>1M', V » "II f 1 ! '* ai|)8 (■'./Y'Vl'd. w It I AGE Foreign Bodies from without 299 Inanimate objects in the ear. Cases. Animate objects in the ear. Cases. Treatment. Foreign bodies in the Eustachian tube and middle ear. Removal of foreign bodies from the ear. Chapter III. Results op Inflammation and Injury. Results of Inflammation 315 Chronic circumscribed ulceration in the external auditory caual. Etiology and treatment. Cholesteatomatous tumors in the auditory canal. Treatment. Exostoses in the canal. Etiology. Osseous closureof the auditory canal. Etiology and treatment. Cutaneous closure of the auditory canal. SesuUs of Injury 336 Epileptiform manifestations from irritation in the auditory canal. Ear-cough — nature and history. Dr. Fox's conclusions. Bleeding from the meatus externus. SUCTION IV. MEMBRA NA TYMPANI. Chapter I. Acute and Chronic Inflammation, Injuries AND Morbid Growths. Acute Inflammation 329 Acute myringitis. Symptoms. Difierential diagnosis between acute myringitis and acute otitis media. Etiology. Treatment. Chronic Inflammation 833 Ulcers in the dermoid layer. Symptoms. Etiology. Treat- ment. Perforation of the membrana flaccida. Cases. Treatment. Traumatic Injuries 342 Perforating wounds. Cases. Fracture of handle of malleus. Reproduction of the membrana tympani. Medico-legal significance of traumatic injuries of the drum-head. Morbid Growths 348 Wart-like bodies on the drum-head. Endothelial cholesteatoma of the membrana tympani. Cholesteatoma of the drum-head. SECTION V. MIDDLE EAR. Chapter I. Acute Catarrhal Inflammation. Subjective /Symptoms 352 Pain. Vacuum in the tympanum. Effects of talking, cough- ing, sneezing, and eructation. Hardness of hearing. Tinnitus aurium. Double hearing, or subjective echo-like sensation ; para- cusis duplicata ; subjective alteration in pitch. Cases. Intra-tym- panic pressure during phonation. Acute aural catarih in infants. CONTENTS. XI PAGE Objective Symptomi 369 Eetraotion of the membrana tympani. Spontaneous rupture of the membrana tympani. Course. Etiology. Earache from teeth- ing, and from whooping-cough. Diagnosis and prognosis. Treatment 877 Anodynes. Irrigation of the naso-pharynx. Paracentesis of the membrana tympani. Chapter II. Chronic Catarrhal Inflammation. Subjective Symptoms 381 Tinnitus aurium. Hardness of hearing. Pain. Throat symp- toms. Condition of Eustachian tube. Vertigo. Hearing better in a noise. Hereditary tendency. Odor. Objective Symptoms 387 Appearances in external auditory canal. Membrana tympani, changes in color. Calcareous deposits. Changes in position of membrana tympani. Implication of the sympathetic and other nerves ; flushing of the cutaneous surface adjacent to the ear. Cases. Condition of the pharynx and throat. Loss of function in the velum. Changes in the voice. Changes in the Eustachian tube. Adenoid growths and granulations in the naso-pharynx. Inflation and auscultation-symptoms revealed in Eustachian tube and tympanum. Effects of inflation on the membrana tympani. Etiology. Chapter III. Treatment of Chronic Catarrhal Inflajima- TION. Constitutional and Local Remedies 404 1. Introductory remarks. Constitutional remedies and hygiene. Applications to the nares, naso pharynx, and throat. Irrigation of the naso-pharynx by means of the nasal douche. 2. Applications to the Eustachian tube. Excision of the tonsils. Clipping the uvula. Applications to the cavity of the drum. 3. Operations with the knife on the drum-head. Permanent open- ings in the drum-head. Methods, eyelets, rings, etc. Tenotomy of the tensor tympani. Operations of Weber-Liel, Qruber, J. Orne Green, and others. Forms of tenotomes. 4. Removal of fluid and inspissated matter from the cavity of the drum and Eustachian tube. Cases. Electricity in Aural Diseases 433 Historical Sketch. Mode of application of electricity to the organ of hearing. Brenner's normal formula of the reaction of the audi- tory nerve. Investigations of Erb, Moos, and Hagen, and of Schwarlze, Schulz, and Benedikt. Intra-tubal electrization. Xll CONTENTS. PAGE Chapter IV. Untjsdai. Diseases of the Middle Eae. Functional Bisiurbances 439 Objective snapping noises in the ear. Historical sketch. Simul- taneous spasm in the soft palate and elsewhere. Cases. The author's observations of a case. Etiology. Treatment. Organic Disturbances 447 Extravasation of blood into the tympanum in Bright's disease of the kidneys. Otitis media hemorrhagica (Roosa). Tubercular dis- ease of the ear. Desquamative inflammation of the middle ear ; cholesteatoma of the petrous bone. New formed membranes and bands in the middle ear. The corpuscles of Politzer and Kessel ; Prof. Wendt's examination. Embolism in the mucous membrane of the tympanic cavity. Primary cancer of the middle ear. History, course, and symp- toms. Etiology. Treatment. Cancer of the mastoid process. Emphysematous tumor over the mastoid portion. Hairs in the mastoid cells. Chapteh V. Acute Pdrulent Inflammation. Subjective Symptoms 457 Itching in throat and ear. Pain. Alteration in hearing. Ver- tigo, fever, and delirium. Objective Symptoms 459 Membrana tympani ; changes in color, spontaneous rupture. Course 461 Possible fatality of the acute form of purulent Inflammation of the middle ear. Cases. Etiology ... 464 Cold bathing ; its effects on the middle ear. Acute inflammation of the tympanic cavity produced by concussion. Diagnosis 468 General remarks. Earache from decayed teeth. Appearances of tlie membrana tympani, differential diagnosis. _ Prognosis and Treatment ......... 470 Nature and object of treatment. Depletion and anodynes. Para- centesis of the drum-head. Chapter VI. Chronic Pckulent Inflammation. Etiology and Symptoms 474 Introductory remarks. Diphtheria as a cause. Chief symp- toms, hardness of hearing and persistent discharge. Appearances of external auditory canal. Appearances of the drum-head and the tympanic cavity. Treatment 481 Introductory remarks. Chief remedies to check the chronic dis- charge. Mode of instilling nitrate of silver. Powdered substances for insufflation. Alum and other astringents used in chronic otitis media purulenta. CONTENTS. Xlll PAGE Chapter VII. Course and Consequences op Chronic Puru- lent Inflammation of the Middle Ear. Hardness of Hearing and Deafness 492 The artificial membrana tympani, history and forms. Mode of application of tlie artificial membrana tympani. Action of the arti- ficial membrana tympani. Its protective function. Paper disks of Blake. .Epileptiform Manifestations and other Nervous Phenomena . . . 500 Introductory remarks. Etiology and treatment. Various nervous phenomena produced by chronic purulent inflammation of the middle ear. Paralysis of the facial nerve. Cases. Alterations in gait. Irritation of the chorda tympani. Anomalies of taste and salivary secretion in chronic purulent disease of the tympanum. Vertigo and reflex psychoses from chronic purulent inflammation of the middle ear. Oranulations and Polypi 510 Polypoid hypertrophy of the mucous membrane of the middle ear. Treatment of granulations. Aural polypi. Classification and histology ; fibromata, myxomata, angioma. Organized vesicular polypus, containing necrosed long process of the incus. Symptoms of polypus in tlie ear. Spontaneous detachment of polypi. Treatment of aural polypi. Forms of in- struments for the removal of polypi. Treatment of ear after re- moval of aural polypi. Chapter VIII. Course and Consequences of Chronic Puru- lent Inflammation — Continued. Ulceration of the Mucous Membrane of the Tympanic Cavity, Perios- titis and Caries of various parts of the Temporal Bone, and their results 536 Exfoliation of the cochlea. Exfoliation of the cochlea, vestibule, semicircular canals, and deeper parts. History and treatment. Mastoid disease ; symptoms and course. Periostitis of the outer surface of the mastoid portion of the temporal bone. Congestion and inflammation of the mucous membi-ane lining the air-cells of the mastoid cavity. Caries and necrosis ; followed by meningitis, thrombus in the lateral and other sinuses of the brain, embolism, pyasmia, and cerebral abscess. Cases. Treatment of mastoid dis- ease. Artificial perforation of the mastoid portion of the temporal bone. History. Modes of perforating trephining the mastoid. The point to be chosen for the operation. Instruments to be used. Bibliography. XIV CONTENTS. SECTION VI. DISEASES OF THE INTERNAL EAR. PASE Ci-iAPTEK I. Primary and Secondary Inflammation. Introductory Remarks 550 Anomalies of formation. AnEemia, hyperEemia, and inflammation of the internal ear. Hypersemia of the labyrinth. Primary Inflammation of t\e Internal Bar 553 History, observations of Deleau and Meniere. Meniere's disease, or labyrinthine vertigo of Hinton. Observations of Brunner, Knapp, Moos, and others. Otitis labyrinthioa of Voltolini. Etiology and treatment of primary inflammatory disease of the labyrinth. Trau- matic injuries. Fracture of the base of the skull. Cases. Symp- toms. Secondary Inflammation of the Internal Ear 563 Deafness from concussion. Cases. Hardness of hearing, and total deafness after cerebro-spinal meningitis. Observations of various authorities. Prognosis and treatment. Disease of the in- ternal ear from syphilis ; from typhoid fever. Aural vertigo from chronic catarrh of the middle ear. Cases. Aural vertigo with variable hearing. Aural vertigo resulting from secondary inflam- mation of the labyrinth. Apparent motion during vertigo. Vertigo from cerebral tumors. Chapter II. Morbid Growths op the Auditory Nerve. Fibrous Tumors 581 Cases of Landiforth, Lev§que-Lasource, Boyer, Carr^, and others. Sarcoma 581 Cases of Voltolini and Forster, Cruveilhier, Moos, and Boettcher. Symptoms. Tumor of each auditory nerve, case with ante and post mortem notes. Microscopical examination of both cochlesB. Case of probable cerebral tumor, aural notes. Pathological changes found by Moos in the organ of Corti in a case of cerebral tumor. Fibro-Sarcoma 591 Observations of Boettcher. Case of tumor involving common trunk of auditory and facial nerve. Changes in the vestibule and semicircular canals. Glioma of the auditory nerve. The Labyrinth in Ileo-Typlms 593 Fatty metamorphosis of the organ of Corti. Amyloid degenera- tion. Corpora amylacea, observations of Lucse and Riidinger. Morbid States of the Auditory Nerve 594 Hallucinations of hearing in the insane. Nervous deafness. The effects of quinine on the ear. Observations of Roosa and Hammond. COXTENTS. XV SECTION VII. DEAF MUTES AND PARTIALLY DEAF CHILDREN. PAUK Chapter I. Methods of Relief and Education. Deaf-Dumbness 599 Introductory remarks. Congenital and acquired forms of deaf- dumbness. Modes of instruction by dactylology and lip-reading. Bell's system of visible speech. Partially Deaf Children 604 Remarks and statistics. Methods to be adopted in teaching par- tially deaf children. Suggestions of Blake. Ear-trumpets. LIST OF ILLUSTRATIONS. FI«. PAGE 1. The auricle . ... . . 19 2. Muscles of the auricle, outer surface . (Henle) 20 3. Cartilage and muscles of auricle, posterior view . (Plenle) 31 4 Diagram representing the topographical relation of the component resonant cavities of the external ear . . . . .34 5. Centres of development of the temporal bone . . (Gray) 38 6. Outer surface of left temporal bone (Smith and Horner) 39 7. Inner surface of left temporal bone . (Smith and Horner) 39 8. Under surface of left temporal bone . . . (Gray) 41 9. Transverse section of the entire auditory apparatus of the right side (Gray) 44 10. View of outer surface of membrana tympani . . (Gruber) 47 i Diagram of section of stretched membrane . . . 51 18. Geometric divisions of the membrana tympani . . (Kessel) 57 14. View of inner surface of membrana tympani . (Gruber) 63 15. Membrana tympani of dog . . . . 65 16. Malleus ..... . (Henle) 69 17. Ligamentous support of ossicles viewed from above (Helmholtz) 73 18. Incus . . . . . ... (Henle) 74 19. Stapes ....... (Henle) 76 20. Right tympanic cavity viewed from above ; malleo-incudal and incudo- stapedial joints ..... (Henle) 80 21. Inner side of outer wall of the right tympanic cavity. Hammer and Anvil in situ; canalis musculo-tubarius laid open . (Henle) 80 22. Section through tlie long axis of malleus at right angles to the mem- brana tympani, from an adult .... (Brunner) 82 23. Inner wall of tympanic cavity .... (Gray) 83 24. Nerves in and about the tympanum . . . (Heath) 89 25. Transverse section of the cartilaginous part of the Eustachian tube near the foramen ovale .... (Henle) 106 26. Palatal muscles viewed from behind . . (Gray) 108 27. Mastoid portion of the left temporal bone, laid open and viewed from behind ......... 114 28. View of the entire right middle ear, laid open by incision from above downward, through the centre of the cavity, parallel to the long axis (Gruber) 131 B XVIU LIST OF ILLUSTRATIONS. Pia. PAGE 39. External view of a cast of the left labyrinth . . (Henle) 124 30. Section of the pyramidal portion of the right temporal bone through the vestibulum, parallel with the outer wall of latter; view of inner wall ... ... (Henle) 135 31. Osseous cochlea laid open .... (Henle) 137 33. Transverse section of the first coil of the cochlea of a child one and a half years old .... . (Waldeyer) 130 33. Transverse section of the organ of Corti . . (Waldeyer) 134 34. Membranous labyrinth of man .... (Rudinger) 138 35. Transverse section of the bony and the membranous semicircular canal of man ....... (Rudinger) 139 36. Transverse section of an ampulla of a fish : floor and w^all (Rudinger) 141 37. Otoliths from various animals .... (Rudinger) 143 38. Scheme of the membranous labyrinth of mammals ,. (Waldeyer) 143 39. Auditory ossicles in connection ; viewed from in front ; right side (Henle) 160 40. Ear-mirror ... .... 166 41. G-ruber's aural specula ....... 167 43. Bonnafont's otoscope ....... 168 43. Sigle's pneumatic otoscope .... . 169 44. Kramer's ear-speculum ...... 169 45. Blake's middle ear-mirror . ... 171 46. Delicate forceps for removing foreign bodies from the ear . 173 47. Cotton Kolder . . . . .174 48. Ear syringe and olive-shaped nose-piece .... 175 49. Tin basin used in syringing ear . ... 176 50. Tobold's laryngeal apparatus . . . . .177 51. Forehead mirror ........ 178 53. Eustachian catheters of hard rubber . . . 181 53. Bonnafont's nose-clanip ....... 183 54. Auscultation tube . . . . 183 55. Insertion of the Eustachian catheter ..... 185 56. Inner view of the right half of the head ; autero-posterior section ; Eustachian catheter in situ .... (Gruber) 186 57. Fixation of the Eustachian catheter in position, preparatory to inflation 187 58. Politzer's air-bag for inflating the middle ear . . . 190 59. Blake's tuning-fork . . . . . . .300 60. Clinical tuning-fork ..... .200 61. Konig's rod as modified by Blake . . . 210 63. Othajmatoma and resultant deformity . . (Gruber) 348 63. Delineation of operation on cleft lobule . . . (Knapp) 357 64. Forms of aspergillus flavescens removed from the human ear . . 379 65. Forceps for removal of foreign bodies from the ear . . . 397 66. Aural douche of Clarke . ..... 378 67. Paracentesis-knife . . . . 379 68. Weber-Liel's graduated metallic Eustachian catl;eter and bougie catheter of gummed silk ...... 411 69. Politzer's eyelet and eyelet forceps ..... 418 70. Weber-Liel's tenotome . . . . . . .433 LIST OF ILLUSTRATION'S. XIX FIG. PAGE 71. Gruber's, J. 0. Green's, and Hartmann's tenotomes . . . 424 72. Politzer's monometer ....... 444 73. Toynbee's artificial membrana tympani ..... 494 74. "Wilde's snare . , . . . . . .519 75. Blake's Wilde's snare ■with adjustable paracentesis-needle . . 519 76. Silver probe for manipulating polypi ... . 530 77. Permanent platinum-wire loop on flexible shaft . . . 520 78. Polypus scissors ........ 531 79. Polypus hooli . . . . . . . .523 80. Toyubee's lever-ring forceps ..... .523 81. Forceps for removal of a polypus or a foreign body situate near the mouth of the external auditory canal .... 533 82. Mastoid sequestrum, outer surface . . . 534 83. Mastoid sequestrum, inner surface .... 534 84. Mastoid sequestrum, outer surface .... 536 85. Mastoid sequestrum, inner surface . . . 536 86. Strong knife for incising softened outer mastoid table . . . 543 87. Drill and bit for perforating the mastoid portion of the temporal bone. (A. H. Buck) 544 ERRATA. Page 73, 13th line from bottom, /oc Fija:. 18, «, read Fig. 17, e. "319,20th " " top,/o)- Dr. C. T. Blake, «ffifZDr. C. J. Blake. PAET I. ANATOMY AND PHYSIOLOGY. Editorial Department. 17 Third. He should be able to perform the operation of paracen- tesis, or apply the methods of inflation, as the given case may de- mand. Fourth. He should know how to remove foreign bodies by the use of the syringe and warm water, and how to avoid placing them beyond the reach of all means of removal. With these qualifications and the knowledge of general means of combating disease, he has the power of greatly diminishing the prevalence of ear troubles, and saving the patients from their hazardous consequences. OPENING OF THE HOMCEOPATHIC COLLEGE OF PHYSICIANS AND SURGEONS. As announced by the College prospectus, this institution opened its doors for instruction November 5th, 1879. The amphitheatre being well filled with students and friends of the enterprise, the presiding ofEcer said, "inasmuch as we had been in- structed from early life to never engage in any great and impor- tant undertaking without first invoking aid from Deity, we intro- duce the Kev. J. Hazard Hartzell, D. D., for that pui'pose." Alter a very eloquent prayer by this able Divine, the Dean ad- dressed the class substantially as follows : Ladies and Gentlemen : We meet for the purpose of consummating the effort made by the Trustees and Faculty of the College of Physicians and Surgeons of Buffalo. Feeling a lively interest in the welfare and success of the enter- prise, as one of the projectors, I am induced to preface this Course of Lectures by a few remarks, which may tend to disabuse the minds of some present, who appear to have been misled by the many efforts of our opponents, to misrepresent our legal and moral right to an existence as an institution. A brief history of our un- dertaking may not be uninteresting. 18 The Physicians and Surgeons' Investigator. SaflSce it to say that, some time since, a little band of liberal phy- sicians — residents of the Queen City — deemed it their prerogative to discuss the question that is before the medical world to-day, viz : What constitutes a good physician f The discrepancy of opinion in this, as in all subjects of para- mount importance in Science, Art, Politics and Keligion, led to estrangement. Those who had not lime enough in their vertebral columns to maintain their integrity succumbed to the pressure made by the anti-rational class, and I regret to say joined them in their ignoble and unmanly attempts to ruin us and the cause we represent — that of rational medicine. Our opponents in this city consist of three classes: 1st. Those whom we would not recoguize as teachers, on account of incompe- tency. 3d. Those who never accomplish anything themselves, on account of lack of ambition, and naturally or readily oppose every new enterprise that they cannot dictate. The 3d class, like the first two, frankly concede that our platform is theirs, practically, but not to promulgate ; and they oppose us for what they term a non-policy movement. These are the men who are fearful of losing their laurels by the establishment of a school in their midst which has ability, ambition and honesty for a basis. These gentlemen have made several futile efforts to have us misrepresented in the State Society, bat their re- quest was refused by the gentlemanly and very efiBcient President, Dr. Asa S. Couch, who (responded as follows : " The State Homoeo- pathic Medical Society is too liberal and dignified a body to enter- tain your expressions for a moment. Do what you please locally, but we should consider it undignified, unprofessional, unjust and uncalled for." One would think that after such a scathing rebuke any gentlemen would desist from such public demonstrations. Not «o with these men; their malicious venom is daily thrust hither and thither, and at home and abroad they still misrepresent us by re- porting that we have no legal authority — that our School is an ad- vertising medium for Dr. Pierce ; that we are uneducated physicians and pseudo-Homoeopathists, Allopathists, Eclectics, &c. Outside of this city very little hostility has been evinced. One ■or two editors of HomcEopathic Medical Journals have intimated SECTION I. EXTERNAL EAR. CHAPTER I. THE AURICLE. Fig. 1. ANATOMY. TuE external ear comprises the auricle and the external audi- tory canal. The auricle, or ear of common language, is formed of a cartilaginous sheet, from one to two millimetres thick, with various depressions and elevations. Extrinsic and intrinsic ligaments and muscles are inserted into it ; it is well supplied with hlood vessels, lymphatics, and nerves; and it is covered with skin. The auricular cartilage is of the riticularl^^ariety, and the various depressions and elevations into which it is twisted have received the following names : helix, antihelix, fossa of the helix, fossa of the antihelix, the tragus, the antitragus, the lobule, and he concha. The entire auricle is also .ailed the pinna. These portions of the auricle have received other names from some authors, hut those given here are, perhaps, the most commonly used in English. Henl^ and others give to the fossa helicis the name of fossa navicu- laris or scapha, and to the fossa antihe- licis the name of fossa triangularis. I PI .1 ,11 The Auricle. — a. Helix, u. , prefer, however, the names suggested by A^tiheiix. 6. Fossa of the heiix. Gray, because they will naturally occur <*• ^"^^^ °f "i« antiheiix. e. , • , 1 ■ , 1 . 1 , Tragus. /. Antitragus. A. Lo- to any one acquainted with the anatomy huie. g. cunoha. 20 EXTERNAL EAR. of the auricle, and the combination of a few words will supply the terms necessary in the designation of the various parts of the pinna. Fig. 3. Muscles OP THE Auricle, Outer' Surface. (Henl6.) — &. Incisure auris. c. Spina heliois. h. M. auricularis superior, g. M. helicis loaj'or. /. M. heliois minor, u. M. tragicus. u. M. an^i- tragicuR. Muscles of the Auricle. — The extrinsic muscles of the auricle are those which move it as a whole, and are the I. Attollens aurem. II. Atrahens aurem. III. Eetrahens aurem. The intrinsic muscles of the auricle, or " proper muscles of the ear," are seven in number. These have also been denominated vestigia, a name well chosen as indicative of their condition in man. Henl^ says:' " These muscles, with one exception, run between the various portions of the auricular cartilage and the external auditory canal. They are all muscles of animal life ; but on ' Eingeweidelelire, s. 736. •THE AURICLE. 21 account of their extreme thinness are pale, and lie immediately upon the cartilage, into the fibrous layer of which they are in- serted by means of short tendinous fibres. They are not equally persistent ; whether they are all equally developed at first and finally become atrophied through disease, can only be decided by a statistical comparison of the ears of adults and children." Five of the proper muscles of the auricle are on the anterior surface and two are on the posterior surface of the organ. Those on the anterior surface of the auricle are the tragicus, the antitra- gicus, helicis major, helicis minor, and the two on the posterior surface are the transversus auriculoe and the obliquus auricidce. Fig. 3. -5 /— Cartilaqb and Mdscles of Auricle, Posterior View. (Henle.)— /. Cartilage of externa autiitor7 canal, e. Surface of attachment of same to the edge of the hony canal, d. Cartilage of the pinna, c. Cauda helicis. Z. Eminentia scaphse. g. Eminentia fossffi couchce. ft. Transverse muscle of the auricle, b. Oblique muscle of the auricle. In some rare cases, a third muscle is found in the auditory canal, and is called the M. incisurce Saniorini. It lies below, and further in the auditory canal than, the M. tragicus. Ligaments of the Auricle. — The ligaments of the auricle may also be divided into an extrinsic and intrinsic set: The first con- nect the auricle with the side of the head, and the second con- nect' the various parts of the cartilage together. The former, the most important, are two in number, anterior and posterior. 22 EXTERNAL EAR. The anterior ligament extends from the process of the helix to the root of the zygoma. The posterior ligament passes from the posterior surface of the concha to the outer surface of the mastoid process of the temporal bone. A few fibres connect the tragus to the root of the zygoma. " Those connecting the various parts of the cartilage together are also two in number. Of these, one is a strong fibrous band, stretching across from the tragus to the commencement of the helix, completing the meatus in front, and partly encircling the boundary of the concha ; the other extends between the concha and the processus caudatus."' Bloodvessels and Lymphatics of the Auricle. — The arteries sup- plying the auricle are, the posterior auricular^ from the external carotid ; the anterior auricular, from the temporal ; and the auricular branch, from the occipital. The veins follow the arte- ries in their general distribution. The auricle is supplied with a beautiful and very rich net- work of capillary lymphatics, an important consideration in aural disease; Nerves of the Auricle. — The nerves are most numerous on the posterior surface of the auricle, while the concave surface and the lobule are comparatively poorly supplied with nerves. In some of the lower animals, the mole variety especially, the nervous supply of the auricle is so rich and so peculiar in its development, as to endow the auricle with valuable tactile powers.^ The nerves of the auricle are derived from the auricu- laris magnus, from the cervical plexus ; the posterior auricular, from the facial ; the auricular branch of the pneumogastric ; and the auriculo-temporal branch of the inferior maxillary nerve. Integument of the Auricle. — The cutis of the auricle is a con- tinuation of that of the face and head, which, after coverino- the cartilage, forms a fold at its base, called the lobule. In some rare instances the cartilage of the auricle may extend into the lobule, and then the usually harmless operation of piercing it for purposes of adornment may give rise to serious chondritis. 'Gray's Anatomy, p. 639. 2 Max Schultze's Archiv, 1870. THE AUKICLE. 23 The auricle is abundantly supplied with sebaceous glands from 0.5 to 2.0 mm. in diameter, which are most numerous and highly developed in the concha. The entire surface of the pinna or auricle is covered with downy hairs, which attain their most luxuriant growth near the meatus and on the tragus, to which fact the latter spot owes its Jiame of "goat" or tragus. Sudoriferous Glands. — The sudoriferous glands are most abun- dant on the posterior surface of the auricle, an important con- sideration in the management of the ears of infants, for if their auricles are pressed constantly against the head, as is too apt to be the case, chafing of the parts must be the inevitable result. The modified sudoriferous glands of the cutis of the external ear are developed into ceruminous glands in the external audi- tory meatus.' PHYSIOLOGY. The use of the extrinsic auricular muscles is usually very imperfectly developed in man, although the ability to move the auricle is now and then met with even in the most cultivated. It has, however, been supposed, that as civilization has elevated man above a merely animal existence, the power to move the auricle freely and voluntarily, has diminished as the necessity of such a function would cease with a less savage life. Such indeed seems to be the rational view to take of the use of these muscles. That they are capable, however, of culti- vation does not seem to be an uncommon observation. All are familiar with the story of Albinus, the anatomist of the eighteenth century, who could move his auricles so well, that he was in the habit of removing his wig in order to demon- strate to his class the power he possessed over them. Sir Astley Cooper has recorded a case^ in which the auricles were in constant motion whenever great attention was necessary. Two physicians of my acquaintance can move the auricles markedly with ease. I have very often seen the auricles move unconsciously in my patients, when standing behind them, and they were obliged to be more than usually attentive. But this motion was not continual ; it appeared to me to be an entirely ' Kessel, Strieker's Handbuch, p. 841. ' Phil. Traus., London, 1800. 24r EXTERNAL EAR-. involuhtary endeavor at an adjustment of the auricle in the most advantageous position for hearing. When suddenly surprised by an unusual or loud noise, I am sensible of a very marked movement, entirely involuntary, of my own auricles. 1 have seen marked contraction in the region of the tragicus and anti-tragicus muscles, during the application of the constant electric current by means of a ball-electrode. The general opinion is that a small ear, well shaped, is a sign of careful breeding, whereas the large elephantine auricle is accepted as a type of vulgarity ;' however, the unfortunate possessor of a large auricle is compensated for his so-called misfortune, by the popular belief that the large auricle is a sign of good nature and generosity. This may be the modern idea, but Giotto, in his drawing of Envy, in the chapel of the Arena at Padua, represents the auricle as superhuman in size, its long axis as a continuation of that of the horizontal ramus of the inferior maxillary bone, and without a lobule. It is also a matter of interest that the position and shape of the auricle are national peculiarities, as seen on the ancient Egyptians, the trait being carefully preserved even in the rude attempts at works of art made by the artists of the age and country. It is also said that the Egyptians, even in the present day, possess this peculiarity of high-placed auricles, and as late as 1840 there was in " Paris a teacher of Arabic — a Oopt of Upper Egypt — who possessed this conformation in a most decided degree."* However significant the shape of the auricle may be, it is probably not so significant of caste as the shape and texture of the hand, although, without doubt, it has a great significance. Prof. Meyer^ states, that it has already been noted by previous observers that malformations of the external ear are found in the greatest number in connection with arrested development in the region of the first (Kiemenspalte) branchial or visceral fissure, viz., with cleft palate, and other forms of retarded development in the bones of the head and face. The explana- ' ParvEe malos mores decent, magnce at erectee indices sunt stultitise aut loquacitatis. Opera Galeni, iy. 797. Kiihn, Leipsic, 1833. 2 J. Williams, Treatise on the Ear, London, 1840, p. 80. 