Wv' *^^ fyxmll Ilmm0itg pilratg ,&r- 3-frrRA^t4A^ 3 THE GIFT OF Cornell University Library A manual of otology. 3 1924 012 169 193 The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924012169193 A MANUAL O T O L O G- T II BY GOKHAM BACON, A.B., M.D., PEOFESSOK OP OTOLOGY IN CORNELL BNIVEESITY MEDICAL COLLEGE, NEW YORK ; AURAL SHBGEON, NEW YORK EYE AND EAR INFIEMAEY. WITH AN INTRODUCTORY CHAPTER. CLAEENCE JOHN BLAKE, M.D., PROFESSOR OP OTOLOGY IN HARVARD CNIVEESITY. WITH 110 ILLUSTRATIONS AND A COLORED PLATE. LEA BROTHEES & CO., NEW YORK AND PHILADELPHIA. 1898. Entered according to the Act of Congress in the year 1898, hj LEA BROTHERS & CO., In the Office of the Librarian of Congress. All rights reserved. DOKNAN, PBINTEE. PREFACE. In preparing this Manual of Otology I have espe- cially tried to meet the demands of the student, by giving him a short and compact treatise of the subject, and at the same time affording him a book of easy reference, since he may not always find the time neces- sary for consulting the many excellent and more ex- haustive treatises upon otology which have been pub- lished not only in this country but also in England and on the Continent. In a work of this character it is impossible to de- scribe all the operations mentioned in the larger treatises on aural surgery, but a sufficiently full consideration is given to those particular diseases of the ear with which the student and practitioner will frequently meet to enable them to properly understand the condition and apply the appropriate treatment. So far as is possible, I have been guided in the selection of material by the results of my own experience. I can fairly claim for the volume the merit of practicability. And here I cannot too strongly emphasize the great importance of treating all diseases of the ear in their disease and intracranial complications. To these sub- jects I have purposely allotted considerable space on account of their major importance and the successful results that have of late followed operative interference therein. In the preparation of this Manual I am greatly in- debted to the kind assistance of my friend and col- league, Dr. Clarence J. Blake, of Boston. 63 West Fifty-fourth Street. New York. September, 1898. CONTENTS. CHAPTER I. PAGE Anatomy and Physiology op the Ear . 17 CHAPTEE II. Methods of Examination op the Eak .... 53 CHAPTER III. Diseases op the Auricle ... .83 CHAPTER IV. Diseases of the External Auditory Canal . . .97 ^ CHAPTER V. Diseases and Injuries of the Drumhead and Middle Ear . . 124 CHAPTER VI. Otitis Media Purulenta Acuta, or Acute Purulent Otitis Media . . 139 CHAPTER VII. Adenoid Growths. Enlarged Tonsils. Diseases op THE Nasal Passages . . .157 CHAPTER VIII. Otitis Media Catarrhalis Chronica, or Chronic Ca- tarrhal Otitis Media ... . 190 viii CONTENTS. CHAPTEB IX. PAGE Otitis Media Pubtjlenta Chbokica, oe Chronic Puru- lent Otitis Media, or Chronic Suppurative Inflam- mation OF THE Middle Ear 224 CHAPTER X. Granulations and Polypi — Caries and Necrosis or THE Temporal Bone 253 CHAPTER XI. Diseases op the Mastoid Process . . . 272 CHAPTER XII. Brain Abscess. Thrombosis of the Sigmoid and other Sinuses. Leptomeningitis . . . . 316 CHAPTER XIII. Diseases of the Sound-Perceiving Apparatus . 357 CHAPTER XIV. Deaf-Mutism . . . . 377 INTRODUCTION. The growth of medical educatioQ during the past thirty years, shown in no way more markedly than by the establishment of special lines of research, has re- sulted in the practical advance of the so-called special- ties in medicine, and, as a necessary result, an extension of medical school work to enable it to include for the student such information in the special branches of his profession as he may be able to apply in the course of a general practice. The extent of this instruction is limited both by the time which may be allotted to it in deference to the de-- mands of other departments and by the ease or difficulty attending the particular form of clinical instruction. The inaccessibility of all but the outermost parts of the organ of hearing to other than individual inspec- tion, and the difficulty therefore of demonstration of diseases of the deeper portions of the ear, except to small classes, or sections of a class, greatly limit the amount of instruction in clinical otology which may be given in the usual medical school course. The supple- menting of undergraduate teaching by graduate instruc- tion in the special branches of medicine has done some- thing, to compensate for this defect, but has opened the door to an evil in the establishment of short courses in otology, as in other departments, which can, in a limited X INTRODUCTION. time, afford ouly a little knowledge and enable the superficial student to assume that he has acquired an ability in special practice which could really be ob- tained only through long and serious study. The difficulty here presented, which can be met only by a considerable extension of the medical school cur- riculum and by the establishment of graduate depart- ments of medical schools and graduate schools giving only long courses to small classes or to individual students, and including abundance of clinical material with adequate opportunities for continual observation of cases, is in a measure temporarily provided for by the publication of elaborate text-books, carefully com- piled and richly illustrated. The demand for such text- books has resulted in their numerous production, and at the same time has awakened in both the student and the practitioner the desire for more compact compila- tions which affijrd in a small and conveniently accessi- ble compass the information most desirable from a practical point of view. In a field comprising, as does otology, so much of interest and importance, and so many minute definitions, the selection and condensation of the subject-matter is a task of no little difficulty, and one which is to be accomplished only by the presenta- tion of some of the subjects in a merely suggestive form in order that space may be accorded for the necessary elaboration of others. The book here presented has this aim in view, and, in addition to a text covering the more important points in regard to which the student and practitioner require immediate information, it is so compiled as to be a text- book of moderate dimension and a book of ready refer- ence. INTR OD UOTION. xi So intricate is the structure of the temporal bone and so important the study of the relationships of its com- ponent parts, not only to the understanding of the physi- ology of the organ of hearing, but also as a preparation for intelligent surgical treatment of its diseases, that even the most careful and painstaking reading must be sup- plemented or accompanied by a study of sections of the bone itself in order to gain an accurate knowledge of its anatomy. If, in addition to this, the student himself makes sec- tions of the temporal bone, it will not only make his knowledge more exact, but the manual process of section- making will help to fix in his memory dimensions and points of relationship which as a surgeon it will be neces- sary for him to bear constantly in mind. In that important portion of clinical work in otology which includes hearing-tests, such knowledge of acous- tics as is necessary to an understanding of the process of sound-transmission within the ear itself is of importance to the student and a necessity to the special practitioner, and to this may well be added such further knowledge of the general subject as may form a basis for original research. This is to be sought either in collateral reading or in lectures on acoustics, and a course of instruction in otol- ogy to be complete should include not only individual study of the minute anatomy of the temporal bone, but a demonstrative course in experimental acoustics as well, in order to lay a proper foundation for the intelligent clinical study of diseases of the ear. In the objective study of his patients the student can- not impress upon himself too forcibly the importance of accurate and repeated observation ; the field for inspection xii INTBOBUGTION. is so small and the variations in appearance in disease so manifold that differential diagnosis is often most diffi- cult, and inspection must be supplemented by careful revision of the history of the individual case and of its cognate symptoms. No amount of reading can compensate for the lack of personal instruction and individual observation, but to the student and the practitioner, to whom this book is commended for the condensed information which- it con- tains, it will be found also to bring that stimulation to further study which is one of the purposes of all teaching. MANUAL OF OTOLOGY. CHAPTEE I. ANATOMY AND PHYSIOLOGY OF THE EAB. In order to study the anatomy and physiology of the ear in a satisfactory manner, the organ of hearing is divided into (I.) the sound-conducting and (II.) the sound-perceiving apparatus. I. The sound-conducting apparatus includes a. The external ear, consisting of 1. The auricle (or pinna) and 2. The external meatus (or external auditory canal). b. The middle ear (or tympanum) (or tympanic cavity), with 1. The membrana tympani and 2. Ossicles. 3. Eustachian tube and 4. Mastoid process. If. The sound-perceiving apparatus (or internal ear) comprises 1, The vestibule, 2, The semicircular canals, and 3, The cochlea. 2 18 MANUAL OF OTOLOGY. Ths latter receives the peripheral expansions of the auditory nerve, the excitation of which produces in the brain-centre sensations which we call sound. (a) THE EXTERNAL BAB. The external ear consists of 1. The auricle (or pinna) and 2. The external meatus (or external auditory canal). 1. The Auricle. The auricle, or pinna, pyriform in shape, is attached to the side of the head by means of ligaments and muscles. It usually forms an acute angle with the lateral portion of the head, although the angle varies in different individuals. The auricle is composed of yellow or reticulated cartilage, except the lower portion, called the lobule, which is formed mostly of connective tissue, in the meshes of which are globules of fat. The lobule contains but few bloodvessels and nerves. The cartilage of the auricle/^bout ^V inch in thickness^ is covered by the perichondrium, and outside of the peri- chondrium is the integument. The latter is more firmly attached to the anterior than to the. posterior surface of the cartilage. The anterior or concave portion of the auricle presents a number of ridges and depressions. The helix (see Tig. ly A) begins just above the external meatus at a point in the concha called the crista helicis, and extends upward and backward, and terminates just above the upper portion of the lobule. The antihelix (K) is another elevation running in a parallel direction with the posterior portion of the helix. It starts by means of two crura above the ANATOMY AND PHYSIOLOGY OF THE EAR. 19 crista helicis and, passing bacliward and downward, ter- minates in the antitragus, ®. Partly closing the external opening of the ear, and opposite the antitragus, is the tragus, Gb Between the tragus and the antitragus is a depression called the incisura intertragica. The fossa of the antihelix or fossa scaphoidea (|^ lies between the Fig. 1. Auricle. (Politzer.) A. Helix. B. Antihelix. C. Tragus. D. Antitragus. E. Lobule, F. Concha. G. Orifice of the external meatus. two crura of the antihelix. There are a few sebaceous glands in the lobule, but they are much more numerous and of larger size in the concha. There are two sets of muscles connected with the auricle. The first set consists of the 1. AttoUens aitrem, (wlrtehH ak e s its origiar-jgem-the epicranial aponeurosis, and is inserted into the convex surface of the aurrdb^. Its action is to support and pull the auricle_]upward. 20 MANUAL OF OTOLOGY. 2. Aitrahens aitrem,(which also arises from the epi- cranial aponeurosis, is attached to the crista helicis) It draws the auricle forward and upward. Fig. 2. The muscles of the pinna. (Gkay.) 3, Retrahens aitrem, ^vhich has its origin from the mastoid process and is inserted into the posterior convex surface of the conchajj This muscle pulls the auricle backward, but the action of all these three muscles is very limited. Some persons, however, have the power of moving their ears quite perceptibly. ANATOMY AND PHYSIOLOGY OF THE EAR. 21 The second set of muscles, five in number, are muscular fibres lying on the concave and convex sur- faces of the auricle (see Fig. 2), and are called 1. Tragicus. 2. Antitragirus. 3. Helicis major. 4. Helicis minor. 5. Transversus auriculae. 6. Obliquus auris. These muscles are rudimentary in man, and have very little action. (^There are also various ligaments, some holding the auricle to the side of tiie head, and others connecting the different portions of the cartilage togetherJ 2. The External Meatus, or the External Auditory Canal. The external meatus, about one and a quarter inches in length, is a continuation inward of the auricle, and consists of a cartilaginous and a bony portion. The cartilaginous portion is not cartilaginous throughout its whole extent, the cartilage being wanting in the upper and posterior portions of the caual, where a mem- branous layer attached to the lining membrane of the canal takes its place. (Fig. 3.) The fissures of Santo- rini, generally two in number, are situated in the lower and anterior wall of the cartilaginous meatus. These fissures, transverse to the long axis of the canal, are openings in the cartilage which are filled in with fibrous tissue, jand are of importance to the aural surgeon, because in examinations of the ear they allow a certain straightening of the meatus, and, further, an inflam- mation of the external auditory canal may extend to 22 MANUAL OF OTOLOGY. the parotid gland through these fissures, and, wee versa, in case of parotiditis leading to the formation of an abscess, the pus may force its way through these open- FlG. 3. , Semi circular Canals. ^ VestiJnde Coclilea A front view of the orgau of lifaring. Right side. (Gray.) ings into the external meatus and give I'ise to an otor- rhoea, the source of which can only be accurately deter- mined by means of the head-mirror and speculum. I The Osseous Meatus. The osseous meatus, forming about two-thirds of the entire external aulitory canal, consists of a bony ring in the infant (the annulus tympanicus) (Fig. 4, C), but develops later in adult life into a bony caoal about three- quarters of an inch in length. In the infant the tympanic ring is attached to the squamous portion of the temporal ANATOMY AND PHYSIOLOGY OF THE EAR. 23 bone by its two extremities, between which is a space which, later, becomes the Eivinian segment, and con- nected with this ring is a membranous canal. Occa- sionally, in the fully developed temporal bone fissures are observed in the upper and posterior walls of the bony meatus. As prolongations of connective tissues extend into these fissures, it is easy to understand how Temporal bone in the new-born infant. (Poi.itzeb.) A. Superior part of the squamous bone. B. Its inferior part below the line of the zygomatic process. C. Annulus tympanicus. D, D. The Assure between the squamous portion and mastoid process, reaching to the stylo- mastoid foramen. E. Stylomastoid foramen. F. Foramen ovale. G. Fora- men rotundum. (Left ear.) inflammatory material may pass through these openings and cause caries of the walls of the canal. The car- tilaginous canal contains soft hairs and sebaceous and ceruminal glands. A few of the latter are found in the bony portion, especially in its upper wall. The lining membrane of the external meatus is simply a continuation inward of the integument of the auricle, and is not a mucous membrane, as was formerly sup- 24 MANUAL OF OTOLOGY. posed. The dermal layer in the bony portion is very thin and closely attached to the periosteum, a fact which accounts for the excruciating pain sometimes observed in acute inflammation of the lining of the external meatus. The blood-supply to the auricle and external meatus comes from the temporal and internal maxillary arteries. The anterior or concave surface of the auricle and the outer portion of the external meatus derive their supply from several branches of the superficial temporal artery. The posterior surface is supplied by a branch of the posterior auricular artery (a branch of the external carotid). The inner portion of the external meatus is supplied by the deep auricular artery (a branch of the internal maxillary artery). The smaller branches of these arteries reach the deeper portions of the external meatus by passing through 1. The fissures of Santorini. 2. Through the fibrous connective tissue which joins the cartilaginous canal to the bony canal, and 3. Through the intermediate membranous layer which covers the margins of the cartilaginous groove. They form a network of capillary vessels on the peri- chondrium and about the hair-sacs and sebaceous glands. These vessels are quite numerous about the upper border of the membrana tympani and extend along the poste- rior portion of the handle of the malleus to its inferior extremity. The veins supplying the two surfaces of the auricle join the external jugular and mastoid veins, although in some cases there are veins that empty into the in- ternal maxillary and temporal veins. Very little is known about the lymphatics of the ear. ANATOMY AND PHYSIOLOGY OF THE EAR. 25 The nerves distributed to the auricle aud external meatus are derived 1. From the facial, through the deep posterior auric- ular nerve, which supplies the posterior surface of the auricle. 2. From the cervical plexus through the auricularis magnus. 3. From the auriculo-temporal (a branch of the tri- geminus), which supplies the skin of the auricle and ex- ternal meatus. 4. From Arnold's nerve, a branch of the pneumo- gastric, which supplies the lining membrane of the external meatus. In children, one of the difficulties in the way of a successful examination of the external meatus is the small size of the cartilaginous portion. The size and shape of the external meatus in the adult are subject to great variations. In some persons the cartilaginous canal is very wide, while in others it is extremely narrow. The diameter of the canal, which, just inside of the external orifice, is about xT^ilr '^^'^ ^* first, becomes wider in its passage inward, and then narrows again at the point of junction with the cartilaginous canal. From this point toward the membrana tympani the bony canal becomes wider. The narrowest part of the bony canal is called the isthmus. It is here that foreign bodies are apt to become wedged, while if they pass beyond this constriction it is sometimes impossible to remove them without displacing the auricle forward, an operation to be described later. The distance from the anterior margin of the membrana tympani to the isthmus is about ^j— /xr inch, while the distance from the posterior margin of the drumhead along the posterior 26 MANUAL ^OF OTOLOGY. wall of the isthmus is but ^^-^ in^h. This fact should be carefully borne in mind in the case of impaction of a foreigu body, which becomes lodged at this point, for serious injury may be done to the drumhead by means of instruments passed along the posterior wall. The cartilaginous canal, in passing inward, turns back- ward and upward, while the bony canal extends forward and downward. In examining the ear, after intro- ducing the speculum, the auricle should be pulled upward and backward, in order to straighten the external meatus and tlius afford a better view of the drumhead. / (6) THE MIDDLE EAE, OR TYMPANUM. The middle ear, as previously mentioned, consists of 1. The tympanum, or tympanic cavity, with 2. The ossicles, 3. The Eustachian tube, and 4. Mastoid process. 1. The tympanum or tympanic cavity is very irregular in shape. Its greatest diameters are^^ose extending antero-posteriorly and supero-inferiorly. The mem- brana tympani or drumhead forms the greater part of the outer wall of the tympanum, and lies at the inner extremity of the bony auditory canal, being placed almost in a horizontal position in the infant at birth, and gradually becoming more perpendicular in the adult. The membrana tympani receives the sound- waves from the external air and carries them by means of the ossicular chain to the labyrinth. The drumhead in the adult is placed obliquely with the long axis of the bony canal, so that the inferior and the anterior walls of the auditory canal are longer than the superior and posterior walls, an important point to be remembered ANATOMY AND PHYSIOLOGY OF THE EAR. 27 in the extractiou of foreign bodies and in other instru- mental manipulations. The raembrana tympani at its margin is attached to the groove in the bony canal, called the sulcus tympanicus, which belongs to the tympanic ring. At the Rivinian segment, previously mentioned, the drumhead is attached partly to the margo tympanicus and partly to the lining membrane of the bony auditory canal. The normal drumhead is of a pearl or grayish color, somewhat oval in shape, and drawn inward, the greatest point of concavity being at the umbo, at which point the inferior extremity of the malleus is attached by being enclosed in the layers of the drumhead. There is a partial convexity or bulging out of the membrana in its anterior and inferior segments, so that the drumhead, while concave as a whole, is convex from the centre to the periphery. The membraua, which resembles gold-beaters' skin in ap- pearance, consists of three layers : 1. An external or dermal. 2. A middle or fibrous, and 3. An inner or mucous layer. The long handle of the malleus lies between these layers and extends upward to the short process. The latter process is recognized as a short teat-like projec- tion, and is a most important landmark in examinations of the drumhead. Situated just in front of and behind this process are two folds/which are very important, for it will be demonstrated in another chapter that when the drumhead is drawn inward these folds stand out very prominently/ There are two striae, first described by Prussak ( gig. . -5," S^S^), which lie just inside of the two folds and which can often be made out in life as two tendinous bands. These slriaj, together with the groove- 28 MANUAL OF OTOLOGY. less fissure, bound a triangular-shaped portion of the membrane, called the membrana flaccida, or Shrapnell's membrane. (Fig. 6, MS.) . This membrane consists of very delicate and loosely-arranged fibres of connective tissue, crossing each other irregularly, and covered by a thin dermic layer on the outer, and mucous layer on the inner surface, and is very much thinner than the other Fig. 5. S MS S' Outer surface of the left tympanic membrane of an adult. (Polttzer.) V. Segment of the tympanic membrane lying in front of the handle of the malleus. H. Posteriorsegmentof the tympanic membrane. S, S'. Prussak's stria3, passing from the short process of the malleus to the spina tyrap. post, et minor. MS. Shrapnell's membrane. portions of the membrana tympani. The inner lining is a continuation of the mucous membrane of the tym- panum. The outer or dermal layer is a continuation inward of the skin covering the external meatus, and contains several strata of pavement epithelium. The middle layer, or lamina propria, consists of two sets of fibrous tissue. The outer fibres are attached to the tip of the malleus and radiate toward the circumference. ANATOMY AND PHYSIOLOGY OF THE EAR. 29 while the iaiier fibres are circular iu their arraugemeut. As previously stated, a network of vessels descends behind the long handle of the malleus, aud at the centre of the drumhead there is a communication between these arteries and veins with a vascular zone which is situated at the periphery of the membrana, and through this with the vessels of the middle ear. The superior wall or roof of the tympanuni consists of a thin plate of bone, upon which the middle lobe of the brain resls. In the infant there is a suture (petroso- squamosal suture) in the tympanic roof (see Fig. 4), through which connective-tissue processes with blood- vessels pass from the dura into the middle ear, a fact which explains why an acute inflammation of the middle ear in an infant is apt to occasion more or less meningeal irritation. In the adult this suture is closed, but in some temporal bones the delicate superior wall is defec- tive, there being several openings, an anomaly which is designated by Hyrtl as spontaneous dehiscence of the tegmen tympani, and is in all probability due to an arrest of development. The inferior wall is much narrower than the superior, and close to it is the fossa jugularis. The proximity of this fossa to the middle ear is to be remembered, because phlebitis and throm- bosis of the jugular vein are complications liable to follow an inflammation of the tympanic cavity. The inner wall separates the middle ear from the labyrinth or inner ear, and presents several points of interest in 1, The promontory which corresponds to the first turn of the cochlea; 2. The fenestra ovalis, which contains the foot-plate of 30 MANUAL OF OTOLOGY. the stapes, and which lies a little above and behind the promontory ; below the fenestra ovalis is 3. The fenestra rotunda, closed by a membrane. Behind these foramina are seen (Fig. 6) 4. The pyramid, a cone-shaped projection containing the stapedius muscle, and Fig. 6. Chorda tympani View of inner wall of tympanum. (Enlarged.) (Gbay.) 5. The aqueduetus Fallopii, enclosing the portio dura, or facial nerve, a slight ridge of bone lying along the upper and posterior part of the inner wall. The facial nerve emerges at the stylo-mastoid foramen. The upper portioQ of the tympanic cavity, which con- tains portions of the malleus and incus, is called the attic. The attic opens into the mastoid antrum posteriorly, while the antrum is the passage of communication between the mastoid cells aud the middle ear. The short pro- cess of the incus lies in the inferior angle of the antrum. In the anterior wall of the middle ear the btmy Eustachian canal is situated. The carotid artery is ANATOMY AND PHYSIOLOGY OF THE EAR. 31 also ia close proximity to the anterior wall, so that in cases of caries or necrosis, fatal hemorrhage may occur. The tensor tympani muscle lies in a bony canal just above and parallel with the Eustachian tube and, passing around the processus cochleariformis, is attached to the upper and posterior part of the handle of the malleus. 2. The ossicles consist of the malleus, incus, and stapes. The malleus has 1. A head which articulates with the incus. 2. A short, and 3. A long process or handle, or manubrium, and Fig. 7. ocessus hrem. r ■ Villi V WX. Qg orbiculare. Head. Ch'-ura. The small bones of the ear, seen from the outside. (Enlarged.) (Gray.) 4. A processus gracilis. The incus, besides 1. The body, which resembles the crown of a molar tooth, has 2. A long process, which articulates with the head of the stapes, as well as 3. A short process. The latter is attached by a fan-shaped ligament to the lower angle of the mastoid antrum. 32 MANUAL OF OTOLOGY. As its name implies, the stapes is shaped like a stir- rup. Besides the head, already mentioned, which artic- ulates with the incus, there are two 1. Crura, and 2. A foot-plate, the latter being attached to the fora- men ovale by means of the annular ligament. The chorda tympani nerve (see Fig. 67) enters the tympanum through a small canal at the posterior border of the membrana tympani and, passing between the long process of the incus and the handle of the malleus, emerges at a small opening close to the anterior border of the drumhead. The articular portions of the ossicles are connected together by capsular ligaments. In addition to these, there are numerous ligaments between the ossicles and the tympanic cavity. The external ligament of the malleus should be mentioned, as it forms the upper boundary of Prussak's space. The other boundaries of this cavity, as shown ia Fig. 8, are, internally, the neck of the malleus ; below, the superior surface of the short process of the malleus, and, externally, the membrana flaccida or Shrapnell's membrane. The conjoined bones, viz., the malleus and incus, serve to divide the attic into two compartments. The outer compartment, or external attic, is situated between the articulating bones and the outer bony wall, being bounded above by the superior ligament of the malleus and the fold of the incus. This external attic is further subdivided into a superior and an inferior cavity (see Fig. 8), the latter being known as Prussak's space, and being bounded superiorly by the external ligament of the malleus and he system of cavities described by Politzer ; internally ; by the neck of the malleus ; inferiorly, by the short ANATOMY AND PHYSIOLOGY OF THE EAR. 33 process of the malleus, and externally by the mem- braua flaccida. Prussak's space communicates with the upper part of the attic, and also with the posterior por- tion of the tympanic cavity by a small opening. Prussak's space, section through the tympanic membrane, malleus, upper and outer tympanic wall of a decalcified preparation (Politzee.) LS. Superior ligament of the malleus. LE. External ligament of the mal- leus. S. Shrapnell's membrane, or the membrana flaccida. O. Prussak's space. R. System of cavities between the body of the malleus and the incus and the external tympanic wall. T. Tendon of the tensor tympani muscle. A good understanding of the subdivisions of the atlic is most important to the aurist, for it is here that the inflammation of the middle ear is occasionally most marked, leading frequently to caries of the walls and of the ossicles. The origin of the tensor tympani muscle is 1. From the cartilaginous portion of the Eustachian tube. 2. From the osseous wall of the pyramid close to the carotid canal, and 3. From the bony canal through which it passes. 3 34 MANUAL OF OTOLOGY. The tendon curves around a bony process, the pro- cessus cochleariformis (see Fig. 6), and is inserted into the upper and posterior portion of the long process of the malleus. The stapedius muscle arises from the bony pyramid through which it passes, and the tendon is inserted into the neck of the stapes. Experiments made by Politzer upon dogs proved 1. That the tensor tympani is supplied by the motor portion of the fifth nerve, and 2. That the central fibres of the stapedius muscle are under the control of the facial nerve. The lining membrane of the middle ear is quite thin, and its epithelium is of the ciliated pavement variety in the upper part of its cavity, while in the lower portion it is ciliated cylindrical. The connective tissue which contains the bloodvessels and nerves serves as a peri- osteum, and the lining membrane of the tympanum is a continuation inward of the mucous membrane of the pharynx and Eustachian tube. There are various folds of mucous membrane between the walls and the ossicles. In the new-born infant the hning membrane of the tympanum contains a great many bloodvessels and has a swollen appearance. During festal life the tympanum is filled with a gelatinous mass, which degenerates rapidly after birth into a thick fluid, owing to (he en- trance of air into the middle ear. This fluid becomes absorbed. The arteries supplying the tympanum are 1 . The tympanic, from the internal maxillary. 2. Several branches from the middle meninweal. o 3. A few branches from the internal carotid. 4. The ascending pharyngeal (a branch of the external carotid), and ANATOMY AND PHYSIOLOGY OF THE EAR. 35 5. The stylomastoid artery. The veins supplying the tympanum communicate with those of the external meatus as well as with the plexus in the carotid canal and the plexus of the lower jaw, and further join the veins of the dura mater by passing through the petroso-squamosal suture. Anatomical investigations undertaken by Politzer prove that " vas- cular connections are kept up between the middle ear and the labyrinth through the osseous. wall separating them." This point is of importance, because it is easy to understand how involvement of the labyrinth may occur simultaneously with acute inflammation of the middle ear. The nervous supply is derived from 1. The sympathetic. 2. Sensory fibres of the trifacial, and 3. The glosso-pharyngeal. Jacobson's nerve, the tympauic brauch of the glosso- pharyngeal, enters the tympanic cavity through a small canal in the inferior wall of the jugular fossa, and joins, at the promontory, the small superficial petrosal nerve. The tympanic plexus lying on the inner wall of the middle ear is composed of 1. Branches of Jacobson's nerve. 2. The small superficial petrosal nerve, and 3. Branches from the carotid plexus. This plexus distributes branches to the fenestra ovalis, the fenestra rotunda, and the lining membrane of the middle ear and Eustachian tube. 3. The Eustachian Tube. This tube is named after Eustachius, who described it more minutely than other writers, although Vesalius had previously discovered it. It ii the passage connecting the middle ear with 36 MANUAL OF OTOLOGY. the pharynx, and through it the external air enters the tympanum. It is about one and one-half inches in riG. 9. Eustachian tube and tympanic cavity. (Politzek ) A. Membrana tympani. B. Head of the malleus. C. Lower end ot the handle of the malleus. D. Body of the incus. E. Short process of the incus. F. Tensor tympani muscle. G. Pharyngeal opening of the tube. H. Isthmus of the tube. I. Tympanic opening of the tube. (Eight ear.) length. The position of the tube is oblique, extending from the tympanum forward, downward, and inward. ANATOMY AND PHYSIOLOOT OF THE EAR. 37 while its axis forms an angle of 135° with the hori- zontal axis of the meatus. It is wider at either ex- tremity than at the junction of the cartilaginous and osseous portions, and is composed of a bony and a car- tilaginous canal. (Fig. 9.) The osseous canal, a continuation inward of the anterior portion of the tympanic cavity, is bounded externally by the tympanic bone, superiorly by the canal of the tensor tympani, interiorly and to the inner side by the canal for the carotid artery. The average diameter of the tube is about -^ inch, although (he greatest diameters vary from -^^ to -^j inch, while its smallest normal calibre is large enough ordinarily to admit a small probe. The cartilaginous canal, about two-thirds the whole length of the tube, is attached at its upper end by connective tissue to the irregular margin of the bouy canal, and has a funnel-shaped opening into the naso- pharynx. The canal is not composed throughout of cartilage, being partly cartilaginous and partly mem- branous. The posterior and upper walls are cartilagi- nous. The membranous portion forms the lesser half of the circumference of the tube, while the cartilaginous portion forms the boundary of one side and the superior wall. The calibre of the tube is slightly sigmoid and cleft-like in shape. The cartilaginous portion is stiff enough to prevent complete closure of the lumen of the canal, although the opposite surfaces of the lining membrane touch one another except at a point very near the union of the cartilaginous and bony portions and at the pharyngeal orifice. The cartilage is composed super- ficially of a hyaline, but in the deeper part of a fibrous, fundamental substance. Zuckerkandl and Urbant- 38 MANUAL OF OTOLOGY. schitseh describe numerous irregular fissure-clefts in the cartilage, aud occasionally a division of the cartilage into several separate portions. The opening of the tube in the naso-pharynx lies on the external wall of the latter, just behind the posterior extremity of the inferior turbi- nated bone, being rounded in the child, but oval-shaped in the adult. The Eustachian tube in children is much wider and shorter, its direction is more horizontal, and it contains less cartilage than in the adult ; the opening also into the tympanum is larger, while the pharyngeal orifice is much smaller, and it is easier to inflate the middle ear in children than in adults, while the secre- tion passes more readily from the middle ear to the pharynx. The raucous membrane lining the Eustachian tube is of a light yellow color and projects somewhat at the pharyngeal opening, but is firmly adherent to the deeper tissues. It is of the ciliated cylindrical variety, the cilia moving in a direction from the tym- panum toward the pharynx, thus aiding the flow of mucus or of fluid from the middle ear or tube toward the pharynx. The mucous membrane in the cartilaginous portion is more fully developed than in the bony por- tion, and contains many acinose glands. In the bony portion there are but few of these glands, and the mem- brane is very thin, smooth, and closely adherent. The tensor palati and levator palati are the muscles that open the tube during the act of swallowing, and thus favor the passage of air toward the tympanic cavity. The tensor palati has its origin from (1) the under sur- face of the sphenoid process, from (2) the extremity of the cartilaginous hook, and also from (3) the mem- branous wall of the cartilaginous portion of the tube. Passing downward around the hamulus pterygoideus, ANATOMY AND PHYSIOLOGY OF THE EAR. 39 it spreads out in the fibrous prolongation of the hard palate. The tendon being quite firmly attached to the hamulus pterygoideus, it acts more fully on the Eustachian tube than on the soft palate when the muscle contracts. Its action on the tube is to separate the outer or membranous wall, together with the cartilag- inous hook, from the inner wall. The levator palati arises from the surface of the petrous bone adjoining the carotid canal. In its course parallel to the Eustachian tube, it is joined by some connective- tissue fibres to the membranous portion which forms the base of the tube, and also to the cartilaginous plate, and is inserted below the pharyngeal opening of the tube into the soft palate. The action of this muscle seems to increase the transverse diameter of the car- tilaginous canal by pulling the lower wall of the tube upward and backward. The arterial supply is derived from (1) the phar- yngeal, a branch of the external carotid artery ; (2) the middle meningeal, from the internal maxillary artery and (3) some small branches from the internal carotid artery. The veins are numerous, and form a plexus which communicates with the cavernous sinus and with the plexus near the temporo-maxillary articulation, and empty into the facial or internal jugular veins. The tensor palati muscle derives its nervous supply from the otic ganglion and from the internal pterygoid nerve, which is a branch of the inferior maxillary nerve. The levator palati is supplied by a branch of the pneu- mogastric and by the facial through the vidian and petrosal nerves. 4. Mastoid Process, The mastoid process under normal conditions communicates with the posterior part 40 MANUAL OF OTOLOGY. of tbe middle ear bj' means of the antrum. In the liglit of anatomical investig-ations, we know that no two mas- toid processes are exactly alike. According to Ziicker- kandl, who made an examination of one hundred mastoid processes in the fresh state and of one hundred and fifly macerated ones, there were absolutely no air Fig. 10. ?cction ?l;o^\ing middle ear and mastoid oelis, pneumatic variety. 1. Membrana lymimiii. 2. Aqueductus Fallopii. 3. Mastoid antrum. 4. Tensor tympani muscle. 5. Malleus and incus. 6. Mastoid cells. 7. Prom- ontory. S. Foramen rotundum. !), Foot-plate of stapes in foramen ovale. 10. Turn of cochlea. 11. Canal of carotid artery. 12. Bony wall of Eus- tachian tube. cavities in 20 per cent, of the specimens. Of the entire number, 38.6 percent. Avere perfectly pneumatic mas- toid proces,ses without diploetio spaces. He also found that in some persons only the upper half of the process was pneumatic, while the lower half was diploetic. It will thus be seen that there are three different kinds of ANATOMY AND PHYSIOLOGY OF THE EAR. 41 mastoid processes : (a) the pneumatic, (6) the diploetic, and (c) a mixed variety or a combination of tiie two. In the pneumatic variety (see Fig. 10) very frequently nu- merous cellular spaces are found extending into the tem- poral bone in different directions, viz., around the lateral sinus, down to the apex, and backward lo the occipital suture — a point to be remembered in operations on the mastoid, for it is most important in such cases to thor- ouglily remove all diseased tissue found in tiiese cells. In an infant at birth there is usually found but one cell the antrum, and the mastoid process is but a small tuber- osity and undeveloped. From birth the mastoid process gradually develojis by extending downward, until at five years of age it is very similar to that of an adult, as regards the position of tiie antrum and arrangement of the cells, except that it is smaller and the bony substance is not as firm and dense. lu a pneumatic mastoid pro- cess, besides the antrum already mentioned, there are usually a number of cells that communicate with one another as well as with the antrum. These contain air, and are lined with a continuation of the mucous mem- brane of the tympanic cavity, and the epithelium is of the non-ciliated variety. Those cells that are not pneu- matic usually contain a fatty substance. The upper wall of the antrum is but a thin lamina of bone, which separates it fiom the dura mater. The lateral sinus is in close proximity to the mastoid cells, and rests against the inner wall of the process. The facial nerve may become involved in inflammation of the mastoid cells, or may be injured during operations, as its course is downward through the cells after passing along the upper portion of the tympanic cavity, A point which serves as an anatomical landmark in operations on the 42 MANUAL OF OTOLOGY. mastoid is the spina supra meatum. This is a promi- nence situated just a little above aud behind the external meatus at the junction of the mastoid process with the posterior wall of the external auditory canal. Occa- sionally there are found cells in the occipital bone that communicate with the mastoid cells. Pus frequently makes its way down to the lowest extremity or tip of the process, and, as the inner wall is very thin, the bone is occasionally perforated, and an abscess may form underneath the muscles and deep fascia in the neck. The lateral sinus occasionally runs out of its usual course, so that great care should always be exercised in oper- ations on the mastoid. As we have seen tiiat the internal structure of the mastoid process is subject to great variations in different individuals, so the outer surface of the same may have a very thick or a thin wall, or may be rounded or flat- tened. It is very generally believed that, in a normal mastoid process, in which the external wall is thick, the bone will be found thin at the mastoid tip and digastric fossa; and, further, that when the mastoid protuberance is small and with a well-defined digas- tric fossa, the lateral sinus is apt to encroach upon the mastoid antrum. As the two mastoid processes in an individual are usually symmetrical, valuable informa- tion can often be obtained by comparing the normal with the one that is inflamed. THE INTERNAL EAE. The inner ear or sonnd-perceiving apparatus consists of the bony and membranous labyrinth, together with the central origin and trunk of the auditory nerve. The Labyrinth. There is a bony labyrinth contained ANATOMY AND PHYSIOLOGY OF THE EAR. 43 within the petrous portion of the temporal bone, and a membranous labyrinth within the bony one. The bony labyrinth is divided into (1) the vestibule, (2) the semi- circular canals, and (3) the cochlea. 1. The Vestibule lies on the inner side of the tympanum in front of the semicircular canals and behind the cochlea, and is the central cavity by which the different parts Pig. II. Opening of aqueductus vesHbuli. Bristle passed through foramen 7-otnndum. Opening of aqueductus cochlese. The osseous labyrinth laid open. (Enlarged.) (Gray.) of the bony labyrinth are in communication with one another. It is somewhat oval or elliptical in shape. On its outer wall is situated the fenestra ovalis, -which is closed by the footplate of the stapes, and the latter is held in position by the annular ligament. There is a small depression, called the fovea hemispherica, at the anterior part of the inner wall, which contains several 44 MANUAL OF OTOLOGY. minute perforations (maculae cribrosee) for the passage of the filaments of the vestibular nerve. The crista vestibuli is a ridge lying behind this depression. At the posterior part of the inner wall is found the opening of the aqueductus vestibuli (see Fig. 11), through which a small vein passes, and it is claimed by some authori- ties that it contains a tubular prolongation of the lining membrane of the vestibule, and that it terminates in a cul-de-sac between the layers of the dura mater. There is an opening in the vestibule which commu- nicates with the scala vestibuli of the cochlea, called the apertura scalse vestibuli cochleae. 2. The Semicircular Canals, three in number, open into the posterior part of the vestibule by five orifices. They are of unequal length, flattened from side to side, and describe almost a circle in each case. The dilated end of each canal is called the ampulla. One of the canals is vertical in direction, and is called (1) the superior semicircular canal; another, directed backward, is also vertical in direction, (2) the posterior semicircular canal ; the third, the shortest of the three, runs in a direction outward and backward, (3) the external or horizontal semicircular canal. Each end that is dilated, or has an ampulla, as well as the smaller end of the external semicircular canal, has a separate opening into the vestibule. The smaller ends of the posterior and superior canals, which join before entering the vestibule, have a com- mon opening. 3. The Cochlea. The cochlea, resembling on a cross- section the ordinary garden-snail shell, consists of a tube which takes two and a half turns about its central axis or modiolus. (See Figs. 11 and 12.) In a macer- ANATOMY AND PHYSIOLOGY OF THE EAR. 45 ated preparation it will be seen that there is an opening or passage between the cochlea and vestibule, and also a communication between the cochlea and tympanum through the fenestra rotunda. The cochlea, conical in shape, is placed almost horizontally in front of the vesti- bule, with its base directed toward the internal auditory meatus and its apex or cupola toward the tympanic cavity. There are several minute openings in the base for the passage of the cochlear branch of the auditory The cochlea laid open. (Enlarged.) (Geay.) nerve. The tube or canal of the cochlea is partially subdivided by the bony lamina spiralis, which com- mences at about the fenestra rotunda and ends at the cupola in the hamulus. The membranous lamina spi- ralis is inserted into this bony lamina spiralis, so that the canal is thereby subdivided into two passages, the superior called the seala vestibuli and the inferior the scala tympani. A second membrane cuts off a portion of the scala vestibuli and forms the scala media or ductus cochleae (see Fig. 13), but the latter properly be- longs to the raembranousllabyrinth. There is a com- munication at the apex of the cochlea between the scalse 46 MANUAL OF OTOLOGY. tympani and vestibuli through the helicotrema of Bres- chetius. There is quite a large canal passing through the centre of the modiolus named the canalis centralis modioli, extending from the base to the cupola. It trans- mits a small nerve and artery. There is an orifice, the aqueductus cochlese, which leads to a canal containing a small vein, and which opens on the basilar surface Fig. 13. LougUndinal section of the cochlea, showing the relations of the scalsc, the ganglion spirale, etc. (Gray.) S. Y. Scala vestibuli. S. T. Scala tympani. S. M. Scala media. L. S. Liga- mentum spirale. Q. S. Ganglion spirale. of the temporal bone. A swelling of the cochlear nerve, called the ganglion spirale (see Fig. 13), lies in a small canal, the canalis spiralis modioli. This canal winds around the modiolus and lies at a point where the bony lamina is attached to the modiolus. Ganglion cells are found in the ganglion spirale, from which nerves pass ANATOMY AND PHYSIOLOGY OF THE EAR. 47 to the bony lamina and organ of Corti. The lamina spiralis terminates in a curved extremity, the sulcus spiralis, the upper lip of which is called the labium vestibulare, the lower lip the labium tympanicum. A delicate membrane, the membrana basilaris (see Fig. 14), completing the scala tympani, extends from the labium tympanicum to the cochlea. The ligamentum spirale is the dilated portion of the membrana basilaris that is attached to the cochlea. The membrane of Reissner is stretched across from the vestibular surface Fig. W. Floor of scala media, showing the organ of Corti, etc. (Geay.) of the periosteum of the bony lamina to the external wall of the cochlea, and forms the superior boundary of the scala media, the lower wall being the membrana basilaris. A very thin membrane, described by Corti, and called the membrane of Corti, or the membrana tectoria, extends across from the attachment of Reiss- ner's membrane and the labium vestibulare to the outer wall of the cochlea. The organ of Corti consists of numerous rods or cells resting on the membrana basi- laris and covered by the membrana tectoria. The two 48 MANUAL OF OTOLOGY. central cells, rod-like in character, are called the inner and outer rods of Corti, and rest on the membrana basilaris, somewhat separated from one another. This intervening space is called the zona areuata. (See Fig. 14.) As the opposite extremities of these rods meet, they form a series of arches covering over the zona areuata. A very small canal is thus formed by these arches and by the membrana basilaris, which passes in a spiral direction throughout the whole length of the cochlea. In addition to the rods of Corti, there are numerous rows of ciliated cells, and these cells receive the nerve filaments. The membranous labyrinth consists of (1) the mem- branous canals, (2) the utricle, and (3) the saccule. The membranous semicircular canals are similar in number, arrangement, and general form to the bony canals, ex- cept that they are only about one-third the size of the latter. They open by five orifices into the utricle, one opening being common to two canals. The ampulla is much thicker than the other portions of the canal, and almost fills the bony encasement. The membranous canal consists of three layers, the inner being formed of polygonal nucleated epithelial cells which secrete the endolymph, a fluid which is contained within the mem- branous tubes. A fluid quite similar to the endolymph, called the perilymph, surrounds the membranous canals and is contained within the osseous canals. The ampullae receive nerve filaments from the vestibular nerve. The utricle, oblong in shape, lies in contact with the fovea semi-elliptica in the superior and posterior part of the vestibule. There is a yellow thickening on the anterior and lateral walls of the utricle, called the macula acustica. A clear, transparent, semi-fluid sub- ANATOMY AND PHYSIOLOGY OF THE EAR. 49 stance covers the neuro-epitheliiim of the macula acustica and contains crystals of carbonate of lime called the " otoliths." The saccule, globular in shape, is situated in the fovea hemispherica, and apparently its cavity is distinct from that of the utricle. It has a macula acustica, and oto- liths similar to those in the utricle. There is a small canal, the canalis reuniens {see Fig. 15), connecting the saccule Fig. 13. ^A mpullre Canalis Rcuniens "with the ductus cochlearis of the membranous laby- rinth. A number of stitt' cilia project from the surface of the macula in both saccule and utricle, and are con- nected with the nerve filaments of the auditory nerve. The arteries supplying the labyrinth are, the (1) in- ternal auditory, which is a branch of the basilar ; (2) some branches from the occipital; (3) the stylomastoid, from the posterior auricular. The internal auditory artery subdivides at the bottom of the internal auditory 4 50 MANUAL OF OTOLOGY. meatus into the cochlear and vestibular branches. The cochlear branch gives o£E numerous small vessels which pass through the canals in the modiolus and enter the substance of the lamina spiralis in the form of a capillary network. The vestibular branch forms a capillary net- work which'is distributed to the membranous labyrinth. The veins from the semicircular canals, the vestibule, and the cochlea unite with the superior petrosal sinus. The auditory nerve, or nerve of hearing, also called the portio mollis, is the eighth nerve. Its superficial origin is at the lower border of the pons from a groove between the olivary and restiform bodies. There are two deep origins, both from the fourth ventricle. The nerve, after winding around the restiform body, passes, together with the facial nerve, across the posterior border of the middFe peduncle of the cerebellum and enters the internal auditory meatus with the facial nerve. At the bottom of the meatus the nerve divides into the cochlear and vestibular branches. The vestibular branch subdivides into the superior, middle, and inferior branches which are distributed to the cristse acusticse of the semicircular canals and the maculse acusticse of the utricle and saccule. The cochlear branch divides into numerous twigs and, after entering the base of the modiolus, passes between the plates of the osseous lamina spiralis, at which point the nerves form a plexus, the " ganglion spirale." From this plexus nerve filaments are distributed to the sulcus spira,lis and organ of Corti. PHYSIOIjOGY. The function of the auricle is to collect the sound- waves and direct them to the membrana tympani. The ANATOMF AND PHYSIOLOGY OF THE EAR. 51 concha is especially important for this purpose, as well as the cavity just beneath the tragus. After the sound- waves have reached the drumhead through the external auditory canal, they are transmitted by the chain of ossicles to the fluid of the labyrinth, the ossicles prob- ably vibrating as whole bodies. The sound-waves then pass through the fluid in the cochlea and reach the organ of Corti. From the nerve filaments in the cochlea the sensations called sound are conveyed through the auditory nerve to the brain centre. According to experiments made by Helmholz, it seems that the power of resonance of curved membranes is much greater than that of flatly-stretched ones, a point of great importance in considering the concavity of the drumhead. Experiments have also shown that the vibrations of the malleus are twice as great as those of the incus and four times as great as those of the stapes. It is probable that by means of the cochlea the pitch of the sound is appreciated, and further that different notes are perceived by certain portions of the spiral scale. As to the function of the fenestra rotunda, it is probable that, owing to its elasticity, when the foot-plate of the stapes is forced in and the labyrinthine pressure is in- creased, such pressure is compensated for by the bulg- ing outward of this membrane. When this delicate membrane becomes thickened through pathological changes, the patient is likely to complain of noises in the ear and vertigo, if the pressure within the labyrinth is suddenly increased. It was formerly believed that the function of the semicircular canals had to do with the perception of the general direction of sounds, but it is more probable, and a fact generally accepted, that the sense of motion 52 MANUAL OF OTOLOGY. and of equilibrium is the function of the semicircular canals and the utricle. By means of the Eustachian tube, air is allowed to enter the middle ear and thus keep the atmospheric conditions equalized on both sides of the membrana tympani. The Eustachian tube is not constantly open, as its permeability varies in different individuals. In some persons a current of air will pass from the pharynx to the middle ear during ordinary respiration, while in others the act of swallowing or a powerful expiratory act, with nostrils open or closed, will be necessary to cause the air to enter the Eustachian tube. When con- striction of the tube takes place, so that the air does not enter the tympanum except with difficulty, the result is that the drumhead and ossicles are forced inward and congestion of the middle ear occurs, followed by adhe- sions and deafness, if not relieved. CHAPTER II. METHODS OF EXAMINATION OF THE EAR. When a patient presents himself for advice and treat- ment for some aural disease, a most complete history of the case should first be obtained. He should be ques- tioned as to whether he has any hereditary tendency to deafness ; then inquiry should be made as to his general health, particularly as to any predisposition to catarrhal disease. The patient should then be questioned as to the exact symptoms for which he comes for advice, and the surgeon should make careful note of the pain, if present, the tinnitus, the discharge, or vertigo. After having obtained (1) a full and complete history of the case in all its details, the surgeon should then (2) inspect with the eye the auricle and surrounding parts, looking for any inflammation of the pinna or external meatus, or any redness over the mastoid process. By palpation some information can be obtained, especially if there be any tenderness on pressure over the mastoid process. It is always well to compare both auricles and both mastoid processes of a patient, for it must be remembered that, in some persons, generally those of at hysterical temperament, pain is occasionally complained of when firm pressure is made over the apex of the mastoid, so that it is always well to compare the two sides. Redness and tenderness over the mastoid are symptoms suggestive of mastoid inflammation or furun- 54 MANUAL OF OTOLOGY. cular inflammation of the external meatus. After having obtained all information possible by inspection and pal- pation, the surgeon should then (3) make a most thorough examination, by means of the head-mirror and specu- lum, of the external auditory canal, the membrana tym- pani, and, if the latter be perforated, of the middle or tympanic cavity. ear A very good head-mirror is the one recommended by Politzer, and shown in Fig. 16. It is a concave mir- FlG. 16. Indirect Ulumlnatioa of the ear. ror, with an aperture iu the middle which allows the surgeon to look through the opening, if he desires to do so, and it should be fastened to the forehead-band or metal spring by means of a ball-and-socket joint. The mirror is two and three-quarters inches in diameter and has a focal distance of about six inches. In order to obtain the best view of the drumhead, the mirror should be pulled down over the eye, so that the surgeon can look through the opening, and to make a thorough METHODS OF EXAMINATION OF THE EAR. 55 examination of the external meatus and membrana tympani, it is most important to" bave good illumination, and for this purpose daylight from a northern exposure is the most satisfactory, since by this ineans the natural color of the drumhead will be observed. Direct sun- light is usually too dazzling. When good natural light cannot be obtained, artificial light should be substituted, such as that from an Argand burner, with or without a Mackenzie's bull's-eye lens and reflector. Some surgeons prefer the electric light, but for ordinary examination gas is still the most practical and desirable. Fig. 17. Mackenzie's bull's-eye lens and reflector. An excellent light is that obtained from a candle fitted in a holder and supplied with a lens. This can be carried by the surgeon in his satchel, and is particu- larly adapted for bedside examinations. Illumination of the ear may be obtained by indirect illumination, as when an Argand burner or natural daylight is used, or by direct illumination, the latter method consisting of an electric lamp attached to the 56 MANUAL OF OTOLOGY. Fig. 18. Direct illuminatioa of the ear. Electric light and portable battery. METHODS OF EXAMINATION OF THE EAR. 57 headband. An excellent electric lamp with head-mirror is the oae devised by Leiter, of Vienna. Another lamp is represented ia Fig. 18. In order to make use of the electric current in a city house, a rheostat has lately been devised, which regu- lates the current so that the surgeon is enabled not only to obtain a good illumination of the ear, but also to make use of a cautery and bone-drills at the same time. (Fig. 19.) For operations on the middle ear, Fig. 19. Electric motor with rbeostat. and for operations performed at night, on account of the danger of conflagration, the electric light is indis- pensable, and should be used whenever possible. For this purpose a storage battery, as represented in Fig. 18, can be conveniently carried by the surgeon. The objection to the photophore for general use is that it becomes very hot when employed for any length of time, and consequently very disagreeable to the sur- geon. 58 MANUAL OF OTOLOOY. Bruntou's otoscope (Fig, 20) is but little used in this country, but is more popular in England. Its advantages, as claimed by the inventor, are its simple construction and easy application ; it can be used with either sunlight or artificial light, and with or without the magnifying glass. The rays of light enter the funnel. An electric light has been adapted to this oto- scope. Brunton's otoscope is obviously useless except for purposes of examination. ■Fig. 20. Brunton's otoscope. When making an examination with a head-mirror, it is of the greatest importance to place the patient in a good position. The ear to be examined should be away from the light. If gaslight be used, the Argand burner should be on a level with the ear, and the rays of light, striking the head-mirror at an angle of 45°, should be reflected into the external auditory canal. Speculum. The speculum that I find most satisfac- tory is that known as Gruber's. It is constructed of silver, the narrow part being highly polished inside, while the dilated portion inside is blackened. There are four sizes of these specula. The end to be intro- METHODS OF EXAMINATION OF THE EAR. 59 duced is conical ia shape (Fig. 21), which allows the speculum to fit more accurately the external meatus, so Fig. 21. Gruber's speculum. that the surgeon is enabled to obtain a better view of both external auditory canal and drumhead. FlQ. 22. Politzer's speculum. Politzer's specula (Fig. 22) of hard rubber are also excellent ones, and will be found especially useful when Fig. 23. OOOo Boucheron's speculum. caustic applications are to be made to the canal or druai- head. The Gruber speculum is also made of hard rub- 60 MANUAL OF OTOLOGY. ber. Another speculum is that devised by Boucheron, of Paris (Fig. 23). I have modified the latter by having the extremity of the narrow end made oval instead of round. Before introducing the speculum it should be warmed, and particular care exercised that it be not pushed in too far, as pressure on the bony canal is quite painful. After Ihe speculum has been warmed it should be held by the thumb and index-finger of the left hand, and with a gentle rotary motion carefully introduced into the meatus, while the auricle, held between the index- and middle-fingers of the same hand, should be drawn outward, upward, and backward. Occasionally, long hairs obstruct the view, so that these must be pushed aside, while any cerumen, scales, purulent or cheesy matter must be removed by syringing or with curettes or forceps, as the case may be. Mistakes are frequently made by beginners in not pushing the specu- lum beyond the hairs at the meatus, which at times are covered with cerumen, so that a diagnosis of inspissated cerumen is occasionally made. Again, if the long axis of the speculum is not directed toward the drumhead, but against the walls of the auditory canal, the student will make a mistake in diagnosis, as the walls are fre- quently smooth, glistening, and pinkish in color, re- sembhng at times an inflamed drum-head. Operating Ear Specula. For operative purposes specula have been devised with a slit-like opening in the narrow part of the speculum, to allow greater play for the use of instruments. A short speculum is especially adapted for such purposes. Blake's oper- ating otoscope " consists of a hard rubber speculum (Politzer), fitted with a metallic rim, to which are at- tached a revolving prism and an arm bearing at its METHODS OF EXAMINATION OF THE EAR. 61 outer end a lens of about an inch focus ; this arm is movable, but sufficiently firm to remain fixed at any angle at which it is placed." All drops or solutions used in the ear should be warmed first, for otherwise they are liable to cause vertigo and inflammation. The syringe is the safest instrument that can be placed in the hands of the be- FlG. 24. Author's curette forceps. ginuer for the purpose of removing cerumen, purulent discharge, or scales, while forceps and curettes should never be used by the inexperienced, nor at any times, except under excellent illumination. The curette forceps (Fig. 24) I have used for many years, and find them especially adapted to removing hardened cerumen when syringing alone has failed. Another pair of forceps that will be found of service are those represented in Fig. 25. 62 MANUAL OF OTOLOGY. In addition to the forceps, it is necessary tliat the sur- geon should be well supplied with cotton carriers (Fig. 26). Those of aluminium I find the most serviceable, Pig. 25. riG. 26. Foreign-body forceps. Aluminium cotton-carrier. METHODS OF EXAMINATION OF THE EAR. 63 on account of their lightness and flexibility. The sur- geon will find it necessary to have several sizes of blunt curettes for the purpose of removing scales, ceru- men, etc., from the auditory caual. APPEARANCES OF THE NORMAL EXTERNAL AUDI- TORY CANAL AND MEMBRANA TYMPANI. In introducing the speculum and pushing .aside any hairs in the meatus, one should observe the appearance of the auditory canal. The osseous part of the normal canal is usually of a delicate pink color and somewhat smooth and glistening. A reflex cough is frequently caused by introducing the speculum, due to irritation of the auric- ular branch of the pneumogastric. Fro. 27. Fiu. 28. Normal drumhead (right ear). Normal drumhead (left ear). (POLITZEK). a. Posterior fold.