the other, can hardly be said to occur.
The muscles of the tube are
1 . The Abductor or Dilator of the Tube. — This muscle is
also known as the spheno-salpingo staphylinus muscle, the
circumflexus palati, or tensor palati mollis. It is probably the
most important muscle of the tube. .
This muscle arises from the sphenoid bone and the carti
lage of the tube. It is inserted on the blunt edge of the car
tilaginous plate along the whole length of the canal. It passes
forward, inward, and downward , and its fibres spread out
EUSTACHIAN TUBE. 215
along the edge of the soft palate, and on the side of the pha
rynx. It enlarges the caliber of the tube by drawing the hook
ofthe cartilage forward and a little downward.
Rüdinger confirms the view expressed by Von Tröltsch
and Mayer that the dilator of the tube passes directly into the
tensor tympani muscle. This is true not only of the tendons,
but also of the muscular fibres.
Fte. 14 .
0
0 0
9 00
20
.8oo
00000000
OOONDE
00000000
0 0
20000 BODO
DOOOODOOGO
VOOO
0
00000O 000
o
OOOOO
Ooo 0
00066OO 600DDDDDDDDD
w
000000
009
0
0000
100000
0
000000DD
0
0
Section of the Upper Third of the Eustachian Tube. After Rudinger .

1. Median cartilage. 2. Lateral cartilage hook. 3. Perichondrium . 4. Submucosa. 6. Inser
tion of the dilator of the tube. 6. Safety tube. 7. Lateral projection of themucousmem
brane. 8. Median projection of the mucousmembrane. 9. Accessory fissure.
Rüdinger compares the rolling of the muscle about the
hamular process of the pterygoid plate of the sphenoid to the
pulley arrangement of the superior oblique muscle of the eye.
This attachment is certainly a point of fixation in the move
ments of the muscle.
2. The Levator Veli Palati.— This muscle is not very inti
mately connected with the tube, and yet it plays an important

part in its mechanism . It arises with a cylindrical tendon on
the lower surface of the temporal bone, on the anterior border
of the entrance to the carotid canal, and by a few fibres from
the cartilaginous portion of the tube.
In the soft palate the muscles of the two sides are closely
connected . From this point they separate, and each one runs
upward, and is firmly attached, in the vicinity of the osseous
tube, not only on the bone,but also to the cartilage and the
mucous membrane of the tube.
Fig . 55 .
0
0080 PM
Ooooºo.2
20
Section of the Middle Third of the Eustachian Tube. After Rudinger.

1 , 2. Cartilage. 3. Dilator of the Tube. 4 . Folds of mucous membrane under the cartilage
hook . 5 . Folds of mucousmembrane in the accessory fissure. 6 . Submucosa .
When this muscle contracts, by its becoming thicker, the

membranous floor of the tube is pressed forward , and thus the
long diameter of the tube is shortened , and the transverse dia
meter is enlarged , that is to say, it is made to gape very
EUSTACHLAN TUBE . 217
widely. * The salpingo-pharyngeus muscle also assists in this

action .
3. The Salpingo-pharyngeus (Rüdinger).--- This is a thin
muscular layer, that passes from the lower end of the tube ob
liquely downwards and backwards, and is connected to the lower
end of the median cartilaginous plate, and to the mucousmem
brane. It is inserted in the posterior wall of the pharynx.
Rüdinger considers this thin muscle to be a fixator of the median
cartilaginous plate, in its various positions caused by the con
traction of the constrictor of the pharynx and the levator palati.
The opening of the Eustachian tube is the result of a com
bination of muscular action . If the three muscles are inner
vated simultaneously, and their contractions occur at the
same time, the hook-shaped cartilage is fixed by the dilator
of the tube and drawn outward, the concave portion of the
tube becomes a little less curved, and the semi-cylindrical
gutter is widened. If the levator of the velum contract, the
space of the tube at the pharyngeal orifice is enlarged more
than three lines.
If the muscles cease to act, the elasticity of the cartilage
comes into play, the canal becomes parrower, without being
at its lower section completely closed, however.t Respiratory
movements of the membrana tympani have been often ob
served, and these occur through this gap in the tube, which
cannot be said to be ever firmly closed. Any one who has
often climbed high mountains and has become “ out of breath ”
from exertion in reaching the top, must have observed in his
own ears this continuation of respiration through the tube.
This fact throws light upon the etiology of cases of diseases of
the middle ear, arising from inflammations of the respiratory
organs, such as Pneumonia and Bronchitis.
BLOOD-VESSELS. .
1. The ascending pharyngeal artery, from the external

carotid .
* Rüdinger , Beiträge zur vergleichenden Anatomie und Histologie der Ohr.
trompete .
# Rüdinger, 1. c., p. 7.
2. The internal maxillary, the larger of the two terminal
branches of the external carotid , also supplies the Eustachian
tube by its middle meningeal branch.
3. Branches of the internal carotid artery,
NERVES.
1. The internal pterygoid , a branch of the third division

of the fifth nerve, sends a supply to the dilator of the tube.
2. The superior pharyngeal, a branch of the second divi
sion of the fifth nerve, sends branches to the pharyngeal
orifice.
3. The glosso -pharyngeal supplies the mucous membrane.
4. The pneumogastric supplies the levator veli palati
muscle .
Historical. — The history of the successive steps by which

the Eustachian tube has taken its true and important position
with relation to the study and treatment of aural disease is a
very interesting one, and has been very succinctly given by
Dr. Ludwig Mayer,* from whose writings the author has
already quoted in the chapter on Foreign Bodies.
As has been said on page 19, Alcmeon and Aristotle knew
of the Eustachian tube, but Eustachius was the first writer
who gave an exact description of it. This is found in the
edition of his anatomical works published in Venice in 1564 .
( Bartholomci Eustachiï Opuscula Anatomica.)
The passage in reference to the tube, as quoted by Mayer,
is as follows :
Ergo a caverna ossis lapidei, in quam meatus auditorius, conchion appella
tus finitur, via in narium cavitatem perforata est : ab illa enim meatus alter
oritur rotundo canaliculo similis, et instar tenuioris calamiamplus, qui oblique
ad interius interiusque basis capitis latus procedens, in medio quatuor forami.
num , totum istud os penetrat atque perfodit. ná posteriori ipsius sede arteria
soporaria calvariã ingreditur : anteriori quartum nervorum cerebri jugum
extra ipsam emergit : externum latus arteriae in dură cerebri membrană dis
tributae aditum patefacit : internum denique fissura quaedam circumscribit,
quae à cuneum referentis ac lapidei ossis extremis partibus, oblique infra et
anteductis, fit. Caeterum hunc meatum , de quo sermo est, arbitrabitur for
* Studien über die Anatomie des Canalis Eustachii. München , 1866.
tasse quispiam eo loco desinere ; res autem non ita se habet, sed alterius gen
eris substantia auctum , inter duos faucium seu gulae musculos, à paucis hucus
que bene cognitos secundum , paulo ante memoratae fissurae ductum ulterius
procedit ; et juxta radicem internae partis apophysis ossis alis vespertilionum
similis in alteram nariam cavitatem terminatur ; et in crassam palati tunicam
prope radicem gargareonis inseritur. Substantia sane ejus, qua extrema fis
surae ossi temporum et cuneo simili communis tangit, cartilaginea est ac
admodum crassa ; huic vero appositae partis substantia exacta cartilago non
est, sed membranosum nescio quid habet, et tenuior eradit a hujus meatus
intena extremitas narium cavitatis medium respiciês robusta est cartilago, quae
plurimum extuberat, mucosaque ; narium tunica obducitur, ac fini ejusdem
meatus quasi canitor praeferta esse videtur. figura teres non est, sed aliquan
tum depressa duos efficit angulos: latitudo cavitatis calamum , quo scribim us,
fere adaequat, sed in fine duplo latior est, quam in principio, quae similiter
mucosa sed tenui induitur tunica . Hoc callidissimum naturae artificium a me
inventum contemni (ut opinor) non debet : siquidem tum philosophis, tum
medicis non parum utilitatis afferre potest. nam antiquiores philosophi, quo
rum numero, ut Aristoteles refert primo de natura animalium undecimo fuit
Alcmeon, capras non modo ore ac naribus, verum etiam auribus quoque spi
rare, forte ob eam causam arbitrati sunt, quod meatum quam descripsi non
ignorarent atque adeo saepius experti fuissent spiritum , ubi ipsum quis cohi.
bet, ad aurium cavitatem vi quadam impulsum recurrere, et instar fluctus,
auditus organa percutere. Erit etiam medicis hujus meatus cognitio , ad rec
tum medicamentorum usum maxime utilis, quod scient post bac ab auribus,
non augustis foraminibus, sed amplissima via posse materias etiam crassas, vel
a natura expelli, velmedicamentorum ope, quae masticatoria appellantur, com
mode expurgari.
The last paragraph of this quotation shows, that Eusta

chius anticipated an earlier use of his discovery than was
made by the profession.
The writers who followed Eustachius up to Valsalva's
time, based their labors on what Eustachius had done. Mayer,
in order to express bis estimate as to their value, quotes
Goethe, who says : “ Denn eben wo Begriffe fehlen , da stellt
ein Wort zur rechten Zeit sich ein .” Where the ideas are
wanting, words serve a very good turn .
Valsalva, however, described themuscles of the Eustachian
tube very exactly , but a hundred and twenty -five years after
Eustachius. He supposed that the function of the muscles
was to keep the tube constantly open. Itwas not until 1850
that the anatomical descriptions began to be accurate . Then
F .Arnold , in his Handbuch der Anatomie des Menschen, published
at Freiburg in Bresgau, in 1851, gave a careful description of
220 AUTHORITIES.
the tube. Merkel, Anatomie und Physiologie der menschlichen

Stimme und des Sprech- Organs, and Tortual, Neuen Untersuch
ungen über den Bau des menschlichen Schlundes und Kehlkopfes,
1861, afterwards described the canal. Von Tröltsch,* in an
article published in his Archives, elaborated the subject much
farther. The labors of Mayer and Rüdinger have broughtour
knowledge of the anatomical structure to the present stage.
It should never be forgotten that Joseph Toynbee was the
first writer, in a paper presented to the Royal Society in 1851,
to show that the faucial orifice was controlled by the muscles
of the palate, and that the act of swallowing affected the
caliber of the tube. Toynbee thought that the tube was com
pletely closed in a state of repose, and although not strictly
correct in this, his labors can hardly be overestimated .
AUTHORITIES.
Bochdalek , Prof. Vierteljahrsschrift für praktische Heilkunde. XXIIL

Jahrgang, Prag., 1866, Bd. 89 .
Gray, Henry . Anatomy, Descriptive and Surgical. Reprint. Philadelphia,
1862.
Gruber , Josef. Lehrbuch der Ohrenheilkunde. Wien, 1870.
Gruber , Josef. Anatomisch -physiologische Studien über das Trommelfell
und die Gebörknöchelchen . Wien , 1867.
Home, Everard. Transactions of the Royal Society of London, 1800, Part II.
Henle , J. Handbuch der Eingeweide-lehre . Braunschweig , 1866.
Hyrti. Lehrbuch der Anatomie des Menschen . Siebente Auflage. Wien,
1862.
Jones , T.Wharton. In the Cyclopædia of Anatomy and Physiology. Lon
don , 1839. Vol. II.
Kessel , J. Das mittlere Ohr. Handbuch der Lehre von den Geweben . 8.
Stricker, IV . Lieferung. Leipzig , 1870.
Kessel, J. A Manual of Histology. By S . Stricker Article, Outer and
Middle Ear. Translated by J. Orne Green. New York, 1872 .
Mayer, Ludwig. Studien über die Anatomie des Canalis Eustachii. München ,
1866 .
* Archiv für Ohrenheilkunde, Bd. I., Heft i., p. 15.

AUTHORITIES. 221
Patruban, Prof.von. In Monatsschrift fürOhrenheilkunde. Jahrgang III.
No. 1.
Politzer, Adam . Die Beleuchtungsbilder des Trommelfells im gesunden
und kranken Zustande. Wien, 1865.
Politzer, Adam , The Membrana Tympani in Health and Disease. With
Supplement. Translated by A. Mathewson, M .D ., and H . G . Newton ,
M .D . New York, 1869.
Rudinger, N . Beiträge zur vergleichenden Anatomie und Histologie der
Ohrtrompete. München , 1870 .
Rudinger, N . Atlas des menschlichen Gehörorganes, herausgegeben von
Dr. Rüdinger. Nach der Natur photographirt von J. Albert. I.-II. Lie
ferung. München , 1867.
'Rudinger, N . In Stricker's Manual of Histology ; Article, The Eustachian
Tube. Translated by J. Orne Green . New York , 1872.
Shrapnell , Henry Jones. On the Form and Structure of the Membrana
Tympani. The London Medical Gazette, vol. x., p. 120 . On the Func
tion of the Membrana Tympani, ibid . , p. 282.
Toynbee, Joseph. The Diseases of the Ear; their Nature, Diagnosis, and
Treatment (Reprint). Philadelphia , 1860.
von Troltsch , Anton. Archiv für Ohrenheilkunde, 1865 .
Von Troltsch , Anton. The Diagnosis and Treatment of Diseases of the
Ear, including the Anatomy of the Organ . Second American edition .
Translated by D. B. St. John Roosa. New York , 1869.
Valsalvæ Viri celeberrimi Antonii Mariæ opera. Tractatas de Aure Hu
mana. Lugdunum Batavorum , 1742.
CHAPTER X .
INJURIES OF THE MEMBRANA TYMPANI.
The diseases of the membrana tympani occur either as a

result of an inflammation of the external auditory canal, or of
the middle ear. I have not seen any cases of independent or
primary myringitis, or inflammation of the drum membrane,
such as are delineated with theoretical minuteness by some
writers on otology. The anatomical structure of a membrane
that has but one layer of tissue peculiar to itself, and that in
its centre , but which is a direct uninterrupted continuation of
the adjacent parts, precludes the idea of an inflammation that
occurs primarily in this part. A glance at the nerve, lymph ,
and blood supply of the partition wall which is called the
membrana tympani, showsthat it has no independent nourish
ment, and strengthens the view that the inflammations that
attack it, must be of a secondary character. I have therefore
discarded the term myringitis, or inflammation of the drum
membrane, except as the name of one of the symptoms of
otitis externa or media , or to describe the inflammation pro
duced by injury. There is probably no independent disease
called myringitis, in the sense that we speak of a keratitis or &
retinitis .
Dr. A . H . Buck * has recently reported a case of interlamellar cyst of the
membrana tympani, which might be supposed to be an independent disease of
this part ; but the history shows that the patient was suffering , at the time of
the formation of the cygt , from chronic eczema of the auditory canal, which
causes the case to be one of extension of disease of the meatus to the drum
head .
The membrana tympani is, however , subject to injury from
explosions, or sudden and violent movements of the atmos
* Medical Record, vol. vii., p. 572 .
INJURIES OF MEMBRANA TYMPANI. 223
phere, which cause the undulations to be condensed and

forced inwards upon the drum -head. It may also be ruptured
by the force of condensed air, as, for example, that which is
found in passing through the lock of a caisson used in build
ing bridges. The membrana tympani may also be ruptured
by blows upon the side of the head or upon the ear, or from
direct injury by the striking of a sharp instrument directly
upon the membrane, and so forth .
The explosion of artillery is not apt to cause rupture of the
drum -head. When we consider the number of persons who
have been thus exposed to injury, it is somewhat surprising
that no more have suffered from this cause. After diligent
inquiry among army surgeons, I have heard of but very few
cases of rupture of the membrana tympani occurring from
this cause ; and although I have seen many patients who
became partially deaf, from the exposures incident to cam
paigning, during our late civil war, I have as yet seen but one
case, where a rupture of the drum membrane occurred from
the explosion of artillery. The long-continued exposure to
heavy firing often , and perhaps always, causes a temporary
ringing in the ears, probably from concussion of the laby
rinth, and sometimes hemorrhage from the vessels of the mem
brana tympani, but very rarely is a rupture produced . The
effects of the concussion do not always pass away, and some
soldiers acquire a chronic inflammation of the internaland mid
dle ears from this cause, just as do boiler -makers, who work
amid deafening noises. Ruptures from concussion do occur,
however. I once saw a woman at the New York Eye and Ear
Infirmary, who had suffered such an accident from the firing
of a pistol near her ear ; and Dr. Hackley observed a similar
result in an actor who was obliged to fire a pistol over his
shoulder during a play. The power of the muscles of the Eus
tachian tube, which act very quickly , and force, as it were, &
current of air in upon the drum membrane from the inner side,
is probably that which counterbalances the effect of a sudden
condensation of air upon the outer side. The little chink ,which
normally exists in the caliber of the tube, is also a source of pro
tection. Those persons who suffer a rupture of the drum -head
from external concussions, probably have some catarrhal affec
224 RUPTURE OF MEMBRANA TYMPANI.
tion which prevents the air from freely circulating in the tubes
and the cavity of the tympanum ; for we can scarcely believe
that so few would suffer this accident,were all drum membranes
equally liable to it. During the heavy fighting of our civil
war, infantry soldiers in the trenches were in the habit of lying
down, while the artillery behind fired over their heads ; and
yet, as I have found by inquiry, rupture of the membrana tym
pani was scarcely heard of.
Gruber's experiments on the cadaver show that the resist
ing power of the membrane is very great. Dr. Schmidekam
assisted Professor Gruber* in these experiments , which proved ,
according to the former author, that the resisting power of the
membrane was greater in man than in the other animals. It
required a column of quicksilver of 143cm . high to rupture the
membrana tympaniof an ear that had lain in alcohol for a few
weeks. The stapes and incus had been removed . The rup
ture was straight and parallel to the lower three -fourths of
the anterior line of attachment of the malleus. In another
case a drum -head , which exhibited the remains of a former
inflammatory process, in the form of a false membrane,
was not ruptured until a column of quicksilver 168cm . high,
was used . Here again the rupture occurred on the anterior
segment.
Gruber also examined the resisting power of the drum -head
by the following experiment: He introduced a catheter with a
bulbous extremity into the Eustachian tube of a fresh subject,
having a healthy membrana tympani, and fastened the catheter
in the tube by means of a stout thread stuck through it. He
then allowed a stream of air from a compression pump - air
that had been condensed four or five fold - to pass suddenly
into the tube, or after closing the tube by tying a cord about
it, he stopped the external auditory canal by means of a gutta
percha plug,with a small tube in it,through which he allowed
the compressed air to pass. Gruber was never able to break
the membrane in this experiment. The gutta -percha plug
with the tube was driven out of the canal, but the membrane
was never ruptured.
* Lehrbuch, p. 332.
RUPTURE OF MEMBRANA TYMPANI. 225
Professor Gruber saw a great many patients who were

engaged in the battles of Schleswig -Holstein and Bohemia in
1864 and 1866 , and although he examined nearly all the
aural patients of the Garrison Hospital in Vienna , he saw but
one where the explosion of projectiles had caused a rupture
of the drum -head. In this case the soldier was knocked sense
less by the explosion of a grenade, which killed two near him .
When he recovered his senses he was suffering from tinnitus
aurium in the left ear, and was deaf on this side. Pain oc
curred , and in three weeks after, when he was seen by Dr.
Gruber, he was found to have a roundish opening about one
and a half lines in diameter, in the anterior and inferior seg
ment of the drum -head . The tubes were pervious, and there
was no evidence that he had previously suffered from aural
disease. This, however, was the only case among hundreds
of soldiers that fought at Königgrätz , who had suffered the
injury which has been detailed .
Dr. Andrew H . Smith , one of my colleagues at the Man
hattan Eye and Ear Hospital, was the medical officer in
charge of the men engaged in laying the foundations for the
bridge from New York to Brooklyn over the East River, and
had many opportunities of observing the effects of compressed
air upon the membrana tympani. Through Dr. Smith 's cour
tesy, I saw some cases that illustrate this subject ; and I here
give from Dr. Smith 's notes, one of rupture of the membrana
tympani which occurred while the patient was passing through
" the lock.”
Dr. Sunith describes the case of rupture of the membrane
as follows :
“ John H ., on May 17th , the pressure being about 35 pounds to the square
inch above the normal ; the patient was attacked while in the lock going down
for the first time, by a severe pain in the right ear, followed by a slight dis
charge from the meatus. No sensation was felt as of anything giving way in
the ear. He completed his watch,and then reported to me. On examination ,
the drum -head was found to be ruptured at its upper edge. The opening was
nearly circular and rather less than a line in diameter. The patient preferred
not to go on with the work , and he was not seen byme again .”
Dr. Smith believes that most of the men who suffered from
aural trouble after having been in the caisson , had previously
some impairment of the permeability of the Eustachian tubes.
15
226 EFFECTS OF CONDENSED AIR .
The men under his care were “ most strenuously " instructed
not to enter the caisson unless they were able , when holding
the nose and blowing forcibly , to feel the air enter both ears.
Nevertheless, cases occurred in which this precaution was
neglected , and the individualwas, in consequence, caught in
the lock unable to “ change his ears."*
Dr. Smith says that the structures within the tympanic
cavity not being acted upon by the increased pressure, “ are
placed relatively in the same position as the skin under a
cupping-glass,” by the continued exposure to the effect of
compressed air , when the Eustachian does not open , or rather,
as we should say, when it does not act well, from swelling
or thickening of its tissue. Then the intense congestion
occurs, which may be followed by inflammation, finally result
ing in perforation of the membrane, as happened in one case
reported by Dr. Smith in his paper.
Politzer 's method of inflating the ears was found very use
ful in treating these cases of simple congestion, which, if they
had not been treated, would have resulted in tympanic inflam
mation and perforation of the drum -head. As an effect of the
use of this method of treatment,many of Dr. Smith'smen were
enabled to continue at their work who could not have otherwise
done so without danger. The treatment became very popular
among themen , so that as many as four or five of them would
come at Dr. Smith 's visit to have their “ ears blown out.”
I saw three or four of these cases of congestion of the tym
panic cavity , they having been sent to meby Dr. Smith , and
was enabled to see the great advantage of skilled medical
advice to these men. Many ears would certainly have been
permanently injured had not Politzer's method been employed
at an early stage of the trouble.t
* This is the term used by the men to signify the operation of holding the
nose and blowing until the air is felt to enter the middle ear. This operation
has to be constantly repeated while the air pressure is increasing in the lock ,
in order to relieve the pain resulting from the pressure upon themembrana
tympani. In some persons the act of swallowing answers equally well.
+ Dr. Smith's paper on “ The effects of High Atmospheric Pressure, includ .
ing the Caisson Disease," received the prize of the Alumni Association of the
College of Physicians and Surgeons for 1873, and will soon be published. My
extracts are taken from the manuscript loaned to me by the author.
EFFECTS OF CONDENSED AIR . 227
A gentleman who once consulted me in reference to what
I deemed to be an incurable chronic catarrh of the middle ear,
which had resulted in thickening and sinking of the drum
head , afterwards came to me with a perforation of the mem
brane of one side and discharge of pus from the tympanum ,
which he stated was caused by a visit to the caisson. The
perforation soon healed, and the hearing was rather worse
than before the accident.
Dr. John Green ,* of St. Louis,had previously to Dr. Smith
made some observations upon “ the physiology of the Eusta
chian tube, during a short exposure to an atmospheric pres
sure of sixty pounds to the square inch .” Dr. Green's obser
vations were made while bridge-piers were being sunk to the
rock underlying the bed of the Mississippi river at St. Louis in
1869- 1870.
The entrance to the chamber of condensed air was “ through
an air lock, or small chamber into which the condensed air
could be admitted gradually , occupying, for the higher degrees
of pressure, from four to ten minutes.” The exit occupied
about the same time.
The accidents to the ears occurred, as in Dr. Smith 's cases,
while passing through this lock. Sudden chilling of the body
from changes in temperature in the chamber were, according
to Dr. Green , causes of catarrhs. This theory is rather more
sufficient to explain the cases of tympanic congestion when the
tube was not completely pervious, than the one of mechanical
pressure, although undoubtedly both causes acted together in
producing aural affections.
Dr. Green notices an interesting phenomenon observed in
coming out of the lock, which Dr. Smith also observed . There
was a spontaneous escape of air through the Eustachian tubes
in a succession of puffs, succeeding each other at intervals of
fifteen or twenty seconds, independently of respiration, and
absolutely without the concurrence of any muscular action .
The phenomenon suggested to Dr. Green “ the action of a
lightly resisting valve, necessitating a slight but perceptive
increase of pressure within the tympanic cavity, to open the
* Transactions of the American Otological Society , 1870.

228 EFFECTS OF CONDENSED AIR.
passage to the pharynx.” Dr. Green observed sereral cases

of rupture of the drum -head and acute catarrh occurring as a
result of the unequal pressure, and of the exposure to an
uneven temperature.
Dr. A . Magnus,* of Königsburg, investigated very carefully
the behavior of the ear in condensed air, in 1863,while a rail
way bridge was building in his city. He proved that the in
jury to the ear was caused by pressure upon the membrana
tympani, because when he plugged the auditory canal hermet
ically, no unpleasant sensations were felt, but when he re
moved the stopper the air streamed with a powerful current
into the canal, and pain occurred very soon . The ear that was
stopped remained without pain , and the Valsalvian experi
ment soon relieved the pain in the uncovered one. Magnus also
proved by an examination of ears when the pressure was being
exerted, that the membrana tympani was actually pressed
inward. The triangular spot was obliterated when the pres
sure was greatest and the pain severe. A patient without any
membrana tympani,who was subjected to the condensed air,
had no pain . Indeed, there was not a trace of an unpleasant
sensation .
The membrana tympani undoubtedly owes much of its
resisting power , as Mr. Shrapnell pointed out, to the existence
of a triangular membrane at its upper portion that is less
tense and thick than the remainder of its structure, the so
called membrana flaccida, or Shrapnell's membrane, which
yields when undue pressure is brought upon it. The mem
brane has, perhaps, some additional defence in its oblique
position in the canal, which causes a portion of it to be covered
by the walls in such a way as not to receive the whole force
of the column of compressed air.t
The membrana tympani is perhaps more frequently injured
by mechanical violence to the head or to the membrane itself.
My friend Dr. Robert F . Weir ,f Surgeon to the New York
Eye and Ear Infirmary, has seen four such cases. In one the
* Archiv für Ohrenheilkunde, Bd. I., p . 270
+ The effects of compressed air upon the hearing power will be again
alluded to in the chapter on Chronic Non -suppurative Inflammation.
1 Verbal communication.
INJURIES OF MEMBRANA TYMPANI. 229
drum -head was ruptured by a blow upon the head with the
hand. In another, fragments of rock from a blast struck the
head and ruptured the membrane. In the third case the
injury was caused by a snow -ball striking the ear ; and in the
fourth a hair-pin was accidentally forced through the part.
In the first three, of Dr. Weir's cases, the rupture was slit
shaped, parallel and posterior to the handle of the malleus.
I have now under my observation a gentleman of about
fifty years of age, whose membrana tympani is said to have
been ruptured when he was a small boy, by blows upon the
side of his head, given by one of his teachers. The membrane
is nearly entirely gone, and there is at times a purulent dis
charge from the tympanic cavity. Teachers and parents who
have the bad habit of striking children unexpectedly to their
little charges, should be warned of the danger of a box on the
ear to the integrity of the organ.
The membrana tympani is sometimes ruptured in attempts
to remove foreign bodies, such as inspissated cerumen, and so
on , by means of a probe, as has been seen in one of the pre
ceding chapters. The text-books of Toynbee and Von Tröltsch
record several interesting cases of injury to the drum -bead by
mechanical violence. The latter author relates one in which a
young man, while going up a ladder, accidentally struck his ear
against a blade of straw , which passed through themembrane
and caused the severest pain , so that he nearly fainted . In
one of Toynbee's * cases the rupture was caused by an unex
pected blow upon the ear of a boy by a tutor. In another
case the ear was hit by a bolster while the boys were engaged
in a playful contest. In both of these cases the rent was
found to be on the lower part of the membrane.
Toynbee also relates a case which is of interest on account
of the nervous symptoms produced by it. A young man of
seventeen, while shooting, in endeavoring to force his way
through a hedge, got a twig into the right auditory canal. It
produced sudden and severe pain , followed by bleeding. Mr.
Toynbee saw the patient a week afterward. The pain speedily
subsided ; but for days after the accident there was “ a feeling
* Text-book , p . 28.
230 CHORDA TYMPANI NERVE .
on the same side of the tongue as if something cold had

been rubbed over it ; the taste on that side also was im
paired .” The sensibility of the tongue to touch was, how
ever, unimpaired.
The chorda tympani nerve was probably injured in this
case ; for the same sensations are sometimes caused when a
bit of cotton or woolen is brought in contact with the cavity
of the tympanum and with the nerve.
The function of the chorda tympani is probably chiefly in connection with
that of taste, and not of hearing.
Professor Flint* relates a casewhich sustains this view . A soldier received
a gunshot wound , the ball passing through the head, entering just above the
ala of the nose, on the left side, and emerging behind the mastoid processofthe
right temporal bone. The wound healed , with the usual symptoms of com
plete facial paralysis on the right side. The buccinator and orbicularis oculi
were completely paralyzed . The hearing was perfect. The sense of taste was
entirely abolished in the anterior portion of the tongue on the right side.
These facts were verified by Professor Dalton of this city.
Experiments upon dogs and cats, and other animals, also show ,according to
Flint, that the chorda tympani influences taste ; for sections of the root of the
fifth pair, or of the chorda tympani, is followed by loss of taste in the anterior
portion of the tongue.
Tbe chorda tympani is given off from the facial, as it passes vertically
downwards at the back of the tympanum , about a quarter of an inch before
its exit from the stylo-mastoid foramen. It ascends from below upwards in a
distinct canal, parallel with the aquæduct of Fallopius, and enters the cavity
of the tympanum through an opening between the base of the pyramid and
the attachment of the membrana tympani. It becomes covered by mucous
membrane, and passes forward through the tympanic cavity between the han
dle of the malleus and the vertical crus of the incus (see Fig. 44 , on p. 194), and
then passes out of the cavity, through the canal of Hugier, at the inner side of
the Glaserian fissure. It then passes downward , between the two pterygoid
muscles, and meets the gustatory nerve at an acute angle, and communicating
with this it passes to the submaxillary gland ; after joining the submaxillary
ganglion it terminates in the lingualis muscle.
Its anatomy seems to indicate that it has very little to do with the function
of hearing. It merely passes through the tympanum , without supplying any
of its tissues, as has already been described in the chapter on the anatomy of
the middle ear.
Claude Bernard also performed experiments upon the chorda tympani of
cats and Albino rats, by cutting out the facial nerve at its exit from the stylo
mastoid foramen . In from six to ten days the terminal twigs of the lingualis
nerve, and the nerve fibres coming from the chorda tympani were found to
* The Physiology ofMan , The Nervous System , p . 157.

have undergone fatty degeneration. Degenerated nerve fibres were also found
in the tip of the tongue, but not in the papillæ . There were also degenerated
nerve fibre in the submucous tissue. *
Severe vomiting sometimes causes a rupture of the drum

head,as does strangulation by hanging. The cases of rupture
that occur during whooping -cough , and sneezing or blowing the
nose, are not properly to be considered in the present chapter ;
for when the membrana tympani is ruptured in such cases,
there is usually, if not always, some pre-existing catarrh of
the Eustachian tube and tympanic cavity. I have seen seve
ral such cases, but in all of them I have been able to trace
disease of the middle ear as having preceded the breaking of
the drum -head. The great accumulation of mucus caused by
the catarrhal inflammation will be very apt to cause a rupture
by mechanical pressure from within upon a distended mucous
membrane and fibrous layer , unless the cavity be emptied by
means of the catheter or Politzer's method .
In countries where punishment is meted out in exact pro
portion to the amount of personal injury done to the person
assaulted, blows upon the side of the head which result in
rupture of the membrana tympani are made the subject of
carefulmedico -legal examination .t
In order to determine the cause of a rupture of themem
brana tympani, it must be seen within a few hours of the
injury ; for suppuration may occur soon after it has occurred,
when it will be impossible to decide whether it had a trau
matic or spontaneous origin .
A traumatic rupture of the membrana tympani, especially
one arising from the perforation of the membrane by a sharp
instrument, is much more apt to cicatrize promptly, without
suppuration, than one that has been perforated in the course
of inflammation of the middle ear.
The force of large waves upon the side of the head in sea
* Monatsschrift für Ohrenheilkunde,No. 1, 1873 , from Comptes Rendus,
Hebdom .des Seances de l'Academie des Sciences, T. lxxv., No. 27. Paris, 1872.
According to the Austrian criminal code, an injury is defined to be a
severe one, when the person suffering it is deprived of his usual health , or kept
from his occupation for a period of notless than twenty days. - Politzer, Wiener
Med. Wochenschrift, Nos. 35, 36, 1872.
bathing, is not an uncommon cause of rupture of the mem

brana tympani. I have seen such cases, and one where both
membranes were ruptured . A wave is sometimes allowed to
strike upon the membrane with great violence , and if it do not
break it, it will at least excite an inflammatory action. Phy
sicians who practice at the sea-side,should warn their patients
of this danger from surf-bathing. Long Branch and Newport,
furnish every year a certain contingent of aural patients from
this cause.
A little care in not allowing the waves to strike the side
of the head in full force, or plugging the meatus lightly with
cotton, will be found to be a sufficient protection from the
severity of the waves. If water be allowed to stay in the
auditory canal for some time, it becomes a source of conges
tion ; but such causes of diseases of the middle ear are more
appropriately considered in a subsequent chapter.
Dr. C . H . Burnett,* of Philadelphia, bas lately reported a
case of evulsion of the membrana tympani, from the splashing
of mud into the ear by a horse while the patient was crossing
the street. The patient was 39 years old , and consulted Dr.
Burnett three days after the accident. He stated that his ear
was sound until the mud came into it. Upon returning to his
shop — he was a machinist — he was examined by some of his
comrades, who said they saw foreign objects in the meatus,
which they proceeded to extract with chips and mechanics' small
tools. Several “ little white pebbles” were taken out, which
were probably the ossicles. Great impairment of the hearing
of the ear followed . The patient was very pale, anxious and
bathed in cold perspiration when he visited Dr. Burnett. A
watch that should have been heard 40 feet was only heard
5cm . The tuning -fork placed on the vertex was heard very
distinctly in the injured ear.
On examination , Dr. Burnett found the meatus uninjured .
A small piece of mud was adherent to the antero-superior
quadrant of the periphery of the membrana tympani. The
membrane was entirely destroyed , except a very narrow bor
der. There were no ossicles visible. The inner wall of the
* Transactions ofthe American Otological Society, 1872.
ympanum was fully exposed to view . The mucousmembrane

was healthy, but slightly abraded on the promontory. Twenty
days after, without treatment, patient was free from pain and
“ ruddy and cheerful.” The border of themembrana tympani
had becomeadherent to the promontory. Of course the hear
ing power was not improved, thanks to the care of his surgical
comrade, who so carefully removed the " white pebbles ” from
his ear.
The explosion of a bag of gas near the ear,may also cause
a rupture of the membrana tympani. Dr. J. Orne Green,* of
Boston , reports such a case. The patient, who was preparing
for an exhibition in which an oxy-hydrogen light was to be
used , was standing a few feet from the bag, and with his left
side towards it at the time of the explosion. The immediate
effect was some slight confusion of intellect, which soon passed
off ; but the next day the left ear began to be painful, and on
blowing the nose, air whistled through it.
Dr. Green saw the patient twelve days after the accident,
and found the membrana tympani red and swollen, and on the
posterior segment just behind the umbo , a rupture 1: lines
long, nearly perpendicular, through which purulent matter
could be forced by Valsalva's method of inflation. H . D . dg.
Dr. Green states that this patient had previously suffered
from impaired hearing and mucous rales in his ears. Many
of the cases of rupture of the drum -head on record , if the
antecedents had been inquired into , would undoubtedly ex
hibit the same condition of things.
The assistant of the patient whose case has just been
quoted, suffered at the same time from the explosion of a bag
of gas, and also received rupture of the membrane, which
resulted in a purulent inflammation of the tympanic cavity.
He was treated by Dr. Henry L . Shaw of Boston. In both
of these cases the rupture healed perfectly , and the hearing
power was partially restored . In Dr.Green's case it became18.
Dr. Green saw two other cases in which the patients suf
fered from the concussion of the same accident. It caused
a loud buzzing in the ear and confusion in the head. The
* Transactions of the American Otological Society , 1872 .
patients consulted Dr. Green on account of the tinnitus which

was caused in one case , but aggravated in the other, for the
latter patient had previously suffered from disease of the mid
dle ear.*
Fracture of the base of the brain involving the temporal
bone, very often produces rupture of the membrana tympani
and consequent hemorrhage from the ears ; but a considera
tion of such cases belongs to the province of general surgery.
Prognosis. — The prognosis in a case of rupture of the mem
brana tympanidepends very much upon the nature of the in
jury that caused it. An accident of this kind, when produced
by the concussion of a heavy explosion or of a severe blow
upon the side of the head , is much more serious in its nature,
than an injury to a drum -head from the forcing through it ofany
sharp body, such as a knitting-needle, pen -holder, twig of a tree,
a blade of straw or the like. The former class of injuries are apt
to produce a concussion of the labyrinth , or a fracture or dis
location of the ossicula , as well as a rupture of the drum -head.
Such a result at once takes the affection away from the category
of simple injuries, and renders it a very serious one, not only
with reference to the hearing power, but also as regards life.
The tuning-fork becomes a valuable assistant to diagnosis in
cases of rupture. Its vibrations will be heard more distinctly
in the injured ear than the other, if the labyrinth be not
injured . A simple rupture usually heals in a few days with
out great injury to the hearing. A suppurative process may
result,however,and become chronic,when the treatment should
be the same as that of any other similar affection arising spon
taneously.
Treatment.- We can do very little indeed , in the way of
treatment, if no inflammatory symptoms, such as pain or swell
ing, occur. Above all, we should not disturb the ear immedi
ately after the occurrence of the injury, as is sometimes mis
* Dr. Green records several other cases of injury of the side of the head
which produced a rupture of themembrana tympani, butas they do not differ
from others that are noticed in this chapter, I beg to refer my readers who
may wish to carry this subject farther , to his interesting paper
FRACTURE OF HANDLE OF MALLEUS. 235
takenly done, by syringing it. There is a very prevalent dis
position in the profession , to syringe the ear in every case of
aural disease that presents itself ; but no ear should be syringed
without a good and sufficient reason. When inflammatory
symptoms occur, they should be treated by leeches,the warm
douche, and by the other means that will be detailed in the
chapter on Acute Inflammation of the Middle Ear. Mean
while the ear should be protected from the cold air, by a bit of
cotton placed in the meatus, and the patient should be kept
under careful but not meddlesome observation .
FRACTURE OF THE HANDLE OF THE MALLEUS.

This rare accident has been described by Menière, Von
Tröltsch, and Weir.* The history of the case of the second
named author is as follows : A man accidentally thrust a
pen-handle which he held in his hand into his ear , in con
sequence of knocking his elbow against a door. The severe
pain caused him to faint. After he recovered , he found
that he heard badly from the injured ear, and he suffered
from tinnitus of that side. Von Tröltsch saw the case a year
after , and from the peculiar slanting position of the handle of
the malleus, and from the fact that it was uncommonly thick
under the short process, he diagnosticated a united fracture
of the manubrium .
Hyrtl, is quoted by Von Tröltsch,ashaving described such
a united fracture in the malleus of a prairie dog. This frac
ture was also situated just under the neck of the malleus. The
membrana tympani of this animal is, according to Hyrtl, very
superficially situated.
Dr.Weir's case is one of ununited fracture.t A man, aged
32, came to Dr. Weir's clinique, at the New York Eye and
Ear Infirmary , on May 11, 1867, and gave the following
history : Four months previously he fell into an open area
way, a distance of about fifteen feet. He became uncon
scious, and remained so for nearly sixteen hours. He had
been informed that his right ear bled for about an hour.
* Von Tröltsch on the Ear, 2d American Edition, p. 151.
+ Trausactions American Otological Society .
236 FRACTURE OF HANDLE OF MALLEUS.
Upon returning to consciousness he felt a severe pain from the

right ear, across the forehead to the other ear. The pain
lasted for nearly a month , and gradually diminished ; but the
great tinnitus, which dated from the time of the injury , con
tinued unabated . There was no history of any foreign body
having entered the ear. The watch was heard upon the
affected side when pressed firmly upon the ear.
The drum membrane was normal in color ; but there was
an irregularity in the handle of the malleus. The bone was
found to be fractured a short distance below the short pro
cess, presenting the appearance shown in the engraving. The
broken ends of the bone were completely and transversely
displaced.
Fig . 66. Fig . 57.
O O
When Dr. Weir caused the patient to perform the Valsal
vian experiment, the fragments came into apposition, and the
line of the bone became regular ; but the posterior portion of
the membrana tympani projected unduly forward from want
of support. In a few moments the displacement recurred ,
with corresponding sinking of the posterior of the drum mem
brane. Dr. Weir's colleagues – Drs. Hackley and Simrock
thought that a faint whitish line, posterior to the malleus,
might be a cicatrix from a laceration of the drum -head. The
patient did not return to the Infirmary.
CHAPTER XI.
ACUTE CATARRHAL INFLAMMATION OF THE MIDDLE EAR .
The nomenclature that I have adopted in lecturing upon

the affections of the middle ear, and the one which I regard
as most in accordance with the anatomy and pathology of this
part of the organ of hearing, may be tabulated as follows :
1. — Acute catarrhal inflammation .
II. – Subacute catarrhal inflammation .
III. — Chronic non -suppurative inflammation, divided into
two forms— catarrhal and proliferous.
IV. - Acute suppurative inflammation .
V . — Chronic suppurative inflammation .
VI. — The consequences of chronic suppuration :
1. Polypi.
2 . Exostoses.
3. Mastoid disease.
4. Caries and necrosis.
5 . Cerebral abscess.
6 . Pyæmia .
7. Paralysis.
By such a classification as this, especially that relating to
the suppurative affections, correct notions are formed as to the
nature of such diseases as polypi and mastoid disease, which
is otherwise difficult. Polypi and exostoses have hitherto
been classified under the diseases of the external auditory
canal. They are certainly, in most cases, situated in this
part; but this is their chief claim to such a classification. In
by far the greater number of cases they are the direct result
of inflammation of the middle ear.
If we were to form our estimate of the frequency of acute
catarrhal inflammation of the middle ear from the number of
238 ACUTE CATARRH OF THE MIDDLE EAR .
cases that occur in the statistics of writers on diseases of the

ear,we should come to a very erroneous conclusion as to the
number of people who suffer from this affection. It is indeed
a very common one. It is difficult to find an adult who has
not at one time or another suffered from “ ear-ache.” Ear
ache is the popular name for acute catarrh of the middle ear.
My own statistics show that of 994 cases of aural disease seen
in private practice, only 55 , or a little more than five in a hun
dred, belonged to the class now under consideration. The
tables of other writers show about the same relative frequency.
That this disproportion does not arise from an actual rarity of
the affection, I think a little thought will show . Such pain
ful affections very often never reach a practitioner, and are
treated at home, a fact which accounts for their infrequency in
statistical tables.
Every physician will at once recall the fact, that it is often
incidentally mentioned, when perhaps he is visiting a family
e quetingfromthe other
bsuffering out,and ththat
feartdiseases, ere hy oorr MMary
at thJohnny ary has had a
severe ear-ache all night, and that there has been great difficulty
in quieting the fearful pain. Very often , indeed , the fact will
be added , that the pain is not yet subdued , and that the family
have quite exhausted the means at their disposal for relieving
it ; and yet, taught by tradition and experience, they do not
expect anything from the physician, whose aid becomes so
efficacious for the pain of colic or of peritonitis. It is to be
feared that many physicians stand helplessly by, and allow
an acute catarrh of themiddle ear to run on to suppuration
of the drum -head , or, worse still, to periostitis of the mas
toid or to meningitis, without an attempt at interference.
A little later, in the discussion of this affection , we shall
discover, I think , that the means at our disposal for its relief
are ample , and that they have what may almost be termed a
brilliant effect, when properly used ; but I wish in the outset
to impress upon the minds of my readers the fact that the
commonly neglected ear-ache of the household is identical
with the disease known as acute catarrhal inflammation of
the middle ear. It will then be evident that we are dealing
with an extremely practical subject, and one on which every
family practitioner is, or should be, very much interested. :
SYMPTOMS OF ACUTE CATARRH . 239
The symptoms of this affection are so characteristic that

in the adult, they point unmistakably in the most cases to its
seat. I say in the adult, for in young children who have not
yet learned to speak, the diagnosis sometimes becomes very
difficult, and it is not always possible .
Symptoms. — The symptomsof acute catarrh may be enume
rated in the following order :
Subjective.
1 . Pain , referred to the depth of the ear.
2 . A sense of fulness in the same part.
3 . Noises in the ear.
Objective.
1. Vascular injection.
2. Bulging outwards of the membrana tympani.
3 . Impairment of hearing.
4. Catarrh of the pharynx and Eustachian tubes.
5. Fever.
The pain is very often the first symptom that is observed.
Children old enough to speak , awake from sleep crying , “ My
ear, my ear.” Adults find themselves without warning at
tacked by a pain which causes themost intense agony — a pain
which forces the strongest men to shriek and tremble, while
children affected with such a disease soon cause the attend
ants to believe that the brain must be the seat of trouble .
Sometimes, however , patients with good habits of observation
notice that the pharynx felt thickened and full, and that the
throat was sore, a short time before the pain in the ear began.
I am inclined to believe that the most patients are aware of
what, for the want of a better name,may be termed a thickness
of hearing, a fullness in the ears, before the attack of pain oc
curs. This pain is described by somepatients as beginning in
the throat and crawling along the Eustachian tube. It is a
disease, however, which may be said to be sudden in its ori
gin , and one which jumps at a bound to its height. It will
pass over the acme, in the most cases, unless at once arrested ,
into acute suppuration of the middle ear; a disease which,
strangely enough, some practitioners seem to invite , by the
240 SYMPTOMS OF ACUTE AURAL CATARRH .
remark which they make, “ It is a common gathering of the

ear, from which we shall get no relief until suppuration is
established.” I intend to combat this idea in the discussion
of the treatment. It is certainly an erroneous and mischiev
ous view of a serious disease.
The sensations of fulness , the noises in the ear in acute
inflammation , are very distressing. The latter symptom , the
technical tinnitus aurium , usually lessens and changes its char
acter with a cessation of the pain . It changes from a puffing
sound, like the puff of a miniature steam engine, to a ringing
or buzzing sensation . The feeling of fulness may last for
somedays after the pain has passed away.
As I have said , the diagnosis of this disease is often diffi
cult in young children, because they are unable to locate the
seat of the pain in words. If, however, we watch a child care
fully who is suffering from pain in the ear, we can usually narrow
it down to the region of the head. Then by means of pressure
upon the tragus, observing if the child winces at this, we can
generally form a conclusion as to the origin of the pain . The
disease with which infantile catarrh of the middle ear is apt to
be confounded is an affection of the membranes of the brain .
Besides this , the physiological process of teething, is often cred
ited with a great deal of pain , which more properly belongs to
the ear. With a certain style ofwhat may be called easy going
practitioners , the diagnosis of difficult dentition , is often suffi
cient to cover a multitude of painful symptoms. Accordingly ,
gums are needlessly lanced , and dangerous delays are allowed ,
until a discharge of pus through the drum -head, makes the
diagnosis for the little sufferer.
The instillation ofwarm water into the auditory canal will
usually temporarily relieve an infantile ear-ache ; and in this
procedure we have a means of diagnosis which is always at
hand. I have seen children who were crying with pain from
inflammation of the middle ear, go to sleep in a few moments
after the instillation of warm water into the meatus. Some
times, however, this procedure will fail to give relief, and we
must depend upon the objective symptoms, of which I shall
soon speak, found in the color of the membrana tympani.
Adults sometimes mistake the pain from inflammation of
SYMPTOMS OF ACUTE AURAL CATARRH. 241
the liningmembrane of the middle ear, for what is termed neu
ralgia . I have seen cases where an anti-neuralgic treatment
by means of quinine and opium , had been tried in vain for a
disease which was really a true inflammation of mucous mem
brane ; but adults usually locate the seat of trouble with exact
ness and accuracy. The pain is indeed neuralgic , and a mo
ment's consideration of the rich supply of nerves to the cavity
of the tympanum , will give the reason for the fact that the
pain follows the course of the 5th and 7th nerves.
The objective symptoms are chiefly to be sought in the
membrana tympani. There is sometimes a pinkish hue to
the whole membrane, again the vascular injection is around
the periphery of the drum -head, and along the handle of the
malleus, while the other parts of the membrane remain of
their normal color. An acute inflammation occurring in a
drum membrane rigid , thickened , and opaque from former
inflammation , is more apt to show localized redness than the
diffuse pinkish tint, that is seen when inflammation occurs in
a membrane that has been previously healthy.
At other times the redness is so intense as almost to pre
vent any recognition of the drum -head, except as an evenly
red surface in which no vessels can be traced .
I think there is always some increased vascularity of this
membrane, in every case of acute inflammation of the lining
of the tube and the cavity of the tympanum , so that we may
find in this symptom the deciding point in doubtful cases,
even in the infants. The membrane has, however, at times
the appearance of glass that has been breathed upon, without
any evident increase in vascularity, even where there is acute
inflammation going on in the middle ear.
The impairment of hearing is not always marked in the
stage of pain . The hearing power may even be augmented
and be painfully acute during the first stage of the disease.
I have known many instances where the acuteness of hearing
was found on accurate examination to be markedly increased
in cases of chronic aural catarrh, in which an acute inflam
mation had supervened. It may be increased also in acute
cases occurring in persons whose ears have been previously
healthy ; that is to say, sounds may seem very loud to them .
16
242 SYMPTOMS OF ACUTE AURAL CATARRH .
I will not attempt any explanation of the phenomenon, but be

content with noting the fact.
Bulging outward of the membrana tympani is a symptom
that may often be observed after the first forty-eight hours of
an attack of acute catarrh . If the disease continue longer
in an acute form , spontaneous perforation is apt to , but
does not always occur. This bulging outward , I have most
frequently observed in the posterior and inferior quadrant,
but also in Shrapnell's membrane, and usually in the posterior
portion of the membrane. It is sufficiently marked to be
detected by any one who is at all familiar with the examina
tion of the normalmembrane. In rare cases — I believe I have
seen but two in my experience — the imperforate membrana
tympani will be found to pulsate synchronously with the pul
sations of the heart. As is well known , it is quite common to
observe a pulsation of the vessels of the cavity of the tympa
num in cases of acute and chronic suppuration of this part ;
but pulsation of the imperforate membrana tympani is a rare
symptom . There must be great increase of the tension of the
membrane when this occurs, from the pressure of the blood
column or of mucus behind it. Increased secretion from the
pharynx and region of the posterior nares is almost always
observed in cases of acute catarrh ; but it requires but a mere
mention at this point.
Febrile symptoms are almost always present in cases of
the disease under discussion. The temperature is usually
quite considerably increased, so that the generalaspect of the
patient, suffering from great local pain , impairment of hear
ing, and a dry, heated skin , is one of intense suffering. Yet
this is the disease which many physicians allow to run its
course, without any of the antiphlogistic treatment that they
would at once resort to , were any other organ of the body sim
ilarly attacked .
Causes. — The causes of this disease are manifold . Any

undue exposure to the influence of cold may produce acute
catarrh of the middle ear. Getting the feet wet, the sur
face of the body chilled by standing or walking in the cold,
are frequent causes of ear-ache. A draught of air blowing ,
CAUSES OF ACUTE CATARRH . 243
for instance, through the window of a railway carriage in
rapid motion , is sometimes a cause of acute catarrh .
Ducking the head under water, and allowing the water that
enters the auditory canal to remain there, is another cause.
Constitutional diseases, such as small-pox, scarlet fever, and
measles, in which the pharynx is affected, are very common
sources of acute aural catarrh. Pneumonia and bronchitis very
often have this affection as a consequence. Coryza or cold in
the head, however caused, very often gives rise to acute
inflammation of the ear.
It arises in the course of syphilitic affections of the pha
rynx and posterior nares ; but, contrary to what has been said
by some authors, I have found no pathognomic evidences of
syphilis in the character of the pain or the appearance of the
membrana tympani in such cases.
The origin of acute catarrh is chiefly to be sought for in
the faucial extremity of the Eustachian tube, and not in the
auditory canal. This explains the fact, that it is much more
important for patients liable to aural disease to protect the
external surface of the body and the extremities from the cold ,
than themeatus and auricle .
Yet it is not to be denied, that inflammation of the middle
ear does occasionally extend from the canal, through themem
brana tympani, and not through the Eustachian tube, for we
have seen that a draught of air upon the side of the head ,
will produce acute aural catarrh , and if cold water enter the ear
through themeatus externus, and remain for a considerable
time, it may also produce acute catarrh of the middle ear.
The use of the nasal douche for the treatment of naso
pharyngeal catarrh, may also produce acute inflammation of
the ear, as I first showed in an article in the Archives of Oph
thalmology and Otology. * My experience has since been con
firmed by many other observers.
In the description of the treatment of the pharynx and
nares in the course of chronic aural inflammation , the subject
of the use of the nasal douche will be more fully discussed .
* Archives of Ophthalmology and Otology , vol. i., No. 1.

244 TREATMENT OF ACUTE CATARRH .
Treatment. The proper treatment of acute aural catarrh

is predominantly an antiphlogistic one. The disease is an
inflammation of the severest form , and can only be success
fully combated by such means as local blood-letting and
opium . A nervous pain in the ear, a true otalgia , is a rare
disease. In fifteen hundred cases , I have seen but one
such affection , and yet an inflammation of the middle ear is
very often treated as would be a case of facial neuralgia ; or
we might even say, that the ordinary treatment for acute
aural inflammation is pre- eminently empirical and without
reason. From the time of the ancients down to our own day,
all kinds of decoctions and mixtures have been poured into
the ears to relieve ear-ache. Some of these agents are of a
negative or slight value ; many of them are of a positively
harmful nature. To the former classbelong such applications
as sweet-oil and laudanum , glycerine,molasses, and so on. To
the latter class belong Harlem oil, Cologne water, ether ,and all
stimulating applications. Poultices are remedies often used ;
but while they generally quiet pain , their application is so
dangerous to the integrity of the drum membrane, especially
if they be used for many hours in succession, that the practi
tioner will do well to avoid them ,unless other means cannot be
employed , or when the latter prove ineffectual. In some cases,
however, the urgency of the pain will demand that poultices
be employed. The chief thing to be done in this disease is
to decrease the heat, swelling, and vascularity of the parts.
Applications of a stimulating nature, made to the membrana
tympani, certainly cannot do this ; and mere emollients, such
as sweet -oil, have a very transitory effect.
I would place local blood-letting as the chief and first
remedy in acute aural catarrh. This blood-letting should be
performed by means of leeches applied to the tragus, and not
to themastoid process . Wilde, and Von Tröltsch , have taught
the profession that this is the best point for the application of
leeches in inflammation of the ears, and the reasons therefor.
At this point, the blood is most easily drawn from the cavity
of the tympanum — the vessels supplying it, and the drum
membrane, inosculating here. The application of from one
to six leeches, according to the severity of the disease and
TREATMENT OF ACUTE CATARRH . 245
the age of the patient, will usually be sufficient to quiet the

most severe pain in the ear, and to check the intensest form of
catarrhal inflammation. I have seen almost magical effects
from their use. One of themost striking of the cases in my
note -book is the following : Iwas called on a very severe win
ter' s day to see a young gentleman in a neighboring city, who
had been suffering for two days from acute pain referred to
the ear. I found the symptoms of acute aural catarrh, in a
reddened but intact drum membrane, congested pharynx, and
so forth . When I entered the room he seemed to be in mortal
agony. He said that he had not slept for forty-eight hours,
and his anxious countenance verified his assertion. I at once
sent out for some leeches, and caused one to be applied to
each ear, and before they had dropped from the tragus he was
asleep, and went rapidly on to perfect recovery. Such cases
might be multiplied , for they are of frequent occurrence in
hospital and private practice .
Leeches are, however, a troublesome remedy, and in coun
try districts they are not always to be had. In their absence
I place the use of warm water as next in efficiency. This
should be poured continuously into the ear, and not used by
means of a syringe, as I have known patients to employ the
water when told to pour warm water into the ear. Clarke's
aural douche (see illustration on page 124) is the bestmeans
ofwhich I know for applying warm water to the ear. Some
times the warm water is unpleasant, instead of grateful, to the
patient, and then the vapor of water or the smoke from a
cigar or pipe may be conducted into the ear. Children may
sometimes be relieved from a commencing attack of acute
aural catarrh, by breathing into the affected ear for a very few
minutes. If leeches cannot be had , and theuse ofwarm water
or of steam does not subdue the pain , cups — wet or dry
applied around the auricle , are sometimes of use, or Hourte
loupe's artificial leech may be applied.
Poultices, as I have said , are only to be used as a last
resort. Then they should be made small enough to be put in
the canal, with only a slight covering of the auricle, but a
denser one over the mastoid ; and their use should be given up
, as soon as the inflammation has abated.
TESIS
246 PARACEN IN ACUTE CATARRH .
If the patient or his friends are told to apply the leeches,

the exact spot upon which they are to be placed should be
marked with ink , or they will be put on the lobe, or on the
neck, or in some other position where their use will do no
good. I have quite often found, that a neglect to state just
where the leeches should be applied , bas caused all the efforts
to relieve pain to be of no value.
Robland's styptic cotton - a preparation of cotton in a solu
tion of alum - prepared by Dr. Rohland of this city , will be
found a very efficient means of arresting the hemorrhage
from a leech bite. The bleeding should , however, usually be
encouraged, by the use of warm compresses, for an hour after
the leech has dropped from the ear.
Paracentesis of the drum membrane is a very efficient
remedy at times, when there is bulging ofthe drum -head, and
we see that perforation is imminent; or even in cases of pro
longed pain without bulging of the membrane,when the leeches
have been used at too late a period, or have proved ineffectual.
Schwartze, of Halle, taught us the value of this means of
treatment in acute cases, and I have found it of great value.
I would even pass a cataract needle through the posterior
portion of the membrana tympani, in any case, whether bulg
ing was seen or not, when the use of leeches did notmarkedly
diminish the severe pain within a few hours. I have done so
with striking effect in some cases. Yet leeches and warm
water , if promptly used, will usually check the progress of
even the severest case . Very often, however, we are not
called until the disease has advanced so far as to involve
every part of the middle ear, when periostitis of the mastoid
has occurred,and suppuration seems to be inevitable .
Paracentesis of the membrana tympani should be per
formed while the head of the patient is well supported,and a
good light is thrown upon the membrane bymeans of the oto
scope attached to a forehead band. A needle, such as is
used in the operation of discision of a soft cataract, is the one
I employ. The pointof opening should be determined by the
seat of the greatest amount of bulging, which I have found to
be in Shrapnell's membrane, and in the posterior and inferior
quadrant of the membrane. The operation causes so little pain ,
TREATMENT OF ACUTE CATARRH . . 247
that this element does not enter into the consideration of the
surgeon. I have found the light of a candle about the best
and most convenient source of illumination , when the opera
tion is to be done in a sick room , and the patient is in bed .
An instrument with an angular handle has some advantages
when the operation is to be done for chronic inflammation,
and we desire to make a larger opening ; but for acute cases
a thorough puncture, through which the blood, mucus, or pus
can be drawn, is usually an opening large enough to relieve
pain . I have more frequently performed the operation in
cases where the severity of the pain has passed, and yet I
have also performed it with the happiest of immediate results
when the patient was at the height of distress.
If we find on examination that the mastoid region is red,
hot, tender , and swelled, it will be necessary to make an inci
sion through its tissues down to the periosteum ; but it is only
very rarely that this is the case in acute aural catarrh. Such
a state of things is more apt to be found in subacute suppura
tion, or as a result of chronic suppuration, under which heads
the subject will be fully discussed.
The condition of the pharyngealmucous membrane should
at the same time be attended to, by means of gargles and
external applications. A saturated solution of chlorate of pot
ash forms one of the best of applications to the pharynx, while
the neck may be enveloped in a warm -water poultice.
The Eustachian catheter, and Politzer's method of inflat
ing the middle ear, should be used as soon as the acute symp
toms have subsided, say in twenty-four hours . If employed
with gentleness , there need be no fear of aggravating the sub
dued inflammation into a relapse .
The hearing should be accurately tested by means of the
watch and tuning-fork , in order to see, after the pain has sub
sided, if any impairment has occurred . If only one ear be
affected , careless patients will believe that the hearing is per
fectly good , after the pain and fulness have passed away ; but
the physician should be sure of this for himself. In half
treated acute catarrh are laid the foundations for that insidi
ous and obstinate disease, chronic non -suppurative inflam
mation of the middle ear.
248 TREATMENT OF ACUTE AURAL CATARRH .
While this energetic local treatment is carried on , the

attention of the physician should be turned to the general
system . It will often be necessary to give a full dose of opium
or morphine at bed -time. It is somewhat remarkable , how
ever , that opium has very little effect, when used without
local depletion , to quiet the pain from aural inflammation .
Very large doses will be taken in vain , unless the localmeans
that have been described are also employed.
The patient should be kept in the house, and in a well
warmed room , during the stage of pain and fever. Pediluvia
and diaphoretics are hardly necessary in case the pain is once
subdued . The diet should be nourishing. The patient should
be enjoined to keep his skin in good order by means of fre
quent bathing, in order to prevent relapses. The improper
habits of life, or the exposures to cold , that have induced this
attack , should be carefully sought out, in order that future
ones may be avoided .
The practitioner who, while treating a grave constitutional
disease, finds this local inflammation breaking out, should by
no means allow the severity or danger of the constitutional
symptoms to prevent him from the proper treatment of the
acute aural catarrh . The local and constitutional treatment
can well go on together ; while the neglect of the ear at the
proper timemay lead to irreparable damage not only to the
health and prosperity of the patient, but it may destroy his
life.
We cannot be too much impressed with the fact that a
neglected acute aural inflammation may lead, through suppu
ration of the middle ear, with all its consequences of caries,
polypi, meningitis, cerebral abscess, pyæmia , to the most
deplorable results.
Better would it be for a child suffering from scarlet fever
or measles to die from the disease, than to recover from the
constitutional affection only to succumb, with great misery, to
the effects of the neglected inflammation of the middle ear.
It is to be hoped that the neglect of treatment of the ear will
not prevail in the next generation to the extent that it does in
ours.
The practitioner who looks through the generally excellent
SUB- ACUTE CATARRH . 249
works on the diseases of children, will be painfully impressed

with the fact,that very little attention is given to the common
complications of infantile diseaseswith acute catarrh and sup
puration in the ear.
The course of a case of acute aural catarrh , promptly
treated in the manner that has been outlined , usually ends in
complete recovery , with integrity of the structure and func
tions of the ear. In less favorable cases suppuration occurs ;
but this is usually tractable, and even then the organ may be
restored to complete usefulness. My published cases show
that fifty of the fifty -nine cases that were recorded recovered ;
while it is probable titt some of the remaining nine did also ,
although I have no notes to show this.
Two died. In one of the cases there were constitutional
symptoms, as I was informed , of fever, and the acute aural
catarrh may be said to have been incidental to typhoid fever.
The other case of death was a case of mastoid disease , and
the patient died of disease of the brain . It will be referred to
in the chapter on the affections of the mastoid .
SUB-ACUTE CATARRH OF THE MIDDLE EAR .
There is a variety of catarrh of the middle ear which is

very common in young persons and in children, that hardly
demands a separate chapter for its proper consideration, but
which differs in so many respects from the ordinary type of
acute catarrh, that it seems to require a more extended notice
than the references thathave been made to it in discussing the
latter-named affection. I have ventured to term this affection
sub -acute catarrh of the middle ear. It hasmany of the symp
toms of the truly acute form . The absence of pain is the chief
distinguishing mark by which it is separated from the latter
form . Some authors, judging from their statistics, have clas
sified it under the head of chronic aural catarrh. While this
view may not be strictly incorrect - for the affection that I am
about to describe, may last for months, and run into the
strictly chronic form — it has, in my opinion , more of the
characteristics of acute catarrh in its nature, and in its readi
ness to yield to treatment, than of chronic inflammation .
250 SUB-ACUTE CATARRH .
Symptoms. The subjective symptoms of sub -acute catarrh

of the middle ear may be stated as follows : It is observed
that the patient, without suffering from pain in the ear, or if
so , from pain that is not long-continued , is very often so
hard of hearing as not to hear ordinary conversation. Very
little is thought of this by the friends of the patient, or per
haps by the medical adviser ; but the trouble recurs, the
attacks becomemore frequent, and the period of impairment
of hearing more prolonged, so that school-life is seriously
interrupted . The general health may, and may not, be im
paired. I have seen many such cases in boys and girls in
excellent general health , as well as in the delicate and
strumous .
The objective symptoms are as follows : The pharynx is
usually in a thickened or granular condition , the normal secre
tion is excessive, and it may be changed in quality , and be
decidedly muco-purulent. The tonsils may or may not be
hypertrophied . The membrana tympani has lost its normal
neutral gray color, and is of a pinkish hue. The vessels are not
usually to be traced upon any part of it. It may be exceed
ingly brilliant. The light spot is usually absent, or is smaller
than usual; a fact which shows that the drum -head is sunken in
ward. The experiments ofMagnus,which have been described
in the tenth chapter, show that any excessive pressure which
pushes the drum -head inwards lessens, or if the pressure be
great enough, obliterates, the light spot. The hearing as
tested by the watch is found to be very much impaired, and
only such conversation as is addressed to the patient, with
his face towards the speaker, is heard .
This impairment of hearing is very often attributed to
“ absent mindedness ” by parents, and to “ stupidity " by
teachers. Children are not usually absent-minded, and when
they are stupid , there is always a cause, which should be
traced out, and the poor child not treated as if it were respon
sible for the disease that has rendered it so. Again and
again will the practitioner find that he is obliged to correct
the false ideas of parents and teachers, who believe that chil
dren do not always prefer to hear, if they can. Malingering
as to deafness, is a deception which children rarely understand,
SUB -ACUTE CATARRH . 251
and which they can never successfully maintain . A child that
does not habitually answer readily when addressed, should
be at once carefully examined as to its hearing power, and
not scolded for absent-mindedness.
Treatment. It is apt to be the case, that proper hygienic
rules have not been observed in the management of such young
patients. They have been allowed to eat and drink food impro
per for growing persons ; for example ,tea and coffee, pastry and
so forth , to the greater or less exclusion of simpler and more
nutritious substances, and thus a capricious state of the appe
tite has been induced. In the case of boys, frequent and pro
longed bathing or swimming, of which ducking the head under
water forms the chief part, is sometimes found to cause or
increase the impairment of hearing. The regulation of the
diet of such patients, the wearing of flannel next the skin , the
abstaining from any habits which may be recognized as pre
disposing to inflammation of delicate structures, building up
of the system by a proper therapeutic course, such as the
exhibition of cod -liver oil and iron , with proper attention
by the use of gargles to the mucous membrane of the
pharynx, will perhaps in time allow Nature to relieve these
cases ; but the impairment of hearing, which is the most
striking and most troublesome symptom , will be the last one
relieved , and it may not be relieved at all, and the patient
grow up to be permanently hard of hearing. We have at
our hands, however , in Politzer's mode of inflating the ears
a method of treatment that has been fully described on page
98a means of instantly improving the hearing, and thus
of removing the most embarrassing symptom in an instant.
The wonder and joy depicted on a little patient's face when
the world of sound opens to him again , after the air has once
entered the Eustachian tubes and tympanic cavities, is some
thing very pleasant to see. In the absence of the air -bag, a
bit of india -rubber tubing inserted in one nostril, the other
being closed, through which air is blown from the lungs of the
surgeon, will do very well. Indeed , where the subjects are
very young I prefer this method, which is Mr. James Hin
ton's adaptation of Politzer's principle .
252 SUB-ACUTE CATARRH .
The pathological changes in these cases, which cause the

impairment of hearing, are probably in some cases simply
plugging of the faucial orifice of the Eustachian tube, in
others of the caliber of the tube and the tympanic cavity by
mucus. Structural changes,such as thickening of the mucous
membrane, bands of adhesions, have not occurred . Hence I
would not class these cases among those of chronic catarrhal
inflammation.
I append three cases , two of which have been before pub
lished ;* but I have been able to follow them up , and note
that the recovery was perfect. I again publish them , with an
additional one of the same character. The cases are very
common, and it is not therefore for their rarity that they are
inserted, but that they may perhaps teach how much may be
done to instantly relieve this form ofdisease. The practitioner
who ignores the ear will certainly pass by, among these cases,
many which , if properly examined and treated ,would add very
much to his reputation, and increase his power of doing good .
CASES.
Case I.- F . S. B.,aged 16 , N . Y ., Sept. 1, 1865. Has been deaf at times for
a number of years, and for the last summer persistently so. His general con
dition is fair ; is well developed . The tonsils had been so much hypertrophied as
to impede respiration ; but they were removed previous to his coming under
my observation . The pharynx secretes excessively, as well as the nasal
mucous membrane. There are numerous granulations scattered over the pha
rynx. The membranæ tympani are pinkish , brilliant in appearance. The
light spot is elongated. The watch is heard about six inches from each
auricle.
Politzer's method was practised three or four times, when the hearing dis
tance extended to sixteen inches on the right side, and ten on the left . A gar
gle containing iodine and brandy was ordered to be used twice a day. Hewas
also to practise Politzer's method twice a week , in connection with the iodine
inhaler. The patient continued to improve, and at the presentwriting , April
20, 1866 , the treatment has been abandoned , the hearing power being nearly ,
if not quite normal. The patient goes to school every day. He was seen by
me for some weeks once a week , while his father ,who is a distinguished phy
sician of this city, carried out the treatment at home, which consisted in the
use of the gargle, inflating the middle ear by Politzer's method once in three
or four days, with attention to the general health . 1872. The patient is
now a young man in college, and has no trouble on account of his hearing.
* American Journal of the Medical Sciences, vol. vii., p. 64.
CASES OF SUB- ACUTE CATARRH. 253
CASE II.—Girl, aged 16,at Eye and Ear Clinic in University Medical Col
lege , March 28 , 1866 . Has not heard ordinary conversation for years, and has
been very much embarrassed in swallowing and breathing, on account of
enlarged tonsils ; general condition is fair ; the voice is extremely nasal ; only
hears when addressed in a loud tone of voice ; the watch is heard two inches
on the right side, one inch on the left ; membranæ tympani present nothing
striking in appearance, except that they are quite brilliant; the tonsils are
excessively hypertrophied . The use of Politzer'smethod immediately improved
the hearing somewhat,which improvement lasted, according to the patient's
statement, about a day. When next seen , the tonsils were excised with the
forceps and scissors, a long outgrowth being dragged down from behind the
soft palate on the right side, which must have pressed upon the orifice of the
Eustachian tube, and then the iodized air was driven into the tube. The
hearing distance became two feet on the right side, and about six inches on
the left. An iodine gargle was ordered, with cod-liver oil, a half tablespoonful
to be taken three times a day. The patient is now under treatment, and still
(April 26 , 1866 ) continues to improve, hearing very well, with no trouble in
respiration . 1872. I have seen this patient several times since, on account of
naso-pharyngeal catarrh , and her recovery of hearing proves to be permanent.
CASE III. - Master — (sent to meby Prof. Fordyce Barker, Jan . 21, 1873),
æt. 14. This boy has had “ a cold ,” and has been very hard of hearing for
some weeks. He is in excellent general health . Themembranæ tympani pre
sent nothing particularly abnormal. The pharynx and nostrils are secreting
excessively . Hearing distance - right ear, * ; left ear, the watch is only
heard when laid on the auricie. He was seen every other day for three
weeks, when the Eustachian catheter and Politzer's method were used , while
a gargle of chlorate of potash was employed at home. At the first sitting
his hearing distance was brought up to 18 R . E ., left , so that conversation
was heard with much more ease, and when his hearing power became is on
each side, and was still improving, he was allowed to return to his school.
The use of the catheter when the patients will submit to it,
and nearly all except infants will do so, causes the action of
Politzer's method to be more powerful. It probably excites
the muscles of the tube to more vigorous contraction. When
children are too young to swallow on the signal, we may still
employ Politzer's method, by putting the tube in one nostril,
closing the other with the finger,and rapidly forcing in the air
in spite of the child's screams, which are not those of pain .
During the swallowing motion that the little one makes, some
air will enter the tube. It is highly probable that infants
sometimes suffer from sub -acute catarrh, which if not relieved
by local treatment passes on to a chronic process, which
end in deaf -muteism . Where any doubt exists, the little
254 OTITIS MEDIA HEMORRHAGICA .
patient should have the benefit of it, by the use of Politzer 's
method,which can do no harm , and may do a vast deal of
good. The existence of a nasal catarrh in an infant, should
be carefully considered by the attending physician, lest it
result in one of the tympanic cavity , and there cause changes
which must leave permanent impairment of hearing.
OTITIS MEDIA HEMORRHAGICA .
I have seen and reported * two casesof acute aural catarrh

which had an unusual course and termination — that is to
say, the course was very acute and terminated rapidly in
perforation of the membrana tympani without suppuration,
but with quite an abundant hemorrhage through the drum
head. It is well established that hemorrhage into the mid
dle ear may occur in the course of kidney disease, just as
from the vessels of the retina ; but the two cases which I
am about to describe certainly do not come under the classi
fication of hemorrhage from blood -vessels made atheroma
tous by renal disease. They are, I think, to be considered
as cases of acute inflammation of the lining membrane of
the middle ear, in which the morbid process has an unusually
rapid and violent course, so that not merely an exudation
through the walls of the vessels, but an actual breaking
down of the walls themselves, occurs ; there is then such an
accumulation of the blood in the cavity of the tympanum
that rupture of the drum -head almost necessarily follows.
It has been often observed that in many cases of paracen
tesis of the membrane, for the relief of inflammation of the
lining membrane of the drum cavity, blood is the only pro
duct that escapes. I think these cases are analogous to those
which I am about to record, and that they serve to explain
them .
CASE I. The first case that directed my attention to hemorrhage through
the membrana tympani, as a consequence of acute inflammation of the middle
ear, was that of a young lady, of rather delicate organization , who was under the
care of Drs. Agnew and Loring . The case was seen in consultation with the

CASES OF OTITIS HEMORRHAGICA . 255
latter-named gentleman , who gave me the history. The patient was deaf
from what seemed to be hypertrophy of themembrane lining thedrum cavity ;
the membrana tympani was thickened , sunken , and immovable ; she was
treated in the usual manner, i. e., the catheter and Politzer's method were
employed , and the attempt made by them to force the drum -head outward .
On the day or day before I saw the patient, and about twenty-four hours after
the catheter and Politzer's method were used , she was seized with violent pain
referred to thedepth of the ear ; to relieve this, paregoric was dropped into the
ear. Dr. Loring and I saw the patient in the evening ; the pain had then
somewhat abated . On examination , I found, after carefully removing the
finid that had been dropped in , that the membrana tympaniwas ruptured , and
that blood was issuing from the pulsating opening . The patient recovered
after an erysipelatous inflammation of the auditory canal and side of the face.
I did not see her again , but Dr. Agnew examined the membrane in a few days,
and could find no rupture, and no trace of it.
I might, perhaps, be slightly in doubt as to the occurrence of a rupture and
hemorrhage from the membrane in this case, had I not seen one subsequently
which was very eimilar, and where , as in this case, no suppuration occurred
after the rupture, and consequently no scar remained . The presence of the
paregoric rendered it somewhat difficult to determine whether the fluid in the
rupture was blood or not ; but I took this fully into consideration, and deter
mined that it was.
CASE II.— This occurred in a gentleman in good health, of forty-seven
years of age. He smoked excessively, but in other respects his habits were
good . He had chronic pharyngeal catarrh , but it troubled him very little.
He did not remember that he had ever had ear-ache as a child or adult. I saw
him on November 7, 1871. His history was as follows: About ten o'clock
to -day, he suddenly experienced a severe pain in his right ear. The pain was
so acute that the patient was obliged to leave his business and go home. The
treatment consisted in the instillation of sweet oil and tincture of opium .
There was no relief, however, until about six P. M ., when “ a loud report
occurred in his head,” and quite a free hemorrhage occurred. The patient
thought more than a teaspoonful of blood escaped . I saw him a few moments
after the hemorrhage had occurred . The pain had entirely subsided ; the
membrana tympani was perforated in the anterior and inferior quadrant, and
a small quantity of dark -colored blood was about and in the opening, while
the membrane was pulsating as in the former case, or rather the blood column
was pulsating in the cavity of the tympanum . This patient fully recovered
without any suppuration whatever. The opening healed , and the hearing,
which was reduced to such an amount as to be expressed by the fraction is,
was restored to a normal standard. The treatment consisted in the careful
use of an injection of tepid water, just after the occurrence of the rupture, with
the subsequent use of the Eustachian catheter, through which air was intro
duced, and Politzer's method of inflating the drum -head.
The history of these two cases, as well as of those cases
of paracentesis of the membrana tympaniwhere blood only
256 AURAL HEMORRHAGE IN BRIGHT'S DISEASE .
escaped, indicates that otitis media hemorrhagica is a much

more tractable form of middle -ear inflammation than true
catarrhal, or suppurative inflammation. They serve to
strengthen the indications for an early perforation of the
drum -head when accumulations occur in the tympanic cavity.
AURAL HEMORRHAGE IN THE COURSE OF BRIGHT'S DISEASE .