3 Ludwig Meyer, Ueberdas Darwinische Spitzohr. Virchow's Archiv, Band 53, Heft 4. .THE AUEICXE. , 25 tioii of Virchow, that these changes are due to inflammatory processes in the earlier days of fcetal development, seemed; sufficient to Meyer, until, as he says, he instituted a careful examination of the form and position of the external ear, in a number of insane people, manifesting those peculiarities de-' scribed and called by him cranium progenieum. In all these cases there was a relative arrest of development of the bones of, the face, especially a malformation of the inferior maxilla, and it should be borne in mind that the inferior maxilla is formed through • ossification in the membrane of the visceral arch. The expectation of finding, in just such cases, characteristic forms of the ear, was not realized, and the theory appeared the less tenable, the further, the investigation was extended to numerous cases of both the insane and the sane. Pathologi- cally, the result of the investigation is considered by Meyer to be unimportant, but he expresses a belief that the significance of the form and position of the external ear is purely of a physiog- nomical character. In connection with a beautiful, well-formed face, we usually find a round, well-formed, small, and close-lying ear; whereas, in macrocephalic heads we find large massive ears, in some cases real elephantine ears ; while the narrow ear, directed backward, the so-called Eaun's ear, accompanies a low, retreating forehead, sharp nose, and narrow chin. A comparative examination of normal male heads seems to indicate that the position of the ear possesses a certain and constant relation to the architecture of the skull, for female heads, with a large facial angle, show a more vertical position of the concha than is usually seen in females and in children who possess, as a rule, small facial angles. In women and children we often find, in connection with a large facial angle, obliquely placed ears, so that the upper part of the helix points backward, and the posterior portion is directed downwards. The cause of this is to be sought for in the relation of the ramiis to the body of the inferior maxilla rather than in the relations of the superior maxilla and the frontal bones toeach other. The explanation of the connection between the position of the ramus of the inferior maxilla and the external ears is to be referred to the development of those portions of the face from the same part of the branchial arch. 26 EXTERNAL EAR. Not only the position of the ears, but the elevations and depres- sions of the auricle, vary even in the same individual. Mr. Darwin's ideas of the significance of certain prominences in the helix are thus given by that distinguished observer: " The celebrated Mr. Woolner informs me of one little pecu- liarity in the external ear {i. e., auricle) which he has often observed both in men and women, and of which he perceived the full signification. Ilis attention was first called to the subject while at work on his figure of Puck, to which he has given pointed ears. He was thus led to examine the ears of monkeys, and subsequently, more carefully, those of man. The peculiarity consists in a little blunt point, projecting from the inwardly-folded margin, or helix .... These points not only pi'ojeet inward, but often a little outward, so that they are visible when the head is viewed from directly in fi-ont or behind. They are variable in size and somewhat in position, standing either a little higher or a little lower; and they sometimes occur in one ear and not in the other. ]^ow, the meaning of these projections is not, I think, doubtful ; but it may be thought that they offer too trifling a character to be worth notice. This thought, however, is as false as it is natural. Every character, however slight, must be the result of some definite cause ; and if it occurs in many individuals, deserves consideration. The helix obviously consists of the extreme margin of the ear folded inward, and this folding appears to be in some manner con- nected with the whole external ear being permanently pressed backward. In many monkeys which do not stand high in the order, as baboons and some species of maccaus,^ the upper portion of the ear is slightly pointed, and the margin is not all folded inward ; but if the margin wei-e to be thus folded, a slight point would necessarily project inward and probably a little outward. This could actually be observed in a specimen of the Ateles beelzebuth in the Zoological Gardens ; and we may safely conclude that it is a similar structure — a vestige of formerly-pointed ears — which occasionally reappears in man."^ ' See also some remarks and the drawings of the ears of the Lemuroidea in Messrs. Miiril's and Mivart's excellent paper in Transact. Zool. Soc, vol. vii. pp. 6 and 90, 1869. ' Darwin, Descent of Man, vol. i. pp. 31 and 23. THE AUEIGLE. 27 Prof. Ludwig Meyer,* in an article referring especially to Darwin's idea, that the common, small projections in the helix of the ear are remnants of the pointed ear of certain Simian races, says that too much importance has been attached to the deviations in the form of the anricle, but he admits that fre- quently we find irregularities in the edge of the helix. To one of these, more prominent than the others, Darwin has attached the significance already alluded to. N'ow, the edge of the helix is rarely completely smooth, and even when any slight ine- quality of the concha escapes the eye, the finger can readily detect it. These are really deficiencies and not absolute promi- nences, and the wider the loss of substance in the helix carti- lage, the more prominent will the remaining portions appear. If, in an ear where one or two such prominent remnants of the helix occur, a line be drawn joining them, it will corre- spond with the outline of the normal helix. That these promi- nences are nothing more than remnants of the helix, is proven by the fact that their inclination and curve correspond entirely with the curve of the helix. That part of the helix which affords the most examples of the peculiarity referred to by Darwin, is most adapted to producing the longest points, since it is the widest portion of the curved helix. These changes in the ear are doubtless not produced during life, but are congenital. They are found in perfection in little children, and are more apt to occur in males than in females. According to KoUman, the helix is not a separate point of development. The auricle consists originally of those formative parts which can be distinctly recognized at the end of the sixth week of fcetal life, as tragus, antitragus, and antihe- lix. From the latter the helix is developed. Hence we see that as interferences in the development of the tragus may cause the presence of a cleft in it, so may disturbances in the development of the antihelix cause deficiencies in the helix. Prof. Laycock says:" "Men of high intellectual attainments, great capacity for mental labor, and great force of character, have a full, perfectly ovoid ear, the helix well developed, the ' Ludwig Meyer, Ueberdas Darwinische Spitzohr. Virchow's Archiv, Band 53, Heft 4. 2 Med. Times and Gazette, March 32, 18G3. London. 28- EXTERNAL EAR. lobule plump, pendent, and unattached to the cheek at its ante- rior margin. These characteristics are seen in all portraits of great men which Lavater gives, and are easily observed in liv- ing celebrities." The same writer also says : " In a perfect ear the ovoid lobule hangs from the cartilage with a rounded lower margin, which, at its inner border, is not confluent with the face. Now, if this inner margin be adherent to the cheek, and at the same time the lobule be only a segment of an ellipse, there is more or less tendency to imperfect cerebral action. A more import- ant form is seen when the lobe is not only soldered to the cheek, but its posterior half cut away, as it were, and the helix defective." A knowledge of these peculiarities in the ear of an individual may become of great legal value, as in the Tichborne case, in which it was shown that the " claimant's" ears were altogether different from those of the lost heir. Comparative Functions of the Auride. — The functions of the auricle are modified by the habits of the animal, and, since in most four-footed mammals the external ear is well developed, we have an opportunity of observing in them a variety of func- tions, acoustic and otherwise, acquired by the auricle. The large, long, and easily moved auricles are found in animals that are timid and often pursued by stronger and sagacious animals, while those which pursue, as lions, tigers, etc., jjossess auricles which are short and directed forwards. "We have no positive means of finding out how sounds are modified by these peculiarities in the auricles of these animals. However, by applying a variety of speaking trumpets to our ears, and by alterations in the position of these artificial auri- cles, as well as of our own by manipulation, we may form at least an approximate idea of the modification in hearing pro- duced by the size, shape, and position of the auricle. By such experiments we see that it is highly probable that ordinary sounds are augmented, and faint sounds rendered very audible to animals with largely developed auricles, by the increased resonance such organs produce, a function of the auricle useful to animals which are rapacious as well as to timid ones which are pursued. THE AURICLE. 29 The auricle is small in seals, walruses, moles, and the manis, but largely developed in some species of the bat, and " is so con- structed as to prevent air from rushing in while flying."^ In birds, the auricle is wanting, as it would probably greatly impede their flight, but in night birds, the power to elevate the feathers around the ear seems to indicate that they can supply themselves at will with a kind of auricle, and that their hearing is thereby augmented, a necessity due to their nocturnal pui'- suits. The auricles of the mouse^ and of the hedgehog' are developed into organs of touch, and the auricles of marine mammals seem to become almost useless : as in the narwhal " the opening of the ear is of the diameter of a knitting-needle,* and in the leopard seal the ears are merely openings in the surface of the skin, which are placed one and a half inches behind the eye,"" while in the sea-otter^ the " ears are less than an inch in length," the animal being at least five feet long. In the water-shrew, an aquatic mammal, the anti-tragus serves as an operculum to the auricle, which fact seems to indicate that the auricle is no longer needed for hearing as soon as the animal ceases to live in the air. In the crocodile, also, the auricle acts as an operculum, and in the whale it is practically absent. Therefore, the fully developed auricle is needed by and found in mammals whose life and condition are aerial, and we find that it ceases to exist, or its functions are altered, in mammals inhabiting the water or living underground. So much influence on hearing was attributed to the auricle by the first Dionysius of Syracuse, that he is said to have con- structed a subterranean cave in a rock, in the form of a human ear, which measured eighty feet in height and two hundred and fifty feet in length ; the sounds of this cave were then directed to a common tympanum, which had a communication with an adjoining room, where Dionysius spent the greatest ■ J. Williams, Treatise on the Ear, London, 1840, p. 35. 2 J. Schobl, Max Schultze's Archiv f. Mic. Anat., 1871, p. 260, four plates. 3 Ibid., 1873, p. 395. * Marine Mammalia of North America, by Chas. M. Scammon, U. S. Rev. Marine, p. 108. 6 Ibid., p. 165. 6 Ibid., p. 168. 30 EXTERNAL EAR. part of his time, to hear whatever was said by those whom his suspicions and cruelty had imprisoned. Mesonant Functions of the Human Auricle. — As early as 1840, J. Williams, M.D., of London, attributed to the " configura- tion and tension of the auricle" the function of determining the " finesse of hearing." This author was led to such a con- clusion by the augmentation of sound obtained by pressing forward the auricle, and surrounding it by the hand, but he mistakenly referred the improved hearing which ensued to the overcoming of what he termed a relaxed condition of the auricle by the support of the hand. It was, on the contrary, due to the augmented resonance of the auricle, brought about by the relative lengthening of the external ear, by pushing the auricle out from the head, and adding to it the resonance of the hand. It is evident, therefore, that writers on the ear long ago noted the phenomena of alteration in the resonant functions of the external auditory apparatus caused by increase or diminution of its depth and position; but that these phenomena depended upon the power of the auricle and the external auditory meatus to act as resonators was not suggested nor proven until Hem- holtz's experiments in acoustics had rendered the subject of resonators clearer, and experiments on the human ear demon- strated that the most probable function of the auricle is that of a resonator, adapted to augment just those high notes or sounds most likely to be of interest and importance to man. According to Dr. Kiipper,' the auricle can reflect sound into the auditory canal only to a limited extent, " because that part of the auricle which would reflect the sound-wave falling on it, into the auditory canal, is very small." Nor does he believe that it is concerned in the direct collection and transmission of sound as the drum-head is, for it is neither so elastic as the latter, nor is it inserted into a bony frame. He also denies it the function of determining the direction of sound, which, he thinks, may be proven by inserting into the meatus, a tube of any kind, thus cutting ofl^ all participation of the auricle in the reception of sound, when it will be found that the direction of sound can still be told. ■ Aichiv f. Ohrenli., vol. vlii. 158. THE AURICLE. 31 This author appears to be wrong in his assertion that the auricle can have no influence in hearing, for it is well known that with the altered shape of the auricle in othsematoma, the hearing is altered. He furthermore argues that the auricle in man is useless, because birds have none ; but birds do not need an auricle, on account of the high resonance of their audi- tory canal, as well as the interference in flying such an appen- dage would entail. Dr. Kiipper, therefore, plades the auricle of man in the " list of organs inherited, but no longer possessed of functions." He, however, ascribes an important part to the auricle in the lower animals, agreeing with Muller' that as it is supplied with so many (17) well-developed muscles, it is well adapted to catch sounds, but especially to express the passions of the animal, as is best seen in the horse. Dr. Kiipper, how- ever, apparently does not believe that the auricle of man, while losing the function so sharply seen in the lower animals, gains a higher and more delicate one, of resonator for the nobler tones of the human voice, as shown by the author. Prof. E. Mach^ considers the auricles in the lower animals, resonators for the higher tones of ordinary sounds, important for them to hear, such as the rustling of grass and leaves. This function depends partly upon the ability of the animals to place the auricles towards the direction of the sound, and thus to alter the clang-tint, which leads to a proximate knowledge of the direction of the sound. A remnant of such a function may still be found in the human auricle, according to Mach, which agrees with the theories advanced, previous to those of Mach, by the author.^ In the summer of 1873, while I was travelling and exposed to a great variety of powerful sounds, of nature and of com- merce, I made some experiments on my own external ears, respecting their power of receiving all or part of the component tones entering into such complex sounds, as the rustling of leaves, the roar of Niagara, the seething and hissing noise heard in the wake of a large steamer, or in the escape of steam from a powerful locomotive or steamboat. I found that by altering the position of my auricle, that is, by relatively lengthening ' Physiologie der Haussangethiere. 2 Archiv f. Ohrenheilkunde, Bd. ix. p. 73, 19 June, 1874. 3 Phila. Med. Times, No. 101, Oct. 4, 1873 ; No. 137, April 4, 1874. S2 EXTERNAL EAR. thereby the "depth, of the external auditory canal, I could aYia- :lyze the composite sounds alluded to, for if I pressed my auricle cfirmly back against my head, I heard the higher sounds, i. e. 'the entire sound became to my ear apparently; of a higher quality, whereas', if I pushed my auricle oiitwardand forward, the deeper partial sounds became more pronounced, and the -entire composite sound became louder and deeper. I joined my friends, Drs. Buck and Blake, and communicated to them what I had very easily found out, and as they are endowed witlj musical or analytical ears, I requested them to repeat these exr •periments upon themselves, which they did ; 3)r. Buck whiJe with me, and Dr. Blake subsequently after we, parted^ and they both have confirmed my discovery. In the autumn of 1873 I published my first paper, and in the spring of 1874 my second paper on what I had observed re? specting the function of the external ear, especially of th^ auricle, viz., that it is a resonator for high notes. The first paper contained chiefly a description of the pheno- mena I had ohserved ; and the second paper was devoted spe- cially to their physical explanation. The substance of the first paper was the following : — Before any further explanation of the functions of the auri- cle, let us briefly consider the acoustic nature of some of the ordinary sounds which are received by it. It is well known that every sound is composed of a collection of " partial tones" or " over-tones" which determine its timbre or clang-tint. Any one of the ordinary sounds of nature, as, for example^ the roar of a cataract or of the surf, and the rustling of the leaves in a forest, is composed of a large number of partial tones, which, for the sake of simplicity, let us call deep, intermediate, and high partial tones. The ordinary normal ear does not isolate any of the partial tones of a composite sound, but perceives them as a whole. This is due to the fact that certain parts of the auricle re- sound best to the high partial tones, while other portions of it resound best to the intermediate and low partial tones, thus insuring the complete reception by the auditory nerve of all the partial tones which compose any given sound falling on the auricle. I have discovered, by experiments upon my own ear, that the-region of the helix and its fossa resound to the deeper THE AURICLE. 33 notes, the antihelix and its fossa to the intermediate notes, and that the concha, " the deep concavity within the position of the antihelix, presenting a semi-spiral course towards the entrance of the auditory meatus," resounds best to the high partial tones. In order to prove this it is necessary to be in the presence of a sound possessing the characteristics of those already mentioned, when, by pressing the auricle at its outer edge gently forward, the sound instantly becomes a deeper one, from th^ augmenta- tion of the resonance for deep tones thus gained by the helix and its fossa. The deep tones, however, are immediately weakened or lost by placing the finger upon the helix and pressing it firmly against the head. Then it is found that the sound becomes one in which the intermediate and higher partial tones are prominent. By pressure upon the antihelix the intermediate tones become weaker, and the higher partial tones are most distinctly per- ceived, on account of their undisturbed resonance in the concha. Firm pressure upon the helix, antihelix, and concha will inter- fere with the resonance of all but the highest partial tones. In the latter instance the resonance of the meatus auditorius ex- ternus has full scope, for this part of the ear, according to Helmholtz, resounds best to notes of the fourth octave (e"-g''). Therefore, if any one of these portions of the auricle has its acoustic functions altered, either by disease or artificially, the tones to which it resounds will be weakened or lost, and the prominence of the other partial tones will change the timbre of the original sound. Experiment will show that by giving prominence to a certain portion of the auricle, viz., the helix and its fossa, a sound may be rendered fuller, and hence louder, from the increased reso- nance of the deeper notes which enter into its composition. This may explain the asserted increase of hearing in some cases of othsematoma, when the swelling may have rendered these particular parts prominent, and thus have increased their reso- nant power. But if the disease advance and produce great swelling and rigidity of the auricle, as it usually does, we can also readily understand the impairment of hearing in these cases. One without an auricle, all the rest of the auditory ap- paratus being normal, can indeed hear sounds, practically very well, but they are altogether difi:erent, acoustically considered, 3 34 EXTERNAL EAR, Fig. 4. from the complete composite sound heard by the possessor of the normal auricle. In the former case, a large number of the partial tones being lost, the clang-tint of the sound is altered ; whereas in the latter case, the auricle receiving and conveying synthetically all the partial tones to the auditory nerve, the timbre of the composite sound is fully perceived. The substance of my second paper,' explaining what I had observed, was as follows : — The auricle, in combination with the meatus anditorius, forms a resonator of a more or less conical shape, closed at the bottom by the membrana tympani, the special function of which is to strengthen by resonance those waves of sound which possess a short wave-length. Let the accompanying diagram represent a section of the external ear, from the membrana tymj)ani to the helix. The section is made from above down- ward, parallel to the long axis of the meatus auditorius exter- nus, and gives an ideal represen- tation of the manner in which the resonator we shall consider, is built up by the auditory canal and the successive columns or cups of air, represented by the concha and fossse of the helix and Diagram representing the Topoqra- antlhellX. lZt.rolZi:V:L Z:::::: The widest diameter of this EAR.-a. Fossa of helix, b. Fossa of antihe- rCSOUant COU'C Or fUDUel, Or miu- lix. V. Concha, m. Meatus auditorius ex- tevnus. t. Membrana tympani. iature " spcaking-trumpet," i. e. the diameter obtained when the helix and lobe are made to approach each other about the opening of the external meatus as a common centre, does not exceed the wave-length of the note to which the resonator thus formed will respond. In order fully to understand how this resonant power is maintained by the external ear, and to sound- waves of what length it specially resounds, let us first consider the resonance of the meatus auditorius externus, and the physical reasons for such a function in it. It is known that the external auditory meatus resounds to the Phila. Med. Times, April 4, 1874. THE ATJEICLE. ' 35 notes e'^ to g'V and that the column of air which most easily resounds to any given note is equal to one-fourth of the length of the wave of sound produced by that note.^ I^Tow, the wave- length is found by dividing the velocity of sound per second by the number of vibrations executed by the sounding body per second,^ and the quarter of the result of this division, i. e. the quarter of the wave-length, will equal the length of the column of air which will act the part of a resonator for the note producing the sound-wave. In order to appreciate this fact, let us work out a simple problem in physics, with the data before us, as follows: As already stated, the notes e" to g'* have 2640 to 3168 vibrations per second, and the volocity of sound in atmosphere at 15° C. is equal to 1122 feet per second. Therefore, the length of the wave produced by the note of 3168 vibrations per second will be found by dividing 1122 by 3168. The answer will be, about three- eighths of a foot, or four and a half inches. 2^ow, the column of air which will resound to the note pro- ducing a wave of that length is equal to one-fourth of that wave- length, or one and one-eighth inch, which is just the short average length of the meatus auditorius externus. Some authori- ties give one and one-fourth inch as the average length of the meatus auditorius externus, but practically the normal human meatus has various lengths, passing gradually from the meatus proper into the concha. And this brings us to the second con- sideration connected with the phenomena of resonance manifested by the external ear, viz., that as the "pitch of a note, let us say of e" or g", falls, the wave-length must become greater, or, in other words, as the number of vibrations per second diminishes, the wave-length increases ; which is but the enunciation of a common law of physics. It is now manifest that the column of air contained by the meatus auditorius externus will not be long enough to act as a resonator for waves of sound the quarter of which is represented by one and three-fourths to two inches. Therefore, the concha is found superposed by nature vpon the external auditory meatus, in order to lengthen it. We have already seen from experiments that the notes which resound to the ' Helmholtz's Tonempflndungen, p. 175, 1870. > Tyndall, On Sound, p. 174, 1869. ' Ibid., p. 84. 36 EXTERNAL EAR. column of air represented by the concha, i. e., the concha in con- junction with the meatus auditorius extern us, are lower than those which resound to the external auditory meatus when it is made to act alone, which can be accomplished by pushing the concha out of place by firm pressure of it against the head. The reason for this becomes very clear when we reflect that a note lower than those represented in the scale from e'' to g"' must have a greater wave-length, and therefore it requires a longer column of air as a resonator. If this lower note should fall in the octave below those notes already mentioned, the addition of the column of air in the concha to that in the meatus would supply the resonator. If to this resonator, composed of meatus and concha, we add the fossse of the antihelix and helix, we of course obtain longer or deeper resonating columns of air ; and I know from my ex- periments that notes of still greater wave-lengths than those alluded to resound to the column of air represented by that con- tained in the fossse of the auricle added to that of the concha and meatus auditorius externus. By holding the hand behind or around the ear, we have the power of adding a still deeper column of air and its resonance to that of the external ear. Hence, the deaf person involuntarily places his hand to his ear, to increase, by resonance, the ordinary sound falling upon it. His hearing is thus strengthened, espe- . cially for those notes of high pitch and short wave-length to which the human voice owes its peculiar timbre or clang-tint. " It is indeed remarkable that the human voice should be so rich in over-tones (Obertone), for which the human ear is so sensitive."' Wlien the wave-length increases, as it does when the note becomes still lower than any of those alluded to, the resonance of the ex- ternal ear ceases to exert any marked influence on the funda- mental note. In such a case it is probable that the resonance of the room or street in which we are placed is aroused by the longer wave of sound ; but nature has supplied us, in the external ear, with an ever-present and delicate resonator for just those notes of short wave-length in which the human voice is so rich and to which it owes its special timbre. "We may, therefore, conclude that the external ear {i. e., the ' Helmlioltz's Touempflndnngen, p. 176, 1870. THE AUKICLE. 37 meatus auditorius externus and the auricle) forms a resonator for those tones having wave-lengths the quarters of which are repre- sented by the various depths of the column of air contained by the external ear. From what has just been shown respecting the resonant func- tions of parts and of the whole of the auricle and external auditory canal in man, it seems fair to suppose that the entire apparatus of the external ear in all animals is adapted to strengthening the sounds uttered by them and their species. The absence of a developed auricle in birds is not, in my opinion, an argument against its utility as a resonator in man, for the wave-lengths of the high notes which the former must both use and hear as a means of intercourse with each other, are so short that they will resound perfectly well in the shallow auditory meatus found in them. Temperature of External Canal. — Dr. E. Mendel,* of the Uni- versity of Berlin, has performed a series of experiments to find the relative differences between the temperature of the rectum and that of the external ear under physiological and pathologi- cal conditions of the general system. In the normal condition, the temperature of the rectum is 0.02° C. higher than that of the external auditory canal. Further experiments in cases of apoplectiform and epilepti- form paralysis show that in such pathological states the tempe- rature is higher than that in the rectum. Sleep-producing doses of chloral do not materially alter the temperature of the rectum, but they reduce considerably the tempei-ature of the external auditory canal. The amount of this depression in the ear varies from 0.04°-l° C. It sets in in from ten minutes to half an hour after the chloral is given, and lasts until sleep is ended. Morphia has also a specific effect in reducing the temperature of the external auditory canal in varying amounts, from 0.1°- 0.45° C. This I consider important for aurists to know, inasmuch as further experiments of MendeP show that even ice-bags fail to reduce the temperature of the external auditory canal as chloral and morphia So. 1 Virchow's Arcliiv, 63 Band, 1874. 2 Loc. cit., p. 141. 38 EXTERNAL EAR. CHAPTER II. THE AUDITORY CANAL. ANATOMY. The Temporal or Petrous Bone. — Before considering the ana- tomy and physiology of the external auditory canal, it will be necessary to examine into the development and anatomy of the temporal or petrous bone. The outer surface of the temporal bone represents the convex curve of a low arch, the spring line of which runs through the outer part of the middle lobe of the brain. The squamous portion, which is the larger part of this Fig. 5. 1 fffrS^uavwu,s 1 fm StyXoioi pvoc. Centres of Development of the Temporal Bone. (Gray.) surface, being thin, and the arch it spans low, the temporal bone would be very weak in resisting external forces, were it not for the support placed on its inner surface by the petrous portion. The temporal bone develops from four distinct centres, exclu- THE AUDITORY CANAL. 39 sive of those representing the internal ear and the auditory ossicles. These are: one for the squamous portion and the zygoma; one for the auditory process, or annulus tympanicus, which finally becomes the tympanic bone, and forms the anterior, infe- rior, and superior part of the osseous auditory canal ; another for the petrous and mastoid portions, and a separate point of development for the styloid process. It appears, from the anatomical investigations of Prof. Po- litzer,' that the styloid proce-ss, the variable form of which is well known, originates from an individual cartilage-centre, which, not only in foetal life but also in the new-born child, is Fig. 6. Fig. 6. OiJter Surface op Left Temporal Bose. (Smith aad Horaer.)— 1. Squamous portion. 2. Mastoid portion. 3. Extremity of petrous portion. 4. Zygomatic portion. 5. Tu- bercle on which the condyle of the lower jaw touches, wheu the mouth is widely opened. 6, Posterior part of the temporal ridge. 7. Glenoid fissure. 8. Mastoid foramen. 9. External auditory meatus surrounded by the auditory process. 10. Fossa for digastric muscle. 11. Sty- loid process. 12. Vaginal process. 13. Glenoid foramen. 14. Part of the Eustachian groove. Fig. 7. Imner Surface of the Left Temporal Bone. {Smith and Horner.) — 1. Squamous portion. 2. Mastoid portion. 3. Petrous portion. 4. Groove for the posterior branch of the middle artery of the dura mater (meningea media). 