- h. Short process, e. Anterior fold, d. Cone of light. e. Long handle of incus. /. Umbo. The normal membrana tympani, when examined with natural daylight, is of a pearly-gray color with a slightly bluish tint, while gaslight gives it a red- dish-yellow color. Other points to be observed are the long handle of the malleus, running downward and backward from the short process to the umbo or central concavity of the membrana. The cone or pyramid of light, as irhown in Figs. 27 and 28, ex- 64 MANUAL OF OTOLOGY. tends from the umbo almost to the lower periphery of the drumhead, with the apex at the anterior part of the umbo. It is supposed to be due partly to the con- cavity of the drumhead and to the angle that the mem- brana tympani forms with the axis of the canal, and partly to the glistening or reflecting surface of the membrana. From the short process, extending forward and back- ward, are several folds called the anterior and posterior folds. The portion of the drumhead between these folds above the short process is called the membrana flaccida, the portion below being the membrana vibrans. In looking at a drumhead, one must note particularly (1) its color, whether normal, congested, opaque, or atrophic, and whether it contains opacities or chalky deposits; (2) the position of the drumhead, whether bulging, owing to a collection of fluid, or whether re- tracted. In the latter case the handle of the malleus, being retracted, will appear foreshortened; the short process will become more prominent, as well as the an- terior and posterior folds, and the cone of light will be distorted or displaced. To decide as to the mobility of the drumhead, and whether bound down by adhesions, in addition to the Valsalvian method of inflation (to be later described), more or less can be determined by touching the different parts with a probe. For this purpose, however, an instrument has been devised, viz., Siegle's pneumatic speculum, consisting of a speculum with i.ts wide extremity closed by an obliquely-placed thin plate of glass, so as to make it air tight when in- serted in the external auditory canal. There is a small opening on the side, connected by rubber tubing with a Politzer bag, or, better still, with the masseur of Del- METHODS OF EXAMINATION OF THE EAR. 65 stauche. (Fig. 29.) It is well to cover the end of the speculum with a small piece of rubber tubing, to make it fit the canal accurately. By manipulating the piston with the thumb, the mobility of the membrane can be determined. I have modified this instrument by sub-. Siegle's otoscope, with masseur of Delstancbe attached. stituting the Gruber metallic speculum for the hard rubber ones, which are, as a rule, attached to this in- strument. (Fig. 29.) The use of the Siegle otoscope, for the purpose of ex- hausting the air iu the external auditory canal, is indi- cated in cases of retraction of the drumhead due to 5 66- MANUAL OF OTOLOGY. catarrhal disease ; (o break up adhesions between the drumhead and walls of the middle ear; in certain cases of tinnitus, which frequently are much benefited after its use, and in cases of dizziness due to increased laby- rinthine pressure from middle-ear disease; also in cer- tain cases of perforation of the drumhead in which it is important to remove the secretion. The " rare- facteur," or masseur, of Delstanche is particularly use- ful in cases of adhesion between the membraua and walls of the tympanum, as rarefying and condensing the air in the external meatus effects what Delstanche calls "massage of the articulation of the ossicles." All instruments, for either rarefying or condensing the air in this manner, should be used with great caution, and only when the surgeon can obtain a good view of the drumhead during such manipulation. APPEARANCE OF THE PHARYNX, NASOPHARYNX, AND NASAL PASSAGES. The surgeon should not consider the examination of the ear complete uutil he has inspected carefully the pharynx, the nasopharynx, and the nasal passages. For this purpose, in order to direct the light, a larger head-mirror is advisable. First of all, the tongue should be depressed by means of a spatula, and the patient directed to make an inspi- ratory effort or to pronounce the word "ah," which latter procedure will raise the soft palate, and thus present an excellent view of the pharynx. Careful attention should be paid as to whether the pharynx is atrophic, hypertrophic, or granular, whether the tonsils are en- larged or not, and whether there are any ulcers. As to the nasal passages, one should direct the patient METHODS OF EXAMINATION OF THE EAR. 67 to close one side of the nose and to force air in and out of the other passage, and to do the same on the other Fig. so. Fig. 31. Colin's nasal speculum. side, in order to determine the perme- ability of these passages. Afterward, in- spection by means of a nasal speculum (Fig. 30) should be made, to ascertain the presence of polypi, or spurs on the septum, or to detect malformations, dis- ease of the bone, or hypertrophic or atrophic nasal catarrh, or ozsena. After the pharynx and the nasal pas- sages have been explored, the attention of the surgeon should be directed to the condition of the nasopharynx. A mirror (Fig. 31) should be warmed and carefully passed behind the soft palate, and the nasopharynx should be so illu- minated by means of the head-mirror, Mirror for posterior that the surgeon can decide if there be any adenoid growths present, or polypi or hypertrophy of the mucous membrane, or any other abnormal change 68 MANUAL OF OTOLOGY. in the tissues. In children it is particularly difficult to employ posterior rhinoscopy, and in such the index- finger can be easily passed up behind the soft palate, and the presence or absence of adenoid growths can be ascer- tained. In nervous or excitable children this method should never be employed, as I have seen little patients, in whom this melhod had been attempted, rendered so nervous that it was extremely difficult for the aural sur- geon to regain their confidence. Whenever possible, it is much more satisfactory and humane to give the patient a whiff of chloroform. EXAMINATIOJSI OF THE EUSTACHIAN TUBE AND MIDDLE EAE. In order to ascertain the condition of the Eustachian tube it is necessary to try one of three methods of in- flation — viz., (a) Valsalvian method, (6) Politzerization, (e) catheterization. A diagnostic tube (Fig. 32), con- FlG. 32. Diagnostic tube. sisting of rubber, from two and one-half to three feet in lenglh, and provided with ivory tips, should be always used. One end is placed in (he surgeon's ear and the other in that of the patient. When inflating the ear by METHODS OF EXAMINATION OF THE EAR. 69 either of the three methods, certain information can be obtained as to the condition of the Eustachian tube. In a normal case when the middle ear is inflated a dull sound or click will be heard. The presence of fluid in the tympanic cavity will give rise to a bubbling sound, while a perforation in the membrana tyrapani will be indicated by a blowing or hissing sound, according to the size of the perforation and the condition of the tube. (a) Valsalvian Method. By this method the patient holds the nose closed with the thumb and index-finger, and, the mouth being also closed, the condensed air in the nasopharynx is forced through the Eustachian tube into the tympanum when the patient makes a forced expiration. This method is useful only in cases in which it is desirable to make a diagnosis of the permea- bility of the Eustachian tube and to determine the mobility of the membrana. The drumhead should be inspected under good illumination whenever this method is employed, but the latter must never be recommended to patients, as it tends to produce congestion of the head, and when frequently practised, and for a long period of time, it is likely to stretch the ligaments of the ossicles, and thus cause a relaxed condition of the parts. This method is of limited value, and should never be used where there is much obstruction of the Eustachian tube. (6) Poliizer's Method. The method of Politzer is best described in his own words, as follows : " The patient, being seated in a chair, takes a little water into his mouth — to facilitate swallowing — which he is re- quired to swallow when told. The surgeon, standing on the patient's right, or in front, introduces the nozzle of the Polilzer-bag one cm. into the nasal orifice of the 70 MANUAL OF OTOLOGY. corresponding side at its posterior angle (Fig. 33), and then compresses witii the left thumb and forefinger the alse of the nose closely round the instrument. The patient is next told to perform an act of swallowing, and at the same moment the surgeon expels the air from the inflating-bag with his right hand. By the condensa- tion of air produced in the nasopharynx in this manner, Fig. 33. Politzer's method. the air is forced into both middle ears, the closure effected by the soft palate is forced open, and its vibra- tions give rise to a dull, gurgling noise, which frequently, if not always, may be taken as an indication that the air has entered into the middle ear." Politzer has partially modified this method by allowing the patieut to inspire through the nearly closed lips, or through a piece of rubber tubing held between the lips while the air is METHODS OF EXAMINATION OF THE EAR. 71 beiag forced into the nasopharynx. By tliis modifica- tion of the original method the nasopharynx is not only closed, but at the same time the Eustachian tube is made more open by the soft palate being pulled back- ward. By inspiration through the mouth air enters the middle ear more readily when the catheter is used than by simple catheterization. In inflating the middle ear, in cases where there is fluid, it is well to have the patient's head inclined for- ward and sideways, ia order to allow the secretion to gravitate toward the nasopharynx. In cases of perforative ioflaramation of the middle ear, it seems to be proved that, by Politzer inflation, the secretion in the middle ear is forced through the open- ing in the drumhead, and not into the mastoid cells. In cases of hypersemia of the middle ear, whh deafness resulting from inflammatory action, inflation of the middle ear in many cases will produce absorption of the exudation, and will also have a favorable efi^ect on the circulation in the tympanic cavity. The fact that a hissing sound is not always heard when the Valsalvian or Politzer's method has been tried does not indicate that there is not a perforation of the drumhead, for there may be so much swelling or constriction of the tube that catheterization will be necessary to force air through the perforation. The Politzer bag (Fig. 34) is pyriform in shape, and should hold about eight ounces. A rubber tube, three inches in length, should be attached to the bag, and the nose-piece should be of glass, large enough to completely fill the nasal passage, glass being easily cleansed and rendered aseptic. It is best to have a small opening on the side of the 72 MANUAL OF OTOLOGY. which can be covered over by the thumb when compressed. The thumb should be immediately re- moved from the opening after compressing the bag, so as to allow the air to enter the bag through this opening, rather than to suck air and some secretion possibly through the glass attachment. Fig. 34. Polilzer bag, witb glass nose-piece. Instead of having the patient swallow water, another method, recommended by Gruber, consists in the pro- nunciation of the word " hock" by the patient at the moment that the surgeon forces air through the nose. With young children both of these methods are unnec- essary, for if the mouth of the child is closed, it will simply be necessary to use the Politzer bag. If the child cries, it will facilitate matters also. (c) Catheterization. Bath hard rubber and silver catheters are used. I prefer, however, the latter (Fig. 35), which should consist of four different sizes, while it is most important that each should have a probe- pointed extremity for introduction into the nose. The catheter should have a double curve, as recommended METHODS OP EXAMINATION OF THE EAR. 73 by Blake. The catheters formerly iu use caused con- siderable pain and irritation when introduced. By using a catheter with a probe-point very little dis- comfort is caused to the patient if the surgeon be skil- ful, and there is little if any danger of lacerating the parts and thereby causing emphysema of the connective tissue of the pharynx and neighboring parts. Fig. 35. Blake's Enstachlan catheter. The use of a 4 per cent, solution of cocaine sprayed into the nasal passages is advisable in all cases before passing the catheter, unless the patient is unpleasantly affected by this remedy. There are two methods gen- erally employed in introducing a catheter : First Method : The patient should be seated opposite the surgeon, and the former's head steadied by an as- sistant or allowed to rest against the back of a chair. The surgeon, either standing or sitting opposite the patient, then places the fingers of the left hand on the patient's forehead, gently pushing upward the extremity of the nose with the thumb of the same hand. With the catheter held in the right hand, the probe-pointed end is introduced very carefully, after being warmed and smeared with olive oil or vaseline. The end of the catheter should be pushed along the lower wall of the nasal passage until it touches the posterior wall of the pharynx, when it is turned obliquely outward, but not sufficiently to be in a horizontal position, and slightly forced into Eosenmiiller's fossa. By withdrawing the catheter and at the same time raising the probe-pointed 74 MANUAL OF OTOLOGY. extremity, the latter will be felt to glide over the posle- rior lip of the Eustachian tube. The point is then turned still further outward and upward, " so that the Fiu. 36. Vertical section of the nasopharynx, with the catheter iutroduced into the Eustachian tube. (Politzee.) A. Inferior turbinated bone. B. Middle turbinated bone. C. Superior turbinated bone. D. Hard palate. E. Velum palati. F. Posterior pharyn- geal wall. G. Roscnmuller's fossa. H. Posterior lip of the orifice of the Eustachian tube. metal ring fastened to its posterior extremity is pointed toward the outer canthus of the eye of the same side." (Fig. 36.) " The direction of the beak corresponds, as a rule, with the axis of the Eustachian tube." (Polit- METHODS OF EXAMINATION OF THE EAR. 75 zer.) The catheter can be held in position by the sur- geon, or, for this purpose, various clamps have been devised. Second Method: By this method the posterior margin of the nasal septum serves as a guide. The catheter is introduced in the same way as in the first method, until the point reaches the posterior pharyngeal wall. In- stead of turning the point outward, it should be turned inward, so that the extremity points toward the other Eustachian orifice. It is brought to a horizontal posi- tion, as determined by the metallic ring on the other end of the catheter. The catheter is then withdrawn until the curved portion reaches the posterior border of the nasal septum. The point of the catheter is now made to describe a complete semicircle by moving its point downward along the velum palati, and then outward. It should thus enter the pharyngeal orifice, and be in- serted afterward in the tube in the same manner as by the first method. Any action of the muscles of these parts that pushes the point of the catheter backward or throws it out of position will interfere with the success of this method. Before the introduction of the catheter the external extremity should be connected with the Politzer bag by means of a piece of rubber tubing about a foot in length, and the bag should have an aperture on the side which can be closed by the thumb of the surgeon when the same is compressed, so that it will be possible for air to enter the bag again without the necessity of disconnecting the tip of the Politzer bag after each compression of the bag, a procedure that is usually extremely disagreeable to the patient. I prefer, in adults, catheterization to the inflation of the ear by Politzer's method, whenever practicable, for 76 MANUAL OF OTOLOGY. several reasons : 1. The air enters the middle ear much more directly, and much more is accomplished by this method when it is carefully performed. 2. Very frequently it is only necessary to force air into one middle ear. Politzer's method should always be employed in the ease of children and in nervous in- dividuals. Before inflating the ear the drumhead should be examined to see if atrophic changes may not have made it very thin. During the first compression of the air-bag very little force should be used. I have seen the drumhead ruptured by Politzer's method when suflScient gentleness was not used in a case iu which the drumhead had become very thin. The obstacles to the introduction of the catheter are various pathological processes that involve the nasal passages, such as hypertrophic catarrh, polypi, adenoid growths, and congenital deformities of the nasal sep- tum and spongy bones. In acute inflammation of the middle ear, with swelling of the orifice of the Eustachian tube, catheterization is difficult and painful, as well as in some individuals in whom its accomplishment is prevented by spasmodic coughing or vomiting. When catheterization is impossible, owing to constriction of the nasal passages, air has been forced into the middle ear by the introduction of a catheter through the oppo- site nasal passage. Various catheters have been devised for this purpose, but the method was first advocated by Deleau in 1827. The diagnostic tube should be used, as in Politzer's method, to determine the permeability of the Eustachian tube, as it is unwise to rely on the statement of the patient. METHODS OF EXAMINATION OF THE EAR. 77 TESTS FOR HEARING. The tests for the hearing-power are of the highest importauce, for by such means the surgeon is usually enabled not only to locate the seat of the trouble, whether in the middle or inner ears, but also to note the course of the disease and the results obtained by treatment. The ear perceives sound-waves communicated to it through the air as well as vibrations transmitted through the cranial bones, so that it is most important in all cases to make separate tests of this power of perceiving these waves. The watch and Politzer's acoumeter are generally used for determining the acuteness of hearing for sound waves transmitted through the air to the drumhead. It is best to have two watches for this purpose, the tick of one being higher than that of the other. First of all, the distance heard by the normal ear is determined and found to be, for example, fifty-six inches. This number will represent the denominator, so that if a patient hears the watch at ten or twelve inches, his hearing distance for the watch should be recorded as being ten-fifty-sixths or twelve-fifty-sixths inches. The patient's normal ear should be carefully stopped by in- serting the moistened finger into the meatus: then the watch should be held at the normal distance from the affected ear, and gradually brought toward it. The patient's eyes should be closed. It is well also to let the patient hear the watch tick before commencing the test. If the watch is placed in contact with the ear and gradu- ally moved further away, the patient will hear the tick at a much greater distance than if the reverse be done. As all watches vary very much as to the pitch and 78 MANUAL OF OTOLOGY. intensity of sound, tests made in this way are necessarily unsatisfactory. For this reason Politzer has devised an acoumeter (Fig. 37), which consists of a horizontal steel cylinder, 28 mm. long, and 4.5 mm. thick, con- nected, by means of a tightly fitting screw, with a perpendicular vulcanite column, at the superior and inferior extremities of which are two semicircles for holding the instrument, the forefinger being placed in the upper, and the thumb in the lower one. A per- cussion hammer is placed just above the attachment of the cylinder, being fastened in an oval orifice of the vulcanite column. This hammer, falling upon the Fig. 37. Politzer's acoumeter. steel cylinder, produces the sound. The posterior short lever of the hammer, when pressed, is not allowed to go beyond a check, which consists of a soft India- rubber plate, so that the hammer always falls the same height and should produce the same sound. There is a ring on the vulcanite column for the insertion of a pin having a round metal plate attached. This pin is inserted and applied to the temple or mastoid process, in order to determine sound vibrations through the cranial bones, and also in cases of extreme deafness, when it is placed in contact with the opening of the external meatus. The hearing distance for the acoumeter should be measured by means of a tape measure, or, better METHODS OF EXAMINATION OF THE EAR. 79 still, the number of feet and inches should be marked on the wall or floor. The only objection to this instru- ment is the fact that it is heard by the normal ear at a distance of forty-five feet, so that in cases of slight deafness it is better to make use of the watch. The patient's hearing power for speech should always be tested, viz., for ordinary conversation as well as for the whisper. Investigations made by Oscar Wolf go to show that vowels are generally perceived at a greater distance and more readily than consonants, and espe- cially words in which the vowels a, e, and i occur. Fre- quently in patients the hearing power for the watch is very good, while conversation is heard with difiiculty, and vice versa. Whispered speech is heard by the average normal ear at a distance of about fifty feet. It must be remembered that the hearing power in a patient is subject to great variations, not only on dif- ferent days, but on the same day. In those affected with atrophic catarrh this is particularly noticeable, the auditory nerve becoming fatigued in a very short space of time, even while the tests for hearing are being made. Note should be made in taking the history of a case as to whether the patient hears high, medium, or low tones of speech. Tests made with the voice are not wholly satisfactory, as it is difficult to raise the voice to the same pitch at each examination. Each ear should be separately tested, and the ear being examined should be directed toward the surgeon, while the other one should be closed with the moistened finger. Besides the watch and acou meter, the aural surgeon should be equipped with (1) several tuning-forks, usu- ally three in number, C— 128, C='— 512, ,C*— 2048 (Politzer), (2) Konig rods, (3) a Galton whistle, (4) 80 MANUAL OF OTOLOGY. several shrill whistles and musical instrumenls for test- ing the hearing of those who are extremely deaf. Ex- periments prove that low-toned tuning-forks when vibrating are better heard when held close to the ear than the high ones, in cases of labyrinthine disease, while in middle-ear affections in which there is consid- erable inability to hear speech, low-toned tuning-forks are but faintly heard. It is well to have clamps attached to the extremities of the forks to prevent overtones. By means of the tuning-fork, a diagnosis can usually be made between disease of the middle and internal ears. In a normal case the tuning-fork, when vibrating and held close to the ear, will be heard more distinctly and louder than when placed against the mastoid pro- FlG. 38. Blake's tuning-fork. cess or on the side of the skull. In other words, the aerial conduction will be better than the bony conduc- tion. If the finger be inserted in the external meatus, the sound will be intensified on the affected side when the tuning-fork is placed against the mastoid process or on the top of the head or against the teeth. The same is true of disease involving the external or middle ear. In a case of deafness, when it is found that a patient hears the tuuing-fork better by the air than by the bone, it is fair to assume implication of the sound-perceiving apparatus, and when the bone conduction is lost it is certain that labyrinthine disease exists. Where one tuning-fork alone is used, the tuning-fork of Blake, METHODS OF EXAMINATION OF THE EAR. 81 512 V. s., see Fig. 38, is to be preferred. As a general rule, although there are exceptions, the higher tuning- forks are heard much better by aerial conduction than the lower ones in cases of disease of the middle ear. The Galton whistle is especially suited for testing the perception of the high notes, and consists of a cylindrical whistle. By turning the screw the note can be changed, and around the side of the whistle is a scale to show the numbers. The whistle has a compass of more than the three highest octaves, with about 6000 — 80,000 vibra- tions per second. Besides the Galton whistle, the Konig rods will be found particularly useful. They consist of rods or cylinders of steel which are of different lengths, producing vibrations of from 20,000 to 80,000 in the second, with intervals of 5000 vibrations. The power of perception of sound transmitted through the cranial bones becomes very much diminished in old age. According to Politzer, after the sixtieth year the cases are rare in which a low-ticking watch is heard through the cranial bones. Einn6's test consists in placing a vibrating tuning- fork against the side of the skull or mastoid process. "When the sound is no longer perceived by bone-con- duction, the fork should be held close to the auricle without again striking it. If heard again, which is the case in the normal ear, this is called the positive Rinne test. The reverse is called the negative Rinne test. This test is of particular value in cases of con- siderable deafness due to middle-ear affections, the nega- tive Einn6 test being marked in these cases unless there is some implication of the labyrinth. In middle-ear affections in which the deafness is slight, Weber's test is more accurate. 82 MANUAL OF OTOLOGY. Weber's Test. A vibrating luaing-fork, usually of 512 V. s., is held on the median line of the skull, or on the forehead just above the nose, or against the teeth or on the median line of the lower jaw, and the conclusion can be reached as to whether (he bone conduction is better on one side or the other. With both Weber's and E.inne's tests in ordinary cases of deafness, a diag- nosis should be made between disease of the middle ear and labyrinth. Occasionally it happens, although rarely, that the vibrations of a tuning-fork sound one-quarter or one- half a tone higher in one ear than the other. This is prob- ably due to increased tension of the labyrinthine fluids produced by pressure of the stapes, or it may be due to congestion of the labyrinth itself. Only one ear is apt to be affected, and it is an easy matter for the surgeon to determine which one it is by holding the tuuing-fork close to his own ear, so that when the patient sings the note heard, he recognizes which side is affected. I have observed this phenomenon in both middle-ear and labyrinthine diseases. In the former the treatment consists of inflation of the middle ear by means of the catheter, and by appropriate treatment for the naso- pharynx, if this region is affected. In labyrinthine dis- ease I have seen it occur in a patient who had a severe attack of influenza. In this case the middle ear was not iuvolved, and the symptom persisted for a long time. CHAPTER III. DISEASES OF THE AURICLE. Malformations. Malformations of the organ of hearing may exist alone or be associated with malforma- tions of other organs, such as want of development of the eye or side of the face on the same side. There may be congenital excessive development of the auricle, the development of two auricles (polyotia), or so-called au- ricular appendages. According to Cassells, excessive development is usually limited to the auricle itself, while want of development is apt to occur with defect of development of the external meatus and tympanum, less frequently with defect of the internal ear. There may be entire absence of the auricle, malformation or absence of the different portions of the ear, viz., the lobule, helix, and antihelix. Imperfect development (microtia) is more frequent. The auricle is generally out of place in such cases, and may resemble a cat's ear ; the lobule is at times adherent to the skin. I have reported a case * of malformation of the auricle in which I performed a plastic operation for the cure of the same. The deformity occurred in a young girl of fourteen. The auricle was attached somewhat higher than the normal one on the other side, and hung down as shown in Fig. 39. The hearing distance was con- siderably affected. The operation consisted in the re- ' Archives of Otology, 1890, vol. xix. No. 1. 84 MANUAL OF OTOLOGY. moval of an elliptical portion of the integument and connective tissue, three-quarters of an inch in width and two and a quarter inches long, from the posterior and upper portions of the auricle, commencing the inci- sion at the beginning of the helix and carrying it along the fold at the attachment of the auricle almost to the Fig. ; Deformed auricle. (Before operation.) lobule, so as to leave as little scar as possible. The integument and connective tissue having been dissected away, the cartilage was bent back upon itself, but not divided, and the different folds and depressions on the auricle were brought out again by this procedure. It was necessary to keep a pad with an elastic band over the ear for a short time. The result was excellent and the hearing distance was improved. (Fig. 40.) This operation can likewise be performed in cases of very DISEASES OP THE A UBICLE. 85 prominent auricles. Congenital deformities are, accord- ing to Virchow, due to early disturbances in the closure of the first branchial cleft, and are often associated with cleft palate and other forms of arrest of development in the facial bones. FiQ. 40. Deformed auricle. (After operation.) A fistula auris eongenita is a short blind canal, with a lining of epithelium which secretes a whitish or milky fluid. The orifice is usually visible just in front of or below the tragus, and there is no communication with either the tympanum or the external auditory canal. Injukies. Injuries of the auricle are not frequently observed by the aural surgeon, as they are more apt to fall into the hands of the general surgeon. Cuts, bruises, burns occasionally occur, and should be treated according to the usual surgical procedures. A case has 86 MANUAL OF OTOLOGY. been reported in which the entire auricle was bitten off by a horse. Traction ou an ear-ring occasionally is the cause of a cleft lobule. The wearing of brass ear-rings at times sets up a severe inflammation of the lobule, and in a case that came under my observation, there was intense inflammation, followed by sloughing of half of the lobule on each side. Since football has become so popular a game, injuries of the auricle are of more fre- quent occurrence. In stitching an incised wound it is well not to include the cartilage, but simply to carry the sutures through the integument ; otherwise there is a liability that necrosis of the cartilage may occur. HEMATOMA AuEis OK Oth^jiatoma. An hsema- toma is the name applied to a swelling, of a bluish-red color, which is due to a sudden effusion of blood betweeu the cartilage and perichondrium, and which is usually caused by a sudden blow on the ear, and is of frequent occurrence among boxers. Such a tumor is at times observed among the insane, and formerly it was sup- posed to be due to ill-treatment. This may have been the case in some cases, but it is more probable that the effusion in such instances is caused by tissue changes in the auricle itself. By severing the restiform body in ani- mals, Brown-S^quard was able to produce a hemorrhage in the auricle. The swelling, when observed imme- diately after its appearance, is of a bluish-red color, roundish in shape, somewhat hard, but with no distinct point of fluctuation. In some instances it is quite soft to the touch. Othsematoma occurring spontaneously is rarely of large size, while in cases due to traumatism the swelling may involve the entire auricle, including both surfaces, and occlude the external meatus, thus producing considerable deafness. Generally, the swelling DISEASES OF THE AURICLE. 87 involves the concha and fossae of the helix and anlihelix, but not the lobule. In othsematoma due (o traumatism there are usually pain, heat, and more or less tenderness. The resulting deformity will depend very much on the extent of the hemorrhage and the injury done to the cartilage. Othsematoma should not be confounded with perichondritis auriculae, as the former occurs suddenly and is generally caused by a blow. As to the treatment, when the swelling is slight, the application of cooling lotions, such as the lead and opium wash, may cause the hsematoma to disappear. I have found it best, however, especially when there is much swelling, to incise the tumor at once and turn out the blood-clots and treat the wound antiseptically. In a case treated recently in this manner I washed out the cavity of the tumor thoroughly with a 1 : 10,000 bichloride solution, and sutured the edges of the wound except at the lowest point, where I inserted a small tent of iodoform gauze. I applied a pad and bandage, with the result that there was little if any deformity. Massage is recommended by some, but should be cau- tiously used. Peeichondeitis AuRiCDLiE. This is a term ap- plied to an acute inflammation of the perichondrium, giving rise to a swelling which is generally hot and painful to the touch, of a darkish-red color, and varying much in size in different cases. It is usually found on the anterior aspect of the auricle, and may close the ex- ternal meatus, and thus interfere seriously with the hearing on the affected side. If an incision were made in one of these tumors, its cavity would be found filled with a thick yellowish fluid, less frequently with pus, and only occasionally are there observed a few red 38 MANUAL OF OTOLOGY. blood-corpuscles. The perichondrium becomes detached from the cartilage, and the latter and the surrounding parts are greatly inflamed, leading to more or less thickening of the tissues with deformity of the auricle. If an incision be. made in the tumor and a probe intro- duced, the cartilage will frequently be found denuded and roughened. The inflammation occasionally has its starting-point in the external meatus, and generally involves the concha and fossa helicis, but does not extend to the lobule. Perichondritis should be distinguished from hsematoma (1) by the fact that traumatism is not apt to be the cause ; (2) in perichondritis, the inflammatory symptoms are more severe and the development of the tumor is more gradual ; (3) the contents of the swelling are either a clear, thick, syrupy fluid, or purulent, while in othsematoma there is always blood at first. In the later stages a differential diagnosis becomes more diffi- cult, as an othaBmatoma may also contain a clear syrupy fluid or pus. The deformity is quite marked in some cases of perichondritis, although in some few instances it may be but slight. The duration of the disease varies from two to ten weeks. In the early stage the treat- ment should be entirely antiphlogistic, consisting in the application of cooliug lotions, lead and opium wash. Later, the tumor should be incised as soon as fluctuation is detected, and thorough aseptic precautions should be observed. A pad and pressure bandage will be found beneficial in some cases as well as massage. Some authors advise the use of a hypodermic needle for the purpose of withdrawing the fluid, and afterward inject- ing into the cavity a solution of tincture of iodine one part, water two parts, and allowing it to remain there dis:eases of the auricle. 89 for a few moments, when it is withdrawn by means of the syringe. Cysts. Under this heading cases have been reported in which tumors in the auricle have developed without any apparent signs of inflammation. The contents con- sist of a clear fluid without any flocculi or blood-cor- puscles. As for a differential diagnosis between cysts and perichondritis, Hartmann considers " that inflam- matory phenomena are altogether absent in cases of cysts, while perichondritis is accompanied with redness, heat, and severe pain. The contents of the swelling in perichondritis are similar to that in cysts, yet the fluid has an unclean, purulent character from the admixture of pus-corpuscles." Certain changes which predispose to the formation of sanguineous tumors are found in the auricle, especially in the dyscrasic and insane as well as in the. aged. Hartmann believes that the process of softening which has been described by different authori- ties is not only the predisposing cause of hsematoma, but is also to be regarded as a preliminary stage of simple cyst-formation. Cases of hsematoma due to traumatism occur quite frequently, however, where there are no changes in the cartilage. Hyperemia. This is observed in some cases as a result of frostbite or eczema, or other cutaneous dis- eases ; also in patients of a neuropathic and hysterical temperament, and in those suffering from valvular disease of the heart. Hypersemia may also be due to the action of heat or cold. The application of poultices may also produce a hypersemic condition and lead to the formation of small abscesses. As to treatment, the cause should be removed, if possible, by constitutional measures. Locally, the lead and opium wash is to be recommended. 90 MANUAL OF OTOLOGY. Dermatitis. Inflammation of the skin of the auricle may be due to the sting of insects, the effects of heat or cold, or to blows, falls, piercing the ears for ear-rings, and mechanical irritation and scalding. The inflam- mation may be very slight or severe enough to lead to gangrene. In the early stage antiphlogistic treatment should be employed by applications of cooling lotions. Erysipelas. According to some writers, erysipelas affecting the auricle may occur as a primary or idio- pathic disease from cold or other causes, but more fre- quently it is due to an extension of the inflammation from the surrounding parts. Leech-bites somet imes cause ery- sipelatous inflammation, as well as injuries to the walls of the external auditory canal, in persons whose general health is impaired. In the light of modern science, it is now generally admitted that erysipelas is due to in- vasion by Fehleiseu's streptococcus erysipelatis. Two cases ^ of erysipelas of the auricle and face, occur- ring as a complication of disease of the ear and secondary to it, came under my observation. In one the patient had an acute suppurative otitis media, and two weeks later the autitragus became tender and inflamed, and on the following day the entire auricle was involved in an erysipelatous inflammation and was twice its natural size. The auditory canal was not involved, but the dis- ease extended ever the scalp and face. When the disease first appeared the discharge from the ear became scanty. The patient had a chill at first, and the temperature varied from 100.5° to 104.5°. He complained also of dizziness. In the second case erysipelas of the auricle followed an attack of acute suppurative otitis media and 1 Archives of Otology, 1887, vol. xvi. No. 2. DISEASES OF THE A UBICLE. 91 furunculosis of the external meatus. The erysipelatous inflammation spread from the tragus of the left ear to the scalp and face, and involved the right ear as well. This patient had a temperature ranging from 102.4° to 104.6°. In both cases the pulse was slow and full, and the general health was below par. In the second case the erysipelas lasted for a week. It is also prob- able that erysipelas of the pharynx may spread to the face by raeaos of the Eustachian tube, tympanum, and external auditory canal. As to treatment, I have seen excellent results follow the administration of drop-doses of tincture of aconite and tincture of belladonna. Locally, the liquor plumbi et opii should be applied. Feostbite. If the auricle be frozen, the ear be- comes yellowish-white in color, and in extreme cases, -if actually congealed, it may be brittle. To restore the circulation in the parts, the patient should be placed in a cool room, and friction should be applied, very gently at first, to the auricle with snow, and afterward with cold water. After the re-establishment of the circulation, warmer water may be used. In favorable cases the circulation becomes re-established, but the auricle is apt to be sensitive for some time afterward. Where the auricle has been frozen and proper treatment has not been carried out, there may result severe inflammation, such as perichondritis, leading ultimately to gangrene. In the latter case amputation becomes necessary. Red- ness and burning of the auricle resulting from frostbite should be treated with cooling lotions; when chronic, the local application of iodized collodion. When the skin is excoriated, equal parts of zinc oxide and boric acid should be dusted over the parts. When ulcera- 92 MANUAL OF OTOLOGY. tions occur as well as gangrene, general surgical pro- cedures should be adopted. Eczema, Acute and Chronic. Eczema afEecting the auricle is very similar to the disease occurring else- where, except that the hearing is liable to be affected, especially when the auditory canal and membrana tympani are involved. The varieties are the erythem- atous, vesicular, pustular, and squamous. The disease may be acute or chronic, although the former is more usual; it may attack all ages and sexes, but is more frequent among children and females. Eczema occur- ring about the pinna may be idiopathic or secondary to that occurring about the head or face. In the acute idiopathic variety one or both auricles may be attacked, or the disease may be limited to one side. , The auditory canal may or may not be involved. In the acute stage the ears are usually swollen, the seat of much burning and itching, and covered by vesicles or pustules, which may become dry and so envelop the auricle with un- sightly crusts. The auricle, in consequence, becomes deformed and unshapely; the meatus may be closed by the collection of crusts or through swelling of the parts, and, as a result, the hearing becomes impaired, so that a sense of fulness in the ears and tinnitus are often com- plained of. Painful rhagades may be found behind the ear. In chronic cases the auricle may be considerably thickened, leading to deformity and stenosis of the external meatus. (Fig. 41.) In children eczema is aggravated by uncleanliness, by picking at the ear, by the use of unsuitable head-coverings, by which means the ears are pressed against the side of the head, thus causing an eczema intertrigo through friction of the surfaces. Anything that tends to impair the gen- DISEASES OF THE A URIOLE. 93 eral health, such as dentition, will act as an exciting cause. An artificial eczema is frequently due to the instilla- tion of improper ear drops, an excoriating discharge from the ear, the effects of heat and cold, and, especially in children, to pediculi about the head. Pig. 41. Thickening and deformity of the auricle, due to chronic eczema. In acute eczema good results often follow the admin- istration of the fluid extract of viola tricolor in x-xx minim doses, especially in young subjects. Particular attention should be paid to the patient's general health. The urine should be examined for albumin or sugar. Diuretics and alkaline waters are required for those of a gouty or rheumatic diathesis. In scrofulous children, cod-liver oil, syrup of the iodide of iron, and the com- pound syrup of the hypophosphites should be prescribed. In chronic eczema Fowler's solution of arsenic should 94 MANUAL OF OTOLOGY. be administered. Nasopharyngeal catarrh or middle- ear disease, if it exists, should receive careful treatment, and the condition of the mouth should be noted to see that there is no dental irritation. As regards local treatment, I have found the officinal zinc ointment all that is required, or the unguentum diachyli of Hebra. The crusts should first be removed, and then the parts well rubbed several times a day with the ointment. When the auditory canal is invaded, the crusts and scales should be gently removed with curettes, and then the zinc ointment applied, or, what is better, the canal may be dusted with a powder composed of equal parts of zinc oxide and boric acid. Occasionally it will be necessary to remove the scales from the meatus by syringing; but, if possible, no water should be used. Should the disease show a tendency to become chronic, especially if there be any thickening, the following ointment will answer well: Acidi tannici, 3j ; vaselini, Sj. — M. In making applications to the external auditory canal, great care should be employed not to injure the membrana tympani. Another ointment for a dry and scaly eczema of the external meatus is the following: Acidi salicylici, gr. j ; tr. benzoini, gtt. ij ; ung, rosse, 3J.-M. In such cases benefit will often follow the applica- tion of a solution of nitrate of silver, grs. x-xx to water Sj, or of acetum cantharidis ; but in painting the canal with the latter, great care should be exercised not to touch the membrana tympani. Ointments containing tar or white precipitate of mercury are occasionally in- dicated in chronic eczema. The following skin diseases are also observed at times on the auricle, associated with the same diseases else- DISEASES OF THE A UBICLE. 95 where on the body, viz., herpes zoster, lupus, erythema, prurigo contagiosa, keloid, molluscum fibrosum, tinea tonsurans, for the treatment of which the reader is re- ferred to the standard works on dermatology. Ossification of the auriole as a result of perichondritis has been reported, but is of very rare occurrence. Deposition of the urates is noticed occasionally in the auriole of a gouty subject. TuMOES OF THE AuRiCLE. Under this heading may be mentioned abscess, atheroma, or sebaceous cyst, fibromxi, myxofibroma, malignant growths, dermoid cysts, warts, papilloma, angioma, lipoma, ncevus maternus, aneu- rismal dilatation of arteries, and cornu cutaneum. Atheroma, or sebaceous cyst, is due to the blocking of a sebaceous gland and the rapid increase of its contents. It is usually fouud in the integument just behind the lobule and close to it, or in the lobule itself. The cyst should be removed with its sac entire, if possible. When the sac cannot be dissected out, the walls of the cyst should be curetted so as to remove every trace of the sac as well as any purulent or cheesy matter. Fibroma. Cases of iibroma are observed at times, the growth, as a rule, involving the lobule. The dis- ease may affect one or both lobules, and is occasionally due to piercing the ears, and is found quite frequently in the case of negro women. A fibroma is made up of fibrous connective tissue, with an occasional admixture of mucous tissue ; it is of a round or globular shape, so uewhat movable, and of more or less firm consistency. After total removal the tumor is not apt to recur. I have reported a case of a fibroma' affecting the lobule 1 " Tumors of the Auricle," Annals of Ophthalmology and Otology, July, 1893, vol. il. No. 3. 96 MANUAL OF otology: of each auricle ia the person of a young lady, aged seventeen, who had had her ears pierced four years previously, and immediately afterward the lobules began to enlarge. The other growths sometimes noticed in the auricle, and previously mentioned, should be excised, if possible, and treated on general surgical principles. Among the less frequent tumors that are occasionally observed may be mentioned cylindroma or myxoma cartilagineum, originating in the cartilaginous meatus, and enohon- droma, having its origin from the cartilaginous portion of the external auditory canal. Syphilitic Diseases. Chancres and gummata have been found on the auricle, but very infrequently. Tu- bercular sypMlides on the auricle have been reported, and these may lead to deep ulcerations. Papular, pustular, and squamous eruptions are observed, but usually in connection with similar eruptions about the scalp and forehead. CHAPTEE IV. DISEASES OF THE EXTERNAL AUDITORY CANAL. Malformations. Excesses of development occur among the malformations of the external auditory meatus, such as unusual dilatation and a double condi- tion of the auditory canal. There may be two separate canals, or a blind canal behind the normal one. Much more frequent, however, are the defects in the formation of the auditory canal, which are usually asso- ciated not only with defects of the auricle, but with defects of the middle ear, and frequently with arrest of development of the cranial bones. The canal may be very narrow or absent, with simply a depression where the meatus should exist. The contraction may be bony or membranous, usually the former. The hearing in such cases varies according to the amount of atresia, but even when there is complete occlusion, if the laby- rinth be normal on the affected side, there will remain some hearing power. As to the propriety of operating on such cases, the general opinion is decidedly against any such procedure, unless there is some urgent necessity for the same, espe- cially if the patient have one good ear. Even when there seems to be every indication that a bony canal exists beneath the integument, the surgeon will often be disappointed if he attempts an operation. When an operation is performed, a crucial incision should be 7 98 MANUAL OF OTOLOGY. made through the soft parts down to the boue, and a silver tube should be inserted to keep the passage open. In such cases there is always difficulty in accomplishing this, as granulations form rapidly and have a tendency to force the tube out. OTITIS EXTERNA DIFFUSA ACUTA, OE ACUTE DIFFUSE INFLAMMATION OF THE EXTERNAL AUDITORY CANAL. Acute diffuse inflammation of the external auditory canal may occur as a result of the iastillation of im- proper drops into the ear, and in a case under my ob- servation St. Jacob's oil caused acute inflammation of the external meatus, as well as of the middle ear. In- juries to the canal from scratching it with hair-pins and other such instruments, to relieve itching, frequently cause diffuse inflammation. Sea-bathing is another cause. As an idiopathic disease, I believe this affection to be extremely infrequent, although cases do occur, followed by suppuration, in which the middle ear is not involved. Diffuse inflammation of the external meatus is of common occurrence in cases of middle-ear suppu- ration, when the discharge is acrid, also in cases of furuncular inflammation of the external auditory canal. Symptoms. In the early stage the meatus is greatly congested, especially so about the bony canal and ex- ternal layer of the drumhead. The cartilaginous por- tion may in some eases be so swollen that but little of the osseous canal is visible. The external meatus be- comes very narrow from the swelling of the tissues, and the dermal layer, being white and sodden from a serous discharge, peels off, lieaving the canal and drumhead extremely red and excoriated. Frequently the dermal DISEASES OF EXTERNAL AUDITORY CANAL. 99 layer peels off, and can be removed by syringing in the form of the canal. On microscopical examination of the dermal lining, micrococci will be found. After removal of the finger-like tube, the canal and drum- head will be found greatly congested and all land- marks of the latter will disappear, so that the bound- ary between the membrana tympani and canal will be lost. The subjective symptoms are radiating pains, especially when moving the jaw, and when the surgeon makes pressure on the tissues in front of the tragus. In some cases there are tinnitus and dizziness ; in others, a sense of itching in the canal precedes the inflammation. The duration of the attack varies from a few days to two weeks, or longer if the disease becomes chronic. The degree of deafness will depend very much on the severity of the inflammatiou. When the canal is very much narrowed and filled with dermal scales, or the outer layer of the drumhead is swollen, there will be considerable interference with the function of hearing. Instead of recovery ensuing in due time, there may be several exacerbations, or ulceration may develop on the drumhead, leading to perforation of the same from without inward; or ulceration may occur on the osse- ous canal, and granulations may spring up from the ex- posed bone. If the disease become chronic, there is usually a thick offensive discharge, containing scales of epidermis and pus cells with micrococci. As the drum- head appears dullish red, difficulty will be experienced in making a differential diagnosis between diffuse in- flammation and chronic otitis media purulenta, espe- cially if there are granulations on the drumhead. 100 MANUAL OF OTOLOGY. There may be granulations and ulcerations on the walls of the canal which may lead to the formation of mem- branous bands, thus causing atresia of the external meatus. As a result of chronic diffuse inflammation, there may follow hypertrophy of the cutis or periostitis of the bony meatus, as well as caries and necrosis. In some instances the inflammation may extend to the parotid gland. Teeatment. In acute cases in which the inflam- mation and pain are not severe, a saturated solution of boric acid should be instilled frequently into the ear. When the inflammation is severe, however, the artifi- cial leech should be applied close to the tragus, and drops of a 4 per cent, solution of cocaine should be used or drops containing liq. Magendie, 3] ; water, Sj. If the canal becomes very narrow from swelling, free in- cisions should be made through the skin and perios- teum. After the acute symptoms have subsided, espe- cially if there be much discharge, and after removing all pus and scales from the meatus by means of the syringe and curettes, boric acid powder should be in- sufflated, or a powder containing equal parts of boric acid and zinc oxide. When the disease has become chronic, and especially if there be granulations, alcohol drops (either pure alcohol or diluted one-half with water and containing boric acid, grs. xx to §j), should be used. In some cases iu which granulations arise from bare bone, these should be removed with a sharp spoon, and the bone scraped. In other cases the granulations may be cauterized with nitrate of silver fused on the end of a probe, or with chromic acid. DISEASES OF EXTERNAL AUDITORY CANAL. IQl OTITIS EXTERNA CIRCUMSCRIPTA ACUTA, OR ACUTE CIRCUMSCRIBED INFLAMMATION OF THE EXTERNAL AUDITORY CANAL, OE FURUNCULOSIS. This is qnile a commoa complaint, especially among those who are suffering from impaired health, and it is occasionally observed among diabetic patients. Furun- cles, however, are found at times in the case of those who are strong and healthy, but children are usually free from them. Mechanical irritation of any kind may be the exciting cause of a furuncle, such as too fre- quent syringing, scratching the ear with a hair-pin or some other instrument to relieve itching of the external meatus. Furuncles may develop during the course of chronic purulent otitis media, or as a result of chronic eczema of the external meatus. There is undoubtedly a micro-organism present to account for the inflam- mation, most frequently the staphylococcus pyogenes aureus and albus, which, according to Loewenberg, finds its way into the superficial layers or deeper parts of the skin by means of the hair follicles or glands. The seat of the inflammation is, as a rule, in the car- tilaginous portion of the external auditory canal. Symptoms. Pain is a prominent symptom, varying in intensity according as to whether the furuncle is seated in the superficial layer of the cutis or in the deeper parts. The patient usually experiences great pain on moving the jaw and on making slight traction upon the auricle. The pain is generally very severe, and keeps the patient from getting any rest at night. There is usually loss of appetite, and fever may or may not occur. When the drumhead is involved or when the lumen of the canal is closed by a furuncle, tinnitus 102 MANUAL OF OTOLOGY. aud deafness will be complained of. Another cause of deafness is a blocking up of the meatus with pus and scales. The seat of the furuncle is usually on the ante- rior inferior wall of the cartilaginous meatus, although there may be several furuncles. When situated on the anterior wall, pain is usually complained of when press- ure is made on the tragus. When on the posterior wall, however, there are very often considerable swelling and redness of the tissues over the mastoid process, which is frequently mistaken for mastoid disease if a careful examination of the external auditory canal is not made. After from three to five days the furuncle will break down and discharge pus ; the more superficial the furuncle, the more readily will it discharge into the meatus. Occasionally the f uruncular inflammation will subside without bursting. After evacuation of the pus, there is usually immediate relief, viz., the pain and other symptoms subside. This is not an invariable rule, however, for at times exacerbations occur, and other furuncles follow one another as a result of the in- vasion of the follicles or glands by the staphylococci. At times there will remain redness of the canal and in- filtration of the tissues after the abscess has subsided, and occasionally granulation tissue springs from the opening in the furuncle, which necessitates its' removal with the curette or snare. There is usually no difficulty in making a diagnosis of furunculosis, especially if a probe be used to touch the parts. A polypus is sometimes mistaken for a furuncle, and so is an exostosis, but the latter when touched with a probe will seem hard and bony. Treatment. In the early stage, especially if the pain be severe, the artificial leech should be applied. DISEASES OF EXTERNAL AVDITO&Y CANAL. 103 and in some cases Leiter's coil will be found useful. When the furuncle is deep seated and very painful, an early and free incision should be made in the abscess, and also in all cases in which fluctuation can be de- tected, as well as in those in which the abscess has burst spontaneously, but in which the openiug is small. After incising the furuncle, it is advisable to syringe the external meatus with a 1 : 3000 bichloride solution, and to direct the patient to instil into the ear a warm saturated boric acid solution frequently during the day. Warm conical-shaped carbolized poultices incased in gauze sometimes afford great relief. The patient should be directed to paint the canal with carbolic glycerin (1 : 30), or to instil drops of bichloride or boric acid solution in order to prevent the bacteria from advancing farther. Menthol is fre- queutly used, and also hydrogen peroxide in cases of furunculosis. Owing to the debilitated and ansemic condition fre- quently observed among these patients, particular at- tention should be paid to the general health. When the furuncle first appears, it is advisable to give the patient several small doses of calomel, to produce a slight laxative effect. The sulphide of calcium, in one- twentieth to one-tenth grain doses, administered every three hours, has seemed to me to have a most curative effect in many cases. For chlorotic females large doses of iron should be prescribed, and the diet should be a nourishing one. Cod-liver oil and the syrup of the hypophosphites are also useful. After the disappear- ance of the furuncle, the patient will often complain of considerable irritation and itchiug about the external meatus. To remove this, ointments containing boric 104 MANUAL OF OTOLOGY. acid or white precipitate of mercury should be applied very lightly to the canal. OTITIS EXTERNA HiEMOKRHAGICA. There seems to be a difEerence of opinion among otol- ogists as to the significance of hemorrhagic vesicles on the walls of the bony auditory canal. The majority of writers^ if they mention the occurrence of these vesicles at all, attach no particular importance to them, consid- ering them for the most part as evidence of middle-ear inflammation. That these vesicles are found in the canal in cases of severe inflammation, no one will deny who has had much experience in the treatment of aural cases. I have likewise seen several cases, which I have re- ported,^ in which such effusions of blood occurred inde- pendently of any middle-ear inflammation, and to my mind constituted a hemorrhagic inflammation of the auditory canal. At first there are usually some pain, slight deafness, and tinnitus. On examination there will be found one or more long shaped swellings in the bony canal, usually on its inferior wall and extending to the drumhead on one side and to the cartilaginous meatus on the other. At times a vesicle is seen 'On the membrana tympani. The vesicle is due to inflamma- tion of the cutis, the dermal layer being raised by the sanguineous fluid. The vesicles are soft when touched with a probe, and are easily punctured. The inflamma- tion, as a rule, reaches its height on the third day, and the duration of the disease is from eight to fourteen days. The walls of the canal become covered with fine white scales. The treatment consists in puuctur- 1 Archives of Otology, 1890, vol. xix. No. 1. DISEASES OF EXTERNAL A UDITORY CANAL. 105 ing the vesicles, evacuating their conteuts, and, after drying the canal with absorbent cotton on a probe, in- sufflating powdered boric acid. OTITIS EXTERNA CEOUPOSA — CROUPOUS INFLAMMA- TION OF THE EXTERNAL AUDITORY CANAL. This is a rare disease, in which the meatus and drumhead are covered by a layer of lymph similar to that found in croup occurring in the larynx. It is generally observed as secondary to otitis media or furunculosis of the canal. The exudate is made up of a tine network containing round cells, nuclei, and epi- thelium. The prognosis is favorable. The false membrane should be removed by syringing and forceps, and boric acid powder should afterward be blown into the meatus. OTITIS EXTERNA DIPHTHERITICA DIPHTHERITIC INFLAMMATION OF THE EXTERNAL AUDITORY CANAL. Diphtheritic inflammation of the external auditory canal is most frequently associated with diphtheria of the nasopharynx and middle ear, especially in cases of scarlet fever. Primary diphtheria of the meatus has been described by some writers as developing during an epidemic of that disease in a canal previously excori- ated from diffuse inflammation. The exudation, of a dirty-gray color, when removed leaves an excoriated and bleeding surface. The prognosis of diphtheria of the canal alone is apt to be favorable, but diphtheria of the middle ear may lead to serious complications, such as necrosis and loss of ossicles, necrosis of the tympanum and external bony meatus. Great deafness from sec- 106 MANUAL OF OTOLOGY. ondary involvement of the labyrinth may ensue. The glands at the angle of the jaw are frequently enlarged. Besides constitutional treatment, including the use of antitoxin, the ear should be frequently syringed with a bichloride solution (1 : 3000), and all scales, etc., re- moved with forceps. Afterward a powder consisting of equal parts of iodoform and boric acid should be in- sufflated. SYPHILIS OF THE EXTERNAL AUDITORY CANAL. Syphilitic affections of the canal are generally con- fined to condylomata, ulcerations, and at times gura- mata. Condylomata appear like granulations, but are differentiated from them by the existence of syphilitic manifestations on other parts of the body. Gummata are seldom confined to the external meatus, but attack simultaneously the middle ear. A gumma may lead to deep ulceration and destruction of the concha. Syphilitic nodules make their appearance at times in the meatus and on the drumhead, which may develop into ulcers. If the patient is improperly treated, the deep ulceration may lead to stricture of the canal. Besides constitutional treatment, such as the administration of mercury and iodide of potash, the ear should be syringed with a bichloride solution (1 : 3000), and all secretion and scales carefully removed. The lotio nigra or iodoform powder should be used. In some cases it will be necessary to cauterize the gum- mata, if very large, with chromic acid fused oh the end of a probe. OTOMYCOSIS. This is a name given to a parasitic inflammation of the external auditory canal. Aspergillus niger,, oe DISEASES OF EXTERNAL AUDITORY CANAL. 107 nigricans (see Fig. 42), is the fungus most couimouly observed, although there are other varieties, viz., the aspergillus flavus and aspergillus fumigatus. Fig. 42. Aspergillus nigricans. (Politzee.) A. Mycelium covered witli numerous fallen spores. B. Hypha. C. Sporan- gium with ripe spores. B'. Hypha. D. Receptaculum. E. Sterigmata with spores. Etiology. The disease is said to be frequent among the Russians who live in poorly ventilated and damp houses, dampness being favorable to the growth of the fungus. According to some writers, an abnormal secretion in the meatus, due to eczema or a slight dis- charge in chronic purulent otitis media, favors the growth of the fungus, while others believe that fungous growths are developed after the instillation of oily solutions. Very frequently the cause of the disease cannot be ascertained. Otomycosis is rarely observed in children or aged persons, but more frequently among the middle aged. 108 MANUAL OF OTOLOGY. while the poor are more often affected thaa those in better circumstances. Symptoms. When the superficial layers alone are affected, there are but few symptoms, but later, when in- flammation occurs, the patient complains of itching and pain, which may be quite sharp in some instances. There are usually some tinnitus and deafness. Appearances op the External Meatus. The canal, especially the bony portion, will be covered with loose scales, which, in the case of the aspergillus niger aud fumigatus, are studded with blackish spots. In cases of aspergillus flavus, the epithelial scales are cov- ered with mycelium, which appears like a yellowish powder. After removing the epithelial scales, the canal and drumhead are usually found red and swollen. The appearances of the disease are quite characteristic when observed through the speculum ; but in order to be sure of a diagnosis a microscopic examination is necessary. Besides the epithelial scales and network of mycelium, one observes under the microscope cylindrical filaments or fruit-stalks, which are supplied with septa or hyphse, and which support the fruit-capsule or head of the fungus. Prognosis. Tlie prognosis is favorable when the case is properly treated, but if neglected the disease may continue for a long time, with many relapses, until the fungus becomes exhausted. Treatment. After removal of all scales, etc., from the canal, the ear should be filled with a solution of bichloride of mercury in alcohol (1 : 3000). Absolute alcohol should be used if it does not cause too much burning, and should always be instilled warm. Other- wise water should be added to the alcohol. This treat- ment should be carried out two or three times a day for DISEASES OF EXTERNAL AUDITORY CANAL. 109 several days, and occasionally after this for several weeks in order to be certain of destroying the fungus. Other solations which are recommended are 2 per cent, alcoholic solution of boric acid or salicylic acid. Some surgeons prefer boric-acid powder instead of an alco- holic solution of the same. POLYPI. Granulations and polypi are found at times in the external auditory meatus, as a result usually of furun- cles or of caries or necrosis of the bony walls, although a fibrous polypus is occasionally met with. For the treatment of the same, the reader is referred to the chap- ter on Polypi of the Middle Ear. ECZEMA, ACUTE AND CHRONIC. Eczema of the auricle has been already described, and the reader is referred to that chapter for treatment of the disease afFectiug the external meatus. Reference has also been made in the same chapter to herpes zoster, lupus, and other skin affections involving the auricle. In herpes zoster the vesicles may be found not only on the posterior surface of the auricle, and especially the lobule and the parts in front of the tragus, but also on the anterior superior wall of the external meatus. Vesicles have also been found on the membrana tympani. SEBOERHCEA. A seborrhoeal condition of the auditory canal is ob- served at times, when it is. apt to be associated with a seborrhoea of the face and scalp. It gives rise to more or less itching, deafness, and tinnitus, especially if the 110 MANUAL OF OTOLOGY. external meatus contain moist scales and seborrhoeal fluid. After the scales have been removed, the best re- sults will be obtained from the insufflation of boric acid or of boric acid and zinc oxide powder. In some cases ointments containing ammoniated mercury, or the red oxide, are to be preferred, while especial attention should be paid to the patient's general health. SEBACEOUS TUMORS. These tumors are found iu the external auditory canal, aud should be treated in the same manner as those in the auricle. Epithelioma at times attacks the external meatus primarily, but is more apt to spread to the canal from the auricle or face. CERUMEN INSPISSATUM, OR INSPISSATED CERUMEN. Inspissated cerumen is a frequent cause of deafness, and when found in one ear it is very apt to be present in the other one as well, so that it is always wise to ex- amine both canals. Cerumen may remain in the canal for years, and in consequence become as hard as bone. The cause of the accumulation seems to be due, in some instances, to a scaly condition of the walls of the canal, which prevents the cerumen from escaping as it should do. Once it begins to accumulate a plug is rapidly formed. In other cases, there seems to be an over- abundant secretion of cerumen, especially in persons affected with acne and seborrhoea of the face. Any- thing which prevents the cerumen from coming out of the orifice, such as atresia of the canal, constriction from swollen tissues or bony growths, or numerous hairs about the tragus, will act as a cause. Another cause is due to the fact that patients frequently try to DISEASES OF EXTERNAL AUDITORY CANAL, m cleanse the ear by pouring soap and water into the canal, and then attempt to dry the ear with the end of a towel, thus pushing the cerumen further in. Symptoms. Cerumen in large quantities may be present in the external meatus for a considerable period without causing any inconvenience, as long as it does not rest against the drumhead, and provided there is a passage for the transmission of the waves of sound to the drumhead. When the canal is closed or the plug falls against the membrana tympani, the patient will then complain of a sense of fulness and deafness. Other symptoms are autophouy, or a hollow sound to one's voice like " talking into a barrel ;" occasionally, giddi- ness and vertigo, and hallucinations of hearing. Ej)i- leptic attacks have been caused by the presence of hard- ened cerumen in the auditory canal. When the plug is very large, it may irritate the walls of the canal and give rise to more or less pain. In aged persons the ex- ternal meatus becomes flatteuerl, so that the cerumen is more likely to accumulate. If cerumen collects and forms a plug it is very likely to recur. iammafed epithelial plugs, or keratosis obturans, may be a cause of deafness in some cases, the plugs being due to a gradual collection and accretion of epithelial laminae derived from the external auditory canal. They give rise to the same symptoms as inspissated cerumen. Diagnosis. Frequently a diagnosis can be made with the eye if the auricle be pulled upward and back- ward. A-fter introducing a speculum, with light re- flected from the head-mirror, yellowish or brownish masses will be seen, and by touching the same with a probe a diagnosis of cerumen or epithelial plug can usually be made. Sometimes an error in diagnosis 112 MANUAL OF OTOLOGY. is made where there are numerous stiff hairs in the canal covered with cerumen. It is necessary to push the specukim beyond these hairs. Again, the spec- ulum may be directed against a layer of cerumen in the wall of the canal, or a wad of cotton, or a foreign body may be smeared over with cerumen and be mis- taken for a plug, or the canal may be filled with dry cholesteatomatous masses, or dried blood. Tests made with tuning-forks will show increased bone conduction on the affected side, unless the inner ear be affected. Prognosis. When the deafness has come on sud- denly, complete restoration of hearing will usually result after removal of the cerumen. One should be guarded in expressing an opinion, however, before removing the plug, for the case may be complicated by adhesive catarrh or labyrinthine disease. Pig. 43. Author's ear syringe. Treatment. When the cerumen or laminated epi- thelial plug is hard, it should be softened by the instil- lation of the following drops : Sodse bicarb., gr. xxv ; glycerin., 3j; aquse, §]. The drops should be allowed to remain in the canal for fifteen minutes before syr- inging. Frequently the plug is so hard that it is neces- sary for the patient to use these drops three or four times a day for several days, before the mass can be re- moved with the syringe. A syringe and warm water DISEASES OF EXTERNAL AUDITORY CANAL. 113 (containing in solution a teaspoonf ul of bicarbonate of soda to the pint) are the best means of removing ceru- men. The syringe that I use is the one represented in Fig. 43, and is made of glass with hard rubber attach- ments and metallic rings. The hard rubber at each end can be unscrewed and the glass barrel can be kept very clean. The syringe holds about two ounces. The piston is packed with asbestos, so that it can be rendered aseptic by immersion in boiling water. The point of the syringe is quite small, to enable the surgeon to direct the stream of water between the wall of the canal and the plug. This is not a safe syringe to place in the hands of the patient. The soft rubber bulb I generally recommend for patients, or the hard rubber syringe with a large tip. Before using the syringe, the surgeon should be sure of good illumination, and should direct the stream of GtTIEMANN & CO. Piis basiu. water between the plug and the canal at different points, in order to have the return current force the obstruction outward. The ordinary pus basin (see Fig. 44), held against the neck and just below the auricle, makes an excellent basin with which to catch the return flow from the meatus, or the basin (see Fig. 45) especially devised for the purpose. A graduated glass vessel, containing a solution of bicarbonate of soda, should be used for 114 MANUAL OF OTOLOOT. holding the clean water, and under no circumstances should the same vessel be used for both purposes. Very little force should be employed in syringing the ear, for fear not only of doing damage to the drum- FlG. 45. head, but also on account of the danger of causing ver- tigo or faintness in the patient. The surgeon should also inspect the ear from time to time, and frequently it will be necessary to remove the plug with curette forceps (Fig. 24) or with blunt curettes, of which there are three sizes. The syringe should always be used, if possible, and only in skilled hands and under good illumination from a head-mirror should curettes or other instruments be employed. After the cerumen has been removed, the canal should be carefully dried with ab- sorbent cotton ou a cotton-holder, made of aluminum (Fig. 26) with a roughened end, and afterward the ear should be inflated by Politzer's method, as the drumhead will usually be found more or less retracted. Then a piece of absorbent cotton should be inserted in the meatus and worn for the rest of the day. In some cases the walls of the canal may be found excoriated, and in such DISEASES OF EXTERNAL AUDITORY CANAL. 115 it will be necessary, after drying the canal, to insufflate some of the boric acid and zinc oxide powder (equal parts). When the plug consists for the most part of layers of epithelium, frequent syringing will often be insufficient, so that it will be necessary to use forceps. POEEIGN BODIES. Foreign bodies found in the external meatus are of every shape and variety. There are : 1. Those that are animate — consisting of various insects — viz., fleas, bed-bugs, cockroaches, etc. 2. Those that are inauimate, such as wads of cotton, pieces of paper, ends of slate pencils, fruit kernels, beads, cherry-stones, etc. 3. Those that are liable to swell and become en- larged, as beans, onions, kernels of wheat, etc. Foreign bodies that do not swell and which do not cause irritation or inflammation of the canal may re- main in situ for many years without causing any dis- comfort. Children are much more apt to put foreign bodies in their ears than adults. Symptoms. There is usually more or less disturb- ance of hearing to almost complete deafness, depending on the size, shape, and position of the foreign body. There may be a sensation of pressure or tension and subjective noises, accompanied by more or less pain, ac- cording to the irritation and inflammation of the canal, drum membrane, or middle ear. The most serious symptoms often arise from unskilful attempts at re- moval of foreign bodies, when the auditory canal is lacerated and the drumhead is injured, and severe in- flammation results. There may be certain reflex phe- nomena, such as pain in the head, vertigo, dizziness. 116 MANUAL OF OTOLOGY. vomiting, and cougb. In one case reported, a persist- ent cough with vomiting was caused by the pressure of two beans in the auditory canal, while in rare instances attacks of epilepsy have been reported as cured after the removal of foreign bodies. Pkognosis. The prognosis is usually favorable ex- cept in cases in which attempts on the part of an igno- rant person have resulted in serious injury to the canal, drumhead, and middle ear ; or in which the foreign body has become wedged in the deeper parts of the canal or middle ear, and severe inflammation has fol- lowed ; or in which the pus has not found an outlet, and brain complications have developed. Teeatmbnt. In regard to treatment much depends on the nature of the foreign body, whether impacted or not, the length of time that it has been in the ear, and the amount of irritation and inflammation of the parts. The first and most important step for the surgeon is to examine the ear with a speculum and good illumina- tion, aud determine for himself, and not rely on the patient's statement, as to the presence of a foreign body in the ear, for I have seen serious harm done when this precaution had been neglected and instruments had been unskilfully used. When this unfortunate acci- dent has happened, it will be necessary at first to reduce the inflammation before attempting the extraction of the foreign body. When, however, there is but little, if any, swelling or inflammation of the canal, and the foreign substance is not wedged in, the syringe and warm water are usually all that are necessary to remove the foreign body. The auricle should be drawn back- ward and upward, while the stream of water is directed between the foreign body and the wall of the canal, and DISEASES OF EXTERNAL AUDITORY CANAL. 