There will, perhaps, be no better opportunity than the pre
sent of alluding to those hemorrhages from the tympanic ves
sels that occasionally occur in Bright's disease. Schwartze
reported such a case* in 1868.
The patient was a non -commissioned officer, of twenty-five years of age,
who suffered from albuminuria , with retinal hemorrhages. There was also
enlargement of the liver and spleen, and infiltration of the lungs. On the 16th
January, 1868, he suddenly complained of pain in his right ear,which had been
previously sound. When Dr. Schwartze saw the patient sume hours after,
the membrana tympani was of a bluish - red color and devoid of concavity.
Some leeches were applied , but they did very little good. The next day the
membrane was of a dark -red color, so that an extravasation of blood into the
cavity of the tympanum was plainly evident. On the 19th there was an
abundant serous discharge, and when the ear was cleansed by a syringe, a
small blood coagulum was removed . Anteriorly and below there was a perfo
ration in the membrana tympaniabout as large as the head of a pin . In the
afternoon a whitish mass came out of the ear, in the water that was instilled
every ten minutes. This mass, which looked like a fibrous coagulum , was one
and a half inches long, and two lines broad , and one-half a line thick . On the
20th another similar mass came out, and on the 22d the patient died. The
discharge from the ear had then become purulent.
The microscopic examination of the mass removed, when it was not quite
fresh , showed an extremely fine granular material, mixed with numerous
scales of epithelium . The post-mortem examination wasmade on the 230 Jan
uary . There was great hypertrophy and dilatation of the left ventricle . Both
kidneys were atrophied . The lungs and spleen enlarged. Pneumonia of both
lungs. Retinitis apoplectica , with retinal detachment on both sides.
EARS. — Hemorrhagic inflammation of themembrane lining the rightcavity
of the tympanum ; cavity of the tympanum filled with bloody purulent fluid .
Membrana tympani greatly reddened and swelled , covered by a thin layer of
pus,and perforated as before stated . Themucous membrane of the Eustachian
tube was also injected, but not so markedly as the tympanic cavity. No affec
tion of the labyrinth .
In the left ear, of which the patientdid not complain during life, the cav.
* Archiv für Ohrenheilkunde, Bd. IV., p. 12.
AURAL HEMORRHAGE IN BRIGHT'S DISEASE. 257
ity of the tympanum was also filled with a bloody serous fluid ; but there was
no inflammation of the liningmembrane. There weresmall ecchymoses on the
mucous membrane of the naso -pharyngeal space. The mucous membrane of
the tube was injected , and mostly so at the faucial orifice of the tube .
In the same year that Schwartze published his case, my

friend Dr. Gouverneur M . Smith read a paper before the
Academy of Medicine,* in which he called attention to the
fact that impairment of hearing was at times one of the symp
toms of Bright's disease, and a symptom that could not be
explained by referring it to uræmia . The author once treated
a case of obstinate suppuration in the middle ear, in a man
of 61 years of age, who, although suffering from Bright's dis
ease, of which he died , complained chiefly of neuralgic pains
referred to his suppurating ear, for three or four months prior
to his death . I have now no doubt that the renaldisease, by
its effect upon the tympanic vessels, was the cause of the
acute suppuration in the ear, and that if I had seen the case
when the rupture of the drum -head occurred , that I would
have found it hemorrhagic in its nature.
The subject is clearly of enough importance, to lead us to
be on our guard for renal disease in cases of hemorrhage into
the tympanic cavity, or even in cases of severe pain in the
ear, occurring in persons who seem to have any disposition to
kidney disease.
* On the Etiology of Bright's Disease ,with Remarks on the Prophylaxis .
Transactions of the New York Academy of Medicine, vol. iii.
NOTE . - Since the publication of the author's cases of Otitis Media Hemor.
rhagica, Dr Mathewson of Brooklyn , and Dr. Hackley of New York, have also
observed and reported at a meeting of the New York Ophthalmological
Society , cases of acute inflammation of the middle ear, in which hemorrhage
occurred through the membrana tympani before any pus appeared . Their
course was quite similar to that of those related on pages 255 and 256 . Dr.
Hackley's case occurred in a young woman who had just passed through the
menstrual period, and the menses reappeared after the aural hemorrhage
eeased .
17
CHAPTER XII.
CHRONIC NON -SUPPURATIVE INFLAMMATION OF THE

MIDDLE EAR.
Both in the ranks of the laity and the profession, the

treatment of aural diseases has of old been stigmatized as
unsuccessful and unsatisfactory. Carefully made observations
of the results of rational and scientific practice, in a large
number of cases, have shown that this reproach can only with
justice, if at all, be applied to two classes of the affections of
the ear. Nearly all the others are singularly tractable when
their course is properly regulated. By these two classes, I
mean chronic non - suppurative inflammation of the middle ear,
and the affections of the labyrinth , or internal ear. In recent
times the generic term , chronic catarrhal inflammation of the
middle ear, is usually employed to designate the former
variety of disease.
I shall soon find fault with the indiscriminate use of this
name, but for the present we may allow it to stand , as giving
a pretty clear idea of the affectionsarranged under it. Statis
tics show that, of every thousand cases of aural disease, that
present themselves in private practice, a little more than one
half are chronic non -suppurative inflammations of the middle
ear.* The disease is called chronic because, when it first
comes to professional notice, it has usually already existed for
months and years, and because, if unchecked, it advances with
destructive progress as long as life lasts. Although the dis
ease often does its work of impairing or destroying the func
tion of hearing, with but few of the subjective evidences of
* New York Medical Journal, August, 1869. TransactionsMedical Society
State of New York , 1871.
CHRONIC NON -SUPPURATIVE INFLAMMATION . 259
what is called inflammation — there may be no heat, redness, or

pain — we find many of the other marks of diseased action, in
swelling, thickening, adhesions, which entitle it to be placed
under this bead . It has also been called a catarrhal inflam
mation , because the cavity, air -chamber, and tube, which form
its seat, are lined by mucousmembrane. We say middle ear,
because these parts form the anatomical centre of the organ
of hearing. It is the same disease which Sir William Wilde
understood , but which, as it seems to me, he inappropriately
called chronic myringitis , or inflammation of the drum -head .
But the drum -head is only one of other parts that is affected
in this disease, and may , perhaps, be scarcely at all injured,
while the most important changes in structure and function
have occurred in other parts of the middle ear. In common
speech — and I do not mean by this, among the laity , but in
the profession — many of the forms of chronic catarrh of the
middle ear have been , from time immemorial, classified as
nervous. The great author whom I have just quoted, did
much to combat this error — an error which not only kept
back the growth of the science of otology, because it retarded
the conception of a successful plan of treatment, but which
also assisted to deepen the reproach which for centuries has
rendered aural disease the bête noir of medical practice.
The reason for this classification of these affections as ner
vous is found in the fact that the poor means of diagnosis ,
which were in the hands of the profession until a few years
since, the absence of a simple otoscope, and the want of
knowledge of the value of the Eustachian catheter, and the
tuning-fork, did not allow of the appreciation of the delicate
changes which make up what the Germans call the “ Krank
heitsbild ” — the picture of the disease. There was another
reason in the fact that the poor, distressed patient, having
gone in vain to his usual consolers , if not curers — the regular
practitioners — often resorted to the charlatan. Under his
wonderful but distressing treatment, added to the trial of the
horrible tinnitus aurium , and impairment of hearing, he became
so utterly worn out and so distrustful of each new adviser,
that the so -called nervousness was very apparent.
The common idea of nervous deafness is that it occurs
260 CHRONIC NON -SUPPURATIVE INFLAMMATION .
chiefly among the weak and sensitive ; but this notion has no
basis in pathology — so -called nervous people are not apt to
be deaf, nor does their sensitive or nervous organism have
much effect upon their hearing power, unless it is already im
paired from an inflammatory cause .
As yet this class of cases comes as a rule to the notice of
the practitioner of modern otology only when the disease is
far advanced .
The following table shows this :
Cases of Chronic Non-suppurative Inflammation. - Whole number,525.
No. of cases of 80 years' standing . . . .
over 40 years ' standing . . .
over 20 " "
between 10 and 20 years' standing
5 and 10 141
" 3 and 5
« 1 and 3 74
one year . .
less than one year . . . . . 13
Whole number . . . . .. . 525
These are the cases of this disease that I have recorded ,

in private practice. It will be seen that by far the larger
number, more than fifty per centum , had observed some loss
of function for more than five years,while about eight per
cent. had been affected for more than twenty years .
Every person has, so to speak, a superfluous amount of
hearing,which hemay lose before his hearing is sufficiently
impaired to annoy him in the common affairs of life. People
who spend many hours of the day in noisy places, such as
boiler-shops, on board steamships, in the stock -board of Wall
Street, as I have seen by frequent examples, may lose very
much of their hearing power before they are at all aware of it.
Then , again, the lower classes, who labor hard all day in the
open air with their fellows, and who live at night in small and
noisy rooms, where the demands upon the hearing power
are very slight, hardly consider its impairment as a loss of
function .
These causes have conspired, with the general ignorance of
the pathology and treatmentof non -suppurative aural disease,
NOMENCLATURE. 261
to render the results of treatment unsatisfactory , as well as to

cause patients to consult a physician at a very late stage of
their trouble. Be all this as it may, we now have tolerably
accurate means of diagnosticating , and fairly successful means
of treating those affections, and it is in the light of these
recent advances that we are now able to speak.
First , as to the nomenclature. I have never been fully
satisfied with the nomenclature of Von Tröltsch , vast improve
ment as it was on those classifications which had preceded it.
Some of them were crude, others fanciful and altogether too
refined. Von Tröltsch classified all non-suppurative disease
as catarrhal, and then separated those in which the catarrhal
symptom - excess of secretion — was not very marked , by plac
ing them under the head of sclerosis or hardening or rigidity
of the mucous membrane. After looking at many ears, in
which there was no trace, either in the pharynx, Eustachian
tube, or cavity of the tympanum , of an excess of secretion
from the mucous membrane, but in which there were marked
changes in the way of increase, hypertrophy or proliferation
of tissue, and in others where the catarrhal symptoms were
very much in the background , although they existed, I felt that
aural catarrh was a meagre and incorrect name with which to
describe such a state of things. The very name “ catarrh," as
applied to a sunken drum -head , immovable chain of bones ,
dry pharynx, easily permeable Eustachian tubes, is repugnant
to all our notions of scientific nomenclature. Whatever may
have been the origin or exciting cause of such cases, they
cannot be called catarrhal, when their examination shows such
a state of things as this.
Gruber hasmade a division in his text-book , and describes
an otitis media hypertrophica, or plastic inflammation ; but I
think his own description of the pathology of the disease
shows that he is discussing not what has hitherto been com
prehended under the head of sclerosis, but an extension of a
suppurative process, such as causes the formation of granula
tions or polypi.
The nomenclature of the author is founded on his own
clinical experience, and upon the reports of the pathology of
this class of cases tbat have been made by Toynbee and others.
262 CATARRHAL AND PROLIFEROUS INFLAMMATION .
Chronic non -suppurative inflammations of the middle ear

may be divided into two great classes ,
Catarrhal,
Proliferous.
I choose the translation of the German word Wucherung
as furnishing the best adjective to describe the changes in the
middle ear, of which I am to speak ; and in what I have to say
I shall attempt to be guided by these divisions.
Some authors and practitioners would admit another clas
sification , based upon the parts involved , and speak of chronic
myringitis, or chronic inflammation of the membrana tympani,
and of chronic catarrh of the Eustachian tube. Whatever we
may believe ofacute inflammation of these parts, I can scarcely
accept the idea of one that has existed for any considerable
space of time without involving either the cavity of the tym
panum or the mastoid cells, or both . The nomenclature, tubal
catarrh, also leads, as I believe, to incorrect notions as to the
therapeutic value of the Eustachian catheter, and of Politzer's
method of inflating the drum cavity. These methods of treat
ment are useful, not so much for what they do to the tube,
but for their effect upon the cavities into which it opens.
When air -bubbles are crackling in the cavity of the tym
panum , as in catarrhal inflammation, or when the tube is greatly
narrowed by the hypertrophy of its lining membranes, but at
the same timewe have, as we always do, in the latter case , a
sunken drum -head, an altered light spot, signs of proliferous
inflammation of many of the structures making up the middle
ear, I do not see how we can with propriety speak of a tubal
affection, even if its symptoms are predominant, and even if
treatment of, and through , the lining membrane of the tube,
does place things in such a condition that Nature will com
plete the cure. No time need be spent upon this question,
which may, perhaps, seem to some a comparatively unim
portant one, had not incorrect notions in the past led to an
incorrect style of treatment. In former times, the membrana
tympani, under the assumption that such an affection as an
independent chronic myringitis existed, was vigorously treated
by instillations of various fluids, and by perforation, and of
late, under the idea that we have a great deal of tubal catarrh
SYMPTOMS OF CHRONIC CATARRH . 263
without further progress in the morbid action, undue stress is

sometimes laid upon applications to the mouth of the tube ;
Politzer's method is substituted for the catheter,when its true
place, valuable and indispensable as it is , except in the case of
very young children , is as an adjuvant to that instrument.
SUBJECTIVE SYMPTOMS OF CHRONIC CATARRHAL INFLAM

MATION .
I think we may assume, from the history of cases, that this

form of disease is either a consequent of frequent attacks of
acute catarrh of the middle ear, or that it occurs in people
who have what we may call a catarrhal diathesis. The dis
ease is, therefore, unlike its companion, proliferous inflamma
tion , not at all insidious in its approach . The patient suffer
ing from this disease, who consults us about his hearing, is
usually aware that there is an excess of secretion in his pharynx,
and that for years he has been annoyed and troubled by being
obliged to use a handkerchief very freely , and by feelings of
fulness referred to the frontal sinus and tympanic cavities.
There is often , also, at times, a sound in the ear like the crack
ling ofair -bubbles. The voices of friends appearmuffled ; and
it is hard , for the victims of chronic aural catarrh ,when the dis
ease is advancing , not to believe that every one is speaking in
a much lower tone than is usual for them . Such patients often
complain bitterly on this subject, and will scarcely admit that
their hearing is at all impaired, or, if so, they stoutly assert
that it is one ear only, when the fact is, that, with one perfect
ear, it is only under peculiar circumstances, certainly not in
ordinary conversation, in front of the patient, will a person be
observed to be at all hard of hearing .
There is a feeling about this that is different from that
expressed about diseases of the eye at least, and I believe, in
mostmaladies, patients will express their feelings, and often
with an exaggeration, rather than with an extenuation of the
symptoms ; but, however much patients with chronic inflam
mation of the middle ear may suffer from impairment of hear
ing, they will often insist that they are hardly affected , or
that they have a very little trouble in that way, when they
264 VERTIGO IN CATARRHAL INFLAMMATION .
can scarcely hear loud conversation addressed specially to

them .
Patients affected with chronic catarrh of the middle ear
also complain, as a rule, of tinnitus aurium , and a sense of ful
ness in the ears. The ears feel as if the auditory canals were
stopped up. They often ask very anxiously if there is not
something in the ear,and seem incredulous when the negative
answer is given . Vertigo is another symptom of which these
patients speak, and it is often considered as undoubted evi
dence that there is disease of the brain . Vertigo is a symp
tom by no means peculiar to catarrhal inflammation. It also
occurs in impacted cerumen , and still more frequently in pro
liferous inflammation, as well as in cerebral disease. When
vertigo occurs in aural disease , it is a consequence of increased
pressure upon the labyrinth through the fenestra ovalis. It is
by no means a serious symptom ,when the cause is to be found
in the middle ear, for it is usually relieved by a mechanical
treatment through the Eustachian catheter. There are many
cases in my note -book which illustrate this, but none more
striking than the following :
A physician consulted me last winter on account of impair
ment of hearing in one ear, accompanied by a tendency to
topple over on that side, which he said was a consequence of
being thrown from his sleigh some months before, when he
suffered a concussion of the brain . He was quite disposed to
regard the tendency to fall over as a cerebral lesion , but the
use of the Eustachian catheter, and Politzer's method of inflat
ing the ear , not only improved the hearing, but took away
the unpleasant sensation . Physician as he was, he was
at first disposed to smile at the idea of using localmeans to
ameliorate this brain -symptom ; but he has continued to be
perfectly relieved from his cerebral malady up to this time,
nearly a year since he consulted me.
I have often heard patients describe the feeling of fulness
in the ears as a sensation as if the ears were plugged with
some foreign substance ; it is almost impossible for them to
avoid the impression that the auditory canals are plugged with
cerumen. Very many times , after I have examined a patient
suffering from chronic disease of the middle ear, I have been
INSANITY FROM AURAL DISEASE . 265
asked to look again to see whether I could not find some hard
ened wax ; and on one occasion a poor fellow , who I suppose
was, to a certain extent, insane, grew very angry and called
me hard names, because I would not remove wax which he
knew was in his ear.
Von Tröltsch * relates a case, from Meyer, of Hamburg,
where a melancholic person was relieved of a sound in the ear,
seeming to him to be the cry of a child , by the removal of a
plug of cerumen, which caused deafness on one side. The
patientmade a rapid and complete recovery from the mental
affection, after the cerumen was removed . It is the opinion
of Schwartzent of Halle, a very careful and competent ob
server, that subjective aural sensations, which are caused by
demonstrable affections of the ear,may, in predisposed per
sons, especially when there is any hereditary tendency to men
tal disease, become the direct cause of aural hallucinations,
that may accelerate the outbreak of a disease of the brain .
Hementions a case where, in his opinion , and in that of one
of the physicians of the Insane Asylum at Halle , a threatened
attack of brain disease was prevented by treatment of the ear.
In some cases insane persons who suffer from aural disease
distinguish its tinnitus from these illusions or hallucinations.
Dr. Koppe confirms this view , and shows that in some
cases hallucinations disappear after treatment of the ear.
I have elsewhere reportedt a case of the suicide of a pro
fessor in one of our educational institutions, who consulted me
on account of impairment of hearing, butmore especially on
account of tinnitus aurium . He said, on leaving the consult
ing-room , that, if he felt sure that I was correct in my opinion
(that he would not get great relief from this very trying symp
tom , tinnitus), he would put an end to his existence ; which he
did a few months after, by blowing out his brains. During
this last summer, a gentleman, a public-school teacher, con
sulted my associate , Dr. Charles S. Bull, in regard to a sup
puration of the ear, which caused considerable impairment of
hearing and great tinnitus. He was exceedingly depressed
* Text-book , second American edition, p. 531.
+ Loc. cit., p . 532.
* New York Medical Journal, August, 1869.
266 INSANITY FROM AURAL DISEASE .
and annoyed by the tinnitus. It is said that he committed

suicide on account of the depression caused by this state of
his ears. There can be no doubt but that this symptom is one
of the most distressing that can befall a patient, and that in
some cases it is the provoking cause of suicide. Again and
again I have satisfied myself that the great depression, which
is the rule in persons whose hearing is impaired , was due
entirely to the aural disease.
Dr. O . D . Pomeroy, * of this city, examined sixty lunatics
at Blackwell's Island Lunatic Asylum , and he found disease
of the ear in many of those who suffered from what may be
called aural hallucinations, although this proportion was not as
large as stated by Schwartze and Koppe.
Dr. C . E . Wrightt publishes a case of a patient in the In
diana State Asylum for the Insane, who attempted to destroy
herself by putting a steel button in her ear. The patient was
discharged from the hospital, as having recovered her reason,
but became nervous and despondent, until she was relieved by
the removal of the button ; and a dread of insanity and of sud
den death , from which she suffered, then also disappeared.
Von Tröltsch speaksof confusion of the intellect, an inabil
ity to keep up a connected line of thought, as a subjective
symptom of chronic aural disease, and I am enabled to verify
this opinion. Over and over again , bave patients with chronic
disease of the middle ear, not suffering from pain but from
tinnitus, voluntarily informed me that these noises, together
with the impairment of the hearing, had a great effect upon
their mental powers. On the other hand , I have seen cases
where most successfulmen , such , for instance, asdistinguished
general officers in the army, and distinguished writers, have
suffered from boyhood with chronic inflammation of the mid
dle ear and tinnitus aurium .
The sounds in the ears, of which patients speak, are
variously described : some speak of a ringing of bells, which
is perhaps the most aggravating form ; others have likened
them to the murmur of trees, the hum of a tea -kettle , etc.
* Transactions of the American Otological Society, Fourth Year , p. 46.

7 Indiana Journal of Medicine, November, 1871.
TINNITUS AURIUM . 267
Wilde is undoubtedly correct in stating that the descriptions
which patients give of the noises depend to a certain degree
upon their fancy, their graphic power of explanations, and not
unfrequently upon their rank of life and the sounds with which
they are most familiar ; thus, he says : “ Persons from the
country or rural districts draw their similitudes from the
objects and noises by which they have been surrounded, as
the falling and rushing of water, the singing of birds, the
buzzing of bees, and the waving or rustling of trees ; while , on
the other hand , persons living in towns, or in the vicinity of
machinery or manufactories, say that they hear the rolling of
carriages, the hammerings, and the various noises caused by
steam -engines. Servants almost invariably add to their other
complaints that they suffer from the ringing of bells in their
ears ; while, in the country, old women much given to tea
drinking sum up the category of their ailments by saying that
all the tea -kettles in Ireland are boiling in their ears. ” No
description of tinnitus aurium has ever surpassed this one
given by the great Irish observer.
Only one thing more need be added as to the nature of
this symptom . The ordinary tinnitus should be distinguished
from a venous murmur transmitted from the jugular vein ,
which runs just beneath the floor of the cavity of the tym
panum , and from the pulsating sound of the internal carotid as
it winds through the apex of the petrous bone. This variety
of tinnitus is not necessarily connected with impairment of
hearing, but is usually dependent upon anæmia or aneu
rism .
Patients suffering from chronic catarrhal inflammation of
the middle ear usually speak of the throat as troubling them
quite as much as their ears. In many cases, however, they
say nothing whatever about the throat, and even if asked
about it, they will insist that it is quite well, although they
will usually admit that they raise a great deal of mucus in the
morning, and that they have sore-throat very often. The
greater number of patients with aural catarrh complain
greatly of the condition of their pharynx and nostrils, and,
under the stimulus of the advertisements and books of char
latans, have usually very much to say of the catarrh, although
268 PROLIFEROUS INFLAMMATION.
they do not always trace a connection between the throat dis
ease and that of the ear.
There are very many other symptoms than these which
have just been enumerated - feelings of fulness, confusion of
intellect, vertigo, tinnitus, and sore -throat- of which patients
with chronic catarrh of the middle ear often complain ; but
they are not usually dependent upon the aural disease, and the
examiner may often throw many of them outof consideration,
and bring the patient back from the long story of head -aches,
dyspepsia, neuralgia , etc., by asking whether, after all, if the
ear and throat were well, they would not consider themselves
in good health , when an affirmative answer is often given.
SUBJECTIVE SYMPTOMS OF PROLIFEROUS INFLAMMATION .
If we now turn to the picture of the subjective symptoms

of what I term proliferous inflammation ,we shall find them
much less positive than those of the catarrhal form . Some of
the patients have no subjective symptoms at all, except that
of loss of hearing, which is of course an objective symptom as
well. They have no sore-throat, no increase of the secretion
of the pharynx or nostrils. Others, again , complain of feel
ings of fulness in the ears, and nearly all of tinnitus aurium .
Indeed, I think the tinnitus is apt to be more troublesome in
the proliferous than in the catarrhal form . This we should
suppose à priori to be the case, because the causes in the pro
liferous variety of middle-ear disease are constantly acting,
while in the catarrhal variety the temporary removal of the
increased secretion will often greatly alleviate this symptom ,
and sometimes completely remove it. The origin of this form
of aural trouble cannot be traced back to infantile ear-aches ,
frequent coryzas, or to naso-pharyngeal catarrh . It is a pe
culiarly insidious affection, one which is usually under full
headway, and which essentially impairs the function of hear
ing long before the patient is aware that he has any affection
of the ears. The pathology of the disease, of which an ac
count will be given a little later on in the discussion of this
subject, explains something of this insidious character.
Catarrhal and proliferous inflammation may exist in one
CATARRHAL INFLAMMATION . 269
and the same ear, when it will be impossible to make a differ

ential diagnosis, yet in the greater number of cases the line
can be drawn between the two forms.
OBJECTIVE SYMPTOMS OF CATARRHAL INFLAMMATION

The objective evidences of chronic catarrhal inflammation
of themiddle ear may be classified as follows :
1. Impairment of hearing.
2 . Changes in the membrana tympani.
3. Imperfect action and changes in the structure of the
Eustachian tube.
4 . Naso -pharyngeal inflammation.
If we exclude the latter, we have also the objective symp
toms of chronic proliferous inflammation.
The tuning-fork is one of the most useful means of diag
nosticating an affection of the middle ear from one of those
the labyrinth . In the catarrhal form of disease its use
is not as essential as in the proliferous, for the good
reason that the subjective and objective symptoms
together form such a decided picture that it would be
hard to fall into error as to the seat or nature of the
trouble . But, in the proliferous form , both sets of
symptoms are often of such a negative character that
without the tuning -fork we should be in some doubt
as to whether we were dealing with a peripheric or
central disease.
Starting from the well-established fact that, if the
auditory canal of a person having healthy ears be
closed by the finger, or in any other way, the sound
made by a vibrating body is heard more distinctly on
the side of the head where the ear is closed , it has
been shown that, in most diseases of the auditory
canal and middle ear, such vibrations are more dis- Tuning
tinctly felt on the affected side , or, if one be diseased, for
on the side of the ear affected, and on which the ticking of
a watch or the sound of conversation is not as well heard .
This subject has been quite fully discussed in Chapter II., and
270 BETTER HEARING IN THE MIDST OF NOISE .
I beg to refer the reader to that for the different views as to

the explanation of the value of the tuning -fork . * The use of
the tuning -fork, as usually employed, must, however, be con
sidered to some extent as a subjective test ; for when it is
used , we must depend on the patient's statement as to the
side on which he hears the vibrations the better. By means
of a double diagnostic tube, however, such as was used by
Lucae in his experiments , we may make the test more exact.
After having, in the doubtful cases of the proliferous vari
ety, settled the fact as to whether we have an affection of the
middle ear or of the labyrinth , the ticking of the watch and
ordinary conversation become the natural tests as to the im
pairment of hearing.
The watch is, however, an inadequate test, for the reason
that has already been mentioned in the introductory chapter,
that is, that some persons can hear a watch quite a number of
inches from the ear, while they hear conversation very badly .
Lucaet explains this fact by saying, that speech is made up of
an extremely complicated system of tones,and sounds ofmost
different tone heights, while the tick of a watch is made up of
a class of very high tones. There are,however, some cases in
which a watch is not heard well, while ordinary conversation
is distinctly appreciated. Careful observation of the lips
of the speaker, by the person whose hearing is defective, may
have something to do with explaining this class of cases.
There is a fact in regard to the hearing power of many
patients suffering from chronic non -suppurative inflammation,
that does not seem to have been as yet satisfactorily explained.
It is the fact, that these persons hearbetter in noisy places than
their neighbors who have normal hearing power. For example,
such patients when in a long American railway carriage, will
not only hear with ease, the person sitting on the same seat
with them , but also the conversation of persons who are
at such a distance that a person with normal ears, cannot
distinguish a word they say. I have often been informed by
* The tuning-forks usually employed are those of the note C such as is
here represented . It is better to strike them on a yielding body , such as the
knee of the examiner, than upon a hard body. That of the note B is also used,
+ Archiv für Ohrenheilkunde, Bd. V ., p . 100.
CHANGES IN THE MEMBRANA TYMPANI. 271
reliable patients, that on actual test they could hear in such

places better than persons with good hearing power. The tick
of a watch , is, however, heard no further under such circum
stances. The author once knew a mail agent, on one of our
railways, who, although very hard of hearing, was never sup
posed to be so, by those who only talked with him amid the
noise of the train . No adequate explanation for this phenom
enon has as yet been given . Dr. Allen , * following Thomas
Willis (see page 35), ascribes it to the increased tension of a re
laxed membrana tympani, this tension being cansed by a reflex
contraction of the tensor tympani from the stimulus of vibra
tions conveyed to the auditory nerve, " by the vibrations of car
riages, drums, leather poundings,” and so forth . There is,how
ever, no proof that the membranæ tympani of such patients are
relaxed. On the contrary, in many cases at least, they are not;
hence Mr. Willis' and Dr. Allen 's explanations are insufficient.
* On Aural Catarrh, p. 33 et seq. London, 1871.
CHANGES IN THE MEMBRANA TYMPANI.
I do not regard the appearance of the drum -head as posi

tively indicative of aural disease. In some few cases we find
the membrane in what may fairly be said to be a normal con
dition in appearance, and yet we may have a very great im
pairment of hearing, which the other objective symptoms as
well as the tuning-fork, show to depend upon disease of the
middle ear. These cases are not common, and then , if the
loss of hearing is great, we may conclude that the alterations
in structure are chiefly upon the inner or labyrinth wall of the
cavity of the tympanum . I think , however, that we very
rarely find an absolute sinking inwards of the membrane,
unless attended by some impairment of hearing. A sunken
drum -head , that is, one in which the head of the malleus
stands out like a miniature button , while the whole membrane
seems collapsed and sunken, is pretty fair evidence of the
existence of adhesions in the cavity of the tympanum , and of
impairment of hearing.
The first question, in studying themembrana tympani, is,
very naturally , What is the appearance of a normal one ?
272 CHANGES IN THE MEMBRANA TYMPANI.
The introduction of Von Tröltsch's method of examining

the membrana tympani has done more than anything else to
stimulate the study of its character. The ordinary anatom
ical text- books give no true idea of this beautiful and im
portant part. Such authorities on aural disease as Kramer,
Wilde, and Toynbee, give descriptions of it that are far from
exact. To Von Tröltsch and Politzer, are we indebted for such
perfect descriptions that we now have a complete guide to the
changes that may occur upon it.
In order to determine what may fairly be considered a
normal membrana tympani, I have examined a number of
what may be considered healthy ears. The persons whose
ears were thus examined were not aware that they had ever
had any kind of aural inflammation, even in childhood. They
did not suffer from naso -pharyngeal catarrh , and never had
suffered from it. The hearing -distance , as tested by the
watch , was normal, and the tuning -fork was heard equally
well on both sides of the head. Such persons are very rare in
any community, and consequently I have only as yet exam
ined seventeen membranes belonging to this class . From
these cases, and the observation of others, I determine that
the color of the membrane may vary from a neutral gray to a
dark blue ; but it is rather more inclined to a gray than to a
blue. The lustre and transparency vary exceedingly ; the mem
brane may be very brilliant and transparent, so that the
stapes shows through, and it may be quite dull and hazy in
appearance.
The light spot at the end of the malleus is usually trian
gular in shape, although not always. It is, perhaps, always
present in some form if the hearing be normal. The head ,
handle, and short process of the malleus are plainly visible.
There may be opacities at themargin of themembrane, where,
as Tröltsch showed , the mucous membrane is thickest. The
gray colormay bemodified by a delicate pinkish injection along
the periphery of the membrane and handle of the malleus.
It is not uncommon to find chalky spots or points of cal
careous degeneration in the membrana tympani. They are
found not only in the ears of persons with impaired hearing,
but also in those whose hearing power is acute. Undue
CALCAREOUS FORMATIONS. 273
weight, should , therefore, not be attached to these appear
ances.
Von Tröltsch * seems to have been disposed to regard these
calcareous formations as connected with high degrees of im
pairment of hearing, but I have not found this to be necessa
rily the case . Politzer † regards them as the products of sup
purative processes that have run their course. In some cases ,
as we know , such inflammatory affections are perfectly recov
ered from , and if the calcareous degeneration do not occur on
an important part of the membrane, it probably will produce
no impairment of hearing of itself.
Moos has proved by one case which he observed, that a
calcareous degeneration may occur in the course of a non
suppurative process. This case was that of a woman more
than seventy years of age, who had chronic catarrh of the
middle ear.
Calcareous degenerations, as shown by the microscopic
examinations of Politzer , usually occur in the fibrous layer.
Where the deposit was not very thick , the integumentwas quite
easily separated from the calcified parts. The mucous layer
was a little more adherent. In some cases both the external
and middle layers were involved in the calcific process. Po
litzer once found a true osseous deposit, together with the cal
careous degeneration, in one of his cases. Black ordark brown
pigment was also found by him and fat globules everywhere .
An acute catarrh of the middle ear in childhood is suffi
cient to change the color or curvature of the membrana tym
pani, and thus render it impossible to say that we are dealing
with a normal membrane. The membrana tympani of the
child differs from that of the adult in being more transparent,
while it is rather of a yellowish tinge than gray, and the han
dle ofthe malleus is not as distinctly seen .
Politzer has shown, in his work on this membrane, that the
triangular spot of light, which is one of the chief points for
study in this part, is due to the manner of the reflection of
light from its surface , and the factors which cause this reflec
tion have been fully detailed on page 189.
* Politzer, TheMembrana Tympani, p. 58.
+ L . c.
18
274 TRIANGULAR LIGHT SPOT.
Politzer* believes that we can form no conclusions as to

changes in the cavity of the tympanum andmembrana tympani,
from alterations in the size and shape of the light spot ; but I
cannot endorse this view . In the first place, if changes have
taken place in the outer layer, or layer of epidermis , the
reflecting power of themembrane is nearly removed , and there
is no light spot. Its absence certainly indicates changes in
the drum -head. Again , if it be smaller than usual, or if it can
be changed in form by the Valsalvian experiment, or by other
methods of inflating the middle ear, I think we may draw
quite positive and valuable conclusions as to the traction ex
erted by the malleus, and as to the inclination of the mem
brane. I do not deny that we may find an irregular or small
light spot on a person with normal hearing power ; but I
believe that such a state of things is rare, and that its shape
and size will be found to be, in the majority of cases, a pretty
fair guide in a general way, as to the loss of function. From
the notes of 94 ears affected with chronic non -purulent inflam
mation of the middle ear, seen at the Manhattan Eye and
Ear Hospital, and recorded by Dr. D . Webster, it is recorded
that
In 59 the light spot was present.
35 " absent.
normal.
smaller.
2 " " larger.
divided (i.e., 2 or more light spots existed ).
The experiments of Magnus in compressed air, which have
been alluded to in the chapter on Injuries of the Membrana
Tympani, also prove that the non -existence of the light spot
does show , that the membrana tympani is forced or drawn
inwards.
CHANGES IN MOBILITY OF MEMBRANA TYMPANI.

If a person, having normal hearing power, forces the air
into the cavities of the tympanum by a prolonged inspiration
and expiration, with the nostrils closed , he has performed the
* The Membrana Tympani, translated by Mathewson and Newton, p. 8.
VALSALVIAN METHOD . 275
Valsalvian experiment for testing the permeability of the

Eustachian tubes,and, on examination during this act,we find
that the membranes moved outward and then inward . This
change takes place, in a healthy membrane, chiefly at the
apex of the light spot,or extremity of the malleus ; but it may
occur in other parts , especially in Shrapnell's membrane. In
the catarrhal form ofaffections of the middle ear, the mobility
of the drum -head is not affected to any extent. It may be
even preternaturally movable . In the proliferous variety, how
ever, adhesions are apt to occur between the malleus and the
membrane,and between the other ossicula, and these will seri
ously affect the normal movements of the drum -head and the
chain of bones. It is true, however , that mere swelling of the
membrane, such as obtains in the second stage of the catarrhal
form , will, to some extent, affect the motions of these parts .
It should not be thought, however, that the middle ear is
in a normal condition , because a drum -membrane moves.
The membrane may move well, and yet the most serious
changes may have taken place in the cavity behind it. Pa
tients who suffer from impairment of hearing have pretty
generally learned the Valsalvian test or experiment, and ,when
they are so deaf as not to hear ordinary conversation at all,
and have been so for years, they will often triumphantly , and
with great skill, show the examiner how well they can blow
air into their ears, as evidence that there can't be very much
thematter with them after all. The promulgation among the
laity and profession of the valuable character of this experi
ment has harmed many ears. It is an experiment simply.
Its chief value belongs to the observer. It is an abuse of it
to make it a method of treatment. It can be theoretically
demonstrated that it is even a somewhat, although slightly ,
dangerous experiment to persons at all disposed to congestion
of the head and neck ; but this danger is not great enough to
lead the practitioner to wholly abandon it as a means of treat
ment, were it not, as I believe, almost useless therapeutically ,
and dangerous to the integrity of the tension of the membrana
tympani. I very often see patients who have learned this
method of treatment, and, having believed that no harm could
ensue from a very frequent performance of the experiment,
276 SIEGLE'S OTOSCOPE.
have been in the habit of inflating the membrana tympani

several times a day. A membrane that has been thus treated
becomes very flaccid , and flaps to and fro , at every swallowing
motion, like the sign -board of a country -inn on a windy day.
Siegle's otoscope, a representation of which is here given ,
enables us to form pretty accurate notions of themobility of
the membrane. The air may be exhausted by means of the
FIG . 59 .
Siegle's Speculum .
lips, while the membrane is carefully watched for its move

ment, or a syringe may be used by an assistant for the same
purpose, while the surgeon examines the movements of the
drum -head . Care should be taken that the speculum , as it
should be called , fit accurately in the auditory canal, so that
a real exhaustion of the air may occur. Of course , the oto
scope must be used to examine the drum -head through the
glass ofthe speculum .
CHANGES IN THE EUSTACHIAN TUBE .
Having considered the appearance of the drum -head in

cases of chronic non-suppurative inflammation of the middle
ear, we have next to examine the Eustachian tube and pha
rynx, and note the changes which appear there. At this point
the boundary line may be distinctly drawn between the ca
tarrhal form and the proliferous form of inflammation. In the
former class of cases, the pharynx and Eustachian tube show
marked evidences of morbid action ; while in the latter there
PHARYNGITIS GRANULOSA . 277
are scarcely any changes in the pharynx, and often no very
striking ones in the Eustachian tube. The pharynx, in a true
case of catarrhal inflammation of the middle ear, is found in
one of the following conditions :
There may be great swelling of the pharynx and of the
tonsils, with or without increase in the amount of secretion .
There may be, however, excess of secretion, without any con
siderable swelling. In such cases the patient is usually very
conscious of the trouble in his throat. He may not be
aware of any pharyngeal affection , and yet have a pharynx
that is considerably relaxed and swollen. If these two symp
toms be not present to any marked extent, we usually find
minute round elevations scattered over the surface, or grouped
in an arch under the uvula. These constitute the disease
known as pharyngitis granulosa. The pathological condition
Fig . 60.
Pharyngitis granulosa .
This engraving wasmade from a drawing, by Mr. G . C. Wright , of the pharynx of a young
lady, who had suffered for many years from a chronic suppurative inflammation of the
middle ear ; but it is a fair type of someof the worst cases of granular pharyngitis, as
seen in chronic catarrhul inflammation .
is a stoppage of the secretions, and subsequently hypertrophy

of the structure. This affection is called by some authors
chronic follicular pharyngitis , and its more advanced stages
glandular hypertrophy ; but I prefer the simple nomenclature
of pharyngitis, in the stage of increased secretion and swelling,
278 APPEARANCES OF EUSTACHIAN TUBE .
and granular pharyngitis, when these characteristics of the

inflammation are less prominent, but where the granulations
or hypertrophic glands are very marked in appearance. If
the tonsils are not enlarged, they often exhibit, by a jagged
appearance, the evidence of former disease.
The rhinoscope often exhibits the same condition of themu

cousmembrane about themouths of the Eustachian tube. Dr.
0 . D . Pomeroy * characterizes these appearances as follows,viz.:
“ 1. - Mucus in the mouth of the tube, with or without
greenish or grayish mucus clinging or adherent to the post
nasal septum , and occasionally filling the nares.
“ II. Increased redness in and about the mouth of the
tube, or paleness of the mucous lining of the part.
“ III. - An oedematous condition of the parts near and in
the mouth of the tube, resulting in more or less of swelling .
" The swelling in the region of the tube, the result of
hyperæmia or ædema, may - 1 . So far obliterate the mouth
of the tube as to cause it to appear as a minute dimple , or
obliterate it entirely ; or — 2 Produce so much swelling of the
collar-like surrounding of the tube as to greatly exaggerate it.
3 . Increase the elevation which separates the mouth of the
tube from the fossa of Rosenmüller. 4. Enlarge the posterior
extremities of the middle and inferior turbinated bones, and
produce a malposition in posterior nares, and give it a rough
and uneven outline. 5 . Cause a ring-like swelling around the
tube , rough , red , and of a macerated appearance.
“" IV.
I - Granulations similar to those found in the pharyns
in granular pharyngitis near the mouth of the tube.
« V . - Polypi in the posterior nares, and more frequently
on the turbinated bones .
“ VI. - An apparent diminution in the mobility of the lips
of the tube during contraction of its muscles.
“ VII. - Whitish striæ , indicating cicatricial degeneration of
the proper substance of the mucous membrane in the region
of the Eustachian tube.”
Very many of the patients who suffer from pharyngeal
* Letter to writer.
EUSTACHIAN CATHETER . 279
and naso-pharyngeal inflammation , scarcely speak of it when
asking advice in regard to the disease of the ears, and it is
only on close questioning that they will admit that they
are annoyed by the accumulation of mucus in the throat, caus
ing frequent expectoration, hawking, and the other symptoms
of chronic pharyngeal catarrh . At other times the catarrh , as
they term it, is sthe great burden on their minds, and they talk
freely of the tumphic style, that bolumns of the
freely of the stuffed feeling in the head , and describe their
symptoms in a graphic style,that has been obtained by a dili
gent perusal of the advertising columns of the daily news
papers.
The Eustachian catheter is a very valuable means of diag
nosticating not only the changes in the cavity of the tympanum ,
but also those in the naso-pharyngeal space. In passing this
instrument through the nostrils it should always be used as a
sound, and the condition of this portion of the mucous tract
carefully noted . The inferior meatus is often found swollen
and even granular. In some cases nasal polypi may exist.
The catheters usually employed are of three sizes,* but it will
be found that one still smaller than that usually employed is
needed , not on account always of the swelling or hypertrophy
of the membrane, but of some abnormal position of the sep
tum which renders the canal very narrow and irregular. The
way in which the air passes through the catheter into the tube
is deemed by many as of much importance in the diagnosis
of chronic catarrhal or plastic inflammation . The passage
of a full and strong current almost necessarily precludes
the idea of any considerable change in the calibre of the
Eustachian tube, unless it be atrophy of its tissue. The
mere fact that air can be made to enter the tube, either by
the Valsalvian experiment, the Eustachian catheter, Toyn
bee's or Politzer's method ; in other words, the fact that the
Eustachian tube is open , so that the patient perceives the ful
ness in the ears which shows that a column of air has been
forced against that already in the middle ear, is no evidence
whatever, that the ear is in a healthy condition. In my own
experience, closure of the Eustachian tube is one of the rarest
* Two of the catheters are figured in actual size on page 94.

280 NOYES' EUSTACHIAN CATHETER .
FIG . 61.
of conditions. Imean, by clos
ure, such a state of things, that,
by trial of the catheter and
Politzer's method , the air can
not be made to enter the ear,
The two nostrils often differ
in size very much. This differ
ence is usually due to a devia
tion of the septum to one side
or the other, in consequence
perhaps, of an injury received
when the patient was young,
and the bone was soft . In
GLLEMANN
some very rare cases not

even the smallest catheter
&CONY
that can be made, can be

passed through the nostril of
one side. For such cases the
catheter has usually been
made longer , and introduced
through the opposite nostril;
but Dr. Noyes,* of this city ,
thinks that this method is
not reliable, because by it
the air simply passes " across
the axis of the Eustachian
tube, and if it pass up the
tube at all, it can only do so
after being reflected from the
outer wall of the trumpet ori
fice.”
Dr. Noyes has therefore
modified the catheter usually
employed , by giving the beak
a double curve.
The engraving shows the
exact size and shape of the
instrument invented by Dr.
Noyes' Eustachian Catheter .
NOYES' EUSTACHIAN CATHETER . 281
Noyes. The following are his directions for using it. “ When
introducing the catheter , it is needful to keep the front close
to the septum , as well as to the floor of the nostril. Arrived
at the posterior edge of the septum , the beak should wind
closely around it, curving obliquely across, and turning up
ward , so as to point toward the Eustachian orifice.”
In order to test the permeability of the tubes, the subse
quent examination of the membrana tympani and the patient's
own sensations become important evidences. The membrana
tympani may, however, become reddened by the mere appli
cation of instruments to the externalmeatus, and to the mouth
of the tube, so that we must be careful to exclude such sources
of error,
The diagnostic tube of Toynbee, by means of which we
listen to the sounds of the air passing through the tube up to
the drum -head , is also a valuable assistance in determining
the patency of the tube and the size of the cavity of the tym
panum . * Kramer claims to determine, by the use of the diag
nostic tube, the character of“ exudation " and the width of the
tube. If there is a piercing (durchgehendes), near, rattling,vesi
cular sound , he then diagnosticates the existence of a free exu
dation. If, however, a sonorous, near, vesicular sound , it is
proof that there is no free exudation ; if there is a distant,muf
fled , vesicular sound, then we are dealing with sub -mucous
exudation, which is united to free exudation , and so on. I
only quote these from the last edition of Kramer' s book , to
show to what lengths a man may go in riding a hobby ; for
Kramer's hobby is the diagnosis of the affections of themiddle
ear,by the sounds heard through the diagnostic tube, caused
by blowing through his catheters.
The true value, however, of the diagnostic tube is only in
connection with the other means that have been mentioned ,
the appearance of the membrana tympani, and the patient's
own sensations.
PATHOLOGY.
After the clinical investigations of Kramer and Wilde, the
first great advance that was made in otology were the dissec
* See engraving on page 97.
282 PATHOLOGY.
tions of Toynbee. The museum of preparations illustrative

of diseases of the ear, in London, is a memorial to Joseph
Toynbee, that will be as enduring as scientific truth . From
the time of Toynbee until now , the dissection of ears of those
who were known to be deaf continues ; and from the labors
of Von Tröltsch , Schwartze, Voltolini, Hinton, Gruber, Ome
Green, Moos,* and others, we have verified on the dead bodies
diseases that have been diagnosticated in the living one, or, I
should rather say,we have learned, from the inspection of the
ears of the cadaver, what is probably the condition of ears
in life.
The pathologicalappearances in chronic catarrhal inflam
mation are
1 . Collections of mucus distending the cavity of the tym
panum .
2. Thickened mucous membrane.
3. Filling up of the cavity by lymph .
PATHOLOGY OF PROLIFEROUS INFLAMMATION .

In the form of inflammation that shows a higher formation
than the catarrhal,there are changes which may have resulted
directly from the increase of secretion ; but the stage of
catarrh having completely passed over, or, in some cases,
never having existed, these pathological appearances may
be properly classed together as evidences of what I have ven
tured to designate the proliferous form . They are :
1. Connective-tissue formations in the cavity of the tym
panum .
2 . The mucous membrane of the tube covered by dense
fibrous tissue.
3. Hypertrophy of the bony walls of the tube.
4. Obstruction of the tube and cavity of the tympanum by
dense fibrous tissue.
* A Descriptive Catalogue of Preparations Illustrative of the Diseases of

the Ear. London , 1857. Archiv für Ohrenheilkunde, Bd. I. - V . Monatsschrift
für Ohrenheilkunde. Guy's HospitalReports . Gruber's Lehrbuch . Transac
tions American Otological Society. Moos' Klinik der Ohrenkrankheiten .
PATHOLOGY. 283
5 . The stapes bone completely and firmly anchylosed to

the margin of the fenestra ovalis.
6 . An exostosis on the inner surface of the neck of the
malleus.
7. Malleus and incus anchylosed together.
8 . Firm bands of adhesions in themastoid cells.
9 . False membrane on the tendon of the tensor tympani
muscle .
10. Partial obliteration of the cavity of the tympanum
from adhesions of the membrana tympani to the labyrinth
wall.
11. Hyperostosis of the petrous bone, and anchylosis of
both stapes .
12 . Atrophy and fatty degeneration of the tensor tympani.
These are actual appearances , of individual cases taken
from Toynbee's catalogue and from the writings of the other
authorities whom I have mentioned ; some of them are per
haps consequences of suppurative inflammation , although I
have been careful to exclude all cases in which there was loss
of the membrana tympani, or other positive evidence of a sup
purative process.
Gruber’s * account of the pathology of otitis media hyper
trophica is, that, “ from some cause or other, there is first a
great hyperæmia with distention of the membrane, and in part
the new formation of blood vessels, and increase of the inter
cellular fluid . The connective-tissue corpuscles are increased .
The tissue of the inflamed mucous membrane is less moist
than in the catarrhal form . The new formations or new ele
mentary formations go on to a higher development. The
most various adhesions may occur, or a soft connective sub
stance appears which is either evenly spread over the whole
portion that was originally inflamed , and thus leads to hyper
trophy of the mucous membrane, or it may go on to granular
formation. Many of these new formations may also undergo
regressive metamorphosis — they may undergo molecular dis
integration, become fatty , and be absorbed.”
* Lehrbuch der Ohrenheilkunde, S. 516. Wien , 1870.
284 CAUSES OF INFLAMMATION OF THE MIDDLE EAR .
CAUSES.
I have endeavored, in recording the histories of about
fifteen hundred cases of aural disease observed in private
practice , to give the probable remote and proximate causes.
These are only to be obtained by a strictly -observed system
of cross -questioning, since, by far the greater number of
patients ascribe their disease to causes which are certainly
very remote if not doubtful, and to others which have cer
tainly had no influence. Thus patients will assert that their
loss of hearing results from cold, when they cannot remember
that they ever had a severe cold affecting the ears, but they
conclude that it must have been a cold ; others, again , declare
that their throats have always been well, that they seldom
require to use a handkerchief, and yet an examination will
reveal a bad condition of the naso-pharyngeal mucous mem
brane .
Judging as well as I am able, from my experience in public
as well as private practice, I am disposed to consider the
following as among the most probable causes of chronic non
suppurating inflammation of themiddle ear :
Remote. — 1. A feeble state of the system , due, for exam
ple, to inherited or acquired sypbilis, phthisis pulmonalis , etc.
2. Defective hygienic management, e. g ., neglect of bathing,
want of exercise in the open air, lack of proper food , etc.
Proximate. — 1. Repeated attacks of acute catarrh of the
pharynx and middle ear, a disease popularly known as ear
ache.
2. Naso -pharyngeal inflammation.
3 . Diseases of the lungs and bronchial tubes.
These proximate causes are chiefly to be made out in the
catarrhal form of chronic inflammation , while in the prolifer
ous form , the practitioner is often greatly in doubt, as to what
may have been the origin or exciting cause of the insidious
affection which goes on so steadily to change of structure and
loss of function. Indeed, we are often obliged to be content
to acknowledge the fact of change of structure without being
able to definitely assign a cause for it. Why the changes that
make up a true case of proliferous inflammation , or one of a
CAUSES OF INFLAMMATION OF THE MIDDLE EAR . 285
bastard form in which the proliferous element predominates,

continue to advance in spite of treatment and of proper
hygienic management, is one of the most disheartening pro
blems that a practitioner who treats aural disease attempts to
solve. It is not strange, that cases of insidiously advancing
impairment of hearing, dependent upon illy defined, but posi
tive causes, have excited the minds of physicians to adopt
even what may appear to be fanciful means for their cure.
The history of coryzas and ear-aches , and of chronic sore
throats, is usually distinct enough in chronic catarrhal inflam
mation , and even if there be no such history, then the appear
ances of the pharynx, and the results of tactile investigation
of the tubes, are sufficient to allow us to determine just what
kind of a process has been going on .
It would be interesting to accurately trace the origin of these
proximate causes. We should find, I think, that the most of
them were due to neglect, or improper management ; for exam
ple, the heads of somechildren are oftentimes vigorously washed
without being thoroughly dried ; they are allowed to remain
in water unduly long ; their legs and chests are left uncovered
in weather in which strong men are clad in beaver-cloth, and
women in furs ; they play about the streets, and sit down,
when tired and warm , on the damp and cold stone steps of
city-houses ; they are held thoughtlessly by an open window
on a cold day ; they are warmly clad by day but insufficiently
covered at night ; in short, the temperature of the body is not
properly regulated , and a pharyngeal catarrh passes in an
instant to the tympanic cavity , where it is an acute catarrh.
If the acute catarrh does not go on to suppuration, it is half
recovered from under the use of anodynes applied to the outer
surface of the drum -membrane ; in which a thickening is left
which forms a good basis for a case of gradual and mysterious
middle-ear trouble , and with no known cause. In large towns
where the system of drainage or sewerage is sometimes im
perfect, foul air may be forced back through the water-pipes ,
and becomes a cause, often unsuspected, of catarrhs of the
worst type.
With older people a slight and neglected coryza or pharyn
gitis is followed by a fulness in the ears, that “ will wear
286 CAUSES OF INFLAMMATION OF THE MIDDLE EAR .
away,” and which does wear away in part ; but if it occurs in

persons who have no good hygienic habits in such matters as
bathing, temperance, and so forth , it leaves behind a residuum
of hypersecretion or proliferation, which, as has been said, is
the foundation for repeated attacks, and, finally , of permanent
thickening.
The syphilitic catarrh of infants and young persons, is the
frequent cause of an affection of the middle ear, which , unlike
its frequent companion, interstitial keratitis, is one of the
worst forms of disease in the obstinacy with which it resists
all treatment. The eyes may, and generally do, get well ; but,
if once the tympanic cavities be attacked , intra-auricular adhe
sions occur, themembrana tympani is drawn inward, the nerve
is secondarily involved , and the loss of hearing often becomes
almost complete .
There are no peculiar aural symptoms by which we may
positively distinguish a case of chronic disease of the middle
ear that was caused by syphilis , from one occurring in a non
syphilitic patient. Yet we may say in general, that a syphi
litic diathesis seems to cause the proliferation of tissue to be
more rapid and less amenable to treatment. Schwartze be
lieves that the pathological change in these syphilitic cases is
a periostitis, and this view seems to be correct.
Just bow it is , that pregnant women are so often affected
by a proliferous inflammation of the middle ear, I am unable
to say ; but it is a fact, that many women have told me, that
they traced their impairment of hearing to their first preg
nancy, and that they became worse at the birth of each child .
I am now in the habit of warning such patients that great
attention should be paid to their throat and ears ,by means of
gargles and Politzer's method, during the period of utero -ges
tation. It is the proliferous form of inflammation, and not
the catarrhal, which I haveusually observed during such cases.
The causes given by patients themselves, taken from my
note-book , are as follows : “ Stuffy sensations in the head ;"
" going in the water very frequently ;" " severe colds in the
head ; ” “ when a child , the earswould stop up, and , would not
hear well for a few days.” The first manifestation was “ a
roaring noise heard at night; " " chronic sore-throat ;" " great
CAUSES OF INFLAMMATION OF THE MIDDLE EAR . 287
deal of ear-ache ; " “ all the colds from which I suffer are in
the head ; ” “ excessive grief ;" " a sound like that of locusts
was the first indication of trouble ; " " by accident I discovered
that I could not hear from one ear ; ” “ I have always had a
great deal of sore -throat ; ” “ diphtheria ; " " typhoid fever.”
One patient gave a graphic account of a gradual loss of
hearing from proliferous inflammation, in the following words :
“ Ten years ago I observed that I could not hear the church
bells , and in four or five years it began to be difficult for me
to hear conversation.” Another ludicrously attributed his
chronic catarrh to exercise upon a gymnastic pole. Another
was quite sure that it resulted from great mental anxiety.
These are fair specimens of the causes assigned by the
patients or their friends for cases of the variety of aural
disease now under consideration. Some of them are far
from being true causes, although the most of them may be
admitted as having at least placed the system in such a con
dition that catarrhal disease or proliferation of tissue was
likely to result. It is undoubtedly true, that any great mental
depression may cause an attack of pharyngitis in a person
disposed to it, and that such a long-continued state of mind
will make such an affection incurable .
Wemay, perhaps, sum up our knowledge of the causes of
chronic non -suppurative disease of the middle ear, by stating
that they are such as dispose to inflammation of mucous mem
brane. Our increased knowledge of the pathology of this
tissue, will serve us in good stead in investigating the affec
tions of a part which is thoroughly lined by it.
CHAPTER XIII .
CHRONIC NON - SUPPURATIVE INFLAMMATION OF THE MIDDLE

EAR - CONTINUED.
TREATMENT
At the beginning of the preceding chapter a table was

given, showing at about what time in the history of their dis
ease the patients from whose cases it was made up consulted
the writer. It may be safely asserted, that the most of these
persons never underwentany serious or rational local treatment
until that time ; so that we may assume that the greater number
of persons in the United States who suffer from the form of dis
ease under consideration, are in the habit ofwaiting for a period
of from five to twenty years before they attempt to get relief.
We must certainly diminish the number of these cases
before we can hope for brilliant results. The neglect of aural
therapeutics by the last and the preceding generation now
recoils upon us. Patients come very late for advice about
their ears, because they have been taught, not by the laity,
but by wise and skilful physicians, that it is not prudent to
meddle with the ear ; that they will outgrow its diseases, as
soon as their constitution is invigorated ; if young girls, that,
when themenstrual function comes on , they will be all right, and
so forth , while, during this time of delay, adhesions between
the membrana tympani and the ossicula , and the walls of the
cavity of the tympanum ,have been forming,and hypertrophy of
the mucousmembrane and atrophy of the tendons of the intra
auricular muscles - in short, all the changes that we have
noted previously – have occurred .
In one respect the treatment of the catarrhalmay be fairly
distinguished from that of the proliferous form . In the ca
tarrhal form we must give a greatdeal of attention to the naso
CONSTITUTIONAL TREATMENT. 289
pharyngeal space, while in the other we scarcely need to treat
it. Perhaps we may classify the treatment as follows :
1. Constitutional and hygienic .
2 . Local blood-letting.
3 . Applications to the naso- pharyngeal space (only appli
cable to the catarrhal form of the disease).
4 . Applications to the Eustachian tube.
5. Applications to the cavity of the tympanum .
6 . Cutting operations upon the membrana tympani and the
ossicula.
In the text-books of Wilde and Toynbee (books that have
deservedly had a wide circulation in this country, and have
done much to call attention to the ear) constitutional treat
ment figures very largely in the treatment. The use of mer
cury and iodide of potassium is strongly insisted upon. We,
of the present time, have grown very skeptical about the con
stitutional treatment of such affections as chronic catarrhal,
and proliferous inflammation of the middle ear. No thought
ful practitioner will attempt to disregard the general indica
tions of a cachexia , or of a debilitated system , in which there
is chronic inflammation of the mucousmembrane of the mid
dle ear ; but the time has probably gone by when a person in
fair health , suffering from chronic aural catarrh, and who bas
no constitutional taint, will be treated by alterative doses of
the bichloride of mercury , followed by the iodide of potas
sium . Ample experience has shown that we can do nothing
for these cases by such a treatment, and I may say, that it has
been abandoned in the infirmaries and hospitals, where large
numbers of cases of aural disease are seen. The constitutional
symptoms of the earliest stages of the disease were usually
those of a coryza or acute catarrh ,which finally settled down
into an insidious and chronic process, when it has become
impossible to trace the remote causes.
The causes of these forms of disease suggest a kind of con
stitutional treatment however, which should never be lost sight
of. Everything that will render a patient more vigorous, and
less likely to take cold , will assist materially in curing or alle
viating a chronic aural catarrh . We shall thus find much to
do, in the way of correcting improper habits of life, in regard to
19
290 TREATMENT OF THE PHARYNX.
bathing, exercise in the fresh air, sleeping apparel, and the

like. Hence the Turkish bath ,* sponge-bathing, walking, rid
ing, boat- rowing, the general application of electricity , iron,
and so forth , become prescriptions which the otologist will be
called upon to give very frequently , ifhe properly appreciates
cause and effect. It is only against specific drugs, where there
is no specific diathesis, against a routine system of prescrib
ing a constitutional remedy in the vague hope, that itmay do
good, that I have been speaking .
The use of leeches in some cases of chronic catarrhal
inflammations that have sub -acute tendencies, is occasionally
of value, although they give no such marked relief as that
which is experienced in acute inflammation. When there are
marked symptoms of congestion, such as fulness and slight
pain , a leech may be applied on the tragus once a week, for
four or five weeks.
TREATMENT OF THE PHARYNX
The treatment of the pharynx may be classified as follows :
1. Injections of the naso -pharyngeal space.
2 . Gargling.
3. Cauterizations.
FIG . 62.
OTTO & REYNDERS.N.Y.
Injections of the naso-pharyngeal cavity by means of the

naso-pharyngeal syringe, I have found very valuable in the
treatment of chronic catarrhal inflammation . The solutions I
use are common salt, permanganate of potash, gr. ß ad 3j, a
saturated solution of chlorate of potash , tar-water, etc . Great
masses of muco-purulent material are often dislodged by this
treatment, even in cases where ordinary inspection does not
show that any has collected . The nasal douche is very fre
quently used for the purpose of cleansing the naso-pharyngeal
* The Turkish bath is one of the best means of keeping the circulation so
equable that catarrhs do not readily occur. It is not a good plan , however, to
allow the head to be wet, during the shampooing process that follows the hot
air bath , neither should patients disposed to aural disease , take the cold plunge
which is often given at the termination of the whole process.
TREATMENT OF THE PHARYNX. 291
space,but it is a means of treatment that is attended with con
siderable danger to the ear, even when all proper precautions
are taken.
The posterior nares syringe is made of hard rubber. It is
a very efficient and safe means of cleansing the pharynx and
nostrils. In cases of acute inflammation of the pharynx at
tended with considerable swelling, it should be used with care ,
or it will abrade and irritate the mucous membrane of the
posterior pharyngeal wall. This abrasion may then lead to
an extension of the inflammation along the tube, to the tym
panic cavity. In chronic cases I have never seen or heard of
any harm being done by the posterior nares syringe.
Dr. Warner, of Ohio , uses an air -bag as the means of forc
ing the fluid through the curved tube, and gives the instrument,
instead of the nasal douche, into the hands of the patient. It
is , however, a rather dangerous plan to trust an operative or
mechanical treatment, such as introducing an instrument be
hind the uvula, to a patient, where it is possible to avoid it.
THE NASAL DOUCHE.
The author has published several cases that illustrate the
dangerous consequences thatmay result to the ear from the
use of the nasal douche. The appliance is, however, so con
venient of application, and it is thought to be so thorough in
its work of cleansing the nostrils and pharynx, that the pro
fession are very loth to abandon it. I am of the opinion, how
ever , that its use should be discountenanced by the profession .
Various criticisms have been made upon the published cases
of injury to the ear from the use of the douche, but I believe
that they have been fully met, and that most of the otologists
on this side of the water, are agreed that the nasal douche,
even when employed with all proper precautions, has produced
serious aural symptoms in quite a large number of cases.
The harmful results are probably due to the entrance of a
large quantity of fluid , in a flood , as it were, into the cavity
of the tympanum along the Eustachian tube, and necessarily
in a direction contrary to the motion of its ciliated epithelium .
The use of the nasal douche was first suggested by Pro
fessor Theodore Weber, of Halle, Germany, and is based upon
a physiological fact that was first promulgated by Dr. E. H .
292 NASAL DOUCHE.
Weber, of Leipsic, in 1847. This fact is, that when one side
of the nasal cavity is entirely filled with fluid by hydro
static pressure , while the patient is breathing through the
mouth , the soft palate completely shuts off the superior
naso -pharyngeal space from the mouth , and does not permit
any of the fluid to pass downwards. The fluid then passes
into the opposite nasal cavity, and escapes through the nos
tril. Prof . Theodore Weber suggested the use of a cup to the
bottom of which was attached a bit of rubber tubing, for the
purpose of taking advantage of this physiological principle.
Such an apparatus is figured on page 124, and is now very
much used under the name of Clarke's aural douche for the
purpose of cleansing the meatus and stilling pain in the ear.
Dr. J. L. W . Thudichum brought this apparatus to the notice
of the English -speaking profession,* and made it more con
venient, so that in America it has acquired the name of.Dr.
Thudichum . It should , however, be called Weber's douche.
As early as 1869, I had found that the nasal douche was
sometimes a troublesome and dangerous appliance, and I
added a note to indicate this, in my translation of Von Tröltsch
on the Ear (second edition , page 369) ; but I was not fully
convinced that it would readily cause acute aural inflamma
tion , until the following case occurred in my practice . The
case has been amplified from the first record that appeared,t
in order to avoid the reiteration ofexplanations,that the criti
cisms upon the case in the Monatsschrift für Ohrenheilkunde,
and by Professor Elsberg of this city , compelled me to make.
Case of Otitis Media Purulenta ,and Pyæmia, from the Use of the Nasal
Douche. On the 12th of December, 1868, I was consulted by a clergyman, forty
nine years of age , in regard to a sub -acute catarrh of themiddle ear, affecting
both sides of the head. The history of the patient was as follows: Some years
before, he was attacked with what seemed to be hay fever, or a form of coryza
attacking certain persons during the summer. This coryza became a chronic
catarrhal inflammation of the naso-pharyngeal space,attended by the usual
symptoms - a sense of stuffiness of the nostrils, frequent expectoration of glairy
mucus,sneezing , and so forth . For the past two months the patient has been in
the daily habit of using Weber's nasal douche, for the purpose of cleansing the
nostrils and of introducing remedial agents into them . He had once before
* On Polypus in the Nose and Ozcena. London, 1869. Lancet, Nov. 24,
1864.
Archives of Ophthalmology and Otology , Bd. I.
NASAL DOUCHE. 293
tried this means of treatment, but it had caused so much unpleasant feelings
in the ears that he was obliged to desist from employing it. A warmer solu
tion was always used in the douche, and it was employed under the direction
of a physician who was probably well aware of Dr. Thudichum 's directions,
and took all the precautions which he advises in his pamphlet. This fact is
mentioned, because the advocates of the douche claim that it never does harm
when properly employed . Dr. Thudichum advises that a solution of salt and
water, or milk and water,but never pure water, should be used, as did Profes
sor Weber some time before . The patient was also instructed to breathe
through the mouth , and Dr. Thudichum observed that very often patients
became confused ,struggled, breathed through the nose, and defeated the plan .
It is during this excitement, that the accident of entrance of fluid into the ear
seems usually to occur. For about two weeks these unpleasant sensations on
using the douche have been again experienced. The patient complains ofbeing
deaf, and of having a full sensation in both ears, almost amounting to pain .
The membrana tympani of each side is found to be reddened . An crdinary
ticking watch , heard by a person with normal hearing power about six feet, is
only heard when placed in contact with the auricle of each side. A leech was
applied to each ear on the tragus, the Eustachian tubes were rendered pervious
by means of the catheter and Politzer's method . In a few days the membrana
tympani assumed a normal appearance, and the hearing was restored by means
of this treatment. The patient then desired that an attempt should be made
to relieve the trouble in the naso-pharyngeal region . The uvula and topsils
were relaxed , the whole mucous menubrane of the upper pharyngeal space
secreted excessively, and the patient had contracted a habit of constantly
endeavoring to clear his nostrils. Fluids passed through the left nostril, but
none through the right. The Eustachian catheter, however, passed without
difficulty . The nostrils were cleansed by means of a nebulizer, salt and water
being used in it , after which the parts were swabbed out with a solution of
arg. nit. gr. x. ad 3j. The patient improved under this treatment until Jan .
28, when he was for some time exposed to the air of a winter's day, with the
head uncovered (at the consecration of a bishop ), when the symptoms, which
had been to a certain extent relieved , returned .
Jan. 31, a gelatinous mass was found plugging up the inferiormeatusofthe
right nostril, seeming to be attached to the floor of the canal. Portions of this
were removed by torsion, at intervals ofaboutthree days, until Saturday,Feb.6,
when what seemed to be the remainder of this growth was removed . The
patient left the office, saying that his nostrilwasmuch clearer, and wentto Yon
kers, a city about fifteen miles by rail from New York . There he again used the
nasaldouche,and again experienced a decidedly unpleasantsensation in his ears,
which , however, did not amount to pain . On Sunday morning and evening
the patient performed his clerical duties, but with a great sense of languor and
uneasiness. On Sunday night, Feb. 7th, at about eleven o'clock ,he was awak
ened by a severe pain in themastoid region of the right ear,which kept him
from sleep. I saw him Monday morning,at about eight o'clock , and noted the
following symptoms: The countenance was anxious and flushed , the skin hot,
pulse about ninety-six , right mastoid region red and sensitive, right mem
brana tympani reddened , watch only heard when pressed upon the auricle.
The patient was asked as to the condition of the left ear ; but he said there
294 NASAL DOUCHE.
was no trouble there . An examination of the tragusand mastoid process failed
to exhibit any symptoms of inflammation in that ear. Two leeches were
ordered to be applied to the mastoid process ,and the patient was to take aq.
acetat. amm. At five P.M ., the pain in the ear had entirely ceased after the
application of the leeches. The patient was breathing hurriedly, however,
his pulse was weak and frequent- about ninety -six - and he complained of
pain and tenderness in the abdominal region . Morph . sulph . gr. b, was
ordered to be taken pro re nata , and a poultice was applied over the abdomen.
Tuesday, Feb. 7. The patient took two powders of morphine, and passed quite
a comfortable night. This morning he complains of pain in the forehead , but
has none in any other part of the body. The surface of the body is dry and
hot. Ordered aq. acetat. ammon , and nutritious diet. Feb. 8 . Last night the
patient was attacked by a severe pain and swelling of the left foot, and at
about half-past seven A.M . he had a severe chill, lasting about fifteen minutes,
not followed by sweating. At about this time a discharge appeared from the
left ear. There has been no pain experienced in this part. He has not slept
well, and his general appearance is bad . Countenance anxious. Breathing
labored . Pulse about 96 . The left ankle and dorsal region of foot are red ,
greatly swollen , and tender. Left membrana tympani ulcerated and discharg
ing freely.
Dr. Foster Swift, of this city , was called in consultation, and the following
treatment agreed upon : The foot was wrapped in an alkaline lotion . Vichy
water was given ad libitum , with beef-tea and wine ; morphine pro re nata.
Feb. 9. Patient does notseem so well. Respiration is hurried . The intellect
is somewhat clouded . Pulse about the same. Face of a sallow hue. The
stimulants are increased ,so that he now takes half an ounce ofbrandy in milk
punch every four hours, day and night. Quin . sulph . gr. ii., every four hours.
The left ear is syringed with lukewarm water, zinc. sulph . applied, and Polit
zer's method used to inflate the drums. The patient is so deaf that he only
hears when spoken to near the ear.
The patient was treated in this manner, until Feb . 22d , the brandy punch
being steadily increased until be was taking two ounces every four hours .
with beef-tea, eggs, etc. His pulse was never over 100, usually about 96 ; the
skin had a saffron hue, and patient lay in a doze, except when the pain from
his foot kept him awake nearly the whole time.
Dr. George A . Peters, Surgeon to the New York Hospital, was called in
consultation a few days ago, in addition to Dr. Swift and myself, and to -day
two openings were made in the foot, one near the internal, and one near the
externalmalleolus. Pus was evacuated. The dorsal region of the foot was
very much swollen , but no fluctuation was detected . The patient's general
condition is now better ; his countenance less anxious ; the respiration is not
so hurried. The urine was several times carefully examined during the treat
ment. No abnormal condition was found, beyond an acid reaction early in the
course of the disease. The heart was also examined , and no organic changes
were found. Several openings were made in the foot from time to time ;
but the patient slowly improved from this time until March 16th , when
he was able to sit up . The membrana tympani healed, and the hearing dis
tance became about one foot on the right side, and four to six inches on the
left. Conversation is heard with ease. Politzer's method has been practised
NASAL DOUCHE . 295
every two days. Quinine and iron have been taken in addition to the stimu
lants. The foot is still swelled , but all the openings but two have healed .
April 4 . The patient has been going about the house for a week . Hearing
power is still further improved. A little erysipelatous soreness of the foot
occurred last night. The naso - pharyngeal catarrh is completely gone. April 7 .
Patient rode out to-day, and gets about the house , employing himself in intel
lectual labor. Tissues of the foot still swelled and rigid ; motions of the ankle
joint unimpaired.
1873. I am in the habit of seeing this patient quite often . He is now in
excellent health , but a very little lame from the inflammation of the foot.
My friend , Professor Elsberg, of this city , published a paper *
in which he claimed that an analysis of the cases that had been
published, of harm to the ear from the use of the douche, showed
that the cause wasuncertain . Dr. Elsberg has had a large expe
rience in treating diseases of the pharynx, and although hehas
prescribed and employed the douche in more than 1600 cases,
he has seen none of the results that Ihave observed. I can only
explain this by the presumption, that when an accident to the
ear occurs, the patients are more aptto consult a person who is
in the constant habit of treating auraldisease than to go on with
the treatmentof the nasal catarrh . Besides, as it is believed by
many otologists, it is possible that the douche sets up a chronic
inflammation of the tympanic cavity , without any acute stage,
and thus the true cause of an insidious chronic catarrh is
passed over and supposed to be an advance of the naso-pha
ryngeal inflammation. Of course it is not believed by the
author that the use of the nasal douche will necessarily cause
aural disease, but that it is a dangerous means of treatment,
which should be carefully watched by the practitioner.
I append, from a paper previously published ,an analysis of
cases in which serious results bave occurred.t Were it expe
dient to further extend the discussion of this subject, I could
add several more, for I am constantly hearing of them from
my professional friends, and seeing them in my own practice.
While preparing this chapter for the press, I am treating daily
a patient suffering from suppuration of the middle ear, that
was caused by the use of the douche.I
* Archives of Ophthalmology and Otology, vol. ii., p. 77.
+ L . C , vol. iii., No. 1.
The famous Cheselden mentions the fact, that syringing the nose when
the Eustachian tube is open , sometimes causes deafness .
296 NASAL DOUCHE.
ANALYSIS OF REPORTED CASES OF INJURY TO THE EAR FROM
THE USE OF THE NASAL DOUCHE.
PATIENT. INSTRUCTOR * IN FloID USED. EAR DISEASE PRO
USE OF DOUCHE. DUCED .
Case I. Rev. Dr. C. A physician. A ofwarm solution Acuta

carbolic acid .
otitis media
suppurativa. Pya
mia. Recovery,
2 Dr. Frank + Dr. Frank . Cold water, which Acute otitis media .
he advises in all Recovery.
cases.
“ 3. Mr. D . Dr.Roosa. Warm solution of Perforation of both
salt and water. I membrane
mi. Recovery.tymps
" 4. First of Dr. C. | A physician.
I. Pardee'st
Warm solution
salt and water.of Otitis media suppura
tiva . Necrosis of
cases . middle ear. Per
manent deafness .
" 5. Second of Par-
dee'e cases . A physician.
Salt and water. Acute otitis media.
Recovery.
Medical student.
" 6. A Physician. A physician. Unstated. Otitis media suppura
tiva chronica.
" 7. Patient at Man - | Unknown.
hattan Eye and
Unknown Otitis media acuta .
Recovered
Ear Hospital.
• 8. Mrs. C.
Dr. Mathewson 's A physician. Warm fluide. Otitis media acuta.
case.
Recovered .
“ 9. Dr.caseHackley's Unknown. Warm salt water. Otitismedia suppura
tiva chronicaon , old
su
.
pervening
perforations.
“ 10. Dr.case.Piffard'ss Unknown. Warm fluids. Otitis media
Recovery . acuta.
“ 11. Judge — A physician Unknown. “ Deafness." Recov .
ery.
“ 12. Dr.caseLoring's! A physician . Warm fluid. Otitis media suppura
. tiva chronica
13. Physician
Dr.Mathewson 's A physician . Uustated . Otitis
Recovemedia
ry . acuta.
second case.
“ 14. Dr.Mathewson
Physician . 's A physician. Unstated. Otitismedia subacuta.
third case .
* 15. Physician. A physician. Warm salt water. Fainting and otitis
media catarrhalis.
“ 16. Dr.roy's . Pome- | Dr. Pomeroy.
O . Dcase. Warm salt water. Otitis
tiva .
media suppura
that• noTheharm
instructor
occurs iswhen
givenit isin properly
order to meet the point
employed . made by the advocates ofthe douche,
+ Archiv für Ohrenheilkunde,
TheMedicalGazette, Bd. V .,23.p. MedicalRecord
vol. vi.,No. 202. , Feb. 1, 1870.
$ Reported by Dr. Pardee, I. c. Verbal report to writer.
S Reported in Archives for Ophthalmology and Otology, vol iii.. No . 2 .
Dr. Pardee, in his paper in the Medical Gazette , claimsthat thedouche is an inefficient, as
well as dangerous instrument. He does not think that the conformation of the nasal pas
sages allows of their being cleansed by such a flood ofwater as comes from the douche.
GRUBER ' S METHOD. 297
GRUBER ' S METHOD .