5. Bevelled edge of the squamous portion. 6. Zygomatic process. 7. Digastric fossa. 8. Ocuipital groove. 9. Groove for the lateral sinus. 10. Position of the superior petrous siniis, ;11. Opening of the carotid canal. 12. Meatus audito- rius internus. 13. Aquaeductus vestihuli. . 14. Styloid process. 15. Stylo-mastoid foramen. 16. Carotid foramen. 17. Spine separating the eighth pair of nerves from the jugular vein. The dark spot in front of tbe number 17 is' the position of the opening of the aqueduct of the cochlea. 18. Points to the Vidian foramen on.the anterior surface of the petrous portion. 19. Origin of the levator veli palatini, and of the tensor tympani muscles. demonstrabte as a separate cartilaginous body, and that the upper end of the styloid process is not found at the external^ visible base of the process, but that it extends upward as far as I Archiv f. Ohrenli., Bd. ix. p. 164. 40 ESTEBNAL EAR. the lower part of the eDiinentia stapedii, along the posterior limit of the tympanic cavity, from which it is separated by a thin osseous lamella. Space forbids a lengtliy consideration of the developed tempo- ral bone, but a few prominent features deserve notice here, as, that under the floor of the tympanic cavity is part of the jugu- lar fossa ; that the anterior wall is part of the carotid canal ; that the roof of the tympanic cavity is a thin bony septum be- tween the brain and the middle ear ; and that the mastoid cells are separated by a thin partition of bone, from the sigmoid fossa, in which runs the lateral or transverse sinus of the dura mater. In addition to these facts may be mentioned that the entire internal ear, or labyrinth, lies in the petrous pyramid of the temporal bone, that the middle ear is formed by the union of the squamous, petrous, and mastoid portions of the temporal bone, and that the osseous portion of the Eustachian tube lies in the inner end of the petrous portion of the temporal bone, through which the tensor tympani muscle maybe said to run on its way to the tympanum. Its moi'e detailed arrangement will be ex- plained when alluding to the soft parts of the Eustachian tube. Furthermore, the levator palati, an important tubal muscle, originates at the under surface of the temporal bone, near the inner end of the petrous part ; the carotid canal passes through this part of the bone, aud the jugular fossa is partly formed by the temporal bone ; the facial nerve passes through this bone from the brain to the face, and the aquseductus cochleae, the im- portant exit for the perilymph of the labyrinth, is placed near the carotid canal on th* under surface of the temporal bone. It is also important for the aurist to bear in mind that on the upper and cerebral surface of the petrous portion are the petro- sal sinuses, and that these are closely connected with the cavern- ous sinus, which in turn is emptied into by the ophthalmic vein, a relationship which may often explain facial and ocular symptoms in obstruction of the sinuses from aural disease. The small opening of the aquseductus vestibuli, on the pos- terior surface of the pyramidal petrous part of the temporal bone, near the entrance of the auditory nerve, must not be for- gotten, as at this point purulent disease may often be found to have entered the cranial cavity from the tympanum and vestibule. The anterior wall of the bony auditory canal forms part of THE AUDITORY CANAL, 41 the glenoid fossa, and it can thus be seen how, iu certain inflam- mations about the ear, movements of the jaw are exceedingly painful. rig.' 8. and Te^nsorzympcmimuscle LEVATOR PALAT ^inigh Qi^a^rOateral Surface '^B"^"'^ of aaratid ea„d CaTuilfor Jacolumia nerve AijundiicTMs Cor/tlate Canal fon-Arrwld't 7,erve Juffitlar fossa, ^'^ginal 2>Tocesi Sty-h- mastoid foramct ■JtigwlaT Surfaee -Auricular fia^ure stvlo-pharyngeus Umder Surface of Left Temporal Bone. (Gray.) At birth the bony auditory canal does not exist ; 'the ring from which it is developed is deficient at the upper fourth, and the canal is represented at that point by the curved lower edge of the squama. The aforesaid ring grows at last into a tube . which forms the posterior, inferior, and anterior wall of the osseous external auditory canal, to which the name of tympanic bone is also given. In the new born child the mastoid portion is also rudimentary and not fully united with the squama. At the line of imperfect union between these two parts of the temporal bone, quite large deficiencies are found in early child- hood and in some cases persist even into adult life. 42 EXTERNAL EAE. Development of the Bony Auditory Canal. — The osseous audi- tory canal, i. e. the inner and major portion of the entire audi- tory passage, is developed from the so-called drum ring, annulus tympanieus or processus auditorius. This ring, which is open or interrupted (for 1-2 mm.) at a point in its postero-superior periphery, has a furrow on its inner edge called the sulcus tym- panieus. This ring, united to the squamous and petrous portions of the temporal bone, gradually grows outward, and forms the antero-superior, anterior and antero-inferior wall of the bony auditory canal. The two prominent points (see Fig. 5) on the anterior and upper part of the ring are called by HenM spina tympanica antica and postiea, and are the terminal points of a ridge forming the upper boundary of a furrow called the sulcus maUeolaris, which finally becomes the posterior boundary of the petrotympanic fissure for the reception of the long process, processus folianus of the mal- leus, and the various soft parts which pass through the afore- said fissure, also called the Glaserian fissure. Developm£nt of the Annulus Tympanieus. — The spina tympanica antica unites with the tegmen tympani and thus completes the petrotympanic fissure posteriorly, but the spina tympanica pos- tica projects beyond or behind the tympanic margin of the squamous portion of the temporal bone, and also behind and above the drum-head, and inserts itself at last into the depression between the head and the handle of the mallet, called the neck, as shown by Henl^. Considered as anatomical points these are quite insignificant, but when taken in their physiological rela- tions with the support they give to the malleus they are of great importance. As the bone develops the spina tympanica antica grows away, as it were, from the spina tympanica postica, and is finally seen at a point far down on the superior wall of the bony portion of the canal, in the fully developed broad tympanic bone. As, however, the spina tympanica postica of Henl^, in the foetal bone, becomes of so much importance as the anterior point of insertion for the ligaments supporting the malleus in the developed organ, Helmholtz has given to it, in its physiological relations, the name spina tympanica major; and to a less prominent point on the postero-superior portion of the I'ing in which the drum-head is inserted, he gives the name of THE AUDITOEY CANAL. 43 spina iympanica minor. The latter forms the posterior point of insertion for the suspensory ligaments of the malleus. The neck of the malleus fits in between these two points in such a manner that the anterior almost torches it. In the perfect bone this relation is not visible from without. The line of attachment of the membrana tympani also shows a slight and ill-defined depression where it passes near and beneath these points, i. e., at its upper periphery above the short process of the hammer. Here the line of insertion of the drum- head is less sharply defined than it is lower down the periphery. At this ill-defined point in the upper part of the periphery of the membrana tympani, " slight pressure with a blunt instru- ment will loosen the membrane from its attachments. In fact it is more truly attached to the cutis than to the bone."' Segment of Hivinus. — This segment in the upper border of the drum-head is called the segment of Rivinus, since it includes the foramen described by E-ivinus, an opening which in some in- stances represents the last trace of the first visceral cleft, but which really has no existence in the majority of normally devel- oped adults. The Auditory Canal. — The external auditory canal extends from the bottom of the concha to the drum-head, and consists of a cartilaginous and a bony portion, the former being about one-third and the latter about two-thirds of the passage. The length of the auditory canal is about one inch and a quarter, and its average width is about a quarter of an inch.^ The canal gradually narrows to the middle of the bony portion, where it widens again gradually to the drum-head. A hori- zontal section, therefore, of this canal will be proximately repre- sented by that of two detruncated cones placed together at their points of detruncation. The auditory canal is lined with skin, a continuation of that of the auricle, and not with mucous membrane. The skin of the canal is extended over the drum- head, forming its dermoid or outer layer, so that a glove-finger ' Mechanism of the Ossicles of the Ear and the Membrana Tympani. H. Helmholtz, Bonn, 1869. English translation by A. H. Buck and Normand Smith, New York, 1873. 2 Kichet, eight to nine mm. at the opening, and from six to seven mm. at the fundus of the canal. (Hyrtl.) 44 EXTERNAL EAR. will represent very well the shape of the cutaneous lining of the canal, the finger-tip heing the position of the drum-head. In the bony portion of the canal, the skin is thin and closely adherent, its silvery lustre having probably led earlier observers Fig. 9. Transverse Section op the entire Auditoet Apparatus of the Right Side. (Gray.) to call it a mucous membrane ; but there is no such membrane in the external ear. In the inferior wall of the meatus there are deficiencies in the cartilage called the incisurce Santorini, and there is a cleft in the upper wall of the cartilaginous part of the canal. The general course of the external auditory canal may be described as sigmoid, or as a spiral turning anteriorly inward and downward, though there are many individuals in whom the auditory canal is so straight that their drum-heads may be seen very easily by direct inspection and without dilation of the cartilaginous part of the passage. I have frequently inspected the drum-head in such cases without the knowledge of the person examined, sometimes while riding in a street car. Such straight canals are invariably wide ones ; and much more com- mon in the black than in the white race. Although the external auditory canal is usually spoken of as tortuous, I have observed that in the negro it is usually wide and straight, so much so, in fact, that in most cases, in this race, I have been able to see the membrana tympani without THE AUDITORY CANAL. 45 the aid of speculum and rfeflected ligbt, being able to look directly down upon the drum-head. I have sometimes, though very rarely, seen the same kind of a wide and straight auditory canal in the white man. Could the large auricle and auditory canal have any connec- tion with the musical talent universally found in the negro race in this country ? In the white race, the wide and straight meatus, according to my observation, is found in individuals more than ordinarily endowed with the so-called musical ear. Upon the entire free surface of the cutis of this canal are found epidermis and soft short hairs, together with the sebaceous glands usually found in connection with them. Throughout the canal, especially in the bony portion, are found vascular papillae arranged in parallel rows, and glandular structures closely resem- bling sudoriferous glands, but which in their modified form are called cerumiuous glands. Ceruminoiis Glands. — These glands begin about two mm. from the opening of the auditory canal, and extend to within two to three mm. of the drum-head ; they are found in the bony as well as in the cartilaginous part of the canal. They are most numei'ous at the junction of the cartilaginous with the bony canal, where they average as many as ten to the square milli- metre. According to Buchanan, there are from one thousand to two thousand in an auditory canal. The thickness of the skin in the cartilaginous part of the auditory canal is one and . a half mm. thick. Vessels and Nerves. — The arteries supplying the auditory canal are branches from the posterior auricular, internal maxil- lary, and temporal. The nerves are chiefly derived from the temporo-auricular branch of the inferior maxillary nerve. There is also an auricular branch of the pneumogastric nerve. PHYSIOLOGY. The acoustic physiology of the external auditory canal has been alluded to in speaking of the functions of the external ear as a resonator. There is one function it possesses, that of causing the ear-wax and some small foreign bodies to fall out from it, which is not fully explained. 46 EXTERNAL EAR. Voltolini' has shown, that if a foreign body is wedged in a swollen auditory meatus, and the former be made smaller by any means, but especially by the galvano-caustic, the body thus reduced will be pressed out by the swollen walls of the auditory canal. This he claims to be an invariable physical process. Perhaps we may explain the natural escape of cerumen from the ear in some such way as the following : The ear-wax is mostly formed in the wide end of a detruncated cone, i. e., near the outer end of the auditory canal. Therefore, as the wax forms, it presses upon the walls of the auditory canal, and the latter being widest towards the mouth, i.e., freest on the outer side of the gradually growing mass of cerumen, the latter meets with the least obstruction just in the direction of its only escape ; hence it will be acted upon very much as if it remained a constant quantity, which is being continually pressed upon from behind, and pushed outward by a gradually narrowing auditory canal ; for, as the mass accretes, it must necessarily, with its naturally lubricated surface, slip into a broader, which is an outer, plane in the external auditory meatus, and thus at last it may be found at the mouth of the auditory canal. Unfortunately, this delicate function is constantly interfered with by those who, in en- deavoring to clean out wax, push in more than they bring out, and thus, in a short time, form obstructive plugs of cerumen. Another mode by which cerumen is aided to fall out of the auditory canal, if let alone, has been suggested to me by watch- ing the gradual outward movement of a scab on the membrana tympani, and of a similar object on the wall of the auditory canal. If a little fleck of blood forming on the membrana tympani, or on the wall of the external auditory canal, be watched for some days, it will be observed to change its position by moving out- ward, strongly suggestive of the manner in which a spot over the matrix of the finger nail will gradually grow to the edge of the nail and disappear. I have watched little scabs of blood thus move from the drum membrane to the wall of the canal, and from the inner part of the latter similar substances may be seen to move outward to the mouth of the meatus. In some such way, I believe the outward growth of the skin of the auditory canal helps to force out the superabundant ear-wax. ' Monatsschr. f. Obrenh., No. 9, 1873, and elsewhere. MEMBRANA TYMPANI. 47 CHAPTER III. MEMBKANA TYMPANI. ANATOMY. The membrana tympani, or drum-head, is composed of three layers, viz. : the external or dermoid layer; the middle or fibrous layer, also called the membrana propria ; and the internal or mucous layer. The Dermoid Layer. — The dermoid layer of the membrana tympani is a continuation of the cutis of the external auditory canal. This may be seen if the skin of the canal be macerated properly, when the entire cutaneous lining may be removed in the shape of a glove-finger, the tip of which will represent the dermoid layer of the drum-head. In this layer there are, how- ever, no hairs nor follicles such as are found elsewhere in the cutis of the auditory canal. In other respects, it is true skin, but extremely thin and transparent. The Outer Surface of the Membrana Tympani. — The dermoid layer is the only one of three layers composing the membrana tympani, which can be inspected directly from without. When the ear is illuminated and a normal membrana tympani examined from ^'S- 1". without, there are several prominent features in it, which at once attract attention, viz. : its almost circular shape and peculiar polish and color ; its vertical and horizontal inclination ; the manubrium of the malleus; the short process of the latter ; the folds of the membrana tympani ; the flaccid portion of the drum head above these folds, called the membrana flaccida or View of outer Sukpace of Mem- BKAKA Tympani. (Gruber.) — a. Malleus ; manubrium, n. Short pro- cess; c. The tip of the manubrium, s. Posterior fold. 48 EXTERNAL EAR. Shrapnell's membrane ; and the bright triangular reflection of light in its antero-inferior quadrant, called the "pyramid of light." Shape of the, Membrana Tympani.—Fov purposes of conven- ience in description, the outline represented by the periphery of the membrana tympani is called circular. This form, however, varies between that of an ellipse and an irregular oval, while in some cases where the lateral portions of the annulus tympanicus are especially curved outward, it assumes a heart shape. It may be strictly considered an ellipse, the long diameter of which, amounting to 9-10 mm., runs from above and in front, downward and backward, and the diameter of greatest width of which runs from below and in front, upward and backward. These measurements are those given by v. Trceltsch, and are nearly in accordance with those of Hyrtl, according to whom the proportion between the diameters is as 4.3'"-4.0"'. Since the difference between them is so slight, and their in- clinations are so nearly vertical and horizontal, the outline of the membrana tympani may be considered circular, and the long diameter is spoken of as the vertical diameter, while the dia- meter of greatest width is considered the horizontal diameter. The membrana tympani is therefore divided into quadrants, which greatly aid in locating any point to be described. Color of Membrana Tympani. — The normal color of the mem- brana tympani is never fixed. Just as some normal teeth are bluish or yellowish-white, so it is with the drum-head, which though perfectly normal may be bluish or yellowish-gray, though more frequently it is found to be the former. The normal color of the drum-head is usually spoken and written of as "pearl gray," but whatever color the membrana tympani may be said to have, that color must always he modified by the physical condi- tions brought about by stretching a slightly transparent mem- brane over a darkened cavity. And this is a modification not sufficiently taken into account by observers. There is there- fore, from the cause just mentioned, an admixture of black with the delicate gray of the membrane, but it is very diflicult to paint a transparent or translucent object, and therefore very diffi- cult to ascribe even a name to the color of a normal membrana MEMBRANA TYMPANI. 49 tympani, since its appearance is partly due to the color whicli its own substance reflects and partly to the color it transmits from the cavity of the drum, the latter feature of course being modified in every imaginable degree by the thickness or thin- ness of the membrana tympani, as well as by the various condi- tions and colors of the contents and lining of the tympanic cavity. Modifications of color similar to those in the membrana tym- pani can be in a measure produced artificially, if we stretch a piece of gold-beater's skin, delicate tissue paper, or sheet gutta percha over a rather shallow cavity rendered dark by covering it in this manner. The color of the membrane thus formed will be composed of the latter's own peculiar tint as an opaque substance and the color of the cavity over which it is stretched and which it transmits. Just such conditions of coloring due to the fact that the membrana tympani is a slightly opaque substance and to the fact that it transmits color from the tympanic cavity must be borne in mind, in any attempt at naming its color, which therefore will ever be composed of the tint of the membrane modifi.ed by the color it transmits. Prof. Politzer defines the color of the normal membrana tym- pani, as " a neutral gray tint, with an admixture of violet and light brown." " That part of the membrana tympani, just behind the lower end of the manubrium, and over the promontory of the cochlea, is rendered yellowish-gray by the rays. of light reflected from the vellow bone of the inner wall of the tympanic cavity." Of course all these shades of color vary a little, even in the normal state ; but greatly during pathological processes in any part of the structures entering into the formation of the drum-head. The membrana tympani owes its peculiar lustre to the delicate and shining epithelium of the dermoid layer. If a fresh membrana tympani be placed in a solution of nitrate of silver the peculiar cement-like substance between the scales of this epithelium will become tinged, while the scales them- selves will remain uncolored, and thus a distinctly marked pre- paration will be made in which the various shapes of the epithe- lial scales become demonstrable under the microscope. 4 50 EXTERNAL EAR. The slightest maceration or exfoliation of this delicate epi- thelium deprives the membrana tympani of its beautiful gloss. The dermis of the drum-head is thickest in children. The Inclinatiovs of the Membrana Tympani. — Another impor- tant feature which attracts the attention of one examining the ear is, that the membrana tympani, in its normal condition, is inclined at an angle of 45° in its vertical plane, and in its horizontal plane is inclined 10° towards the right on the right side and 10° towards the left on the left side. If the planes of both membranse be extended downward until they intersect each other, the angle which they will thus form will be equal to about 130°-135°. Of still greater importance than this, however, is the direction of the walls of the auditory canal from the plane of the mem- brana tympani. Thus if a perpendicular be drawn from the upper pole of the drum-head to the inferior wall of the auditory canal, it will strike the latter about 6 mm. from the inferior pole of the mem- brane. A similar result will be obtained by drawing a perpendicular from the middle of the posterior periphery of the drum-head to the anterior wall of the auditory canal, from which fact it becomes very evident that the antero-inferior part of the mem- bana tympani is further removed from the external opening of the auditory canal than the postero-superior part.' The membrana tympani is inclined the most in very young children, being in the early years of life, almost horizontal in position, and, on account of the sliallowness of the auditory canal at that time, the membrane is very superficial, especially at its upper part. The Manubrium of the Malleus. — Eunning from above down- ward and backward, to the centre of the membrana tympani is seen the ridge formed by the manubrium of the malleus. This slightly elevated ridge, entirely opaque and decidedly whiter than the surrounding drum-head, divides the membrana tympani into two unequal parts, the anterior being the smaller and ' Gruber, Studien uber das Tiommelfell, p. 4. MEMBRANA TYMPANI. 51 the posterior the larger. At the upper end of this ridge is the short process of the malleus, projecting sharply outward, somewhat above the general surface of the handle of the hammer. In gene- ral appearance it is not unlike a pimple with yellowish contents. The lower end or tip of the ridge, which curves slightly for- ward, is flatter, broader, and yellower than the rest of the outer covering of the manubrium. This is due to the fact that the bone proper is spade-shaped at this point, and also because the radial fibres of the membrana propria centre at this lower part of the bone. The lower end of the manubrium draws the membrana tym- pani inward very markedly, and forms that depressed spot in the centre called the umbo. The convex shape of the drum-head from the tip of the manu- brium outward towards the periphery is due to the compara- tively large number of circular fibres at a point between the umbo and periphery, which constrict, as it were, the radial fibres, so as to form a kind of funnel. Fig. 11. Fig. 12. A' Pressure or traction applied to the centre of a membrane stretched over a ring, tends to draw the former into a cone, a vertical section of which is. represented by the line a u a' in Fig. 11. But if a smaller concentric ring be placed at b c so as to resist the indrawing force at u, the curve assumed by the membrane 52 EXTERNAL EAB. is represented by the line a u a' in Fig. 12, and the whole mem- brane is drawn into a concavo-convex shape. The Yellow Spot at the End of the Manubrium of the Malleus. — This spot is not a pathological appearance, but a purely physio- logical condition. It is part of the cartilaginous structure at the end of the hammer. Dr. Trautmann,^ who has made a special study of the spot, concludes that its physiological significance is the same as an epiphysis of a long bone. The diagnostic value of the yellow spot is considered by him to be apparent in cases of thickening of the membrana tympani, when the former will disappear much sooner than the sharp edge of malleus. 2. Opacities of the membrane with thickening change the color of the yellow spot. 3. When the malleus is twisted on its long axis the form of the spot will be altered. 4. If the spot does not move during alterations in the atmospheric pres- sure in the canal, by means of Sigle's speculum, it is fair to con- clude that either anchylosis of the malleus or its adhesion to the inner wall of the tympanic cavity has occurred. In the latter instance the diflerential diagnosis is aided by the neces- sary foreshortening of the handle of the hammer. Folds of ike Membrana Tympani. — Prom the short process of the manubrium of the malleus two delicate ridges may be seen, one passing forward, the other backward to the periphery. These are the so-called folds of the membrana tympani. They are formed by the pressure from behind, produced by the short pro- cess of the malleus. They are important topographical as well as diagnostic points of the membrana tympani. Above these folds is the so-called membrane of Shrapnell,' or membrana flaccida. It owes its flaccidity to the small amount of fibrous tissue entering into its composition, and to the loosely stretched cutaneous and mucous layers of the membrana tympani, which here come together. In this membrane somewhere, there is ' Archiv. f. O. B. xi. p. 99-113. 2 Henry Jones Shrapnell, not Odo Shrapnell, as several German authors have called him. This author's description of the membrana flaccida is found in London Med. Gazette, vol. x. g. 120. MEMBEANA TYMPANI. 53 said to be a normal opening, the foramen of Rivinus, named after the writer, who first called attention to its supposed existence in 1717. Ever since, the dispute has turned upon several points, viz., first, whether there is such an opening ; secondly, is it nor- mal or pathological ; and lastly, in what part of the membrane is it found. Although a number of distinguished observers, among whom may be quoted Patruban, Gruber, Politzer, and Hyrtl, have investigated this point in the anatomy of the membrana tym- pani, the question was for a long time an open one, until Hyrtl denied the existence of a normal opening in the membraua flaccida, either in the adiilt or in the infant cadaver. He, how- ever, admits that a want of development in the membrane in the neighborhood of the Rivinian segment may, in some cases, lead to the formation of a quasi foramen, but the normal existence of such a foramen is not proven. Such testimony as Hyrtl's is incontrovertible in the author's opinion, and can never be over- thrown by the assertion that the opening is so small, that the anatomist must look for hours with a magnifying glass, in order to find it ; nor can I understand how a foramen should be so small as to require such persistent search with a magnifying glass, and yet, when found, be large enough to allow a bristle to pass in and through it. I have surely never seen any opening in this part or any other part of the membrana tympani that was not purely pathological. The occurrence of any opening in the membrana flaccida is most rationally accounted for by Hyrtl's explanation, viz., by a want of normal development, or by a pathological loosening of the fibres of the flaccid mem- brane from their very loose connection with the horizontal edge of the squamous portion of the temporal bone, at that point known as the Rivinian segment of the periphery of the membrana tympani. Pyramid of Light. — The pyramid of light is a name applied to the beautiful triangular reflection of light emanating from the antero-inferior quadrant of the normal membrana tympani. The apex of this triangular reflection touches the tip of the manubrium of the malleus, and its base lies on the periphery of the membrana tympani. It forms with the handle of the malleus an obtuse angle anteriorly, which becomes greater as the 54 EXTERNAL EAK. inclination of the membrana tympani to the auditory canal di- minishes. Its average height is from 1 J to 2 mm., and its average width at the base is from 1 J to 2 mm. This reflection, which has been called an isosceles triangle from its general appearance, is strictly considered pyramidal in shape, and hence the name applied to it by most writers of the present day. Wilde, of Dublin, called it the " speck of light," and many of the Germans call it the "reflection of light." The causes of the formation of this pyramid of light, or, in other words, the optics of this important spot, have been variously explained by a number of careful observers. Wilde, the first to describe it, believed it to be due to the convexity of the membrane, but other observers since that time, among whom may be named Politzer,' Gruber,^ Voltolini,* and Trautmann,* have most clearly shown that such a convexity is not the only cause of the formation of the pyramid of light. From the more recent investigations, it is most conclusively proven that there are three elements indispensable to the formation of this peculiar reflection of light, viz., a shining surface, the inclination of the membrane, and its peculiar funnel-like shape. In these three conditions may be found the solution of three very important questions, viz. : 1. Why do we see such or any reflection from the membrana tympani ? 2. Why do we see this one in the an- tero-inferior quadrant? .And, 3. Why is its shape pyramidal ? The Jirst condition, viz., the reflecting surface, is supplied by the lustrous epithelium of the dermoid layer of the membrana tympani, and thus an answer is given to the first question. The second condition, viz., the peculiar inclination of the membrana tympani, so places the membrane that, by the modi- fications of its surface brought about by the traction inward at the umbo, the only possible spot from which light can be re- flected is just where the pyramid of light is seen. This point will be more fully explained further on. The third condition, viz., the funnel shape of the membrana ' Die Beleuclitungsbilder des Trommelfells itn krauken, und gesunden Zustande, Wien, 1865. 2 Anatomisch. Physiologische Studien, uber das Troinmelfell und die Gehor- knochelchen, Wieu, 1867. 3 Monatsschr. f. Obrenh. Jahrg. vi., No. 8. * Arcliiv f. Ohrenheilkuude, Band ii., N. F., 1873. MEMBEANA TYMPANI. 