117 it is well at the same time to incline the patient's head toward the affected side. Some writers advise that the patient be placed in the recumbent position, so that the head will hang somewhat over the end of the table, and in this way the upper posterior wall of the auditory canal will be below the membrana tympani, and thus form with it an inclined plane. In the case of foreign bodies likely to swell, oil or glycerin should be poured into the canal, and the ear should then be syringed, or after syringing with water the enlargement of the foreign body can be prevented by immediately pouring alcohol into the ear. When the drumhead is perforated or the foreign body has been forced into the middle ear, some writers advise inflation of the ear to assist in the removal of the object. When an insect has gotten into the ear, it is best to kill it first by instillations of oil, when it can usually be removed by syringing or by means of forceps. Oc- casionally a very small insect will enter the ear and give great annoyance to the patient, while it may escape the observation of the surgeon. In such it is always well to syringe the ear. When the patient comes for advice, and on examina- tion it is found that the canal has been lacerated by attempts made at extraction, and especially if the for- eign body cannot be seen, it is always best to allay the inflammation, if possible, before proceeding to any oper- ation. If serious symptoms develop, such as severe pain and meningeal irritation, the surgeon must decide as to the propriety of an immediate operation. In such cases, where the syringe has failed, it will be necessary to resort to instruments, of which all sizes and shapes 118 MANUAL OF OTOLOGY. have been devised, viz., forceps, blunt and sharp hooks, curettes, loops of wire, scoops, etc. No one in- strument is suitable for all cases. It is necessary at times to anaesthetize the patient before resorting to the use of instruments, especially when the body has be- come wedged in the deeper portions of the canal, and in the case of small children. The forceps shown in Fig. 25 and Fig. 46 are excellent ones. In using Pig. 46. Allen's foreign-body forceps. them, however, great care should be exercised not to push the foreign body further inward, if it cannot be grasped at once. A bent probe or a curette can fre- quently be passed around the foreign substance. An old method of removing foreign bodies, which has been revived, consists in dipping the point of a camel's-hair brush into a solution of glue, and touching with it the foreign body, which has previously been DISEASES OF EXTERNAL AUDITORY CANAL. Hg dried, and leaving it there until the brush sticks, and then withdrawing it with the foreign body attached. This method is best adapted to round, smooth sub- stances and to those liable to swell, and also to those cases in which there is no discharge from the meatus, which would prevent the glue from drying. When the raembrana tympani is perforated, injections through the Eustachian tube by means of the catheter will some- times dislodge a deeply impacted foreign body. The galvano-cautery has been used to divide a foreign body piecemeal, which has become wedged in, before attempt- ing to remove it. Occasionally it becomes necessary to detach the auricle and posterior wall of the carti- laginous canal by making an incision behind the pinna close to the canal, when the foreign body has be- come impacted in the bony auditory canal or has been forced into the middle ear. This procedure allows the surgeon much more space for the use of in- struments. Nothing but the syringe and warm water should ever be used by the surgeon, in the ease of a foreign body in the ear, unless he understands thoroughly the use of the speculum and head-mirror and has had great expe- rience in the treatment of aural patients. INGKOWING HAIRS. Hairs from the auditory meatus at times are so thick and long that they may interfere with the hearing, or they may even rest against the drumhead, giving rise to noises in the ear, especially when the patient moves his jaw. Epilation is required in extreme cases. 120 MANUAL OF OTOLOGY. HEMORRHAGE PROM THE EAR. Hemorrhage from the ear, besides being due to direct injuries from foreign bodies, may be caused by fracture of the bony canal following a blow on the jaw. Bleed- ing from the ear, or vicarious menstruation, sometimes occurs in females during the menstrual period. BAR-COUGH. This phenomenon is noticed frequently in patients when examination is made of the ear by the introduc- tion of a speculum. Foreign bodies and impacted cerumen in the external meatus have been known to cause severe attacks of coughing. The explanation is that the cough, reflex in character, is due to irritation of the auricular branch of the'pneuraogastric (which latter supplies the auditory canal). ADHESIONS AND CONTRACTIONS OF THE MEATUS — EXOSTOSIS. Swelling and infiltration of the lining membrane of the external meatus may arise during the course of chronic suppurative otitis media, and in some cases of in- flammation of the external auditory canal, and thus lead to contraction of the external meatus. Du ring the course of long-standing suppuration from the middle ear in cases due to diphtheria or syphilis, or to injuries of the canal from instruments or chemicals, cicatricial stric- tures may result, and give rise to alarming cerebral symptoms, if operative procedures are not immediately undertaken, so that pent-up secretions may escape. When the contraction is due simply to hypertrophy of DISEASES OF EXTERNAL AUDITORY CANAL. ]21 the tissues from inflammatory infiltration, much may be accomplished by treatment. Attention should first be directed to the cure of the chronic otorrhoja if pres- ent, and the infiltration of the tissues will often subside from the use of ointments containing mercury. In the case of strictures, some are circular or annular in shape, and the opening, being as small as a pin's head, may be mistaken by the inexperienced for a perforation in the drumhead. The contraction may in other cases extend from the bony canal to the external orifice of the meatus. Bony strictures are also observed, which are due to periosteal ossification of the walls of the external meatus or to hyperostoses. Osseous strictures are often associated with caries and necrosis of the temporal bone, and develop after sequestra have been removed. The deafness in these cases will depend altogether on the condition of the middle ear, and also on the amount of secretion or epithelial scales that are contained behind the stricture. In making a diagnosis of stricture, a careful examination should be made with the probe to ascertain as to whether it is due to membrane or to bone. Treatment. The most important point in the treatment should be the cure of any otorrhoea or in- flammation of the external auditory canal. If the in- flammatory hypertrophy does not diminish under such treatment, the contracted parts can be dilated by insert- ing plugs of absorbent cotton soaked in a carbolic-acid or boric-acid solution, great care being taken not to leave them in too long at a time, as secretions are apt to be retained behind them. An annular stricture should be excised and further dilated by the use of cotton plugs or the insertion of sponge-tents. If these means 122 MANUAL OF OTOLOGY. • fail, laminaria tents are sometimes employed, but as a rule they are too painful. I have in some cases in- serted rubber tubing, through which I have passed a quill toothpick, the idea being to prevent collapse of the rubber tube, and thus allow the pus to escape, and at the same time to exert continual pressure against the walls of the external meatus. In all cases in which there is suppuration, as in chronic otorrhcea, the pus should be carefully removed by syringing with a bi- chloride or boric-acid solution before inserting the tube. Hard rubber and silver tubes are also used for the same purpose. When the stricture is osseous, very little can be accomplished in the way of dilating the canal except by operation. The latter should never be undertaken, unless pus or some other secretion is prevented from escaping, or where there is extensive caries or necrosis. In such cases, the auricle should be displaced forward and the lining of the posterior wall of the canal dissected away to give a good view of the seat of the operation. Besides hyperostoses, already mentioned, exostoses are found in the canal. They are new formations of bone, and their structure may be very dense, like ivory, or spongy, or even hollow. They may have very broad bases or be pedunculated, and may exist singly in one or both ears, or may be multiple. I have seen cases in which there were many white nodules situated on the walls of the external auditory canal and close to Shrap- nell's membrane. Exostoses may be due to chronic periosteal inflammation of the bony canal as a result of fracture, or may result from chronic suppurative otitis media. Polypi and new cartilaginous growths occa- sionally ossify. Syphilis, gout, and rheumatism are mentioned as causes of these bony tumors, but accord- DISEASES OF EXTERNAL AUDITORY CANAL. 123 ing to my experience, sea-bathing plays a much more important role. Diagnosis. By means of the probe the diagnosis can usually be made, as the tumor will be found hard and resisting, and frequently very tender to the touch. Tebatment. When the exostoses are small and do not interfere with the hearing power, and do not pre- vent the escape of cerumen and other secretion, no oper- ative measures are usually required. A pedunculated growth can easily be removed with the chisel and mallet, but an exostosis with a broad base, of compact tissue, is not easily excised. When it becomes necessary to operate because great deafness has resulted, or because alarming symptoms have ensued from retention of pus, the auricle should first be displaced forward and the tumor removed by means of the mallet and chisel or gouge, or by the burr, which can be rotated by a motor. The most thorough aseptic precautions should be followed, and all instruments thoroughly sterilized. After the removal of an exostosis, the hemorrhage should first be controlled, and then the canal should be filled with a strip of iodoform or boric-acid gauze. The use of mercury and iodide of potash is indicated in all cases in which there is a history of syphilis. Some surgeons recommend painting the exostosis with tincture of iodine, but such treatment is of little if any avail, while there is great danger of causing a severe inflammation of the external auditory canal from its application. CHAPTER V. DISEASES AND INJURIES OF THE DRUMHEAD AND MIDDLE EAR. MYRINGITIS ACUTE AND CHRONIC. This as a disease per se is denied by many otologists who claim that the middle ear is involved at the same time. In the acute stage the drumhead will be found congested in part only or in its whole extent. In the later stage there is apt to be an effusion of serum in the dermal layer as well as slight effusions of blood, while small vesicles, filled with serum, often develop. As a rule, the dermal layer alone is involved ; but in severe inflammation, abscesses sometimes form in the deeper layers of the drumhead, when it becomes much more difficult to distinguish this form of inflammation from acute otitis media. Symptoms. Pain, usually moderate in character, is complained of, although it may be sharp and stinging in severe cases. Other symptoms are a pulsating noise and more or less tinnitus. The disturbance in hearing is usually much less than in cases of acute otitis media, and one is justified in making a diagnosis of acute myringitis when, in spite of more or less swelling or bulging of the membrane, the hearing distance is not materially affected. Frequently, however, the two diseases are associated, or a case beginning as an inflam- mation of the drumhead is followed by acute otitis DISEASJES OF DR UMHEAD AND MIDDLE EAR. 1 25 paedia, so that in many instances it becomes difficult to separate the two. The course of the disease is usually about four or five days. After the vesicles have burst, the membrana assumes a macerated appearance, and the dermal layer peels off, leaving a congested drumhead. In the chronic form there is more or less suppuration, with the formation of granulations or ulcerations on the drumhead, if the disease has run a protracted course. Tkeatment. In severe cases the artificial leech should be applied, while in the mild form of this in- flammation the vesicles burst and recovery generally follows in a few days. The insufflation of boric-acid powder is indicated in the latter cases. In the chronic form boric acid alone or combined with zinc oxide (equal parts) should be insufflated, or drops should be instilled, containing zinc sulphate, copper sulphate, or lead acetate in the proportion of four grains to the ounce. Granulations should be cauterized with nitrate of silver fused on the end of a probe. INJURIES OF THE MEMBRANA TYMPANI. Injuries of the drumhead are usually caused (1) by the introduction of a foreign body ; (2) by a blow or explosion producing a sudden condensation of air in the external meatus or tympanum, or (3) by a fracture of the cranial bones, thus involving the drumhead. Diving, sea-bathing, boxing the ears, the discharge of cannon, and gunshot wounds are frequent causes of rupture ; also violent paroxysms of coughing, vomiting, and sneezing. Again, ruptures are often met with when patients have tried to clean the ears with tooth- picks and hair-pins and have pushed them in too far, so that these and other unskilful attempts at the re- 126 MANUAL OF OTOLOGY. moval of foreign bodies often cause serious trouble. Rupture of the drumhead has been known to follow a too violent inflation of the ear by Politzer's method, and the exhaustion of the air from the external meatus by the use of Siegle's otoscope when attached to a force- pump. In the cases where rupture occurs from the sudden condensation or rarefaction of air, it will gener- ally be found, on examination, that catarrhal changes have taken place in the membrana tympani and there is more or less obstruction to the entrance of air through the Eustachian tube. In direct injuries, the point of rupture is most fre- quently observed in the anterior half of the drumhead, and the size and shape of the rupture or perforation depend to a great extent on the nature of the instru- ment used. A sharp-pointed instrument is apt to cause a wound somewhat round, with the edges covered by dark-red blood, and frequently there are more or less blood in the canal and laceration of the meatus. In- flammation of the middle ear followed by suppuration may result from direct injuries. The shape of the rup- ture produced by indirect violence is, as a rule, gaping, so that the inner wall of the tympanum will be seen. This wall will appear reddish-yellow in color, in direct contrast to the bright red hue observed in cases of acute or chronic otitis media. The most frequent seat of the rupture is in the posterior half of the membrana, and the shape of the perforation is usually round or oval with the long axis of the oval running parallel with the direction of the radiating fibres. There is, as a general rule, but one rupture. When the rupture is due to a fall or blow there may occur at the same time concussion of the labyrinth, with marked deafness, and DISEASES OF DR VMHEAD AND MIDDLE EAR. 127 it is in such cases, as well as in those in which suppura- tive inflammation of the middle ear has developed, that permanent disturbances of hearing frequently remain after the perforation has healed. Besides the causes already mentioned, a case ^ has been reported of injury to the membrana tympani from a twig. The patient was walking through the woods when a twig of a branch penetrated the right auditory canal, rupturing the drumhead. In another patient the injury to the ear was due to a pistol-shot wound. The most serious cases are those in which there is concussion of the labyrinth from a fall or blow, and the prognosis in such instances must always be grave, and on account of their medico-legal significance become of great inter- est to the aural surgeon, who is frequently asked to give expert testimony in court as to the diagnosis and prognosis of such accidents. In order for the surgeon to express an opinion as to whether the rupture is of traumatic origin, it is absolutely essential that the drum- head be inspected immediately afier the supposed in- jury. Just after an injury to the drumhead from a sharp-pointed instrument, as previously mentioned, the edges will be covered ^^•ith dark-red coagulated blood, and if the rupture be large the middle-ear wall will appear yellowish-red. If suppuration has already occurred, it is impossible to make a diagnosis of traumatic rupture. Usually when the perforation has been due to disease of the middle ear, even when of large size, the air gives a sharp hissing sound when forced through the Eustachian tube by the Valsalvian or Politzer's methods, while in a normal ear which has 1 Bacon : Transactions American Otological Society, 1888. 128 MANUAL OF OTOLOGY. been ruptured through traumatism, the escaping air gives a broad, deep-breathing sound. Injuries to the drumhead from sharp instruments, as a rule, heal rap- idly, if inflammation of the middle ear does not follow. If suppurative inflammation occurs, the disease may become chronic and lead to complications, or the drum- head may be thickened and adhesions take place, or there may be concussion of the labyrinth with or with^ out rupture of the drumhead. In all such cases, per- manent disturbances of hearing may remain. In cases in which deafness results from a blow or fall, aud the drumhead and external meatus appear normal, while there is loss of bone conduction, as shown by the tuning-fork, the surgeon should be very guarded in ex- pressing an opinion as to the cause of the deafness, for in such instances much depends on the answers given by the patient, who may he a malingerer. Tuning- fork tests show that the bone conduction is much dimin- ished or even lost in labyrinthine disease, while the patient is apt to complain of subjective noises, giddi- ness, deafness, and a dull feeling in the head. A case' has been reported in which a suit was brought for damages on account of an alleged blow on the ear. In this instance the boy was a catarrhal subject, and the hearing was as much afiiected on one side as on the other. Treatment. It is most important that the instilla- tion of all drops and syringing the ear should be care- fully avoided in, all cases of simple rupture. The patient should be kept quiet, and placed on a low diet for a few days, and a piece of absorbent cotton should 1 Bacon : New York Medical Journal, December 12, 1888. DISEASES OF DRUMHEAD AND MIDDLE EAR. 129 be inserted in the meatus. When inflammation of the membrana occurs, the artificial leech should be applied in front of the tragus (see Treatment of Acute Otitis Media), and, if followed by suppuration, the same treat- ment should be followed as that indicated for acute suppurative otitis media. When concussion of the labyrinth has occurred, permanent disturbances of hear- ing and tinnitus will occasionally remain in spite of all treatment. In some cases, nerve tonics containing strychnia sulphate are indicated. Others improve under the administration of iodide of potash and hypodermic injections of pilocarpine. The constant electric current is beneficial in other instances. A rare form of injury to the drumhead is fracture of the handle of the 'malleus. The injury may be due to a fall or to a direct injury to the membrana tympani. It is possible to make a diagnosis of this condition if the surgeon can discover a false point of motion in the long handle while the patient inflates the ear by the Val- salvian method. OTITIS MEDIA ACUTA, OR ACUTE INFLAMMATION OF THE MIDDLE EAR. Acute inflammation of the middle ear may be either catarrhal or purulent. Very frequently, however, one disease runs into the other, so that it is extremely diffi- cult in some cases to make any distinction. OTITIS MEDIA CATARRHALIS ACUTA, OR ACUTE CATAR- RHAL INFLAMMATION OP THE MIDDLE EAR. There are in the first stage considerable hyperemia and swelling of the lining membrane of the tympanic cavity and that covering the ossicles and inner surface 9 130 MANUAL OF OTOLOGY. of the drumhead. There is probably a more or less hypersemic coadition of the lining membrane of the mastoid cells in many, if not all, cases of this disease. After the acute stage, there follows more or less exuda- tion of serum and exudation cells. In severe cases, there may be ecchymoses. The epithelium lining the middle-ear cavity peels off and becomes macerated. Thick mucus, pus cells, and numerous red blood-cor- puscles are found in the tympanum. In some instances the mucus is very tenacious and stringy, while in others there is a preponderance of pus cells. This affec- tion is what is commonly called "earache" in chil- dren, and some children are especially liable to frequent attacks. It is more often observed during the spring and winter months, when sudden changes in tempera- ture occur. Causation. This disease most frequently follows a pharyngitis or " cold in the head," or it may be due to long exposure to wet and cold, or sea-bathing, or it may be a complication of the acute infectious diseases, such as measles, scarlatina, whooping-cough, or pneu- monia, bronchitis, tuberculosis, puerperal fever, cere- bro-spinal meningitis, and syphilis. Another cause is the use of the nasal douche, by means of which water entering the Eustachian tube sets up an acute inflam- mation. In many instances I have seen the same acci- dent follow the pernicious practice of "sniffing up" salt and water for the relief of nasal catarrh. Teething children are liable to attacks of catarrhal otitis media, which frequently develops into the puru- lent form with perforation of the drumhead. Sea-bathing is one of the causes of this disease as well as nasopharyngeal catarrh, or it may be due to DISEASES OF BR UMSEAD AND MIDDLE EAR. 131 the presence of adenoid growths and enlarged tonsils. In sea-bathing there is a liability that water filling the external meatus may cause an inflammation of the canal or middle ear, while, on the other hand, an acute otitis media may result from water entering the middle ear through the Eustachian lube. Parents should always forbid children to " duck" the head or to dive while bathing, and should always insist that they wear in the ear a piece of non-absorbent cotton wool. Symptoms. There is a dull feeling or fulness about the ear, or the pain may be sharp and stinging in charac- ter and quite severe at night. Infants are liable to scream and to put the hand to the side of the head. Head- ache is sometimes complained of. The pain frequently radiates about the ear and side of the head, and shoots toward the teeth, and the patient may complain of pain on opening the mouth and when pressure is made just below the lobule. In children, more especially, this form of disease is accompanied by fever, while in rare instances delirium and convulsions are observed. In infants meningitis is sometimes suspected until an ex- amination of the ear reveals the cause of the disease. The pain, though much less severe in acute catarrhal than in acute purulent otitis media, is due to the sever- ity of the inflammation itself, to the pressure exerted on the drumhead by the exudation, or to great retrac- tion of the drumhead. The Eustachian tube being constricted, the air does not enter the tympanic cavity, but becomes absorbed, so that the atmospheric pressure on the external surface of the drumhead causes considerable retraction and pain. In the milder cases the pain is of short duration, but 132 MANUAL OF OTOLOGY. in the more severe ones it is apt to continue for several days, wiiile during convalescence the patient has a feel- ing of fulness and pressure in the ear. Tinnitus, or noise in the ear, of a hissing, rushing, singing, or pulsating character, is a source of considera- ble annoyance to the patient. The deafness in the early stage as well as the tinnitus is due to the intense hy- persemia and to inilammatory exudation. The disturb- ance in hearing is apt to be more marked during the stage of exudation, but the degree of deafness does not depend so much on the amount as on the seat of the ex- udation in the middle ear. If both fenestrse in the middle ear are clogged, there is apt to be great deafness. A patient frequently complains of autophony — i. e. , a muffled sound of his own voice, which is likened to the hollow sound heard when talking with the head in a barrel. Another source of annoyance is the hearing by the patient of the same note double — that is, a tuning- fork when vibrating and held close to each ear will seem a tone or half a tone higher usually on the affected side. This same phenomenon also occurs in labyrinth- ine disease. In children the pain is especially apt to come on during the night, while in the daytime they are more or less free from it. Parents very often attach but little importance to such attacks, and consider that it is not necessary to seek professional advice for a mere ear- ache. Repeated attacks, however, frequently lead to changes in the drumhead, and adhesions, and later in life to deafness. There would be far fewer cases of in- curable chronic middle-ear catarrh if these children during early life had received proper treatment. The duration of the disease varies from a few days to a week DISJEASES OF D.R UMHEAD AND MIDDLE EAR. 133 or ten days. There may be several relapses. Much depends on the general condition of the patient and on the causation. Appeaeances of the Membrana Tympani. In the less severe cases the drumhead appears congested, especially about Shrapnell's membrane and the long handle of the malleus. The bony canal may or may not be involved. In severe cases the whole membrane is of a reddish, angry-looking color, and frequently has a gray appearance on account of the infiltration of the dermal layer. The only landmark, the short process, appears as a red or yellowish-white point. The posterior superior quadrant of the membrane may present a bulging appearance due to inflammatory infil- tration. In some cases there may be vesicles and in- terlamellar abscesses. Bulging and exudation sacs in connection with the tympanic cavity are occasionally observed. In other cases there may be a bulging out- ward of Shrapnell's membrane or of the posterior infe- rior quadrant of the membrana vibrans, due to the presence of fluid in the tympanum. The congestion gradually disappears when resolution begins, and the membrana at first assumes a grayish appearance, with small tortuous vessels running from the periphery toward the handle of the malleus. The epidermis peels off from the membrana and bony canal, while the con- gestion remains longest along the handle of the malleus and in Shrapnell's membrane. Tkeatment. Acute catarrhal otitis media in chil- dren is often due to the presence of enlarged tonsils or of adenoids, so that it is of the greatest importance to make a thorough examination of the nasopharynx in 134 MANUAL OF OTOLOGY. all cases. Usually in young subjects it is impossible to obtain a satisfactory view of the nasopharynx with the rhinoscopic mirror, a fact which compels the otologist to make a digital examination of this region. With a rubber band on the index-finger, to prevent it from being bitten, an examination can readily be made ; and, further, while the finger is in the nasopharynx, if ade- noid growths are present, and particularly if they are soft and flabby, the surgeon can scrape away some of these tumors with the finger-nail and break them up, so that something can be accomplished at this time. There are many little patients, however, of a nervous temperament whom it is necessary to ansesthetize even when making an examination. In such cases chloro- form is to be preferred. (For the further treatment of adenoids the reader is referred to the chapter on Naso- pharyngeal Diseases.) In the first or hypersemic stage of acute catarrhal otitis media, the local abstraction of blood by means of the artificial leech is a valuable method of treatment, and if applied early will often cut short the attack and relieve the pain. The leech should be applied in front of the tragus (see method of application under Treatment of Acute Purulent Otitis Media). In children warm water gently poured into the ear will often stop the pain, or the ear may be douched with warm water (containing boric acid, Sj-Oj) every two or three hours. Some surgeons pre- fer dry heat by means of a hot-water bag or a hot bag of salt. In the mild cases the instillation of drops of a saturated boric-acid solution will be all that is neces- sary if careful attention is paid to the condition of the pharynx and nasopharynx. In children, when the Eustachian tube is swollen and DISEASES OF DS UMHEAD AND MIDDLE EAR. 135 the drumhead is very much retracted, a condition of affairs resulting from a nasopharyngeal catarrh, the treatment should consist in inflation of the middle ear by Politzer's method or catheterization, and the appli- cation of astringent sprays to the nasopharynx. After the inflammatory stage has passed, the catheter or Polit- zer's method should be employed, in order to prevent adhesions, to restore the membrana tympani to its normal position, and to remove any mucus or other fluid from the tympanum. If the disease follows a cold, small doses of calomel should be given to produce slight catharsis, and aconite should be administered in small and frequently repeated doses. The patient should be kept quiet iu the house and given a light diet. Gargles are indicated when necessary, and atten- tion should be paid to the nares as well as the naso- pharynx. Instillations of a 4 per cent, solution of co- caine, or of a solution containing liq. Magendie, 3j; aqua, Sj, are indicated in some cases. It is always best not to administer opium unless absolutely neces- sary. Phenacetine can be given, however. Patients who frequently have "colds" should be cautioned against taking large doses of quinine, as deafness is un- doubtedly caused by this practice in some instances. Catarrhal subjects should be impressed with the impor- tance of paying strict attention to the general health. They should lead an out-of-door life as much as possi- ble, protect their feet in stormy weather, and should sponge the neck and chest every morning and follow this up by vigorous rubbing with a coarse towel. Liv- ing in overheated rooms is a frequent source of catar- rhal disease. If there is bulging of the membrane, suggesting the presence of fluid in the tympanic cavity. 136 MANUAL OF OTOLOGY. the drumhead should be immediately punctured. See Treatment for Acute Purulent Otitis Media. SUBACUTE CATARRHAL OTITIS MEDIA. This is a form of inflammation similar to acute catarrh, except that it is milder in character. There is but little pain and inflammation. The patient is usually subject to frequent attacks, while the tonsils are apt to be enlarged and the disease is liable to be- come chronic. This disease is often found among school children, who formerly were thought to be inattentive. Proper hygienic surroundings, tonics, etc., should be prescribed, and treatment directed to the nares and postnares, in addition to inflation of the middle ear by Politzer's method. What is commonly called tubal catarrh is an in- flammation of the Eustachian tube, leading to great retraction of the drumhead. The membrana is usually but slightly congested. As the swelling of the walls of the tube allows but little air to enter the tympanic cavity, the air in the middle ear becomes absorbed, and retraction of the membrana follows. This affection is usually secondary to nasopharyngeal catarrh. 8ero-muGoi(,s catarrh, or hydrops ex vacuo, is in reality another form of acute catarrhal otitis media. In this affection the faucial end of the Eustachian tube is usu- ally congested and swollen, leading to closure of the same. Acute inflammation of the nasopharynx is generally the cause of the disease. The drumhead may be slightly congested as well as retracted, and other changes of color will be noticed, depending on the amount of the exudation, the condition of the middle ear, and the transparency of the drumhead. When the DISEASES OF DRUMHEAD AND MIDDLE EAR. 137 tympanic membrane is translucent and there is a sero- mncous exudation, a line of demarcation between that portion of the middle ear containing air and that con- taining fluid will be distinctly seen. The latter portion usually appears greenish-yellow in color, and the former darkish-gray. "When the patient moves his head, the line of the fluid will change if it be serum. After inflation of the middle ear, air bubbles, as rings, will be seen through the membrane if the latter be trans- parent. The symptoms generally observed are very slight pain, a sense of fulness or pressure in the ear, tinnitus of an intermittent character, autophony, and a cracking sound in the ear, which latter is probably due to a sudden separation of the walls of the Eustachian tube, and more or less deafness. Tests with the tuning-fork show increased bone conduction on the affected side, unless the labyrinth be involved. Prognosis. The prognosis is generally favorable when the inflammation is due to a cold and the patient's general health is good. The disease in some instances becomes chronic, and may lead to adhesions and deafness. Treatment. When there is fluid in the middle ear, it can sometimes be made to disappear by Politzer's method of inflation or by catheterization. A much more satisfactory method, however, is to puncture the drumhead in its posterior inferior quadrant, and then force the fluid out by inflation or by the use of Siegle's otoscope. Careful attention should be paid to the patient's general health, and treatment directed to the nasopharynx, the nasal passages, and the mouth of the Eustachian tube. Catarrhal patients should be advised 138 MANUAL OF OTOLOGY. to follow the same line of treatment as that recommended in the case of acute catarrhal otitis media. Tonics containing iron and strychnine should be given. Whenever possible, I prefer use of the catheter to Polit- zer inflation. In children, however, and in adults of a nervous temperament, and also in all cases in which there is much inflammation and irritation about the faucial end of the Eustachian tube, Politzer's method should be employed. As to the frequency of inflating the ears, a good rule is to inflate the ear at first every day for several days, then every other day, and less fre- quently as the condition requires. A method advocated by Politzer of removing the fluid from the tympanum is as follows: After the patient has taken a little water in his mouth he is directed to turn his head well for- ward and somewhat toward the opposite side, a posi- tion which causes the pharyngeal orifice of the Eusta- chian tube to point directly downward. The patient should keep his head in this position for a minute or two, in order to allow the secretion to flow toward the orifice. Air is then forced into the middle ear by Po- litzer's method. In some instances in which the mucus in the middle ear is tough aud stringy, it is necessary, in order to remove the secretion, to make a free incision in the drumhead, and then inject into the tympanic cavity a very weak solution of sodium bicarbonate. CHAPTEE VI. OTITIS MEDIA PUEULENTA ACUTA, OR ACUTE PURULENT OTITIS MEDIA. Acute purulent otitis media differs from acute catar- rhal otitis media iu the greater intensity of the stage of inflammation, and the occurrence of a purulent dis- charge with perforation of the membrana tympani. In the early stages of tlie disease, there is marked conges- tion of the tympanic cavity and tympanic end of the Eustachian tube. If the inflammation has extended from the nasopharynx, which is usually the case, the Eustachian tube in its whole extent is more or less con- gested and swollen. It is probable that the lining membrane of the mastoid cells is likewise congested at the same time in many, if not all, cases of acute purulent otitis media. In some instances there is hyperaemia of the labyrinth with serous exudation. The inflamma- tory stage is followed by considerable swelling of the lining membrane of the middle ear. The discharge is frequently of a serous character at first, or it may be muco-purulent. Later, however, it becomes decidedly purulent. It may be scanty or very profuse. Acute suppurative otitis media frequently follows the acute catarrhal variety, so that, clinically, the two diseases should be considered as different stages of the same disease, viz., acute otitis media. In cases of tubercu- losis, there is, as a rule, but little hyperaemia, the mucous membrane of the middle ear appearing of a pale, red- 140 MANUAL OF OTOLOGY. dish-yellow color, while the discharge or exudation is apt to be thin and watery. In cases due to influenza — and these constitute by far the greatest number — the discharge is at first sero- sanguinolent and very sticky in consistency. In some cases there is more or less blood, and the stage of in- flammation is marked by great hyperaemia and swelling of the mucous membrane. These symptoms are so con- stant that they are very characteristic of influenza otitis, while the mastoid cells are very often involved at the same time, and in rare instances the labyrinth is affected. Etiology. Purulent inflammation of the middle ear usually occurs in connection with acute or chronic naso- pharyngeal catarrh, and may be due to the same causes that produce acute catarrhal otitis media. Besides the influenza and colds, which are responsible for a great many cases, the exanthematous diseases play a most im- portant role in the causation, especially measles and scarlet fever. Other causes are diphtheria, exposure to wet and cold, smallpox, typhus and typhoid fevers, tuberculosis, pneumonia, whooping-cough, syphilis, ery- sipelas, diabetes, and the puerperal state. Acute sup- puration of the middle ear is due at times to operations on the drumhead, such as paracentesis, to blows on the head or ear, or to falls, to the improper use of instru- ments when attempts are made to extract a foreign body from the external meatus, and to the use of caustic ap- plications. Water occasionally enters the Eustachian tube and middle ear from the nasal douche, and from " snifiing up" salt water and other solutions for the relief of nasal catarrh, and causes severe inflammation of the middle ear and occasionally of the mastoid cells. ACUTE PURULENT OTITIS MEDIA. 141 During dentition there is apt very frequently to be a purulent discharge, and it is most important in such cases to examine frequently the ears during this period. Sea-bathing is another cause of this disease. The drum- head may be ruptured in diving or from the force of a wave striking against the side of the head ; or the cold water filling the external meatus may set up an inflam- mation of the drumhead and later of the middle ear. Frequently, however, I believe that an earache from sea-bathing is due to the fact that water enters the middle ear through the pharynx and Eustachian tube. Children are more frequently subjects of this disease than adults, and it is observed move often in winter and spring, especially during sudden changes of weather. Children are apt to have both ears affected from scarlatina, measles, or diphtheria. Appearances of the Membrana Tympani. In the first stage of inflammation, the drumhead in Shrap- nell's membrane is congested, and the hyperseraia ex- tends along the posterior border of the handle of the malleus. The drumhead becomes gradually pinkish in its entire extent, or of a bluish-red and angry appear- ance, according to the intensity of the inflammation. Ecchymoses or vesicles filled with serum or blood are sometimes observed on the membrana tympani or on the walls of the external meatus. In cases of intense inflammation, marked congestion of the bony auditory canal occurs, so that it is difficult to distinguish where the bony wall ends and the drumhead begins. Exuda- tion of serum and swelling of the tissues gives the drum- head a sodden and lustreless appearance. When the epi- dermis peels off, the drumhead may be mistaken for a polypus, on account of its smooth, glistening, and red 142 MANUAL OF OTOLOGY. appearance. Bulging of the membrana tympani is ob- served most frequently in its posterior half, and this may be due to swelling of the tissues or to interlamellar ab- scesses, or, more frequently, to a collection of fluid in the tympanum. The most frequent seat of the perforation is in the lower anterior or posterior quadrant of the drum- head. It is occasionally, though very infrequently, found in Shrapnell's membrane. When the latter does occur, the disease is mostly confined to the attic, exuda- tion of fluid being found about the articulation of the malleus and incus and in Prussak's space. The ap- pearances of the drumhead in such cases are intense redness in its upper portion, in Shrapnell's membrane, and in the wall of the canal adjacent to it, followed by bulging of the membrana flaccida. If the tissues are not incised at an early date, perforation is apt to result and pus is discharged. The perforation in such cases may heal and the hearing be restored, or adhesions be- tween the ossicles and walls of the tympanum may form and give rise to considerable disturbance of hearing, or the disease may become chronic, when caries of the ossi- cles is the usual result. In influenza eases the drum- head is markedly injected and angry looking, as a rule, and in some cases the perforation has a nipple-shaped projection in the posterior half of the drumhead, out of which the pus escapes with difficulty. Marked pulsa- tion of the fluid will be noticed at this point. In some cases, not only the bony canal but the cartilaginous portion is inflamed. Especially is this the case when otitis media results from injuries to the canal and drumhead from the improper use of instruments or caustic applications. At times the lymphatic glands behind the ear are enlarged. After the discharge has ACUTE PURULENT OTITIS MEDIA. I43 filled the canal the landmarks are not easily made out, so that it becomes necessary to remove the secretion by syringing and by using absorbent cotton on the end of a cotton-holder, before the site of the perforation can be discovered. Cases in which the discharge consists largely of stringy mucus are, as a rule, extremely diiE- cult ones to cure. Symptoms. The disease usually commences with in- tense pain in the ear, of an excruciating and lancin- ating character, not limited to the ear, but shooting in the direction of the teeth, the neck, and in the occipital, parietal, or temporal regions. The pain is more intense at night than during the daytime. As previously men- tioned, perforation may occur without pain in the case of tuberculous subjects. In some persons the pain is not very marked, but such cases are infrequent. The temperature is usually considerably elevated in the case of young children — as high as 105° F. In adults the temperature varies very much, usually from 100° to 102° F. After perforation has occurred, the pain, as a rule, becomes much less severe, and at times ceases at once. In young subjects meningitis is sometimes suspected, on account of a very high temperature and from the fact that the child puts its hand to the side of the head. In some children the disease is ushered in by a convul- sion or severe vomiting. A child that has been scream- ing with pain and that has been on the point of a con- vulsion will suddenly fall to sleep and the temperature will drop several degrees as soon as perforation has taken place. Other symptoms complained of are tinnitus, which is described by the patient as being of a roaring, hissing. 144 MANUAL OF OTOLOGY. hammering, or pulsating character. Such noises are probably due to secretion covering the ossicula and feuestrse ovalis and rotunda, or to a hypersemic condi- tion of the labyrinth, with possibly exudation ; giddi- ness and fulness in the head, and deafness, which may be very slight or well marked, depending on the in^ tensity of the disease, the nature of the secretion, and especially as to whether the labyrinth is implicated or not. After perforation the hearing distance is usually improved. Patients generally hear the watch or acou- meter through the cranial bones. In severe cases of scarlet fever or diphtheria in which the labyrinth is in- volved, or in which acute caries follows, or in cases of syphilis, this power of hearing the watch or acoumeter will be lost. In Weber's test, the vibrations of the tuning-fork are usually perceived better by the affected ear. Course and Complications. Perforation may occur in a few hours, or it may be three or four days or longer before the discharge makes its appearance. Even after perforation has taken place, the pain at times is quite severe. In such cases, it is probable that the peri- osteal layer is involved or the mastoid cells implicated. As a rule, after perforation, all symptoms, such as pain, fulness in the head, and giddiness, are considera- bly less. The duration of the suppurative stage varies from several days to three weeks, or the disease may be- come chronic. A cicatrix may or may not mark the seat of the perforation. During the stage of resolution the membrana gradually loses its deep-red color and takes on a grayish-red appearance ; the landmarks gradually reappear, viz., the handle of the malleus and the short process. In some cases adhesions form between the A a VTE P UR ULENT TITIS MEDIA . 145 ossicula and the tympanic walls, and disturbances of hearing result. Opacities, calcareous deposits, atrophic changes, and thickening of the drumhead are observed in other instances. Acute purulent otitis media is apt to follow a much more protracted and severe course in those who are de- bilitated or scrofulous, or who are suffering from one of the exanthematous diseases, diphtheria, bronchitis, etc., than when it occurs in a patient who otherwise is healthy and strong. In cases occurring during the course of scarlatina, diphtheria, measles, and influenza, the inflammation is frequently apt to be of an intense and virulent nature, and unless a free incision is made at an early date in the drumhead, caries of the ossicles and tympanic walls is the result. To emphasize this point, I would refer to a case of scarlet fever that came under my care a few years ago, and in which acute sup- purative inflammation of the right ear had already taken place at the time of my first visit. The left ear subsequently became inflamed and painful, when a free incision was made in the drumhead, with the result that the left membrana tyrapaui subsequently healed and the hearing on this side became normal, while in the right ear, in which the perforation had taken place spon- taneously, most of the drumhead was destroyed. Permanent disturbances of hearing occur in cases in which the ossicula are bound down by adhesions, or in which there is an adhesion between the drumhead and middle-ear walls, or in which thickening or atrophic changes or calcareous deposits are observed in the drumhead. Deafness is often well marked when great destruction of the drumhead and ossicula takes place, and especially when the labyrinth is aifected. 10 146 MANUAL OF OTOLOGY. Besides caries of the ossicala and walls of the tym- panic cavity, as a result of acute suppurative otitis media, other complications that occasionally follow are facial erysipelas, meningitis, pyaemia and septicaemia, throm- bosis of the lateral or other sinuses, hemorrhage from the internal jugular vein or carotid artery due to acute caries of the temporal bone, and cerebral and epidural abscesses. I have reported two cases in which erysipe- las developed suddenly as a complication of acute puru- lent otitis media, the disease involving the scalp and face and giving rise to considerable constitutional dis- turbance. When erysipelas first makes its appearance, the discharge from the middle ear becomes much less in quantity or ceases altogether. Erysipelas is undoubt- edly due to bacterial invasion of a wound, Felileisen's micrococcus erysipelatis. In both cases referred to, the auricle was first affected. I have also reported a case of pyaemia occurring in connection with acute purulent otitis media in which recovery ultimately took place. That teething is a cause of acute purulent otitis media was clearly demonstrated in the report of a case ' of a child who came under my observation, and who had very high temperature and symptoms of brain compli- cation. The mastoid antrum was carious, and it was necessary to scrape it with sharp spoons. The disease was undoubtedly due to sympathetic irritation from the cutting of four molar teeth ; the child recovered. When pain persists after the appearance of the discharge, and especially if the temperature be high, such indications generally point to mastoid disease or some other com- plication. » Annals of Ophthal. and Otol., January, 1891, vol. iii. No. 1. ACUTE PURULENT OTITIS MEDIA. 147 Diagnosis. Before perforation has occurred, it is impossible to make a differential diagnosis between acute catarrhal and acute purulent otitis media, as in both diseases the first stage is marked by hypersemia of the drumhead. As' previously mentioned, the hyperse- mia is usually more marked and the pain more intense in acute suppurative otitis media. Acute myringitis may be mistaken for acute otitis media. In the former, however, the pain is not so severe, nor is the disturb- ance of hearing so great as in the latter disease. If there be stringy mucus in the discharge from the ear, one may safely diagnose acute purulent otitis media, as mucus is never present in a case of otitis externa or furuncle of the canal. After removal of the discharge by syringing or by means of absorbent cotton on a cot- ton-holder, inspection with head-mirror and speculum will usually reveal the seat of the perforation. In cases in which the latter cannot be seen on account of the curvature of the external auditory canal, a perforation whistle can often be heard by having the patient try the Valsalvian method of inflating the ear, or by Po- litzer's method. This will not succeed, however, when there is great swelling of the Eustachian tube, or when the perforation is in Shrapnell's membrane. It must not be forgotten that, in some cases of acute purulent otitis media, the discharge is almost wholly composed of pus. Malignant disease having its origin in the tem- poral bone may give rise to great difficulty in the diag- nosis during the early stage. I have reported the case ^ of a woman (see Fig. 47) who complained for some time of pain with tinnitus in the right ear, followed by a 1 Archives of Otology, 1SS8, vol. xvii. No. 1. 148 MANUAL OF OTOLOGY. slight serous discharge. Facial paralysis caused her considerable alarm, so that she sought advice. There was considerable induration of the tissues in front of the ear, extending toward the jaw. The pain became Pig. 47. Case ot carcinoma ot the temyioral bone, giving rise to facial paralysis. very severe, as is usually the case iu such patients, an important point to consider, for when it is persistent and cannot be otherwise accounted for, malignant disease should be suspected. This case proved to be a carci- ACUTE PURULENT OTITIS MEDIA. 149 noma, as shown in Figs. 48 and 49. Another case with a similar history also came under my care. Fig. 4S. u. Trabeculas. &. Mastoid sinuses, c. Carcinoma. Prognosis. In simple cases of acute purulent otitis media occurring in healthy individuals when due to cold or nasopharyngeal catarrh, the prognosis is good if the case is properly treated. The prognosis is, how- ever, unfavorable in cachectic, scrofulous, tuberculous, and syphilitic patients, also in severe cases of diphthe- ria, scarlet fever, measles, and typhus fever. In some cases of influenza, a favorable prognosis should not be given. One should consider the following as being un- favorable symptoms, viz., a distressing tinnitus ; severe pain, which has been more or less continuous for sev- 150 MANUAL OF OTOLOGY. era! weeks; a profuse discharge, which has persisted in spite of treatment ; hemorrhage from the ear, caused in most instances by granulations or polypi ; great destruc- FlG. 49. Mastoid sinuses, b. Carcinoma, c. Bone trabeculae. tion of the membrana tympani ; symptoms of mastoid disease ; swelling of the bony auditory canal ; caries of the ossicula and walls of the middle ear ; facial paraly- sis and enlargement of the lymphatic glands in the ACUTE PURULENT OTITIS MEDIA. 151 neck. Facial paralysis sometimes, though very infre- quently, manifests itself in simple acute otitis media even when perforation does not occur, but in such (he paralysis disappears in a few days. Treatment. In uncomplicated cases, the patient should be kept quiet in the house, while in severe cases, he should be put to bed and given a light diet. A trit- urate tablet of calomel, gr. one-tenth, should be admin- istered every hour for six doses, or until a slight laxa- tive action is produced. Aconite in drop doses is also a most valuable remedy when there is fever, and espe- cially in cases due to cold. Tincture of pulsatilla, like- wise given in drop doses, is also indicated in cases in which there is a profuse discharge from the nares or Author's scarificator. nasopharynx, and may be administered alternately with aconite. In the early stage, when there is great hypersemia, the artificial leech should be applied at once in front of the tragus and close to it. When the mastoid is simultaneously involved, it should be placed behind the auricle just over the antrum or the mastoid tip. By such treatment the disease will, in simple uncomplicated cases, frequently be cut short, or it will at least run a much less severe course. The artificial leech consists of a scarificator, Fig. 50, and cupping-glass, Fig. 51. The scarificator has seven 152 MANUAL OF OTOLOGY. lauce-shaped nfiedles, and the depth of the punctures made in the soft tissues can be regulated by screwing or unscrewing the cap on the end of the instrument. The latter being placed in front of the tragus or over the mastoid, according to the indications, the spring is Fig. 51. f Pi t J \i '/ Author's cupping-glass. then pulled back and the tissues scarified. The cup- ping-glass is then immersed in hot water for a few seconds and applied over the bleeding surface. The artificial leech is much to be preferred to the natural one, for the following reasons : 1. The scarificator and cupping-glass are always at hand, while natural leeches are frequently very difficult ACUTE PURULENT OTITIS MEDIA. 153 to obtain, especially at night. 2. Leeches are very re- pulsive and disagreeable to most patients, and especially to children. 3. After the artificial leech has-been re- moved, the bleeding ceases at once, while with the natu- ral leech it is often difficult to control the hemorrhage. I have known of cases in which alarming hemorrhage occurred after the surgeon left the patient. In the case of children, hot water instilled into the ear often affords great relief, as well as douching the ear every hour or two with a warm boric-acid solution. Some patients derive much comfort from the application of dry heat by means of a hot-water bag or hot bag of salt. Drops of a 4 per cent, cocaine solution may be used with benefit, as well as a solution composed of atro- pise sulphate, grs. ij ; boric acid, grs. x; glycerin, 3j ; aqua, Sj. All drops and solutions for the ear should always be warmed. The condition of the pharynx, nasopharynx, and nares should be noted, and treatment directed to these parts whenever necessary. (See Chapter VII.) As micro-organisms travel from the pharynx and nasopharynx to the middle ear by means of the Eus- tachian tube, it is of the greatest importance in cases of measles, scarlet fever, diphtheria, and influenza, to try to prevent the disease from extending to the middle ear. To accomplish this, sprays of boric acid or carbolic acid or bichloride of mercury (1 : 5000) are indispensable, while the ears should be constantly examined for the first evidences of inflammation. As the micro-organ- isms in these diseases are apt to cause acute caries, it is very important that the surgeon should make an early incision in the drumhead, and not wait until perforation has occurred through ulceration. A free incision should 154 MANUAL OF OTOLOGY. be made with a bistoury (see Fig. 52), and not a para- centesis, as was formerly practised, the line of incision extending from just behind the stapes to the lower border of the drumhead and close to the bony auditory canal. After the membrana has been incised, the object of treatment should be, first of all, to promote the dis- charge as much as possible by douching the ear with a Fig. 52. G.TIEMANN&CO. Bistoury for incising drumhead. solution of boric acid 3j to water Sviij, or a bichlo- ride solution (1 : 3000); and, secondly, to try to destroy the micro-organisms. After douching the ear, which in some cases is necessary every hour or two, according to the amount and character of the discharge, it is ad- visable to insert a strip of boric acid or iodoform gauze down to the membrana tympani by means of a probe, as this procedure helps to drain the ear. In all cases of acute otitis media due to cold, the drum- head should be incised (after the leech has been applied) as soon as any bulging of the drumhead is apparent, as well as in those cases in which pain persists in spite of all antiphlogistic treatment; In other instances in which spontaneous rupture has taken place, and in which the perforation is very small, the latter should be enlarged. In some cases, after incising the drum- head, no discharge will appear for twenty-four to forty- eight hours, while in others, it is so thick and tenacious that it is necessary to force it from the middle ear into the external meatus by means of Politzer's method. Great care should be exercised in inflating the ear, ACUTE PURULENT OTITIS MEDIA. 155 especially in the early stage, for fear of increasing the inflammation, and under no circumstances should this be done unless there be a large perforation in the drumhead. After the more acute symptoms have begun to sub- side, a saturated solution of boric acid should be warmed and instilled into the ear several times a day after the discharge has been thoroughly removed by syringing or by absorbent cotton on a cotton-holder. Some cases do well under the so-called dry method of treatment, consisting in the insufflation of various powders into the external meatus, principally boric acid. After the canal has been thorougly cleansed of all secretion and dried as before, boric-acid powder is insufflated, by means of a powder-blower, into the ex- ternal auditory canal, but should never be packed in, as pyaemia has followed from such practice. The dry method should not be employed until after all inflam- matory symptoms have subsided, and never in cases in which there is a small perforation nor in which there is considerable thick and stringy mucus. Hydrastis cana- densis may be combined with boric acid as follows : A paste is made of boric acid and tincture hydrastis cana- densis, and the mass, after it is dry, is thoroughly pul- verized and mixed again with equal parts of boric-acid powder. Astringent solutions are indicated in cases in which the treatment by boric acid solution or powder has not succeeded. For this purpose sulphate of zinc, or sulphate of copper, or acetate of lead in the propor- tion of three to eight grains to the ounce of water, are generally prescribed. Injections of warm water through the catheter into the middle ear are reconimended by Politzer in cases in 156 MANUAL OF OTOLOGY. which the pain is persistent and does not yield to the usual remedies ; also in which the discharge cannot be arrested by local treatment, and especially in cases in which there is a small perforation (nipple-like) in the membrana tympani, and likewise in cases in which the mastoid process is involved. Whenever the mastoid cells are implicated, the treatment described in the chap- ter on Mastoid Diseases should be followed. All polypi should be removed by curettes, the snare, or caustic applications. It is of the same importance to attend to the patient's general health in this disease as in acute catarrhal otitis media. After the perforation has closed, it is advisable at first that the patient wear a small piece of cotton in the meatus, especially during unseasonable weather. The middle ear should be in- flated several times a week, and gradually less fre- quently until the hearing is entirely restored, and the patient should be cautioned to be very careful about exposing himself to draughts and sudden changes in the weather. CHAPTER VII. ADENOID GROWTHS. ENLARGED TONSILS. DISEASES OF THE NASAL PASSAGES. As diseases of the ear are so frequently associated with affections of the nasal passages, the nasopharynx, the Eustachian tubes, and the tonsils, it not only falls within the province of the aural surgeon, but becomes his duty to examine most carefully into the condition of these structures and passages as well as to apply proper treatmeut. When the Eustachian tubes are con- stricted or the patient is unable to breathe through the nose, owing to some obstruction in the nasal passages or to the presence of adenoid growths in the nasopharynx, so that proper ventilation of the middle ear is interfered with, it is useless for tiie surgeon to practise repeated inflation of the ears by Politzer's method, with the ex- pectation of effecting permanent relief, without first removing the cause of the occlusion. Great attention has of late years been paid to the treatment of the nose and nasopharynx, and much ben- efit has resulted from this practice. When a patient has been deaf for a considerable length of time and serious changes have taken place in the drumhead, with adhesions, and especially if there be tinnitus, we should be very guarded in expressing an opinion as to the benefit to be derived from treatment of the nasopharynx and nares. Too frequently one 158 MANUAL OF OTOLOGY. sees patients, the victims of chronic catarrhal otitis media, who have undergone operations on the nose and naso- pharynx without any improvement in the hearing. It is in the more recent cases that one is apt to meet with success, before serious changes have taken place in the membrana tympani. ADENOID GROWTHS. To Dr. Wilhelm Meyer, of Copenhagen, is due the honor of having first directed the attention of the medi- cal profession to the great importance of removing ade- noid growths in the nasopharynx, especially when their presence interfered with the passage of air through the nose and Eustachian tube. Others have followed in Dr. Meyer's footsteps, so that, at the present time, the operation of removal of these growths is frequently performed, and with much success. Not only has deafness been the result in many instances from the presence of these growths, but dis- eases of a nervous character, such as asthma, false croup, as well as malformations of the chest, nose, and throat, have been benefited by their removal. The examination of the ear should never be consid- ered complete until the nose and nasopharynx have been most carefully examined, more especially in the case of children. In about 74 per cent, of Meyer's cases of adenoid disease, there was more or less deaf- ness. As usually observed, adenoid hypertrophy at the vault of the pharynx is of two varieties. In one, there is more or less fibrous tissue associated with the lymph- oid mass ; while in the second variety, it is very scarce. The growths vary much as to size and number. There ADENOID GROWTHS. 159 may be simply a chronic enlargement of the pharyngeal or Luschka's tonsil, situated at the roof of the naso- pharynx, which may fill the space entirely, or the growth may be so small that the surgeon is not justified in removing it. The vegetations may extend from the vault along the posterior and lateral walls of the pharynx, or one large mass or several smaller growths may be found on the posterior pharyngeal wall. The adenoid tissue is, as a rule, bright in color and bleeds readily when examined with the finger or probe. Symptoms. The expression of the face is exceed- ingly characteristic of this disease, as well as the manner in which the patient pronounces certain words. There is difficulty in pronouncing sounds of m, n, and ng, so that the patient talks, as it were, " through the nose." As a result of mouth-breathing, the patient presents a stupid and listless appearance ; he is anfemic ; has drooping eyelids, prominent teeth, and arched palate. He may have what is known as a " pigeon-breast ;" he is apt to complain of frontal headache, a feeling of ful- ness in the nasopharynx, and the sense of smell is im- paired. There is apt to be a persistent catarrh with considerable secretion. The nose becomes pinched, and the alse have a sunken appearance. Snoring is a prom- inent symptom. As a result of the obstruction to res- piration through the nose, deformity of the septum may occur. The appearance of the face, in consequence, may be changed, owing to the imperfect development of the osseous structures of the nose and hard palate. The hearing becomes affected when the normal ventilation and nutrition of the middle-ear tract are interfered with. The mucous membrane at the mouth of the Eustachian tube becomes swollen, as a result of frequent 160 MANUAL OF OTOLOGY. head colds, or the vegetations themselves may encroach upon the orifice of the tube. In consequence, the patient complains of earache, tinnitus, and impaired hearing, and if this condition of affairs is allowed to continue without treatment, permanent changes take place in the structures of (he middle ear, so that the drumhead be- comes retracted, adhesions develop, or the drum mem- braue becomes perforated from a suppurative process. Enlarged tonsils are often observed at the same time, especially in children. Causation. Adenoid hypertrophy is much more frequently seen in children than in adults. In fact, after puberty one meets only occasionally with these growths, although they may be found in rare instances in elderly persons, as well as in infants at birth. Hereditary influ- ences undoubtedly play an important role in causation, as well as residence in damp places. They occur some- times as a result of scarlet fever, measles, diphtheria, debilitating fevers, scrofula, and hereditary syphilis. Diagnosis. In adults, one can usually make a diag- nosis of adenoid hypertrophy by means of the head- mirror and posterior rhinoscopy. With children, how- ever, it is almost always impossible to obtain a satisfac- tory view of the nasopharynx by such means. The surgeon should make a digital examination, and for this purpose should protect his index-finger with a rub- ber band, to prevent the child from biting his finger. If the examiner have a long finger-nail and the vegeta- tions be soft and flabby, he can scrape way or break up many of these vegetations, and thus accomplish some- thing at this time. Treatment. In older children who will submit to local treatment, such as the application of chromic acid ADENOID GROWTHS. 161 or the galvano-cautery, these growths may be removed if they be small and soft. Much may be accomplished by the administration of tonics and alteratives, espe- cially if the general health be impaired. The syrup of the iodide of iron, the syrup of hydriodic acid and cod- liver-oil are remedies that are especially indicated. The most satisfactory and efficient method, however, is by the surgical treatment of this condition. There are a cer- tain number of patients, however, who are of a nervous temperament and who are " bleeders," and in whom it is absolutely necessary to use caustics or the galvano- cautery. As regards operative interference, many and various instruments have been devised for this purpose. Meyer himself used an annular knife, one centi- metre in diameter and twenty -one centimetres in length, which he inserted with the right hand between the septum and the spongy bones as far as the naso- pharynx. By introducing the left forefinger through the mouth and behind the soft palate until he felt the instrument, he pressed the vegetations inside the ring. By drawing the knife outward, the growths were cut off. He further recommended a second method, viz., cauterization with solid nitrate of silver. In adults, the adenoid hypertrophy can be removed without an anaesthetic in many instances, but in chil- dren, according to my experience, it is always advisable to use ether or chloroform. Ether is to be preferred as being safer. Whichever one is used, the patient should not be completely anaesthetized, for fear of blood entering the trachea. The instruments that have been most satisfactory in my hands are the Hooper or Gradle forceps, although in some instances the artificial steel finger nail is used with good results. 11 162 MANUAL OF OTOLOGY. Hooper's Method. The child is placed in a good light and thoroughly ansesthetized and held upright in the lap of an assistant. The operator sitting opposite, after a small-sized mouth-gag has been inserted between the teeth on the right side, removes any mucus that has accumulated in the pharynx. After having made sure of the presence and situation of the growths, the soft palate should be pulled forward and upward by means of a palate-hook held in the left hand. The forceps (Fig. 53) are then introduced, closed, into the nasophar- ynx, and after feeling the growths with the closed end of the forceps, the blades are opened and the growth is seized and removed by direct traction, or by a twisting motion of the forceps, but force should never be used. If there is difficulty in removing the growth, the blades should be released and another attempt should be made to grasp a smaller portion. The surgeon should exam- ine with his fingers from time to time to see if the naso- pharynx is free. The child's head is then held forward so that the blood may flow out of the nose, while the operator scrapes away with the finger-nail of the left hand all ragged edges in the nasopharynx. Although Hooper generally relied on the forceps and finger-nails, he found it necessary in some cases to use other instru- ments. The surgeon who operates very frequently will find that he requires different instruments for different con^ ditions, although he may prefer one particular instru- ment. In using the artificial nail or steel finger-nail, the surgeon should be very careful that it does not come off in the patient's mouth. The Recumbeni Method. The patient is ansesthetized ADENOID OBOWTHS. 163 and placed in a recumbent position on an operating -table, and a mouth-gag is inserted on the right side of the Pig. 53. Fig. 54. Fig. 65. Hooper's forceps. Gradle forceps. Gottstein curette. mouth. The operator, standing on the left side of the patient, introduces the forefinger of his left hand into 164 MANUAL OF OTOLOGY. the nasopharynx, to locate the position of the growth as well as to guide the point of the instrument. The Gradle fwoeps, see Fig. 54, are admirably adapted for the removal of these growths. They are introduced, closed, and afterward opened so as to in- clude all of the growth if possible. The patient should be turned to the right side from time to time to allow the blood to flow out of the mouth and nose. Some blood is swallowed and frequently vomited after the operation. There is less danger that fragments of the growth will fall into the larynx by this method than when the patient is in the upright position. After the operator has satisfied himself that he has removed the growth as thoroughly as possible, he should, for fear of leaving some fragments, either scrape the cavity thoroughly with the steel finger-nail or else with the Gottstein curette. Fig. 55. By means of good illu- mination the curette is introduced behind the soft palate and kept well forward until the vault is reached. At this point the instrument is pushed firmly backward and then drawn downward over the posterior pharyn- geal wall. To control the hemorrhage, the nares should be thoroughly sprayed with ice-water while the patient is in the recumbent position. The patient should always be prepared for the opera- tion. The evening before, a mild purgative should be administered, and he should be given a light diet on the day of the operation, and there should be at least four hours' interval between the last meal and the time of the operation. Cases of severe hemorrhage after operation have been reported, but they are infrequent, and when they do occur are probably due to the hemorrhagic diathesis. ADENOID GROWTHS. 