Gruber adopts a method of cleansing and medicating the
naso -pharyngeal space , for which he claims superiority over the
naso-pharyngeal syringe and the nasal douche. Dr. Gruber
also claims that his method of treatment was promulgated a
year before the nasal douchewas introduced to the profession
that is, in 1863, at a meeting of the medical profession in
Vienna. But Gruber spoke of his method only with reference
to aural disease, while Weber's nasal douche was recommended
as a means of treating the nares. Gruber's method consists in
the use of a two -ounce hard rubber aural syringe, the nozzle of
which is well rounded off, in the following way : The syringe
is filled with the fluid to be injected and placed in one nostril.
The fluid is then forced with more or less vigor into the nos
tril, the other being closed with the finger , if the operator
desires to inject the Eustachian tubes, but left open if the
intention be to simply inject the naso -pharyngeal space . “ In
the force with which I empty the syringe, in the more or less
perfect closure of the other nasal meatus, are found the fac
tors which more or less favor the entrance of fluids through
the tubes. The latter effect may also be increased , after the
syringe is removed , by causing the patient to perform the
Valsalvian experiment.” *
Gruber believes that it is the root of the tongue, as well as
the soft palate , that by instinctive contraction and lifting up
wards shuts off the superior from the inferior pharyngeal
space, and prevents fluids injected by the nasal douche or by
his method from passing downward. This statement is proved
by the fact that when the soft palate is destroyed by ulcera
tion, the fluid may be made to pass out of the other nostril,
as well as if the palate were sound.
Gruber deprecates much instruction to the patient as to
how he shall breathe or hold his palate during the injection
of the fluid , but he prefers to leave him to his own instincts .
A fluid should be used which will do no harm if some of it
pass into the stomach .
* Monatsschrift für Ohrenheilkunde, Jahrgang VI., No. 4 .

298 GRUBER ON THE NASAL DOUCHE.
Dr. Gruber fully corroborates my views that the harmful

effects of the nasal douche are due to the entrance of the
fluid into the middle ear, and he shows that however proper
it may be to intentionally, inject fluid in small quantities into a
diseased cavity of the tympanum , it is manifestly incorrect to
force it into an ear that was previously healthy, with no restric
tion as to quantity , as is done in the use of the nasal douche.
“ The current from the nasal douche is continuous, even
when the cavity of the tympanum is already full ; the fluid in
the pharynx attempts more and more to enter into the middle
ear, and when the pressure is very great, rupture of the mem
brana tympani may occur. I have often seen ecchymoses
on the membrana tympani, that were caused by the nasal
douche.” *
FIG . 63.
net
Nebulizer for Pharynx .
I am very glad to have the views which I first brought

before the profession , thus endorsed by so high authority as
Professor Gruber . It is to be hoped that the method of
anterior syringing, and the use of the posterior nares syringe,
may finally supplant the nasal douche.
The solutions that may be used with benefit as gargles are,
of course, very numerous. The gargle that I most frequently
prescribe is a saturated solution of chlorate of potash . Where
there ismuch granular pharyngitis,a gargle containing iodine,
will probably be more efficacious. I am in the habit of ad
vising patients suffering from chronic disease of the middle
car, suppurative or non -suppurative, to use a gargle of cold
* Gruber, 1. C., No. 8 .
CAUTERIZATION OF MOUTH OF EUSTACHIAN TUBE. 299
water, by Von Tröltsch's method, as long as they live. The

gymnastic exercise of themuscles of the Eustachian tube, is
by no means an unimportantmeans of treatment.
Gargling is a very efficientmeans of cleansing the pharynx,
if it be performed in the manner advised by Von Tröltsch.
The fluid is held in the back part of the mouth , the head
being thrown well back, the nostrils closed by the fingers, and
then the motion of swallowing is performed . With a little
practice, the patient will become very proficient in thismethod.
Those who are skeptical as to the virtue of gargling , and who
claim that the process does not cause the fluid to wash the
pharynx, will be convinced of the contrary by the following
simple experiment: Let the posterior wall of the pharynx
be painted with the tincture of iodine, and then a gargle of
starch -water be used in the manner described , and the charac
teristic reaction will be found in the ejected fluid .
FIG. 64.
ELYNDERS
OTTO-
Pomeroy's Faucial Catheter .
Cauterization of the mouths of the Eustachian tubes, and

of the posterior pharyngeal wall, is ofgreat value in the treat
ment of catarrh of the middle ear. Nitrate of silver in solutions
of from 20 to 100 grains to the ounce of water , is the agent
chiefly to be employed . It should always be used by a nebu
lizing apparatus, in preference to a probang, although where
the granulations are well defined, the individual elevations
may be pencilled with the solutions.
These applications are not very unpleasant, and they are
300 FAUCIAL CATHETERS.
certainly very efficient in diminishing secretion, and in chang

ing the character of tissue. The use of the solid stick is very
unpleasant to the patient, and is, I think, to be avoided .
Dr. O . D . Pomeroy, of this city, who has done much to intro
duce the nitrate of silver treatment of the pharynx in aural
disease, uses a peculiar instrument for making applications to
the mouth of the tube, and for inflating the cavity of the tym
panum .* Although Dr. Pomeroy names his apparatus a fau
cial catheter, I am inclined to think that its chief value is as a
means of making applications to the mouth of the tube, and
not of inflating the middle ear.
The instrument consists of a hard rubber tube, seven and a
half inches in length . Its breadth at its proximal extremity is
one- fourth of an inch , but it lessens towards the beak , which
is a little more than one-eighth of an inch in thickness. The
proximal extremity has a lip for the adjustment of a rubber
tube. At about an inch and a half from this is a perpendicu
lar guide, placed in an opposite direction to the beak of the
instrument. This guide serves to show the direction of the
beak of the instrument when in position . The curved portion
of the tube is one inch and three-sixteenths in length. At a
line or a line and a half from the end of the beak, is an aper
ture of the caliber of a No. 1 Bowman's probe, for the injec
tion of air or fluids. This aperture is so placed, as seen in
the cut on the previous page, as to cause the air or fluid to
be thrown from the operator, or in the axis of the Eustachian
tube. Air is injected into the mouth of the tube by simply
compressing the air-bag, when the catheter is in position.
Fluids, of which a drop or two are sucked up at each applica
tion into the beak of the instrument, are forced into the tube,
in the form of a fine spray.
Dr. Pomeroy thinks that the use of this instrument is ordi
narily simpler than the employment of Politzer's method ; but
in this view I cannot coincide — and as a catheter, I hardly think
it will take the place of an instrument introduced through the
nose. The verdict of the profession has hitherto been for the
method of Cleland, as against that of Guyot, and none of the
* Transactions of American Otological Society, 1872 .

TREATMENT OF EUSTACHIAN TUBE . 301
faucial instruments have, as yet, reversed this judgment. The

faucial catheter of Dr. Cutter,* ingenious as it is, will hardly
supersede the catheter in ordinary use, which is, as bas been
demonstrated, an efficient instrument, and one that in ninety
nine cases out of a hundred is readily introduced, and with no
" guess -work ," as has been said , but with an exact knowledge
of its position .
Solutions of sulphate of zinc, of alum , sesquichloride of
iron, and so on, in weak solutions, may be used with advan
tage by the patient himself during the treatment of naso
pharyngeal inflammation. They are most efficient when used
in one of the nebalizers that are now so largely employed in
the treatment of the throat. — (See Fig . 63.)
THE TREATMENT OF THE EUSTACHIAN TUBE.
Among the means employed in the treatment of the Eus
tachian tube, the use of the Eustachian catheter stands pre
eminent. It is difficult to say whether we treat the tube
or the cavity to which it leads by the means of this in
strument. We may often very much improve the hearing
power of a patient by the introduction of the instrument be
tween the lips of the tube, even when no air, vapor, or fluid ,
is passed through it. After such a procedure it is much
more easy to inflate the ear by Politzer's method. Some have
rather hastily, as it seems to me, concluded that all, or the
greater part of the effect produced by the catheter, might be
had by applications to the mouth of the tube, and have dis
carded the catheter ; but I become more and more convinced
after ten years of pretty steady experience in its use, that the
Eustachian catheter is essential in the treatment of chronic
non-suppurative inflammation of the middle ear. The agents
to be introduced through it are :
Atmospheric air ,
Vapors,
Fluids,
Bougies,
Electricity .
* American Journal of the Medical Sciences, April, 1872.
302 ATMOSPHERIC AIR — VAPORS.
I have placed common atmospheric air first, because I re

gard it as themost important of the agents to be employed .
It is, however, not so efficient in chronic as in sub-acute or
acute aural catarrh , where its effects are almost magical. In
fact, it may be claimed, that there are no idiopathic affections
for which relief is so immediately obtained as acute catarrhal
inflammation of the middle ear ,where inflationsof the tympanic
cavity with simple air are often sufficientto cause a patient, for
whom the world of sound is again open , to shed tears of joy.
Among the vapors employed , I attach most importance to
the vapor of water - steam - an old remedy, but one which had
most undeservedly fallen into disuse in this country, until it
was again employed by myself.
Dr C . I. Pardee* has published a paper, in which he has
carefully noted the results of six cases of the most obdurate
variety of non -suppurative disease of the middle -ear, and in all
of these there was marked improvement, both in the hearing
distance and in respect to the tinnitus aurium , by the use
of steam through the catheter. Dr. Pardee deduced from his
cases the práctical lesson , that in the treatment of the disease
of the tympanic cavity, its condition of moisture or dryness
should be considered , and that when dryness exists , our thera
peutic efforts should tend to re-establish the normal secretion .
I am in full accord with Dr. Pardee's proposition, and
I do not therefore use the vapor of water in the strictly
catarrhal cases, but in the proliferous inflammation, where
adhesions exist, with rigidity and hypertrophy of the mucous
membrane.
The apparatus required for the injection of steam into the
cavity of the tympanum , consists of the following appliances :
1 . An apparatus for generating the vapor.
A nickel-plated copper flask is the best for this purpose,
although a glass flask used over a sand -bath will do very well.
The only objection to the glass flask is, that the fame may
leap beyond the level of the water in the flask , and break it,
as has often occurred to me. Two glass tubes are placed in
the cork , and a very minute opening for the escape of steam .

STEAM . 303
A piece of flexible rubber tubing is placed over each of the
glass tubes. In the free end of one of the tubes is a nozzle
adapted to the Eustachian catheter ; in the other a tip adapted
to an ordinary air -bag.
2 . A hard-rubber Eustachian catheter. A metallic instru
ment cannot be used , on account of its becoming too hot to be
borne. Many practitioners keep the catheter in place by a
Fig . 65.
Apparatus for Steaming the Middle Ear.
holder; but I always employmy fingers for that purpose. Dr.

Pardee gives the following account of the method of forcing
the steam into the catheter, a method which I have found
important to be observed in detail. The steam may be gener
ated by a gas-burner, as depicted in the cut, or by an alcohol
lamp. I prefer the former.
“ The catheter should be placed in themouth of the Eusta
chian tube, and retained in position by the catheter-holder ;
then the small nozzle of the steam apparatus being in the
outer end of the catheter, steam can be forced to the middle
ear by sharp pressure on the air-bag. If the pressure on the
304 USE OF FLUIDS THROUGH THE TUBE .
air -bag is slow , the prolonged contact of the steam is likely to

be unpleasantly felt by the patient, and there is some danger
that it may escape into the pharynx and provoke inflamma
tion there. On the other hand, if it be applied by sudden,
sharp pressure, and the nozzle removed from the catheter after
each puff, no inconvenience is ever felt, and there is no possi
ble danger of exciting inflammatory action in the pharynx."
FLUIDS.
After all the experiments to determine whether duids

forced into the tube through the catheter actually reach
the cavity of the tympanum , it is, I believe, pretty conclu
sively settled that they do, and they may have a decided effect
upon the lining membrane of this part.
Wreden's experiments make it somewhat doubtful,whether
a few drops of fluid, injected through the Eustachian catheter,
actually reach the cavity of the tympanum . All the experi
ments that have been made agree, however, in one fact, that
where a large quantity of fluid is injected en masse, it reaches
the cavity of the tympanum . The usual method of injecting
a fluid into the mouth or caliber of the Eustachian tube is the
following : The Eustachian catheter is introduced in the usual
way, the patient having previously taken a little water in his
mouth . A drop or two of the fluid to be injected is then
placed in the nozzle of the catheter, and at the moment the
patient swallows, it is forced into the tube by an air-bag.
Dr. F . E . Weber , of Berlin , has invented an instrument for
spraying the tube and the tympanic cavity . He calls his
apparatus the “ pbarmaco-koniantron .” It consists essen
tially of a long and flexible Eustachian catheter, which is
passed into the tube as far as the junction of the cartilaginons
with the osseous portion. It is perforated laterally about
1 mm . from its beak , and it is introduced through an ordinary
metallic catheter. The fluid is forced through the lateral
opening in the form of spray, by means of an air-bag attached
laterally to the tube of a small syringe. The fluid to be used
is first driven by the syringe into the nozzle of the catheter,
and then forced forward by the air -bag.
USE OF FLUIDS THROUGH THE TUBE . 305
As has been intimated , Dr. Wreden * does not believe, that

drops of fluid injected in the manner that has been described
through a tubal catheter, reach the cavity of the tympanum ,
but that they pass only to the osseous part of the tube. He
does not deny that injections en masse will reach the cavity of
the tympanum , but he thinks such injections dangerous.
Wreden advises the use of the tympanic catheter— that is,
a catheter that passes beyond the isthmus of the tube , as a
vehicle for introducing drops of fluid into the middle ear.
After the tubal catheter, through which the tympanic one is
passed , is in position and fastened by means of a forehead
band , and the permeability of the tube has been ascertained
by the use of a probe 1.4mm . in thickness, the operator drops
five drops of the solution to be used upon a watch crystal or
other convenient receptacle, draws it up into the catheter and
inserts the instrument as far as the tympanic orifice of the tube.
The drops are then forced into the middle ear by the mouth .
Sensations of fulness in the ear, and an increase of the impair
ment of bearing, usually occur, but they pass off in from 6 to 12
hours. In about 48 hours the beneficial effect should be seen .
Wreden uses the following named agents through the tym
panic catheter, and he insists that the maximal doses should
not be exceeded , lest acute inflammation be excited.
1. Fused caustic potash , one-quarter to one-half grain to
the ounce of water.
2. Liquor potassæ , three to five drops to the ounce of
water.
3 . Concentrated acetic acid , two to three grains to the
ounce of water.
4 . Pure iodine, one- eighth to one-quarter of a grain to the
ounce of a half-per cent. solution of iodine.
5 . Corrosive sublimate of mercury, one-twelfth to one
eighth of a grain to the ounce ofwater.
6 . Nitrate of silver, one- quarter to one grain to the ounce
of water.
7. Sulphate of copper, one-quarter to one grain to the
ounce.
* Separat-abdruck aus der St.Petersburger medicinischen Zeitschrift N . F .
Bd. I. 1871.
20
306 FLUIDS THROUGH EUSTACHIAN TUBE .
8. Sulphate of zinc, one to two grains to the ounce.

9 . Iodide of potassium , two to five grains to the ounce.
10. Sulphate of atropine, one-half to one grain to the
drachm of water.
11. Hydrate of chloral, one to two grains to the ounce of
water.
Wreden uses these agents through the tympanic catheter,
chiefly in the proliferous form of inflammation of the middle
ear. These injections are made every third or fourth day, for
from fifteen to twenty days, and although it is not claimed
that the results are brilliant, they are well worthy of a trial
where all the ordinary means by a tubal catheter have failed.
In chronic catarrhal inflammation the agents named last
on the list are also used, but the caustic applications are
only applied to the cases of proliferous inflammation — the
cases classed under the head of sclerosis by Van Tröltsch .
Kramer was perhaps the first to use the tympanic cathe
ter to any great extent, and bis instrument is essentially the
one that Wreden employs. It is a hard -rubber catheter, made
long enough to reach the tympanic orifice, and is passed into
the tube through an ordinary tubal catheter.
Bishop, of London , invented a nebulizer for the faucial
mouth of the Eustachian tube ; but it was a very inconvenient
instrument, and never came into general use .
Dr. C . E . Hackley's instrument will be found a more effi
cient means of spraying the tube. Dr. Hackley's apparatus
consists of an air -bag, an Eustachian catheter, with a hard
rubber nozzle to fit in its mouth , a piece of rubber tubing, and
a hypodermic syringe.*
“ The nozzle of the air-bag is inserted into one end of the
rubber tube, the tip to fit in the catheter being placed in the
other end. The hypodermic syringe is filled with the liquid
to be employed, then its point passed through the tube and
out through the caliber of the hard -rubber tip for the catheter,
as shown in the cut."
“ The mouth of the Eustachian catheter B being fitted over
the hard -rubber tip A , and held there , if sudden pressure is
* Medical Record ,No. 134.

EUSTACHIAN NEBULIZER . 307
made on the air-bag, while the piston of the syringe is forced
home, the liquid will be thrown through the catheter in the
form of spray.
“ In using this apparatus for the treatment of diseases of
the ear, the catheter should be carefully introduced through
the nose, and placed in position. Then , while the diagnostic
tube is placed in the ear, the hard -rubber tip should be in
serted in the catheter, and air alone forced through to deter
FIG. 66.
DU
NL
II
T
Hackley': Eustachian Nebulizer.

mine whether the catheter be properly in position . If found
to be so, the piston may be pressed on at the same time that
air is forced through. During this experiment the catheter
may be held in position by clamps for that purpose, ormay
be held by the fore and middle fingers of the left hand, while
the thumb of the same hand presses on the piston , the other
hand being used to work the air-bag."
It is well to have a small round opening made in the air
308 POLITZER 'S METHOD .
bag, as at C ; while the air is being forced out this may be

closed by the finger, which then being removed, the air -bag
quickly fills again.
Itmay be said in general terms that the use of spray of
astringent fluids to the Eustachian tube, is chiefly of value in
those cases in which the evidences of catarrh, or increased
secretion, are strongly marked, while fluids are to be em
ployed in the tympanic cavity , when there is marked evi
dence of the predominance of the proliferous form of disease.
The injections of simple air , or of medicated vapors, in
what may be called the mild cases of catarrhal inflammation,
will be found quite as efficacious as fluids or spray. As has
been already mentioned , steam is chiefly applicable to cases
of proliferous inflammation.
I am in the habit of employing Politzer's method of inflat
ing the drum -cavity, immediately after the use of the Eusta
chian catheter, in all cases of chronic disease of the middle
ear, but I cannot believe that it is a substitute for the catheter .
It is very often found that no impression can be made upon
the tube or middle ears by the use of Politzer's method alone,
but after the catheter has been once passed into the mouth of
the tube, and some muscular spasm set up in the abductor
and dilator of the opening, that this means of treatment be
comes effectual at once. It is not well, however, to place the
air-bag in the hands of the patient and advise him to use it.
Such advice will usually be over-regarded, and , instead of
inflating the ears every other day , it will be done every hour
perhaps. Besides , patients are often very unsuccessful in
their attempts to drive air into the ears. Of course there are
cases in which this system of self-treatment must be adopted,
or none at all can be undertaken ; but physicians who treat
aural disease soon learn that, if they wish to achieve the best
results, the treatment must be carried on by the medical
adviser himself, and not be delegated to lay authority .
Some years since, I began to inject vapors into the ear by
means of a simple apparatus* which is represented on the
next page. The apparatus consists of a hollow bulb of
* American Journal of the Medical Sciences, vol. liii., p. 62.

USE OF VAPORS BY POLITZER'S METHOD . 309
hard rubber, which is attached by a bit of rubber tubing to

the air -bag used in Politzer's method. Any fluid that is readily
vaporized is placed upon a sponge contained in the bulb, and
on practising inflation of the ear, the vapor is forced into the
Eustachian tube and the cavity of the tympanum . The tinc
ture of iodine and chloroform are the agents I chiefly employ.
Dr. J. S. Prout, of Brooklyn, taught me the value of chloro
form as a means of diagnosticating closure of the tube. This
vapor will penetrate the ear when air or iodine are not per
ceived, and when all attempts at inflation with air have failed,
or, as should be said , when the patients experience no sensa
tion in the ears from the use of air through the catheter, or by
Politzer's method. Great caution should be used in employ
Fig. 67.
Apparatus for Injecting Vapors into the Nasal Passages.
ing the chloroform ; that is, but a few drops should be used ,
or the most intense pain will be caused . I have seen patients
jump from the chair in surprise and pain, after one careful
inflation ,when only two or three drops were upon the little
sponge in the bulb , and this, after attempts to cause a sensa
tion in the ears with common air had utterly failed. The use
of chloroform vapor is certainly a very valuable diagnostic
means, although I am not so certain of its therapeutic value.
The hollow bulb was recommended as an inhaler by Dr.
310 USE OF VAPORS BY POLITZER ’S METHOD .
Buttles of this city ; but the attachment to Politzer's appa

ratus was first made by myself. The vapor of iodine is very
useful in many cases of naso-pharyngeal catarrh, and may
be used by means of the inhaler that has been described , or
by means of the simple apparatus that is represented on the
previous page. It is very much employed by my colleague,
Dr. Andrew H . Smith, at the Manhattan Eye and Ear Hospi
tal. It consists of a simple glass bottle , whose cork is pierced
with two holes, in each of which is a bent tube ; one of these, a,
reaches nearly to the bottom , the other simply passes through
the cork . The latter tube has india -rubber nose -piece , such
as is used in the ordinary nursing bottles. The other is con
nected to an air-bag, b , by which the vapor of the tincture of
iodine is forced into the nostrils for three or four minutes.
FIG . 68.
Air-bag,with Inhaler Attachment.

Dr. Peter Allen, of London, substitutes a nasal pad,which
is pressed against the opening into the nostrils, for the tube
which , when Politzer's method is employed , is inserted into
one nasal meatus. These air-pads are mounted on a strong
piece of covered cotton wire, and they can be brought together
or separated in such a manner as to stop up the nasal orifices.
There is a hole in each pad, which communicates with two
short bits of india-rubber tubing joining into a single tube. I
have not found the use of the pads as convenient or efficient
as the tip inserted into the nostril ; but as some practitioners
have thought that they were more convenient than the simple
tube, placed in the nasalmeatus, I have given this description
of Dr. Allen 's apparatus.* It can be had at the instrument
makers in New York.
. * On Aural Catarrh , London , 1871, p. 79 .
BOUGIES. 311
BOUGIES .
Bougies, for the purpose of dilating the Eustachian tube,

are highly spoken of by somewriters. Bonnafont and Kramer
were perhaps the first to use them . Guye,* of Amsterdam ,also
employed them , and published three cases of emphysema pro
duced by their use. In the first case there was emphysema
along the neck, as far as the sternum . In three days it passed
away. In the second there was suddenly considerable dysp
næa. The uvula was found to be the cause of the trouble . It
was very much distended with air. An incision in it was made
at once, and the patient again breathed quietly. In the third
case a fold of mucousmembrane in the fauces became so much
swollen immediately after the use of the bougie, that breath
ing became difficult. Here, again , snipping the fold soon
relieved the breathing .
These cases probably show all the danger there is in using
bougies. They are, however, somewhat painful. Among
some 1500 private patients, I have recorded but one case in
which , after a fair trial, air could not be driven into the Eu
stachian tube by means of the catheter or Politzer's method .
In cases where common air did not enter, the vapor of chloro
form did . In this fact, will be found my reason for not resort
ing to the use of the bougie more frequently . Their use is
chiefly to stimulate the mucous membrane lining the Eusta
chian tube, and thus remove the swelling. Complete stricture
of the tube is too rare an occurrence to be really much con
sidered as an indication for the use of the bougies. I find in
injections of vapors or fluids the stimulant thus sought with
out any of the unpleasant features of the bougie treatment,
such as the production of emphysema, breaking of the bougie
in the tube and severe pain . Dr. Noyes reports a case + in
which a fine whalebone olive-tipped bougie passed into both
Eustachian tubes through the catheter, produced suppurative
inflammation of the middle ear.
In the discussion which ensued on this case, Dr. Weir
* Archiv für Ohrenheilkunde, Bd. II., p. 6 .
+ Transactions of the American Otological Society, Third Year, p. 55.
312 BOUGIES - ELECTRICITY.
said that he had tested the merits of the bougie practice for
five years, and felt that in cases where obstruction of the
Eustachian tube did not yield readily to Politzer's bag, the
pump, or the catheter, the bougie was of very material assist
ance. In a large experience he had met with two accidents,
purulent inflammation of the middle ear, and temporary
emphysema of the eyelids, face, and neck. These accidents
occurred from neglect of certain rules which he now carries
out. Dr. Weir uses catgut bougies on which are marked the
length of the catheter , the distance to the isthmus or narrow
est part of the tube, 74 millimetres, then the distance from the
point to the tympanic cavity, 11 millimetres, and finally the
width of the cavity, 13 millimetres. The bougies ranged from
Nos. 2 to 5 of the French Scale .
Dr. Weir's directions as to the employment of the bougies
are so thorough and careful that I transcribe them .
The instrument having been passed through an ordinary
Eustachian catheter, and “ once engaged in the tube is pushed
onward as far as the isthmus, allowed to rest then a few mo
ments and then withdrawn, and air gently blown in through the
catheter. If the air did not readily enter the tympanic cavity ,
all forcible attempts to force it were carefully abstained from
and the bougie reintroduced , either then, or preferably at
another sitting, and carried only to a very short distance, say
one or two millimetres farther on , and the experiment resorted
to , to ascertain if the tube were open .” Dr. Weir has found
the most obstructions in the first portion of the tube, though
in several instances he had overcome total obstructions at the
tympanic orifice. “ The conical French bougies should be
discarded as dangerous, from the tapering ends being too
long ; but the catgut bougies might be made slightly conical
by rubbing them on emery paper.”
ELECTRICITY.
This is an agent whose real value has been much under

estimated in many departments of medicine, but which I am
inclined to believe has been overrated in the treatment of
aural disease. The effects of electricity on the acoustic nerve
DEATH AFTER USE OF THE CATHETER , 313
will be fully discussed in the third part of this volume,

while it is only necessary to say at this point, that not much
is to be expected from the use of electricity in chronic non
suppurative inflammation of the middle ear. Drs. Beard and
Rockwell * think that “ the best results are obtained in those
cases passing from the sub -acute to the chronic stage, and that
then they are brought about by the mechanical action of the
Faradic current, on the adhesions within the middle ear.”
These are just the cases that are amenable to treatment
by the catheter, Politzer's method, and applications to the
pharynx.
Before closing the subject of the employment of the

Eustachian catheter in aural disease , an allusion should at
least be made to the singular dread of the instrument, now
happily dissipated, which obtained in the minds of the pro
fession in England and the United States. This dread seems
to have depended upon two cases of death from the use of the
catheter which occurred in the practice of a certain Dr. Turn
bull, then of London, but who occasionally visited America ,
for the purpose of treating aural disease, until his death, which
occurred a short time since, as I have been informed. These
famous cases were reported in the London Lancet. In the
same journal,t there is a letter from a correspondent ac
cusing this Dr. Turnbull of advertising in the “ Times ” in an
unprofessionalmanner — that is , by stating that he could cure
“ any case of deafness, not arising from organic disease, by the
use of a peculiar remedy."
In order that the length and breadth of this matter of the
death of patients from the use of the catheter,may be fully
presented to the profession and not continue to be darkly
hinted at, I quote from the Lancet ļ the account of the
inquest upon these celebrated cases.
“ On Monday evening an investigation took place at the Carpenters' Arms,
Hoxton , before Mr. Baker, relative to the death of Mr. Wm . Whitbread ,
* A Practical Treatise on the Medical and Surgical Uses of Electricity ,

p . 566 .
7 Vol. II., 1839. Vol. II., p. 558 .
314 DEATH AFTER USE OF THE CATHETER.
aged 66, which was supposed to have been occasioned by an operation lately
performed on him by Dr. Turnbull of Russell Square. It appeared that the
deceased, who was in the enjoyment of good health up to that time, had an
operation performed upon him on Thursday week by the above physician,which
consisted in injecting air through the nostrils for the relief of excessive deaf
ness , under which he had been for some time laboring. Almost immediately
after he was attacked with a violent swelling in the throat, and though the
utmost attention had been paid to him , he expired on Thursday last."
“ Mr. Wickham , a medicalgentleman in the neighborhood, deposed, thaton
making a post-mortem examination of the body,he found that the inflamma
tion in the throat was not sufficient to have occasioned the death of the de
ceased ; death was produced by extensive intlammation of the brain, which , in
his opinion , was occasioned by natural causes, and that neither the operation
nor the inflammation of the throat had anything to do with it."
“ The jury, on this evidence , returned a verdict of Natural death by the
visitation of God .' "
" On Friday morning, at eight o'clock , an investigation , which occupied the

greater portion of the day, was entered into before Mr. Wakeley, M . P ., and a
highly respectable jury of tradesmen , at the Plough Tavern, Museum Street,
to prosecute the inquiry into the circumstances connected with the death of
Joseph Hall, aged 18 , who died whilst undergoing an operation for the cure
of deafness , at the house of Dr. Turnbull, Russell Square , on the morning of
Saturday last . The circumstances connected with the case had created an
intense interest , and during the proceedings the inquest room was attended by
many of the leading members of the medical profession ."
" George Kimbermerely stated that he and deceased were in the employ of
Mr. Jackson , ornamental composition maker, of Rathbone place. He saw him last
alive on Saturday morning, about seven o'clock , at which time he was getting
ready to go to Dr. Turnbull's to be operated upon for deafness, to which he
was subject ; he was in all other respects quite well and healthy."
" Charles Spadbron, of Gravesend, deposed that he saw the deceased about
ten o'clock on Saturday morning at Russell Square. He appeared in good
health. There wero other patients present at the time. Mr. Lynn , the gen .
tleman who assists Dr. Turnbull, was pressed to operate. The deceased filled
the instrument himself, and discharged the air by turning the cock . (The
instrument was here produced, and the witness showed how it was filled .
The bottom of the cylinder was held fast between the feet and the piston ,
worked up and down by the handle until the pump became filled with air.)
The operation was repeated four times on deceased , butthe tube through which
the air passed was removed by Mr. Lynn from the right to the left nostril.
On the tube being taken from deceased's nostril the fourth time, he fell back
in the chair, apparently lifeless , and never spoke afterward.”
" In answer to the coroner, the witness stated that he had had the operation
performed on himself four times at a sitting ; it produced a swimming in the
head , and a portion of the air appeared to escape by the mouth , and the rest
down the throat."
“ Mr.James Reid of Bloomsbury Square,surgeon,deposed to having, by order
CAUSES OF INJURIOUS EFFECT OF CATHETER . 315
of the coroner, made a post-mortem examination of the body in presence of
Messrs. Liston, Quain , Savage, and Lyon . Mr. Reid went into a long general
anatomical statement, but the only points strictly bearing on the case were the
following : That he found a thin layer of blood on the left side of the mem
brane, and globules of air under it, and in the small veins of the brain . That
the left tympanum , or internal ear, bad its lining membrane swollen , of red
appearance, and there was a slight effusion of blood in it. From the known
plethoric habit of the deceased , and from the fact of his having exerted him .
self at filling the air-pump before he was operated upon , he should say the
cause of his death was apoplexy."
“ Mr. Savage, lectureron anatomyat Westminster Hospital, was next exam
ined, and differed from the last witness, and stated that there was extravasated
blood on both sides of the membrane, and that the tympanum of the right ear
was affected as well as the left. He did not consider that deceased died of
apoplexy, but that the injection of cold air, through the Eustachian tubes, was
the primary cause of deceased 's death."
" Mr. Liston, surgeon to University College Hospital, stated that he was
present at the post-mortem examination , at the request of the coroner, and the
probability was,that deceased died in a continued fainting fit. He could not
easily disconnect the forcible injection of cold air into the tympanum from the
effect that followed it. In the region of the tympanum were a number of small
nerves, connected with the most important one in the body, which , receiving
an impression, would cause spasms, or other fatal affections of the heart.
Nothing precisely satisfactory could be come to on account of the decomposed
state of the body.”
“ The coroner complained that though the subject of the inquiry had died
on Saturday morning, no notice of his death had been sent by Dr. Turnbull or
Mr. Lyon to the summoning officer of the district. He wished those gentlemen
to give some explanation of their conduct.”
“ Dr. Turnbull and Mr. Lyon severally entered into an explanation."
" The coroner then addressed the jury at considerable length . And in
accordance with the spirit of his observations, the jury returned a verdict of
Accidental death ,' with a caution to Dr. Turnbull never again to intrust the
instrument of operation in unprofessional hands.” — (Times.)
There are numerous explanations for these cases ; but the
account of the post-mortem is not exact enough to allow
us to say which of them are correct. The first- pamed
patient may have died from the emphysema produced by a
wounding of the tissue by the point of the instrument. An
examination of the tissues of the throat, immediately after the
accident, would have determined this point ; but there is no
account of such an examination having been made. The
experiments of Voltolini* show that all traces of an emphy
* Monatsschrift für Ohrenheilkunde, Jahrgang VII., No. 1.
316 DURATION OF TREATMENT.
sema would pass off within ten hours after death , so that the
post-mortem examination would give no information on this
point.
The surgeon who determined that death was produced by
inflammation of the brain , unfortunately gives no account of
the evidences which led to the formation of this opinion . The
second patient may have died in a fainting fit, or from em
physema.
The air-pump, is now scarcely used in the profession as a
means of injecting air into the Eustachian tubes, because the
air-bag is quite as efficacious, and because it is a much sim
pler apparatus. The management of an air-press should cer
tainly never be left to the patient.
Voltolini, in the experiments to which allusion has been
made, killed a rabbit in a few minutes by wounding the tissue
of the pharynx, by a wire passed through a catheter, and then
blowing forcibly into the opening. He thus produced great
emphysema of the neck and chest. Voltolini believes that the
cause of death of the rabbit, was a pressure upon the larynx
by the emphysematous tissue, and not the pressure upon the
lungs. Turnbull's patients may have both died from the same
cause ; but as we do not know the instrument used , or, in fact ,
any of the details , we can only surmise the real cause.
I need hardly say that the Eustachian catheter has never
been even suspected of being the cause of death , since the time
of these cases, although it is in daily use by physicians in all
parts of the civilized world .
Before passing on to a consideration of the operative treat
ment for this class of aural affections, a word or two should
be said as to the length of time a case should be treated . In
asmuch as we cannot hope, in many of the cases, to do more
than arrest the progress of disease, and perhaps improve the
condition , since we cannot dismiss them as cured — that is to
say, with the hearing perfectly restored , the tinnitus aurium
gone — we desire to know how long we shall treat the ears
locally. The general hygienic treatment, such as the frequent
employment of baths, of a gargle, the exercise of great care
to keep the extremities warm , to avoid taking cold , and so on,
DURATION OF TREATMENT. 317
should be kept up during a patient's life , and he should be

told at the first consultation that he has a life -long warfare to
engage in , unless he desires to end his days with the use of an
ear-trumpet.
But we cannot keep up a local treatment of the Eusta
chian tubes and pharynx indefinitely. Those who believe
that a catarrhal pharynx and nares can be thoroughly cured
in our climate, that a disposition to colds in the head, can
be effectively subdued by the use of the spray of nitrate
of silver, or the spray of any other agent used by means of
the most perfect apparatus, will continue to use these means
of local treatment until the end is accomplished. But those
who have been less successful in such attempts ,must fix some
limit to the time of treatment. If it be proposed to get the
confidence of a patient suffering from chronic non- suppurative
middle-ear disease, which is progressive in its character, it is
proper to tell the whole truth at the first consultation and say
that we have no hope of making bim hear very well again .
It is only a question of arresting the progress of the disease,
and perhaps of increasing the hearing power. To this end ,
about twice a year, they should receive a course of local treat
ment until the disease has ceased to progress, for a period of
time varying from three to eight weeks, while the general treat
ment is to be a life -long course . The only reason that these
limits of time are fixed is, that I have seldom seen anything
accomplished in less than the shorter time, or after the longer
term has expired. Very many patients leave us,at the outset,
never to return . Some of them cannot leave their families to
stay in a large city while their ears are being treated. This
difficulty is being rapidly met. In every considerable town
reputable and educated men, who have found that there is
something more in aural practice than in syringing out the
wax and then dropping in glycerine to restore it, are giving
attention to otology, and the laity are beginning to reap the
fruits of this cultivation of a hitherto barren field .
There is another class, however,whom such advice never
influences. One of their family , has been a victim of chronic
aural disease for a period varying from two to twenty years ,
and they have at last, at the request of the family physician,
318 DURATION OF TREATMENT .
screwed themselves up to the courage of consulting a special

ist. They come in town for a day's shopping, and call upon
the doctor, meanwhile always being in a great hurry, and
sending word to the consulting -room , that they have come
fifty miles to see him . When such advice as I have delineated
is given , and the almost bewildered physician sits down to lay
out a plan of treatment and correct the improper habits of life
that have induced and maintained the disease, he finds that he
is dealing with persons who expect magic ear-drops, vibrators,
or somemysterious and quickly-acting agent that will restore
the hearing in the interim of rest of a New York shopping
excursion. Of course, such patients figure in the statistical
tables under the head of “ seen but once, result unknown,"
although in the mind's eye we can set them down as going
on slowly but surely to the ear-trumpet, and banishment from
social intercourse.
CHAPTER XIV .
THE TREATMENT OF CHRONIC NON -SUPPURATIVE INFLAM .
MATION - CONCLUDED .
OPERATIONS UPON AND THROUGH THE MEMBRANA TYMPANI.

OPERATIONS upon and through the membrana tympani, have
assumed a new importance within the past few years, in chronic,
as well as acute aural disease . It is generally believed that
still more will be accomplished for chronic aural inflammation
by such procedures. There is, therefore, a justification for
a full consideration of this subject, such as I shall endeavor to
give in this chapter.
The reader of otological literature will be almost appalled
by the amount of material on this subject. It begins with
Cheselden's experiments on dogs, and ends as yet, with
Weber's operation upon the tensor-tympani muscle. From
the mass of authorities I have collected such a history of this
subject as will, perhaps, enable the candid professional mind
to come to a knowledge of the true value of these different
proceedings, as far as they have as yet been developed.
I am indebted to a brochure by Dr. Hermann Schwartze,
of Halle,* for the portion of this historical sketch that extends
to our own day, although , wherever possible, I have consulted
the original authorities and verified, and in some instances
amplified , Schwartze's quotations.
1650. — Johannes Riolanus, of Paris, about 150 years be
fore the time of Sir Astley Cooper, who is usually supposed
to be the originator of the operation of perforation of the
membrana tympani, inquired if it would not be possible to
* Studien Beobachtungen über die Küntsliche Perforation des Trommel
fells, Archiv für Ohrenheilkunde, Bd. II., S. 24.
320 PERFORATION OF MEMBRANA TYMPANI.
improve the hearing of the deaf, by destroying the membrana

tympani. He was led to make this inquiry from the fact that
he knew of a deaf person , whose hearing was restored by an
accidental rupture of the membrana tympani, by means of an
ear-spoon .
It is well to remember that, until very recently, there were
no exact measures taken to estimate the amount of hearing,
and that, consequently , such phrases as " the hearing was re
stored,” “ the hearing became perfect,” as they occur in
ancient books, only mean that the hearing was improved,
sometimes very much , sometimes very little.
1722. - About a hundred years later, T . Cheselden, sur
geon to St. Thomas's Hospital, London , well known as the
inventor of the operation for artificial pupil, actually operated
upon dogs, and I quote from his work on anatomy* the de
scription of his cases. Speaking of the membrana tympani,
he says : “ I found it once half open on a man that I dissected,
who had not been deaf, and I have seen a man smoke a whole
pipe of tobacco out through his ears, which must go from the
mouth, through the Eustachian tube, and through the tym
panum , yet this man heard perfectly well. These cases occa
sioned me to break the tympanum in both ears of a dog , and
it did not destroy his hearing, but for some time he received
strong sounds with great horror.”
Cheselden then goes on to say that an anatomist named
St. Andre assured him that “ a patient of his had the tym
panum destroyed by an ulcer, and the auditory bones came
out without destroying the hearing.” I have only been able
to obtain the second edition of Cheselden 's works, but
Schwartze quotes from the seventh , where the author states
that he obtained permission to perform this operation, that
was then esteemed such a formidable one, upon a prisoner. If
the prisoner survived the operation , he was to have his free
dom . Unfortunately for science and for the criminal, the
proposed subject became ill, so that the operation was in
definitely postponed . Sir Astley Cooper t says that such an
outcry was aroused by the inhumanity of the proposed oper
* The Anatomy of the Human Body, London , 1732, p. 250.
| Philosophical Transactions, 1800, p . 152.
PERFORATION OF MEMBRANA TYMPANI. 321
ation, that Cheselden never again obtained permission to per
form it.
1748. — Dienert, of Paris, in a dissertation, recommended
perforation of the membrana tympani for the purpose of
evacuating blood or pus from the cavity of the tympanum .
Itard says that Julius Busson proposed the operation six
years before this.
1760. — The first man who actually performed the operation
as a means of benefiting the bearing, was a person named Eli,*
who seems to have been a charlatan.
Portal and Sabatier, two Paris surgeons, who lived at
the same time as Eli, knew nothing of his operations. Portal
proposed to puncture the membrana tympani, in the cases
where it was greatly thickened. Sabatier, on the other hand,
proposed to perform the operation upon a relaxed membrana
tympani.
1788 . – Wilde quotes a passaget from Dr. Peter Degravers,
of Edinburgh , who lived in 1788 , and who styled himself pro
fessor of anatomy and physiology, which shows that he had
performed the operation. Degravers says: “ I incised the
membrana tympani of the right ear with a sharp, long, but
small lancet. I left the patient in that state for some time,
and afterward observed that it had united . Iincised again the
membrana tympaniofthe right ear, but crucially , and ,on remov
ing some of the parts of the membrane incised, I discovered
some of the ossicula , which I broughtout.” Schwartze naively
remarks, “ There is no account of the results in this case.”
1800. - In the beginning of this century, at about the same
time, and independently of each other, Dr. Karl Himly , then
of Brunswick, Germany, and Sir Astley Cooper, proposed the
operation, especially in closure of the Eustachian tube. Himly
had demonstrated to his students, in 1797, by experiments
upon the human cadaver and living dogs, that the operation
* The following paragraph is quoted by Gairal, Lincke's Sammlung, Bd.
V ., p . 109, in proof of Eli's operation : " Est Lutetiæ homo quidam ELI dictus,
qui surditatem curare audet, dummodo malum nona paralysi nervi septimi
paris oriater, en vero eius methodum tympanum exscindit et suppositum im
mittit. Feci experimenta quædam , quæ satis bene ipsi cessarunt."
+ Aural Surgery English edition , p . 15 .
21
322 SIR ASTLEY COOPER'S OPERATION.
could be easily and safely performed ; but he did not perform

it on the living subject until 1806 . He reports a brilliant
result in one case only, in a person suffering from syphilitic
ulcers of the pharynx, who had been deaf for years from
closure of the Eustachian tube.
After Sir Everard Home had published his paper on the
functions of the membrana tympani, a paper to which allusion
has already been made in this volume, Sir Astley Cooper
published a careful and exact account* of the case of a medi
cal student at St. Thomas's Hospital, in London,who had lost
his membrana tympani, but who, nevertheless, could hear
quite well.
The student was twenty years of age, and applied to Sir
Astley in the winter of 1797. He was attacked at ten years
of age with suppuration in the left ear, and in about twelve
months after with the same disease in the other ear. There
was a profuse discharge for weeks from both ears, and in the
discharge bones , or pieces of bones , were observable . The
patient was totally deaf for three months; the hearing then
began to return , and, in about ten months from the last attack,
it was restored to the state in which it was when he consulted
the great English surgeon . Sir Astley then gives an account
of the means by which he decided that the drum -heads were
perforated. The patient having filled his mouth with air, he
closed his nostrils and contracted his cheeks : the air thus
compressed was heard to rush through the meatus auditorius
with a whistling noise, and the hair hanging from the temples
became agitated by the current of air which issued from his
ear. “ To determine this with greater precision, I called for a
lighted candle, which was applied in turn to each ear , and the
flame was agitated in a similar manner.” The examination of
the case was continued in this thorough manner.
The gentleman, when in company, was capable of hearing
what was said in the usual tone of conversation , and he could
hear with the ear in which there was no trace of a membrana
tympani, better than with the one in which there was merely
a circular opening. When a note was struck upon the piano,
* Philosophical Transactions, 1. a.
SIR ASTLEY COOPER'S OPERATION . 323
he could hear it but two-thirds of the distance at wbich the

examiner could hear it.
Although this case was accessible to the profession from
the year 1800, it is surprising to find the belief still widely
prevalent among the laity and the profession, that the destruc
tion of the membrana tympani involves almost complete loss
of hearing. The advance in the simplicity of means of an
accurate diagnosis in aural disease, is nowhere more distinctly
seen than in a comparison of Cooper's method of determining
whether the membrana tympanibe intact or injured, with that
of the surgeon of the present day, who, with the otoscope, is
able to state just what the condition of the part is, with no
aid from the patient, and in a very brief space of time.
This observation led the way to the operation of perforation
of the membrana tympani * for the relief of impaired hearing.
The only indication that the great English surgeon spoke of
was closure of the Eustachian tube, which he believed arose
from the following causes :
1. A common cold affecting the parts contiguous to the
orifices of the tube, and thereby preventing the free passage
of air into the tympanum .
2 . Ulcers in the throat, from the scarlet fever, which in
healing frequently close the Eustachian tubes.
3 . A venereal ulcer in the fauces , by the cicatrix it pro
duces,may cause a closure of the tube.
4. An extravasation of blood in the cavity of the tym
panum .
The scientific character of Astley' s observations is nowhere
better shown than in these indications, which are exact, and
in consideration of the state of knowledge as to the means of
opening the Eustachian tube, correct. The last-named con
dition , however, cannot be said to depend upon closure of the
tube, but is a simple case of hemorrhage into the tympanic
cavity, which no affection of the tube would be likely to cause.
Mr. Cooper reports four cases :
CASE I. - A woman , thirty -six years old , who had been
affected for eight years. The deafness arose from enlarge
* Sir Astley's paper descriptive of his operations was read June 21 , 1801.
See Philosophical Transactions of the Royal Society of London , 1801.
SE 13TLET COOPEE'S OPERATION.
ment of the tonsil glands ; a puncture of the drum -bead was
made, and while she stayed in the consulting - room for one
hali-bour, she could hear ontinary conversation.
Cuz II - Ann D ., aze pot stated , so deaf as not to hear
words unless spoken elose to the ear. She had been affected
for sir weeks. She could hear a watch when pressed upon
her ear. After the puncture she could hear the watch several
feet.
Case III - J. R ., aged seventeen. The hearing had been
impaired since birth . There was an imperfect state of the
fauces, so that he could not blow his nose . The Eustachian
tubes had no openings into his throat. Puncture of the mem
brana tympani produced such a confusion that he nearly
fainted, but in two minutes he recovered , and, two months
after, his hearing continued perfect.
CASE IV . - A person was sent to Mr. Cooper, who had re
ceived a blow upon the head , which had occasioned symptoms
of concussion of the brain , and was attended with a discharge
of blood from each ear. He recovered from all the effects of
the blow but the deafness. Blood was found in the meatus
by Mr. Cooper. After clearing this away and perceiving no
benefit, suspecting that a quantity of blood was lodged in the
tympanum , in a few days he punctured the membrana tym
pani. Blood mingled with the wax was discharged for ten
days, during which time the hearing was gradually restored .
In closing his paper, Sir Astley states that little pain is
felt in the operation , and that no dangerous consequences
follow .* The Valsalvian experiment was the means by which
he determined whether the Eustachian passage was open or
not, for he says that, when the experiment succeeds, the tube
is open. Besides this , the patient should be able to hear a
watch placed between the teeth or on the temporal bones.
Cooper published his four cases of good results, and , accord
ing to Schwartze and Frank, he was soon inundated by deaf
* Sir William Wilde states that, within a few months of his death . Sir
Astley exhibited the greatest interest in this subject, and left his consulting .
room full of patients for a long time, to send for a man in Bond Street, upon
whom he had operated, in order to exhibit him to Mr. Wilde. - Vide Dublin
Journal, vol. xxv ., 1844 .
PERFORATION OF THE MEMBRANA TYMPANI. 325
persons from all parts of Europe. He then operated on fifty

more cases, but the results were either slight, null, or they
lasted for a short time only. Cooper then declined to see
deaf patients, on account of the fact that he was doing very
little good, and also because his fame as a surgeon was suffer
ing from his reputation as an aurist. After the lapse ofmore
than seventy years , the dispassionate , scientific character of
Sir Astley Cooper's writings on this subject, stands in striking
contrast to the charlatanism of some of those who followed
him in this operation.
After Cooper's operations, a great interest was excited
in France on this subject, and , according to the medical jour
nals of the time, quoted by Schwartze, Riber of Bordeaux,
Maunoir of Geneva, and others, operated, but with no perma
nent results.
In Germany, also , the same interest was created. Michae
lis, a professor in Marburg, informs his friend Hunold , of Ca
pel, that he had operated on one case successfully . Hunold
then proceeded to puncture every membrana tympani to which
he could get access . Finally , Hunold records that he has had
the brilliant result of curing or improving seventy cases out
of a hundred. Subsequently, it was shown by others , that
these results were not only exaggerated , but, that they were
not even at all in accordance with truth. Of Michaelis 's sixty
three cases, in forty -two there was no result whatever ; while
in twenty - one, or one-third, there was greater or less improve
ment. But, of all these, in only one was there a permanent
result six years after ; perhaps the benefit was permanent in
three other cases.
Schwartze says that after Hunold 's marvellous accounts of
his successful results from perforation of the membrana tym
pani, the operation became the fashion, and every one, who
did not have the finest hearing , allowed the drum -heads of the
ear to be pierced. Even the poor deaf-mutes had their drum
membranes perforated. Fashions in medicine are not con
fined to our own time.
To stem this tide of charlatanism , Karl Himly, professor
in Göttingen , wrote a commentary upon the operation , and
showed that it was only in exceptional cases that it was of any
326 PERFORATION OF THE MEMBRANA TYMPANI.
value. These exceptional cases were such as those reported

by Cooper , for the relief of which, since there were no means
of opening the Eustachian tube, paracentesis of the membrana
tympani was a beneficial operation ; but the profession seem
not to have studied Sir Astley Cooper 's cases,but it wasmerely
known that he perforated the membrana tympani with benefit
to the hearing. Himly 's paper excited so much attention that
the operation was not heard of for a long time.
In England , as we have seen, Cooper abandoned the
operation and otological practice. Stimulated by the oppor
tunity for entering an operative field , Saunders opened an
aural clinic in 1804, but soon closed it on account of the poor
results of treatment. He speaks of one case of perforation in
which a good result was obtained. After him came Curtis,
who talks of the operation in very general terms, but without
furnishing cases. Buchanan also promises to describe his
cases, but he never did ; and Schwartze thinks that Degravers ,
the Edinburgh professor, from whom I have quoted, and
Stevenson, are not to be relied upon .
In France, Itard , Boyer, and Deleau wrote upon this sub
ject. Itard was wise enough to perforate a drum -membrane
of a deaf-mute whose tympanic cavity was filled with masses
of tenacious mucus, and he succeeded in removing them after
the operation by syringing. This was an anticipation of Mr.
James Hinton 's operation. In one hundred and seventy other
cases, there was absolutely no result. He calls attention to
the fact that permanent suppuration may occur even when the
operation is very carefully performed.
1822. - Saissy, of Lyons, in his work on the ear, speaks
guardedly of the operation , and of only one case where the
result was entirely satisfactory. Dr. Nathan R . Smith , of Bal
timore,translated Saissy 's book , and invented an instrument
for perforation of the drum -head, which he described in the
appendix to his translation ; but there is no account of the
success of the operation in this country .
Schwartze gives very little credence to Deleau's account
of his successful results. He claims to have improved eigh
teen out of twenty-five deaf persons and deaf-mutes, by the
operation.
PERFORATION OF THE MEMBRANA TYMPANI. 327
Hendriksz , of the University of Gröningen, in 1828, in an

inaugural thesis on the subject,which Schwartze used in his
historical sketch , states that in the institutions for the deaf
and dumb, in Berlin , Vienna , and Gröningen , this operation
was frequently performed. In Gröningen, eighty -one deaf
mutes were operated upon, of whom seventeen received for
the moment a more or less decided improvement. We hear
nothing then of the operation for twenty years, until Hubert
Valleroux, in 1843, wrote an essay upon the danger attending
it. He speaks of two cases of death from it."
Wilde,* in defence of the operation, when performed under
proper indications, says that Dr. Butcher, of Dublin , reported
two cases with a view of showing the ill-consequences result
ing from the performance of the operation , and relates the
cases of two young persons, a man and a woman, in both of
whom it would appear that death ensued from puncturing the
membrane. In the first instance, the only history of the case
is that, prior to this period, she got a severe cold , with a
swelling of the glands of the neck. No account is given of the
cause or origin of her deafness, the condition of the mem
brana tympani, why the operation was performed, in what
manner, by whom , or with what instrument. According to
Wilde, all that we know is, that “ catheterism of the Eusta
chian tube was performed , and said to fail ; hence it was
agreed that themembrane of the tympanum should be pierced,
a small piece being drilled out of the membrane of the right
side.” No exact account of the operation and no names of.
the witnesses are given . Inflammation ensued , and four
months after she died , when the petrous bone was found
roughened and softened, and the membrana tympani entirely
destroyed. This case , certainly, with such a history, can
form no text for a homily against paracentesis of the drum
membrane.
The second case is equally indefinite. Wilde says all that
is known of the case is, that he applied to a surgeon and had .
his tympanum pierced, “ but why, or whether with a gimlet
or a punch, a trocar or a probe,we are not informed . At first
* Text-Book, English edition, p. 297.
328 PERFORATION OF THE MEMBRANA TYMPANI.
the hearing improved , and then relapsed. After some time

head-symptoms set in , and the man died in six weeks.” On
the post-mortem examination , the brain and its membranes
were found in an inflamed condition , and a small abscess in
the anterior lobe of the brain , on the same side upon which
the puncture was made. The cause of the deafness in this
case was found to be a small tumor, about the size of a bean,
lying on the acoustic nerve.
Paracentesis of the membrana tympani was certainly not
indicated in this case, and the two together form no more of
an argument against the operation, than the indefinitely
reported cases of death from the use of the Eustachian cathe
ter do against the use of that instrument.
The treatises on diseases of the ear, of Kramer, Rau , Bon
nafont, Toynbee, and Von Tröltsch , add very little to our
knowledge of this subject.
It has thus been seen, that the first indication which was set
down by the old authors, was closure of the Enstachian tube.
Since the scientific use of catheters and bougies, this is no
longer recognized as a correct indication for perforation of the
drum -head . In the very rare cases in which there is an imper
meable stricture from cicatrization , it would be, however, a
proper operation .
Thickening of the membrana tympani was another promi
nent indication of the old authors — not of Cooper, however.
We now know that a thickening of this membrane that is con
fined to the outer layers,may be removed by appropriate local
applications, while one that has extended to the fibrous, or
mucous layer, or both, is nearly always accompanied by thick
ening of the whole lining membrane of the cavity of the tym
panum , so that this indication may also be dismissed .
A collection of blood , pus, or mucus, in the cavity of the
tympanum , is, then , the only indication of the old writers
which may fairly be said to be up to the present standard of
knowledge. The collections are readily diagnosticated in all
acute and sub-acute cases, and still remain good indications
for perforation of the membrana tympani.
From this chaos of illy -defined indications and imitative
experiment, there came out one fact in proper form . That
SCHWARTZE 'S REVIVAL OF THE OPERATION . 329
one fact was this : That it was pre-eminently proper to perfo

rate the membrana tympani in order to removemucus, blood , or
pus, which could not find an exit through the Eustachian tube.
Sir Astley Cooper's favorable cases showed this fact. Itard 's
deaf-mutewasalso another illustration of its truth ;but, through
out all the history of these cases, we do not find, until we come
down to Saunders,* and later to Hermann Schwartze, of Halle,
that one writer had been able to select this single grain of wheat
from the chaff. Schwartze saw what had been shown by the
cases that were published, and in his first article t revived the
operation of paracentesis , but chiefly applied it to acute disease,
where these accumulations of mucus, blood , or pus, are likely
to occur. The operation is now well established as a means
of treatment in acute cases, and has already been described in
the chapter on acute catarrh of the middle ear.
Schwartze has lately published one hundred cases in which
he has performed a paracentesis of the membrana tympani.
Before passing on to review the methods of writers who, since
Schwartze's paper was published, have modified the simple
operation and enlarged its field , so as to cause it to play a great
part, as they claim , in curing chronic cases of catarrhal and
proliferous inflammation , I will venture to criticise Schwartze's
table of results. Of his one hundred cases, only two were in
persons over fifty years of age, and only seventeen were over
twenty . The remaining eighty-one were under that age, and
forty -six were between one and ten years. In America , our
cases of chronic non -suppurative inflammation occurring in
young persons are usually quite tractable without paracentesis.
We are chiefly anxious to enlarge our therapeutic means for
the cases of persons who are more than sixteen years of age,
and especially for those who are adults in middle life. Again ,
in thirty-four of the cases, the disease , whatever it was, had
not existed for a year. There were only ten cases where the
aural affection had lasted between five and ten years, and in
six cases only , more than ten years. I
These statements show that we have not, as yet, even in
repeated paracentesis of the membrana tympani, found the
* See Introductory Chapter, p . 40 .
+ Archiv für Ohrenheilkunde, Bd. II., p. 36. Ibid., Bd. VI., p 195 .
330 POLITZER ' S EYELET.
remedy for the class for which we in America are most ans
ious - old and neglected cases of chronic proliferous inflamma
tion . Schwartze's contributions, in other words, principally
affect acute and sub -acute disease. The line should have been
a little more distinctly drawn between the cases of sub -acute
and chronic inflammation, for which paracentesis was per
formed .
1845. - It was thought by many that, if a permanent open
ing could be kept in a drum -head, the great desideratum would
be attained . Bougies were placed in an opening made with a
small trephine, and ,when it was found that this excited too
much reaction, a gold tube,three lines long, and having a lit
tle ridge on both ends, was inserted, with a view of keeping
up a permanent opening.* This was years before Politzer
introduced his eyelet. In 1868, Politzer had a case in which
he placed an eyelet in a cicatrix which he had incised.
Although of service in this case, it has proved, however, to be
beneficial only in very exceptional cases, where, perhaps,
repeated paracentesis would do quite as well. Several cases
of accident have occurred in its use. I saw one case in
which the opening had closed and left the foreign body in
the cavity of the tympanum . I saw the case but once. Dr.
Noyest reported another case, where, in attempting to insert
the eyelet, it was lodged , not in the membrana tympani, but
in the cavity of the tympanum . Eighteen days after, at the
patient's solicitation, he was placed under chloroform and the
eyelet removed by making quite an opening in the membrana
tympani. The suppuration from this, opening ceased , and the
opening closed in sixteen days. The hearing distance was
improved , from contact with the meatus, to three and one-half
inches while there was an opening in the membrane ; when
the opening closed, the hearing went back to the first-named
point. This accident of escape of the eyelet into the tym
panum is thus one quite likely to happen , either at the time
themembrane is pierced, or subsequently . The suppuration
which occurs is more apt, however, to force the membrane
into the auditory canal than into the meatus.
* Frank ’s Practische Anleitung , Erlangen, 1845, p . 310.
+ Transactions of American Otological Society ,third year, p. 57.
EXCISION OF THE MALLEUS. 331
The published experience of those who have performed this

operation do not commend it as a successful procedure, and I
believe that it is now very seldom performed .
1867.- Wreden ,* of St. Petersburg , went far beyond the
propositions to make an opening in the membrana tympani,
and excised a portion of the handle of the malleus. Inas
much as the chief vascular supply of the membrana tympani
was along the handle of the malleus, Wreden believed , and
with correctness, that, by cutting this off, there would be less
probability that the cicatrix would form . He says that, when
he removed two- thirds of the membrana tympani and the
handle of the malleus, he never saw the opening fully close .
This operation never found much favor, for the reason that it
proved to be dangerous to the hearing and even to the life of
the patient. It often excited an otitis suppurativa of so severe
a form , as to destroy the remainder of the hearing power. It
may be doubted , too, judging from analogous cases occurring
accidentally, whether even such an opening would not heal.
The regenerative power of the membrana tympani is indeed
marvellous. We need , however, spend very little time over
this operation , for it has been practically abandoned by the
imitators of Wreden , if not by the distinguished author him
self.
Voltolini, t following the suggestion of Erhard , made the
incision with the galvano-cautery, in the hope that the open
ing made in this way would be longer in closing. Hemade an
incision through the centre of the posterior section of the
membrane. There was a crackling sound, as if one passed a
knife through a tense paper. This first operation was on a
patient who had been deaf for three years , and had suffered
from fever, after which he became blind from cataract and
deaf from unknown causes, or at least unstated ones. Imme
diately after the deafness appeared , which is stated to have
been complete, he was treated by the Eustachian catheter, but
without effect.
Voltolini's first operation did not result in much if any
benefit to the patient, but it proved that an opening made by
* Monatsschrift für Ohrenheilkunde, Bd. I.
| Ibid ., Bd. I., p. 39.
332 MYRINGODECTOMY.
the galvano-caustic apparatus could be kept open longer , than

onemade by the knife. Voltolini improved the hearing of a
patient in whose membrane he had made an opening with the
galvano-cautery to such an extent, that a watch which was not
heard before the operation, exceptwhen laid upon the auricle,
was heard more than an inch , and ordinary conversation so well
that the patient, who was a shop -keeper, was able to carry on
his business . The tinnitus aurium and sensations of pressure
in the head were also removed. The painlessness of this
method makes it one to be imitated , and where we find that
the hearing is improved , as long as the opening remains in the
membrana tympani, it would be well to use the galvano -cautery.
1863. — Gruber 's operation, which he calls “ myringodec
tomy,” consists in forming a flap in the membrana tympaniby
means of a knife and forceps. The flap is cut off. Voltolini
shows that this operation is both difficult and dangerous. It
is difficult, on account of the surgeon being obliged to work
with two instruments in a narrow canal. That it is dangerous,
is shown by the histories of the cases which Gruber gives ;
e. g., one patient had fever from the 9th to the 21st of Norem
ber ; and quite severe hemorrhage during and after the opera
tion , so that the auditory canal was several times filled with
blood. Voltolini also calls attention to the fact, thatGruber's
method is but a modification of the old operations with perfo
rators ; but we may say, that all these operations are modi
fications of old ideas and suggestions. In one of Gruber's
cases, the opening still existed five months after the operation
was performed .
1868. - F . E . Weber, of Berlin ,* recommended the division
of the tensor tympani muscle, and the “ abnormal adhesions
that may occur in the region of this muscle .” One of the
chief indications is the relief of pressure upon the labyrinth
from retraction of the tensor tympani. This muscle bas its
origin from the cartilaginous portion of the Eustachian tube,
and runs along the edge of the bony canal, and is inserted by
a well-defined tendon on the inner angle and inner surface of
the handle of the malleus.
* Monatsschrift für Ohrenheilkunde, Jahrgang II., p. 51.

DIVISION OF TENSOR TYMPANI. 333
Weber thus advanced far beyond the idea of maintaining a

permanent opening in the membrane, and carried into effect
an old idea of dividing abnormal adhesions that may form
between the ossicula . *
Dr Weber published an article in January, 1872 , in which
he goes very fully into the object, effect, and manner of per
forming his operation. It is well known that the great Vienna
anatomist, Hyrtl, was the first to suggest this operation, but
Weber was the first to perform it. At the time of the publica
tion of Weber's last article he had operated upon about fifty
cases.
There were two conclusions which led Weber to the per
formance of this operation : 1st, The fact that had been
demonstrated that the tensor tympani muscle kept not only
the membrana tympani and the ossicula with their ligaments ,
but also the labyrinth , by means of the stapes, in a state of
tension, and that, consequently, an increased tension or
rigidity of the muscle prevented the proper conduction of
sound and increased the pressure upon the labyrinth . 20, He
also reasoned that this increased tension would of itself ex
cite and maintain catarrhal inflammation of the tympanic
cavity, especially if there was at the same time an affection
of the tube, and that it might cause a hinderance to the cir
culation in the labyrinth , with tinnitus aurium , etc. In short,
Dr. Weber thought it possible that many varieties of non
suppurative affections of the middle ear might depend upon
excessive contraction of this muscle .
The instrument which Dr. Weber uses for the operation
is exactly figured in the accompanying engraving. A short
and thin hard rubber speculum is used so that there may be
as much room as possible for manipulation . The head is
fixed by a head-holder, to which an otoscope is attached ; the
head may, however, be held by an assistant.
The tenotomy is divided into four stages
1. The membrana tympani is perforated with the hook
shaped extremity of the tenotome, about 1 – 1 mm . in front
* L. C., Jahrgang IV., p. 143.

