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1013 Penn. Avemjs
WasJiington, D. C.
g. W. ilcXeal, P)op.
ARCHIVES
OF
OTOLOGY
EDITED IN ENGLISH AND GERMAN
BY
Dr. H. KNAPP Dr. S. MOOS
OF NEW YORK OF HEIDELBERG
AND
Dr. D. B. ST. JOHN ROOSA
OF NEW YORK
IN CONJUNCTION WITH
Dr. C. R. Agnew, of New York ; Prof. E. Berthold, of Konigsberg ; Dr.
G. Brunner, of Zurich ; Dr. SwAN M. Burnett, of Washington ; Dr. W.
B. Dalby, of London ; Dr. J. Patterson Cassels, of Glasgow ; Dr. E.
Frankel, of Hamburg ; Dr. J. Gottstein, of Breslau ; Dr. E. Gruening,
of New York ; Dr. A. GUYE, of Amsterdam ; Dr. A. Hartmann, of Berlin ;
Dr. C. J. KiPP, of Newark ; Dr. B. Loewenberg, of Paris ; Dr. F. M.
Pierce, of Manchester ; Prof. E. de Rossi, of Rome ; Dr. G. Sapolini, of
Milan ; Dr. Jas. A. Spalding, of Portland, Me. ; Dr. H. Steinbrugge, of
Heidelberg ; Dr. O. Wolf, of Frankfort-on-the-Main ; Prof. R. Wreden, of
St. Petersburg ; and many others.
VOLUME XII.
NEW YORK
^
G. P. PUTNAM'S SONS, 27 & 29 West 23D Street
London: 25 Henrietta Street, Covent Garden.
Wiesbaden : J. F. Bergmann's Verlag
Paris : J. B. Bailliere, 19 Rue Hautefeuille
1883
COPYRIGHT BY
G. P. PUTNAM'S SONS
1883
'RF
\i. 13-
Press 0/
G. P. Fuitzani's Sons
Neiv York
CONTENTS OF VOLUME XII.
NUMBER I.
Disease of the Ear Occurring During the Course of Parotitis. By
D. B. St. John Roosa, M.D i
A Case of Bin-aural Objective Sounds, with Synchronous Movements
of the Membrana Tympani and the Palatal Muscles. By Dr.
Richard C. Brandeis, New York ....... 14
Anatomical Researches on the Deviations of the Nasal Septum. By
B. Loewenberg, M.D., Paris, France. (With five wood-engravings.) 22
Three Serious Cases of Mastoid Disease, with Remarks. By H.
Knapp ........... 44
A Case of Abscess of the Mastoid, with Entire Absence of Tender-
ness, Heat, or Swelling over the Suppurating Part, with a Con-
stant Distant Pain near the Occipital Protuberance ; Trephining ;
Occurrence of Erysipelas During Convalescence ; Recovery. By
F. Tilden Brown, M.D., New York 56
Pedunculated Bony Growth in External Auditory Canal, the Result
of Long-continued Suppuration ; Removal by Snare ; Microscopic
Examination. By David C. Cocks, M.D., New York ... 59
The Examination of Ears by Means of the Tuning-Fork. By J. B.
Emerson, M.D., New York 63
Two Cases of Syphilitic Disease of the Labyrinth, with Remarks.
By David Webster, M.D., New York 76
A Case of Clonic Spasm of the Levatores Palati, Producing a Rhyth-
mical Clicking Noise. By Dr. Cornelius Williams, of St. P'aul,
Minn 83
The New York Institution for the Improved Instruction of Deaf-
Mutes. By D. Greenberger, Principal. (With three drawings.) . 87
Die Taubstummen und die Taubstummenanstalten nach seinen
Untersuchungen in den Instituten des Konigreichs Wiirtemberg
und des Grossherzogthums Baden (Deaf-Mutes and Deaf-Mute
Institutions). Von Medicinalrath Dr. Hedinger. Reviewed by
A. Hartmann .......... 96
^'^B8
8
iv Contents.
12. Lehrbuch der Ohrenheilkunde fur practische Aerzte und Studirende.
(Text-Book of Otology, for Practitioners and Students.) By Prof.
Adam Politzer. In two volumes. Vol. II. (With 152 wood-
engravings.) Reviewed by A. Hartman gg
NUMBER 2.
1. The Effects of Noise upon Diseased and Healthy Ears. By D. B.
St. John Roosa, M.D 103
2. Calcium Sulphide in Aural Diseases. By Gorham Bacon, M.D. . 122
3. Cholesteatoma of the Mastoid Process with Rupture into the Exter-
nal Auditory Meatus after Use of Irish-Roman Baths. By S. Moos,
of Heidelberg. Translated by Porter Farley, M.D., of Roches-
ter, N. Y 129
4. Necrotic Exfoliation of the Superior (?) Bony Semicircular Canal,
Preceded by a Week of Dizziness and Vomiting ; Recovery with
Loss of such Degree of Hearing as had Previously Existed. By
S. Moos. Translated by Porter Farley, M.D., Rochester, N. Y. 132
5. Pyasmic Attacks During and After Recovery from an Acute Purulent
Inflammation of the Tympanum. By S. Moos. Translated by
Porter Farley, M.D 136
6. (Edema in the Temporal and Zygomatic Regions, as a Symptom of
Phlebitis and Thrombosis of the Lateral Sinus. By S. Moos
Translated by Porter Farley, M.D
7. On the Production of Artificial Deafness, and its Bearing on the
Etiology and Evolution of the Diseases of the Ear. By Dr,
Cassells, Glasgow ........
8. Unsuccessful Attempt at Restoring an Ear-Canal Closed by Cauter-
ization with Sulphuric Acid. By H. Knapp
9. Report on the Progress of Otology in the Second Half of the Year
1882. Translated by J. A. Spalding, M.D., Portland, Me.
I. — Normal and Pathological Anatomy and Histology of the Ear. By
Dr. Steinbriigge, Heidelberg.
II.— Pathology and Therapeutics of the Ear. By A. Hartmann, Berlin.
10. Abstracts from the Otological Papers Read Before the American
Medical Association, at its Meeting in Cleveland, O., June 5, 6,
and 7, 1883 183
11. Miscellaneous Notes 184
141
147
154
157
NUMBERS 3 AND 4.
The Hyphomycetes Aspergillus Flavus, Niger, and Fumigatus ;
Eurotium Repens (and Aspergillus Glaucus), and their Relations
to Otomycosis Aspergillina. By Dr. F. Siebenmann, of Brugg,
Switzerland. Translated by J. A. Spalding, M.D., Portland,
Me 185
Contents. v
2. Reproduction of the Membrana Tympani by Skin-Grafting. By
C. W. Tangeman ......... 228
3. Clinical Notes on Ear-Disease: CEdema of the Drum Membrane
Simulating Polypus ; Deafness Improved by Electricity and Phos-
phorus. By P. McBride, M.D., F.R.S.E., F.R.C.P., Edinburgh 231
4. The Etiology and Symptomatology of Autophony. By G. Brunner,
M. D., Zurich. Translated by H. Knapp 238
5. The Histological Condition of Six Temporal Bones Taken from
Three Children who had Died from Diphtheria. By S. Moos and
H. Steinbriigge, Heidelberg. Translated by Charles J. Kipp,
M.D 255
6. On the Influence which the'^Treatment of One Ear Alone Exerts
upon the Other. By Dr. A. Eitelberg, of Vienna. Translated
by J. A. Spalding, M.D., Portland, Maine 266
7. The Influence of Hearing-Exercises on the Sense of Audition of
the Practised and Consecutively on the Other not Practised Ear.
By Dr. A. Eitelberg. Translated by Dr. J. A. Spalding . .279
8. Further Investigations on the Physiological Significance of the
Trigeminus and Sym.pathetic Nerves for the Ear. By E. Berthold,
Konigsberg, Prussia, Translated by Dr. F. E. D'Oench, New
York ............ 292
9. Secondary Symptoms in the Labyrinth as Sequels of Chronic Puru-
lent Inflammation of the Middle Ear. By S. Moos and H. Stein-
briigge, of Heidelberg. Translated by H. Knapp . . . 299
10. Histological Labyrinthine Changes in a Case of Acquired Deaf-
Mutism. By S. Moos and H, Steinbriigge. Translated by H.
Knapp. (With a wood-cut.) ....... 304
11. Neuropathological Communications. By S. Moos. Translated by
H. Knapp . . ........ 309
12. The Diagnosis and Treatment of Diseases of the Ear. By Owen D.
Pomeroy, M.D. Reviewed by Swan AL Burnett . . . 323
13. Report on the Progress of Otology During the First Half of the
Year 1883. Translated by Drs. J. A. Andrews, New York, and
Swan M. Burnett, Washington ....... 325
I. — Normal and Pathological Anatomy and Histology of the Ear. By
II. Steinbriigge, Heidelberg.
II. — Physiology and Physiological Acoustics. By Oscar Wolf, Frank-
furt.
III.— Pathology and Therapeutics. By A. Hartmann, Berlin.
14. Index 365
CONTENTS OF VOLUME XII, NUMBER i.
1. Disease of the Ear Occurring During the Course of Parotitis. By
D. B. St. John Roosa, M.D I
2. A Case of Bin-aural Objective Sounds, with Synchronous Movements
of the Membrana Tympani and the Palatal Muscles. By Dr.
Richard C. Brandeis, New York ....... 14
3. Anatomical Researches on the Deviations of the Nasal Septum. By
B. Loewenberg, M.D., Paris, France. (With five wood-engravings.) 22
4. Three Serious Cases of Mastoid Disease, with Remarks. By H.
Knapp. ........... 44
5. A Case of Abscess of the Mastoid, with Entire Absence of Tender-
ness, Heat, or Swelling over the Suppurating Part, with a Con-
stant Distant Pain near the Occipital Protuberance ; Trephining ;
Occurrence of Erysipelas During Convalescence ; Recovery. By
F. Tilden Brown, M.D., New York 56
6. Pedunculated Bony Growth in External Auditory Canal, the Result
of Long-continued Suppuration ; Removal by Snare ; Microscopic
Examination. By David C. Cocks, M.D., New York . . 59
7. The Examination of Ears by Means of the Tuning-fork. By J. B.
Emerson, M.D., New York 63
8. Two Cases of Syphilitic Disease of the Labyrinth, with Remarks.
By David Webster, M.D., New York 76
9. A Case of Clonic Spasm of the Levatores Palati, Producing a
Rhythmical Clicking Noise. By Dr. Cornelius Williams, of St.
Paul, Minn. 83
10. The New York Institution for the Improved Instruction of Deaf-
mules. By D. Greenberger, Principal. (With three drawings.) 87
11. Die Taubstummen und die Taubstummenanstalten nach seinen
Untersuchungen in den Instituten des Konigreichs Wiirtemberg
und des Grossherzogthums Baden (Deaf-Mutes and Deaf-Mute In-
stitutions.) Von Medicinalrath Dr. Hedinger. Reviewed by
A. Hartmann .......... 96
12. Lehrbuch derOhrenheilkunde fiir practische Aerzte und Studirende
(Text-Book of Otology, for Practitioners and Students.) By Prof
Adam Politzer. In two volumes. Vol. II. (With 152 wood
engravings.) Reviewed by A. Hartmann ..... 99
NOTICE TO CONTRIBUTORS.
The editors and publishers of these Archives beg to offer some
suggestions to authors who propose to favor them with their con-
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1. As original communications these Archives can accept only
such papers as have neither been printed nor are intended to be
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periodicals, will make no abstracts of the original papers published
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2. Authors will receive gratuitously twenty-five reprints of
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4. Authors may receive proofs for revision if they will kindly
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tributors that changes in the copy are equivalent to reserting,
causing so much additional expense. We therefore request
them, to make, if possible, no alterations at all in their MSS.,
or, at least, to limit these to what is of essential importance.
VOL. XII. No. I.
ARCHIVES OF OTOLOGY.
DISEASE OF THE EAR OCCURRING DURING
THE COURSE OF PAROTITIS.
By D. B. St. JOHN ROOSA, M.D.
THE interest lately shown in the discussion of deafness
following mumps, warrants further publication upon
this subject, especially if there are new cases to be pre-
sented. Inasmuch as I have recently had an opportunity of
studying and tracing one of these cases more thoroughly
than has ever before been my fortune, and since two of
them, published in 1874,' have escaped the observation of
some of the recent writers upon this subject, I have en-
deavored to gather together, in the following paper, what
knowledge I have been able to get in my private practice
from a study of disease of the ear occurring during the course
of parotitis. The specialists, both in our country and in
Germany, have seen but few of these cases. It is possible
that general practitioners have seen more of them, but the
facts to substantiate such a supposition have not appeared.
It is much to be desired that any unpublished experience
of this kind should be made generally accessible. I
am emboldened to present in this paper all the cases that I
have seen, of which I have notes, even though some of
them have been printed before, from reading an article by
Dr. Brunner, of Zurich, lately published in these ARCHIVES.
Dr. Brunner says^ : " If Roosa has actually seen as many of
the cases of deafness after mumps, as he says in the discus-
sion of Buck's two cases, I am very sorry that he has not
^ Americanjournal of the Medical Sciences, vol. Ixviii, page 389.
'^ Vol. xi, page 102.
I
2 D. B. St. John Roosa.
given us any more exact communications with regard to
them."
Dr. Brunner is mistaken in supposing that I ever claimed
to have seen many cases of impairment of hearing during or
after parotitis. Any one who is interested in such a small
matter as to what I claimed as to my experience, will find
by reference to the dicussion that occurred in the American
Otological Society, that this remark of Dr. Brunner's is
entirely unjustified.'
I think the papers by Buck, Brunner, Moos, and Knapp
give the idea, that this subject of deafness after mumps
has been greatly neglected by the writers on aural medicine
and surgery, including myself. But the text books of Toyn-
bee, Hinton, and Roosa, as well as that of Dalby, really give
as much information as that contained in some of the recent
papers. The reason for the meagreness of statement is to
be found in the fact, that none of us saw these cases, as a
rule, until they had run their course. It is only during the
last two years, that I have seen a case near enough to its
beginning to allow of any accurate study of its etiology.
Cases of aural disease after mumps came to us, as do so
many cases of deafness after cerebro-spinal meningitis, when
all acute symptoms had subsided, and we could only learn
of them by hearsay. I am very glad to be able to report an
entirely new and acute case in this paper, and one which,
in my opinion, is valuable as indicating the causation, treat-
ment, and prognosis.
There has been, I think, no such silence on the part of
English writers or myself upon the subject, as one reading
recent articles would be led to suppose. Toynbee's reference
to the subject, in his work published in 1860,^ is so complete
that the recent German writers have added very little if any
thing to it. He states that "the peculiar poison which
causes the disease generally known by the name of mumps
is very often the source of complete deafness, which, how-
ever usually occurs in one ear only." In this sentence will
be found an epitome of most that has been said of late
* These Archives, vol. x, p. 274.
* " Diseases of the Ear, " London, page 361.
Disease of the Ear. 3
on this subject, except that very often should be stricken
out. In the first edition of my work on the ear, I men-
tioned mumps as a cause of disease of the ear, while in later
editions, especially in the one of 1878, I gave a fuller notice of
the subject. James Hinton,' in his most excellent work, a
book that is singularly honest and suggestive, uses the
following language, which it seems to me, indicates a com-
prehensive study of the subject, and adds very much to
what Toynbee said twenty-two years ago. " Next, or per-
haps equal, in frequency to scarlatina, in this respect, stands
mumps, which has an effect on the nervous apparatus of
the ear which has as yet received no explanation, and affords
no clue to the use of remedies ; every part of the ear being
normal, so far as examination can extend, but the func-
tion is almost abolished. ' But some cases (the italics are
mine) of damage to the ear from mumps present an inter-
mediate character, showing clear signs of a tympanic disorder
mixed with the fiervous symptoms. The similarity of the
nerve affection that follows mumps to that which ensues upon
parturition, is very striking ; and the resemblance is increased
by the fact that quite frequently the latter affection also is ac-
cojnpanicd with symptoms of a catarrhal character." ' Such a
paragraph as this, atones to a great degree for the vagueness
complained of in the authors who have spoken of disease of
the ear occurring after mumps.
It is to be noticed, however, that Toynbee and Hinton
both speak of the affection as if it were a common one. It
was this statement of Toynbee, that led me to lay no es-
pecial stress upon my first cases — for I supposed I was alone
among otologists in having seen but few of them — and I
published them in an article upon diseases of the internal
ear. In the same way, I published a case, in an article
upon acoustic neuritis and atrophy of the acoustic nerve, in
September, 1881,^ which I had seen and treated for three
weeks. This latter case is one of those presented by Dr.
Buck, at the meeting of the American Otological Society,
a case which he saw after he had been under the care of
* " The Questions of Aural Surgery." Henry J. King & Co., London, 1874.
* These Archives, vol, x, p.
4 D. B. St. John Roosa.
Dr. Ely and myself. I have notes of ten cases of disease
of the ear occurring during parotitis, out of a total number
of more than 4500 cases of aural disease that I have seen
in private practice, and of which I have taken notes.
Case i. — Parotitis. Deafness of one side. Patient first
seen three years after the occurrence of the mumps.
H. A. H., aged twenty-three, student of medicine. Three years
ago the patient had a slight attack of the mumps. During it he
lost the hearing of the right ear. Hearing distance, R ^^^- and
L ff . The membrana tympani appears to be normal. There is
considerable tinnitus mirium. The patient was treated through
the Eustachian tube for about two months. The tinnitus was
usually diminished for an hour or so after the applications through
the catheter.
In this case there was certainly disease of the mid-
dle ear. It will be observed that the watch was heard
"upon the mastoid process, while not upon the meatus.
The case was seen in 1866, when I was not aware of the
value of the tuning-fork in making a differential diagnosis
of disease of the middle ear. Yet, from the results of the
treatment, I am confident that there was an affection of
the middle ear ; as I have said, however, the nerve may
have been affected.
Case 2. — Disease of labyrinth of one side after parotitis.
Patient first seen otie year after loss of hearing occurred.
Miss B., aged twenty-one, June 14, 187 1. Patient states that
she had the mumps one year ago. After recovery, she observed
a buzzing sound like that made by insects. She has not heard
from the ear since. At times there is an unpleasant fulness in the
ear.
The hearing distance from the right ear is normal. From the
left, it is -^.
The membranse tympani are normal. The tuning-fork is heard
only on the right side.
The patient was seen again in September of the same year. She
then stated that she had vertigo occasionally. In other respects
the condition was the same.
Disease of the Ear. 5
The evidence is clear that the labyrinth was the chief, if
not the only, seat of the aural disease in this case. The
foregoing cases are those published in the American Journal
of Medical Sciences, loc. cit.
Case 3. — Disease of labyrinth of both sides after scarlet
fever, measles, and mumps. Patient first seen thirty-one years
after loss of hearing occurred.
Henry N. X., aged thirty-four, Sept. 15, 1873. The patient
states that when two or three years old he had the measles, scarlet
fever, and mumps in one year, and that his hearing has been de-
fective ever since. He never had any discharge from the ears,
and he rarely has tinnitus.
H D, R ^ and L ^ (?)
The tuning-fork is heard better on the better side. The right
drumhead is somewhat sunken. The left one looks well.
Inflation of the middle ear produces no change in the hearing
power.
The meagreness of the history does not enable me to say
whether the loss of hearing was observed immediately after
the attack of parotitis, or after the measles, or scarlet fever.
The absence of ulceration at any time, however, inclines me
to believe it to be a true case of loss of hearing as a result
of parotitis.
Case 4. — Impairment of hearing of left ear, occurring dur-
ing attack of parotitis. Disease of right ear had occurred
previously from scarlet fever. Patient first seen about five
months after attack of mumps.
Mrs. J. S. C, aged about thirty-five, Oct. i, 1875. The patient
states that she had scarlet fever at the age of eighteen. She has
suffered from greatly impaired hearing on the right side ever
since. Last May she had the " mumps." During the course of the
disease, she found that she was deaf in the left ear, She heard
well on one day, and the next day she found herself deaf. There
was no pain in the ear, and no discharge from it. She has suffered
from tennitus aurium since. She hears the watch on the right
side (on that of the ear deaf from scarlet fever), ^^. L ear when
6 D. B. St. John Roosa.
pressed upon the mastoid, ^. She has naso-pharyngeal catarrh.
Both drumheads are of good color, and have good light spots.
The diagnosis made was disease of the middle ear on the
right side and disease of the labyrinth on the left. The
grounds for the diagnosis of labyrinthine disease are,
however, not given, except in the statement that the
deafness occurred suddenly, and that inflation caused no
improvement in the hearing. Unfortunately, I do not re-
member the case with enough clearness to give any more
detailed account of the reasons for believing that the ear
affected by scarlet fever was chiefly so in the middle part,
while the other had a lesion of the nerve.
Case 5. — Impairment of hearing of one side after mumps.
Inspissated cerumen. Hearing improved after its removal.
Patient first seen ten years after the parotitis had occurred.
C. H. T., aged twenty-eight, Oct. 12, 1875. The patient
states that he had the mumps ten years ago. After that he ob-
served that the watch was heard better in front of the right ear
than of the left. He did not regard the condition of his ear very
much until last summer, when he had a sore throat and dyspepsia,
when his attention was again called to his ears. He then ob-
served a drumming noise in the left ear, and some impairment of
hearing. The hearing distance was found to be R |^, L ^'Xt^-
The tuning-fork was heard better in the worse ear. The pharynx
was granular. The right drumhead was very much sunken, and
there were opacities in it. The light spot was of good size.
The left membrana tyro pan i was covered by hard wax. When it
was removed the drumhead was found to be sunken, and it had
no light spot. On removal of the cerumen, the hearing distance
arose from /g- to j^g, and after inflation to ^.
The history and examintion show that this was a case
of disease of the middle ear. It is probable that the hear-
ing power was only slightly impaired, until the attack of
inspissated cerumen, which reduced it so much as to call
the patient's attention to it. From my data, I believe that
the average hearing power of the side affected by the
parotitis was W.
Disease of the Ear. 7
Case 6. — Double parotitis folloived by absolute deafness.
Patient seen thirty-tivo days after occurrence of deafness.
Mabel O., aged four and a half, Feb. 26, 1875. The patient
had parotitis about thirty-two days ago. She recovered promptly.
Five days after began to suffer from impairment of hearing, and
in twenty-four hours she became deaf. For two or three days
there was some unsteadiness in her walk, also occasional vomit-
ing. The little patient was very weak.
The patient was found to be absolutely deaf. The drumheads
were normal in appearance. No improvement resulted from
treatment. That this was a case of disease of the labyrinth is in-
disputable.
Case 7. — Sudden deafness of one ear after mumps. Patient
seen a year after the disease occurred.
R. W. H. of Australia, aged twenty-three. May 3, 1880, The
patient states, that he became deaf rather suddenly in the left ear,
after an attack of mumps about a year ago. He also had a low
fever. Just as he was recovering from the mumps he found that
he was hard of hearing on the left side. He could hear the tick-
ing of a watch however. He has remained hard of hearing from
that time. H D, R f f ; L j\. The bone-conduction for tuning-
fork C is better than aerial on the left side. Both membranae
tympani are opaque. No improvement to the hearing resulted
from inflation.
This is, I think, a clear case of disease of the middle ear
after parotitis ; that the internal ear may also have been
affected, will not be denied. Yet the probabilities are,
that the disease was situated exclusively in the middle ear.
The tuning-fork test is, I think, very reliable in determining
the situation of the lesion, and that certainly positively in-
dicated disease of the middle ear.
Case 8. — This case has already been published twice :
once by Dr. Buck, in the American Journal of Otology ; and
again by myself, in these Archives. The patient was
treated by Dr. Edward T. Ely and myself, for three weeks,
before he consulted Dr. Buck. The reader is referred to
these Archives, vol. x, page 217, for a full account of the
case.
8 D. B. St. John Roosa.
Parotitis three weeks before. Deafness two weeks since. Dizziness
for one week. Dulness of hearing in the right ear also, which soon
passed away. Constant tinnitus.
W. D. C, aged forty-one, sent to me by Dr. J. W. S. Gouley,
June 25, 1881.
H D, R 1^ ; L /o (?)• The tuning-fork is heard only in the
right ear. It is not heard at all by aerial conduction on the left
side.
As I said, in discussing this case in the Archives, although
it had become one of the labyrinth on the left side, it may-
have begun in the middle ear, for on the other side there
was a slight affection of the middle ear, which passed away.
I see no reason why a slight affection of the middle ear
may not have extended and become a serious affection in a
part that tolerates only a very slight lesion ; certainly the
labyrinth is in direct communication by blood-vessels with
the tympanic cavity, which, in turn, through the auditory
canal and the mastoid process is directly connected with
the parotid gland.
Case 9. — Parotitis a year before patient was seen by the
writer. Hearing was found to be impaired soon after.
Janet R., aged twelve, sent to me by Dr. J. W. S. Gouley,
March 11, 1882. The patient had parotitis on both sides a year
ago. She made a slow recovery. Her hearing was found to be
impaired soon after, and it has remained so. Her general health
is fair.
H D, R |-|; L ^-^. She cannot say in which ear the vibrating
tuning-fork is heard, when placed upon the forehead or teeth. In
the left or bad ear the bone-conduction is better than the aerial.
The drumheads are slightly sunken and the light spots are
small. The hearing is diminished immediately after inflation.
The patient was seen a few times, but as she seemed to be rather
worse for treatment of the middle ear, she was dismissed unim-
proved.
This case seems to me to be a clear one of disease of the
middle ear, although I will not undertake to say that there
was not also a lesion of the labyrinth. The fact that she
Disease of the Ear. 9
invariably became worse after inflation of the ear inclines
me to think so. But the fact that there was still consider-
able hearing power left in the ear, inclines me to the belief
that the affection was primarily in the middle ear.
Case io. — Parotitis on each side. Chill fourth or fifth
day after. Great impairmefit of hearing. Recovery of one
side after inflation of the middle ears. Improvement in the
other.
Robert B., aged eight, was brought to me by his mother on
April 24, 1882, with the following history : About three weeks
before he was attacked with mumps, affecting each side. On the
fourth or fifth day after the mumps appeared, he had chilly sensa-
tions one evening, probably in consequence of the lowering of the
temperature of the room in which he was. The next day he had
a high fever ; he vomited ; and on that day it was observed that
he did not hear well. His hearing has not become worse since,
perhaps he is slightly better. He was treated by his attending
physician by being kept warm, and injections of a warm solution
of chlorate of potash were daily made to his throat. He did not
improve much, however. On examination it is found that he
hears loud conversation four feet behind his back. Watch, R
L . T Ji_
¥8> ^ 48-
The tuning-fork is heard much better through the bones than
through the air, on each side.
The right membrana tympani is of good color. There is a well-
formed light spot, and it is not sunken. In the left membrana
the light spot is small.
On inflation of the middle ear by Politzer's method, the hearing
distance for the watch becomes ^^ on the right side and \%, on the
left, while the voice is now heard 30 feet.
The patient remained under observation until June. He was
treated by the use of Politzer's method of inflation, by syringing
the naso-pharyngeal space with a solution of chlorate of potash ;
and he took cod-liver oil. He then w^ent abroad with his
parents. He was directed to continue the treatment, according to
circumstances, during the summer. When he returned in October
he could hear general conversation with ease, but on the right side
the watch was only heard when laid upon the ear, and on the left
side for 8 inches. R 4^^, L 4V Voice 30'. About a month after-
ward, while under treatment, after the escape of quite an amount
10 D. B. St. John Roosa.
of dark-colored viscid material from his nostrils, the patient said
that sounds were unusually loud. On examination the next day-
it was found that the hearing distance of the right ear was j^,
and the left |f . After inflation the hearing distance of the left
ear became normal, while the right remained unchanged. At the
present time, the patient has passed through an attack of inflam-
mation of the auditory canal and tympanic cavity from exposure
to cold, but his hearing has become normal on the left side, while
it remains impaired on the right. Feb. 9. R -^i L ff. Voice on
right side with normal ear closed, 20 feet. The patient is still
under treatment.
This case of impairment of hearing after mumps is a very-
plain one. It is undoubtedly a case of disease of the middle
ear, and not of the nerve. The tuning-fork and the results
of treatment indicate this. Yet he had symptoms that are
sometimes associated with an affection of the labyrinth. It
is quite possible that such an affection might have occurred
in the course of any acute disease, if the patient were ex-
posed to a chilling of the body. I am confident, however,
that if all the cases of impaired hearing occurring after mumps
were observed by an otologist as early as this one was, that a
similar process would sometimes be found. Most of the
cases seen by an aurist are only seen some time after their
occurrence, when the history is very vague. The chief
symptom is said to be sudden deafness. In this case the
deafness was sudden. Had not inflation come to its relief,
within a few weeks, this might have been called a metastatic
case ; and I believe the labyrinth might have been invaded
by the extension of the inflammatory process through the
fenestrae. I see no reason as yet to change the opinion
expressed in my text-book,' and in my article, from which
I have quoted, that in some cases the occurrence of inflam-
mation of the ear after mumps is by direct extension of the
inflammation to the auditory canal, middle ear, and laby-
rinth. That there may be a form of so-called metastatic
inflammation, I do not deny. Whether the channel of com-
munication is through the blood, cannot as yet be deter-
mined. To my mind the probabilities lie in that direction.
* Text-book, 4th edition, 187S, p. 539.
Disease of the Ear. Ii
The theory of a metastatic inflammation in these cases,
is usually not based upon a study of the symptoms at the
time they occurred, but upon reasoning from analogy ; i. e.,
it is said, because the testes and breasts are sometimes
affected by metastatic inflammation, therefore a disease of
the ear, occurring after mumps, is also a metastatic affection.
Hinton, as is seen by the quotation, thought a catarrhal in-
flammation of the middle ear one of the causes, in some cases
at least, of the impairment of hearing ofteii seen after mumps.
As I have shown, my last case was certainly of this char-
acter.
Every one admits that cases of extension of suppurative
inflammation of the parotid gland to the external auditory
canal, are not uncommon. Probably this extension may
take place through the fissures of Santorini. If a suppuration
may extend in this way, why not a catarrhal process ? We
are not without examples of the extension of an inflammation
to the middle ear from the auditory canal and outer layer of
the drumhead. Every physician at all accustomed to see
much of aural disease, has seen cases where from a draught of
cold air, the entrance of cold water or irritating substances, an
inflammation has been set up in the middle ear by extension,
and where the symptoms in the auditory canal have passed
away long before those in the middle ear have been re-
lieved. Dr. Brunner's case, is by no means given with
minuteness. It is impossible to learn from his account of
it, how long after the attack of deafness he saw the patient.
Until we have a more full report, it is impossible to say
whether or not there was at any time, an inflammation of
the middle ear. Certainly, however, there was not at the
time the patient was examined by Dr. Brunner.
Dr. Buck's first case was seen still earlier than my last one.
On the third day of the mumps the patient had " a sharp
pain in the right ear "; on the day following, she discovered
that she had lost the hearing of that side ; on the seventh or
eighth day Dr. Buck saw her. The hearing power seemed
to be nearly gone, but the pharynx gave evidence of having
been recently inflamed, and the drumhead was " slightly
drawn inward." The right Eustachian tube was also
12 D. B. St. John Roosa.
swelled, at least " it was only with difficulty " that air could
be forced through it into the middle ear.
Certainly here is evidence enough, that whatever happened
to the labyrinth, some morbid process had occurred in the
middle ear. I do not know of any natural explanation of
such a case, but to say that the inflammation extended by
continuity of tissue. If an analysis of the ten cases I now
report be made, I think we are justified in assuming:
1. An acute catarrh of the middle ear may occur during
the course of mumps, and be attended by fever and vomiting.
2. This catarrh may extend from the parotid gland,
through the auditory canal and outer layer of the drum-
head, or through the mastoid process.
3. An affection of the labyrinth may occur simultane-
ously, or by extension from the middle ear.
4. It is probable that there are cases where the disease
is transferred to the labyrinth in the same manner that an
inflammation sometimes occurs in the testes and the breasts
during the course of mumps, but this cannot be considered
as proven, until more detailed experience is furnished of
cases observed a few hours after the impairment of hearing
occurs.
Contrary to the opinion of Toynbee, Hinton, and Dalby,'
I cannot regard these cases as among those that often occur,
for after nearly twenty years of active practice among aural
patients, I have notes of but ten cases of disease of the ear
after parotitis. There is certainly no comparison in this
with what occurs in this country after scarlatina, measles, or
typhoid fever. Some inquiry among general practitioners
has always shown that it is rarely observed by them. My
cases were chiefly from places remote from New York City.
Very few are presented at my clinic in the Manhattan Eye
and Ear Hospital. During the last year there is a record
of but one having been seen there by any of the surgeons out
of some twelve hundred cases. My innocent remark at the
American Otological Society, that I had seen enough of these
cases to make me anxious if any one got a disease of the ear
' In a letter just received from Dalby, he says : "I may say that it is within
my experience, in a very large number of cases, that the hearing is completely
lost during an attack of mumps in one or both ears."
Disease of the Ear. 13
during mumps, was in some manner so distorted, that Brun-
ner was led to believe that I had seen many of them. Those
that I have seen convince me that any hope of retaining the
hearing power, must depend upon the prompt use of local
antiphlogistic means. If the labyrinth be invaded, how-
ever, it is doubtful if the cases be not incurable, even if
seen at the instant the hearing becomes affected. But
what is imperatively needed to clear up the whole subject
is the assistance of the general practitioner. If he will call
in the otologist so soon as the hearing becomes impaired
during an attack of mumps, we may explain some, at least,
of the points, that are now doubtful.
A CASE OF BIN-AURAL OBJECTIVE SOUNDS
WITH SYNCHRONOUS MOVEMENTS OF THE
MEMBRANA TYMPANI AND THE PALATAL
MUSCLES.
By Dr. RICHARD C. BRANDEIS, New York.
Bessie K., aged twelve years, came to me in December, 1882,
for the relief of persistent noises in both ears, which had troubled
her for more than a year past. The child, though sufficiently de-
veloped for her years, was pale and anaemic, and wore a peculiarly
harassed look, evidently caused by physical disturbances.
On questioning her I found that the noises complained of had
set in without any assignable cause, and had never ceased since
they were first noticed. They were so loud that they could be
heard by any one near her. As she expressed herself, " it feels as
if there were a clock ticking inside my head."
Although at first very sceptical as to the truth of her story, I was
soon compelled to believe it, because I was able to hear a loud, tick-
ing noise on both sides, at a distance of more than eighteen inches
from the head. The noises were uniform in intensity and fre-
quency, as far as I could determine by a cursory examination.
On careful inspection I found the left membrana tympani
slightly opaque and somewhat retracted, but not sufficiently so to
attract special attention. On the right side the membrane was
atrophic and very flaccid and, as I soon found, moved to and fro
synchronously with the audible sounds. This movement was espe-
cially noticeable at the inferior posterior quadrant of the membrane,
but on careful inspection I found that the other portions also par-
ticipated in the vibrations.
The hearing of the voice and watch was normal on both sides, and
the patient stated that audition had never been noticeably impaired.
14
A Case of Bin- A iiral Objective Soimds. 1 5
When I proceeded to inspect the pharynx, I was surprised to
find that the soft palate and uvula moved up and down in spite of
the most forcible pressure being applied to the tongue by the
spatula, — which was sufficient to place the anterior and posterior
pillars of the fauces on the greatest tension. The retractions of
the velum palati corresponded in frequency and regularity with
the tinnitus, and, as I found, were synchronous with the movements
of the right drumhead.
On inspection of the neck it was found that the muscular con-
tractions also extended to the digastric muscles on both sides, as
well as to the mylo-hyoid and thyro-hyoid muscles, but careful
laryngoscopic examination failed to show any movements of the
larynx, either as a whole or in part.
The palatal contractions numbered from 120 to 124 to the min-
ute, and occurred in cycles, as follows : there would be a forcible
contraction bringing the velum into contact with the posterior wall
of the pharynx, and then eight or ten retractions, less intense, but
much shorter ; then there was again a forcible contraction, and
the short and sharp ones would follow in due succession. This
never intermitted, but continued as long as the patient was under
examination.
By throwing sufficient light into the nasal cavity and dilating
the nostrils, I was able to observe the regular synchronous move-
ments of the palate in the posterior nares, and, by listening
carefully, satisfied myself that the noises were as intense when
heard near the nose as near the ear.
On examining the right membrana tympani, I found that its
movements were synchronous with those of the palate, and corre-
sponded also in violence. There was noticed a violent retraction
of the entire druriihead, but especially of the inferior posterior
quadrant, corresponding with that portion generally occupied by
the cone of light, and this was followed by eight or ten vibrations,
less marked and intense.
I demonstrated the case to my colleagues, Drs. R. O. Born and
F. E. D'Oench, who agreed with me as to the synchronous con-
tractions of the muscles of the palate, and probably of the tensor
tympani. The patient was given dilute hydrobromic acid, ten
drops of which were to be taken four times a day. The medicine
was taken regularly for a week, and at that time I learned that
there had been daily intermissions of the tinnitus, varying from
one half to two and one half hours. At this visit no evidences of
1 6 Richard C. Brandeis,
any movements of the right drumhead could be detected, but the
contractions of the palate were as frequent as before. Owing to
the anaemic condition of the patient, I now suspended the use of
the hydrobromic acid, and administered iron and arsenic instead.
On December nth I saw the patient for the third time, and, no-
ting a return of the movements of the drumhead and an increase
in the intensity of the tinnitus, I brought the patient under Prof.
Knapp's notice, calling his especial attention to the vibrations of the
membrane. When he examined her he failed to observe the phe-
nomenon on which I laid such stress, and I then also satisfied myself
that these vibrations were not uninterrupted. Arsenic and iron con-
tinued, and Politzer's inflation and suction by means of my modifi-
cation of Siegle's speculum applied. These were followed by a
temporary amelioration of the symptoms, which, however, only
lasted one or two days, and when I again saw the patient on the
15th all the phenomena were present. I now introduced Politzer's
manometer, a curved tube, one millemetre in diameter, filled with
colored fluid, into the right meatus, which was also filled with
water, the two columns of fluid being joined by a rubber tube
passed over the proximal portion of the manometer, and prevent-
ing any ingress of air. Decided fluctuations in the column of
fluid contained in the manometer took place, varying in height
from one half to one and one half millemetres. This fluid was
never raised above the zero mark, but fell from it a variable dis-
tance, as noted above, showing that the movements of the drum-
head were not positive, but negative ; in other words, there was no
protrusion, but a marked retraction of the membrane, varying in
frequency from 120 to 126 times in the minute.
In order to determine whether these movements were dependent
upon contractions of the tensor tympani muscle, or whether they
were due to the alternate compression and escape of the air con-
tained in the Eustachian tube and the tympanic cavity, I applied a
thick layer of collodion to the entire surface of the drumhead. As
soon as this became adherent and all the ether had evaporated,
the membrana tympani was drawn outward and was quite rigid.
All movements of the drumhead were suspended, and the noises
were as persistent and intense as before, and were audible at
twenty-one to twenty-four inches. This proved conclusively that
there was no spasm of the tensor tympani which might explain
the synchronous in- and excursions. This immobility obtained
for more than a week, when the collodion began to flake off, and
A Case of Bin- Aural Objective Sounds. 17
as the drumhead was restored to its normal condition, tlie tin-
nitus reappeared as of old.
During all this time there was no appreciable change in the
frequency or the nature of the contractions of the palatal mus-
cles, and in consequence thereof, I was unable to afford the poor
patient any relief from the noises which so sorely distressed
her.
I was very anxious to get a rhinoscopic view of the pharyngeal
orifices of the Eustachian tube in order to determine the effects
which the continuous muscular contractions might have on the
lips of the canal. But owing to the uninterrupted movements of
the palate, and to the small size of the naso-pharyngeal cavity, I
was unable to make an examination. In order to enlarge the
cavity by drawing the soft palate forward, I employed Wales'
method, which consists in passing a narrow band through one of
the nasal passages into the pharynx, then drawing it out through
the mouth and tying both ends over the teeth. Passing the nar-
row tape into the right nasal canal, I succeeded in drawing the
right half of the palate forward and introducing a small rhinal
mirror. I soon had a view of the corresponding opening of the
Eustachian tube ; but owing to the force employed in drawing the
palate forward, I overcame the tendency of the muscular con-
tractions, and thus was foiled in my desire to witness the alternate
opening and closure of the mouth of the tube. I observed, how-
ever, that as long as the traction on the muscles of the soft palate
endured, there was a cessation of the noises in the corresponding
side of the head. As soon as the tape was slightly loosened, these
began to manifest themselves again ; and when the ribbon was
entirely removed, they reappeared with their original intensity.
During this experiment the left half of the soft palate con-
tinued to contract and relax without any diminution in its in-
tensity.
At the next visit which the patient paid me, I introduced two
tapes, one into either nasal canal, and tying both of them so tight
that the palate was absolutely unable to move, succeeded in caus-
ing the noises to disappear entirely for the time being. This was
but sorry comfort ; for as soon as the tapes were loosened and
withdrawn, the tinnitus reappeared with greater force and fre-
quency than before.
This abnormal behavior of the soft palate, and of the posterior
wall of the pharynx, induced me to make an effort to repeat the
1 8 Richard C. Brandeis.
experiments of Gentzen,' and Falkson,^ in order to see whether I
could obtain any graphic illustrations of the excursions which these
parts made. As both these observers experimented upon patients
in whom the orbit had been eviscerated, and the orbital walls
removed, so as to expose the nasal surface of the palate plainly to
view, I was compelled to modify my experiments, as in my case
the parts were intact. I made a small lever of cedar wood, 1.5 mm.
in thickness, 3 ;;/;;/. in width, and 15 cm. in length, and wrapped a
bit of tin-foil around one end of the strip of wood so as to increase
its weight. To the other end of the lever I fastened a small piece
of lead pencil. A small hook was fastened into the middle of the
lever, and a piece of elastic steel wire attached to it, which was
again fastened to a hook in a forehead band, which was passed
around the head of the patient. I now introduced the lever into
the right nasal canal, in such a manner that the end which was
weighted with the tin-foil rested directly on the soft palate. I
was, however, disappointed in my hopes in having the lever move
synchronously with the soft palate, owing to the small size of the
nasal passage, which prevented the lever from moving freely.
Having failed in this endeavor, I made up my mind to have a
depiction of the movements of the palate by introducing the lever
into the oral cavity and placing it on the velum palati. Taking
care that the steel wire was clear of any of the prominences of the
face, I was delighted to find that my pencil moved up and down
with a freedom equal to the retractions of the palate. I found,
however, that the lever was easily displaced from its position as
long as it was in contact with the concave surface of the soft
palate. This was remedied by grooving the tin-foil transversely,
and then passing the posterior ridge behind the free border of
the velum palati. When put in this position, the lever was not
liable to displacement, and recorded the movements of the palate
with great accuracy. The irritability of the soft palate was such,
that it was not possible to keep the lever in position for more than
a few seconds at a time. The drawings were made on card paper,
which was attached to a Marey's sphygmograph, which was placed
before the pencil in such a manner that its movements were lightly
traced upon the paper.
After the pencil began to trace, five or six sharp curves were
' Beobachtungen am weichen Gaumen nach Entfernung einer Geschwulst in
der Augenhohle. Konigsberg, 1876.
^ Beitrag zur Functionslehre des weichen Gaumens und des Pharynx. Vir-
chows Archiv, vol. Ixxix, 1880.
A Case of Bin- Aural Objective Sounds. 19
made in rapid succession, followed by a low curve, and again suc-
ceeded by a number of sharp, short tracings. These corre-
sponded with the contractions of the velum palati, and with the
noises perceived by the patient and observer.
Although cases of objective noises in the ear have been
reported by many observers, among them Lucae,' Politzer,"
Delstanche,' Johannes Mueller," Kiipper,' Poorten,° Holmes,'
and S. M. Burnett,* the text-books generally give but a
meagre account of this condition. In Burnett's treatise on
the ear^ we find a very able and judicious consideration of
objective noises in the ear, with a careful analysis of the lit-
erature to the time of publication.
The four authors first named above have given instances
in which the noises were due to voluntary efforts
on the part of the subjects, and were probably produced
by a voluntary contraction of the tensor tympani muscles,
as suggested by Lucae.
I have a friend, a physician, subject to chronic rhino-pha-
ryngitis who can produce these sounds at will. In his case,
however, I am pretty well convinced that the tinnitus is not
due to any clonic spasm of any of the intrinsic muscles of
the ear, but is owing to forcible contractions of the masseters
combined with a gentle friction sound, produced by the
movements of the condyle of the lower maxilla in the
glenoid fossa. In this case the sounds are distinctly audible
at a distance of several inches from the subject.
Cases in which the noises were of an involuntary nature
afford more interesting features than those above mentioned,
and the explanations given of the causes thereof have been
of various nature. For instance, they have been attributed
by Miiller and others to contractions of the tensor tympani
muscle ; Wreden has reported a case in which the
' Archiv fiir Ohrenheilk., Bd. iii, p. 201, 1867.
^ Ibidem, Bd. iv, p. ig, 1868.
' " Etude sur le Bourdonnement de 1' Oreille," Paris. 1872, p. 47.
* " Manual of Physiology," Eng. Edit., London, 1838-42 vol. ii, p. 1262.
^ Archiv fiir Ohrenheilk., p. 296, 1873.
^ Poorten : Monats. fiir Ohrenh., No. 4. 1878.
' Archiv of Otol., vol. viii, p. 145, 1879.
^ Ibidem, vol. viii, p. 357.
° Philadelphia, 1877, p. 440, et seq.
20 Richard C. Brandeis.
tinnitus was supposed to be due to clonic spasm of the
stapedius muscle. Politzer and Luschka have attributed
the noises to a spasm of the palatal muscles, by means of
which the anterior wall of the orifice of the Eustachian tube
is suddenly drawn away from the posterior wall, and the
noise is produced by the sudden and forcible contraction of
the muscles. I am convinced that this was the cause of the
tinnitus in the case which I have just described, in spite of
the movements of the membrana tympani. This latter con-
dition might lead one to suppose that there must have been
simultaneous or consecutive contractions of the tensor tym-
pani muscle on the right side at least, but I think that this
can be disproved by the fact that the tinnitus remained un-
afTected in spite of the exhaustion of air in the external
meatus, by means of my suction syringe. I applied sufifi-
cient force to draw the entire drumhead and chain of bones
outward, which would have been sufificient to overcome any
tendency to contraction, if only while the instrument was
applied. These movements of the membrana tympani were
probably due to a vacuum in the Eustachian tube and tym-
panic cavity, caused by the sudden opening of the faucial
extremity of the Eustachian tube and the contraction of the
muscles of deglutition, which tended to exhaust the air con-
tained in the cavity of the middle ear.
In Kiipper's ' case which was very similar to mine, the spasm
of the palate could be controlled by the application of pres-
sure on the base of the tongue and on the minor occipital
nerve near the insertion of the sterno-cleido mastoid mus-
cles. I found, however, that when I applied a tongue-de-
pressor the movements of the palate became more rapid,
although the excursions were not so great as before ; but
the contractions of the glossal muscles were somewhat re-
tarded.
The cause of the muscular contractions in my case is dif-
ficult to find, the more so as spasms of the muscles of deglu-
tition are very rarely met with ; and in spite of a very careful
search I have not been able to find any mention thereof in
the more recent treatises on diseases of the nervous system.
^Loc. citat.
A Case of Bi)i- Aural Objective Sounds. 2i
After I had had my patient under observation for some
time, and finding that there were some symptoms pointing
to a tendency to the appearance of the menses, I supposed
that she might have an inclination to chorea. I thereupon
placed her upon a course of arsenic and iron. This, how-
ever, failed to afford any relief, although her general condi-
tion improved considerably. Later, I combined this with
application of the induced current, both generally and
locally, but without any apparent benefit. The patient has
recently passed from under observation, but I have no rea-
son to believe that the condition complained of has been
ameliorated.
ANATOMICAL RESEARCHES ON THE DEVIA-
TIONS OF THE NASAL SEPTUM.
STUDY OF THE DIFFICULTIES WHICH THEY OCCASION IN OPERA-
TIONS, AND ESPECIALLY IN THE CATHETERIZATION OF
THE EUSTACHIAN TUBE ; EXPLANATION OF A
NEW METHOD FOR OVERCOMING THEM.
*
By B. LOEWENBERG, M.D., Paris, France.
{With five 7vood-engravings.)
I HAVE been impressed by the fact that although one
may justly be preoccupied by the difficulties of intro-
ducing the beak of the catheter into the orifice of the Eusta-
chian tube during catheterization, sufficient account is not
taken, in my opinion, of the obstacles which so often inter-
fere with the first act of this operation, that of the passage
of the instrument into the nasal fossae.
It is, however, during this period of catheterization, that
the patient is liable to experience the greatest discomfort,
because the instrument touches hard parts of bone and car-
tilage in the nose, contact with which may become extremely
painful. What aurist has not seen patients so terrified by
the distressing sensations occasioned in the beginning of
catheterization that they interrupted the operation and
absolutely refused its repetition, thus frequently making all
efficacious treatment impossible?
I go so far as to think that the dread inspired in the pub-
lic by Eustachian catheterization proceeds chiefly from the
pain occasioned at the time of the passage of the instrument
through the nose. It has, therefore, seemed to me useful
* The practical portion of tliis work was briefly communicated by the author
to the International Congress of London, and published in the transactions of that
Congress vol. 3, pp. 432-434. The anatomical researches were made during the
winter of 1881-1882. Later articles, such as that of M. Zuckerkandl, not hav-
ing been at the disposal of the author, could not, therefore, be utilized for this
study.
Deviations of the Nasal Septtun. 23
to investigate the causes of this phenomenon more carefully
than has been done up to this time, and to find out whether
it be possible to avoid the inconveniences to which I have
referred.
The following article contains the results of my anatomi-
cal and clinical researches on this subject.
My investigations had for their object the solution of the
three following problems:
1. What is the seat and the nature of the obstacles which
so frequently arrest the catheter during its passage through
the nose ?
2. What is their role in this operation, and in the thera-
peutics of the nasal fossae ?
3. How can one recognize the existence of these obstacles,
and avoid them in a rational and scientific manner ?
I. — SEAT AND NATURE OF THE NASAL OBSTACLE IN CASES
OF DIFFICULT EUSTACHIAN CATHETERIZATION.
A. — Clinical investigations.
Long before undertaking the special researches which
form the basis of the present article, I had learned by prac-
tice that, in the case in question, the obstacle is seated in
the front and lower part of the nasal fossae. It was, there-
fore, evidently useless to have recourse to posterior rhino-
scopy, which generally only reveals to us the reflection of
the back and upper part of the nasal fossae, foreshortened
and from behind.
Facts having proved this to me, I was obliged to use an-
terior rhinoscopy, the examination of the interior of the
nose by the nostrils.
This method demonstrated that in the numerous cases where
the catheter encounters an obstacle in the nasal fosses, this is
not in the tjirbinated bones, as is often supposed, but in the
septum. A priori, one would be inclined to charge this
either to hypertrophy of the lower turbinated bone, which
is so common, or to the presence of mucous polypi ; but in-
spection by the method which I shall explain later, shows
that the much enlarged mucous membrane of the turbinated
bone generally yields enough to a gentle pressure to allow
24 B, Loeivenberg.
the passage of the catheter. As for the mucous polypi,
they let the beak of the instrument go by, taking their origi-
nal position again as soon as it is passed.
TJie obstacle therefore belongs only to the septum ; it forms
there the protuberances or spurs zvhicli I have described in a
previous article.^ I only considered them in that place in
regard to their importance in the treatment of chronic coryza
by the galvano-cautery, and I merely mentioned there the
part they play in the catheterization of the Eustachian tube,
giving notice that I should take up the subject in a later
publication. The present article is intended to realize the
execution of that project.
Having recognized the seat, always identically the same,
of these particular deformities of the septum, and the im-
portant part they may play in catheterization, of which we
shall treat farther on, I was desirous of elucidating the
anatomical pathological-conditions under which these malfor-
mations present themselves. In doing so I was asked to
enlarge the field of study, and to consider various other
points concerning the nasal septum.
B. — Aiiatomical-pathological researches on the deviations of
the nasal septum.
My researches are based, on the one hand, on the dissec-
tion of more than one hundred fresh heads ; on the other,
upon the study of skulls at the Orfila Museum of the
Faculty of Medicine, Paris, and especially of the immense
anthropological collection at the museum of the Jardin des
Plantes. As the cartilaginous framework is more or less
completely lacking in dry skulls, I have examined them
particularly with regard to the conformation of the vomer
and the perpendicular lamella of the ethmoid, while I have
studied the cartilaginous septum from life and from fresh
heads which I have dissected.
Knowing that the reading of dry columns of figures alarms
the most intrepid reader, I refrain from presenting a detailed
table of the different categories of my observations, which
* B. Loewenberg : Contribution au traitement du coryza chronique simple.
In Union medicate, 28 Juillet, 1881.
Deviations of the Nasal Septum. 25
have been made upon hundreds of skulls. I shall confine
myself to stating briefly the principal results of these re-
searches.
Superior horizontal deviation of the nasal septum. — It is
only in about one case out of seven that I have found a
septum absolutely straight in all its parts, consequently in
a much smaller proportion than is generally supposed.
(See treatises on anatomy.)
In other cases, which constitute, as one may see, the very
large majority, one or_ several deviations exist. According
to my investigations, these must be divided into several
groups, which I shall call vertical deviations and horir^ontal
deviations, the latter being divided into superior and inferior
horizontal deviations.
The superior horizontal deviation pertains to the upper
portion of the septum, and particularly to the perpendicular
lamella of the ethmoid. Its convexity is oftener in the di-
rection of the right than of the left, in a proportion which I
have found to be from about three to five.
Inferior horizontal deviation of the nasal septum. — I call
inferior horizontal deviation the lateral deformity of the
lower part of the septum. It occurs, as I said in my com-
munication to the London Medical Congress,' at the junc-
tion of the cartilaginous with the osseous septum ; or, to
express it more precisely, at the junction of the inferior
posterior border of the cartilage of the septum, posteriorly,
with the anterior border of the vomer, and, anteriorly, with
the ridge that surmounts the line of junction of the palatine
apophyses of the superior maxillaries.
It proceeds from the fact that the bony part on the one
hand and the cartilaginous part on the other are not in the
same vertical plane, but join under a dihedral angle project-
ing toward one side. When this deviation extends as far
as the front extremity of the junction, it forms there the
protuberances or spurs which I have described {loc. cit.), and
which are located in accordance with what I have just said
of their origin, in the lower and front part of the nasal
^ Transactions of the International Medical Congress, London, 1881, vol. iii,
P- 432.
26 B. Loeivenberg.
fossae, where this osseous-cartilaginous junction terminates.
In cases where these excrescences are unilateral, they ex-
ist oftener at the left than at the right, as does the convexity
of the lower horizontal deviation, as we shall see later.
I have studied the conformation of the lower deviations,
and the protuberances which result from them, from numer-
ous vertical and transverse sections of the septum. They
have shown me that these projections could be formed in sev-
eral different ways (figs, ii, iii, and iv, at the end of this
paper.) In the great majority of cases it happens in this
way : It is known that the two lamellae of the vomer form
between them a groove, open at the top and in front, which
continues along the crest of the maxillaries, often as far
even as the front and lower nasal spine. The edges or lips
of this groove receive between them the lower edge of the
cartilage, which here presents a very marked enlargement
of triangular shape (figs, i and ii, 4). Any one examining
a certain number of skulls is struck by the fact that the front
part of the osseous septum is often inclined on one side in
such a way as to encroach upon one of the nasal fossae.
In these cases the lip of the vomer and of the crest of the
maxillaries advances toward this side, and makes with the
edge of the cartilaginous septum which inserts itself there,
the acute angle which constitutes the lower deviation. The
angle is therefore formed by a lower osseous plane and an
upper cartilaginous plane.
It is the same with the protuberances which it forms at
the entrance of the cavity.
Often this projection is not confined to the entrance of
the nasal fossae, but extends all along the septum. In very
marked cases the appearance in living subjects is rather
singular; when dilating the nostril and illuminating far into
the interior of the nose, one sees running along the septum
a sort of pad or cushion, placed laterally. As one examines
it from the front to the back, it is seen to rise more and
more, conformably to the direction followed by the osseous-
cartilaginous junction, the projection of which forms it.
Dissection and the study of dried skulls have taught
me that the deviation sometimes continues beyond the car-
Deviations of the Nasal Septum. 27
tilaginous part, and then inclines toward the suture which
follows it ; that is to say, toward the junction of the vomer
with the perpendicular lamella of the ethmoid.
In certain cases where the vomer itself presents no incli-
nation, one of its lips may, nevertheless, advance toward
one side and there form a protuberance with the lower back
edge of the cartilage which inserts itself in this place.
Thus, therefore, the lower deviations and their protuber-
ances are formed by the lateral inclination of the bone and
cartilage, and both contribute usually, as sections demon-
strate, to the formation of the projection. I have, however,
met with subjects where one or the other, alone, was account-
able for the prominence. This particularity was often due
to a marked incurvation of the front and lower part of the
cartilage, or to its oblique implantation (C. figs, iii and iv).
Here the lower swollen edge is no longer exactly encased
in the bony groove, but overruns it on one side, and forms
the projection of itself. In other individuals the effect of
this asymmetry is that the protuberance is formed on one
side by the cartilage, and on the other by the bony sub-
stance (fig. iii), just as if the cartilage had slipped laterally
upon the bone.
Figures ii, iii, and iv represent some of the most remark-
able sections which I have obtained ; they show the different
ways in which the substratum of these deformities is consti-
tuted in different individuals.
Relations of horizontal deviations to each other. — In the
majority of cases I have found that the inferior deviation
forms the reverse of the superior deviation ; that is to say,
that the convexity of the one is turned in the opposite di-
rection to that of the other; for example, in the case most
common, that where the septum deviates to the right in its
upper part, it deviates, on the contrary, toward the left in
its lower part. We have already seen that this conformation
generally involves the existence of a protuberance on the
side of the convexity of the inferior deviation ; here, then,
is the explanation of the greater frequency of the spurs in
the left nostril.
In certain persons the arrangement is still more irregular :
28 B. Locivenberg.
it is like a kind of torsion or undulation of the septum from
top to bottom, by means of which the groove of the
vomer and the crest of the maxillaries do not participate in
the curve of the lower deviation, but deviate in their front
part in the same way as the superior deviation ; for example,
in case of superior deviation to the right, and of inferior
deviation to the left, the right lip of the vomer is projected
into the right nasal fossa, and forms a protuberance there.
In the minority of cases, the convexities of the two hori-
zontal deviations face the same way. Here the lamella of
the ethmoid bulges on one side (superior deviation), and is
as if arched over the vomer; the angle it makes with the
latter constitutes the inferior deviation. The protuberances,
when they exist, are usually found in these cases on the
same side as the two convexities. Sometimes, however,
they are on the opposite side, on account of a species of
twist similiar to that which I have described for the preced-
ing group.
(I will add that I have at times seen something analogous,
but working in a horizontal direction and on the same devia-
tion, the direction of which then varies from the front back-
ward ; for example, an inferior deviation, the front part of
which directed its convexity to the right, the back part to
the left.)
Vertical deviation of the nasal septum. — Besides the
horizontal deviation which I have described, I have found,
either in the living subject or in the cadaver, anomalies of
quite a different kind and which do not seem to have been
appreciated according to their importance. These are
deviations in the vertical direction. They are not, like the
preceding, horizontal or slightly ascending projections, but
folds extending from top to bottom along the sept7un narium in
its front part, consequently pertaining especially to the car-
tilage of the septum. These folds present a convexity
toward one side, a concavity toward the other. When they
extend all the way down, they sometimes obstruct the in-
ferior meatus as a protuberance proceeding from an inferior
horizontal deviation would do.
In addition to the deviations which I have described,
Deviations of the Nasal Septwn. 29
there are in certain cases more complicated and more irregu-
lar deformities, sometimes to such a degree as to defy all
description.
If horizontal deviations are manifestly due to malforma-
tions, I have, on the contrary, seen a certain number of
vertical deviations which proceeded from traumatic causes,
such as a fall, or a blow upon the nose dating from early
childhood. Perhaps the irregular deviations which I have
just mentioned may also be of traumatic origin.
II. — ROLE OF DEVIATIONS OF THE NASAL SEPTUM IN
SURGICAL THERAPEUTICS, AND ESPECIALLY IN THE
CATHETERIZATION OF THE EUSTACHIAN TUBE.
In analyzing exactly the importance of the deviations of
the septum narium, it seems to me that the injurious influ-
ence which they may exercise in regard to the functions of
the nasal fossae has been exaggerated, whereas enough con-
sideration is not given to the impediments they often occa-
sion in the diagnosis and the treatment of affections of
these cavities.
In regard to the first point, it is thought that these mal-
formations may considerably impede respiration and pho-
nation. On this subject, I call attention to the necessity of
distinguishing between the two groups of deviations which
I have established above.
If it be supposed that the horizontal deviations can op-
pose themselves to the passage of air, so far as to hinder
these two physiological actions, it must not be forgotten
that the aerial circulation, although diminished in one half
the nose (by reason of the convexity of the deflected sep-
tum), is therefore all the more free in the other, on account
of its enlargement by the concavity of the septum. There
is therefore compensation. It is otherwise with vertical
deviations; here there can be no question of compensation,
for this deformity narrows one of the nasal fossae from top
to bottom, to the degree of closing it almost entirely in cer-
tain cases, without the other being widened on that account,
at least at the place where the fold begins. Now, it suflfices,
30 B. Loe%ve7iberg.
I think, that there should be in the whole extent of the
nasal canal one single narrowed point which does not allow
the air to pass in sufficient quantity under the ordinary
respiratory pressure, to make respiration by the nose im-
possible.
(I do not insist further upon this point, having enlarged
upon it in my article on adenoid tumors.)
If the influence of deviations on the physiological func-
tion of the nasal fossae is exaggerated, the other extreme
is fallen into, I think, as to their importance for the diag-
nosis and treatment of affections of these cavities. It is,
however, evident, a priori, — and a long experience has
proved it to me, — that the convexity of the deformity may
hide from sight and screen from surgical operation, all or
part of the depths of a nasal fossa, while the concavity may
harbor tumors which run the risk of passing unnoticed. This
is what happens with horizontal and still more with vertical
deviations. We will pass summarily in review, in relation
to the effect of these deformities, the pathology and thera-
peutics of the nasal fossae, and terminate with Eustachian
cathethrization considered from this special point of view.
A. — Simple chronic coryza.
Like many other specialists, I am of opinion that the
principal part in the treatment of chronic coryza belongs to
the galvano-cautery. In a former article {loc. cit.) I treated
this point, and brought forward the difficulties of sparing the
septum in cases where deviation exists. I described in the
same place cauteries made specially for this purpose accord-
ing to a new principle, that of the unilateral action. They
are indispensable in cases of decided protuberances, to avoid
burning the latter, which I consider as noli me tangere, be-
cause the cicatrization of cartilage wounds is extremely
difficult, especially in the case in question, where the peri-
chondrium is necessarily destroyed by the cautery. I will
add briefly that I have succeeded in making these instru-
ments much flatter still, and consequently much easier to
use, by turning back the sheet of platinum upon the flat
side of the cautery.
Deviations of the Nasal Septum. 31
B. — The vmcoiis polypi of the nasal fossce.
In following the old methods, according to which the
mucous polypi of the nose were torn away with pincers with-
out dilating the nostrils or illuminating the nasal fossae, the
turbinated bones have often been fractured — even torn away.
I firmly believe that the protuberances of the septum, often
visible to the naked eye on raising the end of the nose, must
have met with a similar fate. The present methods, which
permit us to radically cure this formerly incurable affection,
are, as is known, the use of either the cold or galvano-caustic
snare, and the subsequent destruction of the pedicles by the
galvano-cautery.
One can readily understand that a marked deviation of
the septum may seriously interfere with this form of treat-
ment. The vertical deviation must be mentioned here in
the first place ; sometimes the convex fold which it forms at
the opening of a nostril masks it completely. It then
becomes very difficult to recognize the existence of the
polypi and to reach them with the snare. Here is a
curious example of this kind, upon which I operated in 1878.
The patient, aged sixty, who had long been affected with
mucous polypi of the nose, presented a vertical deviation.
The cartilaginous septum had deviated from top to bottom,
toward the left. The right nasal fossa, which was very
wide, contained an enormous quantity of tumors easily seen
and taken hold of, and which I was able to extract with
ease by means of the galvano-caustic snare. On the left, after
having removed some polypi which came forward as far as
the entrance of the nostril, I was met by the convexity of
the vertical deviation. Between the projecting fold which
it formed from top to bottom, and the outer wall of the
nasal fossae, there was only an opening the size of a pea,
quite filled by an end of polypous excrescence. On the
other hand, palpation by the pharynx with the finger
showed that the whole portion of the nasal fossa back of
this contraction was filled with polypous masses. The
patient not being able to endure posterior rhinoscopy, and
being obliged to leave Paris at once, I could not operate
32 B. Locivenberg.
upon the polypus from behind, but I was obliged to adopt
the method of tearing away, which I only use in case of its
being impossible to do otherwise.
I took hold of the excrescence with the snare, and gently
drew out, through the small opening, an enormous and very
soft polypus, having exactly the shape and size of a white
worm (larva of Melolontha vulgaris, May-bug) arrived at full
maturity. Immediately after, palpation showed that the
fossa was empty. Had it not been for want of time, I
could have accustomed the patient to rhinoscopy and then
I could have destroyed, as I usually do, the point of im-
plantation of this polypus by means of a galvano-cautery,
bent and introduced by the pharynx under the control of
the mirror ; not being able to do so, I could not promise
the patient that there might not be a relapse.
In the case of another gentleman whom I still see occa-
sionally, there is horizontal superior deviation convex at the
right, and horizontal inferior deviation convex at the left ;
the two nasal fossae were filled with mucous polypi. After
relieving the left of those which obstructed it, I finally found
still another bunch of small polypi, beginning at the pos-
terior extremity of the middle turbinated bone and niched
in the concavity of the perpendicular lamella of the ethmoid,
which had deviated to the right. It required persistent
effort and an energetic but prudent use of the galvano-cau-
tery of lateral action to destroy these tumors and to preserve
the septum intact.
C . — Epis taxis.
I merely mention the difificulties caused by deviations in
cases of obstinate epistaxis, when they hinder the search
after the point of bleeding.
D. — Nasal pharyngeal douche.
I call attention very particularly to the importance of
deviations of the septum in the use of the Weber douche,
not only because the injection passes with diiificulty into the
nasal fossa which is contracted, but because it passes too easily
into the other which is widened. Poured into the latter, the
Deviations of the Nasal Septum. 33
liquid reaches the nasal pharynx superabundantly, and
thence passes, behind, into the narrowed nasal fossa. The
effect of the contraction of the passage is an augmentation
of resistance and of lateral pressure upon the nasal and
pharyngeal walls, and finally the liquid may invade the
Eustachian tube and even the tympanic cavity.
If too strong a pressure be used (a syphon hung too high
above the head of the patient, for example), and a liquid
too cold, too warm, too concentrated, or not enough so, a
violent otitis media may result from this penetration of the
liquid into the cavity.
In my opinion, such imprudences as these have prevented
distinguished aurists, particularly in America, from making
use of this process, which I believe to be excellent, on con-
dition of employing it according to the following direc-
tions :
Injection with gentle pressure (I prefer the use of a
syringe, the stream of which can be immediately stopped
or checked); tepid liquids, consisting of weak solutions;
straight position of head of the patient. Necessity of thor-
oughly teaching the method and having the person in
charge of making the injections practise it before me. In
cases of considerable deviations, inject only by the narrowed
side.
E. — Catheterization of the Eustachian tube.
At the beginning of this article I dwelt upon the importance
of a free nasal passage for Eustachian catheterization. We
have also seen that one must not be satisfied, in this matter,
to speak, as many classical works do, in a general way, of
" deviations of the septum"; but examining the question
more closely, as we have above, we must distinguish between
the different groups of these anomalies. We will now ap-
ply the results of my investigations to this special point.
We must first eliminate the horizontal deviations, which I
call the superior. Not bearing at all upon the inferior nasal
meatus, they could not impede catheterization, which has
this canal for its field of operation.
On the other hand, I think I have found in inferior devia-
34 B. Loewenberg.
tions, and especially in the protuberances or spurs so often
formed by the anterior extremities of these deformities, the
principal cause of the diseases of the nasal passage and of
the difficulties which are so common in operating through
it. Examination of the museum skulls has proved to me
that the inferior deviation directs its convexity oftener to
the left than to the right, and that consequently the pro-
tuberances exist oftener at the left. This particularity
seems to explain a fact known, but insufficiently explained
up to the present time: the greater difficulty of the catheteri-
zation of the left ear.
I am in the habit of accompanying the notes which I take
of all my patients with elementary drawings in cases which
present an anomaly of conformation or any injury worthy
of notice. I represent in this way perforations of the drum,
exostoses of the auditory meatus, obliquity of the uvula,
hypertrophy of the tonsils, deformities of the nasal fossae,
etc., etc. Now, in the majority of my drawings of the sep-
tum narium, I find the protuberance on the left. Since
1877, foi" instance, I have drawn twenty-eight cases where it
occurred on that side, eleven where it existed on the right,
and fourteen where both sides were affected. And yet I
have only drawn cases of nasal obstacles developed to such
a degree that they seriously hindered catheterization, and
of which I wished to keep a memorandum for future use.
We will now inquire how these protuberances, which so
often present the greatest obstacles to catheterization,
impede the progress of the catheter. As I have often
proved by means of the combined method, which I shall
explain later, as soon as the beak of the catheter ap-
proaches the entrance of the nasal fossa it strikes against
the protuberance which faces it, and which obstructs the
width of the inferior meatus where the operation is to be
performed {vide fig. ii, where 2 represents a slightly
developed protuberance). It is then that the Schneiderian
membrane, tightly squeezed between two hard substances,
viz. : the catheter and the osseous-cartilaginous substratum
of the spur, suffers a strong pressure, very painful on ac-
count of its abundance of sensitive nerves. (What occurs
Deviations of the Nasal Septum. 35
here might be compared — mutatis mutandis — to what hap-
pens when the tibia is struck ; the pain results in the same
way from the compression of a thin skin between the con-
tusing body and the underlying tissue in contact with the
bone.) Thence the fact which I mentioned above, and
which is known to all aurists, that many patients at the
beginning of catheterization withdraw the head, and refuse
the continuance or repetition of the operation. If one per-
sist in advancing the catheter, the protuberance causes the
point of the instrument to deviate; it then strikes against
the lower turbinated bone, or else passes into the middle
meatus. In both cases it is manifestly impossible to com-
plete the operation, unless by an energetic downward pres-
sure, very painful for the patient, the instrument be forcibly
drawn back into the inferior meatus and force a passage
while maintaining it. In certain cases of vertical deviation
the fold of the cartilage continues all the way down, and
may obstruct the inferior meatus as a protuberance would
do.
Even Politzer's mode of procedure may become difificult
on account of the protuberances occasioned by one or the
other of these deviations, for their compression by the end
of the balloon causes pain to certain patients. It is useful,
in such a case, to employ the modification which I proposed
long ago, and which, indeed, has been generally adopted :
it consists in adding to the end of the balloon a little soft
rubber tube, which prevents any disagreeable pressure.
I will add that the projections may make the simple
examination with the nasal speculum disagreeable to the
patient, on account of the tip of the instrument striking
against these highly sensitive spurs.
III.— NEW METHOD FOR AVOIDING NASAL OBSTACLES IN
THE CATHETERIZATION OF THE EUSTACHIAN TUBE.
Instead of the probing, so painful to the patient, to which
one is forced to resort in the frequent cases where protuber-
ances exist, is it possible to imagine a truly scientific method
to facilitate catheterization under these circumstances?
36 B. Loewenberg.
I begin by rejecting any sanguineous operation, such as
the ablation of the deviated portion of the septum. In
such an act of surgery, the shot would go far beyond the
mark, especially taking into consideration what I said pre-
viously in regard to the difificult healing of wounds of the
cartilage.
The point, therefore, is to get round the obstacle and not
to remove it inanil armatd. This can be managed in many
cases by a process which is known, catheterization by the op-
posite nostril. But cases where protuberances exist on both
sides of the septum are not rare, as I have already explained,
and then passage is hindered in both nasal fossae, especially
for catheters with a beak long enough to penetrate into the
tube of the opposite side. And it is often very difficult by
this method to make the instrument penetrate far enough
forward into this canal and in a good enough direction to
allow the air to penetrate sufficiently, much less liquid sub-
stances or bougies ! For some years I have used a process
which may be said to allow the catheter in all cases to pass
through tJie narrowed nasal fossa, sparing meanwhile the
sensitiveness of the patient. This method suggested itself
to me from the habit of exploring the nasal fossae of all my
patients : it is catheterization guided by SIMULTANEOUS
anterior rhinoscopy, which process I will now explain.
Great importance is justly attributed to the exploration of
the buccal and naso-pharyngeal spaces, in the study of dis-
eases of the ear. I have insisted upon this point since
1865, and my efforts have perhaps contributed, with those of
such men as v. Troeltsch and Voltolini, to calling attention
to this subject.
The point now is to take another step in advance, and to
join to the indispensable auxiliaries of the aurist the atten-
tive study of the nasal fossae, which is no less important in
his specialty than is that of the pharynx. The importance
of this study is obvious : the interior mucous lining of the
nose is continuous with that of the entrance of the tube;
the permeability of the nasal cavities influences the access
of air to this canal, and finally catheterization and the sys-
tem of Politzer have the interior of these cavities for their
Deviations of the Nasal Septum. 37
operating ground. In considering, therefore, the impor-
tance of the conformation of the nasal fossae for these
operations and of the condition of their mucous membrane
for that of the middle ear, I lay down as a principle the
necessity of exploring the nasal fossce of every person requiring
our attention for an affection of the ear, unless the disease
be manifestly confined to the external ear or to the auditory
meatus (eczema, foreign bodies, furuncles, etc.). I do not go
so far as to require, in every case, the practice of posterior
rhinoscopy, which often necessitates a series of preparatory
visits before succeeding completely. On the other hand,
anterior rhinoscopy is performed with great ease and always
succeeds the first time.
On dilating the entrance of the nasal fossse by means of
the speculum, and projecting (natural or artificial) light into
these cavities by the aid of the concave reflector, the eye
penetrates to a great depth into the interior of the nose.
The first glance shows the conformation of the septum and
of the inferior and middle turbinated bones as well as the
condition of the mucous membrane and its secretion. We
know that in certain cases of abnormal size of the nasal
fossse (ozaena) the eye may pierce as far even as the posterior
wall of the naso-pharynx, and on causing the patient to
make the motion of deglutition the phenomenon of the
pharyngeal contraction may be observed.
In exploring the interior of the nose the glance of the ob-
server includes particularly the anterior and inferior regions
of the nasal fossae, precisely the part where are located the
protuberances which form the special obstacle to catheteriza-
tion in regard to the passage of the instrument through the
nose. This same glance shows the operator whether the
conformation be normal or the reverse, and, consequently,
whether the catheter will pass easily or with difificulty. In
the case where anomaly exists, he recognizes at once the
nature and configuration of the obstacle. Besides, and on
this point I would lay special stress, this observation shows
him at once how he can remedy these inconveniences by my
method: catheterization combined ivith anterior rhinoscopy.
The surgeon would certainly be blamed who performed
38 B. Loewenberg.
an operation by sense of touch and without the aid of sight
upon a part accessible to his gaze — the " oculis subjecta iide-
libus" of Horace. As incredible a thing happens, however,
daily, even in the most difficult cases of Eustachian catheteri-
zation ! No one thinks of performing this operation while
inspecting, at the same time, the nasal fossae, which are
rendered accessible to the sight by the speculum and
lighted by the reflector. This process, the idea of which
ought to come, it would seem, to the mind of every aurist,
has not, to my knowledge, been indicated up to the present
time. I have had occasion to explain it before numerous
confreres, both at the last meeting of the International
Congress of London (1881), and in Paris, and, to my great
surprise, I have met no one who had put it in practice.
Method of Operating. — When catheterization is to be per-
formed upon a patient, and inspection has made evident the
regular conformation of the nasal septum, I take off the
speculum and the reflector, and proceed according to the
usual methods. If, on the contrary, there be a protuber-
ance on the side to be operated upon, I leave the speculum
in its place, and also keep on the reflector to light the oper-
ating ground. It is plain at once that in proceeding ac-
cording to the usual method, that is to say, in
introducing the catheter the point downward, the beak of
the instrument would inevitably graze the protuberance
which bars the inferior meatus to a greater or less extent in
different cases (see fig. i ; the drawing represents a pro-
tuberance slightly developed). But one discovers at the
same time farther beyond, an interstice (iig. i, 3) having
the protuberance on the inside, the inferior turbinated bone
above and behind, and the floor of the nasal fossae below.
It is by this path which presents itself to view, already
marked out, that the catheter is to be surely and easily
directed. To do this, the instrument should first be turned
around its longitudinal axis, so as to place the beak out-
ward and to present it in face of this interstice. In ad-
vancing it will soon be possible (as soon as the protuberance
is passed) to make it resume its normal position, that is, the
vertical direction, for, as we have seen, the horizontal inferior
Deviations of the Nasal Septum. 39
deviation rises as it progresses toward the interior, and soon
lifts itself above the inferior meatus.
One then performs what is called " le tour de maitre "
(the master-stroke), to borrow this term from urethral-vesi-
cal surgery. But it is going a great deal too far to recom-
mend making as complete a movement as is done in the
catheterization of the urethra, that is to say, turning the in-
strument through an arc of 180° around its longitudinal axis.
According to my experience, a rotation of from 45° to 60°
generally suffices to accomplish the object, which is merely
to avoid the protuberance. (Fig. i represents a small pro-
tuberance. It would suffice in such a case to turn about
45° ; where the spurs are more developed in width and
height, an increased rotation is necessary.) Guided by my
method one need no longer perform " le tour de maitre" in
an empirical and exaggerated way, but it becomes a rational
process exactly proportioned to the exigencies of each case,
and where the eye of the operator enables him to avoid all
painful contact. In certain cases where the protuberance
closes the whole width of the meatus, and where the in-
ferior turbinated bone is very large, I have sometimes been
able to manage in anotJier way : As there is often in this
case a little free space left below the prominence, the cathe-
ter must be made flat by turning the beak in or out, and it
can thus be slipped forward. Inspection during catheteri-
zation teaches something more still : it becomes obvious at
once that the opening which is before one (fig. i, 4) could
not, as a rule, give passage to ordinary catheters without
their causing severe pain to the patient on account of their
size, their curve, and the length of the beak. I use, there-
fore, especially for the latter process, where it is necessary to
pass below the spur, delicate catheters having a very short
beak. These instruments are all the more indispensable,
because in spite of every precaution the prominences some-
times press upon the longitudinal axis of the catheter,
causing a deviation toward the exterior. The beak of the
instrument, having passed beyond the nasal fossae, then
finds itself too near the Eustachian tube. When, therefore,
under these circumstances the ordinary catheters having a
40 B. Loetvenberg.
long beak are used, the point, as soon as it is turned so as
to place it in the entrance of the tube, strikes against the
lateral wall of the pharynx and rotation becomes impossible
or, at least, very painful. On the other hand, in using a
catheter with a short beak, its point only describes, in turn-
ing, an arc of a circle of small radius, and can therefore
make the necessary movement of rotation without being in-
terrupted by contact with the pharyngeal wall.
In these cases I like to use catheters of a particular kind :
they are thin instruments, having a beak of only seven mil-
limetres and a half in length, which makes a7t exact right
angle with the stem. This shape not only facilitates the
passage through the nose, but also the rotation of the beak
in the pharynx. I had this pattern made by Luer about
fifteen years ago for a person in whose case the nasal pass-
age was extremely narrowed, probably by protuberances — I
say "probably," for I had not, at that already distant
period, recognized the anomaly in question.
Nezv nasal speculum.
There are at present several kinds of nasal specula, all
more or less useful for the examination of the nasal fossae.
I used at first, in my process of catheterization, the pattern
which I described {loc. cit.), and which is nothing more than
the usual speculum, only with much thinner branches than
are usually made. But all these instruments, for the method
of operation which I have just explained, present the follow-
ing inconvenience : when once the beak of the catheter has
passed through the entrance of the nasal fossa which is nar-
rowed by the protuberance, the further presence of the specu-
lum becomes not only useless, inspection being no longer
necessary, but even troublesome, for it interferes with the
free advance of the catheter, and its fixation at the time when
inspiration is required. If it be taken off at this moment,
it is necessary to turn the screw of the instrument with one
hand while the other secures the catheter. The speculum
being no longer held in place, receives, in unscrewing it,
concussions against the catheter, which are painful to the
patient. I have been led, on that account, after many ex-
Deviations of the Nasal Septum. 41
periments upon the cadaver (by means of a thin sheet of
lead, which is easily shaped as one likes), to a special specu-
lum, different from the old instruments and from the new
model of Creswell Baber. My speculum (fig, v, where it
is drawn a little too long) is a metallic tube shaped like a
truncated cone, at the large end of which a sort of handle
or palette is implanted almost perpendicularly to the axis
of the cone. A rather wide slit extends the length of the
speculum on the side opposite that which holds the palette.
The instrument having thin slides is much lighter than
ordinary specula, and its contact with the catheter would
not displace the latter in so painful a manner to the patient
as the ordinary heavy and cumbersome instruments do.
After having introduced this speculum into the entrance
of the nasal fossa, the palette being above, it is held there
by slightly pressing the latter with the thumb of the left
hand, the fingers of which are placed against the back of
the nose. The slit is in this way directed downward and
horizontally so as to leave the passage free for the introduc-
tion of the catheter. When the catheter has passed the
narrowed part, the speculum is taken off by turning the slit
upward ; it then drops off of itself, the slit making room for
the stem of the catheter.
By using the combination of means just explained, I have
been able to conduct catheterization successfully and with-
out causing suffering to the patient, under circumstances
where the deviation of the septum made the operation im-
possible or, at any rate, extremely painful by other methods.
I have even succeeded where experienced hands had failed,
and where, I hasten to add, I should not, certainly, have
been more fortunate without the aid of my method.
In regard to the sensation experienced by the patient, the
difference between the ordinary processes and mine was such
in many cases that the use of the latter was loudly demanded
by all who had once tested its advantages. But even in
using it, it is often necessary to proceed with much delicacy
and circumspection in order to guide the catheter through
the two or three dangers which obstruct its way.
I say " three " dangers, for the situation is again aggravated
42
B. Loezvcnberg.
in some cases by an elevation of the floor of the nasal fossae,
which then brings the number of obstacles up to three,
counting the inferior turbinated bone and the protuberance.
Explanation of Figures.
I drew fig. i from life, and figs, ii, iii, and iv from sections
made upon three different cadavers, selected from the large num-
5
Fig. i.
Fig. i. — I Inferior turbinated bone. 2 Protuberance of the septum. 3 Free
interstice.
Fig. ii.
Figs, ii, iii, and iv. — Sections of the cartilaginous part of the nose. A, B,
Nasal fossse. C. Septum. D. Inferior turbinated bone. i Cartilage of the
septum. 2 Mucous membrane. 3 Bone. 4 Cartilaginous protuberance.
5 Osseous protuberance.
Fig. V,
Deviations of the Nasal Septum. 43
ber which I have dissected for this purpose. The section was in
an almost perpendicular direction from top to botom, on a slightly-
inclined plane, that is to say, making with the forehead an acute
angle open at the top. As it has only concerned the cartilaginous
part of the nose, the horizontal superior deviation, which bears
particularly upon the perpendicular lamella of the ethmoid, is not
shown in my drawings ; the only traces of it are found in fig. ii,
where it has partially attained the cartilage of the septum also.
Fig. V was drawn by M. Badoureau, engraver. The instrument
is represented a Httle too long in its horizontal dimensions.
THREE SERIOUS CASES OF MASTOID DISEASE,
WITH REMARKS.
By H. KNAPP.
NO department of aural surgery is more important than
the inflammation of the tympano-mastoid cavities,
when it extends into the cranium. The aural questions
are then at once converted into vital questions, which the
specialist has to solve with all the grave responsibility that
is so frequently inherent to the duties of the general prac-
titioner. Despite the decided progress in our knowledge
and management of such cases during the last decades,
there are still many points either unexplained or in-
sufficiently appreciated, if we aim at accuracy of diagnosis
and seek for unambiguous indications of treatment. The
great practical question : " what are the conditions under
which the mastoid process should be opened" ? can to-day be
answered with more precision that it could have been ten
and twenty years ago, yet the most experienced aurist will
not fail to welcome further clinical and pathological con-
tributions either as confirmations or extensions of his views
on this important subject. In illustration of this proposi-
tion, I beg to select three cases from my recent practice,
accompanying them with a few remarks which they forcibly
suggest.
Case i. — Acute purulent otitis from sea-bathing ; perfora-
tion of the occipital bone ; drainage of the cranial cavity for
three months ; death by cerebellar abscess ; autopsy.
Mr. John D. Strickland, of Brooklyn, a healthy man of about
thirty-nine years, consulted me for the first time on Aug. 15, 1882.
44
Three Serious Cases of Mastoid Disease. 45
He was very fond of sea-bathing. During the hot summer of 1882
he went into the ocean every day, swam long against the breakers,
lying by preference on his right side. On Aug. 6th he went swim-
ming at 7 A.M. and felt no immediate pain or discomfort anywhere,
but at 2 P.M. of the same day he experienced earache, headache,
and impairment of hearing. Though these symptoms continued
with varying intensity, he went bathing twice again before he con-
sulted me. I found his right Mtrtd. and dull, bulging in its upper
part, the folds and handle of the left slightly red ; relief normal ;
^ R -|- on application to ear only ; L h 4^ (ear), \ (temple),
o (mastoid) ; V R -^, L f-^-. Tuning-fork from forehead best in
R, better when ears were closed. Politzer positive ; R with a dry
snap, after which h ^ (ear and temple), V |-§-, as in L ear, but
mastoid remains h o. Moderate congestion and swelling of the
pharyngeal mucous membrane. Ordered two leeches behind each
ear, and rest. Bathing forbidden. On Aug. 23d he came again,
materially improved. R Mt still red, L almost normal. Aug.