165 On this account, it is important for the surgeon to be well informed as to the patient's general condition. The operation should never be undertaken if the patient has a cold or symptoms of otitis media, for in a case ^ that I reported, in which the operation was performed when the patient was suffering from an acute pharyn- gitis, not only did purulent otitis media follow, but it became necessary to open the mastoid cells. Great care and gentleness should also be employed when operating, for fear of injuring the mouths of the Eustachian tubes. After the operation, the patient should be watched until the hemorrhage has ceased, and should then be immediately put to bed and kept in a recumbent posi- tion for at least twenty-four hours, and for several days should remain quiet in the house. During this time the diet should be a simple one. The nares and post- nasal cavity should be sprayed with a Dobell or a mild Listerine solution forty-eight hours after the operation, if necessary. In some cases a second operation is required, even if all the growth was removed the first time. lii other cases, especially in adults, the remnants of the adenoid growth should be cauterized with solid nitrate of silver after cocaine has been used. If the tonsils are enlarged, it may be necessary to ex- cise them, as well as to perform some operation on the nasal passages, in order that the patient may breathe easily with the mouth closed. When the child has been in the habit of breathing with the mouth open for a long period of time, it may be necessary to apply a bandage to prevent the jaw I Transactions of the American Otological Society, 1892. 166 MANUAL OF OTOLOGY. from dropping at night, and this should be worn for some little time until the habit has been corrected. In case of severe hemorrhage, applications of per- sulphate of iron should be made, or it may be necessary to plug the posterior nares. Great care should be exercised so that the patient does not take cold after the operation. Usually after the operation there is a decided improve- ment in the hearing, provided the latter has not been affected for a long time and permanent changes have not taken place in the drumhead. Even in cases in which there is a discharge from the middle ear, the sup- puration generally becomes much less at once. The patient's general health is, as a rule, much improved after the operation. I have seen children who were sickly, poorly nourished, and anaemic, show a decided change for the better after removal of these growths. The following case illustrates fhis point : A boy, aged four and one-half years, weak-minded, poorly nour- ished, breathes with mouth open and is very restless at night. There has been a discharge from the ear for about two weeks. Under ether an examination of the posterior nares was made with the index-finger, and the vault was found filled with adenoid masses. These were removed with the Gradle forceps. There was considerable hemorrhage, which soon ceased. Two weeks later there was a very decided improvement in the child's general appearance, as shown by his breath- ing and sleeping better and being in much brighter spirits. The hearing was much improved, and the dis- charge less. His mother was very enthusiastic over the good results of the operation. It does not follow that improvement in the hearing will take place after the operation, without treatment ENLARGED TONSILS. 167 directed to the ear itself, for frequeotly the drumhead is considerably retracted and bound down by adhesions, so that it will be necessary to restore the drumhead to its normal position. ENLARGED TONSILS. Enlarged tonsils or chronic hypertrophy of the ton- sils are undoubtedly an indirect casue of deafness, in that they interfere often with nasal respiration, and by pressure upward prevent the proper ventilation of the tympanic cavity. When removed, the hearing distance is often much increased, but tiie surgeon should always examine the nasopharynx, for frequeutly in children adenoid hypertrophy is associated with enlarged tonsils. Hypertrophy of the tonsil consists of a proliferation of its fibrous stroma together with an unusual increase of its lymphoid tissue. The proliferation of its fibrous stroma is observed more frequently in cases of long standing. Causes. Enlarged tonsils are frequently due to mal- nutrition, scrofula, syphilis, tuberculosis, rheumatism, and indigestion. Exciting causes are frequent attacks of acute inflammation from cold, scarlet fever, diph- theria, measles, whooping-cough, and recurring attacks of quinsy sore throat. Enlarged tonsils have been observed in children soon after birth. After puberty the tonsils, as a rule, begin to grow smaller, and in some cases resume a normal size and appearance. Symptoms. The symptoms are very similar to those observed in cases of adenoid hypertrophy. The patient is apt to be poorly nourished, has difficulty in breathing with mouth closed, and there is apt to be more or less 168 MANUAL OF OTOLOGY. difficulty in speaking. In some cases the senses of hear- ing, smelling, and tasting are impaired. Nervous symp- toms are sometimes observed, such as spasmodic cough, chorea, and epilepsy. Treatment. I consider it advisable to try to re- duce the size of the tonsils by internal medication and by local treatment, whenever practicable, before resort- ing to surgical interference. I think that surgeons are often inclined to operate at too early a date, and in some cases, I believe that much can be accomplished without resorting to excision. In some instances, cheesy matter can be forced out of the crypts by pressure made on the tonsils. In cases of malnutrition the child should be given cod-liver oil, syrup of the iodide of iron, or syrup of hydriodic acid for some little time before resorting to operative measures. Astringent sprays of ferric alum are often useful, and in some cases chromic acid can be applied by being fused on the end of a probe and the latter passed into the substance of the tonsil at several different points. In cases of the hemorrhagic diathesis, it is necessary for the surgeon to make use of escharotics, especially chromic acid or the galvano-cautery loop, or of the cold wire. There are various methods of removing the tonsil. Besides cauterization and ^crasement by means of the galvano-cautery, another method is to excise it with forceps and a probe-pointed bistoury. Some prefer scis- sors, but such practice has for the most part been aban- doned. When the galvano-cautery loop is employed, on account of its being a painful procedure, several drops of an 8 per cent, solution of cocaine should be in- jected into the substance of the tonsil to produce local ENLARGED TONSILS. 169 anaesthesia. This cau only be done in the case of adults. Great care should be taken to include the greater portion of the tonsil within the loop end, and this can usually be best accomplished by means of for- ceps. Traction should never be made upon the loop except when the electric current is passing through it, and the current should be used intermittently. The most satisfactory method and that most uni- versally adopted is tonsillotomy. In the case of young children, an anaesthetic is indispensable, and for this purpose ether is undoubtedly the safest, although many prefer chloroform. In order to perform this operation successfully, the services of an assistant or trained nurse are absolutely essential. In the case of adults and chil- dren old enough to undergo the operation without ether, the assistant should steady the head of the patient, who sits in a chair with his back to the light and facing the surgeon. With a head-mirror the operator should throw a good light into the pharynx. The assistant, standing behind the patient, should not only support the head with both hands, but should make pressure with the fingers of each hand immediately below the angle of the jaw over the tonsillar region, so that the tonsil will be more readily grasped by the tonsillotome. In the case of young children in whom it is necessary to use an ansesthetic, the child should be placed on an operating- table, and the same precautions adopted to prevent blood from entering the larynx as in the adenoid operation. A mouth-gag should be inserted after the child is anaes- thetized, and while the surgeon throws a light into the pharynx by means of a head-mirror, the instrument should be introduced flatwise, like a tongue depressor, until it touches the pharynx. It is then turned so that 170 MANUAL OF OTOLOGY. the entire tonsil or as much as possible of it is included within the ring. With the Mackenzie instrument (Fig. 56), the blade is then pushed firmly and steadily through the hypertrophied tissue. The growth usually Fig. 56. Mackenzie's tonsillotome. adheres to the ring, so that it comes away when the in- strumentis withdrawn. A fork has been added to this instrument, for fear that the growth might drop into the larynx in cases in which an ansesthetic has been adminis- tered. There are several sizes of the Mackenzie tonsil- FlG. 57. G.TIEMANN &.C0. T"°'°°^^ Mattbien tonsillotome. lotome as well as of the Matthieu instrument, (See Fig. 57.) The latter I prefer, but the former is more com- monly used by operators. "With the Matthieu tonsil- lotome the ring is slipped over the tonsil, and instead of pushing, as in the Mackenzie instrument, a cutting EXAMINATION OF THE NOSE. 171 blade concealed within the ring is pulled forward. A fork is applied to this, and the growth is pierced by it before excision. As a general rule, there is but slight hemorrhage after excision, which usually ceases spontaneously. If the bleeding continue, it may be checked by the patient sucking cracked ice or gargling the throat with iced water, or applications of persulphate of iron may be required. In case of severe hemorrhage where several small arteries have been divided, the bleeding may be con- trolled by torsion of the vessels, or by application of styptics, or by the galvano-cautery. Pressure is some- times made over the bleeding surface by means of the finger. Venous and capillary hemorrhages are gener- ally stopped by the application of ice or of some styptic. In alarming cases, in which the hemorrhage is severe, it may become necessary to ligate the common carotid artery, but such instances are exceedingly infrequent ; after the operation, the patient should be kept very quiet in the house, and should be given a light diet for several days. It should not be forgotten, however, that secondary hemorrhage may occur a week after the operation, so that this fact should be constantly borne in mind. Milk and beef-tea should be prescribed for the first twenty-four hours. A gargle or spray of boric acid is very soothing, and should be used, or a gargle of permanganate of potash may be substituted. EXAMINATION OF THE NOSE. Anterior Rhinoscopy. The patient should be seated before the surgeon, and by means of a head-mirror and Argand burner, or by 172 MANUAL OF OTOLOGY. an electric lamp, the anterior nares should be thor- oughly illuminated. A speculum with two blades Fig. 58. ^3r^^^/r r]ii'm'iTrf of nasal duct. istle passed through Steris&ii^s duct. Sectional Tlew of the nose, mouth, pharynx, etc. (Gkay .) (see Fig. 30) should be introduced so that one blade rests against the septum, while the other one is pushed EXAMINATION OF THE NOSE. 173 upward and outward. The patient's head should then be tilted in different positions to enable the surgeon to see the different sides of the nasal cavity. When the patient's head is thrown backward, portions of the in- ferior and middle turbinated bones will be brought into view together with the middle meatus, while with the head inclined forward, the anterior portion of the in- ferior turbinated bone will be seen. Posterior Rhinoscopy. The patient should be seated before the surgeon and his head slightly thrown back, with the light for illumi- nation placed on a level with his ear. The light is then reflected from the head-mirror into the patient's phar- ynx, and the focal distance determined. The tongue FlQ. 59. Tongue depressor. being held down by means of a spatula (see Fig. 59), the rhinoscopic mirror should be first warmed and in- troduced, with the mirror surface upward, between the uvula and the soft palate. The patient should be in- structed to breathe through the nose, so that there will be as much space as possible between the soft palate and the posterior pharyngeal wall. One should change the position of the mirror so as to bring into view the vault 174 MANUAL OF OTOLOGY. of the pharynx, the posterior edge of the septum, the orifices of the Eustachian tube, and the posterior ex- tremities of the turbinated bones. In the treatment of aural diseases it is important for the surgeon not only to make a thorough examination of the anterior and posterior nares, but to remove nasal polypi, and to perform such other operations as may be necessary to establish proper nasal respiration, and thus thoroughly ventilate the tympanic cavity. Nasal catarrh should receive appropriate treatment by sprays and attention to the general health. The surgeon should be prepared to prescribe for all cases of acute nasopharyngeal catarrh or acute rhinitis for aural diseases are very often cansed by these affec- tions, especially when due to influenza. In a work of this character it is impossible to do more than discuss in a brief manner the more important diseases of the nose and nasopharynx. The reader is therefore referred to the standard text-books on diseases of the nose and throat. The diseases that are of especial interest to the otol- ogist are chronic nasopharyngeal catarrh (including hypertrophic and atrophic rhinitis), nasal and naso- pharyngeal polypi, and deflections of the nasal septum. Chronic Catarrh. In this disease there is a parenchymatous swelling of the mucous membrane, which is due to the presence of enlarged bloodvessels, to the infiltration of serum, and to an increase of the connective tissue — hence results hypertrophy. The cavernous tissue on the turbinated bones becomes excessively swollen, and the patient for a time may be unable to breathe through one side of the OHMONIO CATARRH. 175 nose. In a short time the same side may become per- vious, while the other one will be closed. As a result of chronic catarrh, the posterior extremity of the middle and lower turbinated bones may become so much hypertrophied that the tissue may protrude into the nasopharynx and be mistaken for a polypus. True hypertrophy of the mucous membrane is due more especially to an increase in the fibrous or connective tissue. Increase of the cavernous tissue generally affects the anterior portions of the turbinated bodies. Chronic Hypertrophic Catarrh, or Hypertrophic Rhinitis. This affection may follow frequent attacks of acute catarrh, or may be due to impairment of the general health, gout, rheumatism, the excessive use of stimu- lants and tobacco, and hereditary causes. It is very seldom that one meets with a normal condition of the mucous membrane of the anterior and posterior nares. The tendency of the present day is, I think, to operate more frequently than is absolutely necessary. If a number of persons should be examined, who did not even complain of any symptoms referable to the nose or throat, it is probable that evidences of catarrhal in- flammation, or spurs on the septum, or hypertrophy of the mucosa covering the turbinated bodies would be found in many instances. There is undoubtedly an excessive inclination to operative interference on the part of many rhinologists, especially when the deafness seems to be due to catarrhal inflammation. Many promises to improve the hearing by operative measures on the nose have not been carried out, for the reason that catarrhal changes had already taken place in the drumhead, and in some instances, in the internal ear. 176 MANUAL OF OTOLOGY. A surgeon should not operate on the nose simply be- cause the condition of the mucosa covering the turbi- nated bodies is not normal, unless the symptoms are such as to warrant interference. Symptoms. There is a certain amount of nasal ob- struction owing to swelling of the tissues, but this varies in intensity from time to time, according as to whether the erectile tissue covering the turbinated bodies is involved. The voice may have a nasal twang, while the patient, breathing with open mouth, presents a stupid appearance. The patient complains of a dull feeling in the head, difficulty in smelling and tasting, and sneezes frequently. There is usually a marked hypersecretion of mucus, of either a serous or a viscid character. An examination reveals an abnormal redness of the mucosa with a certain amount of hypertrophy. The anterior extremity of the inferior turbinated body may be enlarged, or the mucous membrane covering the entire body may be thickened and corrugated. The inferior turbinated body is more frequently affected than the middle one, although the latter may be decid- edly enlarged and press upon the septum. By poste- rior rhinoscopy, one may find the posterior extremities of the middle and inferior turbinated bodies very much hypertrophied, so that when projecting into the naso- pharynx the growth may present the appearance of a mulberry-like polypus. When the stenosis is due to simple enlargement of the erectile tissue, applications of a 10 per cent, solution of cocaine will cause a marked shrinking of the tissue, while in cases of true hypertrophy cocaine will have but little effect. CHRONIC CATARRH. 177 Treatment. In cases in which there ia but slight hypertrophy, much can be accomplished by having the patient spray the anterior nares with Dobell's or Seller's antiseptic solution. Astringent sprays should be used by the surgeon, and in cases in which there is but slight hypertrophy, the latter can be cauterized with chromic acid. If the hypertrophied mass be sufficiently large so that a loop can be passed around the growth, it should be removed by means of the galvano-cautery. If snaring be inapplicable the flat point of the cautery may be used to destroy the hypertrophied tissue. The superficial sloughs will fall off in a few days' time or within a fortnight. The application of the cautery or of caustic agents should be repeated until the nose is pervious, but a week or two should intervene between the applications. In the mean time the patient should be careful not to take cold, and should spray the nasal passages with a boric-acid solution. Besides local treatment, which is most important, ben- efit will also follow from attention to the patient's gen- eral health, by correcting any digestive disturbance, and prescribing for any gouty or rheumatic diseases. Change of air to a dry atmosphere should be recommended in many instances. Chronic Atrophic Catarrh, or Atrophia Rhinitis ; Ozoena. In this disease atrophic changes occur, so that the nasal passages are usually more pervious than in a nor- njal case. The atrophy, as a rule, is most apparent in the inferior turbinated body. The nasopharynx and pharynx are apt to be iuvolved as well, and when the hearing is impaired it is usual to find the Eustachian tubes dilated, so that air is easily forced into the tym- 12 178 MANUAL OF OTOLOGY. panum by Politzer inflation or by catheterization. The same atrophic changes may talie place in the middle ear and drum membrane, so that the latter may be exceed- ingly thin. Great care should be used in inflating the ear when this has occurred, for I have seen the mem- brane ruptured when forcible inflation was practised. There is very little secretion iu the nasal passages, and the latter are generally exceedingly dry. When green crusts form which give rise to a very offensive odor, the disease is called ozcena. In simple atrophic rhinitis, attention. should be paid to the patient's general health, and alkaline sprays or a spray of albolene, containing 2J per cent, each of camphor and menthol, should be used, In ozsena the proper treatment is to remove the crusts as soon as they form, and advise the patient to use daily a spray of permanganate of potash, boric acid, carbolic acid, or some other disinfectant. Some rhinologists recommend sprays of aceto-tartrate of aluminium, or of tincture of iodine. Others advise the insufflation of antiseptic powders, boric acid, iodol, etc., while the ap- plication of the electric cautery has been recommended as well as the use of the constant current. Chronic Nasopharyngeal Catarrh. The nasopharynx participates in the same changes as are found in chronic hypertrophic or atrophic rhin- itis and chronic pharyngitis. An examination with the rhinoscopic mirror will re- veal the nasopharynx as being simply hypersemic with more or less swelling of the mucosa, and occasionally a swollen condition of the lips of the Eustachian tubes, or there may be a granular condition similar to that ob- CHRONIC CATARRH. 179 served in granular pharyngitis, or atrophic changes may have taken place. The usual symptoms are a feeling of fulness and dis- comfort in the nasopharynx, with an accumulation of mucus which the patient tries to get rid of by hawking or swallowing. At night the patient is apt to complain of a dropping of mucus from the nasopharynx. The above symptoms are observed only in cases in which there is a hypersecretion. Nasopharyngeal catarrh is a disease that is very prevalent in the United States, especially in the larger cities. It is undoubtedly due to the sudden and ex- treme changes of temperature that are so common, and also in a large measure, I believe, to a fine dust, espe- cially in New York. Persons in impaired health are subject to the disease as well as those suffering from a rheumatic and gouty diathesis. Other deleterious in- fluences are living in steam-heated rooms, the abuse of alcohol and tobacco. Catarrh of the nasopharynx is often much benefited by removing some obstruction in the anterior nares, so that the surgeon should be sure to secure permeability of the nasal passages in all cases. The nasopharynx should be sprayed with alkaline solutions in order to remove all secretion. Afterward, astringent sprays should be used, or applications made of nitrate of silver, in simple uncomplicated cases. Where there is a granular condition, it becomes neces- sary to use caustics, viz., nitrate of silver or chromic acid, or the galvano-cautery. In cases of ozsena the crusts should be removed and the same treatment followed as when the disease affects the anterior nares. 180 MANUAL OF OTOLOGY. Some advise scraping the remains of the pharyngeal tonsil, or the local application of the electric cautery after the crusts have been removed. NASAL POLYPI. The mucous polypus is the form of tumor most fre- quently met with in the nasal passages, and is generally found attached to the middle turbinated body. It is usually of a round and smooth appearance, frequently pear-shaped, and of a bluish-gray color. It may, how- ever, not form a distinct tumor, but simply a fringe, constituting what is called " polypoid hypertrophy." These polypi are, as a rule, bilateral and multiple, and vary in size from a very small pea to a walnut. Be- sides the mucous polypus, there are other varieties of tumor which are of rare occurrence, but nevertheless are occasionally observed, viz. : 1. A polypoid growth, usually single, reddish in color and containing fibrous tissue. 2. Papilloma, either single or multiple, which is apt to be attached to some portion of the inferior turbinated body or the adjoining parts. 3. Angioma. 4. Adenoma. 5. Cysts. 6. Osseous tumor. 7. Malignant growth. Treatment. The most successful method of re- moval of nasal polypi is by means of the cold wire or galvano-cautery snares. The surgeon should have thor- ough illumination of the parts, and after applying a 10 per cent, solution of cocaine, should examine the nasal passages with a blunt probe. In some cases it is NASAL POLYPI. 181 necessary to introduce the finger into the nasopharynx. After removing the polypus with the snare, the root should be cauterized with chromic acid or the galvano- cautery. The older plan of using forceps and torsion is at the present time generally discarded. It may require several sittings before the patient is cured. Polypi of the Nasopharynx. Polypi found in the nasopharynx are usually of a fibro-mucous character, but occasionally are very hard and consist of fibrous tissue. Fibro-mucous Polypi. These growths are somewhat firmer in consistency than those found in the anterior nares. They are said to be more frequent in women than in men, and, as a general rule, are attached by a slender pedicle near the borders of the oboanse. The symptoms are those due to nasal obstruction and pressure on the palate. A bluish growth, quite freely movable, will be seen with the rhinoscopic mirror. The polypus will be distinguished from a true fibroma on account of its color, mobility, and softer consistency. It should not be mistaken for a cyst, owing to absence of fluctuation. The growth can generally be removed by means of the cold steel wire, which is slipped around the pedicle. Some prefer to use the galvano-cautery, while others consider evulsion by forceps to be a more satisfactory method. The remains of the pedicle should be treated with chromic acid or the galvano-cautery. 182 MANUAL OF OTOLOGY. FIBROMATA. A fibroma springs from the periosteum and bone, and is most frequently attached to the body of the sphenoid and the basilar process of the occipital bone. It is firm to the touch, of a pale reddish color, and consists of fibrous tissue, round cells, and frequently of dilated vessels. It occurs more often in males than in females, and the development of the growth is not very active after the twenty-fifth year. The tumor is not, per se, malignant, but, on account of the destruction to adja- cent tissue caused by its growth, it is of a dangerous character. It may extend into the nasal passages and cause the nasal bones to expand, giving the patient a deformed appearance called " frog-face." Adhesions may take place in the nose and pharynx, whereby its nutrition may be increased. When ulceration follows there is apt to be a fistid discharge. It may extend to the orbit and give rise to exophthalmos. Deglutition and respiration may be interferred with when it pro- jects downward toward the larynx. The cranial cavity may be invaded, and great pain follow from pressure on certain nerves. Deafness results in some cases from pressure on the orifices of the Eustachian tubes. Exceptional cases occur in which spontaneous cure is established by a sloughing off of the growth. The prognosis is always grave, especially when adhesions have taken place and the patient is suffering from press- ure symptoms. The diagnosis is generally made by posterior rhino- scopy and palpation. A fibroma is hard and firm to the touch, and usually of a pale or dark red color. It is very important to find out first of all about the attach- DEVIATION OF NASAL SEPTUM. 183 ment of the tumor in order to decide if the growth can be removed by means of the cold snare or the galvano- cautery loop. When the base is attached to the phar- ynx alone, the electric loop can be passed aronnd the growth either through the nose or the mouth. Only a moderate degree of heat should be applied when the galvano-cautery loop is used. The galvano-cautery should also be employed to destroy the remnants of the tumor after its removal. Some surgeons prefer the method of evulsion, while the application of electrolysis is recommended by others. When the growth has ex- tended beyond the pharynx, various operative measures have been devised for excising the same, namely, an operation performed through the mouth, or through the nose, or through the superior maxillary bone. It is, however, beyond the province of this book to discuss such operations. Besides the growths already men- tioned, malignant tumors are occasionally met with. DEVIATION OF THE CARTILAGINOUS NASAL SEPTUM. Deviations of the cartilaginous septum, when of re- cent origin, are probably due to some blow or fall, while in cases of long standing, the cause is probably one of faulty development, congenital in character. The cartilaginous septum may be but slightly deflected, or the nasal passage may be so constricted that the patient can with great difficulty force any air through by an expiratory effort. As one side becomes narrowed the other one is correspondingly dilated. Symptoms. The patient is apt to breathe with mouth open, especially at night. There is obstruction to respi- ration on one side, so that when the patient is requested to blow through the obstructed side, the nostril on the 184 MANUAL OF OTOLOGY. dilated side being closed, very little or no air will pass through. . By closing the constricted nostril and repeating the same procedure, a free current of air is obtained. Other symptoms are: disturbed rest at night, a nasal tone to the voice, epistaxis, and, what is of especial concern to the otologist, more or less deafness, or a sense of fulness in the ear, or tinnitus, due to interference with the proper ventilation of the tympanic cavity. The nasal passage being obstructed, it is easy to understand how, by the act of swallowing, the drumhead becomes retracted, and unless this condition is relieved at an early date serious changes are liable to occur in the drumhead, so that a permanent disturbance of hearing results. According to my experience, a very common symptom is a feeling of fulness in the ear, which is very annoying to the patient. It is usually temporarily relieved by inflation of the middle ear, but soon returns. This disease also gives rise at times to headache and reflex symptoms. A diagnosis can readily be made by inspection with a nasal speculum. Fig. 30. The deviated portion is readily seen, constricting the nasal passages, while on the other side the nasal space is unusually dilated. The latter condition will assist the surgeon in differen- tiating from tumors and exostoses. Numerous operations have been proposed and per- formed for relieving this condition, the galvano-cautery being used by some, while the saw has been preferred by others. The operation that seems to me to be most successful is the one devised by Dr. Morris J. Asch, of this city. DEVIATION OF NASAL SEPTUM. 185 The Asch Operation. The instruments used by Asch are two separators (Figs. 60 and 61), one with a blunt edge and the other sharp, to break up any adhesions existing between the septum and the turbinate on the affected side, as also to Fig. 60. Asoh's separator, with blunt edge. Fig. 61. Asoh's separator, with sharp edge. destroy any posterior obstructions. The scissors (Fig. 62) are of two sizes, powerful instruments, curving out- ward from the point of crossing and meeting again in front. Of the blades, one is blunt, while the other is Fig. 62. Asch's scissors. sharp with a triangular blade, the apex of which is at the tip. The other scissors (Fig. 63) are made with the blades bent at right angles, and are occasionally necessary for those deviations that lie low down on the floor of the nose. 186 MANUAL OF OTOLOGY. Of two compressing forceps (Fig. 64) one has a long and the other a short beak. Hollow tubes of vulcanite are used (Figs. 65 and 66), which have a slight curve Asch's scissors. Fig. 64. Asoh's compressing forceps. on the under surface, in accordance with the normal curve at the entrance of the vestibule of the nose. The tubes are perforated to prevent them from slipping Fig. 65. Aseli tubes. when inserted, and vary in size and shape. The Asch tubes (Fig. 65) are five in number, and the Mayer tubes DEVIATION OF NASAL SEPTUM. 187 (Fig. 66) are of six sizes, the latter being more oval and flatter on the sides than the former. These tubes are so constructed that the heat of a sterilizer does not destroy Iheir shape. The patient should be thoroughly anaesthetized, as the local applicatiou of cocaine is not Fig. 66. Mayer tubes. sufficient. The nose should be sprayed first of all with an alkaline antiseptic solution. All instruments, etc., should be sterilized. After the patient is completely anaesthetized, the cone is removed, and is not usually reapplied, as the operation is quickly performed, as a rule. The head should then be drawn backward, so that blood will not enter the larynx, and the table should be so arranged that the surgeon can use either direct or artificial light. Any adhesions existing between the septum and the adjacent mucous membrane are then broken up by means of the blunt separator, which has been introduced sideways on the deviated side. The operator is thus enabled at the time to detect the pres- ence of bony obstructions posteriorly, in which case, and also if the adhesions cannot be broken up, the separator with sharp edges is substituted. Hemorrhage may occur at this step of the operation, but it is generally controlled by an iced spray or by pressure made with cotton on an applicator. The open 188 MANUAL OF OTOLOGY. scissors are then introduced parallel to the floor of the nose, the blade in the concavity or dilated nasal passage, while the blunt edge is over the point of greatest con- vexity. The instrument is next closed so that the blade cuts through the cartilage into the opposite side. The instrument is then opened and withdrawn, but im- mediately reintroduced, the direction of the instrument being upward and pointing to the frontal bone, the blade again in the cavity and crossing the line of the first incision at as nearly a right angle as possible, and at its centre. The incisions will thus intersect each other. The second incision is made by closing the scissors firmly. There are, therefore, four segments as a result of the crucial incision, and these are forcibly pushed into the dilated passage by means of the finger introduced into the deviated side. One blade of the powerful blunt forceps is next introduced into each nostril and firmly closed, so as to straighten the septum and force the broken segments to override each other on the concavity. After withdrawal of the forceps, an iced solution is sprayed into each nostril and sterilized tubes introduced into the nose, a closely fitting one on the constricted side and a smaller one on the dilated side, in order to cause equable pressure, this being usu- ally sufiicient to control all hemorrhage. After the patient is placed in bed, cold antiseptic sprays are used every half hour, and iced cloths are applied externally. The tube in the former concave side is withdrawn permanently twenty-four hours after the operation. Twenty-four hours later, the tube on the constricted side is removed and cleansed, while the nose is sprayed and cleansed with cotton applied to ap- plicators, cocaine being used if necessary. The same DEVIATION OF NASAL SEPTUM. 189 tube is generally reinserted. The patient at this time is allowed to sit up. During the next three or four days, the tube is removed each day and cleansed, and during this time the nose is cleansed, and the patient is instructed how to extract and reintroduce the tube him- self. After this the patient is seen once or twice a week for four weeks, and the tube is finally withdrawn per- manently five weeks from the day of the operation. Occasionally the lower segment of the septum remains thickened at the end of this time, and presents the ap- pearance of a spur. This should then be removed by the electro-trephine or gal van o cautery after the parts have been cocainized. CHAPTEE VIII. OTITIS MEDIA CATARRHAIJS CHRONICA, OR CHRONIC CATARRHAL OTITIS MEDIA. The acute form of catarrh, or frequent attacks of the subacute variety, lead to chronic inflammation of the middle ear. In the chronic form, after exudation has occurred, adhesive processes in the middle ear are apt to develop, leading to adhesions between the drum mem- brane and tympanum, rigidity of the chain of ossicles, and anchylosis or fixation of the stapes. It is not necessary, however, that there should be first of all an exudative catarrh before the adhesive process com- mences, for very frequently the latter starts in as an in- terstitial inflammation in the mucous membrane of the tympanic cavity, with a simultaneous involvement of the labyrinth. Some writers believe that, in these cases, the same pathological process begins at the same time in both the labyrinth and middle ear. This form of interstitial inflammation with labyrinthine implication should in many instances be classified as a disease •per se, since it has no connection whatever with the exuda- tive catarrhal process. It has been called " dry catarrh of the middle ear," or " sclerotic otitis media," and usually gives rise to considerable deafness and tinnitus, while the pathological changes are usually most marked about the fenestras ovalis and rotunda. In the exudative or moist variety of chronic catarrh, CHRONIC CATARRHAL OTITIS MEDIA. 191 the mucous membrane is congested and swollen from infiltration with serum. There is an increase of con- nective tissue which covers the incus, malleus, and attic, as well as the fenestrse ovalis and rotunda. There is more or less thickening and hypertrophy of the lining membrane of the middle ear, due to an increase of round Fia. 67. Internal surface of the left membrana tympanl, enlarged. (Poutzer.) A. Head of the malleus. B. Neck of the malleus. 0. Tendon of the tensor tympani muscle and anterior fold of the membrana tympani. D. Inferior extremity of the handle of the malleus. E. Anterior portion of the mem- brani tympani. F. Posterior fold of the membrana tympani and chorda tympani. G. Incus. H. Short process of incus. I. Long process of incus. cells and also to new connective-tissue formation. At this stage partial resolution may take place through a fatty degeneration of the round cells. The middle ear frequently contains thick mucus. The mobility of the ossicular chain becomes impaired, and in consequence, thpre results more or less deafness, which may be re- 192 MANUAL OF OTOLOGY. lieved at this time by treatment, especially if adhesious have not already taken place. After cessation of the discharge, the mucous membrane loses more or less of its red color, and becomes pale, although it is still thick- ened. The different folds of the lining membrane of tlie tympanum, and the ligaments which bind the ossi- cles together and to the walls of the middle ear, become rigid and thickened. In some rare instances, the mu- cous membrane undergoes a partial calcification. Ad- hesions take place between the inner wall of the middle Section showing (lie inner or mucous surface of the drumhead and ossicles (normal). ear and tlie drumhead by means of bands or strife. The ossicles may be attached to the tympanic walls, and anchylosis may occur, so that the power of vibration of the drum membrane is seriously interfered with. The attic at times undergoes more or less obliteration from the excessive formation of connective tissue and from becoming joined with the ossicles and the inner surface of the drumhead. The conduction of the sound waves by means of the ossicular chain becomes seriously inter- fered with at this stage, owing to the formation of such CHROmO GATABUHAL OTITIS MEDIA. 193 adhesions and the occurrence of anchylosis. The three bones may be anchylosed, or there may be a separate at- tachment between each bone and the tympanic wall. Anchylosis between the stapes and fenestra ovalis gives rise to considerable deafness and to serious results. The edge of the foot-plate may be united with the margin of the fenestra ovalis, or the crura may be bound down by adhesive bands or striae. Such anchylosis may follow an inflammation of the entire tympanic cavity, and be associated with more or less anchylosis of the malleus or incus or both of them. There may be at the same time numerous strise and bands running through the tympanum, with thickening of the membrane covering the fenestra ovalis. Instead of the entire drum cavity being involved, the disease may be limited to a circum- scribed inflammation of the sclerotic or interstitial variety, and confined to the region of the fenestra ovalis. Bony union between the stapes and fenestra takes place in some instances, and when this occurs the deafness is incurable. Certain changes are observed frequently in the fenes- tra rotunda, such as thickening and calcification. The changes in the Eustachian tube depend very much on the nature of the disease in the tympanum itself. There is frequently constriction of the tube in the early stage, when the mucous membrane of the tympanic cavity is swollen and filled with round cells, and before shrink- ing of the tissues and sclerosis have taken place. There is usually at the same time some catarrhal in- flammation of the nasopharynx. It is in this stage of the disease, before adhesions have produced fixation of the ossicles and drumhead, that much benefit follows from inflation of the tympanum, and appropriate treat- 13 194 MANUAL OF OTOLOGY. ment of the nasopharynx and the mouths of the Eusta- chian tubes. In the circumscribed sclerotic form of inflammation, limited mostly to the neighborhood of the fenestra ovalis, the tube is, as a general rule, normal as to its permeability, although there are oncasional exceptions, when there is some constriction. Occasionally (he ven- tilation of the middle ear is interferred with, owing to certain changes having occurred in the muscles of the Eustachian tube. The intra-tympanic muscles are like- wise subject to atrophy, fatty or colloid degeneration. From this description of the pathological changes that are usually observed in this disease, it will be seen that chronic catarrhal otitis media is a term that should include cases of secretive catarrh, in which there is con- siderable hypersemia and swelling of the mucous mem- brane, followed by the formation of adhesions and an- chylosis of the ossicles, as well as cases of sclerotic or interstitial inflammation, which is confined to a limited portion of the tympanum, usually the neighborhood of the fenestra ovalis or fenestra rotunda. It very fre- quently happens that the patient does not seek advice during the first stage, when the surgeon could accom- plish very much by treatment, but only comes when adhesions and anchylosis have occasioned more or less deafness, which interferes with his occupation. The tinnitus at this time is often most annoying and dis- tressing. Heredity plays an important role in the etiology of chronic catarrh of the middle ear, and especially in that form of circumscribed sclerotic inflammation, although very often patients who present themselves are unable to ascribe the disease to any such influences. Other CHRONIC CATARRHAL OTITIS MEDIA. 195 causes are frequent attacks of acute or subacute catarrh of the middle ear, chronic naso-pharyngeal catarrh, diphtheria, the exanthematous diseases, tuberculosis, syphilis, Bright's disease, ansemia, pregnancy, gout and rheumatism, residence in a damp climate, sea-bathing, and the excessive use of alcohol and tobacco. Young persons and children are not so frequently affected with chronic catarrh (adhesive form) as the aged and those in middle life. The former are more frequently the subjects of the so-called moist variety of catarrh, which, as a general rule, affects both ears. As chronic catarrh of the middle ear is usually con- sidered as an extension of the catarrh from the naso- pharynx, it is important, in such cases, to thoroughly examine the latter cavity as well as the nasal passages and pharynx. In some instances, the patient has much difficulty in breathing through the nose with the mouth closed, owing to hypertrophic rhinitis, the presence of a spur or polypus, or a deviated septum. In other cases, the nasal passage is usually dilated, owing to atro- phic changes, and frequently at the same time the Eu- stachian tube is found in a similar condition. In such individuals inflation of the ear is apt to make but little if any improvement in the hearing distance, while tests with the tuning-fork often show loss of bone conduction. An examination of the throat in one case reveals a thickened and dull-red mucous membrane; in another, the mucous membrane is unusually dry and has a glazed appearance. Then, again, the pharyngeal wall may be studded with small elevations, with enlarged vessels leading to them. Appearances of the Membrana Tympani. The membrana appears dull, lustreless, and more or less 196 MANUAL OF OTOLOGY. opaque. Certain portions of the drumhead may be normal in appearance, or the entire membrana may be thickened and milky-wbite. (See Fig. 69.) The opacities vary greatly in shape, being semilunar at times, or there may be a peripheral or circular opacity along the lower border of the membrane, which is compared to the arcus senilis of the cornea. Chalky or calcareous deposits, often crescentic in shape, are found at times in front of the Section of the temporal bone, showing marlied retraction and thickening of the drumhead and anchylosis of the ossicles. handle, although they are also occasionally observed in the posterior segment. Again, there may be chalky spots in both anterior and posterior segments, or a chalky de- posit in one portion, while other parts of the membrana are opaque from thickening. The drumhead, besides being milky-white or yellowish, like parchment, may assume a bluish-white appearance or even reddish-gray, the latter color being due frequently to a congested con- dition of the middle ear, while the drumhead is more CHRONIC CATARRHAL OTITIS MEDIA. 197 or less transparent from atrophic changes. In some instances, the membrana becomes very thin, so that the different portions of the middle ear can be clearly seen, as well as the incudo-stapedial articulation. In such a case, the drumhead may be ruptured when forcible infla- tion of the ear is practised according to Politzer's method. The Eustachian tube is apt to be freely per- vious, so that one should always be most cautious in forcing air into the tympanum whenever such condi- tions are present. There may be atrophy of the membrane in one por- tion, while in another portion there is considerable thickening. On account of the retraction of the drum- head, the handle of the malleus appears foreshortened and drawn inward and upward, and especially so when the inferior extremity is adherent to the inner wall of the middle ear, while the short process stands out prom- inently, as well as the anterior and posterior folds of the membrana. (See Fig. 70.) The membrana flaccida is apt to be sunken in. There may be deep depressions in the drumhead, where the membrane is attached to the tympanic wall. In consequence of the inward and up- ward displacement of the long handle of the malleus, the cone of light becomes distorted and frequently very much contracted. In cases of sclerotic inflammation limited to the region of the fenestra ovalis, an important symp- tom is the appearance of congestion of the promontory, which is seen through the membrana. In this same class of cases, however, there may be simply anchylosis of the stapes, while the drum membrane shows every evidence of being normal. Symptoms. The first symptom to cause annoyance to the patient and make him seek advice, as a general 198 MANUAL OF OTOLOOY. rule, is a tinnitus or subjective noise in the ear, which, though slight at first, gradually becomes more intense, so that he is often very much disturbed by it, while in exceptional cases where the patient is of an extremely nervous temperament, and the disease has lasted for a long time, melancholia has followed. Tinnitus, on the other hand, in cases of chronic catarrh, in which there is some secretion, is usually of a transitory character or else absent altogether. In the adhesive and sclerotic varieties, while the noises may be intermittent at first, they generally become continuous as the disease pro- gresses, especially when anchylosis of the stapes with the foramen ovale has occurred. The noises are apt to be most distressing when the weather is damp and muggy, or after the patient has indulged freely in alco- holic drinks, or is mentally fatigued, or otherwise ex- hausted from some indisposition. They are more likely to be the first premonition of commencing deafness, but this is not the rule, for in some instances the noises and the deafness develop at the same time, while in other cases the first symptom is the deafness. The noises are apt to grow louder as the deafness increases, but they may, on the contrary, become less distressing, and even cease altogether when the deafness becomes profound. The deafness depends veiy much on the changes that have taken place in the drumhead, on the extent of the adhesions, and more particularly on the condition of the foramen ovale and foramen rotundum. The hear- ing often varies at different times of the same day, being more impaired at night, when the patient is fatigued. Change of climate, especially to a high alti- tude, often causes considerable improvement in the hearing, as. long as the patient remains there, to be fol- CHRONIC CATARRHAL OTITIS MEDIA. 199 lowed only by loss of hearing whea he returns to a damp region again. Other symptoms are a sense of weight, fulness, or pressure in the head, occasional ver- tigo and giddiness, which may be permanent, unsteadi- ness in the gait, with nausea and vomiting. A patient suffering from chronic catarrh of the middle ear at times complains of pain in or about the ear, which is generally due to neuralgia, as this disease is often ob- served in neurasthenic subjects. Some persons are dis- turbed by certain sounds, particularly shrill tones, even when the degree of deafness is quite marked (hyperses- thesia acustica). The hearing of ordinary conversation, especially at a dinner or reception, when several persons are talking at the same time, is extremely difficult for a patient suffering from chronic catarrh of the middle ear. He frequently hears the higher notes, especially musical ones, extremely well, and this is often the case when the labyrinth is not affected. If, however, the latter be involved, as shown by tests made with the tuning-fork, not only will there be deafness for speech, but also for the watch and acoumeter, and for musical sounds. The ability to hear better in a noise, more particu- larly in a carriage or railway train, Paracusis Willisi- ana, so-called, is a symptom that is quite frequently noticed in this class of patients. A patient under my care can only hear very loud conversation very close to the ear, but she can easily understand every word spoken in an ordinary tone of voice when she is riding in a railway train. In cases in which the auditory nerve is affected without involvement of the middle ear, this phenomenon is not observed. Some otologists be- lieve this symptom to be due to an increased excitability 200 MANUAL OF OTOLOGY. of the auditory nerve brought about by the concussion, while another explanation (Politzer) is " that the im- provement in hearing is due to the movement of the inflexible auditory ossicula, so that they are placed in a more favorable condition for the conduction of the waves of sound, and that at the same time the endings of the auditory nerve are set in vibration, producing an in- creased sensibility." Although this symptom is un- doubtedly due to middle-ear catarrh, it may be observed in patients in whom the labyrinth is secondarily in- volved, for it is noted in cases in which the bone con- duction is normal as well as in those in which the bone conduction is impaired or lost. It is generally con- sidered an unfavorable symptom. When left to nature the deafness generally increases, so that eventually the patient has great difficulty in hearing at all. Some cases progress slowly, others very rapidly. If the patient be subject to frequent head- colds, the disturbance of hearing is apt to increase quite rapidly, also in cases in which the labyrinth is suddenly involved, or in which the patients are suffering from some exhausting disease, such as syphilis or tubercu- losis. Profound deafness is not very frequent. After steadily growing worse for a number of years, the dis- turbance of hearing may remain quite stationary for a time. "When the disease is confined mostly to the region of the fenestra ovalis, the tinnitus is apt to be troublesome for some years before the patient really knows that he is deaf. Occasionally the deafness is limited to one ear, but this is only for a time, because when the previously normal ear becomes involved, the deafness progresses very rapidly, as a rule. Diagnosis. ' Inspection of the drumhead reveals CHRONIC CATARRHAL OTITIS MEDIA. 201 the existence of chalky deposits or a thickened condi- tion of the drumhead. On the other hand, the sur- geon may find atrophic changes. The membrane is more or less retracted, with prominence of the short process and of the anterior and posterior folds. The cone of light is distorted. By making the patient try the Valsavian experiment, as well as by using Siegle's otoscope, one can observe the mobility of the drum- head. By such means, the atrophic portions bulge out- ward when the air in the canal is exhausted, while the adherent portions remain stationary. By means of the diagnostic tube, when the ears are inflated, the per- meability of the Eustachian tubes can be determined. When the labyrinth is not involved, the bone conduc- tion, as shown by Weber's and Kinne's tests, is better than the aerial conduction, and the higher tuniug-forks are better heard by aerial conduction than the lower ones. If the disease be complicated with marked laby- rinthine involvement, then the lowest tuning-forks are heard by aerial conduction, while the bone conduction is very much impaired or eveu lost. The probe can also be employed to advantage in order to determine as to whether the membrana is adherent to the tympanic wall or not. Peognosis. Much depends on the patient's general health and condition, as well as on the changes that have taken place in the middle ear and labyrinth. The prognosis is much less favorable in those insidious forms of sclerotic catarrh limited to the neighborhood of the fenestrse, and particularly when the labyrinth is in- volved, than in cases in which the catarrh is of the so- called moist variety. When a patient comes for adviee who has had a continuous, subjective noise for several 202 MANUAL OF OTOLOGY. years, and which he likens to the sound of escaping steam, and moreover if the Eustachian tubes are per- vious, and inflation by Politzer's method and the use of Siegle's otoscope do not produce any change for the better in the hearing distance, the prognosis in such cases as to any permanent improvement is extremely unfavorable. Such patients are apt to be neurasthenic or hypochondriacal, and frequently inherit some tendency to deafness. The prognosis is much more favorable when the tinnitus and deafness show even a slight im- provement after inflation of the middle ears. If the disturbance in hearing has come on very gradually, the chances are that the patient will not be profoundly deaf, even if he receive no treatment whatever. On the other hand, if the patient has suddenly become hard of hearing, and there is a continuous subjective noise which is not modified in any way by treatment, and particu- larly if the labyrinth be involved, the probability is that the disease will advance rapidly, and the prognosis is bad, particularly if the patient be suffering from some constitutional disease, such as syphilis, anseraia, or tuber- culosis. A patient's occupation also has considerable to do with the prognosis. Gout and rheumatism play a very important part in this disease, for one meets with chronic catarrh of the middle ear very frequently in such patients. Subjective noises, which sound to the patient like escaping steam, or are pulsating in character, and which are continuous and have existed for a long time, are unfavorable symptoms. On the other hand, if the noise be intermittent, or if the surgeon be able to arrest it even for a short space of time, and at the same time cause a slight improvement in the hearing distance, the chances of some permanent improvement are fairly good. CSRONIO OATARRHAL OTITIS MEDIA. 203 The question often arises as to what is the duty of the otologist in cases just mentioned, in which the prog- nosis is unfavorable, namely, as to whether the surgeon should hold ont any hope to the patient of auy improve- ment. It is possible for the surgeou to determine in a very short time, whether the hearing is likely to be improved by treatment, and until the patient has been seen at least two or three times, and the middle ears have been inflated, the prognosis should be a guarded one. If at the end of this time there is any improve- ment in the hearing distance or the subjective noise, the treatment should be continued. On the other hand, if there be no change whatever, the patient should be informed of the fact that treatment is not likely to be of much if any benefit ; but, as the disease is likely to progress steadily, it is advisable that he should receive regular treatment for a period of six weeks at a time during the spring and fall, in order to arrest if possible the progress of the disease. He should in the intervals consult the surgeon if there be any change for the worse in the symptoms. As previously stated, many of these patients are extremely nervous in temperament and re- quire some encouragement as well as treatment directed to their general condition. Otherwise, if told that the disease is incurable and that treatment is useless, such patients become very despondent, and the deafness is liable to become much worse. They need, therefore, some moral support, and should be under the supervi- sion of the otologist, who should not only see them occasionally, but should also encourage them by stating that possibly the disease may be arrested. Iron and strychnine and the hypophosphites are remedies to be prescribed in many instances. 204 MANUAL OF OTOLOGY. Treatment. The treatment of chronic catarrh of the middle ear should be so directed as to obtain free ventilation of the middle ear, and the restoration of the membrana tympani to its normal position if possible. Catarrh of the nasal passages and nasopharynx should receive appropriate treatment, while if there be any ob- struction in the anterior nares or nasopharynx it should be removed if it interferes with the entrance of air into the middle ear. The mouths of the Eustachian tubes should be inspected, and their permeability tested by Politzer's method of inflation or by catheterization. (See chapter on Diseases of the Nose and Nasophar- ynx.) In the so-called secretive or moist form of catarrh, particularly if of short duration, and if at- tended with more or less swelling of the Eustachian tube, considerable improvement will follow the injection of air iuto the tympanic cavity. According to my ex- perience, the catheter is much more efficacious for this purpose than the method of Politzer, while the improve- ment is much more marked. Inflation in cases of ad- hesive catarrh is not followed by the same improvement as when the disease is of the secretive or exudative variety. The surgeon, when forcing air into the tym- panum, should at first use but little force, either by Po- litzer's method or by the use of the catheter, for, if the tube be very dilated and the membrane flaccid, rupture of the same may follow when too much pressure is used. In those cases in which the tubes are freely pervious, and improvement in the hearing does not follow infla- tion, there is no object in continuing such treatment. Instead of using air alone through the catheter, certain vapors are to be preferred, more particularly the mix- ture of chloric ether and iodine (Blake). This con- CHRONIC CATABRHAL OTITIS MEDIA. 205 sists of tincture of iodine, gtt. xv; chloroform, spir. vini rectif., aa 5ss. Five or six minims of this solution should be dropped into the Politzer bag through the hole in the side, which is then covered by the thumb, when the bag is compressed. The catheter, before in- troduction, should be connected with the Politzer bag by means of a piece of rubber tubing at least a foot long, aud then should be warmed and smeared over with vaseline. It is important for the surgeon to deter- mine, by means of the diagnostic tube, the exact condi- tion of the Eustachian tube. Wheu the vapor is forced into the ear, the patient usually experiences a cool and pleasant sensation. In some instances, the hearing dis- tance is decreased immediately after this procedure, but is improved several hours afterward. When the ears are inflated by Politzer's method, and it is desirable to use the vapor just mentioned, a glass inhaler should be attached to the Politzer bag. A few drops of the mixture should be poured on some absorbent cotton placed in the inhaler. Some surgeons recom- mend to their patients the use of a large inhaler in which chloride of ammonium or other fumes are gener- ated. After filling the nasal passages and nasopharynx with the vapor, they are directed to perform the Valsal- vian experiment. The principal objection to this method is that the patient is apt to inflate the ears too frequently, and thus eventually produce a relaxed condition of the membrana tympani. Vapors of sal ammoniac, acetic acid, turpentine, the different balsams, as well as hydro- gen gas and iodide of ethyl are also used. Besides vapors, some otologists recommend the injection through the catheter of various solutions into the middle ear. Politzer has seen " favorable results follow in a series 206 MANUAL OF OTOLOGY. of cases from the injection of five or six drops of a 2 per cent, solution of pilocarpine." The catheter is first in- troduced and fastened by means of a clamp. A small syringe containing the solution is warmed, and a few drops are then injected into the catheter. By means of the Politzer bag the solution is forced into the middle ear. Liquid vaseline (Ch. Delstanche) or albolene is sometimes used in the same manner as the pilocarpine solution. Some benefit follows from the use of albolene contain- ing 2 per cent, of pilocarpine. If a few drops only are injected into the middle ear, there is not likely to be any discomfort to the patient. As the hearing immediately after the injection is frequently made temporarily worse, it is better to vary the treatment by simply forcing air through the catheter every other time. It is occasion- ally advisable to treat such a patient every day for a week or ten days, but, as a general rule, it is better to inflate the ears not oftener than three times a week. The patient should discontinue treatment after six weeks' time, and have a period of rest. After the first two weeks it may be necessary to catheterize the ears but twice a week. A very mild solution of bicarbonate of soda is recommended by some otologists, and is not likely to cause much irritation of the mucous membrane of the tympanic cavity. Solutions of borax, bichloride of mercury, iodide of potash, which are recommended by some, are contraindicated, since they are liable to cause considerable reaction. Siegle's otoscope and the " rarefacteur " or "mas- seur " of Delstanche ai-e useful instruraeuts in many cases, and especially where there are recent adhesions, and retraction of the drumhead. It is possible to rup- CHRONIO CATARRHAL OTITIS MEDIA. 207 ture the drumhead as well as to cause ecchymoses and inflammation, if too much force is employed when the air is exhausted, so that the surgeon should always in- spect the membrana while using such an instrument. In cases in which there are atrophic changes, as shown by bulging outward of certain portions of the drumhead when the ear is inflated, one should be very cautious when trying this method of treatment, for the mem- brane may be rendered more flaccid without the accom- plishment of anything else. Lucae has devised a pressure probe, consisting of a probe with a cup-shaped cavity on the end, which is applied directly over the short process. Gentle and in- termittent pressure is made on the ossicles by means of this instrument, which moves on a spring. Although considerable increase in the hearing distance and a change for the better in the noises often follow its use, such improvement is not apt to be of a permanent char- acter. With the same object in view, various electrical instruments have been invented, by means of which vibrations are conveyed directly to the ossicular chain through a speculum constructed for the purpose. Although opinions differ as to the benefit derived from such treatment, these instruments should be given a fair trial. Patients are often advised by their physi- cians to make use of the Valsalvian method of infla- tion, and as a result, there is a liability that the drum- head will become very much relaxed. In certain cases in which there is probably a relaxa- tion of the tensor tympani as well as of the malleo-in- cudal capsular ligament, and the corresponding attach- ments, such as would favor a separation of the malleo- incudal articulation, Blake employs a rubber spring. 208 MANUAL OF OTOLOGY. which he introduces into the canal, and applies directly to the neighborhood of the short process, and which acts as a support to these relaxed parts. In a paper on this subject, he reports a case of a musician whose hear- ing in the right ear was normal, while in the left ear there had been in childhood a suppurative process and a subsequent perforation in Shrapneli's membrane, which was dry at this time. The hearing of the left ear was about two-thirds of the normal hearing. He had had a series of head-colds during the past winter, accom- panied by a sense of fulness in the left ear, which had led him to practise the Valsalvian inflation frequently for the sake of the relief it afforded. Three days be- fore his visit he had noticed, while practising on the violin, that when the head was bent forward and to the left, as is often the custom in the rendering of more delicate passages, the tones of the violin sounded dull in the left ear, and there was a definite loss of timbre perception. "When the head was raised, this disability disappeared, to recur immediately on the lowering of the head to the position mentioned. An examination showed the membrana tympani to be intact, except that there was a small dry perforation in Shrapneli's mem- brane. The testimony of the patient was corroborated by tests made with tuning-forks and high musical in- struments. There was considerable movement of the membrana tympani outward when the ear was inflated, such as would favor a separation of the malleo-incudal articulation " within such limits as would permit the passage of the larger sound-waves of the medium and lower tones, but would result in the loss in transit through the articulation of the motion incident to the shorter sound-waves of the qualitative overtones." CHRONIO CATARRHAL OTITIS MEDIA. 209 Blake says " that any mechanical arrangement which would bring about a more natural adjustment of the malleo-incudal articulating surfaces, and would main- tain theoi in that position long enough to allow the re- laxed tissues to normally contract, would not only re- lieve the patient of his recent embarrassment, but would probably have more permanent beneficial effects." Such pressure on the short process was effected by means of a strip of thin, elastic rubber tissue 3 mm. in width and 12 mm. in length, which, being seized at the two ends with angular forceps, was carried into the ear under good illumination, with the convex portion of the resultant ellipse in contact with the short process, when, the two ends being released from the grasp of the forceps and allowed to spring outward against the walls of the canal, a pressure was exerted upon the short pro- cess. With such support to the relaxed parts, it was found that the head could be placed in any position without impairment in hearing for overtones, and the patient was enabled to resume his professional work. Blake has made a change in the preparation of the rubber strip, from the fact that the freshly cut ends of the rubber were found to adhere under the pressure of the forceps, thus preventing the springing apart of the ends when released. The ends should, therefore, be cut, one «t an angle and the other on a curve, the curved end being placed toward the posterior wall of the canal and the convex surface of the rubber strip ; secondly, that portion which was to be brought into contact with the malleus was lightly smeared with vaseline before intro- duction. It was found that absorption of the vaseline produced a partial vacuum beneath the rubber, and re- sulted in so close an adherence of the latter to the. skin 14 210 MANUAL OF OTOLOGY. that the beneficial effects of the spring were of much longer duration. In some cases, where there is a con- siderable relaxation of the membrana, Blake substitutes the paper dressing. (See page 247.) The use of the rubber strip is of benefit in cases of circulatory tinnitus marked by a relaxation of the drumhead and the malleo-incudal joint, as shown by the report of such a case. The treatment must be long continued in many instances in order to get any per- manent result, while the adjustment of such mechanical appliances must always be a matter of more or less ex- periment. A slight change in adjustment may bring about a very decided improvement. NAEKOWING AND STEICTUEB OF THE EUSTACHIAN TUBE. The Eustachian tube may be constricted through swelling of the mucous membrane, or by the formation of connective tissue, which leads to contraction and stricture. The constriction of the canal is usually the result of chronic catarrh, but may be due to the press- ure of a growth in the nasopharynx, and is generally situated in the cartilaginous canal, although osseous growths in the bony canal may lead to stricture of this portion. The presence of a stricture is usually diag- nosed by means of the auscultation tube when Polit- zer's method or catheterization is attempted. Under such conditions no sound is likely to be heard, or else there is a sharp, hissing or whistling sound. There is usually considerable deafness with a distressing tinni- tus, a disagreeable sensation of fulness or heaviness in the head, and occasionally dizziness. In cases of constriction of the tube due to swelling of CHRONIC CATARRHAL OTITIS MEDIA. 211 the mucous membrane, an attempt should be made to relieve this condition by treatment directed to the naso- pharynx, and by inflation of the middle ear through the catheter. When the stricture is not overcome by such measures, bougies should be tried, and for this purpose those made of silkworm-gut, covered over with lacquer and conical in shape, are the best, or, if they have not sufficient resisting power, whalebone bougies, well pol- ished, rounded, and conical-shaped, should be substi- tuted. The bougie should be dipped in liquid vaseline and inserted through a good-sized silver catheter as far as the bony portion of the Eustachian tube. A mark should be made on the bougie so that the surgeon can know the distance that it has been introduced. Care should be taken that the point of the bougie does not injure the drumhead. The instrument should be left in position five to ten minutes. In some cases Politzer uses catgut bougies that have been soaked in a solution of nitrate of silver, while in others he prefers a thin rubber capsule (that is, when the constriction is due to swelling of the mucous membrane), which is attached to the top of the catheter by a thread. By forcing air through the catheter the capsule is inflated. It is claimed by some that by means of electrolysis the cali- bre of the tube is frequently restored. Asa general rule, the results obtained by the measures just described are not very promising, so that they have been discarded by many otologists. In some cases the use of the bougie increases the deafness and the subjective noise, while in other cases, even after successful dilatation of the Eu- stachian tube, no improvement follows. Great care should be exercised not to lacerate the tissues when passing the bougie, for fear of inducing surgical emphy- 212 MANUAL OF OTOLOGY. sema, especially when subsequently inflating the ear. In rare instances the point of the bougie has been broken off in the Eustachian tube, so that the possi- bility of this accident should be borne in mind. Operative Teeatmbnt. Ever since the time of Sir Astley Cooper various attempts have been made by surgeons to maintain a permanent opening in the drum- head, or else to excise one or more of the ossicles for the cure of the deafness and subjective noises. It may be stated in general terms that such operations, per- formed for the cure of chronic catarrhal otitis media, have been unsuccessful, although in a very few instances considerable improvement has followed. Many cases have been made very much worse by operative inter- ference, and the statement made by some otologists, that the operation of excision of the ossicles will not make matters worse, even if it is not followed by some im- provement, is incorrect. In a case which seemed to be an ideal one for removal of the malleus and incus, as these ossicles were bound down by adhesions, the opera- tion was not followed by any improvement to speak of, but, instead, a distressing tinnitus developed. A very nervous patient who submitted to an operation of ex- cision of the entire drumhead, together with the malleus and incus, was assured that the deafness would not be more marked, even if no improvement followed. On recovering from the effects of the ether, the hearing was found to be much worse, and at the present time she cannot even hear with the aid of a conversation-tube. The hearing-distance in the other ear has also decreased very much, as a result of the operation, a phenomenon that is often observed in such cases. Numerous com- plications have followed the performance of excision of CHRONIC CATARRHAL OTITIS MEDIA. 