334 DIVISION OF TENSOR TYMPANI.
FIG . 69.
Weber's Knife for dividing the Tensor Tympani Muscle .
of the handle of the malleus, somewhatbelow and to one side

of the short process.
2. The book -shaped knife is pushed forward into the cavity
of the tympanum — the handle of the instrument being brought

downwards and forwards — and thus it is made to grasp the
tendon . (Just how the operator is to know when the hook is
around the tendon , I am unable to learn from Dr. Weber's
description . I suppose, however, from previous familiarity
with the operation on the cadaver.)
3. While the hook is about or over the tendon , the opera
tor exerts a gentle, drawing pressure upon it, by turning the
handle of the tenotome towards the face of the patient ; the
hook is then turned a third upon its axis, by means of the
button which acts upon the cog, and the tendon is cut. A
distinct crackling sound is heard at the moment of the divi
sion of the tendon .
4. The hook is then brought away from its position by
reversing the action of the button which acts on the cog, and
the instrument is withdrawn.
Dr. Weber at a later date gives the results of his operation
in nine rather ponderous formulas, but they may be summed
up in the statement that it is claimed that the operation, in
most cases for which it is properly performed , diminishes
tinnitus aurium , vertigo, prevents many persons from be
coming absolutely deaf, and that, if a permanent result is
desired , fluid must afterward be regularly forced into the
cavity of the tympanum , by means of a Weber's pharmaco
koniantron.
Weber has reported cases which confirin his view of the
benefit from the division of the tensor tympani. It will be seen,
by reading these cases, that he follows up the operation by
the most decided treatment of the middle ear, thus placing
this operation where, I believe, all perforations of the mem
brana tympani should be placed, as one of the means of
assisting in the thorough medication of the middle ear by in
jections of fluid and air. Although there is usually a tempo
rary effect from the letting up of the intra-auricular pressure,
it cannot be compared to such an operation as iridectomy for
glaucoma, when the use of the knife ends the treatment.
Gruber, in a lecture recently delivered, advocates the divi
sion of the tensor tympanimuscle,on account of the fact demon
strated by Helmholz, that this muscle moves the whole chain of
the ossicula auditus, as well as the malleus, inward , a factwhich

causes us to believe that the intra -auricular pressure must be
increased and morbid changes caused by any excessive con
traction of this muscle. Gruber calls attention to the fact
which he was the first to show , as he claims, that the muscle is
inserted not only on the inner angle, but also on the anterior
surface of the handle of the malleus, and he also alludes
to what we have already noticed in the chapter on the ana
tomy of the middle ear, that the tensor tympani is intimately
connected or united to the tensor palati muscle. This seems
to indicate that the frequent affections of the soft palate
must have some abnormal influence upon the tensor tympani.
Gruber considers the indications for a division of the tensor
tympani to be a retraction or contraction — a shortening of
this muscle. These indications may be known' by studying
the changes on the folds or pockets of the membrana tym
pani.
" If the membrane is drawn very much inward, and the
lower end of the malleus goes with it, while the upper retains
its position, and thus the posterior fold becomes more prom
inent, we have an indication of the abnormal sunken position
of the drum -head .” Gruber admits that this sinking of the
drum -head may depend upon other causes than the retraction
of the tensor tympani; but these may be readily distinguished.
The excessive contraction of the muscle causes the handle of
the malleus to appear broader, and the membrana tympani to
look as if twisted, in a state of what in surgical language is
called torsion . The anterior ligament of themalleus, which
passes from the spina tympanica to the neck of the malleus,
also becomes more prominent, in retraction of the tendon of
the tensor tympani. The finalmark of retraction of the mus
cle, according to Gruber, is the more or less rapid reposition
of the membrane in its former position after the air-douche
has been employed . It is certainly very easy for us to verify
these indications, as given by Gruber, and it is to be hoped
that the operation will have a fair trial in the class of cases
* Seperat-abdruck aus der Allgemeinen Wiener Medizinischen Zeitung,

Jan., 1872.
of non -suppurative disease, for which we have as yet done so
little.
Gruber advises that the tendon be usually divided as
Weber recommends, in front of the handle of the malleus.
FIG 70.
Gruber's Knife for dividing the Tensor Tympani.
The accident that may possibly happen , if the membrane is

opened posteriorly to the malleus, according to Gruber, is a
perforation of the carotid artery, if the carotid canal be incom
plete in its bony wall; but this kind of an accident seems to
be almost impossible, with any care in themanagement of the
22
tenotome. As another argument for the anterior incision, it

is stated , that the labyrinth cannot be entered if the opening
be made in front of themalleus, while the knife might possi
bly go through the foramen ovalis, if the opening be made
posteriorly. Gruber uses a much simpler instrument than
Weber's for the division of the tendon, and one which , in
my judgment, is much more practicable. It is represented
on the preceding page, and consists of a narrow , needle -like
knife, fastened in a handle at an obtuse angle. The knife is
three inches long , and has a blade cutting only on the anterior
edge . This cutting edge is ground to a point, and curved to
such an extent that, when the instrument is passed one-half a
millimetre in front of the malleus, through the membrana
tympani, the shaft of the needle stands parallel to the long axis
of the auditory canal. The point of the knife reaches only a
little above the inner margin of the handle of the malleus, but
does not pass far beyond the posterior segment of the mem
brana tympani.
The pain from the operation of division of the tensor tym
pani is not usually very great, and it is seldom necessary to
etherize a patient for the purpose of performing it. Gruber
performs the operation in cases of what he terms hypertrophic
or plastic inflammation of the middle ear (proliferous inflam
mation), where the ordinary treatment has failed to benefit
the case. The head of the patient is held by an assistant, the
drum -head well illuminated ,and the tenotomeis passed through
the anterior segment of the membrane, and by turning the
outer end of the knife towards the face ofthe patient, the point
is pushed around the handle of the malleus to the other seg.
ment of the drum -head. The incision is then elongated about
three millimetres, while the knife is held in the same position ,
and then withdrawn. There is considerable resistance in the
tissue when the tendon is divided, and a crackling sound is
heard. The hemorrhage from the operation is usually very
slight. The air-douche, by the catheter or Politzer's method,
should be used after the cutting is finished,and the ear closed
lightly with cotton , while the patient should be kept quietly in
the house and avoid taking cold .
Those who doubt whether it is possible to divide the ten
INCISION OF POSTERIOR FOLD . 339
don without also cutting other parts , will have their doubts
removed by performing the operation on the dead body accord
ing to the directions of Weber or Gruber, and then making
an examination of the parts.
Dr. Orne Green recommends that Gruber's operation be
done by making the incision posterior to the handle of the
malleus, and with a little broader knife.*
The results of the division of the tendon are as yet not
remarkably brilliant ; but I think this is due to the fact, that
cases are taken when many more changes than retraction of
the tendon have occurred, and when the condition of the mid
dle ear is beyond all therapeutic aid . It having been demon
strated that the operation is a safe one, and that it usually
has a temporary beneficial effect, especially in diminishing the
tinnitus aurium , and that it sometimes does substantial bene
fit, we may, I think , hope more from it in the future, when it
will be undertaken at an earlier stage of disease of the middle
ear. If thus performed, and followed up by treatment of the
middle ear through the Eustachian tube, I think we may hope
for substantial results from it.
1871. — Lucae, of Berlin , divided the posterior pocket or
fold of the membrana tympani, in what he terms “ dry catarrh
of the middle ear ” (proliferous inflammation ), where there is
a marked sinking inwards of the handle of the malleus, and
great prominence of the short process , and when the Eusta
chian tube is permeable.f Lucae uses a bayonet-shaped
needle, and the incision is made from below upwards, in order
to avoid cuttingthe chorda tympani. If this nervebedivided ,
it is probably not a serious accident, judging from cases
of injury to the drum -head in which the chorda tympani has
been injured. Of 109 cases operated upon by this method,
Lucae claims to have greatly benefited 46, and to have
improved 39, while in 24 there was no benefit from the
operation .
A question of priority has arisen between Dr. Lucae and
* Dr.Green has some preparations made by himself in Wedl's laboratory
in Vienna, in which the fact that the tendon is exactly and cleanly divided
in his operation is clearly shown.
+ Seperat-abdruck aus der Berliner Klinischen Wochenschrift, 1872, No. 4
340 PROUT'S OPERATION.
Professor Politzer in regard to the performance of this opera
tion , but the author will not venture to discuss this subject.
72 Politzer performs the same operation , in order to
render the membrane more movable, under the name
of the incision of the posterior fold of the membrana
tympani. The incision is a longitudinal one, at right
angles to the long axis of the fold , between the short
process of the malleus and the peripheric end of the
fold.*
1870.— Voltolini advised the use of a probe, which
is introduced daily in an opening made by the gal
vanic cautery, for some weeks after. I am not able to
say whether Voltolini has found this method a certain
means of maintaining an opening, but I am inclined to
think not, from the fact that so little is heard from
him on the subject.
Dr. Prout, of Brooklyn , divides adhesions between
the membrana tympani and the promontory with a
very small iridectomy-knife, having a long handle.
His principle of operation is, to divide the adhesions
according to their situation . I have seen him perform
the operation in two cases.
In the first case † the membrana tympani was very
much sunken, and an adhesion to the promontory had
occurred, as shown by an opaque, yellow , immovable
spot on the corresponding point of the membrane. In
performing the operation, Dr. Prout used a knife such
as is here represented .
“ The blade is bent on the flat at an angle of forty
five degrees ; it is triangular in shape, about one and a
half lines long, and three-fourths of a line broad, sharp
at the point and cutting at both edges. The shank is
three inches long, of which the inch next the handle is
not tempered, that it may be bent to any desired
Prout':
Knife . angle . The handle is eight-sided, that it may be
* Translation of Politzer's Lecture,by Dr. Burnett, Philadelphia Medical
Times, vol. ii., No.56.
+ Myringectomy, followed by a decided improvement in the hearing power,
in a case of adhesion between the membrana tympani and the promontory .
Transactions of the Medical Society of the State of New York , 1872.
PROUT'S OPERATION . 341
rotated between the thumb and finger in using it, and is two
inches long."
The patient was 33 years of age, a teacher by occupation,
and had been treated by Dr. Prout for some time previous to
the operation, for advancing non - suppurative inflammation of
the middle ear, but in spite of the use of the catheter, Polit
zer's method, and of the posterior nares syringe, the patient
continued to grow steadily worse as to her hearing , and the
tinnitus aurium became so unbearable as almost to unfit her
for her daily duties.
On October 3 , 1871, the patient was placed under the influ
ence of ether , and Dr. Prout having illuminated the ear by
means of the otoscope upon a forehead band , entered the
knife in frontofthe adhesion, and cut around the promontory ,
with which the end of the handle of the malleus was in con
tact. By means of “ a little cutting , picking, and teasing, a
free opening was made of about one and one-half lines in
diameter.” An attempt was made to remove the piece ofmem
brane adherent to the promontory ; but the operator was not
certain that he succeeded . As soon as the patient recovered
from the ether, she said that she heard better. The warm
douche was used to quiet the pain , which was not severe, how
ever. The hearing power for the voice was much improved
by the operation. The patient was able to hear reading and
conversation at thirty feet in front of her, while before she
could on one side only , and then at ten feet. There was a
slight purulent discharge for about a week after theoperation ;
but no very severe pain . One year after the operation the
opening in the membrana remained of the original size ; the
cavity of the tympanum was dry ; the watch was heard when
pressed upon the auricle— before the operation it was not
heard at all - ordinary conversation was readily heard at the
distance of twenty feet.
Dr. Prout thus succeeded in maintaining what may fairly
be called a permanent opening in the drum -head, and in giv
ing great relief to the patient. His operation of dividing
adhesions, wherever they may occur, is one on the same prin
ciple as that of cutting out a piece of iris in cases of posterior
synechia , and certainly forms a basis for future experience.
342 HINTON 'S OPERATION .
The notes of Dr. Prout's second operation have not yet been
published.
1869. — Mr. Hinton, * of London, believes thatmucus dries
up and becomes dense in the cavity of the tympanum , and
thus becomes a cause of “ confirmed deafness.” He therefore
incises the membrana tympani in order to remove this har
dened mucus.
Mr. Hinton's operation consists of an incision in the mem
brana tympani, through which fluid is injected into the cav
ity of the tympanum and Eustachian tube. The incision is
made with a lance- shaped knife, in the inferior and posterior
quadrant of the drum -head , and is from two to three or even
more lines in length . The syringing is done with some force,
in order to drive out of the cavity , into the Eustachian tube
and pharynx, dried or inspissated mucus, the collection of
which, in many cases, according to both pathological and clin
ical experience, is the cause of the impairment of hearing and
the tinnitus. I bave seen Mr. Hinton perform this operation ,
and two cases upon which it had been performed some time
before. In both these cases the patients were confident that
there was an improvement in the hearing, and a lessening
of the disturbing symptoms for some months after the oper
ation .
The process of washing out the cavity of the tympanum ,
upon which Mr. Hinton lays great stress, is done by means of
a syringe fitting hermetically into the external meatus. A
solution of bicarbonate of soda is used . The syringing,which
I did on one occasion at Mr. Hinton 's clinique at Guy 's Hos
pital, London, immediately after Mr. Hinton had performed
the operation , sometimes causes vertigo, which passes away
in a few moments .
Mr. Hinton once divided the chorda tympani nerve in per
forming the operation of incision of the membrane. “ The
patient felt a sudden shock running down the tongue, the cor
responding side of which suffered an impairment alike of gen
eral and of special sensibility in its whole extent. The patient
began to recover in two or three days." The most frequent ill
* On Mucous Accumulations within the Cavity of the Tympanum , from
the Guy's Hospital Reports, 1869.
HINTON'S OPERATION. 343
effect is an inflammation of the external auditory canal; when

this is apprehended the ear should be syringed through the
Eustachian tube instead of the meatus.
Mr. Hinton performs his operation in sub -acute or quite
recent cases of accumulation of mucus in the cavity of the
tympanum , as well as in those of long standing, such as
have formed the subject of discussion in the preceding chap
ters. I confess to a little skepticism , however, as to the fact
of inspissated mucusbeing the sole cause of the impairment of
hearing in many of the chronic cases. The post-mortem ex
aminations of ears, whose function was much impaired for a
long time, that have as yet been made, do not reveal this as
the only lesion in many cases ; yet I think the operation is a
good one, for it affords an opportunity of medicating the tis
sues of the middle ear.
My own experience in perforations of the membrana tym
pani has been chiefly in the manner of Schwartze and Hinton ;
that is to say, I have made simple paracenteses or openings
into the membrane, and followed them up by treatment of the
diseased membrane of the middle ear. Paracentesis seems to
me a perfectly safe operation ; it is comparatively painless,
and is certainly an adjuvant in the treatment of chronic non
suppurative inflammation . My results are not as good as
Prof. Schwartze's, perhaps because I have been in the habit
of treating many of the cases that he treats by paracentesis,
by simpler means.
It should be added to what has been said , that the para
centesis that is performed in chronic cases should be a larger
one than the puncture made in a bulging membrane, to give
exit to blood or pus.
From the experience which I have had, and from a careful
consideration of the recorded experience of others, I think we
may conclude
I. That paracentesis, or incision of the drum -membrane in
chronic non -suppurative inflammation, is by no means a dan
gerous or painful procedure .
II. That its chief value is in furnishing a means of treat
ing the lining of the middle ear.
III. That it may properly be performed in cases of chronic
344 INDICATIONS FOR PERFORATION OF DRUM -HEAD .
proliferous inflammation, that are still advancing in spite of

local treatment through the Eustachian tube.
IV . Division of the tendon of the tensor tympani, and
division of the adhesions existing between themembrana tym
pani and the walls of the cavity of the tympanum , are opera
tions that deserve a trial, in cases of chronic inflammation of
the middle ear, with symptoms of increased auricular press
ure, not relieved by a fair use of the ordinary means.
In the choice of an instrument for a simple paracentesis, it
seems to me too much has been said . For Weber's opera
tion , Gruber's knife seems to me the best, and for Prout's
operation peculiar instruments are required , which will vary
according to the situation of the adhesions, their size, and so
on ; but for the ordinary paracentesis , whether we require a
long or short incision, a puncture or a flap, an ordinary cata
ract-needle will do very well. Those who prefer an angular
instrument will find Blake's knife, that which is attached to
his modification of Wilde's polypus snare, (which should be
lengthened in the shank, however,) one of the best. The use
of an anæsthetic is not at all necessary , except where adhe
sions are to be divided , and the dissection is to be therefore
prolonged. Some of theGerman authors find the membrana
tympani very sensitive, even under chloroform ; but Ihave usu
ally found it so easy to make a perforation with very little pain
- pain so trilling that it is forgotten in a moment— that I am
at a loss to conceive any other reason why the membrane
should be so sensitive in their cases, than the fact, well known
to American surgeons, that Continental practitioners, who
invariably use chloroform and not ether , as we do in this
country, are so timid in using an anæsthetic, that, very often
they do not place their patients in a condition that we would
consider one of anæsthesia . The patient's head should have
a good rest, and the otoscope be used on a forehead band, so
that both hands may be free. In ordinary perforations for
the purpose of washing out the cavity, the posterior and infe
rior quadrant is, perhaps, the best position for the incision .
Some of the instruments formerly recommended for perforation of the
membrana tympani, were probably never actually used - such as one very
like a cork-screw , and a red-hot trocar. Cooper employed a small trochar in a
EFFECTS OF CONDENSED AIR . 345
canula , the point of the trochar projecting at the most, one and a half lines.
Since the rigid canula would be apt to hurt the membrana tym pani, upon
which it was pressed before the trochar was pushed forward, Saissy used a
canula of elastic wood , which caused no pain. Itard punctured the membrane
with a blunt probe. Richeraud recommended that the opening be maintained
by the subsequent use of the pure nitrate of silver, in solid form ; but I have
found the use of this caustic, one of the most effectual means of closing an
opening from an old suppurative process.*
THE EFFECTS OF CONDENSED AIR UPON THE HEARING POWER .
From some peculiar, but unexplainable tendency in the

human mind , to believe in marvellous cures from means not
usually employed by those who make the practice of medicine
their duty in life, we occasionally hear of persons who have
had their hearing restored by entering and remaining in cham
bers — such as the caisson used in bridge building — where the
air is condensed , or from a stay in the so-called pneumatic
cabinets. The exact observations of Magnus, A . H . Smith,and
Green of St.Louis, show that these accounts of cure of chronic
non -suppurative inflammation are not based on facts . On this
subject, Dr. Smitht says, “ Three cases of extreme deafness
came under my notice ; two of them in laborers, and one in the
person of a gentleman who was advised by a physician to visit
the caisson in the hope that hemight receive benefit from the
action of the compressed air . In all these cases the hearing
was very much improved while in the caisson , but on return
ing to the open air, the former degree of deafness immediately
reappeared .” I saw the gentleman to whom Dr. Smith refers,
and diagnosticated his case as one of chronic proliferous
inflammation of themiddle ear.
It might as well be claimed that deafness is cured by
riding in a railway carriage, because the hearing is tempo
rarily improved while the patient is there, as to assert that
a cure is found in condensed air because persons who enter
* The most complete account of the instruments used or recommended
for perforation of the membrana tympani by various authorities, is found in
Beck 's Krankheiten des Gehororganes. Heidelberg and Leipzig , 1827, p. 45.
+ The effects of high atmospheric pressure, before quoted in Chapter X .
346 EXHAUSTION OF AIR FROM DRUM -HEAD .
an air -chamber when the atmosphere is condensed, hear better

during their stay.
The only conceivable means by which a sunken drum -head
could be improved in position and conducting power, by re
maining in a chamber of condensed air , would be the rupture of
the membrane from the force of the air, or the opening of the
tubes by the patient's efforts to overcome the pressure. Cer
tainly these ends can be accomplished in a simpler and safer
way .
Dr. Smith found, however , that sounds, such as the ticking
of a watch , were not heard more, but less distinctly in the
condensed air of the caisson ; a fact which he accounts for by
supposing that the great pressure on all parts of the auditory
apparatus opposes a mechanical obstacle to the freedom of
vibration . “ At the same time the velocity of the waves of
sound is greater, and hence the pitch is higher. A deep bass
voive is changed to a treble , and the prolonged , heavy sound
of a blast is so modified as to resemble the sharp report of a
pistol."
Magnus* says that the conduction of sound is better in
compressed air, and that we can hear the same tones better
than in the ordinary atmosphere, provided that the membrana
tympani is not placed in an abnormal condition — that is, an
over pressure allowed upon it.
EXHAUSTION OF THE AIR FROM THE DRUM - HEAD.
Politzer, recommends the exhaustion of the air in the ex

ternal auditory canal, by plugging the meatus with a bit of
cloth , saturated with fat, as a means of drawing out a sunken
drum -head , when we have reason to believe that the tensor
tympani is retracted . Experience has not shown this to be a
very efficientmeans of treatment.
Siegle's otoscope, or pneumatic speculum , which has
already been described , as a means of diagnosticating adhe
sions between themembrana tympaniand the walls of the tym
** Archiv für Ohrenheilkunde, Bd I., p. 280.

RESULTS OF TREATMENT. 347
panic cavity , has lately been much used by Dr. H . Pinkney,*
assistant-surgeon to the New York Eye and Ear Infirmary,
as a means of breaking up adhesions in the tympanic cavity ,
and of improving the hearing. Dr. Pinkney attaches the
syringe of a stomach -pump to the apparatus, and exhausts the
air by the use of this instrument. The membrane should be
carefully watched during the process, lest too extensive ecchy
mosis or a rupture occur. I have employed the apparatus in
cases of chronic proliferous inflammation , at Dr. Pinkney's
suggestion, but as yet with no very decided results. I have
also cupped the membrana tympani, and auditory canal, by
placing a cup over the auricle , and exhausting the air by
means of a syringe ; but with no beneficial result.
RESULTS OF TREATMENT.
I began this subject with the statement that the greater
part of the reproach that had been cast upon the therapeutics
of aural disease, in justice applied only to the non-suppura
tive affections of the middle ear. Excluding the diseases
of the labyrinth , which are happily much more rare than
those of any other part of the ear, it is just this class of cases,
that have now been considered - non -suppurative inflamma
tion of the middle ear — that are most intractable . But when
all this is said , before the unpleasant statistics of results are
presented, a few words of explanation should be made. These
affections are pre-eminently local in their character ; that is to
say, a person with this variety of aural disease may have the
best general treatment the world affords, and be under the
most appropriate hygienic conditions ; he may live in a climate
like that of Nice , Mentone, Naples, Aiken , or St. Augustine,
and then he will not recover from his aural disease , nay,more,
he will continue to grow slowly but gradually worse if his
pharynx, Eustachian tubes , and middle ear, are not treated
by the appropriate appliances and remedies.
Until ten years ago there was scarcely a medical college in
the land, except the University of New York , where Prof.
* Verbal communication .
348 RESULTS OF TREATMENT.
Post taught otology in his course of surgery, where diseases

of the ear were even lectured upon with any fulness and correct
ness. And even now , attendance upon the otological course
of our colleges is entirely a voluntary matter with the student.
The result is, that the large mass of general practitioners
know nothing of the rational treatment of aural disease, and a
person who cannot afford to stay in a large city or town
where there is a surgeon who practices otology,must go with
out treatment. Thus many, very many promising cases, from
which good results might be obtained, are never treated .
They are, perhaps, diagnosticated, but, inasmuch as the vic
tims of them are surrounded by, and cannot get away from ,
those who “ never meddle with the ear,” they go down to
their fate .
The following table gives the results of the treatment of
four observers. I can only account for the fact that my per- .
centage of cures is less than the others, from the supposition
that I have seen a proportionately larger number of neglected
cases than falls to the lot of other practitioners. It will be
observed, however, that my cases show a larger percentage
of improvement than those of the other observers . I have
been very careful in the tables of results of treatment that
I have published, to make the standard of cure very high.
Those only are classified as “ cured,” in which the hearing
was restored to a normal condition as tested by the watch , the
tuning -fork , and ordinary conversation . Judged by the ordi
nary use of the term cured , this standard is too high. It is
higher, for example, than that in ophthalmic practice, where
the removal of a cataractous lens, so that the patient gets
sight enough to read coarse print, is called a cure of the
cataract, although the vision obtained may be only two-thirds
of that enjoyed by a person who has never had cataract. In
the same manner we speak of curing a bone affected with
necrosis, by removing the diseased portion , even if consider
able deformity be left. If a patient who has suffered for
months or years from a morbid process in the cavity of the
tympanum , recorers to such an extent that the hearing power
is greatly increased , although it may not becomenormal, he
would be said to be cured , under a standard no higher than
RESULTS OF TREATMENT. 349
that usually adopted in medical statistics, but I have preferred
in my table to put such cases underthe head of “ improved.”
TABLE
Showing the Results of the Treatment of Chronic Non-suppurative Inflam
mation of the Middle Ear.
No. or
REPORTER.
REPORTER. CASES. SE CURED.
CURED. IMPROVED
IMPROVED.. UNIMPROVED.UNKNOWN
* Spencer (St. Louis).. 56 6,of those
169 peractu
ct. 18, 50 pr ct. 10 , 27 pr ct. 20
ally treated.
+Schwartze (Halle)... 23 30 , 20 pr ct. | 94, 60 pr ct. 30, 20 pr ct.
Gruber (Vienna) .... 187 38, 32 pr ct. 61, 60 pr ct. 9, 9 pr ct.
Roosa (New York)...| 514 23, 44 pr ct. 160, 31 pr ct. 171, 34prct. 159
* Reprint from St. Louis Medical Journal.

+ Archiv für Ohrenheilkunde, Bd. I.- V ., passim .
# Monatsschrift für Ohrenheilkunde, Bd. I.- IV., passimo
CHAPTER XV .
ACUTE SUPPURATION OF THE MIDDLE EAR .
ACUTE suppuration of themiddle ear commonly occurs as

a direct and recognized consequence ofan acute catarrh of the
same part. A catarrhal process is unchecked, and passes on
to a suppurative one. In some cases, however, the catarrhal
inflammation is unobserved — we cannot, however, say that it
does not occur — and the first intimation of any morbid action
given by the ear is a discharge of pus from the auditory canal.
I have seen several cases where the patients have assured me
that the first idea that they had of trouble in the ear,was the
moistening of the canal from the flowing out of the pus. An
examination of the ear in such cases has always revealed a
perforation of the membrana tympani. We probably never see
a discharge of pus from the surface of the auditory canal, with
out previous intimation, by pain or swelling, that an inflamma
tion of the part had occurred . It is my belief, however, that
the cases of sudden and painless perforation of the membrana
tympani are nearly always preceded by some premonitory
symptoms, such as pharyngitis, feelings of fulness in the ear,
impairment of hearing, etc . ; but that the failure to notice
them is usually to be attributed to carelessness in observation,
and to be regarded as another indication of the common indif
ference to an inflammation of the ear, that is not positively
painful.
Then, again , there are cases where pain is felt long before
the pus is discharged, but where it is mistakenly referred to
some other part of the body. Neuralgia of the head, is a
diagnosis often incorrectly made for the first stages of acute
catarrh of the middle ear.
It is not to be denied, however,that there are cases of
ACUTE SUPPURATION OF THE MIDDLE EAR. 351
acute suppuration of the middle ear, where the initial symp

toms of swelling of the lining membrane of the Eustachian
tube and cavity of the tympanum are so quickly passed over,
in a few hours , or even minutes, as to be practically unrecog
nizable .
Such a course of the disease is frequently observed in
phthisis pulmonalis, where a membrana tympani will some
times break down from an accumulation of mucus behind it,
and go on to suppuration without a trace of pain .
The usual origin ofacute suppuration is, however, a violent
one. The severe pain of acute catarrh is unrelieved , pus is
formed in the cavity of the tympanum , the lining of the mas
toid cells is very much distended , the outer surface of the pro
cess becomes red, tender, and painful, the head throbs, and the
whole system is seriously disturbed. In young persons delirium
occurs, and in all subjects, there is general febrile excitement,
and the condition of the patient is one of intense suffering.
There is probably no more severe pain to which the human sys
tem is liable, than thatdue to the distension of the little space
called the cavity of the tympanum by mucus, serum , or pus.
Symptoms. The symptoms, then, of this disease are usu
ally pain in the ear and head, constitutional disturbance in the
way of febrile action , with impairment of hearing, and tinni
tus. The membrana tympani also exhibits marked changes
in appearance.
But the pain may be entirely absent, as we have seen, and
yet the inflammatory process, because it is sudden in its
origin , be fairly entitled to the adjective acute. The cases of
the painless form of acute inflammation , in persons suffering
from phthisis pulmonalis before alluded to, are not as amen
able to treatment as the more acute cases. I suppose this fact
is partly to be attributed to the failure in the general nutrition ,
and also to the contiguity of a diseased mucous membrane,
which is constantly acting as an exciting cause of trouble in
the pharynx and Eustachian tube.
Themembrana tympani has usually lost its naturally trans
parent appearance in a case of acute suppuration. It has a
boggy , sodden, or swelled appearance, and has none of its nor
352 ACUTE SUPPURATION .
mal distinguishingmarks in the way of light spot and handle of

themalleus. Yet this is notalways the case. Ihave seen cases
where the transparency of the drum membrane was almost
unimpaired, and the accumulated pus and mucus which were
bulging it out, could be seen through it. In one case , that of
a young lady, I found pus not only in the cavity of the tym
panum , but also between the mucous and fibrous layer of the
drum -head. The pus moved when the head was moved.
She recovered, with perfect hearing power, and a sound
membrana tympani, without an artificial or spontaneous per
foration of the drum -head. The treatment resorted to was the
use of leeches, a gargle, and Politzer's method . There was
considerable pain at the outset, but not the intense pain
which is usually one of the characteristics of acute suppura
tion. The patient visited my office daily during the whole
course of the disease, which occurred in the mild weather of
spring. ,
It is possible that some cases of so -called abscesses of the
membrana tympani,should be regarded as examples of limited
suppuration in the tympanic cavity. I have not as yetseen any
cases, where it seemed to me thatan abscess was confined to
the layers of the drum -head , without any communication with
the cavity of the tympanum or the external auditory canal. It
should be added , that the osseous portion of the bony canal is
often found to be very much inflamed , in conjunction with the
symptoms in the membrana tympani, the cavity of the tympa
num , and the mastoid cells. I may be pardoned for reminding
the student,that it is often impossible to draw the line between
the affections of the three parts of the ear. Their anatomical
connections show that they must of necessity run into each
other, however distinctly they may be separated in their ori
gin . It is rather a predominance than an exclusive localiza
tion of symptoms in a part, that gives rise to an exact classifi
cation of disease. For example, an otitis media , in a young
child , may very readily and rapidly pass on to an otitis in
terna, or inflammation of the labyrinth, and give us much
difficulty in deciding which was the original affection.
Causes. — The causes of acute suppuration of the middle
CAUSES OF ACUTE SUPPURATION . 353
ear are the same as those that have been enumerated in the
chapter on acute catarrh. The chief one is , exposure to cold
- inflammation of the naso -pharyngeal mucous membrane
being the usual starting point.
The violent use of the posterior nares syringe in an acute
or sub-acute catarrh , will also in very rare cases set up acute
suppuration in the tympanic cavity ; at least I have seen
it do so in one case, which was the following : A physician,
aged 27, had suffered for years from chronic naso -pharyngeal
catarrh . During the winter of 1872, he was attacked with
acute coryza and pharyngitis. He had once used the nasal
douche for a similar attack, and it caused such severe symp
toms that he was obliged to desist from it. I was in the
habit of using the naso-pharyngeal syringe for him at irreg
ular intervals, in order to relieve the chronic naso -pharyn
gitis from which he suffered . On visiting him one afternoon ,
when he was suffering from the acute attack, his nostrils
felt so full of secretion that he requested me to use the naso
pharyngeal syringe, which I did , injecting a lukewarm solution
of chlorate of potash. The bulb ofthe instrument caused some
gagging as it came in contact with the swelled wall of the
pharynx. In an hour or two he was attacked with acute aural
catarrh of the left side, which, in spite of the most energetic
treatment by means of leeches , went on to suppuration before
morning. Under appropriate treatment the patient recovered ,
with a sound drum -head , and with the hearing power as great
as before the attack .
The fact has already been mentioned that sea-bathing
sometimes becomes a cause of acute catarrh. In the same
manner , want of caution in protecting the side of the head
from the force of the waves, or the canal from the entrance of
water,may produce acute suppuration.
Scarlet fever, measles, diphtheria , tonsilitis, bronchitis,
pneumonia , and whooping -cough, play an important part in
the production of acute aural disease, and usually , the suppu
rative form is the one first recognized , although , as has been
said , there is probably almost always an unobserved stage of
themilder variety of inflammation .
Injuries of the side of the head , and of tbemembrana tym
23
354 ACUTE SUPPURATION - COURSE .
pani, are causes of acute suppuration of the middle ear of a

very severe nature. This subject, has, however, been discussed
in the chapter on Injuries of the Membrana Tympani.
Course. — The course of acute suppuration is usually violent

until perforation of the drum membrane occurs ; when it opens
- at times with quite a loud explosion - relief to the severe pain
is usually experienced . If no measures are taken to remove
the accumulated pus, and to check its formation, the impair
ment of hearing will continue, although the pain and tinnitus
may be relieved , and we shall soon have a case of chronic
suppuration of the middle ear, and the patient be liable to all
the fearful consequences of this disease. In rare cases, pus
may escape, however, into the Eustachian tube, and the case
go on to resolution with no perforation of the drum -head.
This is more apt to occur in children than in adults.
In the worst event of all, the suppuration may extend into
the brain or the circulation. It may pass through the thin ,
and sometimes porous lamella of bone which forms the roof of
the cavity of the tympanum , or it may go beneath into the
jugular vein , and thus produce blood poisoning or premia
It may also extend to the labyrinth.
The mastoid process is of course always more or less
involved in acute suppuration, or even in acute caiart is
cells form , as the anatomy shows us, an integral part of the
middle ear. Disease of the mastoid process is als a Linger
ous complication ; but for a full discussion of the cat I
beg to refer the reader to the consequences of a SIE
puration .
Under appropriate treatment, howerer, the secream ti
pus usually soon ceases , the membrane closes ung
is restored , and scarcely a trace is seen either sum
ical structure or the functions of the organ ,d ses
which has raged so violently.
With a want of logical reasoning that is recte .NDE
practitioners invite suppuration of thedir e
case of acute catarrh , or “ pain in the ear. Din
that nothing can be done for the hearing m
tympani is once perforated. Our aim DSsis 2
ACUTE SUPPURATION — TREATMENT. 355
prevent or limit suppuration in the ear, but if it do occur, and
even if a large portion of the drum -head be swept away, we
may usually, if the ossicula be left, by prompt, energetic, and
patient treatment, restore it, and with it, the hearing power.
It should be observed, that diffuse inflammation of the ex
ternal auditory canal is often a troublesome complication
in the course of an acute aural suppuration with perforation .
It is probably caused by the irritation of the pus in the audi
tory canal, and perhaps in some cases by the excessive mani
pulation for the purpose of cleansing the ear. Such a com
plication is sometimes embarrassing ; for it may prevent us
from continuing the astringents which are indicated for the
relief of the suppuration .
Treatment. If the case be seen in the earlier stages — that
is, when the pain is still present, and the membrana tympani
is intact— two or more leeches should be at once applied, and
if the appearance of themembrana tympani indicate that it is
about to rupture, or if the pain be not quickly subdued by the
use of the leeches, a paracentesis of the membrana tympani
should be at once performed in the most bulging portion of
the membrane. If the mastoid be red, tender and swelled, it
should be atonce incised down to the bone, except in the case
of young children , where the more yielding nature of the
integument and the periosteum will admit of some delay. If
the mastoid process be simply red and tender, but not swelled ,
the use of leeches will probably subdue the inflammation
without an incision.
The ear should be douched very often, say every half hour,
with lukewarm or hot water, the temperature of the water be
ing determined by the patient's feelings. This procedure the
patient will usually find very grateful. In case of the absence
of a douche,warm water may be dropped into the ear from the
sponge, a procedure as old as the time of Hippocrates. A
douche may be extemporized by the syphon arrangement, of
a bit of rubber tubing in any kind of a vessel that will contain
water. At the same time, especially if the weather be cold , the
patient should be kept in his room , and perhaps in bed, while
pedeluvia and diaphoretics are employed .
356 ACUTE SUPPURATION — TREATMENT.
If the membrana tympani have ruptured , the pus should

be removed at least twice a day, by careful but thorough
syringing. At the same time, Politzer's method of inflating
the ear should be practised. This latter procedure gives no
pain when carefully done, i.e., when the bulb is not too vigor
ously pressed. It at once improves the hearing, helps to
cleanse the ear, and prevents the formation of adhesions in
the cavity of the tympanum , and gives the patient hope and
confidence.
The throat should be kept free of secretion by a gargle.
The chlorate of potash in a saturated solution is the one I
usually use . In cases of scarlet fever, the pharynx will require
themost careful and energetic treatment. The neck should
be kept warm by poultices, and the pharynx be very often
cleansed by the use of a nebulizer, chlorate of potash in
powder placed upon the tongue, and so forth. Dr. Sexton,
of this city, has found great relief in tonsilitis from the use
of the warm douche upon the pharynx, by means of David
son's syringe, or rubber tubing attached to a water faucet.
Relapses of pain should be combated by leeches, warm
water, and the internal administration of opium ; but opium
has very little power in subduing the pain from acute aural
suppuration if used without the local treatment. The admin
istration of calomel or other mercurials , the application of
blisters, will not be required . The former kind of treatment
is useless, while the latter aggravates the suffering of the
patient. Blisters are only applicable , if at all, to chronic aural
disease .
If the case go on well, a physician who does not see much
of this form of disease, will be astonished at the rapidity with
which the suppuration is checked , and themembrana tympani
restored. The impairment of hearing will be the last symp
tom to be fully relieved . The hearing power should be often
accurately tested by the watch and tuning-fork in the course
of the disease, in order that if possible we may not dismiss
the patient until the cure is complete.
The astringent that I usually use in acute suppuration is a solu
tion of sulphate of zinc, which is poured into the ear once or
twice a day, after syringing. The solution should be previously
ACUTE SUPPURATION — TREATMENT. 357
warmed . Should the suppuration continue unduly, the pitrate

of silver may be applied in strong solutions, say from 40 to 80
grains to the ounce. This solution is brushed over the drum
head and in the edges of the perforation. In some cases
it may be necessary to drop the solution into the ear, after
wards neutralizing it by syringing with a warm solution of salt
and water. Indeed , it should be said once for all, that except
in very rare and exceptional cases, cold fluids should not be
dropped into the ear.
From the nature of things, the general practitioner will
see a great deal of this form of disease — if he be on the look
out for it - since it occurs so often in the course of the ex
anthemata and in connection with diseases of the respiratory
organs. It will be seen that there is nothing in the treatment
of this affection that will prevent the usual care of the general
disease. It is a great and often fatal error to wait the subsi
dence of the general symptoms before the aural ones are
alleviated . They are quite as important as the most urgent
constitutional disturbances. Indeed, they are often the un
suspected cause of most of the latter.
It only remains to be said that the results of treatment of
this disease are very satisfactory. Of 32 cases reported by
myself,* 15 were cured, i. e., the membrana tympani was healed
and the hearing power fully restored , as tested by the watch and
conversation. As has been said in another place, the old
writers on diseases of the ear were not in the habit of apply
ing accurate tests as to the restoration of hearing ; so that
their standard of cure is not so high as that which obtains
among writers of the present day. Many of my cases of aural
disease, that have been reported as improved or much im
proved, would have been classed under the head of cured , by
the less exact standard of ancient writers. Where one ear
only is affected , we are apt to be led into error as to the
amount of deafness, unless we are careful to exclude the sound
ear as thoroughly as may be in our examination. Nine of the
cases were improved , and the result in the remainder of the
cases, eight in number, is unknown to me, although it is
* New York Medical Journal,August, 1869. Transactions Medical Society
of the State of New York , 1871.
358 ACUTE SUPPURATION .
highly probable that many of them fully recovered, as they

were chiefly cases occurring in consultation with brother
practitioners,who undertook to carry on the case in the man
ner agreed upon , and who undoubtedly had a good result.
The consequences of a neglected or improperly treated
aural catarrh are, that it runs into a case of acute suppuration ;
but those of a neglected or maltreated acute suppuration are
still more grave, involving as they do all the perils of long
continued suppuration in the ear. And yet, to this day, there
are medical men of very great general intelligence, who think
lightly of such a disease, and gravely advise patients not to
“ meddle " with it. The author has been informed by a dis
tinguished practitioner in this city , that a young man was
once sent to him for advice by an eminent physician, after he
had passed through a severe constitutional disease in which
suppuration in the middle ears had occurred , for whose ears
not one particle of rational advice had been given, although
both membranæ tympani had been destroyed, the ossicula
were gone, and the mucous membrane of the tympanic cavity
was granular. Such neglect needs no commentary.
The course of acute suppuration occurring in the midst ofa
severe attack of scarlatina, is apt to be very violent. The symp
toms follow one another with the rapidity of those of puru
lent ophthalmia. He who wishes to preserve the integrity of
the organ , must be prompt and energetic in his treatment, or
the drum -head and the ossicula auditus will be swept away,
and a profuse and fetid discharge of pus be set up within
forty - eight or fifty-six hours .
It should also be said as supplementary to this subject,
that attacks of acute aural catarrh, or of acute suppuration of
the middle ear, are more dangerous in persons who are
affected with a chronic catarrh of the middle ear. This is
explained by the fact that the drum membrane is so much
thickened in such cases that the exit of the pus or mucus by
its spontaneous perforation is much more difficult. A para
centesis will be much more likely to be required in such cases
than in those occurring in persons with drum membranes of
normal density and tension .
ACUTE SUPPURATION - CASES. 359
CASES.
CASE I - Acute Suppuration from Scarlet Fever - Loss of the Malleusof each
side- Reproduction of the Membrana Tympani- Great improvement in
hearing power.
Harry — ,æt. 9. On February 27, 1872, I was called by Dr.G . S. Winston,
to see the grandchild of a gentleman of this city, in regard to whose case I had
already given advice by mail and telegraph. The history was as follows : The
boy had gone back to his school, after spending the Christmas holidays at home,
in quite as good health as usual ; but soon after arriving he was attacked with
scarlet fever, which rapidly assumed a very severe type, so that his throat was
inflamed and the cervical glands were swelled , and the lining membrane of the
middle ears was in a state of very acute inflammation . In spite of prompt and
energetic treatment, by the physician of the school, suppuration occurred in a
few hours. After the aural symptoms occurred, the discharge of pus became
profuse, so that the ears needed cleansing every half hour. Themalleus bone
of each ear escaped in the pus, and I have them in my possession . When the
severest aural symptoms had subsided , astringents were used in the auditory
canal, and the Eustachian tubes treated by Politzer's method .
As soon as the little patient's general condition would allow , he was
returned to his home, and in a deplorable condition. His ears were discharg
ing thick , offensive pus, in such quantities, that it was only by the greatest
diligence in cleansing that they could be kept clean ; thenaso-pharyngeal space
was secreting muco -purulent material in great masses. The hearing power
was so much impaired that it was only by speaking in a distinct and loud tone,
close to the little fellow 's ear, that he could be made to understand what was
said to him .
The family and friends believed that he would become the inmate of a deaf
and dumb asylum . Indeed, a gentleman - a friend of the family — who had a
child that, having lost her hearing from the scarlet fever, had learned the
method of speech by watching the lips, came to see Harry, and urged that
very prompt measures should be taken to cause him to learn lip reading, inas
much as he felt certain that he would never hear sufficiently to retain his
speech. I at once instructed the family to converse regularly with the little
patient, to read aloud to him , and to urge him to continue to talk , while the
local and general treatment were carried on. This they did with a remarka
ble faithfulness; so that the boy,hearing what was said to him ,never acquired
an unnatural tone of voice.
On examination it was found that themembrana tym pani of each side was
gone, and that the cavity of the tympanum was filled up with granularmucous
membrane. The hearing distance for the watch was on each side. The
voice of a person speaking with great distinctness was heard two feet from
the left ear, and one from the right. Air could be forced through both
Eustachian tubes. The patient's general condition was fair ; but he was suf
fering from some abdominal effusion . Dr. T . F. Cock was called in on this
account,and ordered the tincture of the sesquichloride of iron . The weather
being cold ,the boy was kept in the house, and in a warm room ; while a thor
360 AOUTE SUPPURATION - CASES.
ough local treatment was entered upon . The ears were syringed by some
member of the family every hour during the day, if necessary ; while I visited
him at first twice,and subsequently once a day, and cleansed the ears with the
syringe and cotton -holder, inflated the ears by Politzer's method, and applied
a solution of nitrate of silver, of the strength of forty grains to the ounce, to
the cavity of the tympanum . The family applied a weak solution of sulphate
of zinc in the evening . The naso-pharyngeal space was cleansed by the use of
chlorate of potash. A weak solution of Labarraque's solution of chlorinated
soda was used in the water employed for syringing the ear, in order to dimin
ish the fetid odor of the pus. Under this treatment the patient steadily
improved until the discharge of pus bad entirely ceased from the left ear, and
a membrana tympani had formed at the bottom of the canal, with a small
central aperture, and in the right there was also a membrane, with a larger
opening, and a very slight muco -purulent discharge. On May 11, about three
months and a half from his return to the city , and about five months from the
breaking out of the scarlet fever, he could hear the voice, with his face away
from the speaker, for a distance of twenty feet,and the watch , R . E ., ; L ., fig.
He returned to school in good general health .
January 9, 1873. - He still continues at school,with hearing power the same
as last noted. The membrana tympani of left ear is entirely closed . In the
right there is still a small opening, and occasionally a discharge of pus. The
ear is carefully cleansed at school, an astringent is still used,and Politzer's
method of inflation is occasionally practised.
The above case illustrates what can be done for one of the
severest cases of acute suppuration in the middle ear, result
ing from the pharyngeal inflammation of scarlet fever. Hun
dreds of such cases have become inmates of deaf and dumb
asylums, and are consequently educated in a necessarily im
perfect manner. This boy, although under some obstacles,is
being educated exactly as are his fellows, who enjoy good
hearing power. I think the right membrana tympani will be
finally closed , and that he will then be free from the dangers
attending the chronic suppurative process.
CASE II. - Acute Suppuration of the Middle Ear, occurring in a Child, in con
nection with the Whooping-cough - Membranes healed in about a Month .
March 12, 1872.- Eugene , æt. 1, a rather delicate child , who is pass
ing through the whooping. cough. A few days ago the child cried very much
for some hours, and then a discharge of pus, mingled with blood, was found
from each auditory canal. The spasms of coughing are very severe. I was
called to see the little patient a few days after the discharge of pus occurred ,
and I found on examination that both membranæ tympani were ruptured , and
that considerable pus was being secreted in the cavity of the tympanum .
There was also some naso -pharyngeal catarrh .
ACUTE SUPPURATION — CASES. 361
The following treatment was entered upon : The ears were syringed three
times a day , with lukewarm water, and a solution of sulphate of zinc, gr. ij.
ad 3 ), was afterward dropped into the meatus, and kept there for a few min
utes. I saw the patient three times a week , and cleansed the ear myself.
On April 15, or a little more than a month from the time the perforation
occurred, both drum -heads had healed and the discharge had ceased .
CASE III. - Acute Suppuration in the Course of Chronic Nasal Catarrh

Paracentesis of the Membrana Tympani.
George S., æt. 34. March 13, 1873.--Mr. S . has had “ catarrh ” for two
years, for which he has been in the habit of using injections through the nos
trils by means of Davidson 's syringe. For the past few hours he has had a
pain in the ears, but more particularly in the left, and he cannot hear well.
An examination shows that the patient has a severe form of naso-pharyn .
geal intlammation , attended by a profuse and fetid secretion . The hearing dis
tance is, R . E ., * ; L . E., . The right membrana tympani is sunken and
red. The left membrane is very convex ; a delicate pink tint involves the
whole surface, and there is no trace of the handle of the malleus nor of the
light spot.
The membranewas immediately incised in the upper and posterior quad .
rant, and a small amount of pus was evacuated . The ears were inflated by
Politzer's method , and the auditory canals syringed with tepid water. A
leech was applied upon the tragus of the right ear. A profuse suppuration
occurred in the left ear ; but it was soon checked by the use of a solution , gr.
xl. ad 3 j,of nitrate of silver painted over thedrum -head,and the patient disap
peared from observation , with the hearing distance is on each side, on March
22, or nine days from the date of the first visit. I afterwards learned that he
considered himself entirely well.
CASE IV .- Inflammation of Auditory Canal extending to the Membrana Tym
pani--Paracentesis — Cure.
Mrs. G .,æt. about 35. On April 16 , 1872, I was sentfor, by request of Pro
fessor T. G . Thomas, to see this patient,who had been suffering for a week or
two from occasional attacks of severe pain referred to the depth of the right
ear. These attacks had been alleviated by the application of leeches, but the
pain continued to recur, especially at night, so that the patient was unable to
sleep. I found the lady suffering very much , and she had been awake with
pain all night. The auditory canal was found to be swelled , and there were
two points of suppuration in the cartilaginous part of the meatus. Themem
brana tympani was red , but its whole surface could not be seen on account of
thc swelling of the canal. The auditory canal was scarified at two points, and
the use of the douche ordered every hour ; te gr. of sulphate morphia was
ordered to be taken every hour, until the pain was relieved. In the evening
the pain not being markedly relieved, two leeches were ordered to be applied
to the ear- one on the tragus, the other at the glenoid fossa . This, with the
continuation of the morphia, quieted the pain very much ; but, on the 19th , I
was called early in themorning , to find that Mrs. G . had had a recurrence of
362 ACUTE SUPPURATION — CASES .
the pain , and that she was suffering very much . I then made a paracentesis
of the drum membrane, although the swelling of the canal was so great that
I could only judge of the fact of my instrument - a cataract needle — having
passed through the membrane, by the depth to which it penetrated , and the
yielding sensation communicated to the fingers as the needle passed through
the drum -head. Immediate and great relief from the pain was experienced,
and the patient, under the continuation of the douche, daily syringing , the use
of Politzer's method of inflation, on May 11 she had fully recovered her
hearing power with a moderate amount of suppuration .
I am not able to decide whether this case was primarily

one of otitis externa, or otitis media. I am inclined to think
that it was one of the former, and that the inflammatory pro
cess extended to the membrana tympani from without. I
suppose that the membrane was unusually thick, perhaps
from a previous morbid process, and that this accounts for its
continuing intact for a longer time than usual, although a
membrana tympani that is invaded by disease from the audi
tory canal, will withstand an inflammatory action without
rupture much longer, than one whose mucous layer is the first
affected .
CASE V.- Acute Suppurative Otitis Media of some days standing, cured by one
Application of a forty-grain solution of Nitrate of Silver.
C . C .æt. 1 year. Feb . 16 , 1873. I was asked to see this little patient by
Dr. C. C . Lee. There had been an acute naso -pharyngeal catarrh for some
time, and for a few days there had been a purulent discharge from the left ear.
On examination the drum membrane was found to be perforate , and there
was a profuse discharge of pus. The ear was kept carefully cleansed , and a
warmed solution of sulphate of zinc poured into it ; but it did not yield in a
day or two, when a solution of nitrate of silver, of forty grains to the ounce,
was brushed over the canal and the perforated membrana tympani. Atmy
next visit, the morning after this application was made, the discharge had
completely ceased , and themembrana tympani had healed .
The foregoing cases illustrate the ordinary typeof acute
suppuration occurring in subjects of different ages. The prac
titioner who has not seen much of aural disease, may be at a
loss when called to a case of acute suppuration of the ear, to
know whether its seatis in the auditory canal or themiddle ear.
The parts should be carefully cleansed of pus before a deci
sion is made, although it should be borne in mind , as was
stated in the chapter on acute affections of the canal, that
ACUTE SUPPURATION . 363
suppuration in the middle ear is much more frequent than the

same process in the external auditory canal. If an opening in
the drum -head cannot be detected by the otoscope, the per
formance of the Valsalvian experiment by the patient, or the
employment of Politzer's method, and a subsequent inspection ,
will determine the question. If the membrane be perforate,
the air will be heard to whistle through the aperture, and an
air -bubble , made by the pus or mucus, will be found at the
seat of the aperture. The presence of an air-bubble , before
the parts have been cleansed, is not, as Wilde thought, a
pathognomonic symptom ofa perforation , for I have seen this
bubble when the membrane was intact, but fluid was lying
upon it.
CHAPTER XVI.
CHPOSIC STPPCRATION OF THE MIDDLE BAR
ators in which acute aural catarrh and acute suppu
ration have been considered , have prepared as for th
tion of the disease properly known as chronic suppuration of
the middle ear, which is a direct consequence of these affon
bione It was formerly almost universally known and de
otorrhoea . But this term , simply meaning a dis
ear,, and bein
charge fromm the ear being one that
that does
does not in any proper
way define the seat or character of the the disease , should , I
hanished from the nomenclature of otology . Chronic
suppuration of the middle ear is the affection which , among the
Laits is called “ a running from the ear,” and which has been
so lightly regarded by the profession, that every
die from its direct results, and under the observation of physi
cians, without the suspicion that the disease of the ear, and of
the ear alone, was the cause of their death . In this and the
following chapter, I shall attempt to set forth , in a plain and
simple manner, the exact nature of this disease , and the ea
sons why it should never be neglected , but always kept under
the most careful observation and treatment.
Chronic suppuration of the middle ear is often confounded
with that rare disease, chronic suppuration of the external
auditory canal. Very many times patients have been brought
to me with what the attending physician supposed to be
merely an external otitis, but wbich proved to be really a case
of suppuration of the middle ear, with perforation of the mem
brana tympani. When it was demonstrated that the pus had
its origin , not from the auditory canal, but from the middle
ear, it was usually an easy task to convince the person
CHRONIC SUPPURATION - FREQUENCY, 365
affected of the danger of a neglect of the disease. I feel con
fident that this error as to the origin of the affection is in
many cases the cause of its neglect. An eczema, or a so
called seborrhea, or even a suppurative external otitis ,may,
perhaps,when occurring with young children, be left to itself
or to general hygienic attention and tonic treatment with com
parative impunity ; but the best of such care will not avail
to stop a formation of pus in the cavity of the tympanum or
the mastoid cells, unless local treatment is also employed.
We might almost take it for granted, if such a practice
were not improper in a physician who claims to observe with
exactness, that any case of long-existing suppuration in , or dis
charge of pus from , the ear, will be found to have its origin
behind, and not in front of, the membrana tympani.
I have already,on page 120 of this work, alluded to this
fact of the comparative infrequency of suppurative affections
of the outer ear, as compared with those of the middle part of
the organ ; but the following table brings it out more strikingly
than the mere assertion :
TABLE
Showing the relative frequency of Suppurative Affections of the External
and Middle Ear.
Number of Cases
of Inflammation of Suppura
Institution . External Auditory tion ofMid
Canal, excluding dle Ear.
Eczema.
Brooklyn Eyeand Ear Hospital, 1870 .. ...... . 93 246
Massachusetts Charitable Eyeand Ear Infirmary, 170 464
« ' mc luding 36
including cas
36 cases
1872 . . .. .... . . .
101 0 . . . . . . . . . . . . . . . . . . . . . .
l of myringitis.
c. 38 181
Ophthalmic and Aural Institute, New York, including 11 cases
1870 – 71 . . . .. . . . of inflammation of
memb. tympani.
New York Eye and Ear Infirmary , 1872..... .. 168 660
Manhattan Eye and Ear Hospital, 1872.. 33 218
502 1769
All the cases under the heading Inflammation of the Auditory Canal, were
not necessarily suppurative ; while I have been careful to place only the sup
purative cases in themiddle ear column.
- Is meer 3 TOST
- put - - =- = - . Te * . t pter
. : : .5 - BL such
Buong T . I O IL Tyrion
" I won. - .5 7. 5 a 20 Jet
1- 3 . ince its L" I E S I I . Fiat
* "; r . SUSUR that

met 200 m r Eas: ze he eise in
*! 2 m d2 32 12 : Sia the
* "*",cum 11793
L a i I other
*60mm S 26 Ders estebotom of the
6,46,40 10 " ta k zeins tv - pasi and in the
6,4 ,1," 46. , Tez tre clain of bones, and
Itar, 1- , ir. . arisin aiced ice trastoid cells. In still other
O , those in no continuons outilow of pas, either by day, or
mt nyt,naon the pillon ; bat at intervals there is a slight in
61042 A the unpleasant symptoms, which even assume the
dignity ofan car-ache,after which a free discharge of pus from
CHRONIC SUPPURATION — SYMPTOMS. 367
the ear occurs. On questioning such patients in regard to the

existence of a discharge from the ear, they will usually state ,
that none occurs, except after an attack of ear-ache, although
the fact is that pus is always lying in the part. If we examine
such an ear when the discharge is supposed to have ceased ,
we shall find at the bottom of the canal, and in the cavity of
the tympanum , a hardened mass of dried pus covered over
by cerumen, or epidermis. Impacted cerumen is quite a fre
quent occurrence in the course of a chronic suppurative pro
cess in the middle ear. We shall often come to an erroneous
conclusion as to the cause of a loss of hearing, if we judge of
the case from the presence of hardened cerumen in the audi
tory canal without getting the history .
The membrana tympani presents the most varied appear
ance in different cases of chronic suppuration in the middle
ear ; sometimes, it is entirely swept away, and all the ossicula
with it. The cavity of the tympanum is then an empty cavity
opening upon the canal. Again , there is a rim remaining,
with perhaps the incus and stapes in situ , or dislocated , but
yet present, while the malleus is gone. In other cases the
ossicula are intact and in position , but there are clearly -cut,
well -defined holes, from one to three in number, in the drum
head . The chromo-lithographs exhibit such a perforation ,
with the blood -vessels that are about to repair it, radiating
towards the opening. Sometimes one-half of the membrane
is cleanly cut away. In fact, the appearance of the mem
brane is as various as the number of cases. The description
of no one case will do for another.
When we come to the consideration of the consequences of
this disease, we shall see that besides these changes already
mentioned , we often find growths springing from the mucous
membrane of the tympanic cavity, so -called polypi. Exostoses
may exist in the canal, or even in the walls of the tympanic
cavity ; the bonemay be exposed , i.e., denuded of its perios
teum , roughened and in a condition of caries. The seventh
nerve, in its passage through the aqueduct of Fallopius, may
be destroyed by the morbid process, when the smirk of facial
paralysis is added to the disgusting detail of the ravages of
disease.
T
366
1
pura
otiti
inc!
tha:
ext:
of 1
he
bec
as
.. . - IdeeD I OSE
ALBUMINURIA FROM CHRONIC SUPPURATION . 369
origin of the disease, and that any successful management of

the ear will require great attention to the pharynx and Eusta
chian tube.
The general health of a patient affected with chronic sup
puration of the middle ear is usually impaired , even if none
of the serious consequences have occurred . Such a drain
upon the system is not tolerated with equanimity by nature.
Dr. Hackley * has found albuminuria in a number of cases of
chronic suppuration of the middle ear, where there was no
apparent cause for the disease, except the long-continued
secretion of pus in the tympanic cavity . He is inclined to
think, that such cases are analogous to those of the develop
ment of lardaceous kidney from debilitating diseases.
The fact that a running sore is detrimental to the con
tinuance of good general health , would scarcely need assertion ,
were it not that the author, in common with many others, has
observed a very deeply rooted idea among the laity — an idea
that was first inculcated , and which is even now encouraged
by the profession — that there is no harm resulting from a
chronic ulcerative process in the ear, when it is well out of
sight. It is even at times gravely asserted that such a drain
to the system is salutary, as if our Creator would not have
made the human race with such a one if it were necessary.
I have seen persons who allow their ears to become an offence
to the nostrils of those about them , because they have been
advised by their physician that it was not best to “ meddle
with the ear.” If my reader feels that I have said too much
on this subject, in the different parts of this volume, I beg
that he will ask himself how many cases of death he has
known as the result of a suppurative process in the ear, to
consult his fellow practitioners on the same point, and finally
to investigate the statistical tables of deaf and dumb asylums.
In the answers to these interrogatories will be found a com
plete justification of my earnestness on this point. The anat
omy of the middle ear, showing,as it does, the relations of this
small portion of the organism to themost important parts of
the system , to the great arterial and venous vessels, to the
• Verbal communication at New York Ophthalmological Society .

24
N
370 NEGLECT OF CHRONIC SUPPURATIO .
nervous system , to the organs of respiration , is also of itself

a sufficient proof of the necessary importance of a long -con
tinued suppuration in this part.
There still exists, however, even in the minds of some
physicians, a prejudice against the stoppage of a purulent
discharge from the ear. In the laity this prejudice is widely
spread, and is chiefly dependent upon the erroneous teachings
of the older French writers, Du Verney and Itard . As Wilde
shows, in his classic article upon this disease in his text-book,
“ because it was observed that on the supervention of cerebral
disease, discharges from the auditory canal have lessened ,
practitioners mistaking the effect for the cause , have been led
to believe that the sudden ‘ drying up ' produced a metastasis
to the brain , a notion as crude as it is unsupported .” There
is, I believe , no pathological experience on record which can
sustain the quite common assertion that it is dangerous to
stop a discharge from the ear. There are some cases on
record - of which there are, alas ! many more than were ever
recorded — where disease of the brain has occurred from the
extension of a neglected suppuration to the cerebral mem
branes and substance, and the discharge from the ear has
nearly ceased ; but these certainly form no argument against
the arrest of an ulcerative process before any parts beyond
the cavity of the tympanum are involved .
He who believes that we can easily cause a discharge of
pus to cease, after caries of the temporal bone has occurred ,
will find many cases which will cause him to doubt the effi
cacy of his therapeutics. As wellmight we refuse to heal an
ulcerated hip -joint, as to neglect to check a discharge from a
diseased membrana tympani or lining membrane of the tym
panic cavity.
It is doubtless true, judging from the bistories of cases and
the inspection of the membrana tympani, in which cicatrices
occur, thatmany cases of chronic suppuration are cured with
very slight treatment, or with none at all. The fact remains,
however, that the most of the neglected cases do not so re
cover, and after a purulent discharge from the ear has once
set in , “ we can never tell,” to quote again the words of Wilde,
which should be impressed upon the attention of every prac
HEARING POWER IN CHRONIC SUPPURATION . 371
titioner of medicine, “ how , when , or where it will end, or what
it may lead to." *
A careful treatment is usually required to check the dis
charge and treatthe ulcerated membrana tympani,and restore
the hearing power. Even with the most careful and skillful
treatment, we cannot always succeed in all of these things.
In some rare cases we do not succeed in any of them ; but the
patient, in spite of our best efforts, will go on to his doom .
The degree of the impairment of hearing, in cases of
chronic aural suppuration, is very variable. It depends, of
course, upon many factors ; for example, the condition of the
Eustachian tube, and the integrity of the structure in the
cavity of the tympanum . The hearing power by no means
depends upon the presence or absence of the membrana tym
pani. The chief function of this membrane is probably to
protect the tympanic cavity , and not to transmit the vibra
tions of the atmosphere , which when conveyed to the acoustic
nerve we call sound. I know some persons who have large
perforations in each membrana tympani, and who yet hear
well enough for all the ordinary purposes of life , although not
with perfection. One notable instance of this kind is that of
a busy physician of my acquaintance. As has been already
said in Chapter XIV., Sir Astley Cooper, in a paper published
in the Transactions of the Royal Society in 1800,+ showed
that there could be very good hearing powers with a perforate
membrana tympani; and yet I very often hear the question
asked, aswell by physicians as by laymen, if anything can be
done when there is a hole in this membrane ; and it is also
often stoutly asserted that when this membrane is once gone,
the hearing is irrevocably lost. This false idea continues to
prevail, not only in spite of scientific demonstration of more
than seventy years ago, but also in the face of clinical facts that
are every day within the reach of each attentive physician.
Truly, a lie will travel around the world , while truth is putting
on its boots.
The parts which form the middle ear make up a cavity
which have perhaps as many, if not more , important anatomi
* Text-Book , p. 407.
+ Philosophical Transactions, 1800 , Part I.
372 CHRONIC SUPPURATION — TREATMENT.
cal relations than any one of similar size in the human body.
The cavity of the tympanum is covered above by a thin , rare
fied bony plate , which is in direct communication with the
cerebral meninges ; the floor is close to the great jugular. Its
internalwall is the labyrinth wall, with its two fenestræ , cov
ered only by thin membrane and opening into the ramifica
tions of the acoustic nerve and the fluid which is continuous
with that of the sub -arachnoid space ; while externally we have
a membrane of about the thickness of letter -paper.
Treatment. The proper treatment of a chronic suppura
tion in such a space ,should be a matter of the greatest solici
tude. It involves not alone the hearing power, but also the
life of the patient. There is one pre-requisite to the success
ful treatment of this affection, and that is, a complete removal
of all the morbid material that has formed in the middle ear.
This is simply another way of stating that the parts must be
thoroughly cleansed.
As we have seen in the discussion of the various affections
of the middle ear, their starting -point is usually in the fauces
or pharynx. But the ulcerative process which has been set
up in the tympanic cavity has broken through the membrana
tympani, and the result shows itself in the external auditory
canal. The problem to be solved is, how may we stop the
ulcerative process, heal the membrana tympani, and restore
the hearing power, which has been impaired by the inflamma
tory process in the sound- conducting apparatus ? In many
cases, however, we may be well satisfied if two of these re
quirements be fully fulfilled , while the hearing power is im
proved . A radical cure of a suppurative process in the mid
dle ear, of long standing , is, from the very nature of things,
sometimes impossible.
The old method of treating such a suppuration was to
advise the patient to syringe the ears with soap and water ,
put a blister on the mastoid process, and at the same time
the physician got the system to rights by using alteratives,
laxatives, and purgatives. The general principle of treatment
thus held in view was correct, but in the matter of the local
treatment, which is of farmore importance than the constitu
CHRONIC SUPPURATION — TREATMENT. 373
tional, altogether too much was left to the supposed knowl

edge and skill of the patient or his attendant.
Perhaps not more than one layman in a hundred can, with
out instruction , thoroughly cleanse an ear by syringing. It is
generally thought that any person can syringe an ear, when
the facts are that no patient can properly cleanse his own ear,
and almost every one requires instruction before he can even
syringe the ear of another. In one of the preceding chapters
of this book (see page 128 ), the proper method of syringing
has been carefully described, so that we need not dwell upon
the subject again .
Sometimes the use of the syringe is not well borne by the
patient, the shock of the water being too great. In such cases
the aural douche of Clarke, is a good substitute for the syringe.
Instead of the thin bowl that I have recommended as a recep
tacle for the fluid that comes from the canal,after having been
injected, some practitioners use a vessel such as depicted in
the accompanying cut — the “ iter-becher ” of theGermans. It
FIG . 72.
Vessel used in Syringing the Ear.
is certainly very convenient on account of the fact that it

adapts itself so well to the glenoid fossa, but it is not deep
enough if any prolonged syringing is required . Then the
bowl will do better, and on the whole I think it is to be pre
ferred.
I have known sad cases, where parents, in obedience to their
medical adviser, have faithfully syringed the ears of a child
suffering from chronic suppuration for years, but where the
parts have not been perhaps even once, thoroughly cleansed.
Exuberant granulations or polypihad sprung up, bony growths
had occurred ,which are positive evidences of the imperfect
removal of pus and other hurtful material.
HRONIC SLPPURATION — TREATMENT.
- sethods of cleansing ears affected with

- - D r ocess. That which I usually adopt
- I suggestions of Politzer, Hinton, and
- sizni, a simple method, and capable of
- - by any practitioner, but not by the
-- e personal care and supervision of a
- aury to the successful treatment of any
-- Ouration in the ear. This personal care
.. . iaily, although it is better to have it so;
Ro me very least, be given twice a week , while
- 12e patient is instructed as well as may be,
. -- mus of the duty of cleansing the ear in the
The importance of the cases for which the
- ALL the physician is required, if properly set
- w ww.y with any objections that may be made.
- A would object to the daily attendance of a
IUL ase of suppuration of the cornea , and I
Spooration in the cavity of the tympanum and
prapani is of equal importance, with the disease
: usually adopt is the following : The ear is
- : - " sensed with lukewarm water by means of a
syringe. The bowl to contain the water
- spear, should be held by the patient himself
z child be the subject — and pressed well into
- when no water will be spilled. After this the
wtimi lukewarm water poured from a test tube,
be like, and the meatus carefully stopped by a
i m ol. The Eustachian tube is then inflated by
tiser's method, and to such an extent that a few
oster are forced by the side of the cotton out of
is is, of course, conclusive evidence that the air
Se ined through the tube into the middle ear, and
. we hole in the drum -head into the external canal.
gain carefully syringed and examined by the sur
to the beginning of such a treatment, especially in
ses, small portions of inspissated or glutinous mate
ozen vzil stitillll he found .. These
be found should be then thoroughly
These should
ruloured under a go illumination from
od illumination
rood from aa mirror upon the
CHRONIC SUPPURATION - TREATMENT. 375
forehead, by means of a cotton -holder, which is simply a slen

der steel probe, roughened at one extremity . In the absence
of this instrument, a thin bit of wood, or a match, about
which cotton is carefully twisted , will do very well.
Having satisfied ourselves by inspection with the otoscope
that the ear is thoroughly cleansed, the warm astringent solu
tion should be poured into the ear, and allowed to remain for a
period varying from five to fifteen minutes. If themembrana
tympani be nearly gone, the solution may be swabbed about
the bottom of the ear by means of the cotton -holder , used
under the illumination of the mirror on the forehead.
The choice of an astringent is perhaps not so important
as is often supposed . I usually use the sulphate of zinc for
comparatively recent cases, and the nitrate of silver for old
ones. The sulphate of zinc should be used in weak solutions
- from 1 to 4 grains to the ounce — and the nitrate of silver in
strong ones. Nitrate of silver seems to be of no value in these
cases, unless used of the strength of 40 grains to the ounce.
It may be even used as strong as 480 grains to the ounce.
Dr. O . D . Pomeroy, of this city , reports a case * of “ suppura
tive inflammation of the tympanic cavity , with subjective
symptoms of mastoid inflammation," where, after using solu
tions of from 40 to 80 grains, he finally used the very strong
one of 480 grains to the ounce of water. “ It caused a slight
feeling of warmth and fulness in the ear, but not real pain .
The discharge was entirely arrested by this one application.”
The membrane was found to be healed on an examination
made some six months afterward .
In Schwartze's paper calling attention to the use of the
nitrate of silver, in what he regards as strong solutions, he
advises against the instillation of nitrate of silver where gran
ulations or disease of the bone exists . His exact words are :
“ The caustic treatment only promises a nearly certain result,
when we may exclude with positiveness the existence of gran
ulations upon the exposed mucous membrane, or upon the
remains of the membrana tympani, and when there are no
evidences of ulceration of the bone." +
* New York Medical Journal, Dec. 1872 , p . 631.
+ Archiv für Ohrenheilkunde, Bd IV ., p . 2 .
368 PERFORATIONS OF MEMBRANA TYMPANI.
I do not think there is any one point more than another,

in the membrana tympani, where perforations are apt to
occur. Sir William Wilde, and Moos, quoted by Hinton ,*
affirm that they are most frequently situated in the anterior
and lower part of the membrane, where the air blown through
the Eustachian tube impinges. Hinton has seen quite as
many in the inferior and posterior segments, an experience
which my own quite confirms. I have found them in every
quadrant of the drum -head.
Perforations are sometimes so small as not to be easily
recognized , unless air is forced through the Eustachian tube
and made to pass through them . As has been stated in the
preceding chapter , Wilde thought that a pulsation at the bot
tom of the auditory canal was pathognomic of perforation of
the drum -head. Where this pulsation occurs, it is a very
suspicious circumstance ; but, as has been before said in this
volume, a thin membrana tympani, in a state of acute catarrhal
inflammation , will sometimes exhibit this phenomena when
the drum -head is intact. Mr. Hinton remarks in his excellent
paper on Perforations of the Membrana Tympani, from which
I have just quoted, “ This motion (pulsating) is imparted by
the blood , and implies not necessarily an aperture, but a
thin surface of fluid in contact with a beating vessel.” + The
complete absence of the membrana tympani, especially if
the mucous lining of the tympanic cavity have a granu
lar or velvety appearance, is often very puzzling. Such
cases will sometimes require the most careful cleansing be
fore we can determine how much , if any , of the drum -head
remains.
We need not enter into any detailed account of the condi
tion of the pharynx and Eustachian tubes in the affection
now under consideration , since this subject has been so fully
dwelt upon in treating of the chronic non -suppurative inflam
mations. It may be sufficient to say here that we find in
chronic suppuration, as well as in all the varieties of inflam
mations of the middle ear, except the purely proliferous forms,
that the naso-pharyngeal region has been the usual point of
* Guy's Hospital Reports, 3d Series, vol. xii.
| L . c., p . 630.

chian tube.
puration of the middle ear is usually impaired, even if none
of the serious consequences have occurred. Such a drain
upon the system is not tolerated with equanimity by nature.
Dr. Hackley * has found albuminuria in a number of cases of
apparent cause for the disease, except the long -continued
think, that such cases are analogous to those of the develop
tinuance of good generalhealth ,would scarcely need assertion ,
that was first inculcated, and which is even now encouraged
chronic ulcerative process in the ear, when it is well out of
made the human race with such a one if it were necessary .
I have seen persons who allow their exrs to become an offence
advised by their physician that it was not best to “ meddle
omy of themiddle ear, showing, as it does,the relations of this
small portion of the organism to the most important parts of
* Verbal communication at New York Ophthalmological Society .

24
CHAPTER XVI.
CHRONIC SUPPURATION OF THE MIDDLE EAR .
THE chapters in which acute aural catarrh and acute suppu

ration have been considered, have prepared us for the descrip
tion of the disease properly known as chronic suppuration of
the middle ear, which is a direct consequence of these affec
tions. It was formerly almost universally known and de
scribed as otorrhea. But this term , simply meaning a dis
charge from the ear, and being one thatdoes not in any proper
way define the seat or character of the disease, should , I
think, be banished from the nomenclature of otology. Chronic
suppuration of the middle ear is the affection which , among the
laity, is called “ a running from the ear,” and which has been
so lightly regarded by the profession, that every year people
die from its direct results , and under the observation of physi
cians, without the suspicion that the disease of the ear, and of
the ear alone, was the cause of their death . In this and the
following chapter, I shall attempt to set forth , in a plain and
simple manner, the exact nature of this disease, and the rea
sons why it should never be neglected , but always kept under
the most careful observation and treatment.
Chronic suppuration of the middle ear is often confounded
with that rare disease, chronic suppuration of the external
auditory canal. Very many times patients have been brought
to me with what the attending physician supposed to be
merely an external otitis, but which proved to be really a case
of suppuration of the middle ear, with perforation of the mem
brana tympani. When it was demonstrated that the pus had
its origin , not from the auditory canal, but from the middle
ear, it was usually an easy task to convince the person
CHRONIC SUPPURATION — FREQUENCY. 365
affected of the danger of a neglect of the disease. I feel con
fident that this error as to the origin of the affection is in
many cases the cause of its neglect. An eczema, or a so
called seborrhoea, or even a suppurative external otitis, may, :
perhaps, when occurring with young children, be left to itself
or to general hygienic attention and tonic treatment with com
parative impunity ; but the best of such care will not avail
to stop a formation of pus in the cavity of the tympanum or
the mastoid cells, unless local treatment is also employed.
We might almost take it for granted, if such a practice
were not improper in a physician who claims to observe with
exactness, that any case of long-existing suppuration in , or dis
charge of pus from , the ear, will be found to have its origin
behind, and not in front of, the membrana tympani.
I have already, on page 120 of this work, alluded to this
fact of the comparative infrequency of suppurative affections
of the outer ear, as compared with those of the middle part of
the organ ; but the following table brings it outmore strikingly
than the mere assertion :
TABLE
Showing the relative frequency of Suppurative Affections of the External
and Middle Ear.
Number of Cases
of Inflammation of Suppura
Institution. External Auditory
Canal, excluding
tion of Mid
dle Ear.
Eczema.
Brooklyn Eye and Ear Hospital, 1870 .. ...... 93 246
170
Massachusetts Charitable Eye and Ear Infirmary, S.including 36 cases 464
1872 .. . . . . . ..
l of myringitis.
38 181
Ophthalmic and Aural Institute, New York , including 11 cases
1870 – 71. . . .. . ofinflammation of
memb. tympani.
New York Eye and Ear Infirmary , 1872..... .. 168 660
Manhattan Eye and Ear Hospital, 1872 .... .. 33 218
502 1769
All the cases under the heading Inflammation of the Auditory Canal, were
not necessarily suppurative ; while I have been careful to place only the sup
purative cases in the middle ear column.
366 CHRONIC SUPPURATION - SYMPTOMS.
It will be seen by the table that the cases of chronic sup

puration preponderate over the cases of chronic external
otitis, in a proportion exceeding that of three to one. I am
inclined to believe that the proportion is actually even larger
than this, and that in some cases the diagnosis was made of
external otitis, simply because at the outset the inflammation
of the canalwas so great as not to allow of a view of the drum
head, which was afterwards found to be affected. If I had
been able to exclude the non -suppurative diseases of the canal,
as I have those of the middle ear, the preponderance of
middle ear cases would have been much greater .
Symptoms. - A discharge of pus from the ear is the most

striking symptom in chronic suppuration of the middle ear.
There can hardly be such a thing as a chronic suppuration in
this part without a perforation of the drum -head, through
which the pus escapes. Such a process may occur, however,
as will be seen by reference to a case recorded in the chapter
on the consequences of chronic suppuration , where, although
pus had formed, and probably had existed for weeks in the
mastoid process, it did not at all involve thedrum -head. Such
cases are , however , very exceptional. A chronic suppuration
of the middle ear, almost always involves an ulcerative per
foration of the membrana tympani. When the former term is
used , the latter state of things is understood to exist, what
ever other changes of structure may have occurred . The dis
charge of pus is sometimes very profuse and constant, so that
it streams from the ear. This is more apt to be the case in
young children . In such cases the auricle and external audi
tory canal become red , tender, and even excoriated from the
irritation of the pus in which the parts are bathed. In other
and more numerous cases, the pus lies only at the bottom of the
canal upon the remains of the membrana tympani and in the
cavity of the tympanum , enveloping the chain of bones, and
passing into the cavities called the mastoid cells. In still other
cases , there is no continuous outflow of pus, either by day, or
at night upon the pillow ; but at intervals there is a slight in
crease of the unpleasant symptoms, which even assume the
dignity of an ear-ache,afterwhich a free discharge of pus from
CHRONIC SUPPURATION - SYMPTOMS. 367
the ear occurs. On questioning such patients in regard to the

existence of a discharge from the ear, they will usually state,
that none occurs, except after an attack of ear-ache, although
the fact is that pus is always lying in the part. If we examine
such an ear when the discharge is supposed to have ceased,
we shall find at the bottom of the canal, and in the cavity of
the tympanum , a hardened mass of dried pus covered over
by cerumen , or epidermis. Impacted cerumen is quite a fre
quent occurrence in the course of a chronic suppurative pro
cess in the middle ear. We shall often come to an erroneous
conclusion as to the cause of a loss of hearing, if we judge of
the case from the presence of hardened cerumen in the audi
tory canal without getting the history.
The membrana tympani presents the most varied appear
ance in different cases of chronic suppuration in the middle
ear ; sometimes, it is entirely swept away, and all the ossicula
with it. The cavity of the tympanum is then an empty cavity
opening upon the canal. Again , there is a rim remaining,
with perhaps the incus and stapes in situ , or dislocated, but
yet present, while the malleus is gone. In other cases the
ossicula are intact and in position , but there are clearly -cut,
well-defined holes, from one to three in number, in the drum
head. The chromo-lithographs exhibit such a perforation ,
with the blood -vessels that are about to repair it, radiating
towards the opening. Sometimes one-half of the membrane
is cleanly cut away. In fact, the appearance of the mem
brane is as various as the number of cases. The description
of no one case will do for another.
When we come to the consideration of the consequences of
this disease, we shall see that besides these changes already
mentioned, we often find growths springing from the mucous
membrane of the tympanic cavity, so-called polypi. Exostoses
may exist in the canal, or even in the walls of the tympanic
cavity ; the bone may be exposed, i. e., denuded of its perios
teum , roughened and in a condition of caries. The seventh
nerve, in its passage through the aqueduct of Fallopius, may
be destroyed by the morbid process , when the smirk of facial
paralysis is added to the disgusting detail of the ravages of
disease.
368 PERFORATIONS OF MEMBRANA TYMPANI.
I do not think there is any one point more than another,

in the membrana tympani, where perforations are apt to
occur. Sir William Wilde, and Moos, quoted by Hinton,*
affirm that they are most frequently situated in the anterior
and lower part of the membrane,where the air blown through
the Eustachian tube impinges. Hinton has seen quite as
many in the inferior and posterior segments, an experience
which my own quite confirms. I have found them in every
quadrant of the drum -head.
Perforations are sometimes so small as not to be easily
recognized, unless air is forced through the Eustachian tube
and made to pass through them . As has been stated in the
preceding chapter, Wilde thought that a pulsation at the bot
tom of the auditory canal was pathognomic of perforation of
the drum -head. Where this pulsation occurs, it is a very
suspicious circumstance ; but, as has been before said in this
volume, a thin membrana tympani, in a state of acute catarrhal
inflammation, will sometimes exhibit this phenomena when
the drum -head is intact. Mr. Hinton remarks in his excellent
paper on Perforations of the Membrana Tympani, from which
I have just quoted, “ This motion (pulsating) is imparted by
the blood, and implies not necessarily an aperture , but a
thin surface of fluid in contact with a beating vessel.” + The
complete absence of the membrana tympani, especially if
the mucous lining of the tympanic cavity have a granu
lar or velvety appearance , is often very puzzling. Such
cases will sometimes require the most careful cleansing be
fore we can determine how much , if any, of the drum -head
remains.
We need not enter into any detailed account of the condi
tion of the pharynx and Eustachian tubes in the affection
now under consideration , since this subject has been so fully
dwelt upon in treating of the chronic non -suppurative inflam
mations. It may be sufficient to say here that we find in
chronic suppuration, as well as in all the varieties of inflam
mations of the middle ear, except the purely proliferous forms,
that the naso -pharyngeal region has been the usual point of
* Guy's Hospital Reports, 3d Series, vol.xii.
+ L . c., p . 630.

chian tube.
puration of the middle ear is usually impaired, even if none
of the serious consequences have occurred. Such a drain
upon the system is not tolerated with equanimity by nature .
Dr. Hackley* has found albuminuria in a number of cases of
apparent cause for the disease, except the long -continued
think , that such cases are analogous to those of the develop
tinuance of good general health , would scarcely need assertion,
that was first inculcated , and which is even now encouraged
chronic ulcerative process in the ear,when it is well out of
made the human race with such a one if it were necessary .
I have seen persons who allow their ears to become an offence
advised by their physician that it was not best to " meddle
omyof the middle ear, showing,as it does,the relations of this
small portion of the organism to the most important parts of
• Verbal communication at New York Ophthalmological Society.