55 tyinpani, will explain the pyramidal shape of this reflection, upon the physical law pertaining to concavo-convex mirrors. Not one of these conditions is sufficient of itself to produce a normal pyramid of light on the drum-head. That the lustre of the dermoid layer is an important factor in producing this pecu- liar reflection, may be easily proven by syringing an ear in which the pyramid of light is seen in its normal condition. After a slight maceration of the dermoid layer has been thus produced, and its shining surface destroyed, the pyramid of light will be found to have disappeared or to have become dulled or distorted. In order to prove that the peculiar inclinations of the mem- brana tympani, respecting the walls of the auditory canal, have also their part in the formation of the pyramid of light at that point where it is normally found, viz., in the antero- inferior quadrant, it is only necessary to inspect a normal drum-head in which the reflection of light, in question, is found, during the inflation of the tympanic cavity by the Valsalvan or any other method. It will then be seen that the pyramid of light becomes altered in its position in respect to the malleus. That this reflection can come only from the antero-inferior quadrant, is further shown by an experiment of Politzer's, as follows : — If the auditory canal be removed from the membrana tym- pani, so that the latter is attached only to the annulus tynipani- cus, and the membrane then be revolved, so that other parts of its surface successively assume the position of that from which the pyramidal reflection formerly came, we shall perceive on each of these parts a reflection almost exactly like the original pyramid of light, excepting behind the manubrium, where, owing to the dift'erent curve of the membrane, the reflection in question will be somewhat diflerent, both in shape and brill- iancy. Tlie third important condition in the formation of the pyra- mid of light, is the funnel shape of the membrana tympani, to which is due, according to Trautmann, the pyramidal shape of the reflection under consideration. The Cause of the -Pyramidal Shape. — It is already known that the membrana tympani is drawn inward in such a way by the 56 EXTERNAL EAR manubrium of the malleus and the peculiar distribution of fibres in the membrana propria, that its general shape may be likened to that of a shallow funnel or the flower known as the "morn- ing-glory" or convolvulus.' As its surface is very polished, it may be considered a convex mirror, which, for the sake of better explaining the pyramidal shape of the light spot of the membrana tympani, we may con- sider a convex mirror composed of an indefinite number of sec- tions of convex mirrors with radii varying from that of a mere point to that of the circle which the periphery forms. Now, since it is a law of physics that the image reflected from convex mirrors varies in size directly as the radius of the mirror, we shall have in the composite convex mirror represented by the drum-head, an image, which at the centre, i. e., at the point of the manubrium, is a mere point of light, but which gradually enlarges towards the periphery, until we perceive a triangular spot with its base on the periphery, the height of which depends on the distance of the centre of the mirror from the periphery, and the breadth of the base of which depends on the dimensions of the periphery ; the greater the latter the wider the base of the triangle of light. Dr. Trautmann thus sums up the causes of the pyramid of light : " The normal membrana tympani has quite a high de- gree of superficial lustre, is inclined at an angle of 45° in its vertical plane, and in its horizontal plane it is inclined 10° to- wards the right on the right side, and 10° towards the left on the left side. Furthermore, it is drawn inward so as to form a funnel, the point or apex of which lies in the centre of the ante- rior periphery of the yellow, sickle-shaped expansion at the end of the anterior edge of the manubrium of the malleus, the angle at which the walls of the funnel meet is greater than a right angle, the depth of the funnel is equal to about 2 mm., and the distance from the apex to the perijahery is 2|-3 mm. anteriorly, and 3 mm. posteriorly. "Therefore, a 'spot of light' or a reflection of light from the plane surfaces of the membrana tympani cannot reach the eye of an observer, because the rays of light from without, on ac- ' Voltolini, loc. cit. MEMBRANA TYMTANI. 57 count of the inclination of the menibrana tympani, fall upon the plane surfaces of the same, at a very acute angle, and since the angle of reflection is equal to the angle of incidence, the rays of light reflected from the planes of the membrane which has an inclination of 45°, must strike the inferior wall of the external auditory meatus, and are in consequence unable to reach the eye of the observer. "The relations are, however, different, when we consider the ' reflection of light' which is found in the funnel-shaped tract. On account of the vertical inclination of 45° of the membrana tympani and of its horizontal inclination of 10°, the antero-in- ferior quadrant of the membrana tympani is at right angles .to the illuminating object. Since, now, the illuminating body and the eye are in the same line, or should be, in order to obtain the best possible illumination of the membrana tympani, only the rays of light which fall perpendicularly upon the antero- inferior quadrant can reach the eye, since all other rays are re- flected at such an angle that they strike the walls of the auditory canal ; therefore, the only reflection of light seen by the observer comes from the antero-inferior quadrant of the membrana tym- pani."' Geometric Divisions of the Membrana Tympani. — KesseP has divided the membrana tympani into two grand divisions, one above, the other below the folds of the drum-head, ae, ed. The upper division is subdivided into three sec- tors, viz., aeb, bee, and eed, Fig. 13. The sectors are bounded below by the folds of the membrana tympani and above by the annulus tympanicus and the segment of Rivinus, b c. The middle sector bee, is separated from the other two on each side by the two suspensory ligaments be, ee, of the ' Loc. cit., p. 38. ' Ueber den Einfluss der Binnenmuskeln der Pankenhohle auf die Bewe- gungen und Schwingungen des Trommelfells am todten Ohre. Archiv f. Ohrenheilk. N. F., Band 3, 1874. 58 EXTERNAL EAR. handle of the hammer. Between the anterior suspensory liga- ment, be, and the anterior fold of the memhrana tympani lies the anterior sector, and between the posterior suspensory ligament and the posterior fold of the merabl-ana tympani lies the poste- rior segment. The inferior division of the memhrana tympani, viz., that portion below the folds, is divided into an anterior segment beginning at the anterior fold of the membrana tympani and extending to the pyramid of light, and the posterior seg- ment extends from the pyramid of light to the posterior fold of the membrane. Dr. Kessel says : " Making the pyramid of light the inferior boundary between these segments is not arbitrary, but has a good reason in the fact that the radial fibres, running downward and forward, i. e., in the tract of the triangle of light, from the point of the manubrium of the malleus, in a drum-head of nor- mal position are shorter and therefore tenser and more retracted than those fibres which run directly backward and forward from the manubrium." Annulus Tendinosus. — Before considering the membrana pro- pria, the structure from which the fibres of this middle layer of the membrana tympani arise demands a short description. This is the so-called annulus tendinosus,' or tendinous ring of Arnold. It is a mass of fibrous tissue arranged around the peripheiy of the membrana tympani, effecting the union between the latter and the inner edge of the external auditory canal. The annulus tendinosus is not found, however, at that part of the periphery of the membrana tympani corresponding to the Eivinian segment, nor is it always visible from without, even when present in its normal position, around the periphery close to the annulus tympanicus. The fibres of the membrana propria, the origin of which has just been explained, are not inserted directly into the bone of the manubrium, but into a cartilaginous groove which receives the manubrium and short process. This peculiar structure was discovered and has been fully described by Gruber.^ It presents in general the appearance of a deep groove, when ' The annulus cartilagineus of the older writers. 2 Studien tiber das Trommelfell, u. s. w., pp. 30-27. MEMBEANA TYMPANI. 59 seen from behind after the removal of the malleus. As shown by Gruber, this groove is closed at its upper end so that it forms a cartilaginous cap, which covers in the short process on all sides ; its lower end, on the contrary, is open behind, and it gradually becomes shallower, i.e., flatter, until it is at last lost in the sub- stance of the membrana tympani. It extends from a little above the short process to a point J mm. below the spade-like end of the manubrium. Inner Surface of the Cartilaginous Groove. — The inner surface of this cartilaginous groove, which is in contact with the malleus, is lined by a very delicate layer of connective tissue, between which and the malleus there is found a small amount of fluid resembling synovia. As this condition of discontinuity be- tween the malleus and the inner surface of the cartilaginous groove is considered normal by Gruber, it is fair to presume that, such being the case, the malleus can make a certain amount of motion in this groove, and that therefore there is here a kind of joint. I have seen in Prof. Gruber's clinic, a case which appeared to have two short processes projecting from the upper end of the manubrium. Such an appearance is explained by Prof. G-ruber, as the result of a dislocation or slipping upward of the entire malleus, out of this cartilaginous groove ; the upper of the " two short processes" in such a case is the true bony short process, whereas, the lower one is the aforesaid cartilaginous cap, moulded over the short process and held in the original position of the true short process by the membrana tympani. This condition, Gruber calls subluxation of the cartilage from the short process. Koliicker' regards this hyaline cartilage as a remnant of the cartilaginous malleus of foetal life, and he thinks it is very possible that the osseous malleus is formed about the cartilage, as is the case in the processus spinosus, in which instance the layer of connective tissue found by Gruber between the cartilaginous groove and the malleus, and the comparatively easy separation of the two from each other, becomes perfectly explicable ; but Kollicker does not admit that there is a normally developed and constant space between these two structures. ' Gewebelehre, p. 707. 60 EXTERNAL EAR. The Membrana Propria : the fibrous or middle layer of the Mem- brana Tympani. — Having considered the anatomy and the inspec- tions of the outer or dermoid layer, the anatomy of the middle or fibrous layer of the membrana tympani demands attention. The membrana propria can be subdivided into two distinct and delicate layers, viz., an outer, composed entirely of radiate fibres intimately connected with the dermoid layer of the drum-head ; and an inner layer composed entirely of circular fibres, in close relation with the mucous membrane composing the internal layer of the membrana tympani. These sub-layers of the membrana propria are named, briefly, the radial layer, and the circular layer. The fibres composing the former arise from the annulus tendinosus and the upper wall of the auditory canal, and are inserted into the manubrium of the malleus, centring for the most part at its spade-like tip. The fibres composing the circular layer arise partly from the annulus tendinosus, but the majority of them arise from the substance of the membrana tympani itself (von Trceltsch). Some of them are inserted into the malleus. Of the former kind, viz., those arising from the annulus tendinosus, Gruber says : " They form a very acute angle with the annulus tendinosus, assuming in their progress downward the course of the fibres of the circular layer." These fibres, Prof. Gruber thinks, have either been overlooked heretofore, or considered radial fibres. The circular fibres are most numerous a short distance from the periphery of the membrana tympani. The region of their greatest thickness is in the outer third of the membrane, where they are twice as numerous as the radial fibres; the thickness of the circular layer at this point being 0.026'", while that of the radial layer is equal to 0.018'" (Ger- lach). They are much less numerous at the middle third of the membrane, and almost wanting at the central part of the drum- head. A knowledge of the arrangement of these fibres is impor- tant when considering pathological changes which may have taken place in the membrana tympani. Prof. Helmholtz' thus accounts for the peculiar concavo-con- vex shape of the drum-head : " If the radial fibres of the mem- brana tympani were not united by transverse ones, they would ' Mechanism of the Ossicles of the Ear and the Membrana Tympani, Eng. transl. by Buck & Smith, New Yorls, 1873. MEMBRANA TYMPANI. 61 be stretched in a straight line. In point of fact, however, they maintain a curved shape, with the convexity looking toward the meatus ; hence we conclude that the radial fibres are drawn toward one another by circular fibres, and that the latter are also made tense at the same time. There is, in fact, in the membrana tympani at rest, no other force capable of holding the radial fibres in a curved position, except the tension of the circular fibres." The Descending Fibres of the Membrana Tympani. — In addition to the two layers already described as forming the membrana propria, there is still another layer composed of descending fibres^ first described by Gruber. These fibres are external to the radial fibres, and arise from the upper segment of the annulus tendinosus, and, lying very close to each other, are inserted into the sides and median line of the cartilaginous groove already described. The various layers of the membrana propria, z.e., the three just described as the radial, circular, and descending fibres, are lightly bound together by a very delicate kind of connective tissue. On the other hand, they cling very firmly to the annulus tendinosus, cartilaginous groove, dermoid and mucous layers, as shown by Gruber. Dentiform Fibrous Structure of the Membrana Tympani. — There is in the membrana tympani a set of fibres arranged in a pecu- liar way and first described and named by Gruber the dentiform fibrous structure^ of the drum-head. " They arise near the periphery, about in the middle of the posterior segment, pretty far apart, but as they proceed on their upward course in the posterior segment they approach each other, in order to divide again, at some distance from the manu- brium of the malleus, into, several branches, usually about three, which run in different directions, and are finally lost by inter- twining with the fibres of the membrana propria."* These fibres are not confined to the posterior segment, but traces of them are found throughout the membrana tympani. At their peripheral portion they are between the two layers of fibres composing the membrana propria, but as they approach ' Dentritisches Fasergebilde. 2 Gruber, Studien tiber das Trommelfell, p. 85. 62 EXTERNAL EAR. the centre they are in intimate connection with the mucous layer of the menibrana tympani. These fibres are of tense con- nective tissue, closely resembling tendon. When treated with acetic acid, they exhibit the peculiar connective tissue corpuscles already alluded to as being found in the membrana propria. Prof. Grruber further shows that the fibres entering into the composition of this structure, become most beautifully manifest when viewed by polarized light, when they appear much more brilliantly illuminated than the other tissues of the membrana tympani. Respecting the function of this structure we are told that in all probability it is an apparatus for relaxing the mem- brane, although it cannot be shown as yet that it is a muscular structure. Constituent Elements of the Membrana Propria. — The labors of Toynbee, v. Trcsltseh, Gerlach, and Gruber have added to the knowledge of the nature and dimensions of the constituent ele- ments of the membrana propria. It consists chiefly of connective tissue of that variety half- way between the ordinary fibrillated and the homogeneous con- nective tissue of Reichert as shown by Gerlach. The fibres are 0.004'" broad and 0.002'" thick, and on account of their ribbon-like shape they were once supposed to be un- striated muscle fibres, which they are not. On these fibres, certain peculiar spindle-shaped corpuscles are found. They were once supposed to be peculiar to the membrana tympani, and have been called " corpuscles of the membrana tympani," or the "corpuscles of v. Troeltsch," after the observer who first drew attention to their existence. They are, however, connective tissue corpuscles of Virchow. They are about 0.002'" long and from 0.005 to 0.010'" wide at their broadest part, with from two to' three processes. According to Gruber, these bodies are found in two varieties in the membrana tympani, viz., the spindle-shaped and the stellate variety. The Internal or Mucous Layer of the Membrana Tympani.— The internal layer of the membrana tympani is composed of mucous membrane, a reflection of that lining the tympanic cavity. It is thickest at that point where it leaves the cavity of the mid- MEMBEAJSTA TYMPANI. 63 die ear and passes over the periphery of the drum-head. It grows gradually thinner as it approaches the centre of the mem- brana tympani, where it is extremely delicate. On the inner surface of this layer various observers among whom may be named Politzer, Gerlach, and Kessel, have found villi or papillae. They are said by Grruber to resemble intestinal villi in their appearance. They are usually found in delicate children. These villi may be globular or finger-shaped, the diameter of the former being from O.lO'" to 0.12'" and the length 0.12 to 0.14'" ; the finger-shaped ones vary in length from 0.10 to 0.12'" and in width 0.06 to 0.08'". (Gerlach and Gruber.) Since Gerlach could not discover any nerves in these bodies, and as some of them are connected with the mucous membrane only by means of pedicles, he is disposed to regard tliem as villi rather than as papillae. Fold of Mucous Membrane for the Chorda Tympani. — The mucous membrane of the tympanic cavity covers the entire inner surface of the membrana tympani ; at its upper boundary it is reflected over the chorda tympani and back again to the drum-head. By this means a duplicature or fold of mucous membrane is formed, the opening of which is turned towards the surface of the membrana tympani, and in the cul-de-sac or inner edge of which the chorda tympani is found. Pockets or Pouches of the Membrana Timpani. — This arrangement makes the so-called pockets or pouches of the membrana tympani, first de- scribed by V. Troeltsch. The mu- cous membrane, after passing over the chorda tympani and rejoining the drum-head forming these pouches, passes upward and is reflected in- ward over the roof of the tympanic cavity and the ossicles. Further ex- planation of the pouches will be given under the consideration of the contents of the tympanic cavity. Fiar. 14. View op Iknek Suhface of Mem- BBANA Tympani. (Gruber.) — a. Maa- ubrium of malleus. B . The tip or lower end of manubrium, c. Head of malleus. s. Body of incus. E. Short process of incus. P. Processus lenticularis of incus. G. H. Chorda tympani. I. In- sertion of tensor tympani. 61 EXTERNAL EAR. Comparative Distribution of Bloodvessels in the Memhrana Tym- pani. — In a series of investigations upon the membrana tympani of the mammalia, I have found in the dog, the cat, the goat, and the rabbit, an arrangement of the bloodvessels not hereto- fore described, and totally different from that in man. Prussak,' in his brochure upon the circulation of the blood in the tympanum of the dog, has represented the general topo-. graphy of the vascular system in the membrana tympani of that animal, but it does not point out the ultimate loop-like arrangement of the vessels distributed over the surface of the membrane. The plate which accompanies his article seems to indicate that the delicate vascular loops have been broken by the force of injection, and thus escape the eye of the observer. In my investigations I have found that from the periphery of the membrane a series of vessels run directly towards the manubrium of the malleus ; then each vessel, a point from one- half to one-third of the distance between the periphery of the membrane and the manubrium of the malleus, turns abruptly upon itself and returns to the periphery, thus forming a series of vascular loops at nearly equal distances from each other around the edge of the membrane. A similar series of loops run both anteriorly and posteriorly from the manubrium of the malleus towards the periphery of the membrana tympani, a diagram of which may be seen in Fig. 15, representing the membrana tympani of a dog magnified eight diameters. This arrangement of vessels in the membrana tympani is con- stant in the dog, the cat, the goat, and the rabbit, in conse- quence of which a portion of the membrane between the annu- lus tympanicus and the manubrium of the malleus remains free from capillaries in its normal condition, and it is probable, though not yet proven, that ordinary disturbances in the circulation are likely to interfere with the vibrations of the membrane in these animals. These vascular loops do not exist in the guinea-pig, an animal which has in its membrana tympani an arrangement of vessels peculiar to itself. The general appearance of the membrana ■ Verhandlungen der Kouiglich Saecbsischen Gesellscliaft der Wissenschaften zu Leipsic, 1868. MEMBRANA. TYMPANI. 65 tympani of the guinea-pig, under the microscope, is much more transparent and delicate than that of any of the previously mentioned animals. Fig. 15. Membrana Ttmpani of a Dog. — The wood-cut is from a drawing of a gold preparation made by and in the possession of the author, a, «. Vacancy left by manubrium of malleus. &, 6, b, b. Vascular loops, c, c. Ordinary capillaries. The vessels are arranged in the form of a net, with coarse mesh of quadrangular or pentagonal shape. The radiate fibres are strongly developed in comparison with the circular fibres, which are sparsely distributed throughout the texture of the membrane. They are, however, readily seen, and present an appearance as peculiar to the membrana tympani of the guinea- pig, as the shape of the mesh of the network of bloodvessels in this animal. In no other membrane have I seen as distinctly the blood-corpuscles lying within the capillaries as in that of the guinea-pig. The membranes which show these loops and other vascular arrangements most distinctly are such as have been colored with a solution of the chloride of gold (J per cent). The vascu- lar arrangement can be seen, but not very satisfactorily, in membranes which have been treated with osmic acid or a solu- 5 66 EXTERNAL EAR. tion of carmine. The best specimens, showing not only blood- vessels, but in many cases the delicate nerves of the membrane, I have obtained by preparing the membrana tympani of the dog in the following manner: Remove the membrane from the animal as soon as possible after death. In the majority of my experiments, the animal had been dead but a few^ minutes. Steep the membrane a few seconds in concentrated acetic acid ; then lay it in a solution of chloride of gold, which should be kept at a temperature somewhat above that of the blood, for one-half hour. After this treatment, the membrane should remain twenty-four hours in glycerine, or water slightly acidu- lated with acetic acid, and- exposed to the light till it assumes a delicate purple hue. The older the preparation becomes, the more distinctly are the vessels colored. I have some prepara- tions, mounted in glycerine, now almost a year old, which are better than the day they were made, since the gold has taken an increasing hold upon the tissues of the vessels and nerves. After a number of trials, I prefer leaving the membrane in gly- cerine acidulated with acetic acid, since it demands less care in respect to renewal, and I am never chagrined at finding my specimen destroyed by the evaporation of the water. By this process the loo-ps, and the nerves accompanying them, are most likely to be rendered visible. The arrangement of the nerves, not represented in the wood- cut, is best described as fork-shaped. The prongs embrace the loop; the handle unites with a similar projection from the opposite series of loops. As a rule, the vessels color more readily under the action of chloride of gold than the nerves. How this might be in clear weather, I am not prepared to say, as all of my experiments were performed in the cloudy weather of a "Vienna winter, notwithstanding which, the nerves frequently became richly colored. This method of coloring vessels and nerves I have applied only to the membrana tympani, and hence, I can claim no supe-' riority for it in connection with other tissues. When it succeeds, it is superior to any injection of this very delicate membrane, since the vessels and nerves are rendei'ed visible with a distinct- ness characteristic of the action of chloride of gold, a reaction to which attention was first called by Cohnheim. The bloodvessels are rendered distinct, without becoming MEMBRANA TYMPANI. 67 opaque, so perfectly iu most cases that we can detect the blood corpuscles lying within the capillary. The vessel, furthermore, retains its normal calibre and posi- tion, whereas, wheia we resort to injections, the vessels are apt to be unduly distended, are necessarily opaque, extravasation of coloring matter may take place, or the vessel may be ruptured. The method is more convenient than injection, and as no mechanical force is used, the field of the microscope must of necessity present a very true picture of the tissues as they are in their normal state. The application of this method of coloring to the membrana tympani of man shows the absence of the vascular loops already described, and reveals an arrangement of the vessels similar to that obtained by other observers with injections. The arrangement of the vessels is not unlike the vascular netwoi'k in the membrana tympani of the guinea-pig. In man, however, the mesh is much finer, the vessels coarser. The fibrous layer is, on the other hand, very thick, and is more equally composed of radiate and circular fibres than the mem- brane in the guinea-pig. Since, the membrana tympani of man is supplied by a dense network of vessels, the gold method of coloring it is superior to the usual method by injection, as the entire preparation is less opaque than when the vessels are filled with Prussian blue, carmine, etc. It may, therefore, be concluded that : — 1. There is a distribution of vessels in the membrana tym- pani of man peculiar to him. 2. There is a distribution of vessels in the membrana tympani of the dog, the cat, the goat, and the rabbit, constant in, as well as peculiar to them. 3. A distribution of bloodvessels exists in the membrana tympani of the guinea-pig peculiar to it. SECTION II. MIDDLE EAR. CHAPTER I. TYMPANIC CAVITY. ANATOMY. Under the term Middle Ear are included the tympanic cavity and its two very important adjuncts — the Eustachian tube in front, and the mastoid portion of the temporal bone, and its cells, behind. Ossicles of Hearing. — In the tympanic cavity of all mammals, are three small bones: the malleus or hammer; the incus or anvil •; and the stapes or stirrup. Anatomists of a latter day have shown that the once so-called, OS orbiculare, or os Sylvii, does not exist as a separate ossicle. That which once received this name is the processus lenticularis of the long process of the incus, which fits into a corresponding depression in the head of the stapes. The Malleus. — The malleus, or mallet, received its name from Vesalius, and although some anatomists have failed to see the resemblance to this implement, the ossicle still retains its name, and is divided into head, neck, and handle. At the junction of the latter with the neck, are two important processes, viz. : the sAorf jirocess, Avhich,wheii in its normal situation, pushes the membrana tympani ahead of it, and points towards the auditory canal, and the process of Rau or Folius, which passes anteriorly into the Glaserian fissure. In the foetus and new-born child, this process is about 3J lines long, and can then be removed whole. After birth it unites with the under wall of the Glase- rian fissure, and when the malleus is removed, only a short piece of the former long process is found attached to it. This TYMPANIC CAVITY. 69 remnant was all that was known of the long bony process, td the older anatomists, and it has been called the processus Foli- anus,' after Folius, who, in describing this process, alluded only to the remnant. Fig. 10. Right Malleus; A, from in front; 13, from behind. (Magnified 4 diam. : Henl6.) — a. Head. 6. Short process, v. Long process, d. Manubrium, e. Articular surface. /. Tlie neck. This process, in its most perfect osseous state, was fully described by Jacob E.au^ in his lectures, and his pupils, Valen- tin' and Boerhaave,* call him the discoverer of it. Hence in its perfect state it is called the processus Eavii, since Rau or Ravius was the first to describe the broad end united to the Glaserian fissure. This process has also been called the processus longus seu spinosus. It is united to the Glaserian fissure, in adults only, by a mass of ligamentous tissue, which favors slight motion in any direction. The head and neck of the malleus project into the tympanic cavity, and are entirely free from the membrana tympani. The rounded, smooth surface of the head is directed anteriorly, while the surface which articulates with the incus is directed backward. The long diameter of its articular surface runs vertically, the short diameter horizontally. In the direction of the foi'mer, the articulating surface has been said to resemble a saddle, for the surface is divided a little below the middle by a horizontal ridge, and depressed on each ' Caelius Folius, Venice, 1645. Nova auris iiitenise delineatio. 2 Jacobus Ravius, Professor of Anatomy and Surgery in tlie University of Leyden, 3 1719. * Prselectiones, p. 358. 