28th. Had been less careful. R Mt red all over, and bulging
except at handle, in front of which two hemorrhagic spots. Pain
extending over the adjacent parts of the head, especially toward
the forehead and occiput. I made a paracentesis, 4 mm in length,
in the anterior lower part of the drumhead. Blood escaped, but
no pus. Politzer positive with perforation whistle, but no evacua-
tion of mucus or fluid, though Valsalva's experiment gave a
gurgling sound before the operation. The operation was made in
the forenoon ; at 9 p.m. a profuse purulent discharge set in, and the
pain disappeared. I gave him quinine internally, 0.25 to 0.50 a
day, boracic-acid solution to cleanse the ear with, and impalpable
boracic-acid powder and absorbent cotton to be put in the ear
after the cleansing. During the whole month of September there
was more or less discharge from the ear, pain in ear and head
varying, more pronounced when discharge was scant or ceased,
and absent when the ear ran freely again, which was favored by
warm water and vapor ear baths. The pain in the right occipital
region never left him entirely, and was mostly accompanied by right-
sided frontal headaches. The mastoid region was free from any
abnormity, so often and carefully as it was examined. There was
no fever, no mental disturbance, no cerebral symptoms except the
headache. Patient went to his business off and on, though against
my orders.
On the 4th of Oct., after an absence of two weeks, he presented
46 H. Knapp.
himself to me again, complaining of more pain in his left occipi-
tal region, which, on examination, I found swollen and distinctly
fluctuating, though but little tender to the touch, and not red at
all. The mastoid was normal, the fluctuation and greatest swelling
were 6 cm behind the ear, and 2 cm above the level of the auditory
meatus. I told the patient that between the skull and the scalp
there was pus which must be liberated. He consented, and as he
was very timid and nervous, I took him to the Ophthalmic and
Aural Institute, where, under ether, I made an incision of 3 cm in
length through the fluctuating part of the scalp down to the bone,
and evacuated a considerable quantity of creamy, inoffensive pus.
The bone felt denuded to the extent of 2.5 cm in diameter, but
was smooth, with a depression in the centre of the incision. I put
a small perforated silver tube in the wound, covering it with ab-
sorbent cotton. The patient was not to be induced to stay in the
hospital, but Tirove home greatly relieved. For the next week, he
came to the ofiice with his wife almost every day. There was a
free discharge of creamy pus from the wound. The wound was
dressed twice a day, the canula cleansed and re-inserted. Patient
had lost all pain, and felt very well. The Mt was plainly visible
in its details ; it was red, and had a small, round, clean perfora-
tion in its antero-inferior part. V f^ and the case looked as
if it advanced toward a speedy recovery. This was, however, a
sad disappointment. After a week, he complained again of his
pain over the right eye, which continued more or less intense dur-
ing his whole illness. A considerable quantity of creamy pus,
which never smelled offensive, was discharged through the silver
tube every day. With a probe, it could be distinctly ascertained
that the pus came from the interior of the skull through a canal
in the occipital bone about 4 mm in diameter, with rough, ragged
edges. At the bottom of the canal, the probe pushed against a
resistant fibrous membrane, evidently the dura mater. The outer
surface of the temporal bone, as far as denuded, felt perfectly
smooth, not indicating caries. The patient's pulse was 76, his
temperature not increased. His appetite was good ; his sleep, how-
ever, frequently disturbed by the frontal headache.
On the 19th of October, there was a decided aggravation in his
symptoms. The frontal headache was very severe, prevented him
from sleep ; he felt oppressed, sick at his stomach, was very pale,
and fainted for five minutes. He had chills, and cold and hot
perspirations. When he came to me on the 20th of Oct., I found
Three Serious Cases of Mastoid Disease. 47
his pulse 104 ; temperature 38^ C; his general condition better ;
free discharge from the drainage tube. At the lower part of the
occiput, 5 C7n below and 1.5 an behind the opening, there was a
considerable swelling of the skin, pressure on which indicated deep
fluctuation, and forced a moderate quantity of pus out through
the opening above. I incised the soft parts down to the bone, but
liberated no pus, and inserted a drainage tube into this incision
also.
Oct. 21st. — Felt better ; no chills ; free discharge from upper
opening, none from lower ; swelling, the same ; pulse, 96 ; tem-
perature, 38.8°.
Oct. 23^. — More swelling in lower part ; incisions deeper and
longer ; no pus.
Oct. 24/A. — No pus yet ; swelling less ; pulse 84 ; feels tolera-
bly well.
Oct. 26th. — Had headache yesterday. After poulticing, copious
discharge of pus from the lower opening.
The discharge for the next ten days was interrupted from the
lower, constant and free from the upper, opening. The bone at
the lower incision felt smooth, not depressed in any place.
JVov. 6th. — Had a good deal of headache and vomiting yester-
day. The discharge was scant. Poulticing for three hours was
followed by abundant discharge and complete relief from head-
ache.
For the next nine days, scantiness of discharge, headache,
nausea and vomiting alternated with free discharge and general
comfort. Opthalmoscopic examination, which, in combination
with functional examination, had been frequently made during the
preceding months, now, for the first time, revealed a moderate
swelling at the inferior border of the right optic disc, and some
retinal hyperaemia ; the same condition, less marked, was no-
ticed in the left eye. Then, for two weeks, he felt comparatively
well ; had not had a headache for eight days ; the lower opening
had closed and the swelling disappeared ; the discharge from the
upper was free and steady. I took care to keep the bony canal
open ; whenever granulations formed I scraped them off with a
sharp spoon, especially from the bony walls of the canal.
On November 29th, a fluctuating swelling had formed 2.5 cm up
and back from the originalo pening. On incision a considerable
quantity of creamy pus escaped, and the probe passed also in this
place into the cranial cavity by a narrow, ragged, fistulous canal
48 H. Knapp.
in the bone. A drainage tube — a perforated silver canula — was
inserted. The discharge from this perforation ceased in a few
days, and the opening closed in two weeks.
The original fistula continued to discharge regularly ; the patient
felt tolerably well ; his complexion, which was naturally pale, had
at times a yellowish hue. The symptom of which he complained
most was pain in the right side of his forehead ; the occiput
was also painful at times, the parietal region rarely, the mastoid
never. The mastoid region and its vicinity were, during the
whole course of the disease, free from any abnormity ; the audi-
tory canal was likewise free, the drumhead perforated, but not
bulging ; very little, and, . most of the time, no discharge ; no
granulation tissue in tympanic cavity. As the patient could never
be persuaded to leave his home, I gave his family physician. Dr.
W. F. Schwalm, of Brooklyn, at the beginning of his disease, a
full statement of his condition, telling the patient that rest in bed
was most conducive to his recovery, and that whenever he felt
worse it would be better not to come to New York, but to call me
or another aurist to his bedside, should his physician find it advis-
able. He always assured me that the air did him good, and he
felt a desire to take a drive every now and then.
At the beginning of January, 1883, however, his disease took
a decided turn for the worse. He was obliged to keep his bed ;
had severe headache, nausea, vomiting ; was slightly delirious at
times ; had twitchings in his limbs ; his neck was stiff, and his head
drawn back and to the right side. The purulent discharge from
the opening continued, but was bloody at times. January 9th I
was called to see him in consultation with Dr. Schwalm, and found
him still in the condition just described. On exploring the wound
with a probe, and scraping the osseous canal with a sharp spoon,
a moderate quantity of very dark blood oozed out for about five
minutes. His pulse was 84, his temperature 99° (Fahrenheit).
There was a moderate degree of congestion of the retina, and
some oedematous swelling of the optic disc and its surroundings,
more marked in the right than in the left eye.
On January loth the pain extended over the whole head, the
deliria and convulsive twitchings were more pronounced ; toward
morning he became comatose, and died at 10 a.m., January nth.
January 12th I made a post-morten examination, assisted
by Drs. Schwalm and D'Oench. Seven cm behind and about
Three Serious Cases of Mastoid Disease. 49
3 cm above the level of the auditory meatus, there was a per-
foration in the cranium, from 3 to 4 mm in diameter. The
bone in its vicinity was hyperaemic, but not carious. 2. 5 cvi in
and up there was another small place where the skull was hy-
peraemic and slightly depressed at the centre, but the probe
did not penetrate. This was the spot where the upper perfora-
tion had been, but had closed again. The remainder of the
skull was normal ; in particular I may mention that the skin,
periosteum, and outer bony surface of the mastoid process
and its vicinity, far beyond the mastoid foramen, were per-
fectly normal. The meninges and sinuses of the brain ex-
hibited no alteration. The inner surface of the cranium
showed the same hypersemic condition as described above,
at the places where the two perforations were situated.
The original perforation, which had remained open, was lo-
cated about 1.5 cm above the greatest convexity of the right
transverse sulcus, about 3 cm in and upward from the lateral
angle of the occipital bone. The point of the perforation
was situated either in the lambdoid suture, or near it. The
hyperaemic point, where the last perforation had taken place,
was about in the centre of the right superior fossa of the
occipital bone.
The right half of the tentorium cerebelli was markedly
raised over the level of the left half, but showed no other
abnormity.
On detaching the dura mater from the occipital and pe-
trous bones, it was found unbroken. Only at the place
of the first perforation it was red, thickened, soft, and
uneven, yet not (macroscopically) perforated. The lateral
sinus was intact, containing dark blood, but no coagula, and
its walls were smooth.
At the outer surface of the lateral sinus a thick streak of
pus led along the transverse sulcus to a larger collection
of pus at the lowest part of the sigmoid fossa. Here the
inner table of the bone had completely disappeared in
a round area of about 2 cm in diameter. It was the free
inner open side of an abscess cavity in the interior of
the mastoid process. This cavity had bony and ragged
walls, and a probe penetrated without resistance from it into
the tympanum and auditory canal.
50 H. Knapp.
The petrosal sinuses, as well as the posterior and anterior
sides of the petrous bones and the tegmen tympani, showed
no alteration.
On incising the tentorium cerebelli an abscess the size of
an English walnut was found in the middle and outer part
of the little brain. It was filled with thick, somewhat
greenish, not offensive, pus ; had no distinct walls to sepa-
rate it from the adjacent, not softened cerebellar sub-
stance.
The tissue and ventricles of the brain and medulla oblon-
gata exhibited no lesions discoverable with the naked eye.
I removed the petrous bone and the left hemisphere of
the cerebellum, but only one fact was found of interest for
our present purpose, namely : the mastoid cavity communi-
cated with the tympanic by a very small opening, an
unusually narrow orifice of the mastoid antrum.
REMARKS.
The most important feature of this remarkable case
was the entire absence of external symptoms during the
whole course of a severe suppurative inflammation in the
interior of the mastoid process. Commonly the mastoid
region is tender to the touch, or on percussion ; its integu-
ment is swollen and red, at least in a certain degree.
The next unusual feature was the misleading character of
the pain. In acute and chronic mastoiditis interna the
pain commonly starts from the mastoid region, radiates
over the whole corresponding half of the head, and is most
intense in the parietal region. In our case the mastoid
region was never painful at all, the parietal not much, the
occipital moderately, the frontal most severely and most per-
sistently. This led me into the belief that the inflammation
had extended from the midde ear through the tegmen tym-
pani to the meninges of the adjacent middle and anterior
lobes of the brain.
Then suddenly, in the sixth week of the disease, an abscess
made its appearance three or four centimetres behind and
two centimetres above the mastoid process, and probing
Three Serious Cases of Mastoid Disease. 5 1
demonstrated that the pus came from the cranial cavity,
through an opening in the occipital bone or in the lambdoid
suture. This was followed by an abscess from gravitation
at the lower part of the occiput, and later by another
abscess farther back and upward on the cranial bone, like-
wise through a perforation of the skull. My opinion then
was that a communication between the middle ear and the
cranial cavity had formed, and that the pus was deposited
between the dura mater and the bone : in the front part,
causing the frontal pain ; in the back part, causing the
occipital pain, as well as the perforations of the bone. As
the case was of recent date, and the evacuation of pus
was followed by complete though only temporary relief of
the symptoms, I thought that extensive caries interna did
not exist, and that the patient would soon get well if the
outlet of the pus was kept free. I had no doubt that
the escaping pus was furnished by the cavities of the tym-
panum and mastoid, and crept along the transverse sulcus
between bone and dura mater, and expressed my views in
this respect to Dr. W. J. Morton, to whom I had an oppor-
tunity of showing the case at my office.
The supposition of a cerebellar abscess could not be
entertained with any degree of probability before the last
two weeks of the patient's illness.
The most noteworthy features of the whole case are, it
seems to me, the perforations in the temporal bone so far
away from the original seat of the inflammation, and the ef-
fectual drainage of an intracranial suppuration for three
months. The autopsy showed that in this case, as in most
others, the chief focus of the formation of pus was the mas-
toid cavity, and I shall, in future, be more inclined to open
this cavity, even when no external signs of mastoid suppu-
ration are present. In this way a life may be saved every
now and then. If the operation proves the diagnosis to be
incorrect, it rarely does harm, and may even do good by its
" revulsive effect." Among others, SCHWARTZE, whose
merit in this department is so deservedly praised, draws the
indications for opening the mastoid wider than I have hith-
erto done. My hesitation as to the more frequent perform-
52 H. Knapp.
ance of this operation was based on two facts : (i) We see so
many cases with severe otitis media, even when pronounced
cerebral symptoms are present, get well ; the natural fatal
termination is rare, almost exceptional, while, on the other
hand, the statistics of the operation show a considerable
death-rate — about 1 1 ^ in Schwartze's series. (2) I have as-
sisted in a number of trepanations of the mastoid, and have
performed some myself, where the diagnosis was erroneous,
the extension of the disease taking place not through the
mastoid, but through other well-known channels. Even if
such cases afterward do not terminate fatally, the fact of
having undertaken an important operation on an erroneous
supposition, is humiliating and depressing.
Among the variety of symptoms in acute and chronic
otitis media, the one which has guided me more than any
other, is persisteiit headache radiating from the ear over the
corresponding half of the head. If this was present, and
the mastoid showed any symptoms of active participation
in the inflammation, I thought trephining indicated. The
case under consideration, and a few others that have been
published,' make, however, the operation justifiable even
when there are no external symptoms of mastoid suppura-
tion present, provided that sinus thrombosis can be excluded.
In recommending an extension of the indications for
trephining as above stated, I am satisfied that we shall oc-
casionally be disappointed, even if mastoid symptoms are
pronounced, and beg to report briefly a case in support of
my opinion.
Case 2. — Chronic mastoiditis interna; sclerosis; trephin-
ing; no pus ; deatJi from meningitis or abscess.
Mrs. Rob. Libas, ast. forty-five, of New York, under the care of
Dr. Schwedler of this cit}', consulted me with the doctor Dec.
6, '79. She had never had otorrhoea ; six months previously, for
the first time, pain behind the right ear ; autophony. In Sep-
tember and October intense headache, almost constant, most on
vertex and occiput.
Status prcBsens. — Pain on pressure behind ear ; vertigo ; loss of
appetite ; pale complexion ; hearing almost normal ; h ^, v f^.
' See the case of Dr. F. T. Brown in this number.
Three Serious Cases of Mastoid Disease. 53
Tuning-fork from forehead on both sides. Mtt somewhat sunken ;
handles retracted. Right mastoid from its tip to 1.5 C7n above
its base slightly swollen from thickening of subcutaneous layer ;
skin somewhat red and wrinkled. My diagnosis was that an
acute catarrhal otitis had induced a chronic mastoiditis interna,
with extension of the irritation to the adjacent intracranial struct-
ures. I recommended rest, local depletion ; counter-irritation
and derivatives to bowels and skin.
On Jan. 28, '82, I saw the patient again with Dr. Schwedler.
The treatment had been carefully carried out, and the patient
had had all the benefits rest could give her, yet she had never
since been free from right-sided headache. The mastoid was
tender on pressure and somewhat puffy. No discharge ; hearing
normal. The pain in the head was such, and had lasted so long,
that we thought trephining should no longer be delayed. As the
patient gladly consented, I opened the mastoid with a drill on
Jan. 29th. Periosteum and bone proved healthy. The drill en-
tered 9 mm before the cavity was reached. There was free cap-
illary bleeding from the bone, but no escape of pus. No general
reaction followed the operation ; the wound suppurated ; the bone
was bare but smooth. The patient felt better for a month, then
the headache returned, and she died in June, 1880, from meningitis
or abscess.
It is a pity that the autopsy in this case could not be ob-
tained. Sclerosis of the mastoid terminating fatally is not
common, and there is a number of cases on record in
which the trephining of the mastoid under similar conditions
brought entire and permanent relief, as, for instance, in
the case which I published in the tenth volume of these
Archives, p. 365, etc.
Another case, with imperative indications for trephining,
and a perfect success of the operation, may conclude this
communication.
Case 3. — Acute purulent tympatto-mastoiditis ; severe head-
ache ; optic neuritis; opening of mastoid; recovery ; res-
toration of normal hearing.
Mr. Sam. Rosenthal, set. twenty-five, of this city, called me to
his residence on May 25, 1882. Three weeks previously, after an
54 H. Knapp.
exposure, he had had severe earache and headache on his right
side, followed in a few days by profuse discharge from the ear.
The pain abated for several days, then it returned, and lately the
discharge had become scant, and the headache more intense. I
found perforative otitis media purulenta ; the mastoid, which on
both sides was unusually developed, somewhat swollen and pain-
ful ; the hearing greatly reduced, bone-conduction preserved
distinct though not very marked neuro-retinitis in the right eye,
and some congestion and oedema of the retina also in the left.
The headache was very severe ; the patient was feverish, had no
appetite, could not sleep, and was greatly depressed. I told him
to come to the Ophthalmic and Aural Institute, and if in a few days
there was no decided improvement, the bone behind his ear would
require an operation. He came at once, had leeches applied before
and behind his ear, stayed in bed, took an aperient, and perspired
freely. The symptoms abating in no way, I made. May 30th, with
a strong knife, a deep incision, 3 cm in length, from the tip of the
mastoid process to its basis, i cm behind the insertion of the auricle.
The lower part of the bone felt hard and smooth, the middle and
upper rough and soft, so that the knife, used with considerable force,
cut through the bone i cm in length. I enlarged the incision by in-
serting the sharp end of the ivory handle of the scalpel into it, and
broke the bony edges off by pressure from within outward. Hav-
ing thus obtained an opening of i cm long and 6 mm broad, I
introduced a sharp spoon, explored the interior of the mastoid
process, and discovered a large abscess cavity, the walls of which
were rough and, at the medial side, defective. I evacuated the
contents with the spoon as far as feasible, and then syringed the
cavity with a concentrated warm solution of boracic acid. After
this I inserted a perforated silver tube, covered it with absorbent
cotton, and held it in position by a flannel roller. The wound
was syringed and dressed in this way twice a day. On the second
day the water injected into the mastoid escaped from the ear-
canal. The syringing had to be done gently, as the patient felt
dizzy when the water was injected into the mastoid, but not when
injected into the ear. There was a good deal of granulation tissue
in the mastoid cavity, which was repeatedly scraped out with a
sharp spoon. The partition walls had all been broken down by
the suppuration, and the rough walls could be felt on all sides
except the inner, where the spoon pressed against soft tissue,
the dura mater. The suppuration gradually diminished, the
headache disappeared, the neuro-retinitis improved, and the
Three Serious Cases of Mastoid Disease. 55
patient was discharged from the hospital twenty-five days
after the operation. He came to me twice a week ; when
I syringed the cavity and kept it and the opening clear from
granulations. The cavity gradually diminished in size. At the
beginning of October there was no discharge from the wound any
more. I left the canula off ; the wound soon closed with a
depressed scar, and the patient has had no trouble since. On Oct.
3jst the Mt was found restored, the handle of the malleus red,
the light spot almost normal ; h -i^, v ff. The patient made a
business journey through the country for six weeks, which caused
no discomfort, and he has remained well up to date, February, 1883.
In this case the pus had no doubt penetrated from the mas-
toid into the cranial cavity as in the first case, which is
clearly demonstrated by the severe cerebral symptoms, the
neuro-retinitis, and the defects in the inner table of the
mastoid found on probing during and after the operation.
The outer table, which was soft at the time of the opera-
tion, would surely have given way soon, and the pus would
have found an external outlet, as is noticed so frequently.
Yet the operative treatment was decidedly indicated, as it
furnished an early, direct, and free avenue for the removal
of the morbid contents of the mastoid cavity, either spon-
taneously or by instruments. In our first case this avenue of
exit was established by nature, but it proved insufficient by
being too late and too far away from the original focus of
suppuration. Only the entire absence of any abnormity
in the mastoid region deterred me from an operation which
might possibly have saved the patient's life. The happy ter-
mination of the third case, and the post-mortem conditions
of the first, furnish as good an illustration as can be obtained
of the importance of opening the mastoid early and suffi-
ciently in purulent mastoiditis interna which extends into
the cranium ; and even if nature has established an opening,
this opening may require operative enlargement, or another
may be necessary at another place if the course of the disease
continues unfavorable. To the reader acquainted with the
modern otological literature, I need not say that this rule,
so forcibly suggested by the above cases, has been emphati-
cally advanced by Schwartze and others as the result of
similar observations.
A CASE OF ABSCESS OF THE MASTOID, WITH
ENTIRE ABSENCE OF TENDERNESS, HEAT,
OR SWELLING OVER THE SUPPURATING
PART, WITH A CONSTANT DISTANT PAIN
NEAR THE OCCIPITAL PROTUBERANCE.
TREPHINING ; RECOVERY ; OCCURRENCE OF
ERYSIPELAS DURING CONVALESCENCE.
By F. TILDEN BROWN, M.D., New York.
John McOnerney, age forty-eight, came to Doctor Roosa's clin-
ic at the Manhattan Eye and Ear Hospital on September 14,
1882. Examination by Drs. Edward T. Ely and F. T. Brown
showed a muco-purulent discharge from the right ear, partial loss
of the membrana tympani, diminished calibre of the auditory
canal, no swelling or redness behind the auricle, 7io tender-
7iess on pressure or percussion over the mastoid, inability to hear a
watch on contact, tuning-fork heard but by aerial conduction.
The sole cause of his coming to the hospital, was great pain at a
point along the right superior curved line, two centimetres from
the occipital protuberance ; occasionally radiating along the right
border of the parietal suture over the frontal bone to its interior
angular process ; thence above and below the orbit.
Previous history. — No direct injury, but had a fall on back of
head one month before. Had never had syphilis ; was perfectly
temperate, and had always been well until the fourth of last June,
when he experienced gradually increasing pain in the right ear. Mor-
phine gave temporary relief. Five days after, a discharge appeared.
The pain continuing, a blister was applied behind the ear, and on
June i6th, he was able to go to work, but returned in a few hours
with still greater pain. For the three weeks following, morphine
(hypodermically) was given twice daily ; this failing, chloroform
inhalation was resorted to. Late in July, Wilde's incision was made
56
A Case of Abscess of the Mastoid. 57
at the New York Eye and Ear Infirmary, but the pain became, al-
most at once, more intense. A few days later a bone-operation was
proposed, but the patient's family objecting, he came with a letter
from his physician to the Manhattan Eye and Ear Hospital. Here
careful watching for two days and nights verified his story of pain,
sleeplessness, and loss of appetite, but no abnormal temperature
was detected.
The result of a consultation was to defer operation until
thorough anti-neuralgic treatment had been tried. Quinine, alco-
hol, and galvanism were ordered. Five days later the patient was
no belter, and perforation of the mastoid was determined upon
despite the absence of satisfactory local symptons. It was per-
formed by myself under the advice of Dr. Ely. The periosteum
was healthy, and on its section the bone presented a similar
appearance. Brainerd's drill sunk one and a half centimetres,
entered a cavity, when about four grammes of pus came away. A
warm solution of boracic acid, thrown into the meatus auditoriiis,
found exit through the wound, bringing pus. The dressing was
antiseptic and directed to favor free drainage and prevent occlu-
sion. Pain was at once and permanently removed. Two weeks
later the patient went home, but returned daily for dressing. The
discharge now amounted to three grammes in twenty-four hours,
and a watch could be heard on contact. On the evening of No-
vember fourth pain was felt about the auricle, followed by a chill
with subsequent fever ; the pain prompted a vigorous application
of camphorated oil. Toward morning the patient vomited. I
was sent for the following night when I found him with a pulse of
90 ; temperature, 103° ; tongue coated ; bowels constipated ; pu-
pils normal in response to light. Probe passed readily, but the
discharge was slight. The tissues about the wound and over the
parotid region were oedematous and but slightly sensitive ; this
pallor suggested serous rather the haemostatic injection, and
might have been either the erysipelatous cause, or the blistering
effect, of camphorated oil applied to relieve deeper pain. The
diagnosis of erysipelas was made on the fourth day ; this disease,
still indifferently marked, had extended to the left malar bone ;
pulse was 98 ; temperature, 103-!° ; delirious through the night ;
sight was indistinct ; had convergent squint ; pupils responded
feebly to light ; had moderately rhythmic vibrations of the right
forearm. I was again led to doubt the absence of meningitis, and
called Doctor Roosa in consultation, who, on examination, found
58 F. Tilden Broivn.
slight cerebral impairment and homonymous double vision exist-
ing ; the ocular media were clear. Optic discs not seen on account
of want of illumination. The mastoid perforation was free, and
afforded no evidence of retained pus, although the discharge was
greatly diminislied. For this reason Doctor Roosa and myself con-
cluded that meningitis due to adjacent suppurative mastoid disease
did not exist, and that the diplopia, with other nervous symptoms,
was due to a peripheral hyperaemia of the pia mater, by continuity
of tissue with the facial erysipelas, resulting in irritation of the
sixth nerve at its point of exit.
This belief proved to be correct, for the intensity of the symp-
toms subsided, and in eight days convalescence began. The
discharges from both channels had ceased, and one week later the
wound completely closed. This was an agreeable surprise, for
in its relationship to disease of the mastoid, I viewed the erysipe-
las as analogous to epididymitis succeeding a gonorrhoea, and I
expected a return of the discharge as the erysipelas subsided.
It seems to me that there are three points of interest in
this case :
1. The entire absence of tenderness, heat, or swelling
over the suppurating mastoid, while there was a constant
pain referred to a point near the occipital protuberance.
2. The difficulty in differentiating the symptons of facial
erysipelas from those of meningitis.
3. The direct suggestion made by the case, of the value
of active counter-irritation in the treatment of subacute or
chronic suppuration of the middle ear.
PEDUNCULATED BONY GROWTH IN EXTERNAL
AUDITORY CANAL, THE RESULT OF LONG-
CONTINUED SUPPURATION ; REMOVAL BY
SNARE; MICROSCOPIC EXAMINATION.
By DAVID C. COCKS, M.D., New York.
Mr. S., set. twenty-eight, clerk, was sent to me by Dr. A. N.
Brockway, Nov. 5, '82. Patient states that twelve years ago he
had earache ; ear lanced by Dr. Packard. Otorrhoea, which
followed with short intermissions, continued to date. He has
noticed, and could feel with his finger, the growth for which
he now seeks advice, for the past seven years, and during
that time it has not altered much in size. He has had severe pain
in that ear repeatedly, and at the present time is suffering more
intensely than usual. Shaking the head during the attacks of pain
was followed by a slight discharge of pus. Examination shows
the external meatus of the left ear filled by a polypus. A fine
probe can, with care, be insinuated between the growth and the
canal for ^", except backward, where an obstruction is met about
}i" from the meatus. The growth was covered with a moist
mucous membrane. When the probe was withdrawn a drop of
fetid pus escaped. The patient being very nervous, ether was
administered, and the wire of Blake's snare placed around the
growth, and it was then that a suspicion of the growth not being
an ordinary polypus was first formed, for the wire loop on being
drawn tight did not readily sever the polypus from its base. Steady
traction was then made, and the growth suddenly came out, hav-
ing been severed from its base while the wire still tightly encircled
it. The pedicle, broad and short, was situated on the posterior
wall of the external canal, about at the junction of the bony and
cartilaginous portions. On examining the growth, a facet was
59
6o
David C. Cocks.
noticed at the inner end, and inspection revealed a small polypus
situated in the middle ear (the membrana tympani having been
destroyed). This, after the bleeding was controlled, was seized
with forceps and removed.
A microscopic examination of the growth by Dr, J. L.
Minor, Microscopist to the N. Y. Ear and Eye Infirmary,
showed it to be an osseous polypus. The polypi were
placed in a bottle and left for two months. At the end of
that time the investing mucous membrane had disappeared,
and the extent of the bony change was then first seen. The
growth was smaller only by the loss of its external membrane.
It was white, hard, and gave forth a click characteristic of
bone when touched by a probe.
DR. minor's report.
The macroscopic appearance of the two bony tumors is
well shown in the accompanying cuts (see figs, i and 2), which
represent the real sizes. The larger one is an irregular
cylindrical mass, with a convex upper surface of compara-
tive smoothness, an irregular, nodulated under surface, a
roundish outer extremity, and a smooth articular concavity
on its inner end. Its measurements are: length, 15 mm.;
Bony Grozvth in External A uditory Canal.
6i
breadth, lo vivi.; thickness, 7 mm. The smaller tumor is
an irregular prismatic mass, on the outer surface of which
is a smooth convex articular surface, corresponding to the
concavity of the larger bone. Its measurements are : trans-
verse, 6.5 vim.; longitudinal, 3.5 mm.; vertical, 4.5 mm.:
weight of larger, 0.8/ smaller, 0,1 gramme.
Both tumors are hard and bone-like, and each is covered
by a dense periosteum-like membrane, which closely ad-
heres to the smooth surfaces, and is torn and irregularly
attached to the rough surfaces.
Microscopic examinations were made from dried and hard-
ened specimens, consequently the structure of the mem-
brane was not seen. The substance of the tumors, how-
ever, leaves no doubt of its nature, for the entire mass
consisted of perfectly formed bone-tissue, with beautifully
marked Haversian systems, as is shown in fig. 3, which
was drawn from a section ground to extreme thinness.
These osteomata undoubtedly arose from masses of granu-
lation tissue, which were associated with the inflamma-
tion of the middle ear. Osteoblasts from denuded bone,
falling upon granulations, found a nidus for growth and
reproduction. This accounts for the ossification; and to
62 David C. Cocks.
explain the separate bones with articulating surfaces, we
may suppose the ossification to have been in two contiguous
granulation masses, motion between which was furnished by
the movements of the canal, incident upon motion at the
temporo-maxillary articulation.
The subsequent history is as follows : The whole canal
was syringed twice daily with a saturated solution of boracic
acid ; and with the exception of a slight erysipelatous attack
involving the pinna and surrounding tissues, which lasted
four days, the case progressed steadily toward a cure.
The syringing with boracic acid was continued morning
and evening. After drying the canal thoroughly, the whole
canal was tightly packed with absorbent cotton. The base
of the growth dried up, the discharge diminished, a new
membrane gradually formed, and by November 27, 1882,
all discharge had ceased.
Politzer's method of inflation was practised daily, and
on December istthe hearing power was as follows : L E |-§-,
R F 60.
^ ^ 50-
There is now a membrane which can be made to move
backward and forward when air is alternately forced in and
out of the canal through a Siegle's speculum, and the hearing
on this side is above the standard.
February 10, 1883, L E||; R E |^.
I have been induced to place this case on record because
of the rarity of polypi which have undergone bony meta-
morphosis.
Note. — In the text-book of the " Diseases of the Ear," by Dr. Adam Polit-
zer, translated by Dr. J. P. Cassells, of Glasgow, edition of 18S3, published by
Henry C. Lea's Son & Co., Philadelphia, reference is made, on p. 639, to
this subject. Isolated ossification (Cassells) and calcification of aural polypi are
rare, and on p. 618 he speaks of pedunculated exostoses, but his examples are
not like the case reported.
THE EXAMINATION OF EARS BY MEANS OF
THE TUNING-FORK.
By J. B. EMERSON, M.D., of New York City.
AT the suggestion of Dr. St. John Roosa, I began, more
than a year ago, some investigations of tuning-fork
tests, as applied to ears with normal hearing. The results
which I have obtained seem to me sufificiently interesting
to be submitted to the profession.
Over one hundred persons with normal hearing were tested
somewhat superficially, and the results were uniformly simi-
lar. I then made fifty of these cases the subject of very careful
testing, and I have tabulated the result with a view to their
study. The standard of hearing was a watch, heard at forty
inches and over. I found that at least two thirds of those
who supposed their hearing was normal failed to come up
to this standard. The hearing of some, however, was so acute
that they perceived the ticking at fifty, sixty, seventy, and
one at eighty inches. No allowance has been made for this
excess, but all such cases have been entered in the table
ac 40
as -^-^.
The fifty cases include persons of a great variety of con-
ditions in life, of both sexes, and they range in age from
seven to sixty years. Some of the tests were made in com-
parative quiet, others amidst the noises of a hospital clinic ;
I hoped by testing in this way to get an average which might
be useful in all circumstances. This is to be taken into
account as one of the factors that may explain the absolute
differences of duration in the tabular statement. Another
63
64 J. B. Emerson.
cause for this difference is that my tuning-forks did not
vibrate as long after extended use as they did when new ;
and my A fork finally snapped when subjected to a strain
which it had resisted hundreds of times. It is thus seen that
the steel in tuning-forks, like that in railroad use, deteriorates
from continued vibration. The note, however, remained
unchanged to the last. A third factor to explain the abso-
lute difference of duration is the inability of some persons
to keep their attention fixed, or to appreciate the more
delicate shades of the test. This is especially the case in un-
cultivated and ignorant persons.
The forks used were : 1st. A fork 32-|- cm. long, with cylin
drical prongs and handle, giving a note more than an
octave below the middle C (middle C is c ' = 264 double vi-
brations according to Helmholtz), and called A (no double
vibrations, H.). 2d. Another fork about 17 cm. long, with
rectangular prongs and conical handle, giving a note one
octave above middle C and called c" (according to Helm-
holtz c^ = 528 vibrations).
In using the forks, I have endeavored to obtain a uniform
strength of vibration, striking them on my knee and holding
them in corresponding positions for each individual : foracrial
conduction about half an inch in front of the concha, and
moving continuously to avoid exhaustion and the " deaf
spots " ; for bone-conduction, the end of the handle of the
fork at the junction of the mastoid and squamous portion of
temporal bone just behind the ear.
In determining the duration, I struck the fork at an exact
five or ten seconds of the watch, and noted the time to the
nearest five seconds when the patient ceased to hear the
sound ; the question being asked, " which is louder, through
bone or through air?" and answer noted.
While I can only claim approximate results, I think I am
justified in believing that all grosser sources of error have
been avoided ; and for practical purposes the results may be
regarded as fairly representing the average.
From a tabulated statement (which for brevity's sake is
here omitted) of the fifty cases, the following results were
obtained:
Examination of Ears by Tuning-Fork.
65
In every case the A fork was louder when heard through
bone, and the c '^ fork, when heard through air.
The average duration in seconds was as follows :
A fork
Air-conduction
Bone-conduction .
Excess in air-conduction
c' fork
Air-conduction
Bone-conduction .
Excess in air-conduction
A and c ^ forks
Air-conduction
Bone-conduction .
Excess in air-conduction
31
18
13
36
16
20
34
17
A and c^ are both heard longer through aerial than
through bone-conduction.
The difference between air- and bone-conduction is less
for the A note than for the c' note; A being heard about
1.75 times longer through air than through bone; while c^
was heard about 2.25 times longer through air than through
bone.
For both A and c", the average duration is twice as long
through the air as it is through the bone.
Several months since I began to apply the same tests to
persons who had disease of the middle ear ; and I have also
tabulated the results for the following fifty cases.
66
y. B. Emcrsoji.
li. c
C •
c
V .
u
, 0
si
s§
?§■
No.
Disease.
Age.
Hearing
Distance.
in a
a
^^1
^8
1= a
5|
>« 0
00
0 w
>« 0
00
J= 0
■z: 0
.2 0
cn H)
!rt >-•
.ax
2 '5
3 3
11
11
s<
^°
Q-«
3.2
w
w
Ot. med. cat. subacute
36
tj 24
A.' Bone.
C Bone.
10
20
15
20
5
I
Cicatric. Mt . . . .
T 2
^ — ¥7
A. Bone.
C. Bone.
0
20
20
15
5
20
Ot. med. cat. chron. .
26
R = i!
A. Bone.
C. Air.
15
20
10
10
5
10
2
Cicatric. Mi. . . .
L = A
A. Bone.
C. Air.
5
10
10
15
5
5
3
Ot. med. cat. chron. .
50
T 18
^ TO
A. Bone.
C. Bone.
A. Bone.
10
30
12
15
20
15
5
10
5
3
C. Air.
30
20
10
4
Ot. med. sup. chron. .
Ot. med. cat. chron. .
16
TJ 12
T 20
^ — T7
A. Bone.
C. Air.
A. Bone.
C. Air.
A. Bone.
10
15
25
20
10
10
10
15
10
5
5
10
10
Ot. med. cat. acute — 2
R = n
C. Air.
30
15
15
5
days
24
L = ^
A. Bone.
C. Air.
20
30
10
15
10
15
R = il
A. Bone.
10
20
10
C. Bone.
30
20
10
6
Ot. med. sup. chron. .
12
L = i^
A. Bone.
10
^5
15
C. Bone.
30
15
15
R = ^4
A. Bone.
C. Bone.
15
10
15
10
7
Ot. med. cat. chron. .
28
T S
^ — ¥(T
A. Bone.
15
5
10
C. Air.
10
25
15
8
Ot. med. cat. acute. .
34
R .30
A. Bone.
C. Air.
A. Bone.
30
15
30
15
10
25
15
5
8
C. Air.
20
10
10
9
Ot. med. cat. chron. .
35
R = A
A. Bone.
C. Bone.
A. Bone.
5
20
10
20
25
20
15
5
10
C. Bone.
15
20
5
' A. means A fork =110 vibrations. C. means c" fork = 528 vibrations.
Examination of Ears by Tuning-Fork.
^7
,-
,
U
u
.ic
C in"
C •
4> .
i>
<■%
^i
o§
°g
0 3
u. °
S8
1 tj
is
No.
Disease.
Age.
Hearing
Distance.
•c-c
3 C
0 0
— (U
j: c
0 0
2K
2I
.- 3
IT 0)
11
c "
u- 0
isfe
Q^
3*0
Q
W
w
lO
Ot. med. sup. chron. .
23
A. Bone.
C. Bone.
A. Bone.
0
0
10
2
2
5^
C. Air.
20
10
10
A. Bone.
15
15
II
Ot. med. cat. chron. .
44
C. Air.
A. Bone.
C. Air.
20
10
20
10
15
10
10
10
5
A. Bone.
0
5
5
12
Ot. med. sup. chron. .
50
C. Bone.
A. Bone.
5
5
ID
10
5
5
C. Bone.
• 5
10
5
R = M
A. Bone.
10
10
18
C. Bone.
25
15
10
13
Ot. med. sup. chron. .
L = A
A. Bone.
0
10
10
C. Bone.
10
15
5
R = A
T = 8
A. Bone.
10
30
20
14
Ot. med. cat. chron. .
38
C. Bone.
A. Bone.
C. Bone.
10
10
5
15
30
15
5
20
10
15
Ot. med. cat. chron. .
50
R = fz,
A. Bone.
C. Bone.
A. Bone.
0
4
10
10
15
10
5
C. Air.
20
25
5
16
R = /.
A. Bone.
C. Bone.
5
5
5
5
15
15
10
10
Ot. med. cat. chron. .
55
T 0
A. Bone.
C. Bone.
ID
15
5
10
■R 0
A. Bone.
0
10
10
C. Bone.
0
10
10
17
Ot. med. sup. chron. .
23
T 84
A. Bone.
C. Air(?)
10
15
10
10
5
18
■D 8
A. Bone.
C. Bone.
5
10
10
15
5
5
Ot. med. cat. chron. .
25
T 6
A. Bone.
C. Bone.
5
5
10
5
5
68
y. B. Ei)icrson.
No.
Disease.
Age.
Hearing
Distance.
<S
a 3
•o-a
3 e
o o
(A
On
kt
tt
^l
a: r
< 3
o'~.
— C
§.2
So
O
1^ -
?1
35 u
4) c
3-a
s-a
XCD
U
Q
W
o5
W
19
23
24
25
26
27
Ot, med. cat. chron.
Ot. med. cat. subacute
Ot. med. cat. chron. .
Ot. med. sup. chron. .
Ot. med. cat. chron. .
Ot. med. sup. chron.
Ot. med. cat. chron.
Ot. med. cat. chron.
Ot. med. cat. chron. .
30
34
47
i6
26
23
T 2
R
=
H
L
=
c
R
=
H
L
=
2
R
p
T5
L
=
2
R
=
-h
L
=
20
R
=
A
T-
^^,
8
L =
R =
L =
A. Bone.
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Air.
A. Bone.
C. Air.
A. Bone.
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Air.
A. Bone.
C. Bone.
A. Bone.
C. Air.
A. Bone.
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Air.
A. Bone.
C. Air.
A. Bone.
C. Air.
10
15
15
25
5
15
15
25
15
15
20
15
5
15
lO
5
15
5
10
lO
10
15
ID
5
15
15
20
15
5
10
15
15
15
o
15
lO
15
lO
15
10
15
5
lO
10
10
o
lO
ID
25
15
15
20
30
O
15
lO
15
O
10
5
10
lO
10
20
15
5
lO
5
5
20
10
10
15
15
20
20
lO
10
15
15
5
10
10
10
10
15
15
5
10
5
Examination of Ears by Tnning-Fork.
69
No.
Disease.
Age.
Hearing
Distance.
O) 3
-c-a
3 a
o o
(A I
,
u
C m'
^•S
^■g
> C
0 0
c 0
<35
4iS!
<-d
o.S
v^ C
<« 0
gS
C C
0 0
oO
= 1
Q^
c« 0
^ 0
1'
28 Ot. med. sup. chion.
29 Ot. med. sup. chron.
30 Ot. med. sup. chron.
31 Ot. med. sup. chron.
32 Ot. med. sup. chron.
33 Ot. med. cat. chron.
34 Ot. med. cat. chron.
35 Ot. med. cat. chron.
36 Ot. med. cat. chron.
19
30
28
]6
13
65
35
34
13 0
T 20
T? 12
T 0
•Q .20
L = il
R
4
L
12
R
. c
L
0
R
c
50
L
2
R=
n
on
L=
n.
at i'
R =
A. Bone.
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Air.
A. Bone.
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Air.
A. Bone.
C. Air.
A. Bone.
C. Air.
A. Bone.
C. Air.
A. Bone.
C. Air.
A. Bone.
C. Air.
0
15
10
15
5
15
25
20
5
5
15
30
20
10
0
10
10
10
10
30
10
25
15
30
15
35
10
20
15
35
15
35
15
40
0
25
10
15
0
30
0
20
10
20
15
15
10
20
15
15
0
15
20
15
5
0
20
20
15
5
10
15
15
10
5
10
10
15
15
!.=;
20
20
15
5
10
20
20
''
5
20
15
15
20
10
20
20
25
25
5
30
20
10
10
70
y. B. Emerson.
No.
Disease.
37
38
39
40
41
Ot. med. sup. chron.
Ot. med. sup. chron.
Ot. med. sup. chron.
Ot. med. sup. chron.
Ot. med. sup. chron.
42 ; Ot. med. sup. chron.
43 Ot. med. cat. chron.
44
45
Ot. med. sup. chron.
Ot. med. sup. chron.
Age.
17
37
17
47
16
19
54
13
Hearing
Distance
■R 10
P 4
^^ — TTf
T 0
^ — ¥Ty
P 6
^^ — T^
T 30
T 18
^ TTT
[ — ao
'- — 4 5
p 20
^^ — Tff
T 0
^ TTT
T 6
J-* T7T
L =
V 9
•a -a
3 e
o o
-u
en I
•SCQ
1
B
0 (0
«> .
Oc
O-o
0 0
J. °
S 0
'^
C 0
< 5!
33 ■"
.- 3
0 ^
•« a
c
0-"
Sc
a 0
00
.2 0
.2 0
go
?! c
1'
A. Bone.
C. Bone.
A. Bone,
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Air.
A. Bone.
C. Air.
A. Bone.
C. Air.
A. Bone.
C. Bone.
A. Bone.
C. Air.
A. Bone.
C. Air.
A. Bone.
C. Bone.
A. Bone.
C. Air.
A. Bone.
C. Air.
A. Bone.
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Bone.
A. Bone.
C. Bone.
20
lo
5
40
1
15
45
5
35
15
40
5
20
15
15
0
15
10
15
5
25
5
15
30
30
35
25
10
15
25
20
20
10
25
20
2Q
10
25
15
20
25
30
25
20
5
35
30
30
25
15
15
5
20
10
10
15
15
5
5
10
5
10
10
15
20
5
25
5
Examination of Ears by Tuning-Fork.
71
,-
,
c
u
u
<.2
OS
0 a)
4)
>
No.
Disease.
Age.
Hearing
Distance
Which is louder,
or Bone-Conduc
.t8
u
go
P
•^ c
0 —
I-2
a 0
1'
_ 0
II
i.2
46
Ot. med. cat. subacute
49
R = ^
L = ^
A. Bone.
C. Bone.
A. Bone.
20
20
15
20
15
1
C. Bone.
20
15
5
Ot. med. cat. chron. .
R = it
A. Bone.
C. Bone.
10
15
30
20
20
5
47
Ot. med. sup. chron. .
23
L = ,S
A. Bone.
C. Bone.
5
10
20
20
15
10
48
Ot. med. sup. chron. .
R = ^
A. Bone.
C. Bone.
15
20
20
20
5
Ot. med. cat. chron. .
9
L = f^
A. Bone.
C. Air.
25
30
25
30
49
Ot. med. cat. chron. .
23
R = H
T 20
A. Bone.
C. Air.
A. Bone.
C. Air.
15
20
15
20
20
15
20
15
5
5
5
5
50
Ot. med. sup. chron. .
32
t{ 0
T 0
A. Bone.
C. Bone.
A. Bone.
0
0
0
2
2
5
2
2
5
C. Bone.
0
5
5
In every case the patient asserted that A was much
louder through the bone than through the air. In 39 ears
the c'' was heard louder through air ; in the remaining 61 ears
it was heard louder through the bones. The middle C (c '
Helmholtz) tuning-fork was used in some of the " 39 " ears;
with it the sound was heard longer through the bone. In
26 of the 39 ears the hearing was W and over.
Average duration, in seconds, for 26 ears :
A. Air-conduction
Bone-
Excess of bone-conduction
^5
2
^2 y. B. Emerson.
Bone-conduction heard 1. 13 longer than aerial conduction.
c^ Air-conduction . . . . . 21
Bone- " ..... 15
Excess air-conduction ..... 6
Aerial conduction heard 1.4 longer than bone-conduction.
A and c ^ Air-conduction .... 18
Bone-conduction . . . . . . 16
Excess air-conduction ..... 2
Aerial conduction is heard 1.13 longer than bone-conduc-
tion.
In 13 of the 39 ears the hearing was -^-^ and under.
Average duration, in seconds, for 13 ears :
A. Air-conduction . . . . . 12
Bone- " ...... 14
Excess bone-conduction .... 2
Bone-conduction heard 1.16 longer than aerial conduction.
c ^. Air-conduction . . . . . 18
Bone- " 17
Excess air-conduction ..... i
Aerial conduction 1.05 longer than bone-conduction.
A and c ^ Air-conduction .... 15
Bone-conduction ...... 15
Equal.
In 61 ears, in which the c" tuning-fork was heard louder
through bone, the average duration was :
A. Air conduction ..... 7
Bone- " 18
Excess bone-conduction . . . . 11
Bone-conduction heard 2.57 longer than aerial conduction.
c ''. Air-conduction . . . . - . 12
Bone " 18
Excess bone-conduction .... 6
Examination of Ears by Tiuiing-Fork. 73
Bone-conduction 1.5 times longer than aerial conduction.
A andc". Air-conduction .... 10
Bone-conduction ..... 18
Excess bone-conduction .... 8
Bone-conduction heard 1.8 longer than aerial conduc-
tion.
Average duration, in seconds, for the entire 100 ears :
A. Air-conduction ..... 10
Bone " 17
Excess bone-conduction .... 7
Bone-conduction 1.7 longer than aerial conduction.
c^. Air-conduction ..... 16
Bone " 17
Excess bone-conduction .... i
Bone-conduction 1.06 longer than aiirial conduction.
A and c ". Air-conduction .... 13
Bone-conduction . . . . . 17
Excess bone-conduction .... 4
Bone-conduction 1.3 longer than aerial conduction.
From a study of the foregoing table the following con-
clusions seem to be reached :
1st. Relying on the statements of patients in regard
to the loudness of tuning-forks, as a test in ear troubles, will
lead to error unless account is taken of the fork used. As a
rule, in normal ears high notes are heard louder through
aerial conduction, and low notes louder through bone-
conduction. This is true also, to a limited extent, in dis-
eased ears, as verified by the thirty-nine cases cited.
2d. The relative duration of aerial and bone-conduction is
a better test. In normal ears, in all cases the tuning-
fork is heard longer through air than through bone, the
proportion being greater for high than low notes ; and for
the middle C (c') it should be heard about twice as long
through air as through bone, the average duration in
74 y- B. Emerson,
my cases being for bone seventeen seconds, and for air
thirty-four seconds. Any marked departure from this in-
dicates disease.
3d. In external- or middle-ear disease this proportion
is reduced, and in well-marked cases the average bone-con-
duction remaining the same or being increased, the aerial
conduction will be reduced until it becomes equal to or
much less than bone-conduction. In one hundred ears
tested, the average duration was for bone seventeen seconds,
for air thirteen seconds, or 1.3 longer through bone
than air. This reduction obtained also in the thirty-
nine cases in which air-conduction was louder than bone-,
the average duration in those ears being equal.
4th. When the bone-conduction is longer than aerial con-
duction, and yet much less than the average duration of
bone-conduction for normal ears, it is an indication not only
of middle-ear trouble, but that the nervous apparatus is in-
volved. Case 50, in the foregoing table is an illustration of
this.
5th. If the proportion between bone and air remain the
same, and the hearing power much lowered, it is probably
an indication of disease of the internal ear. Air-conduction
markedly exceeding bone-conduction the bone-conduction
may be entirely lost, and yet air-conduction continue to a
limited extent.
The two following cases illustrate this.
Case I. Mr. , forty-five. Chronic alcoholism.
D. air. D. bone,
A bone 30 20
c ' air 45 25
A bone 30 15
c^ air 40 15
H R
40
Case 2. Mr. , twenty-three. Meningitis.
D. air. D. bone.
A bone 10 3
c ' air 25 5
A bone 10 5
c ^ air 25 TO
Examination of Ears by Tuning- Fork. 75
Average duration, in seconds :
A and c ^
Air-conduction ...... 27
Bone " . . . . . . . 12
Excess air-conduction .... 13
Aerial conduction is heard 2.25 times longer than bone-
conduction.
Before closing I would acknowledge my indebtedness to
Drs. Roosa and Pomeroy for the use of their clinics at the
Manhattan Eye and Ear Hospital.
TWO CASES OF SYPHILITIC DISFIASE OF THE
LABYRINTH, WITH REMARKS *
By DAVID WEBSTER, M.D., New York.
THESE two cases are selected from a number of cases of
syphilitic disease of the ear, occurring in the practice
of Dr. C. R. Agnew and myself, for presentation to this So-
ciety, because the records of them are reasonably complete,
and because of the interest that has been manifested in this
class of affections during the last few years.
The diagnosis of lab\Tinth disease was based in both
cases upon the total, or almost total, deafness of the affected
ear to external sounds, and to the tuning-fork. In the first
case there may be room for question as to the diagnosis.
The autophony, the patient's voice " sounding to himself
as though he were talking into a barrel," seems to be a
symptom of middle-ear disease. But the absence of all
abnormal appearances of the membrana tympani, and the
inability of the patient to hear the tuning-fork in the
deaf ear while he heard it well in the other, as also the
suddenness with which the deafness was ushered in, seemed
to render the existence of labyrinth disease extremely
probable.
In the second case, I think the most sceptical will
not question the diagnosis.
The cases are both remarkable, I think, on account of the
recovery of hearing, which occurred after months of total
deafness. What the specific lesion of the labyrinth was
which prod'iced the deafness I am unable to say. It may
* Read before the N. Y. State Medical Society, Feb. 6, 1883.
76
Tivo Cases of Syphilitic Disease of the Labyrinth. jy
have been congestion, or it may have been inflammation,
or it may have been a periosteal thickening similar to that
affecting the orbital walls in the secondx:ase. Possibly, some
one who has given more thought to this subject than I have
may, on reading the cases, be able to arrive at a more posi-
tive conclusion as to the nature of the lesion.
In the first case only one ear was affected throughout the
course of the disease. This ear either became suddenly
deaf, or else its hearing was gradually lost without attract-
ing the attention of the patient, until he accidentally made
the discovery. It remained totally deaf, or nearly so, for
several months, when, under antisyphilitic treatment, the
hearing was gradually recovered, and there has been no re-
lapse up to the present time.
In the second case, one ear became deaf and remained so
for several months, when it gradually recovered its hearing,
and retained it for nearly a year, when the patient awoke
one morning with the same ear again totally deaf. After
some months' treatment the hearing was partially recovered,
but, soon after, the patient turned up "deaf as a post"
in both ears. He is still totally deaf in the ear first
affected, and probably will always remain so. The hearing
of the other ear was so far recovered under treatment that
he hears conversation readily.
In the second case a great deal of vertigo is complained
of. In the first case there was none.
Case i. — May 27, 1874. O. W., aged forty-one, physician, says
that he had what some of the most prominent physicians in New
York diagnosticated as pulmonary tuberculosis, at the age of
twenty-five. The pulmonary disease was a sequel of measles, and
was accompanied by copious and frequent haemoptysis.
After physicians and friends had given him up, he gradually
recovered under a very free use of whiskey, and an out-of-door life.
Four months ago, he had an attack of irregularity of heart-
action, following extreme exhaustion from extraordinary loss of
sleep in attending to his professional duties. The action of the
heart was tumultuous, irregular ; now rapid, now slow ; at times
fluttering, and again intermittent. The attack lasted thirty hours
and did not recur.
78 David Webster.
For the last three months he has suffered from intermittent
fever, with neuralgia. He has severe headaches every night, com-
ing on at 9 or lo o'clock, and continuing all night, keeping him
awake for hours at a time. These neuralgic pains have frequently
been felt in both his ears, and about three weeks ago he discovered,
for the first time, that his left ear was totally deaf. He has since
experienced a very annoying ringing in the affected ear, and a very
little pain.
Hearing power : right, normal ; left, click of nails at three
inches.
Tuning-fork, on teeth or forehead, heard only in right ear.
Pharynx slimy.
Auditory canals and membranag tympanorum, normal.
Eustachian tubes easily opened by Valsalva's method.
His voice, which to others seems normal, sounds to himself as
though he were talking into a barrel.
As the history seemed to point to malarial poisoning as the cause
of his troubles, it was suggested to the patient that he should put
himself upon large doses of quinine. This he objected to, how-
ever, because the drug had always acted very unpleasantly upon
his nervous system. He believed that five grains would set him
crazy. He was, therefore, placed upon a mixture containing chi-
noidin, arsenic, and strychnia. He was advised to drink half a
pint of milk four times daily, not to do any night work, and to
rest for an hour or two, regularly, at noon.
July ist. — The patient now recollects that about three months
ago he had an ulcer on the back of his neck. From six weeks to
two months he has had tibial periostitis, and tender spots on each
ulna. The neuralgic pains continue. The hearing of the left ear
has slightly improved, the click of nails now being heard at three
feet. The patient was now placed upon iodide of potassium, in
increasing doses, with cod-liver oil.
'yuly 15^//. — No headache ; no neuralgic pains. Has slept well
for the last eight or ten nights. Some tibial tenderness remains.
The left ear hears the watch in contact, and the voice as in ordi-
nary conversation, at ten feet. There is less tinnitus aurium.
y^uly 28M. — Has had ulcers on velum for the last ten days, but
they are now nearly well from cauterizing with nitrate of silver.
The left ear now hears the watch at a quarter of an inch.
Aug. 2^th. — Mucous patches and ulcers on tongue, lips, and
buccal mucous membrane. The left ear hears the watch at one
and a half inches.
Two Cases of Syphilitic Disease of the Labyrinth. 79
The patient was now advised to place himself under the care of
Dr. F. J. Bumstead.
I complete the history of the case by the following extract from
a letter from the patient, dated May 8, 1879, about five years
after we first saw him :
" I am very happy to inform you that my general health is now
first-rate. I can hear a watch tick at arm's length with my left
ear, but not quite so clearly as with my right. It does not trouble
me, however, in any way whatever, and my left ear is just as good
as my right for purposes of auscultation. For ordinary conversa-
tion, practically the left ear is as perfectly good as the right, and
I can hear ordinary conversation quite as well as before my left
ear became deaf. You will doubtless recollect that the last lime I
saw you I had mucous patches in my mouth and throat in large
numbers. Dr. Bumstead at once placed me upon blue mass and
iron, which, together with potass, iodide, I continued to take for
two years, taking from six to ten grains of blue mass with half that
quantity of ferri sulph. daily ; at one time taking this for nearly a
year without intermission. I had returns of the mucous patches,
ulceration of fauces and soft palate, and had, two or three times,
ulceration of the epiglottis, which was very nearly destroyed, the.
disease proving very obstinate and unyielding. During the last
year that I took it, 1 took not less than six ounces of the blue mass.
Since that time I have had no manifestation of the disease whatever,
and have taken no medicine. During all the treatment I never be-
came salivated, and no physiological effects whatever were shown.
My health is now as perfectly good in every way as ever, and I
may say my hearing is perfectly restored. I consider mine as a
typically bad case with a typically good result. No doubt exists
in my mind that had I neglected treatment, or followed it care-
lessly, the disease would have caused my death."
Case 2. — B. M., aged 43, druggist, came under observation in
January, 1878. He stated that he had contracted syphilis while
in the army in 1862. The chancre was followed by an eruption,
and some loss of hair, but no sore throat or enlargement of glands.
He had nocturnal pains in his left shoulder, disturbing his sleep,
for a year, on returning from the war. His left shin was then ten-
der and painful for over a year. An ulcer appeared on his sternum
in 1863. There are now eight sores over his sternum, with evi-
dences of necrosis. Six months ago the right eye began to pro-
8o David Webster.
trude, and there is now very marked exophthalmos. There is no
diplopia, and the eye moves freely in every direction. Vision
f^ each eye, and no lesion to be seen with the ophthalmoscope.
The exophthalmos seems to be the result of orbital periostitis.
The right ear became deaf gradually about four months
ago. It now seems to be totally deaf to external sounds, not even
hearing the tuning-fork when applied to the forehead or teeth, but
hears a constant singing. The hearing of the left ear is normal.
There is no visible lesion of the external or middle ear on either
side, and the Eustachian tubes are pervious. The patient has
much vertigo, feeling at times as though he were walking like a
drunken man.
He was placed upon mercurial inunction.
Feb. xgth. — The gums were "touched," and the mercurial oint-
ment was discontinued about a week ago. There is less tinnitus,
and the ear is recovering its hearing.
The patient was now placed upon a saturated solution of iodide
of potassium, commencing with five drops three times daily, and
increasing the dose two drops daily.
March isf. — The patient says he can hear with his right ear as
well as ever, that the ringing has left it, and that he is no longer
troubled with vertigo. He is taking seventeen drops of the sat-
urated solution of iodide of potassium after each meal.
JVov. 2d. — The patient has been overworked, and has not slept
well for two weeks. He complains of pain in his left elbow and
left leg. In both ears the hearing remains normal. The vision of
both eyes is normal, and the exophthalmos of the right is no more
marked than when first seen. He has been taking iodide of po-
tassium, gr. XX, fer in die, all summer. Advised to stop the iodide
and resume mercurial inunction.
Fed. iif/i, 1879. — The patient awoke a few mornings ago with
the right ear again deaf, and the tinnitus as bad as ever. The left
arm and leg have not been painful for two months past. The
sores on his sternum are gradually healing. The principal trouble
now is with the right side of the head. The scalp about the ver-
tex is tender on pressure, and there are shooting pains through the
right side of the head. He complains of a dull, heavy feeling,
and tires easily. Ordered mercury with iodide of potassium.
Se/>t iS^/i. — The patient now hears the tuning-fork with his right
ear, though less than with his left, and he hears click of nails at
two inches. The tinnitus is less intense. The drum-membranes
Two Cases of Syphilitic Disease of the Labyrinth. 8i
appear normal. The sores on the sternum are nearly healed.
The scalp at the vertex is still tender. Walking up stairs fatigues
him and causes palpitation. The exophthalmos is no worse, and
vision is ff. Ordered blue mass with iron and quinine.
Nov. 26th, 1880. — The patient comes to the office so deaf that he
has to be communicated with in writing, and with so much vertigo
that he is unable to go about alone. He says that he heard very
well with his left ear until he received a blow on the left temple
with a car-brake, about two months ago. Some swelling followed,
and he soon began to lose the hearing of tlie left ear. It grew
gradually worse until about four days ago, when he became totally
deaf and has so remained. He hears a great roaring continually
in his left ear. His voice is elevated in pitch. The right ear is
absolutely deaf to all tests; the left hears click of nails in con-
tact. The tuning-fork placed againt the forehead or teeth is
faintly heard in the left ear. He cannot perceive any improve-
ment with audifan or hearing-tube. Right drumhead sunken,
reddened at periphery, and light spot small ; left in a similar con-
dition. Eustachian tubes open on using Politzer's method. Ad-
vised to push mercurial inunction.
Dec. yl. — Mouth touched. H D R o., L — - Can now un-
derstand sentences shouted into left ear. To take iodide of
potassium, gr. v, ter in die, and increase the dose two grains daily.
Is less dizzy ; came over from Jersey City alone to-day. The
ulcers of his sternum are not yet healed.
Dec. 23^. — Now hears sentences, uttered distinctly, at ten feet.
H D R o, L ''f'^'. Has taken up to fifty drops, thrice daily, of a
saturated solution of iodide of potassium. Yesterday an iodide
eruption appeared. He has a catarrhal discharge from his nose,
and is still greatly troubled with tinnitus. To stop the iodide,
and to snuff up salt and water every morning. After thus cleans-
ing the nares, he is to apply Smitli's powder (arg. nit. gr. v., potas.
sulph. 3 ss., bismuth, subnitrat. | i. 1U.) by means of a powder-
blower. To drink milk freely.
April gih, 1881. — Patient thinks that he hears better than when
last seen, but the usual tests show no change in his hearing.
On January 19, 1883, I asked Dr. J. Oscroft Tansley to make a
careful examination of this patient's condition, and he gave me
the following notes :
" H D Right^nails at five feet ; watch, not at all. The left
ear was closed with a towel, yet I cannot but think that the nails
were heard in the left ear and not in the right.
82 David Webster.
" H. D. Left=:watch at two and a half inches. Tuning-fork
heard only in left ear when placed on middle or extreme right of
teeth or forehead. Closing the left, it was heard only in the left
ear. Closing the right, it was heard only in the left ear. Closing
both, it was heard only in the left ear.
" Tuning-fork, left ear, by aerial conduction, forty-five seconds ;
by bone conduction, fifteen seconds. The right ear cannot be
made to hear the tuning-fork either by aerial or by bone-conduc-
tion. The patient says he feels the vibrations, but does not hear
the sound, with that ear.
*' Appearances : Left membrana tympani slightly removed from
normal appearance. Malleus drawn slightly backward and a little
foreshortened. Light spot slightly cut off on base, but of
normal brilliancy. Drumhead not thickened at all, but translucent.
Right membrana tympani presents same appearances as left.
Malleus not so much, if any, foreshortened. Light spot, bright
and glistening. Base, perhaps, slightly indistinct ; otherwise
normal.
"Both membranas act well under Siegle's tympanoscope.
" Diagnosis : Right, labyrinthine or nervous deafness. Left,
otitis media catarrhalis, with labyrinthine complications. Patient
has occasional vertigo, with inclination to fall laterally, and a
feeling of heavy weight in head. During the time of his total
deafness in both ears he experienced singing noises, but has had
none since."
A CASE OF CLONIC SPASM OF THE LEVATORES
PALATI, PRODUCING A RHYTHMICAL
CLICKING NOISE*
By Dr. CORNELIUS WILLIAMS, of St. Paul, Minn.
LATE ASSISTANT SURGEON AT THE NEW YORK OPHTHALMIC AND AURAL INSTITUTE, SURGEON TO
THE OUT-DOOR DEPARTMENT MT. SINAI HOSPITAL, ETC., ETC.
Violetta Z., twelve years old ; good frame ; full-blooded bru-
nette ; weighs ninety-one pounds. She has not yet menstruated,
nor are there any menstrual molimina.. Her mother is a French-
American, in good health. There are seven children, all living,
Violetta being the sixth. The father was a German, well educated,
and a talented musician. He was drowned some eight years ago,
in a fit of insanity. In the mother's family there have been some
cases of Pott's disease. The immediate family and near of kin
are all healthy, and of more than average intellectual develop-
ment. They are all of strongly-marked nervous temperament, and
the father was extremely so.
When Violetta was ten years old, having occasion to get up
during the night, she lost her way in going back to her bed, and
reaching her grandmother's room by mistake, she laid her hands
upon the aged lady in the dark, and so alarmed her, and was her-
self so much frightened by the grandmother's shrieks, that she
almost went into convulsions. She refused to return to her own
bed, but lay in her sister's arms, starting and sobbing, the night
through. Next day she was extremely pale and nervous, nor did
she recover her wonted spirits for a number of days. This hap-
pened in the spring of 1880, and a short time after this the child
discovered that a strange clicking sound was produced in her
mouth, but suffering no inconvenience from it she mentioned it
to no one. In the June following she fell into Lake Elmo (Minn.),
* Shown at a meeting of the Ramsey Co. Med. See. in Jan., 1883.
83
84 Cornelius Williams.
and came near being drowned, and a short time after this she
called the attention of her mother to the clicking, which had now
become constant. The family medical attendant was consulted,
who pronounced it a common affair ; the uvula was cut off en-
tirely, and one tonsil was amputated without result as far as con-
cerned the clicking. The patient is in good general health ; ap-
petite and digestion good ; sleeps well. She is easily fatigued,
but is kept up by any excitement. There has been for the last
three years diurnal incontinence of urine, the act of micturition
recurring about every half hour, but at night it is hardly ever
necessary for her to get up more than twice. Dr. S. W. Hand,
who was kind enough to examine her, informs me that there is
considerable leucorrhoea, and that the urethra is unusually large
and patulous. He explored the bladder and found no evidence
of stone. The act of micturition is not painful. Drs. Hand,
Boardmann, Abbott, and Wheaton examined her heart at my re-
quest, and report that there is nothing abnormal about it.
Upon looking into the patient's mouth, it is perceived that the
velum palati is rapidly raised and lowered without being made
tense in its entirety. At the moment of relaxation of the levatores
a sound is produced which is as much as can be like the ticking of
a small brass clock, and in a still room it may be heard at a dis-
tance of twenty feet. The clicking corresponds to a complete
contraction and relaxation of the levatores palati, and by actual
count is 120 a minute, with very little variation in frequency at
any time. When the mouth is opened widely, the azygos uvulae
is sometimes seen to contract, but such contraction would seem to
be physiological. The tone of the clicking is changed by closing
the nose and by otherwise altering the usual conditions of the
mouth and nose as to the volume of air contained, but that, or
any other manipulation, procures the cessation of the noise or its
cause. Laryngoscopic examination shows the larynx to be normal,
save a slight congestion. Rhinoscopy is not practicable. Oto-
scopy reveals the membrana tympani of each ear slightly indrawn,
the handle and short process of the malleus of the right being ab-
normally prominent. Light spot gone from both Mtt.
By means of the diagnostic tube, I am able to hear the clicking
sound in either of the patient's ears — more distinctly in the right.
It may very well be likened to the ticking of a watch under a
pillow, or the sound of the foetal heart. If there is any movement
of the membrana tympani, I have not been so fortunate as to ob-
A Case of Clonic Spasm of the Lcvatorcs Palati. 85
serve it. The girl's voice is natural, and she can sing with cor-
rectness, uttering the chest notes without difficulty, but is unable
to produce head notes at all. In running the scale, a decided
tremolo is remarked. The patient, of necessity, breathes through
the mouth, and from habit keeps it open during sleep. When
there is tonsillitis, to which she is subject, there is considerable
druling. At such times she is apt to have glottic spasm. The
spasm of the levatores ceases during sleep. At irregular intervals,
perhaps fifty or a hundred times through the day, there is an in-
terrupted spasm of the diaphragm, giving rise to a sudden and
deep inspiration in two or three motions, as in sobbing, followed
by prolonged expiration. At times, it may be for an hour or half
a day, she hears in her ears a sound comparable to the rapid revo-
lution of a small fan-wheel. Acuteness of hearing normal.
This affection is in all probability choreic. The history
is exquisitely that of chorea. Weir Mitchell lays great
stress upon climate and season in the etiology of chorea, his
observations showing the disease to be more prevalent in
spring and in cold climates. Chorea is infinitely more
frequent in girls at about this patient's age than in any other
class at any other age. Sir Thomas Watson has found
chorea to be much more frequent in brunettes than in fairer
persons. Whatever the predisposing, the immediate exciting,
cause is oftener fright than any other. It is impossible to
say, in any given instance, absolutely, that a child has not
had rheumatism. According to A. Jacobi the disease
is suflficiently common in infants, and it is well known that the
proneness to cardiac complications does not depend upon
the severity of the joint affection. Fugitive pains in the
limbs and slight elevation of temperature may then very
well be the only obvious indication of a morbid condition
which maybe accompanied by the deposition of particles of
fibrine more or less minute or numerous upon the valves of
the left heart, and hence the possibility of embolism. The
levator palati is supplied with motor filaments by the facial
through the connection of its trunk with the Vidian by the
petrosal nerves ; the stapedius is also supplied by a filament
from the facial. Choreic spasm of muscles supplied by the
facial is common enough, but a choreic affection of the
muscles of the soft palate has been heretofore unknown.
86 Cornelius Williams.
The only similar case I have been able to find recorded,
is that by E. L. Holmes, these Archives, vol. viii, p. 144.
No mention is made of such a disorder by any of the
standard works wherein the subject is treated and which
are accessible to me, except in Ziemssen it is stated that :
" Spasm of the soft palate is almost entirely unknown ; even
the behavior of the affected muscles in spasms proceeding
from the facial nerve, and in those proceeding from the mo-
tor filaments of the trifacial, is unknown." Irregular twitch-
ings of some of the palatine muscles are observed, in
advanced cases of locomotor ataxia, etc. Rhythmic choreic
contraction of any muscle continued for so long a time
would be an extraordinary circumstance. The contractions
of the palate muscles in this case continue with about the
same frequency at all times during the patient's waking
hours, and do not vary more than four to six in the minute.
They do not seem to be influenced by exercise, or having
the attention drawn to the matter. The levator palati,
though a Voluntary muscle, is not in all persons under per-
fect control of the will, therefore any psychic excitement
would be less apt to influence its movements.
The clicking noise is probably occasioned by the vacuum
produced at the moment the superior surface of the
velum leaves the roof of the naso-pharynx to which it has
been applied by the spasm. I had an opportunity of watch-
ing the behavior of the velum palati during an attack of
acute tonsiUitis, and found that though the spasm of the
levatores continued without abatement the clicking ceased,
and the elevation was not so considerable because of the
swelling of the parts, which prevented the complete closure
of the posterior nares. When I showed this case at
the meeting of the Medical Society, it was stated by some of
the gentlemen present that a similar condition existed
in the case of a demented woman then in St. Joseph's
Hospital. Upon examination of this woman, however, I
found that the noise in her mouth is produced by closure of
the mouth, placing the tip of the tongue against the lower
teeth, and approximating tongue and soft palate, a trick
which she had acquired, but which failed her when the mouth
was opened ; of course any one can do the same.
THE NEW YORK INSTITUTION FOR THE IM-
PROVED INSTRUCTION OF DEAF-MUTES.
By D. GREENBERGER, Principal.
( With three drawings})
CONSIDERING that many of our pupils come to us
by the advice of those who are engaged in the
specialty to which this journal is devoted, it may not be
amiss to give, in the following, an account of the workings
of this Institution.
The school has been in operation since March i, 1867.
Beginning with a small number of pupils, its sphere of use-
fulness has gradually extended, and now it is the largest
articulation school in the country. Its affairs are managed
by a board of trustees, consisting of fifteen members, who
are elected by the " Association for the Improved Instruc-
tion of Deaf-Mutes." Deaf-mute children, whose parents
have been residents of this State for the last three years
preceding the application, may be supported at public
expense. Pupils from other States are charged for their
board and tuition. During the sixteen years of its existence,
the Institution has received pupils from almost every State
in the Union, and its former graduates are scattered over
the land, taking their places in society as useful citizens.
The system of instruction in use at this Institution is
what is commonly known as the oral method. The pupils
learn to speak orally and audibly, and to understand what
is said to them by observing the movements of the speaker's
lips. The language of natural gestures, which every intelli-
gent deaf-mute child invents for himself, and by means of
87
88
D. Greciiberzer.
The Nezv York Institntio7i for Deaf-Mutcs. 89
which he makes himself understood before entering school,
forms the medium of communication between the teacher
and pupil during the first school year. Afterward all signs
and gestures are discarded during the hours of instruction.
The questions put by the teacher and the answers given by
the pupil are purely and exclusively oral. The manual, or
"deaf and dumb" alphabet, is not employed in this Insti-
tution.
In explaining, to the readers of this journal, the method
of teaching deaf-mutes to speak, it seems hardly necessary
to call attention to the fact that the vocal organs of our
pupils are commonly in the same normal condition as those
of hearing persons. We do not receive children whose loss
or want of speech was caused by paralysis of any part of
the vocal machinery, nor do we admit those who fail to
acquire speech on account of mental imbecility. Our Insti-
tution is intended for those only who are of ordinary intelli-
gence and remained mute, or became so, in consequence of
congenital or acquired deafness. The name '* deaf-mute "
is misleading. People who have not given any thought to
the matter are apt to believe that the persons to whom
that name is applied are afflicted with two distinct infirmi-
ties, viz. : deafness and mutism. Hence I have often been
told : " You have one advantage, namely, that your pupils
cannot disturb you by making a noise." But this is not so.
Deaf-mutes can make a noise, and as a rule use their voices
.a great deal. During an experience extending over a period
of more than twenty years, I have never met a deaf-mute
who did not use his voice in calling others, or in expressing
his feelings, emotions, etc. Of course, the sounds produced
are inarticulate. These children do not learn to imitate
articulate speech, because they do not hear. But, having
the use of their vocal organs, we can teach them to articu-
late on the following principle : Each of the elements of
speech requires its own particular configuration of the
mouth and special disposition of the tongue, etc. These
various changes of the relative positions of the vocal organs
during the formation of speech can be seen by the deaf-
mute, and he can learn to imitate them. He can also feel
go D. Greenberger.
the breath which is emitted from the mouth during speak
ing, and the vibrations caused in the larynx during the
utterance of the vowel sounds and vocalized consonants.
The beginning is made with short words of easy pronuncia-
tion, as : bow, paw, toe, papa, tic, tea, etc. The mode of
procedure is as follows: The pupil stands before the teacher,
so as to have a full view of her mouth. She lets him put
one of his hands on her throat and hold his other hand
before her mouth at a distance of two or three inches, while
she slowly and distinctly pronounces the word paiv, for
instance. The child feels, with one hand, the expulsion of
breath which is emitted from the teacher's mouth in
forming the sound of p, and with his other hand, he feels
the vibrations caused in her throat by the enunciation of
the sound of aw. At the same time, he has to watch care-
fully the motions of her mouth. After the process has
been repeated several times, he is required to imitate what
he has seen and felt. An intelligent child will succeed in
this after a few attempts, though the voice is usually either
too high or too low, and has to be regulated accordingly.
The art of lip-reading is acquired incidentally during the
instruction in articulation. While watching the movements
of the teacher's lips and trying to imitate them, the deaf
child learns to distinguish between these various move-
ments. Our pupils read the lips of strangers almost as
readily as those of their teachers. They understand what
is said to them in a whisper as well as what is spoken in a
loud voice, and many who have keen eyesight can read the
lips at a distance of sixty or seventy-five feet. To those
who can hear, it often seems a matter of great surprise that
a deaf person should be able to understand what is said to
him by merely observing the movements of the lips. But
it must be remembered that whenever there is one sense
lacking, some other or others will become more efficient
through increased use. Deaf-mutes therefore are very
quick to receive impressions through the sense of vision.
It is not likely that they see every one of the movements
of the tongue, but they see the principal ones and guess
the rest. Sometimes it is sufficient for them to read a few
The Nezv York Institiition for Dcaf-Miites. 91
leading words of a sentence and they supply the others. A
moustache of ordinary size does not hinder lip-reading, be-
cause it partakes of the movements of the lips, but if the
latter are entirely hidden by an unusually heavy growth of
hair, then labial reading is rendered difificult, and sometimes
impossible. Some deaf-mutes learn to read the lips with
remarkable facility. A young lady, a former graduate of
this Institution, who is totally deaf, goes into society and
takes part in a general conversation of a large company,
and often strangers do not notice that she cannot hear.
During the lessons, the pupils often stand around the
teacher, so that some can see the side only of her mouth,
yet they understand what she says and follow the lesson.
To teach pupils to speak and read from the lips is not
the most difficult part of our task. The instruction in lan-
guage and the mental development, present far greater dif^-
culties. There are some pupils who acquired a knowledge
of language through the ear before they became deaf. But
these form a very small minority. The great mass of them
have no knowledge whatever of the English language, and
can communicate only by means of natural gestures which
every deaf-mute child of ordinary intelligence invents for
himself to make known his wants to others. The range of
this language varies in each individual according to the
degree of his intelligence. At best, it is a very inferior
mode of conveying thought, and cannot be used as a basis
from which we could translate into our language. Besides,
the natural order in which these signs are used is different
from our conventional arrangement of words in a sentence.
For instance, if a deaf-mute beginner were to make the
simple statement, " I see a book on the table," he would be
very apt to express it thus : " Table book on I see." Think-
ing in pictures instead of words, he sees in his mind's eye
first the table, then the book, and then he thinks of the
relation between the two objects and of himself.
We find that in studying the vernacular of their country,
our pupils have all the difificulties that other people
encounter in studying a foreign language. Many ingenious
and scientific plans have been devised by deaf-mute in-
D. Grcenbcrs'er
TJie New York Institution for Dcaf-Mutes. 93
structors to overcome these difficulties. In this Institution
we have tried several of these scientific systems and discarded
them. For the last three years we have employed the natural
method, by which our pupils learn the English language
in the same manner as it is acquired by a hearing infant.
We call attention to the objects on hand in the school-room,
and teach their names ; when a child motions to tell the
teacher that he wants a drink of water, he is taught how to
ask for it in words; when he comes in from a walk and tries
to tell what he has seen, he is taught how to express it in
words, etc., etc. I have found that since we have em-
ployed this natural method, our pupils make more rapid
progress in the use of spoken language than they did
formerly, when we followed a scientific system based upon
the rules of grammar. Everybody knows that it requires
years to study a foreign language from books, whereas the
children of immigrants coming to this country and mingling
with others in the streets, learn to speak English well in a
few months. The reason is, that they learn it in a natural
way, which is far superior to the most ingenious artificial
system that could be devised. The superiority of the
natural method of teaching language over all grammatical
and scientific systems has also been clearly demonstrated in
the case of deaf-mutes.
In addition to acquiring the use of articulate speech and
learning to read from the lips, the pupils are instructed in all
those branches which are taught to hearing children in the
common schools. Our older scholars are quite proficient in
arithmetic, geography, history, grammar, natural history,
natural philosophy, drawing, etc. In September, 1881, one
of our graduates passed a successful examination for admis-
sion into the Columbia College School of Mines, and was
duly enrolled as a student. The branches in which he was
examined were algebra, geometry, French, and German.
He is now in the Sophomore class.
The new and beautiful home which was erected for this
Institution at a cost of about $150,000, has been completed
and in use since the fall of 1881. It occupies the entire
front of the block on the westerly side of Lexington Ave-
94
D. Greenberger.
67th Street.
68th Street.
The New York Institution for Deaf-Mutes. 95
nue, between 67th and 68th streets. The site and neigh-
borhood are as ehgible as any on Manhattan Island. The
ground is high and well drained, and Central Park is within
a short walking distance. The building itself contains all
the appointments that architectural skill, sanitary science,
and experience with deaf-mutes could suggest. No expense
and no pains have been spared to make this building per-
fectly well adapted to the wants and requirements of the
class of unfortunates it is intended to shelter. The class-
rooms are light and airy ; the dormitories are roomy and
well ventilated ; the bath-rooms and lavatories have an
ample supply of water ; the gymnasium and play-rooms are
large and commodious. Proper accommodations for the
sick are provided on the top floor of the south wing, and
perfectly isolated from the rest of the building, so as to
afford the means of quarantining cases of contagious disease
in case of necessity. The dining-rooms, the culinary
apartments, etc., are fully in keeping with the style and
character of the rest of the establishment. The building is
lighted by gas and heated by steam. All precautions that
human foresight could suggest have been taken against
danger by fire.
REVIEWS.
Die Taubstummen und die Taubstummenanstalten
nach seinen Untersuchungen in den Instituten des
Kdnigreichs Wiirtemberg und des Grossherzogthums
Baden. Von Medicinalrath Dr. Hedinger. Stuttgart : Verlag
von Ferdinand Enke, 1882. (The Deaf and Dumb and the Deaf
and Dumb Institutions, after his Investigations in the Institutions
of the Kingdom of Wiirtemberg and the Grand Duchy of Baden.)
Reviewed by A. Hartmann, Berlin.
Translated by D. Greenberger, Principal of the Institution for the Improved
Instruction of Deaf-Mutes, New York.
The monograph by Hedinger now before us owes its origin to
investigations of pupils of the institutions for deaf-mutes in Wiir-
temberg and Baden. In the first part of the book, which treats
of general matters (forty-five pages), we find accounts of the in-
ternal arrangements and size of the institutions ; then follow short
remarks on congenital and acquired deafness, which are based
upon individual statistical records. Toynbee's observations are
extensively quoted, while more recent and exact investigations are
not mentioned. Likewise, in the discussion of the degree of hear-
ing, only deaf-mutes whom Toynbee examined are considered,
besides those of the institutions of Wiirtemberg and Baden. In
reference to attempted cures of deaf-mutism, Hedinger lays stress
upon the importance of treatment by medical specialists. He does
not consider it out of question " that at least in the case of those
who are not totally deaf, the power to distinguish vowels, and to
appreciate sound in general, may be preserved, if it cannot be im-
proved."
"At any rate the hearing of a large proportion of the cases of
acquired deat-mutism that annually enter the institutions, might
have been preserved to a greater or less degree." These views
96
Review of Hedingers Deaf -Mute Statistics. 97
seem to conflict with the statement made in the introduction, that
so far no cure of deaf-mutism has been effected.
In reply to this, the reviewer takes the liberty to remark that in
our literature there are a number of cases recorded in which such
cures proved successful. Based upon this experience it must be
reiterated again that it is desirable that deaf-mutes should be sub-
jected to a professional examination and eventually to proper
treatment.
In the chapter on the education of deaf-mutes, the resolutions of
the Congress of Deaf-Mute Teachers, at Milan, are published,
and the advantages of the oral method especially pointed out.
But we must not forget that deaf-mutes who have been educated
to use written language only, attain to as high a degree of moral
and intellectual development as those who have been taught to
articulate. Though they are very much hindered in their inter-
course with hearing persons, yet they have the advantage that a
considerable portion of time which has to be spent in the training
of the voice, can be applied to intellectual development. This
is of so much more account, as we find that the articulation of
many deaf-mutes is imperfect, and the power of reading the
lips leaves a great deal to be desired. Conception of ideas and a
knowledge of the vernacular are gained by means of spoken as
well as written language.*
The branches which are taught in schools for deaf-mutes and
the question whether it is best to educate them in institutions or
at their homes are discussed in special chapters, and the advan-
tages and disadvantages of boarding- and day-schools are carefully
weighed. The author seems to consider boarding-school life the
' Here I must interrupt the reviewer for a moment to say, with all due re-
spect and regard, that there is no force whatever in his arguments against the
oral method. Of late years the system has been so much improved that, under
the '^liarrre of a competent teacher, deaf-mutes may acquire the power of speech,
and the facility to read the lips during the first four or six months of the course.
Henceforward their progress in the various branches of study must be far more
rapid than in the case of those who are educated by means of writing and dac-
tylology. For it must be remembered that we can speak a sentence in one ninth
part of the time that is required to write it, or in one third of the time required to
spell it on the fingers by means of the manual alphabet. In regard to the results it
must be admitted that the articulation of some deaf-mutes, who have been edu-
cated by the oral system, is imperfect, and that their power to read the lips
leaves a good deal to be desired. But even an imperfect articulation, proves of
incalculable value in the intercourse with hearing and speaking people, few of
whom understand the sign language ; even the least successful scholars learn to
speak intelligibly enough to be readily understood by their parents and friends,
who soon become accustomed to their peculiar enunciation ; and the number of
those who learn to speak and read the lips so well that they can easily com-
municate with strangers is increasing from year to year. — The Translator.
98 A. Hartmann.
most appropriate for the first half of the number of years of
school time, and day-schools for the other half.
The second part of the monograph consists mostly of tables
showing the results of examination of 415 deaf-mutes. Of this
number, 181 were cases of congenital, and 234 of acquired, deaf-
ness. The first table shows the names, ages, causes of deafness,
condition of the drumhead and of the nose and mouth, examina-
tion of the hearing, and special remarks. In the second and
third tables statistics of congenital and acquired deaf-mutism are
given separately. Then follow two combining tables, and table
VI is a summary of the whole statistics.
It is to be regretted that the examination into the causes of
deafness, which is of paramount importance, is the weakest point
of Hedinger's investigations. He seems to have relied entirely
upon institution reports. The reviewer inclines to this view,
because he thinks that if the author himself had gathered the
statistics, or if he had delegated somebody else to do it, we would
not find the following among the causes of deafness, viz. : *' in
consequence of vaccination, convulsions, sleeplessness during the
first year, teething, sickness," etc.
The reviewer frequently found during his own examinations,
how deficient the records of deaf-mute institutions are in regard
to the origin of the loss of hearing, and therefore called attention
to the fact that special statistics of deaf-mutes have no value
unless the investigations are made by means of exact lists of
questions. Hedinger, too, acknowledges this, although he does
not act accordingly, for he says that we must be very careful in
drawing certain inferences from statistics, and that above all close
examination, full lists of questions, and less regard to personal
statements are necessary, lest Ave should fall into the same errors
and meet with the same reproaches that other disciplines, espe-
cially political economy, justly incur.