24
370 NEGLECT OF CHRONIC SUPPURATION .
nervous system , to the organs of respiration, is also of itself

a sufficient proof of the necessary importance of a long -con
tinued suppuration in this part.
There still exists, however, even in the minds of some
physicians, a prejudice against the stoppage of a purulent
discharge from the ear. In the laity this prejudice is widely
spread , and is chiefly dependent upon the erroneous teachings
of the older French writers , Du Verney and Itard. As Wilde
shows, in his classic article upon this disease in his text-book,
“ because it was observed that on the supervention of cerebral
disease, discharges from the auditory canal have lessened,
practitioners mistaking the effect for the cause, have been led
to believe that the sudden ' drying up ' produced a metastasis
to the brain , a notion as crude as it is unsupported ." There
is, I believe, no pathological experience on record which can
sustain the quite common assertion that it is dangerous to
stop a discharge from the ear. There are some cases on
record - of which there are, alas ! many more than were ever
recorded — where disease of the brain has occurred from the
extension of a neglected suppuration to the cerebral mem
branes and substance, and the discharge from the ear has
nearly ceased ; but these certainly form no argument against
the arrest of an ulcerative process before any parts beyond
the cavity of the tympanum are involved .
He who believes that we can easily cause a discharge of
pus to cease, after caries of the temporal bone has occurred ,
will find many cases which will cause him to doubt the effi
cacy of his therapeutics. As wellmight we refuse to heal an
ulcerated hip - joint, as to neglect to check a discharge from a
diseased membrana tympani or lining membrane of the tym
panic cavity.
It is doubtless true, judging from the histories of cases and
the inspection of the membrana tympani, in which cicatrices
occur, that many cases of chronic suppuration are cured with
very slight treatment, or with none at all. The fact remains,
however, that the most of the neglected cases do not so re
cover, and after a purulent discharge from the ear has once
set in , “ we can never tell,” to quote again the words of Wilde,
which should be impressed upon the attention of every prac
HEARING POWER IN CHRONIC SUPPURATION. 371
titioner of medicine, “ how , when , or where it will end, or what
it may lead to." *
A careful treatment is usually required to check the dis
charge and treat the ulcerated membrana tympani, and restore
the hearing power. Even with the most careful and skillful
treatment, we cannot always succeed in all of these things.
In some rare cases we do not succeed in any of them ; but the
patient, in spite of our best efforts, will go on to his doom .
The degree of the impairment of hearing, in cases of
chronic aural suppuration, is very variable. It depends, of
course, upon many factors ; for example , the condition of the
Eustachian tube, and the integrity of the structure in the
cavity of the tympanum . The hearing power by no means
depends upon the presence or absence of the membrana tym
pani. The chief function of this membrane is probably to
protect the tympanic cavity , and not to transmit the vibra
tions of the atmosphere, which when conveyed to the acoustic
nerve we call sound . I know some persons who have large
perforations in each membrana tympani, and who yet hear
well enough for all the ordinary purposes of life , although not
with perfection . One notable instance of this kind is that of
a busy physician of my acquaintance. As has been already
said in Chapter XIV ., Sir Astley Cooper, in a paper published
in the Transactions of the Royal Society in 1800, + showed
that there could be very good hearing powers with a perforate
membrana tympani ; and yet I very often hear the question
asked , as well by physicians as by laymen, if anything can be
done when there is a hole in this membrane ; and it is also
often stoutly asserted that when this membrane is once gone,
the hearing is irrevocably lost. This false idea continues to
prevail, not only in spite of scientific demonstration of more
than seventy years ago, but also in the face of clinical facts that
are every day within the reach of each attentive physician .
Truly , a lie will travel around the world , while truth is putting
on its boots.
The parts which form the middle ear make up a cavity
which have perhaps as many, if notmore , important anatomi
* Text-Book, p. 407.
† Philosophical Transactions, 1800, Part I.
372 CHRONIC SUPPURATION — TREATMENT.
cal relations than any one of similar size in the human body.
The cavity of the tympanum is covered above by a thin , rare
fied bony plate, which is in direct communication with the
cerebralmeninges; the floor is close to the great jugular. Its
internal wall is the labyrinth wall, with its two fenestræ , cov
ered only by thin membrane and opening into the ramifica
tions of the acoustic nerve and the fluid which is continuous
with that of the sub -arachnoid space ; while externally we have
a membrane of about the thickness of letter -paper.
Treatment. The proper treatment of a chronic suppura
tion in such a space, should be a matter of the greatest solici
tude. It involves not alone the hearing power, but also the
life of the patient. There is one pre-requisite to the success
ful treatment of this affection , and that is, a complete removal
of all the morbid material that has formed in the middle ear.
This is simply another way of stating that the parts must be
thoroughly cleansed.
As we have seen in the discussion of the various affections
of the middle ear, their starting- point is usually in the fauces
or pharynx. But the ulcerative process which has been set
up in the tympanic cavity has broken through the membrana
tympani, and the result shows itself in the external auditory
canal. The problem to be solved is, how may we stop the
ulcerative process , heal the membrana tympani, and restore
the hearing power, which has been impaired by the inflamma
tory process in the sound -conducting apparatus ? In many
cases, however, we may be well satisfied if two of these re
quirements be fully fulfilled , while the hearing power is im
proved . A radical cure of a suppurative process in the mid
dle ear, of long standing, is, from the very nature of things,
sometimes impossible .
The old method of treating such a suppuration was to
advise the patient to syringe the ears with soap and water ,
put a blister on the mastoid process, and at the same time
the physician got the system to rights by using alteratives ,
laxatives, and purgatives. The general principle of treatment
thus held in view was correct, but in the matter of the local
treatment, which is of far more importance than the constitu
tional, altogether too much was left to the supposed knowl

edge and skill of the patient or his attendant.
Perhaps not more than one layman in a hundred can, with
out instruction, thoroughly cleanse an ear by syringing. It is
generally thought that any person can syringe an ear, when
the facts are that no patient can properly cleanse his own ear,
and almost every one requires instruction before he can even
syringe the ear of another. In one of the preceding chapters
of this book (see page 128 ), the proper method of syringing
has been carefully described , so that we need not dwell upon
the subject again .
Sometimes the use of the syringe is not well borne by the
patient, the shock of the water being too great. In such cases
the auraldouche of Clarke, is a good substitute for the syringe.
Instead of the thin bowl that I have recommended as a recep
tacle for the fluid that comes from the canal, after having been
injected, some practitioners use a vessel such as depicted in
the accompanying cut - the " iter-becher ” of the Germans. It
FIG . 72.
Vessel used in Syringing the Ear .
is certainly very convenient on account of the fact that it

adapts itself so well to the glenoid fossa, but it is not deep
enough if any prolonged syringing is required . Then the
bowl will do better, and on the whole I think it is to be pre
ferred.
I have known sad cases , where parents, in obedience to their
medical adviser , have faithfully syringed the ears of a child
suffering from chronic suppuration for years, but where the
parts have not been perhaps even once, thoroughly cleansed.
Exuberant granulations or polypi had sprung up, bony growths
had occurred , which are positive evidences of the imperfect
removal of pus and other hurtful material.
374 CHRONIC SUPPURATION — TREATMENT .
There are several methods of cleansing ears affected with

a chronic suppurative process. That which I usually adopt
is a combination of the suggestions of Politzer, Hinton, and
Schwartze. It is, I think, a simple method , and capable of
being fully carried out by any practitioner, but not by the
patient or a nurse. The personal care and supervision of a
medicalman is necessary to the successful treatment of any
case of chronic suppuration in the ear. This personal care
need not always be daily, although it is better to have it so ;
but it should , at the very least, be given twice a week , while
the attendant of the patient is instructed as well as may be,
for the performance of the duty of cleansing the ear in the
intervening time. The importance of the cases for which the
daily attendance of the physician is required, if properly set
forth , will do away with any objections that may be made.
No one certainly would object to the daily attendance of a
physician upon a case of suppuration of the cornea, and I
submit that a suppuration in the cavity of the tympanum and
membrana tympani is of equal importance, with the disease
of the organ of vision.
The method I usually adopt is the following : The ear is
first carefully cleansed with lukewarm water by means of a
good hard -rubber syringe. The bowl to contain the water
coming from the ear, should be held by the patient himself
unless a very young child be the subject — and pressed well into
the glenoid fossa , when no water will be spilled . After this the
ear is filled with lukewarm water poured from a test tube,
a spoon , or the like, and the meatus carefully stopped by a
bit of cotton -wool. The Eustachian tube is then inflated by
means of Politzer's method, and to such an extent that a few
drops of the water are forced by the side of the cotton out of
the canal. This is, of course, conclusive evidence that the air
has been forced through the tube into the middle ear, and
through the hole in the drum -head into the external canal.
The ear is again carefully syringed and examined by the sur
geon. At the beginning of such a treatment, especially in
chronic cases, small portions of inspissated or glutinous mate
rial will still be found. These should be then thoroughly
removed under a good illumination from a mirror upon the
CHRONIC SUPPURATION - TREATMENT. 375
forehead , bymeans of a cotton-holder, which is simply a slen

der steel probe, roughened at one extremity. In the absence
of this instrument, a thin bit of wood, or a match , about
which cotton is carefully twisted , will do very well.
Having satisfied ourselves by inspection with the otoscope
that the ear is thoroughly cleansed, the warm astringent solu
tion should be poured into the ear, and allowed to remain for a
period varying from five to fifteen minutes. If the membrana
tympani be nearly gone, the solution may be swabbed about
the bottom of the ear by means of the cotton -holder, used
under the illumination of the mirror on the forehead.
The choice of an astringent is perhaps not so important
as is often supposed. I usually use the sulphate of zinc for
comparatively recent cases , and the nitrate of silver for old
ones. The sulphate of zinc should be used in weak solutions
- from 1 to 4 grains to the ounce — and the nitrate of silver in
strong ones. Nitrate of silver seems to be of no value in these
cases, unless used of the strength of 40 grains to the ounce.
It may be even used as strong as 480 grains to the ounce .
Dr. O . D . Pomeroy, of this city , reports a case* of “ suppura
tive inflammation of the tympanic cavity , with subjective
symptoms of mastoid inflammation ,” where, after using solu
tions of from 40 to 80 grains, he finally used the very strong
one of 480 grains to the ounce of water. “ It caused a slight
feeling of warmth and fulness in the ear, but not real pain .
The discharge was entirely arrested by this one application.”
The membrane was found to be healed on an examination
made some six months afterward .
In Schwartze's paper calling attention to the use of the
nitrate of silver, in what he regards as strong solutions, he
advises against the instillation of nitrate of silver where gran
ulations or disease of the bone exists. His exact words are :
“ The caustic treatment only promises a nearly certain result,
when we may exclude with positiveness the existence of gran
ulations upon the exposed mucous membrane, or upon the
remains of the membrana tympani, and when there are no
evidences of ulceration of the bone.” +
* New York Medical Journal, Dec. 1872 , p. 631.
† Archiv für Ohrenheilkunde, Bd IV., p. 2 .
N
376 CHRONIC SUPPURATIO — TREATMENT .
The experience of American otologists , has been that strong
solutions of nitrate of silver may be safely and profitably used,
even where there are granulations and polypi. Indeed I would
especially recommend it for some of these cases, although I
admit that their value is often strikingly seen in obstinate
cases of chronic suppuration , where the membrane is not yet
in what may be termed a very proliferous condition. It is
not necessary to neutralize the solution by the use of salt and
water.
An efficient method of applying nitrate of silver to the
whole mucous tract of the middle ear, at least to the lining of
the cavity of the tympanum and the Eustachian tube, is the
following : The solution is dropped into the cavity of the tym
panum through the external meatus, and then forced through
into the tube by two or three puffs from the ordinary air -bag
used in Politzer's method . Of course the patientwill taste the
nitrate of silver, if it be used in this manner.
Mr. James Hinton , of London, recognizing the fact upon
which I have laid so much stress, that thorough cleansing of
the ear is the first requirementof all treatment of chronic sup
puration in this part, advises the forcible syringing of the
tympanic cavity, by means of a syringe whose nozzle is made
to fit into the external meatus, so as to exclude all the exter
nal air. He also syringes the tympanic cavity through the
Eustachian tube, and uses, both for this external and internal
syringing , solutions of carbonate of soda , say of twenty grains
to the ounce. I believe this latter method of washing out the
cavity of the tympanum , was revived and applied to cases of
suppuration, by Dr. Millinger, of Vienna. I have found the
washing out of the middle ear, with the solution of soda, a
very useful adjuvant in these obstinate cases now under con
sideration ; for it must always be borne in mind, if we would
avoid great disappointment, that these cases are usually
obstinate, and often trying to the patience of the practitioner.
I cannot say very much for the method of forcing fluid into
the auditory canal, with the nozzle of the syringe placed her
metically into the meatus . I sometimes resort to it ; but I
have usually found it rather violent in its action, as it is apt
to cause dizziness and vertigo.
It is necessary and proper, in some cases that have resisted

less active treatment, to apply the solid nitrate of silver to the
edges of the perforated membrana tympani, as well as to the
tympanic cavity. It is best applied on a probe, upon the
point of which it has been fused, in a platinum cup placed
over a lighted lamp or gas-burner. This treatment, unlike the
others, is apt to cause pain , which usually passes away on
pouring warm water into the ear. It is a method, however ,
only to be resorted to when other means fail..
ocus Tull
I have not found powders useful in checking chronic sup

purations of the ear. They usually act as foreign bodies, and
fly up the meatus. There is a story told of an itinerant quack,
who stopped discharges from the ear by filling the ear with
plaster of Paris in a fluid state. Its hardening would certainly
prevent any emergence of pus for some time.
As has been before said , the cleansing of the ear by the
medical attendant should be performed about three times a
week. If the suppuration be profuse, the patient should be
seen daily. Here ,as in other departments of otology, we meet
with great prejudice on the part of the laity . They have been
so accustomed to be sent off with a prescription for a “ run
ning from the ear,” that they are quite amazed at being asked
to come to the office daily , or three times a week . Yet this
will often be necessary, and here as elsewhere there remains
some pioneer work to be done in the education of the people.
Dr. Beard, * of this city, believes that the galvanic current
is sometimes a powerful adjuvant in healing a suppurative
process in the middle ear, just as it is in healing ulcers in
other parts of the body. An electrode with a long narrow
extremity, covered with a little cotton, is passed into the audi
tory canal through a rubber speculum . The canal is usually
filled with warm water. The electrode is connected with the
negative pole of the battery. The positive pole is placed either
in the hands of the patient or at the back of the neck. Only
very weak currents and short applications are borne, and the
treatment should be cautiously conducted . Drs. Mathewson
and Prout, in conjunction with Dr. Beard, have been testing
* Verbal communication .
378 CHOICE OF ASTRINGENTS.
the plan of treatment, in cases at the Brooklyn Eye and Ear

Hospital. The character of the discharge soon begins to
change under this treatment, and in some cases the cure
seems to have been more speedy than it would have been
without it.
In cases of chronic suppuration of the tympanic cavity, where the opening
in the drum -head is very small, or when from any other reason it is very
difficult to thoroughly remove the pus, I have found benefit - in connection
with the use of Politzer's method of inflation — from the use of Siegle's oto
scope attached to a syringe, for the purpose of sucking out, as it were , the
fluids from the drum -cavity. After all the other means of cleansing the part
have been thoroughly used , it will still be sometimes found that more pus
may be evacuated by the suction method.
Dr. C . I. Pardee,* of this city , believes that the choice of an astringent
may be regulated by the character of the secretion. If the secretion from
the exposed tympanic cavity be predominantly of a mucous character, Dr.
Pardee uses nitrate of silver. When the secretion is chiefly purulent, he uses
weak astringents of sulphate of zinc, acetate of lead, and alum . It would
certainly be a great advance did we have more certain indications for the use
of strong or weak astringents ; but I am not prepared to give a positive opin
ion as to the correctness of Dr. Pardee's theory . I may only repeat, what
was said in substance in the preceding part of this chapter, that any of the
well known mineral astringents do very well, if the parts are thoroughly
cleansed, and if none of the consequences of the suppurative process have as
yet resulted . It should not be forgotten that the pharynx and nostrils will
often require nearly as much treatment as the ear.
THE ARTIFICIAL MEMBRANA TYMPANI.

This contrivance is at times a valuable means of treating
a chronic suppurative process in themiddle ear. We have
already, on page 43, seen that a New York layman was the
actual inventor of a substitute for the natural membrane.
This gentleman used a bit of paper moistened with saliva for
this purpose in his own ear, and showed it to Dr. James
Yearsley of London, who seized upon the idea, and gave it to
the profession, substituting cotton-wool for the paper. Besides
acting as an artificial membrane, the cotton-plug is sometimes
used as a means of treating a chronic suppurative process in
the ear. It is then packed in the canal quite thoroughly.
When it is employed for the purpose of improving the hear
* Transactions of American Otological Society, Fourth Annual Meeting,
1871.
ARTIFICIAL MEMBRANA TYMPANI. 379
ing, having been slightly moistened, it is inserted under in

spection — that is, while the parts are well illuminated by the
otoscope by means of a pair of forceps, that should be very
weak in the spring, so that the blades may come together
with very little pressure.*
The appropriate position for the cotton where it will im
prove the hearing, will be found, if it is to do any good, by
placing it on different parts of the exposed tympanic cavity ,
or the remains of the drum -head, until the patient experiences
an improvement in the hearing power. I have seen several
patients who used this kind of an artificial membrana tym
pani, and who were very skillful in its employment. +
In 1853, Toynbee suggested another artificial membrana
tympani, without knowing of the previous invention . Toyn
bee's appliance consists of a thin disk of vulcanized rubber, in
Fig . 73 .
Toynbee's Artificial Membrana Tympani.
the centre of which is attached a fine wire about an inch long,

which terminates in a little ring, to enable the finger to more
readily grasp it when its removal is desired . An improvement
upon the original method of attachment of the wire, is to
insert it spirally into the disk, like a cork -screw in a cork.
We can never tell without trial, whether the artificial mem
brana tympani will, or will not improve the hearing. Inas
* Yearsley on Deafness, p . 245.
† An artificial membrana tympani was employed more than two hundred
years before Yearsley ,but not for the purpose of improving the hearing. Marcus
Banzer , in 1640 , recommended for this purpose a tube of elk 's claw , which was
covered by a piece of pig 's bladder. Leschevin in 1763, Auten reith in 1815 ,
and Lincke in 1840, continued to employ such an appliance. Lincke used thin
silver or gold tubes, somewhat conical in shape, from five to eight lines in
length, and of from two to three lines in thickness. The outer end of the tube
had a rim to prevent it from slipping too far into the meatus. The inner end
was covered by a thin piece of gold -beater's skin , which was varnished .
Lincke's Handbuch , p . 447.
380 ARTIFICIAL MEMBRANA TYMPANI.
much as I am sometimes asked if an artificial membrana tym

pani will do any good, if the membrane be intact, it may be
as well to state, that it is only of service in cases of partial or
complete loss of the drum -head. Von Tröltsch relates a case
of a deaf judge who used to improve his hearing temporarily
by pressing upon themembrana tympani with a probe ; but I
have never been able to increase the hearing power by any
similar procedure upon a membrana tympani that was com
plete. The improvement to the hearing that does sometimes
occur when the cotton wool, or the membrane of Toynbee is
used, is probably due to the restoration of the interrupted
Fig . 74.
Method of Inserting Artificial Membrana Tympani. - Toynbee.
continuity of the ossicula auditus to the fenestra ovalis and

the labyrinth . Toynbee, explained its benefit by stating that
it occurred as a result of the closure of the membrane ; but
this has been shown to be an erroneous explanation. Cases
have been seen where the perforation was not closed by the
artificial membrane, and yet great improvement to the hear
ing resulted from its use. When the patient first begins to
wear this membrane, it should be used but for a very short
CHRONIC SUPPURATION - PROGNOSIS. 381
time during the day. It is always a foreign body, and hence it

is liable to produce irritation and increase the suppurative pro
cess. Lest any should think, that the artificial membrane is
not a practical and valuable means of alleviating some cases,
I may state that I have now under observation five patients,
for whom I first introduced the membrane, who have worn it
for years, with uninterrupted benefit to the hearing power. I
have taught several other persons to apply the membrane,
and with benefit ; but inasmuch as I have not seen them for a
long time, it is not quite certain , although probable, that they
are still using the substitute for the natural membrane. I am
in the habit of tentatively applying the artificial membrana
tympani in all old cases of chronic suppuration in the middle
ear, when the loss of hearing is very great. If one ear be
sound, so that the hearing for ordinary purposes is very good ,
as it always is under such circumstances, it is not worth while
to use the artificial drum -head for the diseased ear. An ex
cessive inflammatory action in the remains of the drum -head ,
or in the middle ear , precludes any use of the artificial mem
brane. The patient for whom it is to be employed, should
also be an adult, and possessed of a considerable amount of
intelligence. It is not of any use in the case of children, or
of unusually beedless or stupid adults. The wire to which the
disk is attached , sometimes becomes separated in removing
the membrane, and the disk of rubber is left behind . This
accident, although a very insignificant one — for the disk is
readily removed by syringing — is very apt to frighten the
patient, unless he has been previously warned not to be dis
turbed if such an accident occur, and not to allow any im
proper attempts to remove such a foreign body.
Prognosis. — The prognosis in chronic suppuration of the
middle ear depends upon a variety of local and constitutional
symptoms. If the consequences of chronic suppuration have
occurred, such as exfoliation and death of bone, the formation
of polypi, exostoses and so on , the treatment is apt to be pro
longed, and in some cases ,may never be entirely or even par
tially successful. Again , when the membrana tympani is
entirely removed , and one or more of the ossicula lost, the
382 CHRONIO SUPPURATION - PROGNOSIS .
prognosis is grave. Yet the membrana tympani has a regen

erative power second to that of no other membrane of the
body. I have repeatedly seen it entirely restored after all
but a narrow rim had been entirely swept away. This has
occurred at times in cases of long standing. The prompt
healing of the drum -head after operative perforation and in
acute inflammation, is a matter of common experience .
The state of the general system will also at times influence
the prognosis to a marked degree. Patients with phthisis
pulmonalis seldom recover from a spontaneous rupture of the
membrana tympani. The physician will find ample material
for general advice in some cases, and yet there are many in
which local treatment only is required ; while it is essential
in all. We may say, on the whole , that the prognosis can
never be decidedly given , so long as the membrana tympani
is open, for this membrane is essential to the safety of the ear
from renewed attacks of acute suppuration . All our efforts
should be directed, therefore, to closing up this opening.
There can be no danger from closing it too soon. Our chief
difficulty will be in closing it at all. If regular and careful
treatmentby a physician , continued for months, fails to close
the opening, or to cause the discharge of pus to cease, the
patient may perhaps be given up, as one for whom there is no
hope of cure. The family and friends should be taught to
cleanse the ear thoroughly , as long as any purulent forma
tion occurs, and they should know that the chief danger to
the ear, and the general system , lies in an accumulation and
retention of pus.
CASES.
CASE I.- Chronic Suppuration of twelve years standing — Exostosis of Tym

panic Cavity - Patient under treatment for more than three years- Both
Membranæ Tympani healed - Hearing distance remains the same.
W . P . H ., æt. 32. June 1869. History — Ten or twelve years ago, from
some cause to patient unknown, the right ear began to discharge, and then
the left. They have discharged at intervals ever since. Occasionally there is
pain in the ear.
The hearing distance is — R ., 1 ; L ., . The right membrana tympani is
in a state of ulceration ; about one-third is gone. The lower and posterior
CHRONIC SUPPURATION - CASES. 383
quadrant remains. Considerable pus lies in the cavity of the tympanum .
The left membrane is nearly gone. There is a small granulation springing
from the cavity of the tympanum . The pharynx is tolerably healthy.
The patient was ordered to use the warm douche daily. He visited me
three times a week , when the ears were cleansed by the syringe and warm
water, and Politzer's method , and , an astringent, usually the sulphate of zinc,
was instilled. In November, in about four months from the time of my first
seeing him , the left membrana tympani had healed. The granulation disap
peared with no other treatment than the cleansing and the use of an astringent.
March 17, 1870 — The right membrana tym pani now exhibits a clearly cut
opening in the posterior and inferior quadrant. A small amount of pus oozes
from it . A minute but positive elevation of bone comes out to the opening.
The hearing is at times very poor, on account of the blocking ofthe tympanic
cavity by pus. The patient has been under my observation ever since first
note, often coming to the office every day. Nitrate of silver, nitric acid ,
various astringents, with the continuance of the douche and syringe , have
been employed in vain . March 17, 1871 — The patient has just passed through
an attack of acute catarrh , induced by taking cold . The hearing distance
became during this attack . Leeches were used , and subsequently the
catheter, steam being passed through it. After the subsidence of the inflam
mation , the opening in the membrana tympaniwas found to be very much
smaller. It was then cauterized with the mitigated stick of nitrate of silver,
melted upon a probe, and in a few weeks it healed entirely ; so that in October,
1872, he was dismissed , with H . D . R ., * $ ; L ., 4., and both drum membranes
healed .
I have not attempted to give the full notes of this interest

ing but tedious case. I have inserted it to show what perse
verance on the part of the patient will finally accomplish in
some cases of chronic suppuration. There were no peculiar
means of treatment adopted during thethree years the patient
was under my care ; but he was informed that it might require
years to heal the drum -heads. He realized the danger from
a continued suppuration, as well as the inconvenience and dis
comfort, and he determined never to give up the attempt to
cure it. Very few patients will submit to such a prolonged
observation or treatment without faltering in their allegiance
to their medical adviser .
CASE II. - Suppuration in both Tympanic Cavities for fifteen years, a result of
the Pharyngeal Inflammation of Scarlet Fever— No treatment since first
attack - Healing of one Drum -head, with great improvement to hearing
power - Other Membrane still open .
Mr. A., æt. 26. Nov. 1870 — Since patient was 11 years old,when he had
384 CHRONIC SUPPURATION _ CASES.
scarlet fever, he has had a discharge from both ears, with great impairment
of hearing. Hearing distance, right ear, it ; left, a's. The membranæ tym
pani on each side are removed by ulceration . There is a large amount of pus
in each canal, with granulations which bleed readily .
The ears were treated by the warm douche, the syringe, and Politzer's
method of inflation . The latter at once improved the hearing, so that the
watch was heard at 4 inches, 4 , on the left side. Some inflammatory reaction
was caused in a few days by the cleansing process, and the douche only , could
be employed . The patient was seen from once to twice a week , and used the
douche and an astringent at home. One year after, his hearing distance was,
R ., ; L ., 41. The leftmembrana tympani has just healed.
April 16 , 1872, or nearly a year later, having been seen at longer or shorter
intervals ever since, and having kept up the treatment at his home, the hear
ing distance of left ear is 19. The patient has still occasional attacks of sub
acute suppuration from right ear. His hearing power for conversation is
excellent, and no true pus is found in right tympanic cavity , but some stringy
mucus is forced out by Politzer's method . January, 1873 — The patient is
still seen at long intervals. The condition of the ears remains about the same.
CASE III. - Suppuration of both Middle Ears, occurring without pain - Half
of each Membrana Tympani gone - Moderate amount of pus secreted
Treatment did not avail to improve the Hearing Power- Artificial Mem
brana Tympaniused with benefit.
E . R. T., æt. 28. Nov. 1872 — Three months since , patient found, on
awaking in the morning , that both ears were discharging. There was no
pain experienced in them . He had had naso-pharyngeal catarrh for some
time, which had been treated regularly by the use of the nasal douche and
the posterior nares syringe. The patient is not in very good general health .
He has had a pulmonary hemorrhage, and evidently bas phthisis pulmo
nalis. He hears the watch six inches on the right side, two inches on the
left . Hearing distance, R ., ; L ., . The pharynx is granular. The
anterior and inferior quadrant of the membrane is gone. The remainder
of the membrane is white, and does not reflect light. The left membrane
also has a large perforation , the anterior half being absent, and the remain
der of the membrane looking like the right. There is a moderate amount
of pus secreted in the tympanic cavity. The auditory canals are red and sen
sitive. The patient has already had more or less systematic treatment, and he
cleanses his ears daily by syringing. There are great variations in the hearing
power.
The patient was seen daily for somesix weeks,and efforts made to heal the
membrana tympani by the use of sulphate of zinc, alum , sulphate of copper,
nitrate of silver, in solution and in solid form . Cod-liver oil was given , and the
general condition improved , but the membranæ tympani did not heal in the
slightest, although the discharge was lessened ,and the condition of the audi.
tory canals was improved.
February 15, 1873. - The patient's hearing power continued to grow worse,
when the artificial membranæ tympani were inserted , with immediate benefit
CHRONIC SUPPURATION — CASES. 385
to the hearing power, so that he could transact his business, which was that
of a commercial traveller. Hearing distance, R ., ; L., .
April 15 . — The patient is still wearing the membranes with the same
benefit. The ears are daily cleansed by syringing,and an astringent is dropped
upon them . Mr. T . says that he cannot bear " at all ” without the artificial
membranes.
It has been a common observation with the patients who

use an artificialmembrana tympani, that they cannot hear as
well after removing the artificial drum -heads, as they did
before wearing them . Yet in some cases, the improvement
continues for hours after they are removed . The latter effect
is probably due to the fact that the restored continuity of
the ossicula and the fenestra ovalis is kept up, even after the
agent that caused the restoration is removed .
CASE IV . - Chronic Suppuration of ten years duration stopped in three days,
by the removal of a small granulation through the Drum -head, and the
application of nitrate of silo r - Hearing power improved .
R . R ., Nov. 8 , 1872, sent to me by Dr. H . C , Eno. When the patient was
16 years old he “ got cold in the right ear;" the ear was very painful ; it dis
charged and has continued to do so ever since. It has been under careful treat
ment for some months, and does not discharge asmuch as it did . The hear
ing distance is 48
On examination, a slightamountof pus is found upon themembrana tym
pani. On removing this, a small granulation is seen to come through the
membrane in the anterior and inferior quadrant.
November 9. - The granulation was removed by means of a pair of angular
forceps. A solution of nitrate of silver, gr. 40 ad 3 .j, was applied in the open
ing, after a thorough cleansing of the ear by syringing and Politzer's method .
November 10. — The opening in the membrane has closed . The patient
remained under observation until Nov. 22, and suppuration did not again
occur. The hearing distance became 46.
It may be thought that these cases illustrate the bright

side of the treatment of chronic suppuration ; but I do not
think they are any more than average specimens of cases of
simple ulceration, that is, ulcerations unattended by death of
bone. When caries or necrosis of any part of the walls of
the cavity has occurred, the prognosis is very unfavorable
for a perfect arrest of the morbid process. I have not found
so much difficulty in relieving uncomplicated cases of chronic
suppuration, as in finding patients who were patient enough
386 CHRONIC SUPPURATION - CASES .
to submit to the tedious treatment necessary to a cure. Dis

trust of the advice of the profession is nowhere more common
than in cases of chronic suppuration , in regard to which the
laity have been taught two erroneous and contradictory doc
trines, first, that a discharge from the ear is seldom checked ;
second, that it is dangerous to arrest it, if we can .
CHAPTER XVII.
THE CONSEQUENCES OF CHRONIC SUPPURATION OF THE
MIDDLE EAR .
IF a chronic suppurative process in the middle ear re

mained a simple ulcer, with none of the consequences that are
very liable to result from it, it would , perhaps, be a condition
of things to be preferred to a chronic proliferous process in the
same part. For in simple chronic ulceration the hearing power
is often very good, the tinnitus aurium is not usually exces
sive, and sometimes does not exist, and it may generally be
relieved by simple syringing and inflation of the ear. These
are the symptoms which are so trying, in the non -suppurative
form of disease, that people have become insane on account
of them . But the almost inevitable consequences of chronic
suppuration in themiddle ear, are dangerous to the health and
life of the patient. Hence the importance of the subject, and
the interest which every physician should take in arresting the
advance of these sequelæ of disease.
It is in view of these effects of chronic suppuration of the
middle ear, that English life insurance companies are said to
decline to insure the lives of persons that are affected with the
disease. A little consideration will show , that any person who
has a hole in the membrana tympani, and an ulcerative pro
cess in the parts beyond, has a much less chance for long life,
than one whose brain and vascular circulation are not thus
exposed to the ravages of disease. Very few persons com
paratively ,who suffer from chronic suppuration , live out their
days, while many of them die very young.
On page 237 of this volume, these consequences are tabu
lated . It is now proposed to enter into a discussion of their
388 AURAL POLYPI.
nature and treatment. At the risk of reiteration , it should be

again said, that none of the results of chronic suppuration
should ever be regarded as independent affections.
- POLYPI.
Celsus and Pliny used the term polypus for a tumor spring
ing from any cavity of the body. The name was adopted
under the old system of nomenclature ,when an exact know
ledge of the nature and structure of growths or parts was not
regarded in giving them a name. It is an unfortunate one,
for there is scarcely any resemblance between the many footed
aquatic animal after which morbid growths were called, and
the exuberant granulations or tumors which arise from the
cavity of the tympanum and the auditory canal. It is prob
ably too late , or too early, to effect any change in the nomen
clature, and we must be content with the name aural polypi
for all the growths that occur in the ear, except for those
of an osseous structure or a cancerous nature.
The best classification of aural polypi seems to me, to be
that of Steudener,* who divides them into three varieties :
1. Mucous polypi.
2. Fibromata .
3 . Myxomata.
To this we may add a fourth class :
4 . Angioma ; a case of which , as occurring in the ear, was
first reported by Dr. A . H . Buck .t
Cases of epithelioma, sarcoma, and cholesteatoma have
also been reported , but they do not properly belong to
the subject of aural polypi, although they are sometimes con
founded with the simple growths, and perhaps arise from
them . For the sake of convenience, their consideration will
be deferred until the benignant tumors have been considered.
Kessel | also reports a peculiar growth which is called a clot
ofblood in process of organization, but it hardly requires a
separate classification .
* Archiv für Ohrenheilkunde, Bd. IV ., p. 203.
+ Transactions of the American Otological Society, 1870.
Archiv für Ohrenheilkunde, Bd. IV ., p . 187 .
AURAL POLYPI. 389
The mucous polypi are altogether the most frequent of
those found in the ear. The fibromata, or polypimade up of
denser connective tissue than the mucous growths, are next in
frequency. Buck thinks that about one in ten of all the
polypi that have been microscopically examined, belong to
the class of fibroma. Myxoma has been reported by Steu
dener only , so far as I have been able to find.
Nature of Aural Polypi. - In an article published in 1864,*

I attempted to show on clinical grounds, that aural polypi
were analogous in structure to exuberant granulations, occur
ring as direct results of an ulcerative process. This view at
once clears up the nature of these growths and takes away the
fictitious importance which the view that regards them as inde
pendent tumors caused them to assume. Professor Theodore
Billroth, in 1855 , whose monograph I had not then seen , exam
ined seven polypi which were found in the external auditory
canal, and Kessel t quotes him as stating that the chief con
tents of those polypi were granulation material, although he
states that the existence of ciliated epithelium and the vascu
lar network entitles them to the rank of independent tumors.
Billroth's idea as to the nature of mucous polypi is perhaps
themost correct and the simplest. They consist of a delicate
but loose stroma of connective tissue. In the meshes of this
connective tissue are round, spindle-shaped or stellate cells,
and they are covered by a single or multiple layer of epithe
lium cells.
The fibrous polypi consist of a dense connective tissue,
having but few cellular elements in its fibres and covered by
pavement epithelium .
Angioma is made up of newly formed vessels, or of vessels
in whose walls are newly formed elements. It is quite a com
mon variety of tumor, although the case to which allusion has
already been made, is the only one that has been reported as
having been found in the ear. Virchow I named the form
which Dr. Buck examined ,angioma cavernosum , because it was
* American Medical Times, August 6, 1864.
† Archiv für Ohrenheilkunde, 1. c.
1 Die krankhaften Geschwülste IV ., Bd. I., Hf. ., p. 307.
390 AURAL POLYPI.
characterized by the existence of a network of blood spaces,

occupying the place and doing the work of capillary vessels.
It may be said in general terms, however, that aural
polypi are growths covered by laminated epithelium , and that
they consist of loose connective tissue, containing round and
fusiform cells and a proportionately large number of blood
vessels. Their internal structure in some cases gives evidence
of the formation of glands.
Dr. H . C. Eno, pathologist to the Manhattan Eye and Ear
Hospital, and assistant-surgeon to the New York Eye and Ear
Infirmary, examined three specimens of aural polypi, which I
removed from the auditory canal, and made drawings of their
structure. These drawings will, I think , better illustrate the
nature of these growths than further remarks.
Fig . 75.
в
Section of Aural Polypus, Case I.

A . Layer of laminated epithelium , similar to that of skin . B , B . Epithelial cones, the com
mencement of gland formation . C. Loose connective tissue, containing round and spindle
cells and some fibres. D . Blood-vessels .
CASE I. — Thomas Gibney, age 23. March 14 , 1871. Brooklyn Eye and
Ear Hospital.
History. - Seven days ago extensive swelling in meauricular region ; gran.
ulations springing out of auditory canal.
Diagnosis. - Abscess of anterior wall of auditory canal, with polypoid
growth arising from same point.
Treatment.– Polypus removed and abscess opened ; ordered chloral hydrate ,
AURAL POLYPI. 391
gr. xv.; if does not sleep well to-night, to come at 12 M . March 16th - Con
tinue treatment. March 18th — Touched polypus with nitric acid. March 21st
- Much better, touched with argent nit. mit.
It should be said that the usual point of origin of aural

polypi, is the cavity of the tympanum . They may arise from
the auditory canal, but if so , they are the result of suppuration ,
that has been prolonged ,or thathas been augmented by the use
of poultices, and which have rapidly broken down the integu
ment of the canal, and rendered it more like its neighbor, the
mucousmembrane of the tympanic cavity. Polypi and granula
tions often, however, have their seat in the canal, but they are
usually accompanied by the same growth in the deeper parts ,
when the whole character of the tissue lining the canal has
been changed by an ulcerative process, extending from the
tympanic cavity. As will be seen by comparing the illustra
tions of Case I., which arose from the auditory canal, with
those that sprang from the cavity of the tympanum , the only
essential difference is that the epithelium is thicker.
FIG . 76 .
BA
Section of Aural Polypus, Case II.
A . Epithelium . B. Substance of polypus,madeup of a mass of round cells about the size of
white blood corpuscles. C , C . Capillary vessels, containing white blood corpuscles.
CASE II. —Mary Jane N.,æt. 13. January 10, 1872. Manhattan Eye and
Ear Hospital. Otitis media suppurativa, with polypus in right ear . Polypus
nearly fills auditory canal. Discharge from both ears from scarlet fever since a
child . Large perforations in membranæ tympani. Polypus removed with
spare .
392 AURAL POLYPI.
Fig . 77.
S OCO
Do 2000
Section of Aural Polypi.

A , C, and D , same as in Fig. 75. E . Gland lined with cylindrical epithelium . F. Trans
verse section of the same.
CASE III. — Mary Ann McC .,age 14. January 24, 1871. Manhattan Eye
and Ear Hospital.
History . - Discharge from right ear since a child. Cause unknown.
Diagnosis. — Otitis media suppurativa, with polypus of right ear.
Hearing. - R ., watch heard on contact. L ., normal.
Meatus.- R., full of pus.
Treatment.- Syringed. January 31st — Two polypi removed with spare.
Douche and syringing. Politzer,warm douche. Nitric acid to stumps. Hear
ing distance increased to 2".
Aural polypi are more rarely found by the physicians of to
day,than by our predecessors, for the simple reason that aural
diseases are more carefully observed , and they have no such
opportunities to occur, as were enjoyed when a discharge of
pus from the ear was not treated. A tumor can scarcely arise
from a tympanic cavity or an auditory canal that is kept thor
oughly freed from the pus of a chronic suppurative process .
MALIGNANT GROWTHS .
The malignant growths that have as yet been found in the
ear, and which may be mistaken for malignant polypi, are epi
thelial carcinoma, fibrous and medullary carcinoma. Gruber*
. * Text-book, p. 597.
MALIGNANT GROWTHS. 393
relates a case where an epithelial carcinoma originated in

the integument in the region of the mastoid bone, gradually
destroyed the mastoid process, and finally reached themucous
membrane of the middle ear. The membrana tympani was
destroyed by the growth . The patient heard a watch when
laid upon this ear ; he had no tinnitus aurium , and so few
symptomsbeyond extremely slight lancinating pain , that after
the tumor had existed for three years he still did his work
as a day laborer.
Dr. Robertson of Albany, * reports a case of supposed poly
pus in the ear,which proved to be, on microscopic examination ,
a specimen of " fasciculated sarcoma corresponding to plates
of tumors constituted by embryonic tissue, found in the
Manual d 'Histologie Pathologique, by Cornil and Ranvier of
Paris.” An attempt to remove the growth by cutting off
pieces of it, caused a hemorrhage of fourteen fluid ounces in
a few moments. The hemorrhage was arrested by a tampon
of cotton dipped in a solution of persulphate of iron.
Cholesteatoma, the pearl tumors of J. Müller, have also
been found in the cavity of the tympanum arising from an
inflamed or ulcerated mucous membrane. They consist, ac
cording to Gruber, t of small degenerated epithelial cells,
between which lie cholestearine crystals and other fatty ma
terial. They sometimes destroy the bone by pressure, and
they may even extend into the cranial cavity.
Osteo -sarcoma of the cavity of the tympanum , extending
into the auditory canal, was also observed by Böke. The pa
tient died ofmeningitis. Wildeş reports an interesting case of
osteo -sarcoma. A boy of seven years of age, in apparently good
health, was brought to Mr. Wilde on account of a discharge
from the external auditory canal. A small polypus was dis
covered. It was removed, but it returned quickly on the third
day. It was again and repeatedly removed , but it recurred
again and again , and subsequently the child was seized with an
epileptic fit. A fluctuating point was then found upon themas
toid process ; this was cut down upon at once,and the opening
gave exit to a large amountofpus. The abscess communicated
Lehrbuch , p . 597. Gruber, 1. c. S Text-book, p . 208 .
394 MALIGNANT GROWTHS.
by a fistula with the externalauditory canal. A fungous growth

soon sprouted up through the incision. Repeated attacks of
epilepsy occurred, and death soon ensued . Upon examination
there was found an osteo -sarcoma of the petrous and mastoid
portions of the temporalbone. Wilde, thinks that the original
disease was in the bone, and that the aural discharge and
fungous were but secondary appearances. The history is not
detailed enough to allow us to state with any positiveness the
first cause of the affection, but it may have been an ulcer in
the tympanic cavity, which secondarily involved the bone.
These malignant tumors of the ear should be carefully dis
tinguished from the benign mucous and fibrous polypi thatare
the frequent results of a neglected suppuration . Yet it should
be remembered that the malignant growths may be also the
result of the same original process. This fact adds to the
importance of the subject. Perhaps some of the cases of
death from the removal of aural polypi, should be referred to
the extension of the malignant disease , rather than to the
excision of a tumor from the ear.
Treatment. — The treatment of an aural polypus should

begin with the removal of the growth . I have said begin with
deliberation, because it is a mistake to suppose that the
removal of the polypus will be any more than the beginning
of the treatment of the disease of which the polypus is a
symptom . Besides, aural polypi often spring up very rapidly,
even after they have been thoroughly removed , and when they
are simple growths ; moreover , we are often obliged to remove
them several times from the ear, especially where we cannot
have full control of our patients and cause them to attend to
the after-treatment.
Wilde's snare, as modified by Blake, will be found the best
instrument for the removal of well-defined polypi with a pedi
cle. In Wilde's snare , the bar which carries the slide, and the
arm which supports the wire used in cutting off the polypus,
are in one piece. Dr. Blake has substituted a movable tube
of German silver (d ) for the fixed arm . “ This tube expands
at the outer ends into a flattened head ( f ), having two open
ings for the passage of thewire ; the inner end of the tube fits
AURAL POLYPI - TREATMENT. 395
into a broad band on the slide-bar (6). The ends of the wire
passing down the tube are fastened to a pin on the upper part
of the slide (c), below which is a ring, by which traction can
be made.” The instrument is better than Wilde's, because it
can be turned in any direction without injuring the walls of
the canal. A paracentesis needle may also be used in the han
dle, but it shonld be rather longer than the one in the cut.
Fig . 78.
NO
Blake's Modification of Wilde's Snare, with Puracentesis Needle.
Scissors may sometimes be used with advantage to remove

aural polypi. I have found those that are here represented
very convenient, especially for the removal of growths from
the walls of the auditory canal.
FIG . 79.
Scissors for the Removal of Aural Polypi.
Forceps may sometimes be employed , although I prefer the

snare and scissors to all other mechanicalmeans for removing
polypi or granulations. Forceps, unless used with great gen
tleness and care, may wrench more than the morbid growth
from the cavity of the tympanum , and thus do great harm .
Very small pedunculated growths, such as was found
in the case recorded on page 385,may be often removed by
the simple angular-toothed forceps, figured on page 80 of
396 AURAL POLYPI - TREATMENT.
this work. True exuberant granulations, having no pedicle ,

but arising from a broad surface , usually resist treatment with
great obstinacy , because they are difficult to reach and entirely
remove with instruments, and because they usually cover
carious or necrosed bone. Caustics are perhaps the only
means of removing such growths. The agents I usually em
ploy for such cases are strong solutions of nitrate of silver
from 40 to 480 grains to the ounce — and fuming nitric acid .
The nitrate of silver may be poured in upon the part, and
then neutralized by the subsequent instillation of a solution
of common salt.
FIG . 80.
Hinton 's Forceps.
Dr. O . D . Pomeroy* reports a case of “ the removal of a

polypoid granulation of ten years standing, by four applica
tions of a forty -grain solution of nitrate of silver.” A pipette
was used to drop the nitrate of silver upon the growth .
Although it is evident from the history,that the disease which
allowed the formation of the polypus — a chronic suppuration
from scarlet fever — had existed for ten years , it does not cer
tainly appear that the polypus had been in the ear so long.
The polypus is said to have sprung from the membrana tym
pani, which was perforate , however.
I am in the habit of treating granulations that arise from
the cavity of the tympanum ,where it is somewhat dangerous
to use forceps, scissors, or snare , by numerous punctures with
a cataract needle. The puncturing causes considerable hem
orrhage. After the blood is wiped away, a caustic should be
* Medical Record , vol. vi. Reported by D . Webster, M .D .
AURAL POLYPI - TREATMENT . 397
applied. Nitric or chromic acid may be thus used, by means
of a glass rod , a cotton -holder armed with cotton, or a bit of
wood .
The pain from these applications is usually so little, that
even children will bear them without shrinking. The granu
lations are of such a low grade of organization that they have
very little sensitiveness. There are, of course, many other
agents than those that have been mentioned, which may be
profitably used in cauterizing the bases of polypi that have
been removed by instruments, and in destroying fungous
granulations. Chromic acid is very much employed, as well
as the acid nitrate of mercury.
Fig . 81.
Angular Glass Rod for applying Acids to the Cavity of the Tympanum .
Dr Edward H . Clarke often injects a solution of the per

chloride or persulphate of iron into the interior of a polypus,
and with the happiest results.* Two or three drops of the
liquor ferri perchloridi, of the liquor ferri persulphatis, are
injected into the growth by means of a hypodermic syringe.
The galvano -cautery is said to be an efficient and painless
method of removing granulations from the cavity of the tym
panum . Dr. Blake does not consider it a painless method of
perforating the drum -head however, he having witnessed its
operation , in Vienna, in some experiments made by Politzer,
Chemani,and Moos. Allusion has already been made, on page
331, to this means of puncturing the membrana tympani. In
each of the cases observed by Blake, where an attempt was
made to perforate the membrana tympaniwith a galvano-cau
tery , the pain was so severe that further attempts were aban
* On Polypus of the Ear, p .61.
398 AURAL POLYPI.
doned . It is probable,however, thatit is not so painful a process

when used to remove granulations. Schwartze * speaks very
highly of the galvano-cautery for the purpose of removing mor
bid growths. Although the pain is considerable, much more
severe than from the use of the pure nitrate of silver, the reaction
is slight. Schwartze also believes that the galvano- cautery is
a more efficientmeans of removing the growth than the ordi
nary caustics.
No matter which of the methods that have been detailed
be employed in removing an aural polypus, the subsequent
treatment will be the same. The case, after the removal of
the growth - if caries, necrosis, or exostosis do not exist
is one of simple chronic suppuration, that should be managed
in themanner that has been set forth in the preceding chapter.
The removal of the polypus may improve the hearing very
much, or it may scarcely benefit it. If the polypus were a
mere mechanical obstruction to the entrance of sound , its
removalwould of course at once restore the hearing power ;
but, as has been seen, it is much more than that. The prog
nosis in regard to the hearing power in cases of aural polypi
should always be guarded . The hemorrhage from their re
moval is usually trifling. If it be excessive, as in Dr. Robert
son 's case of carcinoma, a tampon saturated in sulphate of
iron will arrest it. I usually employ Rohland's styptic cotton
for the arrest of hemorrhage from the base of a polypus, if the
use of cotton-wool do not check it at once .
BLAKE'S MIDDLE EAR MIRROR.
Dr. Blake has invented a middle ear mirror, for the pur
pose of examining cases of suppurative inflammation of the
middle earmore accurately , than can be done with the aural
speculum .t It is said to be especially useful in detecting the
exact site of small granulations. The use of Dr. Blake's
instrument, as he himself states, “ is of necessity limited to a
very small number of cases , as both a moderately wide meatus
and a comparatively large opening in the membrana tympani
* Archiv für Ohrenheilkunde, Bd. IV ., p. 8 .
+ Transactions of the American Otological Society, 1872, p . 83.
MIDDLE EAR MIRROR . 399
must exist, to permit of the introduction of a mirror of suffi
cient size.” The instrument was first constructed to accurately
determine the origin of a growth which was external to the
membrana tympani, but which was hidden from view by the
conformation of the external auditory canal.
The mirror is attached to Weber's tenotome, the cutting
hook being replaced by a polished steel mirror of from one
sixteenth to one-eighth of an inch in diameter. In somecases
Dr. Blake thinks a larger mirror may be used . “ The mirror
is made by flattening out the end of the shaft, bending it
at the proper angle, tempering and polishing it. The shaft is
ductile , so that the angle of the mirror can be varied at will.
Shafts of various lengths, with mirrors of various sizes, may
be rotated by movement of the stud in the handle.” *
Fig . 82.
Blake's Middle Ear Mirror.
For the benefit of the student and young practitioner, we

may formulate our knowledge of aural polypi as follows :
I. — True aural polypi are morbid growths analogous to
exuberant granulations.
* Messrs. Otto & Reynolds, of this city , have greatly improved Weber's
tenotomeand Blake's middle ear mirror, by placing the tenotome and mirror
in a slit canula , so that no unscrewing is needed to remove them .
400 EXOSTOSES .
II. — They are the result of a long-continued , or recent and

violent purulent inflammation of the cavity of the tympanum
or external auditory canal - usually of the former.
III.— Their removal is but the beginning of a treatment of
the disease of which they are consequences and symptoms.
IV . — The hearing power of the patient will not be restored ,
although usually improved by the removal of an aural polypus.
V . - Malignant growths occur in the ear, which assume the
form of, and may bemistaken for, simple polypi.
EXOSTOSES.
Exostoses, hyperostoses or bony growths sometimes occur

in the osseous portion of the auditory canaland in the cavity
of the tympanum . Theymay be divided into two great classes
— the congenital and acquired forms. With the congenital we
have very little to do. Inasmuch as they are not consequences
of chronic suppuration, they do not usually , if ever, become a
source of trouble, and are generally seen incidentally — that is,
when a patient's ear is being examined for some disease inde
pendent of the exostosis. In these congenital cases the whole
caliber of the canal is sometimes invaded by a general thick
ening of the bone, but more frequently the growths extend
from one point with a pretty well defined pedicle .
Professor S .Moos* believes that osseous tumors in the ex
ternal auditory canal are relatively frequent, and he has ob
served three cases of the symmetrical formation of exostoses
in both auditory canals, in persons who consulted him for a
catarrh of the middle ear. “ The tumors developed invariably
from the upper wall of the external auditory canal, close to
the drum -head , and opposite Shrapnell's membrane.” None
of the patients had ever suffered from gout, rheumatism ,
syphilis, or a suppuration in the ear. Moos thinks that these
cases were consequent upon irritative processes occurring at
the time when the annulus tympanicus unites with the squa
mous portion of the temporalbone. Dr. Gruering reported
* Archives of Ophthalmology and Otology, vol. ii., p '36.

CONGENITAL EXOSTOSES . 401
two similar cases at a meeting of the New York Ophthalmo

logical Society, in April, 1872 .
These congenital bony growths do not require treatment,
and should not be interfered with.
When the subject is old ,and the auditory canal is naturally
narrowed by the alteration in position in the lower jaw , some
trouble may be experienced from the impaction of wax in the
ear in cases of congenital exostoses, inasmuch as the usual
means of its removal— the motions of the jaw - cannot produce
the same effect upon the narrow passage.
Bonnafont* reports an interesting case of an aural exosto
sis, which, so far as I can judge from the history, which is not
very detailed nor exact,seems to have been congenital, and to
have continued to grow after birth . It completely obliterated
the auditory canal : “ Observation d'un cas de surdité complète
de l'oreiile gauche due à l'obliteration de conduit auditif par une
tumeur osseuse, siégeant près la membrane du tympan, guérie par
le trepanation de la tumeur.” There was no history of previous
pain or suppuration. By the use of a point of nitrate of sil
ver, for six sittings, the bone was exposed at the centre of the
growth, and it was then removed by boring into it with a rat
tail file. In ten applications of this file, which were not
very painful, an opening was made. A whalebone probe was
then fastened in the opening. This opening was kept up for
some months, and after it was made the tick of the watch was
heard for some inches. Someyears after, the opening through
the exostosis still remained .
Professor H . Welcker,t of Halle, in an article upon bony growths in the ear,
found upon the dead subject, gives some interesting facts in regard to these
formations. Welcker quotes from Seligman, who found exostoses very fre
quently in the external auditory canals of the skulls of American Indians,that
had been misshapen by pressure exerted upon them in infancy. “ Of six such
skulls, fivewere found to have this kind of exostoses." Seligman was inclined
to believe that these growthswere a peculiarity of race ; but Welcker does not
agree with him , because he found them in other Indians not of the tribe
whose skulls were examined by Professor Seligman, and whose bones had not
been changed by pressure. Welcker also adds that these exostoses are not
* Monatsschrift für Ohrenheilkunde, Jahrgang II., No.8 . Lue à l'Académie

Impériale de Médecine, 26th May, 1868.
+ Archiv für Ohrenheilkunde, Bd. I., p. 171.
26
402 INFLAMMATORY EXOSTOSES.
extremely rare among the cultured population of Europe, and as shown by

the text-books and C. O . Weber's collection, the external auditory canal is a
favorite position for them . Welcker thinks that Seligman 's observations show
that exostoses of the external auditory canal are more frequent among the
Indian tribes than among the people of Europe, although he does not think
there is any race peculiarity in them . The exostoses found by Seligman , in
such relative frequency among North American Indians,seem to plainly belong
to the class of congenital growths which have been reported by Moos, Gruen
ing, and Agnew ; but I have no doubt that their origin was, as Moos states,
due to some local irritation , which caused a proliferation of bone.
INFLAMMATORY OR ACQUIRED EXOSTOSES.

The cases of acquired exostoses are a much more serious
matter than the congenital affections of the same kind. They
arise in the course of a chronic suppuration of the middle ear ;
they usually grow with more or less rapidity, and they may
finally block up the tympanic cavity and cause retention of
pus with all its fatal results. Such a case will be found at the
close of this section . They are the results of a local irritation ,
which has caused in the first place a periostitis , and seconda
rily an enlargement of bone. This local irritation may be
either the constant presence of pus on the walls of the canal,
or the extension of the inflammation of the lining membrane
of the cavity of the tympanum , a membrane which is essen
tially a periosteum , to the true periosteum of the osseous canal.
Toynbee was inclined to ascribe great importance to the
existence of a rheumatic, gouty, or syphilitic diathesis in these
cases of acquired and growing exostoses. In his work upon the
ear, he details nine cases of bony growths in the external audi
tory canal, which he evidently regards as an independent dis
ease,and he remarks that “ they seem to be the result of a rheu
matic or gouty diathesis .” The author published four cases,*
in which there was no such diathesis ,but in which the growths
were general enlargements of the periosteum , and of the bone
structure beneath . They were morbid growths consequent
upon local irritation. A more complete experience has sub
stantiated this view . Besides, a careful examination of the
history of Mr. Toynbee's cases causes the doubt to be raised
* New York Medical Journal, vol. ii., p. 424.
INFLAMMATORY EXOSTOSES . 403
whether a diathesis had much to do with the formation of

several of them ; while some of the others probably belonged
to the congenital form . In Case III., reported by Toynbee, a
discharge had existed from the ear for eleven years. There
was a perforation of the membrana tympani. In Case VI.
there was also a discharge. In Case VII. the exostosis was
found to be thebase of a polypus. In Case IX . there had been
a discharge from the ear wben the patient was a boy . Nine
cases are reported in all ; but the histories are not very fully
given.
Virchow * says that local influences are in very many cases
the exciting cause. “ Some have, indeed , educed the fre
quent cases where certain constitutional diseases , especially
rheumatism , arthritis, syphilis, scorbutus, rachitis, have pro
duced bony tumors, as being something opposed to these
local causes. Undoubtedly the field of these conditions was
formerly too amplified , and we may say that scorbutus is now
almost entirely excluded from the list of causes, and that the
gouty enlargements of bone are no growths, but only deposits ;
but we cannot deny the influence of the other so - called dys
crasia , especially of the rheumatic , syphilitic , and rachitic
diatheses. In spite of this, their influence should not be over
estimated.”
Polypi are frequently found upon the exostoses that arise
in the course of a suppuration in the ear. This is, of course,
proof that the tissue beneath is one that has been recently
the seat of inflammation.
Dr. Agnewt has seen quite a number of cases of exostoses
arising in cases in which the membrana tympani was sound ,
and which he believes were due to local irritation after birth,
such as the use of instruments for the purpose of cleansing or
scratching the canal, the formation of furuncles in the same
part, and so forth .
The cases of acquired exostosis that I have seen , with one
exception, arose in connection with suppuration in the middle
ear. In that one exception , the exostosis was so large that
* Die Krankhaften Geschwülste II., Bd. I., Hälfte, p. 73, et seq . passim .
+ Verbal communication , New York Ophthalmological Society .
404 EXOSTOSES - CASES .
the condition of the membrana tympani could not be posi

tively known, and, unfortunately, I saw the case but once.
Treatment. The treatment of these growths should reach
the starting point — the middle ear. We should endeavor to
cause the suppuration in this part to cease. If this is impossi
ble, as it may be in the chronic cases in which exostoses occur,
the parts should be kept scrupulously free from pus, so that no
blocking up of the morbid material may occur. The patient
should be taught to use a cotton -holder and the warm douche
with which to cleanse the canal, and Politzer's method , to force
the purulent material ont of the tympanic cavity . Iodine may
be painted on the growths with, I think , some benefit, and if
a diathesis play a marked part in causing their enlargement,
the appropriate constitutional treatment should be given . If
the exostoses grow to such an extent as to occlude the canal,
Bonnafont's operation should be performed, and a space made
through the growth for the exit of pus.
CASES.
The following cases will give a fair idea of the appearance

of the exostoses thatare consequences of chronic suppuration.
Some of them have been previously published ;* but inasmuch
as the subject is an interesting one, and the book in which
they appeared is now out of print, they may perhaps be repro
duced with propriety.
CASE I. - Mr. C., æt. 39, was seen in April, 1864, in consultation with Dr.
C . R . Agnew , under whose care he had been for some time. He had lost,
before coming under observation, the hearing of his right ear by inflammation
and caries ofthe middle and internal ear. Previous to the above date, Dr. A.
had removed a sequestrum consisting of the cochlea and semicircular canals
from the depths of the external auditory canal of the ear, and thus terminated
the inflammatory action . In early life , Mr. C. had also suffered from “ inflam
mation " of the left ear, producing the bony growths in the external auditory
canal, which render his case the subject of present description . He now hears
with his ear a watch tick at a distance of five inches. In the auditory canal,
near the meatus, are two bony enlargements, which rise from the anterior and
posterior walls, and project in a conical form , so as to occupy at least three
* Von Tröltsch on the Ear, second American edition , p. 131..

EXOSTOSES - CASES. 405
fifths of its caliber. These tumors have all the physicalappearance of exos
toses, and seem to have originated in periosteal inflammation . They have
been steadily treated formany weeks by the localapplication of the saturated
tincture of iodine, and certainly not diminished in size. Pressure upon them
excites pain and induces an increase of swelling in the skin which covers
them ,and thus temporarily adds to the deafness. The entire absence of hear
ing in the fellow ear, and the failure of simple means to render the exostoses
smaller, have suggested the propriety of some surgical operation for their
removal. Such a proceeding has been thus far postponed by the occurrence
of an acute attack of inflammation in the parts extending to the tympanum ,
with symptomsofmore than usual cerebralirritation . From this disagreeable
complication he has entirely recovered under Dr. Agnew 's care.
His general health being impaired, he went abroad, and while in London
consulted Mr. Toynbee, who used bougies, hoping to dilate the canal ; but,
according to Mr. C .'s statements, they caused much pain and accomplished
nothing. Through Dr. Agnew 's courtesy , I again saw the patient in the
spring of 1865 , and found that the growths had so much increased that only a
small probe could be passed between them , and the hearing more impaired .
The patient could still, however, hear the watch tick , but only when laid on
the auricle.
The patient whose case is here given , died about two years
after, of inflammation of the membranes of the brain, induced
by suppuration in the cavity of the tympanum , the pus not
being able to find an outlet on account of the presence of
exostoses. Dr.Agnew exhibited the brain and temporal bones
before the New York Pathological Society. The history of
the other ear of this unfortunate patient will be found in
the section on caries and necrosis.
CASE II. - A gentleman , æt. 40, whom I saw but once , in June, 1864. He
states that he had a “ running " from his right ear for a number of years. For
some two or three years past he had observed that the ear was stopped up.
He was accustomed to remove the accumulating discharge by thrusting in a
match armed with cotton . There is seen a bony growth arising from the
posterior wall of the meatus, and involving the whole caliber of the canal,
except a space large enough to admit an ordinary sized silver probe. Through
this opening a slight amount of purulent discharge, constantly makes its way.
There was some hyperæmia of the pharynx, and there was a small ulcer
on one of the tonsils. The patient was in excellent general health , was rather
a free liver,and said he had constitutional syphilis ; but no good evidence of
its existence now existed . The patient had never had rheumatism or gout.
CASE III. - Mr. S.,æt. 25 , Conn . February 6 , 1865 (a patient sent to me by
Dr. Alfred North , ofWaterbury ,Ct.).— When the patient was three or four years
ofage he had scarlet fever, atwhich time his ears began to discharge,and they
406 EXOSTOSES - CASES.
have continued to do so at intervals ever since, with attacks of pain in the ears,
which sometimes lasted for weeks, and prevented him from any occupation for
the time. Eight years ago his ears were examined and polypi discovered , one
of which was removed by caustics. The attacks of pain have continued to
occur, the discharge continues, and his hearing is becomemore and more im
paired . He is just now suffering from acute pain referred to the left ear. He
hears the watch about one inch from each ear.
In the right meatus there is seen a bony growth reaching nearly out of the
orifice of the external meatus, and arising from the posterior wall. The space
between the growth and the anterior and upper wall is about large enough to
admit of the introduction of a camel's hair brush. In the left meatus, there is
seen a gelatinous granulation , also reaching nearly out to the orifice of the
meatus.
On blowing air into the cavity of the tympanum , by means of the Eusta
chian catheter, air and fluid are heard making their exit into the external
meatus ; but the blocking up of this passage prevents their emergence. On
the right side pus may be seen in the orifice between the bony growth and
the wall of themeatus.
The confinement of the fluid in the middle ear accounts for the pain in the
left side, and the indication of treatment was to secure its free exit. This was
done by removing the gelatinous growth by torsion , the patient being ether
ized , and rendering the Eustachian tubes permeable by the use of the well
known means — the catheter and Politzer's method . The granulation was
found to have its origin from a general bony expansion of the meatus. This
growth had no one growth of attachment, but involved all the sides of the
meatus, somewhat more expanded externally, giving the bony canal rather a
funnel-shaped appearance. The bone was roughened. The pain in the ear
disappeared as soon as these means for securing an outlet to the pus, con
stantly secreted from the cavity of the tympanum , and passing through the
perforated membrana tym pani, had been taken , and the hearing was so much
improved that the watch was heard about four inches from the left auricle.
He remained under treatment for a few days,and then returned to Waterbury,
and has been under the careful and able observation of Dr. North, who has
applied remedies of various kinds to the left meatus, the patient keeping the
Eustachian tubes permeable by means of gargles and Politzer's apparatus.
The last time I saw the patient was in October of this year (1865 ), when the
following note was made: “ He had had no attack of pain in the ear since the
first date. There is still a considerable discharge of pus from each ear. He
hears ordinary conversation well,and the watch ten inches from his left ear,
and two inches on the right : a gain of one inch and nine inches respectively."
The bony growth on the right side has not increased any, and that on the left
is now smooth , and has a somewhat glistening appearance. June, 1868 – Pa
tient still remains free from any disturbing symptoms.
Dr. North writes me, March 25, 1873, that “ the patient's general health is
good. He hears ordinary conversation readily, and Dr. North's watch 81
inches from the left auricle and 1 } from the right. The bony growth has a
smooth, shiny appearance, and only admits the passage of an ordinary sized
probe. The discharge from the ear is slight and of a watery nature. He has
EXOSTOSES - CASES. 407
no pain in either ear. Any increase of the impairment of hearing is always
relieved by an application of tincture of iodine to the bony growths.”
CASE IV . - Woman, æt. 27, at the New York Eye and Ear Infirmary. No
reliable history could be obtained from the patient as to her ears , except that
she had been occasionally hard of hearing for someyears. She was quite sure
that she never had had a discharge from the ears ; was in good general health ,
and had always been so. She could hear the watch two feet from the left
auricle, and twelve inches from the right. The left membrana tympani
showed evidences of previous inflammatory action , there being thickening of
its mucous and fibrous layers. There is a bony enlargement of the posterior
wall of the right meatus, so large as to prevent any view of the membrana
tympani. The patient was seen but a few times, not continuing under treat
ment.
CASE V. - Mr. W .,æt. 23, a patient sent to me by Professor Fordyce Barker,
of this city. Had scarlet fever when young,and since that time has suffered
from purulent discharge from the ear, and has been quite deaf. General
health is excellent. No gouty , rheumatic, or other diathesis. Hears ordinary
conversation very near at hand with very great difficulty . The watch is heard
when pressed upon right meatus ; not at all on left. A gelatinous polypus
was found attached to the hypertropic posterior wall of the auditory canal. It
was removed by torsion,and nitric acid applied to its roots. On left side there
is a pedunculated bony growth , arising from the posterior wall, nearly occlud.
ing caliber of canal. Naso -pharyngeal catarrh . June, 1868 - Patient has
been under observation since first date. Now hears conversation much better ;
watch at a distance varying from one to two inches on right side. Secretion
of pus, which when patientwas first seen was profuse, is now slight. Growths
remain the same.
CASE VI. – Miss ,æt. 25. March , 1873. I was asked by Dr. E .G .Lor
ing to assist him in the examination , under ether, of a case of tumor blocking
up the external auditory canal,with a view to its removal if practicable. The
tumor was so sensitive to the touch of a probe, that no thorough examination
could be made. The patient was about twenty-five years of age, and had suf
fered a great deal from what she called rheumatism of the back, but which
seemed to have been neuralgia. She was rather smalland delicate, but in fair
general health . She was placed under the influence of ether, and a thorough
examination was made by Dr. Loring, Dr. Pardee, and myself. The tumor
arose from the posterior portion of the osseous canal of the right ear, and
nearly occluded the passage. There was a minute opening between it and
the anterior wall, through wbich a No. 2 Bowman's probe could be passed
into the cavity of the tympanum . The tumor was of bone, and covered by a
movable integument,which was red and very sensitive. On passing the probe
into the minute opening that has been mentioned , it could be passed under
the growth , and when pressed upon the growth was seen to move slightly,
The history of the case was, that there were frequent attacks of pain in the
ear, without discharge, until the patient was eleven years old, since which
408 MASTOID DISEASE .
timethere has been no true “ ear-ache,” and no discharge, although the parts
are tender, and there is a great feeling of fulness in the ear. The watch is
not heard at all on the affected side. The tuning -fork is heard better than in
the other ear, which is normal. The examination , during the anaesthetic
state , of the tumor by the probe, caused it to be very sensitive when the patient
recovered from the ether. The aural douche was used to quiet the pain . The
patient was advised to continue to use the douche ; but inasmuch as there was
no pus in the tympanic cavity, and the removal of the growth seemed to
involve considerable danger from periostitis, any further treatment was delayed
until urgent symptoms should arise. May 8, 1873 — There is considerable pain
in thedepth of the ear, and Dr. Loring and Iadvise, that some operative means
be taken to remove the growth .
The history of this case indicates that there was originally

a suppurative action , for we can hardly believe that very
severe pain occurred so frequently as was stated , until the
patient was eleven years old , with no suppuration. The
exostosis , which probably then began, has been growing ever
since, until it has reached the present limits , where it seri
ously threatens the future of the patient.
MASTOID DISEASE .
As we have seen , in considering the diseases of the middle

ear, and in discussing its anatomy, the mastoid process is neces
sarily involved in any severe inflammation of this part of the
organ of hearing. This may also be the case in an acute or
chronic inflammation of the auditory canal, for the mastoid
process opens into this part also. Yet there is a form of
mastoid inflammation which assumes such importance , and
overshadows the inflammatory action in other parts to such
a degree, that it demands an especial study, and especial
treatment. The usual treatment of an acute inflammation of
the external and middle ear soon causes the symptoms of the
inflammation of the lining membrane of the mastoid cavities
to subside ; but when the mastoid process is involved in the
course of a chronic suppurative process, the ordinary treat
ment will not avail. More prompt and decisive means are
usually required . Under such circumstances, diseases of the
mastoid often assume such proportions of severity and danger,
that we are justified in speaking of mastoid disease as a com
MASTOID PERIOSTITIS. 409
plication requiring especial notice and treatment. Perhaps it

is a complication or consequence of chronic suppuration in
the middle ear, only second in gravity to an extension of the
inflammation to that portion of the dura mater covering and
running into the tympanic cavity.
The diseases of the mastoid that may arise as a conse
quence of a chronic inflammation of the middle ear may be
divided into the following varieties :
1. Inflammation of the periosteum .
2. Caries and chronic suppuration.
It is true, as has been already indicated, that the first
form often arises in the course of an acute catarrh , and that
it perhaps always exists to a more or less extent in this dis
ease ; but it is no less true that a chronic suppurative process
that has been going on quietly for years perhaps, will suddenly
becomean acute inflammation of the mucous membrane and
periosteum of the part, and require especial and prompt treat
ment. The mucous membrane lining the mastoid cells is so
closely connected to the bone, that, like themucousmembrane
of the cavity of the tympanum , it is essentially a periosteum .
Caries and necrosis are of course the same affections that
occur so frequently in other parts of the middle ear, and from
the same cause - imperfect removal of the pus that has been
forming.
Sclerosis and hyperostosis of the bone has also been con
sidered as a separate morbid condition by Agnew * and A . H .
Buck ,t but as admitted by the latter author, the cases are not
yet numerous enough to allow us to make a positive diagnosis
of this disease from clinical facts. We are, perhaps, justified ,
in this practical treatise, in classifying this class of cases
under the head of periostitis.
Symptoms. — The symptoms of mastoid periostitis are usu

ally sufficiently striking to arrest the attention of the medical
adviser so soon as they occur.
During the course of an acute or chronic suppurative pro
cess in the middle ear, the patient begins to complain of great
* Transactions of the American Otological Society.
† Archives of Ophthalmology and Otology, vol. ii ., No 1.
410 MASTOID PERIOSTITIS — TREATMENT.
pain behind the ear, the mastoid process becomes red , tender,
and swelled . This is the usual course, although at times the
pain is not referred especially to the mastoid , even when it
is evidently involved , as shown by the redness or tender
ness of the part. The pain is usually of the severest kind,
preventing the patient from sleep and from his usual occupa
tions, although hemay not be confined to the house .
The early diagnosis of this affection is by no means an
unimportant matter. A delay in the recognition of the true
state of things allows of the extension of the disease to the
brain through some of the numerous foramina which transmit
the minute branches of the middle meningeal artery. Pus
may also be carried into the circulation through the mastoid
vein which passes to the lateral sinus.
Professor Alfred C . Post, of this city , who was one of the
first physicians in this country to give diseases of the ear the
same attention that was paid to other parts of the body, has
seen several cases where disease of the brain and death have
resulted from the non -recognition of mastoid disease.
Many neglected cases run their course, however, with great
suffering to the patient, and with much loss of function, with
out destroying life. This is proven by the frequency with
which mastoid cicatrices are seen in our aural cliniques. The
history of such patients usually shows that they have had a
narrow escape, but that nature has at last given relief by
an external opening through which the pus and dead bone
made their way.
Treatment.— The treatment ofmastoid congestion and peri

ostitis is very simple . An incision should be made through
the integument and periosteum down to the bone. The inci
sion should be from below upward , lest the knife should slip
and pass into the tissues of the neck . The opening should
not be a puncture , but a cut of from three-quarters to an inch
and a half long, or even longer, according to the age of the sub
ject. The incision should be parallel to the attachment of the
auricle. Even if the posterior auricular artery be wounded, the
bleeding can be readily arrested by pressure or torsion. I
have never found any alarming hemorrhage. A free escape of
MASTOID PERIOSTITIS — TREATMENT. 411
blood is desirable. The surgeon who has not made this inci
sion in cases of mastoid periostitis will, perhaps, be surprised
at the depth of the tissues when they have become infiltrated
from an inflammatory action of some days standing. I have
sometimes been amazed at the depth to which the scalpel
entered , especially when pus has formed . Pus will not be
found in the majority of the cases, but the indications for an
early , free, and deep incision are imperative when we find red
ness, tenderness, and swelling of the mastoid process in con
nection with an inflammatory process in the ear.
It should be remarked , however, that there are some inno
cent cases of mastoid disease thatmay occur in the course of
an acute catarrh — cases that will not demand the incision that
hasbeen described. Young children, especially children of stru
mous habit, at times suffer from an infiltration of the tissues
of the mastoid , which may, if carefully watched , be allowed a
little more delay than the same class of affections occurring in
an older subject. There is a phlegmonous inflammation of this
part occurring in young subjects, which does not go on so
rapidly or painfully as a periostitis. Still, in case of doubt, it
is better to err on the side of making the incision. Furuncles
in the auditory canal may cause an oedema of the parts about
the mastoid , that will not require an incision. A little care
in observation will show , however,that while these cases simu
late a periostitis in the swelling and redness, there is not the
exquisite tenderness and dreadful suffering of a true periostitis.
The mastoid gland may enlarge during the course of an acute
catarrh, or in strumous subjects who have no aural disease ,
but such an enlargement will hardly be mistaken for a peri
ostitis.
If the incision be made in the early stages of mastoid
periostitis, pus will not be found, but the relief to the pain
from the hemorrhage, and the letting up of the great tension
of the inflamed periosteum , will be no less marked than if
suppuration has occurred . The incision will be as useful as
the division of the periosteum in a case of paronychia — a com
parison which Dr. Post has been in the habit of making in
lecturing upon these cases. The incision that is recom
mended for the relief of mastoid periostitis , was first urged
412 MASTOID PERIOSTITIS — CASES .
upon the profession by Sir William Wilde. His writings upon

the subject have undoubtedly saved many lives.
After the incision a poultice should be applied, and the
opening maintained by the insertion of a tent a longer or
shorter time, according to the severity of the accompanying
symptoms. The importance of maintaining the opening for
some time in cases of chronic suppuration ,was very well illus
trated by the following case :
In June, 1872, I saw in consultation with Dr. E . G . Loring,
a somewhat remarkable case of chronic suppuration in the
middle ear, with mastoid periostitis, in a gentleman of more
than seventy years of age, in which the opening was main
tained by Dr. Loring, by means of trimming up the edges with
scissors, the use of caustic, a drainage tube, and so forth , for
some three months. Dr. Loring found that the instant the
opening was allowed to close, pain in the back of the head,
and in the depth of the ear, began to recur, which threatened
even the life of the old gentleman who was the subject of the
disease. The patient finally made a perfect recovery from
themastoid disease, and although a man ofmore than seventy
years of age, he is actively engaged in the daily care of large
business affairs. The mastoid periostitis in his case was a
consequence of an unusually severe acute suppuration of the
middle ear, which swept away the drum -head in a short time.
ILLUSTRATIVE CASES OF MASTOID PERIOSTITIS .