70 MIDDLE EAR. side of it. This articulating surface is also' concave in the di- rection of its short diameter, {. e., from without inward. If a shallow oval basin, the long diameter of which is con- siderably greater than its short diameter, be placed across a ridge, and then bent downward, and at the same time slightly twisted on itself, the cavity thus formed will fairly represent the articulating surface of the malleus. The neck of the malleus lies between the head and the manu- brium. It makes, with the former,an angle of about 135° when viewed from in front. It has three surfaces : a hroad inner one directed towards the tympanic cavity, bounded in front by the processus Ravii, or long process, and behind by the long, low bony elevation for the insertion of the tendon of the tensor tympani ; an anterior surface, lying above the ridge joining the processus brevis and the processus longus, and extending to the angle made by the head of the malleus with the neck, and separated from the posterior surface by a sigmoid-shaped ridge for the insertion of the ligamentum mallei externum of Helmholtz. The posterior surface lies between the aforesaid sigmoid ridge in front, the edge of the articulating surface of the malleus above, the low, long process behind, and a line drawn from the insertion of the tensor tympani to the short process below. Of all the surfaces of the neck, the posterior glides most gradually into the manubrium. The handle or the manubrium of the mal- leus, that part of the bone inserted into the membrana tympani, has also three surfaces, which may be considered prolongations downward of those of the neck. Since they all gradually approach each other and are united in the tip or point of the manubrium, the latter may be said to resemble a three-sided bayonet, one ridge of which passes from the short process di- rectly downward to the tip, and is consequently turned towards the external auditory canal. The point or lower end of the handle of the malleus is flattened into a small disk, one surface of which is turned towards the auditory canal. This spot is plainly visible as the pale, round centre of the umbo. The long axis of the handle of the hammer is convex poste- riorly and inward, so that when viewed from without the manubrium appears concave on its anterior and outer surfaces. This is especially marked at the lower third on the anterior surface, so that the manubrium normally appears curved de- TYMPANIC CAVITY. 71 cidedly forward near its lower end, of course in the plane of the membrana tympani. Along the ridge of the manubrium, directed towards the external auditory canal, several little node- like prominences are not uncommonly seen. These are not pathological, but purely normal. Their origin is obscure. Dr. A. H. Buck^ has described a hook-shaped termination anteriorly, of the manubrium mallei in a boy thirteen years old. The manubrium of the opposite side had been destroyed by otorrhcea, so that it was impossible to make a comparison be- tween the mallei in this case. Dimensions of the Malleus — The malleus is nearly 9 mm. long; its manubrium is between 4 and 5 mm. long, and its head is 2^ mm. thick. The latter is the greatest diameter of any part of the bone, which gradually tapers to the point of the handle. The long diameter of the articulating surface of the malleus is about 3 mm. ; the short diameter is between 1 J and 2 mm. Fixation of the Malleus. — The malleus is held in position by four ligaments, viz. : Ligamentum mallei anterius, ligamentum mallei superius, ligamentum mallei externum, and the liga- mentum mallei posterius. The ligamentum mallei anterius is a broad band of fibres which holds the processus Folianus against the spina tympanica major. This ligament may be said to arise from the spina tympanica major and to be inserted along the neck of the malleus all the way from the processus Folianus to the head of the malleus. A part of it also runs from the processus Folianus to the short process of the malleus below, and the membrana tympani above, forming thereby the division between the anterior and posterior pockets of the mem- brana tympani ; another fold of the same ligament runs from the processus Folianus downward with a free margin, as far as the line corresponding with the insertion of the tensor tympani muscle. This makes the limit between the anterior pocket of the drum-head and the tympanic cavity. The round ligamentum mallei superius descends obliquely downward and outward from the tegmen tympani to the head of the hammer. Its function is to prevent the malleus from being forced outward. ' N. Y. Med, Record, Dec. 16, 1873. 72 • MIDDLE EAR. The ligamentum mallei externum is a very important collection of satin-like, tendinous fibres, which radiate from the sigmoid crest on the front of the neck of the hammer and are inserted into the sharp edge of the segment of Eivinus on the temporal bone. It prevents the hammer from being forced inward, and being inserted above the axis of rotation of the hammer, it prevents the manubrium, which is below the axis of rotation, from moving too far outward towards the auditory canal. The ligamentum mallei •- posiicum is really the posterior edge of the ligament just described as the external ligament of the hammer. As the line this bundle of fibres follows passes through the spina tympanica major, and as it represents pretty closely the axis of rotation of the hammer, Helmholtz has sug- gested it should be considered a separate ligament, and has given to it the name it bears. As this ligament and the ligamentum anterius are in a mecha- nical sense one ligament, although the hammer intervenes be- tween them, Helmholtz has called the two sets of fibres the axial ligament of the malleus. Axial Ligament of the Malleus. — The plane of this ligament is not quite horizontal, being a little higher in front than behind. In all its motion as a lever the hammer swings about this axis-ligament as a fixed point. All above the short process of the malleus is above, and all below the short process is below, the axis-ligament. Tlie ligamentum mallei anterius of Arnold was once described as a muscle, the laxator tympani major.' It is not, however, anything more than a ligament which originates from the spina angularis of the sphenoid, passes through the petro-tympanic fissure,^ and is inserted into the malleus. Under the name of ligamentum mallei posticum sen manuhrii, the ligamentum mallei externum of Arnold, Lincke describes a ligament which passes from the upper edge of the end of the external auditory canal to the short process of the malleus, and occupies the position of a supposed muscle, once called the M. laxator tympani minor, or M. mallei exterior sen Casserii. It is ' Sommering. " Glaserian Assure. TYMPANIC CAVITY. 73 now universally acknowledged tliat muscular fibres do not exist here.i Fig. 17. ' LiQAMENTOtrs SUPPORT OF OSSICLES VIEWED PROM ABOVE. (Helmholtz.) — J-h. Attachment of the ligameutum mallei externum. 7t. Head of hammer, i. Body of incus. /. Point of its short process, a. Entrance to the Eustachian tube from the tympanum, c. Stapes, d. Tendon of its muscle. 6. Tendon of the tensor tympani, leaving the cochlear process, ff-ff- Chorda tympani, marking the free edge of the folds of mucous membrane, bounding the pouches, n. The upper tendinous fibres of the ligamentum mallei anterius, originating above the spina tym- panica major, m, J. Malleo-incudal joint. Incus or Anvil. — The middle one of the three auditory ossicles is the incus or anvil. The name is derived from the shape of its upper half. This small bone is divided into a body and two processes, viz., a short and long one. The former of these two processes is also called the horizontal process. It is held to the posterior and to the upper wall of the tympanic cavity by ligaments.^ (Fig. 18, e.) This is an important point in the mechanism of the auditory ossicles.' The longer process is also called the descending ramus of the incus. It curves gradually outward, i. e., towards the external ear, away from the vertical plane of the body of the incus, assuming a slight sigmoid shape ; at its tip it curves rather sharply inward, to unite with the head of the stapes by means of the processus lentieularis. ■ Henle, Eingeweidelehre, p. 745. 2 Ligamentum incudis posleriua et ligamentum incudis superius. 3 Henlfi calls this the incus-tympanic joint, "an amphiarthrosis between the articulating surface of the short process of the incus, and a prominence on tlie posterior wall of the tympanic cavity. I'he articulating surface on the incus is covered with a thin layer of fibrous cartilage." 74 MIDDLE EAR. The narrowest part of the incus is at the middle of the body of the bone ; beneath this part it widens out again anteriorly into the important tooth which locks with the malleus in all its inward movements, and posteriorly into the descending ramus or long process. The articulation between the malleus and incus is a true joint, in which is found a meniscus.' Fig. 18. , Right Incus. (Magnified 4 diam. : Henl6 ) — X. Inner surface. -B. View in front. .4/7. and St'. Body. b. Short process, e. Long process. ' d. Processus lenticnlaris. /, Articular surface for the head of the malleus, u. Surface which lies in contact with wall of tympanic cavity. If this articulation is viewed on its outer surface, i. e. on that side towards the external auditory canal, it would seem that the incus quite overlapj^ed or embraced the head of the malleus ; when viewed from its tympanic side, however, it appears that the largest share in the joint belongs to the malleus. This is due to the wonderfully peculiar structure of this joint, the true nature and function of which were first pointed out and explained by Helmholtz in 1869.^ Dimensions of the Incus. — The greatest length of the incus is in a vertical line passing from the top of the body of the bone through the long process. It measures 7 mm. The horizontal upper edge of the body measures 5 mm. Its greatest thickness, 2|- mm., is at its articulating sui'face for the malleus. Malleo-Incudal Joint. — Before Helmholtz's investigations, the • shape of this articular surface was usually described as resem- bling a saddle. In order to gain a clearer idea of the mechanism ' Riidinger. 2 Mechanik der Gehorknochelehen und des Trommelfells, Bonn ; also Pflu- ger's Archiy f. Physiologie, 1 Jalirgang. TYMPANIC CAVITY. 70 of this joint, Helmholtz makes use of a different comparison. "It is, in fact, like the joint used in certain watch-keys, where the handle cannot be turned in one direction without carrying the steel shell with it, while in the opposite direction, it meets with only slight resistance. As in the watch-key, so here,, the joint between hammer and anvil admits of a slight rotation about an axis drawn transversely through the head of the ham- mer toward the end of the short process of the anvil ; a pair of cogs oppose the rotation of the manubrium inward, but it can be driven outward without carrying the anvil with it."' It is of the kind of joint known as ginglymus. The mechanism of this joint is best understood when it is known that the malleus, as a whole, is a lever, the fulcrum of which passes just below the short process. This, of course, leaves the head and neck, %. e. the articulating surfaces for the malleo-incudal joint and all the free tympanic parts of the malleus, above the line of support of the lever, the manubrium being below. The latter is the long arm of the lever, and consequently all its movements are repeated in an opposite direction on the head of the malleus. Each inward movement of the manubrium, therefore, causes a slight outward motion in the head of the malleus and a firm locking of the malleo-incudal joint, by which the incus is carried about an axis drawn transversely through the head of the hammer toward the end of the horizontal or short process of the incus. The incus being also suspended as a lever, about the line just named, when all above that line moves outward, all below the line moves inward, i. e., as the upper part of the incus is moved outward the long process swings inward and carries the stapes ahead of it, thus forcing the foot plate of the latter into the oval window. The Stapes or Stirrup. — The smallest bone in the body and the innermost of the three auditory ossicles is the stapes or stirrup. Its name is derived from the striking resemblance it bears to a stirrup. It is divided into a head or capitulum, a neck, two branches or legs (crura), and a foot-plate or basis. The head, which is really a cup-shaped button, is placed at ' Helmholtz's Mechanism of the Ossicles of the Ear, etc., English translation by Buck and Smith, 1873, p. 33. 76 . MIDDLE EAR. the junction of the two crura. It is designed for the reception of the processus lenticularis of the incus, with which it forms a ball-and-socket joint. There is a meniscus in this joint according to Riidinger.' On the posterior surface of the head of the stapes the stapedius muscle is inserted. Fiar. 19. KiGHT Stapes. (Magnified 4 diam. . Henl6.) — A. From within. B. From in front. O. From beneath, b. Foot-plate or base. d. Capitulum. c. Anterior, u^ posterior shaft or cms of stapes. The two crura or branches are furrowed on their inner surface, which makes them lighter, yet does not deprive them of strength. They arise from the basis forming a graceful arch and unite above in the head, as already stated. The foot-plate of the stapes is oval or slightly kidney-shape, thicker at the periphery than in the centre, is slightly convex towards the vestibule, and concave on its tympanic surface ; it fits into the oval window, where it is held by a fibrous packing. This permits of a slight inward and outward movement on the part of the base of the stirrup. When the stapes is in position, the long axis of its base is horizontal and coincides with that ^ of the oval window. In this position its convex edge looks upward, and its concave edge, which gives it its slight kidney- shape, looks downward. ■» The ligamentum ohturatorium stapedis is a thin membrane stretching aci'oss the space between the base and the crura; it is attached to the crista of the former and the furrow on the inner edges of the latter. "^ Dimensions of the Stapes. — The stapes measures nearly 4 mm. from its head to the under surface of the foot-plate. The latter is 2J mm. long in its horizontal diameter, 1 mm. in its vertical ' Virchow's Archiv, Bd. xx. 1860. Monatsschr. f. Ohrenh. Jan. 1873. 2 Eiidinger, Atlas of Osseous Anatomy of Human Ear, edited by Blake, Boston, 1874, p. 9. TYMPANIC CAVITY. 77 diameter (the boiie of course must be imagined in normal posi- tion), and about | of a millimetre thick, at its edges. It is slightly concave towards its centre. Joint between Base of Stirrup and Oval Window. — According to Helmholtz,' the base of the stapes is surrounded at its edge by a lip of fibro-elastic cartilage 0.7 mm. thick. The union between the base of the stirrup and the wall of the labyrinth appears to be formed by means of the periosteum of the vesti- bule, extended over the base of the stapes (Henl^), but the fibrous lip on the edge of the base of the stirrup is not attached to the fenestra ovalis. The mucous membrane of the tympanic cavity extends over the outer or tympanic surface of the base of the stapes. In 1869 Dr. A. H. Buck examined very closely the fixation of the base of the stirrup in the oval window, and made the following conclusions : — ^ 1. The base of the stapes is fastened to the edge of the round window by a ligament or elastic fibres. 2. The fibres of the ligament gradually converge towards the edge of the base of the stapes. 3. The ligament arises from the periosteum in the neighborhood of the oval window and passes over to the base of the stirrup, where it again assumes the function of peri- osteum. 4. The breadth of the ligament is the same all around the periphery of the base of the stapes. Dr. Gustav Brunner,^ of Zurich, regards the malleo-incudal and incudo-stapedial joints as a variety of symphysis or synchon- drosis. He is disposed to regard the coimections between the ossicula auditus not as true or ordinary joints. As described by him, they .are all of peculiar construction, since between the cartilaginous surfaces of the bones there is a fibrous or fibro- cartilaginous intermediate substance. Dr. E,iidinger^ reasserts the true joint-like structure of the articulations of the ossicula. He also maintains his view that in both the malleo-incudal and incudo-stapedial joint there is a ' Op. cit., pp. 34-35. 2 Archlv f. Opb. and Otol. von Knapp u. Moos., 1 Band. Cavlsruhe, 1870. ' TJeber die Verbindung der Qeborknoclielchen, namentlicb, des Haramer- Ambossgelenka, Vorlauflge Mittbeilung. M. f. O. No. 1, 1872. * Ueber die Gelenke der Qeboiknochelcben, M. f. O. No. 3, 1873. 78 MIDDLE EAR. fibro-cartilagiaous disk connected with the capsular ligament, but not with the hyaline covering of the articular surfaces of the bones. Dimensions of the Vssicula Audilus. — Urban tschitsch,' by com- paring the auditory ossicles of 50 different tympana, found that the malleus varied in length from 7.0-9.2 mm. ; the average length is 8.5 mm. The short process varies from 1.2-2.6 mm., with an average length of 1.6 mm. The long process (the Folian process) was found in one case, an individual 30 years old, to be 2.5 mm., and in another, a man 20 years old, 5.8 mm. long. The manubrium has an average length of 5.0 mm. from the short process to the point. In the incus, the distance of the upper end of the articular surface from the free end of the horizontal ramus is, on the average, 5.3 mm. The under end of the surface of the joint is 4.6 mm. distant from the incudo-stapedial joint. The incus is the most porous of the ossicles. The average length of the stapes is 3.7 mm. ; its average breadth between the rami, 2.3 mm. Its head is either entirely straight (29 times), or else inclined towards the anterior (18 times) or posterior (3 times) limb ; in one case the head pointed upward, i. e. towards the upper edge of the foot-plate of the stapes. The entire paper of Dr. Urbantschitsch will amply repay a careful reading. According to the investigations of Dr. C. J. Blake,^ the weight of the ossicula auditus varies greatly with the age and indivi- dual. It is also worthy of note that the proportionate weight of the ossicula, one to another, is not constant. Dr. Blake states that in the new-born child, the proportionate weight of the malleus to the incus is generally as 20 to 17, and in a malleus weighing 20 milligrammes, the weight would be distributed as follows : " the capitulum mallei, including that portion of the neck just above the processus brevis, 16 milligrammes ; the pro- cessus longus, including the processus brevis, 4 milligrammes." "In an incus weighing 17 milligrammes, the corpus incudis, including the processus brevis and the base of the processus ' Archiv fur Ohrenheilkunde, Band. xi. p. 1-11. ' Diatribution of Weight in tlie Ossicula Auditus. Transactions Amer. Otol. Hoc, vol. i. p. 543. TYMPANIC CAVITY. 79 longus as far downward as the lower lip of the inferior articu- lating surface, 14 milligrammes ; and the processus longus, with the 08 ienticulare attached, 3 milligrammes, the corresponding stapes weighing very nearly 4 milligrammes. In the adult, the weights of the malleus and incus are, as a rule, more nearly equal ; in some cases, however, the proportionate weight of the malleus to the incus is as 7 to 8." The distribution of weight above and below the axial line — the line about which the malleus tends to swing (see p. 72) — is as follows, according to the investigations of Dr. Blake : In a malleus which weighed 21 milligrammes, and the incus 25 milli- grammes, the combined weight of the portions of these two bones, above the axial line, the line of section in the experi- ments, was 30 mg. ;. that below the line, 16 mg., or in the pro- portion of 15 to 8. This preponderance of weight in the parts of the malleus and incus above the axial line, tends to act as a mechanical counterbalance, and renders the two bones better able to vibrate upon the axial line. It also serves to increase the delicacy of a mechanism which responds to sound-waves in excursions so infinitesimal that the highest powers of the micro- scope cannot render them visible, as shown by Helraholtz. The Tympanum. — The tympanic cavity is about half an inch in height and width and a line or two deep, measuring from within outward. It is lined with mucous membrane, which is reflected over all the tympanic contents, and is a continuation of that of the throat, nose, and Eustachian tube. The drum cavity lies entirely within the temporal bone, and is bounded by a roof and floor, and the four walls. The roof, or tegmen tympani, is the boundary between the base of the brain and the tympanum. This osseous partition is very thin, and in some cases congenital fissures in it persist ; in such instances the only boundary at the dehiscences, between the tympanum and the cerebral cavity, is formed by the mucous membrane of the former and the membranes of the brain. It is evident that in such cases, pathological processes in the drum- cavity are especially liable to pass upward to the brain. ■ The Malleo-incudal Joint and surrounding parts viewed from above.— U the tegmen tympani be removed, let us say, from the 80 MIDDLE EAR. Fig. 20. right tympanic cavity, the malleo-incudal joint and the incudo- tympanio joint will be laid bare, and just in front of the head of the malleus, but below it, will be seen the tendon of the tensor tympani muscle coming upward and inward from the left, to be inserted into the tubercle on the neck of the hammer. Above this tendon,, winding from within outward and to the right, around the neck of the malleus, is seen the chorda tympani, a branch of the facial nerve, on its way to the Glaserian fissure. Of course this pic- ture is to be reversed for the left ear. The suspensory ligament of the mal- leus is attached to the roof of the tympanic cavity. Bight Tympanic Catitt viewed FROM ABOVE ; MaLLBO-INCUDAL AJfB iHCUDO-TTMPANio JOINTS. (Magni- fied 2 diam.: Henle.) — e. Head of mal- leus, e. Short process of incus. /. Tendon of tensor tympani muscle. d. Capsule of incudo-tympanic joint a, Ligamentum mallei anterius. b. Chorda tympani. The Floor of the Tympanum. — The floor of the tympanum is not much more than a groove between the outer and inner wall. It is below the lower periphery of Fig. 21. IHSEE Side of the Oiitbe Wall op the Rioht Ttmpasic Catitt ; Hammer and Anvil in aiTC ; Canalis Musculo-tobakius laid open. (Magnified 2 diam. : Honlo.)— 6 J. Tensor tym- pani. d. Head of the malleus. 7i. Tip of the manubrium mallei, e. Short,/, long process. ^.Pro- cessus lenticulai-ls of the incus, c. Chorda tympani. k. Septum tubic. J. Eustachian tube. t. Membrana tympani. the drum-head, the opening of the Eustachian tube, and the opening in the mastoid cells. It is entirely within the boundary TYMPANIC CAVITY. 81 of the petrous portion of the temporal bone and above the jugu- lar fossa. The outer Wall of the Tym-panum. — The outer wall of the tym- panic cavity is composed mainly of the membrana tympani. The bony framework of the annulus tympanicus around the membrana tympani, constitutes the limit of the outer wall of the tympanum. In connection with the outer wall, i. e., in it or on it, we find the manubrium mallei, the chorda tympani, and the duplicature of mucous membrane about it, which, also forms the so-called pockets of the membrana tympani. The pockets or pouches of the membrana tympani are the dupli- catures of mucous membrane around the chorda tympani in the horizontal portion of its passage through the tympanic cavity. They were first described by von Troeltsch, in 1856,* and are situated on the inner side of the upper part of the drum-head. The posterior pouch lies between the malleus and the posterior periphery of the membrana tympani, and is the larger of the two. It contains in its structure fibres of the fibrous laj-er of the drum-head. The shape of the posterior pouch is triangular or tent-like, the apex of which is directed inward, and its base outward. It is about 3 mm. high, and 4 mm. broad. This pouch is best seen when the inner side of the drum-head is viewed, but it can also be seen from the outer side, when the drum-head is thin and properly illuminated. The anterior pouch lies in front of the malleus, and is smaller than the posterior pouch. It is composed of mucous membrane only. It is not so well marked as the posterior pouch, but con- tains " all the parts which proceed from or enter the Glaserian fissure."^ It is much lower and shorter than the posterior pouch. There is a third pocket or pouch of the membrana tympani described by Prussak^ and Grustav Brunner.'' This cavity is bounded behind by the neck of the malleus, below by the upper ■ Wurzburg Transactions. 2 See Koosa's translation of v. Troeltsch on the Ear, N. Y., 1869, pp. 33-.j3. 3 Archiv fiir Ohrenheilkunde, vol. iil. * The Connections between the Ossicles of Hearing. Archives of Oph. and Otol., vol. iii. pp. 145-173, 1874. 6 82 MIDDLB EAR. surface of the short process of the hammer, in front by the rnembrana flaccida, and above by a ligamentous band, the liga- mentum mallei externum, which is inserted between the margo tympanica and the spina mallei. This cavity is separated from Fig. 22. Section thkouhh the long Axis of the Malleus at right anbles to the Membrana Ttmpaiti, from ax Adclt. (Brunner.)— S- Bony ridge at llie upper segment of the drum- head. (The segment of Eivinus, according to Helmholtz.) g. Head of malleus, -p. Reck of malleus, o. Handle of malleus. Z. Short process, y. Memhrana flaccida, /i. Lig. mallelexternum. m. Chorda tympani. n. Tendon of tensor tympani. i. A cavity according to Prussak. w. Carti- lage. &,&. Fibres of the membrana tympani. c. Dermoid layer of membrana tympani. e. Haver- sian canals. /. Medullary space. the anterior tympanic pouch by the upper blind end of the latter ; posteriorly, it communicates with the tympanic cavity by a good-sized opening, above the position of the posterior tympanic pouch. This pouch, being thus placed in communica- tion with the tympanum, may become filled with mucus or pus, and it may, in consequence, be ruptured. Many cases of earache, which present no features of disten- sion of the drum-head proper, nor, in fact, of the region of the TYMPANIC CAVITY. 83 membrana flaccida, may be relieved instantly by puncturing the latter at the third pouch. The point of the puncturing in such cases is just above and in front of the short process. As a general rule, when there is great earache, attended only by redness of the flaccid part of the drum-head, and neither congestion nor bulging of the drum-head proper, a cut into the congested flaccid part will relieve, in most cases, the suffering. Mucus or pus will usually escape ; sometimes only blood. Inner Wall of Tympanitm. — On the inner wall of the tympanic cavity there is found a convexity, the promontory caused by the* projection outward at that point of the lower turn of the cochlea. This eminence is usually seen through the membrana tympani, as a pale yellowish spot. At this point the inner and outer walls of the tympanum are closest to each other. Above the promontory, in a depression named the fossula fcnestrce ovalis, of Eiidinger, is the oval window, fenestra ovalis, which receives the foot-plate of the stapes. Behind the promontory is the Fig. 23. Chorda Ty Ikkek Wall of Tympanic Cavity. (Gray.) niche in which is found the round window, fenestra rotunda. The long diameter of the oval window is 3 mm., and its short diameter 1.7 mm. The diameter of the round window is 2 mm. A ridge starts above the oval window and curves backward and downward behind the promontory and round window. This ridge is the posterior limit of the inner wall of the tym- 84 MIDDLE EAR. panum, and marks the position of the canal for the facial nerve, which escapes from the tympanum at the stylo-mastoid foramen. The course of the facial nerve will he considered further on. Eminentia Stapedii. — Behind, and a little below the line of the oval window, is a bony eminence, the eminentia stapedii. This little conical eminence is hollow and contains the stapedius muscle, to which it gives origin. The tendon of this muscle, after passing through a small opening in the apex of the emi- nence, runs a little upward and forward, forming an obtuse angle with the long axis of the muscle, and is then inserted into the edge of the articular surface of the head of the stapes.' The stapedius muscle is supplied with a branch from the facial nerve. Function of the Stapedius Muscle. — According to HenM,^ it is probable that the stapedius muscle serves to hold the stapes in a firm position rather than to move it, and that it acts only when there is danger that an undue force communicated to the malleus will be conveyed to the stapes by means of the inter- vening incus. Its action then is to prevent the stapes from being forced into the oval window. Fixator Bassos Stapedis. — Riidinger has described an organic muscular structure on the tympanic surface of the stapes, which he calls the fixator haseos stapedis. It arises from a small bony ridge (diameter 0.80 mm.) situate one millimetre from the upper and posterior circumference of the oval window, and is inserted into the angle formed by the leg of the stapes and its somewhat projecting foot-plate. It is supposed to be an antagonist of the voluntary muscle, the stapedius, and prevents the latter from forcing the stapes too far into the vestibule.^ Topographical Relation of the Sla-pedius Muscle to the Facial Nerve. — Prof. A. Politzer* has added greatly to the knowledge respecting the relation of these parts to each other. In the ' Henle. 2 Eingeweiclelelire, p. 749. 3 Das hautige Labyrintli, by Euclinger, Strieker's Handbuch, pp. 912-913, 1872. ' Prof. Politzer, Zur Anatomie des Geliororgans, I. Ueber das Verhaltniss des Muse. Stapedius zum nervus facialis, II. Ueber den Processus Styloideus, Arcbiv f. Ohrenh., cap. ix p. 158. TYMPANIC CAVITY. 85 foetus only the upper part of the stapedial cavity is separated from the facial canal by bone, the lower part having free com- munication with the canal. At this point, the soft tissues sur- rounding the muscle and the nerve are in contact. In the adult, however, the communication between the bony cavity contain- ing the muscle and the facial canal is less free, being effected by means of one or more small openings or by one long slit-like aperture 3-5 mm. long, and J mm. wide. Transverse sections of this muscle show that it is a triangular prism ; longitudinal sections show that its general form is pear-shaped. In addition to the anatomy. Prof. Politzer has added to the knowledge of the physiology of the stapedius muscle. He shows that this muscle acts as a laxator of the membrana tyni- pani, and, as far as its effects upon the labyrinth are concerned, it diminishes the pressure in that cavity by drawing the stapes out of the oval window.' The oval window is separated from the round window by the tract of bone corresponding to the posterior surface of the promontory. They are about two milli- metres apart. The plane of the former looks outward, and is nearlj' vertical in its position ; that of the latter looks backward and downward. The oval window is the entrance to the_ vesti- bule and mediately to the cochlea. The round window is an exit from the cochlea into the tympanic cavity. This window, however, in its normal state, is hermetically closed by a mem- brane, the membrana tympani secundaria, or membrana fenestrte rotundse. "Well forward, on the inner wall, towards the tympanic open- ing of the Eustachian tube, are the processus cochleariformis, the spoon-shaped tympanic end of the septum tuboB, which separates the Eustachian tube from the bony furrow containing the tensor tympani muscle, and the tendon of the latter, as it passes to the malleus. The processus cochleariformis is the fulcrum over which the tendon of the tensor tympani plays. Tensor Tympani Muscle. — This muscle originates from the anterior mouth of the canalis musculo-tuharius of the pyramidal portion of the temporal bone, the upper wall of the cartilage of the Eustachian tube, and from that small portion of the sphe- noid bone which joins the temporal bone, the processus angu- ' Loc. cit., p. 162. 86 MIDDLE EAR. laris. The muscle then passes over the septum tubas and enters the canalis tensoris tympani.