Careful readers will receive with reserve the statements about
the influence of diseases of the nose and pharynx upon deaf-
mutism. Hedinger found affections of the pharynx in 157 and
affections of the nose in 112 of all deaf-mutes. In the opinion of
the reviewer it does not seem judicious to draw any conclusion
from this as to whether these affections are to be considered causes
of deaf-mutism. Hedinger's tables themselves show that a large
percentage of those who lost their hearing through cerebro-spinal
meningitis and diseases of the brain are suffering with affections
Reviezv of Politzers Text-Book. 99
of the nose and pharynx, in which case such affections cannot be
considered of etiologic moment. Likewise, we know that even
among persons of normal hearing the percentage of diseased con-
dition of the nose and pharynx is quite considerable. Therefore,
if we find the same condition as frequently among deaf-mutes,
we must not infer that these diseases are to be considered causes
of deafness. Equally cautious we have to be in utilizing the oto-
scopic results, because we know that even among persons of
normalhearingwe very frequently find deviations from the normal.
If the author believes that his investigations are the first otologic
examinations of deaf-mutes, we take the liberty to call his attention
to the researches of Victor Bremer, de Rossi, Roosa, and Beard.
Apart from the criticisms which we considered our duty to ex-
press in reviewing the monograph before us, we feel constrained
to express our high esteem for the author on account of the
industry and perseverance which were required to undertake such
extensive investigations and to complete them.
II.
Lehrbuch der Ohrenheilkunde fiir practische Aerzte
und Studirende. (Text- Book of Otology, for Practi-
tioners and Students.) By Prof. Adam Politzer. In two
volumes. Vol. II. With 152 wood-engravings. Stuttgart:
Ferdinand Enke, 1882. '
Reviewed by A. Hartmann, Berlin.
The first volume of Politzer's text-book having found general
recognition, the appearance of the second was looked forward to
with interest. Now that this volume lies before us in imposing
proportions after an interval of four years, we are not sur-
prised that the most thorough and careful preparation of this vol-
ume has consumed so great a length of time. Politzer's work,
now completed, is ^o excellent in its execution that we do not
hesitate to pronounce it the best and most complete hitherto
written on otology. The anatomy and physiology of the ear as
well as its pathology and treatment have been handled in an
* Excellently well translated into English by J. P. Cassels, M.D., of Glasgow.
One volume of 800 octavo pages. London : Bailliere, Tindall, & Cox. Phila-
delphia : H. C. Lea's Son & Co., 1882.— Ed.
lOO A. Hartniann.
equally thorough manner, and herein the previous meritorious per-
sonal labors of the author have been particularly utilized. Special
mention sliould also be made of the numerously interspersed
patho-anatomical observations and illustrations which alone secure
a high value to the book.
Although most of our readers presumably own a copy of Polit-
zer's text-book, it might not be inappropriate to briefly summarize
its contents and to point out some details which suggested them-
selves to the reviewer on its perusal.
The present volume begins with the description of the adhesive
processes in the middle ear. Politzer points out that in these,
with far greater frequency than in all other forms of inflammation
of the middle ear, symptoms occur which indicate a simulta-
neous affection of the labyrinth, especially in the insidious form
of the disease ending in synostosis of the stapes. In these
cases, clinical observation forces us to the assumption " that the
disease of the two portions of the ear — the middle ear and the
labyrinth — is produced simultaneously by identical trophic dis-
turbances." For the explanation of the continuous noises Polit-
zer refers to the increased pressure in the labyrinth which
starts from the drum cavity, in addition to the affection of the
expansion of the acoustic nerve. In the adhesive processes
Politzer's treatment is confined in the main to the air douche and
injections of a solution of sodium bicarbonate. Politzer regrets
that it has hitherto been impossible to keep an artificial open-
ing in the drum permanently patulous, and believes that the solu-
tion of this problem will signalize a great advance in the therapeu-
tics of affections of the ear. As novel should be mentioned the
division of the anterior malleolar ligament which Politzer has re-
peatedly performed in case the manubrium is much retracted,
when only temporary improvement occurs after the air douche.
About the results of tenotomy of the tensor tympani Politzer does
not express a very favorable opinion. In several patients who
came to him some months after tenotomy had been performed
upon them, complete deafness had ensued in the operated ear. A
mobilization of the plate of the stapes as recommended by Kessel,
Politzer thinks to be impossible of execution according to his
experiments.
The adhesive processes are followed by acute purulent inflam-
mation of the middle ear, which Politzer — perhaps not quite
justly — separates from the acute otitis media, running its course
Reviciv of Politzers Text-Book. loi
without perforation of the membrana tympani. Both affections,
surely, differ only in degree and in the frequently merely acci-
dental occurrence of perforation. In intractable acute suppura-
tions of the middle ear Politzer recommends as excellent treat-
ment injections of warm water through the catheter into the
middle ear when the pains persist even after perforation of the
drumhead, also in those stubborn forms in which the perforation
is situated on a warty elevation of the membrana tympani, and in
painful inflammations of the mastoid process.
Under the head of chronic purulent otitis media, the appear-
ances of the membrana tympani are illustrated by a very large
number of excellent wood-cuts ; the perforation of Shrapnell's
membrane and the vertical sections appear to us especially worthy
of mention. The accompanying description of all the conditions
which are liable to occur in chronic suppuration of the middle
ear is exceedingly complete and instructive. Besides the usual
occurrences, we find a long series of hitherto little noticed and
rare observations, which render the whole chapter one of particu-
lar value. For the removal of inspissated masses from the depth
of the auditory canal Politzer employs a rubber tubule, 4 mm. in
thickness and rounded at the extremity, which is slipped over the
point of the syringe and inserted to the depth of 2 cm. into the
external auditory meatus. For cleansing the recesses of the
middle ear Politzer uses a canula of hard rubber instead of Ger-
man silver. The carious processes in the temporal bone develop-
ing in the course of suppurations of the middle ear, otitic menin-
gitis, and cerebral abscess, are likewise illustrated by a large
number of personal observations and drawings, and are very
minutely discussed. In inflammations of the mastoid process,
accompanied by violent pain, Politzer had very good effects from
Leiter's cooling apparatus ; besides, Politzer places a great value
on irrigation of the drum cavity through the tube. He thus cured
numerous cases in which others thought operative opening of the
mastoid process indicated. The diseases of the mastoid process
and its artificial opening are likewise illustrated by a large
number of wood-cuts.
In his division of the subject, which differs from the ordinary,
the description of suppuration of the middle ear is followed by
that of the affections of the external ear, which are succeeded by
the new formations, otalgia, and the neuroses of the muscles.
The affections of the labyrinth, of the acoustic nerve, and of its
I02 A. Hartinann.
central portion are preceded by an introduction, in which the
difficulties of a satisfactory treatment of this chapter are pointed
out, inasmuch as the number of exact post-mortem researches with
accurate observations during life is still very small. In the same
way the results of our methods of testing the hearing are as yet
rather unsatisfactory for the exact diagnosis.
Meniere's disease is discussed very fully. In Voltolini's in-
flammation of the labyrinth the deafness can be caused either by
a simultaneous purulent inflammation of the labyrinth propagated
from the skull cavity, or by an affection of the trunk or the root
of the acoustic nerve. Although Politzer himself had occasion in
one case to make an exact post-mortem, he still believes that this
form of inflammation can secure the right of being recognized as
an independent form of disease only after repeated post-mortem
verifications.
All the diseases affecting the nervous apparatus are treated with
care and with equal completeness, as well as the affections of the
sound-conducting apparatus ; and here we find also a series of the
most interesting observations recorded. Three smaller chapters
form the conclusion of the book : the malformations of the organ
of hearing, deaf-mutism, and the acoustic instruments for people
with impaired hearing.
VOL. Xli. No. 2.
ARCHIVES OF OTOLOGY.
THE EFFECTS OF NOISE UPON DISEASED AND
HEALTHY EARS.
By D. B. ST. JOHN ROOSA, M.D.*
IN the collected works of Doctor of Medicine Thomas
Willis, published in Amsterdam, a little more than two
hundred years ago, in a chapter upon the sense of hearing,
and in a paragraph relating to deafness caused by relaxa-
tion of the membrana tympani, there is an account of a
somewhat famous woman, who could only hear the voice of
her husband when a servant was beating a drum in the
same room.'
Although this passage is often alluded to, it is seldom
quoted. No apology will, I think, be required for a transla-
tion of it.
"Although hearing is very little produced by the mem-
brana tympani as compared with the proper organ of the
sense, yet it so far depends upon it, that deprivation
or diminution of that sense not infrequently proceeds
from its injury or impeded action. Indeed, a certain kind of
* Read before the Medical Society of the County of New York, April 23, 1883.
' The original reads as follows :
Qiianqiia7H aiidittis a tympana, velut proprio settsionis organo, ininime peragitur,
iamen iste in tantiim ab hoc dependet, ut non raro h tympani actione Icesa, aut
impedita sensus illius privatio, aut diminutio procedat. Enimvero surditatis
species quadam occttrrit, in qua licet affecti auditus sensu penitus ca7-ere videaninr,
quam-diu tamen ingens fragor, uti bombardarum, campanarum, aut tympani
bellici, prope aures circumstrepit, adstantium colloquia distincte capiunt, et inter-
rogatis apte respondent, cessatite vera imniani isto strepitu, denuo statim obsurd-
escunt. Accepi olim a viro fide digno, se fnuliere}?i quce licet surda fuerat,
quousqiie tamen intra conclave tympanum pulsa7'etur, verba quaevis cla7'e audi-
ebat ; quare 77iaritus ejus 7y/7ipa7iista77i pro fervo do7tiestico conducebat, lit illius
ope, colloquia i7iterdu77t cu7/i uxo7-e sua haberet. Etia77i de alio Surdastiv mihi
7iarratu77i est, qui prope coi7ipanile dege7is , quoties una plures ca77ipanae reso7iar-
e7it, vocem quamvis, facile audire, et 7t07t alias potuit. Proctildtibio hortt//i
ratio erat, quod tympa7iu/7i in se co/iii7iuo 7-elaxatu77t, so7ii vehe7ne7itioris it7ipulsu
ad debita/?i te/tsitate/n, quo 77iu7iere suo aliquate7ius de ftmgi potuerit, cogeretur.
103
I04 D. B. St. John Roosa.
deafness occurs, in which, although the patients seem com-
pletely to lack the sense of hearing, yet so long as a great
din, such as that of bombardments, or of chimes of bells, or
of drums, resounds about their ears, they take in distinctly
the conversation of those about them, and answer questions
intelligently, but, upon the ceasing of such tremendous
uproar, they immediately become deaf again. I once had it
from a trustworthy man, that he had been acquainted with
a woman, who, although she was deaf, would, nevertheless,
distinctly hear whatever was said so long as a drum was
beaten within the room, and consequently her husband em-
ployed a drummer as a household servant, in order that by
his aid he might occasionally hold conversations with his
wife. I have also been told of another deaf person, living
near a bell-tower, who could easily hear any voice whenever
the bells were pealing — but not otherwise. Doubtless the
reason of these things is, that the membrana tympani,
habitually relaxed when left to itself, was forced by the
shock of a sound much more intense than usual to a state
of tension sufficient to enable it to perform its function in
some degree." '
In the two centuries that have followed the narration of
Willis's observations, the symptom of hearing better in a
noise, has not only been given the name of the author,
and is known in our time as Paracusis Willisiana, but the
facts as stated by the author, have in turn been denied
and affirmed, and while many have admitted the truth of
the observations, and have conceded that there are some
persons with impaired hearing who hear better in a noise,
Willis's explanation of the phenomenon has been rejected
by them. I doubt, if in this audience of physicians,
there would be found any great unanimity of opinion on
this subject. The writers on aural medicine who allude
to it at all, are by no means agreed upon the facts nor
upon their explanation. Wilde" admits the credibility
of Willis's cases, and argues against the notion of Kramer
^ opera Omnia, Amstelcedamia., apud Henricum Wetstenium. Pars physio-
logica. Cap. xi^, p. 69.
'"Aural Surgery," English edition, p. 289.
The Effects of Noise upon Diseased and Healthy Ears. 105
that the auditory nerve became so excited by these
loud sounds as to be able to do its work better. Wilde ex-
plains the phenomenon by reference to the state of the
membrana tympani, and says that it is remarkable that it
does not occur in cases where that structure has been in
whole or in part removed. Later on, I shall show that Wilde
was in error in thinking that it could not occur when there
was a hole in the drum-head.
Troltsch* says : " These statements (as to hearing better in
a noise) are founded, as a rule, upon a want of exact obser-
vation, as well as upon self-deception." He then relates
one of Willis's cases, and also one reported by an author
named Ficlits. The latter was that of a deaf son of a shoe-
maker, who could only hear conversation in the room, when
he stood near his father and the latter pounded sole leather
upon a large stone. This same boy, heard well in a mill
when it was in action.
I cannot agree with Troltsch, in his idea that the symp-
tom of hearing better in a noise is not a common one. As
I have said, on several occasions, my own experience has
proven that it is a very frequent one. During the subse-
quent part of this paper, I shall have an opportunity of mak-
ing my statement good. Raic,' like Kramer, believed that
better hearing in a noise depends upon excitement of a
torpid acoustic nerve. In somewhat poetic style, he says :
" If the auditory nerve be awakened from its slumber by
loud talking, the patient will momentarily hear even words
spoken in a low tone very well. This sometimes goes to
such an extent, that the hearing is temporarily restored,
to a considerable degree by a loud and regular sound,
for example, during the pealing of bells, drumming,
a ride in a rattling wagon, or the like." Burnett,^ of our
own country, is positive that the symptom is a real one,
but confines it to the later stages of chronic aural catarrh,
" when the condition of the tympanum has become dry or
sclerotic, or when the thickening of the mucous membrane
has become great in the moist form."
'Troltsch, Lehrbucli, 6 Ausgabe, p. 253, passim.
' Lehrbuch, p. 292.
'"Treatise on the Ear," p. 386.
io6 D. B. St. jfohn Roosa.
Dr. E. E. Holt' doubts if, in any case the hearing-power
is improved by noise, and he states that, so far as he is
aware, no one has " ever made a careful investigation to as-
certain whether the claim of such persons was a real one
or not."
In the first edition of my book upon the ear, and in
all the subsequent editions, I related from my personal
experience the case of a mail agent, on one of our railways,
who, although very hard of hearing in a quiet place, could
hear very well in his car amid the noise of a train. I have had
frequent opportunities to study this case, and there is no
question as to the facts. No person who did not know of this
gentleman's infirmity would ever suspect him of impaired
hearing while conversing in the din of a rapidly-going train
of railway carriages. But the instant he reached a quiet
place, it was with the greatest difficulty that he could hear
loud conversation specially addressed to him.
Politzer, in his great treatise, not long since published in
German, and very recently translated into English, has no
doubts as to the existence of these cases, and confirms what
was stated by me years ago, " that the patients can under-
stand speech during such noises much easier, and at a much
greater distance, than people with normal hearing."^ Pol-
itzer, however, states that he has observed this symptom
" almost exclusively in the incurable forms of affections of
the middle ear."
I have known of two cases where this symptom occurred,
in patients who regained their hearing perfectly. While the
symptom frequently accompanies incurable disease of the
middle ear, I believe it is a very frequent symptom in sub-acute
cases, when both ears are affected. Of course, it would not be
observed in disease of one ear only. I also have two cases
under observation in which the drum-heads are entirely, or
nearly removed, and yet these patients hear well in a
noise. One of these, I published in the fourth edition of my
book. While the occurrence of the symptom in sub-acute
cases disposes of the notion, that hearing better in a
' Transactions of American Otological Society, 1882.
° Lehrbuch, p. 233.
TJie Effects of Noise upon Diseased and Healthy Ears. 107
noise implies an incurable disease, the fact that it also may-
exist when the membrana tympani is gone, shows that
Willis's explanation of the phenomenon is not exclusively, if
at all, correct. I have never yet seen the symptom except in
disease of the middle ear. I believe it never occurs except
in cases where the nerve is sound. I have looked over my
cases with great care as to this point, and I have yet to see
a patient who had, as I supposed, disease of the acoustic
nerve, and who yet heard better in a noise. If this be true,
the theory of an extraordinary excitement of the nervous
apparatus, as a cause of the phenomenon, must be rejected.
Politzer explains the symptom by a reference to some effect
upon the ossicnla auditns, made by the great din.' This is
the only theory, incomplete as it is, which fulfils the
conditions made by such cases as those just mentioned,
where, although the membranae tympani were gone, the
ossicula were intact. How the ossicles are affected is a
problem yet to be solved, but when it is solved, it will
be possible to invent an instrument to enable those deaf
from disease of the middle ear, to hear conversation not
only in a noise, but in the quiet of an ordinary room. This
latter will, certainly, not be a task beyond the capabilities
of a physicist of the 19th century.
The statement, that these cases rest upon inexact observa-
tions, will soon be disproven by a ride of a few miles in a rail-
way carriage or in a clattering wagon, with a person deaf from
disease of the middle ear, to ordinary conversation in a quiet
place. Examinations of boiler-makers, or of those who suffer
from affections of the acoustic nerve, will, however, be dis-
appointing, and will lead, as in Dr. Holt's paper, from
which I have already quoted, to a doubt in the mind of the
observer as to the reality of the symptom. I now quote one
of the cases in which the hearing was better in a noise, and
which was one of sub-acute catarrh of the middle ears, from
which the subject fully recovered under my observation.
The writer of his own case is now a practising physician in
this city. At the time of the occurrence of the disease he
was a boy in school, and I reported his case, except as to
the symptom now under discussion, in the American Jour-
' See also A. H. Buck, Medical Reco7-d, July 5, 1875.
io8 D. B. St. John Roosa.
nal of Medical Sciences and in my text-book. Dr. B. writes
to me as follows :
" With regard to the disputed fact of many deaf persons hearing
conversation better in noisy places, I wish to give in brief my
experience. For several years previous to my sixteenth, I had
been much troubled with varying degrees of deafness, due, as I
then heard and now understand, to acute catarrh of the middle
ear, complicating general pharyngeal catarrh. At school I was at
a great disadvantage, suffering at times great embarrassment on
account of my limited hearing. Living far up-town, I was in the
habit of being driven home or to the doctor's by my mother.
When surrounded by the noise of wheels and glass, I invariably
had occasion to request a moderation of her voice ; and she not
infrequently made the remark : " How well you hear in the car-
riage ! " Furthermore, on several occasions, my parents were sur-
prised to find that they could not safely carry on a confidential
conversation requiring only sound enough to suffice their own
hearing powers, while in a quiet room their talk would have been
unintelligible.
" This is only an echo of the experience of many deaf people I
have questioned on the subject."
The other case was that of a student of seventeen years
of age, and is so similar to the one just given that I
simply allude to it. As I have already intimated, the power
of hearing better in a noise is a different subject, from that
of the effect of certain noisy occupations upon the ear.
Patients like my friend, the mail agent, may travel for years
in the din of a train, and always find their hearing improved
and not decreased, so long as it depends upon disease of
the middle ear. Neither do I know of any cases of deafness
that have been caused by such occupations. But although
there is a class of patients who have been made deaf by noise,
often confounded with those whose impairment of hearing
has resulted from catarrh, they should be entirely disasso-
ciated from them. Boiler-makers, and those who become
deaf from an exposure to the continuous shock of loud
sounds, suffer a lesion of the acoustic nerve. These patients
do not hear better in a noise, but they have a source of
The Effects of Noise upon Diseased and Healthy Ears. 109
relief in quiet places, and, like ordinary people, they hear
better away from the din that is such a comfort to a person
deaf from many forms of disease of the middle ear.
I must confess to have assisted in the creation of confusion
in our ideas as to hearing better in a noise, and the effects
of noise upon the ear. In 1874, in an article upon diseases
of the internal ear,' and a few months subsequently in my
book,' I gave the results of my examinations of a certain
number of boiler-makers, and I incidentally assumed that
they heard better in the noise of their occupations. When
the paper by Dr. Holt, to which I have referred, appeared,
I found that he denied the correctness of my main conclu-
sions; that is, that the impairment of hearing in boiler-
makers is generally a result of a lesion of some part of
the labyrinth, and that, besides his doubt that any deaf
person, much less boiler-makers, ever heard better in a noise,
he was inclined to attribute their impairment of hearing to a
disease of the middle ear. I then made a new series of
examinations upon boiler-makers, assisted by Dr. J. B.
Emerson. As a result of these recent investigations, which
were undertaken with the much better means of a differ-
ential diagnosis between diseases of the middle and
internal ear, now at our command, I find that I cannot
agree with Dr. Holt's conclusions, except in one par-
ticular, and that is the one just mentioned, i. e., that boiler-
makers do not hear better in a noise. This incidental
statement made by me, I now find to be entirely incorrect.
But that boiler-makers do suffer from a lesion of the in-
ternal ear, and not of the middle ear, in so far as they have
a peculiar affection from their occupation, I do not think
admits of a doubt. The very fact that they do not hear
better in a noise is an incidental proof that they suffer from
a lesion of the labyrinth. Boiler-makers, like men in
other occupations, often have impacted cerumen, and
occasionally catarrh of the middle ear, but the disease
caused by their occupation, "boiler-makers' deafness," in
my opinion, is easily shown to be a disease of the labyrinth.
' American Journal of the Medical Sciences, vol. Ixviii, p. 381.
' " Diseases of the Ear," fourth edition, p. 509.
no D. B. St. JoJin Roosa.
Other occupations of a similar nature, that is, occupations
amid continuous concussions, undoubtedly cause the same
lesion. A recent visit to an establishment where two
engineers were employed for the production of electric
light, showed me that they had become somewhat hard
of hearing, since they had been engaged in an occupation
exposing them to the sound of regular concussions from the
striking of metallic plates together.
The confusion which I assisted in producing upon the
subject, was not, however, as regards the seat or cause of the
aural lesion, but as regards the ability of these workmen to
hear better in the din in which they labor. It will perhaps
be remembered that in the earlier part of this paper, I
stated that those who hear better in a noise always suffered
from some form of disease of the middle ear. When some
years of observation had convinced me of the uniform-
ity of this rule, I was puzzled to account for my cases
of so called boiler-makers' deafness, which, in my paper
upon this subject, I had assumed were also improved by
being in a noise. I had said : " It will be observed that
the subjects of it (boiler-makers' deafness) hear very well in
the tremendous din of a boilei'-shop, while they are quite
deaf in an ordinarily quiet place."' This remark, I am
constrained to say, although in my text-book, is strikingly
incorrect. Boiler-makers, as we should naturally believe, are
no exception to the rule, that those who have disease of the
nerve hear worse in a noise. Boiler-makers hear so badly in
their shops that they have a language of signs that is quite
elaborate, called a " boiler-maker's language." They hear'
no better in a noise than do people with sound ears ; on the
contrary, they hear better in a quiet place.
If, however, a person deaf from disease of the middle ear,
who hears better in the noise of a railway train, enters a
boiler-shop, that person will hear better than the boiler-
makers, or than persons with sound ears.
It is only very recently that I have been able to send a
patient suffering from chronic disease of the middle ear, who
heard well in a railway carriage, to a boiler-shop. I had
predicted, that although boiler-makers with disease of the
' " Treatise on the Ear," p. 510.
The Effects of Noise upon Diseased and Healthy Ears. 1 1 1
acoustic nerves, and persons with sound ears, hear very
badly in the dreadful din, such a patient would hear well in
such a place.
The patient whom I sent, is a lady of about thirty years
of age, who has had chronic disease of the middle ears, of
the proliferous form, for many years. She cannot hear the
watch at all, and conversation only when directed into the
ear, and then with dif^culty. In the cars she hears very
well. She only hears the tuning-fork by bone-conduction.
Her account of the experiment is as follows :
" I went with my husband (he has excellent hearing) this
afternoon to the boiler-shops of the Dickson Co. (Scranton,
Pa.), where the noise is perfectly deafening. I could dis-
tinctly hear what my husband said, although he purposely
spoke in a low tone, while he could not hear a word I said,
unless I puf my mouth to his ear and screamed. I think,
perhaps, cars and boiler-shops are the places for me to
live." In a subsequent note she informs me that she could
not hear the watch tick, although she hears conversation so
easily.
In this case it will be noted that the improvement does
not depend upon the loud fone of the speaker.
Boiler-makers speak in graphic language of the effects
of the din upon their ears. Said one of them to me :
"Those heavy hammers jar every nerve in the body." They
do not find much relief from wearing cotton in their ears,
except when first entering the shop. An experienced
workman, however, told me that all old boiler-makers had
learned to equalize the pressure and reduce the shock by
opening the mouth frequently. Of course, by this procedure
they open the Eustachian tube more freely.
My reasons for contending that the lesion in these cases
is situated in the nerve predominantly, are that the aerial
conduction was always louder than the bone-conduction, as
tested by the tuning-fork " C," and that it was heard longer
than by bone-conduction. The only apparent exceptions to
this rule were those in which, in addition to the lesion of
the acoustic nerve, there was also inspissated cerumen.
When the wax was removed however, and the cases were
112 D. B. St. John Roosa.
transposed into their proper place, of diseases of the acoustic
nerve produced by concussion, the tuning-fork was heard
through the air louder and longer than through the bone. I
consider all the other tests that we as yet have, for the
differential diagnosis of affections of the middle and internal
ear, as so much inferior to this, although of great corrobora-
tive value, that I am constrained to consider all observations
upon boiler-makers that have not been made in this way, as so
defective as to tell nothing of the true seat of the disease.
As has been suggested by many writers, there is no doubt
that something might be done to avert the consequences of
those concussions in producing disease of the acoustic
nerve, if workmen could be induced to wear ear protectors,
but from some reason or other, they are, as a rule, quite
averse to wearing cotton in their ears, or any contrivance
for protecting their ears from the effects of a great and
constant concussion. Almost all boiler-makers say that
they were deafer at first than after they had become accus-
tomed to the occupation ; and they all say that they
hear better after a period of rest, say from Saturday to
Monday.
That excessive sound must necessarily be as harmful
to the nerve of hearing, as is excessive light to that of
sight, is a natural deduction from our knowledge of the
effects of the waves that produce those two senses, and all
experience confirms the belief that there maybe an accoustic
neuritis produced by noise, as well as an optic neuritis caused
by exposure to a glare.
The fact that most patients suffering from disease of the
middle ear hear better in a noise, especially that of a rail-
way car, I find as a result of a series of examinations
extending over many years, and embracing several thou-
sands of cases. Wherever this symptom is not present, I
have found that either the disease was primarily or second-
arily one of the labyrinth or acoustic nerve.
I have gone with such patients to a train in motion, and
I have always found their statements correct. From hear-
ing a voice with difficulty directly in the ear, they have been
enabled to hear it twenty feet, that is to say to hear conver-
The Effects of Noise upon Diseased and HcaltJiy Ears. 1 1 3
sation at that distance and with ease. In my experience they
do not always hear a watch tick farther, but most of these
marked subjects hear a watch a very short distance, if at all,
in a quiet place. There is, I think with Politzer, sometimes
an improvement in this respect also.
This symptom would often be found in acute disease of
both sides did such diseases last long enough to admit of
proper tests. To say that the whole explanation is to be
found in the fact that the voice is raised when in a noise, is
to forget that even in a quiet place, with just such an
elevation of the voice, these patients do not hear as well as
they do in the noise. Besides, the elevation in the voice is
usually only slight, and sometimes it is not at all raised.
I have yet to find a case where a mistake was made in a de-
liberate statement by a patient, that conversation was heard
better in a noise. When the symptom does occur, it is so
marked that no mistake can be made. When a patient does
not know whether he does or does not hear better in a noise,
we may assume that he does not, and when he does not,
the case will, I think, always be found to be one in which
the nerve is somewhat involved.
The cases upon which my conclusions as to boiler-makers'
deafness depend are as follows :
Case i. — Boiler-maker twenty years ; disease of acoustic
nerve.
John F., set. thirty-five. Has been in the business for twenty
years. Hearing was good when he began ; began hearing noises
in his ears ; then became hard of hearing gradually. Cannot now
hear a lecture. Does not hear better in the noise of the shops, but
he assists his ears by watching the lips of those speaking to him.
Was most deaf after working in a boiler. Did not use cotton,
because it made him worse when removed. Hissing tinnitus all
the time.
Duration Air. Duration Bone-, in seconds.
H R = /g, aerial cond. best 23 11
HT 3 u << l( „„
i-, = 4% 20 9
M T Rt, good color ; good light spot, not sunken.
M T Lft, sunken ; 2 light spots, good color.
Says that he has never had catarrh.
114 D. B. St. John Roosa.
Case 2. — Boiler-maker thirty years. Disease of acoustic
nerve.
X. Y., forty-six years of age. Has been in the business for
thirty years. Hearing was good when he began his work. Now
cannot hear well when spoken to. Thinks he hears better in a
noise, because people speak louder. No pain at any time, but has
noises, and hearing failed gradually. Has used cotton, but does
not like it.
H R =r /g-, aerial cond. best ; watch not heard on mastoid.
1^ = 4 8
Aerial cond. Bone-cond. in seconds.
Rt, 26 12
Lft, 21 8
M T Rt, opaque ; no light spot, vascular along handle of the
malleus.
M T Lft, opaque ; sunken, no light spot.
Pharynx sound.
Case 3. — Boiler-maker tivcnty-four years. Disease of nerve
07ie side, of the middle ear and nerve on the other.
Forty-seven years of age. Has been in the business twenty-
four years. Hearing was good before he began it. Sissing
tinnitus. Deafness came on gradually, but was worse when he
was " holding on " ; no pain. Cotton did no good.
H R = ^% aerial but no bone-conduction.
H L = ;f^ " feels something ; bone-cond. distinct.
D. Aerial cond. D. Bone-cond.
R, 6 o
L, o 12
M T R, opaque rim ; vascular malleus ; no light spot.
M T L, good color ; vascular malleus ; no light spot.
Pharynx catarrhal ; uvula elongated.
Case 4. — Boiler-maker twenty-four years. Disease of acous-
tic nerves.
Fifty-one years of age. Has been in the business twenty-four
years ; previous to which his hearing was very sharp, now is very
poor. Sissiiig tinnitus ; does not hear any better in the shop or
car. Wears cotton at times. No pain in ear. Health good.
Voice at 4 feet.
The Effects of Noise 7ipon Diseased and Healthy Ears. 1 1 5
H R = :j% aerial feeble ; no bone-cond.
H L = /g "
D. Aerial. D. Bone.
R, 5 O
L, 6 o
M T R, opaque (wax).
M T L, opaque on periph. ; no light spot.
Pharynx in good condition.
Case 5. — Boiler-maker twelve years. Disease of acoustic
nerve.
M\.. twenty-five. Has been in the business twelve years. Hear-
ing is good ; no pain or noises.
D. Aerial. D. Bone.
H R = -f-^, aerial best. 21 7
H L = ii " " 20 10
M T R, good light spot ; opaque on periph. and above.
M T L, " light spot ; opaque.
Catarrhal pharynx.
Case 6. — Assistant in boiler-shop for one and a half years.
Works ten hours a day. Thinks his hearing is good enough.
Hears ordinary conversation with his face away from the speaker
about twenty feet.
H D, R ear, aerial conduction louder, air 10, B 5
" L, H, " " " " 16, B 4
Memb. tymp., R, small light spot, opaque.
" L, " " " vascular.
Pharynx healthy.
Case 7. — Boiler-maker thirteen years. Disease of middle
and ititernal ears.
Has been in the business thirteen years. Hearing always good.
Never protected his ears. Had a pain in left ear once, but
no discharge. Whispers heard by others not heard by him.
Does not hear better in noise.
D. Air. D. Bone.
H R = j^, bone-cond. best. 10 9
HL=^ " " " 13 7
M T R, good color and light spot.
M T L, sunken, opaque ; small light spot.
Tonsil enlarged. Pharyngitis.
ii6 D. B. St. jfoJm Roosa.
Case 8. — ^t. eighteen. Boiler-maker for fifteen months.
Disease of acoustic nerve.
Has been in business fifteen months. Hearing good when he
came. Not so good now. Hissing tinnitus. No pain. Does not
hear better in noise.
D. Aerial. D. Bone.
H R = ^^ aerial best 12 9
HL = i| " " 14 7
M T R, small light spot ; prominent short process.
M T L, no light spot ;
Slight pharyngitis.
Case 9. — TJiirty years a boiler -maker, hispissated ceru-
men ; disease of acoustic nerve.
^t. forty-nine. This subject is what is technically called a
"holder-on." His duties keep him inside of the boiler hold-
ing on to the rivets. The shock of sound is much greater
here than in the open air of the shop. Thirty years a boiler-
maker. Three and a half years in navy. Ears were good when
he went into the present business. Hears better when he gets
away from noise. Voice, 6 '. Watch, ;^, each side.
Tuning-fork :
R. E. L. E.
A C Louder 8 AC Louder 8
B C " 3 B C " 4
Inspissated cerumen on each side. After removal of large plugs
of very hard wax, H D for the voice increased to 18', and the
watch was heard, when pressed on each side, -i-^. The duration
of the aerial conduction was increased, but no change in the in-
tensity with which it was heard.
It is interesting to note in this case, that the aerial conduc-
tion was louder and longer, even w^hen the ear was plugged
with wax. This shows a more marked lesion of the nerve, than
the other cases in which inspissated cerumen was found —
for in these latter the bone-conduction was better until the
wax was removed, when the aerial conduction was found to
be as is usual in those suffering from boiler-makers' deaf-
ness.
The Effects of Noise upon Diseased and HealtJiy Ears. 1 1 7
Case 10. — Boiler-maker thirty-one years. Disease of acous-
tic nerve.
James L., forty-seven. Boiler-maker thirty-one years. First
job was a riveter, and in twenty days could not hear well ;
tinnitus like bees ; never had earache ; healthy ; rheumatism ;
voice 20'.
^ A> L A"' Aerial conduction better each side.
R, aerial, 12 sec. Bone-, 8 sec.
L" „ " " « <'
9 9
R M T, Good light spot. Good lobe.
(( a
Both opaque on periphery.
Healthy pharynx.
Case i i . — Boiler-maker for twenty years. Inspissated
cerumen removed from both sides ; disease of acoustic nerves.
Mi. thirty-nine. Has been twenty years in the business. Ears
were sound when he began ; had an occasional earache as a boy.
He can't hear a whisper ; does not hear well in a boiler-shop.
Watches the mouth and gestures. Hears the voice in a quiet
room 40'. Watch, R j\, L 4"^; R side the aerial conduction is
better. On the left the bone-conduction is better.
R, Aerial conduction is heard 12 seconds.
Bone- " " 6
L, Aerial " " 12
Bone- " " 8
Pharynx is sound.
Inspissated cerumen is found on each side. After it is re-
moved the watch is heard better on each side ; e. g., R -^, L/-g.
Relative distinctness of bone- and aerial conduction not changed.
Duration of the sound about as before.
Case 12. — Boiler-maker twenty-five years. Inspissated
cerumen; both sides. Disease of acoustic nerves.
M\.. forty-three. This man has been a boiler-maker twenty-five
years. He had good hearing when he began his work. Never
had an earache. Hears the voice in a quiet room 30'. Watch
^f^ on right side, -^^ on left side. R side, Bone-conduction much
more distinct; L side, the same.
ii8 D. B. St. John Roosa.
Duration : R aerial conduction, 5 seconds ; bone, 12 seconds.
Left side, aerial, 14 seconds ; bone-, 11 seconds. Inspissated
cerumen, each side, removed. After removal of wax watch was
heard j% and :^o" 01^ the right and left sides respectively, instead
of :i^ and /g-. The aerial cofiduction beca?ne better in each ear.
Duration as follows : R, aerial, 18 seconds; bone-, 13 seconds ; L,
aerial, 22 seconds ; bone-, 12 seconds.
As is seen, the peripheric trouble (inspissated cerumen)
masked the disease of the acoustic nerve in this case, but
when the wax was removed, the lesion of a boiler-maker's
ear was found to exist.
In case number seven, the bone-conduction was decidedly
louder than the aerial, but the tuning-fork was heard much
longer through the air than through the bone. The left
drum-head was sunken and opaque, and there was consider-
able throat trouble. From these data, I conclude that there
is disease of the middle as well as of the internal ear in that
case.
From all the observations I have been able to make upon
this subject, I think, I am justified in drawing the following
conclusions :
1. There is a large class of people suffering in quiet places,
from im.pairment of hearing, who hear very acutely and with
comfort amid a great din or noise.
2. The disease causing the impairment of hearing thus
relieved is situated in the middle ear. It is usually ob-
served in the chronic, non-suppurative form of disease of the
middle ear, but it may also be found in acute or sub-acute
catarrh of this part, as well as in a chronic suppurative pro-
cess with loss of the whole or a part of the membrana
tympani.
3. The proximate cause of this phenomenon is not as yet
positively known. It is probably to be found in some
change in the action of the articulations of the ossicula
audit us.
4. The hearing-power of persons working in such a din as
that of a boiler-shop invariably becomes impaired.
5. The lesion caused by this occupation is one of the
labyrinth, or of the trunk of the acoustic nerve.
The Effects of Noise upon Diseased and Healtliy Ears. 1 19
6. Persons thus affected do not hear better in a noise.
Their hearing-power is better in a quiet place, and becomes
better after prolonged absence from the exciting cause of
their impaired hearing.
7. The cases of inspissated cerumen, catarrh of the mid-
dle ear, occurring among boiler-makers, are such as occur
among those employed in various occupations and only
mask and complicate the fundamental primary trouble, so
long known as boiler-makers' deafness.
8. In diseases of the labyrinth or acoustic nerve the tun-
ing-fork "C" is heard louder and longer through the air
than through the bones of the head.
For an account of my first examinations of the hearing of
Boiler-makers, the reader is referred to my work on the Ear,
edition of 1877, and to the American Journal of Medical
Sciences, 1874.
120 D. B. St. John Roosa.
TABLE SHOWING THE RESULT OF THE EXAMINATION
Length of Time a
Boiler-maker.
Case I, 20 years
2, 30
3. 24 "
4. 24 " . .
5> 12 "
6, \\ "
7. 13 "
8, 15 months
9, 30 years .
10, 31 "
IT, 20 "
12, 25 "
Hearing Dis-
tance.
Cannot hear
ordinary con-
versation.
■p Pressed T 3
R
T Laid
■L' us
■DO TO
Voice 4 feet.
RO T P
RA, L
Voice 20 feet.
R ? T 10
Ji^ LaJ^d L Pressed
TJ 5 T 12
Voice 6 feet.
Ji 0 TO
Voice 20 feet.
K> Laid T 8
Voice 40 feet.
■RIO TO
Voice 30 feet.
R L^d 2_ L ^
Aerial Con-
duction.
Better than
bone.
Feeble.
Better than
bone.
Better than
bone.
Better on
right side af-
ter removal
of •wax.
Better on
each side af-
ter removal
of wax.
Bone - Con-
duction.
None on
right side.
Better than
aerial.
Better on
left side.
Better wi-
til wax was
removed.
1 Pressed after removal of wax.
'"' ^'g and j*j after removal of wax.
TJie Effects of Noise 2ipon Diseased and Healtliy Ears. 121
OF TWENTY-FOUR EARS OF TWELVE BOILER-MAKERS.
Duration
of Aerial and Bone-
Conduction
Diagnosis.
Remarks.
Aerial :
RE
23 sec, L
E, 20 sec,
Disease of
Has hissing tin-
Bone :
internal ears.
nitus.
R E
II '
Aerial :
9 "
RE
26 '
Bone :
21 "
•'
R E
10 '
8 "
R E
R E
6 "
0 '
Aerial :
.
Disease of
Pharynx catarrhal ;
Bone :
0
12 "
internal and
middle ear.
uvula long ; mt. vas-
cular along malleus.
Aerial :
R E
5 '
Bone :
6 "
Disease of
internal ears.
R E
0 '
Aerial :
' 0 "
R E
21 "
Bone :
20 "
"
Thought he heard
very well.
R E
7 '
Aerial :
10 "
R E
10 '
Bone :
' 16 "
"
"
R E
5 "
4 "
Aerial :
Disease of
Left mt. sunken ;
RE
10 '
' 13 "
middle and
small light spot ;
Bone :
internal ears.
pl;aryngitis.
R E
9 "
Aerial :
7
RE
12 '
Bone :
' 14 "
Disease of
internal ears.
Slight pharyngitis.
R E
9 '
Aerial :
7 "
R E
8 "
Bone :
8 "
"
Inspissated ceru-
men, each side.
R E
3 '
Aerial :
4 "
RE,
12 "
Bone :
9 "
"
R E
8 "
Aerial :
9 "
RE
12 "
Bone :
12 "
"
Inspissated ceru-
men, each side.
R E
6 '
Aerial :
8 "
R E,
5 "
Bone :
' 14 "
"
RE
12 "
ii' "
' After removal of wax, aerial became R E, i8 seconds, L E, 22 ; bone re-
mains nearly the same : R, 13 seconds, L, 12.
CALCIUM SULPHIDE IN AURAL DISEASES.
By GORHAM bacon, M.D.,
AURAL SURGEON, NEW YORK EYE AND EAR INFIRMARY.
THAT calcium sulphide is one of the most valuable
drugs we possess in the treatment of aural diseases,
especially those attended with suppuration, I think no one
will deny who has given the drug a fair trial. Dr Sexton, I
believe, was the first to advocate its use in diseases of the
ear, in an article published in the January number of TJie
Anicricati Journal of Otology for 1879. During the past two
years I have used the drug in both dispensary and private
practice, and have been much pleased with the results ob-
tained. Ringer, in his work on " Therapeutics," says : " The
sulphides appear to me to possess the property of prevent-
ing and arresting suppuration. Thus, in inflammation
threatening to end in suppuration, they reduce the inflam-
mation and avert the formation of pus. After the formation
of pus, the influence of this group (sulphides) on the suppu-
rative process is still more conspicuous ; then the sulphides
hasten maturation considerably, whilst at the same time
they diminish and circumscribe the inflammation, promote
the passage of pus to the surface, and the evacuation of the
abscess." " In boils and carbuncles these remedies yield
excellent results. When the skin is not yet broken and the
slow-separating core not yet exposed, the sulphides often
convert the boil into an abscess, so that, on bursting, pus is
freely discharged, and the wound at once heals ; or if the
centre of the hardened, swollen tissues is not yet dead, the
pustule dries up, the inflammation subsides, and a hard knot
Calcium Sulphide in Aural Diseases. 123
is left, which disappears in a few days without the formation
of a core and without any discharge. These remedies,
meanvvhile, improve the general health, removing that de-
bility and malaise so markedly associated with boils and
carbuncles." Ringer goes on to say that in children of a
strumous diathesis, where the phalangeal bones are affected,
the sulphides will benefit considerably, especially in those
cases where the shaft is found enlarged, very pale, and the
cancellous structure infiltrated with straw-colored firm
substance.
In most of the cases of acute otitis media in which I have
used the calcium sulphide, suppuration had already com-
menced, but in several, where the mem. tympani was highly
congested and bulging, all the inflammation subsided under
the use of this remedy, and I believe that it will prevent
the formation of pus in many cases, if given sufficiently
early in the course of the disease. Its most decided action
seems to be in those cases of otitis media in which the dis-
charge has already commenced, as well as in cases of furun-
cles in the ext. auditory canal, where it will either arrest the
inflammation and cause the boil to dry up, or it will promote
suppuration and cut short the disease. Those patients
subject to furuncles are generally badly nourished and in
poor health, which is an indication for the administration of
the drug.
The pain so frequent in these diseases, even when the
periosteum is involved, is often relieved at once. In diffuse
inflammation of the ext. auditory canal, and in mastoid dis-
ease, whether affecting the pneumatic cells or the perios-
teum and tissues externally, great benefit will be obtained
from its use. I would not hesitate, however, to perform
paracentesis where severe pain was caused by bulging of the
mem. tym. ; nor in cases of mastoid disease, where there were
symptoms pointing to the presence of pent-up pus, and the
patient suffering severe pain, with danger of further compli-
cations, would I hesitate to perforate the bone. But the
fact, that since I have used calcium sulphide in acute inflam-
mation of both middle and external ears, I have had no
serious mastoid complication, and have not been obliged to
124 Gorliaui Bacon.
resort to the knife, I attribute to the early administration
of this remedy.
In acute inflammation of the ear, before the formation of
pus, I have been in the habit of prescribing aconite for the
reHef of pain, besides giving the sulphide. Appropriate
treatment should be applied to the naso-pharynx and neigh-
boring parts, and particular attention should be paid to the
condition of the teeth.
The dose must be adapted to each individual case. In a
child, y\) or ^l gr., or even lower, may be used, while in an
adult, from yL to \ gr. may be given several times a day or
every two hours. In some cases a small dose seems to
answer better than a larger one, and vice versa.
As regards local treatment, where there was suppuration,
I have had the best results from the use of powders —
either boracic acid or iodoform ; or else I have used the
boracid acid et calendula, as recommended by Dr. Sexton,
or boracic acid et hydrastis canad., prepared as follows :
equal parts of boracic acid and tr. hydrastis canaden. are
thoroughly mixed and evaporated to dryness; then the
residue is thoroughly pulverized and mixed again with equal
parts of boracic-acid powder.
The following cases are examples of those in which I have
found great benefit from the use of calcium sulphide.
Case i. — A. S., set. twenty-nine, male, came to the infirmary
Mar. 6, 1883. Had a severe pain in the left ear the Saturday pre-
ceding ; lost the hearing in the right ear in 1863 from typhoid
fever ; tuning-fork when placed on the vertex heard only in the
left ear.
Exai7iination shows : Left Mt inflamed in lower portion ;
macerated in appearance, bulging slightly above. Discharge com-
menced two days ago, and is slight. He is subject to con-
siderable nasal catarrh, for which he has been using the nasal
douche.
Treatment : Calcium sulphide, gr. -^^ every three hours ; canal
insufflated with pulv. acid, boracic. et hydrast. canad. Hearing
much affected. Could only hear shouting voice. Watch, -^-^.
Mar. gth. — No pain now ; hearing the same and appearance of
Mt unchanged. Calcium sulphide increased to gr. \.
Calcium. Sulphide in Aural Diseases, 125
Mar. 16th. — Hears watch now, ^ ; no discharge now. Infla-
tion by Politzer's method has been used occasionally.
Case 2. — Patient, male, a;t. forty-five, presented himself Feb.
20th, and gave the following history : The right ear has been dis-
charging and painful for six days ; left ear for eight days. No
perforation to be seen in left Mt, which is bulging.
Treatfnenl : Canals dried with absorbent cotton, and boracic
acid insufflated. Calcium sulphide, gr. yV> given.
Feb. 23^. — Discharge less in left ear; in right one about the
same. Right auditory canal filled with pulv. acid, boracic. et
hydrastis canad.
Mar. 2d. — No perforation seen in either mem. tympani ; con-
gestion has disappeared in both except at upper segment, around
the short process and manubrium.
Case 3. — Patient, female, set. twenty-eight, anaemic, came to
infirmary Feb. 13th. She had measles three weeks ago, and both
ears have been discharging ever since. Both canals filled with
muco-pus. Pulv. acid, boracic. et hydrastis insufflated, and cal-
cium sulphide given ; patient very deaf.
Feb. 2T,d. — Great pain and noise in right ear ; same treatment
continued.
Feb. 2\th. — No pain, but great noises.
Mar. qt/i. — Left Mt slightly pinkish, and a very small perfora-
tion at upper part ; no discharge whatever. Right Mt slightly
congested ; no perforation ; no discharge. Hearing distance
much improved.
Mar. i2,th. — No discharge from either ear; both J// clearing
up. Hears loud voice in left ear ; right normal.
Case 4. — Patient, female, set. twenty-two. The history in this
case was that four weeks ago the left ear began to ache till the
following Thursday, when it broke ; it discharged a week and
then stopped.
Canal dry, very little discharge. Abscess over the mastoid
process with deep-seated fluctuation ; considerable swelling and
induration of the tissues extending down the neck. Patient very
anaemic. No treatment except calcium sulphide, gr. y'o, every
three hours. She returned the following Friday, and said she
was better ; to continue same treatment.
Feb. 20th. — Swelling and fluctuation over the mastoid process
entirely gone ; also the induration in the neck. No discharge
from the ear for nearly two weeks ; general health and appear-
ance improved.
126 Gorham Baco7i.
Case 5. — Patient, female, set. nineteen, has chronic pharyngitis.
Came to infirmary ten days ago, when I removed inspissated
cerumen from her ear. Hearing good, and she had no further
trouble till Oct. 21st ; both ears then began to pain her, especially
the left.
Examination showed : Both auditory canals narrowed and in-
flamed. The Mt could not be seen in either ear, but there were
evidences of perforation in the left ear. Calcium sulphide, gr. y^,
given.
Oct. I'jth. — Both auditory canals free from inflammation and
shedding epithelial layer ; both Aft almost normal in appearance,
but slightly congested. Hearing has improved each day ; same
treatment continued.
Case 6. — Mrs. H., set. forty, came to my office Nov. 14th. Has
naso-pharyngeal catarrh. She said that three weeks ago the left
ear began to feel stuffed up and to itch. Last Friday, com-
menced to pain her severely, keeping her awake at night. Dis-
charge appeared to-day for the first time.
Examination : Furuncle in left ext. auditory canal, lower por-
tion, which was discharging, and which obscured Mt. Canal dried
with absorbent cotton and filled with pulv. acid, boracic; aconite
in small doses given for the pain, and pil. cal. sulphid., gr. -^V.
There were some deafness and autophony Nov. i6th. Pain
less yesterday, and last night she slept much better. Acid, bor-
acic. at calendula insufflated, and she was given some of the pow-
der to use herself once every day. Aconite and calcium sulphide
continued.
Nov. 20th. — Pain has steadily decreased, and last night there was
none. Epithelium desquamating from Mt and inner end of ext.
auditory canal. Every trace of the furuncle gone. Mt very
much congested and dull and macerated in appearance. Hearing
improved. No autophonous noise to-day. Treatment continued.
She continued steadily to improve, and Nov, 24th hearing almost
normal.
Case 7. — J. G., male, set. four and a half, came to my office
April 3d, suffering with severe earache. The child was delicate
and had grown very rapidly. Had an earache first two months
ago. Since Sunday last the right ear has been very painful. Ear
pains him now very severely at times. The auricle stands out
abnormally from the head. Canal contains some pus. Consid-
erable tenderness over the mastoid. No fluctuation.
Calcium Sulphide in Aural Diseases. 127
Treatment : Calcium sulphide and aconite in small doses.
April 4th. — The child was feverish during the night up to four
o'clock, when he slept. No pain in the ear, however.
April ^th. — The pains, which recurred at times, were less severe
and much less frequent. Appetite improved. Tenderness less
over the mastoid. Same treatment continued.
April 6ih. — Patient had more pain last night at times, which was
very severe. Calcium sulphide given every hour.
April ']ih. — Patient had but little pain after nine last evening.
Has been much better all day. No pain. He continued steadily to
improve until April nth, when discharge ceased entirely, although
it had never been profuse. Tenderness over the mastoid almost
gone, and the redness and swelling which appeared a few days
ago in front of the auricle have disappeared. The child was seen
again April i6th, when almost all the inflammation had gone and
the child was feeling perfectly well.
Case 8. — Patient, aet. fifty-nine, Irish, came to infirmary Jan. 9th.
He has been suffering since Christmas night with severe earache
in left ear. The ear broke that same night, and the discharge,
which has been profuse, has continued ever since. He complains
of noises in the ear, and he has a dull pain over the mastoid.
There is considerable deafness.
Exa?7iination showed : Left auditory canal filled with muco-pus ;
Mt infiltrated, fleshy-looking, with a perforation in the lower
portion. Calcium sulphide, gr. yV, given, and canal cleared of
muco-pus with absorbent cotton, and pulv. acid, boracic. et hy-
drastis insufflated. Discharge diminished under treatment until
Jan. 25th, when the auriclebecame very much inflamed at the anti-
tragus. The inflammation continued to spread until the auricle
was entirely involved and twice its natural size on Jan. 26th. The
ext. auditory canal was not involved in the inflammation. The
discharge diminished in quantity. Mt very much congested.
The erysipelatous inflammation extended over the mastoid, over
parts in front of the auricle, and gradually over the whole scalp,
forehead, and left eye ; also over the neck. The pain in the
mastoid was not increased, but dull in character.
'jFan. 27/A. — Patient seized with a chill during the evening ; dizzy.
Jan. 28th, temperature 104.5° \ pulse 124 in the evening ;
discharge free from the ear ; Mt less congested. He was given
appropriate treatment, including local applications for the erysipe-
las, but at the same time was ordered to take calcium sulphide, gr.
128 GorJiam Bacon.
\ every three hours. The erysipelas subsided, and the pains in
the ear and mastoid almost gone on Jan. 29th ; discharge less but
thicker. Mt less congested, and perforation seen in lower pos-
terior segment. The sulphide given less often, owing to diarrhoea,
undoubtedly caused by this drug. The discharge ceased Feb.
2d, and the noises disappeared about the same time.
Feb. \2th. — Watch, left ear, /y^, but loud voice heard. Mt vtry
little congested in lower segment ; perforation healed.
Feb. jq/h. — Returned, saying he had taken a fresh cold, and he
complained of an itching sensation last night in the same ear. Mt
covered with muco-pus, and a perforation in lower quadrant.
Watch, -^ after Politzer inflation. Pulv. acid, boracic. et hydrast.
insufflated every day, but the discharge remaining unchanged, I
ordered him to resume calcium sulphide ; the discharge com-
menced immediately to diminish in quantity until Feb. 28th, when
it ceased altogether. Politzer inflation used. The Mt continued
to clear up, and on March 13th, the hearing distance was almost
normal. He returned April 13th and said he felt entirely well.
Hearing normal.
It is difficult to decide how much of the success in treat-
ment to attribute to the calcium sulphide, as local means,
Politzer inflation, etc., are employed as well, but in Case 4,
nothing but the calcium sulphide was given — no local treat-
ment whatever ; while in the last case, during the second
attack of otitis media purulenta, the discharge did not
grow less under local treatment till the calcium sulphide was
given. In Case 7 nothing was given but the calcium sul-
phide and aconite.
CHOLESTEATOMA OF THE MASTOID PROCESS
WITH RUPTURE INTO THE EXTERNAL AUDI-
TORY MEATUS AFTER USE OF THE IRISH-
ROMAN BATHS.
By Prof. S. MOOS, of Heidelberg.
Translated by Porter Farley, M.D., of Rochester, N. Y.
IN volume viii of this journal I have described four
cases of severe disease of the mastoid process, among
which there was one case of acute caries of the posterior
wall of the external meatus, complicated with choleste-
atoma of the mastoid process. Recovery followed, but there
was a large defect in the bony parts involved. I am now
able to report a similar case in which recovery was perfect.
In the first week of May, 1881, I was summoned to Carlsruhe
by Dr. Schuberg to visit one of his patients, who for a long time had
been confined to his bed by an exceedingly painful affection of the
left external auditory meatus.
At my first visit, May 12th, I learned the following history :
The patient, a merchant thirty-three years old, of strong consti-
tution, had been successfully treated twelve years previously by his
physician. Dr. Schuberg, for a suppuration of the left mastoid pro-
cess. The abscess had then been opened by a proper incision,
and the wound healed so well that at present a scar is scarcely per-
ceptible. There was no subsequent discharge, and until his pres-
ent affection the patient is said to have heard well with that ear. In
other respects his general health until recently was good.
Three months ago rheumatic pains appeared in the extremities,
and for their relief an Irish-Roman bath had been ordered. On
129
130 'S. Moos.
the day following the bath, the patient was attacked with severe
pain in his ear, and with shooting pains through that side of his
head. A purulent discharge from the ear was accompanied by a
remission of the pains. The rheumatic pains, however, continued.
A second Irish-Roman bath was ordered. The pains in the ear
reappeared, and continued during the last weeks. At times
they were terrible. A swelling of the sub-auricular glands had
appeared.
At present the patient appears quite sick, and complains of pain
deep in his ear. The ear, however, is not sensitive to pressure,
either upon the external passage or on the mastoid process, which
last, with the exception of the above-named scar, is in every respect
normal. Upon examination, several polypi are seen upon the inner
third of the external passage ; nevertheless, by Valsalva's experi-
ment, one can hear a distinct sharp hissing of the air, followed
immediately by a somewhat freer discharge of pus mixed with
cholesteatomatous masses. The tuning-fork placed on the skull
is heard on the diseased side.
The treatment ordered was boracic acid and the air douche.
From the 12th to the 15th of May, several large cholestea-
tomatous masses were discharged, some spontaneously, and some by
syringing. Meanwhile the patient remained free from pain.
On May 15th, with Wilde's snare, I removed two polypi from
the lower and posterior wall of the external auditory meatus.
During the operation, and subsequently, great quantities of
cholesteatomatous matter were discharged. There was a kidney-
shaped perforation of the drum membrane. The labyrinth wall
was gray-red. There was great and permanent improvement in the
subjective symptoms. On May 21st, the patient visited me at
Heidelberg. There was still a discharge of the same matter. On
June 2 ist he visited me a second time at the Heidelberg clinic.
At this time, by good illumination I succeeded in probing a cari-
ous opening in the posterior wall of the inner third of the external
auditory meatus. It was about the size of a pea, and the probe en-
tered in a slanting direction nearly a centimetre. The treatment
with boracic acid was continued. The patient visited me eight
times up to the 4th of July. On the 27th of June I assured my-
self that the caries was healing, and that the repair of the drum
membrane was begun. On the 4th of July recovery was complete,
and the patient had a very satisfactory degree of hearing. Up to
the present time he remains sound.
Cholesteatoma of the Mastoid Process. 131
Genetically, this case may be regarded as follows :
The suppuration of the mastoid cells, which occurred
twelve years before, healed just as did my case above re-
ferred to, and there intervened between the recovery from
the first attack and the onset of the second, a period of
perfect health. In this case the symptoms of renewed in-
flammation may perhaps be attributed to the use of the
Irish-Roman baths. But there can be no doubt that the
accumulation of concentric epidermis masses in the antrum
mastoideum, with their slow growth through a long course
of years, was a contributory cause. In view of the patho-
logical anatomy of the case there can be no question that
there was atrophy of the bony parts, due to the pressure of
these constantly increasing epidermal masses.' An acute
caries of the anterior wall of the mastoid cells appeared as a
reactive symptom, caused by sudden swelling induced by
repeated use of the Irish-Roman bath. The severe pain was
due partly to this process and partly to the resistance
offered by the posterior portion of the mastoid cells, in
which sclerosis had probably taken place during the disease
twelve years before ; so that, though this part presented no
objective symptoms, its condition certainly had much to do
with the excruciating nature of the pain.
It is possible that the first attack of pain occurring after
the first bath, with three days' remission after the appear-
ance of a discharge from the ear, was caused by a simple
acute attack of inflammation of the middle ear, and that
the second period of pain was due to the perforation of the
posterior wall of the external meatus. But judgment upon
this point must be reserved, as the condition of the drum
membrane during the latency of the disease was not known.
'The enormous size to which the masses sometimes attain has been proved
by examinations which I have made on the cadaver. Before me Bezold observed
a case in the living subject and published it. See Arch, fiir Augen- tind Ohren-
keilk., Bd. iii, p. 99, and Bd. v, p. 9S.
NECROTIC EXFOLIATION OF THE SUPERIOR (?)
BONY SEMICIRCULAR CANAL, PRECEDED BY A
WEEK OF DIZZINESS AND VOMITING. RECOVERY
WITH LOSS OF SUCH DEGREE OF HEARING AS
HAD PREVIOUSLY EXISTED.
By Prof. S. MOOS, of Heidelberg.
Translated by Porter Farley, M.D., Rochester, N. Y.
ON May 14, 1881, I received from Dr. Thornwaldt, of
Danzig, the following clinical history, which was
brought to me by the patient himself :
"A student, Mr. R., has been repeatedly treated by me for dis-
ease of the ear. When I first examined him about two years ago,
I found the following condition : There was a copious fetid sup-
puration from the left ear. There was absence of the anterior half
of the drum membrane, and the remaining half consisted, for the
greater part, of scar tissue. The handle of the hammer was fixed
to the opposite wall of the tympanum. Denuded bone could be
felt by the probe in that part of the tympanum upward and for-
ward from the promontory. The air douche by means of the
catheter indicated a much contracted Eustachian tube, while upon
the right side the air very easily entered the tympanum. Hearing
on left side markedly diminished. The tuning-fork held on the
skull was heard on the left side. The suppuration ceased after treat-
ment of the middle ear by disinfectants and astringents, but only
to return from time to time.
" About four weeks ago, after an absence of a year, R. came
to me again for treatment. He was then very sick with
chills, high temperature, and severe attacks of dizziness. There
was a foul suppuration from the left ear, and severe pains shooting
132
Necrotic Exfoliatio7i. 133
through the entire left half of the head. After syringing with a so-
lution of boracic acid, and catheterization, there was a speedy im-
provement of the general condition ; the swelling of the external
passage diminished, and there then appeared quite a large, hard
granulation growing from that place where I had previously found
denuded bone. As this granulation appeared to have a broad
base, I have tried to destroy it by caustics and the galvano-cau-
tery, but up to this time without any satisfactory result. Soon
after beginning my last course of treatment, during the act of syr-
inging, a small rough piece of bone was washed out."
At my examination, May 14th, I learned that the disease had
existed since the seventh year, and had followed scarlet fever.
The patient was very pale and dejected, but was free from fever,
pain, vertigo, and subjective noises. A low-ticking watch, held
upon the forehead, was heard upon the diseased side, and the
tuning-fork held in like manner was heard only on that side.
Hearing distance for speech was only about two metres. The left
external auditory meatus was so filled with polypi that it was im-
possible to determine the condition of the deeper parts of the ear.
The treatment with solution of boracic acid was at first con-
tinued. Cn addition to this, up to May 21st, three applica-
tions of the galvano-cautery were made to the polypi
without any reaction and without any disturbing symp-
toms during the intervals between the operations. On
the 2ist the patient sent for me, as he could not go out on
account of severe vertigo and vomiting. On that day and
the following one I found the condition in the ear to be the same
as before. I visited the patient once or twice a day until the
29th, and every day found a normal condition of the pulse, tem-
perature, and pupils. With the exception of vertigo and vomiting
there was no abnormal symptom, such as constipation. There
were great apathy and nearly total loss of volition, in a patient
naturally ambitious and industrious. I directed abstemious diet
and confinement to the bed. At first I endeavored by Charcot's
quinine treatment to overcome the symptoms, but without success ;
so that I then limited the amount administered to the degree of
simple saturation. As to the dizziness, the patient, upon repeated
questioning, stated that when he looked at an object it appeared
to move in an upward direction. On the 29th of May occurred
the last attack of dizziness and vomiting. On the 31st the
patient appeared again at my clinic. When I examined him with
134 •S'- Moos.
reference to the advisability of a repetition of the use of the
galvano-cautery, I discovered embedded in the granulations a black
body which felt rough when touched with the probe, and which I
easily removed with the forceps. The fragment was buckle-
shaped, nine mm. long and about one mm. broad. The slight
amount of soft tissue upon it proved upon microscopic examina-
tion to consist only of pus corpuscles and margarine crystals.
This bony fragment was for the most part carious, but in certain
parts of its concave surface a distinct groove was visible. Hear-
ing was entirely lost on the left side, and has so remained to this
day. But there has been no return of the vertigo or vomiting, and,
in consequence of the continued treatment with the galvano-
cautery, recovery proceeded so rapidly that as regards caries,
necrosis, and the formation of polypi the patient could be re-
garded to be well at the beginning of August. It is now possible to
form a better judgment of the condition of the deeper parts. The
greater part of the drum membrane is absent. Its anterior and
lower margins still remain, and from the latter a triangular tag of
cicatricial tissue projects toward the promontory, with which its
extremity is united. The malleus and incus are absent, and I have
never been able to satisfy myself of the presence of the stapes,
although I still have the patient under observation. The recovery
from the disease has been accompanied by a highly gratifying
improvement in the mental condition of this naturally talented
young man. He at least so expresses himself, and so does his
mathematical teacher.
This history, aside from its practical value, is of great
physiological interest.
After the disappearance of the vertigo, which was ex-
perienced in an early stage of the disease, it reappeared
violently, accompanied by vomiting, upon an irritation of
the labyrinth. These symptoms disappeared upon the dis-
charge of one of the necrosed semicircular canals, and the
patient simultaneously lost such remnant of hearing as had
till then been retained. The case also shows that irritation
of the nerve terminations in the crests of the ampullae may
cause the same symptoms as an irritation of the cerebellum,
the centre of muscular co-ordination, and that upon the
paralysis or destruction of the nerves of the ampullae the
vertigo disappears.
Necrotic Exfoliation. 135
Such clinical experiences are more valuable than physio-
logical experiments. In such experiments there is great
danger of accidental injury to the brain ; but no such com-
plication existed in this case ; for pulse, temperature, and
all the functions of the brain remained normal. The obser-
vations of these experiments, made by Nature herself, are
valuable because of their cleanness. The more such obser-
vations multiply, the better furnished are we for the support
of our views concerning the function of the semicircular
canals and their adnexa, and that, too, with material far
more reliable than is furnished by artificially instituted
experiments.
Moreover, the latest results of experimental physiology
are confirmative of the view that the nerves of the vestibule
stand in close connexion with the function of muscular co-
ordination, notwithstanding the contrary results reached by
Baginsky, which we have elsewhere referred to, and have
disputed on pathological grounds. Hogyes," upon the
strength of his experiments, speaks as being certain that the
vestibular terminations of the acoustic nerve constitute a
special apparatus which, according to the position of the
head and body, co-ordinate the movements of the eyes, and
probably also control all those muscles which are concerned
in maintaining bodily equilibrium.
' The true causes of the vertigo which accompanies increase of pressure in the
tympanum. Prof. And. Hogyes, of Klausenburg. Arch, fur die ges. Physio-
logic, Bd. xxvi, p. 558.
TYJEMIC ATTACKS DURING AND AFTER RE-
COVERY FROM AN ACUTE PURULENT
INFLAMMATION OF THE TYMPANUM.
By Prof. MOOS, of Heidelberg.
Translated by Porter Farley, M.D., Rochester, N. Y.
THE following case is the only one in my practice in
which pyaemic attacks have occurred during the acute
stages of an inflammation of the middle ear, and in this they
even continued, although for only a short time, after the
closing of the perforation. I publish the case, although I
have to offer only opinions as to the connection existing
between the symptoms. Perhaps others who have made
similar observations may confirm my suppositions :
F. von T., student, came under my treatment May 5, 1881.
For many years he has had nasal catarrh and a sensation of
obstruction in the right nostril. His present disease of the ear be-
gan three weeks ago, following a renewed attack of his catarrh, and
beginning with pain in the right ear. For three days he had been
deaf in that ear. Since the last night he had experienced violent
pulsation in it. The right external meatus was moistened with a
little pus. The right drum membrane was flat, thick, and of a
grayish red. The handle of the malleus was not visible. The
mucous membrane of the right inferior nasal meatus was hy-
pertrophied. The tuning-fork was heard by bone-conduction only
on the right 3ide. The watch was heard only on contact. Words
could be distinguished at two metres. Under treatment by the
nasal and air douches and afour-per-cent. solution of boracic acid,
136
PycBinic Attacks. 137
improvement began in a few days. On the nth of May the
patient went out to walk, and was so imprudent as to sit down in
the open air, notwithstanding the prevalence of a strong northeast
wind. In hardly more than five minutes he experienced a chill
and renewed severe pain in the right ear.
Nevertheless, on the morning of the 12th, I found only a con-
siderable congestion of the vessels near the handle of the malleus.
There were no visible signs of exudation in the tympanum, but
hearing was almost wholly lost. In spite of the negative result of
this examination with reference to exudation in the middle ear,
there was by evening of the same day a profuse discharge of pus
and a perforation in the anterior inferior quadrant of the drum
membrane.
Treatment : Rest in bed ; frugal diet ; boracic acid.
Until May i6th, there was a profuse, painless discharge. On
the 19th, the perforation had closed ; there was no discharge and
the patient felt well.
May 20th, 5.30 P.M. — Chill; temperature, 40.3°; pulse, 112.
Loss of appetite ; constipation ; restless night ; frontal headache.
May 2\st, morning. — After severe pulsation in the right ear
during the night, there was a renewed discharge through a
new perforation in the inferior posterior quadrant. Temperature,
37° ; evening 39°.
May 22d, morning. — Temperature, 37°. Local condition and
treatment the same as before. At noon a chill. At i p.m., tem-
perature 39.1° ; at 4 P.M., temperature 40.4° ; at 6 p.m., 40.6°.
Shortly after followed a chill. At 9 p.m., temperature 38.4°. At
midnight, temperature 38.8°. Frontal headache.
From this time I was in daily consultation with Prof. Friedreich.
Ordered quinine, 0.3 every three hours.
May 22,d, 6 a.m. — Temperature, 36.5°. Quinine was used from
this time until May 29th. Rochelle salts to correct constipation.
Local treatment as before.
May 26th. — Discharge from ear ceased.
May 2']th. — Closure of perforation. At 9,30 a.m., a chill ;
sweating till 2 p.m. At 4 p.m., another chill. At 6 p.m., sweat.
At 8 p.m., another chill. Continual headache.
May 2?>ih a?id 2gth. — -The fever has subsided. Sweating con-
tinues. General condition comfortable. Hearing nearly normal.
There is recovery from the local disease, without any perceptible
changes in the drum membrane.
138 5. Moos.
Prof. Friedreich examined the internal organs twice daily dur-
ing the entire prevalence of the fever, but was unable to detect
any abnormal condition other than a slight enlargement of the
spleen. The urine contained no albumen.
When attacks of pycemia occur in the course of a chronic
suppuration of the ear, we can judge more correctly of the
history of the disease than when they occur in acute cases.
In the first place, we are justified in assuming a diseased
condition of the petrous bone, especially a gradually pro-
gressive caries which favors the propagation of the disease
to one of the sinuses of the brain. It is quite otherwise
when, as in this case, these attacks occur during the acute
stage of inflammation in a previously healthy ear. If the
case is not one of acute caries, associated with purulent in-
flammation of the tympanum, such as we had no reason to
believe this to be ; or if the presence and malign influence
of micro-organisms in the inflamed parts can be excluded —
though such a condition of affairs is possible in a simple
non-purulent inflammation (Zaufal) — the following theories
of the condition must be considered :
1. Intermittent fever. This diagnosis could not be ac-
cepted, in spite of the ascertained enlargement of the spleen.
The type of the fever negatived it, and so too, especially,
did the fact that the chills came on during the use of the
quinine. It is well known that the occurrence of new chills
and increase of temperature contra-indicate the presence of
intermittent fever.
2. Phlebitis and thrombosis of one of the veins or sin-
uses near the tympanum. This would scarcely be possible
during the course of an acute affection of the middle ear,
without the presence of certain abnormities in the structure
of the organ which would favor a rapid extension of the in-
flammation to the neighboring veins. As such may be
mentioned :
(«) Defect in the bony structure of the floor of the tym-
panum, which was observed by Toynbee- fifty-four times ;
also immediate contact of the inflamed mucous membrane
with the sinus of the jugular vein, and consequent phlebitis
and thrombosis of that vessel.
Pycemic Attacks. 139
ib) Defect in the roof of the tympanum, which would
favor the extension of the inflammation to the superior
petrosal sinus. Toynbee observed such defects twenty-five
times, and they have been observed at different times by
Hyrtl, Troeltsch, Retzius, Biirkner,' Jaenicke,^ and Flesch."*
In case of possible participation of the mastoid cells in the
purulent inflammation there are other conditions to be con-
sidered :
if) A canal lined with dura mater, extending from the
mastoid cells beneath the superior semicircular canal to the
posterior surface of the pyramid, and which opens above
into the sulcus petrosus, between the porus acusticus int.
and the entrance to the aqueductus vestibuli (Retzius,
Voltolini).
{d) A venous canal which begins in the mastoid cells and
ends in the sigmoid sinus at the junction of its descending
and horizontal parts. (My own observation. See VircJioivs
y4r^/^., vol. xxxvi, p. 15.)
ie) Finally, we must remember the possible existence of
numerous small veins which may extend from the mastoid
cells toward, and discharge into, the lateral sinus.
Opposed to the theory of phlebitis and thrombosis of a
large vein or sinus, there were in this case no observable
metastatic centres of inflammation, such as are generally
caused by the breaking down of a large thrombus. As to
the repeated failure of Prof. Friedreich to discover any trace
of embolism in the lungs, it may be objected that there
perhaps existed small infarctions in the lungs, so centrally
situated and so covered with normal lung tissue as to make
their recognition by physical examination impossible ; but
in such a case, there would certainly have been some other
symptom present, such, for instance, as dyspnoea.
Upon the theory of a phlebitis and thrombosis of a small
sinus, for instance the superior petrosal, the non-discovery
'Contribution to normal and pathological anatomy of the ear. Arch. f. 0.,
Bd. xiii, p. 163.
^ Anomalies of the base of the skull, and thinning and perforation of the
lining membrane of the tympanum. Inaug. Diss., Kiel, 1877, pp. 5-14.
' The recognition of so-called dehiscence of the lining membrane of the tym-
panum. Arch, f O., Bd. xiv, p. 15.
140 S. Moos.
of embolisms in the parenchymatous organs is more easily
understood. The course of the fever, too, and the variations
of temperature contra-indicate an inflammation of a large
sinus, such, for instance, as the lateral sinus. When this
condition exists, without any other complications in the
cranial cavity, the fluctuations in temperature between the
chills, especially if they are long separated, are much
greater ; or if the chills occur with short intervals, the tem-
perature remains continuously very high. For instance, in
a case of Schwartze's, with no other brain complications,
and in which an autopsy was made, the temperature fell
3.9° C In a case which was observed in Friedreich's clinic
and was published by me, the fall was 4.8°.^
Wreden considers these great fluctuations of temperature
a very important symptom for the diagnosis of phlebitis
and thrombosis of a large brain sinus ; and he was the first
to call attention to the importance of the course of the tem-
perature in the recognition of this condition.^
It appears probable to Friedreich and me that in our
case the pyaemic symptoms were due to an inflammation of
a small brain sinus, probably the sinus petrosus superior.
Whether this disease always runs a favorable course remains
doubtful.
^ Arch. f. O., Bd. xii, p. 129.
''Contributions to the Pathology of the Ear. Second paper. These Arch.,
vii, p. 465.
'These Arch., iii, 2, p. 173.
OEDEMA IN THE TEMPORAL AND ZYGOMATIC
REGIONS, AS A SYMPTOM OF PHLEBITIS AND
THROMBOSIS OF THE LATERAL SINUS.
By Prof. MOOS, of Heidelberg.
Translated by Porter Farley, M.D., Rochester, N. Y.
tN volume vii, p. 469, etc., of Arch. OptJial. and Otology,
I have published four cases of phlebitis and thrombosis,
of the sinus lateralis, among which the fourth, on account
of its clinical history, is particularly noticeable.
Besides continuous diffuse headache and a temperature
ranging between 38.6° and 40° (without chills), and was no
other symptom present except a swelling, which was de-
scribed by the patient himself as sausage-shaped, and ex-
tended from the temple to the front of the ear on the dis-
eased side, and which he had noticed at his own home. I
noted down the appearance in the following words : " In
the temporal region above the concha is a diffuse, oedema-
tous, painless, colorless swelling, which extends forward and
downward, and is lost in the region of the tragus." At the
autopsy, circumscript meningitis and a phlebitis and throm-
bosis of the sinus lateralis were found. During the epicrisis I
made the remark that I regarded the symptom of oedema as
very important ; but as being pathognomonic only when an
accompanying caries of the squamous portion of the tempo-
ral bone can be excluded. It is as characteristic of a phle-
bitis and thrombosis of the sinus lateralis as is oedema of
the mastoid region (Griesinger), or as is oedema of the eye-
141
142 vS. Moos.
lids and eyeball, of thrombosis of the sinus cavernosus
(Huebner).
Since I published this case I have seen another in which
I likewise observed oedema in the temporal region. Al-
though I observed it for scarcely a day, and although the
intracranial disease was probably complicated, and although
I did not finally obtain the results of an autopsy, I cannot
refrain from again speaking more particularly on this sub-
ject. Reflection has satisfied me that this symptom is of
rare occurrence, and for the reason, as we shall later see,
that the anatomical conditions upon which it depends are
peculiarities of development of an exceptional nature. For
this reason I would again call the attention of the profession
to this subject. Perhaps others have made similar observa-
tions, and by their publications may throw further light
upon the matter. It is only by increase in their number
that diagnoses based upon probabilities can gain in cer-
tainty.
This second case is as follows :
S. P., a maiden lady, thirty-one years of age, was subject during
former years to a discharge from the right ear, but without any
considerable discomfort until twelve days ago, when she was at-
tacked by a steadily increasing pain, deep-seated in the right ear,
and shooting through that half of the head. At the same time,
there appeared upon the surface of the right mastoid process a
large and gradually increasing tumor ; likewise " a hard oedema
of the right temple and the adjoining region of the zygomatic
process." (Statement of the physician in charge, Dr. W. of K.,
Rheinpfalz.) The skin was hot. The temperature had up to
this time not been taken. There were great thirst, no appetite, and
no chill. The physician in charge had, six days before, made
an incision over the mastoid process, and he stated that much pus
had been discharged, but there had been no decided collapse of
the tumor. The severe pain, however, subsided. Since day be-
fore yesterday, there had been loss of consciousness, no vomiting,
no change in the pupils, pulse ranging between forty and fifty-six.
Treatment had been by use of ice and cathartics.
I saw the patient for the first time at six o'clock on the even-
ing of January 3d. She was absolutely unconscious. The pu-
CEdeina in the Temporal and Zygomatic RegioJis. 143
pils reacted sluggishly, but alike on both sides. The pulse was
occasionally intermittent, fully fifty-six in a minute. There was
diffuse oedema of the temple and the zygomatic region, with slight
reddening of the skin. In the right incisura intertragica is a
dirty foul-smelling secretion. The right external meatus is closed
by a large polypus, which is attached to the posterior wall. Upon
the middle of the greatly swollen mastoid process is a wound
about an inch and a half in length. The skin already has a
gangrenous bluish-red appearance.
Although under these circumstances the case seemed hopeless,
I nevertheless proposed to the attending physician and the rela-
tives, as a last resort, the free opening of the abscess, which was
readily acceded to. I made the operation with the cartilage-
knife in the direction of the former wound, and by a long inci-
sion penetrated a deep carious opening in the mastoid process. A
great quantity of ichorous matter was discharged. The periosteum
was everywhere loosened from the bone. I easily and repeatedly
passed the nozzle of a rubber syringe into this carious opening,
and drove the water from it through the external auditory meatus.
After the bleeding stopped the pulse rose to 88, and the patient
raised her hand repeatedly to the diseased ear. Half an hour
after the operation the pulse was 60. During the following night
the condition remained unchanged. At nine o'clock the next
morning there was no discharge from the wound ; the pulse was
48, the temperature 40.6°. The right pupil Avas much the larger.
Stupor continued to increase, and two hours later death oc-
curred.
I could not obtain an autopsy.
These symptoms, proceeding from the great nerve cen-
tre, suggest the following conditions to be considered in
making a diagnosis :
I, Abscess of the brain ; 2, oedema of the brain; 3, men-
ingitis ; 4, phlebitis and thrombosis of the sinus later-
alis.
Abscess of the brain. As two days before there were
no brain-symptoms, its acute stage being short must have
been marked by very violent symptoms, such as convul-
sions or the appearance of sudden paralysis ; but such was
not the case. The high temperature, over 40°, although
taken only once, argues against this diagnosis.
144 •S". Moos.
CEdema of the brain was excluded by the persistent
cephalic pulse and by the decided dilatation of the pupil on
the aiifected side during the last hours of life. In view
of these symptoms, and notwithstanding the absence of
vomiting, I inclined to the diagnosis of meningitis, compli-
cated, as these cases due to otitis so frequently are, by a
phlebitis and thrombosis of the sinus lateralis. The absence
of chills is explained by the probable fact that the throm-
bus had not yet broken down.
There was no reason to suspect a caries of the squamous
portion of the temporal bone, a condition which I have fre-
quently observed, but as yet only in children under two
years of age.
Attatomical Cotuiection between (Edema of the Temporal
Region and Phlebitis and Thrombosis of
the Lateral Sinus.
When oedema of the temporal region appears coincidently
with a thrombosis of the lateral sinus, and when it can be
shown that it does not depend upon caries of the temporal
bone, the question remains whether it is possible to associ-
ate the two conditions upon anatomical grounds. This can
be done by a consideration of the parts concerned in refer-
ence to their manner of development. In the petro-
squamous fissure runs the petro-squamous sulcus, which,
according to Luschka,' is to be regarded as the original
sinus transversus, Kirchner° gives a picture of this. Its ex-
ternal opening is sometimes found still in the horizontal
part of the squamous portion, behind the posterior articular
process ; it is the foramen jugulare spurium, which, how-
ever, is frequently found near the posterior root of the
zygomatic process (Luschka, /. c). This sinus either opens
into the sinus lateralis, or it perforates the squamous portion
and anastomoses with the deeper temporal vein. According
to Kolliker,^ it originates during the foetal development of
the jugular veins. He writes as follows :
' Die Anatcmie des menschlichen Korpers, Bd. iii, 2, Tubingen, 1867.
^ Beitrag zur Anatomie der ausseren Ohitheile. Habilitationsschrift, Wiirz-
burg, 1S81.
^ Kolliker : Entwickelungsgeschichte des Menschen und der holieren Thiere,
Leipzig, 1879, p. 928.
(Edema in the Temporal and Zygomatic Regions, 145
" The first branchlets of the jugular veins are within the
cranial cavity and flow together on each side into one vessel,
which may be regarded as the beginning of the actual
jugular, and which later appears as the sinus transversus.
This vessel, however, does not leave the cranial cavity
through the foramen jugulare, but through a special open-
ing anterior to the ear, which, as Luschka has shown, may
even be present in the fully developed skull, and is there
found in the temporal bone above the glenoid cavity.
Later this opening closes, and the blood of the cranial
cavity is discharged through an internal jugular, an off-
shoot from the lower end of the primitive jugular, near the
ductus Cuvieri, so that then the original vein appears as an
external jugular."
Zuckerkandl's ' investigations show that the relations
above described are not so very rare even in adults. In 280
skulls he found the sinus petro-squamosus twenty-two
times, and the foramen jugulare spurium three times.
Moreover, Kieselbach,^ in the case of a child one and a half
years of age, could not demonstrate any connection between
this sulcus petro-squamosus and the sulcus sigmoideus.
The appearance of the symptom in question assumes the
existence of a petro-squamous sinus, and its communication
on the one side with the sinus transversus, and on the other
with the deep temporal vein after passing through the tem-
poral bone. According to the anatomical investigations
above described, these conditions but seldom exist, and
therefore oedema of the temporal region, as a symptom of
thrombosis of the lateral sinus, will be of rare occurrence.
Though this is an indirect sign, its diagnostic value is as
great as is that oedema over the mastoid process which
appears after the extension of the thrombosis in the emis-
sarium which runs outward through the fossa sigmoidea.
That this symptom, first pointed out by Griesinger,^ may
be actually pathognomonic is proved by an autopsy made
' Beitrag zur Anatomic des Schlafenbeines, AI. f. O., 1873, No. 9.
^ Beitrag zur normalen und pathologischen Anatomie des Schlafenbeines mit
besonderer Riicksicht auf das kindliche Schlafenbein, A. f. O., Bd. xv, p. 253.
^ Arch. f. Heilk., Bd. iii, page 437, ff.
146 5. Moos.
by him and by another made by me. Griesinger' truly
says :
" Against the explanation of that swelling by thrombosis
of the emissary vein, it cannot be objected that the emis-
sary vein conducts the blood from the sinus outward, and that
externally none of its branchlets are affected by its obstruc-
tion. The emissarium communicates between the sinus
and the post-auricular veins, and the direction of the flow of
blood in it is determined by the direction of greatest pressure."
This entire quotation may be adopted as an answer to a
somewhat similar objection in reference to oedema of the
temple. I had still before me the task of further examining
the specimen of the first-described case, to discover, if pos-
sible, whether it possessed any such abnormity of develop-
ment. In reference to the sinus this was not possible,
because the diseased and altered lateral sinus, as well as the
greater part of the dura of the affected temporal bone, had
been already cut away.
In reference to the sulcus, etc., I can now make the fol-
lowing supplemental communication :
There is in this specimen a so-called sulcus petro-
squamosus two mm. in length. By the side of this, and per-
forating the squamous portion of the temporal bone, is an
emissarium whose external opening is two or three mm. above
the root of the zygoma. There is no foramen jugulare
spurium. There is, however, near the posterior root of the
zygoma, and above the spina supra meatum, a depression,
an egg-shaped cavity eight mm. long, five mm. high, and five
mm. deep ; but it has a blind ending.
In this respect the oedema of the temporal region in our
first observation is only incompletely explained. It is
possible that it depended upon the fact that the cicatriza-
tion upon the mastoid process obliterated a number of veins,
and that therefore throughout the region of their anasto-
moses oedema was easier caused during the thrombosis of
the sinus.
Further observations are necessary to determine this
question.
' Z. c, pag. 447, und Gesammtabhandlung im Bd. i, Diagnostische Bemerk-
ungen iiber Hirnkrankheiten, pag. 458,
ON THE PRODUCTION OF ARTIFICIAL DEAFNESS,
AND ITS BEARING ON THE ETIOLOGY AND EVO-
LUTION OF THE DISEASES OF THE EAR*
By Dr. CASSELLS, Glasgow.
EARLY in the year 1876, my study of the ear, both
in a healthy and in a diseased state, led me to con-
clude that a certain degree of tympanic tension was neces-
sary, not only for the health of its tissues, but for the
maintenance of the sense of hearing, and that disturbances
in this tympanic tension produced an immediate defect in
the power of hearing articulate speech.
How I came to look at this subject, in this way, is easily
told. In the first place, I saw that the apparatus of hearing,
in a state of health, was a most perfect barometer ; that the
ear, more readily than any other organ in the body, made us
aware directly of the existence of the atmosphere, and that
the effects produced by its weight on the ear were often
attributed to other causes.
I shall now quote from my original MS. the exact words
in which, in the year 1876, I formulated my theory of the
etiology and evolution of ear-diseases : the propositions are
as follow :
1st. That a certain degree of tympanic tension is essen-
tial to perfect function, i. e., perfect hearing.
2d. That the essential cause of all the affections of the
* Read in the subsection of Otology of the British Medical Association meet-
ing in Cork, in August, 1879. A brief abstract appeared in the British Medi-
cal yotirnal, vol. ii, 1879, p. 328.
147
148 Dr. C as sells.
organ of hearing, is a disturbance of the normal tympanic
tension.
3d. That all the pathological phenomena of the diseases
of the ear evolve themselves with regular sequency.
I now wish to explain one or two points, in regard to
these conclusions, before I go farther.