The two first of the following cases are from the notes of
Dr. David Webster, House Surgeon in the Brooklyn Eye and
Ear Hospital, where they were under my care, and are strik
ing evidences of the prompt relief afforded by timely interfer
ence :
CASE I. — Chronic Suppurative Otitis Media - Cessation of Discharge- Mastoid

Periostitis — Incision — Recovery.
Eliza N .,æt. 18 , had a discharge of pus from the right ear for two months.
The discharge suddenly ceased , and the patient was attacked with severe
pain and swelling over the mastoid , which grew worse and worse for several
days, and caused her to visit the hospital. Dr. Roosa diagnosticated mas
toid periostitis, and at once (May 10 , 1869) made a free incision down to
MASTOID PERIOSTITIS - CASES . 413
the bone. No pus was found, but there was free hemorrhage, which was
encouraged by the use of warm water. The membrana tym pani was found to
be removed by suppuration, but there was a slight discharge from the canal.
A tent was placed in the wound and a poultice applied over it. May 11,
patient has had no pain and has slept well. The tent was reapplied and the
poultice continued . May 16, the swelling of themastoid is gone. There has
been at no time a discharge of pus from the incision , but there was a copious
one from the meatus. The patient was very pale when first seen , but the
administration of iron and the cessation of pain have restored the normal con
dition. She has not since returned to the hospital.
CASE II. - Chronic Suppurative Otitis Media - Mastoid Periostitis and Caries
- Incision - Recovery.
Margaret O ., æt. 48 , came to the hospital June 21, 1869. Three months
previously she had variola, and in the third week of that disease a purulent
discharge began from the left ear. This discharge ceased , when , a week
and a half ago , great pain , preventing sleep , set in . There was found to
be considerable swelling and puffiness above the ear, with tenderness behind
it, but no swelling. There was greatædema of the eyelids, and the patient
seemed to be in great agony. The auditory canal was swelled , but scarcely
any pus was found in it. Dr. Roosa made incisions down to the bone above
and behind the ear ; from the latter pus escaped , and a probe passed in a direc
tion slightly upwards, forwards, and downwards into the mastoid cells. The
surface of bone about this opening was roughened. The same treatment as in
the former case was prescribed. Hydrate chloral gr. xv. was given at bed
time. Dr. Webster saw the patient the next day, when the pain had en
tirely ceased. June 28, no pain or tenderness. Politzer's method of inflation
was practised, and the warm douche used .
July 12. A minute opening about a quarter of an inch from the attachment
of the auricle still exists. The probe passes upwards and forwards into a
superficial opening in the bone. No swelling , pain , or tenderness about the
ear. The membrana tympani has healed. Hears the watch 6".
CASE III. — Chronic Suppurative Otitis Media - Mastoid Periostitis — Incision
Recovery.
William G .,æt. 30, came to the Manhattan Eye and Ear Hospital, June
13 , 1870. In December, 1869, he first experienced a sharp pain in the left
ear, which was most severe at night. This pain continued for two months,
at the end of which time a discharge occurred from the ear, which has
continued more or less until now . Two months later the mastoid process
became swelled and tender, and it was opened and poulticed by a physician .
A great quantity of pus, as the patient says, was discharged,and the pain ,
which was severe, was relieved . About four weeks after this the pain in the
ear again occurred, and the patient presented himself at the hospital. He pre
sented the appearance of a great sufferer ; he was pale and haggard , his hands
were tremulous, and his countenance was anxious. He complained of great
pain , referred to the depth of the ear and to the head . The mastoid process
414 MASTOID PERIOSTITIS - CASES.
was red and hot, but not swelled or tender. The auditory canal was exceed .
ingly sensitive. The membrana tympani had been removed by suppuration ,
and there was a thin coating of pus on the floor of the cavity of the tym
panum . Air was forced into the middle ear by Politzer's method , and leeches
were applied to the tragus and mastoid . On the next day warm water was
frequently instilled .
June 14. The pain in the ear has decreased, but there is more redness of
the mastoid . Leeches, to be followed by a poultice, were ordered. I did not
see the patient after his second visit, in consequence ofmy absence from town,
until the 20th, when I found fluctuation in front of themeatus, as well as great
tenderness over the mastoid , with an increase of the constitutional symptoms,
The patient was then admitted as an in -patient, and having given him a dose
of whiskey on account of his very shattered condition , I proceeded to make
free incisions down to the bone in front of and behind the ear. The bone was
not denuded or roughened . A tent was inserted and a poultice , the latter to
be renewed every three hours. The patient slept well that night for the first
time in some weeks, taking a dose of fifteen grains of hydrate of chloral.
June 28. The patient has since been free from pain . The incisions have
nearly healed . There is a slight discharge of pus from the auditory canal.
He hears a watch when it is laid upon the ear. His general condition is now
very good, and he is discharged at his own request.
It is somewhat remarkable that this patient experienced so
many painful symptoms of mastoid disease for so long a time,
and yet escaped without disease of the bone. His affection
was never more than an affection of the living membrane, with
some periostitis, while in a case about to be detailed , ofmuch
less severity, death of the bone occurred, and meningitis, with
a fatal result, supervened . I now think that a free incision
should have been made over the mastoid when I first saw the
patient, although there was then only some redness of the
process and no tenderness, the pain being referred to the
depth of the ear. In the light of my present experience, in
all cases where there is deep -seated pain referred to the cavity
of the tympanum , which is not at once, that is to say, in a few
hours, relieved by leeching and the warm douche, even if the
mastoid cells do not seem to be involved, I should consider
myself as giving the patient the benefit of a doubt by such a
depletion as a free incision will afford.
CASE IV . --Chronic Suppurative Otitis Media of years' standing - Exacerbation
- Mastoid Absce88— Incision - Recovery.
CASE IV .- Gracie B., æt. 13 . April 25 , 1872, I was summoned to New .
burgh, by Dr. S. Ely , to see a case in consultation, which Dr. E . justly regarded
MASTOID PERIOSTITIS — CASES. 415
as urgent. The patientwas a healthy girl,who had had a discharge from her
left ear for years, and who for the past few weeks suffered from an exacerba
tion of the disease,with acute symptoms. Dr. Ely had observed that themas
toid process had become red , and swelled , and tender, within the last few days.
We found the patient in bed , and evidently in great suffering , with consider
able constitutional disturbance, hot skin , and frequent pulse. The neck was
very much swollen , as was the whole integument of themastoid . There was
a profuse discharge of pus from the ear. On consultation it was agreed that
an opening down to the periosteum should be made at once ,which I proceeded
to do, the patient being under the influence of ether. The opening was sur.
prisingly deep , so that the knife passed through three-quarters of an inch of
tissue before the bone was reached . Pus escaped quite freely. The wound
and the ear were syringed with lukewarm water, and an examination made
for a fistula , but none was found. The bone was denuded of periosteum .
The membrana tympani had been long since removed by suppuration. The
patient had a fair night, sleeping without an anodyne, and rapidly recovered
after the opening had been made. A poultice was applied for a short time, and
then the opening was allowed to heal. The ear was treated in the usualman
ner in cases of chronic suppuration .
June 19, 1872. The patient came to town to visit me. On examination , the
membrana tympani was found to be removed by ulceration , and a small
amount of pus lay in the tympanic cavity. The cicatrix on themastoid is one
inch long and one -half inch from the auricle. The patient states that the
wound healed in about one week after it was made.
Dr. T. Blanch Smith , of Nyack , has furnished mewith the

notes of the following case of mastoid disease, which termi
nated fatally. Although the affection of themastoid cannot
be said in this case to have been a consequence of a chronic
but of acute suppuration , it is none the less instructive.
CASE V . - Otitis Media Acuta, with Mastoid Periostitis- Acute Suppuration ,
Apparent Recovery - Recurrence of Symptoms-- Coma — Death.
December 31, 1870, I visited Mrs. B . V .,æt. 58, and found her suffering from
pain in the left ear and side of head ,moderate febrile excitement, occasional
rigors, nausea, and vomiting at long intervals. There was much tenderness
over the left mastoid process and the infero-posterior margin of the meatus
externas. Glances which I obtained of the membrana tympani did not reveal
any marked change in its color or shape.
These symptoms,which I referred to acute inflammation of the tympanum ,
came on with considerable rapidity about thirty -six hours before I saw the
case, and were clearly traceable to an antecedent catarrhal pharyngitis.
The sore-throat, though moderately severe, had existed two weeks before
attention had been attracted to any ear trouble, and had been allowed to run
on without systematic treatment up to the time ofmy visit.
Verat. virid., nitrate potash ,and morphia internally, with warm water and
416 MASTOID PERIOSTITIS. — CASES.
laudanum locally, served to mitigate considerably the distressing symptoms
until on January 3d, the fifth day from the commencement of the aural symp
toms, therewas a purulent discharge from the ear followed by marked allevia
tion, but not complete removal, of pain . Quinine and iron were next used
internally, and carbolic acid solution locally .
A discharge, pain in the ear (tolerably severe at times), and decided ten
derness over mastoid cells, without redness of surface or fluctuation , continued
to about January 9, when the abatement of these symptoms was so decided
that the patient drove out in a closed carriage, and her general health con.
tinued to rapidly improve to a point when I discontinued regular attendance.
On January 24 , not having seen Mrs. V . for four days, I was requested to
call again . I learned that she had gone on very smoothly up to the 21st,
when she found that the discharge had ceased ,and the tenderness and pain
were gradually becoming intensified . The patient thought she had “ taken
cold in the ear ” by neglecting to carefully protect her head when accompany
ing her friends to the outer door. Her pains I found were now more severe
than before, and extended from themeatus over the sides and back part of the
head and neck . There was neither redness nor swelling over the mastoid
cells , and the tenderness was less acute than in the first attack , but the fever
was sharper, nausea more persistent, and vomiting more frequent.
With the addition of a brisk cathartic, the same treatment was adopted as
in the early period of the disease. On the 25th , I found my patient in a much
less comfortable condition than I had anticipated , the distressing symptoms
not having been so decidedly mitigated by the prescription as on previous
occasions. The patient seemed exhausted by loss of sleep , pain , etc. I ordered
the anodyne to be given at shorter intervals unless the pain abated or sleep
was secured . On the 26th , visited Mrs. V . at my usual hour, and on meeting
her husband ,was told by him that she did not seem any better, although she
was very drowsy orstupefied . On reaching the bedside, I saw my patientwas in
a perilous condition . The pupils were moderately dilated ; conjunctiva of left
eye so edematous as to protrude between the partly opened lids, and deeply
stained by large ecchymoses ; respiration 42, not stertorous ; pulse 128 ; sur.
face of face and hands livid ; top and back part of head hot ; slight discharge
from ear ; no convulsive movements. Mr. V . stated that at 11 P . M . preceding
night, she complained of a very curious and unpleasant sensation , saying she
felt as if she wanted “ to fly in the air," and also of something wrong about
her eyes, repeating, “ I can't see anything." These peculiar sensations and
expressions the husband attributed to the effects of morpbia, and so was not
specially alarmed until I told him I thought her in a hopeless condition . She
continued to sink, without remarkable change in the symptoms, until she died ,
fifty-eight hours from the development of these grave features ofthe case.
CARIES AND SUPPURATION OF THE MASTOID .

Caries of the mastoid is an extension of the inflammatory
process that has been described under the head of periostitis.
The pathology of caries of this bone is well described by
CARIES AND SUPPURATION OF THE MASTOID . 417
A . H . Buck ,* as follows: “ The cells being filled with a swelled

and congested mucousmembrane, a stasis occurs in the local
circulation, the bone is not well nourished, and the contents
of the cells break down into pus. The bony partitions then
become dissolved , a granular detritus is formed, or the bony
parts separate as a whole from the surrounding healthy parts.”
This form is, of course ,more dangerous than mere periostitis ;
and yet cases of caries and necrosis are sometimes relieved at
the great cost of unnecessary suffering to the patient, by Na
ture's slow process of casting out diseased bone. After the
detailed account that has been given of the symptoms of mas
toid periostitis, it is perhaps unnecessary to dwell at length
upon the clinical features of caries and necrosis. It is, more
over, oftentimes impossible to draw the line between a case of
periostitis and one of caries.
In many cases the symptoms of caries of the mastoid do
not differ essentially from those of mastoid periostitis. There
is then the same redness, tenderness, and swelling of the
process , attended by deeply seated and intense pain . In
others, however, the redness, tenderness, and swelling are
entirely absent, while the pain referred to the depth of the
ear, will be the only marked symptom . This pain is not
relieved by leeches, and anodynes will only veil the symptoms
for a brief period. Usually, however, even in the insidious
cases, tenderness will be shown upon firm pressure on the
part. Yet the surgeon may cut down upon a bone to find it
diseased, when he had not been previously able to positively
diagnosticate this state of things. It may be said , however,
in general terms, that any deep -seated pain referred to the
mastoid or its region , occurring in the course of an inflamma
tion of the ear, should be looked upon with suspicion , even if
there be no redness, tenderness, or swelling of the process
itself.
The auditory canal is often involved in cases of caries of
the mastoid . A fistulous opening is sometimes found leading
from this part into the mastoid cells , in which case, granula
tions are usually found in the canal. The presence of granu
* Archives of Ophthalmology and Otology, vol. iii., No. 1.

27
418 CARIES AND SUPPURATION OF THE MASTOID .
lations in the canal should lead us to examine the part very

carefully to see if a fistula may not be found. As will be seen
by reference to Case I., dead bone may sometimes be removed
through the canal. A clinical fact of some importance in the
diagnosis of mastoid disease, is the one that the chronic or
acute suppurative process in the middle ear, is often very
much less violent, or entirely checked at the time of the out
break of the periostitis . This fact applies to both forms of the
disease. Yet it is a mistake to suppose that mastoid perios
titis, or caries, may not occur while a free discharge of pus
is taking place from the ear. While these pages are passing
through the press, I am treating an acute case of mastoid sup
puration and caries, in which the discharge from the auditory
canal is profuse.
Treatment. — The first step in the treatment of a case of

supposed caries of the mastoid , is to divide the tissues over
the process down to the bone, as was recommended for cases
of mastoid periostitis . If a fistula be found , it will be simply
necessary to enlarge this, so as to give a free exit to the pus.
If the bone be very soft, a stiff probe will sometimes be suffi
cient, but usually a small drill will be required. If there be
no fistula , and we have decided that dead bone is probably
beneath the outer table, a small trephine may be used, and
the process opened — the periosteum being , of course , first dis
sected up. The trephine should be worked in a direction
inwards, forwards, and upwards. There can be no positive
directions given as to the depth to which the instrument
should go. By reference to the anatomy of the mastoid pro
cess (page 206 ), it will be seen that the thickness of the outer
layer of bone varies somewhat in different cases. The opera
tion should go on very slowly , frequent pauses being made to
see how deep the instrument has gone. It is impossible to
say in a given case at what depth we shall reach the cells, or
free spaces, and thus make an outlet for the pus. Dr. Agnew
was obliged to go to the depth of five-eighths of an inch in
one of his cases, and then found only sclerosed bone. Dr.
D . C .Ambrose, of this city, removed a piece one inch long from
the mastoid process of a young woman of twenty years of age.
CARIES OF THE MASTOID - TREPHINING . 419
The cell structure will ordinarily be found at a depth of from

one- sixth to one-fourth of an inch . In infants the outer shell
of bone is so thin that true trephining will probably never be
required ; but any firm instrument will make the required open
ing. In case of an emergency, a surgeon has been known
to use a common gimlet, to open the mastoid process (see
Case III.). The lateral sinus will always be avoided by keep
ing the instrument as directed above.
The after treatment is the same as thatof an operation for
necrosis in other bones. The wound should be dressed from
the bottom with lint, and kept open for some time. The pa
tient should be kept free from all noise and excitement.
Historical. — The history of the operation of trephining or

opening the mastoid process, is an interesting one. It is
here given as it appeared in an article upon the affections of
the mastoid by myself, with some amplifications, that a subse
quent investigation have allowed me to make.*
From a monograph on this subject by J . Arneman * Pro
fessor in the University of Göttingen, published in 1792, we
learn that Riolanus (in 1649, according to Adolph Murrayt),
was the first author who inquired into the propriety of per
forating the mastoid process in cases of occlusion of the Eusta
chian tube, for the purpose of removing, by injections through
the opening,morbid secretions in the mastoid cells and cavity
of the tympanum . Rollfink, afterwards, in an anatomical dis
sertation , published at Jena in 1656, also advocated the opera
tion. J. L . Petit, according to Von Tröltsch, I was the first
who actually performed the operation, which he did by means
of a gouge and hammer.
Then we come to Valsalva's case , published nearly a hun
dred years after the suggestion of Riolanus, which has been
claimed by all the authors as a case of perforation of the mas
toid , and injection through it of the middle ear. One writer
(Von Tröltsch ) states that an otorrhea was thus cured by
* Transactionsof American Otological Society , 1870 .— Medical Record, 1870 .
+ Lincke's Sammlung, IV., p. 33.
| Bemerkungen über die Durchbohring des Processus Mastoideus in ge
wissen Fällen der Taubheit.
420 VALSALVA ON MASTOID FISTULA .
Valsalva. I have examined the original passage in order to

verify this claim made for Valsalva, and , if I am correct, there
is no such claim by Valsalva himself. He simply states that
he injected a fistula existing in this part, in the case of a
nobleman ; with what result he does not say. The following
is the side-note to the passage :* “ Observatio ulceris processum
mamillarem , per quod injecta , statim in oris cavitatem , licet unde
quaque illasam transmittebantur.” The passage itself is as fol
lows : “ Adeoque mitto prolixius confirmare per quondam meam
in virohumane observationem , de nobili scilicet viro, ulcere ad pro
cessum mamillarem , cum hujus carie laborante in quod quæ injicie
bantur, illico ad fauces perveniebant adeoque a tympano, quo per
illius processus sinuositates ascendebant, per tubam certe derive
bantur, etc .
I have ventured to translate the passage with some free
dom , but with correctness, as follows. After speaking of the
Eustachian tube as a passage to the pharynx, Valsalva says :
“ I beg to confirm what I have said, by an observation made
on the living subject, a nobleman,who was affected with caries
of the mastoid process. The fluids that were injected into
this ulcer passed through the sinuosities of the mastoid pro
cess into the tympanum , and thence through the tube to the
fauces.”
Valsalva is here demonstrating the function of the Eusta
chian tube. He makes no claim to have perforated the mas
toid , but he simply asserts that he has injected a fistula in the
mastoid , and that the fluid thus injected passed into the mouth .
I cannot find any evidence in the passage or the context that
his patient was cured of an obstinate otorrhæa, as asserted by
Von Tröltsch , so that I think Valsalva must be left out, so far
as any evidence from this passage goes , in the enumeration of
those who have recommended or performed the operation of
which we are speaking.
The surgeon to whom we are indebted for having fairly
established opening of the mastoid as a legitimate surgical
procedure, is Jasser,t a regimental surgeon , who, in 1776 , first
performed it. His patient was a soldier, who had suffered for
* Tractatus de aure Humana , 1742, p . 89.
+ Lincke's Sammlung, Bd. IV ., p. 195.
JASSER S AND BERGER 'S OPERATIONS. 421
many years from suppuration and pain in the ears,which was

not relieved by active but judicious antiphlogistic treatment.
In this case there was an abscess of the mastoid , and death of
the bone, and thus the operation was performed under indi
cations which any good surgeon of the present day would
accept as peremptory. Although Jasser's operation was a
creditable one to its author, it has been misunderstood, and
classed by Wilde in the list of the same operations performed
with such indications as “ obstinate deafness."
Arneman, in the pamphlet before alluded to , details five
other cases, from Fielitz, in which the operation was per
formed, and claims that in only one was there a bad result,
and then death ensued. He admits, however, that it may be
performed without avail. The bad result occurred in the case
of Berger, a Danish surgeon, who caused it to be performed
on himself, and died of meningitis induced by the opera
tion. Berger had suffered for years from very great vertigo
and noise in the ears, and gradually lost his hearing power.
He got no relief from the ordinary means of treatment, and
his malady, which placed him out of the society of his friends,
troubled him very much . He finally determined to have the
operation of trephining the mastoid performed, in order to
inject the parts and remove the hardened secretion. Berger
evidently suffered from what we should now term chronic pro
liferous inflammation of the middle ear ; and viewed in the
light of our present knowledge, there was no proper indication
for the operation of trephining the mastoid . Dr. Kölpin per
forated the process to the depth of three lines. The incision
does not seem to have reached the cells, for an injection made
in the opening did not pass into the throat. On the day after
the operation a chill occurred. These chills continued to
recur, and on the twelfth day Dr. Berger died . Adhesions
of the dura mater to the skull were found, and effusion of a
transparent gelatinous fluid between the arachnoid and pia
mater, as well as over the whole surface of the cerebrum and
cerebellum .
The second case detailed by Arneman , has no more accu
rate statement as to the pathological condition of the ears of
the patient upon whom it was performed, than that he was
422 TREPHINATION OF MASTOID .
wholly deaf in both ears. The operation did no good , but

caused temporary blindness and faintness. In the third case
there is also no account of the cause of the deafness : the re
sult was an improvement of the impaired hearing as long as
the wound was kept open . The opening was maintained by
means of a leaden probe until cicatrization occurred.
The fourth case was that of an old lady, who had lost her
hearing from a quartan fever. She had noise in both ears.
The process was perforated , and injections of lukewarm water ,
which passed out of the nostrils, were made. After the injec
tions had been made for four days there was a complete resto
ration of the hearing ( sic ), while the openings closed readily.
The fifth case was one of chronic suppuration in the ear,
with acute exacerbations. The result was a cure , after injec
tions for twelve days.
These statements must of course be taken with some
allowance, inasmuch as with the exception of two cases — the
first and the last — there is no exact knowledge of the disease
causing the symptoms of deafness and tinnitus. But even
these show that perforation of themastoid is not a dangerous
procedure, and that when performed under such indications
as those in Jasser's case , it is not only a very simple, but a
very beneficial operation.
In Frank's treatise on the ear several cases are alluded to ;
but here also the indications which direct their performance
are wanting, and they are consequently useless as guides to
the surgeon.
A surgeon named Weber , in 1825,* made an opening into
the mastoid in a case of caries of the bone, but evidently with
great anxiety, lest he might not undertake a sound surgical
procedure, although his patient had symptoms which would
not allow us to hesitate for a moment. He used a trocar,and
went about three lines before he came to the cells. The pa
tient recovered.
Arneman , in a style of surgical writing which has now,
happily for us with our more accurate knowledge, passed
away, lays down the following indications for the performance
* Lincke's Sammlung, Bd. IV ., p . 90.

TREPHINATION OF MASTOID . 423
of the operation. They are inserted here in order that the dis
trust with which surgeons have looked upon interference with
the mastoid process in aural disease, may be accounted for.
I.- In any case of absolute deafness, or in any case where
the impairment of hearing is constantly increasing, and for
which all other remedies have been used without effect.
II. — When, in case of an ulcer or suppuration of the ear,
the morbid material has become collected in the cells of the
mastoid , or the cells have become carious. ( This is certainly
a good indication , and the one upon which Jasser acted.)
III. - If the normalmucous secretion has become hardened
or collected in excessive quantity .
IV. - In cases where pain and noise , which would finally
destroy the hearing, have existed in the ear for a very long
time.
V . - In cases of stoppage of the Eustachian tube not reme
died by injections.
The simple operation of creating an external opening for
retained pus, and thus preventing its passage to the brain
and into the circulation, was thus so distorted from its proper
application , by the improper indications for its performance,
that the leading writers seem to have been in as great a state
of bewilderment about it as were the English and American
surgeons, until a few years since, in regard to the use of the
Eustachian catheter. The text-books either mention it to
condemn it, or in such a way as to plainly show that they do
not realize the true indications for its performance.
So valuable a work as that of Wilde, for example , con
founds such an operation as that performed by Jasser with
the others quoted by Arneman, which were undertaken because
the first operation had been successful, and without any regard
to the condition of the ear, but for the relief of a symptom
deafness.
In the general advance of our exact knowledge of diseases
of the ear , the merits of the operation of perforating the mas
toid were again discussed , and it has now been replaced where
Jasser first placed it, on a sound basis. Von Tröltsch, in
1861, reported a case of acute suppuration in the middle
ear, with perforation of the membrana tympani, in which he
424 INDICATIONS FOR TREPHINING THE MASTOID .
opened the mastoid with a probe, some days after he had

made Wilde's incision with only partial relief.
In such disrepute was this operation at that time, because
of the unhappy fate of Berger,who caused it to be performed
with no good indications, that Von Tröltsch confesses that he
would have hesitated to undertake this simple surgical proce
dure with any but the instrument which he employed. The
case was a successful one. Eight cases are reported by
Tröltsch ; that of Petit is considered the first, and Jasser's the
second ; but Valsalva's injection of a fistula already existing is
considered as an operation .
Jacoby* has especially put the profession under obligations
by his valuable reportsof cases, with the indications for the per
formance of the operation . Very recently Köppe and Schwartze
report a case of epilepsy caused by retained pus in the middle
ear, which was relieved by perforation of the mastoid .
In concluding this subject, before giving the illustrative
cases, the conditions underwhich the mastoid may be properly
operated upon , either in periostitis or caries, may be formu
lated as follows :
I. — The integument and periosteum should be freely di
vided over the mastoid in all cases in which there is pain ,
tenderness , and swelling in the part. - (Wilde.)
II. — Such an incision should also be made whenever severe
pain , referred to the middle ear, exists, and is not relieved
by the usual means, i. e., leeches, warm water , etc.
III. — An explorative incision should be made when we
have good reason to suspect the existence of caries and re
tained pus in this part.
IV . — The mastoid bone should be perforated after such an
incision wherever the bone is found diseased , or a small fistu
lous opening should be enlarged. It should also be perforated
when we have good reason to believe that there is pus in the
middle ear or mastoid cells which cannot find an exit by the
external auditory canal.
V . — The mastoid should be perforated in the case of a
suppuration of long standing, with frequent and painful ex
acerbations.
* Archiv für Ohrenheilkunde, Bd. IV ., p . 212 .
MASTOID CARIES — CASES. 425
The operation may now be sure to be fairly established ,

and is frequently undertaken, it having been performed by
Follin , Schwartze, Pagenstecher, Hinton (London ), Jacoby,
Agnew (New York ), Colles (Dublin ), and by myself since 1859.
Dr. A . H . Buck has appended to his article on mastoid
disease, from which I have quoted, a table containing thirty
four cases of opening the mastoid, beginning with Arneman.
Drs. Weir, Laight, and Buck of this city, Drs. Newton of
Brooklyn, and North of Waterbury, Conn., are among the
surgeons who have operated since 1870, and this sound sur
gical procedure may be said to be fairly established in the
profession. Twenty-six of the thirty-four cases reported by
Buck resulted in recovery .
CASES.
It would be easy to insert very many cases of trephination

of the mastoid that are now to be found in the literature of
otology, but in adherence to the plan of this work , a few are
selected which will clearly exhibit the symptoms of caries of
the mastoid , and the clinical facts of those cases for which
perforation of the process is performed.
CASE I. — Otitis Suppurativa Media – Caries of Mastoid — Incision through
Periosteum - Removal of Sequestrum through External Auditory Canal
Recovery.
This was undermy care at the Manhattan Eye and Ear Hospital, and has
already been reported by Dr. C . I. Pardee,* but chiefly with reference to its
being a case of otitis media , caused by the use of the nasal douche. I saw this
patient, who was a man of about thirty- five years of age, soon after the inflam
mation of the ears had occurred , which was about nine months before he pre
sented himself at the hospital in October, 1869. He was then suffering from a
suppurative inflammation of the middle ear, but the amount of pus discharged
through the perforation in the membrana tympani was slight. There was
considerable swelling ofthemucousmembrane of the cavity of the tympanum ,
and the hearing was greatly impaired . He could not hear a watch at all.
He was under my care for this suppuration of the ears for eight weeks, when
he disappeared , and I next saw him , as just stated, some nine months after, at
the hospital, when I found his condition had become worse, and that it was
alarming . He complained greatly of pain in the head , which prevented him
from pursuing his avocation , which was that of a plumber. The auditory
* New York MedicalGazette, vol. vi.,No. 23.

426 MASTOID CARIES — CASES.
canal of the left side was filled with granulations, themastoid process was red,
tender, and painful. Just in front of the meatus there was an abscess, and a
small fistulous opening just above the same part. The hearing on that side,
as tested by the watch and voice,was completely gone. On the other side, the
ear was in substantially the same condition as when I first saw him .
I immediately made incisions down to the bone, rather against the patient's
will, just behind ,above, and in front of the attachment of the auricle. I found
no dead or exposed bone, but quite a large amount of pus was evacuated . The
patient immediately began to improve. In a few days Dr. Pardee removed a
piece of the mastoid structure through the auditory canal,the pain in the head
disappeared, the suppuration from the mastoid ceased, the granulations were
removed from the canal, and the patient resumed his occupation .
The notes of the following case, except so far as they relate
to matters observed by myself, were furnished me by Dr.
Hubbard, of Bridgeport, through whom I saw the patient.
CASE II.- Sub-acute Aural Catarrh , Membrana Tympani intact- Suppura
tion in Mastoid Cells — Opening of Mastoid Process — Death .
Dr. Hubbard was consulted in December, 1869,“ by W . E. S.,æt. 38, by
profession a mechanic, with good physical development and unexceptionable
habits, on account of a severe influenza, from which he was suffering ,and
which was at that time epidemic in this city (Bridgeport). His mother and
one sister, I have reason to believe,died of tubercular inflammation . Hitherto
he had suffered no severe illness since the ordinary diseases of childhood , from
all of which he made perfect recoveries. The attack of influenza was charac
terized by severe irritation of the whole respiratory system , with marked
impairment of the special senses of taste and smell. The auditory apparatus
was not at first, however, specially implicated . I prescribed for his ' cold'
several times during the acute stage, as an office patient. But he at those
visits made no mention of any trouble about his ears. Later he reported that
he had lost his cough , but complained of catarrh of the fauces and nasal pas
sages, for which I prescribed the nasal douche, and gargles made stimulant
and astringent by alum , chlorate of potash , chlorate of sodium , tannin , etc.
To the use of these he ascribed considerable improvement. I then lost sight
of him until about the first of April, 1870, when he consulted me on account
of an annoying tinnitus affecting only the right ear. At the same timehe
reported that he had occasionally, for several weeks immediately preceding ,
suffered moderate hemicrania of the affected side. Inspection showed marked
enlargement of the mastoid process ,which he declared had been at no time
the seat of pain, and yielded no suffering under firm pressure. Specular exam
ination showed a moderate degree of congestion of the membrana tympani,
and by Politzer's method the Eustachian passage was found to be pervious.
The middle ear was occasionally inflated, however, and warm water injections
to the meatus externus ordered daily at bedtime, and a blister directed to be
applied over the mastoid process. At the same time I continued constitutional
reatment by quinine, iron, and strychnia , as he had been the subject some
MASTOID CARIES— CASES. 427
time previously of malarial infection . Under this course the apparent conges
tion of themembrana tympani disappeared , but the tinnitus was in no degree
diminished . At this stage of the case, having met, as well as I was able , all
rational indications, leaving to me only an empirical course, I advised him to
consult Professor Roosa ,and he advised me to renew the blister to themas
toid region, also to apply a leech to the tragus, and repeat it after a stated
interval, after which he requested to see him again ."
My notes, on seeing the patient, are : - Hearing distance, right side, 2" ,
tested with a watch that should be heard 3' ; membrana tympani opaque ; no
light spot ; handle of malleus injected . A very feeble current of air passes into
the Eustachian tube. Patient complains ofa very annoying buzzing sound in
his ear. There is a very slight want of symmetry in the mastoid, no pain
referred to it, no tenderness in any part of it ; no pain in the ear. Two leeches
ordered to the tragus and a blister to the mastoid. One week later I again
saw the patient ; the symptomswere the same. He had had some pain in the
ear one night since his visit. I injected steam into the middle ear, and sug
gested that leeches be again applied .
(I again copy Dr. Hubbard's notes.)
“ These measures were faithfully carried out, but with no good results.
The time having come for another visit to Dr. Roosa, the patient called at my
office, when examination revealed fluctuation at the summit of the mastoid
process, indicating, however, a small quantity of fluid , and attended , as it
seemed to me, with too little pain to be explained by the theory of a perios
titis. I thereupon advised him to postpone his visit to New York, and poul
tice the tumor for twenty- four hours , and then report again. At his next visit
I found the swelling and fluctuation slightly increased , and I freely incised the
integuments to the bone, liberating about half a drachm of thick , healthy.
looking pus without disagreeable odor. I then probed the wound , expecting
to find denuded bone, but I failed to detect a greater degree of roughness than
is peculiar to that portion of the cranium . I advised him to keep the wound
open and favor the discharge by poulticing. The discharge for the succeeding
few days was little , but resulted in a marked diminution of the tinnitus and a
corresponding sense of relief to the patient. He now failed to report to me
for about a week , and meanwhile, from lack of attention , the incision healed,
and when he presented himself again there was a re-accumulation of pus in
much greater quantity than previously. This I evacuated , and found it of
the same character as before. Thereafter the wound was kept open and the
tinnitus ceased, and the patient declared to me and others that he was a new
man .' From this timemy regular attendance ceased until May 12 , 1870, when
I was recalled and obtained the following history : He had continued in his
improved condition until the evening previous, which he was passing in social
enjoyment with his family and a brother who was paying him a visit, and,
when laughing violently at some burst of humor, he stopped suddenly and
exclaimed : “ There, I guess I have laughed too hard , for I have mademyhead
ache.' No further reference was made to his suffering until he had retired to
his room at bedtime, when he informed his wife that he was suffering from an
intense frontal headache ; he also complained of rigors, and passed an uneasy,
sleepless night. Notwithstanding a resort to several domestic remedies,
428 MASTOID CARIES - CASES .
May 13, I found the patient still suffering from pain through the forehead and
temples ; pulse 70, regular, and with steady rhythm ; tongue brawny, a thin
white fur upon it ; intellect clear ; skin unusually open , and feeling like the
third stage of a paroxysm of intermittent fever, which I confess I was disposed
to consider it, inasmuch as he had previously suffered from that disease. I
did not consider the symptoms sufficiently clear to indicate anti-periodic treat
ment,and I therefore temporized by giving the following palliative (a mixture
of morph ., aconite, and camphor water ). May 14th , found him no better.
Skin still open ; pulse 68, with slight unsteadiness of rhythm , coating still
more inflammatory ; headache the same ; urine rather copious ; intellect in
the morning clear, but once had requested an imaginary window -frame to be
removed from his bed ; pupil unaffected , no intolerance of light or sound ;
tem per cheerful. I abandoned the malarial theory , and expressed myself to
the friends as apprehensive of basilar meningitis, consecutive to subacute
inflammation of the mastoid cells. Ordered an active cathartic, and 3 ss bro
mide of potassium , combined with the iodide. May 14th , P.M . – Visited him
in consultation with my partner, Dr. D . H . Nash. No relief; on the contrary ,
an increase of the cerebral disturbances, occasionally delusions and illusions of
mind , and mostly of the ludicrous sort; pulse slow and somewhat staggering ;
no pain in the ear or its surroundings ; bowels had moved freely two or three
times; urine still copious ; has had no sleep . Continue the bromide of potas
sium mixture, apply large blister to the nape of the neck , and give gr. SX
hydrate of chloral, and repeat in four hours if necessary, 15th - Had slept
about two hours ; general condition no better ; decidedly humorous in his
behavior ; double vision ,without apparent strabismus, could not read ; pulse
60 , more irregular ; had less pain in the head , or at least he said less about it.
Continued same line of treatment, with addition of gr. ij calomel once in four
hours. Blister acted thoroughly. 15th , P.M . - Condition little changed .
Prognosis to family - fatal result, qualified by suggestion of possible relief
from trephining mastoid process. May 16, A.M . - Patient worse ; suggested
the counsel of Dr. Roosa ; treatment the same. Met him at 9 P.M ., with Dr.
Nash . Agreed to diagnosis of meningitis , with probable origin from mastoid
cells . Determined on free explorative incision upon the mastoid process, and
use of trephine if developments indicated it. Accordingly Dr. Roosa made an
incision one inch and a half long , parallel with the attachment of the auricle
(about one half-inch posterior), down to the bone, permitting thorough exam
ination with the finger as well as with the probe. This means, however,
failed on the part of either of us to discover either necrosis or a denuded state
of the bone. After a long search , and when the search and further proce
dure were about to be abandoned , the probe (in the hands of Dr. Hubbard, R .)
- Bowman's No. 1 - caught in a little depression, and by considerable pressure
passed the external table of the cranium , into the interior of the mastoid por.
tion of the temporal bone, to the depth of one and a half inch , without other
resistance than that afforded by the external table . The orifice was now
enlarged sufficiently to favor the escape of any pus thatmight be in the depths
of the bone, an opening three-eighths of an inch in diameter, but no great
quantity of pus escaped (just a trace, R .). Subsequent examination with the
probe revealed a cavity of considerable size, caused by the breaking down of
MASTOID CARIES — CASES. 429
the mastoid cells. (The incision was carefully syringed with tepid water, and
the opening plugged with lint, R .) 17th - I first observed dilatation of the
pupils, with gradually increasing drowsiness, attended by delirium . This
condition continued, with occasional aggravations, until the 19th , when the
patient passed slowly into a state of profound coma, and he died without con
vulsions, at 2 o'clock A .M ., May 20 . No post-mortem examination could be
obtained ."
I have only to add a few words to the history thus so graphically given by
Dr. Hubbard. On the evening of the operation , or the third and last time I
saw the patient, I examined the case as carefully as possible, and I found the
membrana tympani intact and translucent, no congestion whatever. There
was no bulging in any part of its surface. The patient, who recognized me
perfectly, and showed that his memory was unimpaired, heard my watch
about six inches from the ear - a decided improvement upon the hearing
power on the two occasions when I had previously seen him . There was
absolutely no tenderness in any part of the mastoid . Besides a very minute
opening near the superior boundary of the process, which was scabbed over,
there seemed to me to be no abnormal appearance in this part, and I examined
it very carefully . On probing this minute opening , which was the trace of
Dr. Hubbard's incision of some weeks before, there was no escape of pus.
So doubtful did the case seem to me, even with the history of the abscesses
which had been opened , that I hardly expected that the free incision which I
made would reveal anything abnormal.
There are several points in this case which distinguish it

from any that I have seen , or that I have been able to find
reported.
I. — There never was a suppuration of the membrana tym
pani. A primary inflammation of the mastoid cells or their
lining membrane, or of the periosteum in this region, is very
rare, as is a middle ear inflammation in which the mastoid
becomes involved, without suppuration in the cavity of the
tympanum . I have seen one case, however, in which the use .
of the nasal douche caused an inflammation of the mastoid
of one side, without suppuration in any part of the ear, while
in the other , suppuration of themembrana tympani occurred .
But the mastoid inflammation was quickly overcome by the
use of leeches.
II. — Until the formation of the abscess, there were no
marked symptoms indicating the true seat of the disease.
The symptoms were rather those of a chronic inflammation
of the middle ear, that is to say, tinnitus, fulness, and occa
sionally slight pain. Certain it is, there was none of the
430 MASTOID CARIES — CASES .
agonizing distracting pain of which patients with periostitis

usually complain.
III. — The interval of apparent recovery after the evacua
tion of the pus.
In reviewing the case, the conclusion seems to me inevita
ble that we had from .the beginning to do with a subacute
inflammation of the mastoid portion of the middle ear, and
which smouldered until the blazing up in the abscess opened
by Dr. Hubbard. The origin of this was,of course, the coryza,
or cold in the head . It was perhaps an inflammation of the
mastoid and tympanic cavity which extended less rapidly than
usual to the periosteum and tissues lying upon it, and it was
on this account a concealed and dangerous foe. According
to a theory of mine the second attack was essentially a new
process attacking the former seat of disease, or locus minoris
resistentice — “ the weak spot,” as patients say, induced by some
exciting cause that is unknown. The integrity of the nerve,
up to a late period, is shown by the amount of hearing power
exhibited on the evening that the perforation of the bone was
made.
Dr. C . R . Agnew reports a case which has been alluded to
in the account of caries of the mastoid , an outline of which,
made up from Dr. Agnew 's report, is herewith presented .
CASE III. - Acute Otitis Media - Mastoid Periostitis – Opening of Mastoid by
a Gimlet – Subsequent Trephining - Hyperostosis of Mastoid Cells - Re
covery .
Miss X , in middle life, caught cold and a sore throat, after exposure in the
country on the 26th of August, 1864. Immediately after she was seized with
violent pain in the right side of the head and corresponding ear. On Septem .
ber 5 , a swelling began in the mastoid region , the severe pain from the ear
having continued until that time. On the 30th of September, the pain er .
tended rather suddenly down behind the course of the sterno-cleido-mastoid
muscle. On the 20 of October, an incision was made over the mastoid , and it
was perforated by means of a gimlet. Pus followed the incision through the
periosteum , and also on the withdrawal of the gimlet. Dr. Agnew first saw
the case a year after this, when there was considerable swelling of the auditory
canal. The concha and mastoid region was tender to the touch, and over the
center of the mastoid was a small fistulous opening which passed into a narrow
sinus, running through the bone towards the tympanic cavity. This sinus
was with difficulty entered by a No. 4 Bowman 's probe. The principal sub
jective symptoms were pain in the temporal bone, apprehension of brain dis
MASTOID CARIES - CASES. 431
ease, slight loss of memory, nervousness, and wakefulness. The face was
anxious; the operation was advised, but it was declined.
In February, 1870, the patient had an alarming attack. The principal
symptoms were a feeling of “ general agony," and paralysis of the right 7th
nerve, with obstinate vomiting. This was on Friday, and on the Wednesday
following , the paresis had disappeared , but there was some loss of memory
and a slight degree of aphasia .
On February 21, 1870, Dr. Agnew " proceeded to trephine the mastoid
through a sweeping cut, using for the purpose a half-inch instrument (trephine)
with the pin in the mouth of the sinus,” a dense button of bone nearly three
eighths of an inch thick . Dr. Agnew believes that the cells were filled by a
dense bony growth . Drs. Van Buren , Loring ,Keyes, and myself were present
at the operation . The sinus was enlarged by using a triangular steel bit, so
that the entire depth of the track opened was about five-eighths of an inch .
No pus was found ; no caries of the bone. The patient experienced a marked
amelioration of her symptomsafter the operation , and, as Dr. Agnew informs
me, continues well at this time, now three years since the operation .
Dr. D . R . Ambrose, formerly house-surgeon to the Man

hattan Eye and Ear Hospital, lately trephined the mastoid
process, in a case of peculiar interest, the notes of which the
Doctor has given me, besides allowing me to see the patient.
CASE IV . - Mastoid Periostitis - Abscess — Incision - Polypoid Grouths from
Wound — Trephining - Bone found very dense - Removal of Plug one inch
long - Recovery.
“ Miss S. C.,age 19,cameunder observation February 15, 1872, complaining
of deafness in right ear, and stated that about four years ago she had an
attack of severe pain in that ear,accompanied with slight hemorrhage, and
followed by discharge of pus. H . D . R . E ., watch pressed upon auricle . Voice
in very loud tone about six inches from the ear. There was a small quantity
of cerumen adhering to the wall of canal. The membrana tympani was
clearly visible, but showed evidences of previous trouble. Right Eustachian
tube closed , and impervious to Politzer's method or the catheter, after fre
quent local applications of nitrate of silver.
“ Left ear normal.
“ The small quantity of wax having been removed ,treatment by electricity
was commenced and continued three times a week for about six weeks, at the
expiration of which time H . D . R . E .; voice, in tone of ordinary conversation,
distinctly heard at fifteen feet. This gave great satisfaction , as she had been
much disheartened by prospect of complete and permanent deafness of that ear.
Patient was now discharged.
“ On 20th of April, 1872, she had an acute attack of periostitis in external
auditory canal,which involved the mastoid cells,and in spite of leeches,warm
water douches,and incision down to the bone of the canal, resulted in abscess
of mastoid cells.
432 MASTOID HYPEROSTOSIS - CASE .
“ The abscess protruded through the posterior wall of canal, and , on being
opened with a bistoury, discharged a considerable quantity of pus.
“ The ear was now frequently cleansed with lukewarm water ; but, not.
withstanding this, there soon sprang from the mouth of the abscess polypoid
growths, which astringents, including the solid stick of nitrate of silver, and
several excisions, failed to subdue. There still remained a constant aching,
with , occasionally , sharp darting pains in mastoid process, which radiated to
different quarters of temporal region . On two occasions patient found small,
thin scales of bone in the purulent discharge. I then passed a silver probe,
bent, through the opening of the abscess, and could distinctly detect dead
bone, both in posterior and superior portions of mastoid cells. The end of the
probe was blackened with sulphur or phosphorus. I was very careful not to
push the probe beyond the level of themouth of the abscess, lest I should do
irreparable damage to the labyrinth wall, and not too far behind or above,
for fear that in the former direction I should encroach upon the transverse
sinus, and in the latter push through to the dura mater. Meanwhile the mas
toid process, at its lower portion, becamered, slightly swollen,and very tender
to the touch .
" After patient and persevering efforts to effect a cure by keeping the ear
cleansed as thoroughly as possible ,and by taking tonics and nutritious diet for
six weeks without any substantial improvement, I resolved upon trephining,
lest by further delay the inflammatory action should extend to deeper and
more important parts ,and hopelessly destroy her power of hearing in that ear,
if not terminate her life.
" On the 1st of June, 1872, after making an incision two inches and a half
long, down to the bone, parallel with the auricle, and half an inch from its
attachment, I separated the periosteum from the bone to an extent sufficient to
admit a quarter -inch trephine, and inserted that instrument on a line with
superior border of external meatus, and about half an inch from the attach
ment of the auricle, directing the instrument slightly forward in a horizontal
position . After the trephine had penetrated to the depth of half an inch , and
finding myself on just as firm bone as at the commencement, I heartily wished
the affair was over with ; but remembering that Tröltsch says that the depth
to which we must go is sometimes very considerable,' I regained my courage
and persevered with the operation until I felt a slight yielding beneath the
instrument. I immediately withdrew it and tried , with moderate force, to
extract the plug of bone with bone forceps, to which , however, it did not yield
in the slightest degree. Again the trephine was replaced , and, after a few
more gentle turns, there was a very perceptible sensation of further yielding
beneath the instrument ; and a second time the trephine was withdrawn and
a second ineffectual effort made to extract the plug,though it yielded slightly
to lateral pressure. The trephining was again renewed, and, after a few gentle
turns, withdrawn ; and now the plug was easily extracted . The instrument
was repeatedly withdrawn and very lightly worked after the first yielding was
detected , lest by a sudden giving way of parts beneath , it should be suddenly
plunged into the mastoid cells, and, in a moment, defeat all my hopes from
the operation . The plug having been withdrawn, I was surprised at the small
amount of pus that escaped , for this, together with the bone dust, certainly did
MASTOID HYPEROSTOSIS - CASE . 433
not exceed one drachm . This led me to suspect that I had not entered the
mastoid cavity at all ; and to remove all doubts upon this point, I passed a bent
probe through the opening of the abscess, and another through the wound
just made, and could distinctly touch and move the one with the other.
“ The wound was then syringed with warm water, to which was added a
few drops of carbolic acid, and then plugged with lint, which treatment was
continued daily, and sometimes twice a day, for six weeks, when the wound
completely healed ,without any discharge from the ear, and without a single
uncomfortable sensation remaining. The constant aching and frequent dart
ing pains with which the patient had been so long harassed were almost
instantly relieved ; for the next day, after all effects of anæsthetic had passed
off, she complained of nothing but the soreness of the wound , nor did she com
plain of anything more from that day throughout the entire liealing process.
The polypoid growths also , which had resisted all other measures that I
had used , ceased, in a few days, to grow , and soon entirely disappeared , with
out any additional treatment than simply cleansing the ear. This was appa
rently a perfect cure until four weeks after the wound had healed — ten weeks
from the date of the operation - when , after exposure to a draught of damp
air, she was suddenly seized with sharp pain in the same ear, which was soon
followed by a throbbing sensation .
“ Examination revealed inflammatory action only on anterior and inferior
walls of canal. The application of mild current of electricity would relieve all
pain within ten minutes, while a strong current aggravated it. But the pain
would return again during the night, and sometimes within an hour after the
application . Injections of warm water were then substituted with similar
results , and patientwas put on quinine and iron , and five grains of iod . potass .
three times per day. These attacks of aching and darting pains becameof very
frequent occurrence- every two or three days, and sometimes as often during
twenty -four hours — with an occasional discharge of a few drops of blood from
the ear. Upon the superior wall of external canal there is a hard bony sub
stance, almost invariably covered with a purulo-gelatinous material, a little of
which, on the end of the probe, emits a very offensive cadaverous odor. This
part is very tender when pressed upon by the probe.
“ H . D . R . E . Voice slightly raised above ordinary conversation heard dis
tinctly at fifteen feet.
“ March 17th , 1873. - I induced the patient to go to the Manhattan Eye and
Ear Hospital, to get the advice of Dr. Roosa .”
I found the patient in a comparatively comfortable condi
tion , able to pursue her ordinary avocation, and it seemed to
me that there was an exostosis of the osseous canal, and per
haps of the tympanic cavity, and that the pain was due to
periostitis. I advised the use of iodide of potassium and the
continuation of the warm douche. The process of sclerosis
of the osseous structure is probably going on . The change in
the bone is similar to thatwhich occurred in the preceding case .
28
434 CARIES AND NECROSIS.
CARIES AND NECROSIS OF THE TEMPORAL BONE.

The surgeon is often baffled in his efforts to check a dis
charge of pus from the ear, because it comes from a part of
the bone that has been softened by a carious process . It is
not always possible to positively decide that the bone is in
this condition, for the part thus affected may be sufficient to
maintain a suppurative process, and yet be very small and
hidden from view . Even the proper use of a probe in a dis
eased cavity of the tympanum , in order to enable us to decide
as to the existence of caries, is a delicate matter, and should be
undertaken with care,lest important parts be penetrated. The
careful surgeon is, therefore, often in doubt as to how much
of the bone may be invaded, even when he finds a superficial
point that gives evidence of disease. The probe cannot be
used in the ear as a diagnostic means, with that freedom that
it is employed in solid parts that have no such important and
delicate surroundings.
All parts of the temporal bone may become carious as
the result of a chronic suppurative process. The osseous por
tion of the auditory canal is one of the favorite positions for
such a morbid change. The upper wall of this canal is but a
short distance from the dura mater and the cerebrum , and
we have already discussed the relations of the mastoid cells
to the lateral sinus. Thus we may have inflammation of
the brain and affections of the venous circulation , even when
the caries is confined to the external ear. It is probable ,
however, that caries of the auditory canal is usually the result
of a chronic suppuration of the middle ear, and not of a
primary and independent affection of the peripheral portion .
The anatomical relations of the cavity of the tympanum , than
which there are none more important in the whole system ,
necessarily involve serious consequences from caries of any
part of its walls. These consequences also necessarily include
great impairment of the hearing, while we may have menin
gitis, cerebral abscess , pyæmia , paralysis, or fatal hemorrhage.
Indeed, in the treatment of any of these consequences of a
chronic suppuration, we are always treading upon dangerous
ground , which may break under our feet at any moment. In
CARIES AND NECROSIS . 435
some fortunate cases, however, none of these unpleasant results ,

except the loss of hearing , occur ; the diseased bone is thrown
off, and the parts heal. Nearly the whole of the temporal
bone may be cast off in this manner without involving the life
of the patient.
It has already been seen that the ossicula auditus may
become carious and lost in the course of an acute suppuration.
The same thing may occur in the course of a very chronic
process, and small points of dead bone are frequently found
when the cavity of the tympanum has been for a long time
exposed from a loss of the membrana tympani. It is shown,
however, by Case II., page 426 , occurring in my practice, that
caries may occur with an intact drum -head. Dr. Orne Green *
has also published a report of a post -mortem examination ,
that illustrates the same fact. Dr.Geo. E . Francis , of Wor
cester,made the autopsy.
A man twenty-five years of age, who was subject to
catarrh, had had a discharge from his ear for two years ;
at times acute symptoms occurred . Two months before
death he could not hear conversation. He also had cerebral
symptoms, dizziness, headache, double vision, and partial
paralysis, but of what regions is unknown . He died coma
tose, and at the autopsy a collection of pus was found in the
brain , just over a carious spot communicating with the tym
panic cavity . The pus lay directly upon the bone.
Dr. Green examined the bone, and found a sinus through
the upper osseous wall of the auditory canal, just above and
external to the small process of the malleus. The point of an
ordinary probe could be inserted in this opening, and it com
municated with the auditory canal and the small cavity in
front of the handle of themalleus. From this cavity it passed
backwards and inwards into a circular cavity about one-quar
ter of an inch in diameter in the cancellated structure of the
bone. The roof of bone over this cavity had entirely disap
peared , so that, there was a direct communication with the
brain . All the walls of this space were irregular and carious.
“ The membrana tympani was entire and apparently healthy, and
* Transactions ofthe American Otological Society , 1871.

436 CARIES AND NECROSIS .
of normal transparency and thickness in every part below the

small process of the malleus bone.”
The head of the malleus and the whole of the incus were
wanting, but it could not be positively stated , that they were
not removed during the dissection. They must certainly have
been in a softened, diseased condition, or they would not have
escaped so readily. Von Tröltsch reported a similar case to
this, and called attention to the little cavity , which is a part
of the tympanic cavity , and is situated just above and external
to the head of the malleus. In a normal condition , it is sepa
rated from the auditory canal by an extremely thin layer of
bone. Von Tröltsch dissected a specimen in which he found
a polypoid growth springing from this point and projecting
into the canal
Dr. O . D . Pomeroy* has reported a case of exfoliation of
the whole of the temporal bone, except the lower part of the
external auditory canal and the inner part of the petrous por
tion. The patient recovered, of course with loss of hearing and
FIA . 83. Fig . 84 .
Thoo Views of Temporal Bone exfoliated in the course of Chronic Suppuration. From
Dr. Pomeroy's Collection.
facial paralysis. The patient was a boy aged twenty months ,

and had a discharge from the ear, accompanied by severe
* Transactions American Otological Society, 1872.
CARIES AND NECROSIS. 437
pain for three months before Dr. Pomeroy saw him . There
was mastoid periostitis, and an incision was made. Two days
after another was made, and the bone was found uneven and
rough , and there was a fistula leading into the mastoid cells .
For three months after, the child did moderately well, although
there remained considerable swelling in front of the auricle.
At the end of this period, a small piece of dead bone was
observed behind and a little abovethe external auditory canal,
and in about a month afterwards it becamemovable , and was
grasped by forceps and some traction was made upon it, but
so much hemorrhage was caused that the attempt to remove
the dead bone was given up. In about six weeks the mother
brought the child to the Manhattan Eye and Ear Hospital,
and also the dead bone that is represented in the accompany
ing engravings,which were made from a photograph prepared
under the direction of Dr. Pomeroy.
Six months after the child was doing well. The aperture
through which the sequestrum passed had closed . The dis
charge of pus was moderate and the general health of the child
was good.
Wilde,* Agnew ,t Gruber,# and Voltolinis have reported
cases of the extraction through the externalmeatus of the whole
of the internal ear, during the life of the patient. Wilde's case
occurred in the practice of Sir Philip Crampton . The patient
was a young lady, who , after the most urgent symptoms of
inflammation of the brain , with paralysis of the face, arm and
leg, and total loss of hearing of one side, recovered from
the head symptoms and paralysis of the extremities after a
copious discharge of pus from the ear. “ One day Sir Philip
perceiving a portion of loose bone lying deep in the cavity
of the meatus, drew out the whole of the cochlea and semi
circular canals."
Dr. Agnew 's case occurred in a patient who suffered from
exostosis consequent upon chronic suppuration of the oppo
site ear, and who afterward died of brain disease dependent
* Text-Book , p . 37.
+ Von Tröltsch on the Ear, American Edition,
Lehrbuch, p. 542.
& Monatsschrift für Ohrenheilkunde, Jahrgang IV ., p . 84.
438 NECROSIS OF INTERNAL EAR.
upon retention of pus by the exostosis. The case as regards

the exostosis will be found on page 404 ofthis work.
The patient was a gentleman of thirty-eight years of age,*
who had suffered from chronic suppurative inflammation of
the middle ear for the greater part of thirty -two years. Three
years before the patient came under Dr. Agnew 's observation ,
after a severe exacerbation of the aural inflammation, com
plete loss of hearing occurred in the ear, and paralysis of the
facial nerve of that side. Granulations continued to recur
constantly . On the 16th of April, 1862, the patient was in a
deplorable condition ; he had suffered for months from pain
in the ear , loss of sleep, loss of appetite and dizziness . The
concha was swelled and extremely tender ; a pear-shaped
polypus, of fibrous character,which was kept bathed in very
fetid pus, projected from the meatus. Dr. Agnew placed the
patient under the influence of chloroform , and removed the
polypoid mass by means of Wilde's snare. In attempting to
get the snare about the base of the polypus, he encountered
a solid body in the middle ear,which proved to be the ne
crosed internal ear. An incision was then made into the audi
tory canal, in order to enable the forceps to grasp the seques
trum . Dr. Agnew 's report says : “ Having got the body in
the grasp of the forceps, a slight rocking motion , with trac
tion, enabled me to extract it.” The whole of the internal ear
- vestibule, semicircular canal, and cochlea - were found to be
removed.” This patient lived four years after this, and never
had any painful symptoms from that side of the head after
ward .
Gruber's case occurred in a child thirteen years of age.
Both cochleæ were exfoliated , and yet the patient recovered ,
with no facial paralysis an evidence that the cavity of the
tympanum was left in a comparatively sound condition.
Voltolini'st case was one that occurred in the practice of
Dr. A . Jacobi, of Berlin . The whole labyrinth was removed
from the ear of a child that is still living. The substance of
the cochlea was not fully united with the surrounding bony
substance of the petrous bone, which , as Voltolini remarks, is
* American Medical Times, vol. vi., p. 183.
+ Monatsschrift für Ohrenheilkunde, Jahrgang IV ., p . 84.
CARIES AND NECROSIS. 439
evidence that the disease dates back to an early period in the
life of the child .
Toynbee* reported four cases of necrosis of the cochlea
and vestibule, in which the parts had been exfoliated during
life. One of them is Wilde's case, already quoted. The pa
tients were adults, with the exception of one, a child of seven
years old .
The following engravings illustrate the ravages which
chronic suppuration makes upon the bony tissue of the ear.
They were made from photographs of the bones, and are from
the collection of Dr. C. E . Hackley, who kindly allowed this
use of them .
Fig . 85. Fig. 86.
Left Temporal Bone, from Case I. Inner Surface of the same Specimen, showing
Exterior view , showing the external meatus, c. The restibule. d. d. Thewindings of the
a, from which the anterior wall has been cochlea , which have been exposed by saw
removed , as has also the inner wall of the ing away portion of the bone. e. The
middle ear. b . The mastoid process. tympanum , communicating with f, the
mastoid cells, which have been exposed
by chipping away a thin layer of bone.
History.— CASE I. (Figs. 85 and 86 ). — Left temporal bone

from a man who had phthisis , and died suddenly of pneumo
thorax, August, 1866 . His hearing distance was nothing for
the watch , nor could he distinguish words,though he seemed
* Archiv für Ohrenheilkunde, Bd. I., p. 113.
440 CARIES OF TEMPORAL BONE .
to hear the sound of the voice. He was very much debilitated

when he entered the New York Hospital, consequently no
thorough examination was made of his ears. He had profuse
discharge from both ears, and polypi on both sides. On the left
side, the post-mortem examination showed polypus attached
in the middle ear and extending forwards into the meatus, and
backwards into the mastoid cells ; membrana tympani gone ;
stapes only one of ossicles present ; membrane of fenestra
rotunda gone.
FIG . 87.
Left 7 emporal Bone, sawed through External Meatus,Middle Ear, and Cochlea .
The pieces are turned to one side, showing - a, Mastoid process . b, b , Externalmeatus, ending
in c, the middle ear. At a there was an opening downwards through the bony meatus, and
at e an opening upwards, by which there was a free communication with f, the mastoid
cells , which were separated from the interior of the cranium by a very thin layer of bone at
g . h , h , show the cochlea sawed through .
CASE II. (Fig. 87). — Left temporal bone from — , who

entered the New York Hospital August, 1866 , with great fever
and pain in the left ear ; had been sick two days. His disease
ran much the course of typhoid fever, without marked head
symptoms other than the acute pain in the ear (which only
existed the first two days). When a child he had discharge
from the ear and post-aural abscess and disease of mastoid
process.
On the autopsy, pus was found under the dura mater and
in mastoid cells ; the whole temporal bone was gone from the
infiltration of pus through it ; the membrana tympani was
completely destroyed ; the base of the stapes was the only
CARIES OF TEMPORAL BONE. 441
part of the ossicula remaining ; there was an opening from the
outer part of the bony meatus upwards into a cavity which
also had an opening outwardly.
FIG . 88 .
Right Temporal Bone, from Case V ., showing the Cranial Surface of the Bone.
At a the bone was very thin , and broke away when the dura mater was removed ; the bone was
much hollowed out about b , the middle ear.
CASE V. (Fig . 88). — August 18 , 1868. - H . O .applied atNew

York Eye and Ear Infirmary , on account of pain in right ear,
saying he had a “ kernel ” (wax ?) removed from his ear two
years previously, by one of the surgeons of that institution.
The right membrana tympani was found injected , right Eu
stachian tube obstructed . H . D . — Right ear, pressed ; Left,
18. Applications of warm water, with occasional leeching,
were ordered. After some time the walls of the meatus
swelled so that the walls of the membrana tympani could
not be seen. Under varying treatment the state of the case
was sometimes better, sometimes worse, till March , 1869.
During his attendance the patient twice stopped coming,
thinking he was well,when he complained of pain over the
right side of the head , starting from the ear. Expecting
meningitis, he was taken as an in -patient at the Infirmary,
April 1st, 1869, treated again with leeches, cold to head, bro
mide of potash, and tonics. About May 1st, 1869, he showed
occasional delirium , and contraction of the muscles of the
nape of the neck ; had retention of urine ; pulse 110- 130 ;
temperature 102°. Died May 10th . No discharge from ear
for thirty-six hours preceding death . On autopsy, twelve
hours after death ,we found the brain slightly congested ; the
right optic nerve (which went to an atrophied eye) was atro
442 CARIES AND NECROSIS — PROGNOSIS .
phied both before and behind commissure ; the meninges of the

base of the cerebellum , and upper part of the spinal cord , were
covered with lymph and bathed in sero- pus (about two oz.) ;
right auditory nerve very red ; periosteum over the posterior
part of the right temporal bone was very easily detached ; the
bone under it was greenish, infiltrated with pus ; the passage
from the middle ear to the mastoid cells was much enlarged,
with only a thin wall of bone between it and the brain . On
detaching the pericranium this wall was broken through.
Membrana tympani entirely gone ; the promontory was rough
ened ; the stapes was the only one of the ossicles left in
position .
Prognosis. — The prognosis of caries and necrosis of the
temporal bone dependsupon several factors. To a marked de
gree it is influenced by the age of the patient. Young children
will throw off quite large portions of the bone, and yet come
off with their lives,while older persons will usually succumb to
one of the many consequences, such as pyæmia , hemorrhage,
abscess, which may result from death of bone in this part of
the body. The situation also of the dead bone will influence
the prognosis of caries to a marked degree. Caries of the
mastoid, especially when occurring in young children , is very
often recovered from . Caries and necrosis of the walls of the
middle ear is of course the most dangerous of all that may
occur, especially caries of the upper and lower wall. It bas
been seen that the whole internal or labyrinth wall may be
destroyed , and the contents of the external ear be exfoliated,
and yet the patient recover. In these cases the necrosed
internal ear seems to have passed through a sound tympanic
cavity .
The prognosis of caries and necrosis of the temporal bone
is, however , always grave under any circumstances, and no
life can be said to be what the life insurance companies call a
good risk, if a chronic suppurative process has gone on to this
extent. The ossicula auditus may be thrown off with com
parative impunity, as we see by cases all about us ; yet
even these cases, unless the suppuration has entirely ceased ,
belong to a class of cases of whose results we must always
CARIES AND NECROSIS — TREATMENT. 443
stand in dread . Until the parts have healed, and some kind
of a neo-plastic membrana tympani has formed , we are not
safe in giving a decidedly favorable prognosis.
Treatment.— It is impossible to give any specific rules for

treating caries and necrosis of the bony parts of the ear.
Each case must be judged by itself, under the general rules
of treatment that have been given as appropriate for chronic
suppuration ; the chief of these rules, I may venture to repeat,
are a thorough removal of the accumulating pus before it has
time to produce its corroding and destructive effects, and
careful attention to the general health and habits of the pa
tient .
Gruber * mentions one means of treating caries of the tem
poral bone, in which I have no experience, but of which he
gives a favorable report, in some cases where the severe pain
was not relieved by local antiphlogistic and anodyne treatment.
This is the actual cautery. The iron is applied at several
points over the mastoid process. After the bony slough is
removed , an irritating salve may be applied to continue the
counter irritation . Dr. Post, of this city, also speaks well of
the actual cautery as a less painful means of treating mastoid
periostitis than the incision. I have no doubt, judging from
a recent experience in a case of Dr. H . G . Newton 's — which I
saw in consultation - where Dr. Newton trephined the mas
toid process for continuous and severe pain referred to the
middle ear, but without finding dead bone,that such openings
will do very much to relieve the deep-seated pain of caries
that is referred to the ear and the brain .
The facilities for treating chronic suppuration , since we
have Politzer's method of opening the Eustachian tubes, are
much greater than those enjoyed by our predecessors. We
may, by the employment of this method , more thoroughly
cleanse the tympanic cavity from pus than by the simple use
of the syringe. In the chapter on chronic suppuration, a
detailed account of the means of thoroughly cleansing the ear
has already been given .
* Lehrbuch, p . 552.
444 CEREBRAL ABSCESS.
A patient with caries of the temporal bone should be made

aware of the gravity of his condition , so that he and his
friendsmay be on the lookout for serious symptoms, which
may be promptly treated , and that they may not fall into the
error of supposing that no harm can possibly come from “ a
simple running from the ear.”
If polypi or granulations have occurred in connection with
caries of the canal or tympanic cavity, they should be removed
with care, lest severe hemorrhage occur, or other harm to the
parts. The galvano-cautery has proved an efficient and safe
means of removing such granulations,* and of causing the
bone to heal.
Fatal hemorrhage has occurred from 'caries of the bony
canal, in which the internal carotid passes through the apex
of the petrous portion of the temporal bone, as well as from
destruction of the bony wall that separates themastoid pro
cess from the lateral sinus, and also from the breaking down
of the thin plate of bone that forms the floor of the cavity and
separates it from the jugular vein. Fortunately for the lives
of many patients, there is a tendency to thickening, or hyper
plasia of the bony walls of the tympanum , in some cases, and
thus they are protected from the corroding effects of pus."
CEREBRAL ABSCESS.
The proceedings of pathological societies and surgical
records show , that abscess of the cerebrum more frequently
results from disease of the middle ear than from any other sin
gle cause. Of seventy -six cases of cerebral abscess collected
by Drs.Gull and Sutton, twenty -five, or about one-third, were
* Archiv für Ohrenheilkunde, Bd. VI., p . 116 .
+ Gruber, Lehrbuch , p . 543. Gruber states that Billroth has tied the com
mon carotid artery for a case of aural hemorrhage, which occurred not from
caries, but from a congenitaldefect in the bony wall. The hemorrhage ceased
for ten days after. After all attempts to restrain the hemorrhage were fruit .
less , Billroth ligated the left carotid , and two days after the patient died from
severe hemorrhage from the right ear, the nose , and mouth . A child , for
whom parents would not allow the operation , died from the same cause ,
Koeppe reports a case of hemorrhage from the lateral sinus, through the nose
and ear. This was in consequence of destruction ofthe bone.
Reynold 's System of Medicine, vol. ii., p . 544.
CEREBRAL ABSCESS. 445
directly traceable to chronic suppurative processes in the
middle ear. Lebert,* in his article upon this subject, con
siders that aural disease is the cause of cerebral abscess in
about one- fourth of the published cases.
There is usually caries in connection with the cerebral
abscess, but cases have occurred in which , although the dis
ease of the ear extended to the brain , there was no death of
bone. The anatomy of the cavity of the tympanum ,especially
of the roof, or tegmen tympani, where a process of dura
mater actually extends into the tympanic cavity, and where
there may normally be a gap in the bone, has taught us how
easily this may occur. The cause of the extension of a sup
purative process to the brain is undoubtedly very often that
which Mr. Toynbee so clearly sets forth in his chapter on this
subject — that is, the non -escape of the pus externally through
the membrana tympani. The perforation of the membrana
tympani in acute inflammation usually prevents any such dis
aster as the passage of the pus to the brain or the circulation .
Rupture of the membrana tympani is, therefore, a con
servative process , if suppuration has once been established ;
for there is no other safe way of escape for the pus, except
through the Eustachian tube- - a means of exit which is one of
the last that nature chooses. Abscess of the brain in acute
disease was only once observed by Mr. Toynbee.
A direct communication usually takes place between the
diseased mastoid or petrous portion of the temporal bone and
the brain substance through the meninges, but the dura mater
and other membranes may be healthy, and even a portion of
healthy brain may lie between the diseased bone and the cere
bral abscess. The chronic disease of the ear may be going on
very well, until somemechanical injury - exposure to cold , or
the like - sets up an acute process, which extends to the brain
through the delicate bony walls of the tympanic cavity, or the
cancellous structure of the mastoid bone.
Patients suffering from chronic suppuration of the middle
ear cannot be too much guarded against blows or falls upon
the ear, or against exposures to sudden changes of temperature,
* Virchow 's Archiv , Bd. X ., p. 391.
446 CEREBRAL ABSCESS.
drafts of air, or the like ; for the table of cases appended to this
chapter, shows that meningitis, cerebral abscess, and pyæmia
may, from such exciting causes, be the termination of a puru
lent discharge from the ear.
The symptoms of brain disease are sometimes very insi
dious. At times there is a chill or a convulsion, or nausea
and vomiting ; at others, only increased pain in the ear, fol
lowed in rapid order by paralysis, coma, and death . In very
rare cases there are absolutely no symptoms, except those
of a chronic suppurative process in the ear, until death
occurs.
The table of fatal cases of aural disease resulting from
chronic suppurative processes, that has just been alluded to,
was compiled from various sources, in order to show the
variable character of brain symptoms supervening on otitis
media purulenta, and the anxiety with which such a case,
especially if united with caries or necrosis of bone, should be
regarded.
It is interesting to note how slowly the profession came to
recognize the fact that when pus was found in the brain com
municating with the ear, that it was on its way inwards, and
not making an external opening. It seems to have been hard
for the medical men of a few generations back , to believe that
aural disease could cause any serious affection, or that it was
a matter of much account, although people were dying all
about them from the results of aural disease alone, Lebert*
says that Morgagni, “ with his good tact and close observa
tion of Nature ,” discovered that the ear was often the cause
of purulent affections of the circulation and brain substance ;
but Itard took a step backward , and discovered a kind of
cerebral abscess which broke out through the ear. Lalle
mand again placed the subject in its right light, and showed ,
what we now clearly see, in cases of cerebral abscesses occur
ring in connection with suppuration of the ear, that the organ
of hearing was the part first affected .
It is generally believed that a suppurative process in the
ear is necessary for the production of an abscess of the brain,
* Virchow 's Archiv , Bd. IX., p. 382.
PY EMIA . 447
and this is probably the fact ; but one case that I observed,
leads me to suspect that there may be such a thing as a
chronic cerebral abscess leading to disturbing aural symp
toms, such as tinnitus aurium and pain in one side of the head,
without any primary aural affection. I treated a gentleman
of about twenty-nine years of age, for somemonths, for such
symptoms as have been indicated , and when he died a cere
bral abscess was found. He could hear the watch for but three
inches from the left ear, which was the affected one, and the
drum membrane was sunken . I supposed the case to be one
of chronic proliferous inflammation of the middle ear. The
patient got no relief ; he became very despondent on account
of his tinnitus aurium and pain , gave up his business, and died
at Sag Harbor, L . I., of malignant pustule , about two years
and a half after I first saw him , and three years and a half
after his first aural symptoms. Dr. Geo . A . Sterling, of that
place, made a post-mortem examination. He found “ great
injection of the pia mater over petrous portion of temporal
bone, and an abscess about the size of a ten cent piece in the
brain substance. It was bounded by inflammatory adhesions,
and contained about ten drops of pus. The abscess was situ
ated on the left side, in the superior lobe, one inch from the
median line and two inches from the coronal suture.” This
patient never had a suppurative inflammation in the ear, and
it is possible that the cerebral abscess was the cause of his
very distressing symptoms, although the data are not full
enough to allow us to give a positive opinion. There is no
account of an examination of the temporal bone.
The text -books on pathology give very full accounts of
cerebral abscess. The author has had but the space to
plainly mark them out as one of the consequences of chronic
suppuration of the middle ear.
PY EMIA .
The author has already (on page 292) related a case

which shows that pyæmia , or metastatic abscesses, from the
entrance of pus into the circulation through the mastoid
veins or the lateral sinus, may result from aural disease.
448 PYEMIA AND PARALYSIS.
Mr. Prescott Hewitt,* in 1861, related a similar case, and with

the like happy result of recovery. Mr. Hewitt's case was in
substance as follows: A young lady, eighteen years of age,
had a discharge from the ear, as a consequence of measles.
About four weeks after the occurrence of the discharge, she
was seized with severe chills, which were followed by much
fever, a furred tongue, and typhoid symptoms, with suppres
sion of the discharge. When Mr. Hewitt saw the patient the
chills continued , the skin had assumed an earthen hue, and
the fever was intense . The intellect was clear, but there was
pain extending down the side of the neck, along the course of
the jugular vein , and the head was inclined to that side.
There was swelling at the base of the neck . In eight days
pus appeared in one of the sterno- clavicular articulations. In
a few days one knee became involved, and symptoms of pneu
monia appeared , which soon subsided. In about seventeen
days from the beginning of the phlebitis, swelling and pain
occurred over one of the hip - joints, a deep abscess formed,
but it was opened early , and the joint did not become involved.
The patient ultimately recovered under treatment by wine and
morphia .
This case and the one already referred to, give the clin
ical features of purulent infection from suppuration in the
ear. The pathological characteristics of the disease are seen
in the table of fatal cases appended to this chapter. Professor
Lebertt bas given us the fullest account of the inflammations
of the sinuses that may lead to purulent infection ; but the
proper limits of this volume do not allow of a fuller discussion
of this dangerous, but by no means hopeless disease.
PARALYSIS .
Paralysis of the seventh nerve, as it passes through the

tympanic cavity , in the Fallopian canal, must of necessity be
a consequence of many suppurative and carious affections of
this part, and yet it cannot be said to be a frequent affection
in the course of chronic suppuration of the middle ear. In
* London Lancet, Feb . 2, 1861.
+ Virchow 's Archiv , Bd. IX ., p. 381.
PARALYSIS. 449
the greater number of the cases in which it occurs, it is perma

nent, from the fact that the nerve tissue is destroyed by the
ulcerative process; but I have seen cases of temporary paraly
sis of the seventh, which were probably due to pressure upon
the nerve trunk ; for, when the suppuration of the ear was
checked, the functions of the nerve were restored , and the face
resumed its normal appearance.
Paralysis of other parts of the body, and complete hemi
plegia , may occur in the course of meningitis and cerebral
abscess ; but these necessary consequences of the destruction
of brain substance hardly require a separate notice .
It is possible that a blood clot might form between the
dura mater and the bone, from rupture of a branch of the
middle meningeal, from caries of the temporalbone, and hemi
plegia be induced by pressure communicated to themotor tract,
or as Mr. Hutchinson says, as quoted by Dr. Hughlings Jack
son,* by squeezing the blood from the corpus striatum , or tha
lamus opticus. The author has published two cases of hemi
plegia , occurring in coincidence with chronic suppuration of
the middle eart which are here reproduced as good illustra
tions of the subject, although it is not claimed that they should
be regarded as positively consequences of chronic suppuration .
A boy ten years of age was brought to me for advice on May 10,
1869. He had had a discharge from the left ear since he was
an infant, and about four weeks ago hewas affected with a num
ber of paralytic symptoms that came on gradually. He be
cameunable to speak distinctly , or to swallow his food properly,
and finally he could not walk steadily . There was paralysis of
the seventh pair on the left side, and of the left arm and leg, so
that he could not grasp well,and he dragged his foot in walking.
These symptoms came on gradually , in the course of some
hours, a fact which indicated hemorrhage between the dura
mater and the bone. The rightmembrana tympaniwas intact,
but thickened,and it had no light spot. The leftwas ulcerated
and perforated. Its remains were very vascular. His hearing
distance was ds" from the right ear, and 7 " from the left.
Under the usual treatment the membrana tympanihealed, and
* Reynold 's System of Medicine, vol. ii., p. 505.
+ Transactions of the American Otological Society, 1870.
29
450 PARALYSIS .
the hearing power became normal. The paralysis was nearly