213 the drumhead and ossicles, such as purulent otitis media, mastoid empyema, and burrowing abscess of the neck, etc., so that these accidents should always be borne in mind when a patient seeks advice as to the propriety of such an operation. Cooper and others obtained brilliant results at first by making an artificial opening in the drumhead, but were obliged to abandon the operation, because the aperture soon became closed by newly-formed connec- tive tissue, and the deafness was the same as before. At first, as suggested by Cooper, a portion of the drum- head was excised. This was followed by an operation devised by Wreden, in which he excised a portion of the long handle of the malleus. Later, an attempt was made by means of nitrate of silver, sulphuric acid, and the galvano-cautery to produce a permanent opening. Such openings are apt to close very soon, and although the hearing-distance may be increased and the subjective noises lessened for the time being, while there is an opening in the drumhead, nevertheless, when the latter closes, both noises and deafness may be very much worse. The object of making an artificial opening is for the relief of deafness and distressing tinnitus in cases in which the ossicles are bound down by adhesions, when the membrana is very much thickened or filled with calcareous deposits, when there is a stricture of the Eustachian tube which cannot otherwise be overcome; also in exploratory operations (to be described more fully), as well as for the purpose of mobilizing the ossicles, especially the stapes. As the object of such an opera- tion is to allow the sound-waves to strike against the foot-plate of the stapes and reach the labyrinth immedi- ately, it stands to reason that such an operative pro- 214 MANUAL OF OTOLOGY. cedure will be unsuccessful when there is anchylosis of the stapes, or thickening and calcification of the mem- brane of the foramen rotundum, or implication of the labyrinth. The operation should not be considered for a moment unless there be excellent bone conduction. Politzer has devised an eyelet of gutta-percha for inser- tion in the artificial openiug, but it has l^een found im- possible to keep this in place. When the drumhead is very much retracted, the long handle foreshortened, and the posterior fold stands out prominently, and there is also considerable deafness, with Fig. 70. Ilandle of malleus foreshortened ; anterior and posterior folds of the drum- head verj' prominent. loud subjective noises, which it is impossible to relieve by other treatment, Politzer recommends section of the 'poderior fold of the membrana tympani. (See Fig. 70.) The incision is usually made just behind the short pro- cess, by a small knife, rounded at its point and espe- cially adapted for the purpose. DIVISION OF THE TENSOR TYMPANI MUSCLE. Tenotomy of this muscle, with the object of allowing the drumhead to regain its normal position, aud thus relieve the increased pressure within the labyrinth, was CHRONIC CATARRHAL OTITIS MEDIA. 215 first performed by Weber-Liel, although Hyrtl had pre- viously suggested such an operation. In cases in which retraction of the drumhead is due to this cause alone, such an operative procedure is indicated, but, unfortu- nately, these instances are infrequent. One is much more apt to find not only shortening of this tendon, but also adhesions in the tympanic cavity, with a shrink- ing of the folds of the mucous membrane and of the ligaments. In order to divide this tendon, an incision is first made in the drumhead either in front of or else behind the handle of the malleus, preferably in the latter posi- tion. An instrument (see Fig. 71) curved on the flat Fig. 71. Gruber's tenotome. is then introduced through this opening for a distance of at least 3 mm., the tenotome being directed below the tendon of the tensor tympani. By depressing the handle so that the point of the instrument is pushed upward, the tendon is generally divided when the blade is with- drawn. The results obtained by this operation have not been successful, as a general rule, so that it has been practically abandoned, as cases have been reported where considerable increase of the deafness has followed its performance. Kessel in 1871 advocated the removal of the drum- head and excision of the malleus and incus, and since that time surgeons in this country and Europe have recommended different operations of a similar character, for the relief of extreme deafaess, vertigo, and tinnitus 216 ' MANUAL OF OTOLOGY. aurium in cases of chronic catarrhal otitis media. Some otologists excise the incus alone, while the latest opera- tion to attract attention has been the removal of the stapes, or stapedectomy. In cases of suppurative otitis media of a chronic nature, in which the malleus and incus are carious, surgeons are agreed as to the pro- priety of removing these bones on general surgical prin- ciples, and the benefit derived from such an operation has been clearly proved. In cases, however, of chronic non-suppurative inflammation of the middle ear, in which there is obstruction to the sound transmission through the chain of ossicles, owing to thickening of the mucous membrane of the middle ear, adhesions, and anchylosis, such an operation as removal of the drum- head with the malleus and incus is uncalled for if there be bony anchylosis of the stapes. As Blake has ex- pressed it, " the stapes holds the key to the situation," and it is undoubtedly true that, in many cases which have been followed by improvement after excision of the malleus and incus, this change for the better has been due to mobilization of the stapes. Kessel further removed the columella in birds without causing disturb- ance of the co-ordination, and demonstrated the fact that escape of the perilymph did not cause permanent im- pairment of hearing. Operations for the purpose of mobilizing the stapes have been advocated by different surgeons ever since Kessel, in 1875, reported a case in which he practised " circumcision " of the stapes, after dividing the tendon of the stapedius muscle. He fur- ther expressed an opinion that still further improvement would have followed, had the stapes been extracted and a membrane been allowed to form in the foramen ovale, which would have vibrated more readily than the stapes OHBONIO CATARRHAL OTITIS MEDIA. 217 that had been mobilized. Blake has reported a series of cases in which he removed the stapes, the various steps in the operation being as follows : " The ear to be operated upon should be first carefully tested as to its hearing power, both by aerial and bone-conduction, and with due reference to the possibility of sound trans- mission, either by aerial or bone-conduction, to the other ear. The external auditory canal should be cleansed of cerumen and loose skin, and then washed with a weak bichloride solution on a cotton-tipped probe and stopped with antiseptic cotton until the time of the operation." The instruments used are a paracentesis needle, a small angular knife for the division of the articulation of th6 incus and stapes, a small blunt hook, and a pair of light but strong angular forceps, to which may be added a small rectangular knife to be passed between the incus and the stapes, after division of the joint, and a pair of very fine, straight-tipped forceps for the removal of a portion of the bone if fractured in the attempt at extrac- tion. The surgeon should be provided with a number of cotton-tipped probes, a bowl containing a solution of bicarbonate of soda, also vessels containing a saturated solution of boric acid in alcohol, and a 4 per cent, solu- tion of cocaine. The instruments should be thoroughly sterilized, and the hands of the operator scrubbed and rendered aseptic. Before using the instruments, they should be dipped in the alcohol and boric-acid solution. If possible, the operation should be performed under conditions of local ansesthesia so as to " permit of the conscious and undisturbed co-operation of the patient." Just before the operation a few drops of a 4 per cent, solution of cocaine are injected into the middle ear through the Eustachian catheter. The patient is placed 218 MANUAL OF OTOLOGY. in a high-backed chair, his head being firmly held by an assistant. An incision is then made (see Fig. 72), " beginning at a point midway between the short pro- cess and the tip of the long process of the malleus and close to the manubrium, then extending upward along the posterior ligament of the short process and following the periphery to a point posteriorly on a line with the tip of the manubrium." A large flap falls downward and outward, leaving an unencumbered opening with free access to the subsequent field of operation. Any Fig. 72. bleeding from the edges of the cut is controlled by the application of the sterilized cocaine solution. The hearing should be then tested and the operation con- tinued, by dividing the tendon of the stapedius muscle with the short curved knife or an angular one, " a larger angular knife being subsequently passed behind the incus to insure separation." At times it is advis- able to remove the incus at this step in the opera- tion. By means of a probe and blunt hook, after testing the hearing, one can then decide whether the stapes shall be mobilized mechanically by dividing the folds in the niche, or by circumcision, or whether it is better to ex- tract it. If the former has been decided upon, the re- gion of the fenestra ovalls should be painted with cocaine, and an instrument, similar to the one devised by Kessel or Politzer, should then be introduced between OHMONIG CATARRHAL OTITIS MEDIA. 219 the crura and the lower wall of the niche, and au inci- sion made from right to left. If this is not followed by decided improvement, an attempt should be made to stretch the adhesions between the anterior and posterior crura and the walls of the niche. Before extracting the stapes, it should be mobilized. A blunt hook, curved very slightly backward, is then passed behind the head and between the crura, either from below upward or in the opposite direction. The resist- ance offered when traction is made varies in different cases. At the moment of removal, however, the pulse often becomes slower in frequency, but is occasionally accelerated, and at times there is some vertigo. Hem- orrhage sometimes follows division of the stapedius muscle, but this can usually be controlled by a cotton- tipped probe. Sterilized cotton or gauze should then be inserted in the meatus, and the patient kept quiet for a few days. The results following extraction of the stapes have been decidedly unsatisfactory, and the oper- ation of stapedectomy has been generally condemned. Of twenty-one cases reported by Blake, in only three was there any appreciable improvement following the operation, and in but two of them was this gain suffi- cient to be of material advantage. On the other hand, cases have been reported by other observers in which alarming symptoms have been due to this operation, such as intense vertigo, facial paralysis, and deafness. Before resorting to mobilization or excision of the mal- leus and incus, or removal of the drumhead, every other method of treatment should first be tried, while opera- tive measures should never be considered if there is labyrinthine disease. Moreover, the surgeon should explain to the patient the possible dangers of any opera- 220 MANUAL OF OTOLOGY. tive procedure, and he should never make promises as to any permanent improvement in either the deafness or subjective noises. If the patient clearly understands the situation and is anxious and willing, under these circumstances, that an operation on the membrana tympani should be performed, the surgeon should first of all do an " exploratory tympanotomy," by making an incision in the drumhead exactly similar to the one already described (see Fig. 72) in the operation of stapedectomy. Thus the area of the tympanum is ex- posed at a point where surgical access to it is most de- FlG. 73. Triangular incision in the posterior-superior quadrant for exxiosing ttie articulation of the incus and stapes. sirable, while an incision made at this point affords a stiff flap, the edges of which can be brought together and held in position by a paper dressing until the heal- ing, which is usually complete in three days, has been effected. The formation of a cicatrix opposite the niche in the posterior superior segment is also avoided. An- other method of exposing the articulation of the incus and stapes is shown in Fig. 73. In some persons it is necessary to administer an antes- thetic, but, if possible, the operation should be done by injecting a few drops of cocaine into the middle ear CHRONIC CATARRHAL OTITIS MEDIA. 221 through the Eustachian tube or else by the following method, described by Blake as follows : "In a series of experiments on the progressive growth of the dermoid coat of the membrana tympani, made several years since, it was found that the movement outward from the centre of the membrane at the tip of the malleus toward the superior and posterior periphery was slowest in the inferior third of the posterior segment (A), see Fig. 74, more rapid in the middle third (B), and most rapid in the upper third (C), and that the rate of movement, as shown by small pieces of paper pasted upon the mem- brane, bore a proportionate relation to the corresponding Fig. 74. degree of vascularity of the three sections mentioned; while a recent series of tactile examinations shows that the sensitiveness of the posterior segment of the mem- brana tympani has the same relative correspondence, and therefore that an incision begun opposite the round window causes increasing pain as it is extended upward and forward along the periphery." A preliminary in- cision 2 mm. in length is first made close to the poste- rior periphery, opposite the round window, and to this a 2 per cent, solution of cocaine should be applied. After waiting a minute, the cut should be extended up- ward in the direction already described, and cocaine should again be applied as before. By this method the incision can gradually be extended, without much if any 222 MANUAL OF OTOLOGY. pain, to a point opposite the centre of the posterior liga- ment of the short process. Tests of hearing should now be made, so that the surgeon can determine as to the advisability of further operative procedure. He may decide to divide the tendon of the tensor tympani and mobilize the malleus, or he may divide adhesions which bind the malleus and incus to the walls of the tympa- num, or he may mobilize the incus or stapes, or he may conclude to excise the malleus or incus or both of these. Operations performed under the most favorable circumstances, although followed by temporary im- provement at times, do not offer much hope to the patient, if he be a sufferer from chronic non-suppurative otitis media. Surgeons generally are opposed to any radical operation on the membrana tympani or ossicula in this disease. Otalgia. In this affection, an examination made with the head-mirror and speculum will show an absence of every sign of inflammation of the auditory canal or drumhead. The pain is usually referred to the ear, but it is reflex, and most frequently due to the irritation caused by the presence of decayed teeth. It may also arise from some laryngeal irritation. The pain may be localized in the external or middle ear, being due to an affection of the sensory nerve or nerves supplying th« ear, the most frequent causes of such neuralgia being hysteria, cold, inflammation of the nerve-trunks, and pressure on them from tumors of the brain or from caries and necrosis of the temporal bone. Otalgia is at times connected with neuralgia of the fifth nerve. Neurasthenic patients who have chronic catarrhal otitis media occasionally complain of pain over the mastoid process which is neuralgic in character. CHRONIC CATARRHAL OTITIS MEDIA. 223 Clicking Tinnitus. This is an objective form of noise which is often audible to the surgeon as well as to the patient. In some instances, it can be heard a few feet from the patient, while in other cases, it can be de- tected only with the aid of the diagnostic tube. This clicking noise, which has sometimes a metallic sound, can at times be produced at will by the patient, but it is not generally under his control. It is an infrequent form of tinnitus which may cease at times, only to return again. The opinion is held by some otologists that the noise is due to spasmodic action of the tensor tympani or stapedius muscles. It is more probable that it is caused by a spasmodic contraction of one or more of the palate muscles, whereby the mouth of the Eustachian tube is opened and shut, particularly if the mucous membrane is sticky from the presence of mucus. The treatment consists in relieving the catarrhal condition, and the administration of tonic remedies, especially strychnine. CHAPTER IX. OTITIS MEDIA P0IIULENTA CHKONICA, OR CHRONIC PURULENT OTITIS MEDIA, OR CHRONIC SUPPURA- TIVE INFLAMMATION OF THE MIDDLE EAR. This disease is one of the most important ear a£Eec- tions that claim the attention of the otologist, and is very frequently met with among the poorer classes, owing to neglect of treatment, for there is on the part of a great many persons a strong superstition, as it were, against " checking any discharge from the ear," for fear that some serious disease will attack some other part of the body. Besides, the advice is often given to patients who are suffering from this affection that they will " outgrow " the discharge, so that, as a result, the surgeon often finds great destruction of the drum- head, a carious condition of the ossicles and temporal bone, and occasionally some intracranial complication. Of 234 patients suffering from chronic purulent otitis media, large granulations or polypi were found in the middle ear or external meatus in twenty-four cases, the discharge being of long duration, offensive in character, and associated with more or less caries of the ossicula and walls of the tympanum. Among the most fre- quent causes, besides cold and influenza, were scarlet fever, diphtheria, whooping-cough, measles, teething, meningitis, tuberculosis, nasopharyngeal catarrh, and adenoid growths. Since scarlet fever, measles, diphtheria, and the in- CHRONIC PURULENT OTITIS MEDIA. 225 fluenza are responsible for most of the cases of acute as well as of chronic purulent otitis media, it is of the greatest importance that the ears should be frequently examined during the course of one of these diseases. Prompt and early treatment will often effect a cure. Neglect of treatment, or " letting the ears take care of themselves," results, as a rule, in chronic purulent otitis media, with caries of the ossicula and other complica- tions. If a free incision is not made and proper drainage from the middle ear established in a case in which muco-pus is contained within the tympanum, there is then great danger, especially in the exanthematous dis- eases, that the acute inflammation will become chronic. The pus, not having a free" exit, forms caseous masses in the attic and antrum, leading frequently to inflammation of the mastoid cells. Anatomical Appearances. The mucous mem- brane of the middle ear becomes much thickened, due to infiltration with round cells and to the enlargement of the bloodvessels and the formation of new ones. The epithelium frequently changes its character, so that, instead of being ciliated, it becomes epidermal, the epi- dermis extending from the external meatus into the tympanum. The mucous membrane is usually of a deep red color, and granulations are often found on its surface, while in the deeper layers the lymphatic vessels are usually enlarged. As a result of chronic suppuration, besides granula- tions and polypi that frequently develop from the mucous membrane, one notices connective-tissue bands that bind together the drumhead and ossicula to the walls of the middle ear. These new formations are 15 226 MANUAL OF OTOLOGY. permanent, as a rule. In some cases there are ulcera- tions in the middle ear, as well as a carious condition of the ossicles and tympanic walls. There may be a small perforation of the drumhead, or the loss of substance may be extensive, so that a mere rim of the membrana tympani remains. The drumhead may or may not be considerably swollen or thickened, with hypertrophy of the dermal layer. There may also be calcareous deposits between the layers or an excessive development of connective tissue. After cessation of the discharge, the perforation either remains open or else is closed by thin cicatricial tissue, which frequently adheres to the wall of the middle ear. When a rim of membrane remains in the upper part of the middle-ear cavity, the Idng handle of the malleus usually rests against the inner tympanic wall. The tympanic end of the Eustachian tube is generally swollen, and the glands are enlarged, so that the calibre of the tube is frequently diminished. Occasionally, however, but very infrequently, the tube is dilated. Symptoms. If there is a free exit for the pus, the patient does not usually complain of any pain. If, ou the other hand, there is an obstruction to the escape of pus, which is due to the presence of granulations or polypi, and if there is caries of the temporal bone, not only severe pain occurs, but unpleasant symptoms are complained of, such as oppression and a feeling of ful- ness in the head and ear. The pus may be prevented from escaping on account of a small perforation, or there may be inspissated masses in the tympanum. Obstruction to the escape of pus may also give rise to vertigo, nausea, vomiting, a staggering gait, great tin- nitus, facial paralysis, and, in extreme cases, choked CHRONIC PURULENT OTITIS MEDIA. 227 disk and retinitis. In such cases, when free drainage has been established and all granulations have been removed, these symptoms will disappear, unless the labyrinth' has become involved or some intracraDial complication has developed. Tinnitus is not usually so troublesome in chronic otorrhcea as in chronic catarrhal otitis media. The deafness varies very much in the same individ- ual, depending largely on the amount of secretion, the extent of the swelling of the mucous membrane, and also as to whether the Eustachian tube is patent or not. Id some cases, especially of scarlet fever, diphtheria, typhoid fever, and syphilis, the deafness is very great. This is occasionally due to implication of the labyrinth, or to the ossicles being bound down by adhesions, or to anchylosis of the ossicula. As the mucous mem- brane is apt to be more swollen during damp and cold weather, the hearing is usually better when the atmos- phere is warm and dry. The deafness is sometimes more marked after cessation of the discharge, a phe- nomenon which is probably due to the fact that the newly-formed connective-tissue bands are more tense after the suppuration has stopped, since the hearing often is markedly improved when the discharge reappears and the connective tissue becomes relaxed. Bone-conduction, as a rule, is excellent in chronic otorrhcea, as shown by Weber's and Rinne's tests, ex- cept when the labyrinth is implicated. Character and Amount of the Discharge. The secretion from the ear varies very much in its char- acter and amount, being thin and watery in some cases and thick and stringy in others. At first, when the inflammation has become chronic, and before granula- 228 MANUAL OF OTOLOGY. tions or polypi have formed or the bone has become necrotic, the discharge is apt to be yellowish, laudable pus. It is usually more copious in children than in adults. In some eases in which there is a nasopharyn- geal catarrh, there are long strings of mucus, which oc- casionally have to be removed with forceps from the meatus. These cases are often obstinate to treatment. The discharge may also be of an acrid nature, so that the external meatus and auricle are apt to be consider- ably excoriated. When blood-corpuscles are mixed with the discharge, it generally denotes the presence of granulations or polypi. The discharge varies in color from a light yellow to a greenish hue. When, however, it is brownish and has a fetid odor, the chances are strongly in favor of the existence of caries or necrosis of the middle ear or antrum, or possibly of the mastoid cells. A profuse discharge is significant of mastoid inflammation. APPEARANCES OF THE EXTERNAL AUDITORY CANAL AND MEMBRANA TYMPANI. When the ear is examined with a head-mirror and speculum, more or less secretion will be found in the external meatus or middle ear, or crusts, due to dried secretion, will be adherent to the inner end of the canal or drumhead. When the secretion is profuse, the dermal layer of the drumhead and external auditory canal will appear macerated, on removal of which, the parts beneath will have a red and glistening appearance. One notices exostoses at times on the walls of the bony auditory canal, and the calibre of the latter may be considerably diminished if granulations on its walls coalesce and form bands. In order to secure a good view of the external CHRONIC PURULENT OTITIS MEDIA. 229 meatus and drumhead, it is absolutely necessary, first of all, to syringe the ear and remove all secretion and moist- ure by means of absorbent cotton applied on a cotton carrier. Boric acid or bichloride of mercury should be used in the solution. The next step in the examina- tion, after inspecting the external meatus, is to note carefully the condition of the drumhead, as well as the site and extent of the perforation. The latter is most frequently found in the anterior inferior quadrant, although it is often observed in the posterior superior quadrant. The perforation may be extremely small, or the entire drumhead may be destroyed, the latter condition being frequently met with in severe cases of scarlet fever and diphtheria. The hole is usually round or oval, but may be semilunar, kidney- or heart-shaped. There may be two or even three openings in the same membrana tympani, but one perforation is the rule. The kidney- or heart-shaped orifice is found generally in the lower part of the drumhead, with the long handle of the malleus dividing it in the centre. When there is considerable loss of substance, the handle of the malleus will be in contact with the inner wall of the tympanum. In cases in which the perforation is ex- tremely small, a diagnosis can be made by having the patient try the Valsalvian method, when a small drop of pus will be seen exuding through the aperture, or, by means of the diagnostic tube, the surgeon will be able to hear a perforation-whistle, when the patient inflates the ear by the Valsalvian method, or the surgeon forces the air through by Politzer's method or by catheteriza- tion. When the perforation is a large one, the middle ear appears of a deep red color, except in tubercular cases. 230 MANUAL OF OTOLOGY. when it is pale. As the Eustachian tube is frequently dilated in these cases, a solution syringed into the ear may pass quite readily into the nasopharynx. When there is great loss of substance in the posterior half of the membrane, the incus and the incudo-malleal articu- lation come into view, and occasionally the foramen rotundum and the stapes in the foramen ovale. After cessation of the discharge, the inner wall of the tympa- num often becomes of a whitish-gray color. The drum- head, or whatever remains of it, varies in color from grayish to a dull red. When there is an unhealthy discharge, the membrana appears thickened, and the edges of the perforation are red and granular. After cicatrization has taken place, the margins of the orifice gradually become thinner and assume a normal appear- ance, and frequently become attached to the inner wall of the middle ear, in which case the hearing-power is usually decreased. PERFORATION IN SHRAPNELL's MEMBRANE. A perforation in the membrana flaccida is occasionally overlooked, owing to the fact that there may be another perforation in the membrana vibrans. It is most im- portant to remember in this connection that, in about 70 per cent, of all cases, there are certain folds or redu- plications of mucous membrane, horizontal in position, in the upper part of the normal cavity, which interfere with the proper drainage of the tympanic attic. Be- sides these folds in the neighborhood of the attic, there are others irregularly placed about the round window and stapes, and still others, but principally strise, very near the mastoid antrum. There are cases in which great congestion and swelling of these folds take place, in CHRONIC PXJRXJLENT OTITIS MEDIA. 231 which all communication with the mastoid cells is cut off. An examination of such a case will reveal an otherwise normal membrana vibrans, except that there is great congestion in Shrapnell's membrane and along the handle of the malleus. Such inflammation is occasion- ally observed in patients who are suffering from nervous exhaustion. The pain is apt to be very severe, and follows a feeling of fulness in the ear. The proper treatment consists in a free incision along the upper border of the drumhead from the short process carried backward and sufficiently deep to divide the layer of vessels that assist in forming the inner manubrial plexus. When the patient performs the Valsalvian experiment, or the surgeon inflates the ear by Polit- zer's method, the air does not, as a rule, pass through a perforation in the membrana flaccida. The danger of inflammation in this portion of the drumhead consists in the fact that there is great diffi- culty in draining the attic, and, as the pus is likely to decompose rapidly, the result is that caries of the ossicles is liable to follow, with more or less loss of hearing. Unless a free incision is made at an early date in the drum membrane, the inflammation may ex- tend to the antrum and mastoid cells, or a carious open- ing may occur in the thin plate of bone forming the roof, and give rise to epidural abscess or to a temporo- sphenoidal abscess, as happened in a case of mine, to which reference is made in the chapter on Brain Ab- scess. In a certain number of cases, perforation of Shrapnell's membrane is the result of a general purulent otitis media, the inflammation ceasing in the tympanic cavity, but remaining obstinate in and about the attic. The perforation may be a small one, or the entire mem- 232 MANUAL OF OTOLOGY. brana flaccida may be destroyed. As a result, loss of bony substance takes place, so that a considerable por- tion of the attic is disclosed. Granulations or small polypi are frequently found in this region. If the discharge is checked, the movement of the ossicula is much hampered, frequently by thickening of the folds of mucous membrane and by adhesions. In making a diagnosis of perforation, it is always important to touch with a probe the different parts of the drumhead and middle ear, not only to see if a carious spot can be found, but also, when cicatrices of the drum membrane have taken place, to determine whether there is adherence of the cicatrix to the bony wall. In this connection, Siegle's otoscope will also aid in determining this point. With the probe the surgeon can frequently decide as to whether there is anchylosis of the ossicles, and whether the small bones are bound down by connective-tissue bands. The disturbances of hearing are apt to be very marked in such cases, and especially when connective tissue is found about the fenestrse rotunda and ovalis. Connective-tissue bands sometimes become calcareous or ossified, in which case the degree of deafness becomes extreme. Peognosis. The deafness, after cessation of the discharge, frequently remains stationary. In other cases the degree of deafness progresses steadily, which is due to increased rigidity of the newly-developed connective tissue or to anchylosis of the ossicles, or pos- sibly to involvement of the labyrinth. As long as there is a discharge from the ear, the patient should be im- pressed with the importance of having the ear properly cared for, since neglect of treatment is likely to lead to some dangerous complication. The state of the general CHRONIC PURULENT OTITIS MEDIA. 233 health is to be especially considered in regard to the prognosis. The latter is much more favorable when the disease occurs in a person of good health than in one suffering from tuberculosis, syphilis, the exan- thematous diseases, diphtheria, typhus and typhoid fevers. Unfavorable symptoms are a profuse discharge of long standing, and especially if it has a fetid odor, continued pain, narrowing of the external meatus, droop- ing of the posterior upper wall of the external auditory canal, a brownish discharge from the admixture of blood-corpuscles, the presence of cheesy masses in the discharge, and granulations and polypi. Teeatmbnt. To properly treat the ear, it is of the first importance (1) to remove thoroughly all secretion from the tympanum and external meatus ; (2) to estab- lish as perfect drainage as possible; (3) to check the discharge and bring about cicatrization of the perfora- tion. One should, first of all, syringe the ear with water that has previously been boiled or that contains boric acid in solution (10 grs.-Sj), or carbolic acid (2 per cent.), permanganate of potash (5 per cent.), or bichloride of mercury (1 : 3000). The latter is indicated in all cases in which micro-organisms are present in the discharge, especially those found in cases of scarlatina, diphtheria, or influenza. There is one precaution that should be taken in regard to the use of bichloride of mercury in chronic otorrbcea, which is, that great care should be used in the case of children and also in all individuals in whom the Eustachian tube is dilated, for in such, the solution is apt to enter the nasopharynx. It is well, therefore, in order to avoid this accident, to use but little force, and also to incline the patient's head 234 MANUAL OF OTOLOGY. toward the affected side. The ear should never be forcibly syringed, for fear of causing vertigo. After all secretion has been syringed out, the external meatus and middle ear should be dried as thoroughly as possi- ble by means of absorbent cotton on a cotton-holder. The cotton should be gently pushed down to the mem- brana tympani and rotated, in order to absorb the secretion. When the perforation is large, the purulent discharge can frequently be forced out of the middle ear by means of Politzer's method of inflation, or by the use of the catheter, or it can be removed through ex- haustion of air by means of Siegle's pneumatic specu- lum. Another method consists in forcing a stream of water, containing common salt or boric acid (grs. x-§j), through the Eustachian catheter and middle ear, espe- cially if there are accumulations of caseous or cholestea- tomatous masses in the tympanic cavity. The syringe can be attached to the catheter by means of soft rubber tubing. When the discharge is profuse, the ear should be syringed or douched at least three or four times a day; otherwise, less often. It is difficult for the patient to syringe his own ear satisfactorily. When intrusted with a syringe, the best one is that made of hard rubber, with a large blunt point. A soft-rubber bulb-syringe is also a perfectly safe one. After thorough removal of all secretion, the next step in the treatment consists in the instillation of as- tringent solutions containing either zinc sulphate, copper sulphate, or lead acetate, three to eight grains to the ounce of water, with the addition of a drachm of glyc- erin. The solution should always be warmed first, as cold is apt to cause pain or dizziness. When the per- CHRONIC PURULENT OTITIS MEDIA. 235 foration is small, the solution will frequently not enter the tympanum, unless the head is held to one side and the ear is inflated by the Valsalvian or Politzer methods, thus allowing the fluid to pass in when the air-bubbles escape. As thorough drainage is essential, it is much better, when the perforation is small and the discharge profuse, to enlarge the oritice by incising it. When this has been done, solutions can be more thoroughly applied to the middle ear. A solution that is espe- cially beneficial in uncomplicated cases is one containing boric acid, grs. xv; zinc sulphate, grs. viij ; glycerin, 5] ; water, Sj. — M. The solution should be instilled into the ear several times a day. When zinc sulphate does not seem to cheek the discharge, then copper or lead should be substituted. If the perforation be large, and the surgeon can see the patient frequently, the so- called dry treatment is generally much more satisfactory than the use of drops. Frequent syringing of the ear often keeps up the discharge in many cases, so that it becomes necessary to resort to the so-called dry method, which consists in the insufflation of boric acid or some other powder into the middle ear, after the secretion has first been most carefully removed by syringing and the use of absorbent cotton on a probe. Finely-powdered boric acid should be blown through a speculum into the middle ear by means of a powder blower. The powder should never be packed in, for fear of prevent- ing the escape of the pus, and thus inducing septicsemia. Besides boric acid, other powders are frequently used, such as iodoform, especially ia cases of caries or syphi- litic disease, or boric acid and iodoform mixed in equal parts, or equal parts of boric acid and zinc oxide. lodol is sometimes substituted for iodoform, but it is not as 236 MANUAL OF OTOLOGY. efficient in its action. The ear should be cleansed and the powder insufflated once a day, and less frequently as the discharge becomes diminished in quantity. Oc- casionally, after several insufflations of powder, the dis- charge ceases. The dry treatment is not indicated, as a rule, when there is considerable mucus or when the perforation is small. After the canal has been filled with powder, a piece of aseptic absorbent cotton should be placed in the meatus. When granulations have formed and the mucous membrane is considerably swollen, great benefit will follow the instillation of alcohol into the canal. Being a stimulant, as well as an antiseptic, its use is particu- larly indicated in cases in which the discharge contains cheesy masses. Soft granulations shrivel up and fre- quently disappear, while the alcohol forces its way into the various bony cavities. Pure alcohol should not be used where there is acute congestion or any symptoms of mastoid tenderness, and as it frequently causes severe pain, it should always be diluted with water at first and gradually increased to its full strength. The alcohol drops should be used at first two or three times a day, and gradually less often as the discharge becomes less. It is well to combine boric acid with the alcohol in the proportion of grs. xv-Sj. When the secretion has a bad odor, iodoform or iodol should be substituted for the boric acid. It is generally considered best not to carry out this method of treatment when caries exists. In cases in which there is a swollen condition of the mucous membrane, nitrate of silver (grs. x-xx to water Sj) is sometimes used to advantage. The secretion in the ear should be first removed by syringing, and then application made to the middle ear by means of cotton CHRONIC PURULENT OTITIS MEDIA. 237 on a cotton-carrier. The contraindications to its use are the presence of large granulations, a small perfora- tion of the drumhead, and caries of the temporal bone. To prevent the discoloration of the skin of the meatus, which is likely to follow its use, the surgeon should make an application of a solution of iodide of potash to the walls of the canal. It is impossible, however, to tell at a first examina- tion just what plan of treatment should be followed. After trying the dry method, a change to the instillation of astringent solutions, or of alcohol, will frequently bring about excellent results, and vice versa. THE WICK TEEATMENT. This method consists in the introduction of a strip of boric-acid or iodoform gauze, or a long, wick-shaped piece of absorbent cotton, into the external auditory canal down to the perforation in the drumhead. The gauze or cotton-wick should be changed several times during the day, if saturated with discharge. It is obviously necessary to syringe away all secretion and to dry the caiial and middle ear, if possible, before in- troducing the gauze or cotton-wick. When granulations spring from the drum membrane or the cavity of the middle ear, which do not shrivel up under the alcohol or dry methods of treatment, and especially in cases in which the mucous membrane of he tympanum is studded with numerous excrescences, which give it a granular appearance, it then becomes advisable to destroy these granulations by means of caustics or by the galvano-cautery, or by scraping them away with a sharp spoon or curette. 238 MANUAL OF OTOLOGY. Caustics should not be applied except in those cases in which the granulations can be easily seen, while great care should be exercised not to touch the external meatus with the caustic solution. The application of liq. ferri sesquichloridi is sufficient in some instances to cause the granulations to disappear. The solution should not be used again until the eschar has come away. Nitrate of silver or chromic acid, fused on the end of a probe, is indicated in some cases, and particularly the acid, which penetrates more deeply into the tissues, but which causes more pain. Before touching a granu- lation with chromic acid the mucous membrane should be swabbed with an 8 per cent, solution of cocaine. E.B.MEYROWITZ-NY -TTIllllfa Polltzer'a sharp spoons. Some prefer the galvano-cautery. It gives rise to more pain at the time of its application, but the granu- lations are more thoroughly destroyed, while there is usually no reaction. Scraping the granulations away with a sharp spoon (see Fig. 75) is one of the best methods, and instruments of different sizes and shapes have been devised for removing not only granulations on the drumhead or tympanic walls, but also those on CHRONIG PURULENT OTITIS MEDIA. 239 the ossicles and in the attic. The walls, when carious, can also be scraped at the same time, a procedure which often hastens the cure. When the perforation is in ShrapnelPs membrane, the first indication for treatment is to drain the attic, and if the perforation is a small one, it should be enlarged so as to enable the surgeon to wash out the attic and Prus- sak's space with a canula and middle-ear syringe (Fig. 76). For this purpose a 1: 3000 bichloride solution is the best, or a solution containing carbolic acid. After Fig. 76. Blake's middle-ear syringe. thorough removal of all secretion or caseous masses, astringent solutions containing zinc, copper, or lead should be injected into the attic by means of the middle- ear syringe, or alcohol and boric acid, or alcohol and iodoform should be used according to the indications. Finely-powdered boric acid is sometimes insufiiated through a slender canula. But little force should be used in syringing, as the patient is likely to complain of considerable vertigo. The apparatus (Fig. 77) devised by the late Dr. J. Hewitt is an admirable one for washing out the attic. 240 MANUAL OF OTOLOGY. and especially so after removal of the ossicles. The tubes are of glass and can readily be kept clean. By having a piece of tubing attached to the bulb, the latter can be placed on the floor and compressed by the foot, so that both hands of the surgeon remain free. Fia 77. Hewitt's apparatus for washing out the attic. If after several weeks' treatment by means of instil- lation and the use of powders, the discharge remains the same and the odor is fetid, the surgeon should then re- move the carious ossicles and scrape the attic. It is in the surgical treatment of these cases, in which the suppuration is kept up by a carious condition in the upper portion of the middle ear and the antro-attic and walls of the middle ear, that one is apt to obtain very brilliant results. When the suppuration is limited to the upper portion of the tympanum, a cure can un- doubtedly be effected in a certain number of cases by excision of the carious ossicles, and by scraping and curetting the attic. In most instances there follows an improvement in the hearing. CHRONIC PURULENT OTITIS MEDIA. 241 There are, however, a large number of cases of long- standing suppuration, where removal of the ossicles does not go far enough, and where it is much better to cut down on the antrum from behind the auricle, and per- forate the bone with chisels and mallet. Besides excis- ing carious ossicles, one can by this means reach the antrum much more readily, and thus remove any cheesy matter, which so often collects in this cavity. After such an operation the discharge does not cease at once in the majority of cases. It is usually neces- sary to continue the treatment previously described, namely, washing out the attic with the middle-ear syringe and using solutions and powders, before a com- plete cure is established. The operation of removal of the hammer and incus is indicated not only in eases of perforation of Shrap- nell's membrane, in which the secretion has persisted in spite of long-continued antiseptic treatment, but also in those cases of chronic otorrhcea in which there is but a rim of membrane left in the upper part of the tym- panic cavity, and in which there is evidently some ob- struction to the escape of the pus, which, becoming stagnant in the attic, causes caries of the ossicula and attic walls. Where cholesteatomatous masses form in the attic, the operation is likewise indicated. Operation. The external auditory canal should first be syringed with a bichloride solution 1 : 3000, and afterward carefully dried with absorbent cotton applied on a cotton-holder. All instruments used should be thoroughly sterilized. As the operation is a painful one, it is usually best to anaesthetize the patient, although in some adults who are not of a nervous tem- perament, cocaine may be locally applied. An incision 16 242 MANXTAL OF OTOLOGY. should theu be made in the drumhead along its upper border close to the bony wall, and the attachments of Fig. 78. Fig. 79. Politzer's forceps. the malleus, the ligaments, and the tensor tympani muscle carefully divided with a knife, as rep- resented in Fig. 78. There is usually considerable hemorrhage, which impedes the progress of the operation. Syringing with hot water will frequently control this. If not, the canal should be plugged with strips of iodoform gauze and the operation suspended for a few moments. The blood should be Author's knife for incising wiped away frequently with ab- the membrana tympani and i _l ^^ j.i. i i t for diviaing adhesions. sorbent cotton on cotton-holders, CHRONIC PURULENT OTITIS MEDIA. 243 SO that the surgeon can see the different steps of the operation. The head of the malleus should be disar- ticulated from the incus and then seized with a pair of forceps (see Fig. 79) and removed. When there are 'adhesions, these must be divided before attempting to extract the hammer. To remove the incus is a more difficult matter. If the long process can be seen, it should be seized with a pair of forceps, after the con- nection between the incus and stapes has been divided by a knife. When this is impossible, an incus hook should be carefully introduced in the upper part of the tympanic cavity behind the incus, and the latter should FiQ. 80. Hewitt's incus hook. be pulled downward and forward. An instrument that is well adapted for this purpose is the incus-hook de- vised by the late Dr. J. Hewitt, shown in Fig. 80. The hook is passed upward behind the incus and then brought directly outward and downward. The incus is more apt to be carious than the malleus, and fre- quently the incus cannot be found. After excision of the ossicles, the attic should be carefully curetted to remove all granulation tissue, great care being taken not to injure the facial canal and nerve. The external meatus should then be syringed with bichloride solution. 244 MANUAL OF OTOLOGY. and a strip of iodoform gauze pushed down to the middle ear, and a piece of absorbent cotton inserted out- side of this. Besides removal of the carious ossicles and scraping of the tympanic cavity, it is advisable in some cases in which there is caries of the bony wall just above and bordering on the perforation in Shrapnell's membrane, to remove this with a sharp spoon or by means of a pair of forceps especially designed for this purpose. ATTENTION TO THE GENERAL HEALTH. When the discharge from the middle ear has been checked (in cases of chronic suppurative otitis media), a child, previously pale and ansemic, often assumes a healthy appearance, so that it is important first of all to arrest the discharge, and particularly to remove all caseous masses, which, if absorbed, may lead to tuber- culosis. I have seen the health of a tuberculous patient greatly improved after the removal of softened bone and cheesy masses from the mastoid cavity. It becomes the duty of the aural surgeon not only to arrest the dis- charge and to improve the hearing, but also to inquire most carefully into the patient's general health. Errors of digestion should be corrected. Strumous children should be given cod-liver oil, syrup of the hypophos- phites, or syrup of the iodide of iron. Many patients suffering from chronic otorrhoea are broken down in health, or sufferers from tuberculosis or syphilis. Change of climate is often desirable, especially for those who are afflicted with catarrh. The surgeon should never fail to examine carefully the nasopharynx, especially in children, to see if there are adenoid growths or enlarged tonsils. CHRONIC PURULENT OTITIS MEDIA. 245 Proper treatment of the nares and nasopharynx is indicated in all cases whenever required, by means of sprays, by the removal of spurs on the septum, etc. See chapter on Nasal Diseases. ARTIFICIAL MEMBEANA TYMPANI. Yearsley in 1848 recommended the application of a ball of cotton to a drumhead that had been partially destroyed, for the improvement of the hearing-distance, while in 1852 Toynbee gave to the profession the arti- ficial drum membrane which bears his name. See Fig. 81. It consists of a round disk of thin rubber about 6 mm. in diameter, attached at the centre to a piece of wire by means of which the artificial drum membrane can be introduced in the canal and properly applied. Fig. 81. Pig. 82. Toynbee's artificial drum membrane. Artificial membrana tympani for use in practice among the poor. Politzer has devised another form of membrane, con- sisting of a piece of rubber 1 cm. long, which is cut from the side of an India-rubber tube 2-3 mm. in thick- ness. The lower end, being perforated, is fixed to a moderately strong wire. See Fig. 82. This appliance. 246 MANUAL OF OTOLOGY. being inexpensive, is especially adapted for use among the poor. A very simple device for improving the hearing consists of a piece of rubber tubing which should be cut ofE to correspond to the length of the external auditory canal, and so rounded at the inner extremity as to rest against the remnant of the drumhead. Hassenstein has invented a pair of forceps for grasp- ing a finely-rolled, wick-shaped piece of wadding. Ch. Delstanche uses a ball or roll of cotton which has been twisted about a thin wire, and which the patient can be taught to make for himself. Toynbee's membrane is but seldom used at the present day, as its applica- tion seems to cause irritation of the external meatus and of the drumhead, and, besides, patients often complain of a disagreeable noise in the ear while talking or eating. The cotton ball or wick, on the other hand, can be used even when thei-e is slight moisture, as this will be ab- sorbed by the wadding. The borated cotton, or cotton soaked in astringent solutions, or smeared over with vaseline, can be used according to the condition of the middle ear. The patient should be instructed by the surgeon to introduce the artificial membrane by means of Hassen- stein's forceps, or other instruments adapted for the pur- pose, and he will soon become very proficient in apply- ing the membrane to the exact spot at which the hearing is improved. The first application of an artificial membrane may not be followed by improvement, so that the surgeon should make several attempts before deciding as to whether it is indicated or not. Different views have been expressed by surgeons as CHRONIC PURULENT OTITIS MEDIA. 247 to the mode of action of the artificial membrane, some holding that it is simply necessary to close the perfora- tion, while others believe the improvement in hearing to be due to the pressure exerted against the remnant of the drumhead and ossicles. The latter view is probably the correct one, as the improvement in the hearing often follows wheu pressure is made just over the stapes. The artificial membrane should be tried in all cases in which local treatment has failed to improve the hearing-distance. It should never be used in the case of children or when there is much if any discharge. It is contraindicated when it causes irritation or in- flammation or any dizziness. As the artificial drum membrane is liable to cause a certain amount of irritation, it should be applied and left in situ for an hour or so at first, and the time gradually increased each day. The cotton must be changed as often as it becomes saturated with any dis- charge, and in such cases, the ear should be syringed and dried before it is reapplied. After the patient has learned the mode of application of the membrane, he will be able to change it frequently himself. It is often advisable for him to do this each day. In a case of permanent perforation of the drumhead, cicatrization of the same may at times be brought about by touching the edges with nitrate of silver fused on the end of a probe, or by scarification of the drum membrane, while incisions made near the opening occasionally produce a similar result. Another pro- cedure (Blake) consists in the application of a disk of paper a little larger than the perforation to be covered. Ordinary writing-paper is used for this purpose, be- 248 MANUAL OF OTOLOGY. cause (1) any desired thickness can easily be procured, and (2) the sizing, used in finishing the paper, when moistened is sticky enough to make the paper adhere to the membrana tympani. Such a disk is best intro- duced by means of a probe tipped with cotton and dipped in water, so that the paper adheres to the moist- ened cotton until it comes in contact with the membrana tympani. The disk of paper should then be firmly pressed into position by a cotton-holder tipped with dry cotton. The paper dressing is useful in only a limited number of cases, viz., those in which the perforation is small, and the infiammation has subsided, and there has been cessation of the discharge, the external surface of the drumhead having resumed a normal condition. It can also be applied to advantage in cases of rupture or mechanical injury, the paper dressing keeping the edges of the wound in apposition. Such , a disk of paper will remain in situ until either the perforation (a small one) becomes closed, or until some slight dis- charge from an inflammatory process washes it away. In cases in which the defect in hearing seems to be dependent on a relaxed cicatrix, as shown by increased impairment of hearing when the cicatrix bulges out, and by an improvement when the same returns to its posi- tion again, an attempt is sometimes made to bring about contraction of this relaxed tissue by means of multiple incisions made in the cicatrix with a fine needle. There is usually more or less disturbance of hearing, not only during the course of the suppuration, but also after cicatrization has taken place. Improvement of hearing follows in some cases from the use of Siegle's otoscope, or, better still, Delstanche's masseur, especially CHBOmC PURULENT OTITIS MEDIA. 249 when the deafness is dependent on adhesions that can be broken up by the rarefaction or condensation of air in the external meatus. The pressure probe (Ijucae) is useful in other cases, although the improvement in hear- ing, that at times is very marked, does not as a rule con- tinue. The probe consists of a round cup-shaped disk which is attached to a long handle, and which works on a spring. The disk is placed usually on the short process, and intermittent pressure is made on this spring. DIVISION OF ADHESIONS. EXCISION OF OSSICLES. As the result of adhesions due to chronic purulent otitis media, permanent disturbances of hearing remain; also, occasionally, distressing tinnitus or vertigo, unless relieved by an operation. The ossicles may be so bound together and to each other that nothing but a radical operation will afford any relief. No definite promise should be made to the patient as to any permanent improvement in the hear- ing or the tinnitus or vertigo, but it may be stated, as a general rule, that when the bone-conduction is better than the aerial conduction, and the ossicles are bound down by adhesions, as a result of chronic sup- purative otitis media, the hearing is generally im- proved by an operation. The nature of the adhesions should first be determined by means of Siegle's otoscope and a probe. With a suitable knife, band-like forma- tions between the handle of the malleus and the incus and stapes should be divided, as well as adhesive bands between the ossicles and tympanic walls. In some cases, the hearing shows a permanent improvement, while in others, it is but temporary. If division of adhesions and mobilization of the stapes are followed 250 MANUAL OF OTOLOGY. only by a temporarily improved condition, and the patient is willing to undergo a further operation, then the malleus and incus should be excised. The different steps in this operation have already been described. (See pages 220 and 241.) CHOLESTEATOMA AND EPITHELIAL MASSES IN THE TYMPANIC CAVITY. During the course of chronic suppurative otitis media, there are found at times in the secretion masses of epi- thelial cells, not only in the external meatus, but also in the middle ear. The patient may not suffer any particular discomfort, and these- epithelial scales may be found in the discharge for years. If, however, there is any hinderance to the escape of the pus, these masses often form a large plug and give rise to considerable pain and pressure symptoms, such as vertigo and vom- iting. If not removed, they lead to ulceration of the bone or to an intracranial complication. When the disease is limited to the attic, there being a small per- foration in Shrapnell's membrane, caries of the ossicula is likely to occur, or the disease is likely to extend to the brain through the tympanic roof. The term cholesteatoma is applied generally to a col- lection of epithelial cells, round or polygonal, arranged in concentric layers, and mixed with fat globules and crystals of cholesterin. Sometimes the whole mass is covered by a pearly, shining membrane. There is a great difference of opinion among patholo- gists as to the formation of these masses, some main- taining that a cholesteatoma in the temporal bone is of heteroplastic formation, while others consider it to be a retentive tumor. Still others believe these scales to CHBONIO PURULENT OTITIS MEDIA. 251 be formed in the external meatus and to extend through a perforation into the middle ear and antrum. As op- posed to this latter view, it may be stated that a case of cholesteatoma of the tympanum has been reported with- out any evidence of suppuration of the middle ear or perforation of the drum membrane. Such cases are extremely infrequent, however, as cholesteatoma is usu- ally observed in cases of chronic suppurative otitis media. A cholesteatoma may be found in the middle ear, antrum, or mastoid cells, the latter being the most fre- quent seat of the disease. In some cases the cholestea- toma is of small size, while in others it is very large, leading to more or less destruction of bone from pressure and absorption, or there may be extensive caries. The middle ear, antrum, and mastoid are sometimes trans- formed into one large cavity, or there may be consid- erable destruction of the margo tympani, or of the pos- terior and superior bony walls of the external meatus. The symptoms vary according to the size and nature of the collection of scales. There is generally a feeling of fulness or heaviness, or there may be considerable pain, headache, and vertigo. The cholesteatomatous masses either escape through the perforation, or they are apt to extend to the antrum and mastoid cells, and to lead to mastoid disease or some intracranial compli- cation, so that an operation becomes necessary. The pus not being able to escape may give rise, through absorption, to septicsemia or pysemia, or meningitis may follow, or cerebral abscess, or sinus phlebitis, or severe hemorrhage from erosion of the lateral sinus or carotid artery. It is very important to make an early diagnosis of 252 MANUAL OF OTOLOGY. cholesteatoma, as the disease is a destructive one, and radical treatment is required at an early date if one is to establish a cure. The diagnosis can only be made with certainty when the surgeon can see masses of epi- thelial cells either in the external meatus or else pro- truding from a perforation in the drumhead. Fistulous openings occur in the bony meatus in some cases. When there is a considerable discharge of epithelial scales from the middle ear, associated with pain in the mastoid process, it is probable that the latter is involved, and an immediate operation is indicated. Treatment. If there is a large opening in the drum membrane and the cholesteatomatous masses are not excessive, an attempt should be made to wash out the tympanum with a bichloride solution by means of the middle-ear syringe. See Figs. 76 and 77. When the perforation is small and is in Shrapnell's membrane, it should be enlarged and the attic irrigated in the same manner. This plan of treatment should not be con- tinued for a long time unless decided improvement en- sues, on account of the complications likely to develop. If the patient complains of pain or dizziness, and the cholesteatoma is in the antrum or mastoid process, the operation of opening the antrum and cells should be performed at once (see chapter on Mastoid Diseases), so that the cholesteatomatous masses can be reached and scraped away with curettes. If the ossicles are found carious, they should be excised and the attic curetted, great care being taken not to injure the facial nerve. In certain cases, when the disease is limited to the middle ear, attic, and antrum, Stacke's operation is indi- cated. This operation is described in the chapter on Mastoid Diseases. CHAPTER X. GEANULATIONS AND POLYPI — CAEIES AND NBCBOSIS OF THE TEMPOEAL BONE. GEANULATIONS AND POLYPI. Geanulations should be considered under the same classification as polypi, for they are observed generally in connection with chronic otorrhoea, and, besides, a granulation may develop into a polypus. Occasionally, granulations as well as polypi appear during the course of an acute purulent otitis media; but, as a general rule, they are the result of long-continued suppuration from the middle ear, with or without caries. Large, flabby granulations frequently conceal a carious spot either in the bony auditory canal or in the tympanic cavity, or a carious ossicle may be embedded in granulation tissue. Polypi are generally attached to the mucous membrane of the tympanum, less frequently to the wall of the ex- ternal meatus and membrana tympani. Cases have been reported in which polypi have been found in the tym- panic cavity without perforation, but such instances are extremely infrequent. When attached to the external meatus, the most frequent site is the posterior superior wall of the bony canal close to' the membrana tympani. There may be a perforation in Shrapnell's membrane with a polypus protruding through the opening. Polypi are found simultaneously in the middle ear, on the drum- head, and in the external auditory canal. They vary 254 MANUAL OF OTOLOGY. greatly in size, being at times extremely small, or suffi- ciently large to fill the external auditory canal and to protrude from it. The external meatus is liable to be enlarged by the pressure of the growth. A polypus may be attached by a slender pedicle or by a broad base. There may be but a single one, or there may be several. They vary in shape, being either smooth and club-shaped, or they resemble a raspberry, and have a knobbed and glandular appearance. They are bright red frequently, but when exposed to the air they generally lose their color and become pale and pinkish. Four varieties of polypi are usually described, viz. : 1. Mucous polypi. 2. Fibromata. 3. Myxomata. 4. Angiomata. The most frequent varieties are the mucous polypi and fibromata. Myxomata are very rare. 1. Mucous polypi are more frequently observed than any of the others, and histologically are identical with polypi found in the nares and nasopharynx. They are formed of a delicate and loose stroma of areolar con- nective tissue, in which are enclosed round cells and occasionally a few spindle-shaped cells. These polypi contain numerous bloodvessels, and generally have an irregular surface, due to their papillary and glandular structure. Cysts, considered by some as retention cysts, are found in these polypi. The epithelium on the inner surface is usually of the cylindrical or ciliated cylin- drical variety, while that covering the surface exposed to the outer air is pavement epithelium. A soft or mucous polypus may gradually become trans- formed into a fibroma by the bloodvessels becoming oblit- GRANULATIONS AND POLYPI. 255 erated, and by the cellular elements becoming changed into spindle-cells and connective-tissue fibres. Section of mucous polypus. 2. Fibromata. A fibroma is covered with pavement epithelium, and is composed of connective tissue with spindle-cells interspersed in its meshes. It has fewer bloodvessels than a mucous polypus, and in consequence is paler in color, and does not bleed so readily when touched with a probe. It is of a firm consistency, but does not contain cysts and tubular glands. It is usually attached to the periosteal lining of the tympanum or external meatus, and its growth is much slower than that of a mucous polypus. 256 MANUAL OF OTOLOGY. 3. Myxomcda. Myxomata are observed very infre- quently. Histologically, the tumor consists of a multi- ple layer of pavement epithelium for its external cover- ing, into which flat papillse project. The stroma is of an homogeneous gelatinous tissue, and contains spindle- and star-shaped cells. There are also round, granular cells with a round nucleus similar to lymph corpuscles. 4. Aru/iomata. These polypi are very vascular, and consist of a network of blood spaces which seem to take the place of capillaries. The blood enters these spaces directly from the arteries, and thence goes to the veins and back into the general circulation. When examined under a microscope, the growth is found to consist of bloodvessels connected with a large and irregular central cavity containing fibrous connective tissue. Although a polypus in the external meatus, as a rule, has its attachment to the osseous wall, it occasionally happens that a large polypus springs from the cartilagi- nous canal, especially if there is a sinus at that point leading to carious bone. A granulation or polypus often develops in the audi- tory canal from a point where a furuncle has existed. A polypus sometimes contains osseous deposits. Symptoms. When granulations or polypi do not interfere in any way with the drainage from the middle ear, there may be no other symptoms except that the discharge contains a little blood. On the other hand, if a polypus prevents the pus from escaping, the patient is apt to complain of a feeling of pressure and heaviness in the head, dizziness, and tinnitus, nausea, vomiting, and even epileptiform symptoms. In extreme cases, paralysis of one side of the body and anaesthesia of the extremities are due to the presence of polypi. The secre- GRANULATIONS AND POLYPI. 257 tioa, by being forced back into the antrum, may become stagnant, so that cheesy masses are formed, the result being caries and necrosis, or mastoid disease, and pos- sibly an intracranial complication. In the report' of a case of chronic purulent otitis media occurring in a young man, twenty-four years of age, the symptoms complained of were nausea, vomiting, unsteadiness in the gait, and marked deafness. There was facial paral- ysis of one side, and both auditory canals were filled with granulations. After removal of all granulations and polypi, so that there was free drainage from each ear, there was a marked improvement in the patient's gen- eral health, appetite, etc., a decided change for the better in the hearing, and a disappearance of the vertigo and unsteadiness in gait. The facial paralysis eventually dis- appeared. Occasionally, but very infrequently, a poly- pus is cured by spontaneous shrivelling. Polypi some- times come away in the discharge spontaneously as a result of the growth becoming turned on its axis and the blood supply being interfered with. Sometimes granulations coalesce, leading to constriction of the meatus and retention of secretion. In order to make a diag- nosis of a granulation or polypus, it is first of all neces- sary to remove all secretion by syringing. Then the canal should be dried by means of absorbent cotton on a cotton carrier. The surgeon should be careful to dis- tinguish a granulation or polypus from a bulging drum- head, from which the dermal layer has come away, or from an exostosis, or a malignant growth (epithelioma or sarcoma). With a good illumination and a probe, one can distinguish an exostosis by its being very hard ' Bacon : Archives of Otology, March, 1884, vol. xiii. No. 1. 17 258 MANUAL OF OTOLOGY. and immovable, and frequently very sensitive to the touch. An atheroma or sebaceous tumor of the external meatus, although of very infrequent occurrence, might be mistaken for a polypus. In order to decide the point of attachment of a polypus, the probe should be passed around the growth until the point has been determined. A large granulation or polypus projecting from the ex- ternal auditory caual has at times the appearance of a furuncle, but a probe introduced into the canal and passed around the growth will aid one in making a diagnosis. Where the growth is malignant, a diagnosis can only be made with certainty when a section of the same has been examined under the microscope. One of the most important symptoms, however, is pain, which is usually very severe. Peognosis. The prognosis depends very much as to whether the polypus is attached to the external meatus or tympanic cavity, and also as to whether there is caries of the ossicles and bony walls of the external meatus and middle ear. It is frequently difficult, even with a probe, to determine the point of attachment of a polypus, and in some cases this cannot be ascertained until a portion at least of the growth has been removed. Cases are much more favorable where the polypus is attached to the external meatus, unless associated with caries of the bony wall. It is stated by some that the appearance of the tumor will aid one in determining the point of its origin, viz., that a red, raspberry-like tumor with an irregular surface springsfrom the middle ear, but a smooth and pale growth has its point of attachment to the external auditory canal. GRANULATIONS AND POLYPI. 