The first of these is, in regard to the amount of the nor-
mal tympanic tension.
For all purposes I think that we may regard its measure
as the difference between the air-pressure, at any level upon
the outside of the membrana tympani of a healthy ear,
plus the traction force of the accommodating apparatus of
the organ, on the one hand, and, on the other, the oppos-
ing air-pressure within the tympanum, plus the resistance of
the tissues ; but the exact difference between the weight of
the air-pressure on the inside and that on the outside of the
tympanum, could be ascertained with the greatest exact-
ness, experimentally, by those who are better circumstanced
than I am, in respect to carrying out such experiments.
In saying that the pathological changes " evolve " them-
selves from this common cause — disturbed tympanic ten-
sion,— I do not mean that " the compound parts of an aggre-
gate have passed from a more to a less diffuse state," which
is the meaning generally attached to the term " evolution."
What I do mean is, that there is to be seen in the diseases
of the ear, an expanding or unfolding or an opening out of
these pathologic processes, from a simple to a complex con-
dition.
As all the facts upon which my conclusions are based are
familiar to most of us here, I shall only speak of them in a
general way.
On examining the healthy ear, what strikes one is the
amount of elastic tissue and muscle which enters into the
construction of the apparatus of hearing, and that there is
also a perfect accommodation-apparatus, by which the ear
adjusts itself to changes in the atmospheric pressure, and
that there is every provision made in the apparatus of hear-
ing, to avert the consequences that might follow the too
sudden rarefaction or condensation of the air, either inside
or outside of the tympanum.
Production of Artificial Deafness. 149
That the immunity from all annoyances or injury which
the healthy ear enjoys, in these circumstances, is due to the
power that it possesses of adjusting itself to the respective
air-pressures, cannot, I think, be questioned.
The second formula that I have stated is founded on a
sound and sufficiently large clinical experience, and I deem
it to be a just inference from the first proposition, although
I can see that there exists a gap between them. To fill up
this gap gave me some thought, for I saw that it was neces-
sary to prove, that a disturbance in the tympanic tension
could cause tissue-change in the structures of a healthy
ear.
To accomplish this, the following experiments for the pro-
duction of artificial deafness, were undertaken.
The experiments were performed on the 5th of November,
1876, on a man aged forty-three years, in a room, the tem-
perature of which was 64° F.; air quiet and no apparent
currents ; clear, dry weather.
Here is the state of the man's ears before being experi-
mented on : His hearing distance, on both sides, to articu-
late speech, was perfectly normal ; a watch, the normal
hearing distance of which was six feet, was heard by him on
the right, six feet clearly and distinctly, and faintly on the
left at four feet.
The right membrana tympani was normal in concavity ;
cone of light interrupted in the centre, otherwise membrana
tympani quite normal in all respects. He is a nasal breather
by habit. The left Eustachian tube is slightly catarrhal.
Two methods were now used to disturb the balance of the
tympanic tension. One, the Valsalvian method, of inflating
the tympanum, was employed to increase the density of the
air contained in the tympanic cavity. The other, known as
Maissiafs experiment, was used for the purpose of rarefying
the air in that cavity.
I have now to ask your attention to the results of these
experiments, only with reference to my second formula.
The Valsalvian experiment gave no positive results to this
particular investigation. On observing the membrana tym-
pani during the experiment, only the usual and well-known ap-
150 Dr. Cassclls.
pearances were to be seen, but no change of tissue whatever ;
there was, however, a sensation of stuffiness in the ears,
with a slight whizzing, subjective tinnitus; there was no
appreciable influence produced on the acuteness of the
hearing, judged by the watch and voice, while the experi-
ment lasted.
Maissiafs experiment : This experiment was introduced
by Maissiat in 1838, who proved by it, that the air in the
tympanic cavity is rarefied. Toynbee, who seems to have
adopted this experiment, declared that it condensed the air
in the tympanic cavity, a statement which has been shown
to be incorrect by Politzer, who, using more exact experi-
ments, confirms the opinion of its discoverer.
In order to produce an artificial deafness in the same way
as a natural deafness is caused, Maissiat's method of rarefy-
ing the air contained in the tympanic cavity was employed
in the following manner.
First stage of experiment. — A manometer (similar to the
one figured on page 153 of Politzer's " Lehrbuch der Ohren-
heilkunde ") was hermetically fixed in the outer orifice of
the external meatus of the right ear. The act of swallow-
ing was now performed in a deliberate manner several
times in succession, water being used to facilitate this pro-
cess, during the performance of which the nostrils were
open. While this stage of the experiment was being carried
out, no movement took place in the mercurial column of
the manometer.
Second stage. — The act of swallowing was now repeated,
in the same manner as in the first stage, while the nostrils
were held firmly closed, and the following phenomena were
observed and noted :
At the first act of deglutition, the column of mercury in
the instrument descended considerably. On this act being
repeated a second time, it still farther descended ; during
the third repetition of it, the mercury was drawn altogether
into the meatus.
Third stage.— Th.& experiment was now repeated without
the manometer, but in every other respect the same as in
the last stage.
Production of A rtificial Deafness. 1 5 1
While the act of swallowing was being carried out, its
effect on the membrana tympani was observed : the first act
of swallowing caused this membrane to vibrate backward
and forward several times and then to recede a little,
becoming at last visibly more concave. With this, there
was aroused, at once, a sensation of dulness in the general
hearing. On a repetition of this act, the membrane became
still more concave, and now signs of congestion began to
appear on its surface, along the anterior aspect of the
handle of the malleus. At this stage there were now experi-
enced a general and deeper muffling of all sounds and a
slight tinnitus. With the third act of swallowing {the nos-
trils meanwhile having been kept rigorously closed tJiroiigJioiit
the experiment^, the following facts were observed : The
membrane was rigidly fixed, the congestion of its tissues
was increasing rapidly, and looked as if it would go on
doing so, were the conditions of the experiment to con-
tinue.
There was, at this stage, a complete mufifling of all
natural sounds, such as the singing voice, articulate speech,
the crackling of the fire in the grate, and the noise of the
street traffic ; all heard distinctly by the subject of the
experiment, at the outset and before being experimented
on, were now all perceived, as if the ear were stuffed with
cotton-wool, but the tic-tac of the watch was heard ringing
out clearly and distinctly and at an increased distance to
that at which it was heard at the outset of this experiment.
Instead of being heard at six feet, as it was then, it was
now heard as a clear metallic clink at a distance of nine to
ten feet. The subject of the experiment, who was breath-
ing and speaking during its continuance, without in any
way affecting or altering its condition, declared that he
thought the reason why he heard the watch so well, was
that he heard nothing else distinctly.
The perception of aerial tones of the diapason, ranging
from ^1 = 5 12 to ^2 = 1024, held close to the ear, was almost
completely extinguished ; the perception of transmitted
tones was slightly diminished.
Fourth stage. — On the patient releasing his nostrils and
152 Dr. Cass ells.
swallowing a few times in succession, the membrane soon
regained its normal position, and in an hour or so afterward
the hyperaemia of its surface had diminished ; the dulness of
hearing lasted for some time afterward.
FiftJi stage. — The orifice of one meatus was hermetically
sealed up, and the other left open. Maissiat's proceeding
was then performed to the same extent as in the third stage,
already described. After performing the act of deglutition
three times in succession, all the sensations and appearances
that were called forth in the third stage of the experiment,
were now experienced and seen on the membrane of the
left and open ear, while in the right and closed ear, no such
sensations were felt. On the instant, however, that the
plug was removed from the meatus of the right and hitherto
closed ear, similar sensations to those which had been felt in
the left ear all along, now made themselves known at once
in the right, showing that the air in the cavity of the tym-
panum had been exhausted, and that the membrana tym-
pani had been pressed in by the superabundant outside
air-pressure; this conclusion was tested in the following
way :
A pneumatic speculum was now inserted into the orifice
of the right meatus, that canal being hermetically closed by
the instrument.
The last stage of the experiment was then repeated in all
its details, and the membrana tympani inspected, while
these were being carried out. Scarcely any motion was to
be seen in the membrane of the closed ear, and none of the
subjective symptoms were called forth in it so long as the
canal remained closed. On the left ear all the former
symptoms were as prominent as ever. Air was now admit-
ted to the canal of the hitherto closed ear, and the behavior
of the membrana tympani watched. It was seen to be
drawn in suddenly with a bang toward the tympanum, and
to remain in that position, its surface being very concave.
All the former sensations and appearances were now felt
in the ear and seen in the membrana tympani ; so great, in-
deed, was the congestion of the membrane, that I began to
fear that a veritable ear-disease had been created in the sub-
Production of Artificial Deafjiess. 153
ject of the experiment, who, I may add, was a man of edu-
cation, and accustomed to weigh fine distinctions, and to
compare and to differentiate the sensations of sound and
feeHng.
I have now finished the narration of these experiments.
It would, however, be premature to draw any conclusions
from them, owing to their limited range and duration, and,
therefore, incompleteness. But I think this incompleteness
may be for the present moment legitimately supplemented
by a " scientific use of the imagination."
If, therefore, three of the more common symptoms of
ear-disease can be produced artificially by an experiment in
a few minutes, and in the order in which they appear natu-
rally in disease, then, I ask, is it not a warrantable inference
to say that a continuance of the same experiment for a few
hours or days would lead to the further development of
these symptoms, and to the production of more complex
tissue-changes ?
Be that as it may, I have to express the hope that you
will not regard my theory in respect to the etiology and
evolution of the diseases of the ear, as the production of a
"luxuriant fancy and few facts," but that you will see that
it is the outcome of a fairly wide experience, and that it is
built upon a physiological and clinical foundation.
Nevertheless, if I only succeed in enlisting your interest
in the subject of my paper itself, I will be content.
UNSUCCESSFUL ATTEMPT AT RESTORING AN
EAR-CANAL, CLOSED BY CAUTERIZATION
WITH SULPHURIC ACID.
By H. KNAPP.
The Sister of Charity, St. V., of the Asylum St. Vincent de Paul
of this city, while suffering from neuralgic pain in the left ear
on Nov. 21, iS8i, thought to find relief in the topical application
of ether, but by mistake poured concentrated sulphuric acid,
directly from a little bottle, into the ear. Immediately afterward
she had excessive pain, but was free from it the following day.
Extensive ulceration and profuse discharge set in. Her physician
kept the ear clean by syringing, and endeavored to keep the canal
open by inserting pledgets of lint steeped in medicated vaseline,
by laminaria probes, and other contrivances, but the gradual closure
could not be prevented.
When she came to me in February, 1882, the meatus auditorius
was completely obliterated, and the auricle reduced to about one
third of its natural size by the contraction of cicatrices which
occupied its whole anterior surface. She heard the tick of the
watch on contact with the ear and the adjacent parts ; V was ■§-§-.
She suffered from noises in the ear, and her own voice sounded
stronger on that side of the head, a symptom which distressed her
greatly. The other ear was healthy.
Thinking that the scar might, perhaps, not extend to the bottom
of the ear-canal, and even if it did, the caustic might not have
destroyed the drum membrane, or might at least have left the
tympanic cavity intact, I held an attempt at the restoration of
the canal juL,tifiable. With a long, narrow-bladed (Graefe's cata-
ract) knife I penetrated 2.5 an. into the depth of the canal, and
enlarged the wound on both sides until the blade of the knife
154
Attempt at Restoring an Ear-Canal. 155
struck the bone in the inner portion of the canal. After the
arrest of the moderate hemorrhage, I introduced a perforated
silver tube, which was removed and re-introduced three times
daily, the tube and the wound being, of course, carefully cleansed
each time. The tube had a tendency to come out, and as, in a
a week, it could not be introduced so deep as at the beginning, I
made the incision larger than before. The knife was advanced
in the direction of the canal until its point was arrested by hard
bone, the promontory. The depth of the wound was fully 3 C77i.,
and its calibre was enlarged by incising the tissue down to the
bone on the anterior, inferior, and posterior sides of the canal.
Though I had undoubtedly opened the tympanic cavity, nothing
but a moderate quantity of blood escaped.
I inserted a longer and broader silver tube, which was changed
two or three times a day. The patient experienced little pain,
and noticed that both the tinnitus and the autophony had disap-
peared. Her hearing also was better and "more natural." This
comfortable condition, however, was not of long duration. The
thick canula, which completely filled the new canal, and was held in
position by a pad of absorbent cotton, over which the nun's white
head-dress passed, surrounding the scalp as a tight-fitting cap, had
likewise a tendency to come out, and when pressed in too firmly
by the cap, it would inflame the parts and cause pain. Gradually
it had to be replaced by thinner and shorter ones. When the
canal showed a decided tendency to narrow again, I inserted a
laminaria bougie, which dilated the canal, but caused pain and
inflammation, and had to be left off.
The patient considered even a partial restoration of the canal
to be of material benefit, for she was free from the annoying re-
inforcement of her own voice so long as the canula was in. With
the greatest persistency she had the new canal syringed out and
the canula inserted two or three times daily, but in spite of every
endeavor we lost ground, and as I knew of no mode to keep the
canal permanently open, I advised her at the end of four months
to give up further treatment. The canal closed again ; the tinni-
tus and autophony returned as before.
From the complete failure of the operation I concluded
that the concentrated sulphuric acid which was poured in
had reached and cauterized the whole extent of the ear-
canal, including the drum-head. The subsequent cicatricial
156 H. Knapp.
occlusion must have been total. If this condition prevails,
I am inclined to think that a restoration of the canal is next
to impossible. I base this opinion on the fact that hitherto
all our endeavors to accomplish so simple an object as to
keep an artificial perforation of the membrana tympani
permanently open have proved fallacious.
REPORT ON THE PROGRESS OF OTOLOGY IN
THE SECOND HALF OF THE YEAR 1882.
1. — NORMAL AND PATHOLOGICAL ANATOMY AND HIS-
TOLOGY OF THE EAR.
By Dr. H. STEINBRUGGE, Heidelberg.
Translated by J. A. Spalding, M.D., Portland, Maine.
1. J. G. Wagenhauser. Contributions to the anatomy of
the temporal bone in children. Archiv f. Ohr., vol. xix, part
2, p. 95-
2. Arthur Bottcher. Cotugno ; the aqugeductus vestib-
uli, and later authors on the membranous labyrinth. Archiv f.
Ohr., vol. xix, part 2, p. 148.
3. Eugene Frankel. Further investigations concerning
ozsena simplex. Virchow's Archiv, vol. xc, 1882.
I. Wagenhauser's contributions to the anatomy of the tem-
poral bone in children are divided into two parts, the first of
which discusses the fossa subarcuata ; the second, " the petroso-
squamous fissure and the extension of the dura mater as a lining
membrane of the tympanum." After summing up the data con-
cerning the fossa subarcuata which have been given by other
authors, particularly by v. Troltsch, the author describes the pro-
gressive alterations which take place in this region at different
periods of intra-uterine life and in newborn children, and illus-
trates them with plates.
The cavity which lies beneath the superior semicircular canal
undergoes a considerable enlargement during the sixth and
seventh months, and expands into a canal which reaches the
157
158 H. Stcinbriigge.
external surface of the skull, where it exhibits an orifice 5 min.
wide. The fossa does not enlarge at a later date, but on the con-
trary, in newborn children it again appears somewhat smaller,
while its canal-like continuation to the outer surface of the skull
is closed over by cartilage. The cavity retains its form up to the
third or fifth year of life. The author then studied the topo-
graphical relations of the fossa subarcuata in the foetus and
young children from successive sections of the temporal bone
made perpendicular to the longitudinal axis of the pyramid in a
direction from inward outward. All of the sections of the dura
mater which penetrated into the canal showed a larger vein and a
smaller artery. Bands of connective tissue with numerous small
vessels penetrate into the spongy wide-meshed bony substance
almost as far as the semicircular canals, and further outward into
the neighborhood of the antrum, without, however, taking any
part in the lining membrane of this cavity. These conditions
also are illustrated by sketches. AVagenhauser here reminds us
of the possibility lately suggested by Prof. Lucae, that morbid
processes might be conducted from the interior of the skull to the
labyrinths of children by means of these vascular bands of con-
nective tissue, as well as of the importance of the vessels, which
have just been described, in the nourishment and further develop-
ment of the temporal bone of children.
The fact that the fossa subarcuata undergoes considerable
enlargement in various animals, and even embraces a portion of
the cerebellum, induced the author to extend his investigations
amongst several mammals.
In the second portion of his work, the author mentions the
sutures (mastoid-squamous, fiss. tympano-mastoid., petro-tym-
panica), which originate from the union of the individual por-
tions of the temporal bone, and then describes in detail the fiss.
petroso-squamosa, its origin by imposition of the tegmen tympani
upon the squamous bone, and further, the process, inf. tegm.
tympani which separates the fiss. petro-squamosa from the fiss.
Glaseri, and the oblique fiss. tegm. tympani. The relations of
the fibres of connective tissue which penetrate these fissures were
studied in various sections, which are illustrated in a third plate
by sketches from the temporal bone of a child of four years of
age. The result shows that in newborn children, all along the
entire course of the fiss. petro. -squamosa, a direct continuation
can be discovered between the lining membrane of the cranial and
Progress of Otology. 159
tympanic cavities, which in older children is interrupted by the
development of the proc. inf. tegm. tymp. in the anterior portion
of the tympanum, and these may extend from the middle of the
tympanum to the cavities of the mastoid process. Hence, when
the bony union of the fissure advances, the connection between
the dura mater and interior lining membrane is limited to the
posterior portion of the tympanum and the beginning of the
antrum. In describing the extension of inflammatory processes
from the tympanum, mention is made of a small vein which is
visible in all of the sections just above the fissure. Inasmuch as
the vein opens into the transverse sinus, it may lead To phlebitis
and thrombosis. The propagation of morbid processes from the
tympanum to the dura mater, as well as disturbances of nutrition
in the bony tegm. tymp., which in such cases appears surrounded
both above and below with diseased periosteum, are likewise
emphasized.
In conclusion, the author reminds us of the extension of
morbid processes in an inverse direction from the interior of the
skull to the tympanum, and cites the case, published by Moos
and the reviewer, on the formation of a neo-membrane in hemor-
rhagic pachymeningitis with these words : " The above-mentioned
authors are inclined to oppose the propagation of a morbid con-
dition from the dura mater to the tympanum by this process."
As this quotation might be misconceived by readers to whom
the original of our work was unknown, as if this were simply a
case of agreement concerning well-known points, we should like
to define it more precisely by saying that our discovery of a neo-
membrane in the middle ear is tmique, and offers an entirely new
argument in favor of a systematic connection between the cere-
bral membranes and the lining membrane of the tympanic cavity.
In the darkness which still envelops the incipient stages of
hemorrhagic pachymeningitis, we have no right to explain the
participation of the tympanic mucous membrane in this morbid
process as simply due to the propagation of an inflammation, just
as happens in most suppurative inflammations of the tympanum
due to infection. The formation of the neo-membrane was,
therefore, purposely designated as one of the ''''partial symptoms "
of the pachymeningitis, and it was also urged that the regional
distribution of the middle meningeal artery, which sends the
petrous branch to the tympanum through the Fallopian canal, must
be considered in any explanation of the morbid process.'
' These Archives, vol. xi, p. 97.
i6o H. SteinbriifTZe.
'dA'
The reviewer finally expresses the opinion that morbid pro-
cesses are much less frequently transmitted from the interior of
the skull to the tympanum, " and at all events this will be of
slighter importance in a practical point of view." We cannot
unreservedly assent to the first point, since the examination of the
middle ear, as the author himself remarks, is usually neglected in
making post-mortem examinations. So far as concerns the
" practical point of view," nothing can be objected if the author
is simply speaking of the indications for proper treatment. But
at the close of our work we emphasized the fact that the objective
examination of the ear in such cases might furnish important sup-
port for the diagnosis of pachymeningitis.
2. Bottcher protests against the various erroneous assertions
concerning the relations of the aquseductus vestibuli and its con-
nection with the saculi vestibuli, which have found reception in
the text-books and journals. The great number of these errors
forbids a detailed reference. But Bottcher is justified in remind-
ing us that it was his investigations which first proved the con-
nection of the aquseduct with both sacs, so that the importance
of the same as an endolymphatic space originating from the
epithelial labyrinthine vesicle was put beyond the question of
doubt. The membranous portion of the aquseduct completely
fills the bony canal, and consequently is not, as other authors
urge, surrounded by a perilymphatic space. Just as little is there
any communication of the perilymph with the dural space which
the blind sac-like end of the aquseduct encloses.
3. Frankel reports his various experiments at inoculation with
the nasal secretion of a patient who had suffered for some time
with simple oza^na. This girl, set. seventeen, who had suffered
since childhood with double otorrhoea, was treated with cotton
tampons, by means of which the author was enabled to collect
great quantities of nasal secretion. After the tampons had
remained for two hours in the nose the secretion appeared like a
clear neutral watery fluid, free from smell, and on microscopic
examination showed only a few cellular elements and scattered
micro-organisms. If the tampons remained for four hours, the
secretion was more turbid, it smelt mouldy, and was slightly alka-
line. If they remained from six to eight hours the secretion
became dirty-yellow, and alkaline with an odor like the discharge
in ozaena, while under the microscope it showed numerous cells
and a large number of the lowest types of organisms in active
Progress of Otology. l6l
motion. The cells could be demonstrated partly as lymph-
corpuscles and partly as structures like giant-cells, with numerous
nuclei, which showed where subdivision had taken place, while
other cellular bodies were discovered in a condition of regressive
metamorphosis. When the micro-organisms had been tinted by
the Koch-Ehrlich method, they could be distinguished as micro-
and raegalo-cocci, and further as delicate, slightly tinted, and
coarser, deeply tinted rods. Transmission of the secretion to the
nasal mucous membrane of rabbits (instilled or injected) did not
produce any disease corresponding to rhinitis, nor did the intro-
duction of the secretion beneath the eyelids produce any catarrhal
conjunctivitis. But injections into the subcutaneous tissues were
followed by fatal phlegmon. The author defends his former
opinions concerning the fetor in the secretion against Bosworth,
Herzog, and Bresgen, and insists once more that the micrococci
can only give rise to fetor when they reach a nasal secretion
which has undergone a change in its chemical composition by the
disappearance of Bowman's glands. It is from this point of view
also that the favorable action of the treatment by tampons can be
explained. Frankel, however, recommends that the tampons
should be renewed every six hours in difficult cases, lest in them,
also, the collected secretion should undergo decomposition. In
less severe cases the tampons can be left in the nose overnight.
These experiments prove further that the micro-organisms found
in the secretion are not pathogenous. The fatal result in experi-
ments with animals was due to septicsemic processes, for only a
few bacteria were found in the blood, while in the pus of the
animals it could not be proved that the rods had undergone
multiplication.
Rhinitis atrophica occupies an exceptional position amongst
diseases of the nasal mucous membrane, since it is rarely accom-
panied by a disease of the ear. But if from any reason an aural
affection becomes associated with this type of rhinitis, it behaves
in a most obstinate manner toward any and every treatment.
Under such circumstances, therefore, the prognosis is rendered
very much more unfavorable by the associated disease of the nose.
After describing the pharyngitis sicca which sometimes accom-
panies ozaena simplex, and usually makes its appearance with
atrophy of the glands of the mucous membrane, Bottcher gives
us an account of the post-mortem conditions in a man who had
died of pernicious anaemia at the age of twenty-five, having suf-
1 62 A. Hartmann.
fered since childhood with an offensive discharge from the nos-
trils. The mucous membrane of the nostrils, both of which were
very capacious, was reddened and partially slate-colored ; both of
the inferior turbinated bones were atrophic and discolored, whilst
offensive masses of secretion were found in the nose. The most
important alterations were visible on microscopic examination.
The olfactory region showed remarkable changes, for Bowman's
glands had for the most part disappeared, and the tissue of the
mucous membrane had undergone infiltration with small cells, while
both the vessels and nerves were normal and the epithelial layer
preserved. The acinous glands in the respiratory tract were nor-
mal, but a portion of the mucous membrane in the same district
was also infiltrated with small cells. No loss of substance could
be detected.
Frankel is therefore of the opinion that the destruction of Bow-
man's glands is the chief factor in the origination of the offensive
odor ; the function of the acinous glands of the respiratory tract
alone does not suffice to protect the nasal secretion from the de-
composing action of micro-organisms. The author finally de-
scribes the operative methods which have been recommended for
the cure of ozaena : amongst others, scraping the nose with the
sharp spoon, as practised by Bovel, as well as the total removal
of the inferior, with partial resection of the middle, turbinated
bone, which has been recommended by Volkmann. Frankel pre-
fers the milder action, of the galvano-cautery to the scraping
method. So far as concerns Volkmann's operation, which does
not take proper account of the foundation and nature of the dis-
ease, since the disagreeable odor persists even after subsequent
atrophy of the turbinated bones, further experience is demanded
before we can ascribe to this method the effect of a radical cure.
II. — PATHOLOGY AND THERAPEUTICS OF THE EAR.
By a. hartmann, Berlin.
Translated by J. A. Spalding, M.D., Portland, Maine.
A. GENERAL.
I. K. BiJKKNER, Gottingen. Progress in the treatment of dis-
eases of the ear during the last ten years. Arch. f. Ohr., vol.
.xix, p. I.
Progress of Otology. 163
2. L. Jakobson. Report of the aural patients examined and
treated at Prof. Lucae's clinic, from April, 1877, to April, 1881
Ibid., p. 28.
3. VVagenhauser. Report of the aural clinic at Wiirzburg
for the years 1880 and 1881. Ibid., P- 55-
4. Kirk Duncanson. Report of the ear dispensary. Edin-
burgh Med. Jour., October, 1882.
5. Agnew and Webster. Clinical contributions to otqlogy.
These Archives, vol. x, p. 335.
6. R. ScHALLE, Hamburg. On aural and naso-pharyngeal dis-
eases, and some of their methods of treatment. These Archives,
vol. xi, p. 113.
7. VoLTOLiNi. On the use of quinia in aural affections. M.
f. O., No. 10, 1882.
8. EuLENSTEiN, Erlangcn. Affections of the ear during the
course of ilio-typhoid fever. I?iaugural Dissertation, 1882.
9. Weidenbaum. On the diagnosis of deafness in recruits.
St. Petersburg jned. Wochensch., No. 32, 1882.
10. VoLTOLiNi. On the simulation of deafness. M. f. O.,
No. 9, 1882.
11. McBride. The causes of tinnitus aurium. Med. Times
and Gazette, Aug. 26, Sept. 16, 1882.
12. R. C. Brandeis. Two cases of tinnitus aurium, due to
disturbances in the current of the cervical blood-vessels. These
Archives, vol. xi, p. 155.
13. Walb, Bonn. Boracic acid as an antiseptic. Centralbl.
f. klin. Med., No. 34, 1882.
14. A. Lucae. On disinfective precautions in the use of the
air-douche. Arch. f. Ohr., vol. xix, p. 132.
15. Creswell Baber. a waistcoat-pocket aural reflector
and set of specula. The Lancet, Sept. 2, 1882.
16. George Abbot. New aural forceps. /^^/V., Aug. 26, 1882.
17. Baratoux. Audiometers. Rev. mens, de laryng. d' otoL,
etc.. No. 8, 1882.
18. A. Burckhardt-Merian, Basel. One hundred schematic
tables for drawing the observed conditions of the ear. Benno-
Schwabe's Verlag, Basel, 1883.
19. Moos, Heidelberg. Etiology and condition of forty cases
of congenital deafness. These Archives, vol. xi, p. 299.
20. F. Karsch. Statistics of deaf-mutes in the Palatinate.
Friedreichische Blatter f. ger. Med., vols, ix and x, 1882.
164 A. Hartmann.
21. J. A. Campbell. Helps to hearing. 8vo., pp. 108. Chi-
cago : Duncan Bros., Publishers, 1882.
22. L. TuRNBULL. Importance of careful examination of the
ears in effecting life insurance. Virginia Med. MontJiIy, Sept.,
1882.
23. C. J. Kipp. Deafness accompanying sparkling synchysis
of the vitreous. Trans. Am. Otol. Soc, 1882.
24. R. C. Brandeis. Exhaustion versus inflation. Trans.
Am. Otol. Soc, 1882.
1. Burkner's review of the progress in the treatment of dis-
eases of the ear, in the last ten years, is about complete, and, on
the whole, embraces all that is essential. But his judgments are
not always to be assented to. Thus, in his description of para-
centesis of the Mf, it would seem as if this operation were some-
thing that had been devised in the last ten years, while it is plain,
even from Frank's old hand-book, that this operation was per-
formed long ago, under about the same indications as to-day.
Frank even recommended it in the case of small children, just as
is now done by Biirkner. Beyond this, we must emphatically
protest against Burkner's criticism of electro-therapeutics : " On
the whole, aural surgeons are generally unanimous in rejecting the
therapeutical value of electricity." In opposition to this we might
quote what Erb says ' of Brenner, that " his services cannot be
diminished by the defective knowledge and jealous opposition of
aurists of even the greatest renown, who would gladly rejoice if
they could silence such important facts." Favorable results "^ from
the use of electricity have been reported, especially by Hagen,
Moos, Politzer, and Urbantschitsch.
2. Jakobson's report of the Berlin University Policlinic ex-
tends over a period of three years and a half. Preliminary re-
marks are made upon the value and defects of all statistical tables.
Four thousand and seventy-nine patients with four thousand and
seven forms of disease were treated. A few cases are reported in
detail, amongst them one (No. 4) of a cancroid of the ear, which
was partially removed with the sharp spoon, but reappeared. It
ceased, however, to spread after being repeatedly and thoroughly
syringed, and then dusted over with herba sabin. pulv. and alum,
ust. pulv.; ann.. Amongst other cases we may notice two in which
' " Handbuch der Electrotherapie," 2te Halfte, p. 620.
* See cases from V. Troltsch's Policlinic, Arch. f. 0., vol. xix, part I, p. 58.
Progress of Otology. 165
subjective noises were caused by muscular contractions. One of
the patients complained of ringing in the ear whenever he nipped
his eyelids together, while simultaneous incurvation of the Mt
could be seen by the naked eye and demonstrated by the manome-
ter. The ringing is to be referred to contraction of the tensor
tympani muscle. The second patient heard a brief ringing, like
^*, when he snapped his teeth together. When contracting the
masticating muscles (the teeth being closed) he heard a roaring
on both sides. The phenomenon was explained as depending
upon some associated movement of the intrinsic muscles of the
ear.
Lucae's method of testing the hearing with tuning-forks of
various pitch, both by aerial and bone-conduction, is next cited,
and Dennert's views especially criticised. Jakobson also regards
a total and irregular diminution of the perceptivity for various
tones of the scale, as diagnostic of disease of the sound-perceiving
apparatus.
In case of regular diminution, or if lower tones are heard
better than high, or inversely, with symmetrical decrease or
increase, as we go up or down the scale, Jakobson thinks
that it is impossible to make an accurate diagnosis between dis-
eases of the sound-conducting and sound-perceiving apparatus.
He lays less stress upon the comparison of aerial and bone-con-
duction than upon disproportional diminution of perception for
high tones, which, in his opinion, allows us with great probability
to diagnosticate nervous deafness. The prognosis in cases of the
latter variety is very unfavorable.
The last pages of the report give the result of therapeutical ex-
perience, especially in the treatment of suppuration of the middle
ear. In a great majority of these cases, especially in those which
are acute, Prof. Lucae abstains from syringing and the use of the
air-douche through the tubes. He is satisfied with simply cleans-
ing the inner ear through the external meatus. The secretion is
held in check by boracic acid, iodoform, and herba sabina with
alum. Good results were obtained in cases of caries by the in-
stillation of a one- or two-per-cent. solution of copper sulpho-
carbolate.
Jakobson reports beneficial results from the internal adminis-
tration of gelsemium and paullinia. Fifteen to twenty drops of
the tincture of the former were given in case of violent neuralgic
pains, which were independent of the inflammatory symptoms ;
1 66 A. Hartmann.
while the latter was used in the form of powder (0.40) in case of
headaches during the course of the ear-disease.
3. 307 ear-patients were treated at the Wurzburg Policlinic in the
years 1880, 1881. Amongst the clinical cases described, we may
mention one of double othsematoma, which, without apparent
cause, developed itself at a symmetrical point on both auricles.
A female patient complained of a roaring noise which was isochro-
nous with the heart and objectively perceptible. It became much
louder after resort to the catheter, and diminished after pressure
on the carotid artery. After excluding all other possibilities,
Wagenhauser thinks himself justified in locating the original
starting point of the noise in the internal carotid artery.
4. Kirk Duncanson simply gives statistics of the cases that
he has treated.
7. VoLTOLiNi, who has had great experience, thinks that it is
a misdemeanor (!) to give large doses of quinia in intermittent
fevers, on account of the possibility of producing quinine-amau-
rosis or deafness. He recommends smaller doses for longer
periods, and assures us of obtaining better results.
8. The facts upon which Eulenstein's dissertation is founded
were collected by Bezold in Ziemssen's clinic at the Munich
hospital. After close examination for a year, no typhoid pa-
tient had ever shown the characteristic symptoms of catarrhal pro-
cesses of the tubes, incurvation of the Mt, etc. Amongst 1,243
cases of typhoid, there were found 56 cases of diseases of the middle
ear, divided as follows : 41 of suppuration, 2 of otitis media with
tubal symptoms, and 7 of inflammation without perforation and
without incurvation of the Mt. Nineteen cases showed sensi-
tiveness over the mastoid process, and in five of these an incision
had to be made. The author thinks that the affection of the mid-
dle ear is purely local, — though caused by the general affection, —
and notices that it began about the twenty-fifth or thirty-fifth day
of the fever, appearing, however, in three cases previous to the
twentieth day. The prognosis is generally favorable.
The central or nervous form of the aural affection, with nega-
tive diagnostic points, is independent of the catarrhal process, and
may be a sequence of blood-crasis or paresis of the nerve. Men-
tion is also made of the inflammatory alterations in the labyrinth
already demonstrated by Moos, as well as the deafness caused by
various anti-pyretics.
9. Weidenbaum recognizes total deafness as well by the facial
Progress of Otology. 167
expression and peculiarity of speech, as by suddenly awakening
malingerers from sleep, or speaking to them while they lie in the
incipient stages of chloroform narcosis. Deafness in moderate
amount is proved by the usual methods of examination.
10. VoLTOLiNi describes his method of discovering simulated
one-sided deafness. He employs a large trumpet-shaped ear-tube,
and puts it into the asserted deaf ear of the patient, while the
healthy ear is left open. The simulation is discovered by the
patient declaring that he cannot hear at all. In order to conceal,
the deception still further, 3.hoIlozu plug or tube of horn or rubber,
through which the simulant can hear, may additionally be placed
in the healthy ear. A case in which the simulation was thus demon-
strated is appended.
11, McBride refers to the literature on the subject, gives full
details of the causes of subjective noises in the ear, and comes to
the following conclusions : i. Hypergesthesia of the auditory nerve
is never the direct, but may be the predisposing, cause. 2. The
ear ought to be examined in every case in which the cause of the
noises is doubtful. 3. The noises can be caused under the great-
est variety of circumstances, but auto-perception of the labyrin-
thine circulation is a very frequent factor. 4. In certain cases
the ophthalmoscope may help us to decide by analogy whether
the labyrinth is an?emic or hypersemic. 5. The treatment, of
course, depends upon the cause as deduced from the prevalent
symptoms.
13. Walb experimented upon the antiseptic action of boracic
acid, and discovered that it, to a certain degree, prevented putre-
faction and the formation of mould. The experiments were made
with freshly prepared fibrine free from hsematoxylin. Without
the addition of boracic acid, colossal bacteria were present, but
there was no formation of mould ; with a 0.2-per-cent. solution of
the acid added, slight formation of bacteria, but no mould ; with a
0.4-per-cent. solution, first the formation of mould, then the putre-
faction, after which the mould underwent regressive metamor-
phosis.
When a i-per-cent. or a stronger solution was added, the putre-
faction was completely checked, while the formation of mould con-
tinued. Boracic acid, therefore, influences the formation of
bacteria only, but not that of mould. Its use is consequently
indicated in otitis externa, depending upon the formation of bacte-
ria (as denoted by the smell of decomposition), while in otomycosis
it is of no avail.
i68 A. Hartmann.
14. LucAE connects Zaufal's disinfection capsule for the air-
douche directly with the silver catheter. For disinfection he re-
sorts to boiling heat, letting the silver catheter remain all the time
in boiling water.
15. Baber describes an ear-mirror and specula that can be
carried in the waistcoat-pocket.
16. Abbot's ear-forceps are intended by their easier manipu-
lation to be preferable to those commonly in use.
1 7. Bar ATOUX describes the audiometers previously employed,
and mentions Boudet's as he has modified it. He retains the
rheostat and telephone, but omits the microphone. An electric
tuning-fork serves to interrupt the current. Baratoux has there-
fore simply returned to the arrangement which was made by the
reviewer so far back as 1878.
18. Burckhardt-Merian sends us a little book containing on
each leaf — which can easily be torn out — a picture of the Mt with
horizontal and perpendicular sections of the organ of hearing, one
for each ear. The idea is to use them for drawing the condition
of the parts for clinical instruction and consultations, as well as for
the aurist's own use in his note-books, They appear to us to be of
great practical value.
20. Karsch collected the statistics of ^t^i deaf-mutes in the
Palatinate. Of these 340 were male, 293 female. 469 (75 per
cent.) were normal, in a mental point of view ; no (17 per cent.)
weak-minded, but capable of education, and 54 (8 per cent.) more
or less idiotic. Most of the latter were advanced in age. 325 cases
(51 per cent.) were supposed to be congenital, 308 acquired. In
about two thirds of the latter cases the deafness was referred to
diseases of the brain. The epidemic, spinal meningitis, plays the
chief role in these cases, for it was a widely spread disease in the
Palatinate in the years 1864-5, 187 1-2, and in 1874-5. 68 deaf-
mutes had disturbances of sight, but no accurate examinations were
made to discover pigmentation of the retina. A large number of
the deaf-mutes were poorly developed, in a bodily point of view,
35 being rhachitic, and 38 scrofulous. In 9 marriages, which
resulted in 11 deaf-mute children, the father was deaf in 7, the
mother in 2, while in no case were the parents themselves deaf-
mutes. There was only one case in which of the grandparents
one (the mother of the father) was a deaf-mute, and in this case
it was not stated whether her condition was congenital or acquired.
Of those deaf-mutes who were still living, 10 with healthy wives
Progress of Otology. 169
and 2 with deaf-mute wives had begotten 25 children. 22 un-
married and 5 married women with healthy husbands had borne
42 children. Of the 67 children with 5 grandchildren, not one
was a deaf-mute, and of the 58 who were still alive there was not
one that could be called really unhealthy. Particular attention is
paid by the author to the influence of blood-relationship in the
parents. In his statistics, also, the marriages of relatives are
much more extensively represented than appears in the tables of
percentages. Amongst the parents of deaf-mutes were found 63
(11 per cent.) who were as closely related as first or second
cousins. These gave birth to children, 69 of whom were born
deaf and 26 became deaf, /. ^., 1^ per cent, of the entire list of deaf-
mutes. 17 of the deaf-mutes were of low mental development, 5
incapable of being educated, i albino, 2 hemeralopic. Twelve of
the others were otherwise diseased.
Eserichs' hypothesis that deaf-mutism is more frequent in older
formations than younger has not been confirmed in the Palatinate.
Nor is there any support in these statistics of Mayr's supposition,
that the frequency of deaf-mutism stands in inverse ratio to the mor-
tality in children. The social conditions of the deaf-mutes were
very unfavorable, probably from their own extreme lack of de-
velopment. We have mentioned the chief points of this paper, but
are obliged for lack of space to refer our readers to the valuable
original.
21. J. A. Campbell. Though mainly intended for the laity,
this little book contains in a condensed form some information
which the practising otologist will find of value. He will be par-
ticularly interested in the description of the mechanical aids to
hearing. All the forms of ear-trumpets are described and figured,
and the principle of their action explained, as well as the audi-
phone, dentaphone, audinet, and osteophone. A description of
the telephone is added. This is one of the few popular books
which has a value and a raison d' etre. Burnett,
22. TuRNBULL calls attention to the fact that in this country
the attention of insurance companies is not directed to ear-dis-
eases to such an extent as their importance demands. Aside
from the deaths which are likely to arise from the propagation of
inflammation from the middle ear to the brain, there are those of
accident to which the impaired hearing of the individual particu-
larly exposes him. It is estimated that there is in this country
one death from this cause alone every day. T. advises that the
170 A. Hartniami.
following questions be answered by every applicant for life in-
surance : (i) Are you suffering from any form of disease of the
ear ? (2) Have you pain, noises, or dizziness, or any discharge
from the ear? (3) Are you at all deaf? Bqrnett.
23. KiPP has noticed that in a number of cases of sparkling
synchysis there was deafness more or less complete in one or both
ears. Burnett.
24. Brandeis. After enumerating some of the disadvantages
and even dangers of Valsalva's and Politzer's methods of inflat-
ing the middle ear, as well as those attending the use of the
catheter, B. recommends the emi)loyment of Siegle's pneumatic
speculum as an exhauster of the air in the meatus in certain cases
where other means are not admissible or are attended with un-
pleasant results. Burnett.
B. — EXTERNAL AUDITORY MEATUS.
25. W. KiESSELBACH. Attem]:)t to form an external auditory
meatus in a case of congenital malformation of both auricles with
absence of the external meatus. Arch.f. O., vol xix, p. 127.
26. H. Knapp. Congenital fibrous closure of the auditory
meatus ; opening frustrated by hsmatophilia. These Archives,
vol. xi, p. 19.
27. A. DucAU. On a little-known cause of deafness. Rev.
mens, de laryiig. et d' otol., No. 12, 1882.
28. A. DuCAU. A prune-stone lodged in the ear for thirty-
three years. Ibid., No. 7, 1882.
29. A. POLITZER. Parasitic inflammation of the external audi-
tory meatus. Wien. med. IVoc/iensch., No. 29, 1882.
30. A. H. Buck. A case of foreign body in the external audi-
tory canal ; removal by displacement forward of the auricle and
cartilaginous meatus. Netu York Med. Record, Dec. 16, 1882.
31. Sam'l Theobald. Complete closure of both external
auditory canals following otorrhoea. Trans. Am. Otol. Soc, 1882.
32. C. H. Burnett. On the growth of aspergillus in the ear,
with a case of the rare form of the parasite, the aspergillus glau-
cus. Philadelphia Med. Times, Nov. 4, 1882.
33. C. J. Blake. The progressive growth of the dermoid
coat of the membrana tympani. Am. Journal of Otol., Oct., 1882.
25. KiESSELBACH reports the case of a child aged six months,
with a malformation of the auricle which, in the mother's opinion,
Progress of Otology. 171
must have been due to pressure exercised by the umbilical cord.
Both auricles were mutilated, the left more noticeably than the
right. The tragus on the right side was very indistinct to the
touch, while behind it lay a little hollow which appeared to desig-
nate the entrance to the external meatus. The operation was at-
tempted upon this (right) side. Kiesselbach's motive in per-
forming the operation was that, according to Bremer, this condi-
tion of the parts is probably not a simple rudimentary develop-
ment, but one acquired in the early part of intra-uterine life by
external pressure, so that it was quite possible " in a wholly hori-
zontal position of the embryonal Mt that the external portion of
the meatus does not undergo total closure." Inasmuch as the
bony meatus may become developed in an incorrect direction,
owing to the altered conditions of pressure and tension, operative
interference at an early age appears justifiable. An incision into
the hollow before mentioned led down to the subcutaneous fat.
On pressing deeper inward to the periosteum no trace of any ex-
ternal meatus could be discovered. The incision was then ex-
tended to the lower edge of the squamous portion, from which a
fine sound could be pushed into a narrow crevice. The latter
was then enlarged forward and backward, until by examination
with the sound, the annulus tymp. appeared to have been laid
bare. A flap of skin from the auricle was pushed into the incision
and fastened by sutures, one of which struck the trunk of the
facial nerve. On the twelfth day after the operation the child was
taken away by the mother, who was satisfied with what had been
done, " for the child was much more sensitive to noises than be-
fore." This attempt to create an auditory canal may therefore
be said to have miscarried.
27. DuCAU speaks of the frequent cases of contraction of the
external meatus from wearing handkerchiefs over the ears, so that
the auricles undergo constant compression. While v. Troltsch
believes that there are cases of relaxation of the fibrous filaments
which fix the cartilage, Ducau thinks that the trouble lies in a
flattening of the auricles against the skull, so that they become un-
fitted for collecting the waves of sound, whilst the tragus, which
acts like a cover placed over the entrance to the meatus, offers
further obstacle to the entrance of sound. Since instruments
cannot long be borne, Ducau advises that a more permanent en-
largement of the meatus be obtained by the introduction of lami-
naria bougies.
172 A. Hartviaiin.
28. DuCAU reports the case of a plum-stone, which after re-
maining in the ear for thirty-three years, without causing any pain
or inconvenience, was easily removed by syringing.
29. POLITZER briefly depicts the symptoms of otomycosis much
in the same way as in his hand-book. The most reliable treatment
is the use of rectified alcohol as recommended by Hassenstein.
The alcohol is used twice daily, being poured into the ear after
the removal of the fungoid masses, and allowed to remain at least
fifteen minutes. If the remedy causes violent pain, it should be
diluted with distilled water.
30. Buck. The foreign body was a locust bean which had
become firmly impacted in the bony portion of the meatus, but
did not touch the Mt. All efforts to remove it through the meatus
having proved futile, the auricle and cartilaginous meatus were
moved forward, and a hook introduced at one side between the
bean and the canal and there turned at right angles. Very forcible
traction finally brought it away. The author is inclined to think
that in this case the setting forward of the auricle was of but little
advantage in getting at the foreign body, and that the removal
was finally effected only because a greater amount of force was
used than before. These beans are smooth and very hard, and
no impression can be made on their surface unless the instrument
be applied at right angles to the surface. Hence the difficulty
in securing sufficient purchase for the hook to bring it
away readily. A drawing of a hook suitable for such cases is
given. Burnett.
31. Theobald. Upon each side of the normal meatus there
was a cul-de-sac 2 cm. deep on the right side and 1.7 cm. on the
left. Instead of either canal reaching to the Mt, they both termi-
nated in a smooth concave floor which was covered with an integu-
ment continuous with that of the meatus. Loud voice was heard
in the right ear at 6', in the left ear at 9'. Tuning-fork heard
better in left ear. Burnett.
32. C. H. Burnett. The aspergillus glaucus is the name given
by Burnett to the form usually known as A. flavescens. He has seen
only three cases of it. In treatment he has abandoned the alco-
holic method, and now uses boracic acid, borax, boracic acid with
chinoline, or with resercin. Burnett.
■^T,. Blake. A series of experiments extending over a period
of five years has shown that the growth of the dermoid layer
of the Mt takes in general a certain definite direction. Thus,
Progress of Otology. 173
five small discs of paper placed on the surface three above and
two below the malleus handle, all finally reached the periphery
upward and forward — never downward or backward. A diagram
is given showing the path followed by each disc. Burnett.
C. — MIDDLE EAR.
34. J. Baratoux. On perforation of the membrana tympani,
etc. Rev. mens, de larytig. etc., No. 11, 1882.
35. LuDWiG Stacke. On chronic suppurative processes in
the middle ear, and their complications. Inaugural Dissertation.
Rinteln, 1882.
36. Thomas Barr. The treatment of certain forms of sup-
puration of the middle ear. Glasgoiv Med. Jour., No. 5, 1882.
37. Oliver Moore. Acute exacerbation of a chronic sup-
purative inflammation of the middle ear, etc. These Archives,
vol. xi, page 25.
38. S. Moos. CEdema in the temporo-zygomatic region as a
symptom of phlebitis and thrombosis of the lateral sinus. These
Archives, this number.
39. S. Moos. Pysemic accidents in the course of and after
the cure of an acute suppurative inflammation of the tympanum.
These Archives, this number.
40. S. Moos. Cholesteatoma of the mastoid process, with
acute perforation into the external meatus after the use of Irish
Roman baths. Perfect recovery. These Archives, this number.
41. Eitelberg. Cases of periostitis and caries of the mastoid
process. Wien. med. Pres., No. 46, 1882.
42. S. Moos. Necrotic exfoliation of a bony semicircular
canal (superior?), preceded for eight days by vertigo and vomit-
ing. Recovery with loss of the previous remnant of hearing.
These Archives, this number.
43. Despres. Otitis interna. Suppuration of the mastoid
cells. Trephining. Gaz. des hdpifaux, No. 46, 1882.
44. H. Knapp. Trephining of the mastoid in a case of otitis
catarrhalis chronica, with intact membrana tympani. Opening of
the transverse sinus. Recovery by first intention. These Ar-
chives, vol, X, page 365.
45. T. H. Gluck. a case of trephining of the pyramid of the
petrous bone. V. Langenbeck's Arc/iiv, vol. xxviii, page 556.
46. Weber-Liel. An apparatus for washing out masses of
suppurative, thickened, or cholesteatomatous material from inacces-
174 -^- Hartviami.
sible, sinuous, and carious regions of the middle ear, and external
auditory meatus. M.f.O., No, 7, 1882.
47. T. M. Pierce. A case of extensive disease of the left
temporal bone with cerebral hernia. These Archives, vol. xi,
page 313.
48. S. Pollock. An artificial membrana tympani made of
elastic collodion. St. Louis Med. and Surg, your., Oct., 1882.
49. H. Knapp. On the treatment of aural polypi. Trans.
Am. Otol. Soc, 1882.
50. C. S. Merrill. A case of acute middle-ear-inflammation,
with death on the fourth day, from extension of the disease to the
brain. Tra?is. Am. Otol. Soc, 1882.
51. O. D. PoMEROY, The use of soft india-rubber drainage-
tubes in chronic suppurative inflammation of the tympanum, with
narrowing or closure of the meatus externus. Trans. Am. OtoL
Soc, 1882. Reprinted in Am. J^our. of Otol., Oct., 1882.
52. R. J. McKay. Aural polypus, facial paralysis, mastoiditis,
and chronic meningitis, with recovery from the latter. Trans. Am.
Otol. Soc, 1882.
53. A. Mathewson. a case of abscess of the cerebellum fol-
lowing otitis media, months after apparent cure. Trans. Am. Otol. ■
Soc, 1882.
54. C. S. TuRNBULL. Powdered boracic acid in the treatment
of chronic purulent inflammation of the middle ear (otorrhoea).
Trans. Fenn. State Med. Soc, 1882.
55. T. A. Dow^NES, Chronic otitis media purulenta ; its treat-
ment in the Presbyterian Hospital, Philadelphia. Atti. your, of
Otol, Oct., 1882.
56. C. H. Burnett. Further observations on the usefulness
of chinoline-salicylate in^ otorrhoea. Am. your, of Otol., Oct.,
1882.
57. D.I.Reynolds. Otitis media purulenta. Med. Herald,
Nov., 1882.
58. Erastus E. Holt. Boiler-maker's deafness, and hearing
in a noise. Trans. Am. Otol. Soc, 1882.
34. Baratoux gives a general view of the various sorts of per-
forations of the Mt, and the conditions with which they may be
mistaken. The cure of perforation is next discussed. Atrophic
spots and cicatrices can sometimes be distinguished from one an-
other by the fact that the former are generally triangular, while the
Progress of Otology. 175
cicatrices are round. Atrophic patches are usually situated in the
superior and posterior portion of the Mt. Calcareous deposits
and inflammatory processes on the opposite side indicate ci-
catricial formation. A case is communicated in which Baratoux
was able to improve the hearing and stop the tinnitus, after re-
peated application of the galvano-cautery.
■35. Stacke's dissertation contains a very comprehensive
symptomatology of suppurative inflammations of the middle ear,
and their complications, with abundant literary references. He
communicates a case of suppurative otitis media with formation
of cholesteatoma, which ended fatally by inciting meningitis and
thrombosis of the sinus.
■^d. Barr pays attention to suppurative processes of the
middle ear which resist the usual methods of treatment. He
enters very minutely into those anatomical relations of the parts
which tend to retain the products of suppuration in the upper
portion of the tympanum and in the mastoid process, and conse-
quently make these regions inaccessible to the usual therapeutic
treatment as well as to syringing through the auditory meatus.
Barr uses for this purpose a particular kind of syringe, which is
depicted in the original. After removal of the deposits, Barr
employs solutions of silver nitrate and insufflations of boracic
acid. Three successful cases after this method are added.
41. EiTELBERG communicates a case of caries appearing simul-
taneously in both mastoid processes, pleads urgently in favor of
Wilde's incision, with subsequent removal of the sequestrum
through the incision, and supports this by four additional cases.
The opening in the mastoid process, when indicated in serious
cases, should be done as Schwartze urges, at the spot where spon-
taneous opening generally takes place. This situation, however,
in opposition to Schwartze's theories, he found only twice in
fifteen cases at the insertion line of the concha, and once just a
trifle above the linea temporalis.
43. Despres describes a case of acute inflammation of the
middle ear, otitis interna as he styles it, with violent pain and
raging fever. The treatment in the preliminary stage was con-
fined to syringing warm water into the nose. The case soon grew
worse, with high fever, great swelling, and extension of the disease
to the cells of the mastoid process. As Valsalva's experiment did
not succeed, Despres concluded that the Mt was not perforated.
He thinks that the plan of catheterizing in cases of exudation in the
1/6 A. Hartmann.
tympanum, as proposed by aurists, is perfectly useless. The mas-
toid process was trephined, and a large amount of laudable pus
evacuated. The inflammatory symptoms underwent rapid retro-
gression. When the patient was discharged there was but a
slight serous secretion from the mastoid incision. Flax-seed
poultices were the only external application.
It appears to us that the views expressed by Despres justify the
unfavorable opinion of Rene de Calmette on the diffusion of
otology in France, an opinion for which he was violently attacked
by his fellow-countrymen.
45. Gluck attempted on the cadaver to ligate the internal
carotid in its canal, and succeeded in fifteen cases in chiselling
out the artery in its whole course, without wounding the jugular
vein or the transverse sinus. He therefore believes that, in con-
ditions which demand trephining of the mastoid process, we can
gain a more radical cure by resection of the pyramid of the
temporal bone with the chisel. The author subsequently had an
opportunity of proving in a case that such an operation was
feasible. A patient with chronic suppuration of the middle ear
was suddenly attacked, after previous and repeated hemorrhage
from the right ear, with violent headache, sudden fainting, con-
vulsions, and amaurosis, which were followed by a soporous
condition, facial paralysis, and paralysis of the right arm. A
collection of pus between the dura and pia maters, as a result
of the otorrhoea and erosion of the internal carotid, appeared to
be the probable condition, and was thus diagnosticated. After
chiselling away the posterior wall of the meatus, a portion of the
mastoid process and of the temporal bone, the dura mater was
extensively exposed, as a bluish, tightly-stretched, fluctuating
sac. The dura mater was then opened, whereupon about 60
grm. of thick fetid pus which had lain between the dura and the
pia escaped. The finger could be pushed up into the cavity as
far as the internal occipital protuberance. Death ensued on the
following night. At the post-mortem examination the dura mater
was found sunken into the slightly concave surface of the brain
upon the operated side, while its inner surface, from the longitudi-
nal sinus to the base of the brain, was covered with an adherent
layer of pus. The base of the skull was unaltered. There does
not seem to have been any accurate examination of the ear, from
which, however, the disease had its starting-place.
46. Weber-Liel cleanses the tympanum and its cavities with
Progress of Otology. 177
V. Troltsch's atomizing apparatus, to which small curved tubes
are to be attached as necessity demands.
48. Pollock's patient was first placed in a perfectly horizontal
position, and three drops of a solution of tannin in glycerine
were instilled, and on top of that three drops of collodion. In a
few minutes solidification was effected. It was a strong and solid
membrane, and vibrated in Valsalva's experiment.
49. The substance of Knapp's paper is incorporated in the
author's article : " Report of 806 cases of ear-disease occurring in
private practice," etc., published in the September number of
these Archives for 1882.
50. Merrill's patient was a man thirty-two years of age, affected
for the first time with acute ear-catarrh. Death took place four days
after the appearance of the first ear-symptoms. On examination
after death, perforations were found through the roof of the middle
ear and underneath the dura, and on it were a few drops of green-
ish pus. There was evidence of acute meningitis. Burnett.
51. PoMEROY. The closure of the meatus, preventing a ready
outlet for the matter in the drum cavity, forms one of the greatest
obstacles in treating certain forms of middle- ear disease. This is
most commonly found, P. thinks, in children. To obviate this he
uses drainage-tubes of rather soft rubber, beginning with the
smaller sizes, but the largest which the meatus will admit. To in-
troduce it, it should be stretched longitudinally by drawing it over
a probe so as to diminish its transverse diameter. This is then
carefully introduced until its end reaches the drum cavity, when
the probe is withdrawn, and the tube returns to its normal diam-
eter. The outer end of the tube is cut off close to the concha.
The tube can be withdrawn at any time by means of a forceps.
Under the lateral pressure exerted by the tube, the swelling of
the canal usually gives way and the tube becomes loose. It must
then be replaced by a larger one. Through these tubes the middle
ear can be easily cleansed and any desired medication carried
out. Seven cases in which it was used with benefit are re-
lated. Burnett.
In the discussion which followed the reading of the paper, some
members, including the President (Dr. J. O. Green), and Dr,
Knapp, expressed a preference for a silver tube in drainage of the
middle ear. Burnett.
52. McKay. In addition to his other troubles, the patient had
a papillitis of the left eye, and there was considerable congestion of
the right disc. Burnett.
178 A. Hartmann.
53. Mathewson's patient was a child eleven years of age, whose
left ear was affected with a necrosis of the mastoid and a purulent
discharge. Under treatment these symptoms disappeared, and the
child was discharged cured in December, 1880. On the 14th of
March, 1881, there appeared suspicious head-symptoms, but on
examination, the ear was found about as it was when the patient
was discharged. The O. S. showed some fulness of the retinal
veins, but nothing else abnormal. After a brief convulsion the
child died on the i6th of March. On post-mortem examination,
the veins and sinus were found filled with fluid blood ; there was
injection of the meninges, and adhesions at points over the
petrous portion of the temporal bone. Some pus under the dura,
over the tegmen tympani, and in the sheath of the 5th pair, and
an abscess containing an ounce of fetid pus in the left lobe of the
cerebellum. Burnett.
54. Since Turnbull has adopted the boracic-acid treatment
for purulent inflammation, it has become a pleasure to him to han-
dle such cases, so uniform has been his success in treating this
class of diseases which before had been to him only objects of
despair. Burnett.
55. DowNES. The cases, four in number, were under the
charge of Dr. C. H. Burnett. The syringe is used for cleansing
when the discharge is abundant, and cotton on a probe when it is
scant, and powdered calendulated boracic acid blown in in just
sufficient quantity to cover the diseased surface. Burnett.
56. C. H. Burnett finds the salicylate of chinoline, con-
cerning which he first wrote in vol. iv, No. 2, of the Ainencan
'journal of Otology, a valuable adjuvant to boracic-acid pow-
der. Burnett.
57. Reynolds believes in constitutional treatment in addition
to local. The latter consists principally in the application of
Listerine (a compound of boracic acid, eucalyptus oil, thymol, and
some other less important substances), after a thorough cleansing
of the parts by means of the syringe and the catheter. Burnett.
58. Among the men employed in the steam-boiler factory at
Portland, Me., forty were hard of hearing and examined by Dr.
Holt. He found the deafness due to changes of a catarrhal
nature in the sound-conducting apparatus, the incessant noises
agitating the chain of ossicles and producing more or less anchy-
losis in their joints. Bone-conduction in these patients was as
good as in normal ears. The better hearing in noises, which was
Progress of Otology. 179
claimed by over 100 of his patients, was subjected to various tests,
and proved, according to the author, to be a self-deception, based
upon the raising of the voice, which the speakers in a noise did
instinctively. The noise never improved the hearing in any of
the cases that had been tested. Burnett.
D. — NERVOUS APPARATUS.
59. Brunner. a case of complete unilateral deafness after
mumps, etc. These Archives, vol. xi, p. 102.
60. J. Seitz. Deafness after mumps. Corresp.f.SchweizAerzte
No. 19, 1882.
61. E. J. Moure. Case of total deafness after mumps. Rev.
mens, de lary?jg. d' otol., etc.. No. 10, 1882.
62. Extensive fracture of the base of the skull in an infant.
Escape of cerebro-spinal fluid from the ear. Medical Times, No.
1684, 1882.
ST). William James. Sense of dizziness in deaf-mutes. Amer.
your, of Otol., Oct., 1882.
60. Seitz communicates a case of deafness after mumps which
is analogous to that of Brunner. The patient was a student aged
nineteen, in whom deafness had appeared on the right side thirty-
six hours after an attack of mumps, which had ceased on the
sixth day. The deafness was accompanied with a loud roaring and
rushing sound, a metallic clang with every perception of sound,
together with excessive vertigo and difficulty in walking. The
objective condition was negative and treatment of no avail.
61. Moure mentions previous observations of deafness after
mumps, and adds one more to the list. A girl eight years old was
attacked on the fifteenth day of the disease, just when the swell-
ing of the glands had begun to disappear, with total deafness
on both sides..
Pain and other symptoms were absent. Roaring in the ears
appeared a short time later. The examination of the ear showed
nothing abnormal. Treatment was of no avail. Disturbances of
the equilibrium were not noticed.
62. A child aged one year and seven months fell from his bed,
about two feet high, and fractured the base of his skull. He died
on the sixth day from lepto-meningitis. During this time blood,
and particularly cerebro-spinal fluid, escaped from the left ear.
The fracture affected the middle of the left parietal bone, from
l8o A. Hartmann.
which it reached to the external meatus, and along its upper walls
to the annulus tympanicus. It here divided into two fissures, one
of which extended through the internal auditory meatus to the
jugular foramen, the other into the region of the foramen ovale.
The petrous bone itself was not more closely examined. Leaving
aside the rarity of such fractures in the tender age of childhood,
the author insists that such injuries of the external auditory
meatus should be carefully treated with antiseptics (at first syring-
ing with a five-per-cent. solution of carbolic acid, and later with
an iodoform bandage or Lister gauze), on account of the commu-
nication which exists, in all such cases, between the external air and
the arachnoidal space, especially so soon as the fracture extends
as far as the posterior wall of the pyramid.
63. James. Of 519 deaf-mutes subjected to the test, 186 are
reported as not being made dizzy by a rapid whirling of the head
in any direction ; while of 200 students with normal ears, tested
similarly, only one remained exempt. Of those deaf-mutes which
are reported as dizzy, 134 were said to be so only in a slight de-
gree, 199 normally so, and a few cases abnormally so. Forty-three
were subjected to the test of a galvanic current passed through
the head. The current, which caused four normal adults to bend
the head and body strongly over, produced the same effect in only
six among fifty-eight of the class "not dizzy," while in twenty-
three of the class " dizzy," fifteen were affected in a greater or less
degree. It was also endeavored to learn how far the deaf-mutes
were affected with sea-sickness ; and though the report is not
very full, what evidence we have seems to lead to the opinion that
they are not so much affected as those with normal ears. Atten-
tion is called to another phenomenon which seems to point to the
semicircular canals as forming an important factor in the function
of orientation. Deaf-mutes, as a rule, when their heads are under
water, and the effect of gravitation is lost, experience an in-
describable feeling of alarm and bewilderment. This is particu-
larly so when the eyes are closed. The paper is a very suggestive
one, and it is hoped others will follow out the lines of experiment
so well laid out by the author. Burnett.
E. — NOSE.
64. W. J Walsham. The treatment of deflection of the
nasal septum. The Lancet, Sept 23, 1882.
65. Arthur Hartmann. Partial resection of the nasal
Progress of Otology. i8i
septum in cases of excessive deflection. Deutsch. med. Wo-
chenschr.. No. 51, 1882.
66. J. Gruber. a case of inflammation of the naso-pharyn-
geal mucous membrane from the presence of a cherry-stone in the
nostril. M.f. O., No. 7, 1882.
67. Arthur Hartmann. Supra-orbital neuralgia produced
by empyaema of the accessory cavities of the nose, owing to
the hindrance of the escape of the secretion from the middle
nasal meatus. Berl. klin, Worchenschr., No. 48, 1882.
68. Creswell Baber. Remarks on adenoid vegetations of
the naso-pharynx. Brit. Med. Journ., Augusts, 1882.
64. Walsham has repeatedly and successfully performed
Adams' operation for straightening the nasal septum. If the
septum is too resistent, a star-shaped incision can be made
through the mucous membrane and cartilage. Walsham then
proposes to push a narrow knife beneath the mucous membrane,
and to divide the cartilage subcutaneously. In this way he
thinks that we can better avoid all loss of substance with perfora-
tion of the septum.
65. Hartmann has operatively removed a portion of the nasal
septum in three cases of excessive curvature. He operated in
two of the cases in order to facilitate the complete removal of
nasal polypi, and in the third on account of epilepsy. In two of
the cases the prominence was removed with narrow bone-scissors;
in the third an incision made with the scissors, and the prom-
inence removed with a chisel applied in a sagittal direction. The
septum was not perforated in any of the cases. The hemorrhage
was very abundant in the first two cases, and caused considerable
tim.e to be lost in the operation. Chloroform was invariably
given, and the operation done under artificial illumination.
66. Gruber's interesting case was as follows : A woman, set.
twenty-nine, had suffered for a long time from the symptoms of
chronic coryza, with intermittent pain in the head, eyes, and in
the left ear. The middle ear showed the symptoms of hyper-
trophic inflammation, against which the air-douche was useless.
The rhinoscopic condition was negative. Catheterism was
repeatedly performed during a period of six weeks, without
meeting with any obstacle, until one day resistance was felt.
The catheter had struck a foreign body in the pharynx, which
was discovered to be a cherry-stone covered with secretions
1 82 A. HarUnann.
After removal of this foreign body the catarrh and subjective
symptoms disappeared.
67. Hack was the first to observe that supra-orbital neuralgia
may be a purely reflex symptom of disease of the nasal cavities,
and Hartmann now gives us two cases in which the neuralgia was
caused by an affection of the accessory cavities of the nose. In
both cases polypoid swelling of the external portions of the
middle nasal meatus hindered the discharge of the secretion from
the accessory cavities. Cure was obtained by removing the
polypi. The diagnosis of an affection of the cavities in question
can generally be supported by the favorable action of Politzer's
experiment. The characteristic symptom in such cases is the
welling up of thick, fluid pus, when the contracted entrance to
the middle nasal meatus, between the middle and inferior turbi-
nated bones, is enlarged with a thick sound.
dZ. Baber is of the opinion that tonsillotomy should be done
before removing adenoid growths by an operation ; cauterization
of the growths is of no use. At night, the patient ought to wear
■Guye's contra-respirator.
ABSTRACTS FROM THE OTOLOGICAL PAPERS
READ BEFORE THE AMERICAN MEDICAL
ASSOCIATION, AT ITS MEETING IN CLEVE-
LAND, O., JUNE 5, 6, AND 7, 1883.
The following abstracts are taken from the report on the section
of ophthalmology, otology, and laryngology, of the American
Medical Association, published in The Medical Record, June 16,
1883.
In the absence of the Chairman, Dr. A. W. Calhoun, of Atlanta,
Ga., Dr. J. J. Chisolm, of Baltimore, was elected president pro
tern.
Dr. Lawrence Turnbull, of Philadelphia, read a paper on
paralysis of the facial nerve in connection with diseases of the ear.
Acute and chronic disease of the middle ear will give rise to par-
alysis, alteration in taste, touch, smell, gait, and vision; further, to
epileptiform convulsions, hemiplegia, and insanity. He cites four
cases of facial paralysis due to ear disease, of which the first is of
particular interest, as the paralysis resulted from a malignant
intra-aural tumor, which originally was a polypus, and ultimately
caused death by involving the brain.
Dr. W. J. Jarvis, of New York, oti tonsillotomy without hem-
orrhage, distinguishes two kinds of hypertrophied tonsils: (a) the or-
dinary soft variety, which should be removed with the tonsillotome,
by preference, and (b) the hard or scirrhous tonsil, which bleeds
readily, and should be removed with the ecraseur. In one such case,
before it had come under his care, the scissors and tonsillotome had
been used by different surgeons, and each attempt had been fol-
lowed by alarming hemorrhage. He removed both tonsils with the
ecraseur. The operations proved bloodless, caused but slight dis-
comfort, but were tedious, each occupying three hours.
A paper on the action of ?iitrate of silver on the jnucous membrane
183
184 Swan M. Burnett.
of the throat, by Dr. C. Seiler, of Philadelphia, who advocated
very strong solutions, from 20^ to 50^, and the solid stick, gave
rise to an extended discussion on the application of that remedy,
without bringing out any new points.
Other papers were :
On myringitis. By C. Williams, of St. Paul, Minn., read by
title.
On the tinnitis aurium, and the deafness accompanying Bright's
disease. By Dr. Lawrence Turnbull.
On nasal disease, the frequent cause of asthma. By Dr. J. O.
Roe, of Rochester.
On the appearance of the diseased mucous membrane of the
nose and throat of adult patients.
MISCELLANEOUS NOTES.
The committee of organization for the 77ii>-d International Otol-
ogical Congress, Dr. Burchhardt-Merian (Basel), president ; A.
Hartmann (Berlin), L. Loewenberg and Meniere (Paris), had a
meeting in Paris, on March i8th, and concluded to abide by the
decision of the Second Congress, to hold the session of the third
in Basel, Switzerland, the first week in September, 1883. The
committee enlarged their number by the following gentlemen :
Dalby and Urban Prichard, of London ; Roosa, of New York,
and Blake, of Boston.
A French Otological and Laryngological Society has been
founded under the title : SociHe Francaisc d' Otologic de Laryn-
gologie, consisting thus far of 18 members from Paris, 13 from the
French provinces, and 9 associated members from other countries.
The Society will meet three times a year, viz.: in January and
October (ordinary sessions), and in the Easter week (general ses-
sion). It will publish its transactions. The conditions for mem-
bership are :
1. A diploma of M.D.
2. A written application accompanied by a printed essay and a
MS. paper on some subject connected with otology or laryngology.
The only disciplinary measures mentioned in the By-Laws are :
expulsion if a member fail to pay his annual dues after two
official notices.
Communications to be addressed to the Secretary, M. le Dr.
Baratoux, 12 rue Condorcet, Paris.
VOL. XII. Nos. 3 and 4.
ARCHIVES OF OTOLOGY.
THE HYPHOMYCETES ASPERGILLUS FLAVUS, NI-
GER, AND FUMIGATUS; EUROTIUM REPENS (AND
ASPERGILLUS GLAUCUS), AND THEIR RELATIONS
TO OTOMYCOSIS ASPERGILLINA.
By Dr. F. SIEBENMANN, of Brugg, Switzerland.
Translated by J. A. Spalding, M.D., Portland, Me.
LITERATURE.
Bezold. " The Origin of Favus in the Ear." Monats. f. Okr., 1873, vol.
vii, pag. 81.
Arch. f. Ohr., 1870, pag. 197.
"Vortragim. artzt Verein." Munich, 1880.
"Salicylic Acid in Otology." M. f, (?., August and September,
1875.
BisSELL. " A Case of Aspergillus," etc. N. V. Med. Record, 1874, vol. ix,
pag. 86.
"Aspergillus Niger." Trans. Alabama Asso., vol. xxviii, pag.
379-
Blake. " Parasitic Growth," etc.
Blake and Shaw. These Archives, vol. iii, pag. 88.
BoKE. " Two Cases of Favus," etc. M. f. O., i86g, vol. iii, pag. 58.
De Bary. " Eurotium." Beitr. z. Morph., etc., der Pilze, 3te Reihe, 1870.
BowEN. " Case of Parasitic Growth," etc. AT. Y. Med. Record, 1874, vol.
ix, pag. 344.
Burnett, C. H. " Case of Myringo-mycosis." These Archives, vol. iv,
pag. 121.
" Mycelial Tube-Cast of the External," etc. Trans, Pathol. Soc,
Phil., 1874, vol. iv, pag. 2114.
Ditto. Phil. M. Times, 1S74, vol. iv, pag. 284.
"Aspergillus Glaucus," etc. Trans. Int. Otol. Soc, 1876, vol. i,
pag. 75-
" Twenty Cases of," etc. Am, Jour. Otol., 1879, vol. i, pag. 10.
Burnett, S. M. " Otomyces Purpureus," etc. These Archives, vol, x,
pag. 319-
Cassels, J. P. " Note on Fungus," etc. Brit. M. J., 1874, pages 681,
809.
" Myringo-mycosis," etc, Glasgow M. J., 1875,
Cramer. " Sterigmatocystis," etc. Vierteljahrs. d. natiirf. Ges., etc.,
Zurich, 1859.
185
1 86 F. Siebcnma]i)i.
Fischer, E. " Naphthalin," etc. Berlin, klin. Woch., i88i, No. 48.
" Investigations," etc. Berlin, klin. Woch., 1882, No. 8.
Grawitz. "On Fungoid Vegetations," etc. Virchoius Archiv, vol. Ixxxi,
pag. 355-
" The Adaptation Theory of," etc. Berlin, klin. Woch., 1881, Nos.
45 and 46.
Green, J. O. "A Parasitic Growth." Boston Med. and Surg. Jour., Nov.
19, 1868.
"Two Cases," etc. Trans. Am. Otol. Asso., 1869.
Grohe. Inaug. Diss. Greifswalde, 1870.
Berlitt. klin. Woch., 1870, No. i.
Gross. " Fungus of the," etc. Phila. Afed. Times, 1871, i.
Grove. " A Fungus Parasite," etc. 1857.
Gruber. "On Fungoid Growths." M.f. 0., 1870, vol. iv, pag. 113.
"Myringitis." M.f. O., 1875, pag. 9.
Hagen. "Additional Cases," etc. Zeils. f. Parasitenk., 1870, vol. ii, pages
22 and 233.
Hagen and Hallier. " A New Aural Fungus." Ibid., 1869, vol. i, page
195.
Hallier. " Communication on the Aural Fungi." Ibid., 1870, vol. ii, pag.
259.
Hall. "Aspergillus in the Ear." Am. Journ. Med. Sc, 1877, pag. 559.
Hassenstein. " Alcoholbehandlung," etc. Zeits. f. Parasitenk., i86g,
vol, iii,
Hertrich. " A Case of," etc. Aerztl. Intel.-Blatt., 1880, No. 43.
HOTZ, F. C. " A Case of Aspergillus." Chicago Med. Journ., 1876, vol.
xxxiii.
Kilpatrick, a. R. "Vegetable Fungi," etc. Sotith. Med. Rec, Atlanta,
1873, vol. iii.
Knapp. " Myringo-mycosis." Med. Record, N. Y., 1869.
Koch, K. " The Artificial Cultivation," etc. Berlin, 1881.
"Reply." Berlin, klin. Woch., 1S81, 52.
KucHENMElSTER. " The Animal and Vegetable Parasites of the Human
Body." 1st edition.
Leber, Th. " Suppurative Keratitis," etc. v. Graefe's Archives, 1879.
" On the Conditions of Growth," etc. Berlin, klin. Woch., 1882, No.
II.
Levi. " Observation on Otitis," etc. Annales des maladies de /' oreille,
Paris, 1875, vol. i.
Lichtheim. "On the Pathogenic Moulds," etc. Berlin, klin. Woch.,
1882, Nos. 9 and 10.
Liljenroth. "On Otomycosis." Nordische M. Ark., Stockholm, 1872,
vol. iv.
Lowenberg. " On Fungoid Parasites." Paris, 1S80.
Mc. D. " Fungus of the External Ear." Brit. M. Titties, 1875, vol. i.
Manning. "Aspergillus Glaucus," etc. Trans. Texas Med. Asso., 1876.
Mayer. "Observation of Cysts," etc. Milllers Archiv f. Anat., 1844,
pag. 404.
Moore. "Aspergillus," etc. Trans. Nebraska Med. Asso., 1874-76, pag.
119.
Moos. "Profuse Development," etc. These Archives, vol. iii, part i,
pag. 109.
The Hyphomycetes Aspergilhis, etc. 187
NOlting, F. " On a Formation," etc. Zeits. f. Parasitenk., 1876.
Pacini. " Fungus Parasites." Florence, 1851.
PoLiTZER. " On Vegetable Parasites," etc. Wiener m. fV., 1870, No. 28.
" Handbook of Otology," 1882.
Raulin. " Chemical Study," etc. Annales des sci. nat., fifth series, vol. xi,
Paris.
Robin. " Natural History of Vegetable Parasites." Paris, 1853, pag. 518.
RoosA. "Two Cases of," etc. Am. J. Med. Science, Phila., 1870.
SCHWARTZE. " Fungoid Growth," etc. A. f. Okr., vol. ii.
■ Ibid., vol. iv.
" Handbook of Pathol. Anat." (v. Klebs), 1878, vol. vi.
Seely. " Three Cases of Aspergillus." Cincinnati Clinic, 1872, vol. iii.
De Seynes. " Some Species of Aspergillus." Z' institut. May 17, 1876.
SiEBER. Inaug. Diss. Bonn, 1870.
Steudener. " Two New Aural Fungi." A. f. Ohr., 1870, vol. v.
Strawbridge. "Salicylate of Soda," etc. Trans. Am. Otol. Soc, 1878,
vol. ii, pag. 254.
Van Tieghem. " On the Development," etc. Bttll. d. I. soc. hot. de France,
vol. xxiv, pages 96, 206.
Trautmann. "The Parasites of the," etc. Berlin, k. W., 1877, No.
15-
Troltsch, " Handbook." Various editions.
Urbantschitsch. " Handbook." 18S0, pag. 140.
Versari. "Note on Parasites," etc. Rend. ac. d. Sc, Bologna, 1869.
Virchow. " Aspergillus." Virchow's Archiv, vol. ix, pag. 4.
VoLTOLiNl. " On the Theory of," etc. M. f. 0., 1870, pag. g.
Weber, F. E. "On Parasites," etc. M. f. O., 1S68, No. 11.
"Diffuse Inflammation," etc. M. f. 0., 1S68, No. 12.
"Chronic Inflammation," etc. M. f. 0., 1869, No. 7.
WiLHELM. " Aspergillus," etc. Inaug. Diss., Berlin, 1877.
Wreden. " Myringo-mycosis Asp." St. Petersberg. m. Zeits., "lib"], vol.
xiii.
" Six Cases," etc. A.f. Ohr., 1867, part 3.
" On a New Type," etc. International Med. Cong., 1868.
" Myringo-mycosis," etc. These Archives, vol. iv, pag. 87,
There are so many disputed and obscure points concerning
the appearance and conditions of life of aspergillus, that I
gladly accepted the suggestion of Dr. Burckhardt-Merian to
sift the attainable material upon this question, to examine
more closely by cultivation than had hitherto been at-
tempted the botanical side of the question of the origin of
these fungi, and finally by experiments to gain more light,
if possible, upon their pathogenic significance.
This paper consequently will be divided into two parts :
I. The botany {morphology and physiology) of aspergillus
fumigatus, flaviis, niger, and of the eurotium aspergillus.
1 88 F. Sicbenmann.
This portion of the paper being of but little interest to the
practical otologist will be published elsczuhere?
II. An account of mycosis aspergillina in tlie human ear,
with especial reference to the results experimentally ob-
tained. The introduction will give a brief abstract of the
most important articles bearing upon this disease that have
been published in home and foreign journals, which in turn
v.'ill be followed by the report of some new cases.
OTOMYCOSIS ASPERGILLINA.
A. Historical. — The first case of the appearance of
aspergillus in the human ear was reported in the year 1844.
Dr. Mayer found in the ear of a girl, set. eight, with
" scrofulous " otorrhoea, some cyst-like sacs, the walls of
which were fibrous and felt-like, white on the outside,
greenish and granular within, and composed of masses of
fungus. Microscopic examination (300 x) of the latter
showed long, transparent hyphae terminating in a club-like
swelling, which formed the centre of a round greenish head
covered with a layer of small round granules. The latter
were not united closely together, but generally grouped
two by two.
This description is somewhat defective, but accurate
enough for us to affirm with certainty that Mayer's fungus,
which was examined by Robin and declared to be aspergil-
lus nigrescois, was what we call asp.fumigatus.
Pacini (1851) published the second case of aural fungi : A
patient, who had returned from the salt-water baths of
Leghorn, reported that after bathing the water had often
remained in his ears, caused pain and itching, and finally
destroyed the hearing completely. Dr. Bargellini, who first
examined the patient, found in the meatus a few thick-
walled, transparent "vesicles" the size of a millet-seed,
accompanied with a serous discharge, which prevented him
from inspecting the bottom of the meatus. A fortnight
later the meatus was obstructed with white flakes, which,
on being removed with the syringe, soon reappeared. An-
other fortnight later, the meatus was blocked with a black
' Bergmann's Verlag, Wiesbaden, 1883.
TJic HypJioviycctcs Aspergillus, etc. 189
substance. The Mt was covered with a white, fatty mass
composed of epidermis cells, granulations, and fungus. In the
latter Pacini distinguished upon the hyphae the little heads
[sporangia] (60-100 /< diameter), at first bright, yellowish-
red, and later of a dark or black color. The heads consisted
of a receptaculum and of conidia, which were round, and
with a thick translucent epispore hung off radiatingly eight
to fifteen together from the receptaculum (or placenta).
When perfectly ripe, the "spores" broke up and fell irregu-
larly upon the receptaculum. Pacini regarded the my-
celium as an independent alga. The vacuoles and granular
opacities were, in his opinion, the mycelial spores. The
case was probably one of asp. niger.
Grove (1857) found a fungus in an ear which had been
treated for a "scrofulous discharge " with luke-warm injec-
tions of water and instillations of glycerine. The mycosis
was at first unilateral, but subsequently appeared in the other
ear, and was finally cured by instillations of alum. Grove
thought that the fungus corresponded with that described
by Mayer, but the conidia were oval, reddish-brown, and
formed a compact mass which completely enveloped the
end of the broad fructifers (conidiophores). This was evi-
dently a case of asp. flavus.
Kramer (1859) described with great accuracy and compre-
hension a specimen from the human ear of asp. niger,
which he calls sterigmatocystis autacustica.' This fungus
was found in the meatus of a " rather dirty " person, in the
form of a white membrane which rested upon the Mt, and
whose inner surface was covered with black specks sup-
ported by pedicles. The membrane proved to be the
mycelium ; the black points were correctly regarded as
the conidiophores. No one has ever better described than
Kramer the structure of the latter. He is also the first to
show that the sterigmata of this fungus are ramified, a fact
which later fell into oblivion. Kramer reports that the
affection in this case underwent repeated relapses during
the use of glycerine, but was finally cured by the use of
lead acetate (o.io : 30.00).
' This title of sterigmatocystis, for aspergilli with ramifying sterigmata, is
even in our days advocated by the botanist Van Tieghem.
190
F. Siebenmann.
Several observations on aural fungi and their cultivation
were published between 1860-70. Schwartze (i860) ex-
presses the opinion that his aspergillus does not differ
essentially from asp. glaucus.
Wreden (1868) published the first really important work
upon this disease, which he calls myringo-mycosis asper-
gillina. In this paper he gives for the first time a detailed
and botanically exact description of asp. flavus. (which he
calls flavescens), and asp. niger (which he calls nigricans).
He thinks, moreover, that both are to be regarded as
varieties of the same species, asp. glaucus (eurot. asp.-gl.),
and he believes that he has proved this assertion by culti-
vation (asp. gl. cultivated on orange-peel developed the
variety flavescens; upon lemons, nigricans). The "mass of
leptothrix " found in the external layer of an aspergillus
pellicle when removed from the ear, was looked upon as
the direct offspring of the aspergillus. The dimensions of
both fungi are accurately given ; asp. fumigatus does not
appear to have been observed. The chief causes are :
(i) spores from the air; (2) moderately dry soil, upon
which a bit of epidermis (even only microscopically visible)
has been loosened by inflammation. The fungus, there-
fore, does not grow in cases of diffuse inflammation, nor
could it be inoculated upon tJie healthy ear. It prefers the
locality of the Mt and the neighboring portions of the
bony meatus; if the Mt is defective, the disease may
attack the tympanum. The symptoms of myringo-my-
cosis, according to Wreden, are: (i) deafness (occasionally
sudden), tinnitus, pulsating noises in the ear, invariably a
violent, tearing, and piercing pain, which occasionally ex-
tends over the head and neck, increasing to just before
the exfoliation of the fungus mejnbrane, and then suddenly
ceasing; (2) and objective: injection of the manubrial
vessels, loss of brilliancy in the Mt, and the appearance of
a powdery white deposit, which rapidly increases to a com-
pact membrane (1-3 mm. thick) covered with yellowish-
brown and black spots. The structure of the latter is of
the stratified order, the innermost layer resting on the Mt,
and containing many of the spots which, under the micro-
The HypJioniycctes Aspergillus, itc. 191
scope, are discovered to be conidiophores and clumps of
conidia. The inner third of the meatus is at the same time
inflamed, but the secretion is slight and purely serous. If
carefully diagnosticated, the case may be cured in from one
week to three months; if neglected, it may persist for a
year. It is not generally possible to discover and to observe
the removal of a new membrane sooner than in a week, but
in one case, in which the fungus rested in the tympanum,
the membrane developed once, and even twice, within a
space of twenty-four hours. The asp. nigricans causes
more pain than flavescens, but is a rarer variety, 4 to 10
being the proportion.
Wreden regards these aspcrgilli as genuine parasites that
penetrate the skin. The prognosis is very favorable if
the Mt does not undergo perforation, but there is ex-
cessive tendency to relapse. Wreden recommends their
destruction by subchloride salts, especially by calcium
hypochlorate (0.10:30.00), alcoholic solutions of tannin
(0.60:30.00), weak aqueous solutions of lead acetate with
glycerine, and, finally, chlorine water. He also observed
spontaneous cures, as well as cures after the use of sodium
carbonate, oil, or even of fat (!). Fowler's solution, strong
solutions of silver, and corrosive sublimate, are to be
regarded as parasiticides, and inimical to the growth of
fungus. Alcohol is of no essential effect 7ipojt the tissues
of the aspergillus. Wreden found that spores underwent
germination after remaining two days in aqueous solu-
tions of iron sesquichloride, copper sulphate, and iodine-
glycerine.
Weber-Liel (1868) gave an account of three cases of as-
pergillus ; the variety of which was, however, not men-
tioned. He expresses the opinion that the growth of this
fungus is at first saprophytic ; later, parasitic ; and that
anomalous secretion of tJie meat2is offers a favorable nidus for
the conidia. The irritation is due to the tension of the
layers of epidermis while being penetrated by the fungus.