gone when he disappeared from observation .
June 8, 1870. — The patient was again brought to me, and
his mother stated that he was seized with dizziness and loss of
sight while at school. He became so affected that he was fif
teen minutes going two or three blocks, and he was stupid
when he reached home, although he had complete control of
all his limbs. He had sight enough to go about, but not to
read. Two months after this attack, his vision was } in the
right eye, and I on the left. The field of vision was greatly
limited on the periphery. The ophthalmoscope did not detect
any lesion in the fundus oculi. Under expectant treatment
the boy slowly recovered his vision .
The second case was that of a farmer, aged 62, whom I
saw in October, 1869, in consultation with Dr. Losee, of Red
Hook, N . Y . The patient had suffered from chronic suppura
tion of the right ear, since he was a child . Occasionally acute
attacks would occur , culminating in abscesses of the mastoid .
For six years past, the ear had been very quiet. About six
weeks before I saw the patient, he was seized with hemiplegia
of the left half of the body, coming on in the course of a few
hours. When I saw him he was slowly recovering from the
paralysis. The hearing power on the right side was com
pletely destroyed . The cavity of the tympani was exposed
and empty. There was a cartilaginous band extending across
the canal, which I divided, and found that it contained small
bits of dead bone,which seemed to come from the posterior
wall of the canal. The patient fully recovered from the para
lysis, and is still living.
Dr. Hughlings Jackson,* in lecturing upon epileptic, or epi
leptiform convulsions occurring in connection with discharges
from the ear, says, that arguing from the fact that cerebral or
cerebellar abscess may follow disease of the ear, " it becomes
legitimate to inquire if minute changes in tracts of the brain
may not occasionally follow a disease of this apparatus, which
changes may allow occasional discharge of nerve force.” He
is anxious to learn if epileptiform seizures occurring in cases
* British Medical Journal, June 26 , 1869.
PARALYSIS. 451
of discharge of pus from the ear, may not result from minute
changes in venous tracts. There are still great gaps in our
knowledge of epilepsy and paralysis dependent upon aural
disease. Dr Jackson * urges that in all cases of hemiplegia in
children the ear should be examined, and that in such autop
sies the possibility of venous thrombosis from aural disease
should be borne in mind .
The table on the next page, which I have compiled from
various sources, illustrates in a striking manner the fatal con
sequences of some cases of aural disease . Taken in connec
tion with the fact already stated, that suppuration of the ear
is more frequently the cause of cerebral abscess than any
other one disease, these cases form a complete justification, if
one were needed, for the giving up so much space to the con
sequences of chronic suppuration of the middle ear. If the
table shall startle some mind hitherto inattentive to this sub
ject, into a realization of its grave importance , and lead to a
more careful consideration of an ulcerated middle ear, it will
have accomplished its object.
* London Medical Times and Gazette , July 13, 1872 .
TABLE
SHOWING
COURSE
SYMPTOMS
PYÆMIA
CMENINGITIS
AABSCESS
RESULTING
THE
AND
OF
CASES
,OF
ND
EREBRAL
FROM
452
.
DISEASE
AURAL
before
long
How
.
No .
Sex Age .
Cause .
Symptoms .
Disease
or
Abscess
of
Seat Death
acute
symp
in.set
toms
M.1 ale Discharge
Deafness
side
centre
Twenty
the
one
as
well
to
right
in.Won
66hree
from
Abscess
as
bed
-tof ent
of
,cparalysis
side
hemisphere
.one ext
usual
for
ear
morning
several
Nderebral
ays
.
years Ppersisted
ptosis
.also
; aralysis
days
some
for
rigors
rowsy
,dsevere
heli
giddy
ad
became
intervals
flushed
hot
atace
,c;hfrious
ead
on
died
and
;gradually
sunk
.vulsions
just
death
before
-Convulsions
tem
ofthe
Disease
.18 No
acute
symp
.
bone
poral just
until
toms
.
death
before
M.3 ale Disease
neck
ear
pons
acurved
Abscess
.H20
of
and
,rigidly
forward
spine
inthe
va nd
ead
head
movements
.the
Discharge
Soli
curved
for
rotatory
rof
ome
after
;don
2dday
toswallow
.Wied
unable
as
years
four
nearly
symptoms
.these
CEREBRAL ABSCESS.
M.4 ale Disease

generally
tym
middle
throat
Abscess
22
the
,a-Sof
lobeweek
one
for
.inbecame
ore
nd
.effusion
car
the
from
;gDca ischarge
-lipanum
Nllreat
o
.
ries 25
Admitted
Hospital
todied
4,aApril
May
nd
condition
-comatose
semi
and
.after
rigors
5 forty
Female
Suppuration
ADischarge
middle
several
for
the
from
inthe
About
-tofd
.4bscess
years
ear
1wo
cere
lobe
one
Bartholomew
the
of
right
month
internal
'sHtomitted
ospital days
.
comm
bellu
?half
right
of
m(death oss
ar
iddlemuni
bof.L)epower
Itefore
pain
the
directly
Scated
face
.Cspasmodic
with onstant
ome
the
of
portion
right
semi
head
side
diseased
.Bonecame
and
drowsy
.
comatose .
bone
temporal
.6|Male -|Aith
tem
Caries
,w23
death
his
before
day
.the
days
fifteen
About
of
lobe
inright
Abscess
great
dmitted
Dccasionally
bone
Oporal
head
his
of
back
inthe
Cpain
.cerebellum
aries
is
.Illness
vomited
ad
before
days
eleven
began
charge
ear
from
-aollowed
ear
wand
mission
,ffor
rigor
pain
constant
by
ith
che
.
years the
.Hin e
hospital
tohead
walked
the
day
.
died
he
before
.7Male Severe
nights
restless
three
or
Two
of
disease
Chronic
.25
days
seven
About
inmiddle
abscess
Acute
frontal
cerebrum
on deli
and
of
vertigo
day
fourth
the
tympanum
-l.Ohobe
eadache
n
efforts
.Frium
vomit
,cto
-rday
dop
;side
materifth
ight
erebral
ura
Sppression
side
left
.,sof
aresis
ixth
eventh
loughing
.
death
and
coma
,p.28Frincipally
headache
Severe
of
disease
Chronic
seventeen
About
and
suppuration
Diffuse
of
side
right
the
over
3emale
Ptain
,ahead
ear
inright
days
of
sloughing
frequent
he
nd
.acute
tympanum
the
.
days
fourteen
for
vomiting right
of
Jobe
middle
.Dma
hemisphere
ura
pa
tym
of
roof
over
ter
.Bone
;pum
carious
.
sloughing
tym
the
of
dischargeemale
-P29F0aralysis
nerve
seventh
right
of nd
incerebellum
Abscess
,atwelve
.ADisease
bout
,after
ear
the
from
after
Aheadache
vein
the
of
low
nd
abpanum
following
.Inflammation
days
CEREBRAL ABSCESS.
;rtto
increased
headache
weeks
hree
.abeferred
ear
the
on
veslow
aquæductus
the
of
Pain
occiput
and
.forehead
tibuli
the
moving
on
.Rigors
N,svnneck
weating
ausea
omiting
o
.Death
delirium
fourth
the
on
syncope
from
.
ofheadache
increase
the
after
day
.
10Male 13
Languor
of
disease
some
for
poste yncopal
CChronic
Aseizure
the bscess
on
Sifteen
.-Funder
days
.
ear
the , is
insensibility
with
advulsions
-rby
hemi
right
of
lobe
ior
elieved
Saries
ear
right
the
from
pus
of
Ccharge
sphere
.head
evere
;nelirium
day
following
on
c,dacheausea
on
Intense
.vulsions
leg
inleft
cramp
and
pain
.
day
fifteenth
on
coma
insudden
Death
453
No
. Sex
. Age before
long
How
.
Cause .
Symptoms .
Disease
or
Abscess
of
Seat Death
acute
symp
454
.
in
set
toms
.
Male
11 28
weeks
ear
the
of
Disease
hree
received
admission
.TAbscess
ablow
inanterior
-ebefore
Twenty
ight
wmiddle
head
side
the
upon
for
;aDischarge
delirious
after
left
of
lobes
eek
. nd
days
.
years -five
twenty
.Cand
hemisphere
comatose
became
after
days
of
aries
.
died
and .
communi
bone
petrous
.
abscess
with
cating
.
Male
12 27
Pain
internal
Caries
inhead
;paralysis
of
side
right
.of
sloughing
mater
Dura
the
hree
Tmonths
and
.D?)aear
mnine iddle
face
from
eath
nd
lateral
hemorrhage
rom
(fLateral
inflamed
sinus
days
diseased
lateral .
sloughy
and
Psinus
. urulents).| inus
six
for
discharge
.
months
.
13Male Vomiting
upper
8Caralysis
left
of
,pcinouter
Atemporal
part
-seye
Twenty aries
onvulsions
bscess
even
Sidlight
-lbone
;tLdis
weak
.dall
hemisphere
cerebral
inleft
pain
of
before
winges
ays
imbs
charge
ear
the
from
cand ecame
.Bomatose
;sdull
emi
,-drowsy .
death
,coma
convulsion
quite
since
.ear
.
young
CEREBRAL ABSCESS.
.26
14Female
Right .Abscess
ear
right
from
discharge
purulent
weeks
Two
temporal
be
days
Fifteen
surface
inunder
.bone oDelirium
oma
c,. pisthotonos fdeath
lobe
cerebral
middle
.of
ore
5ain
15Female
Cough
temporal
of
,pCaries
Pinlimbs
-tquick
Fifty
cerebral
inleft
.Abscess
days
ulse
hree
urulent
1
Cbone
ear
left
from
.h,cdischarge
onvulsions
oagulum
emisphere
oma
.
insinus
2ain
Female
E16
ear
of
,psDisease
Aconvulsions
head
-nCinthe
Twenty
.of
days
light
ine
bscess
pilepsy
3oagulum
blood
and
fibrin
Scinleft
onvulsions
.agony
iensible
ntense
,Pyrexia
.
death
until lateral
sinus
.
Mitix
|SN517
fofright
had
admission
before
aAmonths
.after
Unknown
lobe
middle
inthe
4bscess
ecrosis
ale
hemisphere
.ofextent
right
ut
Recovered
tosome
meal
hearty
bone
,btemporal
forehead
ains
affected
remained
mind
,IinP.the
sen
and
consciousness
of pilepsy
l, oss
estupor
onvulsion
nd
.adied
a, tertor
incssibility
Female
18
.7of
Great
left
the
debility
Dafterisease
pilepsy
syringing
its
;eAbscess
part inunder
FFour
days
ischarge
Dontinued
.'cear cerebel
the
of
lobe
left
.
lum
-Dtanding
the
'sof
week
of
,wthroat
middle
inright
inAbscess
isease
ore
ith
.difficulty
Male
19
(mbscess
lN?)sternal
throat
of
back
at
.APulceration
obe
wallowing
iddle
yæmia
o
RCnaries
suddenly
ceased
ear
the
from
Discharge
.-iof
lung
the
i
gain
bone
Ptemporal
collapse
.Band
side
inright
ors
ecame
hnd
.,astupid
comatose
eavy
Female
220
Jan
mucous
of
.HEDisease
side
right
-ton
ofTwenty
part
inupper
Abscess
and6hree
arache
eadaches
months
six
last
for
giddiness
of
rmembrane
hpain
.cereb
emisphere
aroxysmal
Pdight
ays
Feb is
-17nsensible
Dtympanum
I.comatose mem
mucous
Tympanic
ear
from
charge covered
and
soft
brane
ca. hild
since with
cheesy
matter
.
9the
5-FFemale
May
wall
upper
of
.O,vCaries
days
Twelve
left
of
inmiddle
Abscess
seemed
7th1omiting
ever
n
w0th
tympanum
1B8of
recurred
.-l,Esymptoms
cerebrum
of
obe
th
ell
ad
x
.Slight
ear
inthe
pain
cruciating
from
Discharge
of
paralysis
CEREBRAL ABSCESS.
the
ear
. ;comatose
side
.,aleft
days
intwelve
died
nd
Twenty
middle
inthe
.Abscess
days
-t;pain
|1wo
2-SFemale
July
following
.3Caries
,fVblow
d2ever
iolent
evere
.
lobe
mus
temporal
beneath
formed
abscess
an
the
upon
blow
.
head cl
.e
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PART III.
THE INTERNAL EAR .

CHAPTER XVIII .
ANATOMY OF THE INTERNAL EAR .

GALEN named the internal ear the labyrinth , although he
did not attempt to describe its various parts. This name
it continues to bear, although so much labor has been given
to its exploration , that we now have the thread to guide us
through its devious passages. Yet in our own time, a part
of this internal ear — the cochlea — is still the subject of vig
orous research and heated discussion, and different views
are yet entertained by competent authorities as to the true
description of its component parts . I shall attempt to give
the student such an account of its anatomy as shall serve as a
basis for the study of its physiology and diseases , without
entering into the discussion of the points still unsettled .*
The internal ear may be conveniently studied by dividing
it into the following parts :
1. The vestibule .
2. The semicircular canals.
3. The cochlea .
4. The auditory nerve.
We shall first study the osseous envelope of these parts,
and then consider their contents ; the latter being, of course,
far more important.
THE VESTIBULE.
The vestibule is considered the essential part of the inter

nal ear by all authorities. A part answering to the vestibule
* In compiling this anatomical sketch, the author has been at times com
pelled , in order to avoid inaccuracy of statement, to use the exact words of the
writer whose work he has used . He has not inserted the quotation marks,
but the authorities he has consulted will be found at the end of the chapter.
The text-book of Henle has formed the basis of the description of the micro
scopic anatomy of the labyrinth.
462 VESTIBULE .
is to be found in all animals in whom an auditory apparatus

can be detected. It is the seat of the principalexpansion of the
auditory nerve upon the saccule, described on page 476 . This
saccule floats in the perilymph and communicates through
that fluid with the membrane of the fenestra ovalis, and con
sequently with the air in the tympanic cavity.
Fig. 89.
Horizontal Section through the Lower Half of the Left Ear. After a Photograph - Rüdinger .
Made from a preparation softened by hydrochloric acid and then hardened in alcohol.
1. Cartilaginous portion of the auditory canal, having a great anterior converity. At figure 1
the posterior wall presses well into the canal, so that it is the narrowest at this point. 2.
Cartilages of the anterior wall of the canal. 3. The osseous part of the canal. 4. Mem
brana tympani. 5 . Carity of the tympanum . 6 . Stapes bone. 7 . Stapedius muscle. 8.
Section of facial nerve. 9. Tensor tympani muscle. 10 . Auditory nerve. 11. Nerve of
the cochlea, 12. Section of the cochlea . 13. Inferior nerve of the ampulla . 14, Section
of the sacculus hemillipticus. 15 . Sacculus hemisphæricus. 16 . Section of membranous
semicircular canal.
The vestibule is an irregularly-shaped osseous cavity, the

diameter of which from above downwards, as also from behind
forwards, is about one-fifth of an inch. It is about one-tenth
of an inch between its inner and outer wall. The semicircular
canals open into it by five orifices behind the cochlea, by a
single one in front. The fenestra ovalis is on its outer wall ;
on its inner are several minute holes, making up the maculæ
cribrosæ for the entrance of a portion of the auditory nerve
from the internal auditory canal. At the posterior part of the
VESTIBULE. 463
inner wall is the orifice of the aqueductus vestibuli, a fine
canal penetrating the vestibule from the posterior surface of
the petrous bone, and contains a tubular prolongation of the
lining membrane of the vestibule, ending in the cranial cavity,
between the layers of the dura mater.
FIG . 90.
Fig . 91.
The Left Vestibule , with the Semicircular The Vestibule. - After Rüdinger.
Canals, from an Adult, seen from 1. The osseous lamina spiralis of the cochlea ,
within .- Rüdinger. beginning below and posteriorly on the
1. The horizontal semicircular canal. 2. The wall of the vestibule . 2. The scala tym
upper semicircular canal. 3. The poste pani and the fenestra rotunda. 3 . The
rior semicircular canal. 4. A briste is scala vestibuli. 4. Fenestra ovalis. 5.
passed through the aqueductus vestibuli, The posterior inferior wall of the lower
and passes into the opening of two canals, ampulla, with the inferior macula cri.
and appears on the upper wall of the ves brosa , which serves as a passage for the
tibule. 5. The mouths of the osseous am fibres of the vestibularnerve to the lower
pilla of upper and horizontal semicircu ampulla . 6 . Fovea rotunda, or recessus
lar canals. 6. The opening of the lower hemisphæricus. In its centre are a num
ampulla of the posterior semicircular ber of fine openings, the macula cribrosa
canal, below the numbers 6 and 7. 7. media, through these the fibres of the
The lower opening, in which the bristle is middle branches of the vestibular nerve
seen , represents the opening of the com pass to the round saccule, which is the
mon passage for two semicircularcanals. blind vestibular end of the scala vesti
buli. 7. The upper portion of the recessus
hemillipticus in which is the upper ma
cula cribrosa . 8. The lower portion of
the recessus hemillipticus, which passes
without any distinct dividing line into
the semicircular canals.
The maculæ cribrosæ on the inner wall of the vestibule are
to be seen with the naked eye on the newly born,but in the
adult they are only to be seen by means of the microscope.
Henle describes four little groups, each having five openings,
and each series of foramina make up what is known as a ma
cula cribrosa. Through the macula cribrosa superior, the
nerves pass to the utricle and to the ampullæ or flask -shaped
openings of the anterior vertical and the horizontal semicircu
lar canals. The nerve fibres to the posterior semicircular
464 VESTIBULE .
canals pass through the inferior macula cribrosa, and those to

the saccule through the macula cribrosa media . Finally,
through the fourth macula cribrosa passes the twig of the
small branch of the cochlear nerve. The scala vestibuli of the
cochlea begins on the anterior apex of the vestibule .
The outer wall of the vestibule is interrupted by the
fenestra ovalis, but it is so completely and smoothly closed by
the base of the stapes bone, that the inner surface of this wall
of the vestibule appears even . On the inner wall are two
depressions, called respectively the recessus sphæricus and the
recessus ellipticus. A minute elevation between them is called
the crista vestibuli. Just above the recessus ellipticus opens
the anipulla or flask -like orifice of the anterior vertical semi
circular canal. The two vertical canals open at the junction
of the posterior and inner wall. On the same line, but a little
higher in the middle of the posterior wall, is the posterior
opening of the horizontal semicircular canal. The lower open
ing of the posterior vertical canal is in the angle formed by
the posterior, lower , and inner wall of the vestibule. The an
terior ampulla of the horizontal canal lies on the outer wall
between the fenestra ovalis and the ampulla of the anterior
vertical semicircular canal.
THE SEMICIRCULAR CANALS.

The semicircular canals are half-elliptical or C -shaped
canals which proceed from the vestibule and return to it again .
They are three in number. Thehorizontal lies with its convex
ity directed laterally. The other two are vertical in position ,
forming a right-angle with each other. The two openings of
the anterior vertical semicircular canal are near each other
and at about the same height. The openings of the posterior
vertical canals are above each other . The horizontal canal
is surrounded , as it were, by the two vertical ones.
There are considerable variations in different individuals,
according to Henle, in the length and curvature of the semi
circular canals, yet the general shape of these parts remains
the same.
The length of the anterior vertical canal, measured on the
SEMICIRCULAR CANALS. 465
convex border, with the ampulla and the common crus,is about
20 millimetres ; that of the posterior is 22mm., of the horizon
Fig . 92. FIG . 93.
up
Osseouts Cochlea and Semicircular Canals , Right Osseous Vestibule, Semicircular Ca .
with Stapes Bone. Left Ear of Adult. nals, Cochlea, and Ossicula Auditus of
- After Rüdinger . Newly-born . - After Rüdinger.
tal 5mm . The part common (canalis communis) to the two

vertical canals is from 2 to 3 millimetres in length. The
diameter in a grown man varies from 1.3 to 1.7 millimetres.
Wharton Jones makes their caliber about one-twentieth of an
inch in a direction from the concavity to the convexity oftheir
curve .
FIG. 94.
The Right Osseous Labyrinth of a newly -born Subject opened on its Posterior Surface.
After Rüdinger.
1. Cochlear fenestra. 2. The osseous spiral. 8. Theosseous spiral canal of the cochlea - canalis
spiralis cochlee - divided by the spiral into two parts , scalæ , or stairways, the lower the
scala tympani, the upper the scala vestibuli. 4. The basis of the internal auditory canal,
with the entrance to the Fallopian canal and themaculae cribrosce. The latter receive the
fibres of the auditory nerve, and the vessels entering with it into the labyrinth . 5. The
Osseous vestibule, opened on its posterior wall. 6. The posterior semicircular canal. 7.
The upper semicircular canal. 9. Horizontal semicircular canal.
Since the semicircular canals all open at both ends into

the vestibule, there would be six orifices were not one of the
orifices common to two of the canals. There are, conse
quently, five. These openings are called ampullæ (flasks) from
30
466 SEMICIRCULAR CANALS.
their shape, and are more than twice the diameter of the
tubes. The inner extremity of the superior vertical canal
has a common opening into the vestibule with the posterior
vertical.
According to Henle,* in the later years of life the semi
circular canals increase in length ; the horizontal canal in
creases the most, and the anterior vertical the least. The
canals also increase very slightly in width ; about 0.7mm .
according to Hyrtl.
The functions of the semicircular canals, according to the
experiments of Flourenst and Goltz, are to preserve the equi
librium of the head , and consequently of the body. Goltz
believes that the semicircular canals are not, so to speak,
essential to the function of hearing.
THE COCHLEA.
This part of the internal ear is so named from its resem
blance to a common snail ; a resemblance which is very
marked. It is one of the most remarkable instances in the
Fig . 95 .
Section through the Apex of the Right Osseous Cochlea, parallel with the base.
2. Lower surface of the section . b . Upper surface of the section . c, * . Canal of facial nerve.
whole body of the compact packing of very important parts.

Wharton Jones & remarks of its function, that the presence of
a cochlea is evidence of a very advanced condition of the organ
* Lehrbuch , p . 762.
† Von Tröltsch , second American edition, p. 505.
| Knapp, Archives of Ophthalmology and Otology, vol. ii., No. 1. Brun
ner, ibid ., 1. c.
& Cyclopedia of Anatomy and Physiology, p. 569.
COCHLEA. 467
of hearing ; " beyond this we can arrive atno definite conclu
sion in the present state of our knowledge.” Recent investiga
tions, however, render it safe to say that one of the functions
of the cochlea is to discriminate between tones. The fibres
of Corti connected to the cells that are to be described, being
the keys of an instrument ofmore than a thousand strings.
FIG . 96 .
Bm
Section of the Temporal Bone, vertical to its Long Axis - Posterior Surface of the Section .
- After Henle.
m . Meatus auditorius internus. c, t, t. Canal of the tensor tympani muscle. 8. m . Canalis
spiralis modioli.
The osseous cochlea lies in front of the vestibule , and be

hind the carotid canal, and forms the promontory by pressing
out, as it were, the bone towards the tympanic cavity. Inwards
it strikes upon the blind end of the internal auditory canal.
The cochlea is aptly compared to a tube tapering towards one
extremity where it ends in a cul-de-sac, and which is coiled like
the shell of a snail round an axis or central pillar. Then we
must suppose this tube divided into passages by a thin parti
tion running throughoutits length , and spirally around its axis.
The tube of which the cochlea is formed — the canalis
spiralis cochleæ , is about an inch and a half long, about one
tenth of an inch in diameter at its commencement, and about
468 COCHLEA.
one-twentieth at its termination. It makes two turns and a

half turn,in a direction from below upwards,from left to right
in the right ear, and from right to left in the left ear. The
apex of the coil is directed forwards and outwards. The base
of the spiral tube runs into the vestibule. The cul-de-sac at
the apex forms a kind of vaulted roof called the cupola.
Fig. 97. sm
cm
ac
Osseous Cochlea (Right) of the Newly -born , opened from the Outer Surface. - After Henk .
8, v. Scala vestibuli. b, t. Scala tympani. 1, 8. Lamina spiralis. C, 6. Crista semilunaris.
a , c. Inner opening of the aqueductus cochleæ . c, m . Canalis centralis. 8, m . Canalis
spiralis modioli.
The first turn of the cochlea bas a circular sweep of a

quarter of an inch , and is wider than the rest. It is separated
from the second turn by a soft bony substance, which extends
a little way between the second and third. The axis is com
posed of the internal walls of the tube of the cochlea and the
central space circumscribed by their turns, in which space are
the filaments of the cochlear nerve running in small bony
canals. The axis is about one-seventh of an inch in thickness
at the first turn , but it becomes thinner from the second turn ,
on to its termination . The axis terminates within the last half
coil or cupola , in a delicate bony lamella , which resembles the
half of a funnel,divided longitudinally, and called the infundibu
lum ( funnel). Wharton Jones compares the appearance of the
axis of the cochlea after the outer walls have been removed,
COCHLEA . 469
to the ordinary pictorial representations of the tower of
Babel.
The cavity of the cochlea is divided into two parts or pas
sages, called scalce, by a thin osseous and membranous spiral
lamina, lamina spiralis ossea . The lower one communicates
with the cavity of the tympanum through the fenestra rotunda,
the upperwith the recessus hemisphæricus ( see Fig. 94, of the
vestibule ). The former space is therefore called the scala tym
pani, the latter, scala vestibuli. In the scala tympani, just
above the membrana tympani secondaria, which closes the
Fig . 98
mals
Ic
Right Osseous Cochlea , opened anteriorly.
m . Modiolus. 1. 8. Lamina spiralis. h. Hamulus. f. c. Fenestra cochlece. t. Section of the
middle wall of the coch 'ea. tt. Its upper extremity. m . d . Modiolus.
fenestra rotunda, is an opening called the entrance of the

aqueduct to the cochlea. The two scalæ communicate at the
apex of the cochlea by a common opening called the helico
trema (a twisted foramen ). This communication exists in con
sequence of the want of a lamina spiralis in the last half coil
of the canal.
Two very small canals called aqueducts open by one ex
tremity into the labyrinth , and by thc other on the surface of
the petrous portion of the temporal bone. One opens into
470 COCHLEA.
the vestibule , and has already been alluded to, and is called
the aqueductus vestibuli ; the other enters into the tympanic
scala of the cochlea, and is called the aqueductus cochleæ .
The length of the aqueduct of the vestibule is about one-third
of an inch ; that of the aqueduct of the cochlea is about one
quarter of an inch. The aqueduct of the vestibule begins by
a groove immediately below and in front of the opening com
mon to the two verticalsemicircular canals. From this the aque
duct turns itself around the inner wall of the common canal,
and runs downwards and backwards. It gradually widens
and opens under a thin osseous projection, seen a little be
hind the middle of the posterior and inner surface of the pe
trousbone, just above the jugular fossa . From the fossa there
is a narrow groove running to the opening of the aqueduct.
FIG. 99.
Apex of the Left Osseous Cochlea opened to show the End of the Lamina Spiralis. After
Henle.
The aqueduct of the cochlea begins by a very small open

ing in the lower wall of the scala tympani, immediately above
the fenestra rotunda. It passes downwards, inwards, and
forwards in the inner wall of the jugular fossa , and opens at
the bottom of a triangular depression , situated towards the
middle of the edge which limits the inner and inferior surfaces
of the petrous bone, and below the internal auditory canal.
THE MEMBRANOUS LABYRINTH .

The Auditory Nerve (Nervus acusticus). — The auditory
nerve, or portio mollis (soft part of the 7th nerve), is the
COCHLEA. 471
nerve of the sense of hearing, and is distributed exclusively

to the internal ear. The auditory nerve arises from numer
ous white lines, or striæ (line transversæ ), which come from
the posterior median fissure in the anterior wall, or floor
of the fourth ventricle. It is also connected with the gray
matter of the medulla . The roots of the nerve are con
nected , on the under surface of the middle peduncle, with the
gray substance of the cerebellum , with the flocculus, and with
the gray matter at the border of the calamus scriptorus. The
nerve winds around the restiform body, from which it receives
fibres, and passes forward across the posterior border of the
FIG . 100 .
LT ZI ZE 18
15
Expansion of the Right Cochlear Nerve, seen from the Base of the Cochlea , from a Laby.
rinth softened in Hydrochloric Acid . After Henle.
1. The branches entering through foramina. 2. Twig passing into themodiolus. 3. Network
in the osseous lamina spiralis. 4. Network on its border . L , T . Labium tympanicum .
Z , I. Zona interna. Z , E. Zona externa of the membrana basilaris. L , S . Ligamen
tum spirale.
crus cerebelli, in the company with the portio dura , or facial

nerve, from which it is partly separated by a small artery.
It then passes into the meatus auditorius in company with
the facial nerve. At the bottom of the internal auditory pas
sage, in the petrous portion of the temporal bone, it divides
into two branches, which are distributed to the cochlea, vesti
bule , and semicircular canals, and are called the cochlear and
vestibular branches.
472 COCHLEA.
The auditory nerve is remarkable for the delicacy of its

structure, which caused the older anatomists to give it the
name of portio mollis. It has only a very thin neurilemma.
The cochlear nerve gives off a small branch, which passes
to the vestibular extremity of the ductus cochlearis, and
through the fourth macula cribrosa to the partition wall of
the two saccules in the vestibule. From the trunk of the
nerve a number of fine twigs arise, which pass through fora
mina direct to the lamina spiralis of the lower coil of the
cochlea. The remainder of the cochlear nerve enters the
modiolus, and is divided into anastomotic divisions. The
fibres becomes separated from the trunk in a line correspond
ing to the course of the canalis spiralis modioli, and permeate
this canal. Here, by the addition of ganglion cells, they be
come gangliose striæ , and finally end, at almost a right-angle
to the trunk , in the osseous lamina spiralis.
The vestibular nerve, after a slight gangliose expansion,
divides into three branches. The upper passes through the
macula cribrosa superior, and ends with three branches on
the utricle , and on the ampulla of the upper vertical and of
the horizontal semicircular canal. A middle branch passes
through themiddle macula cribrosa to the saccule, while the
lower passes through its own osseous canal to the ampulla of
the lower vertical semicircular canal, and its fascicles are
loosely held together. Todd and Bowman regard it as a
direct prolongation of the white matter of the brain .
In the internal auditory canal, the portio mollis forms a
connection with the portio dura by means of a few fascicles of
fibres, which constitute what Wrisberg called the “ portio
intermedia .” It is not decided whether the connecting link
proceeds from the auditory to the facial nerve, or from the
latter to the former . Todd and Bowman believe it probable
that the facial nerve sends some filaments to the blood -vessels
of the labyrinth and the muscular structure of the internal ear.
PERIOSTEUM OF THE LABYRINTH .

The periosteum that covers the walls of the osseous cana]
is, with the exception of that on the outer wall of the cochlea ,
UTRICLE. 473
very delicate . Henle * compares the periosteum of the laby
rinth to one of the parts of the choroid , because it is strewn
with nucleated pigment cells . There are also calcareous
deposits. It is very difficult, according to Henle , to separate
Fig. 101. · Fig . 102.
Periosteum of the Labyrinth. After Hente. Periosteum of the Outer Wall of the Cochlea.
After Henle.
the periosteum of the labyrinth, without also detaching bits of

bone. The periosteum is abundantly supplied with blood
vessels.
UTRICLE AND MEMBRANOUS SEMICIRCULAR CANALS.

The utricle is an elliptical tube, situated on the median
wall of thevestibule. Its longest diameter corresponds to the
FIG . 103.
Utricle and Membranous Semicircular Canals of the Left Side.
* Lehrbuch, p. 774.
474 MEMBRANOUS SEMICIRCULAR CANALS.
height of the vestibule . By means of a fine vascular and

nervous network , and a very delicate connective tissue, it is
fastened to the recessus ellipticus of the vestibule.
The membranous semicircular canals are but the lining of
the osseous canals, and, of course, of the same shape. The
membranous canals open into the utriculus with five openings,
just as do the osseous tubes in the vestibule. At the am
FIG . 104 .
Wall of Membranous Semicircular Canals.

1. Membrana propria , artificially separated edge. 2. Epithdium .
pullæ , the membranous canal fills up the osseous very com

pletely ; but there is some space between the other parts.
The walls of these structures are transparent, as clear as
water, and of great delicacy . After the endolymph is re
moved, they fall together and arrange themselves in rigid
folds. There is, however, a point that is firmer, called the
macula acustica , situated on the median wall of the utricle ,
where a twig of the auditory nerve reaches this wall. The
MEMBRANOUS SEMICIRCULAR CANALS. 475
portion of the ampulla that contains the termination of the

nerve, and which is detected by the naked eye as a whitish
yellow spot, is also of firmer consistency. This point is called
the crista acustica by Max Schultze . It comprises about one
third ofthe wall of the ampulla. It is sometimes surrounded
by a pigmented line.
The wall of the membranous semicircular canals is from
0.02mm . to 0.03mm . in thickness, and is composed of various
layers.
FIG . 105 .
DRAME
A Piece of the Wall of the Utricle, with the Otoliths. After Henle.
Themembrana propria is of reticulate and nuclear fibrous

tissue, ofwhich the periosteum also consists. It is perforated
by blood-vessels. There is a basal membrane next the mem
brana propria, and on the inner surface pavement epithelium .
The macula and crista acustica that have been mentioned ,
are thickenings of the membrana propria caused by the min
nd eaofrt connective
agling ed andand
was calle cattissue, ulus the he ling ooff tthe
of tending he nerves.
The otolith of the utriculus of the mammalia is a smooth,
irregularly demarcated and uneven mass of chalky white pow
der. It was called otoconia by Breschet, ear -sand by Lincke,
and ear-crystal by Huschke. The powder is held together by
an almost mucous substance . The powder consists of crystals
of varying shape and size. The largest are only 0 .012mm .
long and 0.008mm . broad. They are too small to allow the
476 DUCTUS COCHLEARIS.
crystal form to be recognized. The material of which otoliths

is composed is carbonate of lime. Henle says it is unknown
how the otolith is fastened on to the wall of the utricle.
SACCULE.
The saccule is of the shape of a broad flask with a narrow

neck . It lies in the recessus sphæricus of the vestibule. The
neck of this bottle or flask proceeds from the lower wall,
downwards and backwards, and sinks into the upper wall of
the vestibular end of the ductus cochlearis, at nearly a right
angle , so that a blind sac is formed at the junction of the two
parts. Henle compares it to the passage of the cesophagus
into the stomach , and of the small intestine into the cæcum .
THE DUCTUS COCHLEARIS. (LAMINA SPIRALIS MEMBRANACEA OF

THE OLD ANATOMISTS.)
The ductus cochlearis begins with the blind sac in the

vestibule that has been described, and passes through the
whole cochlea to the apex, in which it ends again as a blind
sac. The lower end rests in the recessus cochlearis, and the
upper in the cul-de-sac of the cupola . The ductus cochlearis
is attached on one side to the lamina spiralis ossea, and on
the other to the outer wall of the osseous cochlear canal. On
a transverse section the ductus cochlearis is seen to be trian
gular in shape, and has, of course, three walls, or sides. Two
of these walls diverge from the edges of the lamina spiralis ,
and the other corresponds to the portion of the cochlear wall
between which the insertion of the two others is made. The
lower wall of the ductus cochlearis, which is turned towards the
scala tympani is called the tympanal ; the upper, which sepa
rates the ductus cochlearis from the scala vestibuli, is called
the vestibular wall.
On the osseous border of the lamina spiralis is a soft struc
ture, only to be seen in the uninjured specimen of the cochlea,
which lengthens the lamina spiralis towards the caliber of the
ductus cochlearis. It is called by Henle the limbus laminæ spi
ralis. (See Fig . 106.) It is developed from the periosteum of
DUOTUS COCHLEARIS. 477
the lamina spiralis. This structure gradually decreases in
breadth and height from the base to the apex of the cochlea.
The edge of the osseous lamina recedes more and more at the
same time from the free border of the limbus. This free bor
der becomes a furrow , called by Huschke the sulcus spiralis,
having, of course, two lips. The upper lip is the labium ves
tibulare ; the lower, the labium tympanicum . The vestibular
wall of the ductus cochlearis passes off from the upper sur
face of the lamina spiralis in a line nearly corresponding
to the inner attachment of the limbus lamine spiralis, so
that the latter is almost completely drawn into the ductus
cochlearis.
Fig. 106. Lis
LS
sc
Transverse Section of a Cochlear Spiral, from a Cochlea softened in Hydrochloric Add.

After Henle.
The dotted lines indicatesections of the membrana tectoria and the auditory rods. Ls. Lamina
spiralis. L l 8. Limbus laminæ spiralis . S v . Scala vestibule. St. Scala tympani.
D c. Ductus cochlearis. Lsv. Ligamentum spirale. V . Membrana restibularis. b.
Membrana basilaris. e . Outer wall of ductus cochlearis. * . Bulging of membrana
basilaris .
The upper surface of the vestibular lip of the limbus lamina

spiralis is covered by striæ , which on front view resemble the
anterior surface of the incisor teeth , and hence Huschke calls
them the auditory teeth. These furrows, or striæ , are filled
by small rounded cells. Their number may run as high as
2,500. The limbus is composed of connective tissue, running
in a radiate direction in the furrows, or striæ ; beneath these
furrows the connective tissue is reticulate.
Henle compares the labium vestibulare to a roof over the
sulcus spiralis, and the labium tympanicum to a floor. Within
478 DUCTUS COCHLEARIS .
the labium tympanicum run very fine nerve fibres from the
tissue of the auditory nerve to the ductus cochlearis. The
labium tympanicum consists of two layers, which include the
nerve fibres between them , and then unite beyond it in a
sharp border, from which the membrana basilaris proceeds.
This membrana basilaris, according to Henle , appears as a
process of the upper layer of the labium tympanicum . There
is, however, a structure between them , which corresponds to
the periphery of the nerve bundles.
On the outer portion of the upper surface of the labium
tympanicum are four radiate striæ , which Henle considers as
marks of the nerve bundles running on the lower surface of
this layer. At the periphery of these there are other open
ings.
The membrana vestibularis is attached to the beginning
of the upper border of the ridge of the spiral and to the outer
cochlear wall. There are three layers in this membrane,
which by Kölliker is called Reissner's membrane. It is epi
thelial tissue,which in embryonal life seizes upon the vestibu
lar side of the cochlear canal. This membrane has a number
of blood-vessels .
The membrana basilaris is well shown in Fig. 106 , and
being the part upon which rests the organ of Corti, has at
tracted very much attention from anatomists. It is a con
tinuation of the labium tympanicum . It gradually increases
in breadth from the base to the apex, in the same proportion
that the lamina spiralis with its limbus decreases in size. Its
breadth in the newly -born, in themiddle of the first turn or
coil of the cochlea, is 0 .17mm . ; at the end of the second,
0.45. This space is divided into two parts or zones. The
inner was called by Kölliker, the habenula tectu, and the
outer by Todd and Bowman the zona pectinata. Henle gives
the two parts the simple names of inner and outer zone. On
the inner zone is found the structures making up what is
known as Corti's organ, from their discoverer, Marchese
Corti.* The outer zone is rather broader than the inner.
* Corti was formerly prosector to Professor Joseph Hyrtl, and made the
first exact microscopic examination of the lamina spiralis Ossea, and mem .
branacea .
DUCTUS COCHLEARIS. 479
The basis of the membrana basilaris is a structureless
membrane. On the outer zone especially are peculiar knobby
points. Upon this structureless membrane are the parts
known in their totality as Corti's organ. The fibres of this
structure are arranged along the whole length of the mem
brana basilaris. There are spaces between them , so that they
have a certain resemblance to the keys of a piano.
The ligamentum spirale is the means of attaching the
membrana basilaris to the outer wall of the cochlear canal.
The fibres of which it is composed are like those of perios
teum .
The cavity of the ductus cochlearis is divided into parts by
a membrane running parallel to themembrana basilaris. (See
Fig . 106.) The upper part is filled with endolymph, the lower
contains what Henle calls the terminal auditory apparatus.
The membrane which divides the ductus cochlearis into two
parts is called the membrana tectoria by Claudius, but Corti's
membrane by Kölliker. The membrana tectoria is divided
into three zones. The middle zone is the denser ; the inner is
structureless and has numerous openings. The outer zone is
made up of a very fine and friable network. It is probable,
according to Henle , that the membrana tectoria is firmly fas
tened, and that it is not possible for it to press closely upon
the parts covered by it.
TERMINAL AUDITORY APPARATUS.

Henle terms the important structures of the lower chamber
of the ductus cochlearis the terminal auditory apparatus.
They consist of rod -like bodies, a perforated membrane, and
nuclear cells of various shapes. A fourth part, whose exist
ence Henle thinks is doubtful, are fibres, in which connective
tissue and the ultimate fibres of the auditory nerve are found.
AUDITORY RODS.
The most important, physiologically speaking, of this termi

nal apparatus are the auditory rods, called also Corti's teeth,
480 CORTI'S ORGAN .
or Corti's fibres. They are arranged in regular order, very like

the cords, hammers, or keys of a piano. It is probably their
vibrations that cause us to perceive what we call tones. There
FIG . 107.
500
From the Terminal Auditory Apparatus of a Cat. After Henle.

1. Outer ends of the inner flores. e. Outer Albres. 3. Outer covering cells. 4. Epithelialcells.
are two rows of these fibres, an innerand an outer. The inner
rods arise from the membrana basilaris, on which their inter
nal extremities are fastened, more or less abruptly, towards
the membrana tectoria, without, however, being united to the
latter. The outer rods or fibres join , with their inner extrem
Fig . 108.
Profile View of Outer and Inner Rods.

B . Membrana basilaris (b ), with the terminal nerve fibres (n ) and the inner and outer rods,
i, e. 1. Inner. 2. Outer floor celis. 4. Attachment of the roof cells. H . Epithelium .
ities, the outer end of the inner fibres. Their external ter
minations rest on the membrana basilaris . There are two
varieties of the inner row of fibres or rods; one is smooth and
elliptical in shape, the other cylindrical and broader at each
end .
The outer row of rods is cylindrical in shape, and they
stand at a greater distance apart than the inner. They have
MEMBRANA RETICULARIS . 481
a tortuous course sometimes, like the letter S. The inner row
of fibres is always shorter than the outer. They join together
and form a roof over the inner zone of the membrana basil
aris. The base of this roof is 0.1mm . in breadth . The struc
ture of these rods, as shown by the action of reagents, is a
tissue as hard as cartilage.
Henle calls the terminations of the two rows of rods upon
the membrana basilaris, the lower extremities ; and the extrem
ities which join to make the roof, the upper extremities.
MEMBRANA RETICULARIS.
This is the second of the component parts of the terminal

auditory apparatus It arises from the articulation of the
rods or fibres, and extends to the outer wall of the cochlea
parallel to the lamina basilaris. It is supposed to be a liga
ment to bind the rods together. The tissue of the lamina
reticularis is not less firm than that of the rods, but it is
delicate.
AUDITORY CELLS.
These are cylindrical and spherical elements which are

called cells, because they contain nuclei. They may be con
sidered , according to Henle, as epithelial or ganglion cells.
Some of these cells are called hair cells, stachel cells, and
in them are probably the terminal filaments of the cochlear
nerve .
Henle divides these cells which are not epithelial into two
classes : the roof-cells (deck -zellen ), and floor-cells (boden
zellen). Gottstein calls these hair cells. The roof-cells are
found on the convex side of the roof formed by the union of
the two rows of arches.
The floor cells are found at the angle which the base of
each rod makes with the membrana basilaris.
Henle divides the roof cells into three varieties: an inner,
an onter, and a lower outer.
After the exit of the nerve fibres from the canals of the
31
482 AUDITORY CELLS.
labium tympanicum , the bundles of nerve fibres take two
different directions. One part maintains the original radiate
direction , the other proceeds spirally. These fibres take dif
ferent directions with reference to the fibres of Corti ; at the
Fig . 109.
A
S
1
O
N
ODONO ODOVO
CASSO
HE
SE
Diagrammatic Representation of the Terminal Auditory Apparatus. After Henle.

a. Teeth of the labium vestibulare, b. Epithelial cells of the labium tympanicum . c. Open
ings of these cells. d. Inner rods. e. Outer rods. f. Connecting fibres. g, h, i, k, k'.
First to fourth bundle of spiral nerve fibres. 1. Radiate bundles. m . Upper nerde roof
cells. n . Epithelial cells. 0. Supporting fibres of rods. p . Radiate nerte fibres upon
membrana basilaris. q. Nerve fibre running above rods. u. Membrana basilaris. X.
Upper outer roof cells. y. Lower and outer roof cells.
apex of the cochlea they decrease in number. They do not
lie directly upon the membrana basilaris, but at a certain
height above it. The nerve fibres are probably connected
ANATOMY OF INTERNAL EAR - AUTHORITIES. 483
with the cells at the base of the rods, the so-called floor cells
of Henle. It is possible that they are also connected to the
lower sharp extremities of the upper and outer roof cells .
BLOOD - VESSELS .
The blood passes to the internal ear through the auditiva
interna artery, which is a branch of the basilar, according to
Hyrtl. The basilar comes from the vertebraland the verte
bral from the subclavian. After the internal auditory artery
has entered into the meatus auditorus internus, it divides into
a vestibular and cochlear branch . The cochlear branch di
vides in numerous branches which pass through the foramina
of the tractus spiralis foraminulentus into the modiolus, and
then go on between the layers of the lamina spiralis , and are
finally lost in the spirals of the cochlea . The vestibular artery
passes through the posterior wall of the vestibule in numerous
fine twigs to the soft structures of the vestibule and semicir
cular canals. The stylo -mastoid artery is said to give several
small branches to the labyrinth . It is important to observe
the fact to which Von Tröltsch calls attention — that the blood
supply of the labyrinth and of the middle ear are nearly
separate and independent of each other. This may explain
the relative infrequency of the extension of disease of the
middle ear to the internal ear.
AUTHORITIES .
Boettcher , Arthur, Professor in Dorpat. Kritische Bemerkungen und neue

Beiträge zur Literatur des Gehörlabyrinths. Dorpat, 1872 .
Gollz , quoted by Brunner and Knapp, Archives for Ophthalmology and Oto
logy , vol. ii., No. 1.
Gottstein , J . Ueber den feineren Bau und die Entwicklung der Gehör
schencke beim Menschen und dem Säugethieren . Bonn, Max Cohen &
Sohn.
Gray, Henry . Anatomy, Descriptive and Surgical. Reprint. Philadelphia ,
1862.
484 AUTHORITIES.
Gruber, Josef. Lehrbuch der Ohrenheilkunde. Wien , 1870 .

Henle, J . Handbuch der systematischen Anatomie des Menschen . Braun
schweig , 1866 .
Hyrti, Joseph. Anatomie des Menschen, 7 Auflage. Wien , 1862.
Jones, Wharton . Cyclopædia of Anatomy and Physiology, vol. ii.
Todd , Robert Bentley, and Bowman, William . The Physiological Anatomy
and Physiology of Man. Reprint. Philadelphia , 1857.
Waldeyer, W .* In Stricker's Handbook . Translated by Albert H . Buck.
New York , 1872.
* The best bibliography of the Anatomy of the internal ear, is found in

Waldeyer's article.
CHAPTER XIX .
DISEASES OF THE INTERNAL EAR.
NERVOUS deafness may be defined to be a primary affec

tion of the auditory nerve or labyrinth , or of both . It should
be carefully distinguished from other forms of impaired hear
ing that are accompanied by symptoms of general nervous
disease, or by evidences of secondary affections of the laby
rinth , such as vertigo and tinnitus aurium .
Primary and independent affections of the labyrinth or
internal ear are happily the most infrequent of aural diseases.
We know very little of the nature of these affections, and we
have as yet absolutely no means of treatment for them that
can be said to pe at all successful. The gaps in our knowl
edge on this subject are yet to be filled up by the patient
comparison of symptoms with post-mortem appearances. Of
fifteen hundred cases of aural disease observed by the author
in private practice , but fifty -seven could be fairly considered
to be cases of primary disease of the internal ear. The
statistics of most other writers, and the reports of public insti
tutions show about the same proportions ; Voltolini,* however,
believes that affections of the labyrinth are more common
than is usually believed , but his opinions are as yet not sup
ported by the only reliable evidence, that which has been just
alluded to ,the confirmation on the post-mortem table of symp
toms observed during life.
It has been already said in this volume, that it is quite a
common view that nervous affections of the ear are very fre
quently met with . The kind of nervous affection that is
meant by the laity and those members of the profession who
* Von Trởltsch, Translation, 2d American Edition, p. 498.
486 NERVOUS DEAFNESS .
entertain this notion is quite different, however , from the dis

eases of the nerve apparatus now under discussion. When a
patient is debilitated and unstrung, unsteady in muscular
movement, anxious and despondent, and is at the same time
affected with a chronic affection of the middle ear, he is often
supposed to have a nervous disease of the ear. It is quite
doubtful,however, if in such cases the nerves of the ear are at
all affected . There are certainly no symptoms of derange
ment of the auditory nerve , in the general debility , unsteadi
ness, and anxiety thatare popularly denominated nervousness.
Affections of the auditory nerve make the subjects deaf, and
sometimes cause them to stagger in their gait, but they do
not render them nervous or unsteady in the ordinary accepta
tion of that term . Besides, it cannot be said that nervous
people are especially liable to deafness from lesions of the
labyrinth , any more than they are to atrophy of the optic
nerve. On this point Mr. Hinton * says, that it is difficult for
him to accept debility , nervous or other, as a cause of nervous
deafness. He has not found that the cases of deafness which
appear to him as properly classed among the nervous ones,
occur specially in the debilitated . I am thus detailed upon this
subject of nervous deafness, because there is so much error
in the understanding of what nervous deafness really is, and
because this error leads to a confusion of that common affec
tion, chronic non -suppurative affection of the middle ear, with
the comparatively rare affection ,disease of the labyrinth . It is
probable, however, that secondary disease of the labyrinth
that is, disease extending to this part from the middle ear - is
quite frequent. Weknow at least that affections of the fenes
tra ovalis, or undue pressure of the chain of bones upon this
opening into the vestibule , will cause vertigo, nausea, and
other head symptoms. Post-mortem examinations also show
that changes in the labyrinth are apt to occur in connection
with chronic diseases of the middle ear, even when there is no
suppuration or caries, when , as we have seen, the labyrinth is
sometimes necrosed and exfoliated. Young children who suf
fer from acute inflammations of the middle ear, in consequence
* Nervous Deafness. Reprint from Guy's Hospital Reports, 1867.

NERVOUS DEAFNESS. 487
of the exanthemata , very readily develop head symptoms,

which undoubtedly depend upon extension of the middle ear
disease through the very delicate partition walls separating
the cavity of the tympanum from the brain , or through the
.wall that separates it from the expansion of the cerebrum that
we call the internal ear ; but these cases of secondary affec
tion of the labyrinth are reached by treatment of the primary
affection of the middle ear, and it will not be proper to include
them in this chapter.
Voltolini is quite positive that there is a primary affection
of the labyrinth that is sometimes mistaken for cerebro -spinal
meningitis, and he has written several papers,* illustrated
by cases, to sustain his position . Although his ideas have
been rejected by some other writers, I do not think the ques
tion can be at all considered as a settled one. After a careful
consideration of the history of very many cases of supposed
cerebro -spinal meningitis occurring in young children, the
suspicion is at least a strong one in mymind that Voltolini is
correct in this view , and that an affection of the labyrinth may
occur in young children, and be erroneously supposed to be
cerebro -spinalmeningitis . Unfortunately — although we have
had an epidemic of cerebro-spinalmeningitis in New York - I
have as yet had no opportunity of studying this disease except
from its clinical history, when the victims were brought to me
deaf or blind.
After these general observations as to the nature of so
called nervous deafness , or of what should be termed dis
eases of the internal ear, we may enter upon the consideration
of the symptoms, causes, pathology and treatment of affections
of the auditory nerve and its expansions in the labyrinth .
Symptoms.— There is but one symptom that is absolutely

pathognomonic of disease of the auditory nerve, and that is
absolute deafness. We may, it is true, have mere impairment
of the hearing, and yet find disease of the labyrinth ; but if
the deafness is absolute , or nearly so , we must conclude that
the essential part of the organ of hearing is invaded . It is a
* Monatsschrift für Ohrenheilkunde, Bd. I. and VI.
488 DISEASES OF INTERNAL EAR - SYMPTOMS.
very rare thing indeed , that the impairment of hearing from

disease of the middle ear becomes so profound that words
spoken into the ear through a tube cannot be distinguished ;
but in many of the cases of deafness from cerebro -spinal menin
gitis, from fevers, from apoplexy of the labyrinth , from inju
ries, no words, however conducted to the ear, can be made out
by the patient, and actual deafness, not merely great impair
ment of hearing, exists. The auditory nerve may have some
perception of sound in these latter cases ; but these percep
tions can only be compared to the flashes of light seen by
amaurotic patients. Other symptoms of nerve deafness, such
as vertigo, nausea, vomiting, tinnitus aurium , are also seen in
affections of the middle ear, although very few cases of nau
sea or vomiting occur, unless the nerve expansion in the laby
rinth is involved. A staggering gait, or loss of equilibrium , is
also a symptom of nerve deafness ; at least patients who re
cover from cerebro-spinal meningitis, with deafness , exhibit
this symptom , and the same is true of those who become pro
foundly deaf in an instant, and whose history shows that they
have had a primary affection of the labyrinth .
After these symptoms have been considered , the tuning
fork becomes very valuable as a means of diagnosis in sus
pected nerve deafness. As we have seen in Chapter II., the
tuning- fork is heard more distinctly if the ears be stopped with
the finger or the like, while the handle is placed upon the fore
head or teeth . If a person be affected with nerve deafness, it
is a clinical fact that such a stoppage of the meatus does not
usually at all intensify the sound of the tuning- fork . Of course
there are no appearances upon the drum -head or in the Eusta
chian tube, that give evidence of disease of the labyrinth . We
may have a normalmembrana tympani in cases where we feel
sure from other evidences that the auditory nerve is the seat
of the disease ; and wemay, as I have often had occasion to
observe, especially in deafness from cerebro -spinal meningitis,
find a sunken drum -head and other marks of chronic processes
in the middle ear, which have occurred secondarily to , or in con
nection with , an affection of the labyrinth . The one prominent
symptom , however, in most cases of true disease of the audi
tory nerve, is sudden and complete deafness. Yet it must not
DISEASES OF INTERNAL EAR - SYMPTOMS. 489
be supposed that the deafness is always absolute. I lately saw

a case which has led me to thebelief thatwemay have an affec
tion of the labyrinth, as sudden in its origin as those in which
the patients awake, as they sometimes do, to find themselves
totally deaf of one ear, and yet thehearing be merely impaired.
I confess, however, that it is hard to conceive of a sudden effu
sion into the semicircular canals and cochlea, wbich should be
so circumscribed as to make the patient but partially deaf.
The case in question is as follows : A physician, æt. 33, states
that while a student, in 1869, he was one day studying in a
recumbent position upon a lounge, and when he got up hewas
dizzy and fell down at once . He did not become unconscious,
but he found that he had a ringing in his left ear. He tested
his hearing by means of the watch , and found that it was
greatly impaired . From that time to this he has always had
a ringing in his ear, with impairment of hearing. The tuning
fork was heard better in the sound ear. The hearing distance
was — Right ear, 48 ; left ear, 48. The drum -head was a little
sunken , and the light spot was small. Air entered both Eu
stachian tubes. There was no improvement after inflation of
the ears. The patient, who was a careful physician, was con
fident that he never before had any disease of the ears. He
stated also that he became much worse, as to the ringing ,
when overworked or fatigued from any cause . I am not ready
to affirn , that this is a true case of primary affection of the
labyrinth ; but it seems to me that this is probably the case .
Deafness to certain tones must of necessity be due to some
affection of the cochlea, and this is an affection sometimes
seen, as has been known since the experiments of Wollaston,
who found that some persons were unable to hear the chirping
of a cricket, which is the highest tone known. If we accept
the theory of Helmholtz , that Corti's organ in the labyrinth is
a resonance apparatus, and that individual fibres of the audi
tory nerve in the cochlea are tuned for certain notes, the patho
logy of such cases becomes clear. It should be remembered,
however, that this symptom , as well as double hearing, like
tinnitus aurium , may be merely secondary to an affection of
the middle ear, which causes pressure and hyperæmia of the
cochlea. Indeed, double hearing, or the hearing of the last
490 DOUBLE HEARING .
tones or syllables repeated or echoed , is usually a secondary

symptom of middle -ear disease . It has been observed by Sir
Everard Home,* Gruber,+ Moos, and Knapp. $ In Knapp 's
case, which occurred in a patient suffering from acute aural
catarrh , the patient heard all sounds of the three upper octaves
double. Both ears of this patient were affected with this
double hearing. This trouble increased until “ all musical
sounds appeared to him perverse , and music in general,which
he had liked passionately , became a perfect horror to him .”
The explanation of these cases, as has been already inti
mated, is to be found in a change in the pressure upon the
fluid in the labyrinth , and thus the ends of the nerve fibres
are incorrectly tuned. It is hardly necessary to more than
allude to the symptom of tinnitus aurium in primary disease
of the labyrinth . It scarcely differs from the sounds heard
by those who suffer from chronic non- suppurative inflamma
tion, although in many cases of total deafness no tinnitus
exists. We may then believe that the function of the nerve is
completely destroyed.
Pain is not usually a symptom of disease of the nerve,
except in the form which Voltolini calls inflammation of the
membranous labyrinth . In these cases it may exist. Nausea,
vomiting, and convulsions, as well as opisthotonos and deli
rium , may be symptoms of labyrinth disease, as well as of
cerebro -spinal meningitis and of acute catarrh of the middle
ear.
The symptoms of inflammation of membranous labyrinth
thathas been mistaken for cerebro -spinalmeningitis, should be
carefully considered in order that the practitioner may be able
to clear up the doubts which have been thrown upon the exist
ence of this disease. Gruber || unites with me in believing that
such a disease may occur. If we find a child suddenly taken
with severe vomiting, followed by stupor or delirium , who
never has any paralysis, but slight opisthotonos, such as chil
* Transactions of Royal Society, 1800.
+ Lehrbuch , p. 626 .
| Klinik der Ohrenkrankheiten , p . 319.
& Transactions of the American Otological Society , 1871.
| Lehrbuch , p. 552.
MENIERE'S CASES. 491
dren have with acnte otitis media , and if we see this child
recover in a few days, except that it is absolutely deaf, and
walks with a staggering gait, I think it is more reasonable to
think of an affection of the ear as the cause of these symptoms,
than of a disease of the brain and spinal cord.
Having seen many cases in which such a history was clearly
given, I must believe in a primary acute inflammation of the
labyrinth , and I trust the attention of physicians will be
directed to the differential diagnosis between this affection
and cerebro-spinal meningitis.
The late Dr. P. Ménière, of Paris, published several obser
vations of cases of loss of equilibrium accompanied by deaf
ness , which have very improperly led to the classification of a
large class of different forms of disease of the labyrinth under
the head of Ménière's disease. These cases have the usual
history of what we may suppose to be effusion into the laby
rinth — that is, nausea, vomiting, vertigo, and inability to walk
straight, with sudden deafness. There was an autopsy in one
case, which has been repeatedly quoted . This case, however ,
was not a true specimen of the cases from the clinical history
of which Ménière made his diagnoses. It was that of a
young woman who, while menstruating, caught cold and be
came suddenly deaf. Her chief symptomswere vertigo and
frequent vomiting. Dr.Ménière examined the ears and found
all the parts healthy except the semicircular canals, which
were filled with a reddish plastic substance replacing the
labyrinth fluid . The vestibule also exhibited traces of this
exudation, but the cochlea, brain , and spinal cord were normal.
The subject of the occurrence of these symptoms and the
cases reported by Ménière , especially the one accompanied
by a post -mortem , are indeed important, but it seems to me
a mistake to classify symptoms of effusions into the labyrinth ,
from whatever cause,under such a name as Ménière 's disease,
and to infer that lesion of the semicircular canals only is to be
found in such cases.
In recapitulation, it may be said that the chief symptoms
of labyrinth disease are
Deafness , usually nearly absolute, and occurring suddenly.
Vertigo.
492 ELECTRICITY IN DIAGNOSIS .
Nausea and vomiting.

Loss of equilibrium .
Inability to hear the tuning-fork more distinctly in the
affected ear.
ELECTRICITY IN THE DIAGNOSIS OF DISEASE OF THE AUDI

TORY NERVE .
Electricity has been much used in the diagnosis of disease

of the auditory nerve, and some authorities believe that we
have a positive means of diagnosis in the employment of the
galvanic current. My friend, Dr. Roger S . Tracy, has taken
the pains to go over the literature which I have collected
upon this subject for me, with a view to the determination of
the side on which lays the weight of evidence as to the reac
tion of the auditory nerve under galvanism . The method of
using the current should be first described .
The galvanic current is applied to the middle and internal
ear by means of an electrode insulated to the end, introduced
into the external auditory canal (which has been previously
filled with warm water ), until it touches the membrana tym
panum , or is firmly pressed against the tragus, the other elec
trode being held in the hand of the opposite side. The second
electrode may also be introduced , through a catheter, into the
Eustachian tube, and even into the cavity of the tympanum ,
as by Wreden, of St. Petersburg.
When the galvanic current is passed through the ear in this
manner, certain sounds are heard by the patient, described as
hissing, roaring, ringing, etc., which have been formulated by
Brenner, who, after a long series of careful observations, has
established a formula for the reaction in the normal ear, which
he claims to be constant. He has also determined formulæ
for some diseased conditions. Brenner and his followers hold
that these acoustic phenomena are all due to a direct irrita
tion of the auditory nerve by the current, while others have
considered the irritation to be reflex, through themedium of
the trigeminus. It is not claimed that the faradic (induced)
current produces these effects, or at least not to the same
degree as the galvanic current.
ELECTRICITY IN DIAGNOSIS . 493
Dr. Hagen , of Leipsic, in an able monograph,* takes strong
ground in support of Brenner, and thinks the following points
may be considered established :
1st. That the auditory nerve reacts to the galvanic current.
2d. Through the galvanic irritation of this nerve, we can
learn its condition, which we cannot learn in any other way.
3d. With this assistance we can with certainty diagnosti
cate a perforation of the drum -head .
4th . The passage of the current through a diseased ear
informs us whether, in addition to visible changes in the
organ , the nerves are also affected .
5th. That when, with subjective symptoms of tinnitus, etc.,
the galvanic reaction indicates hyperæsthesia of the nerve, it
is in some cases possible to abolish these sensations perma
nently , or for a time.
Dr. Wreden , of St. Petersburg, t on the other hand , by a
series of carefully conducted experiments upon sound and
unsound ears, claims to have established the fact that the
sounds heard in the ear during the passage of the electrical
current, are due to the contraction of the small muscles of the
middle ear, and not to the direct or reflex irritation of the
auditory nerve, as Brenner and others have asserted .
He has used for these observations small sounds, one of
which , for what he calls tubal electrization, is introduced ,
through the catheter, the whole length of the Eustachian tube,
and the other, for middle ear electrization , projects two milli
metres into the cavity of the tympanum , being insulated
throughout the portion lying in the tube. These electrodes,
for greater accuracy in their introduction, have each three
marks upon them ; one indicating the exact length of the cathe
ter through which the electrode is introduced, the second, 24
millimetres from the first, the length of the cartilaginous por
tion of the Eustachian tube, and the third , 11 millimetres from
the second, the situation of the tympanic extremity of the tube
in adults.
By tubal electrization he claims to irritate the fifth nerve,
* Praktische Beiträge zur Ohrenheilkunde. Leipsic, 1866.
| Beiträge zur Begründung einer Lehre über die electrische Reizung der
Binnenmuskeln des Obres.
494 ELECTRICITY IN DIAGNOSIS.
and produce contractions of the tensor tympani, and by middle

ear electrization, the seventh, or facial nerve, with consequent
contractions of the stapedius.
In view of the importance of his researches, it may be well
to give here someof the proofs which he adduces in support
of his position.
1st. During the passage of the galvanic or faradic cur
rent, by means of tubal electrization , an inspection of the mem
brana tympani will show a decided drawing inwards of the
membrane, at the opening and closing of the circuit. This
motion of the drum -head is accompanied by a sound readily
appreciable by the otoscope.
2d. At the same timewith these objective phenomena, the
patient feels an evident contraction in the ear, which an edu
cated person always refers to the membrana tympani.
3d . By the second method of electrization , an insulated elec
trode in the middle ear, a sensation as of a powerful blow is
felt in the ear, accompanied by giddiness and faintness.
4th . He has observed a case of clonic spasm of the stape
dius muscle, in which every muscular contraction was accom
panied by sensations and sounds precisely similar to those
produced during the passage of the electrical current.
5th . Even the adherents of the theory of direct irritation
of the auditory nerve acknowledge that no current will pro
duce sounds in healthy ears, unless it is strong enough to
excite contractions of the muscles supplied by the facial nerve.
In this conditio sine quâ non is included, of course, the contrac
tion of the stapedius.
6th . Hehas repeatedly had opportunity to observe, that in
cases of complete facial paralysis, in which a simultaneous
paralysis of the auditory nerve could be excluded, even the
strongest currents failed to produce any sensation of sound,
either by tubal electrization or by the external meatus. This
complete absence of result in such cases is inexplicable upon
the theory of irritation of the auditory nerve.
7th . The well-known fact of the absence of sounds dur
ing the passage of the current, in some persons whose ears
are diseased , but whose auditory and facial nerves are healthy,
can be explained by immobility of the stapes (from anchylo
ELECTRICITY IN DIAGNOSIS . 495
sis or other cause), while on Brenner's theory it is inexpli
cable.
8th . The absence of all sensations of sound during tubal
electrization , where the membrana tympani is destroyed, and
both incus and malleus gone,as in a case reported by Wreden ,*
is likewise difficult to explain on Brenner's theory.
Drs. Erb and Moos, of Heidelberg , adhere to the theory of
Brenner, and the former has written a monograph in its
support.
Schwartze, of Halle , and others equally eminent as observ
ers, dispute Brenner's conclusions.
The questions at issue cannot yet be considered settled ,
though the stronger arguments at present appear to favor the
theory of muscular contraction.
I beg to refer those who are interested in Brenner's for
mula to the article upon aural disease in Beard and Rockwell's
treatise on electricity.I
Dr. C . J . Blake, who is a believer in the theory that the
auditory nerve is actually excited by galvanization after the
method of Brenner, has sought some other means of demon
stration of the condition of the auditory nerve, than the ability
to obtain a certain formula , which , as even the advocates of
Brenner's theories admit, sometimes does not exist. He finds
that “ the passage of the galvanic current increases not only
the limit of perception of musical tones, but also the intensity
of perception , the degree of increase in intensity of perception
being a measure of the degree in which the auditory nerve
responds to the stimulus." The following case, given by
Dr. Blake in the article from which I have quoted, will give
his views as to the value of this method of determining the
state of the auditory nerve.
“ A man thirty -two years of age, first noticed diminution of hearing and a
rushing sound in both ears, ten years before the date of his application for
treatment. His general health had been good with exception of occasional
attacks ofmalarial fever, for relief from which he had used quinine in large
* Op . cit., p . 33.
+ Archives of Ophthalmology and Otology, vol. I., No. 1, 1869.
| Medical and Surgical Uses of Electricity, p. 546.
& Brown-Séquard's Archives, June, 1873.
496 DISEASES OF INTERNAL EAR - CAUSES.
quantity. The hearing had so far diminished that the watch was not heard
when pressed upon the auricle, and the tuning -fork held between the teeth ,
was heard only in the left ear. In the right ear, however, a tone of 50,000 v . s.
was distinctly heard, and in the left ear a tone of 45,000 v. 8. Themembrana
tympani of both ears was transparent and apparently normal, except that it
was quite concave. The hearing was not improved by the use of either Polit
zer's air -douche, or the catheter. No formula of reaction could be obtained ,
but the use of the cathode increased the perception for high musical tones to
60,000 v. s., and for duration of hearing of the tuning-fork , from twenty
seconds to thirty-five seconds." *
“ This increase in the perception formusical tones persisted but a short time
after the application of the current ; the duration of perception of the tuning
fork , however, continued to increase, but never reached the normal standard ,
and the improvement in the general hearing was, on the whole, so very slight,
that the use of the current was finally abandoned . This case presented several
points of interest. So far as could be determined , the middle ear was in a
healthy condition , with exception of such changes as were evidenced by the
concavity of themembrana tympani. Assuming the auditory nerve to be in a
normal state, we should expect an increase in the limit of perception for high
musical tones, as was the case on account of the increased tension of the mem
brana tympani; the same condition would tend to diminish the hearing for
lower tones, as was the case in the test with the tuning-fork , and in the hear
ing for the voice. The use of the cathode increased the hearing for the voice ,
and for the watch , slightly and decidedly increased the perception for high
musical tones, and also the duration of the perception of the tuning-fork ; and
an excision of a portion of the membrana tympani, which operation was sub
sequently performed , had no appreciable effect upon the hearing whatever. ”
Causes. - Instead of attempting to divide the diseases of
the labyrinth into numerous forms, I have thought it would
better accord with the present state of our knowledge, if the
causes that are known to produce primary disease of the
internal ear were tabulated and discussed. We shall then at
least see the gaps in our knowledge, which is, after all, the
best view for the scientific student to take.
I will venture to tabulate the causes of disease of the
internal ear as follows :
* “ The tuning-fork, a 562 v. 8., being struck by the spring-hammer with a
force equivalent to one pound falling one inch , the normal duration of hearing
is from 55 to 60 seconds."
+ " In the majority of cases in which this latter operation is performed , the
perception for high musical tones is immediately increased ; in one case in
which the experiment was made, the patient heard a tone of 100,000 v . s. dis
tinctly, after the operation, the extreme limit before the operation having been
only a tone of 35,000 v. 8.”
DISEASES OF INTERNAL EAR - CAUSES. 497
Proximate causes
Injuries.
Hemorrhages and effusions.
Inflammation of the membranous labyrinth.
Internal administration of quinine.
Concussion of the nerve, and its expansion .
Remote causes
Syphilis .
Cerebro-spinal meningitis .
Fevers.
The exanthemata .
Mumps.
Cerebral tumors.
Aneurism of the basilar artery.
INJURIES .
It is readily seen that a fracture of the petrous portion of

the temporal bone, attended, as it must necessarily be, by
laceration of the tissues of the membranous labyrinth , with
unstringing of the fibres that make up Corti's organ, must
produce great impairment, if not total loss of the functions of
the auditory nerve. Such an injury may be accompanied by
hemorrhage through the membrana tympani ; but a case of
Zaufal's, quoted by Politzer,* shows that a hemorrhage may
occur from the ear after an injury when the drum -head is
intact. In this case a fracture occurred through the upper
wall of the pyramid and the opposite wall of the tympanic cav
ity , and extended to the upper wall of the osseous part of the
auditory canal, without having injured themembrana tympani.
A serous discharge from the ear, after a fracture of the
base of the skull, is a symptom that is spoken of by most
surgical authorities. The fluid that escapes is usually cerebro
spinal fluid , but Politzer f quotes a case from Fedi, in which
the fluid must have come from the labyrinth , for there was no
trace of a fracture of the skull found in the post-mortem ex
* Läsion des Labyrinthes Archiv für Ohrenheilkunde, Bd. II.
+ L . C.
32
498 HEMORRHAGE INTO LABYRINTH .
amination,made three years after the injury , although the

stapes was fractured, and there was a free communication
between the cavity of the tympanum and the vestibule. Hyrt),
after removing the fluid from the canal of the spinal cord in
the cadaver of a child, once found that the injecting material
forced into it passed into the cavities of the labyrinth. He is
of the opinion that the labyrinth fluid in this case, was con
nected with that of the cerebro-spinal cavity by holes which
existed in the meatus auditorius internus, near the entering
fibres of the auditory nerve. It is therefore conceivable, as Po
litzer suggests, that the cerebro-spinal fluid may, in somecases,
flow from the ear, after an accident, without a fracture of the
base of the skull. The question as to whether the cavity of the
spinal column and the labyrinth are normally in communica
tion with each other in the adult subject is not yet settled.
In foetal life such a communication exists. It is unnecessary
to dwell upon the kind of injuries that may produce injuries
to the labyrinth. The text-books on general surgery are the
proper sources of information of this kind, and to them I
may be permitted to refer the reader for a fuller account
of such injuries.
HEMORRHAGE OR EFFUSION.
I think we have a right to conclude, from the clinical his
tory of certain cases, that a hemorrhage or effusion of serum
into the membranous labyrinth may occur without any well
defined cause. Of course , in atheromatous degeneration of
other blood - vessels of the body, we may also suppose that
such a hemorrhage sometimes occurs. The following case is
a fair type of what is meant by hemorrhage or effusion into
the labyrinth :
Profound Deafness of both Ears,accompanied by Vomiting, and loss of Equi
librium , occurring in one night.
A healthy young man of 22, consulted me at the instance of Dr. Howard
Pinkney , and gave the following history : His occupation was that of a wag .
oner. He was attacked one night with vomiting and dizziness , and in a few
hours he found himself completely deaf in both ears. He could not hear the
loudest sounds. The nausea and dizziness continued for about two weeks.
HEMORRHAGE INTO LABYRINTH . 499
He was so weakened that he could not get out of bed, but he retained his
intellect and consciousness, and he stated that there was no paralysis of any
part of his body ; he could lift his head , his arms,move his legs, and all parts
of his body. There were no cases of cerebro -spinal meningitis in the place
where this attack occurred . He had had a suppuration in the right ear some
years before, and could not hear well from that ear before this attack . It is
now three months since his deafness came on , and he is no better. The patient
is ruddy , and in vigorous health ; there is no cardiac or renal disease. He has
not had syphilis . He walks with a staggering gait. His intellect is un
clouded . He has tinnitus aurium , which he compares to the chirping of
crickets. The vision is good. He is still dizzy at times. An objective exam
ination showed evidences of old inflammation in the rightmembrana tympani;
but there was no inflammatory action going on . The membrane was trans
parent, except on the posterior and inferior quadrant, where it was sunken
and adherent to the wall of the tympanic cavity . The left membrana tympani
was normal. He did not hear the watch at all , nor words spoken through
a tube placed in the external meatus. Air enters both Eustachian tubes.
The tuning-fork was notheard better when the ears were stopped.
I think there is no reasonable doubt that this was a case
of hemorrhage into the semicircular canals and the cochlea. I
have seen several such , and some where no vomiting occurred,
butsudden deafness with absolutely no premonition. We are
still in need, however, of post-mortem investigations to estab
lish our theories founded on clinical experience. Inasmuch as
such patients do not usually die of the labyrinth disease, we
have not the same facilities for clearing up a diagnosis that
we have in fatal affections.
The following case was furnished me by Dr. R . S. Tracy,
who observed it while house physician in Bellevue Hospital.
It seems to be one of inflammatory effusion into the labyrinth ,
and to fairly belong to this group of cases, although both
Dr. Tracy and myself agree that the evidence is not quite
positive.
Syphilitic Periostitis of Internal Auditory Canal, or of the Periosteum of the
Labyrinth .
Patrick Freely ,æt. 40, native of Ireland, laborer . Admitted to Bellevue
Hospital, March 27, 1868.
The patient was first seen in the evening, at about six o'clock . He was
then seated on a stool beside his bed, with his head between his hands, and
elbows on his knees, rocking himself from side to side, with frequent groans,
as if in considerable pain . On my approach he looked up, and, when spoken
to, replied that he was unable to hear a word, that he had acute pain in his
head, shooting through from ear to ear,and that he felt giddy, so that he stag
500 PERIOSTITIS OF LABYRINTH .
gered in walking like a drunken man . This was all the history that could be
obtained from him , as he could not hear the loudest shouts uttered close to his
ear, and he was found to be unable to read or write. All doubt as to his actual
deafness was dispelled by his manner of speaking . His voice was very loud,
and badly modulated . He was given one-half grain of morphine, to relieve
his pain , and left till morning .
The next day he had less pain , and remarked that it was always worse at
night. He was found to have enlarged post-cervical ganglia ,and a copper .
colored , non -inflammatory papular eruption over the whole body. A cicatrix
was also found upon the glans penis.
From the evidence of syphilis present, the nocturnal exacerbations of the
pain in his head , the fact that his deafness was of recent occurrence (a fact
learned from his friends), its symmetrical character, and the absence of other
cerebral symptoms than deafness and a certain degree of giddiness, the diag
nosis was made of syphilitic periostitis of the internal auditory canal, and he
was given iodide of potassium , in ten -grain doses, three times a day.
He continued in much the same condition , excepting that his pain was
somewhat alleviated, until the morning of April 1st, when he was found to
have marked facial paralysis on the left side. The face was considerably dis
torted whenever he talked or laughed .
April 5th . – Eruption fading rapidly. Facial paralysis also improving. No
lesion of sensation ormotion in any other part of the body.
April 6th . - Facial paralysis almost gone. On the evening of this day,
when spoken to in a loud voice , he heard what was said to him — the first indi
cation ofa returning sense ofhearing.
April 10th.— Pain in the head entirely gone. Hearing somewhat further
improved . Eruption stationary .
April 11th.— Patient hears now when addressed in a tone but little louder
than ordinary conversation . But it has been noticed for several days, since he
began to regain his hearing , that after conversing for a short time his hearing
becomes blunted , perhaps from local congestion .
April 13th . - Hearing still further improved. Still complains of dizziness ,
and his gait is unsteady. Eruption disappearing.
April 14th. - Facial paralysis gone. Hears when conversed with in an
ordinary tone.
April 21st. - Continued improvement. Still staggers in walking, and com
plains of noises in his ears. Eruption gone.
May 11th. - Patient continued to improve steadily, his gait becoming more
natural, and his dizziness less and less , until to -day ,when he was discharged
at his own request, not perfectly relieved, but in pretty good condition .
This case is, I think, another hint at the truth of Volto
lini's idea of a true inflammation of the membranous laby
rinth, although it is not a pure case of this disease. It was,
perhaps, one of effusion about the trunk of the auditory and
facial nerves.
INFLAMMATION OF MEMBRANOUS LABYRINTH . 501
INFLAMMATION OF MEMBRANOUS LABYRINTH .
Inflammation of the membranous labyrinth , suppurative or

exudative in character, is, as I have already said , a disease,
which I unite with the author just alluded to , in believing may
exist, and that it may be and is mistaken for cerebro-spinal
meningitis. I would ask those who see a great deal of dis
eases of children, to accurately note the symptoms of doubtful
cases of cerebro -spinal meningitis, and see if we may not have
a primary inflammation of the labyrinth , as well as one of the
membranes of the brain and the medulla oblongata. The
symptoms of epidemic cerebro -spinal meningitis , as given by
Clymer,* are , “ great prostration of the vital powers, severe
pain in the head and along the spinal column, delirium , tetanic
and occasionally clonic spasm , and cutaneous hyperæsthesia,
with , in some cases, stupor, coma, and motor paralysis, at
tended frequently with cutaneous hæmic spots .” Dr. Clymer's
definition is so comprehensive and guarded that it would be
difficult to say, that the symptoms of labyrinth disease as
given by Voltolini, may not accord with those of cerebro -spinal
meningitis. I am inclined to think that Dr. Clymer has made
his definition very comprehensive , in order to take in the
sporadic cases. Voltolini regards these as affections of the
labyrinth . Voltolini says, “ The children are attacked quite
suddenly, and without apparent cause ; consciousness is soon
lost as a rule, but thehead is frequently grasped with the hands.
There is severe ferer, a fixed countenance. They bury the
head in the pillow . There are sometimes slight symptoms of
paralysis, but they are never permanent ; occasionally there is
vomiting. Sometimes the disease has something of an inter
mittent character. The cerebral symptoms soon disappear,
but the patient is found to be perfectly deaf, and walks with a
staggering gait.”
Voltolini lays particular stress upon the absence of facial
paralysis in these supposed cases of cerebro-spinal meningitis ,
* Reprint from the American edition of Aitken's Science and Practice of
Medicine, 1872.
+ Monatsschrift für Ohrenheilkunde, Jahrgang I., No. 1.
502 INFLAMMATION OF MEMBRANOUS LABYRINTH .
and he asks how is it possible to have an exudation in the

medulla oblongata , at the origin of the auditory nerve, with
out having at the same time one of the facial, when the fibres
of the two nerves are so near each other. Dr. H . Knapp can
not agree with Voltolini in his idea of primary inflammation
of the membranous labyrinth , and has discussed the subject
quite fully in a “ clinical analysis of inflammatory affections of
the middle ear.” * Knapp 's argumentagainst Voltolini's view
is embraced in the following question : “ If the same complex
symptoms in some cases produce deafness, in others blind
ness, and in many others neither, why should we call the
first group otitis labyrinthica, mistaken for meningitis , while
in the second group the dependence of the ocular affection
on the cerebro -spinal disease may be demonstrated ?" Vol
tolini went too far in thinking that there was no such dis
ease as cerebro-spinal meningitis, which causes deafness ;
but because so -called “ spotted fever” does exist, and trans
mits disease to the auditory and optic nerves, this fact fur
nishes no evidence that primary affections of the nerve-trunks,
or of their expansions, may not occur, just as we may have
primary neuritis optica. But here, also, gaps in our knowl
edge are to be filled, a task that must be performed by the
post-mortem examinations of the practitioners of the present
or future.
Severe Headache and Vomiting - Partial Delirium - Deafness in a few days
No Paralysis – Recovery of all symptomsbut Deafness.
Sally A ., æt. 13, May 3, 1873. Three months ago this child was attacked
with vomiting and pains in the head . She became only slightly delirious,
There was no paralysis of any kind. The hearing was found to be impaired
in a very few days, and she became deaf soon , and has remained so. She
was taken sick on Saturday, and on Wednesday she heard as badly as now .
She is now perfectly deaf, but concussions hurt her ears. She walks with diffi
culty, that is, the gait is staggering.
The practitioner will judge for himself as to how much

inflammation of the spinal cord, or membranes of the brain ,
there is in such cases as the above.
* Archives of Ophthalmology and Otology, vol. ii., No. 1.