* Its tendon passes over the pro- cessus cochleariformis, and turning outward, crosses the tym- panic cavity at right angles to the belly of the muscle, to he inserted into the malleus. The tensor tympani is connected with the dilatator tubae or tensor palati, by both tendinous and muscular fibres, as shown by Kessel, Riidinger, Mayer, Rebsa- men and others. The motor nerve of the tensor tympani is derived through the otic ganglion^ from the motor root of the trigeminus.' The tensor tympani muscle has been described as a penniform muscle,* in allusion to its appearance, which is due to the fact that the muscular fibres arise from the periosteum of the upper wall of the bony canal in which the muscle lies, and pass into the tendon which lies on the under edge of the muscle; the latter is turned towards the floor of the canal. As the fibres of the muscle are short, a large portion of the tendon is within the canal. Within the canal the muscle is covered by a peri- osteal sheath, which is continued over the free portion of the tendon, crossing the tympanic cavity, and is there covered with mucous membrane. This sheath of the free tympanic part of the ligament, Toynbee called the tensor ligament of the membrana tympani. Helmholtz has found that in some cases the ligament is movable within this sheath, as described by Toynbee ; on the other hand, Henl^ has never found them entirely separate, nor differing from similar fibrous structures of other tendons. In any event, the play of the tendon within the sheath cannot be very great, on account of the slight motions of the malleus, as shown by Helmholtz. The transverse section of a perfect tensor tympani muscle measures 2f mm., the length of its tendon from the processus cochleariformis to the insertion into the malleus is 2| mm., and the length of the muscle from its extreme origin on the Eusta- chian tube to the turn of the processus cochleariformis is 2.2 centimetres, somewhat more than an inch, as shown by "Weber- i This canal is not always perfectly closed, and hence it has been called the semi canalis tensoris tympani. ! Henl§, Eingeweidelehre, p. 747. 3 Ludwig and Politzer, Meissner's Jahresbericht, 1860, p 583. « Helmholtz. TYMPANIC CAVITY. 87 Liel. The tendon of the tensor tympani is inserted on the anterior surface of the inner edge of the manubrium, rather than on its posterior surface ; hence, traction inward of the muscle will bring about a rotation of the malleus about its long vertical axis, and thus twist the posterior surface of the handle of the malleus outward, and with it the posterior segment of the membrana tympani. It therefore often seems, in certain pathological retractions of the malleus, that the anterior seg- ment of the membrana tympani is sunken, and that the anterior outline of the manubrium is especially prominent. Anterior and Posterior Walls of Tympanic Cavity. — The most important point in the anterior wall is the tympanic opening of the Eustachian tube, situated considei-ably above the floor of the tympanum, an arrangement which often produces a reten- tion of small amounts of fluid in the cavity. It remains to consider, now, the posterior wall of the tympanic cavity, in which is situated the important opening communi- cating with the mastoid' antrum, and by that means with the mastoid cells. The mastoid antrum is a cavity of irregular shape, the roof of which is a continuation backward of the tegmen tympani. It is formed by a hollowing out of the basis of the pyramidal part of the temporal bone, which is joined to the mastoid portion and the upper part of the latter. This cavity may extend forward into the root of the zygomatic arch and downward into the mastoid cells. It communicates with the tympanum by means of a wide opening, the under edge of which is about on a level with the oval window. The floor of the tym- panic cavity rises backward to meet this opening, in the same waj- as it rises anteriorly to the opening for the Eustachian tube. ■ Course of the Facial Nerve. — Although the canalis facialis has been already mentioned in connection with the inner wall of the tympanum, further attention should be given at this point to the course of the facial nerve, and the important relations it sustains to the structures in the posterior portion of the tym- panum and to the mastoid cells. The facial canal rises at the fundus of the internal auditory meatus, and after leaving it passes somewhat in front of and 88 MIDDLE EAR. further outward than it, between the cochlea and the semi- circular canals, above the roof of the vestibule. Upon i-eaching the plane of the inner wall of the tympanic cavity, it turns' suddenly backward at right angles to its former course, and running above the position of the oval window, curves gradu- ally backward and downward, to escape from the tympanic cavity at the stylo-mastoid foramen in the postero-exterior sur- face of the petrous bone. In the anterior wall of the facial canal, i. e. in that surface turned towards the tympanic cavity, very near the stylo-mastoid opening, is a small foramen leading to the canalis chordce, which, leaving the facial canal at an acute angle, runs upward and forward through the substance of the petrous bone to the tympanum, in the lower external corner of which it opens. (Fig. 23.) Development of the Bony Canals in and about the Tympanic Cavity. — 1. Carotid canal. The carotid canal is the simplest in structure and formation of the canals in or about the tympaT num.^ It appears about the third or fourth month of foetal life, as a simple furrow on the inner side of the blunt point of the petrous part of the temporal bone. By the end of the fourth month a bony ridge rises out of the furrow on the tympanic side and pushes its way between the cerebral carotid and the tympanum, thus forming a bony partition between them. Au- otlier osseous ridge grows from below upward and joins this first ridge, forming with it, by the ninth foetal month, the complete carotid canal. 2. Fallopian canal. This canal, too, appears at first as a simple broad groove in the tympanum. About the third month of fcBtal life this canal begins to form by the gradual growth of thin bony lamellae. The eniinentia stapedii forms as a branch- like projection from the facial canal. The formation of the Fallopian canal is not complete until after birth. Dr. Riidinger also -describes a constant opening in that part of the facial canal over the oval window. This would seem to correspond to that one described by Dr. Zuckerkandl as the point of entrance of the stapedial artery into the tympanic cavity. The history of ' Genu canalis facialis, at which point the canal for the great superficial petrosal nerve joins the facial canal. (Henle.) 2 Prof Riidi-ngei-, Monatsschr. f Ohrenh., No. 5, 1873. TYMPANIC CAVITY. 89 the development of the canaliculus chordae, the canaliculus tympanicus and mastoideus Arnoldi,and of the hony portion of the Eustachian tube and semicanal of the tensor tympani is, in many respects, according to Riidinger, similar to the above. Jji/mphatic Cavity in the Facial Canal.- — On the inner side of the facial canal, Dr. Eudinger' has described an empty space lying between the nerve trunk and the periosteum. This cavity or cleft, as it would appear in a transverse microscopical section, presents a sharp definition, and appears as a constant occurrence in every individual case examined. The supposition is that this space marks an extension of the arachnoideal sac of the brain running along the facial nerve, and is similar to that which is known to accompany both the optic and the acoustic nerve ; it may therefore be regarded as a lymph cavity. Chorda Tympani Nerve. — The chorda tympani, as already indicated, is a branch of the facial nerve. After its entrance Fig. 24. Neeves IK AND ABOUT THE Tympakhm. (Heath.)— !• Sensory portion of fifth nerve with Gaserian ganglion. 2. Tensor tympani mnscle. 3. Motor portion of fifth nerve passiag beneath the ganglion. 4. Malleus. 5. Small superficial petrosal nerves of Arnold. 6. Incus. 7. Otic ganglion. 8. Facial nerve. 9. Chorda tympani. 10. Membraua tympani. 11. Tensor palatl muscle. 12. Middle meningeal artery. 13, 13. Lingual nerve. 14. Auriculo-temporal nerve. 15. Inferior dental nerve, 16. Pterygoideus externus. 17. Pterygoideus interuus. IS. Internal maxillary artery. 20, 20. Mylohyoid nerve. into the tympanic cavity it becomes invested with mucous membrane, and, ascending into the cavity, follows quite closely ' Ueber den canalis facinlis in seiner Beziehung, zuin siebenten Geliirnner- ven beim Erwachscnen, M. f. O., 1873, No. 6. 90 MIDDLE EAR. the posterior periphery of the membrana tympani until it reaches the height of the tendon of the tensor tympani, when it winds forward, above this tendon, between the malleus and incus, and finally escapes from the tympanic cavity at the Gla- serian fissure, through the canal of Huguier. It then descends between the two pterygoid muscles, to unite with the gustatory nerve, and is finally distributed with it to the submaxillary gland ; it then joins the submaxillary ganglion and terminates in the lingualis muscle, as shown by Gray. This nerve has very little sensibility according to Vulpian,' whose experiments have shown that the chorda tympani contains both centrifugal and centripetal fibres, the latter serving as a means of excito-motory irritation, destined to act on the sublingual gland. According to Vulpian, and Prevost of Geneva, part of the chorda tympani accompanies the lingual nerve in its peripheric distribution, furnishins branches to all the terminal filaments of the latter. This nerve has no connection whatever with the auditory nerve, and therefore no phenomena of the former can be construed into symptoms of diagnostic value respecting the nerve of hearing. Nerves supplying the Mucous Membrane of the Tt/mpanic Cavity. — The nerves supplying the mucous membrane of the tympanic cavity as well as that of the Eustachian tube and mastoid cells, are derived from the tympanic plexus, an anastomosis between the otic ganglion, petrosal ganglion of the glosso-pharyngeal nerve, and the carotid plexus, by means of the superior cervical ganglion of the sympathetic nerve.^ The otic ganglion is situated on the inner side of the sensory division of the inferior maxillary nerve, and sends several small " branches to it. It is important to bear these relations in mind when considering certain neuralgias in and about the ear, which might otherwise prove very puzzling. In an infirmary practice, numerous cases of earache are con- stantly seen, which are solely and clearly due to imperfect teeth. By means of the otic ganglion, the soft palate, the drum-head, and tensor tympani muscle, the lining membrane of the cavity ' Gazette Medicals de Paris, Feb. 15, 1873. ' Bischoff, Microscopische Analyse del- Kopfnerven, Munchen, 1865. TYMPANIC CAVITY. 91 of the tympanum, and the integument of the external ear are put in sympathetic relation with each other and with the nervous system. Perhaps certain epileptiform phenomena which have been observed in connection with well-marked disease of the middle ear, as well as similar phenomena which could be seen to be connected with an obscure disease of the organ of hearing, may be explained by reflex communication through the tympanic plexus, especially through the petrous ganglion of the glosso- pharyngeal, to the brain and spinal cord. The tympanic nerve or Jacobson's nerve is a branch from the petrosal ganglion' of the glosso-pharyngeal nerve ; " it enters a small bony canal on the base of the petrous portion of the tem- poral bone, ascends to the tympanum, enters this cavity by an aperture in its floor close to the inner wall, and divides into three branches, which are contained in grooves upon the surface of the promontory."^ This is the largest nerve branch given to the tympanic cavity, and therefore it has received its special name and consideration from most anatomists. Since, however, the tympanic nerve contains so large a number of large ganglion cells, either solitary or grouped, and thus makes numerous con- nections with other important ganglia and nerves, the name tympanic plexus is now given to what formerly was named, in its tympanic portion at least, the tympanic nerve. Bloodvessels of the Tympanic Cavity. — The chief artery of the tympanic cavity runs along the floor of the tympanum and over the promontory. The capillaries of these vessels empty at last into the veins of the periosteum.^ According to Gray, the arteries supplying the tympanic cavity are as follows : The tympanic branch of the inferior max- illary which is given to the membrana tympani, the stylo-mastoid branch of the posterior auricular, distributed to the back part of the tympanic cavity and mastoid cells, a number of smaller branches from the petrosal branch of the middle meningeal, and branches from the ascending pharyngeal and internal carotid. The veins of the tympanic cavity terminate in the middle menin- geal and pharyngeal veins, which form a plexus near the glenoid ' Anderscb. * Gray. » Kessel. 92 MIDDLE EAR. articulation, and then empty into the interiial jugular vein. It is very important to bear in mind these distributions of blood- vessels, when the ear is to be leeched. Dr. ZuckerkandP has described as constant, an artery which he has termed the arteria stapedia. This artery is a branch of the stylo-mastoid artery, which enters the tympanum through an ever-present triangular opening in that part of the facial canal passing just above the fenestra ovalis. This small vessel descends through the membrana obturatoria of the stapes, either to anastomose with a branch of the artery following Jacobson's nerve, or to break up into secondary anastomoses before it reaches this point. Before the artery passes the stapes it gives off a branch to the anterior crus of the stapes and to the ante- rior part of the membrana stapedia which it divides in two, a second branch to the hinder crus and to the posterior part of the stapedial membrane, and a third arteriole usually from one of the lateral branches passes inward to the foot-plate of the stapes. PHYSIOLOGY. The function of the tensor tympani muscle is somewhat like that of the palmaris,^ i. e. it is better adapted for tension than for motion. It also appears that, by exerting a slight tension on the membrana tympani, this muscle can bring about a muffling or damping effect without any visible movements in the ossicles. In 1860, Politzer' showed that the tensor tympani was sup- plied by a branch of the motor division of the fifth nerve. Later, Voltolini^ performed a series of experiments which led him to the following conclusions: — " 1. Irritation (by electricity) of the trigeminus produces dis- tinct and powerful contractions of the tensor tympani, which can be kept up for some time on the dead animal ; these con- tractions can almost always be produced even by weak streams of electri-city. " 2. The same result can be obtained by irritation of the facia- ' Ueber die Arteria Stapedia des Mensclien,Monatssclir., f. O. No. 1, 1873. « Henle, op. cit. p. 748. a Meissner's Jaliresbericht, p. 583. * Virchow's Archiv, Band 65, p. 467. TYMPANIC CAVITY. 93 lis, bat usually only by strong electric currents, and tbe irrita- bility is generally soon lost. " 3. During this contraction of the tensor, the drum-head is drawn strongly inward by means of the manubrium, but, of course, these excursions of the drum-head vary in different ani- mals ; in guinea-pigs they are so small as to be undistinguishable unless an indicator is attached to the membrane. " 4. During such a contraction of the tensor and the consequent tension of the membrana tympani, a simultaneous ascent of the lymph in an opened semicii'cular canal becomes visible in the dead animal, and when the tension is removed the fluid sinks back. "5. In no instance, neither by excitation of the trigeminus, nor of the facial nerve, nor even by mechanical movement of the stirrup, was a simultaneous movement in the membrana tympani secundaria visible, not even by microscopic observation of a reflection, or an indicator attached to the membrane. " 6. During irritation of the trigeminus, and the consequent contraction of the tensor tympani, there ensues a contraction of the palatal muscles and an opening of the Eustachian tube, for the anterior membranous wall is drawn away from the posterior cartilaginous tubal ridge." The fact that the tensor tympani can be put into motion by excitation of two cerebral nerves, as above stated, may, accord- ing to Voltolini, be used as an explanation of the power the muscle has of both voluntary and involuntary movement. In one of his experiments, Voltolini observed that excitation of the facial nerve produced contractions in the tensor tympani and stapedius muscle. Such a process, says the observer, is of highest importance in the act of hearing, if, indeed, such a pro- cess occur in the living ear, which is not to be doubted ; in such an event the stapedius muscle acts as a cheek on the movement of the hammer by the tensor tympani.' The reflex movements of the tensor may be accounted for by the branch of the trige- minus which passes through the otic ganglion. Then arises, as Voltolini suggests, the important question whether the fibre from the facial nerve, supplying the tensor, also passes through the otic ganglion, or goes directly from the facial to the muscle ; in the latter case the muscle would evi- ' Loc. cit., p. 479. 94 MIDDLE EAR. dently possess power of voluntary motion. Although no one has demonstrated that a branch of the facial nerve does pass directly to the tensor tympani, the muscle certainly possesses power of voluntary contraction, as held by Johannes Miiller, Voltolini, and others. Physiological Nature of certain Tympanic Bands, heretofore con- sidered Pathological. — Dr. Yictor Urbantschitschi has pointed out the physiological nature of certain membranous and cord-like adhesions in the cavity of the tympanum, which have heretofore been considered pathological. As he states. Prof. Politzer was the first to express the opinion that such might be the case, and the former has verified this opinion by a series of careful and copious investigations on the cadaver of embryos, new-born children, and adults. Dr. Urbantschitsch has frequently found, in the new-born child, membranous and cord-like connections between the inner side of the vertical shaft of the incus and the inner wall of the tympanum. This has been considered pathological by Toynbee and other authors; but Urbantschitsch has shown that these formations are remnants of an embryonic fold, running from the vertical ramus of the incus to the inner wall of the tympa- num, entirely inclosing the stapes. This was seen eight times in embryos, fifty times in the new-born child, and sixteen times in fifty examinations of the tympanic cavity in the adult. There is also an embryonal stapedial fold which sometimes leaves as residue small membranes or cords passing from. the head and shafts of the stapes. But this observer does not assert that all of the connecting bands or membranes which he has described are always of a .physiological nature ; he believes that their occurrence, without any morbid changes in the tympanic cavity, would not justify the conclusion that a pathological pro- cess preceded their formation. Similar connections between the posterior, anterior, and exterior surface of the vertical ramus of the incus with the structures of the tympanum are shown to be normal. The first point agrees with the investigations of Lincke; the second point agrees with the statement of v. Troeltsch. ' Beitrsig zur Bntwickelungsgeschichte der Paukenholile. Report of Koyal Academy of Sciences, Vienna, Jan. 1878.' TYMPANIC CAVITY. 95 The horizontal ramus of the incus may be joined to the external wall of the tympanum, and with the mastoid cells, by similar membranous connection. The union with the outer wall has already been shown by Zaufal to be a normal one. This was found by Urbautschitsch in eighty per cent, of all the adults examined. The membrane so frequently found between the tendon of the tensor tympani and the antero-superior wall of the tympa- num, as described by Prussak, Gruber, and Zaufal, has been observed in adults by Urbantschitsch, sometimes as a perfect membrane, and sometimes perforated in the middle or repre- sented only by a few adhesive bands. Hyrtl's discovery that osteophytes are regularly found in the tympanum of many of the mammals, is carried still further by Urbantschitsch, who shows that there is in the tympanum of man, a series of membranous bands containing structures similar to osteophytes which are of a physiological nature. They were found in one-third of all the adult tympana examined. Hyrtl says that these osteophytes are formed in the tympana of animals during the early years of life ; Urbantschitsch has found them in the tympanum of the new-born child sixteen times in fifty examinations. These are usually found on the eminentia pyramidalis. They may also be found on the hinder and outer wall of the tympa- num, and on the border of the round window. They are usually in connection with a membranous or cord- like sti'ucture. Meckel has described a bony ridge between the eminentia pryamidalis and the oval window. In one case, among fifty examined, Urbantschitsch found a bony growth between the eminentia pryamidalis and the inner wall of the tympanum. The posterior wall of the tympanum often contains a bony formation resembling a lamella. " This forms, either alone or in combination with membranes, a partition which divides the posterior portion of the tympanic cavity into a superior, larger space, and an inferior, smaller one." Function of the Bound Window and. its Membrane. — In 1871 I made some investigations into the condition of the membrana secundaria, or the membrane of the round window, during the 96 MIDDLE EAR. movements of the ossicles of hearing ; and the excursions per- formed by it were measured under the microscope. During these investigations I also noticed the eft'ect of varying laby- rinthine pressure upon the small bones of hearing and the membrane of the round window. All the observations, were made upon temporal bones from human subjects, as soon as possible after death. Of the ten specimens thus used, eight were from males and two from females ; the ages varying from six years to forty-five years. During the intervals between the experiments, the temporal bones were kept in a ten per cent, solution of alcohol. To pre- pare the bones for examination under the microscope, the Eus- tachian tube was removed up to its bony portion, but the membrana tympani, with the annulus tympanicus, the chain of ossicles, and the labyrinth, were left entirely intact. In order to obtain the best view of the fenestra rotunda, the floor of the tympanum was removed as high as the round window, till it and the promontorium cochleae were fully ex- posed. The chief difliculty experienced in thus exposing the round window is the liability to encroach upon the posterior semicircular canal. To avoid this, a view of the window was first gained, by cautiously chiselling away the posterior portion of the floor of the tympanum. Then the entire preparation was turned for- ward about an axis running through the porus acusticus in- ternus and the external auditory meatus, and the bone was chiselled away in all directions, excepting outward and upward, till a perfect- view of the round window was obtained. The preparation was then fastened firmly in a vise, and laid so as to be conveniently approached by a microscope, and to receive, by means of a condenser, light from a kerosene lamp. The prepa- ration now lay so as to expose the chain of ossicles from under- neath, and the membrana tympani secundaria, at an angle of about 45°. These were sprinkled lightly with powdered starch,' so as to insure bright vibrating points. Sources of Sound. — As sources of sound, four organ-pipes were used, of respectively 50, 140, 630, J160 vibrations per second. The first was a' reed-pipe, the three remaining ones were stopped ' Lissajou's Method. TYMPANIC CAVITY.' 97 pipes. These were connected with the ear, in each case, by means of a gutta-percha tube one metre long, and one-half cm. wide, fastened to the side of the reed-pipe ; but in the case of the other three, at the closed end. The free end of the connecting gutta-percha tube was supplied with a tapering glass tube, pointed with sealing-wax, moulded to the external auditory meatus, thus procuring an air-tight communication between the organ-pipe and the membrana tym^ pani. All unwished-for vibrations were avoided by placing the pipes upon sepai-ate tables, and in some instances they were held in the hand during the sounding of a note. This necessitated all vibrations which reached the ear to pass through the con- necting gutta-percha tube. The position of the glass tube in the external auditory meatus has great influence on the experiments. When the tube is directed downward and forward, the experiments are almost invariably successful, but in any other position they may be partially or entirely unsatisfactory. For, in the former position, the sound-waves strike more di. rectly against the membrana tympani and the hammer, whereas in any other position they are forced against the sides of the auditory canal, and are deflected and destroyed before they reach their destination. This seems to indicate that sound, entering the external auditory meatus, produces no easily dis- tinguishable efl'ect upon the ossicles of hearing and the laby- rinth, by simple conduction through the bony walls of the audi- tory canal. It must, indeed, be forced against the membrana tympani, and through it act upon the ossicula auditus. These, in turn, act like a lever, communicating their movements to the fluid of the labyrinth and the membrane of the round window. Upon producing a note upon a given organ-pipe connected with the ear, as already described, the chain of bones was seen to vibrate in excursions, bearing a fixed relation to each other.' At the same time, their motion was communicated through the labyrinth to the membrane of the round window, upon which • The movements of these bones, in connection with sound-waves, have also been observed, and their excursions measured by Politzer and Buck. 7 98 MIDDLE EAR. the excursions of the shining particles maintained an almost constant relation of equality with those of the stapes. The excursions, both upon the chain of ossicles and upon the membrane of the round window, varied in their length with the pitch of the note produced by the organ-pipe ; the longer excursion corresponding to the deeper note. By the use of a syren, which was fitted to a pipe opened at its side to accommodate the gutta-percha connecting tube, excur-. sions synchronous with the revolutions of the disk were pro- duced upon the chain of ossicles and the membrane of the round window. These could be counted during the early revolutions of the disk ; but as they increased and the note ascended, the vibrating points became lines diminishing in length with the increasing rapidity of the revolution. During these observations one preparation was found which did not respond to the notes of the organ-pipes as the previous ones had done. The ossicula auditus manifested some very slight vibratory motions, but the membrane of the round window showed none. In order to explain this apparently abnormal result, and to find out whether an increased or diminished labyrinthine pres- sure could have produced it, the following experiments were instituted : — Upon a perfect petrous bone, which failed to respond to the soundfi produced by the already-mentioned pipes, the superior semicircular canal was opened at its summit, and to this open- ing one end of a small glass tube, 1 centimetre long by 5 mm. wide, was hermetically sealed. The bone thus modified was placed in water and brought under the air-pump, in order to remove any air which might have entered the labyrintTi. After these arrangements the glass tube, sealed to the superior serai- circular .canal, was connected by a gutta-percha tube, of similar diameter, to a reservoir of water, consisting of a funnel placed in a retort-holder, and which could be elevated or depressed at will. The pressure exereiBed by the water upon the labyrinth could; be easily seen with the unaided eye, as the varying height of the funnel caused the column of water to press with a greater or less force upon the membranie of the round window. - TYMPANIC CAVITY. 99 Witli these modifications the preparation, which formerly failed to respond to the notes of the organ-pipes, was placed in connection with the sources of sound, and the chain of bones, as well as the memhrane of the round window, was observed during the passage of a note to the ear. The desired excursions now became apparent upon thfe hither- to abnormal specimen, and resembled .those upon other prepara- tions so long as the pressure was maintained at a certain grade ; but wh6n increased or diminished beyond a given point, the excursions ceased upon the ossicles and the meriibrane of the round window. This was observed to he the case sooner during the occurtence of high than of low and pov)erful notes. The human ear, in the living state, sometimes fails to perceive high notes, while lower ones are distinctly heard. Perhaps such phenomena may be explained by an application of the results obtained in these investigations, in which artifi- cial labyrinthine pressure interfered with the action of the chain of ossicles and the membrane of the round window, sooner in connection with high notes than with lower ones. Pathological processes, with results of a purulent,' serous, or hemorrhagic^ nature, have been observed, and their injurious effects upon the sense of hearing noted. In such cases it may be supposed that the increased amount of pathological fluids in the labyrinth interfere with the action of the chain of bones and the membrane of the round window, just as the artificial pressure did in my experiments. In addition to these destructive changes, which follow patho- logical processes in the ear, the perilymph of the labyrinth may be subject to great fluctuations in its amount, since the arach-- noid sac and the labyrinth are so intimately connected, as ex- periments of "Weber-Liel* and Hasse show. The latter says :* "All vertebrates possess a duct which originates in the vesti- bule ; and in all animals, with the exception of the Plagiostomes, ' Moos, Deafness in ITeiiingitis Cerebro'-Spinalis. Archives of OphtlialmOl.' 'and OtoL, vol. i., No. 3, 1870. 2 Mops's Four Cases of GnnshotWounds of tlie Ear, Arehives of Opli. and Otol., vol. ii. p. 343. 3 M. f. O. August, 1870. « Anatomische Studien, No. xix. p. 768. 100 MIDDLE EAR. in which it passes directly to the surface of the skull, this duct enters the cavity of the cranium and there terminates either in a closed sac at the confines of an epicerebral lymph-cavity, or opens into the same. This is the ductus endolymphaticus or the aquseductus vestibuli with the saccus endolymphaticus, the former of which, in most vertebrates, arises from the sacculus, that is, from the inferior portion of the vestibule. " Every increased or diminished pressure of the fluid of the liquor cerebrospinalis in the subarachnoid cavity will make itself felt per continuitatem through the saccus and the ductus endolymphaticus, in the interior of the auditory apparatus, in the endolymphatic cavity and upon the terminal apparatus of the auditory nerve found therein. "We may thus explain most easily the impairment of hearing for high tones in cases of in- creased pressure." In concluding this account of my experiments, I would call attention to a fact of interest respecting the direction of a line described by a vibrating starch-point upon the membrane of the round window. It was observed that such a line invariably remained parallel to the plane of the membrana tympani. An explanation may be found in ultimately discovering an unequal tension of the membrana tympani secundaria, depen- dent upon the manner of its insertion into its frame. The following deductions may be drawn from the foregoing experiments : — 1. The excursions of the chain of ossicles of hearing bear a fixed relation to each other. 