Boke (1869) saw an asp. (fumigatus ?) after the use of an
ear-lotion which contained numerous spores in a state of
germinal activity. In 1870 Hassenstein recommended
192 F. Siebenmann.
spiritus vini red. to be dropped into the ear in eases of otomy-
cosis.
In the same year Voltolini described a case of flavus, with
ramifying sterigmata, and thought from his experimental
cultivations that penicillium, aspergillus, and sterigmato-
cystis were merely varieties of one and the same species.
Gruber also published at this time the first botanical de-
scription of asp. fiunigatiis as found in the hiunan ear. The
descriptions are not absolutely accurate, but the identity of
the fungus cannot be doubted. Karsten described the
specimen as about one half the size of fumigatus, otherwise
it was identical with this species. Cultivation showed that
asp. flavus appeared to be a variety of penicillium, ffom the
fact of the occurrence of accessory conidiophores in fumiga-
tus or flavus. Steudener describes still another case of asp.
with small, smooth, black spores ; the basidia were of a
smoky gray. He also mentions the demonstration by
Politzer of a Mt which was penetrated by a fungus ; a con-
dition by means of which the latter author hopes to support
his theory of the parasitic nature of aural fungi. But Steu-
dener replies that he had seen numerous dry aural prepara-
tions in which the Mt, previously imperforate, had been de-
stroyed after death by fungi whose nature could not be de-
cided, and consequently that Politzer could not thus prove
his theory. These fungi were probably saprophytes ; the
fungi of which we are here speaking ?;^z/^r appear as genuine
parasites in the vegetable and animal kingdom.
In 1873 Wreden reported seventy-four cases of myringo-
mycosis. He concludes that this affection is an independent
parasitic disease of the ear, the specific fungus of which is
aspergillus with its numerous varieties. Asp. nigricans ap-
pears twice as often as asp. flavescens. In myringo-mycosis
the pseudo-membrane occasionally covers the neighboring
portion of the meatus, but rarely extends beyond the inner
third. Its outer surface turned toward the cavity of the
meatus is usually of a lardaceous appearance, while on the
inner surface the ripe sporangia shine through as yellowish
or black specks which are occasionally arranged in a circular
form. Suppurative otitis opposes, serous otitis favors, the
The Hyphomycetes Aspergillus, etc. 193
growth of the fungus. " It is impossible for me," says
Wreden, " to accept a myringo-mycosis without subjective
symptoms of disease." He defends his former opinions,
with exception of the fact that he formerly met with the
asp. flavus more frequently than with asp. niger. His last
conclusion, however, is new: "The ascomycete form (the
utricular fruit) of the aspergillus has been found." This
consists of round, double-contoured sacculi filled with
round spores (see plate I, fig. 3, these ARCHIVES, vol. iv).
The conidiophores were septated. Wreden found this fun-
gus, which he calls otomyces purpureus, in an ear near the
conidiophores of asp. nigricans.'
Bezold (1873) furnished the next contribution to the origin
of aural fungi. The two chief causes of its growth are: {ci)
the intrusion of portions of fungus ; {U) morbid condition of
the epithelium. He shows from his list of several cases
that the previous presence of oil in the meatus is one of the
most important causes. The nature of the disease is at first
saprophytic, then parasitic. The assertion, that the
fungus membranes are not a pure saprophytic formation,
is proved by their firm adhesion to the terrain, the swell-
ing, redness, and exfoliation of the region, the fact that the
exfoliated epidermic cells are interspersed with fungus, and
the repeated relapses despite careful cleansing. Two years
later this same author recommends the local application
of acid salicylic, 2.00 ; aqua dest. and alcohol, aa 50.00: but
^ This description does not coincide with that of De Bary's perithecium, nor
with the sclerotiumof the asp. niger of Wilhelm and Van Tieghem, for the latter
are larger, opaque in the first stage, and without spores, while in the second
stage they contain free asci with bean-shaped spores. Besides this the ear does
not offer those conditions which we must regard as necessary for the formation
of sclerotia. In order to settle this question at once I will anticipate the his-
torical development of our subject by referring to an article of S. M. Burnett
(these Archives, vol. x, p. 319). A man affected with psoriasis of the right
meatus. Instillation of tinct. opii one part, sweet oil two parts, glycerine
two parts, was soon followed by pain and increased deafness. The meatus con-
tained a substance resembling a blood-clot, which, on examination, showed
Wreden's otomyces purpureus without spores or sterigmata. The mycelium
and epidermis were also tinted red. I have seen a similar condition of purple-
colored epidermis and fungi in a case of asp. fumigatus (see case lo, posted).
As the above descriptions of otomyces show its identity in structure and dimen-
sions with a mould (which has repeatedly been found in the ear and likewise
causes irritation and itching which lead to scratching and bleeding excoria-
tions), it is probable in the above case that the coloring matter was foreign,
and originated from the blood corpuscles.
194 F- Siebcnmami.
even with this treatment he met with one relapse in two
cases. Experiment shows that the salicyhc acid used in
this way exerts an active influence upon the fungus, and
especially upon the conidia. One-per-cent. solution of
carbolic acid has no effect, nor has calc. hypochlor. A
moderately strong solution of potass, hypermang. is more
reliable.
In 1879, C. H. Burnett reported twenty cases of asp. niger,
in some of which the fructifying organs of the fungus mem-
brane were absent. His botanical determination is very
arbitrary. The affection first shows itself on or near the
Mt, especially the lower half ; also in the tympanum as
a yellowish dust-like deposit, which later undergoes trans-
formation into a pseudo-membrane. At a later stage
the conidiophores and mycelium can no longer be dis-
tinguished. The meatus then appears as if obstructed with
a plug which bears great resemblance to a wad of news-
paper, and does not unroll or break up in water as is
the case with a plug of cerumen. A slight serous discharge
accompanies or even generally precedes the mycosis. As-
pergillus is not observed in company with suppurative
otitis. Subjective symptoms are rarely absent ; deafness
and pain are well marked when the mycosis has invaded the
Mt. The causes are: mechanical irritation of the meatus,
lack of cleanliness, removal of the ceruminous layer by
scratching, syringing with soap and water, bathing, besides
transportation from ear to ear by cotton, syringes, and
specula. Burnett also thinks that the disease at first
saprophytic may at a later stage become parasitic. The
patients' surroundings were generally good. The membrane
should be removed by delicate manipulation ; syringing
of alcohol pure or diluted with water (i to i or i to 2),
Relapses were occasionally noticed, even after a cure by this
medication had lasted for months and years. Instillations of
silver nitrate are useless ; sodium subsulph. is better (0.18 :
30.00). Eczema of the ears should never be treated with
oily substances, for they afford too favorable nourishment
for aspergilli. Some fungi appeared in ears which Burnett
had treated for perforation, eczema, pruritus, etc., with
TJie Hyphoniycetes Aspergillus, etc. 195
caustic or astringent remedies. Case seven is interesting
in regard to the role which, according to Burnett, ceru-
men plays in the origin of aspergillus.
A young boy suffered in the summer of 1875 from itching and
pulsation in the right ear. The ear was then syringed, but the
deafness gradually increased. In October, several months after
the irritative symptoms had all disappeared, Burnett removed a
plug of cerumen which enclosed a tuft of aspergillus. The ear at
once became normal in all respects. There was no relapse,
although no further treatment was instituted.
Bezold, in 1880, reported forty-eight new cases of otomy-
cosis. He found one case of this disease in every sixty-five
aural patients, a very curious fact, when compared with the
statistics of Blake and Shaw (1873), of but one case in 1,652
aural patients. In nineteen cases the course was free from
symptoms and the discovery of the fungus accidental.
Simple syringing sufficed for a permanent cure.' It is
generally in these benignant cases that we find an old per-
foration of the Mt, through which the process extends to
the tympanum. In the remainder of Bezold's cases, the
mycosis was complicated with itching, exfoliation of
epithelium, moderate deafness, pain, and serous discharge;
in four cases acute perforation of the Mt, with long-con-
tinued pain and protracted recovery. The varieties were
asp. niger 11, flavus 8, fumigatus 18. Cultivation proved in
his opinion that all were genuine. Bezold also thought
that he had discovered perithecia in a dry preparation of
asp. niger, but the description is not full, and even its yellow
color does not correspond with Van Tieghem's account.
The causes are : (i) the introduction of irritating foreign
bodies which at the same time furnish a good nidus, e.g.,
portions of plants, tea, liquors, fat, oil — out of forty-eight
patients, thirty-eight had instilled oil into their ears ; (2)
desiccated tympanic secretion. An interesting discovery
was made in one patient, in one of whose ears oil was in-
' Wreden knows nothing about otomycosis without symptoms, a singular fact,
which may be explained by remembering that he does not recognize the
invasion of asp. fumigatus, which is without a doubt often free from symptoms
(ten out of eighteen according to Bezold).
196 F. Siebenniann.
stilled for deafness, when an asp. niger subsequently appeared
with inflammatory symptoms and perforation of the Mt ;
in the other ear were found the conidia of asp. niger- — but
they were simply in a condition of rest.
Lowenberg considers that the presence of aspergillus is
due: (i) to the eczematous action of rancid oils and fats; (2)
to fungoid elements in old aqueous remedial solutions
(tannin, zinc sulphate). As prophylactic he suggests: (i)
that we should avoid the introduction of oil and fat ; (2) use
alcoholic solutions, or solutions containing as little water as
possible, — these should then be diluted to the proper pro-
portions with ^^z7/;/^ W(^/^r just before using them for the
ear ; (3) the instantaneous heating of all instruments which
have been used in ears affected with mycosis.
I have now given a brief account of all accessible papers
bearing upon the subject of hyphomycetes. It has of course
been impossible for me to give proper attention to all of
the American papers, which are especially productive in
clinical cases. And beyond this, I am obliged to confess
that I have made no mention of many other articles upon
the same topic, for my aim has been simply to show in broad
outlines the process of development of the various opinions
that have been advanced from time to time during the last
forty years, on the nature and treatment of the affection
under discussion.
I will now offer a brief account of several cases which
have been observed at the clinique of Prof. Burckhardt-
Merian, and which are of much interest, throwing light as
they do upon the methods of treatment to which we resort
and the etiology of the disease.
Case i. — Mr. S., set. thirty, January 20, 1874, has complained
for four weeks of itching in his right ear, and used glycerine
daily to relieve the unpleasant sensation. The meatus is partially
closed with whitish shreds composed of aspergillus and epithelium.
Ordered a two-per-cent. solution of carbolic acid in glycerine,
twice daily.
January, 315/. The aspergillus has disappeared, but the meatus
is still somewhat obstructed. Zinc sulphate, 0.05 ; glycerine
25.00. Cure.
The Hyphomycetcs Aspergillus, etc. 197
jFuly \']th. — Fiisl relapse. Tinnitus is very much marked,
especially in the morning. Abundant masses of aspergillus are re-
moved in the form of membranes. Solution of potass, hyperman-
ganate at night, and the meatus to be cleansed with absolute
alcohol.
Dee. \th. Subjective and objective conditions normal.
1875, March 23^/. — Second relapse. Clumps of aspergillus lying
directly in front of the left Mt. Instillation of oil.
April 6th. The ear has apparently been entirely obstructed since
the last report. Some whitish crumbs with adherent aspergillus
are removed by means of hooked probes. After the meatus is
thoroughly cleansed, the Mt looks reddened, but the meatus
normal.
April loth. Blackish-gray masses of aspergillus as large as a
pea are scraped away from the annulus tympanicus and Mt by
means of hooks. Insufflation of pulverized salicylic acid.
April i^th. Well-developed clumps of aspergillus. The patient
is directed to bathe his ear daily for a quarter of an hour with
acid, salicyl., 4.00 ; alcohol absolutum, 100.00, and then to syringe
the ear. He is to continue this for three days.
April 2/^th. The ears appear free from aspergillus, and hearing
is normal.
1876, jl^uly 29th. — Third relapse. The left ear feels as if it were
stopped up. The patient of his own accord has instilled into the
ear an alcoholic solution of salicylic acid in order to relieve the
intense pain. Whitish masses removed from the meatus show dead
aspergillus elements. The recovery now became complete,
although no further treatment was employed. There have been
no relapses up to this date.
The notes show that aspergillus made its appearance during the
long-continued use of glycerine in the ears. We see a relapse in
six months, and two others at intervals of about a year. The
attacks are relieved by the use of various medicines : Potass, hyper-
mang., carbolic acid water, zinc sulphate in glycerine {zvhich has
the property of favoring the formation of futigus). A fourper-
cent. solution of salicylic acid in alcohol produces rapid recovery in
the last two relapses. Insuflatiofis of salicylic acid are inefficacious.
Oil appears to ijicrease the affection. The attack begins twice in
the summer, and once each in the winter and spring.
Case 2. — Mr. W., 1874, March 19th. His hearing on the right
side has slowly decreased during the last month, and he has suf-
198 F. Siebenmann.
fered from stretching and itching in the meatus. There have been
neither tinnitus nor pain. The cerumen contained some snow-
white dotted patches of asp. fumigalus, with club-shaped conidi-
ophores. Hearing : R, Politzer 25 c/n.; L, normal. Treatment :
removal with the syringe and instillation of a one-per-cent. solu-
tion of carbolic acid in glycerine once daily.
March 27///. A few whitish flakes are still syringed away.
Hearing normal. The carbolic-glycerine solution is continued
eight days, and produces a definite cure.
Recovery after the use of a one-per-cent. solution of carbolic-
glycerine, which, in the opinion of Bezold, has hardly any influence
upon the vitality of aural fungi.
Case 3. — Mrs. A., December i8th, 1875 ; has complained for a
year of gradually increasing itching of the left ear, which has
caused her to scratch it excessively. Since October, small fu-
runcles, intermittent pain, slight discharge. The meatus was not
examined by the physician then in charge, but camomile tea was
ordered as an instillation.
The hearing is watch 5 cm.; meatus filled with lumps of asp.
niger. After their removal, H 40 ctn., meatus hypersemic. In-
sufflation of alum and gum.
Dec. 2\st. Left ear again " stopped up," violent pain, increased
discharge, meatus obstructed with a thick membranous deposit,
consisting simply of aspergillus, which is at once removed. In-
stillations of ol. amygdal.
Dec. 23^/. An hour afterward the hearing had again become
obstructed. The patient told us that she had laid some mouldy
grapes close to the ear-cotton in a table-drawer. A sac-
shaped cast of the meatus is syringed out and found to consist of
aspergillus. Daily cleansing with a four-per-cent. alcoholic solu-
tion of salicylic acid.
Dec. 2()th. H 120 ctn.: meatus less swollen and dry. A large
number of whitish scales, which are lying rather loosely in the
meatus are removed. The microscopic examination shows that
these are only bits of epidermis. Daily cleansing with the pre-
vious alcoholic solution.
1876, J^afiuary e^th. No itching. Another epidermic sac,
which looks like silk-paper, is removed.
February nth. Perfect recovery, with normal conditions.
The local application of alufn, gum, and oil does not exert any
favorable influence upon the course of the disease. Rapid recovery
TJie Hyphomycetes Aspergillus^ etc. 199
after the use of a fourper-cent. alcoholic solution of salicylic
acid. The aspergillus may have been introduced within the meatus
upon the cotton that had lain near some tnouldy grapes.
Case 4. — Oct. 28, 1878. Mr. G., has had frequent colds
duruig the last four years. During one attack he took an Irish-
Roman bath, and noticed on the following day, in both ears, a
roaring, which has persisted ever since. He has also had repeated
abscesses in both meatus alternately. His hearing has slowly
deteriorated from some unknown cause. During the last month
he has had eczema of meatus and pain in the ear, for the relief
of which glycerine has been used. H, Politzer, left, 20 cm. ; right,
I cm. Meatus blocked up with eczema, showing just inside a bit of
aspergillus (fumigatus ?). The right meatus is filled with whitish-
gray masses of aspergillus. The crusts are softened with a two-
per-cent. solution of salicylic oil, and the ear subsequently syr-
inged with a solution of sodium sulphate.
Nov. %th. Left, H, 60 cm. ; meatus clean ; right, H, 5 ctn. with
fresh aspergillus in the meatus. Ordered for both ears three
times daily, for fifteen minutes each, a bath of four-per-cent.
alcoholic-salicylic acid, and then to use the syringe. After using
for eight days, stop using for same length of time.
Nov. i()th. Left ear, H, 40 on. ; right ear, H, 80 cm. Both
meatus free from aspergillus, slightly congested, and containing
shreds of epidermis. The itching persists despite the use of an
arsenical solution internally, and tar externally. Still both meatus
remain permanently clean.
An eczema of the auricle is treated with instillations of glycerine,
ivhereupon the deepest parts alone of the meatus become affected with
aspergillus. Brief applications of salicylated oil, syringitig with an
aqueous solution of sodium sulph., are inefficacious. Definite cure of
the mycosis after the use of a four-per-cent. alcoholic solution of
salicylic acid. The eczema is not wholly removed, but remains dry.
Case 5. — Dec. 10, 1878. Mr. B. has suffered for three years
with slowly diminishing hearing, itching, and exfoliation of scales
from both meatus. He had previously been troubled with a
watery discharge, but never with pain. He is accustomed to
remove the cerumen by scratching.
Hearing : left, Politzer, 200 cm. ; right, 60 ctn. The left ear
exfoliates scales of epidermis in lamellae. The right meatus con-
tains cerumen and aspergillus fumigatus (white, like meal . We
ordered for the right ear the use, three times daily, of the four-per-
200 F, Siebeinnami.
cent, alcoholic-salicylic-acid solution, to be followed up with
glycerine. For the left ear, only glycerine at first, and the above
alcoholic solution in case the itching continued. Cure.
Eczema of both meatus, which the patient scratches a great deal,
and thus retnoves the cerumen. Aspergillus in one ear only. Cure by
salicylic acid iu- alcohol.
Case 6. — Sept. i, 1879. Mrs. H. The right ear is normal.
The left ear, during the last five years, has frequently been filled
with cologne water, etc., for the relief of toothache. Incessant
tinnitus, like the noise of railroad cars ; meatus normal ; Mt
opaque and concave. Treatment : air-tight tampons, previously
covered with freshly prepared emollient ointment. Internally,
hydrobromic acid, gtt. xv, ter in die.
Sept. 8th. The roaring has disappeared, but the meatus is filled
with asp. niger. A few bleeding excoriations and minute ab-
scesses are visible. Tampons of salicylic cotton (five per cent.)
without the ointment.
Sept. i^th. The aspergillus has apparently disappeared. Four-
per-cent. alcoholic-salicylic solution brushed on, and the meatus
filled with simple salicylic cotton. The hydrobomic acid aban-
doned.
Sept. 2jth. Aspergillus has disappeared. The tinnitus has re-
appeared. Hearing, 20 cm. For the sake of experiment, perma-
nent closure of the meatus with salicylic cotton covered with
emollient ointment.
Oct. 4th. The whole meatus is again filled with aspergillus.
Thorough cleansing of the whole interior of the meatus with the
alcoholic-salicylic solution. Simple cotton in the orifice.
Oct. nth. The meatus is losing its epidermis. Embrocations
of alcoholic-salicylic acid, and continuation of the obturation
with simple cotton. Pain has entirely disappeared. Recovery.
After hertnetically closing the meatus with plugs of cotton covered
with emollient oint7nc7it, we see a rapid {eight days) development of
luxuriant aspergillus. Despite which, however, no spores could be
discovered in the oi?itme?it. {In my opinion the fungus in question
never thrives upon this substratum?) The ointment increased the
eczema, partly by direct contact with the skin of the meatus, partly by
rendering the cotton plugs so ifnpervious to air as to prevent the escape
of the evaporating moisture in the bottom of the tneatus. The latter
circumstance also explains the manner in which the ointment favored
the development of the fungi.
The Hyphomycetes Aspergillus, etc. 201
Case 7. — Mrs. H. has suffered for six years with gradually in-
creasing, intermittent pains in both ears, with but little otorrhoea.
'yiine 20, 1880. Chronic eczema of both meatus. Hebra's
ointment to be applied twice daily with dossils of lint.
Dec. T,d. The chronic eczema still persists, and there is much
itching. Aspergillus niger on both sides. Ordered the alcoholic-
salicylic solution, to bathe the ears with twice daily for ten to
fifteen minutes.
December \^ih. No more itching. After removal of loose masses
of aspergillus, the meatus are clean. Cured without a relapse.
The patient returned, May 30, 1882, with otitis ext. desquam.
Itching was not noticed, nor was there any trace of aspergillus in
the portions of cuticle removed. Uninterrupted cure.
A chrofiic eczettia with slight exudation is increased by the applica-
tion of an ointmefit, and aspergillus appears. Cure by the four per-
cent, alcoholic-salicylic-acid solution. The eczema reappears at a later
date, but does not give off any exudation, as a result of which the
meatus remains free from the fungus.
Case 8. — Mr. W., January 21, 1882. For two weeks, excessive
itching in both ears, and a feeling as if water were boiling, in the
the left ear particularly. He has used a white salve for three days,
in the hopes of improving his condition. Squamous, extremely ir-
ritable eczema upon the neck and scrotum. Aspergillus fiiger on
both sides. (Conidia, 4-6 ?nm. diameter ; sporangia all broken
off ; numerous delicate white pellicles composed of epithelium,
fibrinous and structureless masses, detritus, and cocci.) Ordered :
alcoholic-salicylic ear-baths. As the patient did not return, we
assume a recovery.
Eczema on various parts of the body, excessive itching in both ears,
appearance of aspergillus niger.
Case 9. — Mr. H., aged eighteen, April 2, 1882, had suffered
since childhood with caries of the temporal bone, which, however,
healed a year ago.
In the right ear, although there has been no discharge for
years, the meatus is filled with cerumen, upon which we see white
tufts of aspergillus fumigatus, which have developed without any
symptoms (especially without itching). There was no treatment
and no relapse. The mass removed from the ear consisted of
white bunches of mycelium which had been torn away from their
resting-place, and stratified thick clumps of epithelium. The
latter is white upon its lower surface, (the one formerly turned
202 F. Sieberuncwin.
toward the skin of the meatus,) is composed of swollen layers
of epithelium, and is entirely devoid of mycelium. An occasional
hyphomycete can be discovered in the middle layers. The upper
surface (formerly turned toward the cavity of the meatus) is
half covered with cerumen. The other portion shows with the
microscope about thirty grayish-green granules, which upon
closer examination are evidently the heads (sporangia) of asp.
fionigaius. The external layers of the skin are here and there, in
company with the overlying fungi, tinted purplish-red.
Upon a scab we find afi entirely superficial aspergillus fumigaius,
which has grown zvithout any symptoms, and which does not relapse
after its tnechanical refnoval.
Case lo. — Miss F., aged twenty-five, chronic suppuration of the
middle ear for years.
1882, April 2^th. Ordered, for reasons concerning which Prof.
Burckhardt-Merian will in due season justify himself, zinc sul-
phate, 0.10; glycerine, 20.00; aqua destillata, 5.00. Thorough
syringing every two days with boracic acid in aqueous solution.
After examination of the oih^r perfectly clean ear, boracic acid is
insufflated.
May ^th. Patient writes us that after the last insufflation of
the boracic-acid powder, she perceived in her ear an itching and
tickling which constantly increased ; the hearing also was a great
deal worse. She sent at the same time a " croupous " cast of the
meatus, with the remark that it had been forced from the ear on
that very day, during a violent fit of sneezing and coughing.
May 10th. A similar tube-like tissue was syringed out. Or-
dered the alcoholic-salicylic bath three times daily for a quarter
of an hour. This treatment was followed by a violent attack of
ciysipelas, which extended from the ear over the head. Perfect
recovery.
The two masses which had been forced from the meatus were
precisely similar to one another ; a thick, grayish-yellow, rumpled
flexible tube, about two cm. long and one half cm. thick, having
the appearance and consistence of a croupous membrane. Re-
action slightly acid. On the first day there was no odor, but on
the second it became somewhat more marked, but never putrid, re-
minding us of the exhalation from long-haired dogs. The centre
of the tube is occupied by a very narrow canal entirely filled with
pus, mucus corpuscles, and debris. The canal is open at both
ends where it appears enlarged and spout-shape. The outermost
The Hyphomycetes Aspergillus, etc. 203
envelope (which could be removed with the greatest facility) pre-
sents itself in the form of a brilliant, transparent, smooth, occa-
sionally bluish-black, thin membrane, the inner surface of which
is almost entirely covered with a fine chocolate-brown, felt-like
lining. The surface of the granular layer, which lay in contact
with the latter, shows a similar fibrous structure and color. The
two envelopes, however, do not show the same stratification, for
here and there their individual layers fold complexly around one
another, or again separate regularly. The fissures and cavities
which thus arise are also provided with a dark, fine, granular
layer. The gray membranes consist mostly of large fungus my-
celia, free from epidermis ; the dark, felt-like membranes of
similar hyphse, together with numerous large dark conidiophores
of aspergillus niger. The latter are easily recognized by the
naked eye as the fine marginal fringes upon the little shreds under
the protecting glass. The fruit-heads (sporangia) consist merely
of the vesicles and sterigmata, while the ripe dark conidia lie de-
tached upon them (not in chains) ; many of them are swollen,
while but few are provided with embryonic sheaths. I shook
the fluid in which the preparation was contained (muddy water
with black sediment) over some wheat-bread, and obtained in
thirty-six hours an exceedingly luxuriant pure culture of asp.
niger, which became one half cm. thick in forty-eight hours.
After depositing some of the shreds from the membranes with the
conidiophores which grew upon them for twelve hours in alcohol,
salicylic-alcohol, naphthaline-alcohol, salicylic-paste, and boracic
paste, I washed them and subsequently prepared them, after
Koch's method, with gelatine. The boracic-paste preparations
flourished abundantly, and some of the salicylic-paste preparations
showed a few ripe conidiophores. The shreds which had been
treated with alcohol and alcoholic solutions did not grow.
Appearance of asp. niger, in a case of middle-ear suppuration,
under the use of boracic acid and zinc-glycerine. Four-per-cent. alco-
holic-salicylic solution successfully employed.
In my own practice, I have lately met with the following
cases of otomycosis.
Case i. — Mr. B., set. forty, a joiner. Aspergillus fumigatus,
which ran along without symptoms, six months ago, with excep-
tion of a slight otorrhcea of brief duration, lies in the shape of a
black powder upon the surface and within a mass of cerumen di-
rectly in contact with the Mt. After removal of this cerumen.
204 F. Siehcmnann.
the meatus and Mt appear normal. No treatment and no
relapse.
Spontaneous recovery of aspergillus funiigatus, dependent upon oc-
clusioti of air by a ceruminous plug.
Case 2. — Mr. O. A., ret. thirteen. April 29, 1882. Suffered
since last autumn from double otitis media catarrhalis, with per-
foration of Mt. On the left side, discharge for a few weeks and
intermittent pain ; at present, deafness and tinnitus only. Right
ear: hearing, W=o ; large defect of Mt ; secretion alkaline and
offensive. The meatus is otherwise clean. Left ear : W, 2 C7n.;
meatus slightly swollen. A gray, firmly-adherent plug completely
fills the meatus in the region of the Mt. Ordered ear-baths of
three-per-cent. aqueous solution of sodium carbonate.
May 2d. Removed from the left meatus an inodorous plug
composed of several layers of epidermis, parallel with one another,
and as thin as paper. The superficial layers are covered with
sporangia of aspergillus fumigatus, similar ones being found
deeper down. Lukewarm water injections.
May 1th. The posterior half of the Mt is lost, the anterior
superior quadrant downy, as far as the margin of the perforation.
Young mycelium and sprouting conidia were removed ; no old
fungus membranes or conidiophores. Alcoholic-salicylic acid,
twice daily, for fifteen minutes.
May gth. A portion of the shreds, which did not, however,
contain any young mycelium, or but a few, if any, conidia, un-
derwent germination (in eight per cent, gelatine) in three days'
time. Alcoholic-salicylic ear-baths three times daily.
May ij\th. Recovery ; hearing decidedly improved ; no re-
lapse.
Perforation of the Mt on both sides. Aspergillus thrives only on
the side in which the secretion is scanty and free from decomposition.
Five days after removal of the aspergillus, a relapse, due to germina-
ting conidia which had been left behind. The daily (twice) use of
the alcoholic-salicylic-acid bath, for a week, does Jiot kill the conidia,
but finally brings about a permanent recovery.
Case 3. — Mrs. H, set. forty-eight. October 2, 1882. Deafness
and subjective noises in the left ear for three weeks. Instillations
of oil. Itching at the bottom of the meatus, and eczema on vari-
ous parts of the face. Aspergillus fumigatus in the inner third
of the meatus and on the Mt. Salicylic-alcoholic bath, three
times daily, for a quarter of an hour.
The HypJioniycctcs Aspergillus, etc. 205
Oct. igth No itching ; some swelling ; subjective noises un-
altered. Insufflation of aspergillus niger, and instillation of
oil.
Nov. 6th The latter, in the normal ear, are unaltered. The
tinnitus is present in both ears, but the hearing in both is good.
Eczema of the face j aspergillus fumigatus in the left ear. Cure
by the use of alcoholic-salicylic ear-baths. The ijistillatio?i of oil and
insufflatiofi of aspergillus niger does not produce any relapse.
B. Pathogeny and Pathological Anatomy. — After nu-
merous experiments at cultivation, I am of the opinion
that there are four things necessary for the origin and
growth of the various forms of aspergillus vegetation : (i)
conidia or spores, (2) a peculiar condition of the terrain, (3)
a temperature from 20° to 40° C. [68° to 104° F.], (4) a
moderately abundant supply of air.
The conidia of the three varieties of aspergillus with
which we are now concerned are suspended everywhere
about us, and, as a matter of course, not infrequently in the
air of our dwelling-houses. In order, therefore, to explain
any given attack of otomycosis, we have no need of search-
ing for obscure and hidden causes — such as damp, mouldy
dwellings, the instillation into the ear of medicated fluids
containing conidia, or of substances more or less inclined
to undergo decomposition. More than this, such conditions
as these are of no importance whatsoever in an etiological
point of view, for the aural aspergilli (aspergillus fumigatus,
flavus, and niger) only flourish in a high temperature, or
when bits of vegetation or the medicines supposed to be in-
troduced into the ear contain a large percentage of nitro-
gen ' ; the medicines, moreover, ought to contain carbonic-
acid gas, as well as traces of mineral salts and alkalies, which
is, however, by no means the case with our usual remedies.
Why, then, should fluids be more dangerous in this re-
spect than the common air?
Every normal ear offers the two succeeding necessities : a
' For the last year I have left about twenty of the most common solu-
tions used in office-practice, upon my desk, opening them from time to time to
admit the air, and, at a later date, examining them microscopically. I have
never found aspergillus but once, and then as a scanty mycelium upon a tannin
solution. Penicillium is by no means infrequent in boraic-acid solutions.
2o6 F. Siebetiniann.
temperature of 20° to 40° C, and free access of air. But
such an ear is unfavorable as a nidus for fungi, in so far as
pure unaltered epidermis is, as experiments show, a poor
soil for aspergillus, while only when moist, and even then
but scantily, does it afford sufficient nourishment for the
growth o[ funiigatiis alone. We can, therefore, affirm zvith
certainty that the latter variety of aspergilhis alone cafi flour-
ish in a normal auditory meatus, but even this only under
the rare and even abnormal circumstances that the entire
district is moist and continues moist for day after day.
(Case No. 9.) Under these circumstances, however, the
mycelium does not penetrate the epidermis, even when the
latter is moist (an aspergillus-strewn epidermis on Koch's
serum jelly is never penetrated ; the latter remains free
from fungus elements), for here the chemical and mechan-
ical activity of the fungus meets with very energetic resist-
ance. Still, the epidermis undergoes rapid decomposition
so soon as it contains for a greater or less length of time
the amount of water necessary for the energetic growth of
the aspergillus, but decomposing skin is not only a poor
soil for the conidia of aspergillus, but it may even inter-
fere prejudiciously with their vitality. This is a fact which
coincides with our experience that, despite the probable
abundance of conidia in the air within the meatus, otomy-
cosis is a comparatively rare disease.'
Inasmuch as simple mucus and the mucous membranes
are incapable of affording good nourishment to aspergillus,
we must at once reject the idea that this fungus might pos-
sibly insinuate itself into the healthy mucous membrane of
a tympanum, either from the conidia passing through the
Eustachian tube or through a perforation in the Mt.
What are the abnormal conditions of the ear which offer
a favorable foothold for the growth of aspergillus ? The first
which experience teaches us to reject is any that is accom-
panied with suppuration, for pus decomposes rapidly within
the ear, its reaction is almost always highly alkaline, and its
presence is sooner or later accompanied by the formation of
' Bezold, as we have seen, counts one case of fungoid invasion to every sixty-
five aural patients.
The Hyphoniycetes Aspergillus, etc. 207
ammonia and sulphite of ammonium, which are highly in-
imical to the growth of aspergillus. Experience also teaches
us that we find a much more favorable soil in the presence
of serum, at least of animal serum, and we shall not go far
astray if we conclude from this fact that aspergillus will at
least flourish equally well upon the serum of human blood.
I regret to say, however, that as yet I have been unable to
extend my experimental cultivations upon this base ; still,
its composition — a mixture of some soda- and magnesia-
salts, fatty acids, and especially of albuminates and water —
would appear to favor the above-mentioned idea. And if
we consider additionally that almost every case of otomy-
cosis is accompanied or preceded by a thin serous discharge,
since (i) old perforations of the Mt, with degenerated lining
membrane of the tympanum and serous secretion, are
found in one third to one quarter of all the cases of otomy-
cosis at my command ; (2) in all the other cases preliminary
symptoms of acute dermatitis of the meatus or Mt, and
exfoliation of the epidermis, are rarely absent (Burnett, etc.,
"prodromal symptoms" — -such as redness and loss of re-
flex on the Mi), and that eczema of neighboring portions
of the skin is frequently observed ; (3) and that whenever
there is an inclination to eczema of the external ear the
fungus invades the moist but never the squamous variety,
we shall not err in asserting tJiat almost without an exception
a free layer of serum affords the aspergillus the original, the
most favorable, and perhaps, after all, the only possible, soil
upon zvhich it can flourish. The most decisive fact is the
one to be discussed hereafter : (4) that the fungus, even
when otherwise entirely capable of life, ceases to grow so
soon as the disease of the meatus, which produces the exu-
dation, is healed or confined within moderate limits. The
primary cause is consequently an inflammation of the skin or
middle ear, but it must not be one zvJiich secretes a serum
capable of undergoing rapid decomposition. (The fungus
membranes in our cases of otomycosis have always been
neutral or shown a slightly acid reaction.) A hundred
conidia which are lying about in the secretion, either in a
state of rest or germination, will perish, where one will de-
2o8 F. Siebenmann.
velop any great amount of growth or gain a strong foothold,
for the secretion from a layer of serum which is thin, in-
odorous, and free from bacteria for any considerable num-
ber of days is, in the majority of diseases of the external and
middle ear, a rarity ; moreover, even in such cases, the es-
cape of the discharge is so much interfered with by the
swollen condition of the meatus, that at a later date we
are still sure to meet with a stagnation and consequent de-
composition of the secretion. To this chain of circumstan-
ces do we owe the fact that otomycosis aspergillina is not
more frequently met with. The rule is, decomposition of
the more copious or more purulent secretion in the ear, or
desiccation of the slight secretion. In the first case the
conidia which have fallen off cannot germinate, or, if
germination has already begun, it ceases at once, and the
shreds of mycelium are soon washed away in a dying con-
dition. If the secretion, on the contrary, is at this time in
a state advancing toward desiccation, the fungus must al-
ready have undergone luxuriant development, or even be
in the stage of fructification, before it can gain any foot-
hold. Only then will it be capable of keeping up a lively in-
terchange of matter in the substratum or of liquefying the
same, and, subsequently, by the product so originated, of
irritating the underlying corium to renewed secretion, and
thus of ensuring a continuation of its own existence. But
if, at the moment in which the secretion is rapidly growing
poor in fluid elements, the fungus is still backward in its
growth, it ceases to develop so long as the serous soil con-
tinues to undergo desiccation. The cure of the excoria-
tions which furnish the secretions can then go on undis-
turbed ; the dry serous layer changes into a scab which
rests upon the regenerated epidermis, and carries upon its
surface the fungus elements in a stationary condition.
Finally, it loosens without giving rise to any symptoms,
falls at a later stage from the ear, or has already become
enveloped in a layer of cerumen.
The statistics of Wreden and other observers show that
children are rarely affected witJi otomycosis. The chief reason
for this fact may lie in the circumstance that children are infre-
The Hyphomycetes Aspergillus, etc. 209
quently affected with those inflammations of the external
meatus which furnish only a slight amount of secretion ; in
other words, the otitis externa of children is generally of
the diffuse type. Besides this, it is a matter of every-day
observation that eczema in children, with equally extensive
propagation and similar localization, is much more " fluid "
than when observed in adults. For this very reason, then,
the soil is in those cases much more unfavorable for the
growth of fungi, because a moderate secretion undergoes de-
composition sooner than one which is deficient in fluid
and less abundant in quantity. This inclination to decom-
position is, moreover, extraordinarily furthered by the re-
markable narrowness of the juvenile meatus, which becomes
much more marked by the swelling of the walls, so that the
secretion stagnates in much greater quantity than in the
meatus of adults. Beyond this the cerumen in the youth-
ful meatus is generally more fluid, and must consequently
exercise a deteriorating influence upon the growth of fungi.
Finally, we must not forget that in the early years of life
at least, affections in the auditory meatus are not generally
noticed by the child or taken care of by its parents.
Every thing that has a tendency to transform a suppura-
tive otorrhoea into a serous, or to diminish the amount of the
secretion, or to prevent decomposition, favors the grozvth of
fungus. Almost every observer, therefore, of otomycosis
reports cases in which, during the treatment of suppurative
otitis with astringents and disinfectants, they suddenly saw
under their very eyes as it were, the formation of aspergillus
in the meatus, or on the Mt, and even in the tympanum.
The solutions of tannin and zinc, as well as glycerine, ap-
peared to act most mysteriously in these cases, and yet this
is little to be wondered at, when we reflect that various al-
buminates offer an especially favorable nidus for the growth
of fungi when they have been experimentally mixed with
these very solutions.
It is a well-known fact that acute inflammations of the
skin may originate from contact with water and aqueous
solutions, oils, and fats, and that when they are present they
can often be unfavorably influenced by the same applica-
210 F. Siebenmann.
tions. For the same reasons instillations, cleansing of the
healthy ear with soap and water, applications of oils and
ointments (Steudener, C. H. Burnett, Mayer, Bezold, etc.),
have been known to produce, maintain, and even to in-
crease an acute inflammation of the meatus and Mt. Par-
ticularly will this be liable to happen if the fats are in a
rancid condition. In cases of chronic inflammation, the
usual treatment by such remedies as these will be more
likely to facilitate the exfoliation of the epidermis and to
incite a serous secretion. Almost every one of Bezold's
patients with otomycosis had previously resorted to the in-
stillation of oil. Cases, consequently, are by no means rare
in which the otomycosis made its appearance as the asso-
ciated symptom of a general eczema, or at least of an incli-
nation to an " eruption " on various parts of the body, in
which case then an attempt was made to relieve, in the
above-mentioned manner, the itching in the meatus, or the
tinnitus, as well as the decrease of hearing.'
Scratching also is one of the irritative causes. The simple
introduction of an ear-speculum, left in position for a short
time, was followed in one case^ by an increased inflamma-
tion and the sudden diffusion of aspergillus, which previ-
ously had lain dormant in the meatus. The same may
happen in the cases of operative interference, introduction
of vegetable growths, plugs of cotton, etc. Since, as we
shall see later, the transformatory products of aspergillus
irritate the ear extremely, we should not be at all surprised
that the aspergillus can extend its locality.
For the same reason, it is a matter of course that the trans-
portation of the secretion of an ear thus diseased to a
healthy ear can again excite in the latter an eczema, which
may in turn become the transporter of the germs of asper-
gillus. Nor, further, should we be surprised, in the case of
such a double disease, that the affection on both sides should
be complicated witJi the IDENTICAL fungus, because the
' Out of fifty-Lhree cases of otomycosis observed and accurately described by
Wreden, Burnett, etc., forty-two suffered from other diseases of the ear, or the
ear had undergone washing with soap and water, cleansing, instillations, or me-
chanical injuries, etc.
^ Politzer's " Lehrbuch," p. 696.
77^1? Hyphontycetes Aspergillus, etc. 21 1
conidia of this species, after being transported, obtain rapid
possession of the new terrain, so that there is no room left
for the germination and growth of other conidia which may
possibly be floating in the atmosphere. A certain idiosyn-
crasy, which we will later mention, may exert some influ-
ence upon this condition.
Fresh cerumen not only does not favor, but it really preju-
dices, the growth of aural fungi. For this reason also the
absence of cerumen may be said to favor otomycosis, al-
though we cannot tell whether an abnormal condition of this
secretion (as in chronic inflammation), or its direct removal
(by washing or scratching), is the cause.
The coagulation of albumen, as observed in the serum in
the shape of a more or less extensive precipitate after the
use of zinc sulph., is also favorable to the appearance of
fungus.
Bezold has particularly emphasized the eczematous action
of various oils, and especially their specific and favorable
action upon the growth of aural fungi, and my experiments
fully confirm this observer's views. The cause, however,
does not lie, as has hitherto been assumed, in the good
nourishment which the oil offers to the aspergillus, but
rather in the circumstance that the oil restrains the forma-
tion of atmospheric mycelium and conidiophores in favor
of the more extensive development of the thallus, and
that by mechanical occlusion of the air it increases the
fermentative action of the aspergillus.
The relative amount of sugar in the serum of the blood
does not appear to exert much influence upon the appear-
ance of otomycosis. Burckhardt has frequently seen otitis
media in diabetic patients, but never knew it to be accom-
panied by aspergillus mycosis. Experiments also have con-
vinced me that the aspergillus does not flourish any better
upon saccharine albuminous solutions than upon similar
concentrated solutions which are free from sugar. A slight
amount of sugar appears to favor the early appearance of
schizomycetes, and thus to deteriorate the soil for the
growth of aspergillus.
Whenever we recall to mind the innumerable cases of
212 F. Sicbenuiann.
complete recovery, in which repeated relapses have occurred
after months or years, we cannot help believing that there
must be some individual dispositions^ or, as we may say,
idiosyncrasies, for otomycosis. In order to explain these
facts, we must recur to well-known laws of dermatology: (i)
that the reaction which follows any given irritation of the
skin may vary a great deal, depending upon the individual,
just as the course of the common type of eczema shows vari-
ous peculiarities in various individuals — one person, for in-
stance, after a given irritation, remains with a perfectly
healthy skin, another is regularly affected with an erythema,
followed by desquamation, while a third suffers from an
eruption of vesicles, etc. ; (2) that the secretion of excori-
ated patches, with reference to the relative amount of pus
corpuscles contained in the secretion, is likewise subjected
to as many individual variations.
Whoever, then, has the peculiarity of suffering from a
purely serous, scanty discharge (with but little tendency to
decomposition) after having met with some slight external
or internal irritation upon the wall of the meatus, and whose
meatus is so formed that this secretion cannot easily un-
dergo stagnation, will naturally and easily be inclined to
otomycosis.
Beyond this we recognize a special disposition for especial
SPECIES of aspergillus in the ear, and particularly for those
occurring in animal bodies.
In the seventy detailed cases of otomycosis which were
available, we found a large number in which the affection
repeated itself after an absence for months and years as
certified to by a physician. Yet, in nearly all of them we
discovered the striking fact that the aspergillus observed in
the relapses was always of the same species as that observed
in the original attack.
This discovery coincides with a series of other facts
which could easily serve to support the above theory of the
individual disposition for particular " species."
Raulin's investigations show that even with slight alter-
ations in the amount of salt in its typical nutrient fluid, the
aspergillus niger, which had previously luxuriated upon this
TJie Hypliomycetes Aspergillus, etc. 213
soil, at once disappears and gives way to other fungi. Ad-
ditionally, it has been shown beyond a doubt, that injections
of asp. fumigatus and flavus are fatal to rabbits, while those
of asp. niger are innocuous ; secondly, that the two former
fungi flourish remarkably well, the latter very poorly or not
at all, upon the serum of beef and dog's blood; finally, that
in the lungs of birds the aspergillus fumigatus alone has
been very frequently observed. Indeed, Lichtheim had
already remarked that certain species of animals were sus-
ceptible alone to certain varieties of mycosis. But in ad-
dition to this, the experience which has been gained from
the observation of otomycosis in man allows us to draw the
further conclusion that the disposition varies also within
particular species of animals.
It is also clear that the JicigJit of the temperature in the
human ear cannot be without influence upon the frequency
of the appearance of this or that variety of fungus. Thus,
for example, the aspergillus fumigatus most frequently
found in the ear is by its nature the commonest of the three
species of aural fungi ; it is, morever, so far as its nourish-
ment is concerned, much more modest in its demands than
niger and flavus. But in spite of all this, it is a fact that
the temperature offered by the inflamed, or even by the
normal, ear (36° — -39° C. : 98° — 104° F.), corresponds much
more perfectly to its necessities than to those of either of
the others, for where the temperature is but a little below
this height the variety fumigatus is absent. Aspergillus
flavus has the least desire for warmth of any of the species,
and it is an additional matter of fact that the extensive
statistics of Bezold and Wreden show that this variety is
very rarely met with in cases of otomycosis aspergillina.
Other hyphomycetes have been discovered in the ear,
where they are capable of playing the same parasitic role
as the aspergilli. But all of those, like these aspergilli, also
depend upon higher temperatures in order to appear out-
side the human body. But when the temperature is only
precisely as high as that of the human body, the penicillium
and the eurotium cease to grow, absorb no more nourish-
ment, and undergo no further septation. Nor, as we have
214 ^- Siebenmann.
already seen, do they appear to favor a region which con-
tains much albumen, but, on the contrary, acid saccharine
solutions. Penicillium and the eurotia have also rarely
been found in a prolific condition upon the living tissues,
although, like the aspergilli, they form membranes and can
act as a ferment. But in the latter point of view the inter-
change of matter, as well as the growth, proceeds very slowly ;
peculiarities which would similarly fail to favor its continued
existence in the ear. Thus, for example, tufts of glaucus
and repens which I planted upon the edge of a large defect
in the Mt, disappeared without a trace in the course of the
next eight days. On the other hand, I thrice found
EUROTIUM REPENS upon cerumen which had just been
removed from the ear. A year ago I examined a plug of
cerumen which Dr. Burckhardt had removed from the
meatus after recovery from otorrhoea, and found it covered
with fine golden-yellow granules and some black down.
The latter consisted of the dead vegetations of eurotium
repens, while the former represented the perithecia of the
same fungus.
Just a few days ago I met with a similar condition, but in
this case the perithecia and conidiophores of eurotium
repens were embedded in the cerumen. A third preparation
consisted of a lump of cerumen with membranes of the
same fungus.
In all three cases, the mycosis was confined to the ceru-
men, which, being a bad conductor of heat, is of a much
lower temperature than the surrounding walls of the meatus.
In spite of this the opportunities for development did not
suit this fungus, as was demonstrated by the formation of
the perithecia which had already taken place in cases one
and two.
I have never seen the eurotium grow upon fresh cerumen,
and the cultivation only succeeded when the latter had
been kept from two to four weeks under a moist bell
glass.
Statistics of Burnett, Wreden, etc., show that otomycosis
is much more frequently observed in the second half of the
year. Thus if I reckon as " cases " the relapses which have
The Hyphomycetes Aspergillus, etc. 215
been noticed after months of freedom from the disease,
I get the following table :
January to July July to December
Burnett 5 18
Wreden 3 11
Burckhardt 5 7
13 36
Nevertheless, this observation does not stand in any con-
nection with remarkable alterations in the amount of
conidia in the air. For the aspergilli flourish most
abundantly when the temperature is high ; and yet the
extremely hot summer months of July and August show
but five cases, whilst thirty-one were observed in the
remainder of the year. It is impossible for me to say
whether there are more opportunities for fungus growth
(eczema of the ear, etc.) during this period than at any
other time of the year. It is possible that this proportion
is quite accidental, and that it would vary with a larger
number of cases. Still I thought it necessary that this fact
should not be left unmentioned.
The favorite situation of the fungus pellicle is the Mt and
the inner third of the meatus, more rarely the tympanum,
and still more rarely the two outer thirds of the meatus.
The pellicle sometimes envelops the whole wall of the
meatus from the Mt to the external orifice.' This condi-
tion of affairs is not particularly worthy of remark when we
consider that the three aural aspergilli demand not only a
warm soil in which to grow but warm air also, and that they
find both of these favorable circumstances in the vicinity of
the Mt. Additionally, this region is free from cerumen.
The anatomical structure of the Mt, especially the
delicacy of its epidermic layer, which is easily exfoliated
even when an inflammation is of but slight degree, and per-
haps the arrangement of its blood-vessels and lymphatics,
contribute to the fact that moderate exudations (those with
' The swelling and excoriation often extend upon the auricle, but upon the
latter we never have found any hyphomycetes.
2i6 F. Siebenmann.
but slightly fluid and serous discharge, and consequently a
favorable terrain for aspergillus) are more easily produced
in this structure than in other parts of the ear. Burnett,
who has had an opportunity of seeing mycosis in its earliest
possible stages, observed that the fungi showed a predilec-
tion for the deepest portion of the Mt, a phenomenon
which must depend upon the drainage-relations of the
meatus for the secretion which arises in cases of myringitis.
No post-mortem examinations have yet been made in
cases of otomycosis, and pathological anatomy, especially
the microscope, has never yet been able to contribute any
thing decisive toward an explanation of the question
how and whether the structure of the auditory meatus is in-
fiuenced by the presence of aspergilli. Observations on the
living, however, show that the fungi usually cling very
closely to the nourishing soil, and that the latter after
mechanical removal of the iungus of ten appears reddejted and
usually excoriated. The question of the relation of the
Mycelium to the tissues to which it is attached has been par-
tially answered in one of the preceeding sections of this
paper, in which we offered proof that the fungus cannot
penetrate the mucous membrane or the epidermis when
intact, but that it takes root in the freely effused serum. In
all our cultivations of aspergillus upon surfaces of a firm
(not porous) or fluid substratum we have never seen (macro-
scopically or microscopically) the young mycelium pene-
trate deeply below the surface ; in every case the thallus
maintained its superficial existence. Such experiments as
these would throw much doubt upon the suggestion that
under precisely similar circumstances the mycelium might
penetrate into or between the extremely resistant cells of
the rete-mucosum. The case is quite different when
the conidia have become enveloped in the tissues by direct
or by vascular inoculation. Leber saw his aspergillus
develop into threads in the anterior chamber of the eye,
while Koch, Grawitz, etc., saw conidia germinate in various
coarse organs which do not contain air. I have seen this
same process after enclosing a fresh cultivation in ten-per-
cent gelatine. The hardened mass was, after a few days, ex-
The Hyphomycetes Aspergillus, etc. 217
amined microscopically, and aspergillus fibres more than one
cm. in length occasionally discovered. Although they have
but little intolerance for the removal of air, yet they
underwent germination in all of these cases, because the
other conditions for their growth were favorable. So much so,
indeed, that the mycelium became the object of so extensive
development from endosmotic processes and chemical altera-
tion of the adjacent tissues, that it occasionally entirely sep-
arated the structures through which it ran. But in vegeta-
tions upon open surfaces, — as is the case in the ear, — the
conditions are entirely different. The pressure caused by
the absorption of nutrition in a mycelial cylinder which is
sinking from the surface toward the interior, will, of course,
act equally upon all portions of the cell-walls. But in-
asmuch as the current of the humor flows upward and out-
ward, and can more easily devote itself to the new formation
of branches upon the surface where the resistance is
slighter, the pressure deeper down will never be so forcible
as in the above-cited case, so that as a matter of course
the mycelium will never cause any interruptions of con-
tinuity.
If mycelial fibres in the living ear become accidentally
enveloped by the development of the adjacent cells of the
rete, which are so rich in protoplasm, their downward and
deeper growth ceases. But, as the case goes on, lying, as
these fibres do, between the epidermis cells which have, in
the meanwhile, undergone cornification, they are pushed to
the surface and finally exfoliated. Such an occurrence as
this is by no means infrequent, as the stalk of the mycelium
always adheres very closely to the substratum, and it is,
moreover, an easy way in which to explain Bezold's discov-
ery in the ear of shreds of epidermis zvhich have been pierced
by fungus.
The inoculation experiments of the above-named investi-
gators prove that the vital force offers great resistance to so
strange an intruder, and that the exclusion of air, after a few
days, puts an end to its existence in the depths of living
animal tissues.
The fact that myringomycosis aspergillina can lead to
2l8 F. Sicbcnviann.
penetration of the Mt, simply proves that the irritation set
up by the presence of the mycelial membrane can excite the
myringitis to such a height as to destroy by suppuration
the entire thickness of the Mt. Since Gruber has shown'
that " at least ninety-five cases out of a hundred of primary
acute myringitis are complicated with perforation," we
must not be surprised at the frequency with which perfora-
tion of the Mt is noticed in cases of myringitis aspergillina,
but, on the contrary, at its rarity. Bezold, e.g., found only
four cases of perforation in forty-eight cases of otomycosis.*
After examining Politzer's preparations of a perforated Mt,
overgrown with fungi, Steudener remarks, as above cited,
that such developments of fungi in anatomical dry prepara-
tions are frequently observed as post-mortem appearances,
and prove nothing concerning their existence during life.
TJie firm attacJimcnt of the membrane, as is generally the
case upon the bare rete or corium, is also noticeable in all
other vegetations which are cultivated upon a firm sub-
stratum, and can be easily explained by the fact that the
mycelium adjusts itself accurately to every inequality of the
terrain, fills up all sinuosities, and embraces any jutting
promontories. If, additionally, the exudation upon which
the fungus grows is tenacious or crust-like, if the asper-
gillus (as is particularly the case with the species fumigatus)
rests upon a thick flake of epithelium, and if even individual
fibres of mycelium are surrounded by epithelium, then we
have causes more than sufificient to explain the above phe-
nomenon in harmony with the results of our experiments.
Although it often happens that the otomycosis again
makes itself visible in a day or two after careful removal of
the fungus, and offers an obstinate resistance to treatment,
yet this is no proof at all that the fibres have taken root in
the living tissues. For this occurrence can be easily ex-
plained by the peculiarity which the conidia possess of
clinging so firmly to the walls of the vessels which contain
the nourishing fiuid, that it is a matter of exceedingly great
difficulty to syringe them off and wash them away. Thus,
^ Monats. f. Ohr., 1875, No. 9.
' The reports of other authors on this point are either absent or inaccurate.
The Hyphomycetes Aspergillus, etc. 219
in case number two {of my ozvu series), even after powerful
syringing for two or three days, we found very young my-
celial membranes, composed for the greater part of germi-
nating conidia and fresh, firm, short mycelium. Amongst
these, moreover, even by the most careful examination, it
was impossible to discover any older fibres of the same
structure and thickness as offered by the thallus (stalk) of
the membrane originally syringed from the ear.
We are therefore justified in concluding that : Aspergillus
in the ear rarely clings as a membrane to the epidermis
{fumigatus) ; usually {always in the case of fiiger and favus)
it rests tipoji the surface of the exposed retc or corium, with-
out penetratijig the latter. On the contrary, mycelium of the
deeper layers of the thallus may become surrounded by the
cells of the rete Malpighi.
C. Symptoms and Course. — {d) Subjective symptoms
are occasionally absent : generally we have deafness, tin-
nitus, pain, itching, and a discharge. Moos was the first
(1871) to report cases of asp. niger without any symp-
toms. Burnett's similar cases appeared at a later date.
Bezold says, that of forty-eight patients affected with
otomycosis, nineteen were entirely free from subjective
symptoms, and that of these, at least ten were affected
with asp. fumigatus. Three of my own cases of fumigatus
proceeded without symptoms. We consequently see that of
twenty-two cases of otomycosis from asp. fumigatus, eleven
{fifty per cent^ were free from subjective symptoms. It is
also very probable that this percentage may be even still
higher. The possible cause of the comparatively innocuous
qualities of asp. fumigatus lies in the fact of its greater
delicacy of structure, that it forms less luxuriant vegetation,
and that these tufts of fungus undergo fermentation in the
weakest degree, as was shown by our experiments. Besides
this, the species fumigatus generally rests upon clumps of
epidermis or on thickened and desiccated secretion, so that
in all cases in which this species is observed the nerves of
the corium are normally covered and protected.
Deafness and tinnitus are particularly well marked when
the fungus grows upon the soil which has been furnished by
220 F. Sicbcmnann.
the secretion from a myringitis. At such times the patients
usually complain that the ear is " stopped up," Hearing is
generally so extensively reduced that neither Politzer's
acoumeter nor the watch are at all heard. Buzzing, roaring,
pulsating noises, howling, whispering, and rustling (No. 3
of my own cases) are generally complained of as being per-
sistently present. The pain is of a tearing nature, usually
intermittent, often worse at night, while occasionally it
spreads over the entire half of the head.
Itching is very rarely absent. It excites the patient to
bore and to scratch, and so contributes essentially to an
increase of the inflammatory symptoms.
Most authors mention that the affection is accompanied
with a slight, aqueous, serous discharge. The diluted nature
of the secretion arises from the fact that the fungus abstracts
from the serum all of its firmer albuminates, and leaves
behind the water and most of the salt (as happens with
serum-jelly, gelatine, and the albumen of hens' eggs). But
this salt water, with which, as a result of the fermentative
properties of the aspergillus, unknown products of division
and combustion, to say nothing of resinous matters from
the fungus membrane, are mingled, is, of course, not an
indifferent fluid. It must possess irritating qualities, and to
this circumstance is to be ascribed the extreme difficulty of
obtaining spontaneous recovery in a case of otitis suppura-
tiva when complicated with otomycosis aspergillina. For
under these conditions we have a vicious circle ; the asper-
gillus increases the inflammation, and this in turn by more
abundant production of serum furnishes new and more
nourishing pabulum for the continued existence of the
aspergillus. In this way the fungus can insure a prolonga-
tion of its existence within the auditory meatus.
Otomycosis has no especially characteristic subjective
symptoms. Depending upon its locality, we see the symp-
toms of an otitis externa, a myringitis, or a chronic catarrh
of the middle ear predominate.
The one significant symptom in a large number of cases of
otomycosis is the occasional removal by scratching, etc., of
a fungus membrane from the ear, and that until a new
The Hyphomycetes Aspergillus, etc. 221
membrane is formed the subjective symptoms abate in
severity, and then again increase. This spontaneous loos-
ening of otherwise firmly adhering membranes is observed,
after a while, upon all albuminous foundations, and also
upon gelatine, especially at the period of the highest devel-
opment of the aspergillus, i. e., in four or five days after
being sown. The cause of this phenomenon lies in the in-
creased fluidity of the nourishment. In the living tissues
we have still another cause, in that the fermentation when
at its height particularly irritates the nerves and vessels of
the corium. It is probable, therefore, that at this time the
outermost cells of the rete undergo suppuration and subse-
quent exfoliation, the secretion becomes as a whole much
more active, the fungus membrane grows loose at several
points, and at last is easily movable upon its foundation.
If it happens then to be washed away by fluids, or scratched
out, it first of all leaves upon the wall of the meatus a por-
tion of its mature conidia, an accident which is most likely
to happen when we recall the extremely fragile connection
at such a time between the conidia and sterigmata.
(^) Amongst the objective symptoms, in case the Ml
is intact, are a slight reddening of the locality which the
fungus is about to attack, injection of the manubrial vessels,
with absence of the light spot, and a serous secretion gen-
erally within twenty-four hours. These symptoms are fol-
lowed by the appearance of a mealy-white deposit, which
rapidly undergoes transformation into a compact membrane,
is occasionally exfoliated in from five to eight days, and
under favorable circumstances regenerated in two days. If
the membrane has not been covered with fluid, if neither
oil nor instillations have been previously used, if the secre-
tion is moderate and the nourishment of the aspergillus
normal, we can see upon the surface of the membrane
which is turned toward the air, a greater or less number of
the characteristic conidiophores, which at first are white or
gray, then of a darker color. If the growth of the fungus
is impeded by lack of sufficient food, the mycelium pre-
dominates, and may entirely fill the meatus with a fuzzy
plug that bears great resemblance to a mass of cotton-wool.
222 F. Siebt'iunann.
At other times, the mycelium is so scanty that only traces
of the same are to be met with in the shape of threads. In
still other cases we simply find a more or less thick, fatty-
looking " croupous " membrane. If the exudation is very
extensive in amount, the masses, when thrown off rapidly
one after another, may become compressed in the narrow
space of the meatus into a firm plug (neither unrolling nor
breaking up in water), which looks, as Burnett expresses
himself, like a " wad of moist newspaper." The walls of
their fissure-like or cyst-like cavities are often thickly strewn
with conidiophores. I have never discovered any epidermis,
epithelial elements, or cholestearine amid such luxuriant
vegetation, but, on the contrary, excessively long conidio-
phores, abundant and large mycelium, swollen and un-
swollen conidia, and a granular mass which resembled that
discovered in the thallus of fungi which had been cultivated
upon serum jelly, and consisted evidently of coagulated
albumen. Many of the sporangia {all of them when the
membrane has been syringed away) have already lost most
of their conidia, and consist merely of the receptaculum
and sterigmata (especially in the case of fumigatus). Close
by we find younger, smaller, and brighter conidiophores, in
which the connection of their conidia is much firmer, owing
to their less mature condition. It is consequently plain
that the size (and partly the color) of the various portions
of the fungus cannot always decisively prove the species.
We must, therefore, frequently rely upon cultivation (ten-
per-cent. gelatine solution with an addition of one half per
cent, tannin). This is particularly true in the case of the
fungus-down which is found in the ear, for it may not be an
aspergillus at all, but belong to an entirely different species
of hyphomycetes.
The scattered, darker., piinctiforin spots which are usually
observed upon the lotver side of the meinbrane {the one tur?ied
toward the nidus), have led Wreden to the erroneous con-
clusion that the conidiophores are usually turned toward
the surface of the Mt. But these embedded sporangia and
free conidia are, as cultivation teaches us, the remnants of
old cast-off membranes, only a part of which, as in every
TJie Hyphomycctes Aspergillus, etc. 223
cultivation, undergo germination, while the larger part
become enveloped in the thallus of the new membrane, and
remain there unaltered. Sclerotia have never yet been
found in the ear, for the temperature and locality are
unfavorable to their development.
These fungi rarely possess any odor. They occasionally
smell like mould, never as if putrid. This appears to verify
the assertion that aspergillus cannot grow upon a putrify-
ing secretion. Cultivated aspergillus smells strongly of
mould, especially in the stage of fructification.
The duration of the disease depends of course upon
various circumstances, and may extend over months, and
even to a year. Otomycosis in the middle ear is very
obstinate, because the sinuous cavities of this district are
almost inaccessible to medication.
Eurotium repens has no subjective symptoms. Objec-
tively it appears as an envelope or covering to ceruminous
plugs, either as a fine woolly (mycelium) or greenish
(conidiophore) deposit, or as a fine sulphur-yellow layer
(perithecia), in which case we find it mingled with broken-
down, discolored, gray, or brown conidiophores. Euro-
tium is also found embedded in masses of cerumen. Its
conidiophores are then to be discovered as black dots upon
the yellowish or brown bits of cerumen as they float about
upon the water syringed from the ear. The invariable
long-oval form of the conidia is characteristic, and quite
different from that of the conidia of aspergillus.
D. Diagnosis. — Asp. flaviis and niger can generally be
recognized by the naked eye, and very easily with a magni-
fying glass, while the discovery and examination of asp.
fumigatus and eurot. repens demands the assistance of
the microscope. The addition of a small quantity of liquor
potassae with glycerine clears up the epithelial fragments,
and shows off the fungus more distinctly.
E. Therapeutics and Prophylaxis. — A few cases of
spontaneous recovery, without any assignable cause, have
been observed. Others have been noticed in which the ceru-
men covered over or enveloped the aspergillus, and my experi-
ments have really shown that, saying nothing of its capacit)'
224 F. Siebenmann.
of cutting off the entrance of air, fresh cerume)i is hostile to
the grozvth of aspcrgillns. In Burckhardt's sixth case, the
mycosis disappeared spontaneously as soon as the cerumen
had been removed from the ear, where it was exciting
eczema.
Syringing zvitli luke-ivarni ivater has frequently cured
cases, in which, however, the epidermis was intact, and the
fungus lay dead in the meatus (usually asp. fumig.). Alka-
lies have rarely proved useful as instillations and ear-baths,
although, if properly concentrated, they cause more altera-
tions in the structure of the fungus (by swelling) than acids
and salts, and even in slight quantities, as proved by
experiments, they interfere decidedly with the growth of
the same. But despite these facts, their unfavorable action
upon otomycosis may be explained by the circumstance
that they increase the secretion of serum by maceration of
the epidermis and rete, and thus yield more abundant
nourishment to the fungus in the living ear.
The only exception is, that a weak solution of sodium carb. (or
bicarb.) is useful for softening masses of epidermis which have
become overgrown with the fungus.
The following remedies are contra-indicated, because they
may excite an eczema : the sulphates generally, silver nitrate,
strong solutions of carbolic acid, and instillations of oil.
Glycerine, solutions of zinc, alum, aqueous solutions of
tannin, favor the growth of fungus by affording suitable
nourishment, or at least by making the serum more favor-
able for their reception.
Wreden's favorite and infallible remedy is freshly-pre-
pared calc. hypochlorosa (o.io : 30.00), but Bezold was un-
able to obtain any benefit from its use.
Fresh chlorine-, bromine-, or iodine-water, and strong so-
lutions of potass, hypermang., are extremely efficacious.
Potassium chlorate has no influence upon the conidia.
These aqueous solutions, however, all possess the disad-
vantage of being unable to remain long enough in contact
with fresh sporangia (clusters of conidia; little heads of
conidia) to exercise any paramount influence upon them.
The Hyphomycetes Aspergillus, etc. 225
(Thus, in the case of ripe, cultivated conidia, thrown upon
water, we have to agitate the fluid for a long time, and very
carefully, before we can succeed in covering them entirely.)
And if the membrane is thick, aqueous solutions can rarely
reach the interior, to say nothing of the lowermost layer.
Of all the aqueous solutions, I have obtained the best re-
sults from lead acetate (o. 10 to 0.60 : 30.00) instilled or in-
jected into the ear. For all that, however, this remedy does
not in any way infliience the vitality of the fungus. Here
again we see an exemplification of the fact that the action
of any remedy, even if well recommended, and justly so, in a
case of otomycosis, does not depend upon any direct organic
injury to the fungus which the remedy may cause, but
upon the alteration to which it gives rise in the soil upon
which the fungi flourish. Lead acetate, as we know, simply
limits the amount of secretion; it has "drying" qualities.
The same can be said of alcohol and various alcoholic solu-
tions of salicylic acid (t^o- to four-per-cent.), in the latter of
which we possess, according to our experience, a sovereign
remedy against otomycosis.
The favorable action of alcohol, which is confirmed by
almost every one who has ever employed it, depends upon
the circumstances : (i) that the spirit is very easily diffused
as well through dry as moist membranes, and that it also
comes into most intimate contact with the sporangia ; (2)
that it dissolves the resinous portions of the fungus ele-
ments, deprives the latter in this manner of their protecting
envelope, imbibes the water, and renders the protoplasm
incapable of life, — if salicylic acid is dissolved in the alcohol
the former penetrates all parts of the fungus, especially the
organs of fructification ; (3) and this is the most important
of all, that the very qualities zvhicJi have made alcohol so use-
ful an adjuvant in the treatment of chronic inflammation of
the external and middle ear, render it invaluable in the treat-
ment of otomycosis.
The action of alcohol is, consequently, a double one : //
kills the fungi and diminishes the amount of secretion. The
former action, however, is much less powerful than the
latter, for experiments teach us that this process may cost
226 F. Siebemnann.
at least ten hours, while after the use of alcohol for two to
three hours at the most, in divided intervals of a quarter of
an hour each, the fungus cannot find any nourishment in
the ear ; it must fall from its position and subsequently be
driven from the ear. As we also know from Bezold's ex-
periments, that the mycelium, chiefly, is less accessible to
the action of salicylic-alcohol than the conidia, and that
those fibres which have by chance penetrated into the skin
must of course offer still greater resistance ; so, therefore, I
regard this fact as one of the most decisive supports for the
opinion which I have gradually reached while preparing
this paper : that the aspcrgillus in the ear finds its FAVORABLE
nidus only in certain anovialons secretions, and in its existence
is bound closely down to these ; bnt that, even when acting
parasitically, it does not penetrate to any depth into the tis-
sues.
Solutions of corrosive sublimate in alcohol (i : looo), and
naphthalin in alcohol (i : 20), do not exert any greater specific
energy than spir. vin. rectif.
The permanent destruction of the eurot. repens can be obtained
by simply removing the old cerumen upon which it vegetates.
Treatment of this fungus alone is quite unnecessary, as its pres-
ence does no harm of any sort.
The prophylaxis against otomycosis may thus be summed
up, and the most important advice of all is this :
Do not allow the walls of the meatus to be deprived of
their cover of cerumen.
Prevent any loss of epidermis, and consequent exposure
of the rete to the open air for any length of time.
Avoid all unnecessary application of fats to the ear, as well
as aqueous instillations or injections.
Be very careful in the use of zinc sulphate, glycerine,
tannin (and possibly of gelatine).
Treat all secretory processes of the external and middle
ear in the dryest possible manner, bearing in mind, of
course, the alcoholic treatment of suitable cases of this
nature, as suggested by Weber.
Endeavor to prevent all mechanical injuries in cases of
The Hyphomycetes Aspergillus, etc. 227
eczema of the external ear, and resort eventually to the ex-
hibition of arsenic, iron, cod-liver oil, etc.
Be careful to cleanse all instruments which have been
used for the removal or examination of any fungus mem-
branes that have made their appearance in the ear, or which
may have become contaminated by the secretion which
favors the growth of aspergillus, etc.
On the contrary, I do not lay much stress upon Lowen-
berg's advice to heat the instruments, to add only water
that has been boiled to the saturated or alcoholic solutions
at the last moment before using. For, in my opinion, the
danger of an infection by mycelium or conidia from long-
standing aqueous solutions is not any greater than that of
an invasion from the conidia which are almost always pres-
ent in the air, cotton, etc., and, in point of fact, in almost
every aural secretion.
F. Prognosis. — This is, of course, somewhat unfavorable
for the original disease when complicated with mycosis, for
it is then extremely obstinate toward the customary reme-
dies, (Bezold emphasizes the tardy recovery of perforations
of the Mt when complicated with mycosis,) while a spon-
taneous cure is very rare and slow of accomplishment.
Salicylic acid in alcohol {four per cent.') is an absolutely re-
liable remedy for the mycosis itself. But after this affection
is removed, the original disease — even if rendered less se-
vere, as in the form of dry eczema, pruritus, etc. — may
continue, and in its exacerbations give rise to relapses of
mycosis. Moreover, even when completely cured, the ear
may offer some locality of less resistance to disease than
before, and so with a new outbreak of eczema become affect-
ed once more with proliferation of the various species of
aspergillus.
REPRODUCTION OF THE MEMBRANE TYM-
PANI BY SKIN-GRAFTING*
By C. W. TANGEMAN,
ASSISTANT TO DR. SEELY'S EYE AND EAR CLINIC, CINCINNATI.
Joseph M., set. twenty-eight, farmer by occupation, consulted me
at my office for deafness and a purulent discharge from the mid-
dle ear, that had existed since he was eight years old, as one of
the sequelae of measles. Patient stated that he could not hear an
ordinary conversation at all ; he had consulted a number of phy-
sicians, but the most that had been done for him, was to amputate
the uvula and prescribe ear-drops, and M. was discharged with
the caution never to attempt to have the discharge checked ;
as being an excretion from the brain, the result would be fatal
if interfered with. Is it not strange that such advice can be given
by physicians at the present time, in spite of the advancement of
modern otology ? The patient's hearing had been reduced to
j^-g- on the right side, and -^ on the left side ; he had the appear-
ance of an idiot, and seemed utterly indifferent to every thing
that occurred around him. I cleaned the ears by means of the probe
and cotton, and examined the membrange tympani with the mirror
and speculum. The membranes had central perforations, but so
large that only a narrow rim remained ; the lining of the tympanic
cavity was very much thickened, and but very little air could be
forced through the Eustachian tubes.
After the ears were inflated and thoroughly cleansed, the tym-
panic cavity and auditory canal were packed full of " Morson's "
impalpable boracic acid. This plan of treatment was repeated as
often as the boracic acid dissolved, and in the course of one month
i
* Compare a paper by Dr. Ely on skin-grafting in chronic suppuration of the
middle ear. These Archives, vol. ix, p. 342, 1880. — Ed.
228
Reproduction of the Membrance Tympam. 229
the discharge ceased ; hearing had improved somewhat — -^ on
the right side, and 4^ on the left side, — and treatment was dis-
continued.
Two years later patient again consulted me for deafness (the
discharge had not reappeared), asking that the perforations of the
drum membranes be closed in some manner, if possible. He was
so persistent in his desire that I concluded to try transplantation,
since the openings were so large and the trouble of so long stand-
ing that an attempt at reproduction of the destroyed tissue by
means of caustics and irritants, would have been a waste of
time.
It has long been a well-known fact to physiologists and sur-
geons, that portions of integumentary scructure, when completely
detached and transplanted to other parts of the body, retain their
vitality and grow on the surface to which they have been fastened.
In connection with plastic surgery the most brilliant results have
been achieved by the application of this principle. The mem-
brana tympani is more rapidly reproduced than any other struct-
ure or membrane of the body, when in a certain condition. At
one time it was thought that a point of great importance thera-
peutically could be gained, in chronic otitis media, if a perma-
nent opening could be kept in the drum-head : while even the
basis of the principle was wrong, surgeons failed to establish a
permanent opening. But in the above case. the perforations were
caused by a chronic inflammation which left the edges of openings
rounded and thickened.
The loss of hearing was attributed by the patient to the absence
of the drum membranes, and he was willing to undergo any opera-
tion that promised improvement. He could test for himself the
size of the perforations by Valsalva's method of inflating the ears,
the air passing through as readily as though there was no impedi-
ment. The prognosis concerning the power of hearing was grave
enough, but good results could be promised more readily than to
gaarantee a restoration of the membranes. The first step in treat-
ment was to treat the middle ear. This was done by inflating the
ear and saturating a pledget of cotton with Pagenstecher's ointment
and putting it into the auditory canal. This soon reduced the thick-
ened condition of the mucous membrane of the middle ear and also
improved the acuteness of hearing. I now denuded the edges of
the perforation by means of a long, narrow-bladed knife, while
the ear was illuminated with the concave mirror. A piece of skin
230 C. W. Tangeman.
a little larger than the opening was taken from the arm of the
patient, and placed with its raw surface toward the denuded edges
of the drum-head, and retained in position by the use of a little
collodion. In the course of three days the whole mass separated
and came away, leaving the perforations larger, if any thing, than
they were prior to the operation. Not being satisfied with the
result, I made another attempt ; but instead of using one large
piece of skin, the graft was cut into small bits and placed in posi-
tion as before ; the auditory canal was plugged with a pledget of
cotton saturated with yellow oxide of mercury ointment placed
there for the purpose of exciting inflammatory action, which was
necessary for union between the grafts and the membrane.
Twenty-four hours after the operation the cotton was removed
and the drum-head inspected. Only little change could be noticed,
but the grafts had all been retained in position, and the general
appearance was good ; cotton was replaced. Twenty-four hours
later, a narrow bridge of tissue was thrown across the opening,
dividing it in two parts — the lower and posterior one closing com-
pletely in seventy-two hours after the operation. The upper
opening remained for some time, but gradually getting smaller,
until the patient found it quite difficult to force air through the
small opening. The other ear progressed equally well, but patient
could not remain any longer for treatment, and passed from my
observation, with drum membranes and hearing practically per-
fect. H., both ears, |-|.
While there were two very small perforations remaining, I do
not hesitate to state, that in a very short time they will entirely
close.
The whole appearance of the patient had changed ; he
looked bright and cheerful, and could hear as well as any-
body.
CLINICAL NOTES ON EAR-DISEASE: CEDEMA
OF THE DRUM MEMBRANE SIMULATING
POLYPUS; DEAFNESS IMPROVED BY ELEC-
TRICITY AND PHOSPHORUS."
By p. McBRIDE, M.D., F.R.S.E., FR.C.P. Edinburgh,
AURAL SURGEON AND LARYNGOLOGIST OF THE EDINBURGH ROYAL INFIRMARY.
IT is my purpose in this paper to call attention to two
somewhat uncommon forms of ear-affection, which may,
I trust, prove of some interest to the members of this So-
ciety. The first of these is one of oedema of the drum
membrane simulating polypus.
I have no doubt that many cases, similar to that
about to be described, have been observed ; but from a
perusal of otological literature, it seems to me that too lit-
tle reference is made to the possibility of mistaking an
oedematous tympanic membrane for a polypus. It is true
that such a mistake should not be made by an expert, and
yet, I believe, it would be an error in diagnosis not at all
inexcusable in a practitioner who was not in the habit of
examining cases of ear-disease every day. I have now seen
several cases in which it was by no means easy to arrive at
a definite conclusion after one examination only ; but as
most of the patients were examined at the dispensary, I
have no record sufficiently accurate to bring before you.
Of one case, however, which occurred in my private prac-
tice, I have full notes bearing upon the point in ques-
tion.
* Read before the Medico-Chirurgical Society of Edinburgh.
231
232 P. McBride.
The patient was an elderly gentleman, deaf in both ears. On
the left side the drum membrane was normal, and an afi'ection of
the auditory nerve was diagnosed after examination with the
tuning-fork. In this ear he heard my watch when in contact with
the auricle, instead of at the normal distance of thirty inches.
The right ear was almost absolutely deaf, and there was a history
of suppuration and discharge from it. On examination with the
speculum and reflected light, little pus was found. A light spot
was, however, seen, which rose and fell synchronously with the
pulse — showing that in all probability a perforation of the mem-
brane existed. In the position usually occupied by the drum-
head was seen what to the unaided eye was indistinguishable from a
polypus, filling up tlie entire caliber of the meatus. The polypoid
mass presented a very distinct convexity toward the meatus, and
had the well-known polished oedematous look of a mucous growth.
A probe was then gently introduced along the wall of the meatus,
and its point passed well beyond the most prominent part of the
convexity before it encountered a slight resistance. Now the
difficulty was to decide, whether the resistance was due to the
close contact of a polypus with the sides of the canal, or to the
fact that the supposed growth was in reality an oedematous drum
membrane.
Of course, a little more pressure exercised with the probe would
have decided the question, but would also have been an unjusti-
fiable proceeding ; for, slight as was the force used, it was suffi-
cient to produce vertigo and a transient feeling of faintness.
An examination of the ear then, extended to the utmost limits
compatible with due caution, proved nothing definite, but left the
diagnosis between polypus and oedematous swelling of the drum
membrane uncertain.
The fact that very slight pressure on the tunaor produced
such marked symptoms of giddiness and faintness, showed
an intimate connection between the polypoid mass and the
stapes — for the symptoms described could, I think, only be
attributed to the propagation of the pressure from the
probe to the contents of the labyrinth through the stirrup
bone.
Having arrived at this conclusion, three alternatives pre-
sented themselves. The mass might be (i) an oedematous
drum membrane, the result of chronic suppuration of the
Clinical Notes on Ear-Disease. 233
middle ear ; (2) a polypus attached to the stapes ; or (3) a
mucous growth, the inner surface of which was in contact
with that ossicle. In view of the somewhat greater prob-
ability of the first-named condition, treatment by means of
syringing with boric lotion and the insufflation of boracic
acid in impalpable powder, several times daily was recom-
mended.
In about a month after the first consultation the patient was
again seen. The hearing power had much improved, and a
comparatively normal membrane, in which the manubriutii
mallei could be distinctly traced, replaced the anomalous
growth. A small perforation existed which, though invisible,
could be detected with the auscultating tube.
Now, in a case like the one first described, it is extremely
unpleasant to contemplate the possible effects of attempted
removal of the oedematous tympanic membrane, and I
think the record of the case shows that the diagnosis could
not, in the beginning, be made with certainty.
The differentiation of cedemaof the drum membrane from
polypus is, then, a matter of some importance, and one de-
serving of more attention than has so far been bestowed
upon it by authors of otological works.
The next case which I wish to introduce to your notice is
one of marked deafness, in which a very considerable
amount of improvement was effected by the use of elec-
tricity,— at first alone and afterward in combination with
the internal administration of phosphorus.
At present the general attitude of aurists toward elec-
tricity as a therapeutic agent is one of scepticism, although,
of course, there are some distinguished exceptions.
Thus Moos has recorded a case of nervous deafness cured
by the use of the constant current, but Roosa has criticised
the result on the grounds that the patient was distinctly
hysterical, and that she was probably under the influence of
quinine when the hearing was at its worst. The deafness
of cinchonism, we know, is almost universally recovered
from. Moos has, however, recorded another case, that of a
young man deaf after cerebro-spinal meningitis, in whom
234 P- McBride.
galvanism produced marked improvement (Erb. Electro-
therapie, 628). Weber-Liel, too, reports good results from
his intra-tubal method of applying electricity ; but then his
mode of using the remedy seems to require the use of those
means of opening the Eustachian tube which so often give
satisfactory results without the addition of the electric
current.
Dr. Woakes applies one electrode to the veil of the palate
or within the Eustachian canal, and thus causes contraction
of those muscles which open the tube. Here, again, it may
be objected, that only another plan of ventilating the tym-
panum is substituted for Politzer's inflation. The excellent
results obtained by Duchenne (De 1' electrisation localisee,
826-852) in some cases of deafness have always been too
little regarded by otologists, for if they be accurate, — and
we have no reason to doubt the accuracy of the great
French physician, — the electrical treatment of ear-disease
has been much underrated by recent writers.
Now, in the case which I am about to describe, the only
treatment used was the passage of an induced current from
ear to ear, the sponges being pressed upon either tragus,
and, after the effects of electricity had been clearly demon-
strated, the internal administration of phosphorus.
The patient, E. W., aged forty-three, a nurse, consulted me first
some years ago. At that time I noticed that electricity produced
a marked improvement, but as treatment directed to the naso-
pharynx was also used, and a daily record not kept, I was unable
to draw any absolutely convincing deductions. The case, how-
ever, is shortly referred to in a paper on " Nervous Deafness "
which appeared in the Lancet of 1881.
In February of this year the patient again came to Edinburgh,
and an opportunity was afforded of a careful re-investigation.
She has been deaf, to her knowledge, for years, but in 1878 or '79
had very severe neuralgic pains, and thinks that from that time
the hearing was worse. The deafness is made worse by sore
throat, to which the patient is rather subject. She has had tinni-
tus of the sea-shell variety, but not constant or troublesome.
There is no vertigo. Menstruation once intermitted for a time,
but is now regular.
Clinical Notes on Ear-Disease. 235
When the patient is excited, she feels a lump in her throat, and
the pharynx was not easily excited by tickling with a brush. I
may here state that these two were the only facts pointing in any
way toward hysteria. In phonation the uvula is drawn toward
the right. The hearing distance for a watch normally heard at
about thirty inches is :
Left ear : Contact with the auricle.
Right ear : Just off the tragus.
The tuning-fork placed on the brow is best heard in the left or
worse ear.
The drum membranes are very slightly concave, but otherwise
normal. The Eustachian tubes are pervious, and Valsalva's infla-
tion renders the hearing worse. An induced current just strong
enough to produce pricking was used for a few minutes at each
sitting, one sponge being applied over each tragus, with the fol-
lowing result :
After the first sitting a slight improvement was noticed.
After the second, on the nth of February, the hearing dis-
tance was :
Left : Just off the ear.
Right : One half inch.
On the 1 2th of February the hearing power was, before the
application of electricity, the same as above, but afterward rose
to : Left, \ inch ; right, -f inch.
On the 13th it rose to : Left, f inch ; right, i inch.
On the 15th it rose to : Left, i inch ; right, i^ inches.
Electric treatment was now intermitted, and on the 23d of
February the patient began to take -jV gr. of phosphorus twice a
day.
On the 6th of March hearing distance was : Left, i inch ;
right, i;^ inches.
On the nth of March hearing distance was : Left, i inch ;
right, 2\ inches.
This was my last examination of the case, and I made one final
trial with electricity. It produced an increase of \ of an inch in
the left ear, but did not affect the right. The patient then left
Edinburgh. Being desirous of obtaining some other data besides
that furnished by the watch test, I requested E. W. to let me have
a few observations of her own as to the amount of improvement
in hearing effected. These comprised the facts that she heard a
dining-room clock tick which was before inaudible, that she
236 p. McBride.
could hear the same clock strike at a greater distance, and that
she heard a railway-whistle not heard before. She also stated
that she was wakened by the fall of a wine-glass in the room
above the one in which she slept.
Now the principle factor of deafness in this case was un-
doubtedly the presence of proliferous inflammation in the
tympanum, and as far as the want of hearing was due to
this cause, it was probably irremediable.
Another element, however, contributed to diminish
further the hearing power already greatly impaired by
organic disease, and in removing this secondary factor of
deafness electricity and phosphorus did good service. The
course of events in this case was, I believe, as follows : The
patient's hearing was so far impaired by the organic disease
that she was in a condition to feel acutely any slight addi-
tion to her deafness. Neurasthenia of the auditory nerve
then occurred, probably as a result of an atonic condition
of the nervous system generally, and hence the increased
deafness, which was remedied by the use of electricity and
phosphorus — the one a local, the other a general, nerve tonic.
This subject of neurasthenic deafness I have already con-
sidered at some length in the paper before referred to, and
I will not trouble you with a recapitulation of the facts
there stated.
One aspect of the case in question requires to be some-
what more fully discussed. In stating that there was, under
the influence of emotion, the subjective feeling of a lump in
the throat, and that the pharynx did not readily resent
tickling with a camel's-hair brush, I stated all that could be
said in favor of any hysterical element. Now there seems
to be at present very great confusion as to the meaning of
the latter term. Some authorities seem inclined to place
every symptom, from malingering — provided always it oc-
curs in the female — up to marked neurasthenia, in the same
category. I cannot but think that we should recognize the
possibility of a neurasthenia as distinct from hysteria alto-
gether. In the case I have described, for instance, the
patient was a sensible and intelligent woman, showing no
Clinical Notes on Ear-Disease. 237
inclination to crave sympathy. Moreover, she at once
stated that she heard the tuning-fork through the skull-test
in the worse ear, — a fact which, from the point of view of
most aurists, would at once exclude the idea of hysterical
deafness.