259 Tebatment. The treatment of granulations is best accomplished by means of (1) curettes or sharp spooDS ; (2) caustic applications ; (3) galvano-cautery ; (4) astrin- gent solutions and alcoholic drops. The speediest and most satisfactory method of remov- ing granulations from the middle ear or external meatus is by means of curettes, sharp spoons, or the so-called ring-knife. The canal should first be cleansed of all secretion and carefully dried, and then a few drops of a 4 to 10 per cent, solution of cocaine instilled warm into the ear. After a few moments, the canal should again be dried, and the granulations carefully removed. In the case of children, it is usually advisable to administer ether or chloroform, as it is next to impossible to iseep Fig. 84. Sharp curettes. the head still during the required manipulation. Sharp spoons (see Fig. 75) of different sizes and shapes can all be fitted in the handle for the purpose of removing granulations on the tympanic walls, the external meatus, or the drumhead. Sharp curettes (see Fig. 84), of which there are three sizes, as well as the ring-knife of Politzer, are better adapted to certain cases. The latter instrument can be slipped over a granulation, especially when it is attached to the wall of the external meatus. The knife is then withdrawn quickly, by which means the growth is excised so as to come away on the concave surface of the ring. There are two sizes of the ring-knife, the larger one being 3 to 3J ram. in diameter, while the smaller one is from IJ to 2 mm. 260 MANUAL OF OTOLOGY. After removal of the granulations, it is further neces- sary to cauterize the root or base with nitrate of silver or chromic acid, or to instil into the ear alcohol drops, the latter, however, being contraindicated when there is caries or necrosis. When the patients are of a nervous temperament, it is frequently impossible to scrape away the growth by means of instruments. In such cases, the application of caustics should be tried. For this purpose various remedies have been proposed. For small granulations, a drop of tincture of chloride of iron should be applied to the growth, or the latter should be touched with nitrate of silver fused on the end of a probe, the instrument being first heated red-hot in an alcohol lamp, and then dipped into some powdered nitrate of silver. This plan of treatment is advisable, especially when small granulations are attached to the middle ear cavity or the drum membrane. Chromic acid is a much better caustic, as it penetrates more deeply into the tis- sues than nitrate of silver. It is important, however, that this acid should only be applied to the polypus itself, and that great care should be exercised not to touch the drumhead or wall of the external meatus, otherwise severe inflammation is apt to follow. A probe should be heated and plunged into powdered chromic acid. The polypus should not be cauterized a second time until the slough has come away. If the acid occasions much pain, the polypus should be swabbed with cotton soaked in boric- acid solution, and afterward dried. It is often advisable to blow into the ear a small amount of boric acid powder after the cauterization. Galvano-cautery. The galvano-cautery is particularly adapted to the removal of large granulations. The use of alcoholic drops has been described in GRANULATIONS AND POLYPI. 261 Chapter IX.; these may be employed with excellent results in the case of small granulations, especially when they are soft and flabby. In some cases great benefit will follow the insufflation of equal parts of zinc oxide and boric acid powder. The same powder is often used after granulations have been excised with instruments. Treatment op Polypi. Whenever a polypus is large, and particularly if it have a pedicle, the best method of removing the same is by means of Blake's snare. The instrunaent (Fig. 85) consists of a metal canula through which a loop of wire is drawn. Instead Pig. 85. Blake's polypus snare. of having both ends of the wire wound around and fast- ened to a slide-ring, as was formerly in vogue, there is substituted a cleat, around which one end of the wire should be securely fastened ; on the side of the shaft is a similar cleat to secure the other end of the wire. When fastened in this manner, it is evident that by making traction on the slide-ring, the wire loop in pro- cess of withdrawal through the canal will, instead of merely constricting the growth, have a distinct cutting motion which will greatly facilitate the removal of the more resisting polypi. Both ends of the wire can, how- ever, still be fastened to the cleat on the slide-ring, if the surgeon so desire. The finest malleable wire or a very 262 MANUAL OF OTOLOGY. fine silver or brass wire is to be preferred. The instru- ment, moreover, is so constructed that the handle, slide- ring, and canula can be removed, and the shaft made available as a handle for a paracentesis knife or for curettes or sharp spoons. There is also a small canula which is particularly adapted for the purpose of excising small polypi in the tympanum. Before attempting to snare a polypus, the canal should be carefully syringed with a bichloride solution, 1 : 3000, to remove all secre- tion, and then carefully dried. Cocaine solution, 10 per cent., should then be instilled warm into the ear, and after a few moments the surgeon should make out with the probe the point of attachment of the polypus. It requires considerable practice and skill to apply the loop of wire about the growth. The removal of the latter may be followed by considerable hemorrhage, which can be controlled by tamponing the canal with styptic cotton. After the larger portion of the growth has been excised in this way, the surgeon will then be better able to make out the point of its attachment, the condition of the tym- panic cavity, and also as to whether there are other polypi or not. When a polypus is found protruding from a small perforation in the drumhead, it is often advisable to enlarge the opening first before making an attempt to excise the tumor. A method formerly in vogue, but now generally dis- carded as being unscientific, is avulsion by means of forceps. The operation consists in seizing the polypus with a strong pair of forceps, and, by twisting and pull- ing, the growth is removed. If attached to the auditory canal, this procedure is not attended with danger, but if arising from the tympanic cavity or drum membrane, GRANULATIONS AND POLYPI. 263 great damage may be done by forcible extraction. Curved scissors will be found useful for snipping off a polypus growing from the external meatus. After snaring off the polypus, the root should be cauterized with chromic acid or nitrate of silver, and a strip of iodoform or boric-acid gauze should be pushed down to the drumhead. Eepeated cauterization should be per- formed until the growth is entirely destroyed, and in the mean time any discharge from the ear should be treated as described in Chapter IX. Besides astringents and powders, which can be used in, some cases after removal of the growth, the alcohol treatment is often indicated. This method is useful not only for the purpose of shrivelling up the roots of polypi and granulations on the membrana tympani and in the external auditory canal, but also in those cases in which the polypi are situated in the tympanic cavity, and in cases of exostosis of the external meatus where the growth cannot easily be reached. In a great many persons of a nervous temperament, as well as in children, it is impossible to use the snare or other instruments unless an anaesthetic is administered. In a great many individuals, it is impossible to lay down rules for any particular plan of treatment. After excis- ing a polypus with the snare, it may be necessary to complete the operation with a ring-knife or sharp spoon, especially if the bony walls of the external meatus or tympanic cavity are carious. The galvano-cantery is highly recommended by some surgeons where the poly- pus is large, and is of the hard or fibrous variety, and when the snare or other instruments cannot be used. It has the advantage over caustic remedies, in that its action is more rapid and thorough, while the pain 264 MANUAL OF OTOLOGY. is but momentary, ceasing immediately after the cau- terization. CAEIES AND NECROSIS OP THE TEMPOEAL BONE. In acute purulent otitis media, where pain is a prom- inent symptom, there is probably more or less inflamma- tion of the periosteal lining of the bony meatus and middle ear. This is apt to be the case when the disease is due to scarlatina, measles, diphtheria, tuberculosis, syphilis, or influenza, and unless vigorous antiphlogistic measures are adopted during the early stage (see Chapter VI.) caries and necrosis of the temporal bone are apt to follow. When acute otitis media passes into the chronic form, and proper drainage has not been estab- lished for the escape of the pus, polypi and strictures of the external meatus may develop, the secretion is apt to become stagnant, and, as a result, decomposition takes place, so that ulceration of the tissues follows and the bone becomes carious, especially if the patient has scrof- ula, tuberculosis, or some other cachexia. The point of caries may be a small one, or there may be extensive destruction of the temporal bone. The micro-organisms are not so apt to attack the compact bony tissue as the pneumatic and diploetic varieties, and the disease is more likely to involve the mastoid cells and the posterior superior wall of the external meatus than the other por- tions of the temporal bone, although it must not be for- gotten that the disease may affect the tympanic roof and give rise to meningitis, or to an extra-dural or temporo- sphenoidal abscess, or, starting in the mastoid cells, the destructive process may lay bare the lateral sinus, and cause thrombosis of the sinus or an abscess in the CARIES AND NEGBOSIS OF TEMPORAL BONE. 266 cerebellum. Cases have occurred in which the disease has extended to the labyrinth, and given rise to symp- toms suggestive of an abscess in the cerebellum, viz., nausea, vomiting, vertigo, tinnitus, facial paralysis, great pain, and a staggering gait. In such a case, where the pulse was slow and the patient complained of vertigo, vomiting, severe headache, and deafness, on opening the mastoid antrum, a carious condition of the semicircular canals was found, which accounted for all these symp- toms. In still another case which came under my care, and in which a diagnosis of " probable cerebellar abscess " was made from the following symptoms, viz. , vomiting, a staggering gait, with a tendency to fall toward the right side, double choked disk and retinitis, all these alarming symptoms disappeared when the foul- smelling pus and granulations were removed from the external auditory canals and free drainage was estab- lished. There was considerable caries of the tympanic cavities as a result of the chronic suppuration. Still another case of extensive caries of the temporal bone due to chronic otorrhcea occurred in a man, thirty years of age, who was under my care, and who eventu- ally died of a temporo-sphenoidal abscess. The drum- head was destroyed almost entirely, and there was exten- sive caries of the inner wall of the middle ear and anterior bony wall of the external meatus. (Fig. 86.) The case is more fully referred to in the chapter on Intracranial Complications. At the post-mortem examination, a large carious opening in the middle cranial fossa was found involving the glenoid fossa. As a result of caries and necrosis, large cavities may be found in the temporal bone. When chronic otorrhcea has existed for some time, and especially when there has been caries of the 266 MANUAL OF OTOLOGY. tympanic walls and ossicula, one finds very frequently a sclerosed condition of the mastoid process, which is as hard as ivory. Unhealthy granulations often conceal carious bone, the mucous membrane being generally ulcerated and in an unhealthy condition, while the ossic- ula are also carious. Caries of the ossicles may occur Fig. 86. Large carious opening in the middle cerebral fossa. independently, the disease being limited as a rule to one bone, generally the incus. Frequently the body of the incus and head of the malleus are carious. The malleus and incus are frequently found embedded in a mass of granulations. Caries of the handle of the malleus is not often observed, and it is seldom that the malleus alone GABIES AND NECROSIS OF TEMPORAL BONE. 267 is involved. The foot-plate of the stapes generally remains in situ, although the head and crura may be destroyed. If the foot-plate comes away, and the laby- rinthine fluid escaijes through the foramen ovale, pro- found deafness is apt to follow. A patient may have fairly good hearing, even when the drumhead and the malleus and incus have been destroyed, provided there is no fixation of the foot-plate of the stapes. Symptoms. Pain is one of the most important symp- toms, and it is apt to be very severe and continuous, although in tuberculous subjects, the disease may occur without pain. The pain is sometimes due to retained secretion, but more frequently it is caused by inflamma- tion of the periosteum or of the bone itself. Other symptoms are tinnitus, vomiting, vertigo, insomnia, elevation of temperature with occasional chills, and in- creased pulse-rate. The discharge is quite characteristic, being generally increased in quantity, foul-smelling, and containing some blood-corpuscles, and, occasionally, gritty particles of necrosed bone. The external meatus is generally filled with granulations which bleed easily. The remaining rim of the drumhead is swollen and red in appearance, while, if the antrum is invaded, there may be a bulging of the posterior upper wall of the external meatus. After syringing the canal and drying the same with absorbent cotton, the probe is the most valuable instrument for determining the existence of caries. The bony walls of the meatus are sometimes carious, while abscesses form in the soft tissues about the ear, or over the mastoid, or below the auricle. Occa- sionally, there is an abscess above the pinna, but rarely in front of it. The pus may force its way into the external auditory canal through one of the fissures of 268 MANUAL OF OTOLOGY. Santorini, or it may break through the soft tissues about the auricle, or it may force a passage to the nasophar- ynx, and give rise to a retropharyngeal abscess. As a result of the formation of abscesses, various fistulse are found, either in the region of the mastoid, or above, in front of, or below the auricle. Facial paralysis is another symptom of caries of the temporal bone, and may occur as a result of an inflamma- tory exudation in the sheath of the nerve. There may or may not be caries of the Fallopian canal. When the latter talies place, it does not necessarily follow that there will be facial paresis. The paralysis may or may not be permanent, depending largely on the extent of the inflam- mation. As a result of paralysis, there may be conjunc- tivitis of the same side with ulceration of the cornea. Prognosis. When there is good drainage for the secretion and the patient is otherwise in good health, the prognosis is much more favorable than when it occurs in individuals suffering from some exhaustive disease. The destructive process may be limited to the attic and tympanic roof, or it may extend to the dura and brain, while, on the other hand, there may be extensive disease of the temporal bone leading to the formation of a large sequestrum without fatal result. Caries and necrosis may terminate in recovery with or without much loss of bone substance, or various com- plications may ensue, viz., meningitis, brain abscess, sinus thrombosis, septicsemia, pyaemia, hemorrhage from the internal carotid artery or internal jugular vein. As a result of deep-seated caries large sequestra may be formed, including a portion or even the whole of the labyrinth. The outer wall of the mastoid process is occasionally exfoliated. See Figs. 87 and 88. CARIES AND NECROSIS OF TEMPORAL BONE. 269 The auditory canal should first of all be syringed with antiseptic solutions, and as perfect drainage as possible established by means of curettes and sharp spoons. In the case of fibrous strictures of the meatus, very small Fig. 87. Fig. 88. Sequestrum consisting of the outer wall Sequestrum consisting of a por- of the mastoid process. tion of the mastoid process. rubber tubing, through which is passed a quill tooth- pick, may be used, the quill keeping the tube pervious for the esca^je of the pus, while the rubber exerts elastic pressure on the walls of the meatus. Sometimes caseous masses in the middle ear are rapidly forced out and the pain is relieved by syringing with a warm boric-acid solution through the Eustachian tube. When the caries is superficial, excellent results follow in many cases from the injection of Villate's solution. Dilute sulphuric acid, 1 in 3, is instilled into the ear by some surgeons as well as dilute nitric acid (^ per cent.) for the purpose of dissolving the carious particles. Such treatment can only be of a temporary character. 270 MANUAL OF OTOLOGY. Whenever possible, the carious bone should be scraped, and any loose sequestra removed. Scraping of the bone is indicated only when the disease is superficial, and when performed great care should be exercised not to penetrate the labyrinth if the inner tympanic wall be in a carious condition. The surgeon should likewise be careful not to injure the Fallopian canal and cause facial paralysis, nor to penetrate the middle cranial fossa through the tympanic roof. After such an operation on the bone, the auditory canal and middle ear should be syringed with bichloride solution, and powdered iodoform, or iodoform and boric acid insufflated. Boric-acid gauze and absorbent cotton should then be inserted in the meatus. When a sequestrum has formed, it should be grasped with suitable forceps, and extracted through the external auditory canal, if possible, but very little force should be employed. In some cases when the sequestrum is large, it can be crushed or broken by means of forceps. In other cases, especially when the disease is extensive, it is much better to cut down on the mastoid, making the incision close to the auricle and down to the bone. The auricle can then be displaced forward, and the cartilagi- nous canal separated from its attachment, in order to allow more space for the operator. If the disease be extensive, it may be necessary to enter the antrum and cut away the posterior superior bony wall, and make one large cavity of this portion of the temporal bone (see Stacke operation). GENERAii Treatment. While local treatment is of especial importance, attention to the patient's general health should never be neglected. As the disease is apt to occur in those who are debilitated, it is highly impor- GARIES AND NECROSIS OF TEMPORAL BONE. 271 tant to prescribe a good nourishiog diet, if possible, and plenty of out-of-door life. Cod-liver oil, the hypophos- phites, and syrup of the iodide of iron are particularly valuable in the case of tuberculous or strumous children. Iron, quinine, and strychnine are indicated in ansemia, while iodide of potash should be given if the cause can be traced to syphilis. Treatment op Facial Paralysis. Large doses of potash iodide are recommended by some in the early stage when the bone is first inflamed. Counter-irritation over the mastoid by means of iodine ointment is advised by others. The discharge from the ear should be prop- erly treated, and any carious bone removed. After the inflammatory symptoms have subsided, electricity should be tried. If the muscles do not respond to the faradic current, galvanism should be substitued. Frequently no improvement follows until after some weeks have elapsed. CHAPTER XI. DISEASES OF THE MASTOID PEOCESS. Before entering into a consideration of the diseases of the mastoid process and their complications, it is neces- sary to consider the anatomy of the temporal bone as well as its position in relation to important structures, such as the large bloodvessels, the dura mater, and the brain. The temporal bone consists of a squamous, petrous, and mastoid portion. Ossification of the temporal is developed by ten centres, viz., six for the petrous and mastoid portions, one for the squamous and zygoma, one for the tympanic plate, and two for the styloid process. Inflammatory changes of a destructive character are more apt to take place in the petrous and mastoid portions than in the squamous and tympanic. During the first years of life, the points of union between these different por- tions are very vascular, and at times are not firmly united, so that inflammatory products, especially tuber- cle bacilli, can easily break through these vascular walls, and give rise to a collection of pus in the soft tissues behind the auricle, a condition of affairs which is of quite frequent occurrence in scrofulous children. In the child, the external auditory canal is as large in proportion as in the adult, except that in the former the canal consists almost wholly of cartilage, while in the adult it is bony for two-thirds of its length. In the infant at birth, there is an incomplete ring DISEASES OF THE MASTOID PROCESS. 273 with two tubercles, one iu front and one behind; these tubercles approximate one another in the lower wall of the meatus at the glenoid fossa, and form a foramen which does not become closed until the fifth or sixth year of age. This aperture, however, sometimes remains open permanently, or it may be covered by thin fibrous tissue, and, as it is in close proximity to the parotid gland, it is easy to understand how inflammation may Fig. !S9. Section of bone showing the inner or mucons surface of the drumhead ; aJso the articulation of the head of the malleus with the body of the incus contained within the attic. extend from the external meatus to the parotid gland, or vice versa. During an attack of mumps the drumhead is frequently congested, and in some cases the labyrinth is affected as well. 18 274 MANUAL OF OTOLOGY. The tympaniiDi communicates with the Eustachian tube in front, and the mastoid antrum and cells behind. The drumhead forms the greater part of its outer wall. Beneath the floor of the tympanum, and separated from it by bone, is the jugular fossa posteriorly, and the caro- FiG. go. Section showing the antrum situated just above and a little behind the ex- ternal auditory canal and communicating with the mastoid cells. tid artery anteriorly. In the upper portion of the tym- panum is the attic (Fig. 89), containing the articulation of the head of the malleus with the incus ; the attic opens posteriorly into the mastoid antrum (Fig. 90), and the latter into the mastoid cells. Tiie tegmen tyrapani, or roof of the middle ear, consists of a very thin plate of DISEASES OF THE MASTOID PROCESS. 275 bone upon which rest the dura mater and brain. In some cases, there are defects in the tegmen tympani, which are covered over with fibrous tissue, so that in acute otitis media the inflammation may extend directly to the dura, and give rise to meningitis or brain abscess. In cases of fracture of the temporal bone the tympanic roof may be involved, symptoms indicative of such being escape from the meatus of blood and cerebro-spinal fluid. There are many veins, and they have an important bearing, since inflammatory products are occasionally carried by them to the large sinuses and to the brain itself. Of considerable importance is the mastoid vein which proceeds from the sigmoid sinus directly through the skull externally, and, joining a large vein from the occipital region, passes to the deep cervical vein, which ultimately unites with the vertebral. The course of this vein is not constant, however. The mastoid vein may become involved when a thrombus is found iu the sig- moid sinus. The veins from the tympanum empty partly into the middle meningeal, partly into the sigmoid sinus, and partly into the superior petrosal sinus. The mastoid veins, as a rule, enter the sigmoid sinus. Too much stress cannot be laid upon the importance of remember- ing the position and relation of these veins one to an- other, as will be seen in a later chapter on intracranial complications. When the chorda tympani nerve is injured, as may happen from a blow or fall, there will be occasionally observed a loss of the sense of taste in the anterior two- thirds of the tongue on the side affected. The facial nerve may be paralyzed in its course through the middle ear from injury due to an operation, or to disease of the middle ear, or the facial paralysis may be of central 276 MANUAL OF OTOLOGY. origin. As a result of such paralysis conjunctivitis occurs, and occasionally ulcerations on the cornea, the patient being unable to close the eye. The sense of smell is impaired. The patient has difficulty in masti- cation, the food collecting between the cheeks and gums on the affected side. Taste is affected through the chorda tympani. The patient is unable to whistle. In paralysis of the facial due to a central lesion, the patient can generally close the affected eye, and the muscles of the face are much less affected, while the chorda tympani is not involved. In children, the wall of the canal for the facial is extremely thin, and occasionally there is a small opening in this wall, so that facial paralysis is of more frequent occurrence in children than in adults. It is important to remember the course of the Fallopian canal, for the surgeon is likely to injure the nerve during operations on the mastoid as well as when excising cari- ous ossicles. The facial canal, in its course through the upper parts of the tympanum, lies just above the fora- men ovale and directly behind the attic and antrum, so that the surgeon must avoid the inner and anterior wall of the antrum. After removing carious ossicles, great care must be exercised in scraping the attic. The patient's face should be constantly watched to see that there is no twitching of the facial muscles. Even when this pre- caution has been taken, facial paralysis has occurred, as the muscles will probably not respond to stimulation when the patient is completely under the influence of an anaesthetic. In early life the mastoid process is but slightly developed, and consists principally of the an- trum, which is large and very near the surface of the skull. The ossicula in the infant are of almost the same size as in the adult. DLSKASKS OF THE MASTOID PROCESS. 277 The mastoid cells in adult life vary very much as to size, aud from anatomical investigations it is known that Fig. 91. Pneumatic mastoid process. Fig. 92. Inner surface of a diploL-tic mastoid process, witli the groove for the sigmoid sinus lying just above the cells. 278 MANUAL OF OTOLOGY. no two processes are exactly alike. The cells in one case may consist of large air spaces, which communicate with one another, as in Fig. 10, the so-called pneumatic mas- toid process, or they may be arranged as in Fig. 91 ; or the mastoid process (Fig. 92) may be composed of small- celled diploe and osseous tissue filled with fatty sub- stances ; or the mastoid process may be sclerosed. The pneumatic mastoid process is generally larger than either the diploetic or sclerosed varieties. In some cases, the mastoid is composed partly of pneumatic cells and partly of diploetic tissue. According to my experience, in cases in which the external wall of the mastoid process is small, and especially when the lower portion is poorly developed, the lateral sinus is more likely to run close to the antrum than in those cases in which the mastoid is filled with large air-cells. In such, moreover, great care should be taken not to injure the sinus when opening the mastoid antrum. The bony wall between the mastoid cells and the sigmoid sinus is very thin, and in some cases there are defects in the bone that are filled in with fibrous tissue. In the child, there is an opening found in the petrous bone on its posterior surface, the fossa subarcuata, lying between the external auditory meatus and the groove for the superior petrosal sinus. It terminates in a series of cells just beneath the superior semicircular canal. It is usually of small size in the adult, and oftentimes closed. Soon after birth, this canal gradually fills up with more or less bony tissue, so that eventually it is but a small sinus, even if it exists at all. It is of importance, be- cause when present, inflammation may extend from the mastoid cells to the brain, as a vein enveloped in dura mater^passes through it. The mastoid antrum, in the DISEASES OF THE MASTOID PROCESS. 279 child just after birth, is covered by a much thinner layer of bone than in the adult, so that pus makes its way much more readily to the external surface of the skull. The mastoid process does not assume the typical shape until the child is about three years of age. The mastoid antrum is the point that the surgeon should always ex- pose when operating for mastoid disease, especially when some intracranial complication has occurred, for it is here that most pathogenic processes have their origin. MASTOIDITIS EXTERNA. Primary Acute Inflammation of the Mastoid Periosteum. Primary inflammation of the mastoid cells, without in- volvement of the tympanic cavity, is rare, although such cases do occur and have been reported, the congestion first appearing in the periosteum covering the mastoid, or else in the cell spaces of the mastoid itself. The causation of mastoid periostitis is frequently obscure, but it may be due to cold, injury, or extension of the inflam- mation from a furuncular condition of the external meatus. The hearing in such cases is generally normal, as no changes are apt to take place in the drumhead. There may be a slight congestion of the posterior bony wall of the external meatus. The auricle is apt to stand out prominently, while the tissues over the mastoid are pain- ful to the touch, red, and cedematous. The pain is apt to be severe in some cases, and there may or may not be considerable fever. When one or more furuncles have formed in the external meatus, the inflammation may extend to the soft tissues about the ear, and especially in the mastoid region, so that the parts are very tender and cedematous, with the auricle standing out prominently. 280 MANUAL OF OTOLOGY. The beginner is very likely to mistake this condition for disease of the mastoid process, but the presence of a fur- uncle in the canal will give the surgeon a clue as to the causation. It is possible, however, in severe cases of acute otitis media, for the periosteum over the mastoid process to be affected, especially in strumous subjects. Unless a free incision is made down to the bone, there is a liability that the latter will become involved, and the inflammatory process extend to the mastoid cells. The disease may run its course in a few days, and sub- side rapidl}', or suppuration may take place. The abscess may open into the external meatus through one of the ineisurse Santorini. As a result of periostitis, the superficial layers of bone underneath may become ne- crosed unless an incision is made through the periosteum down to the bone. In the early stage of this affection, the artificial leech should be applied, followed by the Leiter cold coil. If these measures do not afford relief, a free incision should be made through the soft tissues over the mastoid down to tlie bone. If the boue beneath has become carious, this should be removed with chisels and gouges. MASTOIDITIS INTERNA. Primary Acute Inflammation of the Mastoid Cells. Cases have been reported from time to time, and un- doubtedly occur, in which the mastoid cells are primarily involved. The disease may be due to cold, trauma, syph- ilis, or the influenza, or may develop spontaneously. The micro-organisms of influenza or the diplococcus pneumoniae may be found in this disease, as well as other microbes. The symptoms are pain in the region of the mastoid, which, though slight at first, usually DISEASES OF THE MASTOID PMOCESS. 281 becomes very severe and throbbing. This is followed by tenderness on pressure over the mastoid bone, and if the pus makes its way through the bony wall, fluctuation will be detected in the soft parts, and the auricle will stand out prominently. In this affection the disease may reach its height in a week or ten days, and the inflammation subside without suppuration, or an abscess may form which may perforate the outer cortex after several weeks of suffering. There is always danger that the inflammation may extend to the sigmoid sinus if pus forms and it is not evacuated. As in periostitis of the mastoid, so in this disease, the hearing is usually unaffected. It is difficult to make a differential diagnosis between primary mastoid- itis and mastoid periostitis, except that in the former the pain is deeper seated. If a subperiosteal abscess has already developed, it will be impossible to tell whether the mastoid cells are implicated or not, until a free incision has been made down to the bone, and the latter has been examined for a sinus. It is always well in such cases to open the cells to see if pus has already formed. The prognosis is usually favorable in simple, uncom- plicated cases. The surgeon should be guarded in ex- pressing an opinion, however, when the disease exists in a syphilitic or cachectic individual. The treatment of this disease is similar to that for acute mastoid inflammation occurring secondarily to acute purulent otitis media. Acute Inflammation of the Mastoid Cells Occurring in Connection vrith Acute Suppurative Otitis Media. Inflammation of the mastoid cells occurring secondary to acute otitis media is the form most frequently ob- 282 MANUAL OF OTOLOGY. served. The disease is apt to start in the nasopharynx, and to extend by the Eustachian tube to the tympanum, and thence through the antrum to the mastoid cells. The inflammation of the cells may follow an acute catarrhal or acute suppurative otitis media, or occur as a result of chronic purulent otitis media, frequently of long standing. Mastoid disease developing in connection with chronic purulent inflammation of the middle ear will be described separately. Acute inflammation of the mastoid cells may follow long exposure to wet or cold. Other causes are the exanthematous diseases, diphtheria, tonsillitis, bron- chitis, typhus and typhoid fevers, tuberculosis, syphilis, the influenza, the use of the nasal douche, and " sniffing up " salt and water for the relief of nasal catarrh. It is probable that, in almost all cases of acute otitis media, the mucous lining of the mastoid cells is simultaneously involved. The diploetic mastoid cells are not affected as often as the pneumatic variety. In some pneumatic processes, the opening from the antrum into the cells is large. If, however, the opening be small, or it becomes occluded through swelling of the mucous membrane, the escape of pus is prevented, and the discharge, being forced back, forms an abscess. Since the influenza made its appearance in this coun- try some eight years ago, there have been, according to my experience, many more cases of mastoid disease than ever before. It is only a few years ago that but twelve, or at most twenty cases of this disease were recorded in the annual report of the New York Eye and Ear Infir- mary. In the report for 1896 there were 135 mastoid operations, while for 1897 the number had increased to 161. Formerly, it was the exception for the mastoid DISEASES OF THE MASTOID PMOCESS. 283 cells to be simultaneously involved in a case of acute otitis media. During the past few years this condition of affairs has been very frequent. A patient will have a sudden severe earache, which is followed in a few hours by a bulging of the drumhead and symptoms of mastoid inflammation. Of twenty cases that came under my observation recently in private practice, all had acute otitis media. In seventeen, there M'as acute inflammation of the mastoid cells, and in seven, it was necessary to open the mastoid process. In ten, recovery tools place without operation. Of these, the drumhead was punc- tured in six cases. In one of them, viz., that of an infant, several months old, in whom alarming symptoms developed suddenly, suggesting a meningeal complica- tion, puncture of the drumhead gave speedy and marked relief. Symptoms. The most prominent symptom is pain in the mastoid process, which is apt to radiate in different directions, upward in the temporal region, and downward and forward toward the teeth. Great pain is felt on per- cussion of the bone, or when firm pressure is made. The pain on pressure is usually limited to the region just over the mastoid antrum or to the middle and lower thirds, especially at the tip. Sensitiveness to pressure does not necessarily signify that the bone is diseased at that par- ticular point, so that it is always important to make a careful examination of the entire mastoid process during an operation in this region. In some cases pus forms in the mastoid cavity with very little, if any, pain. This sometimes happens when the disease occurs in connection with tuberculosis or influenza. As mastoid disease is frequently observed during the course of scarlatina, diphtheria, and the other infectious diseases, it is most 284 MANUAL OF OTOLOGY. imperative for the surgeon to make a free incision in the drumhead at an early date. An abscess in the mastoid cells, occurring secondarily to acute purulent otitis media, is more apt to be located in the middle and lower thirds than in the upper third. Other symptoms of mastoid inflammation are: increase of surface-temperature of the affected side ; bulging of the posterior and upper por- tions of the drumhead, with drooping of the adjacent soft parts of the external meatus ; after perforation has occurred, the appearance of a nipple-like process, at the extremity of which is found a minute opening, and pro- fuse discharge from the ear. The temperature may vary from 99.5° to 104° or 105° F. Asa rule, in simple un- complicated cases, it is lower in adults than in children. A patient with extensive caries of the mastoid cells and Avith a carious opening into the cranial cavity, may have a temperature but slightly above normal, so that a com- paratively low temperature does not necessarily signify that the case is not one of considerable gravity. Young infants frequently have a temperature of 105°, while in adults one is much more apt to find the temperature below 100° F., even when extensive mastoid disease exists. Great surprise is often expressed by the general practitioner that there can be any serious disease with such a low temperature. I have never seen a case of acute inflammation of the mastoid cells without some elevation of temperature, and I look upon this symptom as having a very important bearing on the diagnosis. If a patient is under observation who has had an acute purulent otitis media for at least a week or ten days, and an examination reveals a bulging of the upper wall of the auditory canal and drumhead, and there is pain on pressure over the mastoid antrum or tip, and further, if DISEASES OF THE MASTOID PROCESS. 285 there is some rise in temperature, frequently very slight, and especially if there is a profuse discharge, these symp- toms, taken together, are very characteristic of mastoid inflammation. The condition of both mastoid processes should always be compared, because in some persons pressure made over the normal mastoid causes pain, especially in hysterical subjects. Bulging of the upper and posterior portion of the drumhead and drooping of the adjacent cutaneous lining of the external meatus are, to my mind, absolute symptoms of mastoid involve- ment, and I believe that in such cases it is always necessary to perforate the mastoid cells. It was for- merly taught that oedema and redness of the tissues behind the ear, with prominence of the auricle, were evi- dences of mastoid disease. Surgeons have frequently waited for these symptoms as well as for the appearance of fluctuation. An operation should never be deferred till such a late stage, as valuable time may be lost by so doing. The fact must not be overlooked that redness and oedema over the mastoid, and tenderness on pressure, occur in cases of furunculosis of the external meatus. An examination of the auditory canal will exclude tills. Acute inflammation of the mastoid cells may terminate in recovery without the formation of an abscess, but what happens more frequently, pus forms and carious destruc- tion of the bone results, so that after weeks of suffering, a large sequestrum may be found. In influenza cases, rapid destruction of bone is the rule, so that it is impera- tive in such to open the cells very early. The pus may force its way through the tympanic roof, and give rise to meningitis or brain abscess, or may cause destruction of the thin plate of bone covering the sigmoid sinus, and cause thrombosis, or perforation may take place at the 286 MANUAL OF OTOLOGY. mastoid tip (Bezold), thus allowing the septic matter to burrow beneath the deep fascia, and give rise to septicae- mia and pyaemia, or to a post-pharyngeal abscess. In the pneumatic mastoid process, where the cells are large and the outer cortex thin, the pus is more likely to force a passage externally and form a subperiosteal abscess than in the diploetic and sclerosed processes. In the latter, according to my experience, the tendency is for the pus to escape through a carious opening in the tympanic roof, and give rise to an extradural abscess or an abscess in the brain-substance itself. Facial paralysis is observed in some instances as a result of disease of the mastoid process itself as well as of injury inflicted by the surgeon during the opera- tion. In a child, one and one-half years of age, in whom facial paralysis made its appearance before operation, the mastoid cells were found extensively diseased, so that it was necessary to remove considerable bone in all direc- tions. Although the prognosis as to recovery from the paralysis in such cases is usually considered unfavorable, steady improvement followed the applicatiou of elec- tricity, although the facial muscles did not respond for some time to the electric current. In this case an abscess had formed over the mastoid process. This was incised and a sinus was found, with the probe, leading down to the antrum and tympanum. Such abscesses behind the auricle are frequently observed in children who are stru- mous or tuberculous, and the disease in some cases is more marked in the antrum than in the middle ear itself. In young children, as previously mentioned, the different portions of the temporal bone are not united except by fibrous tissue, so that purulent secretion can easily force its way through, especially as the outer wall of the DISEASES OF THE MASTOID PROCESS. 287 antrum is particularly thin. The pus escapes through a carious opening in the external wall of the antrum or else through the masto-squamosal suture, and as the peri- osteum is not so firmly adherent in a direction upward over the squamous portion as downward toward the tip, the subperiosteal abscess is generally situated above and behind the auricle, with the latter standing out promi- nently. As such an abscess is more frequently seen in cachectic subjects than in those who are healthy, there is apt to be very extensive caries, not only of the mastoid antrum, but also of the squamous portion of the tem- poral bone. In an infant operated upon but a short time since, there was a large subperiosteal abscess with extensive caries extending to the middle cranial fossa. The pus had undoubtedly burst through the antrum while the drumhead was not even perforated and but slightly congested, showing that the disease was coniincd prin- cipally to the antrum. The surgeon should always in such cases, after making a free incision in the soft parts, make a thorough examination with the probe for carious bone, as in most cases it will undoubtedly be found. Some portions of the temporal bone are more fre- quently attacked by caries and necrosis than others. As to frequency, the different portions are involved as fol- lows : 1. The mastoid process. 2. The antrum and tympanic roof. 3. The bony wall of the tympanum covering the sigmoid sinus. 4. The posterior bony wall of the external meatus. 5. The floor of the tympanum, including the posterior wall of the canal for the carotid artery. Lastly, the petrous portion, including the bony labyrinth. The various bacilli and cocci (monococci, diplococei, streptococci, and staphylococci) found in the mastoid 288 MANUAL OF OTOLOGY. antrum, reach this cavity, as a rule, by means of the Eustachian tube. It is possible, however, for a puru- lent discharge in the ear to escape into the nasopharynx and cause a pneumonia, or if swallowed, the patient may have a foul-smelling diarrhoea. The streptococcus pyog- enes and the staphylococcus aureus are frequently found, not only in the purulent secretion from the middle ear, but also in cases of brain abscess, suppurative lepto- meningitis, and thrombosis of the sigmoid sinus, espe- cially when the thrombus has become disintegrated. Occasionally one discovers the presence of the staphylo- coccus pyogenes albus and citreus, the bacillus pyogenes foetidus, and the diplococcus pneumonise of Fraenkel. According to my experience, when streptococci are pres- ent, the inflammation is apt to be of a severe type and to resist the ordinary treatment, while complications are likely to follow. In a case recently seen in consultation, the acute otitis media followed an attack of tonsillitis. Both mastoid processes were involved, and the sigmoid sinus was thrombosed on the right side. Streptococci were found in the discharge. The case terminated fatally. It is advisable to examine microscopically the pus from the tympanum and to have cultures made, since much information can be obtained in this way as to the prob- able severity of the disease and as to the prognosis. A short time ago a patient was under my care, who had an acute purulent otitis media in consequence of an acute nasopharyngeal catarrh. As there was considerable pros- tration, which was out of all proportion to the symptoms, the temperature being but slightly above 99° F., a cul- ture was made and the Loffler bacillus was found. On the following day a fibrinous cast was discharged from the tympanum through the perforation. DISEASES OF THE MASTOID PROCESS. 289 The prognosis is generally favorable in a simple un- complicated case, if the disease is of recent origin. When occurring in connection with influenza, typhus fever, scarlatina, measles, tuberculosis, and diphtheria, on account of the rapid destruction of the bone which fre- quently takes place, the prognosis becomes more grave, particularly if the disease has existed for a long time. In ten days' time, particularly if the patient has diph- theria, scarlet fever, or influenza, the. entire mastoid process may be filled with pus, and with a carious open- ing into the posterior or middle fossa. Frequently in cases of mastoiditis where streptococci are present, the surgeon will find the sigmoid sinus embedded in pus and granulations, even when the disease has existed for a short time, and the symptoms have not been indicative of any gravity. It is not always possible to tell whether the brain or the sigmoid sinus is implicated before the operation is performed, so that, until the condition of the mastoid cells has been investigated, the surgeon should be guarded in his opinion as to the prognosis. Teeatment. If the surgeon is fortunate enough to see a case of acute inflammation of the mastoid cells in the first stage before pus has formed, the artificial leech should be applied at once in two or more places on the mastoid bone, and especially just over the antrum and over the tip. It is advisable at the same time to make a free incision in the drumhead, along its posterior bor- der from a point nearly opposite the stapes down to the lowest point of the membrane, especially if there be any fluid' within the tympanic cavity. For this purpose a large knife should be used (see Fig. 52), and in the location just mentioned, in order to drain the attic and antrum, if possible. The day has gone by for using 19 290 MANUAL OF OTOLOGY. a small paracentesis needle. After the patient has been put to bed, the Leiter coil (see Fig. 93) should be adjusted and kept in place for at least forty- eight hours before being removed. The cold generally re- lieves the pain at once, but if left on for too long a time it may mask other important symptoms. The coil consists of a malleable plate which can be so Fig. 93. Leiter coil. moulded as to fit any mastoid process. Ice-water, by the siphon principle, passes through this coil by means of rubber tubing attached to the coil. The upper tube connects with a basin containing water and a large piece of ice, while the lower basin catches the water which has passed through the coil and the other tube. The best manner of arranging these basins is to place one on a DISEASES OF THE MASTOID PROCESS. 291 level with the patient's head, and the other about six inches lower. In this position, the water is thus pre- vented from flowing too quickly through the tubes. I cannot too strongly protest against the frequent use of blisters for just these conditions, a practice which is not only pernicious, but which tends to aggravate the disease. Many a case of mastoid disease that has come under my care has been due to the application of a blister behind the ear, for the relief of an acute otitis media. After the soft parts behind the ear have been inflamed by such measures, it is almost impossible to make a diagnosis of mastoid disease. If, instead of recommending blisters or poultices, the physician would apply a leech, and if the pain were not relieved by it, and the drumhead were bulging, would make a free incision, there would be fewer cases of mastoid disease under the care of the otologist. By means of the treatment here outlined, it is possible to relieve the pain in many cases, and to abort the disease if the case be a simple uncomplicated one. This plan of treatment is, however, less successful in cases of mas- toiditis occurring in connection with scarlatina, influ- enza, syphilis, and tuberculosis. When the mastoid cells are involved during the course of one of the exanthema- tous diseases, influenza, or diphtheria, the surgeon should first of all make a free incision in the drumhead (see Chapter VI.), and if the inflammatory symptoms do not disappear quite rapidly under the above-mentioned treat- ment, the mastoid cells should be opened early, otherwise there is likely to be a rapid destruction of bone. After the drumhead has been incised, it is well to douche the ear at first with a saturated boric-acid solution every hour or so, according to the amount of the discharge and the degree of pain present. In cases due to scarlatina, 292 MANUAL OF OTOLOGY. diphtheria, or iufluenza, it is better to use twice a day a solution of bichloride of mercury (1 to 3000). The patient should be kept in bed for some time, even after the acute symptoms have passed off. It is well to give calomel in small doses at the commencement of the dis- ease, until slight catharsis is produced. Tincture of aconite is also a valuable remedy in the inflammatory stage. Chloroform should always be administered when incising the membrana tympani, and especially should this be done in the case of children ; but this anaesthetic should be used most cautiously, however, and only in such quantity that the patient will not feel pain when the incision is made. In a case under my care, in which the acute otitis media occurred duriog an attack of measles, the tem- perature suddenly rose to 104° F. There was inflam- mation and bulging of both drumheads, together with tenderness on pressure over the antrum and lower third of the mastoid process on each side. Incision of each drumhead and the application of the Leiter coil, with frequent syringing of the auditory canals, was the treat- ment employed. After incising the membranae tympani, the temperature fell to 100° F. The patient recovered without operation. In a child of eleven, who had a sudden attack of grippe and tonsillitis, followed by earache on the left side, and inflammation of the mastoid process, the tem- perature was 103° F. There were tenderness on pressure over the middle and lower thirds of the mastoid and bulging about Shrapnell's membrane. In spite of the treatment, which consisted in the application of leeches, incision of the drumhead, and the use of the ice-bag (see Fig. 94), the mastoid symptoms became more marked, and DISEASES OF THE MASTOID PROCESS. 293 the temperature rose to 106.2° F. It was necessary to open immediately the mastoid cells and to remove granu- lations and softened bone. The temperature varied from 104.2° to 105.2° F. At this time evidences of pneu- monia were discovered. Two days later the tempera- ture began to decline gradually, and perfect recovery followed. Another case under treatment was very sim- FlQ. 94. Author's ice-bag for application over the maBtoid process. ilar to the preceding one, in which the first symptom was a severe earache. The drumhead was incised. The temperature remained high, and symptoms of pneumonia were detected. The child recovered. When the tem- perature remains elevated after the mastoid cells have been opened, one can be fairly confident that some com- plication exists, possibly a pneumonia, or thrombosis of the sigmoid sinus, or other intracranial disease. There 294 MANUAL OF OTOLOGY. are cases, however, in which the temperature remains high after operation, and in which the cause is undoubt- edly due to septic absorption. This is especially the case where considerable pus has been found in the mastoid cells, and where the temperature has been considerably elevated some days before the operation. I have several times been inclined to perform some further operation in certain cases in which the temperature has not come down soon after opening the mastoid cells. It is always advis- able to abstain from administering antipyretics in cases of mastoid disease or other complications, because it is most important for the surgeon to make a diagnosis at a very early stage, and to operate immediately in case of some brain complication, if he wishes to meet with suc- cess. If it is desirable to reduce the temperature, it is better, especially in the case of children, to resort to sponging the body with alcohol and water. If the rise in temperature is due to the presence of pus, it is impor- tant for the surgeon to find this out as soon as possible. During dentition children are very apt to have attacks of acute suppurative otitis media, and occasionally the mastoid process becomes secondarily involved. In a case^ of acute suppurative otitis media, which was character- ized by high temperature and symptoms of brain impli- cation, and in which it was necessary to remove carious bone from the mastoid antrum, the patient recovered, but the causation of the disease was most obscure until four molar teeth made their appearance. Inflammation of the mastoid cells may follow the unskilful attempt at removing adenoid vegetations. Such a case was under my observation, and it is surpris- 1 Bacon : Annals of Ophthalmology and Otology, Jan., 1894, vol. ill. No. 1. BISSASBS OF THE MASTOID PBOOESS. 295 ing that similar instances are not more frequent, when one considers how roughly the operation is occasionally performed, and how often the orifices of the Eustachian tubes must be lacerated. The case reported' was that of a young woman, twenty-four years of age, who com- plained of a sore-throat. She was told by her physician that she had adenoids, and on the following day he ex- cised the growths. She soon afterward had an attack of earache, followed by mastoid inflammation. This case illustrates two most important points : First, that all operations should be done with as much gentleness and skill as possible, and, secondly, that an operation for the removal of adenoids should never be undertaken until all acute symptoms have subsided. It is important in this connection to refer to a compli- cation that is an extremely infrequent one, viz., the so- called white erysipelas affecting the scalp. In a case of a young woman, who had an acute suppurative otitis media followed by mastoid disease, the cells were opened and the entire bony contents removed with granulations. The temperature, instead of falling, gradually became higher, reaching 104.4° F. Later the patient had a chill lasting twenty minutes and vomited. It was noticed that the scalp near the wound was oedematous, tender to pressure, but not pinkish in color. The tenderness and oedema gradually extended over the scalp, while the dis- charge from the ear and wound was much diminished in quantity. The temperature in a few days became normal, and the patient made an excellent recovery. Another point of interest in the case was the fact that, before the operation, the urine was found to contain a 1 Bacon : Transactions of the American Otological Society, 1892. 296 MANUAL OF OTOLOGY. large amount of sugar, which disappeared, however, before the patient left the hospital. Several urinary examinations were made afterward, but no sugar was found. The case before the erysipelas developed pre- sented symptoms characteristic of septic absorption. The so-called white erysipelas has been known to affect the eyelids, the scrotum, the prepuce, the vulva, and the inferior extremities of persons who are enfeebled by dis- ease. The glycosuria seemed to be of nervous origin and due to reflex action. Indications foe Operation. It is undoubtedly true that some cases of simple uncomplicated inflamma- tion of the mastoid cells do recover spontaneously if left to nature alone, while, on the other hand, it must not be forgotten that lives have been sacrificed because the operation of opening the cells had been deferred too long. As the operation is a comparatively safe procedure, if performed under aseptic conditions, I think that where we are at all in doubt, one should always err on the safe side, and open the cells at once. I would not, however, be understood to make light of the operation of perforat- ing the mastoid, because it should never be undertaken by one who does not thoroughly understand the anatomy of the temporal bone, and who has not had considerable experience in treating aural diseases. If, under the use of antiphlogistic measures and the Leiter coil, the pain rapidly subsides, while the discharge becomes less and the symptoms generally improve in a few days, the temperature showing no evidence of septic absorption, then the chances are that an operation will not be necessary. On the other hand, if the pain per- sists and (he temperature remains high after the appear- ance of the discharge, and especially if the latter be DISEASES OF THE MASTOID PMOCESS. 297 profuse, and inspection of tiie drumhead shows the latter to be bulging in its upper and posterior quadrant, with drooping of the adjacent soft tissues of the external meatus, and, moreover, if there be considerable deafness with pain on pressure over the mastoid process, these symptoms, taken together, should make the surgeon decide upon an immediate operation. It is not safe to delay operation in cases of mastoid disease caused by the influenza, scarlatina, measles, diph- theria, or where there are streptococci present in large numbers in the discharge from the ear. Experience has shown that complete destruction of the bony cells and per- foration of the inner wall can take place, in such cases, in an incredibly short space of time, without the usual well- marked symptoms of mastoid disease. In a patient, fifty years of age, who was under observation a short time ago, and who had been treated for two weeks for an acute purulent otitis media, with tenderness over the mastoid cells, it was deemed best to open the cells, owing to the fact that there was a profuse discharge, which did not yield to treatment, as well as a temperature slightly above normal, which persisted, and tenderness on pressure just over the apex of the mastoid. In this case the cells were entirely destroyed, and there was a large carious opening over the lateral sinus. The patient was up and about, and did not complain of pain in the mastoid, except when firm pressure was made over the tip. This latter symptom is a most valuable one, and should never be lost sight of in arriving at a diagnosis. Undoubtedly, in the near future, otologists will be more ready than ever to make cultures from the pus in purulent otitis media, for considerable information can be obtained in this way as to the prognosis and treatment. 298 MANUAL OF OTOLOGY. Operation. Before undertaking an operation either for mastoid disease or one of the complications arising from it, the surgeon should first of all find out about the patient's general condition. A thorough urinary analysis should be made and the patient's heart and luugs examined. On the day of the operation the patient should have nothing but liquid food, and even this should be forbidden for at least three hours before taking the anaesthetic. If possible, a laxative should be administered the evening before, followed by some min- eral water in the morning. Fig. 95. R**-^ sterilizer. Ether is to be preferred, on account of its being un- doubtedly a safer ansesthetic than chloroform. In short operations, however, chloroform can be used if carefully administered. The ether should be given by a thor- oughly competent assistant, who should attend to this duty alone, and thus relieve the surgeon of this anxiety. All instruments should be thoroughly sterilized, and for this purpose the sterilizer, Fig. 95, is a very con- I DISEASES OF THE MASTOID PROCESS. 299 venient one. The blades of the scalpel should be dipped in a boiling 5 per cent, carbolic solution or in absolute alcohol. The hands of the operator and of his assistants should be thoroughly scrubbed with soap and water by means of a nail-brush, and afterward washed with bichloride solution, 1 to 3000. The instruments used in a mastoid operation are the following : One narrow and one broad scalpel, artery Fig. 96. Politzer's periosteal elevator. forceps, periosteal elevator, dressing forceps, gouges and chisels, a mallet with lead filling, sharp spoons (four sizes), retractors, grooved directors, probes, catgut liga- tures, needles, and silk sutures. The hair of the patient should be shaved within a radius of about three inches of the auricle. The parts thus shaven should be scrubbed with soap and water, and afterward washed with a solution of bichloride of mercury, 1 : 3000. The external meatus should be syringed with a warm bichloride solution, then dried and filled with a narrow strip of iodoform gauze. The 300 MANUAL OF OTOLOGY. head should then be wrapped with a towel, previously soaked in bichloride solution and wrung out, and fast- ened with a safety-pin. Similar towels should be laid over the patient's neck and shoulder. After these pre- cautions have been taken, the auricle being gently pulled forward by an assistant, an incision should be Fig. 98. CMsels ana gouges. (Sohwartze's.) made by the surgeon, just behind and close to the auricle, from the extreme tip of the mastoid to a point just above the upper border of the auricle. The soft parts and periosteum should be divided, and the latter pushed aside by means of the periosteal elevator. Hem- orrhage should be controlled by means of the artery clamps and by pressure. The entire surface of the DISEASES OF THE MASTOID PBOOESS. 301 bone should then be carefully examined for a carious spot or sinus, and, if found, an opening at that point Fig. 99. r . Is Sharp spoons. Fia. 100. Macevven's burrs. should be made iuto the cells by means of a gouge and mallet. A large gouge should be used at first, and all 302 MANUAL OF OTOLOGY. diseased bone carefully removed with sharp spoons. The surgeon should endeavor to reach the antrum, knowing that the latter is just above and behind the external meatus. Great care should be taken in scrap- ing the antrum for fear of injuring the facial nerve. Macewen uses burrs (Fig. 100), which can be rotated by means of an electric motor (Fig. 19). He prefers them to chisels and gouges. They are excellent in- struments when carefully handled ; but when consider- able bone is to be removed and the operation is to be performed as quickly as possible, the surgeon can work more rapidly with chisels, gouges, and rongeur forceps. If there is no sinus evident, nor a soft spot of bone, the surgeon should first of all chisel an opening into the antrum and establish communication with the tym- panum. A guide for this operation is the spina supra- meatum, a point about one-quarter of an inch below the linea temporalis. The bone should be removed at this point and the instrument directed downward, forward, and inward in order to reach the antrum. The entire external wall of the antrum should be removed. Small pieces of bone should be cut away at a time, and the parts carefully inspected by means of good illumina- tion. A probe or director should be constantly used to see if an opening has been established into the antrum. The sharp spoon will also be found very useful in this step of the operation. As a general rule, the bone should not be entered at a depth greater than five- eighths or three-quarters of an inch, for fear of injuring the facial nerve or external semicircular canal. There is also danger of wounding the lateral sinus and dura mater in either the posterior or middle cranial fossa, DISEASES OF THE MASTOID PROCESS 303 unless one uses the chisels carefully and in the direction already mentioned. The opening in the bone should be cone-shaped from without inward. After establishing a communication with the antrum and attic, the surgeon should then turn his attention to the other portions of the mastoid, re- membering that in some acute cases the pus is mostly limited to the middle portion, while in others it is found in the tip, with granulations and softened bone. In some instances the sigmoid sinus will be found ex- posed and bathed iu pus and covered with granulations. In scraping away the granulations it is an easy matter to wound the sinus. A thorough examination should be made of the tip, to see if it be perforated, for in some cases pus may burrow down the neck beneath the deep fascia. If an abscess has already formed in the tis- sues just about and below the tip, it should be freely opened and the pus evacuated. The tympanic roof should be examined to see that a carious opening does not exist. All softened bone, granulations, etc., should be thoroughly removed by means of sharp spoons, and the mastoid cavity thoroughly irrigated with a 1 : 3000 bichloride solution. If possible, the surgeon should try to force some of the solution through the antrum and the external meatus. A small perforation in the drumhead should be enlarged. The cavity in the bone should then be packed with narrow strips of iodoform gauze, and afterward several sutures may be taken in the upper and lower angles of the wound to diminish the size of the opening. Larger strips of iodoform gauze should then be placed about the ear, so as to cover the wound and the auricle, and outside of this bichloride gauze, while the whole should be covered with a layer 304 MANUAL OF OTOLOGY. of absorbent cotton and bandaged. It is frequently advisable to change the outer dressings on the following day, if they have become saturated and stiffened so as to be uncomfortable to the patient. Unless the patient has more or less fever, with pain, the packing in the mastoid itself should be left in place for at least two or three days without being removed. If the iodoform gauze is left in situ too long, it may become adherent to the bone cavity, and cause bleeding when removed. After the first dressing the gauze, when repacked, should be loosely applied so as to allow the cavity to fill up as rapidly as possible with granulation tissue. Several days should elapse between the dressings, if possible, for frequent syringing with antiseptic solution has a tendency to prevent the granulations from growing. After the operation the patient usually experiences great relief, and the temperature, if elevated, becomes lower. The discharge from the ear is usually much diminished in quantity or ceases altogether. The time before cicatrization takes place varies from two to six weeks. It is longer frequently in cachectic or scrofulous individuals. If all of the carious bone has not been completely removed, a second operation becomes neces- sary. When granulations are exuberant, they should be cauterized with a solid stick of nitrate of silver. Silver drainage-tubes, iron nails, rubber tubing, etc., should never be used for purposes of drainage, as iodo- form gauze is to be preferred. In some cases, if the antrum has not been opened and there is no communication with the middle ear, and the disease is limited to the middle or lower third, and especially if the inflammation occur in a pneumatic mastoid process and be near the external surface, the DISEASES OF THE MASTOID PROCESS. 305 surgeon may allow a blood-clot to form, and he may close up with sutures the entire wound, provided, how- ever, that every trace of disease has been thoroughly removed with sharp spoons. If the patient should complain of pain, or there should be a rise of tempera- ture, the wound should be immediately reopened and treated by packing it with iodoform gauze in the usual way. As to the treatment of an abscess behind the auricle, frequently observed in the case of scrofulous children, it is not sufficient to make an incision and evacuate the pus, for it must be remembered that the purulent matter has forced its way, in all probability, either through, the outer wall of the antrum or through the petroso-squamosal suture, and that in such a condition of affairs considerable carious bone undoubtedly exists. The child should be etherized and a long incision made behind the auricle close to the bone, and the condition of the antrum and cells carefully investigated. Diet. After the operation it is desirable to keep the patient quiet in bed for a few days at least, until the temperature becomes normal and the patient feels in- clined to sit up. While there is any elevation of tem- perature the diet should be a light one, consisting for the most part of milk and beef tea. After a week's time, if the temperature be normal and the case pro- gress favorably, I frequently allow a hospital patient to go home and be treated as an out-patient, impressing upon him the importance of remaining in-doors during inclement weather. Attention to the Genbeal Health. Particular attention should be paid to the general health, espe- cially when the patient is cachectic or scrofulous. In the 20 306 MANUAL OF OTOLOGY. latter case cod-liver oil, iron, strychnine, or the hypo- phosphites are indicated, while syphilitic or tubercular subjects should have appropriate constitutional treat- ment. This is a subject of the greatest importance, for in many instances local treatment alone avails but little if attention to the general health is neglected. MASTOID DISEASE OCCURRING IN CONNECTION WITH CHRONIC PURULENT OTITIS MEDIA. Very often, during the course of chronic otorrhcea, the ossicles are carious, while the antrum is apt to be filled with purulent material, and, in some instances, the entire antrum and mastoid process may contain cholesteatomatous masses, or there may be within the bony cavity cheesy matter, softened bone, or granula- tions, or tubercular material. In other cases the mucous lining may be very much thickened so that the cells are obliterated, while in still other instances the granulation tissue contained in the cells may turn into bone, so that the mastoid process becomes wholly or in part changed into dense osseous tissue as hard as ivory. There may be a circumscribed caries of the mastoid process, or it may be very extensive, leading to various complica- tions. For instance, a patient recently came to my clinic who had had a discharge from the ear for ten months. He complained of pain and tenderness over the mastoid process, especially the tip. A leech was applied, which gave some relief. He returned in a few days, and there were evidences of slight facial paralysis on the same side as the ear inflammation. He was immediately admitted to the hospital, and, under ether, great destruction of bone was found, with the DISEASEii OF THE MASTOID PBOCESS. 