2. The excursions of the ossicles of hearing are communicated through the labyrinthine fluid to the membrane of the i-ound window. 3. The excursion of the membrane of the round window generally equals that of the stapes ; but it may equal that of the membrana tympani, at the point of the manubrium mallei. 4. The pressure within the labyrinth, increased beyond cer- tain limits, causes cessation of the action of the membrane of the round window and the chain of ossicles of hearing. This occurs sooner in connection with high notes than with the lower notes of the scale. 5. If the labyrinthine pressure is greatly diminished or totally TYMPANIC CAVITY. 101 removed, the chain of ossicles may continue to vibrate, but they exert no influence upon the membrane of the round window. 6. The vibrations of the membrane of the round window vary from jTj^-^ mm. to -^-^ mm.' A dift'erenoe of opinion has existed respecting the part the membrane of the round window plays in the conduction of sound. Without doubt the excursions of the ossicles of hearing are conveyed through the water of the labyrinth to the membrane of the round window, as shown by the experiments of the author, and later by the corroborative experiments of Weber-Liel. Some authorities have thought that perhaps the membrana tyrapani secundaria participates directly on the sound waves transmitted to it by the membrana tympani through the air of the tympanum. Johannes Miiller inclined to this opinion, but the experiments of Schmiedekam and Hensen seemed to show that he was incorrect in his views. Recently Weber-LieP has performed a series of experiments which are not only very in- teresting, but tend to decide this question affirmatively. These experiments were performed on nine fresh preparations of the ear ; seven were from man, one from a calf, and one from a horse. The ears were prepared for examination in a way similar to that described on page 96. The sources of sound were the human voice and three organ- pipes ; the fundamental notes of the latter were such as gave 180, 210, and 540 vibrations per second. The sounds from these pipes and the voice were conveyed to the prepared ears, in a manner similar to that described on p. 97. The preparations were sprinkled with starch, illuminated, and held firmly, in the manner described at the same place. The first results of Weber-Liel's observation were in entire harmony with those obtained by the author. But Weber-Liel then carried his experiments further, and obtained the following results : — ' All the measurements I obtained may be found recorded in the Archives of Oph. and Otol., 1872. 2 Centralblatt f. Med. Wiss., Jan. 8, 1876. 102 MIDDLE EAR. 1. If the incudo-stapedial joint is divided, and the incus pushed somewhat aside, and then the tympanic cavity hermeti- cally closed by a firmly inserted pane of glass (a microscopic cover) on the artificially opened side, while the Eustachian tube is kept slightly open, then microscopic examination of the mem- brane of the round window through the glass cover reveals, almost invariably, that also under these circumstances during the sounding of the pipes and during the singing of deeper notes, the particles of starch or the reflecting points on the membrane performed excursions, which were but slightly less (1| : 2) than those occurring before the division of the incudo-stapedial joint ; these excursions, however, were observable only on certain parts of the membrana tympani secundaria. They did not occur when the cavity of the tympanum was reopened. On the head and rami of the stapes faint simultaneous vibra- tions were observed in two cases. 2. Upon slightly rarefying or condensing per tubam the air in the tympanic cavity of the preparations arranged as above, no change was produced in the width and direction of the excur- sions ; when the air became more condensed, the high notes first ceased to produce vibrations ; with increasing condensation, the deeper notes ceased to have effect. 3. In order to exclude the possibility of the communication of sound waves from the oval window (foot-plate of stirrup) through the labyrinth to the membrana tympani secundaria, the labyrinth was opened and tlie vestibule exposed from behind. After the fluid of the labyrinth had escaped, sound-waves con- ducted by the membrana tympani to the labyrinth, produced no visible effect on the membrane of the round window. This negative result is attributable to the loss of pressure consequent upon the escape of the labyrinth-fluid ; for, when the cochlea was sawed transversely through, a narrow glass tube placed in the transversely sawed scala tympani, and the latter, with the glass tube, filled with various heights of water, by means of which once more a certain amount of pressure was brought upon the labyrinth side of the membrane, then, when the tympanic cavity was again closed, immediately the excursions became once more visible upon sounding the organ-pipes or singing. 4. With some of the preparations, a glass tube was cemented to the temporal bone, and through this tube, by means of a rub- TYMPANIC CAVITY. 103 ber pipe, the labyrinth being undisturbed, sound vibrations were conveyed to the bones of the head. So excursions were per- ceptible, neither with the tympanum opened nor closed. These experiments seem to prove that the membrane of the round window may be set in vibration by sound-waves from the membrana tympani conveyed through the air of the tym- panic cavity. The Power of Muscular Accommodation. — According to Prof Lucse's experiments,' the ear has, in the tensor tympani and stapedius muscles, an apparatus for accommodating itself to various sounds. The first muscle aids in the accommodation for low musical tones, the latter accomplishes the same for high, unmusical sounds. Abnormal contraction of the tensor tympani, within sufficient antagonism of the stapedius, produces a modification of percep- tion, termed by Dr. Lucse "low hearing;" an analogous condi- tion of the stapedius muscle in its relation to the tensor tympani produces " high hearing." Action of the Tensor Tympani and Stapedius Muscles. — Confirma- tory observations of Drs. Mach and KesseP show that the traction on the stapedius muscle drives the head of the malleus inward, and the lower part of the membrana tympani outward. The substance of these observations is in harmony with the cele- brated theories of Weber. Bibliography of the Mechanism of the Membrana Tympani, of the Auditory Ossicles, and of the Membrana Tympani Secundaria. 1851. Weber, Edward. TJeber den Mechauismus dos mensclilichen Gelioror- gans. Bericht iiber die Verhandlungen der Konigl. Sachs. Gosellschaft der Wissenscliaften zu Leipzig. 1856. Meyer, G. Hermann. Lehrbuch. der Physiolog. Anat. des Menschen, p. 276. 1861. Fick, Adolph. Lehrbuch der Anatomie und Physiologic der Sinnesor- gane, p. 138. ' ' Die Accommodation und Accommodationsstorungen des Ohres. Dr. A. Lucse, Berlin Klin. Wochenschrlft, 1874, No. 14. Abstract by Dr. Jacoby, Archiv f. O. Band ix. p. 184-185. ' Beitrage zur Topographie und Mechanik des Mittelohrs. Wiener Sitz- ungsb., 33 April, 1874. 104 MIDDLE EAK. 1861. Magnus, A. Beitrage zur Anatomie des mittleren Ohres. Virchow's Archiv. Band. xx. 1864. Politzer, A. Arcliiv f. Ohrenheilkunke. 1865. Wimdt. Lelirbuch der Physiologie des Mensclien, p. 571. 1866. Funke, O. Lelirbuch der Physiologie, Bd. ii. 1868. Henke, A. Der Mechanismus der Gehorknochelchen. Zeitschrift fiir rationelle Medizin. 1868. Hensen, V. Versnche iiber den Mechanismus, und die Schwingungen der Gehorknochelchen. Arbeiten aus dem Kieler Physiologischen In- stitut, pp. 68-86. 1869. Helmholtz, H. Die Mechanik der Gehorknochelchen und des Trommel- fells.' 1870. Buck, Albert H. An investigation concerning the mechanism of the ossicula auditus. Archives of Oph. and Otology, vol. i. 1871. Burnett, C. H. An investigation concerning the mechanism of the ossicles of hearing and the membrane of the round window. 1874. McKendrick, John G. Physiological Laboratory, University of Edin- burgh. Edinburgh Med. Journal, January. 1876. Weber-Liel. Centralblatt fur Med. Wisseusch, Jan 8. CHAPTER II. EUSTACHIAN TtJBE AND MASTOID PORTION. ANATOMY. The Eustachian tube, though discovered by Vesalius, gets its name from Bartolommeus Eustachius,^ who gave a more com- plete description of it than any of his contemporaries or prede- cessors. Though it is generally conceded that Vesalius was the discoverer of the tube, some authorities think that even Alc- meon^ and Aristotle* knew of its existence. The Eustachian tube is the only means of aerial communica- tion between the pharynx and middle ear. It opens into the pharynx a little above the floor of the nose, and passes back- ward, upward, and outward to the cavity of the tympanum, forming an angle of 40° with the horizon, and 135° with the axis of the external auditory canal. The pharyngeal mouth of the tube is wide, but the tube narrows rapidly to the isthmus, • Pfluger's Archiv fur Physiologie, I. Jahrgang. ; Bonn, 1869. 2 1500-1574. 3 570 B. C. ■> 384-333 B. C. EUSTACHIAN TUBE AND MASTOID POETION. 105 from which point it widens again to the tympanic cavity. It therefore resembles, somewhat, two short and wide-based cones, placed point to point, their junction marking the position of the isthmus. The pharyngeal mouth of the tube is oval in shape, being 9 mm. high and 5 mm. wide. At the isthmus, the junction of the osseous with the cartilaginous part of the tube, the diameter is 1.5 to 2 mm., and the greatest diameters of the osseous canal vary from 4 to 4.5 mm. The entire length of the Eustachian tube is 35 mm., a little more than 1 inch ;. the bony portion being 11 mm., and the cartilaginous part 24 mm. long. Bony Foriion of the Eustachian Tube. — As already indicated, the Eustachiau tube is composed of a bony arid a cartilaginous portion. The former lies entirely within the petrous bone ;' the latter portion is joined to the former and is about two-thirds of the entire tube. The calibre of the bony portion is triangular, the angles, however, are rounded by the mucous lining of the tube. Its average diameter is about 2 mm. The outer wall of the three composing this triangular bony tube, belongs to the pars tympanica, the tympanic bone, the inner wall separates the tube from the carotid canal, and the upper wall is formed inter- nally by the septum tubse, and the floor of the canal for the tensor tympani, and outwardly it unites with the outer wall of the bony tube in the petro-tympanic or Glaserian fissure. The posterior wall of the bony portion of the canal is somewhat longer than the anterior wall. Usually the bony Eustachian tube is twice as wide as the semi-canal of the tensor tympani, but in some instances these relations are reversed, as shown by Elidinger. Cartilaginous Portion of the Eustachian Tube. — In order to understand the true form of this part of the Eustachian tube, one must imagine a shell of cartilage, not quite an inch long, bent so that a section of it at right angles to its long diameter resembles a hook or shepherd's crook. The longer portion of this section of cartilage will represent a section of the inner ' In some cases the large wing of the sphenoid bone unites in the formation of the osseous part of the Eustachian tube, or at least it forms with the pars petrosa, tlie sulcus petro-sphenoidalis for the reception of the cartilage of the tube. (Kudinger, Die Ohrtrompete, p. 2.) 106 MIDDLE EAR. Fig. 35. wall, the shorter portion represents that of the anterior or outer wall, and the curve shows the position of the roof of the Eu- stachian tuhe. It will be seen, therefore, that this part of the tube is not a complete and round cartilaginous canal, but rather a flattened tube, the posterior wall and roof of which are made entirely of cartilage, while the anterior wall is of cartilage only in its upper part, its lower por- tion being muscular^ and com- pleting the tube. The upper part of the inner cartilaginous wall, as well as the roof of the tube, is fastened to the base of the skull by means of the basilar libro-cartilage. The lower end of the inner wall is movable. That part of the cartilage of the Eustachian tube which curves forward to form the upper part of the outer or anterior wall of the tube, is widest and most movable in its middle portion; it is narrower and more firmly fixed at its two extremities, viz., above, where it is joined to the jagged bony edge of the osseous canal, and below, to the pterygoid process. The calibre of the tube, in the main, is not round but cleft- like, and slightly sigmoid in shape ; however, that portion of the calibre lying in the curve formed by the cartilage as it turns forward, i. e. that part lying entirely within cartilagi- nous boundaries, is round and more open than the rest of the lumen of the tube, owing, probably, to the stiffness of the cartilage. This fact would always insure at least a portion of the tube's being more likely to be free from obstructions or from having its two sides stick together. To this more patu- lous part, Riidinger has given the name of safety tube (Sicher- Transverse Section of the Cabtii,a- GiNous Part op the Eustachian Tube NEAR THE FoRAMES OvALE. {Henl6.) — 6. Section of the iaternal carotid, a. Carti- lage of the tnbfe. k. Third branch of the trigeminus, g. Middle meningeal artery. /, e Transverse section of the external and internal pterygoid muscles, d. M. epheno-staphyliuus (tensor palati). c. Transverse section of the M. petrostaphy- linns {levator palati). • Formerly, this part of tlie canal was called membranous, but since muscu- lar tissue is so intimately concerned in its formation, Kiidinger proposes to call it muscular, as being more truly descriptive. EUSTACHIAN TUBE AND MASTOID PORTION. 107 heitsrohre), and to the cleft-like calibre of the tube below this rounder lumen, he has given the name of "accessory cleft," (Hilfsspalte), " since, according to Du Bois Eaymond, these terms express most clearly their physiological importance."' The posterior cartilaginous wall of the Eustachian tube projects well into the pharynx, forming there a prominent ridge, the anterior boundary of the fossa of Rosenmiiller. Into the latter, the Eustachian catheter is often placed in mistake for the pha- ryngeal mouth of the Eustachian tube. When the latter is to be catheterized, this prominent ridge, marking the termination of the cartilage of the Eustachian tube, should be sought for and thoroughly located with the beak of the catheter. In order to do this it is well to allow the catheter to pass first into the fossa of Rosenmiiller, then to glide gently forward over the aforesaid cartilaginous lip, by which act the beak can hardly escape going into the pharyngeal mouth of the tube. As already stated, the cartilaginous shell of the Eustachian tube is adherent at its curve or roof to the base of the skull, by means of the basilar fibro-cartilage ; the edges of the shell, i. e. the edges of the anterior and posterior lips of the cartilage of the tube, are free, and from them important muscular structures arise. The inner dilator of the tube, or the salpingo-phari/vgens muscle, is one of these, and arises from the edge of the posterior cartilaginous wall of the Eustachian tube, and passes towards the superior constrictor of the pharynx. There is also an inti- mate topographical^ relation between this inner wall and the inner surface of the levator palati (petro-staphylinus, Henl^), which muscle, in conjunction with the salpingo-pharyngeus, the inner dilator of the tube, brings about movements of the cartilage. " If the levator palati be pulled upon in a fresh pre- paration, the under end of the inner plate of cartilage will be pushed inward and upward, by which, means, the pharyngeal mouth of the Eustachian tube will be considerably widened."^ Since, then, the conjoined action of these two muscles, the levator palati and the salpingo- pharyngetis, together with the dilatator tubae or tensor palati, yet to be described, brings about ' EMinger, Die Ohrtrompete, p. 7. 2 This muscle sends a few fibres to the posterior cartilaginous wall of the Eustachian tube near the junction of the cartilage with the bony portion of the tube. " Rudinger, Die OhTtrompete, p. 4. 108 MIDDLE EAR. these changes in the pharyngeal mouth of the Eustachian tube, it can easily be seen how the act of swallowing, which brings them into action, opens the tube and ventilates the middle ear. Fig-. 26. Palatal Muscles viewed from behind. (Gvay.) — The Eustadiian tabe is sliown here, ia its regional relations to the palatal muscles, hut not in its true anatomical shape. Tensor Palati Muscle. — The most important of all the muscles of the Eustachian tube is the tensor palati.' This muscle arises by a flat tendon from the posterior edge of tbe hard palate, in intimate connection with the tendon of its fellow of the opposite side, and, gradually narrowing into the tendon which passes ' This muscle has received various names : Tensor veil ; Tensor veli palatini ; Dilatator tubse (Rudinger) ; Spheno-salpingo Staphylinus, etc. EUSTACHIAN TUBE AND MASTOID PORTION. 109 around the pterygoid hook, spreads out again from this point into a fan-shaped muscular layer, the free broad edge of which is inserted into almost the entire length of the anterior lip of the cartilage of the Eustachian tube. Respecting the much-disputed origin of the tensor veli, it may be said that, according to the investigations of Dr. Urbant- schitsch,' there are individual variations in the origin of this muscle from the membranous part' of the Eustachian canal. In some cases such an origin is wanting. Hence has arisen the great difference of opinion between many noted investigators of the anatomy and physiology of this tube. A very important variation also occurs in the connection between the tensor tympani and tensor veli, for sometimes such a connection is not to be found, while in other cases it un- doubtedly exists. In one instance it was found that the spindle- shaped tendon of the tensor tympani passed entirely into the middle belly of the tensor veli muscle. These facts are in harmony with the well-known investigations of "Weber-Liel. By the contractions of this muscle the anterior wall of the cartilage of the tube is pulled outward and downward, and thereby the calibre of the canal is widened. According to the investigations of RiJ dinger,^ itisshownthat there is a direct connection between the tensor palati (Dilatator Tubse) and the tensor tympani muscle. Not only do the tendi- nous fibres, but also the muscular fibres, of the one pass over into those of the other, at the upper part of the Eustachian tube. This connection is of the greatest importance when considering the cause and treatment of certain forms of hardness of hearing due most probably to a kind of paresis in the tensor veli. The Inner Pterygoid Muscle. — This muscle is considered by Weber-Liel as specially belonging to the muscles of the Eusta- chian tube.^ According to his observations some of the upper, shorter, and hinder fibres of this muscle are inserted into the fascia of the floor of the tube throughout its length, and are ' Zur Anatomie der Tuba Eustachii des Menschen. Victor Urbantscliitsh. Med. Jahrbuch, 1 Heft, 1875. 2 Op. cit., p. 6. s ProgreBsive Schwerhorigkeit. Berlin, 1870, p. 68-71. 110 MIDDLE EAR. then lost in the fibrous covering of the petrous bone. Its func- tion is that of a tensor of the fascia of the Eustachian tube. The Liffamertfa. Salpingo-pharyngea. — Dr. Zuckerkandl' has described a constant and peculiar anatomical connection between the Eustachian tube and the constrictors of the pharynx, under the name of the ligamenta salpingo-pharyngea. His statement is that upon laying bare the posterior wall of the pharynx and dissecting off the mucous membrane, along the periphery of the pharyngeal opening of the Eustachian tube and adjacent parts, there will be found three, four, or five, perhaps more, tendinous, rarely elastic cords, attached to the pharyngeal end of the hooked cartilage of the tube, and to the outer wall of the same, which in their fullest development are likened to the tendinous cords of the valves of the heart. This anatomical arrangement, it is said, produces a free opening of the Eustachian tube at each contraction of the superior and middle constrictor of the pharynx. The same observer has described a salpingo-pharyngeal recess below the faucial mouth of the Eustachian tube.^ Mucous Membrane of the Eustachian Tube. — The mucous mem- brane of the Eustachian tuhe is a continuation of that of the pharynx. It is supplied with ciliated epithelium, the cilia of which move in a direction from the tympanic cavity towards the pharynx, thereby favoring the passage of fluids from the cavity of the drum and tube into the throat. The Eustachian tube is very rich in glands at certain plaCes ; although the upper concave portion of the cartilaginous roof of the canal is entirely free from glands, the sides of the tuhe, in the pharyngeal portion, are richly supplied with " acinous mu- cous glands," emptying into the folds of mucous membrane, as shown by Riidinger. These mucous glands do not differ from those of the oesophagus and pharynx. In the upper portions of the tube, towards the tympanic cavity, all glands become sparse. In addition to the glands just named, Gerlach^ has shown the ' Zur Anatomie und Phvsiologie der Tuba Eustachiaua. M. f. O., 1873; No,. 13. * Monatssclir. f. Ohrenh., No. 3, 1875. 3 Zur Morphologic der Tuba Eustachii. Sitzungsberlchte d. Erlanger Physi- calisch-Med. Soc. Abstract by Von Troeltsch, A. f. O,, vol. x. p. 53, 1875. EUSTACHIAN TUBE AND MASTOID PORTION. Ill mucous lining of ithe cartilaginous portion of the tube is richly supplied with follicular glands, which are most numerous at its middle part. Placed still deeper in the submucous connective tissue, are numerous acinous glands. The follicles of the tubal mucous membrane are about half as large as those of : the pharynx, but take in the entire depth of the mucous membrane. Tonsilla Pharyngea. — According to the investigations of San- torini' and Luschka,'' it is shown that the lining structures of the roof, and to a great extent the hinder wall of the nasal part of the pharynx, are composed of a tissue so strikingly like the substance of the tonsils that it has been named the '.'pharyn- geal tonsil." Luschka states that this spongy tonsillar substance, of a maxi- mum thickness of 7 mm., which he has never failed to find, extends from the posterior boundary of the roof of the nasal cavity to the edge of the foramen magnum of the occipital bone, where it either assumes a more or less uneven surface, or, breaking up into separate sebaceous glands, is gradually lost in the pos- terior wall of the pharynx. The same kind of structure forms the chief constituent of the recessus pharyngeus, and extends in a thinner layer over the ridge of the pharyngeal mouth of the Eustachian tube. Differences in Size and Shape of Mouth of Eustachian Tube.— Dr. Urbantschitsch,' a writer distinguished for conscientious research, has described some great variations in the shape and size of the pharyngeal mouth of the Eustachian tube. These variations occur not only in those of the same age, but also in the same individual. The variation in form of the cartilaginous part of the tube is observed to occur in both the posterior and anterior wall. The former may terminate in a sharp point, or it may be very blunt and rounded at the lower and posterior end ; it may also be corrugated on the surface towards the lumen of the pharynx, or curled decidedly upward and forward ' Panna, 1775. 2 Del- Schlundkopfdes Menschen. Tiibingen, 1868, p. 20-37. 3 Anatomische Bemerkungen liber die Gestalt und Lage des Ostium pliaryn- geum tubse beim Menschen. A. f. 0., Vol. x. pp. 1-7, 1875. 112 MIDDLE EAR. towards the so-called floor of the tube. Another curious devia- tion found in the posterior wall of the tube is a bifurcation, the hinder limb pointing backwards, the anterior curling forwards. The various deviations in shape, position, and direction of the walls of the tube, described by Dr. Urbantschitsch, apply only to the mouth, and not to the cartilage in its upper parts. They may, in many cases, cause a widening or a narrowing of the mouth without, of course, producing changes further up the calibre of the tube. According to the same authority, the direction of the pharyn- geal mouth of the tube is generally oblique from above and in front, backward and downward ; in exceptional cases the axis of the mouth of the tube may run vertically or even horizon- tally. Bloodvessels and Nerves of the Eustachian Tube. — The arteries supplying the Eustachian tube are the fharyngeal from the external carotid, the middle meningeal branch of the internal maxillary, and various small branches of the internal carotid. The nerves are distributed as follows : The tensor palati, or the dilatator tubse muscle, is supplied by a branch from the otic ganglion, and also by a motor branch from the internal pterygoid nerve. The levator palati muscle is supplied by the facial nerve through its connection with the vidian and petro- sal nerves as well as by a branch from the vagus. The inner dilator of the tube, the salpingo-pharyngeus, is supplied by the glosso-pharyngeal nerve. The inner pterygoid muscle is sup- plied by the inferior maxillary nerve. The mucous membrane of the tube is supplied by branches of the glosso-pharyngeal nerve, which also supplies the mucous membrane of the tym- panic cavity. The Mastoid Portion and its Cells. — The mastoid portion is that highly important part of the middle ear situate behind and partly below the cavity of the tympanum. It corresponds to the protuberance behind the auricle. This hollow portion is developed partly from the squamous portion, but chiefly from the petrous part of the temporal bone. As is well known, the temporal bone is formed from three distinct pieces, the squama, the annulus tympanicus, and the petrous pyramid. The squama EUSTACHIAN TUBE AND MASTOID PORTION. 113 is divided into two parts, viz., the vertical and the horizontal portions. The horizontal portion is subdivided into an inner and ail outer lamella, the latter of which forms part of the air- cavities of the mastoid portion. This portion of the temporal bone has a distinct existence by the fifth fcetal month. The mastoid portion is really a continuation of the petrous part of the temporal bone, backward and downward. In the new-born child it extends half an inch beyond the hindmost boundary of the squama, and forms a three-sided pyramid, the point of which is behind, the base of which is in front towards the tympanum, and the sharp free edge of which is directed down- ward. The outer surface of this pyramid corresponds of course to the outer wall of the mastoid portion, the inner surface divides the mastoid cavity from that of the cranium, and the upper surface is in the same plane with, and is a continuation backwai'd of, the upper surface of the petrous portion of the bone. All of these features are most clearly seen in the new-born child. The upper surface of the mastoid portion unites with the postero-external edge of the roof of the tympanum. This is marked by a furrow until immediately after birth, when it usually becomes invisible. The outer surface shows a deficiency in the child a few mouths old, at its upper and anterior edge, in the shape of a fissure named the mastoid-squamous. Sometimes at this early age, the fissure is not at all marked, its place being represented by a series of irregular openings varying from two to three mm. in diameter, as though union between the squama and the outer mastoid wall were already far advanced. The inner surface is quite concave, and over it runs a furrow, which at last is fully developed into the sigmoid sinus. The mastoid foramina are found near that point where the upper and under edges of the mastoid portion meet. In some cases the foramina are not complete until the occipital bone joins the mastoid edges. These openings are for the passage of arteries to the dura mater, and for small veins which connect the transverse or lateral sinus with the veins of the scalp. Mastoid Cells. — Within the mastoid portion are found the delicate mastoid cells. These are a series of bony air chambers of variable size, communicating with each other by means of 8 114 [IDDLE EAE. foramina in their thin walls. They communicate with the tympanic cavity by means of the mastoid antrum, and are lined by a continuation of the same mucous membrane lining the Eustachian tube and tympanic cavity. The quantity and de- velopment of these cells vary, not only in diiferent individuals, but in the same individual, on tlie two sides. It is of the highest importance to understand their general distribution in the adult bone, in order to diagnose and treat inflammatory processes arising there, or which have spread to that part from the tympanic cavity. Fig. 37. Mastoid Portion op the Left Temporal Bone laid open and viewed from behind. — A. Mastoid cells extending from the mastoid process below, upward and inward, over the lateral sinus B. u. The zygoma. In the mastoid portion of the child it is found that the sep- tum dividing the mastoid cavity from the sigmoid sinus is very thick, and hence inflammation is not likely to pass from the former to the latter, as it is in adults, in whom this septum is always thin. Hence, in very young children, meningitis very rarely, if ever, occurs from inflammation of the mastoid cavity, from which inflammation tends to pass outward rather than inward, not only because the dividing septum between it and the sigmoid sinus is thick, but because, as already stated, the outer wall of the mastoid portion is imperfect in early child- hood. This is the reverse of what Ave find in the adult, so that EUSTACHIAN TUBE AND MASTOID PORTION. 115 in the latter, everything favors a passage of disease inward towards the brain, while in the child, the conditions are in favor of a passage of disease outward. The lower pointed part of the mastoid portion is known as the mastoid process ; to it the sterno-cleido-mastoid muscle is attached. The development of the mastoid process is greater in the strong aiid muscular, while it is less developed in the weak and in children. The mastoid portion is also subject to diiFer- ences of development in different races, being small and solid in negroes, while in Mongoliaus'it is found much more highly developed than in Caucasians, as shown by Welker. By the eighth month of foetal life the mastoid cells are very distinctly seen as depressions in the bone of the mastoid portion. These cells are not developed first at that part of the foetal temporal bone which, at a later period, corresponds to the mastoid process, but from the upper and hinder parts of the mastoid antrum, i. e. from above downward, as demonstrated by Schwartze and Eysell.' In the first year after birth the mastoid cavity loses its pyra- midal shape by assuming a more ovoid form, and the mastoid cells are formed gradually. Those which are included in the upper and outer portion of the mastoid portion where it joins the squama, are the most highly developed at this time, and lined with mucous membrane, while the mastoid process as yet contains no air cells. From this time on, the external differ- ences of this part of the temporal bone are much less than the differences in development of the air-cells within, for the latter are subject to the greatest variations in number and distribu- tion, as can readily be seen in the skulls of adults. The mastoid antrum, which is a connecting air chamber between the tympanic cavity and the air-cells of the mastoid portion, is of a triangular shape. Its position is somewhat above, in front of, and further inward than, the rest of the mastoid cells. Its walls, with the exception of part of its outer wall, are formed by the petrous part of the temporal bone, and communicate by numerous perforations with the mastoid cells, with which it is surrounded on all sides excepting in front and on the inner side. Anteriorly it has a wide opening into the tympanic cavity, and ' Aichiv f. Ohrenh., Baud i., 1873. 