Most persons are at times, even when apparently quite
healthy, subject to a feeling of languor and lassitude. This
condition is due, I take it, to deficient activity of the ner-
vous system, and when it is continuous, may be described
as neurasthenia. Now, if the normal channel through
which impressions are conducted to a nerve of special sense
be already imperfect, the corresponding sense will naturally
suffer most, and the therapeutic indication is to apply elec-
tricity locally and nerve tonics to remedy the general con-
dition. As a final argument against the hysterical theory,
I may state that I have also observed improvement in
hearing follow the use of electricity in the manner described
in the male, although I have no extended notes of such
cases.
This neurasthenic element should be looked for in
patients already deaf from organic disease, but in whom
increased deafness occurs under circumstances which can
have no influence in changing the pathological condition
already existing in the ear, e. g., emotion, fatigue, dys-
pepsia.
THE ETIOLOGY AND SYMPTOMATOLOGY OF
AUTOPHONY.
By G. BRUNNER, M.D., Zurich.
Translated by H. Knapp.
IT may, perhaps, not need a special excuse if, from the
opportunity afforded by some personal observations, I
endeavor to throw some light on a subject of great physi-
ological and clinical interest which, nevertheless, has been
rather neglected in literature.'
I mean the phenomenon of autophony, i. e., the patho-
logical resonance of one's own voice, as well as of the
sounds caused by one's own respiration and circulation.
The question is whether autophony is produced only by
insufficient closure of the tube or by the opposite con-
dition, the obstruction of the Eustachian canal. It is a
fact that very distressing trumpet-like, full-sounding res-
onance of the voice and respiration occurs when the
tube remains patent, as is demonstrated by the experi-
ments and clinical observations of Poorten, Flemming,
and others. Closure of the tube, although not a firm
one, is necessary for normal hearing. Hensen also, in his
physiology of hearing, has adopted this proposition, and
says, "that ordinarily no noise penetrates through the tube
into the ear — i. e., if a sounding body is approached to the
orifice of the tube through the mouth, it is perceived the
' Only the text-books of Urbantschitsch and Hartmann contain a short para-
graph on autophony, but we look in vain for a discussion on this subject in the
treatises of Politzer and Van Troeltsch, who do not devote a special chapter to
diseases of the tube.
358
The Etiology and Symptomatology of Aiitophony. 239
more indistinctly the deeper it is introduced ; as soon, how-
ever, as the tube is opened a change takes place, and auto-
phony occurs, i. e., the person's own voice is perceived
sounding strong in the interior of the ear." Does the same
phenomenon occur when the tube is closed ? On this point
authors differ. Urbantschitsch says in his text-book (page
232) that in stricture or closure of the tube patients fre-
quently complain of a sensation of fulness in the ear, and
of a strong resonance of their own voice, at times so much
increased that they only dare to speak in an undertone.
He likewise mentions (page 313) autophony as among the
symptoms of acute otitis media, without, however, express-
ing his opinion on the causal connection between closure of
the tube and autophony. According to Gruber, on the
other hand (page 576 of his text-book), stenosis and
obliteration of the tube are in themselves not sufificient
to produce morbid subjective symptoms in the organ of
hearing.
How can these differences be made to agree? The con-
ditions unfortunately often are not so evident, as in the
case of Poorten, where, in consequence of a diphtheritic scar,
the faucial portion of the tube was gaping, and I can confirm
the observation of Urbantschitsch that autophony occurs
not very rarely in the course of acute or subacute inflam-
mation of the middle ear — that is, where we can expect the
closure of the tube to be rather stronger than weaker ; and
I may add that in some such cases, on Valsalva's or Politzer's
experiment, even on catheterization, the air entered the ear
with difficulty or not at all.
In spite of this we should think twice over before we
designate obstruction of the tube as the cause of autophony,
for though in certain cases this seems probable, many more
weighty arguments are against it. The fact that autophony
is by no means a constant companion of closure of the tube
ought to make us hesitate, and give us a hint that other
causes must produce it. If obstruction of the tube alone
occasioned resonance of one's own voice — an assertion
which to my knowledge has not been made with such
generality by any person — autophony would be met with
240 G. Br7inner.
much more frequently ; it is too distressing a phenomenon
to be disregarded by any patient. I have compiled the
recorded fatal cases of obliteration and closure of the tube,
but among the few which had been observed during life, I
have found as symptoms only high degrees of hardness of
hearing, no autophony. This is illustrated by a case of
Gruber,' and an observation of Oscar Wolf,'' where a
bullet of a gun located in the tube had closed it com-
pletely.
Physiology, unfortunately, offers no reliable assistance in
settling the question under consideration. We know that
in ordinary circumstances the tube is lightly closed, and
opens more readily toward the fauces than in the oppo-
site direction. We know, further, that one's own voice
does not enter the ear through the tube, but in the ordi-
nary way, through the external canal ; but whether the
Eustachian tube forms an outlet for the sound-wav-^es enter-
ing through the membrana tympani, and what influence its
obstruction may have on the resonance in the ear, the text-
books on physiology give us no information, if the com-
plete silence of authors does not warrant the conclusion that
physiologists do not at all attach such a significance to
the tube.
We have, therefore, to rely exclusively on clinical ex-
perience, which, I think, doubtlessly demonstrates that
closure of the tube in itself does not sufifice to produce
autophony. What are the other causes that may produce
it ? The investigations of Moos, Hartmann, and others
have demonstrated that the tube in its faucial portion, im-
mediately behind its pharyngeal orifice, is closed in a valve-
like manner, the soft membranous wall pressing against the
cartilaginous. Now we can easily imagine that the inflam-
matory swelling in acute catarrh of the middle ear renders
the soft lateral wall less adapted to bring about the valve-
like closure, whether the inflammatory process has relaxed
it, or the inflammatory oedema has made it less pliable.
When one's own voice has once penetrated into the interior
' Page 575 of his text-book.
' These Archives, vol. ii, No. 2, page 58.
The Etiology and Symptomatology of Autophony. 241
third of the tube, it may, perhaps, resound in the ear even if
the canal is closed in its further course. Autophony would
in this case occur, not in consequence but in spite of the
closure of the tube.
I will now relate some clinical histories which illus-
trate the foregoing remarks, but I may first give the results
of an observation made upon myself not referring to auto-
phony but to the easier performance of Valsalva's experi-
ment in faucial and tubal catarrh.
For ten years I have been suffering somewhat from chronic
catarrh of the middle ear, and both my tubes, especially the
left, are no longer so pervious for positive and negative
pressures on Valsalva's experiment as before, not even im-
mediately after the nasal douche, whereas air and liquid
can without difficulty be forced into the ear through the
catheter.
On Valsalva's experiment, I feel a certain tension in
my left ear, as though the air would break through, but it is
not the sensation, well known to me formerly, of a
full rush of the air into the tympanic cavity, with extensive
motion of the whole drum-head, and frequently I have also
the well-known feeling of pressure in the ear, especially
during the cold season. In the winter of 1881 I contracted
a mild angina with slight transient pain in the ear without
disturbance of hearing, and on the second day of the
affection, which, by care and frequent gargling, terminated
in four days, I observed that each Valsalva's experiment in-
flated the left drum more easily and completely than had
been the case for many years. This condition lasted thirty-
six hours. I have made the same observation in others ; I
remember, for instance, a patient with chronic nasal and
secondary middle-ear and tubal catarrh who always con-
sidered it a bad symptom, when, on blowing the nose,
the air rushed easily and noisily into the ear. He always
then knew that something was wrong wuth his ear.
This temporarily increased facility of Valsalva's experi-
ment at the beginning of pharyngeal and tubal catarrhs has
no doubt been observed also by others, but has, to my
knowledge, never been described. Is it the increased and, at
242 G. Brnnner.
the beginning, more liquid secretion which relaxes the
tubal valve, (just as immediately after the use of the nasal
douche with alkaline solutions the Valsalvian experiment
succeeds more easily and with a sounding noise,) or is the
catarrhal relaxation of the mucous membrane the cause of
the easy performance of Valsalva's experiment ?
First Observation.
Mr. F., set. thirty-four, consulted me September 26, 1875,
on account of autophony, which had greatly distressed him
for a year. His own voice sounds in his right ear very
unpleasantly, rough, and hollow, and the rough resonance
which he notices only on uttering the consonants m and «,
disturbs him excessively in speaking. He can avoid it for
some moments by a forcible inspiration through the nose with
closed mouth, and in doing so he distinctly feels that something
in his right ear moves like a valve. For a few moments his voice
sounds natural ; very soon, however, he feels that something in
his ear moves outward, and the old condition is re-established.
To speak without impediment, he is obliged constantly to
inspire through the nose and afterward carefully to expire through
the mouth, for when he expires with the mouth closed, tlie
distressing symptom reappears.
In the recumbent position, and on inclining his head forward
and toward the diseased side, the unpleasant phenomenon dis-
appears ; on raising his head, it returns.
Mr, F, experienced the symptom for the first time twenty years
ago, but then only several times during the whole year, and
a single forcible inspiration through the nose sufficed to keep it
off for a long time ; only during the last year it has become
so permanent that intermissions of one or two days, at the highest,
are rare exceptions.
The hearing distance in the diseased right ear was ^^%
centimetres for the watch ; in the left, ff|- centimetres. In
accordance with this, the patient had no difficulty in hearing
ordinary conversation, or in perceiving any external tones and
noises.
As long ar: the resonance of the voice lasted, a tuning-fork
(c') was heard from all points of the skull only in the right
(diseased) ear. When the resonance of the voice disappeared
after nasal inspiration, there was no longer any pathological rein-
forcement of bone-conduction.
The Etiology and Symptomatology of Aiitophony. 243
The resonance of the voice could also be noticed in the
right ear if, while the patient was speaking, I put the auscultation
tube alternately from one ear to the other.
The consonants m and n had a peculiar metallic or hissing
secondary sound, and at the same time a snapping noise like the
tubal sound was heard during the act of swallowing. Nothing of
the kind could be perceived when the other consonants or the
vowels were uttered. The patient said quite correctly that he
would be all right if he could eliminate the m and ?i from the
language. The respiratory noise, also, appeared intensifiea and
resonant in the right (diseased) ear, but quite normal in the left.
Rhinoscopy discovered the orifice of the tube and its surroundings
normal.
In the same way, the air-douche and the probing of the tube
with catgut bougies demonstrated that the tube was not stenosed.
A bougie of i mm. in thickness could, without notable resistance,
be introduced into the tympanum. As long as the bougie re-
mained in the tube the resonance of the voice was absent, and
remained so for some time afterward, which made the patient
quite happy ; how long I cannot say, as I have not seen him
since. I intimated to him, however, that the improvement would
be only temporary.
The inspection of the drum-heads furnished help in explaining
the autophony. A slight diffuse opacity and foreshortening of the
parts situated above the manubrium were present on the left side,
as well as on the right. Curvature and cone of light fairly nor-
mal. No movement of the drum-head was noticeable on examina-
tion whilst the patient was making the forced nasal inspirations,
nor later, when he had the sensation of something in the ear
moving outward. The pneumatic speculum moved the drum-head
and the manubrium on the right side and the left, though not
very extensively. The aspiration showed no immediate nor any
subsequent influence on the resonance of the voice. Neither
atrophic patches of the tympanic membrane nor traces of exuda-
tion in the drum cavity were present.
Remarks. — There seems to be no doubt that, in the
foregoing rather marked case, we had to deal with deficient
closure of the tubal valves. This is proved, above all,
by the constant, although transient, effect of forced in-
spiration with the mouth closed, during which, by the
momentary rarefaction of air, the relaxed walls of the
244 ^- Brunner.
tube were brought in contact, from which, after a short
time, they returned either spontaneously or by the opening
effect of the expiratory current into the gaping condition
which evidently was their position of equilibrium.
If obstruction of the tube were the cause of autophony,
the effects of expiration and inspiration would give opposite
results — if the expiratory current alone (without closure of
the nose) would at all sufifice to open the tube.
Tjje occurrence of the resonance of the voice with the
nasal consonants vi and ii, which also have been called
resonants, is easily explicable. They are formed, as is well
known, by an exclusion of the mouth by the velum palati
during the expiratory current, whereby the air is forced to
escape through the nose, producing co-vibrations in the
naso-pharyngeal space and the nasal cavity. It is evident
that in this way the voice enters the insufificiently closed
tube, under more favorable conditions than is the case with
the other consonants.
This symptom seems to be constant — at least I have
observed it in the other cases, though not so pronounced.
The favorable effect of a marked inclination of the head
forward is equally constant. It disappears at once when
the head is raised beyond a certain point. The cause of
this is probably a greater congestion. I shall return to this
point later. The continuation of the improvement after the
catgut bougie had been removed, was probably the result of
the irritation and swelling of the mucous membrane pro-
duced by the bougie. This swelling usually lasts a certain
time, and may be considered sufBcient to cause the closure
of a very slightly gaping canal.
The sonorous, trumpet-like sound of the voice is, I think,
the result of a change in the conditions of resonance.
The ear is accustomed to receive sound-waves which im-
pinge upon the drum-head and chain of ossicles from with-
out, and for this kind of transmission resonance is evidently
as much as possible eliminated (by the great deadening
power of the drum-head and the smallness of the vibrating
ossicles which are nowhere in immediate osseous contact
with the walls of the tympanic cavity). The conditions
The Etiology and Symptomatology of AiitopJiony. 245
are entirely different if the sound-waves enter the drum
through the tube, in which case the column of air in the
middle ear and the walls enclosing it are easily excited into
co-vibrations.
We must bear in mind that the autophony developed
very gradually in the course of twenty years, and showed its
first traces in the fourteenth year of age. At that time a
mere inspiration through the nose was sufficient to keep it
off for a long time. The changes in the tube must there-
fore have been very slowly progressing, and very gradually
developed in intensity. It must be left undecided of
what kind these changes were, whether we had to deal
with atrophic or with sclerosing processes in the walls of
the tube, or whether, perhaps, a congenital anatomical pre-
disposition was present. This much is sure, that there was
no scar drawing the walls of the tube apart, for the pharynx,
and the orifice of the tube showed nothing marked.
The disease in this, as in almost all cases, was one-sided.
Second Observation.
Autophony in chronic naso-pharyngeal catarrh.
Susan G., aet. twenty-four, unmarried, complains of hearing,
during speech and singing, a disturbing resonance in her left ear
for more than a year. It seemed as though her voice, instead of
escaping through the mouth, went into the left ear. During eat-
ing also she had the sensation as though a door was constantly
opening and closing in the left ear. Six months previously the
autophony had been almost unbearable ; not only every tone in
speaking but every inspiration sounded in the ear, and during drink-
ing she had often been under the impression as if the liquid went
into the ear instead of going downward. If then she pressed
strongly on the neck below the angle of the lower jaw, the sensa-
tion for a moment was less annoying.
Tinnitus aurium was formerly present, off and on — now no
longer. She has been subject to colds for many years, and the
nose sensitive to every current of air. Rhinoscopy shows nothing
abnormal at the mouth of the tube, h R \^ centimetres, L -f^^
centimetres. Both drum-heads are somewhat opaque, especially
the right. In repeating the alphabet, autophony was particularly
noticed with the letters m, n, i, u. On Valsalva's experiment both
246 G. Brujiner.
drum-heads moved readily, positively as well as negatively. On
the left side, the posterior superior part chiefly bulges ; the end of
the malleus seems somewhat fixed.
On catheterization and auscultation, the initial short puff,
which in the normal condition introduces the characteristic infla-
tion-noise {bruit de pliiie), resulting probably from the separation
of the opposed walls of the tube, is v/anting. The air enters at
once in a full stream without a marked beginning ; on the other
(right) side, however, the initial puff is distinct. When suction is
produced by means of the air-bag and catheter, the air is distinctly
heard to escape from the tympanic cavity, whereas, on the right
side, this does not occur even during the act of swallowing.
I diagnosticated insufificient closure of the lower end of the
tube, probably in consequence of chronic naso-pharyngeal catarrh.
Having had good results from injections of sulphate of zinc through
the catheter, I began treatment with their use, and ordered at the
same time the nasal douche and gargling. The first injection (-J- <jC)
removed the symptom at once, and the patient was quite happy
at being able to speak again without experiencing the unpleasant
concussions in the ear. After the improvement had lasted thirty-
six hours, the patient returned on the third day, still considerably
improved, the resonance of the voice being only insignificant. In
conformity with this, I found that the initial puff was well pro-
nounced on inflation, and I was obliged to employ a certain
pressure to open the tube without having the patient swallow. I
again injected the solution of zinc ; after the third sitting, the
patient did not return for the reason that, as I learned, the diffi-
culty was removed and she has been well up to date (fifteen
months).
There seems to be no doubt that we had to deal in this
case with an insufficient closure of the pharyngeal part of
the tube. Nothing supports the supposition that the tube
was closed also in its upper portion.
Less explicit is the following observation, in which auto-
phony appeared in the course of an acute inflammation of
the middle ear.
Third Observation.
AutQphony in the course of an acute otitis 7nedia.
Mr. K., school-master, about forty years of age, using snuff a
great deal, considerably hard of hearing from chronic middle-ear
The Etiology and Symptomatology of Aiitophony. 247
catarrh for many years, especially on the left side, contracted in
winter a very severe purulent rhinitis, with subsequent purulent
inflammation of the right middle ear, and tenderness by pressure
on the mastoid process. In the third week, when the acute symp-
toms had disappeared, the opening in the drum-head, after re-
peated paracenteses, had closed, and the purulent secretion
formerly copious, had ceased, yet considerable inflammatory
swelling in the middle ear was still present, and the hearing bad.
Distressing autophony set in, which, though transient, had oc-
curred several times in former years.
The autophony was very obstinate, and disappeared very
slowly, the free intervals gradually becoming longer in the hori-
zontal position in bed, and also for hours during the day it was
absent. Bending the head forward or to the side made it disap-
pear for a short time. Negative Valsalva's experiment and strong
nasal inspiration acted in the same manner, though in a less
degree ; whereas positive Valsalva and strong expiration caused
resonance of the voice. Inflation, with weak — either positive or
negative — pressure of the bag, produces a strongly consonant,
blowing noise, but without the opening puff. The resonance of
the voice was particularly strong at in and n, and the patient, on
sounding the consonants, experienced " a rough clatter in the ear
— /. <?., a metallic clang, with vibrations of the drum-head." He
placed the clang at the end of the once-marked or at the end of
the twice-marked octave. His own respiration appeared in the
ear like a blowing sound which, like the resonance of the voice,
could also objectively be perceived. Treatment was directed to
cure the tympanic and naso-pharyngeal catarrh : nasal douche,
injection of sulphate of zinc (|- to \ <fo) through the catheter,
which, I may add, by causing burning in the ear, demonstrated
the absence of swelling of the tube. The patient recovered his
former hearing, and the autophony disappeared completely.
Fourth Observation.
The following case, observed as early as twelve years ago, seems
to be particularly instructive concerning the occurrence of auto-
phony during obstruction of the tube.
A woman of forty-five years of age, who had been long subject
to colds, contracted an acute inflammation of the right middle ear,
with sensibility on pressure on the mastoid process, tinnitus, sen-
248 G. Brunner.
sation of obstruction, and considerable impairment of hearing.
Autophony appeared on the diseased side in the second week.
I saw her at the end of the second week. /; R = o, L =
^^ cm. The upper portion of the right drum-head was slightly red-
dened, somewhat dull and retracted, without perforation, and
without symptoms of accumulation of liquid in the drum. The
very intense and distressing autophony which was noticed, not only
in speaking, but during respiration and with each movement of the
lower jaw, was also objectively discernible through the otoscope.
Gn the right side the patient's voice sounded unusually strong,
with a rough clang, as through a long tin pipe, falling into falsetto
during loud speaking ; the respiratory noise was loud and wheez-
ing. On the left side none of these symptoms. The tuning-fork
(c*), placed on the middle of the vertex, showed no distinct oto-
scopic difference between the right ear and the left.
The patient had noticed that the autophony became weaker or
disappeared as long as the diseased ear was held tightly closed with
the finger, of when the external canal was filled with warm water.
Inflation had no influence on the autophony. The strongly
consonant auscultatory noise made the impression as though it
were very distant in the pharynx or at the beginning of the tube.
Though inspection of the drum-head failed to discover the pres-
ence of liquid in the drum cavity, I made a paracentesis of the
drum membrane on the strength of Gruber's statements. This
operation did not change the autophony. At the beginning no
air passed through the opening ; but as soon as repeated strong
inflations forced the air audibly through the opening in the drum-
head, the subjective and objective autophony had suddenly disap-
peared. No trace of secretion had been evacuated through the
perforation. The air hissed during blowing of the nose with
great readiness through the perforation. The improvement lasted
until the next morning, though the patient could not force air
through the opening longer than the previous evening. Two days
later, when I saw the patient again, the perforation was closed
without any reaction, but the autophony had reappeared in its
full strength. The air-douche through the catheter had no effect.
Injection of a solution of zinc removed the resonance of the voice
at once, but it reappeared the next morning. Two days later
inflation of air and a solution of zinc proved inefficient. I intro-
duced a catgut bougie about i mm thick through the catheter. It
was held tight in the middle of the tube, and could not be pushed
The Etiology and Symptoiiiatology of Autophony. 2^19
farther ; but now the autophony had disappeared, yet returned
when I withdrew the bougie, to disappear again when I reintro-
duced it. I now passed a bougie of about f mm. in thickness,
which, likewise, was held tight at the above-mentioned place, yet
finally entered the tympanic cavity, whereupon the autophony
ceased (also for the otoscope). I left the bougie in position for
ten minutes. The patient felt quite easy in the ear ; the constant
tinnitus had somewhat subsided ; it returned, however, before the
bougie was withdrawn. The autophony, on the other hand, had
disappeared, yet the patient said, on leaving, that she had the
impression as though the resonance of her voice would soon
reappear. It did so. The further course may be briefly related as
follows : The difficulty proved to be very obstinate, the autophony
and impairment of hearing diminishing very gradually, the former
disappearing not before three months and a half, when also the
acuteness of hearing was improved. The disease, on the whole,
was an obstinate tubal and tympanic catarrh, for which the fol-
lowing treatment was ordered : At the beginning, repeated local
abstractions of blood ; then the nasal douche, gargling, injections
through the catheter of a -^ to \ <^ solutions of sulphate of
zinc. I will mention that, three months after the onset of the
disease, Valsalva's experiment did not succeed, and the air did
not pass through the catheter in a full stream, but interruptedly,
with a sharp, short crepitation, after having overcome a consider-
able resistance. The solution of zinc, injected into the tube, caused
only very slight burning in the ear, demonstrating that the tube
was still stenosed.
From the results of the air-douche, Valsalva's experiment,
the later exploration, etc., we are compelled to assume a
stricture or an occlusion of the tube in its middle portion,
and consequently to concede the occurrence of most pro-
nounced autophony in obstruction of the tube. Formerly
I, however, endeavored to explain the case by an abnor-
mal resonance produced by occlusion of the tube.
If, at present, I am of opinion that obstruction of the
tube in itself does not suffice to produce autophony, I
principally support my belief by reasons of clinical experience,
and therefore do not hesitate to assume in the case under
consideration an insufficient closure of the faucial portion
of the tube, together with a catarrhal stenosis of its mid-
250 G. Brunner.
die and superior portions. I am quite aware that I am
standing here on disputed ground, and that we are still
insufficiently acquainted with the pathological conditions
under which resonance in the ear occurs. It is quite pos-
sible that autophony is brought about under different cir-
cumstances : so much, however, seems to be certain, that
it ought to be far more frequent if mere obstruction of the
tube were sufficient to produce it ; it is surely absent in
many pronounced cases of tubal obstruction.
Fifth Observation.
Mr. S. T., aet. sixty-two years, merchant, for the last three
months so much reduced and nervous, by dyspepsia and care,
that he had to keep his room ; complains of late of left-sided
autophony, which almost drives him to despair.
In former years he travelled for a snuff-manufacturing house,
and used snuff to a very great extent.
Years ago he had an attack of autophony, which, however,
disappeared after a single application of the nasal douche and
Politzer's experiment. Now it has been present again for three
weeks in the left ear, off and on, and also in the right ear, though
in a less degree. It set in suddenly, beginning regularly with
crepitation in the ear, " with the sensation as if in the interior
something gave way and air entered where it ought not to be."
At the same time the patient has a strange sensation of the pres-
ence of a foreign body, and hears every respiration like a rushing
stream of water ; each pulse-beat is heard dull in the ear, as is
his own voice, especially at uttering m and n. He dis-
tinguishes two or three degrees of intensity of his autophony,
each beginning with a peculiar noise. The first degree begins with
the above-mentioned crepitation (like firing by platoons), the
second begins with a distinct snap in the ear, and the third by a
loud explosion (almost like a cannon), after which the autophony
is almost unbearable. The patient in this condition sought relief
by lying down in bed on his back, or in a sitting pos-
ture, leaning his head and chest considerably forward. In this
way he could control the resonance, but only so long as he kept
up these positions ; for by raising his head beyond a certain
sharply defined limit, the autophony recurred. At the beginning
and the end of the affection, a moderate inclination was sufficient ;
The Etiology and Symptomatology of Aiitophony. 25 i
at the height of the disease, liowever, when the autophony
was most intense and obstinate, he had to lean very deeply for-
ward in order to obtain the desired effect. At those times, the
horizontal decubitus was not always efficient, yet on the whole, he
was least annoyed at night when he lay in bed, and the phe-
nomenon did not reappear until some time after rising in the
morning. After his meals he commonly felt better ; before break-
fast, worse.
The examination of the drum-head, with the exception of a
diffuse opacity, showed nothing remarkable ; no injection, no
abnormal concavity, no distinction between right and left ; /z =
-g'/o c^i- on both sides. He thought his hearing was good — as good
as before autophony set in ; V -^"; no pain. The Valsalvian
experiment did not succeed, of which I convinced myself by
simultaneous auscultation and inspection of the drum-head.
Ordinary inflation through the catheter produced no improve-
ment. During inflation I heard a distant noise without the
characteristic dilatation puff. Only when I injected, during the
act of swallowing, a few drops of liquid Q^ solution of sul-
phate of zinc), the crackling noise sounded nearer, and the
autophony disappeared for twenty-four hours thereafter. The
injected liquid causing intense burning in the ear and redness
of the drum membrane — both, however, disappearing quickly, —
the sensitive and timid patient refused the further employment
of the catheter, as well as any heroic treatment.
I had, therefore, to confine myself to the nasal-douche, insuf-
flation of \'/o of nitrate of silver with starch powder into
the nose, and the application of Politzer's experiment, both in
the positive and negative methods. The positive method was not
always successful ; the negative method (in which the bag acts by
suction during swallowing), as well as the positive, if successfully
applied, had only a temporary effect. The negative method
yielded, on the whole, more satisfactory results than the positive.
Inflation of the powder into the nose or the naso-pharnygeal cavity
afforded, almost always, relief from or removal of the autophony,
and mostly for a longer time than Politzer's experiment. After
four weeks the autophony gradually subsided and finally disap-
peared.
Remarks on the foregoing case. — The conditions of the
tube may give rise to some doubt. On the one hand, the
failure of Valsalva's and Politzer's experiments, the effect
252 G. Brunner. •
of the air-douche as detailed above; on the other hand,
the occurrence of autophony with crepitation or a snap,
and the constant sensation as if something in the ear was
giving way, are difficult to reconcile. The most plausible
supposition seems to me that the faucial portion of the
canal, which forms a vertical fissure, has a tendency to dilate
and gape ; but that the upper narrower portions were sten-
osed, as a usual condition in middle-ear catarrh. I consider
the latter condition, as I have stated above, to be irrele-
vant, and refer the autophony to the altered configuration
of the lower portion ; while the latter, in the normal state, is
closed, and when opened spontaneously closes again.
I consider in our case the equilibrium as very unstable, —
perhaps reversed, — and find it very remarkable that the
lower degrees of autophony begin with a crepitation, the
higher with a distinct snap, evidently produced by a sudden,
very energetic separation of the walls of the tube.
Chronic catarrhs may, in some cases, be the cause of
autophony, in consequence of atrophic processes, wasting
of the parts, or alteration of their elasticity, or of the tonus
of the muscles. All agents that produce congestion of the
mucous membrane or increased secretion — the nasal douche,
insufflation of arg. nitr. cum amylo into the nose — tem-
porarily removed or diminished the autophony. The favor-
able effect of eating, the unfavorable effect of fasting, as well
as the influence of the position of the head, regularly mani-
festing themselves in my cases, are of great interest. It
may not be easy to explain these facts. Probably the
greater filling of the blood-vessels had a decided influence,
for the patient stated that the autophony disappeared or
diminished if he felt his head congested.
It seems contradictory that the autophony did not only
disappear by forcible nasal inspiration and the negative
methods of Valsalva's and Politzer's experiments, but also,
though less regularly, by the positive method. We can
imagine that an external impulse is sufficient temporarily
to close the pathologically open tube, or to open it when it
is closed. We refer to Hartmann's' experiments, according
' Mittheilung iiber die Function der Tuba Eust. Arch. f. Anat. und Phys.,
1877, P- 546.
The Etiology and Symptomatology of Autophony. 253
to which increase of pressure in the naso-pharyngeal cavity
crowds the membranous wall of the tube against the carti-
laginous roof.
From so few observations, to which, however, I might
add some others, I would not make positive deductions ; our
material and our knowledge are still too incomplete. A
few comprehensive remarks may, in conclusion, be permitted.
Apart from the cases in which autophony was produced by
cicatricial contraction in the pharynx, it seems chiefly to
accompany acute and chronic naso-pharyngeal and tympanic
catarrhs, especially in persons suffering from habitual naso-
pharyngeal catarrh. Among the five patients two were
accustomed to take a great deal of snuff. In three auto-
phony had begun insidiously. Several years previously it
showed itself, usually only on one side ; only in the last ob-
servation traces were noticed on both sides. Its cause, I
consider to have been a patulousness of the tube, in conse-
quence of insufficiency of the valve-like closure of the phar-
yngeal orifice ; or an alteration of equilibrium in the parts,
with a tendancy to rupture of the closure ; possibly also a
spasm of the dilatator muscles. In the further course of the
canal there may be an obstruction to which I, however, am
not inclined to ascribe an essential causal significance.
Although in all cases the annoying, frequently unbear-
able, resonance of the patient's own voice, respiration, and
pulse constitute the principal complaint, it is evident that
the other symptoms vary somewhat, according to the cause
and degree of the patulousness.
In my observations (of catarrhal deafness) the autophony
never lasted the whole day uninterruptedly; it disappeared
during rest in bed, and could also be dispelled for a shorter
or longer time by certain manipulations e. g., by inclina-
tion of the head, by the negative method of Valsalva's and
Politzer's experiments, forcible nasal inspiration with the
mouth closed, that is to say by rarefaction of air in the
drum cavity," but also by introduction of irritating liquids
' I have mentioned above and sought to explain, that exceptionally also the
positive methods of Valsalva's and Politzer's experiments remove the autophony
for a short time (see above, fifth observation).
254 G. Brunner.
into the tube, and of irritating powders into the nose or the
naso-pharyngeal cavity.
The resonance of the voice could generally be also ob-
jectively perceived, but not always distinctly (for instance
in the fifth case), a fact which I am unable to explain.
Rhinoscopy has thus far not given me any assistance in
arriving at an anatomo-pathological diagnosis.
The prognosis does not seem to be unfavorable in the
catarrhal cases (see above), but in the fourth observation
the autophony lasted fully three months.
THE HISTOLOGICAL CONDITION OF SIX TEM-
PORAL BONES TAKEN FROM THREE CHIL-
DREN WHO HAD DIED FROM DIPHTHERIA.
By S. moos and H. STEINBRUGGE, Heidelberg.
Translated from the German by Charles J. Kipp, M.D.
WE are indebted for these temporal bones and the
following note to our esteemed collaborator, Dr.
Fraenkel, Prosector in Hamburg. " All of the temporal
bones were taken from children either under or just over
one year of age, who had died from diphtheria of the
pharynx or the upper air-passages. Only in one of the
cases was the naso-pharyngal cavity not involved. In each
of the children tracheotomy had been performed. Two
were girls and one was a boy."
METHOD OF EXAMINATION.
The temporal bones had been preserved in Muller's fluid.
After careful macroscopical examination of all the parts, the
pyramids were separated from the rest of the bones, and
placed in a one-per-cent. solution of osmic acid ; subse-
quently they were decalcified according to the method we
have repeatedly described. The drum membranes were
studied from transverse and parallel sections. They were,
however, allowed to remain in connection with the handle
of the malleus and the annulus till these were completely
decalcified in solutions of chromic acid, gradually increasing
in strength from one sixth per cent, to one per cent. After
decalcification they were washed in water and then kept in
alcohol for a time. For the purpose of making sections,
255
256 S. Moos and H Steinbrilgge.
the drum membranes, with the handle and the annulus, were
imbedded in liver.
First {right) Petrous Bone.
The cartilaginous part of the external canal was wanting
in the preparation when received. The membrana tympani
was injected radially ; the handle of the malleus was not
visible. The cavum tympani was filled with muco-purulent
exudation, and its lining membrane was thickened. No
microscopical examination of the lining membrane could be
made, as the labyrinth had not been sawed off with sufifi-
cient care.
The microscopical examination of the drum membrane
showed that the cutis and the layer of mucous membrane
were thickened and infiltrated with small cells; the blood-
vessels were everywhere distended, and at many points in
their vicinity were extravasations of blood. The membrana
propria, with the exception of a cleft between the radial
and circular layers, which contained granular cells, did not
at all participate in the morbid process. The epithelium of
the mucous membrane was preserved in part.'
Upon the cutis and mucous membrane of the drum mem-
brane were found thick layers of coagulated exudation ; the
exudation was also seen on the ossicles, on the tympanic
pouches, and the chorda tympani. These exudations could,
however, be readily lifted off with the forceps from the
structures beneath them.
The niche of the foramen rotundum was filled with co-
agulated blood. All the parts of the labyrinth were normal,
and showed nowhere the hypersemia found in the left tem-
poral bone. The peri- and endo-lymph were coagulated in
the cochlea, but not as completely as in the left ear. A
narrow strip of coagulated, lymph-like exudation was found
on the inner surface of the sacculi and ampullae.
* Reserving to ourselves further investigation, we may mention here that the
mucous membrane lining the handle of the malleus was covered with cylinder
epithelium ; and also that in all of the temporal bones examined here, the wall
of the labyrinth was covered with cylinder epithelium — a condition at variance
with that found in adults.
Histological Changes in Diphtheria. 257
Second {left) Petrous Bone.
The cartilaginous external canal was absent. The layers
of epidermis and cutis of the drum membrane were thick-
ened ; the handle of the malleus was not visible. The
antrum and tympanic cavity were entirely filled with a tena-
cious mucous mass. This mass was composed of exfoliated
ciliated epithelium, pus corpuscles, and pigment. The
mucous membrane covering the tegmen tympani showed a
hemorrhagic infiltration. The vessels in the mucous mem-
brane lining the ossicles were very full. On the inner
surface of the drum membrane was a thick exudation which
could be pulled off with forceps. The drum membrane
showed the same histological condition as that in the right
ear. The membrana propria was entirely intact.
The mucous membrane covering the labyrinth wall was
increased in thickness up to 0.5 mm., and was infiltrated
with small cells. The blood-vessels were over-full, and the
vessels in the bony case of the labyrinth were in the same
condition. The endo- and peri-lj^mph of the vestibule were
coagulated to a yellowish gelatinous mass. In the scalae
and in the ductus cochlearis of the cochlea this same
change had occurred. The blood-vessels of the cochlea
were distended. All the structures of the labyrinth were
in all other respects normal.
Third {right) Petrous Bone.
The epidermis of the external canal was swollen and was
easily removed. The outer layer of the drum membrane
was thickened ; the handle of the malleus was not visible.
The central part was drawn inward in the shape of a funnel.
The antrum, the tympanic cavity, and the tuba were filled
with a tenacious mass composed of mucus, pus, and blood
corpuscles. The vessels of the thickened mucous membrane
of the drum membrane and of the tympanic cavity were re-
markably numerous and very full.'
' The blood corpuscles in these vessels appeared of a square form in conse-
quence of the stagnation. The same condition was found in all the other tem-
poral bones.
258 5. Moos and H. Steinbriigge.
Microscopically the drum membrane did not differ from
Nos. I and 2. The glands of the tuba were normal.
The mucous membrane of the promontory was swelled
and infiltrated with blood corpuscles, pus cells, and large
granular cells (regressive metamorphosis) ; in some places it
measured 0.5 vim. in thickness. The vessels were over-full;
the epithelium was preserved. The hollow spaces in the
bony surroundings of the labyrinth (pneumatic spaces ?
spongy tissue of bone ?) connected with the tract of mucous
membrane had apparently also participated in the patho-
logical process. The vessels in these spaces were likewise
much distended, and the tissue lining the spaces was infil-
trated with cells and blood corpuscles.'
The membrane of Reissner in the cochlea was completely
collapsed. The lymph in the scalae of the cochlea and in
the ductus cochlearis was coagulated only superficially.
The A. auditiva was well filled with coagulated blood, as
were likewise the vessels entering the canal of Fallopi.
As the child from whom this specimen was taken was not
more than one to two years old, the presence of a small
yellow nucleus of bone is especially noteworthy.
Fourth {left) Petrous Bone.
The cutis of the external auditory canal was loosened.
There was no pus in the auditory canal. The short process
was distinctly visible, while the handle of the malleus was
only indistinctly seen. The entire middle ear, including
the lumen of the tube and the antrum, was filled with mu-
cus. The mucous membrane of the entire middle ear was of
a reddish-yellow color ; it was thickened and infiltrated with
pus cells, and presented everywhere a close net-work of very
full blood-vessels. Extravasations of blood and dark granu-
lar pigment were found at different points. In several
' A similar condition we found in transverse sections of the handle of the
malleus of another petrous bone. In this instance there were seen at its
periphery spaces or lacunas of various sizes, filled with the same substance
as was infiltrated in the mucous membrane of the drum membrane and
connected with it. In the case under consideration we found the same pro-
cess in the crura of the stapes.
Histological Changes in Diphtheria. 259
places a fibrous mass (fibrin ?) was entangled in the mucous
membrane.
The mucous membrane covering the promontory was here,
as in the bones previously described, much swollen and
hyperaemic, while its epithelium was well preserved. Its
thickness measured 0.5-1 mm. Blood extravasations were
found in and upon the mucosa. The lymph in the scalae of
the cochlea was coagulated. The examination of the
structure of the labyrinth, the expansions of the nerve,
and the trunk of the nerve itself gave negative results. A
large nucleus of bone was found on the posterior wall of the
vestibule, whence it extended to the base of the cochlea
and completely surrounded the acoustic and facial nerves.
Fifth {right) Petrous Bone.
The dermoid covering of the external auditory canal was
as easily detached as in the other preparations. There was
no pus in the external canal. A small perforation was
found in front of the umbo. In no other respect did the
drum membrane differ from those already described. The
tympanic cavity and antrum were filled with mucus and
pus, and the mucous membrane was much swollen every-
where. The contents of the tympanic cavity consisted of
pus cells, globules of oil, and rather pale granular cells.
The mucous membrane over the promontory was in this
preparation as much swollen as in the others, and was in-
filtrated with blood corpuscles and numerous round cells of
various dimensions; its blood-vessels were much injected.
The blood vessels of the cochlea, as well as the vessels en-
tering the bone with the periostal layer of the lining mem-
brane of the tympanic cavity, were likewise very full. The
epithelium of the mucous membrane over the promontory
was well preserved ; it was here also everywhere of a cylin-
drical form. The surface of the mucous membrane formed
elevations and depressions which were lined with cylindrical
epithelium ; sections of the depressions presented appear-
ances similar to tubular glands. In the niche of the fora
men rotundum, in front of its membrane, were found groups
of cells similar to pus cells, among which were several larger
26o 5. Moos and H. Steinhriigge.
ones apparently undergoing fatty metamorphosis, as they
were stained black by osmium. Besides these, the niche of
the foramen rotundum was filled with a substance closely
resembling coagulated perilymph, and pretty numerous ad-
hesions between the membrane of the foramen rotundum
and the mucous membrane were still visible.
The endolymph in the sacculus and utriculus was coagu-
lated ; the perilymph in the scala tympani was also con-
gealed and filled a part of the stairway.
Sixth {left) Petrous Bone.
The epidermis of the external canal was readily removed
in patches, and on its surface was found a mucous exudation
consisting of pus cells and very many granular cells. The
drum membrane was intact in its continuity. Its epider-
moid layer was not as much thickened as in the other speci-
mens. The vessels of the cutis and mucous membrane were
everywhere visible and very full of blood. In both layers
small and large extravasations of blood were found. The
membrana propria was unaffected. On the inner surface
of the drum membrane was found a thick membranous ex-
udation, which extended uninterruptedly across the malleo-
incudal point tp the tegmen tympani, into the tuba and over
the floor of the cavum tympani ; it covered in the same
manner the wall of the labyrinth up to the region of the
stapes. The entire cavity of the middle ear, from the tuba
to the antrum was filled with a mass composed of pus cells,
innumerable granular cells, and isolated fat globules. The
mucous membrane of the tympanic ostium of the tuba was
less hyperaemic than the dermoid and mucous layers of the
drum membrane; there were, moreover, no extravasations of
blood seen here, and its epithelium was well preserved. The
mucous membrane over the promontory did not differ in
thickness, vascularity, and condition of epithelium from the
preparations previously examined.
The perilymph of the scala tympani was firmly coagu-
lated ; that of the scala vestibuli less so.
Accidental Conditions.
In one of the cases a concretion composed of phosphate
Histological Changes in DiphtJieria. 26 \
of lime was found in the lining membrane of the internal
auditory canal.
The condition of the tensor tympani muscle was espe-
cially worthy of note. This muscle presented in transverse
sections of the part situated within the semicircular canal
all the characteristics of tendon, and sections cut nearer to
the Eustachian tube contained in the centre only scanty
bundles of muscular fibres, near which were seen true
fat-cells, stained black by osmium, and groups of other
cells which resembled the fat-cells but were not stained.
This paucity of muscular fibres, which was observed in
the tensor muscles of all the petrous bones examined, is
evidently not at all connected with the diphtheria, as the
signs of a degeneration of the muscular substance were
wanting ; but it seems probable that it is due to an incom-
plete development of the true body of the muscle in the
earliest period of life, and that later functional exercise
causes an increase of volume, and thereby a predomination
of true muscular over the tendinous tissue.
SUMMARY OF THE ALTERATIONS OBSERVED.
External Auditory Canal.
In two of the six preparations examined, the cartilaginous
auditory canal was wanting. In the remaining petrous
bones the epidermis of the canal was either detached or
could be readily pealed off, but in only one case (No. 6')
was pus present at the same time.
Since granular cells were found together with the pus
cells, this change may have occurred during a later stage,
while the exfoliation, as such, may possibly have been
connected with an earlier stage.
Drum Membrane zvith Handle of Malleus.
Perforation of the drum-head was seen but once. In
six cases nothing could be seen of the hammer, excepting
' The absence of a perforation in the drum-head would seem to indicate an
independent participation of the external canal in the morbid process, if the
looseness of the epidermis is not regarded simply as the result of maceration.
262 5. Moos and H. Stcinbrugge.
Case 4, in which the short process was visible. In one case
radial injection of the deruwid layer was visible to the
naked eye. The microscopic examination revealed in all
of the cases intense injection, great fulness of the vessels,
and extravasations of blood in the vicinity of the vessels,
while infiltration with pus cells was seen in only one half of
the cases.
The inembrana propria was intact in all of the cases
except the first, in which granular cells were found in a
narrow cleft between the radial and circular layers.
The mucous membrane of the drum membrane showed
in all of the six cases, like the cutis, great fulness of the
blood-vessels and many extravasations of blood in their
neighborhood ; furthermore, infiltration of small cells in
part of the cases, and infiltration of pus cells in the
majority ; the latter was seen in the highest degree in
Case 6. In addition, there were considerable deposits
of coagulated exudation. Prolongations of the mucous
membrane, altered as described, were seen to enter with
the blood-vessels into the interior of the handle of the
malleus.
Contents of the Tympanic Cavity.
The tympanic cavity contained in the first case mucous
and pus; in the second case, tenacious mucus; in the third
case, viscous mucus, pus, and blood ; in the fourth case,
mucus and a fibrous mass which was entangled with the
mucous membrane ; and in the fifth and sixth cases, mucus,
pus, and granular cells (stage of regression).
Lining Membrane of the Promontory.
In all of the cases this membrane was increased in thick-
ness from 0.5 to I mm.. The epithelium was intact in all
the cases. The blood-vessels were here also enormously
full, and the extravasations which in the other regions of
the organ of hearing could only be seen with the microscope,
could here be recognized by the naked eye.
In one half of the cases there was simple infiltration of
Histological Changes in Diphtheria. 263
the mucous membrane with round cells, in the other half
pus cells and round cells were found together, and in two
of these cases larger cells undergoing regressive metamor-
phosis were also present.
Prolongations of the mucous membrane, thus altered even
in its deeper layers, were observed to accompany the blood-
vessels into the capsule of the labyrinth at many places.
The mucous membrane lining the antrum was changed in
the same manner as that of other parts of the middle ear.
The changes in the lining membrane of the tube were less
marked.
The labyrinth was found to be normal in every respect,
the only change being a coagulation of the lymph, which
was observed in most of the cases. In one of the cochlear
canals, in which the lymph was not coagulated but had
escaped, Reissners membrane was found completely col-
lapsed. The particulars will be given in another article.
There can be no doubt that diphtheria existed in the
cases described, as it is stated in the notes kindly sent us
by Dr. Fraenkel, that in all except one of the cases the naso-
pharyngeal cavity was involved. But whether the described
changes in the middle ear occurred simultaneously with and
independently of the diphtheritic process in the naso-pharyn-
geal cavity, or whether the disease extended per continui-
tatem through the Eustachian tubes to the ear, we have
not, unfortunately, been able to decide. To enable us to
decide this point we should have been in possession of the
cartilaginous tubes with their faucial orifices. In the rem-
nants of the cartilaginous tube which were found attached
to one of the preparations, and in the mucous membrane of
the osseous tube, the morbid changes were even less marked
than in the tympanic cavity itself. It must therefore re-
main undecided whether the diphtheritic virus can, under
certain circumstances, pass through the tube without causing
marked alterations in it, and find the conditions favorable
to its development only in the tympanic cavity.
Although we must decline to express an opinion as to the
form of the diphtheritic affection which existed in the naso-
pharyngeal cavity of the children, whose death was probably
264 vS". Moos and H. Stemhrugge.
caused by an extension of the morbid process downward in
the air-passages, we may be permitted to state that, in our
opinion, the disease of the middle ear either followed one of
the milder forms of diphtheria or corresponded to the initial
stage of this disease (excepting, perhaps, two cases), since
the membranous deposits could be readily removed, were
easily broken up, and did not present the appearance of
exquisite diphtheritic membranes which, as is well known,
present under the microscope a net-work of fibrin in which
cells are embedded. That the disease was of a mild form and
was already on the wane, was evident in two of the cases in
which granular cells were found, which may be regarded as
an indication of a regressive metamorphosis of the exuda-
tion. Additional proof that the disease was of a mild char-
acter, or was at least in four of the cases in the initial stage,
is furnished by the facts that the epithelium of the mucous
membrane of the tympanic cavity was preserved, and that
the blood-vessels of this membrane were hypersemic in all
of the petrous bones which we examined. The intense in-
jection of the blood-vessels in the mucous membrane, caus-
ing rupture of their walls and extravasations, which, ac-
cording to the unanimous statement of authors, is always
present at the beginning of the diphtheritic process, disap-
pears in the later stages of the severer, malignant forms of
diphtheritis.'
We would call special attention to the absence of micro-
organisms in all the diseased parts. We were at least un-
able to find such either in the tissues, the blood-vessels, or
in the free exudation.
Especially worthy of note seems to us the fact that the
hyperaemia and infiltration of the mucous coat of the
middle ear could also be demonstrated in the periosteal pro-
* According to Uhle and Wagner this is due to the great infiltration of the
mucous membrane with pus corpuscles, or with fibrin and molecules of albumen,
by which compression of the blood-vessels, and anaemia, necrosis, and later
gangrene of the mucous membrane is produced. Klebs* regards the diphthe-
ritic necrosis as the result of a paralysis of the blood vessels caused by micro-
organisms, in consequence of which stagnation of the blood, globar stasis,
occurs. Compare with regard to this also the 5th case of Wendt, Archiv
f. Heilk., Bd. xi, p. 257.
* Transactions of the 2d Congress for Internal Medicine.
Histological Changes in Diphtheria. 265
longations which, in company with the blood-vessels, enter
the walls of the tympanic cavity and the ossicles. The
same can be said of the membranous lining of the pneu-
matic and spongy cavities in the neighborhood of the mid-
dle ear. This observation furnishes an explanation of the
early participation of the bone tissue, and the rapid destruc-
tion of the auditory ossicles, which, as is well known, oc-
curs in some cases of malignant scarlatina, with or without
diphtheritis.
ON THE INFLUENCE WHICH THE TREATMENT
OF ONE EAR ALONE EXERTS UPON
THE OTHER.
By Dr. A. EITELBERG, of Vienna.
Translated by J. A. Spalding, M.D., Portland, Maine.
WHARTON JONES' was the first to suggest the
possibiHty that one ear might exercise some
sympathetic influence upon the other. More accurate ob-
servations, however, in this direction have since been made
by Weber-Liel and Urbantschitsch, — the former discovering
a diminution in the deafness and subjective perception of
noises in the one ear after tenotomy of the tensor tympani
muscle of the other,^ while the latter observed the same
phenomena after tenotomy of the stapedius muscle, ° as
well as after division of the posterior fold."
Urbantschitsch has recently returned " to the question of
the sympathetic influence exerted upon the one ear by the
treatment of the other, and mentions additional cases in
which, at the moment of passing the bougie through the
Eustachian tube of one side, the perception of subjective
noises, as well as the deafness on the other side, underwent
a distinct alteration. At his request, I have lately exam-
ined a large number of persons to discover what effect, if
any, the treatment of the one ear exerts upon the hearing
' Cited in Frank's " Lehrbuch der Ohrenheilkunde," 1845.
"^ Monatssch. f. Ohrenhlkde., 1874.
^ Wiener med. Presse, iSyj.
" Monatssch. f. Ohrenhlkde., 1877.
' Ueber den Einfluss von Trigeminusreizung auf Sinnesempfindungen, etc.,
Pfiiigers Archiv f. Physiol., Band xxx.
266
Treatment of One Ear Influencing the Other. 267
and perception of subjective sounds in the other. Although
the citations just quoted show that there can be no doubt
of a sympathetic connection between the two ears, yet I
felt that the subject deserved a more thorough investiga-
tion, especially as regarded its frequency as well as its
amount, than it had hitherto received from otologists. I
investigated particularly the immediate sympathetic action
directly after each treatment of the one ear, as well as its
duration, during a prolonged course of treatment, and the
final result after all treatment had been abandoned. It is
to the results thus obtained that I now beg to call the at-
tention of the profession.
All of the experiments were made under precisely similar
external conditions in a room that was but slightly exposed
to the noise of a crowded city thoroughfare. The watch
with which I tested the hearing was always held in precise-
ly the same direction, i. e., in the axis of the auditory mea-
tus. In order to avoid all possible mistakes from those
vacillations in the amount of hearing to which all persons
are by nature subjected, the limit of hearing in every per-
son whom I examined was not accurately decided upon at
any one visit until after repeated and most careful measure-
ments and tests. The number of patients examined was
fifty; but as ten of them gave extremely uncertain and con-
fusing answers, I have rejected them entirely. My results,
therefore, are based upon the investigation of only forty
cases. Each one of these, however, will be given in sepa-
rate detail, because in no other way can we obtain so clear a
picture of the results of my investigations. Beyond this, I
can thus offer to every reader an opportunity to take ex-
ceptions if he chooses to the correctness of the conclusions
which I have drawn.
Cerumen.
Case i. — 20th Sept., 1882, Leontine L., set. forty-two. Right
ear, cerumen. Before removal of the plug, hearing : R, watch
on concha; L, 128 cfji.^ After removal of the plug : W., R, 81 ;
L, 138.
' My watch is heard at a distance of 600 cm. by the nonnal ear.
268 A. Eitelberg.
Case 2. — 21st Sept., 1882, Max. P., set. twenty-three. L,
cerumen. Before removal : L, 38 ; R, 103. After removal : L,
53 ; R» 60.
Case 3. — 2Sth Sept., 1882, Gustav. N., aet. nineteen. L,
cerumen. Before removal : L, 8 ; R, no. After removal : L,
64 ; R, 174. 3d Oct. : L, 53 ; R, 80.
Case 4. — 2d Oct., Max. L., a;t. thirty. R, cerumen. Before
removal : R, on the concha ; L, 26. After removal : R, 102 ; L,
44.
Case 5. — 3d Oct., Franz R., ast. nineteen. L, cerumen. R,
cicatrix. Before removal : L, on the concha ; R, 46. After
removal : L, 14 ; R, 57.
Case 6. — 6th Oct., Friedrich B., set. seventy-seven. R, ceru-
men. Before removal : R, on the concha ; L, 3. After removal :
R, on the concha ; L, 3.
Case 7. — nth Oct., Jacob M., set. forty-one. R, cerumen.
Before removal : R, 14 ; L, 12. After removal : R, 17 ; L, 12.
Case 8. — 21st Oct., Jacob P., cet. thirty-eight. L, cerumen.
Before removal: L, 36 ; R, 21. After removal : L, 10 ; R, 21.
26th Oct. : L, 112 ; R, 23. 31st Oct. : L, 140 ; R, 95. 2d Nov. :
L, 102 ; R, 72.
Case 9. — 24th Nov., Johann R., set. fifty-seven. R, cerumen.
Before removal : R, o ; L, i. After removal : R, o ; L, i. 27th
Nov. : R, 3 ; L, 5. 4th Dec. : R, 3 ; L, 17. nth Dec: R, 6 ;
L, 35-
Case 10. — 27th Nov., Paul R, set. twenty-two. R, cerumen.
Before removal: R, 18; L, 126. After removal: R, 150;
L, 230.
Case n. — 7th Dec, Friedrich R., set. fifty-two. L, cerumen.
Before removal : L, on the concha ; R, 4, After removal : L, 4 ;
R, 2. 9th Dec. : L, 4 ; R, 6.
Case 12. — 24th Sept., Wenzel L., Kt. twenty-seven. Cerumen
in both meatus. Before removal of the L plug : L, i ; R, 103,
After removal : L, 15 ; R, 103.
Otitis externa circumscripta.
Case 13. — 22d Sept., Julius S., ret. sixteen. R, otitis ext. cir-
cumscripta. Before treatment (induction current on the affected
side) : R, 95 ; L, 170. After the treatment : R, T15 ; L, 170.
Treatment of One Ear Influencing the Other. 269
Case 14. — 26th Sept., Rosalie L., zet. forty-three. L, ot.
ext. circ. Before treatment (drainage tube smeared with ung.
cinereum) : L, 20 ; R, 50. 28th Sept. : L, 20 ; R, 50. The otitis
is healed.
Case 15. — 7th Oct., Theresa G., ast. fifty-one. R, ot. ext.
circ. Before the treatment (drainage tube with ung. cinereum) :
R, 70 ; L, 88. 9th Oct. : R, 50 ; L, 60. The otitis is no better.
The drainage tube not well borne.
Case 16. — 24th Nov., Johann V., set. twenty-one. L, ot. ext.
circ. Before treatment (induction current on the side affected) :
L, 6 ; R, 600.
Aspergillus niger.
Case 17. — 27th Sept., Rosa S., set. twenty-two. L, aspergillus
niger. L, 20 ; R, 250. Spiritus vini rectificatus. 30th Sept. :
L, 20 ; R, 250.
Myringitis acuta.
Case 18. — loth Nov., Johanna G., set. nineteen. R, myringitis
acuta for three days. R, 24 ; L, 194. 14th Nov. : R, 75 ;
L, 260. Myringitis better. 20th Nov. : R, 212 ; L, 300.
Myringitis cured. 23d Nov. : R, 323 ; L, 410 ; violent naso-
pharyngeal catarrh. 28th Nov. : R, 430 ; L, 400. ist Dec. : R,
450 ; L, 450 ; after alternately occluding both ears, 7th Dec. :
R, 600 ; L, 600.
Exudation in tympanum.
Case 19. — 19th Sept., Franz P., set. twenty-seven. R. exudation
in the tympanum. R, 3 ; L, on the concha. After using
the catheter on the right side : R, 4 ; L, on the concha.
Tyfnpanitis phlegtnonosa acuta.
Case 20. — 29th Sept., Martin Z., set. fifty-six. L, tymp.
phlegm, acuta. L, on the concha ; R, 35. After catheterization
on the left side : L, 2 ; R, 23. Twenty minutes later : L,
2 ; R, 40.
Case 21. — i6th Oct., Karl H., set. thirty-four. R, tymp. phlegm,
acuta, for two days ; R, on the concha ; L, 150. After paracentesis
of the R Mt : R, on the concha as before, but weaker ; L, 250.
1 8th Oct.: R, o (abundant discharge of pus) ; L (tympanitis
phlegm, acuta on this side also), 50. After syringing the right ear:
R, o; L, 50, 19th Oct.: R, o (much pus) ; L, 22 ; (tymp.
270 A. Eitelberg.
phlegm.). After syringing and using the catheter on the right
side : R, o; L, 22. 20th Oct.: abundant pus in each meatus, and
the hearing could no longer be accurately tested.
Tympanitis puridenta.
Case 22. — 23d Oct., Joseph E., aet. seventeen. L, rupture of Mt
by a slight blow on the auricle : L, 20 ; R, 13. Induction current
on the affected side. 2d Nov.: L, 8 ; R, 12 ; L, Tympanitis puru-
lenta, syringing, boracic acid. 4th Nov.: L, 8 ; R, 14. The
otitis is moderating. 8th Nov.:L, i] ; R, 18. i6th Nov.: L, 22 ;
R, II. 20th Nov.: L, 41 ; R, 20. 23d Nov.: L, 31 ; R, 17. The
otorrhcea has ceased. 27th Nov.: L, 47 ; R, 18 ; cold in the head.
30th Nov.: L, 45 ; R, 35. 4th Dec: L, 105 ; R, 75 ; mucous
membrane paler, nth Dec: L, 105; R, 112. The perforation
has not yet cicatrized.
Case 23. — 7th Nov., Hermann H., aet. forty. L, tympanitis puru-
lenta for nine days : L, i ; R, 184. After syringing the left
meatus: L, 11 ; R, 215. loth Nov.: L, 5 ; R, 525. Left, pus
tinnitus. Lead acetate. i6th Nov.: L, 13 ; R, 600. 23d Nov.,
L, 43 ; R, 600. L, polypoid granulations ; spiritus vini rectifi-
catus. 30th Nov.: L, 82 ; R, 600. The otitis has ceased, the tin-
nitus is less ; there is a small perforation in the posterior superior
quadrant of the Mt. 5th Dec: L, 150 ; R, 600.
Case 24. — i8th Oct., Jacob M., aet. forty-eight. R, tympanitis
purulenta since day before yesterday: R, o ; L, 60. After syringing
the right ear : R o ; L, 75. 19th Oct.: R, o ; L, 60. A great deal
of pus in the right meatus. After syringing the right ear: R, o ;
L, 70.
Case 25. — 24th Oct., Theresa K., aet. twenty. L, tympanitis
purulenta for several days past: L, 200 ; R, 250. Lukewarm water
for syringing the ear. 26th Oct.: L, 300 ; R, 450. The secretion
is less.
Case 26. — i6th Sept., Edward S., aet. eighteen. Has had pain in
the left ear for over a month, and subsequent to an attack of angina.
The upper wall of the external meatus is very prominent (abscess).
L, I ; R, 85. i8th Sept.: L, 2 ; R, 95. Spontaneous opening of
the abscess early this morning. Tympanitis purulenta with per-
foration. After using the syringe : L, 2 ; R, 117. 21st Sept.: L,
61 ; R, 140. Lead acetate. 26th Sept.: L, 74 ; R, 164. 29th
Sept.: L, 142 ; R, 208. Tinnitus in the left ear. 5th Oct.: L, 128 ;
Treatment of One Ear Influencing the Other. 271
R, 170. Lead deposit, otorrhoea diminished. 12th Oct.: L, 230 ;
R, 230. The otorrhoea has ceased. The ears are tested separately,
with the other hermetically closed.
Case 27. — ist Dec, Anna P., set. twenty-eight. L, tympanitis
purulenta chronica. On the right side, a cicatrix after tymp. puru-
lenta : L, 10 ; R, 140. Lead acetate. 6th Dec: L, 30 ; R, 380,
The otorrhoea has stopped.
Case 28. — 19th Sept., Johann L., set. thirty-two. L, tympanitis
purulenta since he was six years old, at which time he received a
blow on the head. L, 1 1, R, 124. After treatment with boracic acid:
L, 9 ; R, 124. 27th Sept.: L, 20 ; R, 145. The otitis is very
slight, 6th Oct.: L, 42 ; R, 83 ; slight otorrhoea. 13th Oct.: L,
II ; R, 102. Moderate otorrhoea. 20th Oct.: L, 40; R,
160. Otorrhoea moderate. 26th Oct.: L, 40 ; R, 64.
Otorrhoea diminishing. 14th Nov.: L, 25 ; R, 95. 22d Nov.: L,
15 ; R, 188. The otorrhoea has ceased.
Case 29, — 19th Sept., Marie S., set. thirty-seven. Right tym-
panitis purulenta for about one year, with a perforation ; polypoid,
granulations. R, 10 ; L, 64. After syringing : R, 9 ; L, 97. Lead
acetate. 22d Sept.: R, 98 ; L, 300. After syringing: R, 82 ; L,
160.
Case 30. — 21st Sept., Leni B., set. thirty. Left, tympanitis puru-
lenta, with a polypus, for three years. L, 3 ; R, 166. After
syringing: L, 9 ; R, 202. Spiritus vini rectificatus. 30th Sept. :
L, 19 ; R, 600. Otorrhoea well marked.
Case 31. — 24th Oct., Franz, P., set. fifty-three. Right, tympanitis
purulenta for ten days. R, o ; L, 10. After syringing : R, on the
concha; L, 15. 27th Oct.: R, o ; L, 15. Thick masses of pus.
After catheterization of the left tube: R, o ; L, 15, After
syringing right : R, o ; L, 15.
Case 32. — ist Dec, Katharina, P., ast. forty-four. L, tymp.
purulenta with perforation ; secretion very trifling. Uninter-
rupted tinnitus in both ears for two months ; worse at morn-
ing. R, 44 ; L, 10. Catheter, right side. 4th Dec: R, 86 ; L,
8. Tinnitus unchanged. After catheter (right) : R, 70 ; L, 7.
7th Dec: R, 70 ; L, 4. The tinnitus, right, is louder than left.
After catheterization : R, 63 ; L, 9. The tinnitus is not sensi-
bly altered. 9th Dec: R, 99 ; L, 11. After catheter (right): R, 70 ;
L, 19. The tinnitus is unaltered.
272 A. Eitelberg.
Otitis media catharrhalis chronica.
Case ^tZ- — 6th Oct., Franz K., ast. fourteen, has been deaf in
both ears for three months ; no tinnitus. L, 40 ; R, 70. After
catheterization on the left side: L, 60 ; R, 102. loth Oct.: R,
68 ; L, 70. After catheterization on the right side : R, 93 ;
L, 82.
Case 34. — i6th Sept., Rosa H., ast. thirty-four. L, very violent
tinnitus (ringing and drumming), with but few interruptions since
last spring; R, faint tinnitus. R, 78 ; L, 71. After catheter R :
L, no tinnitus ; five minutes later a booming noise L. " The
noise sounds a great deal different from what it used to." 20th
Sept.: R, 80 ; L, 70. The tinnitus has disappeared, but the head
seems affected ; patient complains of vertigo ; fulness in the
forehead. After catheter on the right side : R, 125 ; L, 116.
"My head feels giddy." 23d Sept.: R, 134; L, 80. Tinnitus
("humming of bees ") slight. After catheter right: hearing R,
165 ; L, 115. In the beginning an indefinable noise, then a
buzzing alternating with ringing. Five minutes later the tinnitus
just as before treatment, and head easier. 27th Sept.: R, 161 ;
L, 128. Roaring and vertigo, which are relieved by catheter on
the right side. 29th Sept.: R, 235 ; L, 176. There have been
neither tinnitus nor vertigo since the last introduction of the
catheter ; head easy.
Case 35. — 28th Sept., Anton K., ?et. twenty-six. The patient
has suffered for a year from intermittent tinnitus in the left ear,
which is occasionally so loud in the early part of the day that he
can hardly carry on conversation with those about him. R, 61 ;
L, II. After using the catheter on the right side : R, 104 ; I^,
14. Tinnitus not altered. 30th Sept.: R, 43; L, 14. Catheter
on right side : R, 60 ; L, 30. Tinnitus unaltered. 4th Oct. : R,
50 ; L, 20. The increase in the tinnitus previously noticed every
three or four days has ceased. After catheter (right): R, 50 ;
L, 20. No action upon the tinnitus. 7th Oct.: R, 35 ; L, 20.
After catheter (right): R, 58 ; L, 20. 17th Oct.: R, 50 ; L, 18.
The tinnitus has been much more violent in the last five days.
Bougie on the right side. 21st Oct.: R, 50 ; L, 20. Tinnitus
less. After bougie (right): R, 50; L, 19. 27 Oct.: L, 19 ; R,
27. After bougie (/^//): L, 20 ; R, 46. Tinnitus unaltered. 2d
Nov.: L, 17; R, 41. Tinnitus unaltered. After bougie left:
L, 17 ; R, 60.
Treatment of One Ear Influencijig the Other. 273
Case 36. — 29th Sept., Paul W., aet. twenty-eight, has been deaf
since childhood, with constant tinnitus in both ears, though
louder on the left side. R, 300 ; L, 76. After catheter {tefi) :
R, — ; L, 95. 2d Oct.: R, — ; L, 80. After catheter {right):
R, — ; L, 56. Tinnitus about the same. 9th Oct.: R, — ; L, 52.
After catheter (right): R, — ; L, 119. Ten minutes later : L, 95.
The right ear has been tightly closed during these previous tests
for the left ear. Tinnitus, left, is less. After catheter (right): R,
— ; L, 130. 14th Oct.: R, — ; L, 116. Tinnitus weaker in both
ears. After catheter (right): R, — ; L, 125. 17th Oct., the
tinnitus on both sides is extremely slight.
Case 37. — nth Oct., Rosalie G., aet. thirty-eight, has been an-
noyed for several months with a continuous tinnitus ("seething "),
which grows more violent when she lies down. She also com-
plains of vertigo and headache. L, 102 ; R, on the concha.
After catheter left: L, 80; R, on the concha. No action upon the
tinnitus. 14th Oct.: L, 97 ; R, on the concha. The tinnitus is
"somewhat more rapid." After catheter left: L, 120; R, 2.
Tinnitus unaltered. i6th Oct.: L, 97 ; R, 3. "Ringing ; and I
feel as if I were going up." The headache is more noticeable on
the left side than the right. After catheter /^// .• L, 103; R, i.
19th Oct.: L, 62 ; R, 4. Ringing is less marked. After catheter
left: L, 94; R, 3. 21st Oct.: L, 106; R, on concha. The
tinnitus and pain in the head are more noticeable on the left side
to-day than yesterday. After catheter left : L, 85 ; R, i. Tin-
nitus and headache as before. 24th Oct.: L, 76 ; R, 2. Head-
ache less ; tinnitus as before. 2d November : R, on the concha ;
L, 80, Tinnitus on the right side now louder. After catheter
right : R, i ; L, 75. Tinnitus somewhat louder. 8th Nov.: R,
2 ; L, 80. After bougie right : R, 2 ; L, — . 2 2d Nov.: R, 2 ;
L, no. Tinnitus less.
Case 38. — 12th Oct., Fanny H., get. eighteen, has been deaf for
several years, and for three weeks has noticed an increased and
intermittent tinnitus (" hammering ") in the left ear. R, 26 ; L,
24 ; after catheter {right): R, 13 ; L, 16, and tinnitus unchanged.
14th Oct.: R, 45 ; L, St,. The tinnitus in the left ear has almost
disappeared, while in the right there is a hissing sound. After
catheter (rz^/z^): R, 63 ; L, 67. 17th Oct.: R, 210; L, 210. No
tinnitus in either ear. Catheter right. 24th Oct.: both ears 250.
When the patient reappeared for treatment a month later (Nov.
28) hearing on the formerly treated {right) side had decreased to
274 -'i- Eitelberg.
85, while on the originally more extensively affected side (left) it
still remained at or about the same as before, 210. The subjec-
tive noises had now left this side of the head and wandered over
to the right.
Case 39. — 13th Oct., Elizabeth B., aet. twenty-six, has been deaf
for five years in both ears, and suffered from continual tinnitus
(" seething"), w/z/V/z is louder in the left ear. The patient was
catheterized, though unsuccessfully for a long time. R, 3 ; L, 3.
After bougie (right) : R, 3 ; L, 3. Tinnitus unaltered. 14th
Oct.: R, 3 ; L, 6. After bougie right : R, 3 ; L, 6. 17th Oct.:
R, 3 ; L, 7 Bougie right. 20th Oct.: R, 3 ; L, 6. After bougie
(right) : R, 4 ; L, 6. 23d Oct.: R, 3 ; L, 3. After bougie (right) :
R, 4 ; L, 4. 31st Oct.: R, 6 ; L, 6. Tinnitus unchanged;
bougie right. 3d Nov.: R, 9 ; L, 7. Tinnitus diminished. After
bougie (right) : R, 10 ; L, 9. loth Nov. : R, 13 ; L, 7. After
bougie (right) : R, 20 ; L, 11.
Case 40. — 6th Nov., Hugo B., ?et. twenty. L, cerumen. Loud
tinnitus on both sides. Before removal of the plug of cerumen :
L, 3 ; R, I. After removal: L, 3 ; R, on the concha. loth
Nov.: L, 7 ; R, 2. 13th Nov.: L, 12 ; R, 2. i6th Nov.: L, 8;
R, 2. 2ist Nov.: R, on concha; L, 5. After bougie (right) : R,
2 ; L, 3. 23d Nov.: R, i ; L, 3. After bougie (right) : R, i ;
L, 9. 27th Nov.: R, 2 ; L, 2. After bougie (right) : R, i ; L, i.
28th Nov.: R, 2 ; L, 12. After bougie (right) . 30th Nov.:
R, I ; L, 8. After bougie (right) : R, 6 ; L, 11. 4th Dec: R,
2; L, 21. After bougie (right): R, 2 ; L, 11. Fifteen minutes
later: R, 11 ; L, 21. nth Dec: R, 10; L, 32. After bougie
(right) : R, 16 ; L, 40. The tinnitus in both ears is much less than
it was at the beginning of the treatment.
The frequent increase and decrease in the hearing of the
ear that was not treated in the cases which we have just
briefly sketched, may depend partly upon spontaneous sub-
jective variations in the function of the auditory apparatus ;
but in many of the cases it cannot be regarded as any thing
else than the result of the influence exerted by the treat-
ment of the one ear upon the other. When I speak further
on of the extreme limits of hearing — the hearing at the
beginning and termination of the period of observation — I
refer to the amounts which were determined at the first and
Treatment of One Ear Influencing the Other. 275
last visits, and simply to the ear which was not directly-
treated.
Amongst the cases treated with the bougie, we have to
draw especial attention to case 39, because for a long time
the use of the air-bag and catheter was absolutely of no
avail, while the introduction of the bougie on 07ie side at
seven sessions increased the hearing power on that side from
3 cm. to 1 1 cm. only, on the other side from 3 cm. to 20 cm., and
also decidedly diminished the extremely annoying subjective
noises on both sides. In case 40, in which the bougie was at
last exclusively employed, the hearing for the watch on the
side that was treated at five sessions with this method
increased from on the concha to 16 cm., and on the side that
had not been treated from 5 cm. to 40 cm,. The subjective
noises in this case also were greatly lessened upon both
sides. In case 15, after two introductions of the bougie, we
observed an increase of 19 cm. in the hearing of the side that
had not been treated, although the procedure had been
without effect upon the side that had thus been treated.
If we consider the forty cases as a whole, we can offer
the following resume : In seven cases (6, 7, 12, 13, 16, 17, 19)
the treatment of the one ear was not followed by any
change in the hearing of the other ; but of these only one
(17) made a second visit, while in all the others we had to
be satisfied with the first examination. But, inasmuch as
the increase of hearing in the ear that has not been directly
treated is only observed after continued treatment of the
other ear, or may only be observed at a later date without
continued treatment, we feel obliged to exclude these seven
cases as belonging to the doubtful list. In those thirty
cases which were tested immediately after the treatment,
we discovered an improvement in the hearing of the ear
that had not been treated, as a momentary influence of the
treatment, to the following amounts — the increased hearing
distance in centimetres is inclosed in parentheses : Case i
(10), 3 (64), 4 (18), 5 (11), 10 (104), 2 1 (100), 23 (3 1), 24 (1 5), 26
(22), 29 (33), 30 (36), 31 (6), 33 (32), 34 (26), 35 (3). The
limits of improvement of hearing extend, therefore, from
3 cm. to 104 cm.
2/6 A. Eitelberg.
On the contrary, in six cases we discovered a diminution
of hearing on the side not treated, as a momentary resiilt of
the treatment : in cases 2 (43), ii (2), 20 (12), 36 (24), 38 (8),
40 (i) cm. We have, therefore, the extreme limits of dim-
inution of hearing varying from i cm. to 43 cm.
The momentary influence of the treatment upon the hear-
ing of the ear that was not treated was null in nine cases,
viz. : 6, 7, 8, 9, 13, 19, 28, 37, and 39.
We meet with still greater variations in those cases in
which the increase of hearing in the ear that has not been
treated is only discovered at a later date. Or, again, when
such an increase has already been observed after the first
treatment, it improves still further during a prolonged
course of treatment, or even if the cases are simply kept
under observation without any treatment whatsoever. I
will here remark that it is chiefly the cases of unilateral
purulent inflammation of the tympanum, whether acute or
chronic, which offer the most extensive variations in the in-
crease of hearing in the ear that has not been treated (as high
as 400 cm^. Where both ears are affected in a similar manner
the improvement in hearing is generally but very slight, some-
times not more than two cm. But even this difference in-
dicates, in many a case, that where the patient could only
once hear by bone-conduction, the hearing by aerial con-
duction is now, for a time at least, restored.
An improvement of the hearing of the ear that had not
been treated was observed in the course of the treatment
of the opposite ear, or in the course of the observation of
the case when the treatment was not carried out for any
length of time, in twenty cases out twenty-eight : in case 8
(51 cm\ 9 (34), II (2), 18 (400), 22 (99), 33 (400), 25 (200),
26 (145), 27 (240), 28 (64), 29 (236), 30 (400), 31 (5), 34 (86),
35 (8), 36 (49). 37 (2), 38 (225), 39 (8), and 40 (37). The ex-
treme limits are therefore 2 cm. to 400 cm.
The hearing of the ear that was not treated was dimin-
ished in the course of the treatment of the other ear in two
cases : in case 3 (30 cm.^ and in case 15 (28 cm^.
The subjective perception of sound was entirely removed
in the one ear by the treatment of the other, in cases 34 and
Treatment of One Ear Influencing the Other. 277
38 ; and it is interesting to note that in the former of these
the noises ceased immediately after each session, and that
in the course of the continued treatment, with more or less
prolonged intervals, they repeatedly altered their character-
istics. The subjective noises were decidedly improved in
cases 35, 36, 37, 39, and 40.
The result of my investigations may be formulated as
follows :
1. The treatment of the one ear causes a distinct im-
provement in the hearing of the other, in a large proportion
of cases ; it rarely causes diminution of hearing.
2. The greatest improvement in hearing on the side that
had not been treated was noted in cases of unilateral, acute,
or chronic suppurative inflammation of the tympanum. It
was additionally discovered that the hearing power on the
side that was not treated, presuming, of course, that the
disease had not already invaded that ear, could be restored
to the normal amount before the morbid process upon the
affected side had run its course.
3. When both ears are affected, the treatment of either
one exclusively often produces an improvement in the other,
and this not merely so far as concerns the hearing, but as
concerns any subjective noises that may have been present.
4. In most of the cases which were under my observation,
the ear that had not been treated did not generally return
at once to a normal condition, but only after a moderate
lapse of time, while on the contrary,
5. In other cases, the hearing which had at first been re-
stored in the one ear by treatment of the other gradually
decreased in the course of observation.
These facts may possibly be explained in the following
manner. Urbantschitsch has shown ' that irritation of the
sensitive fibres of the trigeminus of one side can exercise
upon all of the sensitive perceptions, not only of the side
affected, but of the opposite side also, an influence which
makes itself felt in most cases by an increase, and in a few
others by a decrease in the acuteness of these perceptions.
We are therefore justified in assuming that in the same
* FJliiger's Archiv f. Physiologic, Band xxx.
2/8 A. Eitelberg.
way the influence of the treatment of the one ear upon the
other is purely a reflex action in which the trigeminus is the
most important nerve involved, the irritation exercised upon
the one ear being thus conducted to the acoustic centre,
and thence to the other ear which has not been subjected
to treatment.
The same explanation may sufiflce for those cases in
which the effect of the irritation of one ear upon the other
continues to increase for some time later, although the irri-
tation itself is no longer practised, or has been practised
but once, for, as the above investigations show, after any
given irritation has been practised upon one ear, the acute-
ness of hearing may increase not only upon the side which
has been irritated but also upon the other.
I regret that I was unable in the case of these out-patients
to watch for a longer period the sympathetic action upon the
ear that was not treated, for it appears to me a subject of
great interest to discover how long the same may continue.
Meanwhile I hope that the observations which I have here
published may excite other observers to make more system-
atic observations in the same province.
THE INFLUENCE OF HEARING EXERCISES ON
THE SENSE OF AUDITION OF THE PRAC-
TISED AND CONSECUTIVELY ON THE OTHER
NOT PRACTISED EAR.
By a. EITELBERG,
AURAL SURGEON AT THE GENERAL POLI-CLINIC IN VIENNA.
Translated by Dr. J. A. Spalding.
ACCORDING to the observations of Urbantschitsch,
waves of sound particularly directed into one ear
produce an excitation of the acoustic centres on both sides,
which is followed by an increase of the auditory function in
the other ear, just in the same manner as monocular vision
produces excitation of the optic centres, and consequently
an augmentation of the visual power in both eyes. Similar
investigations, which I have since made on a larger scale,
have yielded the following results.
I will premise that the most suitable persons for submit-
ting to these experiments were those whose hearing distance
for my watch (heard normally at 600 C77i.) varied between 5
cm. and 20 cm. Persons with a greater range of hearing fur-
nished more conspicuous results, but the examinations were
more tiresome and apt to be inaccurate, except when
the persons were well drilled by repeated examinations on
other subjects.
The acuteness of hearing was ascertained in each case
after several identical statements of the person examined,
taking care only that the observations were not taken at
short intervals, for then the excitation of the sense of hear-
279
28o A. Eitelberg,
ing invariably caused mistakes as to the normal auditory
distance.
I convinced myself of the trustworthiness of the state-
ments while standing behind the person, by approaching
the watch to the ear, removing it again, and comparing the
statements with the corresponding distance of the watch
from the ear. I need not mention that the other precau-
tions necessary to avoid mistakes, by intentional or uninten-
tional deception on the part of the person examined, were
carefully observed.
The examination was carried on as follows : The sense of
audition on the one side was excited by the noise of a
watch for a period of from thirty to forty-five seconds,
which was followed by a rest of the same duration, in order
to avoid fatigue of the ear. If I excited the ear longer
than forty-five seconds, attentive and well-drilled persons
would not infrequently state that they heard the tick of the
watch much weaker and even not at all for some moments.
After an examination of five minutes, rarely after a longer
or shorter time, the limit of audition was again obtained, but
never before the termination of the last period of rest, be-
cause, as will be seen by the examples to be mentioned
later, the distance at which any sound is heard, immediately
after the period of excitation, differs essentially from that at
which it is heard after the period of rest. In like manner
the limit of audition was determined at intervals of five
minutes after the cessation of the noise from the watch, in
order accurately to trace the rise or fall of the perception
of hearing on the same, or — which was more important for
our purpose — on the opposite side during the intermission
of the exercises. By the latter term I understand, in contra-
distinction to the period of exercise, those longer intervals
during which the sense of hearing was not stimulated to in-
creased activity by the noise of the watch.
In order to obtain a correct understanding of the experi-
ments I will mention that the period of exercise is meant
whenever the parenthesis "intermission of exercise" is
omitted, and the determination of time (five minutes, etc.)
always indicates after what time and how often the hearing
Influence of Hearing Exercises on Audition. 281
distance was verified. If the record reads, for example :
" fifteen minutes later (intermission of exercise)," the hear-
ing distance was not noted at intervals of five minutes but
only once, namely after fifteen minutes. Other additions
to the records will explain themselves or will, if necessary,
be explained by notes. I will mention that the majority
of my experiments were made on persons who had been
drilled at other investigations, and whose statements had
always been found reliable.
In the first place I shall speak of that group of experi-
ments in which the influence of exercise of the sense of
audition of one side was observed both on the same side
and on the opposite also. To avoid repetition I shall,
however, mention those cases in which on other days the
influence on the opposite ear only was examined.
First Experiment. — Jan. 22, 1883. A. Sch., set. thirty-three.
Hard of hearing for several years. Constant tinnitus on both
sides. Watch: R 4, L 2. Five minutes later : R 7, L 4. Five
minutes later : R 8, L 5. Five minutes later : R 6, L 6. Feb. ist,
watch : R — , L 7. Five minutes later : R — , L 8. Five minutes
later (intermission of exercise): R — , L 7. Five minutes later : R
— , L 9. Five minutes later (intermission of exercise) : R — , L 7.
Second Experiment. — Jan. 26th. H. R., fet. thirty-six. Tinni-
tus on left only. Watch : R 20, L i. Five minutes later : R 25,
L I, Five minutes later : R 29, L i. Jan. 30th : h R 23, L 5.
Five minutes later : R — , L 5. Five minutes later : R — , L 4.
Five minutes later : R — , L 3. Five minutes later (intermission
of exercise) : R — , L 4. Five minutes later (intermission of ex-
ercise), R — , L 5.
Third Experiment. — Feb. 5th. S. Sch., get. twenty-three. Hard-
ness of hearing and constant tinnitus on both sides, the tinnitus
louder on the right : h L — , R 6. Five minutes later : L — ,
R 5. Five minutes later : L — , R 4. Thirteen minutes later
(intermission of exercise) : L — , R 4. Feb. 6th : h R 5, L 7.
Tinnitus louder on the left. Five minutes later : R 4, L 5. Five
minutes later : R 4, L 6. Five minutes later : R 3, L 6. Five
minutes later (intermission of exercise) : R 4, L 5. Feb. 13th :
L 21, R 7. Tinnitus on the left only. After catheterization on
the left : L 15, R 8. Feb. 23d : L 7, R 6. Tinnitus on both
sides. After catheterization on left side : L 7, R5. Tinnitus dis-
282 A. Eitelberg.
appeared on right side : R 5, L 7. Five minutes later : R 7, L
10. Five minutes later (intermission of excercise) : R 6, L 13.
Five minutes later (intermission of exercise) : R 5, L 14.
Fourth Experiment. — Feb. 12th. A. K., set. twenty-seven.
Hard of hearing two months, according to patient's statement.
Constant tinnitus on left only : // R 9, L 6. Five minutes later :
R 10, L 7. Five minutes later : R 11, L 8. Five minutes later
(intermission of exercise) : R 11, L 7. Five minutes later (inter-
mission of exercise) : R 9, L 8. After catheterization on left
side : R 9, L 8.
Fifth Experiment. — March 13th. L. M., set. thirty. R, large
perforation ; L, scar. No tinnitus ; // L 24, R 6. Five minutes
later : L 23, R 10. Five minutes later : L 20, R 6. Five minutes
later (intermission of exercise) : L 20, R 3. Five minutes later
(intermission of exercise) : L 21, R 5.
Si-s.th Experi7}ient. — Feb. 13th. C. St., jet. twenty-three. For
two years, constant tinnitus on the left : h R 60, L 5. Five min-
utes later : R — , L 5. Five minutes later (intermission of exer-
cise) : R — , L ad concham. March 8th : // R 114, L 18. Tinnitus
on left only. Five minutes later: R 114, L 19. Five minutes
later : R loS, L 19. Five minutes later : R 103, L 18. Five min-
utes later (intermission of exercise) : R 118, L 19.
Seventh Experiment. — March 15th. J. V., act. fifty-six. Hard
of hearing about two years. No tinnitus : /; L i, R a^ conch, (by
strong pressure). Five minutes later : L 2, R i. Five minutes
later : L 2, R i. Five minutes later : L 2, R ad conch. Twelve
minutes later (intermission of exercise): \j ad conch.., '^ ad conch.
(only by strong pressure).
Eighth Experiment. — Feb. 20th. A. L., set. eighteen. R, ceru-
men. After removal of the same : // R 40, L 40. Five minutes
later : R 65, L 62. Five minutes later : R 65, L 55. Fifteen min-
utes later (intermission) : R 60, L 52.
Ninth Experiment. — Feb. 2rst. Carl S., ast. five. Perforation
in the posterior superior quadrant (after an injury, Jan. 21st); tym-
panum dry ; R, semilunar calcareous deposit in the posterior half
of the Mt, and a second one as large as the head of a pin, just in
front of and beneath the short process : // R 46, L 10. Five
minutes later : R 39, L 12. Five minutes later : R 44, L 12.
Five minutes later: R 31, L 14. Twenty minutes later (inter-
mission) : R 45, L 12. Twenty-five minutes later (intermission):
R 45, L 12.
Influence of Hearing Exercises on Audition. 283
Tenth Experiment. — Feb. 26th. Gottfried K., set. twenty-nine.
R, tympanitis suppurativa with total loss of Mt; violent and con-
tinual tinnitus in the occiput, especially in the morning : A L 15,
R on gently resting the watch against the auricle. Five minutes
later : L 15, R not even when pressed close against the auricle.
Five minutes later : L 15, R heard when pressed close against the
auricle. Ten minutes later (intermission) : L 14, R heard when
lightly pressed against the auricle.
Eleventh Experiment. — Feb. 27th. Cecelia S., set. twenty. R
chronic purulent suppuration of tympanum for thirteen years ;
polypi springing from the tympanum : h L 34, R o. Five min-
utes later : L 43, R o. Five minutes later : L 45, R o. Ten
minutes later (intermission): L 47, R o.