307 mastoid cells filled with pus and broken-down tissue. The lateral sinus was exposed, and there was a large carious opening in the tympanic roof. This was en- larged and considerable pus escaped from the middle fossa. The boy recovered. This case goes to prove the statement previously made that a patient may have extensive caries and necrosis of the mastoid process, with very few symptoms. The most frequent cause of mastoid disease in connec- tion with chronic purulent otitis media is some interfer- ence with the drainage from the antrum or middle ear, so that the pus collects in the mastoid process and forms caseous material. Constriction of the external meatus, the formation of polypi, granulations, a small perforation in the drum- head, suppuration limited to the attic with perforation in Shrapnell's membrane, and cholesteatomata may cause mastoid disease. Various micro-organisms in the dis- charge from the middle ear or tubercle bacilli may give rise to mastoid inflammation. Other causes are cold, injury, and the various diseases mentioned in the etiology of mastoid disease. Symptoms. The symptoms are very similar to those mentioned in connection with acute mastoiditis, espe- cially when occurring as a result of cold or retained secretion ; but when eburnation of the bone takes place, this process may be gradual and extend over a period of yeai's, so that there are very few if any symptoms. The external auditory canal is frequently found very much constricted and tilled with retained secretion, the latter being foul-smelling and sanious, especially if granulations or polypi are present and there is carious bone. A cholesteatoma may exist for years in the 308 MANUAL OF OTOLOGY. antrum without giving rise to serious trouble until some inflammatory symptoms arise. Although during the course of a chronic purulent otitis media there may at stated intervals be attacks of pain in the mastoid process, which do not lead to ab- scess, it is well to bear in mind the fact that serious complications are liable to develop at any moment, such as sinus thrombosis, meningitis, brain abscess, perfora- tion of the mastoid tip, septicsemia, pysemia, etc., unless operative measures are undertaken at an early period. In tubercular cases there may be great destruction of bone without any well-marked symptoms of pain. In such cases it was formerly considered inadvisable to operate. Experience, however, goes to show that re- moval of carious bone and tubercular material is often followed by marked improvement in the patient's gen- eral health, and such an operation should always be undertaken, provided the patient's general condition is satisfactory. If left to nature, perforation of the external bony wall of the mastoid takes place in some cases, an ab- scess forming in the soft tissues, which ruptures and leaves one or more sinuses leading to carious bone. The external cortex is the most frequent seat of perforation, although the pus may force a passage through in other directions. In Fig. 87 a sequestrum, f in. by f in., is shown which was removed by operation. It consists of the greater part of the external wall of the mastoid of a boy, aged two years, who had had a recent attack of measles. The right ear had been discharging for a month, and an abscess had broken behind the ear, which gave great relief to the pain. DJSEASES OF THE MASTOID PROCESS. 309 Diagnosis. The diagnosis can be made if there be pain on pressure over some portion of the mastoid, with constriction of the external meatus, retention of pus, and the presence of granulations. In cases of choleste- atoma it is more difficult to decide, because frequently the pain is siight ; while, on the other hand, in osteo- sclerosis the pain is often quite severe. A guarded prognosis should always be given when the patient is debilitated, tuberculous, or cachectic, or there is extensive caries and necrosis of the temporal bone or some intracranial complication. Treatment. Whenever symptoms of mastoid dis- ease are at all well marked in a case of chronic puru- lent otitis media, the first object of the surgeon should be to see that there is good drainage from the middle ear. All granulations or polypi should be carefully removed from the canal, so that one can see the drum- head or what remains of it. At times, especially when the pain in the mastoid is due to inflammation itself, and not to the retention of pus or cholesteatomatous masses, antiphlogistic measures will be sufficient ; but, as a general rule, it is much more advisable to open the mastoid antrum, for with only slight symptoms a patient may develop some intracranial complication, and it is not prudent to wait long before operating. If only a rim of the drumhead remains (see Fig. 101), while the ossicles are carious and the disease seems to be limited mostly to the attic and antrum, it is undoubtedly true that in some instances a cure can be established by excision of the drumhead and ossicles, and by curetting and washing out the attic and tympanic cavity with antiseptic solutions through a middle-ear canula. The same holds true of cases in which the perforation is in 310 MANUAL OF OTOLOGY. Shrapuell's membrane and the pus is peut up in the attic. When the attic contains cholesteatomatous masses it is always advisable to open the antrum, for the surgeon can never be certain of the extent of the disease until he has explored the mastoid cells. On perforating the outer cortex of the mastoid he may find complete de- struction of the entire mastoid cavity. Fig. 101. Drumhead almost entirely destroyed. Eim of membrane left in the upper portion. Ossicles bound down by adhesions. Long handle of malleus at- tached to inner wall of middle ear. The surgeon should always operate whenever there are sinuses in the mastoid region leading to carious bone, or when the posterior bony wall of the meatus is diseased. DISEASJES OF THE MASTOID PROCESS. 311 In certain cases in which tlie mastoid becomes ebur- nated and the cells have disappeared, great relief will follow the chiselling away of portions of the- mastoid process, and especially afl opening communicating with the antrum. In chronic mastoid inflammation it is always advis- able to enter the antrum, and thus be able to wash it out, together with the middle ear, through the opening behind the auricle. In a pneumatic or diploetic mas- toid process one should investigate the entire bone, from the antrum down to the tip, being careful not to injure the sigmoid sinus, which occasionally runs very close to the antrum in a sclerosed or diploetic mastoid pro- cess. If the operation is carefully done under aseptic conditions, and the patient's general health is fairly satisfactory, the operation is generally successful. In cases of diabetes, when the disease is in an advanced stage, the operation is one of more or less gravity, but should be undertaken when the patient's life is in danger from extension of the inflammation to the brain. The same instruments are used as in the operation for acute mastoid disease, and the same solutions. The incision is identical with the one recommended previ- ously, so that the entire mastoid process can be inspected. In cases of osteosclerosis it is generally sufficient to chisel away sufficient bone to reach the antrum and establish drainage with the middle ear. Such a pro- cedure generally relieves the pain which is so distressing to the patient. One should, of course, be most careful not to injure the sigmoid sinus, which may be exposed and covered over with granulations, or the facial nerve, or the dura itself. 312 MANUAL OF OTOLOGY. Instead of the disease being limited to the mastoid process, the surgeon may find that the posterior bony wall of the meatus or the walls of the tympanum are carious. With the object of removing the outer wall of the attic and the posterior superior bony wall of the meatus, surgeons have devised different methods of operation — the idea being to expose entirely the tym- panic cavity and remove all carious bone. This pro- cedure, viz., removal of the posterior superior bony wall and outer wall of the attic, is indicated in cases in which there is extensive caries involving the attic and antrum, the middle ear or bony meatus, and especially where there are cholesteatomatous masses or numerous granu- lations or polypi which impede the drainage from the tympanic cavity. Kuster's Method. The auricle is first detached from its insertion, and displaced forward. An incision is made close to the pinna and behind it, as in the mastoid operation, from the tip of the mastoid to the commence- ment of the helix. The tissues are divided down to the bone, and the periosteum pushed aside so that the pos- terior superior portion of the meatus is exposed. The cartilaginous meatus is then, by means of a periosteum elevator, carefully pushed away from its posterior superior attachment, being pulled downward and for- ward. The further steps in the operation depend very much on the extent of the carious bone. If the disease be limited to the outer wall of the meatus, it may be necessary to remove this alone by means, of small chisels or the sharp spoon, or the surgeon may think best to open the antrum in the usual way, and afterward to cut away the posterior superior wall of the external meatus to the tympanum. One should be careful to DISEASES OF THE MASTOID PROCESS. 313 avoid the facial nerve, which lies, however, in tlie deeper portion of the posterior wall. A small gouge or cutting forceps is best adapted for removing the bone. The necrotic malleus and incus should be excised, and, if necessary, almost the entire mastoid process, antrum, middle ear, and external meatus can be transformed into one large cavily. This operation is particularly indicated in cases of cholesteatoma. The wound is then irrigated with bichloride solution and packed with iodoform gauze. A drainage-tube is introduced into the external auditory canal to keep the cartilaginous meatus in position, and the auricle is re- placed. When the wound behind the ear is a large one, it is well to pack it with gauze and allow it to granulate up from the bottom. If, however, the posterior supe- rior wall alone has been removed, the iodoform gauze can be inserted through the external meatus, and the wound behind the auricle closed by sutures. Stacke Operation. Stacke divides his operation into three steps : 1. Incision through the soft tissues. 2. Removal of the cortex of the suprameatal triangle and the posterior bony canal wall, and the extraction of carious ossicles, with curetting of the tympanum, aditus, and antrum. 3. Construction of the flap from the membranous canal and its application to the walls of the bony caualj antrum, etc. The various steps in the operation are performed as follows : An incision is made through the soft tissues, following closely the attachment of the auricle, and extending from one centimetre below the mastoid tip upward to a point a little above and forward of the 314 MANUAL OF OTOLOGY. superior border of the external auditory meatus ; the lower two-thirds of the incision is made directly down to the hone through the periosteum ; the upper third extends through the skin only down to the fascia of the temporal muscle. This muscle and fascia are then drawn aside and an incision made through the peri- osteum underlying them and bordering upon the supe- rior margin of the bony meatus. The periosteum of the anterior flap is then elevated and drawn forward until the suprameatal triangle and posterior wall of the bony canal are plainly exposed, this procedure being simplified at times by cutting away a few fibres of the sternocleidomastoid muscle at the tip, so as to afford greater room. This stage of the operation is completed by separating the membranous from the bony canal by means of a small elevator so that the tympanic ring is exposed. The second step consists in cutting the tensor tym- pani muscle and extracting the malleus, if it is visible, through the canal: then the tympanic ring is cut away in the superior posterior quadrant and the attic opened, a probe being passed upward and backward into the antrum while the overlying cortex and remainder of the posterior bony wall are removed with a chisel. The probe acts as a guard to insure the safety of the facial nerve. By such means the antrum, attic or aditus, and tympanum are converted into one large continuous space, which must be thoroughly curetted for the re- moval of granulations and all soft carious spots in the contiguous walls. The third step in the operation consists in a horizontal incision being made in the vertical meridian of the membranous canal above and extending from the DISEAS£:S OF THE MASTOID PROCESS. 315 tympanic ring, the entire length of the canal, outward to the concha. A second incision is now made, begin- ning in the concha where the first one terminates, and running at right angles to it downward and backward in the canal, thus making a nearly four-cornered flap, which is crowded backward and upward so as to cover as much as possible of the denuded bone, and at times partly covering the exposed wall of the antrum. An- trum, aditus, and tympanum are now packed with gauze, without any irrigation, and the skin of the upper half of the flap closed with sutures, the lower half being covered with antiseptic gauze and bandaged. Various modifications of this operation have been sug- gested and practised by different surgeons. The best method of operative procedure, however, is to first cut down on the mastoid process and lay bare the antrum, and then decide, according to the indications, just what operation is best adapted to each individual case, the object being to remove all carious bone without doing injury to the facial nerve. CHAPTEK XII. INTKACEANIAL COMPLICATIONS. BEAIN ABSCESS. THEOMBOSIS OP THE SIGMOID AND OTHER SINUSES. LEPTOMENINGITIS. As a result of chronic purulent otitis media and mas- toid iuflammation, and, occasionally, of acute purulent otitis media, the thin roof of the tympanum or antrum is liable lo be perforated through osseous erosion, and in consequence there follows either a collection of pus in the middle cranial fossa between the bone and the dura — an extradural abscess — or else an abscess forms in the temporo-sphenoidal lobe. When erosion takes place in the bony wall of the mastoid process, which lies over the sig;moid sinus, a collection of pus usually forms about the sinus, while the latter becomes surrounded with granulation tissue ; or a thrombus forms in the sigmoid sinus itself, or else an abscess is developed in the cerebellum. Before erosion takes place, the tympanic roof or inner wall of the mastoid process becomes very thin and of a dark color. The minute veins are often thrombosed, and, owing to the ulceration of the bone, granulations are thrown out from the external surface of the dura or from the wall of the sigmoid sinus, as the case may be, which is nature's method of resisting the further advance of the disease. Absorption of the carious bone taken place at the same time. One should be very careful, IMTBACMANIAL COMPLICATIONS. 317 therefore, in the removal of polypi from the tympanic cavity, especially when the disease has existed for a long time, for fear of wounding the dura, which rests on the tympanic roof. In the same way, the sigmoid sinus can easily be injured by scraping away softened bone and granulations in operations on the mastoid process. After removing granulation tissue from the dura mater one is apt to find the latter considerably thickened. (See Fig. 103.) Granulation cells and a plastic mate- rial are often found which project upward into the brain substance and become adherent to the pia mater, so that the veins and lymphatics of the pia are liable to be affected. Very small thrombi are undoubtedly carried by the smaller branches of the cerebral arteries which supply the temporal lobe, and in this way give rise to cerebral abscess. The morbid products may also reach the brain tissue by means of the perivascular sheaths. Occasionally it is impossible to find any aperture in the bone, although the latter may be very much discolored. Cases have been reported, especially in children, in which infective processes have reached the dura from the middle ear by means of the petro-squamosal or other sutures, and in such the vessels have been throm- bosed. In tubercular disease the entire petrous bone may become carious and nothing remain of it except a thin shell, and, in consequence of such disease, tubercu- lar meningitis may develop. When erosion of the bone takes place, either through the tympanic roof or through the inner wall of the mastoid, the patient may have a suppurative leptomeningitis, together with an extra- dural or cerebral abscess. The roof of the tympanum may be eroded at the same time that the sigmoid sinus is involved, and. as a result, there may be an abscess in 318 MANUAL OF OTOLOGY. the temporo-sphenoidal lobe, together with an infective thrombus in the sigmoid sinus. When these comph'ca- tions are all present in one case, there is great difficulty in making a diagnosis. The plate of bone separating the sigmoid sinus from the mastoid cells is extremely thin, so that erosion of the bone is very apt to be ob- served at this point. The bone first becomes discolored and softened, and then granulations are thrown out. A collection of pus is found either between the sinus and the bone or behind the sinus, in the direction of the occipital bone. The walls of the sinus become thick- ened and a thrombus forms, the presence of which may not give rise to any immediate mischief ; while, on the other hand, in an incredibly short space of time the patient may have most serious and alarming symptoms of sinus thrombosis. If left to nature, the wall of the sinus may become softened so that a minute perforation takes place. Hemorrhage does not follow, because the vessel is generally occluded both above and below the aperture. By means of the cerebellar veins the infec- tion extends to the cerebellum, or emboli may be carried to the cerebellum through the smaller cerebellar arteries and their perivascular sheaths. As a general rule, how- ever, there is direct contact between the sigmoid sinus and the cerebellar abscess, and the infective processes extend from the dura in the same manner as in the case of an abscess in the temporo-spheuoidal lobe. In ex- tremely rare instances the pathogenic processes reach the cerebellum from the tympanic cavity through the inter- nal auditory meatus along the sheath of the auditory or facial nerve. Besides an extradural abscess, or an abscess in the temporo-sphenoidal lobe or cerebellum, there may be an abscess formed between the dura and INTRACRANIAL COMPLICATIONS. 319 pia mater, which may become circumscribed through adhesions ; in consequence of which there may be inflam- mation and possibly ulceration of the brain tissue, with softening. The pus may escape through a perfo- ration in the membranes of the brain on to the outer surface of the dura or through the roof of the tym- panum. As a general rule, when an abscess has formed in the temporo-sphenoidal lobe, there will be found au open- ing at the base of the brain which communicates with it, so that abscesses occurring in this portion of the brain are generally caused by direct extension from the seat of the disease, a point to be remembered, for, in oper- ating, the surgeon should always try to reach the seat of the infective process. CEEEBRAL ABSCESS. Under this heading should be included (1) extra- dural abscess, (2) intradural or cerebral abscess — (a) cerebral, and (6) cerebellar. Extradural Abscess, As already mentioned, the pus in an extradural ab- scess may be found between the dura mater and tym- panic roof or about the sigmoid sinus after the infective process has extended from the mastoid cells. Fre- quently, when operating for mastoid inflammation, the surgeon finds a carious opening just over the sinus, even when the symptoms were only those indicating mastoid disease. A. boy, ten years of age, who came to my clinic, had a careworn expression, cold hands, a rapid and bound- ing pulse, and a temperature of 103° F. He had no 320 MANUAL OF OTOLOGY. distinct chill, but on the preceding day had felt chilly sensations. He gave a history of an occasional dis- charge from both ears for several years, and for the preceding three days had severe pain in the left mastoid process. He heard the watch only by contact. There was a distinct swelling over the left mastoid, with a point of fluctuation just over the antrum. The mastoid cells were opened, and pus and softened bone were re- moved from the entire process. The sigmoid sinus was not involved. A probe was introduced into the middle cranial fossa through a carious opening in the tympanic roof. The incision was carried upward, and the bone cut away with rongeur forceps and chisels so as to ex- pose the dura and evacuate the pus. While the tem- perature was quite high in this case, it does not follow that this is the rule, for frequently there is but little if any fever. A short time ago a patient came under my care who had a temperature but slightly above normal. He had had a chronic purulent otitis media of some years' duration. He consulted me on account of a sudden pain in the mastoid on the same side. He also had slight facial paralysis. An immediate operation was performed, and not only were the mastoid cells filled with softened bone and pus, but there was a large carious opening through the tympanic roof. This open- ing was enlarged and the pus evacuated. Recovery fol- lowed. It must not be forgotten that a leptomenin- gitis or phlebitis of the sigmoid sinus may complicate a case of extradural abscess. Symptoms. There are no distinct symptoms by which the surgeon can make a diagnosis of extradural abscess before operation, for, as previously mentioned, osseous erosion in the tympanic roof or in the thin plate INTRACRANIAL COMPLICATIONS. 321 of bone covering the sigmoid sinus is frequently only discovered at the time of opening the cells. One must remember that such an accident is liable to occur, es- pecially when streptococci are present in the discharge, or the patient has tuberculosis or one of the exanthema- tous diseases. Most cases of extradural abscess occur in connection with chronic purulent otitis media. It may be stated, however, that cases have been observed in which erosion has taken place during an attack of acute otitis media. One may suspect the existence of an extradural or subdural abscess when the discharge suddenly becomes less or ceases altogether, and the patient shows signs of meningeal irritation. A fatal result may follow from basilar meningitis or abscess of the brain. Tebatmbnt. The same incision behind the auricle should be made as in the operation for mastoid disease. If an opening has occurred in the tegmen tympani or tegmen antri, the incision in the soft tissues should be carried upward and curved forward around the upper border of the auricle, thus displacing the latter forward so that the surgeon will be enabled to cut away the bone with forceps and chisels, and thus have an opportunity of exploring the middle cranial fossa and of removing all carious bone. A narrow strip of iodoform gauze should be inserted through this opening and the wound allowed to fill up with granulation tissue. The mastoid cavity should be treated in the manner already described. See chapter on Mastoid Diseases. The surgeon should never inject any solution into the cranial cavity unless he is certain that there is no opening in the dura. The edges of the wound should be washed with a saturated boric-acid solution. 21 322 MANUAL OF OTOLOGY. Intradural or Cerebral Abscess. Abscesses of the brain occurring as a result of middle- ear inflammation are usually found in either the tem- poro-sphenoidal lobe or the cerebellum. Cases of extra- FlG. 102. 1. Primary abscess cavity connected with sinus in tympanic roof. 2. Sec- ondary abscess cavity in temporo-sphenoidal lobe. Both abscess cavities found free from pus at autopsy. dural abscess are much more frequently observed than abscesses either ia the temporo-sphenoidal lobe or cere- bellum. Cerebral abscess almost always occurs in con- nection with chronic purulent otitis media, although a case' of temporo-sphenoidal abscess has been reported wliich followed acute otitis media (see Fig. 102). In this case the disease was mostly limited to the attic, the 1 Bacon: Archives of Otology, 189G, vol. xxv. No. 3. INTRACRANIAL COMPLICATIONS. 323 acute otitis media being of only eight weeks' duration. Several incisions were made in Shrapnell's membrane, which not only gave exit to a few drops of pus, but afforded, at the same time, great relief to the patient. He finally consented to enter the hospital aud receive 1. Carious opening in tyrapanic roof. 2. Thickened dura turned back, but when in position covers carious opening. proper treatment, but only after serious symptoms had manifested themselves. An operation was performed and an abscess in the temporo-sphenoidal lobe evacu- ated. He died, however, two hours after the opera- tiou, apparently from shock. At the post-mortem a carious opening was found in the tympanic roof (see Fig. 103), with thickened dura over it, and a small sinus in the latter leading to a small cerebral abscess cavity, which was empty. Another abscess cavity was found at the inner half of the third temporo-sphenoidal convo- 324 MANUAL OF OTOLOGY. lution. (Fig. 102.) This cavity was also free from pus, as it had been evacuated at the operation. There was probably some connection between the two abscess cavi- ties, although none could be detected with a probe. In three cases^ of abscess in the temporo-spbenoidal lobe and one in the cerebellum in which an operation was performed, all were due to chronic purulent otitis media. Symptoms. The first stage of abscess is usually marked by irregular symptoms, such as irritability, pain, nausea, or vomiting, and frequently the discharge from the ear becomes scanty or stops altogether. The occurrence of a change in a patient's disposition, viz., a talkative person becoming morose, or vice versa, is another symptom of importance. The patient fre- quently complains of chilly sensations. As the disease progresses the cerebration becomes dull, and the patient appears stupid and restless. When pus has formed in the brain the most important symptoms are a distinct lowering of the pulse-rate and a temperature either slightly above normal or subnormal. There are excep- tions to this rule, for in a case" of temporo-sphenoidal abscess reported by me the pulse was rapid and the tem- perature very high, with marked fluctuations, so that thrombus of the lateral sinus was suspected. The patient was a young man, thirty-two years of age, who had had a chronic otorrhoea on the left side for at least fifteen years, as a result of measles. He received no treatment to speak of during this time, until his family physician was suddenly sent for. He had at that time a temperature of 104° F., an intense headache, and marked pain in the ear. Later he had a severe convulsion 1 Bacon : New York Eye and Ear Infirmary Reports, January, 1897. 2 New York Medical Journal, August 15, 1896. INTRACRANIAL COMPLICATIONS. 325 lasting twenty minutes, with violent muscular twitch- iugs and frothing at the mouth. He also had chills. The symptoms were characteristic of sinus thrombo- sis. At the operation, however, the sinus was found normal, but there was a large abscess in the temporo- sphenoidal lobe. The case proves that, exceptionally, a patient with a cerebral abscess may have chills, a high temperature as well as convulsions, so that a differen- tial diagnosis between abscess of the brain and sinus thrombosis becomes extremely difficult. When aphasia develops in a patient with a chronic purulent otitis media of the left side, it is fairly certain, if the patient be right-handed, that there is a collection of pus in the teraporo-splienoidal lobe.' This symptom is of the highest diagnostic value — optical aphasia, so called and described by different writers. The patient, when shown an object, knows it, but is unable to name it ; but he is able to recognize and understand its name, and will often describe the object. He can sometimes name the object if allowed to handle or smell it. In the case referred to, where the temperature was high, the patient had well-marked aphasic symptoms. Be- sides the difficulty of naming an object, he could not at once or very readily call to mind the appearance of the object. Starr has called this symptom visual amnesia, and says, " it is due to a suspension of function of an association tract lying in the temporo-occipital lobes and occupying the white matter deep under the cortex. It lies in a position in which it is almost inevitably affected by abscess of the temporal lobe developing after otitis media. In left-handed persons it will occur in abscess of the right side." Severe headache is also an impor- tant symptom. Inflammation of the optic nerve may or 326 MANUAL OF OTOLOGY. may not be present. It is more frequently observed in cases of cerebellar than of temporo-sphenoidal abscess. The mastoid cells are often found to be dense and like ivory in cases of cerebral abscess. This seems to me an important point, for in such the pus is likely to perfo- rate the tympanic roof, and thus cause an extradural abscess or an abscess in the temporo-sphenoidal lobe. Percussion of the skull on the affected side frequently causes pain, and Macewen has called attention to the fact that there is a difference in the percussion note on the side of the head in which the abscess is located. Other symptoms sometimes noticed are digestive dis- turbances, increase of reflexes in the limbs of the side opposite to the abscess, a difference in the size of the pupils, and facial paralysis. In cerebellar abscess the most characteristic symp- toms, besides slow pulse and low temperature, are severe headache, nausea, vomiting, vertigo, a staggering gait, and facial paralysis. Facial paralysis may be due to pressure on the nerve in the pons. It must be remem- bered that the nerve may be affected in its course through the middle ear. I have seen a case in which the pulse was slow and the patient had vertigo, vomiting, deaf- ness, severe headache, etc., so that a diagnosis of cere- bellar abscess was made. When the antrum was opened the semicircular canals were carious, which fact ac- counted for the symptoms. It is very important to examine thoroughly the external auditory canals in all cases of suspected cerebral abscess ; for instance, in the case of a child who was brought to my clinic a short time ago, and who had characteristic symptoms of cere- bellar abscess, including choked disks, with retinitis, re- moval of granulations from the middle ears, with the INTRACRANIAL COMPLICATIONS. 327 The establishment of proper drainage, effected a cure, clicked disks and retinitis disappeared. T have reported a case of cerebellar abscess' in which I not only removed a button of bone at point G, Fig. Fig. 104. .1. External auditory meatus. BJ!'. Keiil's l»afce-liiie funniny iMnji icnver margin of tlie orbit throtigli tlie centre of tlie external auditory meatus. C. Trephine opening, ^^ inch in diameter, to exjwse temporo-sphenoidal abscess, centre-pin of trephine being placed 1'.,; inches above the centre of the exter- nal bony meatus. D. Point at which the mastoid antrum should be opened. JC E'. Position of sigmoid sinus. F. Trephine opening, i?.^ inch in diameter, for exposing sigmoid sinus, centre-pan of trephine being placed at a X)Oint 1 inch behind and i^ inch above centre of external bony meatus. G. Tre- phine opening for cerebellar abscess, centre-pin being placed 2 inches )je- hind and ^4 inch below centre of external bony meatus. 104, having first laid bare with chisels the sigmoid sinus, but I also trephined the skull at point C, to in- 1 American Journal of the Medical Sciences, August, 1895. 328 MANUAL OF OTOLOGY. vestigate the temporo-sphenoidal lobe and the upper wall of the tympanic cavity. The case was that of a male, aged thirty-one years, who had had a purulent discharge from the right ear for five years. When ad- mitted to the hospital the prominent symptoms were nausea, vomiting, and vertigo. The vertigo was not only present when lying down, but was much more marked when he tried to stand. He also complained of severe pain in the head. He had a staggering gait from the first, with an inclination to fall toward the left. Other symptoms were facial paralysis (right side), oedema of the right optic nerve, slow pulse, and a tem- perature but slightly above normal. At the autopsy an abscess was found in the right cerebellar hemisphere. (See Plate.) Other symptoms of cerebellar abscess sometimes ob- served are : slowing of the respiration ; Cheyne-Stokes respiration ; repeated yawnings ; slowness of cerebration and general apathy ; irritability and intolerance of light ; delirium ; rigidity of the neck and retraction of the head ; clenching of the teeth from rigidity of the mus- cles; nystagmus ; motor or sensory paralysis. If the medulla be affected at a point low enough, the paralysis may be unilateral and on the same side as the abscess. If, however, the pons be more involved on the side of the abscess, the paralysis will be apparent on the oppo- site side. When there is a cerebellar abscess together with sinus thrombosis, there may be rigors or chills, with high temperature and tenderness along the course of the jug- ular vein, if that vessel be affected. Suppurative lepto- meningitis is another complication which may occur and thus render the diagnosis more difficult. Diffuse lepto- as 0> O 0, 1) ® ? > t. C K 0) 0) 0) « ■0 V yj r- « OS °as « .2 -, 0) G ffl o u > » x; ^ ^ ai < »- 0) C INTRA OR A NIA L COMPLICA TIONS. 329 meningitis gives rise to liigh temperature (witliout re- missions which are characteristic of infective sinus thrombosis), a rapid pulse, general irritability, and with the special senses very acute. Fig. 105. Left temporal bone of a patient who died of cerebral abscess. a, a. Openings in the sclerosed mastoid process, made with chisels. 6. Large carious opening leading into the middle cerebral fossa, c. Zygoma. In 1888 an operation for cerebral abscess following disease of the ear was performed by Dr. Eobert F. Weir and myself. The patient^ was imder my care at the New York Eye and Ear Infirmary for chronic 1 Transactions of the American Otological Society, 1SS8. 330 MANUAL OF OTOLOGY. suppurative otitis media, with extensive necrosis of the temporal bone. He had had a purulent discharge from the ear for the preceding two years. The mastoid pro- cess was opened in two different places (see Fig. 105), and was found very dense, but it did not contain pus. Subsequently an abscess was located in the temporo- sphenoidal lobe and the pus was evacuated. The patient's condition improved somewhat for a time, but he passed into a comatose condition. The immediate cause of death was secondary hemorrhage from a vessel in the brain. When not interfered with by operative measures, a cerebellar abscess terminates, as a rule, in death. The patient may gradually pass into a comatose condition, while the pus from the abscess escapes on to the surface of the brain or bursts into the ventricles. When the pus reaches the surface of the brain, a new inflamma- tory action is set up, leading possibly to acute lepto- meningitis. As a result the temperature becomes high and the pulse rapid. Other symptoms are vomiting, great restlessness, rigidity of the limbs, great weakness, and clonic spasms. When the pus suddenly bursts into the ventricles, the patient's condition changes at once. The temperature rises suddenly to 104° or 105° ; the pulse becomes very rapid ; the respirations are in- creased in frequency ; muscular twitchings occur, fol- lowed by convulsions, coma, and death. Abscesses have become encapsulated and remained quiescent for years without giving rise to serious trouble, but such instances are extremely infrequent. Cases have been reported also in which abscesses in the temporo-sphenoidal lobe have drained through a carious opening in the tegmen tympani, and the pus has escaped INTRACRANIAL COMPLICATIONS. 331 through the external meatus. A cerebellar abscess has also been reported where the pus forced its way through a carious opening in the sigmoid groove, the sinus hav- ing been destroyed. Occasionally, but very rarely, an abscess may drain in this way and be followed by recovery. One should never for a moment anticipate such a result, for the time to operate successfully is at an early date, before the patient has passed into a comatose con- dition. It is frequently very difficult to make a differential diagnosis between cerebral abscess, sinus thrombosis, and meningitis, as at times one or more of these dis- eases may occur in the same case. It is impossible to know the percentage of recoveries of brain abscesses, for, as a rule, all successful cases are reported, but the same cannot be said of unsuccessful ones. Of ninety-two cases of abscess reported to July 1, 1895, by Koerner, fifty-one recovered. Of 139 cases of sinus thrombosis, including some that have not been recorded as yet, ninety-five terminated in recovery, so that the surgeon is fully justified in operating. An exploratory operation whereby the dura is exposed and a needle introduced into the lateral lobe of the cere- bellum or temporo-sphenoidal lobe is attended with but little risk to the patient if aseptic precautions are care- fully followed out. Teeatment. In all operations on the mastoid antrum and cells, and when opening the cranial cavity, the most thorough antiseptic precautions should be fol- lowed. Towels should be soaked in bichloride of mer- cury solution, 1 : 3000, and then wrapped about the head and shoulders. The hair should be shaved about 332 MANUAL OF OTOLOGY. the ear for a considerable area. The mastoid region and the surrounding parts should then be scrubbed with soap and water, and afterward with pure alcohol, or sulphuric ether, or bichloride solution 1 : 3000. The ear should be thoroughly syringed with bichloride solu- tion, 1 : 3000, and then carefully dried and a strip of iodoform gauze pushed down into the meatus. All instruments should be sterilized. The blades of the scalpels can be dipped into absolute alcohol, and car- bolic solution 1 : 20. The surgeon should first of all open the mastoid antrum (see Fig. 90) and make this the starting-point of the operation ; for it is in this cavity that the micro- organisms exist, and where they rapidly fructify as long as the soil is fertile. Antiseptics injected into the middle ear do not reach them. Besides scalpels and retractors, it will be necessary to have a mallet, gouges, and chisels of different sizes, a periosteal ele- vator, forceps for controlling hemorrhage, rongeur for- ceps of different sizes, probes, and exploring needles. After removing all cheesy matter and granulations from the antrum, and excising the ossicles if carious, the condition of the tegmen tyrapani and tegmen antri should be investigated. If a sinus be found leading to the middle cranial fossa, it should be enlarged, and pus, if present (extradural abscess), evacuated. The surgeon should examine the condition of the dura before inject- ing any solution into the extradural cavity. The latter cavity can be safely washed out with a saturated boric-acid solution, provided no opening exists in the dura which leads into the pia mater or brain itself. It is best to do but little irrigation for fear of dissemi- nating the morbid products. The cavity should be INTRACRANIAL COMPLICATIONS. 333 dusted over with equal parts of boric acid and iodoform, and iodoform gauze should be inserted into the wound, so that it may fill up with granulation tissue. When pus is seen to ooze from an opening in the dura, or one has reason to suspect a temporo-sphenoidal ab- scess, the surgeon should extend the previous incision (for exposing the antrum) in a direction upward and then forward around the upper border of the auricle, thus dividing the temporal artery. The hemorrhage from this is easly controlled by means of a ligature. Another incision can be made in a direction upward and backward, and the flaps dissected so as to give the surgeon plenty of room. If the bone just above the external meatus is not too dense, it should be cut away rapidly with large chisels and bone forceps, and the opening enlarged so that the dura can be thoroughly exposed. In some cases, especially where the bone is very dense or the patient is in such a condition that it is necessary to explore the temporo-sphenoidal lobe as rapidly as possible, a disk of bone should be removed with a trephine, the centre-pin of the trephine being placed at point C, Fig. 104, a distance of an inch and a quarter above the centre of the external bony meatus. The trephine opening should be at least three-quarters of an inch in diameter. It is probable that most abscesses in the region are the result of inflammation extending from disease of the antrum. It is, therefore, best to attack the abscess cavity at this point in order to secure the best possible drainage. From this region, also, an exploring needle may be introduced into the temporo- sphenoidal lobe if brain abscess be suspected. The in- strument devised by Horsley is better adapted for this purpose than the exploring needle, as it consists of two 334 MANUAL OF OTOLOOT. blades, resembling an ear speculum, which can be sepa- rated after introduction, thus allowing the surgeon a view of the abscess cavity. The blades can be pushed gently through brain tissue without the use of a knife, until at least the capsule of the abscess is reached. I have been in the habit of using a needle at least one- twelfth of an inch in diameter. The pus is likely to be very thick, so that a smaller one is useless. After the abscess cavity has been detected a free opening should be made in the dura with a scalpel, and if possible the surgeon should make the incision in the brain tissue with a director for fear of injuring some bloodvessel. A free incision can, however, be made in the temporal lobe with a scalpel if the bloodvessels are carefully avoided. Cerebral pulsation may not be evident if the abscess be small and deeply seated. There may, however, be entire absence of pulsation even if the abscess be near the surface and the dura protrude through the bony opening. After making an opening down to the ab- scess, great care should be exercised in evacuating the pus and sloughs. If possible, the little finger should be introduced to remove the sloughs, or a Volkmann's spoon may be used if great care be taken and light be thrown with a head-mirror into the abscess cavity. The surgeon should endeavor to remove all the sloughs, otherwise the cavity is likely to refill with pus. The cavity should then be most gently washed out with a boric-acid solution or a 1 : 100 carbolic solution by mean^ of a double canula, the tube carrying away the fluid from the abscess cavity being a little larger than the other one. But little force should be employed in syringing, otherwise great damage may be done to the INTRACRANIAL COMPLICATIONS. 335 brain tissue. After washing out the abscess cavity, strips of iodoform gauze should be loosely pacijed in for the purpose of draining it. These may have to be changed every day at first, but later less frequently. Under such frequent dressings, boric-acid gauze should be substituted for fear of the toxic effect of iodoform. In the case of an acute abscess, or when all septic matter has been removed, an absorbable decalcified chicken- bone drainage tube can be introduced and stitched to the skin, so as to keep it in position. Outside of the abscess the wound, after aseptic irrigation, should be covered first by several layers of iodoform gauze, and on top of this a pad of bichloride gauze. Outside of this a thick layer of absorbent cotton should be placed, and the whole bandaged. After several days, in the case of a chronic abscess, when the walls have become firm, a 1 : 5000 bichloride solution can be injected into the abscess cavity to ad- vantage. In a case of mine which recovered, and in which streptococci were found, great improvement ensued after using a bichloride solution. In the case of a cerebellar abscess, it is always ad- visable to first expose the sigmoid sinus, as the latter is frequently thrombosed. A horizontal incision should be made in the soft parts and carried backward so as to give the surgeon plenty of room not only to lay bare the sinus, but also to cut away with rongeur forceps the bone lying to the outer and external aspect of the sinus, and reach the abscess in that way. Otherwise the treatment is identical with that already described (abscess in the temporo-sphenoidal lobe.) If the bone be very dense, and for any reason it be- comes necessary to explore the cerebellum for an ab- 336 MANUAL OF OTOLOGY. scess without first investigating the sigmoid sinus, the following method of procedure should be followed : A button of bone should be removed with a trephine (see Fig. 104) by placing the centre-pin of the instrument at a point, G, a distance of two inches behind and one- quarter of an inch below the centre of the external auditory meatus. As shown in the same figure, Reid's Fig. 106. Author's rongeur forceps. base line extends from the lower margin of the orbit through the centre of the external auditory meatus. Tlie directions which were formerly given for exposing the sigmoid sinus by means of the trephine were to re- move a button of bone by placing the centre-pin of the trephine at point F., a distance of one inch behind and one-quarter of an inch above the centre of the external meatus. THROMBOSIS OP THE SIGMOID AND OTHER SINUSES. Before describing the symptoms of sinus thrombosis, it is important to review in a general way the gross anatomy of the brain, particularly as to its venous supply. The superior cerebral veins collect the blood from the upper portions of the cerebrum, and after anasto- mosing with oue another and the inferior cerebral veins Fig. 107. Tina I Sinus Cerebral veins and sinuses. (From Macewen.) 22 338 MANUAL OF OTOLOGY. empty into the superior longitudinal sinus. The in- ferior cerebral veins enter the lateral, cavernous, and superior petrosal sinuses. The middle cerebral vein, after being joined by branches from the frontal and temporo- sphenoidal lobes, pours its blood into the cavernous sinus. The sigmoid sinus is a continuation of the lateral sinus and is that portion which lies in the sigmoid groove. It is joined by the inferior petrosal sinus and forms the internal jugular vein. The sigmoid sinus receives blood from the superior petrosal and occipital sinuses, also from the superior longitudinal and straight sinuses by means of the lateral. The lateral and sig- moid sinuses, together with the internal jugular vein, are of especial interest to the aural surgeon, for it is in these vessels that a thrombus is most frequently found when the middle ear and mastoid cells are involved, although the other sinuses that are in communication with them are liable to be affected, especially the supe- rior and inferior petrosals. Small veins from the mastoid cells and tympanum also enter the sigmoid sinus, more especially at that point called the knee or the anterior convexity of the sinus. A mastoid vein joins the sigmoid sinus at its posterior aspect, and is frequently thrombosed when the former is involved. A thrombus forming in the sigmoid sinus may not only extend to the petrosals, but even to the cavernous sinus as well. Although not constant, there is a communication between the vessels of the external portions of the skull and the sigmoid sinus by means of the mastoid and posterior condylar veins. The latter connect the sigmoid sinus with the vertebral veins and the deep veins in the posterior part of the neck. INTRACRANIAL COMPLICATIONS. 339 LYMPHATICS. The lymphatics in the scalp enter the mastoid, parotid, and occipital lymphatic glands. Some of the lymphatics of the face are superficial and others deep. The deeper ones terminate in the internal maxillary glands, while the superficial ones join the submaxillary and parotid lymphatic glands. The lymphatics within the cranial cavity are situ- ated in the pia mater and choroid plexus, taking their exit from the cranial cavity along the internal carotid and vertebral arteries and internal jugular vein, aud join the deep cervical glands, so that the latter glands are liable to be enlarged when there is some irritation or inflammation within the cranium. Being deeply seated, they are liable to escape detection. From this brief review of the anatomy it will be pos- sible to understand more readily the pathology and symptomatology of sinus tlirombosis. A thrombus may be primary or marasmic, as well as secondary or infective. The marasmic is said to occur almost always in the longitudinal sinus, very seldom in either the lateral or cavernous sinuses. It is observed in the very young or in the aged, aud is generally de- veloped during the course of some wasting disease, such as chronic diarrhoea, pneumonia, tuberculosis, and car- cinoma. The heart's action becoming weakened and the blood being thickened, there is a tendency for coag- ulation to occur. It is the infective or inflammatory thrombus that con- cerns the aural surgeon, and which is due to the presence of a pathogenic micro-organism, and the sigmoid sinus is most frequently affected on account of its anatomical 340 MANUAL OF OTOLOGY. relation to the temporal bone, more especially the mas- toid cells. Infective thrombosis is seldom observed in children and aged persons. It may be due to fractures of the skull, scalp-wounds, anthrax affecting the lips, mouth, or orbital or nasal cavities, and erysipelas of the face and head. Middle-ear disease and mastoid inflam- mation are the most frequent causes. The thrombosis is due to the presence of some pathogenic micro-organ- isms, such as the staphylococcus, the streptococcus, or the pneumococcus. They may exist alone or together in the same case. Experience teaches that the strepto- coccus is the most virulent and gives rise to serious symptoms. The infection may be due to direct exten- sion of the inflammation in the bone to the sinus walls themselves, whereby they become inflamed and thickened and a thrombus forms in the interior of the sinus. There may, however, be fissures in the tympanic roof or antrum through which the infection travels, or small veins in the bone, joining with the sigmoid, become thrombosed and convey the morbid products in this manner. The most frequent cause, however, is by direct contact with the diseased bone. When the sinus is first affected, the endothelium be- comes swollen and desquamates, and coagulation takes place. The deposit of fibrin may be limited to one side of the wall (parietal clot), or the whole circumference of the vessel may be involved (obstructing thrombus). After this the clot, as a rule, breaks down so that pus is formed, and, being filled with micro-organisms, the latter are likely to be carried into the general circula- tion. Ulceration may take place on the wall of the sinus, but hemorrhage does not usually follow, because the thrombi formed above and below this point are firm INTRACRANIAL COMPLICATIONS. 341 enough to prevent the escape of blood. The iDfective material may also be carried by the tributary veins in the neighborhood of the thrombus into the general cir- culation. In some eases a partial re-establishment of the current takes place through the thrombus, by which means the pathogenic material is swept into the general blood current. Another way in which general infection takes place is by the escape of morbid products through the sinus walls into the surrounding parts, so that another focus of infection is established whereby micro- organisms are carried into the circulation through the perivascular spaces and congested vessels. It is probable also that the pyogenic micro-organism may give rise to general infection through absorption by means of the lymphatics. The streptococcus is most frequently found in the lymph vessels. As a result of thrombosis of the sigmoid sinus, the same phenomena frequently occur in the internal jugular vein, especially its upper portion, as well as in the superior petrosal sinus and the anterior and posterior condylar veins. When a thrombus forms within the sinus, certain changes take place in its walls, owing to a peripheral exudation of plastic material which would tend to strengthen the weakened wall if the tissue should be- come changed into connective tissue. The same, if it occurred on the wall next to the brain cavity, would also help to prevent the occurrence of leptomeningitis through the formation of firm adhesions between the dura and membranes. Unfortunately, such is not the rule, as the plastic material is apt to break down and increase the dangers of infection. When, through ulceration of the sinus wall, an opening occurs, the pus may find its way through the mastoid foramen and 342 MANUAL OF OTOLOGY. form an abscess in the tissues in the posterior portion of the mastoid process. A.s a result of infection of the posterior condylar veins, an abscess may develop be- neath the deep fascia in the posterior cervical triangle. In consequence of involvement of the visceral layer of the sinus, acute leptomeningitis is the rule, although in some instances the meningitis becomes localized. When the thrombus breaks down, the bone in its vicinity becomes of a dark-brownish or greenish color, very much softened and eroded. The discoloration or pigmentation is so marked in some instances that the course of the lateral or sigmoid sinus becomes stamped on the cerebellum itself. When the thrombus disinte- grates, the infective particles are generally transmitted first to the small vessels in the lungs, so that infarctions occur, and as a result there may be an infective pneu- monia or gangrene. The pleura, pericardium, brain, kidneys, or liver may also be affected in the same way, or an abscess may form in the cerebrum or cerebellum as a result of thrombosis from extension of the infec- tive processes. Instead of disintegration of a thrombus, the latter in rare instances becomes organized, and in such cases the same reparative inflammation takes place as in other organs of the body. When the infective process has been slight, the oblit- eration of the sinus may be established at that point by means of fibrous tissue, as the result of the formation of granulations on the walls of the sinus and adjacent dura, which penetrate into the sinus itself as well as the surrounding bony tissue. Such granulations tend to prevent the entrance of infective material into the sinus. INTBAQRANIAL COMPLICATIONS. 343 Symptoms. The symptoms should be divided into (1) local, and (2) general or systemic. 1. Local. A profuse discharge from the ear often becomes diminished in quantity. Pain is generally present, being slight in some instances, while in others it radiates over the side of the head and is excruciating. As the mastoid cells are usually affected at the same time, there is more or less pain when pressure is made on the different portions of the mastoid process, and especially in the neighborhood of the sinus and over that point where the mastoid vein takes its exit. (Edema of the superficial tissues about the mastoid tip, extending to the region of the mastoid vein and also to the upper portion of the posterior cervical triangle, with tenderness on pressure over this area, is another symptom of importance, although the same condition of affairs exisls in uncomplicated mastoid disease, espe- cially when perforation has occurred at the mastoid tip (Bezold perforation). When the thrombus has extended to the cavernous sinus and the ophthalmic vein has become engorged, there is likely to be a certain amount of oedema of the eyelids on the corresponding side. The enlargement of both superficial and deep cervical glands is a symptom that cannot be relied upon. In some cases it is present, but absent in others. When the mastoid vein has not become involved, and the thrombus is located in the lower portion of the sigmoid sinus, there may be an over-distention of the mastoid vein. In some instances it has been noted that the veins on the other side of the head were more dilated than usual, owing to an increased pressure. Not only is there tenderness on pressure in the upper third of the 344 MANUAL OF OTOLOGY. posterior cervical triangle, but also very frequently along the course of the internal jugular vein, especially in its upper portion when the latter has become in- volved. This is, however, one of the later symptoms. The patient is apt to have an anxious aud pallid appear- ance, with beads of perspiration standing out on the face and forehead. As a result of infective thrombosis, the tissues in the cervical region become cedemntous aud filled with a plastic exudation, which is liable to break down and form a large abscess, unless the source of the infection be removed. Abscesses occurring in the later stages are observed at times under the deep cervical fascia, along the course of the internal jugular vein, in the deeper portions of the upper third of the posterior cer- vical triangle. Neuroretinitis is noticed in some cases, more espe- cially in the later stages, but is not a constant symptom. 2. The general symptoms are more or less pain in the mastoid region radiating about the side of the head, a chill followed by a sudden rise in temperature to 105° or 106°, nausea, vomiting, vertigo, and constipation. In the late stages there is apt to be diarrhoea, which is due to septic poisoning. When a patient suffering from a purulent otitis media, and especially if there be symptoms of mastoid disease, has a sudden chill, followed by a rise in temperature, the indications point to the formation of a thrombus, provided a careful examination of the patient's general condition has been made and other diseases can be ex- cluded. There are apt to be marked remissions in the temperature, the latter falling frequently to 99°, but only to rise again. Rigors occur either early in thg INTRACRANIAL COMPLICATIONS. 345 disease or may be a late manifestation, and' are accom- panied by profuse perspiration. The pulse and respira- tion are generally accelerated during the course of the disease, becoming markedly so during the late stage before a fatal termination. The patient generally re- tains consciousness up to the end, provided there is no meningitis nor brain abscess. In only 30 per cent, of uncomplicated cases has loss of consciousness been noted. The tongue is apt to be coated and the breath has a dis- agreeable fetid odor. When general systemic infpction has taken place, and the disease progresses unfavorably, there are certain symptoms that predominate, namely, pulmonary, abdominal, or meningeal, according to the organs affected. When the lungs are implicated, the first symptoms are dyspnoea and cough, with more or less localized pain in the chest. These localized areas of pain are due to infarctions. On examining the chest twenty-four or forty-eight hours later, one will hear moist rSles. The expectoration consists of rusty sputum, containing bac- teria and of a very fetid odor. Gangrene of the lung follows, with extensive disintegration. Death in such cases is due to exhaustion. In the abdominal type the disease is likely to be mistaken for typhoid fever. The symptoms are great weakness, loss of appetite, coated and dry tongue, diarrhoea of a fetid character, and delirium. Rigors are infrequent. The meningeal type is less frequently noted than the pulmonary or abdominal, and, when present, is usually associated with one of the preceding forms. Cephalalgia and vomiting are marked symptoms. The meningitis is due to the infective thrombosis, or may occur as a complication. Other symptoms are high temperature. 346 MANUAL OF OTOLOGY. agitatioD, considerable excitement ; tonic and clonic contractions of the face, neck, and upper extremities, or paresis ; squint ; retraction of the head and neck ; delirium in the later stages. Rigors are apt to develop when purulent leptomeningitis occurs as a complication. When the leptomeningitis extends to the spiue there are, in addition, shooting pains in the spinal region, great prostration, and a feeling of tight-cord around the waist or girdle pains. The patient gradually falls into a comatose condition, although the mind is clear in the early stages. Diagnosis. The difficulties in making a diagnosis of sinus thrombosis frequently arise from the complica- tions that are likely to develop, such as meningitis or cerebral abscess, or both. In a simple, uncomplicated case, in which a patient with purulent otitis media has chills, high temperature with remissions, a I'apid pulse, vomiting, and while there is more or less oedema about the mastoid tip, extending upward and over the exit of the mastoid vein and in the upper third of tiic posterior cervical triangle, a diagnosis of sinus thrombosis is comparatively certain. The surgeon should not wait for symptoms denoting disintegration of the thrombus and general systemic infection, as the success of the operation depends almost wholly on its early perform- ance. Still, cases do recover where the operation has been deferred until a late stage, but such do not offer much hope. The Time to Operate. This is a question that has been much discussed by surgeons, and, although opin- ions differ, the sentiment of the majority is certainly in favor of an immediate operation in a ease of sinus thrombosis, as soon as the surgeon is sure of the diag- INTRACRANIAL COMPLICATIONS. .347 uosis. Except in very rare instances, unless an opera- tion is undertaken to remove a thrombus, a fatal result must be expected. The earlier the operation is per- formed the better the chances of success. Another point in the operation about which different, views have been entertained is the question as to the advisability of ligating the internal jugular vein. Those who are opposed to ligation contend that mauy cases have recovered without tying the vein ; that infarctions may be carried into the lungs by the other internal jugular vein, and that, as it is extremely diflScult in many cases to find the vein, owing to the infiltration of the tissues, the procedure adds much to the gravity of the operation. While it is undoubtedly true that minute infective particles can be swept into the circulation, in spite of ligation of the internal jugular vein, the general opinion is in favor of tying the vein in all cases in which the sinus contains putrid material, pus, or a disintegrated thrombus, as well as in those cases in which the pres- ence of a thrombus in the internal jugular is evident from the cord-like induration felt along the border of the sternomastoid muscle. A thrombus may form in the sigmoid sinus in an incredibly short space of time. I have recently seen a case in which thrombosis oc- curred as a result of acute otitis media of only ten days' duration, due to the presence of streptococci. I have also, during the past winter, had under my care a boy of eight who developed an acute otitis media as a result of tonsillitis. When called to see him two days later, a free incision was made in the drumhead. There were symptoms of mastoid disease at that time. At first there was an improvement, but on the third day. 348 MANUAL OF OTOLOGY. after incising the drumhead, the temperature gradually rose to 104.2° F. (rectal), pulse 140. At this time the boy did not complain of pain, but was stupid and in- clined to sleep. Under ether an incision was tlien made behind the auricle, the mastoid cells were exposed from the antrum to the tip, and softened bone removed with granulations. Very little pus was found. The bone was softened, especially in the direction of the jugular bulb, and there was considerable oedema about the mas- toid tip and in the direction of the upper third of the posterior cervical triangle. On exposing the sigmoid sinus it appeared to be normal. A temporary improve- ment followed, but the temperature soon rose again to 104.2° F. (rectal), and two days later, just one week after the beginning of the attack, the boy had a chill lasting about twenty minutes, followed by a temperature of 103.4°, and later 104.4° F. The patient was very drowsy and stupid, and had a rapid pulse. It was decided best to open at once the sigmoid sinus. The sigmoid groove was cut away so that the sinus was ex- posed for at least an inch and a half. A soft clot was adherent to the walls of the sinus near the bulb and removed with a curette. The circulation was re-estab- lished at both ends of the sinus, and the latter was plugged with strips of iodoform gauze, and the wound bandaged. The boy recovered. The case is mentioned to show that, even in patients suffering from acute otitis media, thrombosis of the sigmoid sinus may occur in an incredibly short space of time, and that one must be constantly on the alert for such a complication, especially when the temperature remains high after incision of the drumhead and the presence of streptococci has been demonstrated. INTRACRANIAL COMPLICATIONS. 349 Another case ' which recently came under observation was a child of four years, who had symptoms of sinus thrombosis, with a temperature of 105° F., due to a mastoid inflammation of both sides. In this patient the infection was caused by pneumococci. The boy had an attack of earache first on one side and later on the other. A free incision was made in each drum- head, and for a short time there followed improvement. Both mastoid processes were involved, and it became necessary to remove softened bone and granulations. The temperature immediately fell, and recovery fol- lowed. At the time of each operation the sigmoid sinus was exposed, so that, if necessary, a thrombus could be removed if the patient had further symptoms character- istic of such a complication. Prognosis. If the diagnosis is made at an early stage, and the operation undertaken at once, the chances of a successful result are fairly good, provided the patient's general condition is satisfactory. When septic poisoning has developed, although the chances of a favorable result offer but little hope, one should, never- theless, remove the source of infection at once. Method of Operation. The first step in the operation consists in making the usual incision behind the auricle for exposing the mastoid cells. The antrum should first be freely opened and the contents of the same thoroughly removed. The tympanic roof should be explored for a carious opening. To uncover the sinus, the surgeon should make a second incision through the soft parts at a right angle to the incision already made for the mastoid operation, and this should be carried 1 Transactions of the American Otological Society, 1898. 350 MANUAL OF OTOLOGY. backward so that the flaps can be dissected away from the skull. After having removed all mastoid cells, the sigmoid groove can generally be seen in position. The bridge of bone between the sinus aud the antrum should be carefully removed. The sinus in some instances lies very close to the antrum, so that if the latter be first opened and the bone be chiselled away layer by layer in a direction directly backward, the anterior knee of the sigmoid sinus will come into view, or if the bone be softened just over the sigmoid groove in the middle portion of the mastoid process, the vessel may be laid bare at that point. The sinus should be exposed to view for at least one inch in order to give the surgeon an opportunity to determine the existence of a thrombus, and also to be able to control the hemorrhage, if necessary. The condition of the sinus wall should be noted, whether thickened or covered with granulations or not. If the latter are present they should be carefully scraped away, so that the sinus walls can be thoroughly inspected, and with a probe one should examine to see if a sinus leads to a cerebellar abscess or not. If a thrombus is present, the sinus will appear unusually prominent, and, by palpation, it will seem firm and dense. The sinus may or may not pulsate. It was formerly taught that if pulsation was noted there could be no thrombus, but such a statement is erroneous. An exploring needle should be introduced, and its point should be directed both upward toward the torcular and also downward toward the bulb. The needle may show the presence of serum, pus, a disintegrated clot, or even blood. The withdrawal of blood does not necessarily indicate the non-existence of a thrombus, because the latter may be INTRACRANIAL COMPLICATIONS. 351 very soft (parietal), and there may be a stream of blood running through the centre of the vessel. The only certain method of determining as to the existence of thrombosis is to make a free incision into the sinus wall. If the surgeon determines that there is pus or a disin- tegrated clot in the sinus, or the thrombus has extended into the upper third of the internal jugular vein, as shown by the presence of a cord-like feeling along the sternocleidomastoid muscle, he should, before incising the sinus, ligate the internal jugular vein below the thrombosed portion, and the facial vein should be tied as well. If it has been decided not to ligate the internal jug- ular vein, then an incision should be made in the long axis of the sinus, and all obstructious should be re- moved at once by means of sharp curettes. One should first of all introduce the curette toward the torcular and re-establish the current in this direction. By means of a gauze tampon applied directly at this point, and held in position by means of the finger, the walls that have been incised being folded inward, the hemorrhage can be easily controlled. The curette should then be passed downward toward the bulb, and the current re-established as in the upper portion of the sinus. If the blood cannot be made to flow, one should at once tie the internal jugular vein. If, however, the flow be re-established, a gauze tampon should be applied to control the hemorrhage, while the wound should be dusted over with iodoform and boric acid 1 : 4, and the whole bandaged. It is unnecessary to state that the same aseptic pre- 352 MANUAL OF OTOLOGY. cautions should be carried out as in operations for mas- toid disease or cerebral abscess. The dressings should not be changed for several days if the patient's general condition shows a decided improvement. After an operation on the brain the patient is likely to suffer considerably from shock, so that the pulse be- comes weak and rapid. Besides the use of strychnia, digitalis, nitro-glycerin, and other remedies, the injec- tion into the rectum of the normal saline solution is to be particularly recommended in just such conditions. In extreme cases, intravenous injections of the saline solution are necessary. LEPTOMENINGITIS. There are two varieties of leptomeningitis, the serous and the purulent, the latter being more frequently ob- served as a complication of ear disease than the former. Leptomeningitis is a disease which, starting in the arach- noid, may spread very rapidly until the entire subdural and intraventricular spaces are involved, as well as the pia, and at times the superficial portion of the brain. The cerebrospinal fluid becomes increased in quantity, and the sheaths of the spinal and cerebral nerves are often implicated. This form of inflammation is much more serious and fatal than either thrombosis of the sigmoid sinus or cerebral abscess, and is in consequence much more dreaded by the surgeon. In serous leptomeningitis there is at first a hypersemia, which is followed by exudation of serum in which are often found some flakes of fibrin and at times a few leucocytes. There may be such a rapid accumulation of serum as to give rise to serious pressure symptoms. INTRAOEANIAL COMPLICATIONS. 