CONCUSSIONS — QUININE . 503
CONCUSSIONS.
Workmen employed in hammering large iron plates, such
as are used in making the boilers of steam -engines, are very
apt to lose much of their hearing power. I am informed by
the superintendents and workmen of some such factories, that
a large proportion of the men who have been long in the hor
rid din of a boiler shop, become deaf. So many of these cases
were found, that at one time “ Boiler -makers' Deafness ” fig
ured as a separate disease of the ear in the statistical reports
of one of our institutions where aural disease was treated .
Examination of such cases bas shown me that the lesion caus
ing the impairment of hearing and deafness,must be sought
for in the labyrinth , and that it is probably due to concussion
of the fibres of the nerve in the cochlea and semicircular canals.
Concussions of the labyrinth , from cannonading, such as
are sometimes experienced by soldiers, and sailors also, belong
to this class of labyrinth affections. Deafness from such con
cussions, without an affection of the tympanic cavity , is very
rare however.
QUININE .
There is no doubt but that large doses of quinine may

cause temporary affections of the labyrinth, which are made
known by tinnitus aurium and impairment of hearing. Yet I
am inclined to think that such a congestion is not peculiar to
the membranous labyrinth , but that it may also occur in the
tympanic cavity and in the auditory canal, from the auminis
tration of quinine. It is so well known that buzzing in the ear
is caused by quinine, that many persons who are becoming
gradually deaf from chronic catarrhal or proliferous inflamma
tions of the middle ear, and who, as is the case with mostother
persons in our country, have taken some quinine in their time,
jump at the conclusion that the quinine caused the impair
ment of hearing from which they suffer. Exact examination
often shows that many of such patients have never taken
quinine enough to cause, or even to cure any disease. I
have grown suspicious of quinine, however, in aural disease , in
504 REMOTE CAUSES - SYPHILIS.
any considerable doses; for I have been convinced by experi

ence that it has a peculiar power of congesting the auditory
apparatus. The case on page 155 is an evidence of this fact.
REMOTE CAUSES– SYPHILIS .

Among the remote causes of disease of the internal ear,
syphilis is especially prominent. Yet it should not be for
gotten that syphilitic affections of the middle ear, are more
common than those of the labyrinth. It should also be
remembered that the inflammations of the ear that may occur
in the course of syphilis, have no pathognomonic symptoms.
There are no marks by which we can distinguish them from
other affections of the same nature, in which there is no
syphilitic diathesis. It is only by other evidences of the
existence of the poison in the system that we can be assured
of the syphilitic nature of a given case of aural disease.
Where, for example , in the course of constitutional syphilis ,
we have paralysis of the facial of the seventh pair of nerves
and at the same time the hearing begins to be impaired ,
we have good reason to suspect — if the pharynx and Eusta
chian tubes do not show positive evidences of disease — that
we have also an affection of the portio mollis of this pair.
The tuning -fork will then aid us in making a differential diag
nosis. It is probable, however, that the middle ear is usually
also affected in the cases of impairment of hearing that occur
in the course of syphilitic disease . The pathology of syphi
litic aural disease is not exactly known ; but we have good
reason for believing that we may have periostitis of the laby
rinth as well as gummata . Besides, we may have a lesion of
the meatus auditorius internus, and of the nerve-trunk itself.
Mr. Hutchinson* is of the opinion that all of the cases
which he inspected , of aural disease occurring in the course of
inherited syphilis, are “ due either to disease of the nerve itself
or to some change in non -accessible parts of the auditory
apparatus." I fear that Mr. Hutchinson has not attached
enough importance to the throat symptoms in his cases, and
* A Clinical Memoir on certain Diseases of the Eye and Ear, consequent
on Inherited Syphilis . London , 1863.
NERVOUS DEAFNESS FROM SYPHILIS . 505
that thus he has been led to give diseases of the laby
rinth an undue preponderance in aural affections resulting
from syphilis. The fact that the Eustachian tubes are pervi
ous, goes but a very little way to sustain the theory of laby
rinth disease, and Mr. Hutchinson admits that his cases
showed changes in the membrana tympani, but not " ade
quate ” ones. The following case illustrates the difficulty
of making a positive differential diagnosis between middle
ear and labyrinth disease in the existence of a syphilitic
diathesis :
Acute Pain in right side of Head along the course of the Seventh Nerve, fol
lowed by impairment of Hearing and Tinnitus Aurium - Gradual loss
of Hearing more marked on th : right side- Primary Syphilis one year
since, followed by Mucous Patches and Erythema.
Mr. X ., æt. 29,May 26 , 1873 ,was sent to me for advice, by Dr. R . Hubbard ,
of Bridgeport, Conn . The following history was given by Dr. Hubbard and
the patient : One year ago he had a chancre in the urethra, followed by mu
cous patches and erythema. Hewas treated by the use of mercury and iodide
of potassium , and recovered very rapidly from those symptoms. About five
weeks ago the patient was seized with a severe pain in the track of the facial
nerve, with tinnitus aurium . The tinnitus was compared by the patient to
the peep of a chicken, although this variety of noise was not the only one
observed . There was no pain in the ear itself. The general health is excel
lent. The hearing had gradually diminished in the right ear since the pain
and tinnitus occurred . The pain subsided in a short time ; the tinnitus still
continues. The hearing distance is - R ., Pressed ; L ., 13. The tuning-fork is
heard more distinctly in the better ear. When the right ear is closed by the
finger, however, the tuning- fork is heard better in that ear. The membranæ
tympani of both sides are sunken , that of the left more so. The light spot is
nearly obliterated on the right side. There is a small one on the left . Infla
tion of the ears by Politzer' s method improves the hearing a very little on
each side. The pharynx is secreting excessively.
I suppose this to be a case of sub -acute catarrh of the
middle ear, with a secondary affection of the labyrinth. The
affection of the facial may have occurred during its passage
through the tympanic cavity, or possibly at its cerebral origin .
The tuning -fork indicates that there is labyrinth disease, and
yet the test is not positive, because when the right ear was
closed, the sound of the fork was intensified on the side of the
closed ear. The appearances of the drum -head, and of the
pharynx, as well as the results from the employment of Polit
506 CEREBRO -SPINAL MENINGITIS .
zer's method, are, however, positive proofs that some catarrh

of the middle ear exists. The patient is under treatment both
constitutional and local.
Mr. Hutchinson speaks only of hereditary syphilis in his
book, but there is the same tendency to catarrh of the pha
rynx and Eustachian tubes in inherited syphilis as in any
other form .
The prognosis in disease of the labyrinth , occurring in the
course of syphilis, is very unfavorable. I have never seen a
case of recovery .
MENINGITIS – CEREBRO -SPINAL MENINGITIS.

Meningitis and cerebro-spinal meningitis lead to disease of
the labyrinth by direct transition of the inflammatory action .
Disease of the middle ear also results from those affections, and
I have seen many cases where the two parts of the ear were
simultaneously affected . The deafness is not usually observed
until the patient is aroused from the stupor, when , if the laby
rinth be affected, the deafness is profound, and there is apt to
be unsteadiness of the gait. Knapp * speaks of some cases,
however, where the deafness occurred during convalescence.
This is a state of things that we sometimes see in labyrinth
disease from scarlet fever, where, after a slight catarrhal in .
flammation of the middle ear, the labyrinth becomes suddenly
invaded , probably from the middle ear, and secondary, incura
ble disease of the internal ear occurs. Fortunately , in scarlet
fever and in the other exanthemata, middle ear and not laby
rinth disease is the variety of aural affection usually found .
In cerebro-spinalmeningitis, however, the labyrinth is the part
of the ear that usually is attacked Moos + reports the post
mortem of a case of cerebro-spinal meningitis , in which the
nerve was found to be sound , excepting some congestion of the
sheath up to the meatus auditorius internus, while there was
extension of the inflammation of the dura inater, into both tym
panic cavities. The nature of the lesion in deafness from cere
bro -spinal meningitis is not yet fully made out. Suppuration
of the membranous labyrinth has been found in some of the
very few post-mortem examinations that have been made. It
is probable that the seat of the lesion is to be found in the
* Medical Record, vol. vii., No. 15, p . 340 .
+ Archives of Ophthalmology and Otology, vol. iii., No. 2, p . 177.
Knapp, Archives of Ophthalmology and Otology, vol. ii., No. 1, p. 47.
CEREBRO -SPINAL MENINGITIS — ANEURISM . 507
labyrinth proper, and not in the auditory nerve-trunk, for the

facial nerve is seldom affected .
Von Tröltsch* says that a few post-mortem examinations
show that the morbid changes causing deafness in cerebro
spinal meningitis, are sometimes found in the fourth ventricle .
It is as yet an assumption to say that suppuration of the laby
rinth is the usual lesion.
ANEURISM — TUMORS.
Aneurism of the basilar artery, cerebral tumors , and, in
fact, all varieties of intracranial disease, may cause tinnitus
aurium and impairment of hearing ; butall such cases require
special study, and hardly demand a detailed notice. Griesen
ger says that the symptoms of disease of the nerve, or its
expansion , arising from aneurism , are : Difficulty in swallow
ing ; occasionally spasmodic deglutition ; impairment of hear
ing, or even complete deafness, often appearing at intervals,
with great tinnitus ; difficulty of respiration and articulation ;
interference with the excretion of urine ; without any impair
ment of the intellectual functions ; and , finally , paraplegia .
Van Tröltsch states that a constant sensation of knocking, in
the back of the bead, is also a suspicious symptom .
Dr. Hughlings Jackson believes that deafness (excluding
cases manifestly due to disease of the apparatus of hearing ) is
a rare complication of intracranial disease. It is very much
less common than optic neuritis. Dr. Jackson has not yet
seen an autopsy which showed that deafness had depended
upon adventitious products , nor upon “ any sort of disease of
either cerebral hemisphere.” One caset is recorded , however,
which Dr. Jackson quotes, of tumor of the left cerebral hemi
sphere,where there has been deafness of both ears. Dr. Jack
son thinks that deafness does not result from intercranial
tumor , or other adventitious product, unless the auditory
nerve is actually involved or pressed upon.
Pathology.- In passing over the subject of the causes of
* Von Tröltsch,second American edition, p .511.
+ Royal London Ophthalmic Hospital Reports, vol. iv., part iv., p . 420.
508 PATHOLOGY OF NERVOUS DEAFNESS.
disease of the internal ear, we have alluded to the pathology of
the affection ; but it may be well to tabulate the post-mortem
appearances that have been found in the labyrinth. Inasmuch
as very few of these appearances have been accompanied by
the history of the case, they have not the importance that they
would otherwise have had. Yet they may be of service as a
basis for future investigation :
Absence of auditory nerve, . . . . .
.
. . . . . .
Atrophy of auditory nerve, . . . . . 10
. . . . . . . . . . . . . . .
Suppuration , . . . .
.
Tumor upon , . . . . . . . . 1
Hemorrhage upon , . . . . . .
· · ·
.
29
Thickened membranous labyrinth, .
. . . . . . . . .
. . .
Atrophy ofmembranous labyrinth , .
Congestion ,. . . 1
Suppuration ofmembranous labyrinth , . ·
Serum in labyrinth, . . . . .
CO
2CO
Opaque fluid in labyrinth , . . .
· · · · · · · · · · · ·
Black pigment cells too abundant, . .

Distension of blood-vessels of cochlea, , ,
Black pigment very abundant, . . . . CON I CO
Fluid , opaque, . . . . . . .
Pus in cochlea, .
. . . . . .
Thickened lamina spiralis, .

Osseous wall of semicircular canals incomplete,
Pus in canals, . . . .
Calcareous matter in canals, .
Hemorrhage into canals , . . . .
Hyperæmia of cochlea and semicircular canals,t . .
Ecchynioses in vestibule and cochlea, seen by Politzert
accompanied by ecchymoses ofthe tympanic cavity and
osseous tube, . . . . . . . . .
Hemorrhage into the whole labyrinth , after the action of
the poisons of gout,typhus fever,scarlatina,measles, or
mumps, observed by Toynbee, . . . . .
* The above cases are taken from the tabulated index of Toynbee's cata
logue. Many of them are secondary changes, but they show what may occur
in the labyrinth .
+ Voltolini, Virchow 's Archiv , Bd. XVII.; Schwartze, Archiv für Ohren
heilkunde, Bd. I., p. 206. Schwartze's case was one of acute catarrh of the
tympanic cavity after typhoid fever.
$ Moos, Klinik der Ohrenkrankheiten , p. 311.
& Diseases of the Ear,American reprint, p. 377.
NERVOUS DEAFNESS - TREATMENT. 509
Fibro -muscular tumor in the infundibulum of the cochlea
was found by Voltolini.*
Phosphate of limeon lining of the meatus auditorius in .
ternus, Boettcher ,t . . . . . .
•
Atrophy ofmembranous labyrinth , . .
Soft and swollen , . . . . .
·
·
. .
: : : : : : : : : : : :
· · · · · · · ·
Fatty, . . . . .
Home
·
Endolymph opaque or red , . .
·
.
Labyrinth containing pus, . . . . .
Labyrinth containing cholestearine, . .
Q25PO
· · · · · · ·
Bony degeneration of saccule, . ..
· · · · · · ·
Thickened lamina spiralis, . . .
Fibrous mass in cochlea, . .
Excess of pigment, . . .
Extravasation of blood ,
Bony deposit in meatus auditorius internus,
Atrophy of fibres of auditory nerve, . . . . 31
It must be observed that suppuration in the membranous
labyrinth is, as yet, among the rarest of pathological changes
that has been found in the internal ear, although it is assumed
by some authorities that this is the lesion that usually results
from cerebro- spinal meningitis.
Treatment. - Only generalremarks can bemade in reference
to the treatment of disease of the labyrinth . Each case must
be studied by itself, and treated according to the symptoms.
If we have to deal with a case of true inflammation of the
labyrinth, cold applications to the head and the use of quinine
should be avoided, and our reliance must be on leeches and
counter-irritation, pedeluvia and purgatives. Chronic affec
tions of the labyrinth are , so far as my experience goes,
utterly hopeless. The effusions in the labyrinths due to syphi
lis are less amenable to treatment than any other form of sec
ondary venereal disease. Electricity has a much-vaunted repu
tation among inexact observers, for its cures ofnerve-deafness ;
but there are no authentic cases on record of a cure of a true
inflammatory affection of the labyrinth by this agent. The
only seeming exception to this rule is a case reported by
* Moos, 1. c., p . 316 .
+ Von Tröltsch , translation, p . 499.
| Hinton,Nervous Deafness, reprint from Guy's Hospital Reports, 1867.
510 NERVOUS DEAFNESS — TREATMENT.
Moos, * which he entitles “ Recovery of Complete Nervous

Deafness.” The constant current was used successfully in
what seems to me to have been a case of impairment of
hearing occurring in the course of an hysterical affection. The
patient had acute articular rheumatism , and in the fifth week
hysterical symptoms appeared . There was great sensitive
ness of the ear, such as occurs in other parts of the body in
hysterical women , and increased hearing power. The patient
lay for nine days without moving on the right side, and thus
an ulcer of the concha was caused. She took large doses
of quinine for these nine days, when impairment of hearing
occurred , and continued to increase until the patient was
communicated with in writing. In the eleventh week tetanic
spasms occurred. The galvanic current was then employed ,
twelve elements being used . The symptoms, except the deaf
ness, soon subsided , and a thorough course of galvanization
of the ear restored the power of the right one perfectly, and
of the left in all respects, except the inability to distinguish
the highest note of the seven -octave piano.
I confess I do not feel the enthusiasm over this case which
is exhibited by Professor Moos, which, according to his hopes ,
is to “ toll the knell for all the opponents of the therapeutic
value of electricity in aural disease.” It has, to say the least,
so strong an hysterical element, as to make it doubtful what
pathological process was at the basis of the deafness, and
yet it is an interesting and important case.
Beard and Rockwellt give their views as to the value of
electricity in the treatment of diseases of the auditory nerve
and labyrinth in the following cautious language : “ Cases of
nervous deafness, or of deafness resulting from various patho
logical conditions, with which a morbid condition of the audi
tory nerve is complicated, and all cases of tinnitus aurium ,
whatever may be their supposed pathology, should only be
regarded as hopeless after the failure of persevering and va
ried treatment by electricity , although perfect or approximate
cures will be obtained only in a small percentage of the cases.
The treatment of opacity and thickening of the drum , and of
* Archives of Ophthalmology and Otology, Bd. I., No. 2.
+ A Practical Treatise on Medical and Surgical Electricity, pp. 571-2.
NERVOUS DEAFNESS - TREATMENT. 511
chronic inflammation (with the consequent adhesions and other

morbid changes) of the middle ear and Eustachian tube, offers
a fair and important field for electrical experiment.”
Dr. Knapp says:* “ I have tried it ( electricity) in nearly all
reported cases, but without a shade of improvement.”
Dr. S . Sexton, of this city, Surgeon to the New York Ear
Dispensary, writes me that he has experimented with electri
city in aural disease for two years, both in private and public
practice. He is convinced of the correctness of Brenner's for
mula ; but in all his cases, Dr. Sexton says " there was no
marked improvement in the hearing.” “ In a few cases of
impaired hearing, where there were the accompanying symp
toms of dizziness or nervous headache, the advantages of the
treatment were decided .”
My own experience has been purely negative. I have
never seen any improvement, in any forms of nerve deafness,
from the use of electricity in any form . I fear that we must
abandon the hopes entertained by some, of the powers of this
subtle agent in those as yet mysterious diseases, the affections
of the internal ear.
OTALGIA.
The subject of otalgia belongs, strictly speaking, to the

middle ear ; but I have followed the custom of other text
books, and insert a brief notice of this affection at this point.
True otalgia may occur as a consequence of malarial poi
soning, of syphilis, or of carious teeth . The chief point in the
differential diagnosis is the absence of swelling or redness of
the visible parts of the ear, and the non -impairment of the
hearing. I do not remember to have seen but two cases. One
of these seemed to have been the result of malaria ; the other,
of syphilis.t Dr. R . F . Weir, of this city , has seen two cases ,
the result of decayed teeth . The ear, especially the tympanic
* Archives of Ophthalmology and Otology, vol. ii., No. 1.
+ The author would be very glad of opportunities to examine the labyrinth
in fatal cases of cerebro -spinal meningitis. The petrous bones may be placed
in Müller's fuid . R . Bichromate of potash, 24 grammes; sulphate of soda,
1 gramme; distilled water, 100 grammes. M .
512 OTALGIA .
cavity, is so richly supplied with nerves, that it is surprising

that so few cases of otalgia have been observed . Bonnafont*
says that the disease rarely attacksboth ears atonce, butthat
it readily passes from one to the other, in consequence of the
sympathy between the two sides of the fifth pair. There is
apt, according to the same author, to be injection of the con
junctiva and lachrymation, in connection with otalgia .
The seat of otalgia may be, according to Bonnafont, in the
auditory nerve, the chorda tympani, or the nerve supply of the
tympanic cavity. Bonnafont advises instillation into the ear
of a concentrated decoction of poppy-heads and cataplasms,
or blisters on the auricle and mastoid process.
Grubert reports a case of typical otalgia cured by the use
of iodide of potassium . Quinine was tried , but proved of no
service.
Gruber thinks it possible that there was an exudation
pressing upon the nerve in this case . The symptoms were
spasmodic contraction of the left side of the head, with pain
in the ear occurring at irregular intervals ; the longest inter
missions were a few days. The hearing power was normal,
and there were no pathological objective symptoms.
The following case,which I have as yet seen but once , is a
fair representation of pure otalgia :
Otalgia of Right Side, probably from Syphilitic Exudation on the Seventh Nerte .
A . X ., æt. 27. May 23, 1873.- This patient, who is a physician, says that
he has suffered from more or less acute pain in the right ear and the mastoid
process for three months. Within the last ten days it has been more severe.
The hearing is not impaired . On examination the hearing distance is found
to be normal, but the tuning-fork is heard better on the right side. The mem
brana tympani and mastoid process are in a normal condition . The pain
seems to follow the course of the seventh nerve. The patient has had pri
mary syphilis, and also some secondary symptoms. He has never had any
malarial disease.
I supposed this to be a case of otalgia from exudation

upon the seventh nerve in its course through the tympanic cav
ity , and advised the employment of anti-syphilitic treatment.
* Traité theoretique et pratique des Maladies de l'Oreille, Paris, 1873.
+ Monatsschrift für Ohrenheilkunde, Jahrgang III., No. 9.
PART IV .
DEAF-MUTEISM AND HEARING TRUMPETS.

CHAPTER XX .
DEAF -MUTEISM – HEARING TRUMPETS.
DEAF-MUTEISM is caused by diseases of the middle and

internal ears. These diseases are of various kinds, and have
been fully discussed in the preceding chapters of this work .
The only reason that deaf persons become mutes is that the
disease of the ear occurs either before birth, or so shortly
after, that its victim is unable to learn to imitate speech .
There are no changes in the larynx that prevent deaf-mutes
from articulating distinctly , except those that may possibly
come from disuse of the organ .
Persons who become completely deaf later in life, do not
lose the power of speech ; but they usually speak in an unna
tural tone, because they are unable to hear their own voice
with distinctness.
Deaf-mutes may be divided into two great classes.
I. - The acquired cases, or those in whom thedisease of the
ear has occurred after birth , from some traceable cause.
II . — The congenital cases.
It is very difficult to come to a correct conclusion as to the
relative frequency of congenital and acquired deaf-muteism .
The tables that are made up by the directors of schools for
the deafand dumb are not trustworthy, because they are taken
from the statements of persons who are seldom exact observ
ers — the parents or friends of the children . Dr. George M .
Beard and myself* examined two hundred and ninety-six
cases of deaf-muteism , with their histories, in the schools
of New York City, and Hartford, Conn., and the result of our
examination was, that about sixty-one per cent. of these cases
* American Journal of the Medical Sciences, vol. liii., p. 401.

516 DEAF -MUTEISM .
were probably congenital, and that the remaining thirty -nine

per cent were acquired . Wilde's statistics show that about
fifty per cent. are of the acquired form . The exact truth as
to the time when the deafness occurred , is something very
difficult to ascertain . It is not easy to learn, even when great
pains are taken by persons well competent to observe, whether
a very young infant hears well or not, although we may easily
satisfy ourselves whether or not loud sounds are perceived.
Wilde* says that children appear to be conscious of sounds
during the third month, while at the fourth they show an
appreciation of particular sounds, such as chirping,whistling
and the like. He believes that from the fourth to the sixth
month is perhaps the earliest period at which an opinion
can be formed as to the hearing of an infant. Moreover,
an inflammation of the ear, if not of the suppurative variety ,
may run its entire course in a young child , and never be
recognized by physician or friends as a case of aural dis
ease. It is well known, and the fact has been before alluded
to in this volume, that a suppurative inflammation of the mid
dle ear, in an infant, is sometimes first recognized as such
when the pus breaks through the membrana tympani. The
fact that such severe processes may go on in the ears of chil
dren , and escape recognition, renders it very probable that
even Wilde's proportion , in which he gives fifty per cent. as
the proper one for acquired deaf-muteism , is too low a one.
I am inclined to think that there are many more cases of chil.
dren becoming deaf after birth, than of intra-uterine deafness .
It does not require absolute deafness in a young child to
produce deaf-muteism . A case of chronic aural catarrh, that
would only inconvenience a grown person, willmake an infant
so stupid that it will soon cease to attempt to imitate speech .
We have all grades of hearing power in so -called deaf-mutes.
I have seen two or three cases of children who were being
educated in deaf and dumb asylums, who could bear words
spoken into their ears in a very loud tone. In one case the
parents found it too much trouble — inasmuch as no physician
could be found who would treat the suppurating ear - to teach
* Aural Surgery, English edition, p. 461.
DEAF-MUTEISM - CAUSES. 517
their child to speak . He was consequently losing his speech ,

and also having his life placed in peril by the neglect of the
ulcers in his ears.
Causes. — The causes of deaf-muteism are very graphically
set down in the reports of deaf and dumb asylums, but unfor
tunately these assigned causes are usually incorrect. Thus,
“ colic ,” “ a burn,” “ a fall," " fits,” “ mother marked," * etc.,
figure in such tables as causes of deaf-muteism . Many of the
so -called facts in such tables have been derived from unscien
tific observers ,who sometimes have very positive opinions as
to the causes of disease, and who believe that in a severe
fright to the mother, the marriage of cousins, etc., ample
causes are found for deaf-muteism . The investigation of the
proximate causes of deaf-muteism , show , as has been said ,
that their victims have become deaf from precisely the same
kinds of disease, and in about the same proportion as obtains
in impairment of hearing or deafness occurring at a time of
life that prevents the subjects from becoming dumb as well as
deaf. Of the 296 cases examined by Dr. Beard and myself,
in only 22 cases was the drum -head found to be normal, and
in 200, or more than two-thirds of the whole number exam
ined , there was chronic pharyngitis or tonsilitis. It is thus
seen that the middle ear was usually the seat of the lesion
that caused the deafness. Of the 114 acquired cases, the
membrana tympani was perforated in twenty -nine cases.
Thus, suppurative inflammation does not seem to cause as
large a proportion of deaf-muteism as is usually supposed .
In some of the cases, however,themembrani tympani had once
been perforated and had healed . In Blake's statistics,t forty
per cent. of those examined, forty -one in number, were classed
by him as acquired cases. In twelve of these acquired cases
the membrana tympani was perforated or destroyed on one
or both sides. In thirteen of the seventeen cases, the deaf
ness was traceable to the pharyngitis of scarlet fever or
measles.
* On the Etiology of Acquired Deaf-Muteism , by Clarence J. Blake. Reprint
from Boston Medical and Surgical Journal.
+ Reprint from Boston Medicaland Surgical Journal.
518 DEAF -MUTEISM .
The remote causes, or the causes that tend to produce

disease of the ears in intra -uterine or infantile life , form a
very interesting study, but we have as yet no very accurate
data upon which to discuss them . It is an open question ,
perhaps, whether intermarriage tends to produce disease of
the ear in young subjects or not, or whether it tends to lead
to arrested development in young children ; for there is no
doubt that some cases of congenital deafness depend upon
want of proper development of the auditory nerve and laby
rinth . I was informed at Hartford, that a certain part of our
country, which is somewhat isolated from the other parts of
the Union , and where intermarriages are the rule, furnished
a proportionately large contingent of cases of congenital deaf
muteism . The cases from this district that I saw , were in
persons somewhat deficient in intellect, and we may consider
their etiology as identical with that of idiocy, feeble brains, or
partial development of other parts of the body, such for
example , as spina bifidis, coloboma iridis, etc.
Voltolini's inflammation of the membranous labyrinth is
probably one of the proximate causes of acquired deaf-mute
ism . Von Tröltsch showed that a purulent process is a very
common appearance in the tympanic cavities of half-starved
foundlings. I suppose that the mal-nutrition of parents may be
traced as remote causes for such affections of the middle ear.
We may sum up the causes of deaf-muteism , as developed
in clinical histories and in examinations on the dead subject, as
follows:
1. Inflammation of the middle ear, resulting in suppura
tion , or adhesions, anchylosis of the ossicula auditus, etc .
2. Inflammation of the nerve or labyrinth, resulting in
suppuration or thickening of the membranous labyrinth,
deposits in it, etc.
3. Arrested development of some parts of the essential
part of the auditory apparatus, for example , absence of the
semicircular canals, or of the cochlea.
These are the causes which are shown in the table given
by Moos,* in his account collected from various authorities, of
* Klinik der Ohrenkrankheiten, p. 341.
DEAF -MUTEISM . 519
sections of the ears of sixty deaf-mutes, and they agree well

with the clinical examinations and histories.
Treatment. — There is certainly no peculiar treatment neces

sary for the deafness udiofng young children,
tatewhich crenders
h : by them
a r i s m o f t h e v a l l to t h e l i n c
mute , because they cannot learn to imitate speech ; but I cans p e e
not refrain from alluding to the lingering remains of the bar
barism of the past centuries, which neglects the care of the
ulcerated membrana tympani, and the swollen throats of the
poor mutes who suffer from chronic suppuration and catarrh
of the middle ear. Although the educational wants of deaf
mutes are now well attended to , their medical treatment is
sadly neglected in the asylums and schools of our country. It
was not until the seventh century that deaf-mutes were thought
worthy of an education . The twentieth century will probably
arrive before every school or asylum for these unfortunates has
in attendance a physician who knows how to examine and treat
a diseased ear. These schools are not hospitals , it is true ;
but there is always in them quite a large proportion of young
patients, who still suffer from a disease which , although it
has fully destroyed the hearing , is not yet stayed, and which
often goes on to destroy life. I refer , of course ,more particu
larly to the suppurative forms of disease .
According to the census of 1870, there were in the United
States, sixteen thousand two hundred and five deaf-mutes : of
thesewe may believe that fifty per cent. belong to theacquired
cases. How many of these belong to what may fairly be
called preventable diseases, it would not be possible to say ;
but certain it is , that if diseases of the ear had always rejoiced
in the same attentive treatment as many of the less essential
parts of the body have received, the dumber of these unfortu
nate mutes would have been greatly lessened.
HEARING TRUMPETS.
We have not, as yet, been furnished with an apparatus for
conducting the undulations of sound to the ear, which is at the
same time efficient and unconspicuous. This is the great de
sideratum of most patients who are affected with incurable
520 HEARING TRUMPETS .
impairment of hearing, for nearly all deaf persons would like

to conceal their infirmity . It is possible that the development
of the science of acoustics will yet furnish us with a sound lens,
that will refract and focus rays of sound upon the drum -head
and assist the hearing power ; but in the very nature of things
it is not likely that we shall ever have an apparatus so well
adapted to the pathological changes in a diseased ear, as are
convex lenses to the physiologicalprocess of thickening of the
crystalline lens and rigidity of the ciliary muscle, which we term
presbyopia . The physician can only therefore advise his
patients to use one of the simple conductors of sound that are
here delineated , as being all that science, as yet, offers to the
hopelessly deaf.
Fio . 110 .
bale
Hearing Trumpets.
It will be seen that the first is a flexible speaking tube,

which is very convenient for conversation, and is in fact called
a conversation tube. The second and third figures represent
the ordinary metallic trumpets which aid many persons with
impaired hearing to hear addresses, sermons, and so forth .
In many churches long flexible tubes run from beneath the
pulpit to the seats of those whose hearing is impaired , and are
used as is the conversation tube. I am very much in doubt
as to the value of the so -called auricles , represented in the
fourth figure. The most different accounts are given as to
HEARING TRUMPETS. 521
their value as assistance to the hearing power. They are, of

course, worn over the head and fit into the meatus.
The simpler apparatus are usually the best. It is some
times of advantage to use little clamps which hold up the
auricle , as deaf people do with their hands, in order to catch
all the waves of sound. The small “ invisible " tubes, placed
in the auditory canal, are wholly useless . There is, in fact, no
apparatus as yet invented that is better than the various
forms of curved tubes.
DESCRIPTION OF THE CHROMO-LITHOGRAPHS.
FIG . 1.- Normal membrana tympani.

It is impossible to exactly render the normal tint of this beautiful struc
ture , but this lithograph seemsto me to approximate this to a very satisfactory
degree .
FIG . 2.* _ In this case, that of a man thirty-two years of age, a purulent
inflammation of the middle ear had existed for nearly two years. There was
a perforation in front of the malleus, which finally healed under the applica
tion of nitrate of silver, forming the cicatrix shown in the drawing, and also a
small circular opening through the “ pars flaccida ” — the space within the open
ing,and around the malleus-incus articulation being filled with small granu
lations. After the closure of the lower perforation, these were treated by
application of saturated solution of arg. nit., on a cotton-tipped probe, with
good result. The outer layer of the membrana tympani, above and behind
the processus brevis , was much thickened and congested , and this condition
(as shown in the drawing) continued after the closure of the inferior perfora
tion. This plate is of value, as exhibiting a comparatively rare form and
position of perforation of the membrana tympani, and one not readily amen
able to treatment.
Fig. 3 represents a small perforation , the consequence of purulent otitis

media ,occurring in a boy twelve years of age, and of one year's duration .
There were no granulations at the timewhen the drawing wasmade, and the
perforation was in process of healing, as is shown by the congested blood -ves
sels extending from the periphery towards the perforation . This drawing
exhibits the want of clearness of the outline of the malleus,as the result of
thickening of the outer layer of themembrana tympani,and also the promi
nence of the processus brevis and of the posterior fold , in consequence of the
concavity of the membrana tympani. Through the perforation is seen the
congested mucous membrane of the middle ear.
• The cases here described were treated by Drs. C . J. Blakeand H . L . Shaw , ofBoston.
524 DESCRIPTION OF THE CHROMO- LITHOGRAPHS.
Fig . 4. - A case of purulent otitis media, in a boy twelve years of age.
This drawing represents faithfully the granulations occurring on the mem
brana tympani, and also the thickening of themembrana tympani,subsequent
to the perforation , and during the continuance of the purulent inflammation.
This case was convalescent at the time the drawing was made, under the
application of astringents to themiddle ear,and the granulations were rapidly
diminishing under the application of arg. nit. In this drawing, also, is shown
the peculiar arrangement of the blood vessels passing from the superior wall
of the meatus into the membrana tympani, to assist in forming themanubrial
plexus,and which are congested in consequence of the diseased condition of
the tympanum and membrana tympani.
Fig . 5 represents a case of chronic catarrhal inflammation of the middle

ear,accompanied by great concavity of the membrana tympani. The proces
sus brevis is very prominent, and both anterior and posterior folds of the
membrana tympani are consequently elongated . The handle of themalleus
is much foreshortened , and the lower end nearly in contact with the promon
torium , as is shown by the lighter color of the membrana tympani at this
point, the light rays being reflected directly from the white surface of the pro
montorium . The concavity of the membrana tympani is further evidenced by
the character of the light reflection, which, instead of being a perfect cone, as
represented in Fig . 1, is represented by two small points of light, one close to
the end of the malleus,and one at the periphery ; the intermediate space repre
senting a surface of such degree of concavity that the light thrown upon it
from themirror is focussed at a pointwithin the meatus.
Fig . 6 is a type of cases of chronic catarrhal inflammation of the middle

ear, of long standing, in which the mucous coat of the membrana tympani
has become uniformly thickened , with but a slight degree of concavity of the
membrana tympani ; the latter condition in this case is principally evidenced
by the prominence of the manubrium and processus brevis, and of the poste
rior fold . The samedull gray color is found, as a result of thickening of the
mucous coat of the membrana tympani, following acute inflammation of the
middle ear.
This drawing exhibits also the appearance characteristic of,and the form
peculiar to , large calcareous deposits. The light reflex is wanting, in conse
quence of the presence of the calcareous deposit at the point at which this
appearance is found in the normalmembrana tympani.
FIG . 7 represents a condition common to chronic catarrhal inflammation of

DESCRIPTION OF THE CHROMO- LITHOGRAPHS. 525
the middle ear. In this case the malleus is in contact with the promontorium ,
and the continuance of the atmospheric pressure from without has carried the
membrana tympani inwards, rendering the malleus exceedingly prominent.
The light color of the central portion of the membrana tympani is due to the
reflection of light from the inner wall of the tympanum , and not to thickening
of the mucous coat. This condition is found where the trouble has been con
fined principally to themucous membrane of the Eustachian tube and anterior
portion of the tympanum , without the thickening of the inner coat of the
membrana tympani, which is shown in Figs. 5 and 6 .
FIG. 8 exhibits the result of purulent inflammation of the middle ear of
long standing, in a boy ten years of age. At the time of the drawing the dis
charge had ceased , under treatment with dry cotton packing applied daily,
and the mucous membrane was returning to a normal condition. There were
two large perforations, divided by a narrow bridge of thickened membrana
tympani. The short process of the malleus was very prominent, and the
manubrium in contact with the promontory. The remainder of the membrana
tympani was much thickened. The slight congestion about the short process,
and along the manubrium , was due to the pressure of the cotton plug, as
there was no evidence of a process of repair about the edges of the perforation.
N1
NO2
NO
NO
.
OO
NO
No
NO
3. 5
7 8.
.
HP DUINCY,M AD NAT DEL BUFPONDYLITH ROTON
DISEASES OF THE EAR .

D .R .ST. JOHN ROOSA .
INDEX OF AUTHORS.
| Burnett, C, H ., 282, 340.
Achilini,20.
Agnew , C . R .,
Böttcher. Claudius, 27.
162, 402, 403, 404, 405 , Boyer, 326 .
418 , 425, 430, 431, 437, 438. Bozzini, 89.
Albini, B . G ., 59. Bussen ,Julian, 39.
Alcmæon , 19.
Allen , Peter, 310.
Ambrose, D . R ., 418, 431.
Arneman, J., 66, 419, 421, 422, 425. Camper, 24 .
Apollonius, 30 . Capivacci, 33.
Arnold , F., 26 , 202, 219. Cassebohm , J. H ., 23, 37. .
Aristotle, 19. Casserius, Julius, 21.
Archigines, 29. Celsus, 29, 388 .
Arcularius, Johannes, 32. Cerlata, Peter de la, 32.
Ausspitz, 116 . Cheselden, Thomas, 295, 319, 320, 321.
Chimani, 397.
Autenreith , 379.
Asclepiades, 29. Clarke, Edward H ., 47, 124, 172, 397.
Cleland , Archibald , 38 , 39, 93, 300 ,373.
B. Clymer,Meredith , 501.
Cock , Thomas H ., 359.
Banza,Marcus, 35 , 379. Cohen , 92.
Barker, Fordyce, 407. Collis (of Dublin), 425.
Beard
517 .,
George M ., 313 , 377, 495 , 510 , Conta, Von , 79.
Corti,Marchese, 27, 478 , 479, 482 , 489.
Cotugno, Dominic, 23, 24 , 37.
Beck , Karl Joseph , 38, 41, 105, 345. Cooper,
Benedetti, Alexander, 32. Sir Astley, 40, 319, 320, 321,
Berger, 39, 421, 424. 322, 323, 324, 325, 326 , 328, 329,344,
Berengario, 20. 371.
Bernard , Claude, 230. Crampton, Sir Philip , 437.
Berres, 23 . Curtis, John Henry, 41, 326 .
Billroth, Theodor, 106, 389, 444. Cutter, Ephraim , 301.
Bishop , Edward , 306 . Cuvier, 20 .
Blake, Clarence J., 76 , 87. 134. 139. Czermak , 89 .
164, 106 , 344 , 394 , 397 , 398 , 399 , 495 ,
518 .
Bochdalek , 23, 185. D.
Bonnafont, 26 , 311, 328, 511. Davidson, 356 , 361.
Bowman , William , 300 , 407, 428, 478. Deiters, 27.
Brenner, 466 , 492, 493, 495, 511. Deleau, 41, 326.
Brendel, 23. Deleau (Jeune), 176 .
Breschet, 26 , 475. De Gravers, 321, 326 .
Buchanan , Thomas, 25, 63, 161, 326 . Dienert , 321.
Buck , A . H ., 222, 388 , 390, 425 . Draper, William H ., 136.
Bull, Charles S., 138, 265. Di Rossi, 86 .
Busson , Julius, 321. Duchenne,59.
Butcher, William , 327 . Du Verney, 35, 370.
Buttles, M . S., 310. | De Vigo, 32.
528 INDEX OF AUTHORS .
E. | Hays, Isaac, 152.

Hecksher, 173.
Eli, 321.
Ely , S., 414 . Helmholtz, Heinrich , 188, 335, 489.
Elsberg, Louis, 292, 295 . | Helmont, J. B . Von , 35 .
Eno, Henry C ., 385, 390 . Henle, J.,57 ,60, 61, 189, 210 , 461, 463
Erb , 495. 464, 466, 473, 475 , 476, 477,479, 480,
Erhard , Julius, 42, 46, 74 , 331. 481, 482.
18. Bartolommeo
Eustachius, Bartolommeo,. 20,
20. 21.
21, 218.
218 . | Hendricksz, 327 .
Herodotus, 27 .
E
Hermann, 329.
Hewitt, Prescott, 448 .
Fabricins of Acquapendente, 21, 35. Hinton , James, 42, 45, 98 , 282, 321,
Fabricius Hildanus, 35, 176 . 326 , 342, 343, 368, 374, 376 , 396 , 425 ,
Fallopius,Gabriel, 20, 32, 367. 486 , 509.
Fielitz , 421. Himly, Karl, 325, 326 .
Follin , 425 . Hippocrates, 17, 19, 28 , 31.
Fisher, Lewis, 132. Hoffman (of Westphalia ), 44, 84 .
Flint, Austin , Jr., 230. Hoffman , Friedrich , 37.
Forest, Peter, 33. Home, Sir Everard , 25 , 40, 186 .
Flourens, 466 . Hubbard, Rob’t, 322 ,426 ,428, 430, 490.
Francis, George E ., 435 . Hun, E . R ., 107, 108, 110, 112, 113.
Frank, Martel, 43, 106, 422, 324. Huschke, 25 , 475 , 477.
Hutchinson,
Hunold , 325 .
Jonathan, 449, 504, 505 .
Hyrtl, Joseph, 23, 27, 56, 59, 62, 185,
Gadesden , 32. 235, 333, 466 , 482, 498.
Galen , 19, 30.
Gairal, 321.
Gerlach , 26.
Geynes, 19. Ingrassia , Columbo , 20 ,
Goltz , 466. Itard,
446.
I. M ., 9, 41, 76, 321, 326, 370,
Gottstein. 481.
Goethe, 219 .
Gray, John P., 110.
Garrod
Green . ,J.118Orne.
. 114. 115. 134. 141. 233. Jackson , Hughlings, 449, 450. 451.507.
339, 435. Jacoby (of Berlin ), 424, 425, 438.
Green , John, 227, 345 . Jaeger, Edward, 84.
Gross, S. D ., 152. Jasser, 420 ,421, 423.
Griesenger, 507. Jones, Handfield , 176 .
Gruening, E ., 400 ,402. Jones,
468.
T. Wharton, 25, 186 , 465 , 466,
Gruber, Ignas, 45 , 80.
Gruber, Josef, 23, 47, 55 , 63, 81, 102, K.
111, 115 , 184, 205 , 224, 261, 282 , 283,
297, 298, 332, 335 , 336 , 337, 339, 344 , Kessel. J.. 160. 185. 190 , 193, 203, 206 .
393, 437, 438, 490, 443, 515. Kessel, Adolph , 388.
Gull, Sir William , 444 . Knapp , H ., 48, 105, 134, 141, 466 , 490 ,
Guye, 311. L 502 , 506 , 511.
Guyot (Postmaster of Versailles', 38, Kramer, Wilhelm , 41, 272, 281, 306,
39, 300. 311, 328 .
Gudden , 111. Kölliker, 478, 479.
Köppe, 265, 266, 424, 444.
H. Kuchenmeister, 133.
Hackley, Charles E ., 223, 257, 306 , L.
369, 439.
Hagen , R ., 493. Lavater, 102.
Hallier, 136. Lebert, 445 , 446.
Haller, 24. Lee, Charles C, 362.
Hartman , Johan, 84 . Leschevin , 379.
| Lewis, William B ., 188 .
Hassenstein , 186 .
INDEX OF AUTHORS. 529
wincke, C. F ., 18, 31, 33, 37, 379, 475. | Post, Alfred C., 348 , 410, 411, 443.
Liston, 315. Prout, J. S ., 70, 72, 309, 340, 341, 342,
Loring, E .G ., Jr., 107,407,408, 412,431. 344 . , 191.
Lowenburg , 172 . Prussak
Lucae, August, 26 , 77, 339. Pythagoras, 19 .
Lusitanus, 34.
Q.
M. Quain , 315 .
Mach , 73.
Magnus, A ., 26, 228, 274, 345, 346.
Maunoir, 325. Rau, 328.
Marinus , 19. Reid, James, 314, 315.
Marcellus, 31, 81. Reynolds, 444, 449.
Mathewson, Arthur, 46 , 257, 377. Reiner, 48.
Mayer, Ludwig , 133, 162, 173,218,219. Rhazes, 31.
Meckel, 24. Riolanus, Johannes, 319, 419.
Merkel, 220. Riber, 325 .
Ménière, P ., 235, 491. Rivinus, 22, 184.
Meyer (of Hamburg ), 265. Robertson , Charles A ., 393, 398 .
Michaelis , 325 . Rockwell, A. D ., 313, 495, 511.
Millinger, 376 . Rosenmüller, 278 .
Monro, Alexander, 24. Rollfink , 419.
Morgagni, 22, 24 , 446 . Rüdinger, N ., 47, 174, 182, 197, 212,
Moos, S., 47, 48, 191, 273, 282, 397, 215 , 216 , 462, 463 , 465 .
400, 402, 490,495, 508, 509, 510-518. Rufus (of Ephesus), 19, 54.
Müller, Johannes, 26, 393, 511. Ruysch , F ., 23.
Murray, Adolph , 419 .
S.
N. Sabatier, 321.
Neuburg, 45 , 80.G , 9, 46, 425, 443. Santorini,64.
Newton , Homer Saissy , 41 , 326 .
Noyes, Henry D ., 280, 330 , Sarsonia , Hercules, 33.
North , Alfred , 405, 425 . Saunders, J. C., 40, 326 .
Savage, 315.
P.
Scarpa, Antonio, 24, 37.
Scheibenzuber, 165.
Pacini, 133. Schlemm , 26.
Pardee, Charles I., 296 , 302, 378, 407, Schmiedekam , 321.
425 . Schultze, Max, 475 .
Patruban, Von , 23, 184. Schwartze, Hermann , 40, 46, 75, 76 ,
Paré, Ambrose, 34 . 133 , 144, 246 , 256 , 265 , 266 , 279 , 282 ,
Paullini, 36 . 319, 320 , 321, 324 , 325 , 326 , 327, 329,
Paulus, Æginita, 31. 3:30, 341, 374, 375, 398, 424, 425, 495,
Petit, J. L ., 37, 39, 419, 424. 508.
Peters, George A ., 294. Seligman , Prof., 401, 402.
Peugnet, Eugene, 141. Semeleder, F., 89.
Petrequin , 160. Sequard, Brown, 112, 114 , 495.
Pinkney, Howard, 347,498. Serapion, 31.
Pliny , 19, 388 . Sexton , Samuel, 356 ,511.
Pilcher, George, 43, 177 . Shaw , Henry L ., 233 .
Politzer, Adam , 23 , 26 , 46 , 73 , 74 , 75 , Shakespeare, 167.
76 , 98 , 185 , 187, 226 , 261, 262, 263 , Shrapnell, Henry J., 25 , 184, 275 .
264, 272, 273, 274, 280, 294, 300 , 301, Sims, J. Marion, 173.
318, 309 , 310 , 311, 312, 313, 321, 330, Siegle, 276.
338 , 340, 341, 352, 356 , 359 , 360, 363, Smith , Andrew H ., 225, 310, 345 , 346 .
374, 376, 397, 401,406 , 426 ,431, 436 , Smith , Nathan R ., 41, 326.
437, 443, 497, 508. Smith , Gouverneur M ., 257.
Pomeroy, 0 . D ., 159, 266 , 278, 299, 300, Smith , T. Blanch, 415.
375 , 396 . Sommering, Thomas George, 25.
530 INDEX OF AUTHORS .
Stenon , Nicolaus, 22. | Voltolini, Rudolph , 42, 47, 89, 103, 168,
Sterling,George A ., 447. 169, 188, 282 . 315 , 316 , 331, 332 , 340 .
Steudener, F ., 137, 389 . 437, 438, 485, 481, 490 , 500 , 501, 502,
Stevenson . 326 . 508 , 509, 518 .
Sutton , 444.
Swieten , Van , 38.
Swift, Foster, 294. W.
Wakely , T ., 151.
T. Waltham , Jonathan , 23 , 38.
Tagliacottzi, Caspar, 34. Wallis, John , 36 .
Teulon ,Giraud, 86 .
Warner (of Ohio ). 291.
Thudichum , J. L . W ., 292. Weber, C . 0 ., 402 .
Thurnam , 111. |Weber, E . H . (Leipsic), 73, 292.
Todd, Robert B., 472,478. Weber, Liel, F . E ., 47, 297, 304, 319,
Toynbee, Joseph , 26 , 42, 45 , 111, 147, 402 332, 333, 334, 335, 337, 338, 339, 399,
220, 220, 261, 272, 279, 281,282, 283,
81,282, 283, Weber, Theodor (Halle), 291, 292.
28.), 315 , 328 , 379, 380, 402, 403, 405, Webster. David . 168. 175 . 274. 396 ,
439, 145 , 508 . 412, 413.
Tracy, Roger S., 492, 499. Welcker, H ., 401, 402.
Tröltsch , Anton Von, 26 , 35, 36, 42, 45, We
48,64, 65 , 102, 120 , 122, 176 , 187, 190, 'Weir, Robert F., 63, 211,228, 235,312,
425 , 511.
191, 195 , 203, 215, 235, 244, 265, 266 ,
272, 273 , 282, 292, 299 , 306, 328 , 38 ), Wilde, Sir William , 18 , 42 , 44, 80 ,89,
123, 127, 151, 244
404, 419, 420 , 423 , 424, 436, 466, 482, 314. 321. 324. 3:27 ., 314.
259, 272,
359, 281, 289,.
370, 393
507, 509, 518. 394, 412, 421, 423 , 424, 437.
Turck , 88. Willis, Thomas, 35.
Turnbull, Lawrence, 48 . Winslow , 24.
V. Wreden ,Robert, 133, 140, 266, 305, 331,
492, 493 , 495.
Valleroux, Hubert, 327.
Valsalva, Antoine Maria, 17, 22, 37, Y.
39, 100, 219, 274, 275 , 279, 324, 363,
419, 420, 424 . Yearsley , James, 43, 378, 379.
Varolius, Constant, 21. | Youx, Amedee,
Velpeau , 114.
Vesalius, Constant, 20, 21 z.
Vieussens, Raymond, 22.
Virchow , Rudolph, 107, 109, 445 , 446, ' Zaufal, E ., 497.
508. Zinn, 23.
Vogel, J., 133. Zieussen , 59.
Volcher Koiter, 21. Zoja , Giovanni, 207.
INDEX OF SUBJECTS .
Auricle, Physiognomy of, 102.
Abductor of Eustachian Tube, 352. Auricle, Functions of, 103.
Abscesses ofMembrana Tympani, 352. Auricle, Tumors of, 106 .
Abscesses of Cerebrum , 444 . Auricle, Malignant Disease of, 114 .
Actual Cautery, 413. Aural Douche, 124.
Adhesions in Middle Ear, 341. Authorities, 49,50, 66, 220, 483.
Air Bubbles in Perforation of Mem
brana Tympani, 30.3. B.
Air, Atmospheric use of, through Ca - Blood-letting , Local. 244.
theter, 302. Bougies for Eustachian Tube, 311.
Albuminuria,
tion , 369.
from Chronic Suppura Bougies in Membrana Tympani, 330.
Anti-tragus, 19. Bulging of Membrana Tympani, 2 :2.
Brain , Disease of, 354.
Anchylosis of Stapes, 37 Breathing through the Ear, 19.
Aneurism of Basilar Artery, 507. Bright's Disease, 256 .
Angiomna, 115 , 388.
Aquæductus Fallopii, 198.
Artificial Membrana Tympani, 35, 43 ,
378 . Calcareous Formations in Auricle,118.
Arabians, their knowledge ofOtology, Calcareous Formations in Membrana
31. Tympani, 273 .
Astringents, 129, 356 , 375 , 378 . Canal, External Auditory, 60 .
Aspergillus, 133. ( 'aries of Mastoid , 416 .
Aspergillus, Cases of, 141. ( aries of Temporal Bone, 434, 439.
Atropine in Acute Inflammation, 127. Caries of Teeth , 511.
Auditory Rods, 479. Carcinoma of Middle Ear, 392.
Auditory Cells. 481. Cases, Record of, 67.
Auditory Canal, External, Relations Cases of Foreign Bodies, 173
of, 64. Cases of Parasitic Inflammation , 140 .
Auditory Canal, Blood Vessels of, 65 . Cases of Inspissated Cerumen , 154.
Auditory Canal, Examination of, 80. Cases of Otitis Media Hemorrhagica ,
Auditory Canal, Nerves of, 66 . 254.
Auditory Canal, Osseous, 63. Cases of Sub-acute Aural Catarrh ,
Auditory Canal, Length of, 62. 252
Auditory Canal, Lining of, 62. Cases of Otitis Media Purulenta, 292.
Auditory Cana', Suppuration of, 129. Cases of Death , supposed result of
Auditory Canal, Parasitic Inflamma Use of Eustachian Catheter, 314.
tion of, 133. Cases of Perforation of Membrana
Auditory Nerve, first traced, 24. Tympani, 323 .
Auditory Nerve, 19. Cases of Acute Suppuration of Mid
Auditory Nerve, Diagnosis of Disease dle Ear, 359 .
of, 33 . Cases of Chronic Suppuration of Mid
Auditory Nerve, Anatomy of, 470. dle Ear, 382.
Aurilave, 12 ., 15 ). Cases of Exostoses, 404.
Auricle, Anatomy of. 53 . Cases of Mastoid Disease, 412.
Auriele, Blood Vessels of,59. Cases of Curies, 410.
Auricle. Muscles of, 56 . Cases of ('erebral Abscess, 452.
Auricle, Diseases of, 102. Cases of Otalgia, 512 .
532 INDEX OF SUBJECTS.
Catarrh of Middle Ear, 237, 262 . |Eustachian Tube, Morbid Changes in,
Catarrh of Middle Ear,Sub-acute, 249. 277.
Cauterization of Pharynx, 290. Eustachian Tube first injected , 38.
(auterization of Eustachian Tube, 299. Eustachian Tube, Foreign Bodies in ,
Cerebral Abscess, 444 -452. 73 .
Cerebral Tumors, 507. Eustachian Tube, Anatomy of, 208 –
Ceruminous Gland, 22, 63. 218.
Cerumen , Composition of, 160. Eustachian Tube,Muscles of, 214.
Cerumen , Supposed Functions of, 161. Eustachian Tube, Nebulizer for, 307.
Cerumen , Inspissated , 30, 34, 166. Eustachian Tube, Treatment of, 301.
Chorda Tympani, 21, 204. Eustachian Tube, Escape of Pus
Chorda Tympani, Division of, 342. through, 354.
Chorda Tympani, Injury of, 230. Eustachian Catheter, 93–96, 247, 279,
Cholesteatoma, 393. 313 .
Chloroform , use of, 166 . Eustachius, Poverty of, 21.
Chronic Non -suppurative Inflamma- Ears, Cutting off of, 34.
tion of Middle Ear, 319. Ear-rings, 55, 106 .
Chronic Suppuration of Middle Ear, Ear-drops, 36 , 285.
372 –382. Ear- muffs, 122.
Church , prevented Anatomical Stu Egypt, Specialists in , 28.
dies, 19. Electricity in Diagnosis , 492.
Circumscribed Inflammation of Exter- Electricity in Middle Ear Disease, 312 .
nal Auditory Canal. 13C. Electricity in Checking Ulcerations,
Cochlea , Anatomy of, 466 . 377.
Condensed Air , effects of, 345 . Electricity in Disease of Auditory
Condensed Air as Source of Injury , Nerve, 493 .
223. Emphysema from Catheter, 316.
Concussions, effects of, 503. Epithelioma of Auricle, 114.
Concave Mirror, 81. Epilepsy, 450.
Constitutional Treatment, 289. Exanthemata, 47, 353.
Conversation , Test for Hearing , 68. Examination of Patients, 67.
Cotton, Plugging Ears with , 123. Exhaustion of Air from Drum -head ,
347.
Corti's Organ , 479, 489.
Cleansing Ears,method of, 374 . Eczema of Auricle, 315 - 317.
Cleanliness of Ears , 123. Exostoses, 119 , 400 , 402 , 404.
Cotugnian Fluid , 21. External Auditory Canal, Anatomy of,
Cotton, Styptic, 246. 6 ).
External Auditory Canal, Circum
scribed Inflammation of, 120, 130.
External Auditory Canal, Syphilitic
Deaf-Muteism , 36 , 515 . Ulcers of, 144.
Dentition , Difficult, 2.10. Eyelet, Politzer's, 330 .
Delusions , 33. Eye and Ear Infirmary , New York , 48.
Dilator of Eustachian Tube, 214.
Diagnostic Tube, 74, 97, 281.
Diagnosis , Differential, between Cen Facial Paralysis , 199.
tral and Peripheral Lesions, 33.
Diffuse Inflammation of External Facial Nerve,
Fenestra 19 20 .
Ovalis,
Auditory Canal, 120. Fenestra Rotunda, 20, 198.
Double Hearing, 186 , 490. Fallibility of Galen, 19.
Douche, Vasal, 213 , 291, Fibromata , 388.
Douche, Aural, 124 , 355 . Fistula, Mastoid, 420 .
Draughts of Air, 123 . Fluids through Eustachian Catheter,
Drum of the Ear, 195 . 304.
Ductus Cochlearis, 476 . Forceps, Angular, 80.
Foreign Bodies, 29, 31, 162, 172,
Forehead Band, 86 .
Eustachian Tube, first described , 20. Foramen Rivinian , 184.
Eustachian Tube, Examination of, Fossa Vavicularis, 53.
90 - 92. Fossa Triangularis, 55 .
INDEX OF SUBJECTS . 533
Fossa, Sigmoidea, 205. | Labyrinth , Periosteum of, 472.
Fowler's Solution in Eczema, 118. Labyrinth , Diseases of, 485 .
Fracture of Malleus, 236. Lamina Spiralis Membranacea, 27,476.
Fungus, Vegetable, 135 . Lamps for Rhinoscopy , 90.
Furuncles of Auditory Canal, 130 Laxator Tympani Minor, 21.
Levator Veli Palati, 215.
G. Leeches, 123 , 244 , 290, 131, 355 .
Living Larvæ , 31, 164.
Galvano-cautery , 352, 397. Light Spot, 181, 250 , 274 .
Gargles, 299, 356. Ligaments of Ossicula, 201.
Glycerine, 132, 151. Lobe, 19, 56 .
Goats, Breathing through Ears, 19. Life Insurance, Relations of Aural
Graphium Pencilloides, 136 . Disease to, 387.
Glands, Ceruminous, 63.
Granulations, Polypoid , 396 . M .
Maculæ Cribrosæ , 463.
H . MalignantGrowths, 392.
Malformations of Auricle, 104.
Hairs upon Membrana Tympani, 63. Malleus,
Hallucinations, 162, 178. 186 , 200.
Hæmatoma, 107. Malleus, Fracture of, 235.
Hearing, Tests of, 68. Mastoid Cells, 20, 205 .
Hearing Power, Register of, 70. Mastoid , Caries of, 37, 205, 416 , 425 .
Hemiplegia, 449. Mastoid , Diseases of, 354, 408.
Mastoid , Trephination of, 39, 420.
Hemorrhage into Internal Ear, 498. Membrana
Helix , first named, 19. Basilaris, 478 , 481.
Helix, Etymology of, 53. |Membrana Tympani Secundaria, 198.
Hearing Trumpets,519. Membrana Tympani, Erroneous Anat
Hyperostoses, 404. omy of, 25 .
Membrana
378.
Tympani, Artificial, 35, 43,
I. Membrana Tympani, Perforation of,
Illumination of Ear, 39. 39, 361, 368 .
Intellect, Confusion of, 266 . Membrana Tympani, Method of Ex
Insanity from Aural Disease, 265. amining, 84 .
Membrana Tympani, Evulsion of, 232.
Insanity, Vascular Tumors in, 108. Membrana
Insects in the Ear, 163, Tympani, Bulging of, 242.
Instillations , 29. Membrana Tympani, Changes in , 271.
Incus, 200 . Membrana Tympani,Operations upon ,
Inflation of Middle Ear, 99. 319.
Inhaler, Iodine, 310. Membrana Tympani, Injuries of, 222.
Injections, 29. Membrana Tympani, Resisting power
Inspissated Cerumen, 34, 146 , 153. of, 224 .
Internal Ear, Hippocrates upon, 28 . Membrana Tympani, Increased Ten
sion of, 78 .
Internal Ear, Anatomy of, 483. Membrana Tympani, Anatomyof, 181 –
Internal Ear, Injuries of, 497 . 195 .
Internal Ear, Hemorrhage into , 498.
Internal Ear, Pathology of,508 . Membrana Tympani,Mobility of, 275.
Internal Ear, Diseases of, 485 . Membranous Labyrinth , 501.
Internal Ear, Necrosis of, 438. Meningitis, Cerebro-spinal,506 .
Iodine, Apparatus for Vapor of, 308. Medico-legal Examinations, 231.
Middle Ear, Anatomy of, 23.
Middle Ear, Acute Catarrh of, 237.
Middle Ear, Nomenclature of Diseases
Jugular Vein, 199. of, 237.
| Middle Ear, Mirror for, 398 .
L. Middle Ear, Suppuration of, 364 , 372.
Middle Ear, Chronic Non -Suppurative
Labyrinth , first described , 24. Inflammation of, 258.
Labyrinth , Anatomy of, 461. Middle Ear, Sub-acute Catarrh of, 249.
Labyrinth , Membranous, 470. | Middle Ear, Pathology of, 281.
534 INDEX OF SUBJECTS .
Modiolus, 469. Pharyngitis, Granular, 277 .
Murmur, Venous, 267. Pharynx in Sub-acute Catarrh , 250.
Muscles of Auricle, 55. Phlebitis, 199.
Muscles of Tympanic Cavity, 202 .
Muscida Sarcophaga, 165 .
Perforations of Membrana Tympani,
40, 324, 363.
Myringitis, 222. Perforations, Hearing Power in cases
Myringectomy, 340. of, 371.
Myringodectomy, 332 . Penicillium Glaucum , 136 .
Myxomata, 388. Periostitis, Mastoid , 412
Plastic Surgery , 34.
Polypi, 388 , 390 , 395 .
N. Politzer 's Method of Inflation , 22, 99,
247.
Nebulizer, Eustachian , 307 . Politzer's Method, Allen's Modifica
Nebulizer, Pharyngeal, 298. tion , 310 .
Necrosis of Internal Ear, 438 . Politzer's Method , Hinton 's Modifica
Necrosis of Temporal Bone, 434. tion, 251.
Neoplasia Vascular, 115 . Pocket Posterior, of Membrana Tym
Nervous Deafness, 259, 485 . pani, Division of, 339.
Nerves of Auricle, 60. Posterior Nares Syringe, 353.
Nerves of Tympanic Cavity, 204. Poultices, use of, 12 , 125 .
Nerve, Auditory, 483. Probes in Opening of Membrana Tym
Neuralgia , Catarrh mistaken for, 241. pani, 340 .
Nitrate of Silver, 375 . Probing , danger of, 147.
Noise, better hearing in, 35, 271. Proliferous Inflammation of Middle
Nomenclature of Chronic Non -Suppu Ear, 262.
rative Inflammation, 261. Promontory , 198.
Pregnancy cause of Aural Disease, 286 .
O. Pulsation in Tympanic Cavity , 368.
Pyæmia, 198 , 292, 447.
Otalgia, 511.
Otology, progress of, 17.
Otological Society, American, 47.
Otoscope, 98 . Quinine, effects of, 155 , 503.
Otoscope, Interference, 77.
Otoscope , Von Tröltsch 's, 81.
Otoscope, Binocular, 86. R.
Otoliths, 475 . Results of Treatment,Acute Suppura
Othæmatomata , 107. tion, 357.
Otitis Externa , 119. Results of Treatment, Chronic Non
Otitis Media Hemorrhagica , 254. Suppurative Inflammation , 349.
Otitis Media Hyperplastica, 261. Restiform Bodies , Section of, 112 .
Opium , 30. Rivinian Foramen , 22.
Ossicula Auditus, 20, 200. Rhinoscopy , 89 .
Osteo Sarcoma, 393 . Rhinoscopy, Changes observed in , 278 .
s.
Paracusis Willisiana , 35. Saccule,476 .
Parasiticides, 140. Salpingo-pharyngeusMuscle, 217.
Paracentesis of Membrana Tympani, Santorini Incisuræ , 62.
246 , 320 , 343. Sarcoma of Auricle, 115 .
Parasitic Inflammation of External | Sciatic Nerve, Section of, 112.
Auditory Canal, 133 . Scala Tympani, 469.
Paralysis, 449. Scala Vestibuli, 469.
Parotid Gland, Inflammation of, 64. Scarlet Fever cause of Catarrh , 243 .
Pathology of Internal Ear, 508 . Semi-circular Canals, Anatomy of, 464.
Pathology of Middle Ear, 281. Semi-circularCanals,Functionsof, 166 .
Pharmaco -koniantron , 304. Semi-circular Canals, Disease of, 491.
Pharynx, Treatment of, 290. Skeptic in Medicine, 19.
INDEX OF SUBJECTS. 535
Small Pox , cause of AuralCatarrh ,213. , Trephining Mastoid, 39.
Sonofactors, 70 . Tragus, first named, 19,53.
Specialists in Egypt, 28 . Treatment, Results of, 317, 347.
Speculum , first used , 32. Triangular Spot of Light, 186 ,
Speculum for Anterior Nares, 91. Trichothecium Roseum , 136 .
Speculum , Bi-valvular, 80. Tuning -fork , 71, 79, 148, 269, 488.
Speculum ,Mode of using, 82. Tumors of Auricle, 106 .
Speculum , Siegle's, 276 . Tumors, Cerebral, 507.
Speculum , Pharyngeal, 89. Tubulus Hirsutus, 161.
Stapes, 20, 200. Tympanum , Cavity of, 195 .
Stapedius Muscle, 20, 203 .
Sterility, Ancient Idea of Cause, 34. U .
Steam , use of, 02.
Stemphyllium , 136 . Urine, Ancient Instillation of, 36.
Shrapnell's Membrane, 184.
Suppuration, Acute , of Middle Ear, Utricle, 473.
350.
Suppuration , Chronic, of Middle Ear,
364, 370. Valsalvian Experiment, 275 .
Syringe, first employed , 34. Venesection, 29 .
Syringing, Method of, 128. Vertigo, 147, 264.
Syringing, Naso-pharyngeal, 290.
Syringing, Pharynx ,Gruber's Method , | Vestibule,
Vomiting, Anatomy of, 462.
effect of, 231.
297.
Syringing, Cavity of Tympanum , 342.
Syphilitic Ulcers, 144.
Syphilis, Deafness from , 286 , 505. Warm Water, Instillation of, 28, 260.
Styptic Cotton, 398. Water in the Ear, 243.
Watch as Test of Hearing , 68 .
T. Whooping Cough, 231.
Tensor Tympani, 20, 203. Worms in the Ear, 31.
Tensor Tympani, Division of, 332.
Therapeutics, Progress, 27. Z.
Tests of Hearing, 68.
Tinnitus Aurium . 30, 135 , 147, 240 , 267. Zona Denticulata , 27.
Tones, Deafness for certain , 489. Zona Pectinata, 27.
LANE MEDICAL LIBRARY
To avoid fine, this book should be returned on
or before the date last stamped below .
R121 Roosa , D . B . St . J . 16178
R78 A practical treatise
1876 _ on the diseases of the
NAME ear . 30 ed DATE DUE

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Daniel Bennett St. John Roosa

LEVI COOPER LANE 'FUND

ANATOMY AND DISEASES OF THE EAR .

DISEASES OF THE EAR

THE ANATOMY OF THE ORGAN .

D . B . ST. JOHN ROOSA, M .A ., M . D.,

JOHN F . Trow & Son,

Electrotyped by SMITH & MCDOUGAL, 82 Beekman Street.

ADVERTISEMENT TO THE SECOND EDITION .

20 EAST THIRTIETH STREET, April 4, 1874.

THIS work is intended to be a guide to those who wish to treat

* “ Arbores seret diligens agricola quarum adspiciet baccam ipse nun.

NEW YORK, May 29, 1873.

mina Spiralis Membranacea - Terminal Auditory Apparatus- Auditory

Index of Authors, . . . . . . . . . . . . 525

20. Eustachian Catheters, actual size, . . . . . 94

31. E . H . Clarke's Aural Douche, . . . . . . . . 123

60. Pharyngitis granulosa, . . . . 277

62. Posterior Nares Syringe, . . 290

65. Apparatus for Steaming the Middle Ear, 303

72. Vessel used in Syringing the Ear, . . . . . . . 373

INTRODUCTORY SKETCH OF THE PROGRESS OF OTOLOGY.

THE EXTERNAL EAR.

THERE is perhaps no department of the art and science of

dark ages, than there are in any other field . It is to be feared

* Aural Surgery, English edition , p. 7.

PROGRESS IN THE ANATOMY OF THE EAR .

Hippocrates probably knew very little of the anatomy of

a passage which his predecessors had regarded as impermea

also gave a more exact account of the tube leading from

in themembrana tympani,which he believed to be a constant

of the labyrinth, won such a reputation by his work upon

1747– 1832] Antonio Scarpa issued a work on the structure

1800 ] Mr. Everard Home wrote an excellent, and, for its

nold , Schlemn, Johannes Müller, Breschet, Bonnafont, and

ments,which were supplementary to those of Müller, in show

In the earlier ages the progress in the treatment of the ear

ticular physician for each disease, but no mention is made of

very much of instillations of various kinds for the relief of the

About this time we read of the materia medica of Marcel

ance and empiricism only. One author named Gadesden rec

obstinate abscess of the right ear, by means of a mixture, or

notion that patients always spoke in a low tone when the

1597] Caspar Tagliacottzi,of Bologna, who did so much for

semen, which was generated in the brain , could no longer pass

In the latter half of the seventeenth century , Thomas Willis

* Diseases of the Ear, American translation, 2d edition, p.256 .

* Diseases ofthe Ear. American translation, p. 488.

lost his hearing at eight years of age ; but he became able to

tient died in a few days. This put a stop to the performance

The book is very deficient in its treatment of the Eustachian

* A Treatise on the Physiology and Diseases of the Ear, by John Harrison

also gave us the air - press, by which air or vapors could be

plished anything for aural pathology and therapeutics in any

means of treatment, and is in constant use by many of those

the conical specula , reviving a suggestion of Dr. Newburg of

favor, having passed through two editions, and it has given