Twelfth Experitnent. — March 6th. Helen B., aet. thirty-two.
Deaf for four months since a miscarriage. Tinnitus of slight de-
gree on both sides : /« L 8, R 8. Five minutes later : L 10, R
II. Five minutes later : L 13, R 13. Ten minutes later (inter-
mission): L 12, R II. Ten minutes later (intermission): L 11, R
II. Five minutes later (intermission): L 11, R 9. March 9th :
L 20, R 21. Tinnitus no longer noticed on the right side. Five
minutes later : L 27, R 20. Five minutes later : L 27, R 21.
Five minutes later : L 27, R 24. Twenty minutes later (inter-
mission, during which the patient was tested with the aural ther-
mometer) ' : I, 27, R 24.
Thirteenth Experiment. — -March 7th. Herman H., set. fifty-
seven. Thickened milky-white Mt on both sides. Loud tinni-
tus on both sides : ,^ R 4, L 4. Five minutes later : R 4, L 4 ;
five minutes later : R 4, L 4 ; five minutes later : R 4, L 4 ; five
minutes later : R 4, L 4.
These experiments show that the hearing of the practised
ear increased seven times out of thirteen cases, viz. : in cases
I, 2, 4, 7, 8, II, and 12 ; that it diminished in four cases (3,
5, 6, and 9) ; while in two (10 and 13) the auditory nerve did
not react in the least.
The increase amounted to 4 cm. [i],^ i [2], 2 [4], i [7],
25 [8], II [11], and 5 [12]. The decrease amounted to 2 cm.
[3], 4 [5], II [6], and 15 [9].
' This instrument for testing the temperature in the external meatus is made
by Kappeller, of Vienna, from the suggestions of Dr. Urbantschitsch.
' The figure in brackets indicates the number of the experiment.
284 A. Eitclbcrg.
We notice, first of all, that the positive coefficient of ex-
citation (increase of hearing) is so much the greater, the
greater the original perception for the ticking of the watch,
and that it is so much the smaller the less the original amount
of hearing for the watch. An apparent voucher for this
statement can be seen in the twelfth experiment, in which,
according to tests repeated three days later, after the hear-
ing had increased from 8 cm. to 20 cm. (possibly as a result
of the daily treatment), we discovered a positive coefficient
of excitation of 7 cm., whilst at the first experiment, when
the hearing amounted only to 8 cm., the positive coefficient
(increase) was just 5 cdl We are not, of course, justified in
assuming from this single case that the positive coefficient
of excitation always stands in similar relations to the origi-
nal hearing distance, for many other causes which we shall
later mention exercise undoubtedly a decisive influence
upon the same.
We will now examine more closely two cases (10 and 13) in
which the excitation of the auditory nerve by the ticking of
the watch did not appear to have any influence upon the
hearing distance. In both of these cases we find loud and
continuous tinnitus ; in one case in the occiput, in the other
in both ears. But we must not forget that tinnitus, when
exceedingly loud, is very apt to interfere with that greater
activity of the sense of hearing at which we are aiming in
our experiments by the action of a definite source of sound.
Amongst the four cases in which the hearing was dimin-
ished after our experiment, tinnitus was present in one
(No. 3), but after this subjective perception of noises had
for a time been reduced in intensity by proper treatment,
the second examination, seventeen days later, on February
23d, showed a slight increase of hearing in comparison with
the previous test. In cases 6 and 9 the tinnitus was noticed
on one side only, and that was the one opposite the side ex-
perimented upon. Nevertheless, as we shall later see, even
unilateral t"nnitus can exercise some influence upon the
energy of the hearing of the opposite side.
We have next to discuss the question : How soon are we
to look for the culmination of the increased or diminished
Infliieyice of Hearing Exercises on Audition. 285
excitability of the nerves of hearing ? This appeared to me
to take place at the end of two periods of examination, —
that is to say, in about ten minutes. There are, indeed,
cases in which the culmination is reached after the first
period of examination, while in still other cases, it is not
noticed until after several frequently repeated periods of
examination. Cases of this sort, however, are rare. The
same condition of things is noticed with the decrease and
increase of hearing during the intermissions of examination.
In a few scattered cases I noticed in the periods of exami-
nation and intermission both, that the hearing energy varied
more or less within certain fixed limits.
We have already mentioned the fact that the hearing is
frequently observed to decrease if tested directly after a
phase of excitement. I have repeatedly convinced myself
of this fact, and for lack of space only suggested it once or
twice in the cases here reported, just as for the same reason
I have not given the results of all the tests on every day.
I will now subjoin those experiments in which the action
of the excitation of one auditory nerve was tested merely
in reference to the other ear.
Fourteenth Experitnent. — Jan. 23d. Ottilia Z., set. forty-six.
Tinnitus on both sides for one year : h R 43, L 96. Ten minutes
later : R — , L 116.
Fifteenth Experiment. — Jan. 24th. Anna G., set. forty-four.
Deaf for several years, and lately has had tinnitus on the left side :
R 9, L on the concha. Five minutes later : R — , L on the
concha. Five minutes later : R — , L on the concha. Jan. 25th :
R II, L on the concha. Five minutes later: R 11, L on the
concha. Five minutes later : R 14, L — . Five minutes later
(intermission): R 12, L — . Five minutes later (intermission): R
II, L — .
Sixteenth Experiment. — Feb. 7th. Elizabeth O., set. thirty-
two : R, cicatrix ; L, excessive retraction of the Mt. Tinnitus L
only : L 12, R 6. Five minutes later : L — , R 6. Five minutes
later : L — , R 6. Five minutes later : L — , R 8. Five minutes
later : L — , R 7. Five minutes later (intermission): L — , R 6.
Five minutes later (intermission): L — , R 6. Five minutes later
(intermission): L — , R 6.
Seventeenth Experiment. — Feb. 9th. Elizabeth T., set. sev-
286 A. Eitelberg.
enteen. Deaf for several years ; no tinnitus ; R, perforation
after tympanitis purulenta ; mucous membrane of tympanum now
dry : L 25, R 6. Five minutes later : L — , R 7. Five minutes
later : L — , R 7. Five minutes later : L — , R 7, Five minutes
later (intermission): L — , R 7. Ten minutes later (intermission):
L — , R 6. After catheterization on the left side : L — , R 6.
Feb. 24th : L 20, R 26. After catheterization on the right side :
L 22, R 26.
Eighteenth Experiment. — Feb. i6th. Moritz M., ?et. 54. Has
had myringitis on the right side for a fortnight. Tinnitus :
L 40, R 2. Five minutes later : L — , R 3. Five minutes later :
L — , R 5. Five minutes later : L — , R 10. Fifteen minutes
later (intermission of examination): L — , R 4.
Careful examination of these eighteen experiments, in
which the influence of the excitation of one auditory nerve
upon the other was thoroughly tested, shows a positive co-
efficient of excitation (increase of hearing) in twelve cases,
amounting to 4 cm. [Case i] : 9 [2], 2 [4], 4 [5]. i [7]- 22 [8],
4 [9]' 5 ['2], 20 [14], 2 [16], I [17], 8 [18]. In three we find
a negative coefficient of excitation, 2 [3], 3 [6], and from on
the concha to o [10]. In the remaining experiments the
hearing distance was not altered. In the three cases with a
negative coefficient of excitation the hearing distance was
diminished twice upon the same side ; once it was unaltered.
In the latter case, however (I'o), the hearing distance de-
creased I cm. during the intermission of the examination
(ten minutes). Among the seven experiments in which a
positive coefficient of excitation was discovered on the same
side after excitation of the auditory nerve by the ticking of
the watch, we find six, again, amongst those twelve experi-
ments in which the hearing on the opposite side also was
increased. A searching investigation of these experiments
as here detailed shows that in exciting an ear which is
extremely deaf, the hearing of the opposite ear with better
hearing is perceptibly increased, while, inversely, if we
excite the energy of the better ear by such methods as
have here been employed, it is very rarely possible for us to
discover any increase of hearing on the opposite, deafer
ear. Indeed, to be precise, it would appear as if the hearing
Influence of Hearing Exercises on Audition. 287
of the latter ear were, on the contrary, more frequently de-
creased. But if the hearing happens to increase during the
course of treatment, or under further observation without
treatment, the results which we have previously obtained
undergo alteration according to the amount of the improve-
ment.
We must here take occasion to emphasize the fact that the
influence which the tinnitus may exert upon the excitability
of the hearing of the opposite side is slight in comparison
with that which it exerts upon the hearing of the same side.
It is, however, a fact from which we cannot escape, that the
tinnitus does exert some influence in many cases, since the
positive coefficient of excitation then remains too slight in
comparison with the original hearing distance.
Ten or fifteen minutes sufficed in most of my experi-
ments to obtain the highest degree of hearing for the watch
upon the side opposite the one excited. I was also able
repeatedly to prove to myself that when the period of exci-
tation was carried beyond this extent of time the perception
of sound upon both sides — the originally excited as well as
the opposite side — gradually decreased. The maximum of
excitability was observed in a few rare cases directly after
the first five minutes. In some of my experiments, as
here described, the period of exercise and intermission of
exercise have been specified interchangeably, so that
the increase of hearing coincides with the period of exer-
cise, the decrease of hearing with the intermission of
exercise ; a fact which may prove, in the experiments
concerned, that the increase of hearing is to be ascribed to
the excitation of the auditory nerve, and not, perhaps, to
occasional variations in hearing.
A few of the cases in the intermission of exercise ex-
hibited a gradual diminution of hearing in intervals which
corresponded closely with those of the increase of hearing in
the periods of exercise, and when the excitation of the
auditory nerve of the one side had been followed by a
diminution of hearing upon the opposite side, the in-
crease of hearing in the intermission of the exercise was
noticed in precisely the same manner. It often happened
288 A. Eitelberg.
however, that the diminution in the hearing distances on
the other ear, which followed the excitation of the auditory-
nerve on the opposite side, became still more marked in the
intermission of exercise. We rarely observed a case in
which the increase of hearing that had in any way been
gained remained permanent during the intermission of ex-
ercise. Both an increase and decrease in the intensity of
hearing were occasionally observed in the intermissions
of exercise.
The values which we have just given are, on the whole,
so slight in comparison with those which we obtained in
examining the reaction of the one ear following the treat-
ment of the other,' that the question urged itself upon me,
whether there was any thing more in this whole subject than
simple individual variations in hearing, and whether
the values which we had thus carefully obtained were
not really to be ascribed to these variations? It was, of
course, plain from the beginning that the values in this ex-
amination could not possibly be so large as some of those
obtained in the investigations previously mentioned. For
as that paper shows in complete detail, and to which I will
simply refer for confirmation of my assertions, we had then
to do with a reflex phenomenon which was produced by a
relatively powerful irritation, such as is caused by the
various methods of treatment — bougie, catheter, etc. In
these experiments, however, we are endeavoring by a rela-
tively slight excitation of the auditory nerve of one side, to
arouse increased action in the auditory centres concerned,
and in this manner to demonstrate an increased activity in
the other auditory nerve thus indirectly excited. In a few
of these experiments I have pointed out this relation by
tabulation of the results after the treatment, and after the
excitation of the auditory nerve by the noise of the
watch.
In order to discover the normal variations in hearing, if
any, in the space of half an hour, for instance, I went
through with several verifying experiments. Inasmuch as
these were made partly upon the same persons who had
* These Archives : the preceding paper.
Influence of Hearing Exercises on Audition. 289
been used in the experiments upon which this paper is
based, I have added, in brackets, the number of the corre-
sponding experiment.
First [12] Verifying Experi7Jient. — March 7th. Helen B.,
aet. thirty-two. h R 12, L 13. Twenty-five minutes later : R 12,
L13.
Second [16] Experiment. — Elizabeth O., set. thirty-two. R
9, L 15. Half an hour later : R 9, L 15.
Third Experi7nent. — March 2d. Carl F., aet. thirty-nine. L,
exudation in tympanum. L 30, R 180. Half an hour later : L
30, R 180.
Fourth Experiment. — March 2d. Wenzel R., aet. thirty-one.
L, phlegmonous tympanitis for eight days. L 9, R normal. Half
an hour later : L 9, R normal.
Fifth [17] Experiment. — Feb. 26th. Elizabeth T., set. seventeen.
R 25, L 23. Half an hour later : R 26, L 24.
Sixth [5] Experiment. — March 15th. Lorenz M., set. thirty.
R 6, L 19. Twenty-five minutes later : R 5, L 17.
Seve?ith Experiment. — Feb. 28th. Gustav. R., set. twenty-
four. R, purulent tympanitis for eight weeks. R 8, L, 16.
Twenty minutes later (during which experiments were made
with the aural thermometer) : R 8, L 16.
To these verifying experiments we must add all of those
in which all attempts to excite to increased activity the
auditory nerve of one side, and consecutively that of the
other, resulted negatively. Moreover, we must include in
this list all of those cases in which periods of exer-
cise and intermissions of exercise alternated with one
another in the same session — i. e., to a period of exer-
cise followed by an intermission, and then again a period of
exercise, and so forth, — and in which the hearing dis-
tance of the same or the opposite side varied after the
period of exercise ; while after the intermission it was
precisely the same as at the beginning of the session.
In five of these seven verifying experiments we found
that the hearing distance within a period of half an hour
remained the same. In the verifying experiment No. 5
[17] it varied about i cm. in both ears, and in the verifying
experiment No. 6 [5] it varied R i cm., L 2 cm. after twenty-
290 A. Eitelberg.
five minutes ; in the first case in favor of the hearing dis-
tance, and in the second, against it. But we must not fail
to see that at the time of the verifying experiment No. 5
[17] the hearing distance amounted to R 25, L 23, while on
February 9th, when an attempt was made to increase the
hearing distance for the watch on the same side as well as
on the other, by exciting the auditory nerve of one side
only, the hearing distance on the side opposite the one
directly irritated was only 6 cm. at the beginning, and later,
only reached 7 cm. Still we find that variations of i cm. in
the hearing are much more frequent with an originally
greater hearing distance than with a small one. And then
again, the repeated tests of the hearing distance appeared
to prove that the improvement in the hearing was to be re-
ferred to the excitation of the auditory nerve, since it
continued only during the period of exercise. In the
intermission of the exercise the improvement in hear-
ing retrograded. In the verifying examination No. 6 [5] we
find a spontaneous reduction of the hearing distance on the
verifying day (March 15th), while on the day of the original
test (March 13th) we discovered on the side opposite the
one excited an increase in the hearing distance for the watch
from 6 cm. to 10 cm. directly after the first period of
exercise.
There is no doubt that spontaneous variations in hearing
can be observed within the space of half an hour, and it is
probable that one or the other of the experiments just cited
may be included amongst such instances. But I am of the
opinion that this can only be the case within certain well-
defined limits. On the contrary, my experiments have
shown me that the presence, for a long time (twenty to
thirty minutes), of any foreign body in the ear, such as the
aural thermometer previously mentioned, does not exer-
cise any influence upon the hearing after its removal.
Most of our cases appear to prove that we are right in
asserting that the improvement or deterioration in hear-
ing on the same or opposite side is really produced by the
excitation of the auditory nerve of one side. The explana-
tion of the fact, as has already been mentioned in the intro-
hifluence of Hearing Exercises on A udition. 29 1
duction, must be sought for in the excitation of the acoustic
centres which is thus accomph'shed.
Analogous facts are mentioned by E. H. Weber ' : " Ex-
ercise of the muscles which perform the movement neces-
sary for writing with the right hand assists the correspond-
ing muscles of the left hand so far that the latter hand can
write fairly well at the same time with the right ; the
movements, however, of the two hands, although symmetri-
cal (from right to left), are not equal in extent."
In this same category is to be included the observation
made by Volkmann,' that the refinement by exercise of the
sense of locality in the skin of any part of the body produces
a refined sense of locality on the corresponding point in the
other half of the body.
It is still an open question, however, owing to lack of
material, whether continued exercise of the hearing of one
side can produce in many cases a permanent increase in the
hearing of the same or opposite sides. Toynbee,' neverthe-
less, reports cases in which the methodical use of a hearing-
tube had been of great benefit in improving the hearing of
those who were very deaf.
'Compare Funke, Hermann's " Handbuch der Physiologie," 1880. Band
iii, Theil 2, Pag. 382.
" " Bericht der Sachsischen Gesellschaft f. Wissenschaft," 1858.
'" Diseases of the Ear," edition i860, page 412.
FURTHER INVESTIGATIONS ON THE PHYSIO-
LOGICAL SIGNIFICANCE OF THE TRIGEM-
INUS AND SYMPATHETIC NERVE FOR
THE EAR.
By E. BERTHOLD, Konigsberg, Prussia.
Translated by Dr. F. E. D'Oench, New York.
WE thought that in a former paper we had concluded
to a certain extent the experimental investiga-
tions on the influence of the nerves of the tympanic cavity
on the vascularization and secretion of its mucous mem-
brane, but the appearance of two new papers, one of them
published by Baratoux in 1881 soon after our own, the
other by Kirchner a year later, compels us to renew our
investigations, and verify the results by new tests.
Referring to our first paper, we would call attention to
two points only, in regard to which we differ from the
authors just mentioned.
We had found that injury of the trigeminus, at its trunk
as well as its roots, produced an inflammatory reaction in
the middle ear, and that irritation of the sympathetic nerve
was always followed by a perceptible contraction of the
blood-vessels of the ear.
When, however, the trigeminus was irritated, or the sym-
pathetic nerve cut, the results were always negative, as far
as the blood-vessels of the ear were concerned. We also
found the mucous membrane of the middle ear unaltered,
even when the sympathetic nerve had been divided several
days previously. These negative results are the subject on
292
Influence of Nerves on the Ear. 293
which we differ from the authors mentioned above, though
neither has repeated the experiments to the same extent.
-Baratoux has only investigated the results of dividing the
nerves of the ear, and Kirchner has for the present experi-
mented upon the trigeminus only.
Let us first see wherein Kirchner differs from us. He
chose the mandibular nerve " for practical reasons, as its
ramifications extend into the naso-pharynx, a region fre-
quently of etiological importance for diseases of the middle
ear." He justifies the selection of this branch, which has
nothing to do directly with the ear, by referring to the
peculiarities of the trigeminus, which is known to contain
fibres of widely different functions. " From its final ramifi-
cations reflex action may be induced in the various kinds of
centrifugal nerves." " To this, for instance, we may refer
the observation of visible inflammatory changes in the tym-
panic cavity in dental caries, etc." The endeavor to injure
the animals experimented upon (cats) as little as possible
seems, however, to have furnished the principal reason for
selecting this nerve; the animal was therefore neither
chloroformed nor put under the influence of curare, in order
to exclude every disturbance of respiration or the heart's
action. In our experiments we neither exercised any con-
trol over the injuries of the trigeminus at its trunk or its
roots, nor over the irritation of the latter in the medulla
oblongata, as these injuries extend so deeply. The number
of experiments performed by Kirchner is not mentioned.
Although we had serious objections to Kirchner's method
for theoretical reasons, we thought it necessary to test it.
Our experiments were conducted in conjunction with
Prof. Griinhagen in his medico-physical laboratory, and I am
greately indebted to my honored friend for his sacrifice of
time and labor.
In exposing the mandibular nerve we adhered in general
to Kirchner's directions, but performed the experiments
under narcosis, as former ones convinced us of the necessity
of keeping the animal absolutely quiet in order to observe
under the magnifying glass changes so minute as those
of the varying fulness of the delicate blood-vessels of the
294 E. Berthold.
mucous membrane of the tympanic cavity. We therefore
chloroformed the animals (cats) and injected 0.025 grms. of
morph. hydrochlor. into the jugular vein in order to prolong
the narcosis. As each experiment lasted from one to two
hours, arrangements had been made to prolong the narcosis
whenever there were indications of its cessation. This was
done by introducing a canula into the trachea and connect-
ing it by means of a rubber tube with a bottle containing some
chloroform. The stopper of the bottle had another opening
in order to admit a sufficient supply of air. When the
nerve had been exposed it was not detached at its periph-
eric end and fastened in Ludwig's electrode, as Kirchner did,
but placed upon Griinhagen's electric forceps. We pre-
ferred Griinhagen's instrument to Ludwig's electrode, as the
latter could only be used to advantage when the nerve was
detached near the lower jaw, and we thought it preferable
not to injure the nerve. The bulla ossea was not exposed
until we had satisfied ourselves that the nerve had been laid
bare suf^ciently so that it could be irritated without any
trouble ; the submaxillary gland was easily avoided.
In exposing the nerve squint-hooks were used almost ex-
clusively. After the bulla ossea had been opened with a
pair of needle-scissors, and the mucous membrane incised and
pushed aside so as to admit of an inspection of the interior
of the bulla, one of us observed with a magnifying glass the
appearance of the mucous membrane and the fulness of the
blood-vessels, while the other irritated the nerve.
The result of our investigations performed upon a larger
number of cats was always negative. We never saw any
change in the fulness of the blood-vessels nor the slightest
trace of an increased secretion. In regard to the latter, we
read Kirchner's remarks with some surprise. He describes
the condition of this mucous membrane literally as follows:
" If the exposed portion of the mucous membrane of the
tympanic cavity is incised with a pair of scissors, a cavity
about half the size of a walnut and covered with a white,
shining, moist mucous membrane becomes visible. This
condition continues after the exposure of the tympanic
cavity and is due to the continual secretion of light, thin
Influence of Nerves on the Ear. 295
mucus. If, for instance, a portion of the mucous membrane
is carefully wiped off with a little cotton, it is again covered
in five seconds with a thin film of mucus."
We never saw any thing of this thin coating of mucus in
healthy bullae, nor ever observed any thing else than a
shining interior, and would compare its degree of moisture
with that of the normal cornea or conjunctiva, of which no
one will say that they are always covered with a thin film of
mucus. We are even not satisfied that the inner surface of
the bulla ossea is covered with a mucous membrane, as mi-
croscopic examination failed to show glands of any kind.
We will not deny that they may exist here and there at the
ostium tubae tympanicum, as in the human ear, as we did
not search for them particularly, but it is certain that there
are no glands in the membrane in question. According to
our idea, the so-called mucous membrane of the bulla ossea
of the cat rather resembles a serous than a mucous membrane
and for theoretical reasons we cannot, therefore, understand
the continual secretion of mucus, described by Kirchner.
Neither could we detect an increased fulness of the blood-
vessels after irritating the mandibular nerve. But even if
this had taken place, we would not have regarded our re-
sults thereby disproved. It sometimes occurred in our ex-
periments that a blood-vessel which had been injured, in
exposing the nerve, and had ceased to bleed, began again
when the nerve was irritated. What would Kirchner say,
if we should therefore ascribe to the third branch of the
trigeminus the power of considerably increasing the pressure
in the blood-vessels of the neck, by irritating the mandibular
nerve? Perhaps he would reply the same as we do to one
of his observations — namely, that only then a conclusion can
be drawn as to the vaso-motor properties of a sensitive nerve
by irritating it, when simultaneous irritation of the other
vaso-motor nerves can be excluded, as we have shown in our
former paper.
If Kirchner had, however, attempted to irritate the third
branch of the trigeminus exclusively, nothing would have
been left to him but to divide the spinal cord below the me.
duUa oblongata, thereby " inflicting severe injuries."
296 E. Berthold.
For the present, therefore, we must be content with the
negative result of irritating the trigeminus.
The second experiment of Kirchner we consider still less
conclusive, which verifies our result in regard to the conse-
quences of injuring the trigeminus. As Kirchner disposes
of the subject in seven lines, we reproduce them literally :
" In some experiments, in which we had exposed the third
branch of the trigeminus and torn it out as near as possible
to the base of the skull, we could verify the observations of
Berthold, who, as stated above, had found inflammatory
changes, even to the extent of purulent exudation into
the tympanic cavity, after an intracranial division of the
trigeminus just before the ganglion of Gasser, as well as
after destruction of its roots by dividing one half of the
medulla oblongata." Kirchner does not explain how he im-
agines the physiological connection between the injury of
the third branch of the trigeminus and its consequence, —
the inflammation of the tympanic cavity. We must there-
fore guess at an explanation. If he assumes that he has
torn out the trigeminus to such an extent as also to injure
the fibres extending to the ganglion oticum, it could only
be objected that the proof for this assumption must be
furnished by a careful autopsy. Or does Kirchner assume
that the injury caused by tearing out the peripheric por-
tion of the third branch of the trigeminus extends as far as
the ganglion oticum ? This assumption seems even more
improbable than the former.
As we have no statements in regard to the questionable
connection between cause and effect, we would only call
attention to the fact that purulent inflammation in the im-
mediate surrounding of the bulla ossea frequently produces
the same in the bulla itself, without the third branch of the
trigeminus being injured, as we observed in the fourth case,
reported below, two days after tearing out the ganglion
supremum of the sympathetic nerve.
Turning now to the paper of Baratoux, we need concern
ourselves with the assertion only that an inflammatory re-
action occurs in the bulla ossea after division of the sympa-
thetic nerve, which we had denied. He says, however, that
Influence of Nerves on the Ear. 297
these changes do not appear within a few days after the
operation, but at the end of a month, or even later. As we
killed our rabbits a week or two after tearing out the gang-
lion supremum of the sympathetic nerve, we were obliged
to repeat our experiments and test the statements of Bara-
toux. On May 29, 1882, we therefore operated three rab-
bits in succession, and tore out the ganglion supremum of
the sympathetic nerve. The myosis of the pupil of the
corresponding eye and the well-known dilatation of the
blood-vessels of the ear clearly proved that the operation
had been successful. One of the rabbits died three days
later, but the autopsy failed to reveal a sufficient cause.
The mucous membrane of both bullae was normal, as was
expected. The second rabbit was killed July 25, 1882 —
sixty-seven days after the operation ; the mucous mem-
brane of the bullae was unaltered.
The last of these rabbits was killed with chloroform Jan-
uary 4, 1883. The bullae, when opened, were entirely
empty and free from exudation, though some blood-vessels
seemed to contain more blood than usual. The mucous
membrane was therefore examined at once under the
microscope, but found entirely normal. I would call par-
ticular attention to a specimen of mucous membrane taken
from the bulla ossea and stained with haematoxyline, reveal-
ing the presence of well-preserved non-medullary nerve-
fibres, which proves that eradication of the ganglion su-
premum of the sympathetic nerve is not followed by degen-
eration of all the sympathetic nerve-fibres in the mucous
membrane of the bulla ossea. Before opening the bulla we
satisfied ourselves by the autopsy that we had torn out the
gangl. supr. symp. It is therefore certain that division of
the sympathetic nerve or extirpation of the gangl. supr.
produces no inflammatory changes in the mucous membrane
of the tympanic cavity. It is true that in a (fourth) case
we found pus in the bulla of a rabbit which had lived only
two days after the operation, but in this case the bulla of
the injured side was also filled wih pus, which suppuration
in both ears we could ascribe to the severe suppuration of
the wound which had exceptionally set in.
298 E. Berthold.
We cannot confirm either in their entire extent the
statements of Baratoux on the influence of division of the
sympathetic nerve upon the blood-vessels of the auricle.
Baratoux saw the dilatation of the blood-vessels and the
thermic phenomena, in their greatest intensity, in rabbits
which had been operated about five years previously by
Laborde. In our animals, however, the dilatation of the
blood-vessels of the ear perceptibly diminished after a few
weeks. We never observed hypertrophy of the auricle in
question, as Bidder claims to have seen in young animals
after injuring the sympathetic nerve. As regards the
physiological importance of the sympathetic nerve, we
must therefore maintain our former views that it is a
vaso-motor nerve, and, as far as our experim.ents extend, a
vaso-constrictor nerve for the whole ear (external, middle,
and inner ear), as the blood-vessels always contracted when
the nerve was irritated ; the results of division in regard to
the vessels of the middle ear are, however, negative.
SECONDARY SYMPTOMS IN THE LABYRINTH
AS SEQUELS OF CHRONIC PURULENT IN-
FLAMMATION OF THE MIDDLE EAR.
By S. moos and H. STEINBRUGGE, of Heidelberg.
Translated by H. Knapp.
WE are indebted to Prof. Cramer and his assistant,
Dr. Tuczek, in Marburg, for the opportunity of
examining two petrous bones (membrana tympani, external
ear, and Eustachian tube absent), as well as for the clinical
history and the autopsy-record of the case. The specimen
had been removed from a cadaver twelve hours after death
and preserved in a ^ ^ solution of chromic acid.
Clinical History.
L. T., set. fifty-two, painter, admitted to the Marburg Insane
Asylum, March 17, 1880 ; died May 21, 1882. Diagnosis : par-
alytic dementia.
Father intemperate ; among four brothers and sisters three
showed hereditary taint, one with hallucinations. One brother
made an unsuccessful attempt at suicide, and later died of apo-
plexy. Our patient had been intemperate in Baccho et Venere.
In his youth, visual hallucinations ; always irritable and restless.
In the winter, 1878-1879, he excited attention by his red com-
plexion, exalted notions, and absent-mindedness. In the sum-
mer of 1879 he became more and more inconsiderate, cynical,
and thoughtless, and showed symptoms of monomania of
grandeur. His gait, unsteady for a long time, was conspicuously
uncertain and staggering. He was said to have had at home
visual and auditory hallucinations (the clinking of chains, the
sound of human footsteps), to have spoken of suicide, to have
299
3CX> 5. Moos and H. Steinbriigge.
drunk a good deal, and to have been subject to great sexual excite-
ment. He was transferred from an insane asylum near Zurich to
Marburg, against which he vehemently remonstrated.
Though he did not deny the visual and auditory hallucinations,
he did not regard himself ill.
On admission, March i8, 1880, no essential disturbances
found.
April 26th. — Marked disturbance of gait.
May 1th. — Falls asleep wherever he walks or rests.
March, 1881. — Burns his nates against a stove. The monoma-
nia of grandeur and uncertainty of gait gradually increase. The
right half of his body hangs inert. He drags his legs. His right
shoulder is lower than the left. During the following months his
bodily and mental weakness increases.
Jan., 1882. — Obliged to keep his bed. Gradual loss of weight
(16 lbs. by the end of May). Assumes good manners ; feels
elated.
May 26th. — During dinner falls unconscious ; slight convulsions
of face and hand on left side. Pupils equal; no conjugate deviation
of eyes. Catheterization on account of retention of urine. In the
night, May 26th, hsematemesis. Reflexes preserved. Beginning
drowsiness. Painful distortion of face. Convulsions in the distri-
bution of the facial and in the arm. Pinhead pupils. Increase
of coma until evening of 28th, with diminution of all reflexes.
May 2gth. — Continuous coma. Urine voided in bed. Even-
ing : temp., 39.5° C ; pulse, 120 ; respirations, 2)^. Coarse bub-
bling rales without dulness. Death at 11.30 p.m.
Autopsy, May 30, 1882, 10 a.m., by Dr. Tuczek. — Pupils of
medium size, equal. On opening the skull, half a pint of dark
blood escapes. Roof of skull firmly united to dura at the vertex.
The inner surface of the dura over the whole convexity is lined
with pachymeningitic lamellated pseudo-membranes ; between
them numerous hemorrhages, and on each side a larger bag filled
with blood and clots. After removal of brain the anterior
and middle cranial fossae on both sides found lined with similar
continuous membranes. The brain with the pia weighs 1040
grammes. On the right side, the frontal lobes and the lower seg-
ments of the central convolutions and the anterior segments of
the temporal lobes flattened. In the latter situation, a hsematoma.
The pia on the frontal lobes and the anterior part of the central
convolutions thickened and opaque on both sides ; most intensely,
Secondary Symptojns m the Labyrinth. 301
so as to form tough pseudo-membranes, on the first frontal convo-
lution. The frontal lobes show a beak-shaped contraction ; the
pia can be detached easily and without loss of substance. Cir-
cumscribed atrophy of cortex is not found. Cortex thin on the
whole. At the base, opacities in the subarachnoid tissue, but not
conspicuous in the neighborhood of the nerves. The blood-vessels
at the base and their ramifications in the Sylvian fossse intact.
The insular convolutions well developed. Both optic nerves, which
are thin and flattened, show gray zones and patches on section.
The olfactory nerves well developed ; nothing remarkable in the
other cranial nerves.
The pseudo-membranes cannot be traced into the internal
auditory canals. The medullary substance of the brain, firm,
white ; ventricles not dilated, their ependyma delicate. The pos-
terior half of the eyeballs removed in connection with the optic
nerves. Optic discs white, markedly depressed. The spinal pia
thickened and opaque on the posterior surface, with an osseous de-
posit here and there. The posterior nerve-roots without a distinct
attenuation or discoloration. Their consistency firm. The gray
substance in the posterior columns well marked, extensive in the
lumbar and lower dorsal medulla.
Macroscopic Condition of the Right Labyrinth Wall.
The lining mucous membrane of the inner wall of the
middle ear is so much thickened, that the promontory pre-
sents an almost even surface, the niches being completely-
filled with the hyperplastic mucous membrane. The capitu-
lum of the stapes barely projects over the swollen mucosa.
The crura are destroyed by necrosis, with the exception of
a remnant of the posterior crus.
Macroscopic Condition of the Left Labyrinth Wall.
The mucous membrane is likewise thickened, but less so
than on the right side ; most markedly in the region of the
round window.
Microscopic Cottdition of the Mucous Membrane on Both Sides.
Right. The epithelial cells are large, in part oval, in part
round,with very large nuclei (probably epidermoid metamor-
phosis). Apart from the cells the mucous membrane shows
connective-tissue trabeculae with dendritic branching, similar
302 5". Moos and H. Steinbrugge.
to the dendritic formations which are found in the mucous
stratum of the normal drum-head. The blood-vessels are
not dilated, and are rather empty.
Left. The epithelium is unchanged ; the blood-vessels
are widely distended with blood. Some hemorrhages in
their vicinity.
From the above it follows that on the right side we had
to deal with a chronic purulent inflammation of the middle
ear, on the left with a congestion of the mucous membrane.
Microscopic Examination of the Labyrinths.
Both auditory nerves normal. The entrance to the right
round window very narrow, its membrane partially trans-
formed into connective tissue. The spiral ligament at the
beginning of the first turn at the side of the scala tympani
notched, the periosteum of all the turns of the cochlea
partly thickened, partly notched, especially in the scala ves-
tibuli. At the edge of the periosteum, colloid globules.
Ganglionic region, nerves in the zona ossea, Corti's organ,
normal. Disseminated colloid globules on the external wall
of the semicircular canals. Globular yellow and brown-
red pigment in the connective-tissue layer of the ampulla,
and in the lateral epithelium of the cristae. Unusually nu-
merous, partly round, partly oval conglomerations of otoliths
of ordinary shape between the nervous fibres of the ampullae
and utricle.
The same are found also in the labyrinth of the left side,
which is otherwise quite normal. Besides them, isolated
mulberry-shaped clusters of otoliths are found in the same
region as on the right side, exhibiting the same aspect as
illustrated by Leydig in the labyrinth of the ray.
Remarks.
The alterations described in the right labyrinth — thicken-
ing and notching of the cochlear periosteum, the changes
of the spiral ligament, the scant formation of colloid sub-
stance and pigment — probably have no causal connection
with the morbid processes in the cranial cavity. They must
rather be regarded as sequels of the morbid condition in
Secondary Symptoms in the Labyrinth. 303
the right middle ear, propagated through the membrane of
the round window to the cochlea. The pigment also may
have resulted from secondary congestion in the contents
of the tympanic cavity, not from hemorrhagic pachymenin-
gitis.
HISTOLOGICAL LABYRINTHINE CHANGES IN
A CASE OF ACQUIRED DEAF-MUTISM.
By S. moos and H. STEINBRUGGE.
Translated by H. Knapp.
(With a wood-cut.)
WE owe to the kindness of Prof. A. PoUtzer, in
Vienna, the opportunity of making the following
investigation. He furnished the two petrous bones to-
gether with the brain of a twelve-year-old girl who had be-
come deaf in her fourth year. We handed the brain to Prof.
F. Schultze for the purpose of detailed examination, which,
however, as far as the cerebrum was concerned, proved
impracticable, as it had been damaged in the preserva-
tion fluid. For the description of the other parts of the
brain see later on.
The petrous bones, preserved in diluted chromic acid,
were totally decalcified by us, according to the method
repeatedly communicated in these Archives. It may be of
interest to premise that the osseous nuclei, which we have
found and described so frequently in the petrous bone of
the adult, were absent in the specimens under consideration.
Prof. Politzer has sent us the following notes concerning
the clinical history of the case: The girl was born Sept. 5,
1869. She lost her hearing in her fourth year, exhibiting
symptoms of encephalitis. She retained, however, in a cer-
tain measure, the power of perceiving vowel sounds, and
possessed good mental faculties. Her last disease began
May 14, 1 88 1, with an eclamptic seizure followed by paraly-
sis of the extremities on the right side. Death occurred
two weeks later.
304
Histological Labyrinthine Changes in Deaf-Mutism. 305
AUTOPSY.
Meninges normal. An encephalitic patch, with softening
in the adjacent parts, in the left parietal lobe extending to the
vicinity of the lateral ventricle. Near the cerebral cortex a
cavity, the size of a walnut, covered with granulations on its
floor. Ventricles and cerebellum normal. Acoustic striae
well developed. This observation was confirmed by Profes-
sor Schultze, who found also the medulla and the nuclei of
the acoustic nerves norm.al.
Examination of the Petrous Bones.
The petrous bones were unusually large, considering the
age of the patient, though no essential changes were found
in the external and middle ears. The right tensor tympani
was very flat, but its fibres normal.
The two auditory nerves were firm (the effect of the
chromic acid ?), and, like the two facial nerves, of normal
thickness.
The co7itents of the vestibule, semicircular canals, and
cochlear apparatus were normal on the right side ; whereas
on the left they showed the following changes :
In the connective-tissue layer of the utricle, semicircular
canals, and ampullae numerous colloid globules and molecu-
lar detritus, the latter filling the greater part of the peri-
lymphatic space of the semicircular canals. The calibre of
the membranous semicircular canals and the nuclei of the
epithelium on their internal surface were well preserved ;
the outlines of the epithelial cells, however, were indistinct,
and the papillae not discernible. Nerve region normal.
Blood-vessels well filled.
Right Cochlea.
The anatomical condition of the round window and its
membrane was normal. We found the principal alterations
in the first turn, after three or four sections had been cut off
with a razor, and the pathological conditions now to be
described were most marked at the end of the first cochlear
turn.
3o6
5. Moos atid H. Stcinbriigge.
The changes are represented in the accompanying wood-
cut (Hartnack |), which shows a section carried through
the right cochlea, perpendicular to the longitudinal axis of
the petrous bone. The two leaves of the osseous lamina
spiralis are seen in the centre of the drawing. Between
them is a clear space devoid of nervous fibres. From both
the vestibular and tympanal periosteum of the osseous
zona new-formed bone tissue proceeds, which is interrupted
by smaller and larger lacunse filled with a connective-tissue
net-work containing in its meshes round cellular elements.
The connective tissue in the scala tympani {Sf) is more
distinctly visible than in the scala vestibuli {sv). The
new-formation of bone, on the other hand, is much farther
advanced in the scala vestibuli, more than half the calibre
of which is occupied by broad anastomosing osseous
Histological Labyrinthine Changes in Deaf-Mutism. 307
lamellae, forming smaller and larger irregular cavities which
appear less filled with connective-tissue and cellular ele-
ments than the cavities in the scala tympani. Thus of
the scala vestibuli is left only a small circular space which,
under normal conditions, would about correspond to the
size of the ductus cochlearis. Its outline is formed by
a thin layer of periosteum extending at / over the pre-
served membranous lamina spiralis (;«). In other sec-
tions this portion was even ossified.
The ganglionic region iRg) is preserved, but gives off
only a few nerve fibres ending in the osseous lamina.
In several sections of the spiral ligament in the second
cochlear turn, a cellular infiltration was found. The scalae
of the second and third turns, whose nerves were well
preserved and of normal thickness, as could be seen by
an ordinary magnifying glass, showed under the microscope
accumulations of molecular detritus. Neither Corti's organ
nor the membrana tectoria could be detected in either
specimen (not even in the left, which was otherwise normal).
According to our experience this occurs in all preparations
that have lain too long in chromic acid. To cite
an example : we found this condition in the normal
petrous bone of a criminal, which had been placed in
chromic acid twenty minutes after his execution. We can,
therefore, attribute some significance to the absence of
these organs in the case under consideration only where the
corresponding space was occupied by products of inflamma-
tion (see the drawing).
REMARKS.
In the foregoing case we had to deal with an inflam-
mation of the whole labyrinth of the right petrous bone
occurring in the fourth year of life. The inflamma-
tion had produced in the perilymphatic space of the
semicircular canals, ampullae, and vestibule an exudation
which, in the course of time, had undergone in part colloid,
in part molecular, degeneration. The sequelae of this in-
flammation manifested themselves in the cochlea by prolif-
erations of connective tissue and new-formations of bone
3o8 5. Moos and H. Steinbriigge.
proceeding from the periosteum. This process caused
a partial obliteration of the cochlear cavities in the first
turn and a fixation of the membranous lamina spiralis. The
morbid process stopped at this stage, whereas, in a case ob-
served by Politzer (Compte rendu, second session of the
International Otological Congress, Milan, 1880, page 7, etc.),
a total ossification of the labyrinth took place. The
absence of the nerves, which was total in the first cochlear
turn, must likewise be considered a consequence of the in-
flammation, although the abnormal fixation of the mem-
branous lamina spiralis would in itself have been sufficient
to abolish the function of the nerve fibres even if they had
been quite healthy.
The integrity of the intrinsic muscles of the ear and
of the right acoustic nerve, despite the marked changes in
the cochlea, is very remarkable, but in harmony with the
results we obtained in the examination of specimens taken
from other deaf-mutes.
The pathological condition on the right side does not
fully account for the acquired deafness, since, as above men-
tioned, no changes could be found in the left ear. Our
examination, therefore, does not explain the occurrence of
total deafness, which possibly was chiefly due to a disease of
the cerebral cortex, indicated by the encephalitic symptoms
in the fourth year of the patient. A direct demonstration
could have been furnished only by an accurate examination
of the brain, which unfortunately Avas rendered impossible
by the excessive hardening of the specimen.
NEUROPATHOLOGICAL COMMUNICATIONS.
By S. moos.
Translated by H. Knapp.
I. A Case of Meningitis Acutissima in an Adult.
Rapid Recovery, but Permanent Deafness and Stag-
gering Gait.
Thirty-four weeks ago Mr. W., set. twenty, employe in the
post-office, was seized, without assignable cause, in the afternoon
at five o'clock, with excruciating pain, vomiting, and loss of con-
sciousness. He does not remember whether he had vertigo. The
next morning he was found unconscious in his bed. A physician,
who was called in at once, thought that a severe cerebral affection
or a mental disease had set in, and telegraphed to the father of
the patient. Yet consciousness returned in the course of the fore-
noon, but without the appearance of any new symptoms. The
patient completely lost the hearing in his right ear at noon and in
his left in the evening. No further vomiting ; the headache soon
disappeared. He recovered rapidly, left his bed in a few days,
but has been deaf and has had a staggering gait ever since. He
has no perception of any kind of sound. Physical examination
showed nothing abnormal.
Evidently we had to deal in this case with a meningitis,
which was perhaps limited to the posterior cranial fossa.
The affection must have propagated itself along the auditory
nerves into the labyrinth, producing permanent total deaf-
ness and staggering gait.
II. Two Cases of Oscillatory Movement of the Head
in Bilateral Affection of the Labyrinth.
In my monograph on the deafness consequent on epi-
demic cerebro-spinal meninigitis, I said (page 25) that the
309
310 S. Moos.
staggering observed in children after recovery from that
disease, could appropriately be called " duck-gait," and that
the head repeated the lateral oscillations of the body, with-
out changing its position toward the body. Up to that
time I had never observed a forward and backward move-
ment, nor oscillations or rotations of the head. In the two
years which have since elapsed I have had an opportunity
to convince myself, by the examination of two patients, that
oscillatory movements of the head do occur in children
when both labyrinths are simultaneously affected, either
independently or in the course of meningitis.
Case i. — H. H., a girl of five years, of Kaiserslautern, Pala-
tinate, was brought to me by her parents July 20, '81. In May
of the same year, during which time meningitis, scarlet-fever, and
diphtheria had been prevalent in the place, she fell sick with
headache and vomiting, but without loss of consciousness ; in
fact, her consciousness was undisturbed during the whole dis-
ease. Under the application of cold the symptoms abated
gradually in a week. On the eighth day the parents noticed for
the first time considerable impairment of hearing, which soon
increased to total deafness. Then a period of fluctuation of hear-
ing power set in, during which at times she could understand
loud voice spoken directly into the ear, at others she could not.
Two weeks ago she was unable to hear any thing ; to-day, during
the consultation, she answers correctly all my questions. She still
staggers in walking, and has a tendency to fall sideways. During
the reconvalescence the parents noticed, apart from the deafness,
nothing abnormal as long as the child lay in bed, but as soon as
she was raised, her head oscillated forward and backward or from
one side to the other, so that for two days it was necessary to
steady her head as often as she ate or drank. The oscillations of
the head have not been noticed since.
The objective examination proved completely negative. On
the left side she was totally deaf, and has remained so ; on the
right she correctly repeated loud words, and perceived tuning-
forks C and C but not a' by bone-conduction.
Treatment : Iodide of potassium and salt baths. August loth,
when I saw her last, she understood loud voice at the distance of
one metre.
Case 2. — E. L., a boy of two years, of Ludwigshafen, Palati-
Neuropathological Communications. 3 1 1
nate, was brought to me by his parents July 23, 1882. At the
age of six months he contracted a " severe illness from which he
completely recovered only many weeks later." The symptoms
were : obstinate vomiting during several weeks, convulsions in
arms and legs, periodic strabismus and opisthotonus ; further,
unconsciousness for several weeks. He can neither speak nor
walk, but is able to stand for a short time. One day when he was
taken up during the reconvalescence and seated on the floor,
"his head began to swing so much as to strike the floor, and we
were obliged to hold it steady." The parents did not know
whether the oscillations had occurred also (as in the foregoing
case) when the child was raised in bed.
III. — Annoying Subjective Sensation of Hearing Pro-
duced by a Pair of Eye-Glasses.
Hitzig, Bernhardt, Berger, and Gottstein have advanced
the hypothesis that, under certain physiological as well as
pathological conditions, voluntary contractions of the
mimic muscles of the face may induce simultaneous con-
tractions in the stapedius muscle, accompanied by subjec-
tive sensations of sound. In Gottstein's case there was
blepharospasm combined with spasm of the stapedius mus-
cle. Each attack of blepharospasm was preceded by a
roaring in both ears, disappearing when the blepharospasm
ended. Of late Jacobson has published (Report of the Berlin
University Policlinik, ^./. OhrenJi., vol. xix, i, page 42, etc.)
two cases in which subjective noises were produced by mus-
cular contractions. One of the patients heard ringing in the
ear when he closed his eye. At the same time retractions
of the drum-head could be detected by the ear-mirror and
the manometer, on which account Jacobson refers the
ringing to a contraction of the tensor tympani muscle. In
the second case the patient heard during the closure of the
jaws a short ringing like C*. During contraction of the
masseter muscles with closed teeth he heard a humming
on both sides. Whether this phenomenon was caused by
simultaneous contraction of one of the intrinsic muscles
of the ear could, according to Jacobson, not be made out
with certainty, as objective evidence could not be furnished.
To these observations I can add another :
312 5. Moos.
Mrs. K., sixty years old, consulted me April lo, 1882. At the
beginning of September, 1881, immediately after she had put a
pair of eye-glasses on, she heard a ringing in her left ear, which
disappeared, but returned as often as she put the eye-glasses on
again. The application of a Spanish fly-blister to the left mas-
toid region was followed by numerous abscesses in the left external
ear-canal. As long as they were present, no ringing occurred —
not even when the eye-glasses were used. After the abscesses had
disappeared the ringing in the left ear returned as often as the
patient put eye-glasses or spectacles on, and was accompanied by
a loud, beating noise. As the patient suffered also from palpi-
tations, I advised her to consult Professor Friedreich, who sent
me the following note : " Neither the heart nor any other organ
shows objective changes, and I consider the beating of a purely
nervous nature. Mrs. K., whom I have known for many years,
and who has been under my care several times, suffers from an
extraordinary excitability of the vaso-motor nervous apparatus.
Quinine in small doses and rest formerly always benefited her
very much, and I recommended her the same this time also."
The objective examination of the hearing organ gave on the
whole a negative result : Mild pharyngeal catarrh, drum-head un-
changed, hearing acuteness 16-20 metres for whispered voice.
I advised the patient not to press the eye-glasses on the nose,
but to hold them simply before the eyes. I have not seen her since.
In what way can we account for the ringing in this case ?
According to the investigations of Lucae healthy people
can, by strong innervation of some facial muscles, subjec-
tively produce a deep tone, in consequence of the simulta-
neous action of the stapedius muscles. In the case under
consideration a high tone (ringing) was perceived, which
could not have been the perception of the muscle noise of
the stapedius, but a subjective sensation of hearing caused
by the negative pressure fluctuation of the labyrinthine
fluid, occurring when the contraction of the occular mus-
cles during the application of the eye-glasses excites the
stapedius muscles to concomitant activity.
IV. — A Case of Mimic Facial Convulsions Complicated
with Nystagmus and Vertigo.
In the year 1876 Cyon ' determined experimentally the
' E. Cyon : Les rapports physiologiques entre le nerf acoustique et 1' ap-
pareil moteur de 1' oeil. — Gaz. mdd., 1876, No. 17 ; Vgl. med., BL, 1876, No. 36.
Neuropathological Communications. 3 1 3
physiological connection between the auditory nerve and
the centre of innervation of the muscles of the eye. Cyon
considers the ocular movements following upon injury
to the semicircular canals as the immediate and direct con-
sequence of such injury. The eyes deviate backward and
downward on the same side if the horizontal and the
superior vertical canal (in the rabbit) are excited. They
deviate forward and somewhat upward if the posterior
vertical canal is excited. At the same time the eye of the
other side also deviates, but in the opposite direction. The
pupil of the eye on the side excited contracts, on the other
side it remains wide. At the moment of excitation both
eyeballs are tetanized, then they make rapid spasmodic
movements in the opposite direction, which rarely last
longer than half an hour, and disappear after the division of
the auditory nerve of the opposite side.
Excitation of one auditory nerve causes powerful rota-
tions of both eyes. Division of one acoustic nerve pro-
duces marked downward deviation of the eye of the
same side, and an upward deviation of the other eye.
After division of the second acoustic nerve the deviation
disappears.
The results obtained by Cyon were supplemented and in
part confirmed by the experiments of Hogyes.* This author,
on the strength of his experiments, expresses the opinion
that the vestibular terminations of the acoustic nerve are a
peculiar terminal apparatus which regulates the movements
of the eyes, and probably the movements of all the muscles
subservient to the maintenance of equilibrium, according to
the position of the head or the body. For our purpose an
experiment on a rabbit is particularly interesting, in which
the perilymphatic liquid was sucked out with a glass tube
and air gently blown through the same tube into the
perilymphatic space ; whereupon bilateral movements of
the eye and, on more forcible blowing, marked nystagmus
followed.
Some pathological observations are on record which
' On the true cause of vertiginous phenomena by increased pressure in the
tympanic cavity. PJiUgers Archiv, Bd. xxvi, page 588.
314 S. Moos.
are in harmony with these experiments, or which, in other
words, find in them their only rational explanation.
Schwabach ' observed peculiar oscillatory movements
of the eyes in a case of chronic purulent catarrh of the left
middle ear with a large defect in the drum-head. These
movements were bilateral, horizontal, and directed toward
the affected side. They were produced by pressure on
the mastoid process immediately behind the auricle, or on
the corresponding place in the auricle, only after secondary
purulent infiltration had caused marked swelling in the ear
and the surrounding parts. They disappeared as soon as
the pressure ceased. The ocular movements were accom-
panied by violent vertiginous movements.
In consideration of Cyon's experiments, Schwabach ex-
plains the oscillatory movements of the eyes by an irritation
of the semicircular canals in consequence of increase of
pressure produced by retention of pus. This communica-
tion of Schwabach led E. Pfliiger " soon after to publish a
case of chronic purulent otitis media, with formation of
polypi on the upper wall of the external auditory canal
quite near the drum-head, in which horizontal oscillatory
movements of the eyeballs occurred whenever the polypi
were touched.^
The symptoms of the following case may also in part be
explained by Cyon's experiments.
A forester, sixty-one years of age, consulted me Aug. i8, 1879.
^Deutsche Zeitschr. f. pract. Medicin, 1878, No. 11 ; und ??ted. Centralbl.,
1878, No. 34.
" Nystagmus-like ocular movements in consequence of an aural affection.
Deutsche Zeitschr. f. pract. Medicin, 1878, No. 35 ; and tned. Centralblatt,
1879, No. 22.
^ For the sake of completeness in regard to the movement of the pupil of the
side irritated, as observed by Cyon, I may here briefly report an observation
which I made, fifteen years ago, in Friedreich's clinic, and published in the
Archiv von Ohrenheilkunde, Bd, ii., pag. 197. After the cessation of otorrhcea
and the apparent subsidence of a purulent perforative otitis media on the right
side, persistent headache, tinnitus, vertigo, vomiting, and contraction of the
pupil set in. All these symptoms disappeared when pent-up masses of pus
and epithelium had been loosened by tvv'o applications of the catheter and
then removed by syringing. At that time I considered the vertigo and vomiting
symptoms of increased labyrinthine tension from pressure exerted by the inflam-
matory products on the windows of the labyrinth ; whereas, I regarded the
contraction of the pupil as due to irritation of the otic ganglion. Cyon's exper-
iments furnish a more plausible explanation of the alteration of the pupil.
Neuropathological Communications. 3 1 5
He had suffered for ten years from an aural affection, which had
made rapid progress owing to frequent exposures in the discharge
of his duty. In his right ear he hears a ringing sound constantly,
in his left only occasionally. During the last four years he has
suffered, in consequence of a violent cold, from a characteristic
mimic facial spasm, which occurs only by spells, but which, up to
this day, has never left him, and appears twenty or thirty times
daily. Each attack is accompanied, as I have repeatedly observed,
by countless lateral rotations of both eyeballs, with which, of late,
vertiginous seizures, with a tendency to turn from left to right,
were associated. The patient considers these vertiginous attacks
entirely different from the dizziness which had distressed him
during the first years of his ear-affection. The previous dizziness,
which lasted a long time, he called permanent ; the present, which
occurs during the spasmodic attacks, temporary.
On examination I found on both sides injection of the manu-
brial vessels, both drum-heads partly opaque, partly atrophic, bone-
conduction absent for all kinds of sound, auditory acuteness by
air-conduction on left almost o, on right = tq-oo" '^^^^- ^o^ ^'^^ watch.
In this case we probably had to deal with a spasm of the
stapedius muscle, which accompanied the tic convulsif, and
was caused by a labyrinthine irritation from diminished ten-
sion. The irritation was transmitted, on the one hand, to
the cerebellum ; on the other to the centres of innervation
of the ocular muscles, causing the occurrence of the facial
convulsions, together with vertigo and nystagmus.
V. — A Case of Paralysis (Otitic Reflex Paralysis ?) of
the Trochlear Muscle in the Course of a Purulent Otitis
Media.
( With a temperature curve ^
The publication of the following observation seems of
interest in supplementing the discussion of the previous
case, referring to the relation between the auditory nerves
and the centre of innervation of the ocular muscles.
P., set. fifty, railway employe, enjoyed good health until the
middle of February, 1883. In particular the acuteness of both his
higher senses left nothing to be desired. At that time, after an
exposure, he contracted a coryza, accompanied by violent pain in
3i6 5. Moos.
the left ear, radiating over the corresponding half of the head, with
an evening exacerbation. Loud beating noise in the ear preceded
by several days the occurrence of otorrhoea, which has continued
profuse up to date. The patient has suffered from almost con-
stant pain, particularly in the left supra-orbital region and the
middle of the occiput. Of late he has been feverish ; has had,
at irregular intervals, chills, constipation, and anorexia, and has
lost flesh considerably. In the last ten days he has had double-
seeing on the affected side, and constant tinnitus, without dizzi-
ness, but with swelling in the middle of the left side of the neck.
From March 8th to April 14th he was under the care of Dr. O.
Wolf, in Frankfort-on-the-Main, to whose kindness I owe the fol-
lowing notes :
Otitis Media Purulenta, with Propagation of the Infla7nmation to the
Mastoid Cells.
'' When the patient came to me I found a muco-purulent secre-
tion in the left auditory canal, the walls of which were somewhat
swollen ; the left drum-head tumefied and livid, in its lower part
a small perforation, through which the air on inflation hissed with
difficulty. Mastoid process looks healthy, not painful ; /; = o ;
loud words heard only when spoken near the ear ; bone-conduc-
tion on the left side = o, tuning-forks from the vertex intensified
on the left. Air-douche and insufflation of boracic-acid powder
relieved the pain at once, and raised the hearing acuteness for
whispered voice to one metre. On the eighth day of treatment
the perforation was closed. As, however, the pain returned and
secretion accumulated in the tympanic cavity, an extensive para-
centesis of the drum-head was made, and for several days there
was copious discharge. The pain subsided, but recurred when,
after another week, the opening of the drum-head had closed
again. The paracentesis was therefore repeated, but the pain soon
returned, and on March 25th the mastoid process swelled. Some
days later a bulging of the posterior wall of the ear-canal near the
drum-head was noticed. After continued poulticing a copious
discharge set in March 28th (probably from the bulging part of
the ear-canal), and the patient remained free from pain for a
week. On inflation only slight crepitation was heard ; the hearing
acuteness rose steadily, being on April 5th : // = 20 cm., v (whis-
pered voice) = 5 metres. He was able to take a daily walk for
several days. April 8th the pain returned with renewed violence,
depriving the patient of sleep in spite of large doses of mor-
Neuropathological Communications. 3 1 7
phia ; poulticing also afforded but little relief. The pain ex-
tended to the temple and occiput, and the posterior wall of the
ear-canal bulged again. Once more a moderate discharge caused
relief of pain. As the patient could not have the necessary care
at his residence (where, meantime, a child had been born), I sent
him on April 14th to his home for a few days, with the recom-
mendation to return should pain occur again. I thought that the
frequently recurring pain was caused by accumulation of secretion
in the mastoid, an opening of which, either from the external
ear-canal or behind the ear, might become necessary. Three days
after his departure he wrote me that during the first days he felt
very well, but that now the pain had returned with renewed inten-
sity. Since then I have heard nothing of the patient."
Condition on May ^ih. — The patient looks very ill and anjemic,
is depressed and fretful. Pulse 84, weak ; temperature 38.2°.
Complains of diplopia on left side ; violent pain in the left frontal
and occipital regions ; tinnitus aurium. It is difficult for him to
turn his head on account of an excessively hard swelling which
from the level of the angle of the lower jaw reaches 5-6 centi-
metres downward along the anterior edge of the left sterno-mastoid
muscle. It is as thick as the little finger and covered by skin
of normal appearance ; /^ = 1, F = /i . Bone-conduction for
tuning-forks and loud-ticking watches preserved on the affected
side.
The external ear-canal filled with pus ; its bony portion nar-
rowed to a small slit, yet a small speculum can be introduced.
The lower portion of the drum-head perforated, its posterior upper
quadrant bulging ; mastoid process paii*ful and tender to the
touch, the skin over it unchanged.
As to the diagnosis, the disease evidently was a chronic
purulent otitis media with perforation of the drum-head
and implication of the mastoid process, probably in its an-
terior portion. At the same time, the repeated chills, the
marked emaciation, the diplopia, etc., made me think of an
intracranial complication — i.e., a circumscribed basilar menin-
gitis, perhaps phlebitis or thrombosis of a cerebral sinus, or,
considering the above-mentioned swelling in the neck, phle-
bitis and thrombosis of the jugular vein. I therefore
framed a grave prognosis and insisted upon an ophthalmo-
scopic examination, trusting in this way to arrive at a sure
3i8
5. Moos.
diagnosis. The examination of the eyes made by Prof.
Becker on the same day gave the following result :
"Emmetropia. S. normal on both sides. Ophthalmo-
scopic condition normal. The double images are homony-
mous, increasing in vertical deviation in the lower, in lateral
deviation in the left, part of the field of fixation. Paresis of
the left trochlear muscle. A direct connection between
this affection and a disease of the ear or brain is not demon-
strated ; its possibility, in spite of the negative ophthalmo-
scopic condition, cannot, of course, be denied."
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—
TEMPERATURE CHART.
The local treatment, until the recovery of the patient, was as
follows : Every day the ear was inflated and syringed several
times, after which the ear was filled with warm water, the patient
being on his side, and the inflation repeated. By means of a
Leiter's coil cold was applied alternately to the mastoid process
and to the swelling in the neck, until the pain and swelling disap-
' Explanations : Tageszeit, time of day ; Al>, evening ; Mo, morning ;
Mi, noon.
Neuropathological Communications. 319
peared. Chloral and the narcotics were not borne and were,
therefore, soon discontinued.
Further Course. May ^th. — Chilly feelings and flushes of heat
in the night, May 4th-5th ; excessive excitement after two grammes
of chloral.
May ^th. — In the morning : passage after bitter water ; locally
the same condition. For the first time, some appetite. Pulse 84.
Evening temperature 38.8°. Passed a good night.
May 6th. — In the morning : temperature 37° ; status idem. In
the evening : temperature 38.4°. Night bad. Great deal of pain
in head and nape of neck.
May ']th. — Morning : temp. 37° ; pulse 84, weak ; 4 p.m. : temp.
39° ; evening: temp. 38° ; 12.30 p.m. : sudden fainting turn, with
staring eyes, lasting some minutes. The hard swelling in the neck,
about at its middle, very painful and tender to the touch. Passed
a tolerably good night.
May 2,ih. — Morning : evacuation after bitter water ; feels well ;
appetite moderate ; pulse 84, weak ; temp. 37.2°. Locally, status
idem ; profuse discharge. Evening temp. 38.8° ; night sleepless.
Little pain, much discharge.
May gth. — Hardness and swelling in neck diminishing ; pain
likewise. Pulse 86. Otherwise, status idem. Noon, 36.4.° 4
P.M., temp. 39°. Slit-shaped contraction of auditory canal
lessening. 9 p.m., temp. 38°. Hardness in neck further
diminished, but some swollen glands at anterior edge of the sterno-
mastoid muscles. Patient complains of distress on left side in
swallowing. The examination of the neck, however, shows nothing
remarkable. Night, May 9-10, bad. Intense headaches.
May 10th. — Morning : temp. 37°. Evening : temp. 38°; pulse 84.
A passage after bitter water. Symptoms same as yesterday.
Night of loth to nth restless.
May nth. — Morning : temp. 37.4° ; pulse 84. Less difficulty
in swallowing. The first spontaneous stool for weeks. Other-
wise, status idem. Noon, temp. 37.6° ; 4 p.m., 38° ; 8 p.m., 37°.
Night sleepless.
May \2>th. — Morning : discharge has stopped. Bulging of
drum-head has disappeared. Perforation still present, but even in-
flation liberates no pus. Calibre of ear-canal wider. Temp.
37.2° ; pulse 84, strong. Spontaneous stool. Night best during
whole sickness.
May i^th. — Morning : perforation cicatrized. Night of 14th to
15th good.
320 5. Moos.
May x^th. — Morning: free from pain. Less diplopia. Tem-
perature permanently -normal ; pulse 84. Some tinnitus. Sleep,
stool, and appetite, normal. Drum-head lacklustre. Tube
pervious. Condition of eyes according to Prof. Becker : "Field of
single vision much larger. Homonymous diplopia. The image
belonging to the left eye lower in the lower left half of the field of
fixation." Patient discharged with v = \%, h = 10 cm. The
patient informed me by letter of May 30th that the diplopia
had almost totally disappeared ; and on June i6th that the
noises in the ear had almost entirely disappeared, hearing good,
and eyes likewise very good.
Everybody will recognize the difficulty of appreciating
the symptoms which in this case complicated the inflamma-
tion of the middle ear. I have mentioned above the
different possibilities as to diagnosis. Basilar meningitis or
propagation of the inflammation to the cavernous sinus would
afford a ready explanation of the disturbances in the func-
tion of the first branch of the fifth pair and of the paralysis
of the fourth. The temperature curve is also in accordance
with phlebitis and thrombosis without disintegration of
the thrombus. If, in consideration of the normal ophthal-
moscopic condition, the presence of a phlebitis and throm-
bosis of a larger cerebral sinus, especially the cavernous, be
unconditionally rejected, nothing remains but to suppose,
in harmony with Cyon's investigations, that the retention
of pus in the middle ear produced an irritation of the
labyrinth which did not extend to the cerebellum — vertigo
was absent as long as diplopia was present — but rather
to the centre of innervation of the trochlear nerve of the
affected side. This irritation caused in the corresponding
muscle a reflex paralysis which, with the purulent inflamma-
tion and the retention of pus, gradually disappeared.'
VI — .A Peculiar Perversity of Tuning- of Corti's Organ.
An architect, aet. thirty-two, of excellent musical education,
contracted, fifteen months ago, a violent cold, which left behind
subjective sensations of hearing and a peculiar disturbance of
' The elaborate and interesting paper of Urbantschitsch : "The influence of
irritation of the trigeminus on sensory perceptions, in particular on the sense
of sight," {PJliigers Archiv, Bd. xxx,) unfortunately reached me only during
the correction of the proof of this paper and could therefore not be used.
Neuropathological Communications. 321
musical perception on the right side, arising under certain exter-
nal influences. The sound of a dinner-bell, for instance, or con-
tinuous whistling, causes a ringing of high pitch in his right ear.
Besides, in singing and whistling he hears the high tones a third
of a tone deeper. A low-ticking watch is heard on both sides
equally well and normally — /. e., 2 metres. The tuning-forks of
medium pitch heard equally well by bone-conduction on both
sides ; by air-conduction, all somewhat weaker on the right.
Etiologically, nothing can be ascertained except the cold. Physical
examination shows nothing abnormal.
The patient must have had an unequal degree of tension
in the zona pectinata : the region tuned for the deeper tones
(near the cupola of the cochlea) was somewhat too tightly
stretched; the region tuned for the higher tones (near the
round window) was too much relaxed.
The subjective hearing, in consequence of the effect of
certain objective tones, may, as I have stated in a previous
case, be considered a true neuralgia of the corresponding
nervous fibres.
VII. — Acquired Deaf-Mutism after Mumps.
Since I published — induced by the deliberations of the
American Otological Society on deafness after mumps, —
a case of bilateral labyrinth affection with staggering gait
and permanent abolition of hearing after mumps (these
Archives, German edition, Bd. xi, page 51 ; American edi-
tion, vol. xi, page 13), other cases have been published, viz. :
one by H. Brunner (these Archives, vol. xi, page 102), of
one-sided deafness after mumps; one case by Calmettes ';
one by E. G. Moure {ibid., page 301 , £f.) ; and one by J. Seitz.''
The case of Calmettes was that of a six-year-old
healthy girl, who, during an epidemic of mumps, con-
tracted a mild attack of the affection without pain,
' Sur une consequence peu connue des oreillons. France mid., 22 juillet,
1882, et Revue mensuelle de laryngologie , d' otologie, et de rhinologie, 1882,
pag. 301.
''Deafness after mumps, Correspondenzbl. f. Schweiz. Aerzte, No. 19, 1882.
[Compare further a case of one-sided deafness after mumps, by H. Knapp,
these Archives, vol. xi, page 232, and one of bilateral deafness from mumps,
by the same author, these Archives, vol. xi, page 385, and an elaborate paper,
" Diseases of the ear occurring during the course of parotitis, " by D. B. St. John
Roosa, these Archives, vol. xii, page 1-13. — Ed.]
322 S. Moos.
otorrhoea, or noises, but lost her hearing on both sides,
so that, eight months later, she was able to hear only-
loud voice (" r enfant entendait encore la voix cri^e ").
In the case of Moure, an eight-year-old girl, on the fifteenth
day of an attack of mumps, when the swelling began to
subside, without pain or other symptoms, lost her hearing
completely on both sides in one day. Subjective noises
occurred only later, and were still present at the date
of examination (one month after the occurrence of the
deafness). Examination negative ; treatment of no avail.
The case of Seitz was that of a student, set. 19, whose
parotitis was almost well on the sixth day, when, in
thirty-six hours, deafness occurred on the right side. It was
accompanied by intense humming and roaring ; and metal-
lic tinkling added to all sensations of sound ; further, by
vertigo and disturbance in walking. Examination negative ;
treatment without avail. Seitz supposes a serous exuda-
tion to have been present in the labyrinth.
In the following case, which I shall briefly describe, the total
bilateral deafness occurred in a girl of four years on the fourth
day of double parotitis, which was rapidly disappearing. No
other symptom appeared, and the disease ran its whole course
without fever. The child, who lost the whole wealth of her
vocabulary in a short time, is now in an institution for the deaf
and dumb.
In the cases of Calmettes and Moure, and the one just
related, neither vertigo nor disturbances of equilibrium
were present. The seat of the anatomical disturbance can
have been only in the cochlea.
Of what kind this disturbance was cannot be known
with certainty until more numerous post-mortem examina-
tions of the labyrinth have been made, as the one by
Toynbee thus far stands alone.
REVIEW.
The Diagnosis and Treatment of Diseases of the Ear.
By Owen D. Pomeroy, M.D., etc. With loo illustrations. New
York : Bermingham & Co., 1883. Pp., 392. Price, $3.00.
Whether or not another treatise on diseases of the ear is needed
in addition to the seven native American and several foreign
which are already accessible to the English student, is a question
which must be settled between the publishers and their reading
public. It is a matter of supply and demand which may be safely
left to itself. It interests us only so far as it points to the ardor
with which the field of otology is being worked by American
practitioners. The treatise of Dr. Pomeroy is designed, he tells
us, for the general practitioner, though he hopes the young otolo-
gist may find it of assistance.
The first thing that will strike the reader is the absence of any
consideration of the anatomy or physiology of the organ of hear-
ing. In some particulars this may be of an advantage, since it
enables the author to give more attention in the same space to
matters of diagnosis, etiology, and therapeutics ; but the general
practitioner, for whom the work is mainly intended, is the very
one who stands most in need of such knowledge, and has less
time to hunt it up from the various text-books on anatomy and
physiology.
The interest of the book to specialists will, of course, be in
getting the opinions of a well-known aurist of a wide experience
on those points in otology which are still the subjects of dis-
cussion.
The author holds no extreme views on any of these points, and
his judgments are for the most part conservative in their char-
acter. He is not yet willing to throw away the syringe ; indeed
he has devised one which, on account of its flange protection,
323
324 Review.
renders the performance of this operation entirely free from the
opprobium of "sloppiness" that has been laid up against it in
certain quarters. Dr. Pomeroy seems to have quite a mechanical
turn of mind, and several of the instruments figured in his book
bear his name. We wish that all practising otologists could
acquire the dexterity he seems to have in the use of his " faucial
catheter." His favorite astringent and antiphlogistic is nitrate
of silver, and he uses it in all strengths from 2 grs to | i, to a
saturated solution. He does not ignore others, however, and has
a good word to say for the " dry treatment " by means of boracic
acid in chronic purulent discharges. In the treatment of polypi
he removes them by torsion, in preference to the snare, but has
not found alcohol so satisfactory as some others seem to have
done. His treatment of mastoid disease is that which will be
approved by the majority of aurists.
Considerable space is given to the consideration of perichon-
dritis auriculae.
While the specialist of experience will probably not refer to it
often, the general practitioner will find it a safe and reliable guide
in the treatment of those affections of the ear which are likely to
fall under his observation. Some of the original wood-cuts are
bad, and there has been very careless proof-reading, particularly
as to proper names ; otherwise the " get up " of the book is very
creditable. S. M. B.
REPORT ON THE PROGRESS OF OTOLOGY
DURING THE FIRST HALF OF THE
YEAR 1883.
I. — NORMAL AND PATHOLOGICAL ANATOMY AND HISTOLOGY
OF THE EAR.
By H. STEINBRUGGE, Heidelberg..
Translated by Dr. J. A. Andrews, New York.
1. Biological investigations. Edited by Prof. Gustav Retzius
Second year, 1882. Eight plates, (a) The structure of the mem-
branous portion of the organ of hearing in man. Plates i. and ii.
{d) On avascular epithelial membrane in the membranous portion
of the ear. {c) On the histology of the membranous cochlea of
rabbit. Plates vii. and viii. (d) On the manner of termination
of the auditory nerves in the maculae and cristas acusticse (1871).
2. Three cases of fatal ear-disease, with contributions to the
pathological anatomy of the ear. By Dr. K. Burkner, Gottingen.
Arch.f. Ohrenheilk., Bd. xix, 4, p. 245.
3. A case of cholesteatoma of the temporal bone without caries.
Death from abscess of cerebellum. By Dr. L. Katz. Berl.
klin. Wochenschr., 1883, No. 3.
4. On osseous fistulae in the mastoid process. By Dr. W. Kirch-
NER, Docent of Otology in Wurzburg. With plate ii. Virchow's
Archiv, Bd. xcl, p. 77.
(i,a) In this first essay the author describes the membranous
labyrinth of a human embryo of from five to six months, and fur-
nishes two enlarged explanatory illustrations, which give a view of
the labyrinth from before outward, and inward and backward.
325
326 H Steinbriigge.
The preparation was made by removing the bone and cartilage,
and then hardening in a J-| per cent, solution of hyperosmic
acid. In a preceding plate the author reviews the illustrations of
the schemata of the membranous labyrinth by Breschet, Ibsen,
Reichert, Middendorf, Luschka, Rudinger, Waldeyer, Krause,
Weber- Liel, Wiedersheim, and Hensen. In regard to the obscure
description of the preparation, of which no figures are given, we
must refer to the original, and shall only observe that the author
subdivides the acoustic nerve into an anterior and posterior ramus,
the former supplying the macula of the utriculus, as well as the
ampullDe of the sagittal and horizontal semicircular canals, while
the ramulus basilaris of the posterior branch enters the modiolus
of the cochlea, the ramulus medius of the same belonging to
the macula of the saccule, and a third branch passes from it
to the crista of the ampulla of the frontal semicircular canal.
The ramulus neglectus is absent in man. According to the
author, the nerve-twig described by Reichert and Henle as pass-
ing to the septum between the utriculus and sacculus does not
exist. While, according to this statement, by the addition of the
ramulus neglectus, fishes have seven nerve-terminations, amphibia,
reptiles, and birds, with the nervous termination in the lagena,
have eight nerve-terminations ; the higher mammalia have only six,
but in their stead there is the higher development of the nervous
apparatus in the cochlea. In volume II., the author furnishes
further illustrations of the above-mentioned preparations, and also
of the perilymphatic spaces. The latter is especially gratifying,
because the view of the structure of the membranous labyrinth,
removed from its natural position, does not suffice to explain the
topographico-anatomical relations of the labyrinth.
{i,b) On the external shank of the frame of the cochlea in the
alligator, the author found a mound of cylinder epithelium, between
whose cells are branching capillary vessels with a thin wall, con-
sisting of a single layer, with isolated flat-oval granules on the inner
surface. Connective-tissue elements could not be detected. This
state of things is striking, because true epithelial tissues have no
blood-vessels. The author believes that these latter are related to
the secretion of the endolymphatic fluid, and compares the mound
with the stria vascularis of mammalia.
(i,^) Retzius confines himself to communicating the results of
his recent investigations with reference to certain important parts
in the cochlea of the rabbit. The preparations were made by the
Progress of Otology. yi'j
employment of osmic acid and chloride of gold, according to a
method to be described later. Chromic-acid salts act, especially
upon the hair-cells, in such a varied way that they can be em-
ployed only in exceptional cases.
In regard to the preparation of the epithelium of the crista
spiralis by the silver-staining method, Retzius found a beautiful
mosaic-like marking on the surface of the crista, extending from
the insertion of Reissner's membrane to the outer margin of the
teeth. It is produced by the contours of cells whose granules lie
in the depth of the interdental furrows. The free surfaces of
these cells are, therefore, turned toward the surface of the crista,
and project somewhat beyond the margin of the teeth. The
epithelium is then continued into the sulcus spiralis, and the
cell-fields become more extensive, and terminate in the inner hair-
cells in an almost straight boundary line. The inner hair-cells,
seen from above, appear oval, the longitudinal axis lies in a spiral
direction ; the fine hairs situated on them form outward a
slightly convex arch-line. Besides the familiar layers on the
membrana basilaris, the author distinguishes a second homo-
geneous layer overlying the chordae. This layer begins in the
region of the inner and middle thirds of the membrana basilaris,
and extends to the lig. spirale. According to this, in the rabbit
the sides of the zona pectinata lie between two homogeneous
layers.
In regard to the pillars of Corti's organ, it is to be observed
that their bodies and feet appear longitudinally striped, the stripes
of the feet extending into the external pillars, but not into the
fibres of the zona pectinata. Every foot-plate consists of about 5-6
fibres of the zone mentioned. The connective-tissue supporting
fibre-system in the tunnel described by Deiters and Lavdowsky is
questioned by Retzius. He refers the lines mistaken for it to the
contours of epithelial cells sparsely supplied with granules. These
correspond to the formerly so-called basement cells ; their pro-
toplasm invests the pillars up to the heads ; outward they project
above the external foot-plates ; here, with a somewhat serrated
line, they border upon the rows of the hexagonal fields, which,
according to Retzius, support Deiters' cells.
The cells of Corti (outer hair-cells of Retzius) are cylindrical ;
their surface appears finely granular, and supports a horse-shoe-
like hair-border. Its lower extremity never forms a process ; it
contains a large spherical nucleus. Retzius has been unable to
find Hensen's capsules.
328 H. Steinbriigge.
Deiters' cells are not connected with the former ; we have to
deal with two separate kinds of cells. Its upper, tapering,
thread-like extremity extends with a cone-like expansion into a
phalanx of the lamina reticularis. When in situ, the cells appear
spindle-shaped, and contain a spherical nucleus. Their inferior
process is inserted in the centre of the hexagonal field, and is sur-
rounded by protoplasm which, in all probability, is limited by the
outlines of these fields. Between the rows of Deiters' cells, on
their inner surface, extend the three rows of the outer spiral
nerve-fibres. Their origin and termination are unknown ; perhaps
they originate in the radial fibres.
Inward from the internal pillars is an inner spiral nerve-chan-
nel, a second in the tunnel on the outer surface of the internal
pillar, which is designated a " tunnel-cord." Both nerve channels
are united by connecting fibres. From the tunnel-cord spring the
nerve-fibres, which radiate through the tunnel. Their termina-
tion in the outer hair-cells is still unknown.
Concerning Corti's membrane, the author refers to the oblique
direction of its fibres. On the periosteum of the scalae are endo-
thelial cell-markings, readily demonstrated with silver staining.
(i, ^) This essay is, in part, comprised in the monograph on
the organ of hearing in fishes (compare G. Retzius' anatomical
investigations, first edition, Stockholm, 1872). The author shows
that after losing their myelin-sheath, the nerves enter the epi-
thelial layer of the maculae and cristse acusticse without forming
an anastomosing net-work. The cells are subdivided into true
epithelial cells and supports of the nerve-terminations. The
former, with a conical base, are generally attached to the con-
nective-tissue layer, and contain a nucleus in their inferior
part. Occasionally they are more spindle-shaped (fibre-cells of
Schultze) ; then the nucleus is placed higher. Above the nucleus
they become contracted, to give place to a neighboring nerve-
cell ; then they spread out again, funnel-shaped, toward their
free extremity. They are firmly attached to the neighboring
cells, and are isolated with difficulty. The nerve-end support-
ing cells are bottle- or club-shaped, and have a pretty large,
round nucleus at the point of union with the nerve-fibres, and
above it a somewhat narrow neck, with brownish-yellow pig-
ment granules, and finally a flat, round surface, from which
the auditory hair projects. This is not homogeneous, but con-
sists of from 10-15 very fine cylindrical, straight fibres. The
hairs are destroyed by osmic acid.
Progress of Otology. 329
(2, a) Otitis 77iedia suppurativa chron. dextra j caries of tem-
poral bone ; purulent meni?igitis ; death. A man, get. thirty-six
years, had otorrhoea for eleven years. Sudden pain in right ear
and in head, hardness of hearing, diminution of discharge,
convulsions, delirium, coma. Qidematous swelling on the superior
boundary of sterno-cleido-mastoid muscle. A probe passed
through granulation tissue in the postero-superior wall of the
ext. auditory canal reaches a carious cavity. Drum-head thick-
ened, and rosy-red. Death after three days. Autopsy (incom-
pletely reported to author) : Temporal bone over tympanum
and external auditory canal is black, thin, and friable ; dura
mater in region of temporal bone is injected, thickened, and cov-
ered with pus ; greasy, pappy mass in tympanic cavity.
(2, b) Otitis media suppurativa chron. bilateralis ; thrombosis in
consequence of phlebitis of left bulbus vencR Jugularis j death. A
man, set. twenty years ; bilateral otorrhoea for thirteen years. Sud-
den pain in left ear. Cessation of discharge ; chills, vomiting,
and vertigo, which rendered locomotion impossible. High fever ;
discharge from right ear continued. Bilateral perforation of mem-
brana tympani. Left external auditory canal contracted and filled
with cheesy crusts. In the course of left jugular, up to three
fingers' breadth below mastoid process, a thrombus can be felt.
Hearing distance : r. e., ^; 1. e., yV- Repeated chills ; increased
pain, especially in neck ; apathetic condition ; left mastoid process
red and swollen ; veins of face and left exter. jugular enlarged ;
death after seventeen days. Autopsy of left temporal bone : oval
defect of ossification in antero-inferior wall of external auditory
canal ; firm reddish-brown thrombus in transverse sinus, and in
bulbus vense jugularis, — the latter was cut off in the preparation;
red points and minute holes in the thin fossa jugularis (dehis-
cence in the floor of the tympanum), at this spot corresponding
to the discoloration and infiltration of the membranous venous
wall of the bulbus. Purulent mass in tympanum. The phlebitis
resulted from extension of the inflammation from the floor of the
tympanum to the bulbus ven. jugularis. No metastases in other
organs.
{2, c) Otitis media suppurativa acuta (.?) sin.; caries; menin-
gitis; death. A man, set. seventeen years. Otorrhoea on left
side for eight days ; facial paralysis on same side since three days
ago ; uvula deflected toward right. Left meatus reddened and
swollen ; three small granulations in front of the postero-inferior
330 H. Stembriigge.
perforation in drum membrane. Hearing distance, yV CEdema-
tous spot in front of granulations on the postero-superior wall of
canal. Removal of granulations and cauterization with lapis
inf. Four weeks later nearly all the symptoms disappeared ; general
condition good ; no facial paralysis ; profuse otorrhoea, which
gradually diminished under treatment with boracic acid. One
month later pain developed suddenly in left ear ; otorrhoea
stopped ; relapse of the facial paralysis ; loss of perception for
tuning-fork on left side, notwithstanding return of otorrhoea ;
contraction of left pupil ; nystagmus of both eyes ; total deafness
on left side ; paralysis of abducens on left side ; somnolence ;
paresis of left leg ; pain in all the branches of the trigeminus ;
vomiting ; death about fourteen weeks after beginning of the ear-
trouble. Autopsy : Purulent infiltration around chiasm. The
anterior extremity of left lobe of cerebellum is adherent to pos-
terior margin of temporal bone, around the meatus auditorius
inter.; at the site of this adhesion there is a gelatinous, gray
mass sprinkled with yellow spots, extending on the one hand be-
tween the pons and cerebellum toward the medulla oblongata,
on the other hand into the internal ear ; left abducens flattened ;
left trigeminus less white than right. Left facial and acoustic
nerves consumed in the gelatinous mass. In the cerebellum, cor-
responding to the point of adhesion, is a node consisting of the
same mass, about the size of a cherry-seed. Abscess, the size of
a cherry, in the flattened left pons ; the left striae acusticse
forced apart by projection of abscess, and grayer than on the
right side. At the superior border of the temporal bone are three
small carious places, communicating with an irregular cavity, in-
volving the entire posterior portion of the temporal bone ; this
cavity is filled with greasy, shining, yellowish-white masses (cho-
lesteatoma ?), which infiltrate the posterior wall of the temporal bone
just above the sigmoid sulcus, and is also connected with the
vestibule. The ossicles are wanting. Internal ear destroyed by
the gelatinous mass. Author directs attention to the rapid de-
struction of the auditory apparatus, and supposes that the inter-
current improvement was brought about by the removal of the
granulations and the thorough cleansing of the ear thereby facili-
tated. In regard to the severe neuralgic pain in the region of
certain branches of the trigeminus on left side, it is to be re-
gretted that nothing is said about the Gasserain ganglion.
(2, d) Sarcoma of brain originating in fourth ventricle. A man,
Progress of Otology. 33 1
set. thirty-six years. Increasing weakness in legs ; vertigo, head-
ache, blindness since six months ago, deafness on left side, bi-
lateral neuro-retinitis ; paresis of ocular muscles, /. ^., on right
side ; paralysis of right facial ; disturbance in course of right
trigeminus ; complete deafness on right side, with negative ap-
pearance in ext. and middle ear. Disturbance in course of vagus,
paresis of accessorious, deflection of tongue, interrupted speech,
abnormal sensation of taste. Each half of body paretic, more on
right side than on left ; no disturbance of sensibility ; tendon-
reflex preserved. Death sixteen weeks after admission to hospital.
Autopsy : A tumor extending from the right anterior half of
pons, firmly adherent to the posterior wall of temporal bone,
and extending into the external auditory canal. It terminates in
front at the anterior boundary of pons, and projects posteriorly
i^ cm. Right half of pons almost completely destroyed ; right
facial and acoustic gray, and in the enlarged porus acust. inter,
they are lost in the growth. The latter is grayish-yellow, uneven,
and gelatinous in the centre. Cerebral ventricles enlarged, epen-
dyma thickened. In the white substance of the right corpus
striatum, in the vicinity of its posterior extremity, is a deposit
about the size of a hazel-nut infiltrated with minute hemorrhages
reaching close up to the convolution of the lobus temporalis.
Cochlea normal. The tumor was a round-celled sarcoma. There
was therefore pure nervous deafness, with the auditory organ
intact.
(2, e) Description of a preparation from the author's collection.
Head of an old man ; caries of temporal bone, with fistulous
opening outward. Oval opening in right mastoid process 4 mm.
behind porus acust. ext. This leads into a large cavity in the
mastoid and temporal bone filled with masses of cholesterine,
communicating through a smaller opening with the transverse
sinus, and further with the tympanum and ext. aud. canal. The
descending portion of the facial is almost completely destroyed.
Drum-head and ossicles are wanting. The tympanum also con-
tains masses of cholesterine. Cause of death unknown.