353 the ventricles becomiDg greatly distended. At times acate serous leptomeningitis is localized. If a disk of bone be removed from the skull in a patient suffering from this disease, the arteries and veins will be found large and full, and the pia swollen and infected, while clear fluid will be contained within the arachnoid mesh- work. After making a trephine opening and reflecting the dura, there may be so much fluid that the meshes of the arachnoid protrude and form a hernia of the membranes which are filled with fluid. Purulent Leptomeningitis, [n this disease, which may be due to embolism, there is at first hypersemia and serous exudation, followed by marked dilatation of the veins. The latter at times contain granular coagula. The perivascular spaces are also filled with an exudation of leucocytes. At first the exudation is limited to the arachnoid, as well as the spaces and clefts in the pia mater ; but it is liable to extend to the under- lying brain substance, which becomes soft and moist, while the ventricles are filled with sero-pus. When the base of the brain becomes involved, the disease is likely to affect the spinal cord. Symptoms. Headache is usually the first symptom, which may be localized at first, but which eventually extends over the entire head. Other symptoms are restlessness, insomnia, photophobia, hypersesthesia of the cutaneous nerves, pupils contracted and responding but little to light, abdomen retracted, pulse full and bounding and accelerated, high temperature, and optic neuritis. In the later stages the patient is dull and stupid, and convulsions, at first confined to the muscles of the face and extremities, become general. The pupils are dilated and often unequal, while the pulse becomes 23 354 MANUAL OF OTOLOGY. slower, owing to the cerebral pressure. In the last stages paralyses occur, the patient passes feces and urine involuntarily, the respirations are increased in frequency, the pulse is very rapid, the patient becomes comatose, with symptoms of general paralysis, and death follows. The course of this disease may be extremely rapid, or death may not occur for weeks. Diagnosis. Symptoms suggestive of meningitis are occasionally observed, more especially in children, which are often due to the retention of pus in the middle ear or external auditory canal, so that a diag- nosis of this disease is extremely difficult in the early stage. It is only when paralyses occur and there are optic neuritis and other characteristic symptoms that the surgeon can be sure of the diagnosis. This disease is occasionally associated with thrombosis of the sigmoid sinus or cerebral abscess, or with both, so that when these complications occur a diagnosis is extremely difficult. Peognosis. Although this disease is generally fatal, the prognosis is not necessarily hopeless, for cases have recovered, especially after operation. Treatment. As infective meningitis occurring in this connection is usually due to an extension of the disease from the middle ear or mastoid cells to the men- inges, it is important first of all to open the antrum and explore the tympanic roof when there are symptoms of infective meningitis of the middle cranial fossa, and to remove all purulent secretion between the bone and the dura or pia mater. If the symptoms point to involve- ment of the base of the brain and s[)inal cord, the thin plate of bone covering the sigmoid siuus should be cut away and the posterior cranial fossa investigated. In INTRACRANIAL COMPLICATIONS. 355 cerebro-spinal meningitis, after making an incision in the dura, the pus, if fluid, may flow for some time. It is always well in doubtful cases in which the symp- toms are grave and point to intracranial involvement to make a thorough investigation of the antrum and tym- panic roof, as well as of the sigmoid sinus, for if the operation be carefully performed the danger to the patient is slight, while the local depletion and relief of the tension, especially in a case of serous leptomeningitis, may lead to complete recovery. PYEMIA. Septicaemia and pyaemia are complications that are liable to occur in connection with suppurative otitis media whenever septic material is absorbed, whether in disease of the middle ear, antrum, or mastoid cells, or in thrombosis of one of the sinuses or of the internal ju- gular vein. In cases of perforation of the mastoid tip, whereby the pus makes its way beneath the deep fascia, unless evacuated at once there is great danger that absorption will take place and give rise to blood-poi- soning. If septic particles are carried into the circula- tion from a disorganized clot, infarctions occur in the lungs as well as other organs, and fatal pyaemia is usually the result. This demonstrates the importance of always removing every source of infection whenever the mastoid, antrum, or cells are involved. Some authorities advocate the internal administration of creo- sote and bichloride of mercury, but such treatment is usually of little avail. Pyaemia is not always fatal, for in a case following mastoid disease the lungs were not only affected, but collections of pus were opened in 356 MANUAL OF OTOLOGY. different parts of the body. The patient had chills, a vacillating temperature and sweating, and became much emaciated, but eventually recovered. This was a case in which the pus, after breaking through the mastoid tip, burrowed beneath the deep fascia in the neck. CHAPTER XIII. DISEASES OF THE SOUND-PERCEIVING APPAEATUS. Diseases of the sound-perceiving apparatus are usu- ally classified as primary or secondary affections, the former being much Ipss frequently met with than the latter. Among the earlier writers many cases were called ''nerve deafness" which should have been re- corded as affections of the middle ear, but in the light of our present information there are comparatively few cases of primary disease of the internal ear. Affections of the internal ear may develop idiopathically or be due to severe cold, blows, falls, sunstroke, or to such dis- eases as malarial fever, typhus and typhoid, scarlatina, syphilis, measles, diphtheria, influenza, leucocythsemia, Bright's disease, diabetes, mumps, and locomotor ataxia. Chemical changes in the blood of general diseaees pro- duce disturbances in the auditory centres or in the ex- pansion of the auditory nerve in the labyrinth. Sec- ondary changes take place in the labyrinth from inflammation of the middle ear, but it must not be forgotten that the same cause may produce affections of the middle ear as well as of the labyrinth and the auditory nerve, or that the sound-perceiving and the sound-conducting apparatus may be simultaneously in- volved. This is especially the case in those insidious forms of adhesive catarrh which lead to anchylosis of the stapes. In cases of acute inflammation of the 358 MANUAL OF OTOLOGY. middle ear, owing to the anastomosis between the ves- sels of the tympanum and labyrinth, the latter may become congested, and, as a result, ecehymoses and serous infiltration of the membranous labyrinth may follow, with increase of the intra-labyrinthine pressure. When this occurs the patient may complain of deafness, giddiness, vertigo, nausea, vomiting, tinnitus ; and the ability to hear the tuning-fork by bone conduction may be considerably impaired or even lost. In some cases there is an hypersesthesia of the auditory nerve. In diphtheritic affections the labyrinth may become involved from the entrance of micro-organisms, and in chronic purulent otitis media followed by caries and necrosis the internal ear is liable to be involved. Pathogenic micro- organisms, the streptococcus, the staphylococcus, and the diplococcus of pneumonia may invade the labyrinth from the cranial cavity by means of the aquseductus vestibuli and aquseductus cochleae. In consequence of such invasion there is liable to be a rapid destruction of the connective tissue, or there may be a new growth of connective tissue and bloodvessels leading to bone formation, or the micro-organisms may cause thrombo- arteritis and phlebitis. The auditory nerve is more frequently affected by general diseases than the other nerves of special sense, and certain drugs, such as quinine and salicylic acid, as well as the excessive use of tobacco, may give rise to subjective noises and to deafness if used in large doses or continuously. In certain diseases of the brain and spinal cord, espe- cially epidemic cerebro-spinal meningitis, and in conse- quence of cerebral tumors, disturbances of hearing are due to pressure on the internal auditory nerve or to the extension of inflammatory products from the cranial SOUND-PERCEIVINO APPARATUS. 359 cavity to the labyrinth and auditory nerve trunk. In affections of the brain and medulla the nuclei and roots of the auditory nerve may be involved, and deafness thus produced. Disturbances of hearing are observed at times in diseases of the liver, kidney, uterus, stomach, and also in anaemia and marasmus. Other causes of internal ear disease are aneurism of proximate blood- vessels and malignant growths beginning in the temporal bone. Fracture at the base of the skull may produce temporary or permanent deafness, with or without hem- orrhage from the ear, followed by a serous discharge. Artillerymen and boilermakers are especially liable to nerve deafness, on account of the loud sounds to which they are constantly exposed. Progressive disease affecting the auditory nerve-trunk is seldom confined permanently to one ear, for, sooner or later, the other is likely to be involved. As the root-fibres of the auditory nerve on one side extend into the external auditory nucleus on the other, degenerative processes of one internal auditory nerve may attack the centre and stem of the nerve on the opposite side. In some affections of the internal ear the deafness comes on very suddenly. Especially is this the case in cerebro-spinal meningitis, syphilis, M^niSre's disease, as well as in consequence of falls and blows. Besides giddiness, deafness, vomiting, and loss of hearing by bone conduction, the patient often complains of disturb- ances of equilibration, which are at times so marked, as in M6ni&re's disease, that the patient is unable to stand without support. Besides the causes already mentioned, it is undoubtedly a fact that hereditary influences play an important role, and also that a sudden mental dis- turbance, such as fright, may give rise to an affection 360 MANUAL OF OTOLOGY. of the internal ear through a sudden disturbance of the circulation of the labyrinth. Children are more frequently the subjects of disease of the internal ear than adults, for the reasons probably (1) that they are more prone to the exanthematous diseases and cerebro-spinal meningitis, and (2) in chil- dren the communications between the cranial cavity and the middle and inner ears and also between the tympanum and labyrinth are more direct than in adults, so that inflammatory products are more liable to be carried from the cranial cavity and the middle ear to the labyrinth. Very young chidren, or the aged, are more frequently the subjects of labyrinthine disease than those of middle age. In diseases of the auditory nerve the hearing is not so subject to marked fluctuations as in middle-ear dis- ease. If the deafness due to a nerve lesion does not become worse, it is apt to remain about the same from day to day, although impaired health, bodily fatigue and worry, as well as over-indulgence in the use of to- bacco and alcohol tend to aggravate the disease. The prognosis is, as a rule, unfavorable, although very much depends on the causation, the intensity and the duration of the disease. In recent syphilitic disease much can be accomplished by general constitutional treatment and by the hypodermatic injection of pilocarpine, and un- doubtedly in many cases in which there is serous and possibly small-celled infiltration, permanent restoration of hearing may follow. On the other hand, it is proved by clinical observation that deafness often remains after extensive effusion of blood has taken place in the labyrinth, with the invasion of the various cocci, and especially where there is extensive caries or necrosis SOUND-PEROEIVINQ APPARATUS. 361 of the temporal bone. In order to make a differential diagnosis between middle-ear and internal-ear affections, it may be slated, as a general rule, that 1. In diseases of the inner ear, low-toned tuning- forks are heard better than the higher ones by aerial conduction, if any fork is heard at all ; while in disease of the middle ear, if the nerve be not affected, the reverse is true — i. e., the higher forks are heard better. 2. In disease affecting the labyrinth or internal audi- tory nerve, the bone conduction becomes very much im- paired or lost, as shown by Rinn6's or Weber's tests (see chapter on Examination of the Ear). In the case of a person with normal hearing, a vibrating tuning-fork should be placed on the mastoid process, and the surgeon should be notified by a signal from the patient when he ceases to hear the sound. If the fork is then held close to the meatus, it will still be heard several seconds longer. In middle-ear or external-ear diseases the tun- ing-fork will be heard much longer when placed on the mastoid than when held close to the meatus. lu a case of deafness in which the labyrinth is involved the bone conduction becomes much impaired or lost altogether. Ifotes of a low pitch are, as a general rule, heard better than high ones. In consequence, the watch is not heard as well as the voice. Other important instruments for testing the hearing are the acoumeter, the Galton whistle, and Konig's rods. When the acoumeter is not heard by bone-con- duction, there is a reasonable certainty that the internal ear is affected. It must not be forgotten, however, that diminished bone-conduction is frequently observed in cases of adhesive catarrh of the middle ear as a result 362 MANUAL OF OTOLOGY. of secondary implication of the internal ear, or of intra- labyrinthine pressure. If a patient presents himself suffering from consider- able deafness of recent origin, and if an examination shows that the drumhead is normal and the Eustachian tube pervious, it is presumable that the case is one of disease of the auditory nerve. It is often difficult for the surgeon to differentiate between a middle-ear affec- tion, in which there are symptoms of vertigo, dizziness, and tinnitus, and an affection of the brain itself. The same symptoms observed in labyrinthine disease may occur in disease of the central nervous system. In the latter there will be such other symptoms as cholsed disk, paralyses, loss of sensation of one or both sides of the body, and diminished or increased tendon reflexes. HYPEREMIA OF THE LABYKINTH. Hypersemia of the labyrinth is likely to occur in a severe case of acute purulent otitis media, especially if due to scarlatina, diphtheria, or other acute exanthema- tous diseases. It is also observed in cases of tumor of the brain in which there is an obstruction to the escape of blood from (he inner ear, and in patients suffering from olher general diseases, such as typhoid or typhus fevers, cerebro-spinal meningitis, and in cerebral congestion accompanying diseases of the lungs or heart. It follows the administration of certain drugs, such as nitrite of amyl, quinine, and salicylic acid. Unless the hyper- semia is of a temporary character there may be pigment exudations in the labyrinth, or the membranous laby- rinth may become thickened. The symptoms in the acute stage of hyperaemia are vertigo, giddiness, vom- iting, inability to walk steadily, tinnitus, and a feeling SOUND-PEBCEIVING APPARATUS. 363 of fulness about the ears. Very often it will be noticed, on examination of the ear, that there is a slight conges- tion of the vessels along the handle of the malleus and of the bony canal adjoining the drumhead. It is very difficult to make a differential diagnosis in hypersemia of the labyrinth and of the brain centre, owing to the similarity of the symptoms. The treat- ment depends altogether on the cause. The patient should be kept quiet and put on a simple and whole- some diet. If occurring in connection with congestion of the brain, cold applications should be applied to the head. Small doses of calomel to produce watery evac- uations are also useful. When the drumhead is simul- taneously iujected, the local abstraction of blood from the ante-auricular and mastoid regions is important, as well as the application of the Leiter coil. ANiEMIA OF THE LABYRINTH. This afEection is observed in cases of general anaemia and chlorosis after great loss of blood, or there may be some obstruction to the blood-supply of the labyrinth, due to the pressure of a tumor, an aneurism, or there may be atheromatous changes, etc. In a case of great loss of blood, followed by ansemia of the labyrinth, the symptoms are deafness, extreme tinnitus, faintness, ver- tigo, nausea, and vomiting. As to treatment, this should be directed to the cause. When the disease is chronic, iron should be given, while a change of air is often advisable. HEMORRHAGE INTO THE LABYRINTH. Slight extravasations of blood occur in the labyrinth as a result of disease or of fracture at the base of the 364 MANUAL OF OTOLOGY. skull, or such extravasations may be due to concussion of the skull or to extensive necrosis of the temporal bone. When due to disease, the walls of the vessels may be weakened by atheromatous changes or by intense hypersemia during the course of scarlet fever, diph- theria, mumps, smallpox, pernicious anaemia, diabetes, and other diseases. INCREASED PRESSURE OF THE LABYRINTHINE FLUID FROM DISEASE OF THE TYMPANUM. As already mentioned, vertigo and disturbances of equilibration are prominent symptoms of labyrinthine disease. In cases, however, of middle-ear disease, or those in which a plug of cerumen presses against the drumhead so that the foot-plate of the stapes is forced inward and the pressure of the labyrinthine fluid is in- creased, the patient often Complains of more or less ver- tigo. The membrane of the foramen rotundum should, under normal conditions, by bulging outward compen- sate for the pressure exerted upon the foot-plate of the stapes. It is possible to explain the occurrence of the vertigo as being due to unusual pressure from the laby- rinthine fluid on account of congestion of the blood- vessels or to the fact that the membrane covering the foramen rotundum will not bulge outward, owing to thickening having occurred from catarrhal changes. A patient came under my care a short time since who complained of severe vertigo. He was unable to leave his room for several days on account of the severity of the attack. The history was that he had had a plug of inspissated cerumen removed from the ear by syringing a few days previously, and that since then he had been troubled with severe dizziness. He SOUND-PEECEIVINO APPARATUS. 365 was a man of iine appearance and of excellent health. An examination was made of the urine, heart, lungs, etc., as well as of the fundus of the eyes. Nothing was found to explain the vertigo except the condition of the ear, there being slight retraction of the drum- head and catarrhal changes. Inflation by Politzer's method daily for several days eSeoted a cure. In syringing the ear at times the patient will complain of sudden vertigo, and occasionally fall from the chair, owing to faintness. Such a phenomenon is undoubt- edly due to sudden pressure exerted on the foot-plate of the stapes. Aural vertigo is occasionally induced by the presence of a polypus which is attached in the neighborhood of the stapes. When this occurs, the patient often com- plains of a sense of fulness in the ear, with a distinct subjective circulatory tinnitus. The vertigo may be so severe that the patient is unable to maintain an erect position. The removal of such a polypoid growth must be performed most carefully, as the necessary manipu- lation is apt to cause increased vertigo and accompany- ing nausea. OTITIS INTERNA, OR INFLAMMATION OF THE LABYRINTH. Inflammation of the lining membrane of the bony labyrinth, as well as of the membranous labyrinth, may be either primary or secondary, the former being extremely infrequent. The secondary form, as a rule, follows inflammation of the middle ear, and is liable to occur as a result of diphtheria, scarlatina, tuberculosis, or extensive caries and necrosis of the temporal bone. In such cases the labyrinth may be filled with pus. 366 MANUAL OF OTOLOGY. while the walls of the membranous labyrinth become thickened and eechymosed. Chronic inflammation of the labyrinth, though ex- tremely infrequent, does occur, and, as a result, there is an increase of connective tissue with hyperostosis and calcareous deposits. The saccule and ampullae become thickened, and finally there may follow atrophy of the membranous labyrinth and disappearance of the organ of Corti. It is extremely difficult to make a diagnosis of acute inflammation of the labyrinth, for the symptoms, which are generally noticed in children, are quite similar to those observed in meningitis followed by recovery, except that in the former the disease comes on very suddenly, and the more serious symptoms last for about a week. The child is apt to have fever, more or less congestion of the face, vomiting, delirium, deafness, vertigo, convulsions, and coma. MENlilEE's DISEASE. M6ni&re's disease is an aifection of the semicircular canals, even extending into the vestibule. It was first described by M6ni6re, of Paris, as being due to an effu- sion of blood or an acute exudation into the semicircular canals. A great many cases of aural vertigo, which are due to the presence of a plug of cerumen in the external meatus or to disease of the middle ear, give rise to many symptoms of this disease and are erroneously classified as M4ni6re's disease. The name of M6ni6re's disease, however, should be limited to those cases in which there is a sudden effusion of blood into the semicircular canal, followed by deafness, giddiness, SOUND PERGEIVING APPARATUS. 367 great tinnitus, vertigo, a staggering gait, nausea, and vomiting. The patient may have some premonitory symptoms, such as those already mentioned, or may fall suddenly to the ground from loss of consciousness, which is followed in a short time by great pallor of the face, cold perspiration, extreme deafness and tinnitus, with an inclination to vomit and more or less vertigo on trying to walk. The disease is not confined to those who are in poor health, but it may attack strong and healthy individuals, who previously had not suffered from any ear disease. Occasionally, a patient may have some premonitory symptoms, such as slight dizziness, tinnitus, and some deafness, before the more serious symptoms manifest themselves. The cause of the disease is very obscure, some ob- servers attributing it to excessive heat of the sun. The deafness is usually very marked, so that the patient can only hear very loud sounds close to the ear. The watch and acoumeter cannot be heard by contact. Bone-conduction, as shown by tests with the tuning- fork, is very much impaired or lost altogether. If an examination of the ear be made at the time, the drum- head will usually be found normal, as well as the Eustachian tube. Even after the patient has recovered from the vomiting and the unconsciousness, the giddi- ness and staggering gait may persist and be very slow in disappearing, so that it may be some time before the patient can walk without a cane, and he is apt to incline his body to the affected side in walking. The disturb- ance of hearing generally remains, although there may be some improvement, while the tinnitus is often most distressing. The milder attacks of this disease are sometimes mistaken for biliousness, but a careful con- 368 MANUAL OF OTOLOGY. sideration of the symptoms already mentioned should make the differential diagnosis comparatively easy. Meniere's disease is sometimes suggestive of disease of the brain. In the latter, however, there are generally symp- toms denoting paralysis of other spinal or cerebral nerves, but it must not be forgotten that giddiness, vomiting, nausea, and tinnitus are symptoms quite characteristic of brain affections. I have already referred to a case of chronic purulent otitis media (in the chapter on In- tracranial Affections), in which the patient had all the symptoms of a cerebellar abscess, giddiness, vomiting, a staggering gait and choked disk, but who finally re- covered after proper drainage of the middle ears had been established by scraping away all granulations from the external meatus. A positive diagnosis can only be made of Meniere's disease if the surgeon knows that the patient, before the attack, had normal hearing, and, further, that an examination of the ear made a short time afterward shows the Eustachian tube to be pervious and the drumhead normal. In cases of long standing, the prognosis as to the deaf- ness is unfavorable, and it is only in recent cases that one can hope for even a little improvement. The treatment should consist in the use of cold com- presses to the head and the application of the Leiter coil about the ear. Calomel in small doses should be given to produce slight catharsis. Sinapisms should be ap- plied to the back of the neck and the calves of the legs. The patient should be kept absolutely quiet in bed and given a very light diet. Some observers recommend iodide of potash, while others, particularly Charcot, have found much benefit from the administration of quinine in rather large doses. Bromide of potash and SOUND-PEROEtVINO APPARATUS. 369 dilute hydrobromic acid in fifteen-drop doses are of service in relieving the giddiness. The best results seem to be attained from the injection of five or six drops of a 2 per cent, solution of pilo- carpine through the catheter into the tympanum, or from the hypodermic injection of the same remedy and in the same strength. This treatment should be con- tinued for a period of at least four weeks, and injections should be made hypodermically or the solution used through the catheter every other day during this time. The surgeon should be very cautious with this drug and should follow the directions already given. (See Chapter VIII.) Electricity is of but little service in this disease, and should never be used in the early stage for fear of in- creasing the tinnitus and giddiness. Especial attention should be paid to the patient's general health, particu- larly if there is a gouty or rheumatic diathesis. Tonics are indicated in cases where the general condition also demands them. MUMPS. Although disease of the middle ear may occur as a complication of mumps, as shown by the usual appear- ances of inflammation of the drum membrane, there are a certain number of cases in which the labyrinth is either primarily or secondarily involved. As a general rule, only one ear is implicated when the disease affects the labyrinth. The diagnosis is made from the occur- rence of sudden deafness with impairment or loss of bone-conduction, as shown by tests made with tuning- forks. Tinnitus is also a troublesome symptom at times. Much can be accomplished by the use of hypodermic 24 370 MANUAL OF OTOLOGY. injections of pilocarpine if the case be seen at an early date. As a general rule, however, these patients do not come to the aural surgeon for treatment until the deaf- ness has existed for a long time. The application of a blister behind the ear is of benefit in some cases. SYPHILIS. Syphilis affecting the labyrinth does not generally develop during the secondary stage when the skin is covered by an eruption or there is a throat affection, but is more apt to be observed during the third stage or even several months or years after the first inoculation, when no signs of syphilis can be discovered on the body. There may be a middle-ear catarrh or purulent inflam- mation at the same time. In many cases of syphilitic ear disease great thickening of the drumhead takes place, and fibrous bands are found within the tympanic cavity. In recent cases it is possible that there is a plastic exudation in the labyrinth, but this is not cer- tain. In a later stage the following abnormal appear- ances have been found, viz., condensation of the peri- osteum of the vestibule, fixation of the foot-plate of the stapes, and great infiltration of the different portions of the membranous labyrinth. The deafness, as a general rule, comes on very sud- denly, and is attended with considerable tinnitus. Pain is not usually complained of, but there are frequently more or less vertigo and disturbances of equilibration. An examination shows that the Eustachian tube may or may not be involved, according as there are throat symptoms. The drumhead is frequently found very much retracted, opaque, and thickened. The deafness is in most cases profound, and is more apt to affect both SOVND-PERCEIVING APPARATUS. 371 ears than one alone. The disease being confined mostly to the labyrinth, the watch and acoumeter are frequently not heard at all. While tests with tuning-forks show a very much diminished or even absent bone-conduc- tion, low tones are much better heard by aerial conduc- tion than high ones. A diagnosis is difficult in many cases unless there is a syphilitic history or there are evidences of the disease in other parts of the body, particularly the eye or the teeth. The suddenness of the attack is a suspicious point; but it must not be forgotten that the deafness may come on quite gradually. Hereditary syphilis is, I believe, much more frequent in children than is generally supposed. There may be middle-ear disease at the same time that the labyrinth is involved. Other symptoms characteristic of syphilis are opacity of the cornea, from interstitial keratitis, and peculiar changes in the teeth, Hutchinson's " pegged teeth," so-called. Autopsies made in the case of new- born children who were syphilitic have revealed more or less suppurative otitis media, with thickening of the drumhead and adhesions. There was more or less pus in the vestibule, the organ of Corti was destroyed, while the labyrinth was hypersemic and contained effusions of blood. The prognosis is, as a general rule, unfavorable, especially in the case of congenital syphilis and when the disease has existed for quite a period of time. It is only in the recent cases that one can hope for much improvement, and even in such, very often, there is but little change for the better. This does not mean that there should not be carried out a prompt and ener- getic treatment which must be kept up for some time. 372 MANUAL OF OTOLOGY. The treatment depends very much as to whether there is any manifestation of the disease in other parts of the body. lu some cases it is advisable to use mercury in addition to the iodide of potash. In prescribing the former, I generally advise using inunctions behind the ear over the mastoid process. The best results will generally be obtained from hypodermic injections of a 2 per cent, pilocarpine solution, gradually increasing the dose from four or six drops until the patient expe- riences the physiological effect of the drug. Great care should be taken in its administration on account of its depressing action. Boilermaker's deafness. The deafness observed in the case of boilermakers, who are subject to the incessant hammering inside of boilers, is due to an affection of the labyrinth. It has been suggested that there may be some loosening of the articulating joints of the ossicula from the loud vibrations, but from all the cases that have come under my observation, tests made with tuning-forks have demonstrated the fact that there was impaired bone- conduction, showing that the disturbance of hearing and tinnitus were not due primarily to middle-ear in- flammation, although in these patients one frequently finds evidence of catarrhal changes in the membrana tympani. There is very little that can be done in the way of treatment. If the disease is not far advanced, a change of occupation may occasion considerable improvement in the hearing. SOUND-PERCEIVINQ APPARATUS. 373 ACTION OF CERTAIN DRUGS. The continued use of certain drugs, such as quinine and salicylic acid, for a long time and in large doses, undoubtedly causes disturbances of hearing and tinnitus that may in some cases be permanent. It is supposed by some that the action of quinine upon the ear is similar to the effect produced on the retina, viz., anaemia. The common practice of "aborting a cold" by the administration of large doses of quinine is, in my opinion, an exceedingly bad one, and much injury to the hearing has been brought about by such treatment, especially in those who inherit a tendency to deafness and who are sufEerers from more or less middle-ear in- flammation. PRIMARY DISEASE OF THE BONY I^AB YRINTH tNE CAPSULE. Politzer,' under this heading, has described a disease which was formerly supposed to be a form of chronic adhesive otitis media, but which, from numerous autop- sies, he has proved to be due to a " circumscribed dis- ease of the bony labyrinthine cap8ule,"and, as a result, there is formed a neoplastic bony tissue which gradually takes the place of the normal bone, and finally, closing the foramen ovale, produces anchylosis of the stapes. At times the disease attacks the greater portion of the capsule, so that this same neoplastic tissue involves the foramen rotundum and extends toward the cavity of the labyrinth. Most of the patients observed by Politzer were totally deaf, and in only one case was 1 Archives of Otology, ]894, vol. xxiii. p. 255. 374 MANUAL OF OTOLOGY. bone-conduction for a loud-ticking watch retained. The ages varied from fifty-five to fifty-eight years, and the appearances of the drum membrane were such as are generally observed in the case of old people, viz., thick- ening of the drumhead with opacities, and, in some in- stances, atrophic changes. Besides the deafness, other symptoms noted were persistent tinnitus, which in some cases ceased when the deafness was profound, while in others it persisted ; occasional sensations of pain of a tearing nature ; dull and heavy feelings in the head, and vertigo. The sensations in the head and vertigo might have been due to the advanced ages of the patients. The disease could not be attributed to any particular cause, although gout, syphilis, and heredity probably played an important role. Politzer believes that this disease exists much more frequently than one is justified in assuming from the cases already reported, and further that it may produce serious deafness in young subjects. The treatment is very unsatisfactory, but Politzer is of the opinion that if a diagnosis can be made at an early period before the deafness is marked, the disease may be prevented from becoming any worse by the administration of large doses of iodide of potash, which should be kept up for a year or more, with stated intervals, when the drug should be discontinued. Any operations looking to the excision of the stapes should not be considered for a moment. DEAFNESS DUE TO OLD AGE. After middle life the ability to hear the notes of a Galton whistle or of the Konig rods becomes lessened, so that in testing the hearing power of persons of ad- SOUND-PERGEIVING APPARATUS. 375 vancing years one must make some allowance for the age of the patient. The otologist is frequently con- sulted by very old persons who complain of inability to hear conversation, although otherwise they enjoy ex- cellent health. Upon making an examination of the drumhead it will very likely be found thickened, retracted, and opaque, and in some cases atrophic, with evidences of implication of the labyrinth and auditory nerve. Very little encouragement should be given to such patients, for the prognosis is usually unfavorable. There may, however, be another cause for the impaired hearing, namely, collapse of the cartilaginous meatus, so that the anterior and posterior walls touch each other and leave but little space for the entrance of sound-waves. I have improved the hearing of such patients by introducing small silver tubes especially constructed for this purpose. DISEASES AFFECTING THE AUDITORY NERVE. Diseases affecting this nerve are, as a general rule, due to secondary causes, such as meningitis, cerebro- spinal meningitis, aneurism of the basilar artery, when there is apt to be more or less congestion of the neuri- lemma of the nerve. In purulent meningitis, and when there are extensive caries and necrosis of the temporal bone, the nerve is likely to be inflamed and infiltrated. Atrophy of the auditory nerve results from diseases of the brain and cerebellum, and occurs in certain cases in which tumors of the brain press upon the nerve, the latter disappearing altogether in some instances ; also from affections of the spinal cord, especially locomotor ataxia. 376 MANUAL OF OTOLOGY. NEW-GROWTHS AFFECTING THE INNEK EAR. New-growths affecting the labyrinth and auditory nerve generally have their origin in the cranial cavity or the middle ear. Cases have, however, been reported of primary sarcoma and of neuroma of the auditory nerve. The new-growths that are most frequently observed in the external meatus and tympanum which involve the petrous boue and inner ear are the epilhe- liomata and sarcomata. HYPERiESTHESIA ACUSTICA. Occasionally in neurasthenic or highly nervous indi- viduals, or those recovering from a long illness, certain sounds give rise to painful sensations in the ear. This same phenomenon is observed also in certain forms of sclerosis of the middle ear and in acute and chronic dis- eases of the middle ear and labyrinth. It is a curious fact that such patients are often extremely deaf. CHAPTEE XIV. DEAF-MUTISM. Deaf-mutism may be congenital or acquired — e. g., due to some disease affecting the ear soon after birlli. Heredity is one of the most frequent cause?, as well as consanguineous marriages. In many instances of con- genital deaf-mutism the hereditary tendency is traceable to some forefather, although occasionally children are born deaf who present no hereditary history whatever. Acquired deaf-mutism is usually due to some intra- cranial or general disease, such as meningitis, hydro- cephalus, cerebro-spinal meningitis, injuries of the audi- tory nerve from falls or blows, scarlatina, measles, typhus and typhoid fever, diphtheria, mumps, inflam- mation of the labyrinth, and syphilis. It is occasionally impossible to tell whether a case of deaf-mutism in an infant be congenital or acquired, for until the child is a year and a half old the defect in hearing is not noticed, so that the parents often believe that the child had good hearing up to a certain age, but that the deaf- ness came on suddenly. Anatomical investigations show that congenital deaf- ness is due to some arrest or defect in development of the temporal bone, such as bilateral atresia of the external auditory canal, imperfect development or absence of the tympanic cavity, defects in or bony closure of the fenestra rotunda, anchylosis of the stapes, and arrest of develop- ment of the labyrinth or auditory nerve. 378 MANUAL OF OTOLOGY. In acquired deaf-mutism, the principal anatomical changes are constriction of the external auditory canals of both sides occurring in early life, which usually is due to a severe attack of diphtheria or scarlatina in which there has been a purulent inflammation of the middle ear, followed by extensive caries and necrosis of the temporal bone. Other causes are the formation of adhesions with anchylosis of the ossicula, and certain changes in the labyrinth and auditory nerve from the general diseases already mentioned. A baby brought to my observation a short time ago, although he had learned to say a few words, had gradually lost all power of speech and hearing. On closely questioning the mother, it was ascertained that the child had had a fall from a baby-carriage some months previously. Children are, as a rule, apt to be dumb if the deaf- ness comes on during the first three or four years of life, and even later. If the child be bright and intel- ligent, and have already learned to read, dumbness may be prevented if the parent or guardian show very watchful attention. Children who lose their hearing after seven years of age are scarcely ever dumb. In testing the hearing of a child that is deaf and dumb the surgeon should stand behind the child, ^here he cannot be observed, and then either clap his hands or blow a shrill whistle or trumpet. If the child hear any sound whatever he will naturally turn his head in the direction from which it comes. By some expression of the face the child will often demonstrate to the surgeon whether he hears low or high tuning-forks when they are placed on the mastoid process and other portions of the skull. If it seems certain that some perception of sound exists, the surgeon DEAF-MUTISM. 379 should test each ear separately to see if the patient hear vowel sounds and speech. As to the prognosis, it is more favorable in congenital deaf-mutism than in the acquired form. Occasionally, but very infrequently, some improvement occurs in the case of congenital deaf-mutism, while in profound deaf- ness which has followed an attack of scarlet fever, diph- theria, or some intracranial disease a change for the better is seldom observed. Teeatmbnt. If, in a case of deaf-mutism, the drumheads are retracted, thickened, and present other changes of a catarrhal character, or the Eustachian tubes are constricted so that the air does not easily enter the tympanic cavities, the surgeon should inflate the ears by Politzer's method or by catheterization, while the same general treatment should be carried out as has been indicated in the chapter on chronic catar- rhal otitis media. If the external auditory canals have become very much contracted from suppurative inflam- mation of the middle ear, which has been due to scarlet fever or diphtheria, an attempt should be made to dilate the canal and to treat the case on general surgical prin- ciples according to the indications. When the labyrinth has become involved owing to cerebro-spinal meningitis or some other disease, the patient should be given strychnine or other nerve tonics, and strict attention should be paid to the patient's general health. Iodide of potash is indicated in some cases, especially of a syphilitic character. Pilocarpine is a remedy that should be tried if the patient's general health is good and the deafness has been acquired and is due to labyrinthine disease. It is most important to administer this drug very 380 MANUAL OF OTOLOGY. cautiously, on account of its depressing action on the heart, and for a period of at least six weeiis. In a case^ of extreme deafness in an adult, caused by typhoid fever, in which the patient was unable to hear the voice through a speaking-trumpet with one ear, it was necessary to give pilocarpine hypodermatically for a period of six weeks before any marked improvement took place. It is wiser to discontinue the treatment for a few days if the patient becomes very weak. INSTEUCTION AND EDUCATION OF DEAF-MUTES. There are two methods or systems by which deaf- mutes are educated, one the so-called French system of instruction, consisting in an artificial finger-alphabet, with a series of signs and gestures, and the other the pure oral or German method, which consists in the employment of articulate speech and lip-reading. At the International Congress held at Milan in 1880 it was the unanimous opinion that the German method was the better one, and at the present time lip- or speech-read- ing is generally taught not only in Europe, but also in the United States, to the exclusion of the sign language. The German method necessitates great skill and patience on the part of both teacher and pupil. In order to become proficient in lip-reading, it is first of all necessary that the child possess ordinary intelligence and noruial vocal organs. A child who is a congenital deaf-mute should be at least seven years of age before such instruction is begun, and, in order to be able to understand and communicate perfectly with others, this teaching should be continued for seven or eight years. 1 Bacon : New York Medical Journal, July 24, 1897. DEAF-MUTISM. 381 Some deaf-mutes are taught to speak very distinctly, while with others it is almost impossible to understand what they say. As it is difi&cult for the deaf-mutes to modulate the voice, there is often an unpleasant harsh- ness of speech. The French system is occasionally employed in the case of deaf-mutes who are deficient in intelligence and who cannot master the oral method. It is often im- possible to teach lip-reading to those who have been deaf for many years and who are accustomed to using signs. When a child has suddenly become deaf from some general disease, such as scarlet fever or diphtheria, it is important for the patient himself to read aloud for an hour or two each day in order not to lose the art of speech. For all who have recently become deaf, and who cannot be cured by treatment, whether children or adults, an attempt should be made at once to teach lip-reading, provided, of course, the child be old enough. When speech has once beea acquired it is much easier to instruct the patient than when the deaf- ness is congenital. The German method, or the science of lip, speech, or expression reading, consists in teaching the deaf-mutes to watch the lips and tongue as well as to produce first of all the simple articulate sounds, and eventually the more complex ones. After being instructed in all the sounds necessary to the language, the pupil is then taught how to form words, and the meaning of such words is conveyed to the child by means of pictures, models, etc. The use of signs should be prohibited, for otherwise the pupil will not be apt to master the German method, since the 382 MANUAL OF OTOLOGY. former is much easier to learn than the latter and re- quires much less patience and perseverance on the part of the patient. The general education of the child should be carried on at the same time. An intelligent and observing pupil soon learns to notice not only the movement of the lips, but also the position of the tongue, the general shape of the mouth, and the facial expression. He also watches the brow expression, the twinkle in the eye, and the involuntary movement of the head. A great many persons of a neurasthenic tempera- ment, and who are quite deaf, owing to chronic catarrhal otitis media, and who consequently are unable to take part in general conservation, occasionally become morose aud despondent. These unfortunate patients, after receiving instruction in lip- or speech-reading, are often enabled to resume business and to become again useful members of society, while the feeling of despondency and isolation gives place to renewed interests and am- bitions. EAE-TEUMPETS AND OTHER AIDS TO HEAEING. Ear-trumpets are of service in certain forms of deaf- ness, more especially when due to chronic catarrh of the middle ear, in which the drumhead and ossicular chain are present. In those cases in which the labyrinth is affected and the function of the auditory nerve is com- pletely destroyed, an ear-trumpet is generally useless. As the object of the hearing instrument is to collect the sound-waves and conduct them to the auditory appa- ratus, it stands to reason that the efficiency of the in- strument depends on the surface by which the sound- waves are collected and reflected to the drumhead. DEAF-MUTISM. 383 When two persons desire to carry on a conversation, the best instrument for this purpose is the " conversa- tion-tube," Fig. 108, consisting of a tube about four Fig. 108. Conversation-tube, feet in length, with a bone tip at one end for insertion into the external meatus, while at the other end there is a mouth-piece, shaped like a cup. In talking into the mouth-piece, the person speaking should hold the mouth Fig. 109. Ear-trumpet. close to it, and should at first speak in an ordinary tone of voice, for loud sounds spoken through the tube are sometimes distressing to the patient and cause giddiness. 384 MANUAL OF OTOLOGY. For the purpose of hearing at greater distances various trumpet-shaped instruments have been devised (Fig. 109). As the external meatus occasionally becomes irritated from inserting the conical end in the canal, an otophone has been constructed (Fig. 110), whereby this annoyance is prevented. The sound-waves in this in- FiG. no. Otophone. strument are transmitted through a rubber disk which is tightly stretched. Very small trumpets are useless, as well as the various tubes which are introduced into the canal. There is an exception to this rule, and that is in the case of a collapsed meatus, a subject already referred to. In aged persons the walls of the meatus sometimes collapse, so that it is difficult for the sound- waves to be transmitted to the drumhead. In such cases a silver tube is useful in holding the walls of the meatus apart. Rhodes' audiphone consists of a flexible, fan- shaped plate of vulcanite which has been lacquered and which has a handle attached. By pressing the upper border of the instrument against the upper incisor and canine teeth, a curved surface is presented, with the convexity forward. The sound-waves are collected by the audiphone and carried through the teeth and bones of the skull to the internal ear. This instrument has DEAF-MUTISM. 385 a very limited use, and is never recommended unless the patient has a good set of teeth. Politzer has devised an instrument the " principle of which depends upon the vibration of the cartilagi- nous plate of the auricle being transmitted by an elastic sound-conductor to the membrana tympani." It con- sists of a narrow drainage-tube, 4 to 5 mm. long and 2 mm. thick ; one end, which is clipped, being brought into contact with the drumhead, while the other end, which lies in the concha, is in contact with the cartilage of the auricle. The effectiveness is increased by having a round rubber plate near its outer end. The instru- ment is of most benefit in cases of middle-ear catarrh when the membrana tympani is flaccid, but is useless in cases of rigidity and anchylosis of the ossicula. 25 INDEX. A BSCESS of brain, 316 il cerebellar, 326 cerebral, 822 extradural, 319 intradural or cerebral, 322 subdural, 318 temporo-sphenoidal, 325 Acute circumscribed inflamma- tion of tbe external auditory canal, 101 diffuse inflammation of the ex- ternal auditory canal, 98 Adenoid growths, 157 causation of, 160 diagnosis of, 160 symptoms of, 159 treatment of, 160 Adenoids, excision of, causing hemorrhage, 164, 166 followed by mastoid disease, 165 improvement in hearing after, 166 removal of, steel finger-nail for, 164 Alcohol treatment in chronic purulent otitis media, 236 Allen's foreign-body forceps, 118 Ampulla, 44 Ana;mia of labyrinth, 363 causes of, 363 symptoms of, 363 treatment of, 363 Angiomata, 256 Annulus tympanieus, 22 Antihelix, 18 Antitragus, 19 Antrum, disease of, excision of ossicles in, 309 guide for opening the, 302 mastoid, 30 Aphasia, 325 Aquseductus cochlese, 46 Fallopii, 30 vestibuli, 44 Artery forceps, 299 Artificial leech, 151 Asch's compressing forceps, 186 operation, 185 scissors, 185, 186 separators, 185 tubes, 186 Atheroma of auricle, 95 Attic, 30, 32, 142 acute inflammation of, 142 Attollens aurem muscle, 19 Attrahens aurem muscle, 20 Auditory canal, external, 97, 106 diseases of, 97 eczema of, 109 foreign bodies in, 115 furunculosis of, 101 herpes zoster of, 109 inflammation of, acute cir- cumscribed, 101 diffuse, 98 chronic diffuse, 99 croupous, 105 diphtheritic, 105 malformation of, 97 operation for, 97 normal, appearance of, 63 polypi of, 109 sebaceous tumors of, 110 seborrhoea of, 109 syphilis of, 106 nerve, 50 diseases affecting the, 375 causes of, 375 Auricle, 50 abscess of, 95 atheroma, 95 388 INDEX. Auricle, blood-supply of, 24 congenital deformities of, 85 cysts of, 89 deformity of, from chronic eczema, 92 deposition of urates in, 95 dermatitis of, 90 dermoid cysts of, 95 description of, 18 eczema of, 92 erysipelas of, 90 erythema of, 95 fibroma of, 95 frost-bile of, 91 function of, 50 herpes zoster of, 95 hypersemia of, 89 injuries of, 85 keloid of, 95 lupus of, 95 malformations of, 83 operation for, 83 malignant growths of, 95 moUuscum fibrosum of, 95 myxofibroma of, 95 nervous distribution of, 25 ossification of, 95 porrigo contagiosa of, 95 sebaceous cyst of, 95 syphilitic diseases of, 96 tinea tonsurans of, 95 tumors of, 95 BISTOUBY for incising drum- head, 154 _ Blake's Eustachian catheter, 73 middle-ear syringe, 239 operating otoscope, 60 paper disks, 247 polypus snare, 261 rubber spring, 207 tuning-fork, 80 Blood-clot in mastoid disease, 305 -supply of auricle, 24 of external meatus, 25 of tympanum, 34 Boilermaker's deafness, 372 causes of, 372 Boucheron's speculum, 59 Brain, abscess of, 322 causes of, 322 Brain, course of, 330 diagnosis of, 331 pathology of, 316 prognosis of, 331 symptoms of, 324 treatment of, 331 venous supply of, 337 Brunton's otoscope, 68 CANAL, extern? 1 auditory, 97 Carcinoma of temporal bone, 148 Caries of posterior bony wall of external meatus, 312 Carotid artery, 274 Catarrh, 174 chronic, 174 atrophic, 177 danger of forcible infla- tion in, 178 treatment of, 178 hypertrophic, 175 causes of, 175 symptoms of, 176 treatment of, 177 nasopharyngeal, 178 causes of, 179 symptoms of, 179 treatment of, 179 Cat's ear, 83 Cerebellar abscess, 326 pathology of, 318 prognosis of, 330 symptoms of, 326 treatment of, 335 Cerebral abscess due to acute otitis media, 322 facial paralysis due to, 328 percussion of skull in, 326 with chills and high temper- ature, 324 fossa, middle, large carious opening in, 266 Cerumen inspissatum, 110 diagnosis of. 111 prognosis of, 112 symptoms of, 111 treatment of, 112 Cholesteatomatous masses in the attic, 310 Chorda tympani nerve, 32 INDEX. 389 Chronic diffuse inflammation of external auditory canal, 99 Clicking tinnitus, 223 Cochlea, 44 cupola of, 45 Colin's nasal speculum, 67 Concha, 19 Conversation-tube, 383 Corti, membrane of, 47 organ of, 47 Cotton-carrier, aluminium, 62 Crista helicis, 19 vestibuli, 44 Croupous inflammation of ex- ternal auditory canal, 105 Cupping-glass, 152 Curette forceps, 61 DEAF-MUTISM, 377 causes of, 377 pathology of, 377 prognosis of, 379 treatment of, 379 Deafness due to collapse of carti- laginous meatus, 375 due to old age, 374 from quinine, 135 prognosis of, 375 Decalcified chicken-bone drain- age-tube, 335 Dermatitis of auricle, 90 treatment of, 90 Dermoid cysts of auricle, 95 Diagnostic tube, 68 Differential diagnosis between perichondritis auriculae and hsematoma, 88 Diphtheritic cast from the mid- dle ear, 288 inflammation of the external auditory canal, 105 Disease of middle and internal ears from mumps, 369 diagnosis of, 369 treatment of, 370 Drumhead, bistoury for incising, 154 danger of rupturing from forci- ble inflation, 76 perforation of, 247 Drumhead, treatment of, 247 by nitrate of silver, 247 by paper disks, 247 by scarification, 247 rupture of, from diving, 125 Dry method of treatment in chronic purulent otitis media, 235 EAE, anatomy of, 17 -cough, 120 external, 18 foreign bodies in, 115 persistent cough due to, 116 prognosis of, 116 symptoms of, 115 treatment of, 116 internal, 42 affections of, 357 diseases of, 357 causes of, 357 diagnosis of, 361 due to injuries, 359 due to micro-organisms, 358 prognosis of, 360 symptoms of, 359 middle, danger of removal of polypi from, 317 dry catarrh of, 190 examination of, 68 granulations of, 253 treatment of, 259 by sharp curette, 259 inflammation of, chronic purulent, 224 inflation of, Gruber's method, 72 Politzer's method, 09 Valsalvian method, 69 polypi of, 253 diagnosis of, 257 prognosis of, 258 symptoms of, 256 treatment of, 259 by avulsion, 262 by galvano-cautery, 263 with polypus snare, 261 varieties of, 254 angiomata, 254 390 INDEX. Ear, middle, polypi of, varieties of, fibromata, 254 mucous, 254 myxomata, 254 physiology of, 17 syringe, 112 syringing of, basins for, 113,114 Eczema, 93 artificial, from use of improper ear drops, 93 intertrigo in children, 92 of auricle, 92 symptoms of, 92 treatment of, 93 varieties of, 92 of external auditory canal, 109 Electric light and portable bat- tery, 56 motor and rheostat, 57 Electricity in Meniere's disease, 369 Erysipelas of auricle, 90, 95 causation of, 90 treatment of, 91 a complication of acute puru- lent otitis media, 146 Ether instead of chloroform in mastoid operations, 298 Eustachian catheter, 73 Blake's, 73 obstacles to introduction of, 76 tube, 35 blood-supply of, 39 catheterization of, 72 examination of, 68 of orifices of, 174 functions of, 52 narrowing of, 210 diagnosis of, 210 treatment of, 211 by bougies, 211 osseous, 37, 40 stricture of, 210 Exostoses of external meatus, 120, 122 diagnosis of, 123 treatment of, 123 External auditory canal, 21, 97, 106 ear, 18 meatus, 21, 120 Extradural abscess, 319 pathology of, 319 symptoms of, 319 treatment of, 320 UACIAL nerve, 41 r paralysis of central origin, 276 due to extradural abscess, 320 due to injury or middle-ear disease, 275 due to malignant disease, 148 Fenestra ovalis, 43 Fibroma of auricle, 95 Fibromata, 182, 255 diagnosis of, 182 symptoms of, 182 treatment of, 183 Fibro-mucons polypi, 181 symptoms of, 181 treatment of, 181 Fissures of Santorini, 21 Fistula auris congenita, 85 Foramen, stylo-mastoid, 30 Forceps, foreign-body, 62 Fossa of antihelix or fossa sca- phoidea, 19 subarcuata, 278 Fovea hemisphaerica, 43 Frog-face, due to a fibroma in nasopharynx, 182 Frost-bite of auricle, 91 treatment of, 91 Furunculosis of external auditory canal, 101 rt ALTON whistle, 81, 374 U Ganglion spirale, 46 Gottstein curette, 163 Gradle forceps, 163, 164 Gruber's method of inflation of middle ear, 72 speculum, 58 tenotome, 215 HEMATOMA, appearances of, 86 auris, or othsematoma, 86 causes of, 86 -INDEX. 391 Hsematoma, deformity resulting from, 87 treatment of, 87 Hearing distance, 77 tuning-fork for testing the, 79 watcli for testing the, 77 Helix, 18 Hemorrhage after excision of tonsils, 171 causes of, 364 from ear, 120 into labyrinth, 363 Herpes zoster of auricle, 95 of external auditory canal, 109 Hewitt's apparatus for washing out the attic, 240 incus-hook, 243 Hooper's forceps, 168 method of removing adenoids, 162 Horsley's instrument for explor- ing brain, 333 Hydrops ex vacuo, 1 36 Hyperaemia of auricle, 89 treatment of, 89 of kbyrinth, 362 causes of, 362 diagnosis of, 363 symptoms of, 362 treatment of, 363 \ Hypersesthesia acustica, 299, i 376 Hyperostoses of external meatus, 122 TNCISURA intertragica, 19 I Infarctions due to sinus throm- bosis, 342 Inflation, forcible, danger of rup- ture of drumhead from, 76 Influenza a cause of mastoid dis- ease, 282, 283, 285 Ingrowing hairs in external meatus, 119 Inspissated cerumen, 110 Internal ear, 42 Intracranial complications, 316 Iodoform gauze as a dressing in mastoid disease, 303 TACOBSON'S nerve, 35 u Jugular fossa, 274 KELOID of auricle, 95 Knife for incising membrana tympani and for dividing adhesions, 242 Konig rods, 81, 361, 376 Kiister's method, 312 T ABYEINTH, 42, 362 Li anaemia of, 363 blood-supply of, 49 concussion of, due to injury, 127 disease of, due to action of drugs, 373 hemorrhage into, 363 hyperaemia of, 362 inflammation of, 365 membranous, 48 syphilis of, 370 Labyrinthine disease due to ac- tion of drugs, 373 Lamina spiralis, 45 membranous, 45 osseous, 45 Laminated epithelial plugs, or keratosis obturans. 111 Leiter coil, 290 Leiter's electric lamp, 57 Leptomeningitis, 352 acute, due to cerebral abscess, 330 purulent, 353 diagnosis of, 354 prognosis of, 354 symptoms of, 353 treatment of, 354 serous, 352 Levator palati muscle, 39 Ligamentum epirale, 47 Ligation of infernal jugular vein, 347, ,351 Lobule, 19 cleft, due to wearing brass ear- rings, 86 Lofiler bacillus in middle-ear dis- ease, 288 Luqa^'s pressure probe, 207 392 INDEX. Lupus of auricle, 95 Luschka's tonsil, 159 Lymphatics of scalp, 332 MACEWEN'S burrs, 801 Mackenzie's bull's-eye lens and reflector, 55 tonsillotome, 170 Macula acustica, 48 Malignant disease a cause of acute purulent otitis media, 147 Malleus, excision of handle of, 213 fracture of handle of, 129 short process of, 63 Masseur of Delstanche, 65 Mastoid abscess in children, 287 antrum, 30, 274, 279 cells, inflammation of, acute, due to acute purulent oti- tis media, 281 causes of, 282 course of, 285 micro - organ- isms in, 287 prognosis of, 286, 289 s-ymploms of, 283 treatment of, 289 primary acute inflamma- tion of, 280 causes of, 280 differential diagnosis of, 281 prognosis of, 281 symptoms of, 280 treatment of, 281 disease, blood clot in, 305 due to chronic purulent otitis media, 306 causes of, 307 diagnosis of, 309 prognosis of, 309 symptoms of, 307 treatment of, 309 danger from use of blisters in, 291 diagnostic symptoms of, 285 Mastoid disease due to diabetes, 311 due to exantnematous dis- eases, 291, 292 due to removal of adenoid growths, 294 due to teething, 294 early operation in, 285 facial paralysis in, 286, 306 following excision of ade- noids, 165 free incision of drumhead in, 284, 289, 291 iodoform-gauze dressing in, 303 micro-organisms in, 287 secondary operation in, 304 operations, injury to dura in, 302 _ _ to sigmoid sinus in, 302 line of incision in, 390 periosteum, inflammation of, primary, 279 causes of, 279 symptoms of, 279 treatment of, 280 by artificial leech, 280 by Leiter coil, 280 process, 39, 272 acute inflammation of, 281 anatomy of, 274 in children, 276 danger of delay in operations on, 297 diploetic variety of, 41, 278 diseases of, 272 pneumatic diploetic variety of, 278 varieties of, 40, 278 primary acute inflammation of, 280 sclerosed, 311 treatment of, 311 sequestra from, 269 tip, tenderness on pressure over, 297 vein, 275, 338 Mastoiditis externa, 279 interna, 280 Masto-squamosal suture, 287 Matthieu tonsillotome, 170 Mayer tubes, 187 INDEX. 393 Meatus, external, adhesions of, 120 blood-supply of, 24 contractions of, 120 exostoses in, 120, 122 hyperostoses in, 122 ingrowing hairs in, 119 isthmus of, 25 nervous distribution of, 25 or external auditory canal, 21 Membrana basilaris, 47 tectoria, 47 tympani, 27, 63 anterior folds of, 64 artificial, 245 opening in, 213 flaocida, or Shrapnell's mem- brane, 28 injuries of, 125 diagnosis of, 127 prognosis of, 127 treatment of, 127 normal, 27 posterior folds of, 64 progressive growth of der- moid layer of, 221 section of posterior folds of, 214 vibrans, 64 Membrane of Corti, or mem- brana tectoria, 43 flaccid, or Shrapnell's mem- brane, 64 of Keissner, 47 Membranous labyrinth, 48 Meniere's disease, 366 causes of, 367 prognosis of, 368 symptoms of, 367 treatment of, 368 Meyer's annular knife for exci- sion of adenoid growths, 161 Micro-organisms in acute puru- lent otitis media, 153 Microtia, 83 Molluscum fibrosum of auricle, 95 Mouth breathing due to adenoids, 159 Mucous polypi of middle ear, 254 Mumps, 369 Muscle, attollens aurem, 19 attrahens aurem, 20 Muscle, levator palati, 39 of auricle, 19 retrahens aurem, 20 stapedius, 34 tensor palati, 38 tympani, 31, 33 Myringitis, acute, 124 symptoms of, 124 treatment of, 125 chronic, 125 symptoms of, 125 treatment of, 125 Myxofibroma of auricle, 95 Myxomata, 256 NASAL passages, appearance of normal, 66 diseases of, 157 polypi, 180 . treatment of, 180 septum, cartilaginous, deviation of, 183 diagnosis of, 184 symptoms of, 183 treatment of, 184 Nasopharynx, 134 appearance of normal, 66 digital examination of, 134 Nerve, auditory, 50 chorda tympani, 32 -deafness, 357 facial, 41 Jacobson's, 35 Nervous distribution of auricle, 25 of external meatus, 25 of tympanum, 35 New growths affecting the inner ear, 376 Nose, examination of, 171 OSSEOUS erosion of tympanic roof, 316 meatus, 22 Ossicles, or ossicula, 31 excision of, 212, 215, 249 Ossification of auricle, 95 Otalgia, 222 Otheematoma, 86 Otitis externa circumscripta acu- ta, 101 394 INDEX. Otitis externa circumscripta acu- ta, causes of, 101 diagnosis of, 102 symptoms of, 101 ! treatment of, 102 crouposa, 105 diffusa acuta, 98 causes of, 98 symptoms of, 98 treatment of, 100 chronica, 99 diphtheritica, 105 hsemorrhagica, 104 interna or inflammation of laby- rinth, 365 causes of, 365 diagnosis of, 366 media acuta, or acute inflam- mation of middle ear, 129, acute catarrhal, 129 purulent, 139 j catarrhalis acuta, 129 i appearance of membrana; tympani in, 133 causation of, 130 symptoms of, 131 treatment of, 133 chronica, 190 exudative variety of, ' 190 sclerotic variety of, 190 adhesions in, 192 1 anchylosis of ossi- cles in, 193 appearances of mem-; brana tympani in, 195 atrophic changes of drumhead in, 197 causes of, 195 diagnosis of, 200 heredity in, 194 obliteration of attic in, 192 prognosis of, 201 symptoms of, 197 treatment of, 204 subacuta, 136 treatment of, 136 chronic catarrhal, 190 purulent, 224 purulenta acuta, 139 Otitis media purulenta acuta, ap- appearances of mem- brana tympani in, 141 complications of, 144 course of, 144 diagnosis of, 147 etiology of, 140 free incision in, 153 micro-organisms in, 153 pathology of, 139 permanent disturbances of hearing in, 145 prognosis of, 149 symptoms of, 143 treatment of, 151 use of powders in, 153 chronica, 224 anatomical appearances of, 225 appearances of external auditory canal in, 228 of membrana tympani in, 228 character of discharge in, 232 diagnosis of, 232 perforation in Shrap- nell's membrane in, 230 prognosis of, 232 symptoms of, 226 treatment of, 233 by Blake's middle- ear syringe, 239 by excision of carious ossicles, 240 by Hewitt's appara- tus, 240 by caustic applica- tions, 238 by instillation of alco- hol, 236 of astringent solu- tions, 234 by insufflation of pow- ders, 235 by sharp spoons, 238 by syringing thrfluffh Eustachian tube, 234 by wick method, 237 INDEX. 395 Otitis media, subacute catarrhal, 136 Otoliths, 49 Otomycosis, 106 aspergillus flavus, 107 fumigatus, 107 niger or nigricans, 106 etiology of, 107 symptoms of, 108 treatment of, 108 Otophone, 384 Ozsena, 384 treatment of, 178 PAEACUSIS Willisiana, 199 I Parietal clot, 340 Parotiditis due to inflammation of external meatus, 273 Perichondritis auriculae, 87 appearances of, 87 deformity resulting from, 88 treatment of, 88 Petroso-squamosal suture, 29, 305, 317 Pharynx, appearance of normal, 66 Plexus, tympanic, 35 Pneumococci a cause of mastoid disease, 349 Pneumonia a complication of mastoid disease, 292 Politzer's bag, 72 eyelet, 214 forceps, 242 head-mirror, 54 method of inflation of middle ear, 69 of removing fluid from tym- panum, 138 periosteal elevator, 299 ring-knife, 259 sharp spoons, 238 speculum, 59 Polyotia, 83 Polypi, fibro-mucous, 181 mucous, 180 nasal, 180 of external auditory canal, 109 of nasopharynx 181 Porrigo contagiosa of auricle, 95 Primary disease of bony laby- rinthine, capsule, 373 symptoms of, 374 treatment of, 374 Processus cochleariformis, 34 Promontory, 29 Prussak's space, 32, 33 Pyaemia, 355 causes of, 355 symptoms of, 356 Pyramid, 30 RAEEFACTEUR or masseur of DeLstanche, 65 Eecumbent method of removing adenoids, 162 Eeid's base line, 336 Eeissner, membrane of, 47 Eetrahens aurem muscle, 20 Ehinitis, 175 atrophic, 177 chronic atrophic, 177 nasopharyngeal, 178 hypertrophic, 175 Ehinoscopy, anterior, 171 posterior, 173 mirror for, 67 Ehodes' audiphone, 384 Einne's test, 81 Eivinian segment, 23 Eongeur forceps, 336 OACCULE, 49 kJ Saline solution, normal, 352 Scala tympani, 45 vestibuli, 45 Scarificator, 151 Schwartze's chisels and gouges, 300 Sclerotic otitis media, 190 Sebaceous cyst of auricle, 95 Seborrhoea of external auditory canal, 109 Semicircular canals, 44 functions of, 51 Septicaemia, 355 causes of, 355 symptoms of, 356 Sero-mucous catarrh, 1 36 prognosis of, 137 396 INDEX. Sero-mucous catarrh, symptoms of, 137 treatment of, 137 Sharp curettes, 259 spoons, 301 Shrapnell's membrane, 28, 64 perforation in, 230, 239 Siegle's pneumatic speculum, 65 Sigmoid groove, defects in, 278 sinus, 338 knee or anterior convexity of, 338 Sinus thrombosis due to acute otitis media, 347 re-establishment of blood- current in, 351 time to operate in, 346 Sound-conducting apparatus, 17 -perceiving apparatus, 17 Spina suprameatum, 42 Stacke operation, 313 modifications of, 315 Stapedectomy, 217 alarming symptoms following, 219 Stapedius muscle, 34 Stapes, excision of, 217 Steel finger-nail for removing adenoids, 164 Sterilizer, 298 Streptococci in brain abscess, 335 in sinus thrombosis, 347 Stylo-mastoid foramen, 30 Sulcus spiralis, 47 Suppurative leptomeningitis due to osseous erosion, 317 Suture, petroso-squamosal, 29 Symptoms of Meniere's disease due to middle ear disease, 368 Syphilis of external auditory canal, 106 of labyrinth, 370 diagnosis of, 371 prognosis of, 371 symptoms of, 370 treatment of, 372 Syphilitic diseases of auricle, 96 TEETHING, a cause of acute purulent ostitis media, 146 Tegmen tympani, defects in, 275 Temporal bone, caries of, 264 cholesteatoma of, 250 diagnosis of, 251 pathology of, 250 symptoms of, 251 treatment of, 252 necrosis of, 264 causes of, 264 frequency of involvement of different portions, 287 prognosis of, 268 symptoms of, 267 treatment of, 269 Temporo-sphenoidal abscess, 322 causes of, 323 prognosis of, 331 symptoms of, 324 treatment of, 331 Tenotomy of tensor tympani mus- cle, 214 Tensor palati muscle, 38 Thrombosis of sigmoid and other sinuses, 336 course of, 342 diagnosis of, 346 different types of, 345 pathology of, 318, 341 prognosis of, 349 symptoms of, 343 time to operate, 346 treatment of, 349 Thrombus, 339 obstructing, 340 primary or marasraic, 339 causation of, 339 secondary or infective, 339 causes of, 340 micro-organisms in, 340 Tinea tonsurans of auricle, 95 Tongue depressor, 173 Tonsils, enlarged, 167 cause of, 167 symptoms of, 167 tonsillotomy for, 169 treatment of, 168 excision of, hemorrhage from, 171 Toxic effects of iodoform gauze, 335 Toynbee's artificial membrane, 245 Tragus, 19 INDEX. 397 Treatment of acute circumscribed inflammation of external auditory canal, 102 diffuse inflammation of ex- ternal auditory canal, 100 inflammation of mastoid cells occurring in connection with acute purulent otitis media, 281 of adenoid growths, 160 of adhesions and contractions of external meatus, 121 of ansemia of labyrinth, 363 of brain abscess, 331 of caries and necrosis of tem poral bone, 269 of cerebellar abscess, 335 of cerumen inspissatum, or in- spissated cerumen, 112 of cholesteatoma of temporal bone, 252 ofchronic atrophic catarrh, 178 hypertrophic catarrh, 177 nasopharyngeal catarrh, 179 of deaf-mutism, 379 of dermatitis of auricle, 90 of deviation of cartilaginous nasal septum, 184 of disease of middle and in- ternal ear due to mumps, 370 of eczema of auricle, 93 of enlarged tonsils, 168 of erysipelas of auricle, 91 of exostoses of external meatus, 123 of extradural abscess, 320 of facial paralysis due to caries of temporal bone, 271 of fibroma of auricle, 95 of fibromata of nasopharynx, 183 of fibro-mucous polypi of naso- pharynx, 181 of foreign bodies in ear, 1 1 6 of frost-bite of auricle, 91 of furunculosis of external au- ditory canal, 102 of granulations of middle ear, 259 of hsematoma auris or othema- toma, 87 of hypersemia of auricle, 89 Treatment of hypersemia of la- byrinth, 363 of increased pressure of laby- rinthine fluid, 365 of injuries of membrana tym- pani, 128 of leptomeningitis, 354 of mastoid disease in connec- tion with chronic purulent otitis media, 309 of Meniere's disease, 368 of myringitis, acute, 125 chronic, 125 of narrowing and stricture of Eustachian tube, 211 of nasal polypi, 180 of otitis externa circumscripta acuta, 102 diffusa acuta, 100 media, catarrh alls acuta, 133 chronica, 204 subacuta, 136 purulenta acuta, 151 chronica, 233 of otomycosis, 108 of ozsena, 178 of perforation of drumhead, 247 in Shrapnell's membrane, 230, 239 of perichondritis auriculae, 88 of polypi of middle ear, 259 of primary acute inflammation of mastoid cells, 281 disease of bony labyrinthine capsule, 374 inflammation of mastoid peri- osteum, 280 of sclerosed mastoid process, 311 of sebaceous cyst of auricle, 95 of sero-mucous catarrh, 137 of syphilis of labyrinth, 372 of temporo-sphenoidal abscess, 331 of thrombosis of sigmoid and other sinuses, 349 of tumors of auricle, 95 Trephining for abscess in temporo- sphenoidal lobe, 333 for cerebellar abscess, 336 398 INDEX. Tubal catarrh, 136 Tumors, sebaceous, of external auditory canal, 109 Tuning-fork, Blake's, 80 -forks for testing hearing dis- tance, 79 Tympanic cavity, 26 epithelial masses in, 250 plexus, 35 Tympanotomy, exploratory, 220 Tympanum, blood-suppl'y of, 34 description of, 26 nervous distribution of, 35 UMBO, 63 Urates, deposition auricle, 95 Utricle, 48 of, in yALSALVIAN method of in- T flation of middle ear, 69 Vestibule, 43 Vicarious menstruation, 120 Villate's solution, 269 Viola tricolor in treatment of acute eczema, 93 Volkmann's spoon, 334 WATCH for testing hearing distance, 77 Weber's test, 82 White erysipelas of scalp a com- plication of mastoid disease, 295 yONA arcuata, 48