(3) Man, set. thirty-eight years. Had typhoid in 1868, variola
in 1871. A polypus was removed from the left ear five years ago.
Came under treatment Sept. 20, 1882, with profuse otorrhoea and
pain in left ear. Superior cartilaginous wall of ext. meatus much
depressed, in consequence of which the canal is constricted. The
meatus was dilated by means of a tent, after which a perforation
332 H. Steinbriigge.
was revealed in the postero-superior quadrant of the drum-head.
Pressure over mastoid process is not painful ; skin covering
mastoid, normal. Small polypoid excrescence removed from
posterior part of external aud. canal. Treatment : Tents soaked
in carbolized oil. After feeling well for eight days, pain occurred
suddenly in left side of occiput. Ice-bag, bromide of potass.;
later cataplasms, without benefit. Taken to hospital. Meatus
aud. ext. again completely closed, in consequence of sinking of its
upper wall. Pulse slow, paralysis of left abducens, rhythmical
contraction of both sterno-cleido-mastoid muscles. Sensorium
clear. Chill, and sudden death. Autopsy : In the left cere-
bellum is a cavity containing thick, green pus. The dura mater
on the posterior surface of the petrous bone is thickened and
grayish-red, and at this place the perforation in the bone by
masses of cholesterine forms an expansion of from 2-2|- cm.
Rupture of tegmen tympani and of the postero-superior wall of
ext. aud. meatus. No caries anywhere. Author believes that
after recovery from the previous otorrhoea, inspissated pus re-
mained in the upper cells of the mastoid process. " This formed
the nucleus for the further excessive proliferation of the epider-
moidal cells of the mass of cholesterine." The sinking of the
upper wall of the ext. aud. meatus is very remarkable, and the
author expresses the opinion that this projection should be in-
cised early and energetically.
(4) The author first discusses the origin of the osseous affec-
tions of the mastoid process, which may arise partly indirectly as
a result of disease of the mucous lining of the middle ear, and
partly later when the purulent process in the tympanum has
ceased for some time. For the better understanding of the dif-
ferent courses which the pus may take in perforating the walls
of the mastoid process, the author thus discusses the development
of the mastoid cells in the child from the antrum mastoideum
described by Schwartze and Eysell, the fissura mastoideo-squamosa
(Gruber), the vasa emissaria and the subdivision of the air-con-
taining and spongy spaces. Then follows the description of an
interesting preparation, which exhibits a division of the mastoid
process into three parts formed by two bony septa. Only the an-
terior portion communicated with the antrum, v/hile the pneu-
monic spaces of the posterior and inferior portions were completely
closed, to which condition attention was directed in regard to the
dangers of an eventual development of a purulent inflammation.
Progress of Otology. 333
The spontaneous evacuation of the pus and the formation of a
fistula occurs either through the inner wall of the mastoid process
which is very often thin, through its outer wall, or through the
posterior wall of the ext. aud. meatus. The former mode, to which
Bezold was the first to direct attention, is illustrated by a case
and drawing of the preparation. When perforation takes place
through the outer wall, the swelling is generally on the upper
portion of the mastoid process and toward the occipital region ;
the board-like induration along the neck — which is characteristic
in cases of perforation of the pus through the inner wall — is
wanting, and the auricle is considerably pushed out from the
head. Should the pus force a way into the ext. aud. meatus,
we find long tortuous fistulous tracts in the soft parts, which open
at some distance from the defect in the bone.
The author further mentions that in the fully developed tem-
poral bone, the antrum lies on the postero-superior wall, next to
the inner border of the ext. meatus ; while in childhood it is situ-
ated much farther outward.
In regard to the formation of a fistula in the posterior wall of
the ext. meatus, its frequent extreme thinness as well as the fissure
observed in consequencce of arrested development, are presented
for consideration. The author also directs attention to the fact
that the inflammation may spread in a reverse direction, from the
ext. meatus to the mastoid cells, and give rise to the formation of
fistulas, relative to which he communicates a case.
In conclusion, Kirchner considers the period at which the com-
plications in the mastoid process arise. These complications directly
follow the acute purulent inflammation in the tympanum, or they
occur after some time from cold or excitement ; then again, they
are developed in consequence of exacerbations of the affection in
the tympanum. It is known that sero-mucous exudation of the
tympanum may result in serious disease of the mastoid cells
(Zaufal). The author describes three interesting cases in which
a catarrhal exudation, after having been forced into the mastoid
cells by violent blowing of the nose, gave rise to an inflammatory
affection in them, which receded in one case, but leading, in the
other two, to the formation of an abscess, which, in the case of one
of the patients, necessitated the opening and scraping out of the
diseased bone. Kirchner, therefore, advises the perforation of the
drum membrane before Politzerization, when inflammation in the
mastoid is threatened.
334 -^- Steinbriigge.
EMBRYOLOGY.
Carl v. Noorden. The development of the labyrinth of
Teleosts. From the Physiological Institute at Kiel. Arch. f.
Anato77iie u. Physiologic v. His., etc., 1883, Anatom. Abtheilimg, 3.
Heft, p. 235.
The author examined clupea harengus (herring), gobius niger
(gudgeon), gasterosteus aculeatus (bansticle), cottus scorpius
(sea scorpion), salmo salar (Rhine salmon), and salmo fario
(salmon trout). Soon after the rudiment of the eyes, a small
roundish epithelial thickening appears behind them, as the rudi-
ment of the organ of hearing, which is pocket-like, invaginated,
and is contracted into a vesicle forty-eight hours after con-
ception. Neither at this time nor in later stages, did the author
find a diverticulum of the vesicle corresponding to the recessus
vestibuli, as has been observed in the embryos of birds and
mammalia (contrary to Vogt). The epithelial covering of the
vesicle is thin and has but one layer, until the latter is enlarged in
the parts lying toward its ventrum, at which time the epithelium
found here has increased in height, while in the rest of the parts
of the vesicle it is level, with cubic or fiat cells. At two points
on the prominent medio- ventral aspect of the epithelial border,
the primary deposits of otoliths take place ; here appear also the
hairs which, at first very fine, later increase in thickness, support
the otoliths, and belong to the macula acustica. Soon after the
rudiment of the otoliths, the epithelium becomes thickened in
three places, on the external wall of the vesicle, into oval
eminences which indicate the first appearance of the cristse
acusticse of the ampullae. These, therefore, appear before
there is a trace of the semicircular canal. Upon these
appear now also the rudiment of the hairs, in the form of
the smallest, at first very spare cones, which then rapidly
increase in number and size. The origin of the semicircular
canals takes place in such a manner that a tri-pointed thick-
ening projects from the surface of the internal wall of the vesicle
(in the salmon). Upon these three points arise three cristae, and
opposite these, on the anterior and posterior walls of the vesicle
as well as upon the base of the vesicle three smaller
cristse are developed, which grow toward the former and
unite over a crest into rods. At the point of the union a
raphe persists. These cristse are made up in part of a nearly homo-
Progress of Otology, 335
geneous mass, which is interposed between the epithcHum and
the connective tissue surrounding the vesicle. This is to be
regarded as a secretory product of the epithelial cells, coming from
the base of the latter (membrana prima, Hensen). The author,
therefore, calls this a basement-mass in contrast with the cutic-
ular secretions which proceed from the free surface of the cells.
This mass, which is at first completely homogeneous and some-
what firm, is separated more and more into lamellae, while from
the boundary of the connective tissue it is penetrated by cells
supplied with offshoots. Under the influence of these cells the
basement-mass is liquefied, dissolved, and its place taken by
embryonal connective tissue in which capillary vessels develop
later. In a few days the entire trabeculse consists of connective
tissue. Therefore, the actual construction is derived from the
basement-mass and not from the connective tissue. The author
emphasizes this condition in order to express the belief that
the constructive capacity proceeds from the middle blastoderm
and that the latter only approaches the external blastoderm.
Soon after the transformation of the basement-mass into
connective tissue, cartilage enters the trabeculae from the vicinity of
the vesicle. In some fishes this is persistent, in others it passes
into osseous tissue. In regard to the development of cartilage,
the author observes (with Hensen) that this is always geneti-
cally united with the sheath of the cord. The cord itself is
not concerned in this ; its sheath, on the other hand, becomes
thicker, and wherever groups of cartilage cells were observable
in the microscopic section, the direct connection with the sheath
of the cord was demonstrable. The trabeculse which overarch
the three cristse, accordingly form three tunnels, which open into
a space above the otoliths. The posterior otolith-mass sinks
more and more to the bottom, whereby a wide-sacked diver-
ticulum, the future sacculus, is formed, while the space which
lodges the other otoliths becomes the utricle. " Up to the time
when the semicircular canals are fully developed, there is no trace
of the rudiment of the ductus endolymphaticus ; its formation
undoubtedly takes place at a very late period of the development."
336 Oscar Wolf.
II. — PHYSIOLOGY AND PHYSIOLOGICAL ACOUSTICS.
By OSCAR WOLF, Frankfort.
Translated by Dr. J. A. Andrews, New York.
1. Dr. J. Baratoux, of Paris. De 1' audition coloree. Revue
mensuelle de laryngologie, d'otologie et de rhinologie. No. 3
Paris: chez Octave Doin, 1883.
2. Dr. W. Bechterew, of St Petersburg. Effects of division
of the acoustic nerve, with discussion of the importance of the
semicircular canals for the equilibrium of the body. Pfliigers
Archiv f. d. gesammte Physiologic, Bd. xxx., pp. 312-347.
3. Dr. W. Baginsky, Berlin. On the physiology of the
cochlea. Report of the meeting of the Royal Prussian Academy
of Sciences, in Berlin, 1883. Vol. xxviii., pp. 686-688.
4. Dr. V. Urbantschitsch, Vienna. On the effect of irrita-
tion of the trigeminus on the organs of the senses. Pfliigers Arch,
f. d. gesammte Physiologic, Bd. xxx., pp. 131- 175.
5. Sulla fisiologia dell' orrechio, tre lezioni del Dottor E. de
Rossi. Estratto dell' Archivio Medico Italiano, fasciculo Marzo
e Aprile, 1882. Historical review of the application of acoustics
to the organ of hearing, on the part of the different physiologists
of the last decade, from Johannes Miiller to Helmholtz and
Hensen, with reference to the physiology of the labyrinth ;
concluded by a brief consideration of the question of the forma-
tion of the semicircular canals or the organ of equilibrium.
6. Dr. P. McBride, M.D., F. R. C. P., Edin. A new theory as
to the functions of the semicircular canals. Journal of Anatomy
and Physiology, vol. xvii.
7. Dr. P. McBride, M.D., C. M.,F. R. C. P. E. Physiology
of auditory vertigo and some other neuroses produced by ear-dis-
ease. Address delivered in the section of otology at the annual
meeting of the British Medical Association, in Worcester, August,
1882. British Med. Journal, Dec. 30, 1882.
8. Dr, C. H. Burnett. Is the corda tympani a separate and
distinct cranial nerve ? Med. Times, Feb. 24th.
(i) Baratoux calls the phenomenon of chromatopsy in cer-
tain tone-perceptions discovered by Nussbaumer (1873) "audition
coloree." Bleuler and Lehman [see these Archives (German),
Bd. X., p. 256] selected the term, " sound-photisms " (Schallpho-
tismen), while the English call it " color-he3,ring." Baratoux
Progress of Otology. 337
reproduces an observation by M. Pedrono, which this author has
recently published in the Annales d'oculistique. This " color
hearer," a professor of rhetoric, perceived certain color-images
when certain sounds were produced. The ordinary conversational
tone of voice gave rise only to a faintly declared perception of
color ; but it was settled that certain distinctly and loudly pro-
nounced vowels produced several colors. When the deepest
vowel, U, was sounded, the person examined perceived the dark-
est color, while the higher vowels, A and O, produced a brighter
color-picture. Among the consonants, only the sibilants gave rise
to noticeable perception of color. A chord produced mixed
colors ; discord isolated certain colors. The tone-tint had a very
powerful effect ; it gave various colors to music played on differ-
ent instruments : on the piano it appeared of a blue color, and
red on the clarionet. When, finally, the particular color-hearer
says that agreeable voices appeared yellow to him, the reviewer
must wonder at the man's imagination, which, at all events, was
abnormally sensitive (he is designated in the report as " ce
malade "), and such subjective statements should be accepted
with a certain amount of caution ; at all events, we should be on
our guard against deducing physiological laws therefrom.
(2) After a brief review of the investigations on the functions
of the semicircular canals, W. Bechterew furnishes us with re-
sults of division of the acoustic nerve, which he practised on dogs.
He selected this genus of animals because Flourens' phenomena
had hitherto been very little investigated in dogs. Division of the
acoustic nerve without injury to the contiguous parts of the brain,
is exceedingly difficult. Bechterew adopted the following method :
The animal being narcotized, the occipital muscles are divided ob-
liquely, down to the bone, below and parallel to the crest extend-
ing from the tuber occipitale to the mastoid process : then an
opening is made somewhat higher up and at the side of the articu-
lation between the occipital bones and the atlas ; through this
opening is passed a round, thin style, with its extremity bent at an
angle. When the foramen auditorium inter. (.? Rev.) is reached,
the nerve is divided. The author presents a series of results from
his own experiments and those of other investigators, the essential
points of which are as follows :
(a) Unilateral division of the acoustic nerve in dogs gives rise
to forced rotatory movements about the longitudinal axis of the
body toward the side of the division, of the same character and
338 Oscar Wolf.
peculiarities (divergence of the eyes, nystagmus, rotation of the
head) as in unilateral destruction of the olivary bodies, or injury
to the central gray substance in the postero-lateral portion of the
third ventricle, or, finally, in separation of one of the peduncles of
the cerebellum.
{b^ The forced rotatory movements which occur after division
of the acoustic nerve, as obtains in all other eases, are persistent
only for a short period after the operation, but at that time they
are performed almost without interruption ; later, however, they
occur in paroxysms, which are relieved by pauses, during which
the animal's movements are restrained on the side corresponding
to the injury. In time, however, the rotary movements cease, and
circular movements, mostly toward the operated side, take their
place and are accompanied by distinct disturbances in the equi-
librium of the body, which manifest themselves in a constant in-
clination on the part of the animal to fall toward the side on which
the division was made.
{c) All the phenomena noted must be regarded as reflex, be-
cause they also occur in animals whose cerebral hemispheres have
been destroyed or placed in a state of functional inactivity by
narcotization.
(^) After bilateral division of the auditory nerves, the animals
exhibit principally marked disturbances in the equilibrium of the
body, which are expressed in an inability to stand and walk, with
complete absence of paralysis of the extremities.
{/) The hypothesis of Goltz, in regard to pressure-fluctuation of
the endolymph, satisfactorily explains the function of the canals as
that of a peripheral organ which is directly related to the main-
tenance of the equilibrium of the body, although this needs more
confirmatory facts.
(/) The semicircular canals are organs which serve to main-
tain the equilibrium not alone of the head, but of the entire body.
At the same time, functionally, they are very closely related to the
function of the organ of hearing.
(^) In all probability, the influence of sound-impression on the
movements and equilibrium of the body takes place through the
medium of the semicircular canals.
The reviewer regrets that the foregoing work does not finally
settle the important question regarding the function of the semi-
circular canals. The author confines himself more to a critical es-
timate of the views of other investigators, rather than to furnishing
Progress of Otology. 339
proof in support of his own conclusions. We neither find a complete
description of the condition and final behavior of the animals oper-
ated on, nor an indication of their number. Not a single report of
an autopsy is furnished ; at the same time, the author's method of
operating described above, furnishes no security against injury of
other important adjacent structures in division of the acoustic
nerve. A complete report of a post-mortem dissection would have
shown what changes, if any, had taken place in the central organ
and its membranes in consequence of the operation.
(3) The investigations of W. Baginsky, furnish us with a very
valuable addition to our knowledge of the cochlea. He seeks to
prove experimentally in dogs that the vibrating parts of the mem-
brana basilaris increase in width from the base toward the apex
of the cochlea ; consequently the vicinity of the round window
would react to high tones, that of the apex of the cochlea to
low tones. After opening the bulla ossea in the animals experi-
mented on, one cochlea was widely broken open, in order to pro-
duce complete deafness, and thus exclude this ear ; a small
portion of the cochlea on the other side was injured by being
opened or bored into. The hearing capacity of the dogs was then
tested (with organ-pipes from C to c")' and after a few weeks,
when no further changes had taken place in the hearing power,
the animal was killed, and the labyrinth examined. At the points
of injury was a cicatricial formation, and destruction of the
auditory-nerve fibres, while the rest was normal. Therefore, the
anatomical examination of the cochlea, whose apex had been
injured by being penetrated with a punch, showed the upper turn
and the greater part of the middle turn to be filled with fibrous
cicatricial tissue, with destruction of the normal contents ; the
inferior rest of the turns and the remainder of the labyrinth were
normal. On the other side the cochlea was either almost com-
pletely filled with cicatricial tissue, and at those places where, in
the other cochlea, the former soft parts were demonstrable, all the
nerve fibres and ganglion cells were degenerated. After a few
days, the dogs whose cochleas had been wounded at the apex by
means of a punch (after the ear had been rendered deaf) were
roused simply by a report. But at the close of the first week they
reacted distinctly to c'', occasionally to c'\ In the course of the
second week, reactions to c''' and c'" only, occasionally c", were
'The reviewer would have wished that the author had stated more precisely the
manner and method of testing the hearing, as well as the precautions for exclud-
ing sources of error.
340 Oscar Wolf.
added. So long as the animals lived, deeper tones, as c'" rel. c"
were not heard. Dogs in which the base of the cochlea was
injured by breaking away a piece of the promontory, were also
temporarily deaf. Sometimes in tliese cases, not the entire
cochlea, but only the inferior turn either in both scal^e or in the
entire scala vestibuli, and a portion of the scala tympani was filled
with fibrous cicatricial tissue, and the membrana basilaris was
destroyed there. In the more fortunate cases (dogs), after a few
days, reaction occurred to tones ; in a number of dogs no differ-
ence was observed in regard to the beginning and strength of the
reactions between high and low tones. A second equally large
number of dogs began simultaneously to react to high and deep
tones, but the reactions to low tones were distinctly stronger at
first than were the reactions to high tones. Finally, in a third
smaller number of dogs, there were at first reactions only to low
tones (the lowest 3-4 octaves), and reactions to high tones did not
occur until after 8-14 days. The author explains this circum-
stance by saying that after the operation the fluid contents of the
cochlea escaped, and that the inflammation spread from its start-
ing-point over the membranous parts of the cochlea, but that in
consequence of the slight injury, the wound soon healed, and the
inflammation receded in an inverse direction up to a certain limit.
(4) The observation that ear-patients experience an improve-
ment in the acuity of vision during the treatment of the ear, led
Urbantschitsch to make a number of experiments in such a man-
ner that the vision was tested in every case at the beginning of
treatment, also in the different stages of the ear-affection. Among
twenty-five ear-patients, vision was improved in twenty-one cases,
and this improvement occurred in the majority of cases within the
first days of treatment. The experiments further showed the inter-
esting fact that unilateral ear-disease influenced not alone the
eye of the corresponding side, but also its fellow ; at least, in the
majority of cases of unilateral ear-disease, there was improvement
in the vision of the eye on the opposite side, which was sometimes
much more considerable than that of the other eye corresponding
to the affected eye.
Inasmuch as no changes were observable in the fundus oculi,
the author refers the phenomenon to reflex origin. He was
strengthened in this view by further experiments, in which he
found that irritation of the ear influenced the vision. The passage
of a bougie through the Eustachian tube, by irritating the tri-
Progress of Otology. 34 ^
geminal branch frequently improved the hearing without Politzeri-
zation ; this was likewise brought about by reflex action through
the medium of the auditory centre.
(6) In this essay the author endeavors to prove that the func-
tion of the ampullary nerve-terminations is not alone that of a
space- and equilibrium-sense, but that they are likewise concerned
in every act of hearing. The former physiological proposition
would suffice if the ampullae and semicircular canals constituted
a system in themselves, isolated from the organ of hearing, and
hence less exposed to external influences. However, the connec-
tion with the utriculus, whereby some of the sound-waves are
transmitted to them ; further, the undeniable stimulation of the
ampullary nerves by every acoustic impression, which declares itself
in certain reflex movements, lead us to suppose that they serve
other purposes. These reflex movements consist in an involuntary
rotation of the head and eyes toward the side whence aloud sound
proceeds. The author alludes to the instantaneous muscular
actions of game when frightened by a noise ; further, to the experi-
ments of Cyon and Hogyes, who demonstrated the connection
between the vestibular nerve and the centre which presides over
the movements of the eyes ; and to the fact that in abnormal ex-
perimental as well as pathological irritation of the labyrinth, rota-
tion takes place toward the affected side (cites only Spamer),
and finally reaches the conclusion that (i) the nerve terminations
in the ampullae are sympathetically excited by every sound-impres-
sion, and (2) the effect of the irritation consists in a rotation of the
head, eyes, and trunk toward the irritated side, with active tension
and increased activity of the muscles thereby concerned.
Steinbrugge.
(7) In this discourse, McBride first considers the different
nerve-tracts which connect the ear with the central organ ; then the
familiar reflex phenomena which may be excited through the ter-
minations of the ram, auricul. n. vagi, trigeminus, chorda tympani,
vestibular nerve, and directs attention to the circumstance that
reflex effects are most marked when several nerves are irritated
simultaneously. For example, injections of cold water into the
external aud. meatus gave rise to more marked vertigo than when
warm water was used, because in the former case, besides the irri-
tation of the trigeminal fibres, the pressure upon the labyrinthine
fluid should also be taken into consideration. If we further bear
in mind the physiological law that the shorter the nerve-tracts
342
A. Hartinann.
leading to the central organ are, the more powerful will be the
reflex actions, it will be easy to understand that pathological irri-
tations of the organ of hearing may be accompanied by very active
reflex symptoms, in support of which, cases of epilepsy, psychical
disturbances of various grades, as well as auditory vertigo, are
adduced. With respect to the latter, which, in pronounced cases
is accompanied by nausea, vomiting, and syncope, the author refers
the order of these symptoms to a greater labyrinthine irritation
primarily transmitted to the vertiginous centre, and is there propa-
gated to the vomiting-centre, as well as to the cardiac inhibitory
centre. In the case of gastric vertigo dependent on gastric irrita-
tion, the stimulation of the centres takes place in a reverse order.
The author maintains that the pathological symptoms are not due
to vaso-motor influences, but are of direct reflex origin (opposed
to Woakes). In order to prove that reflex actions may depend on
propagation of the irritation of sensitive and motor tracts, but also
on their transmission to other sensitive nerves, the author alludes
to cases of pain in the knee in hip-joint affections, pain in the ear
from toothache, pain in the shoulder and mammary gland in dental
neuralgia. Steinbrugge.
(8) An exposition of Sapolini's theory that the corda tympani
— the thirteenth cerebral pair — is the nerve of speech. B. thinks
this supposition substantiated, to some extent at least, by clinical
experience. If a child under six years old loses hearing in both
ears it is apt to lose, at the same time, its power of speech, either
entirely or partially. In such cases B. thinks the ear-disease must
have been accompanied by injury to the corda tympani.
Burnett.
III. — PATHOLOGY AND THERAPEUTICS.
By a. HARTMANN, Berlin.
Translated by Swan M. Burnett.
general.
I. E. DE Rossi, Rome. Eleventh annual report of clinic,
1881-1882.
Progress of Otology. 343
2. Marian, Aussig. Report of ear cases treated from Oc-
tober, 1880, to October, 1882. A.f. Ohrenheilk., B. xx., p. 13.
3. Christinneck. Statistical report of the ear-clinic at
Halle a. S., from October 15, 1881, to October 15, 1882. Ibid.,
p. 24.
4. K. BuRKNER. Report of cases treated at my policlinic
for diseases of the ear in 1882. Ibid., p. 43.
5. H. Dennert, Berlin. Remarks on the report of Dr.
Jakobson. Ibid., B. xx., No. i.
6. L. Blau, Berlin. Communications from the department
of diseases of the outer and middle ear. Ibid., B. xix., Nos.
2 and 3.
7. Graf. Antisepsis in otology. Berl. klin. Wochensch., No.
14, 1883.
8. R. Ariza, Madrid. Resena del segundo ejercicio del insti-
tuto de terapeutica operatoria del Hospital de la Princesa,
1882.
9. Saml. Theobald, Maryland. Hints in regard to the treat-
ment of a few of the commoner middle-ear affections. Med.
Journ., March i, 1883.
10. Schilling, Munich. Prophylaxis against the toxic
effects of salicylic acid and quinine. Artzl. Intell.-BL, No.
3, 1883.
11. Fuerstner, Heidelberg. Psychic disturbances in ear-
diseases. Berl. klin. Wochensch., No. 18, 1883.
12. NoQUET, Lille. Hereditary syphilis ; loss of substance in
the velum palati ; ulceration on the left tonsil, etc. Rev. mens.,
No. 5, 1883.
13. Schwabach, Berlin. Deaf-mute statistics and deaf-mutism.
Real.-Encyc. d. ges. Heilk.
14. S. Sexton. Tubercular syphilide of the ear. Journ. Cut.
and Ven. Diseases, June.
15. S. Sexton. The significance of the transmission of
sound to the ear through the tissues in aural disease. N. Y.
Med. Record, July 28, 1883.
344 ^' Hartinann.
1 6. J. P. WoRSELL. Deafness among school-children. Trans.
Ind. State. Med. Soc, 1883.
(i) The eleventh annual report of Rossi's otological clinic
shows 569 cases arranged in a systematic method. A detailed
account is given of twenty cases of acute or chronic purulent
middle-ear disease attended with more or less serious complica-
tion. In case No. 6 the tragus was missing, and there remained
of the external meatus only a small canal, from which by pressure
a thin purulent discharge came. After an incision into the cica-
trix, there was found behind it a large cavity from which the
sequestra were removed by means of a sharp spoon. Case 11 was
that of a boy of eleven years, who, after an aural discharge in
childhood, could hear neither the watch nor voice. The tuning-
fork was heard through aerial conduction on the right side. The
membrana tympani was cicatricial, atrophic, and calcareously de-
generated ; the hammer handle immovable. Under chloroform,
Rossi made a flap on the right side from the posterior upper quad-
rant of the Mt, with its base below, and loosened the anchylosis
between the stapes and anvil. After the operation, they stood
I mm. apart. No improvement in hearing. The flap in the Mt
healed rapidly. Among the other clinical histories there were
many mastoid affections in which operative measures were re-
sorted to.
(2, 3, 4) These three statistical reports, which appeared in the
Archiv f. Ohrenheilkunde, contain tables showing the form of dis-
ease, the age and sex of the patient, and the course of healing.
On the worthlessness of statistics of the latter kind it has been re-
marked at another place. Ideas regarding healing and material
improvement are so different, that results are not comparable.
Though it is pleasant to learn that with Marian only 6.2, fo, in
Halle only 2.8 ^, and with Burckner only 3.5 fo remain uncured, we
are by no means able from these figures to draw any conclusions
as regards the prognosis of ear-affections in general. The report
from the policlinic at Halle contains many important observations.
In forty-three cases of paracentesis of the Mt there was 41.2 fo of
subsequent inflammation. Since no unfortunate results have
been reported from other quarters, the opinion of Christinneck
appears correct — that the method of after-treatment must be held
responsible for the unfortunate difference. The after-treatment
consisted in injection per tubam, and was the cause of the irri-
Progress of Otology. 345
tation. The treatment of otorrhoea by iodoform has not proved
efficacious. In a two-and-a-half-year-old girl a round-celled sar-
coma was observed which undoubtedly originated from the dura
mater or from the outer periosteum of the mastoid region. The
first symptom was facial paralysis, which manifested itself after
acute febrile symptoms. Soon there appeared a swelling in the
mastoid region which spread gradually beyond the ear to the
temporal region. There was never any discharge from the ear.
Later on there were chills, hemiparesis, and convulsions.
On section there was found an external tumor the size of a man's
fist. The greater part of the temporal bone was destroyed, and
the tumor mass connected itself directly with the temporal lobe
of the brain. The excision of the Mt with the hammer was per-
formed without result in one case on account of a tormenting
tinnitus. Healing took place with a remaining large perforation of
the Mt. Loosening of the auricle for the purpose of removing a
sequestrum in the external meatus was performed once. In con-
clusion five cases of operation on the mastoid are reported.
(5) In his remarks on Jakobson's report, Dennert criticises
the objections made against his method of testing the hearing
power. Our space will not allow us to go into a detailed consid-
eration of the author's views, for which we must refer the reader
to the original.
(6) From Blau's observations we select his description of
otitis externa circumscripta. B. describes a special form of dis-
ease which differs from the ordinary furuncle in this, that the
very extensive swelling and excessive pain are not relieved by in-
cision. If, moreover, the parts about the ear and the neighboring
lymph-glands are swollen, it is easy to be led to supposing a re-
tention of pus in the middle ear. B. has observed ten such cases,
eight on the lower and two on the upper posterior wall of the
meatus. In treatment he limits himself to the employment of
ice and iodine preparations. B. has not demonstrated the connec-
tion between diabetes and furunculosis.
The treatment of purulent middle-ear inflammation is treated of
in detail.
(7) Graf speaks of the presence of micro-organisms in ear-dis-
eases, and of the hyphomycetes in otomycosis as well as of
schizomycetes in otorrhoea, diphtheria of the ear, the presence of
micrococci in furuncles, and comes to the conclusion that the aur-
ist as well as the surgeon should employ asepsis and antisepsis,
and recommends for the latter boracic acid.
346 A. Hartinann.
(8) The otological division of the report of the Hospital of the
Princess is from Ariza, and contains, besides a description of the
methods of examination, a large number of clinical observations
on various ear-diseases.
(9) T. has sometimes succeeded in aborting furuncular in-
flammations of the meatus by a liberal application of the yellow
oxide of mercury ointment. For the relief of pain he has found
instillations of the baume tranquille of the French Codex very
efficient. He does not resort to incisions, except when they are
likely to give vent to pus. In the diffuse inflammation of the
meatus due to aspergillus, he has found a powder of equal parts
of boracic acid and oxide of zinc efficacious. In acute inflamma-
tion of the middle ear, he finds instillations of a four-grain solu-
tion of sulph. of atropia useful for the relief of pain. Incisions of
the Mt are not to be made too hastily. They should be deferred
until there is a marked .bulging. In the treatment of chronic
otorrhoea no one remedy has given him such satisfaction as the
powder of boracic acid and oxide of zinc in equal parts. He
prefers this to the boracic acid alone. He applies it by means of
an insufflator. Burnett.
(10) Schilling, in accordance with the data obtained from
Kirchner's experiments on animals, and the clinical symptoms
observed after the administration of large doses of salicylic acid
and quinine, employs, as an antidote, preparations of ergotine, and
has obtained excellent results from the administration of an in-
fusion of ergot and salicylic acid equal parts, or quin. two parts,
and ergot three parts.
(11) FiJRSTNER relates that two women, one anaemic and the
other strumous, but both having an hereditary psychic taint, were
affected with subjective noises to such an extent that they sank
into melancholy, with hallucinations of hearing. When the
cause was removed, the ear-symptoms and psychosis were abol-
ished. .He mentions the cases reported by Moos and Tuczek,
and calls to mind the condition of irritation in acute middle-ear
inflammation, which he refers to a meningeal irritation or an in-
crease of intracranial pressure. Finally, he mentions a case of
psychosis which suddenly subsided on the appearance of a pro-
fuse otorrhoei. In this connection there are other observations
which Fiirstner has not mentioned.
" Insanity often makes its appearance as one of the symptoms
of suppurative middle-ear inflammation," says Moos on page 54
Progress of Otology. 347
of his paper on epidemic cerebro-spinal meningitis, and relates
a case in point.
(12) A ten-year-old boy came under the care of Noquet,
with a destroyed uvula and a triangular defect in the soft palate.
On the left tonsil there was a round ulcer with a gray bottom and
sharp edges. The teeth were opaque, brown, small, obliquely set,
and with irregular surfaces. The submaxillary glands were some-
what swollen. With the destruction of the palate there appeared
a high degree of deafness, which was somewhat improved by in-
flation. Other signs of syphilis were not present, nor did the
clinical history give any positive data for such a diagnosis ; but
from the character of the teeth and the appearance of the ulcer,
Noquet felt justified in diagnosing syphilis. The general treat-
ment consisted in the administration of the syrup of Ghibut (con-
taining mercury and iodine), while the local applications consisted
in pencilling the ulceration with a strong solution of nitrate of
silver and the employment of the nasal douche. After three
months' treatment, healing took place, with normal hearing and
cicatrization of the ulcer. The results of the treatment, N.
thinks, sustain the diagnosis. A previous anti-scrofulous treat-
ment had proved valueless.
(13) ScHWABACH has worked up very carefully and completely
the statistics on deaf-mutes and deaf-dumbness in Eulenburg's
" Encyclopedia." The information furnished by the latest publica-
tions is made use of, and the statistical part contained in sixteen
tables is based on the results of the last census.
(14) The histories of three cases of tubercular syphilide of
the ear are given in detail with illustrations of the appearance in
two. From these histories it appears that this affection is among
the tertiary forms of syphilis. Burnett.
(15) S's conclusions are : (i) The fact that the sound is heard
better through the tissues of one side simply indicates that the
better ear wholly or in part excludes such transmission. It does
not prove that the auditory nerve in either is affected. (2) When
the conducting apparatus is damaged or destroyed, there will be
no air-transmission on that side, whereas the tuning-fork will be
heard best or altogether on that side. (3) In labyrinthine dis-
ease pure and simple, the tuning-fork will be heard best by air-
transmission. (4) The tuning-fork is, therefore, of less value in
diagnosing between middle-ear and nerve disease than has been
supposed. Burnett.
348 A. Hartmaiiji.
(i6) There were 491 children examined. Among these there
were 72 who had impairment of hearing in both ears, and 53 in
which it was limited to one. Burnett.
EXTERNAL EAR.
17. Weil, Stuttgart. Contribution to the knowledge of othse-
matoma. Mon. f. 0/ire?iheilk., No. 3, 1883.
18. Holland. Case of foreign body remaining in the ear
for twenty years. Brit. Med. Jom-nal, Feb. 3, 1883.
19. J. M. Booth, Aberdeen. On ceruminous accumula-
tions in the external meatus. Lancet, March 10, 1883.
20. Baudrimont. Fracture of the anterior wall of the
meatus and luxation of the lower jaw. Bull. et. mem. de la soc.
de chirurg. de Paris, 7, viii, p. 487.
21. C. J. Blake. Accumulation of epidermis in the external
auditory canal. Bost. M. and S. yournal. May 10, 1883.
(17) Weil observed in a child of fiveyearsan athsematoma the
sice of a hazel-nut on the inner side of the concha. Recovery by
means of massage and compression.
. (18) Holland removed a small iron ball from the ear of a
patient who reports that it had remained in the depths of the ear
for twenty years.
(19) Booth observed in three workmen from the same work-
shop impaction of cerumen occurring at the same time. The
men had been worked hard for three months before, and all were
affected with catarrh. The author is of the opinion that the
catarrh was in a causal relation to the accumulation of the
cerumen.
(20) Baudrimont makes the following categories in cases of
fracture of the auditory canal : i. The canal may be fractured,
and yet its lumen may remain intact. 2. By the fracture the
anterior wall may be driven backward and the lumen diminished.
3. By a luxation of the condyle of the lower jaw the canal may be
completely closed. The fracture may occur from a fall or blow on
the chin. Swelling in the vicinity of the ear is not present in the
beginning ; sometimes it comes to an inflammation of the joint,
associated in one case with anchylosis. The hemorrhage is some-
times consitierable. The wound of the soft parts is at right
angles to the axis. Very frequently there was a concomitant
fracture of the lower jaw and of the condyle. Fracture of the
anterior wall was most frequently observed in absence of the
Progress of Otology. 349
back teeth. One case is related which proves that a complete
luxation of the lower jaw with impaction of the condyle in the
external meatus can occur without a fracture of the head of the
condyle. It occurred in the person of an old man of sixty-three
years, who fell heavily on his chin. There followed pain in both
ears, inability of closing the mouth, complete deafness, and hem-
orrhage from the ears. The angle of the jaw lay on the edge of
the sterno-cleido-mastoideus, and the place of the head of the
condyle was vacant. The lumen of the canal was filled with a
hard mass. The reduction of the lower jaw was effected on both
sides, with attendant improvement in hearing and normal move-
ment of the jaw. The healing was tedious and accompanied by
suppuration.
(21) Blake. In those quite rare cases, where the mass of
epithelium fills the canal, and its centre has undergone fatty
degeneration, making it impossible to seize the mass or any part
of it with the forceps, B. bores into the mass with a cotton-
tipped probe dipped into caustic potash. This converts the mass
into a soluble soapy substance which can be washed away with
the syringe. Of course this may have to be repeated a number
of times. Burnett.
MIDDLE EAR.
22. Dr. E. J. Moure. Acute middle-ear catarrh, with facial
paralysis. Revue mens, de laryn., etc.. No. 4, 1883,
23. Dr. A. BiNG, Vienna. Catarrh of the middle ear. Wiener
Med.-Blat., No. 4, 1883.
24. Dr. T. BoBONE, St Remo. Some observations on purulent
otitis in phthisis. Boll, delle mall, dell orecch., etc., No. 3, 1883.
25. E. Marpurgo, Trieste. Contribution to the pathology and
therapeutics of perforation of Schrapnell's membrane. Archiv f.
Ohre7iheilk., B. xx., p. 264.
26. C. H. Burnett, of Phila. Advantages of the dry treat-
ment of otorrhoea. Amer. Joiil Med. Sci., Jan., '83.
27. H. Schwartze. Second series of fifty cases of surgical
opening of the mastoid. (Conclusion.) Archiv f. Ohrenheilk., B.
xix., p. 217.
28. A. H. Buck, New York. Sclerosing otitis of the mastoid.
Med. Record, March 10, 'Bi'^.
29. V. Urbantschitsch. On dilatation of the Eustachian
tube. Med. Fresse, 1883.
350 A. Hartmann.
30. Dr. VoLTOLiNi. Two peculiar ear-diseases. Mon. f.
Ohrenheilk., No. i, 1883.
31. BoKE. Two otological communications. Archiv f. Ohren-
heilk.^ B. xx., p. 47.
32. Dr. B. St. J. Roosa. A lecture on the treatment of chronic
suppuration of the middle ear. N. V. Med. Joii'l, May 19, "^i.
33. S. Sexton. Earache in children. Med. Record, May 5,
'83-
34. O. D. PoMEROY. A case of chronic suppurative otitis
media illustrating the action of boracic acid in its treatment. The
Planet, July 15, '2>2>.
35. E. D. Spear. Otitis media purulenta. Bost. M. and S.
you I, May 24, 'Zt,.
36. L. TuRNBULL. Observations on caries of the mastoid
process of the temporal bone in children. Phila. Med. Times,
July 14, 1883.
37- W. J. Martin. A case of mastoid disease, producing
phlebitis and death. N. Y. Med. Times, Aug., 1883.
(22) Moure describes a case of facial paralysis which made its
appearance in the first stage of an acute inflammation of the mid-
dle ear. The paralysis remained after the closure of the perfora-
tion in the Mt, and disappeared only after a period of four
months. After the subsidence of the otorrhoea, the treatment
consisted in the employment of the electric current and derivative
applications to the mastoid. Moure thinks that the facial paraly-
sis was due in part to mechanical pressure of the secretion, and
partly to the swelling and hypersemia of the mucous membrane
of the drum cavity.
(23) BiNG describes an ordinary case of catarrh of the middle
ear, and accumulation of secretion in the drum cavity without in-
flammatory appearances on the Mt. Relief by means of inflation
and gargles without perforation of the Mt.
(24) BoBONE gives his observations on purulent inflammation
of the middle ear in phthisis. He discriminates between cases which
appear before the lung affection, or in its first stages, and those in
which the lung affection is far advanced. A characteristic ap-
pearance of the otorrhoea of consumptives is its symptomless
appearance. The opening in the Mt is small only in the begin-
ning of the affection ; later it increases in size, but the Mt is not
inflamed. On the mucous membrane of the drum cavity there
are small torpid granulations. In the first stages of phthisis heal-
Progress of Otology. 351
ing can be expected ; in the advanced stages we can only disin-
fect the middle ear. The antiseptic treatment of Bobone is that
of Bezold. Healing is also hastened by a residence at St. Remo.
Bobone thinks that climate has as favorable an influence on the
ear-disease as upon the lung affection.
(25) Marpurgo prefaces his extensive work with a review of
all previous publications on the perforation of Schrapnell's mem-
brane, and communicates eleven observations of his own. In
perforation of Schrapnell's membrane, the Mt is dry and lustre-
less, not swollen. The perforation is sometimes greater, sometimes
less. In the first case it is frequently the result of a carious pro-
cess on the upper edge of Rivini's notch. The perforation
whistle is frequently lacking, because the space above the short
process where the perforation opening is found communicates
with the remaining part of the drum cavity only by a small
opening. Pathological alterations close this opening. As a
further peculiarity of this perforation, Morpurgo mentions fre-
quent acute exacerbation of the inflammatory process. In regard
to the course and prognosis of the affection, all authors are agreed
as to its long duration and the infrequency of complete cure. In
treatment, Morpurgo recommends in the first place intra-tympanal
injections, for which he employs Weber's tympanal catheter. A
healing of the perforation cannot even then be counted upon,
and the duration of treatment is very long. The injections are
combined with the alcohol treatment. In conclusion, his own
individual observations are communicated with statistics of the
cases reported hitherto.
(26) In cleansing the ear, B. has not entirely discarded syring-
ing, but he would have it done generally by the physician. The
patient may keep the ear clean by means of a twisted pencil of
absorbent cotton. The " dry method," of course, consists in the
application of powders to the diseased surface after it has been
thoroughly cleansed and dried. He condemns powdered alum on
account of its tendency to produce furuncles in the ear. The
author has found the mixture of powdered boracic acid and
calendula, as recommended by Sexton, very efficacious. He has
also used with satisfaction : Resorcin, 3 i ; boracic acid, § i, and
salicylate of chinoline, 3 ss- 3 i. These powders he applied by
insufflation, and not by pouring them into the meatus through a
speculum. As a matter of statistics, he gives fifteen consecutive
cases treated by the "moist" method, in which the average dura-
352 A. Hartmann.
tion of treatment was 212 days, wliile in fifteen consecutive cases
treated by the dry method the average duration of treatment was
seventeen to eighteen days, Burnett.
(27) ScHWARTZE communicates the clinical histories of a sec-
ond series of fifty cases of opening of the mastoid, and adds some
remarks on the general results of his operation. Of the one
hundred cases operated on seventy-four were cured, six remained
unchanged, and twenty died. Schwartze concludes from these
results that the fatality, so far as regards the operation, is very
small indeed. Among the twenty fatal cases there were many in
which death was entirely independent of the operation. Making
abstraction of these, the fatal cases amounted to only six per
cent. Schwartze protests against the strictures made by Politzer,
that a number of his cases would have recovered without operation.
The hearing power was completely normal in nine cases of the
second series ; in the remaining favorable cases it was more or
less reduced. In thirty-three cases, after the subsidence of the
suppuration, there was cicatrization of the defect in the Mt.
(28) Under this title B. treats of that rather uncommon form
of mastoid disease which is known also under the names, hyper-
ostosis, sclerosis, or osteo-sclerosis of the mastoid. He gives Dr.
C. R. Agnew credit for being the one to first call attention to the
fact that inflammation of the mastoid cells need not necessarily
tend toward caries of its bony structures. Only two cases, which
were undoubtedly of this nature, have come under the observation
of the author, and these he gives in very great detail ; also one
from the practice of Dr. J. Orne Green.
The characteristics of this form of mastoiditis he sums up as
follows : I. Decided and persistent pain in and around the
mastoid, though there may be an adequate outlet for any pus
secreted in the antrum, and nothing like acute inflammation of
the middle or external ear, and despite the employment of means
which usually allay inflammations in these parts. 2. Redness,
swelling, and tenderness of the outer mastoid. Actual enlarge-
ment of the bone is, of course, positive evidence. 3. A previous
chronic purulent inflammation of the drum-cavity leads us to sup-
pose that the cells have been obliterated or greatly reduced in
size by earlier attacks of subacute ostitis. In treatment he
recommends trephining. Even if no pus is found, as is usually
the case, the mere opening of the bone seems to exercise a good
influence on the progress of the inflammation, probably in the
manner of a counter-irritant. Burnett.
Progress of Otology. 353
(29) According to Urbantschitsch there remains after a
chronic middle-ear catarrh a narrowing of the tube, especially fre-
quent at the isthmus, although the entrance of air is not apparently
hindered. For purposes of diagnosis in chronic middle-ear catarrh
U. as regularly inserts bougies into the tube as he inspects the J//
with the mirror. He employs the French bulbous bougies. The
bulb of the bougie makes the examination less painful, and facil-
itates the accurate determination of the locality of the stricture of
the tube. He holds that it is necessary to dilate the tube in all
cases of diminished hearing power, and subjective noises in which
a bougie of one and one-third mm. thickness cannot be made to
enter the osseous tube, or only enter with great difficulty. He
begins with small numbers, and a four weeks' treatment is gener-
ally sufficient to produce a satisfactory dilatation of the canal. The
dilatation may be made daily, or every two or three days, accord-
ing to the sensitiveness of the patient. He has frequently seen
persons who are affected with migraine, trigeminus and occipital
neuralgias relieved of their troubles by these dilatations. He has
also frequently seen subjective noises and deafness which were
not improved by the air-bath, remarkably improved by a few dila-
tations. The improvement produced by the dilatation is not to
be referred to a mechanical or local action, but to reflex influence
which is generated by the irritation of the sensitive twigs of the
trigeminus, especially the tubal branches, and which thence extends
to all the senses, and of course to the ear.
A successful result of dilatation is also apparent in chronic
purulent middle-ear inflammation when it is associated with nar-
rowing of the isthmus of the tube.
(30) A twenty-year-old patient of Voltolini's had for five or six
years a feeling as if a valve were suddenly closed in front of his ear,
which occurs quite frequently and lasts for some time. An exam-
ination made when the " valve " was down discovered the thin
atrophic Mt bulged forward like a sack and filled with foam. By
negative Valsalva's experiment the valve disappears and the Mt
reposes against the labyrinth wall. By the smallest movement of
the muscles of deglutition the former condition returns. The
diagnosis was made of dilatation of the tube with exudation into
the drum cavity. After repeated paracentesis of the Mt the phe-
nomenon disappeared. The dilatation of the tube was confirmed
by the insertion of catgut bougies. On the Mt each respiration
could be observed. It was drawn inward during the inspiratif n
354 ^- Hartmann.
and bulged outward at expiration. During the pronunciation of
each vowel V. saw the Mt make a small but clearly dis-
tinguishable excursion. On pronunciation of the letter R it had
a fluttering vibratory motion. The author finds in this observa-
tion a confirmation of his former experiments, according to which,
during the pronunciation of various vowels and consonants, a
complete occlusion of the cavum pharingo-nasal by means of the
soft palate does not take place. The reviewer holds that this
observation is not conclusive, since the movements of the Mt can
also be brought about by contractions of the palatal muscles.
(31) BoKE shows in his first communication that fatal hemor-
rhage from the ear is not always from the internal carotid. In
two of the cases described by him previously, the bleeding con-
tinued for fourteen days, but was stopped by cold water. In one
case the blood came from the bulbus venae jug. and apparently
also from the stylo-mastoid artery ; in the second case from the
sinus petr. inferior. Lately it has happened to Boke to be able
to stop a profuse arterial hemorrhage by means of alum powder
and a charpie tampon, and essentially to improve the otorrhoea by
subsequent treatment. On the basis of his experience Boke feels
justified in concluding that " profuse hemorrhage from the ear is
always an important symptom ; the prognosis is always to be held
in reserve, and ligation of the carotid has no scientific basis."
The second communication is a case in which a high degree of
vertigo, inclination to vomit, and facial paralysis accompanied an
acute middle-ear inflammation. These symptoms disappeared
after paracentesis of the Mt and evacuation of mucus from the
middle ear by means of the catheter.
(32) The author is not yet ready to discard the syringe properly
and carefully used as a means of cleansing the ear. Nor does he
adopt, to the exclusion of other means, the so-called dry treat-
ment. The solutions he has found of most benefit are sulph. zinc
and sulph. alum i to 4 grs. to an ounce of water. In removing
granulations he employs fuming, nitric and chromic acid and nit.
silver in solution of 20 to 60 grs. to an ounce. He finds alcohol
valuable. Burnett.
{^y"^ In the treatment of acute inflammations of the ear in chil-
dren, Sextcn does not find much relief from leeches, thinks my-
ringotomy seldom necessary, but places much reliance on the
internal administration of aconite, gelseminum, pulsatilla, and
sulphide of calcium. (! Ed.) Burnett.
Progress of Otology. 355
(34) As a result of a rather extensive experience in the employ-
ment of boracic acid, Pomeroy is an enthusiastic advocate of its
use in chronic suppurative otitis, where there are no polypi or
granulations. Where these occur as complications, no benefit
follows the use of the acid until they are removed. For their re-
moval he uses nitrate of silver in strong solution, or fused on a
probe. Burnett.
(35) Nothing new on this subject is offered. Granulations are
treated by caustics — nitrate of silver being preferred. The so-
called dry treatment also receives recommendation at his hands.
Burnett.
(36) Some general considerations regarding the nature of the
affection and the usual methods of treatment are given. This is
followed by the recital in detail of a case of encephaloid cancer
involving the temporal bone, mastoid cells, and the antrum, show-
ing itself first in the external osseous meatus as a polypoid growth
from diseased bone. It was in a boy four years of age. It was
removed three times, but recurred, and finally killed the patient.
Burnett.
(37) The patient was a boy seven years of age who had a puru-
lent discharge from the right ear for some years. During an acute
attack the mastoid region became painful and swollen. Soon a
discharge of offensive pus took place from the ext. meatus. This
was followed by swelling of the neck, forehead, and eyelids.
There was exophthalmus and congestion of the conjunctiva ; the
parts around the right jugular vein were hard and sensitive.
Temp., 104°. He died on the eighth day. No post-mortem.
Burnett,
nervous apparatus.
38. G. C. Harlan. A case of sudden deafness after mumps.
Med. News, March 24, 1883.
39. Dr. Burkner, Gottingen. A case of sudden loss of hear-
ing-power in one ear during mumps. Berl. klin. Wochenschr., No.
13, 1883.
40. Dr. Seligsohn, Berlin. Deafness after mumps. Deutsche
med. Wochenschr .., No. 4, 1883.
41. H. Knapp. a case of double-sided deafness after mumps.
These Archives, vol. xi, p. 385.
42. Dr. Brunner, Zurich. Otitis labyrinthica infantum (Vol-
tolini). Corresp.-Bl. f. Schw. Aertze, No. 10, 1883.
43. Dr. Gelle. a clinical study of Meniere's vertigo in its
356 A. Hartniann.
relation to alterations of the oval and round windows. Archiv. de
Neurol., No. 12, 1883.
44. P. MariiS and G. L. Walton. Vertigo in tabes. Rev. de
niM., No. I, 1883.
45. M. BouCHERON. Troubles in equilibration in small
children affected with deaf-dumbness by otopiesis. Compte
reiidue, Feb. 20, 1882.
46. Dr. Grazzi. Meniere's disease and its cure. Gaz. degl.
Osptt., Nos. 99-100, 1882.
47. Walton. Deafness in hysterical hemi-ansesthesia. Brain,
vol. XX.
48. Gesell, Berlin. Same in Verh. der Phys., No. 8, 1883.
49. S. Moss. Neuropathological contributions. These Ar-
chives, vol. xii, p. 309.
50. Heilly. Note on a case of blindness and word-deafness.
Prog. mMical, No. 2, 1883.
51. Magnan. a case of word-deafness. Soc. d. bid. et gaz.
d. hop., No. 59.
52. A. Vetter. On the sensorial function of the cerebrum,
etc., from new experiments and clinical observations. Deiitsch.
Archiv., B. xxxii.
53. H. Donkin. Left hemiplegic and left-sided deafness
from brain injury, etc. Brain, Jan., 1883.
54. E. Gampietro, Naples. On acute hydrocephalus and
otitis in children, and some trophic changes in the ear in lesions
of the medulla. Giorn. int. del. sc. tned.. An. v., p. 301.
55. D. Webster. A case of syphilitic disease of the laby-
rinth, etc. The Pla7iet, April 15, 1883.
(38) The patient was- a female twenty-three years of age, and
had mumps three years ago. The day after the commencement
of the attack there was a roaring sound in the R ear, associated
with complete deafness. No pain ; no discharge. For more than
a month afterward there were dizziness and a tendency to pitch
forward. There is still a constant tinnitus, and the watch is not
heard on that side. Conducting apparatus normal.
Burnett.
(39) Burkner's case was in the person of a boy seventeen
years of age who, on the second day of a parotitis, had loud
subjective noises on the right side, and on the next day was com-
pletely deaf. There were, besides, vertigo of eight days' duration,
vomiting, and imperviousness of the tube.
Progress of Otology. 357
(40) Whilst in the foregoing two cases deafness made its ap-
pearance at the beginning of the mumps, in the case communi-
cated by Seligsohn — a young girl of sixteen years — it manifested
itself only after a lapse of two months. The author thinks in this
case syphilis had something to do with the development of the
deafness.
(42) Brunner takes up arms in defence of the existence of
an otitis labyrinthica sui generis, and cites in support of his opin-
ion that in the Canton of Zurich, where all his cases occurred,
there has been no epidemic cerebro-spinal meningitis for twenty
years or upward. He also brings Voltolini's arguments to the
support of his position.
(43) Gelle discusses in his paper the clinical and experi-
mental data in regard to the vertigo of Meniere's disease, and
seeks to show that it is not due to labyrinth affection, but to
middle-ear disease. In support of this opinion, a post-mortem
examination of a case from Charcot's clinic is cited, in which an
affection of the peripheral part of the organ of hearing existed
with a normal labyrinth. G. hoped to find a proof of the correct-
ness of his position in experiments instituted for the purpose of
determining the movableness or immovableness of the labyrinth
windows. If the air in the external meatus is compressed by
means of a Politzer bag when the ear is normal, there is an altera-
tion in the tone of a tuning-fork placed on the forehead at each
compression. If the stapes is immovable, no such alteration in
the tone is observable. When the ligaments are loose, on the
other hand, such a compression acts very strongly, causing a
shock to the labyrinth, with vertigo and subjective noises. Ac-
cording to the phenomena following this experiment, G. diagnoses
a normal, impeded, or ankylosed condition of the conducting
apparatus.
Meniere's vertigo was observed in 53 cases, in 22 of whom the
same phenomena could be produced by air-compression in the
external ear. In the 31 cases in which no vertigo could be pro-
duced, II had a suspension of sound-perception during the com-
pression. In 20 cases sound-perception was in nowise changed
during the compression. The therapeutics and prognosis of the
affection are also considered.
(44) Marie and Walton examined twenty-four patients at the
Salpetriere affected with tabes, and came to the following conclu-
sions : I. In tabes more or less pronounced vertigo analogous to
358 A. Hartniann.
Meniere's is oftener present than is generally supposed (in two
thirds of the cases examined). 2. The beginning of the trouble
is often concomitant with the appearance of the tabes (in about
one half of the cases ; in one case it came on twenty-five years,
and in three fifteen years, after the beginning of the tabes). 3. The
vertiginous symptoms are not due to a degeneration of the audi-
tory nerve analogous to that of the optic nerve, since the physio-
logical action of the nerve is unchanged. 4. The phenomenon
can be logically ascribed to a destruction of some of the fibres of
the auditory nerve which go to the semicircular canals, and which
may be considered as the nerve of equilibration.
(45) BouCHERON considers the alteration in gait as well as the
changes in disposition and sudden outbursts of anger, etc., in the
deaf-mutes, as the result of a condition he terms otopiesis {pv<i ooTOiy
ear ; TTiSffi?, pressure). He thinks that through swelling of the
tube a vacuum takes place in the drum cavity, causing the atmos-
phere to act on the J// with a pressure of from 200 to 1000 gr,
which is conveyed by the chain of bones to the labyrinth. By a
few inflations the hearing-difficulty is removed, as well as the
altered gait and affected disposition.
The reviewer cannot refrain from expressing his surprise that
the French Academy should allow such opinions so at variance
with all known physiological and physical laws to be laid before it.
According to these laws, the formation of a complete vacuum in a
cavity of the body, and the one-sided operation of the atmos-
pheric pressure on its elastic walls, seem impossible. We have
no doubt that in some cases of deaf-mutism inflation is advanta-
geous ; in fact we have reported such cases ourselves, one of
which Boucheron had seen. We must express our decided oppo-
sition to the theory of Boucheron.
(46) Grazzi describes the various forms of Meniere's disease,
and recommends the employment of quinine, which has proved
efficacious in two cases.
(47, 48) Walton examined thirteen patients in Charcot's clinic
affected with hysteric hemi-ansesthesia, in regard to their hearing-
power, and classifies them in the following categories : i. In total
hemi-ansesthesia tlie Mt of the affected side can be touched with-
out causing pain or producing any reflex phenomena. Politzer's
inflation (in a permeable tube) caused no sensation in the ML
Sound-perception is equally reduced, nor is a tuning-fork placed
on the head heard on the anaesthetic side. 2. In partial hemi-
Progress of Otology. 359
ansestliesia (in which sensation of pain is absent, but some other
qualities of sensation remain) touching the Mt was felt, but it was
not painful. The entrance of air into the middle ear was likewise
felt, but not so distinctly as on the sound side. Deafness is partial
and shows itself, according to Walton's observations, in various
degrees : (a) aerial vibrations were well, but bone-conduction
badly, perceived ; (<J) the former well, the latter not at all ; {c) the
first badly, and the latter not at all. In the cases of the latter
category the perception of the higher tones is the first to dis-
appear. 3. In bilateral anaesthesia there is bilateral deafness,
corresponding in degree to that of the anaesthesia. The analogy
between the cases of partial anaesthesia where the bone-conduction
is suppressed but aerial conduction remains, and senile deafness,
seems to point to the supposition that it is erroneous to refer the
latter to deficient bone-conduction. It is evidently not due to
deficient bone-conduction, but to some difficulty in the perceiving
apparatus.
Walton describes in his paper also the symptoms of transfer,
adding an observation of his own. He arrives at the following
conclusions : i. The sensibility of the deeper parts of the ear,
including the middle ear, disappears /dirZ/^wz/ with the hysterical
hemi-anjesthesia of the other parts of the body. 2. The degree
of deafness corresponds with the degree of the general anaesthesia.
3. If the deafness is incomplete, bone-conduction is more reduced
than aerial conduction. 4. In transfer, the hearing as well as the
sensibility of the deeper parts of the ear increases exactly in the
same degree on the one side as it diminishes on the other.
(50) In a case of word-deafness, without special interest, the
autopsy revealed on the left side yellow softening occupying the
upper half of the first temporal convolution, a greater part of the
lobulus parietalis inferior, and the gyrus uncinatus. A thrombus
was found in the corresponding branch of the art. foss. Syl.
(51) The patient of Magnan, aged 51, had suffered with
disturbance of speech for two years in consequence of apoplectic
seizures. He could understand what he read, but not what was
spoken to him. The word-deafness was, therefore, unlike that of
the other case of the same author {Gaz. des hdp., February 12,
1880). Death occurred through tuberculosis. Post-mortem :
Softening in the third frontal convolution, and a similar lesion
in the first and second temporal convolutions.
Brown-Sequard brings the objection that there is no such
360 A. Hartinann.
centre, and that he has frequently seen such lesions post mortem
without a corresponding anomaly.
(52) Vetter reports a case in \vhic]:i there was, during an
apoplectic seizure, complete right-sided hemiplegia and hemi-
ansesthesia. The latter affected all the qualities of sensibility and
the higher senses on the right side, so that the senses of smell,
taste, and hearing were abolished on that side. There was right-
sided hemianopsia. Post-mortem : An apoplectic cyst the size of
a hazel-nut on the left side occupying the anterior part of the
lenticular nucleus, and the posterior part of the internal capsule.
A second, rust-colored patch was situated in the medullary sub-
stance of the occipital lobe, close to the outer wall of the posterior
horn of the left lateral ventricle. Recent changes were found in
addition.
The case is of especial interest in regard to the totally crossed
deafness by a lesion of the internal capsule, there being no other
autopsy of this condition on record.
(53) The steel wire of an umbrella was thrust near the outer
corner into the right eye of a boy, aet. 12, while he was looking
through a key-hole. He fell on the floor, and drew the wire out
himself. In the next days he was paralyzed and completely deaf
on the left side. In the course of four weeks the deafness and
hemiplegia disappeared ; paralysis of the right abducens remained.
According to Ferrier, the instrument may have passed through
the anterior part of the internal capsule, and may have penetrated
into the superior end of the first temporal convolution, behind the
Sylvian fissure. Ferrier, on the strength of his experiments,
places the acoustic centre in that locality. As the corona
radiata of the temporal lobe is situated in this vicinity, a totally
crossed deafness would have to be referred to this place.
(54) Gampietro's views on the cases described by him do
not correspond with general opinion. Otitis labyrinthica in hy-
drocephalus, he thinks, depends upon some alteration of the vaso-
motory centre, and is accompanied by nutritive disorders in the
ear and brain. Disturbances in the equilibrium of the nutritive
forces may be produced also by injuries, and the subsequent
otitis interna may be caused by nervous disturbances of the vaso-
motor centres, the sympathetic and trigeminus. We are most sur-
prised by the author's proposition to perform myringotomy and
paracentesis of the vestibule in acute hydrocephalus if all other
remedies fail. He even states that this operation had proved very
Progress of Otology. 361
satisfactory in several severe forms of internal otitis. Unfortu-
nately he does not communicate details of these cases.
(55) The chancre was observed in 1865. In Oct., 1876, im-
pairment of hearing with subjective noises was first noted. Pharynx,
external and middle ears in good condition. Left ear perfectly
deaf in November. R side H. D. ^. He was ordered mercurial
inunctions, and large doses of brom. potass, to procure sleep. He
developed "bromism," which disappeared after he ceased taking
the bromide ; was then ordered iodide of potassium in good doses.
In Jan., 1877, the watch could be heard on contact on the left
side, and his disagreeable head symptoms had subsided.
Burnett.
NOSE.
56. LowENBERG, Paris. Les deviations du septum nasal, etc.
Frogres med., 1883. Abstract of the author's paper in these
Archives, vol. xii, p. 22, etc.
57. Dr. Petersen, of Kiel. Subperichondrial removal of the
cartilaginous nasal septum. Berl. klin. Woch., No. 22, 1882.
58. Dr. HoADLEY Gabb, of Hastings. Epistaxis. Escape of
blood through the lachrymal canal. Brit. Med. Journ., April
14, 1883.
59. Creswell Baber. Cases of nasal polypus projecting
into the naso-pharynx. With remarks. Brighton Lancet, Jan. 27,
1883.
60. Dr. ScH.\FER. A case of fatal ulcerous inflammation in
the right half of the ethmoid bone. Frag. tned. Woch., No. 20,
1883.
61. R. Wehmer, Frankfort o.-M. Adenoid vegetations in the
naso-pharyngeal cavity. Der pract. Arzt., Nos. 2 and 4, 1883.
62. WiLH. Roth, in Vienna. Chronic pharyngitis. Anatomi-
cal and clinical studies. Toplitz & Deuticke, Vienna, 1883.
6t^. Dr. GoTTSTEix, in Breslau. New tubular forceps for
operations in the larynx, pharynx, and nose. Berl. klin. Woch..,
No. 24, 1883.
64. Dr. LiEBiG. Nasal probang. Miinch. drztl. Intellig.-BL,
No. 21, 1883.
(57) Petersen reports three cases in which he removed
pieces of the cartilaginous portion of the nasal septum, but pre-
served the perichondrium and mucosa on both sides. The de-
tached flap was fastened at its edges to the surrounding parts, yet
362 A. Hartinann.
not so tightly as to prevent escape of pus. The author thinks in
this way to make after-treatment unnecessary ; where, however,
this should be needed, he recommends the inhalation tubes of
Feldbausch, especially when the distortion reaches very high up.
(58) A patient suffering from spasmodic cough bled from the
nose. After stopping the hemorrhage by a plug of lint, a copious
bleeding occurred through the right tear-duct.
(59) Cr. Baber describes three cases of nasal polypi extend-
ing into the naso-pharyngeal cavity, and removed by him with the
cold snare. The snare was introduced through the nose and laid
around the polypus with the index finger passed through the
mouth into the pharyngeal space. The author dwells upon the
importance of examining carefully the naso-pharynx in cases of
obstruction of the nose. To diminish the secretion after opera-
tions he recommends spraying the nose with equal parts of alco-
hol and water. The same solution is recommended for coryza.
(60) A patient suffering with coryza and headache, had, when
first seen, swelling of the eyelids, pain in the eye, pressure in the
frontal and nasal regions on the right side, but only scanty secre-
tion. In spite of lancing several abscesses developing in this local-
ity, death ensued under distinctly meningitic symptoms. The
autopsy showed ostitis purulenta orbitse starting from the right
ethmoidal cells, and causing inflammation of the pia and dura,
and the formation of an abscess the size of a walnut. Purulent
infiltration was present in the superior part of the nasal cavity.
(61) Wehmer, in a short discourse, treats of the adenoid
vegetations in the naso-pharyngeal cavity. Among the many
operative procedures he recommends, as the most appropriate
for the practitioner, the sharp spoon and the ring-knife, because
they require the least practice on the part of the physician and
the patient.
(62) Roth gives a general description of the different forms
of chronic pharyngitis. Anatomical studies, though mentioned in
the title, are not contained in the paper, which is composed of the
literature on the subject and clinical observations of the author.
The different forms are divided into two principal groups, anom-
alies of secretion and anomalies of texture," each group being
subdivided a^ain, yet he states that he considers the different
forms only as degrees (stages) of the same process. The paper
contains nothing new, but the description of the affection is in-
teresting andtolerably complete, so that every one who is not famil-
Progress of Otology. 363
iar with the incident literature will read the brochure with
satisfaction.
(63) Gottstein's tubular (or canula) forceps consists of a
tube and a double-branched handle. One toothed spoon is fast-
ened to the end of the tube, whereas the other spoon is movable
against the first in a joint connected with the second branch of
the handle by a wire passing through the tube. The second
branch of the handle is fastened to the tube itself. The advan-
tage of the instrument is found in the fact that the portion which
is introduced into the nose, the pharynx, and partially also into
the larynx, does not consist of two branches, but a tube. The
forceps portion can be put in any position, and by applying can-
ulas of different size, the instrument can be used for the larynx,
pharynx, and nose.
(64) Liebig's nasal probang consists of a spiral of German
silver.
INDEX.
ABBOT, GEO. New
Aur. Forceps . . .163
Abscess of Cerebellum . .178
Accessory Cavities of Nose,
Empyema of . . . .182
Acoustics Applied to Otol-
ogy 33^
Adenoid Vegetations, 182, 362
Agnew and Webster. Clin.
Contrib 163
Anatomy and Histology,
Normal and Path. Re-
port on . ... 157, 325
Antisepsis in Otology . . 345
Aquaeductus Vestibuli . .160
Ariza, R. Clin. Report . 343
ArtificialJ// of Collodion . 177
Aspergillus Flavus, Niger,
and Fumigatus ; Euro-
tium Repens, and their
Relations to Myringo-
mycosis, 185-227 ; As-
pergillus, Literature of,
185 ; Aspergillus Glau-
cus 172
Audiometers, Baratoux . .168
Aural Therapeutics, Prog-
ress on 164
Autophony, Etiology and
Symptomatology of . . 238
Autopsy, in Mastoid Dis-
ease 48
BABER, C. Waist-coat-
Pocket Ear-Mirror,
J 63 ; Adenoid Vegeta-
tions, 182 ; Nasal Poly-
pus 361
Bacon, Gorham. Calcium
Sulphide in Aural Dis-
ease 122
Baginsky, B. Cochlea . . 339
Baratoux, Audiometers,
168 ; Perforation of
Mf, 174 ; Color-Hear-
ing 33^
Barr, Thos. Treatment
of Ot. Med. Sup. . . .175
Baudrimont. Fracture of
Meatus 348
Bechterew, W. Division
of acoustic nerve . . . 337
Berthold, E. Further In-
vestigation on the Physi-
ological Significance of
the Trigeminus and
Sympathetic Nerves on
the Ear 292
Blake, C. J. Growth of
Dermoid Coat of Mf,
172; Accumulation of
Epidermis in Ear-Canal 349
Blau, L. Clin. Report . 343
Boke. Hemorrhage . . 350
Bottcher, A. Aquasduct.
Vestibuli 160
Boiler-Makers' Deafness,
109, 178
Bony Growth in Ext.
Auditory Canal • • • 59
Booth, J. M. Cerumen . 348
Boracic Acid as an Anti-
365
366
Index.
septic, 167, 355 ; in
Otorrhoea 178
Borbone, T. Otit. Pur. in
Phthisis 349
Boucheron, M. Equilibra-
tion and Otopiesis . . 350
Brandeis, R. C. Bin-
aural Objective Sounds
with Synchronous Move-
ments of the Mt and
the Palatal Muscles, 14;
Tinn. aur., 163; Exhaus-
tion versus Inflation . .170
Brown, F. Tilden. Abscess
of Mastoid; Trephining;
Recovery 57
Brunner. Deafness after
Mumps, 179 ; Etiology
and Symptomatology of
Autophony, 238 ; Otit.
Labyrinthica Infantum . 355
Buck, A. H. Partial De-
tachment of Auricle for
Removal of Foreign
Body, 172 ; Sclerosing
Mastoiditis 349
Biirkner, K. Progress of
Aural Therapeutics, 164;
Clin. Report, 343 ; Deaf-
ness from Mumps. . . 355
Burckhardt-Merian. Dia-
grams for Drawing Mt^
163, 168
Burnett, C. H. Aspergillus
Glaucus, 172 ; Chinoline-
Salicylate in Otorrhoea,
178 ; Chorda Tymp.,
336 ; Dry Treatment . 349
Burnett, S. M. Aspergillus
Purpureus 193
CALCIUM Sulphide in
Aural Disease . .122
Campbell, J. N, Helps to
Hearing 169
Cassels, J. Putterson. On
the Production of Arti-
ficial Deafness, and its
Bearing on the Etiology
and Evolution of the
Diseases of the Ear . . 147
Catheterization of E. T.,
New Method of Avoiding
Nasal Obstacles • • • 35
Cerebral Hernia in Disease
of Temp. Bone . . .174
Cerebro-spinal Fluid Es-
caping from Ear in Frac-
ture of Base of Skull . 179
Cerumen 348
Chinoline - Salicylate in
Otorrhoea 178
Cholesteatoma of Mastoid, 129
Chorda Tymp 342
Christinneck. Clin. Report 343
Cocks, Dav. C. Bony growth
in Ext. Ear-Canal ; Re-
moval 59
Color-Hearing .... 336
Compression of Ear-Canal,
a Cause of Deafness. . 171
Convulsions, Mimic Facial,
Complicated with Nys-
tagmus and Vertigo . .312
Coryza, Simple Chronic . . 30
DEAF-MUTES, the N.
Y. Institution for the
Improved Instruction of,
87 ; Method of Teach-
ing, 88, 97 ; Statistics,
98, 168, 347 ; Sense of
Dizziness in . . . . 180
Deafness, Artificial, 147 ;
Improved by Electricity
and Phosphorus, 231 ;
From Compression of
Ear-Canal, 171 ; In Hys-
terical Hemi-an^sthesia,
358 ; Changes in Brain,
360 ; From Brain Injury,
360 ; In School-Chil-
dren 348
Dennert, H. On Jakob-
son's Report .... 343
Dermoid Coat of Mt,
Growth of 172
Despres. Otit. Int. ; Tre-
phining 175
Index.
367
Development of Laby-
rinth . . . . . . . 334
Diphtheria, Alterations in
the Ear Due to . . . 255
Donkin, H. Deafness from
Injury of Brain . . . 356
Downes, T. A. Treatment
of Otit. Purul 178
Drainage-Tubes in Suppur.
Otit 177
Ducau, A. Prune-stone in
Ear Thirty-three Years,
172 ; Deafness from
Compressing Ear-Canal, 171
Duncanson, Kirk. Report
on Dispensary .... 166
EARACHE in Chil-
dren -354
Ear-Canal, Accumulation
of Epidermis in, 349 ;
Closure of, 172 ; Frac-
ture of 348
Ear, Diagnosis and Treat-
ment of Diseases of ;
Text-book, by Pomeroy . 323
Eitelberg, A. Influence of
the Treatment of One
Ear on the Other, 266 ;
Influence of Hearing-
Exercises on the Sense
of Audition, 279 ; Mas-
toid Disease . . . .175
Electricity, its Use in Ear-
Disease 233
Emerson, J. B. The Ex-
amination of Ears by
Tuning-Forks ... 63
Epistaxis ; Bleeding
Through Tear-Canal . 362
Equilibration and Otopie-
sis . . . . . . .358
Ethmoid, Ulceration in . 362
Eulenstein. Ear- Affections
in Ilio-Typhoid . . .166
Eust. Tube, Dilatation of 353
Exfoliation of Bony Semi-
circular Canal . . . 132
Exhaustion versus Infla-
tion 170
External Ear-Canal, Ab-
sence of 170
FACIAL Paralysis in
Ear-Disease . 182,
Forceps, Tubular . . .
Foreign Body Removed by
Partial Detachment of
Auricle
Frankel, E. Ozaena .
Fiirstner. Psychic Disturb
ances in Ear-Disease
Furuncle, Treatment
350
363
172
160
343
346
pABB, H.
Epistaxis . 361
Gampietro, E. Hydro-
cephalus and Otitis . . 356
Gelle. Meniere's Vertigo, 355
Gluck, T. H. Trephining
of Petrous Bone . . .176
Gottstein. Canula For-
ceps 361
Graf. Antisepsis . . . 343
Grazzi. Meniere's Disease, 356
Greenberger, D. N. Y. In-
stitution for Deaf-Mutes, 87
Gruber, J. Cherry-Stone
in Naso-Pharynx . . 181
HARLAN, G. C. Deaf-
ness from Mumps . 355
Hartmann, A. Partial Re-
section of Nasal Septum,
181 ; Empyema of Aces-
sory Cavities of the
Nose 182
Heilly. Blindness and
Word-Deafness . . . 356
Helps to Hearing . . . 169
Hemorrhage from Ear . 354
Holland. Foreign Body
in Ear Twenty Years . 348
Holt, E. E. Boiler-makers'
Deafness 178
TLIO-TYPHOID Fever,
Y Ear-Affections in . . 166
Influence of the Treatment
of One Ear on the Other, 266
\6S
Index.
Influence of Hearing-Ex-
ercises on the Sense of
Audition in both Ears . 276
JAKOBSON, L. Report
of Lucae's Clinic from
1877 to 1881 .... 164
James, W. Sense of Dizzi-
ness in Deaf-Mutes . .180
Jarvis, W. J. Tonsil-
lotomy without Hemor-
rhage 182
KARSCH. Statistics of
Deaf-Mutes . . .168
Kipp, C. J. Deafness and
Synchysis Vitrei . . .170
Kisselbach, W. Absence
of Ext. Ear-Canal . .170
Knapp, H. Three Serious
Cases of Mastoid Dis-
ease, with Remarks, 44 ;
Unsuccessful Attempt at
Restoring an Ear-Canal
Closed by Cauterization
with Sulphuric Acid, 154;
Closure of Ear-Canal,
Hematophilia, 170 ;
Treatment of Polypi,
172; Trephining of Mas-
toid in Catarrhal Otitis,
Opening of Transverse
Sinus, 173 ; Deafness
from Mumps . . . .355
LABYRINTH, Second-
ary Changes in the, in
Otitis Media, 299 ; His-
tological Changes in the,
in a Case of Acquired
Deaf-Mutism, 304; Syph-
ilitic Disease of . , 79, 361
Liebig. Nasal Probang . 361
Life Insurance, Examina-
tion of Ears for . . . 169
Lowenberg, B. Anatom-
ical Researches on the
Deviations of the Nasal
Septum, 22 ; Nasal Sep-
tum 361
Lucse, A. Disinfection in
Air-Douche .... 168
M^'^:
AGNAN. Word-Deaf-
less ...... 356
Marian, A. Clin. Report . 343
Marie, P. Vertigo in Tabes, 356
Martin, J. W. Mastoid
Disease, Phlebitis . . 350
Mastoid Disease, Three
Serious Cases of, 44, 56 ;
Cholesteatoma of, 129 ;
Trephining in, 52, 53,
56, 173, 175 ; Meningitis,
papillitis, recovery . .177
Mastoid, Opening, 352 ;
Sclerosing, 352 ; Caries,
355; Phlebitis and Death 355
Mathewson, A. Abscess
of Cerebellum . . . .178
McBride, P. Clinical
Notes : (i) (Edema of
Mt Simulating Polypus ;
(2) Deafness cured by
Electricity, 231 ; Semi-
circular Canals, Audi-
tory Vertigo, 336; Tinni-
tus Aurium 167
McKay, R. J. Mastoiditis,
Meningitis, Recovery . 177
Memb. Tymp., Perforation
of, 174 ; Reproduction
of, by Skin-Grafting,228;
Qidema of the. Simulat-
ing Polypus . . . .231
Meningitis Acutissima,
Leaving Permanent
Deafness and Staggering
Gait 309
Merrill, C. S. Acute Oti-
tis Pur. ; Death on 4th
Day 177
Middle Ear, Cleansing of,
176 ; Inflammation of,
Death on 4th Day, 177 ;
Catarrh of, 350 ; Suppu-
ration of, in Phthisis . . 350
Minor, J. L. Microscopic
Examination of Bony
Growth in Ear-Canal . 60
Index.
369
Moore, Oliver. Acute Ex-
acerbation of Otit. Pur. 173
Moos, S. Neuropathologi-
cal communications, 309;
Cholesteatoma of Mas-
toid, 128 ; Exfoliation
of Bony Semicircular
Canal, 132 ; Pysemic At-
tacks in Pur. Otit. Med.,
136; Forty Cases of Con-
genit. Deafness . . . 163
Moos & Steinbriigge, Al-
terations in the Ear from
Diphtheria, Examination
of six Temporal Bones,
254 ; Secondary Symp-
toms in the Labyrinth as
Sequels of Chronic Puru-
lent Inflammation of the
Middle Ear, 299 ; His-
tological Labyrinthine
Changes in a Case of
Acquired Deaf-Mutism,
304 ; (Edema of Tem-
poral and Zygomatic
Regions as a Symptom
of Phlebitis and Throm-
bosis of the Lateral Si-
nus ....... 141
Morpurgo, Perforation of
Schrapnell's Membrane, 349
Moure, E. J. Deafness af-
ter Mumps, 179 ; Facial
Paralysis 349
Mumps, Deaf-Mutism af-
ter, 321 ; Diseases of the
Ear Occurring during the
Course of, 179 ; Deaf-
ness from . . . 356, 357
N
ASAL Polypus
362
Nasal Septum, Anatomical
Researches on the Devia-
tions of, 22 ; Difficult
Catheterization, 23, 2)Z \
Treatment of Deflection
of, 181 ; Removal of .361
Nasal Speculum, New . . 40
Naso-Pharyngeal Douche. 32
Naso - Pharynx, Cherry-
Stone in 187
Neuropathological Com-
munications .... 309
Noise, the Effect of, on Dis-
eased and Healthy Ears 104
Noorden, C. v. Develop-
ment of Labyrinth of
Teleosts 334
Noquet. Syphilis . , . 343
OBJECTIVE Sounds
with Movements of
Mt and Palatal Mus-
cles 14, 83
(Edema of Temporal and
Zygomatic Regions, as a
Symptom of Phlebitis
and Thrombosis of the
Lateral Sinus .... 141
Oscillatory Movements of
the Head in Bilateral Af-
fections of the Laby-
rinth 309
Otit. Externa Circum-
scripta, Peculiar Form
(Blau) 345
Otitis in Children and Hy-
drocephalus .... 360
Otit. Labyrinthica Infan-
tum 355
Otit. Med. Sup. Chr., 173, 175
Otit. Med. Treatment . . 346
Otit. Purul., Treatment . 178
Otological Congress, Third
International .... 184
Otomycosis Aspergillina,
185 ; Historical, 188 ; Pa-
cini, 188 ; Grove, 189 ;
VVreden, 190, 192 ;
Weber-Liel, 191 ; Boke,
191 ; Voltolini, 192 ; Be-
zold, 193, 19s ; C. H.
Burnett, 194 ; S. M. Bur-
nett, 193 ; Lowenberg,
196 ; Siebenmann, 188 ;
New Cases by Sieben-
mann, 196 ; Pathogeny
and Pathological Ana-
tomy of, 205 ; Symptoms
370
Index.
and Course, 219 ; Diag-
nosis of, 223 ; Therapeu-
tics and Prophylaxis,
223 ; Prognosis, 227 ;
Politzer on . . . .' .172
Otorrhoea, Treatment 351. 354
Ozsna 160
PARACUSIS Willisiana 104
Paralysis of the Trochlear
Muso^e in the Course of
Purulent Otitis Media
(Complicated Case, with
Temperature Chart, Re-
covery) . . . . .315
Perversity of Tuning of
Corti's Organ .... 320
Petersen, Removal of Nasal
Septum 361
Petrous Bone, Trephining
of 176
Pharyngitis, Chronic . .362
Pierce, T. M. Disease of
Temp. Bone and Cere-
bral Hernise . . . .174
Politzer, A. Otomycosis . 172
Pollack, S. Artif. Mt of
Collodium 177
Polypi, Nasal 31
Pomeroy, O. D. Drainage-
Tubes in Otit. Sup., 177;
The Diagnosis and
Treatment of Diseases
of the Ear : Text-book
reviewed, 323 ; Boracic
Acid 350
Probang, Nasal .... 363
Psychic Disturbances from
"Ear-Disease .... 346
Pyaemia in Pus. Otit. Med. 132
QUINIA in Aural Affec-
tions 166
RECRUITS, Deafness
in 166
Report on Ear Clinic of
Lucai 164
Report on Ear Clinic at
Wiirzburg 166
Report on Ear Clinic of
Kirk, Duncanson . . 166
Reports, Clinical . . 342, 343
Restoration, Unsuccessful,
of an Ear-Canal . . . 154
Reynolds, D. J. Otit. Pur. 178
Roosa, D. B. St. John.
Disease of the Ear Occur-
ring during the Course of
Parotitis, i ; The Effects
of Noise upon Diseased
andHealthy Ears, 103 ;
Treatment of Chronic
Otorrhoea 350
Rossi, E. De. Applied
Acoustics, 336 ; Clin.
Report 342
Roth, W. Chronic Pharyn-
gitis 36 r
S CHAFER. Ulceration
in Ethmoid . . . .361
Schalle, R. Aural and
Naso-Pharyngeal Disease, 163
Schilling, Prophylaxis . . 343
Schrapnell's Membrane,
Perforation 351
Schwabach, Deaf Mute Sta-
tistics 343
Schwartze, H. Opening of
Mastoid 349
Seitz, J. Deafness after
Mumps 179
Seligsohn. Deafness from
Mumps 355
Semicircular Canals ;
Equilibrium . . 337, 341
Sexton, S. Syphilide of
Ear, 343 ; Tissue-Con-
duction, 343 ; Earache
in Children 350
Siebenmann, F. The Hy-
phomycetes Aspergil-
linus Flavus, Niger and
Fumigatus ; Eurotium
Repens (and Aspergillus
Glaucus), and their Rela-
tions to Otomycosis As-
Index.
371
pergillina 185
Simulation of Deafness . 167
Skin-Grafting, Reproduc-
tion of Mt by . . . .228
Spear, E. D. Otis. Pur. . 350
Stacke, L. Ot. Med. Sup.
Chron 175
Steinbriigge, H. and Moos.
See Moos and Stein-
brugge. 369
Subjective Sensation of
Hearing from Wearing
Eye-Glasses . . . .311
Synchysis of Vitreous and
Deafness ..... 170
Syphilitic Ear-Affection . 347
TANGEMAN, C. W.
Reproduction of Mt
by Skin-Grafting . . . 228
Temp. Bone, Anatomy, in
Children 157
Temporal Bones, Histology
of, in Diphtheria . . . 255
Text-Books and Mono-
graphs Reviewed. Hed-
inger, 96 ; Politzer, . . 99
Theobald, Sam. Complete
Closure of Ear-Canals,
172 ; Treatment of Some
Ear-Diseases .... 343
Tinnitus, Causes of, 167 ;
Due to Disturbance in
Cervical Vessels . . .163
Tissue-Conduction . . . 347
Tonsillotomy, without
Hemorrhage . . . .182
Trigeminus and Sympa-
thetic Nerves, their Phys-
iological Significance for
the Ear 292
Trigeminus Irritation. Re-
flex on Senses .... 340
Tuning-Fork, for Exami-
nation of Ear . •. . . 62
Turnbull, C. S. Boric Acid
in Otorrhoea . . . .178
Turnbull, L. Examination
of Ears for Life Insur-
ance, 169 ; Facial Paral-
ysis in Ear-Disease, 182:
Caries of Mastoid . . 350
URBANTSCHITSCH,
V. Irritation of Tri-
geminus, effect on Senses,
340 ; Dilatation of E.
Tube 349
VERTIGO, Auditory, 341,
357, 358; In Tabes . 357
Vetter, A. Function of
Cerebrum 356
Voltolini. Peculiar Ear
Diseases, 350 ; Quinia
in Aur. Affections, 166 :
Simulation of Deafness, 167
WAGENHAUSER.
Anatomy Temp.
Bone in Children, 157 ;
Report on Aural Clinic,
Wiirzburg 166
Walb. Boracic Acid as an
Antiseptic 167
Walsham, W. J. Treat-
ment of Deflection of
Nasal Septum . . . .181
Walton, G. L. Vertigo in
tabes, 356 ; Deafness in
Hysterical Hemi-anses-
thesia ....... 356
Weber-Liel. Apparatus for
Cleansing Middle Ear . 176
Webster, Dan. Clin. Con-
tributions, 183 ; Syphi-
litic Disease of Labyrinth,
76 ; Syphilitic Disease of
Labyrinth 356
Wehmer, R. Adenoid Veg-
etations 361
Weidenbaum. Deafness in
Recruits 166
Weil. Othaematoma . . 348
Williams, Cornelius. Clonic
Spasm of Levatores Pal-
ati, Producing a Rhyth-
mical Clicking Noise . Zt,
Word-Deafness .... 359
Worsell, J. P. Deafness in
School-Children . . . 344
R^ Archives of otology
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