116 MIDDLE EAR. on its inner side it is bounded by that part of the petrous bone covering in the horizontal semicircular canal. It is stated in a valuable paper by Schwartze and EjselP that the general shape of the mastoid cells is that of a hollow pyra- mid, and that their axes run like the radii of a hollow sphere, towards their centre, viz., the mastoid antrum. The air-containing cavities fill the entire mastoid portion of the temporal bone, and in most cases thej' spread downward and outward to the very point of the mastoid process. Limits of the Mastoid Cells. — The mastoid cells extend as far backward as the Emissarium mastoideum, where they are in close contact with the outer side of the groove for the mastoid sinus, and they are found as far forward as the external auditory canal. Mastoid cells are also found continuous with those which reach as far forward and upward as the petro-squamous suture, above that point where the outer table of the mastoid portion is nearest the inner table, that is, the outer wall of the sigmoid groove. In a temporal bone shown in Fig. 27, in which the section of the mastoid portion has been made in the plane of the pos- terior surface of the petrous portion, and carried through the mastoid where the inner and outer tables nearly meet, character- istic air-cells are seen lying above this point in a tent-like space half an inch high, the apex of which points into the cranial cavity, and the floor of which is in the same plane as the upper surface of the petrous portion. The outer side of this tent-shaped cavity shows on section that it is continuous with and a part of the outer wall of the mastoid portion, which has grown inward, away from the squama. The lowest limit of the mastoid cells is the tip of the mastoid process. Those cells which are developed from the petrous part of the bone are the largest ; those which arise from the squama and lie over the external auditory canal are the smallest. PHYSIOLGGY. The Amount of constant Fatulence of the Normal Eustachian Tube. — Some investigators and writers, among whom are Lucfe and Schwartze, have thought that every act of breathing is con- ' Archiv f. Olirenlieilk., Band i. pp. 168-169, 1878. EUSTACHIAN TUBE AND MASTOID PORTION. 117 veyed to the drum-cavity by a normal tube, and they have de- clared that this can be shown not only by the oscillations of the manometric column placed in the external auditory canal, but also hy a direct viewing of the motion of the drum-head at each respiration. Politzer, on the contrary, denies this, believing that the tube ie opened only at swallowing, and the facts are in his favor. Mach and Kessel think the movements of the drum-head observed by Lucse and Schwartze are due to a to-and-fro motion of the column of mucus, in the capillary safety tube, produced by rarefaction and condensation of the air at the faucial mouth of the Eustachian tube. During regular respiration through the nose the relation of the parts about the faucial mouth of the Eustachian tube does not materially change. The pharyngeal opening of the tube either remains at rest or opens and closes slightly with succeeding in- spiration and expiration, after a few moments coming again to rest. On pronouncing the vowels, particularly a, e, and i, the mouth of the Eustachian tube opens downward and forms an oblique triangle on the lateral wall of the pharynx.' According to a subsequent paper by Zaufal,^ Biddei-^ was the first to examine the normal relations of the parts in the naso- pharyngeal space. His investigations were succeeded by those of Schuh' and Voltolini,' the latter being the first, however, to view the tubal ridge through the intact nose. Subsequently observations of these parts were made by Michel in 1873, and by Zaufal in 1875. Dr. Zaufal examined the movements of the tubal opening by means of long funnels armed with mirrors, in- troduced into the nares and passed back into the nasopharynx. It is now generally conceded, through the labors of Eiidinger and others, that there is a small part of the normal Eustachian tube, the so-called safety tube, in its upper part, under the cai'ti- laginous hook, always wide enough open to allow a recoil of air to occur from the drum-cavity, if the drum-head is suddenly driven in, as in explosions, and also to permit a slow equaliza- ' Die normalen Bewegungen derRaohenmiiridung der EustacliiscUen Rjlirc. Prof. Zaufal, Archiv f. Olirenh., Band ix. 1875, pp. 133 and 228. 2 A. f. Ohrenh., vol. x. p. 19, 1875. ' Doi-pat, 1838. * Wiener Med. "Woclienschr., No. 3, 1858. . * 1861. ll>i MIDDLE EAR. tion of pressure in the tympanic cavity, from the pharynx, in- dependently of the act of swallowing. But this " canal of safety" is not wide enough to allow constant ventilation of the drum-cavity to go on. Therefore, to insure ventilation of the tympanum, the normal tube is opened at every act of swallowing. Prof. Moos,^ after a careful study of the Eustachian tube, con- ducted chiefly by transverse sections of the frozen preparation, concludes that the tube when in a state of rest is closed at a point just behind the funnel-shaped end of the faucial opening, and that the closure extends bver about two-fifths of the length of the canal. On the lower surfaces or floor of the tube the closure is effected by the longitudinal folds of mucous membrane' which, as seen in cross-section, form a considerable prominence, literally a valve, the size of which is subject to individual variations. On the opposite surface of the canal, under the cartilage hOok or roof, there is another prominence of mucous membrane, heretofore overlooked. These two prominences or folds of mucous membrane, judging from analogues in animals, seem to facilitate, by their rapid and EJasy unrolling, th(6 pates- cenee of the tube. The islands of cartilage described by Zuckerkandl,^ and hinted at by Rudinger,^ are regarded as fibro-cartilage, having physio- logically the function of sesamoid bones, in the mechanism of the tube, by their connection with the submucous tissue, the fascia or ligamenta salpingo-pharyngfea and the tendon of the tensor veli. In the horse the inner belly of the abductor tubse is inserted into such a cartilaginous disk. That the Eustachian tube is practii3ally closed, except at swallowing, is further proven by observations on themselves by Poorten,^ Eudinger,' and Yule, in all of whom, when the tube was either voluntarily opened as in Yule, or involuntarily opened as in Eiidinger and Poorten, the voice was heard abnormally loudly and painfullys The same is proven by the observations of W. Flemming, of Prague.^ ' Beitrage ziir novmalen nnd patliologiscbien Anatomie iind znr Pysiologie der Eustacliisclien Rohre, Wiesbaden, 1874. Blake's Report, 1875. American Otological Society. 2 Centralblatt, 638, 1874. a Op. cit., p. 3. - Monatsscbr. f. ObrenUeilk., No. 3, 1874. " Ibid., No. 9, 1873; 5 Monatsscbr. f. O., No. G, 1875. EUSTACHIAN- TUBE AND MASTOID PORTION. 119 Mr. Yule^ has given an account of the muscular process seen to occur in his own throat during the voluntary act of opening the Eustachian tube, a power which he seerns to possess. "When he makes the contractions for opening the tube, it is noted : " First, that the velum palatidoes not change either its position or its shape, in fact, that it remains unmoved ; and further, that it does not become tense, but hangs as soft and flaccid to the touch as at ordinary times of rest. Secondly, that the only parts that do move are the two posterior pillars of the pharynx ; and their motion is ample and decided, and altogether unmis- takable. They both move inwards simultaneously towards the middle line, moving from their old position from one-half to three-fourths of an inch. This action is not spasmodic, but perfectly steady, and can be sustained for some considerable time at will, the pillars maintaining their new position all the while." Mr. Yule is quite satisfied and certain that during this period the Eustachian tube is open, and he concludes that from the flaccid condition of the velum, and also from the fact of its position and form remaining unaltered, the tensor and levator palati can have no participation in the opening of the tube, and that the muscles most evidently concerned are the palato-pharyngei. Mr. James Ilinton^ taught that, since the salpingo-pharyngeus is united at its lower attachment with the palato-pharyngeus, and as this muscle during swallowing is drawn inwards, the salpingo- pharyngeus is drawn inwards also, and so draws the projecting cartilaginous lobe of the tube, to which it is attached superiorly, away from the opposite wall. Therefore, the new direction given to the salpingo-pharyngeus by the movement inwards of the pillars of the fauces, is the cause of the opening of the tube. This seems to give but a partial explanation of the mode by which opening of the Eustachian tube is accomplished. In the process, as thus explained, it would seem that the tensor palati and the anterior wall of the tube are supposed to remain fixed, the movement being confined to the muscle attached to and operating upon the posterior wall. In swallowing, however, ' On Opening and Closing tlie Eustachian Tube. C. I. P. Yule. Journal of Anat. and Physiol., viii. 1873. 2 Questions of Aural Surgery, p. 101. London, 1874. 120 MIDDLE EAH. the velum palati is thrown into motion, and the anterior wall of the Eustachian tube is thereby drawn away from the poste- rior wall. At the same time, doubtless, the muscles acting upon the posterior wall of the tube are forced into contraction, and help to draw the two walls apart. Prof. Riidinger' agrees Avith Rebsamen that the opening of the Eustachian tube is brought about by the action of several muscles. The former supposed that the three muscles — the di- lator of the tube or tensor veli, the levator veli, and the sal- pingo-pharyngeus — act simultaneously ; by the action of the first, the cartilage hook is fixed and drawn outward ; by the action of the other two the posterior wall is drawn inward and upward, the result being a patulence of the Eustachian tube. When the muscles relax, the natural elasticity of the cartilage causes it to resume its original position, and the tube becomes narrower. Prof. Moos coincides with the view respecting the action of the tensor veli upon the anterior hook of the tubal cartilage, but rejects the idea that the levator veli assists in widening the tube. By direct inspection of the pharyngeal end of the Eustachian tube. Dr. MicheP has observed tlaat, at the act of swallowing, the velum palati rises and pushes a fold of mucous membrane into the tubal opening between the tubal ridge and the outer edge of the posterior nostril. At the termination of the act of deglutition the velum falls back to its original position and the mouth of the tube is freed from the above-named fold. These observations of Dr. Michel have been confirmed by subse- quent study of the faucial end of the Eustachian tubes in a young man who had lost by necrosis all the osseous contents of the nasal cavities and the bony roof of the nose.^ In this case the entire nasal cavity and the nasopharyngeal space were exposed to view, and the cavity from one tubal mouth to the other, with ' Die Ohrtrompete, Municli, 1870, p. 6. 2 Das Verhaltniss der Tubenmiinduiig zum Ganmensegel am Lebenden be- traclitet durch die Nase. Berlin. Klin. Woehenschr., 1873, 34. s Neue Beobachtiingen uber da.s Verhalten der Rachenmundung der Tuba und iiber die Thatigkeit der Musculatur des Schlundkopfes. Berlin Klin. Woehenschr., No. 41, 1875. See abstract by Dr. Zaufal, Archi\'- f. O., B. xi. pp. 60-63. EUSTACHIAN TUBE AND MASTOID PORTION. 121 the insertion of the velum palati, could be seen at a gin nee. The observations already made by Dr. Michel were thus supple- Fig. 1 \ ' M'" t N M L G F E B C W W' W View of the entire Hioht Middle Ear, laid opes by an incision prom above downward, through the centre of the cavity, parallel to the long axis. (gl'llbei'.) -.—Above the line A B, the outer half; below the line, the inner half. — T,T', T". Eustachian tube. T'. The isthmus. T". The tympanicopeniug. K, K'. Section of the cartilage ; between these points the groove of the so-called membranous part of the tube is seen, below which the muscles of the tube are seen in section. H. The manubrium of the malleus, with a remnant of the tendon of the tensor tympani. Behind the manubrium maybe seen the descending process of the incus ; above, the articulation of the malleus and the incus. Between the manubrium of the malleus and the shaft of the incus may be seen the chorda tympani running from behind and below, up- ward and forward, which also marks the edge of the folds of the membrana tympani. "W. Entrance to the mastoid cells. W. Large cavity in mastoid cells. The inner half ; below the line A B. — CC. Part of the petrous portion of the carotid canal (opened). N, M. Eustachian tube. L. Canal of the tensor tympani muscle. F. Eostrum coch- leare with part of the tendon of the tensor tympani. G. Promontory on the inner wall of the tym- panic cavity ; on the posterior boundary the niche of the round window. E. Stapes. D, Trans- verse part of the Fallopian canal. C. Eminentia pyramidalis with the tendon of the stapedius muscle still attached to the head of the stapes. W. Entrance to the mastoid cells. W. Mastoid cells. mented by watching the act of swallowing in this young man. It was found that during this act, two long vertical ridges form 122 MIDDLE EAR, on the posterior pharyngeal wall behind the lower end of the tubal prominence. These produce an upward movement and project from 1 to IJ cm. above the surface of the velum, but leave a space about 1 cm. broad between them. In singing, in- stead of such ridges, moderately thick folds are formed. From the formation of these ridges Dr. Michel is led to suppose that the floor of the tube is pushed upward by the combined action of the levator palati and the pterygo-pharyngeus, the latter by its contraction and consequent thickening pushing upward the former muscle. The tendency in swallowing, therefore, would seem to be to force the floor of the Eustachian tube upward and its two walls apart. Conjoint Physiology of the Eustachian Tube, Tympanic Cavity, and the Mastoid Cells. — According to the carefully conducted experiments of Macli and KesseP on the functions of the tym- panic cavity and the Eustachian tube, it is shown that sound- waves will produce the greatest eflfect when, in the middle ear, the following three conditions are maintained, viz. : — 1. The Eustachian tube must, as a rule, remain closed. 2. It must, however, be opened occasionally for purposes of ventilation. 3. The tympanum should be in connection with large irregu- lar cavities. These conclusions are based on the following observations and facts : — The length of most of the audible sound-waves is so large that the entire head of the hearer is, as it were, submerged in the wave of sound, and in the case of deeper sounds, all of the superficial parts are subjected to the same variations in pressure. If, then, the membrana tympani were exposed equally on both sides to the waves of sound, it could not be set into perceptible vibrations on account of this simultaneous and equal pressure on both its surfaces. Therefore, these observers conclude that " the waves of sound ' Die Function der Trommelliolile und dor Tuba Eustacliii. SitzungsbericUte del- li. li. Academie d. Wissench., 1873. See also Archiv f. Olirenh. N. F., Band ii. p. 116-191. EUSTACHIAN TUBE AND MASTOID POETION. 123 will produce the best efleets upon the membrana tympani when it is unexposed on one side to the sound-waves, i. e., when the Eustachian tube is closed." On the other hand, it must be remembered that a difference in the atmospheric pressure on both sides of the membrana tympani is a serious interference with the mobility of the mem- brane. Therefore, the Eustachian tube must be opened now and then in order to restore the equilibrium in the pressure of the air on each side of the membrane, which may have been in- terfered with by various physical causes. The capacity of the tympanum must not siuk below a certain limit if variations in pressure of a given amount are to produce vibrations of the membrana tympani of a corresponding amount ; for if the capacity of the tympanum is small, then very slight excursions of the membrana tympani will produce considerable expansive power of the inclosed air, which will operate against further increase in the vibrations. This is a very important circumstance in the consideration of the excursions produced by deep tones. In order that the latter may be received, the tympanum must have a certain depth and a generous capacity. Tlierefore the tympanum is in connection with the cavities of the mastoid process, and those of other portions of bone. A larger tympanum with perfectly regular outline and form would be impracticable from its great resonance. Therefore, the irregular, spongy, bony cavities, with which the ear is connected, appear to be of the greatest advantage. SECTION III. INTERNAL EAR. CHAPTER I. LABYRINTH AND AUDITORY NERVE. ANATOMY. The internal ear, sometimes called the labyrinth, is composed of a bony portion or case, and a membranous portion contained in the latter. The bony portion of the internal ear consists of the vestibule, the central portion, with which the cochlea is connected ante- riorly, and the semicircular canals pos- teriorly. Ficr. 29. The Vestibule. — The vestibule is a small cavity situate just beyond the inner wall of the tympanum. This wall is common to both cavities, and in it is the oval window, into which fits the foot-plate of the small stirrup bone. A section of the vestibule parallel to its tympanic wall is round or elliptic, but a section at right angles to this, and running parallel to the floor of the tympanum, is in general of a pear shape, the point of which is directed forwards. This of course indicates that there is a general ten- dency on the part of the four walls of the vestibule to unite anteriorly near the cochlea. The average distance of the outer from the inner wall of the vestibule, is External View op a Cast op THE Left Labtrtnth. (Henle.) — /. Fenestra cochlefe or round win- dow, a. Fenestra vestibuli, or oval window, b. Ampulla of su- perior semicircular canal, e. Am- pulla of posterior semicircular canal, d. Common shaft of union of these two canals, c. Ampulla of the horizontal semicircular canal. g. Tractus spiralis foramiuosus. LABYRINTH AND AUDITORY NERVE. 125 from 3 to 4 mm. ; its long diameter, running between its ante- rior and posterior limits, is about 5 mm., as given by Henld On the inner walls are found two depressions separated by a narrow, sharp ridge ; the anterior depression is the recessus sphmricus for the reception of the sacculus rotundus, and the posterior depression is the recessus ellipticus in which lies the utriculas. The ridge between these grooves is the crista vesiibuli. SECTrOX OF THE PYRAMIDAL PART OP THE RIGHT TEMPORAL BOXE, THROUGH THE VESTI- BULUM PARALLEL WITH THE OuTER WALL OF LATTER ; VIEW OF INNER WALL. (Heale.) — a. ComiQon opeDing of the superior and posteiior semicircular canals, b. Siaus sulciformis. c. Ampullar end of anterior vertical or superior semicircular canal, d. Recessus ellipticus. e. Crista vestibuli. /. Section of the small canal which conveys the branch of the vestibular nerve to the pyramid of the vestibule, g. Section of the facial canal, h, Recessus sphecricus. i. Canal of the tensor tympani. J. Scala vestibuli. k. Lamina spiralis. I. Scala tympani. jn. Inner opening of the aqufflductus cochlese. n. Crista semilunaris, o. Recessus cochleoe. p, Possa jugnlaris. q. Ampullar opening of the posterior vertical, or posterior semicircular canal. r,r. Sections of this canal. 0. Posterior opening of the horizontal semicircular canal. The latter finally terminates above the oval window, on the outer wall, in a sharp point named the pyramis vestibuli. Below, the crista vestibuli divides into two branches, the one skirting along the lower edge of the recessus sphosricus, and the other running backwards towards the ampulla of the posterior semi- circular canal. These branches inclose the recessus cochlearis ofReichert. The recessus ellipticus is further bounded below by a shallow furrow, the sinus sulciformis. The Ampullar Mouths of the Semicircular Canals. — On the upper wall of the vestibule, just above the recessus ellipticus, is the ampullar opening of the superior semicircular canal ; in the angle between the posterior and inner wall near the inner open- ing of the aquseductus vestibuli, is found the ampullar opening 126 INTERNAL EAR. of the commou end of the superior and posterior semicircular canals. At about the same height in the centre of the posterior wall is the posterior opening of the horizontal semicircular canal. The lower opening of the posterior semicircular canal is in the angle formed by the union of the posterior, the inferior, and the inner wall of the vestibule. The anterior ampullar mouth of the horizontal semicircular canal is in the outer wall between the oval window and the ampulla of the superior semicircular canal. Maculce Cribrosce. — These are groups of fine microscopic open- ings through which the nerves enter the vestibule. The superior group is found at the upper spinous termination of the crista vestibuli ; a second group is in the recessu^ sphsericus, and a third is situate at the ampullar opening of the posterior semi- circular canal. Through the superior cribriform spot nervous filaments pass to the utriculus and to the ampullse of the superior and the horizontal semicircular canals, through the middle cribri- form spot nerves pass to the sacculns, and through the lower spot the ampulla of the posterior semicircular canal is supplied. Reiehert has described a fourth cribriform spot, in the upper part of the recessus cochlearis, near the origin of the lamina spiralis. This gives admission to a filament from the smaller branch of cochlear nerve, M'hich is distributed to the septum between the sacculi in the vestibule.' The Cochlea. — The bonj"^ cochlea may be described very briefly as an osseous canal twisted spirally two and a half times about a bony pillar. This shape closely resembles that of a snail-shell, and has suggested the name of the cochlea. The bony cochlea may be divided into the spiral canal, modiolus, and the lamina spiralis ossea, which, projecting from the modiolus into the calibre of the canal of the cochlea, termi- nates above at the helicotrema in what is named the hamulus. The Canal of the Cochlea. — The cochlear canal starts at the ex- treme outer and lower corner of the vestibule, and winding outward and forward makes in its first half turn the promon- tory of the inner wall of the tympanum. 1 lienU. on. cit. D. TGO. LABYKINTH AND AUDITORY NERVE. 127 Each turn of the cochlea is shorter than the previous one, and rising above and beyond it outwardly forms the peculiar resera- Fig. SI. Osseous Cochlea LAID OPEN. (Magnified 4 diam.; Heul6.) blance indicated by its name. The heiglit of the cochlea is equal to the diameter of its base, and measures about 4 or o mm. The entire length of the cochlear canal is from 28 to 30 mm. The modiolus, which may he considered as representing the axis of the cochlea, is nearly in the axis of the porus acusticus internus and about at right angles to the long diameter of the pyramid of the petrous bone. The point of the cochlea is di- rected outward, forward, and downward. The latter part of the cochlea, the cupola, is separated by a thin plate of bone from the canal of the tensor tympani muscle, while in front the coils are very close to the carotid canal. The diameter of the canal of the cochlea is about 1 mm. at its widest part; from the begin- ning of the last half turn it becomes much smaller. A trans- verse section of the cochlear canal varies in shape, being sometimes elliptical and at others semicircular. Its more com- mon shape is that of a segment of a circle, the point of which is directed towards the axis of the cochlea. The thickness of the dividing wall between the turns of the cochlea is 0.3 mm. at the lower turn, and 0.03 mm. at the upper part of the canal. The Modiolus and Lamina Spiralis Ossea. — The general shape of the modiolus is pyramidal. At its base the diameter is 2 mm., at the. apex J mm., and its height is 2J mm. 128 INTERNAL EAR. The modiolus is not only the bony axis about which the cochlear canal is twisted, but it is traversed by numerous canals for the transmission of the branches of the cochlear nerve, which is finally distributed like fringe on a bony shelf running spirally around the modiolus and projecting into the canal of the cochlea. This bony shelf is the lamina spiralis ossea. The Scalce. — The lamina spiralis ossea divides the canal of the cochlea into its scalse. The upper one of these is the scala vestibuli, beginning at the vestibule and continuing to the helicotrema ; the lower one, the scala tympani, may be said to begin at the helicotrema and end at tlie round window. The general relation of the spiral bony lamina to the scalse, and the I'elation of the latter to each other, will be understood, perhaps, better if the reader imagines himself starting from the vestibule along the upper surface of the bony partition between the scalse, and continuing until he reaches, at the helicotrema, the sharp hook-like end of the bony lamina. At this point he must imagine that what has been the floor of the scala vestibuli now becomes the upper surface or roof of the scala tympani. If the scala tympani be traversed, in imagination, two and a half turns will reach the membrane of the fenestra rotunda. The lamina spiralis ossea forms only part of the division between the scalse ; as it does not pass as a bony septum from the modiolus to the opposite Avail of the canal, the separation of the two scalse from each other is not complete until the soft parts are added to the osseous structures. The lamina spiralis is thicker at its lower end than at the top of the modiolus. At the former point it may amount to 0.3 mm., but at the upper part, only to 0.15 mm. The width of the lamina spiralis is 1.2 mm. at the lowest part, and 0.5 mm. at the upper part. The Semicircular Canals. — To the posterior part of the vesti- bule are attached the three semicircular canals. These are named according to their positions and planes, the superior, the posterior, and the horizontal semicircular canal. Although there are three distinct canals, there are but five openings from them into the vestibule. This is due to the fact that two of the canals, the superior and the posterior, are joined to a common shaft just before they reach the vestibule. The LABYRINTH AND AUDITORY NERVE. 129 position of these openings on the wall of the vestibule has been described already (p. 125). At one end, each of the canals has a dilated portion, its ampullar enlargement. These enlargements contain soft parts of similar name and shape, the ampullae of the membranous semicircular canals. The latter will be de- scribed later. Dimensions of the Semicircular Canals. — The length of the posterior semicircular canal is the greatest of the three, amount- ing to 22 mm. The length of the superior canal is 20 mm. and that of the horizontal canal is only 15 mm., as shown by Hushke and Henle. The common shaft of the superior and posterior canals is from 2 to 3 mm. long. A transverse section of these canals is elliptical. The long diameter is to the shorter as 2 : 3 or 3 : 4. The longer measures, in man, from 1.3 to 1.7 mm. (Henl^). Ampullar Enlargement. — The shape of the ampullse is that of an ellipsoid. The ampulla of the superior and of the posterior canal is sharply defined from the rest of the canal as well as from the vestibule by a ridge, but the horizontal semicircular canal glides gradually into its ampullar end. , The height of the ampulla, in the centre, is about 2.5 mm., not quite as great as the longer diameter of its calibre. The Planes of the Semicircular Canals. — The superior and the posterior canals are in vertical planes at right angles to each other. The horizontal semicircular canal, as its name shows, is in a plane at right angles to that of both the others. The top of the superior canal points upwards, making thus a visible ridge on the anterior surface of the petrous bone. The top of the posterior canal points directly backwards, as does that of the horizontal semicircular canal. Soft Parts of the Cochlea. — If a transverse section of the canal of the cochlea be examined under the microscope, the manner in which the canal is subdivided into its scalse will be seen. This division is first indicated by the projection of the lamina spiralis ossea into the calibre of the canal. The free end of this bony shell would therefore form a good point for beginning the 9 130 INTERNAL EAR. consideration of the topographical arrangement of the different parts of the cochlea. Fis. 33. a— Transyeb.se Section of the First Coil of the Cochlea op a Child one and a half TEAR old. (Magnified 100 diam. : Wftldeyer.i) — The membrana tectoriais sketched from another preparation of the same cochlea. SV. Scala vestibali. ST. Scala tympani. y. Ductus cochlearia. a. Vestibular lamella of the lamina spiralis ossea. w. Tympanal lamella of same. x. Cochlear nerve, ft, n. Osseous wall of cochlea, g, o. Periosteum. /, p. Cushion of connective tissue (lig. spirale of KOUiker) partially loosened from the bony wall, and thickened near the ductus cochlearis, into a special fibrous mural layer for the latter, i. Stria vascularis, o. Point of union between the periosteum and the cushion of connective tissue. I. Lig. spirale ; Henli. j. Lig. spirale accessorium, with the vas prominens. k. Sulcus spiralis externus. b, e, Keissner's membrane only the two end pieces shown; the rest indicated by a dotted line. &, c. Crista spiralis, e. Its most prominent part in profile; the so-called "auditory teeth." d. Membrana tectoria. v. Sulcus spiralis internus. a. Point of entrance of the nerve (Habenula perforata). u, I. Membrana basilarig. «, q. Cortis organ, c, q. Zona denticulata. i, r. Zona arcuata. q, I. Zona pectinata with epithelium, t. Region of inner ciliated cells. 8. Thinnest part of the mem- brana basilaria under Corti's organ, r. Region of outer ciliated cells. Strieker's Handbuch, etc., p. 932. LABYRINTH AND AUDITOEY NEKVE. 131 ■ Soft Parts of the Lamina Spiralis Ossea. — Upon the upper surface of the lamina spiralis ossea is placed the vestibular lamella, and upon the under surface, is placed the tympanal lamella of the lamina spiralis ossea. Through the bone lying between these lamellae runs the nerve on its way to its termi- nation at the organ of Corti and the ciliated cells, a description of which will follow later. The tympanal lamella is continued in the same plane, directly across from the under edge of the lamina spiralis ossea to the opposite wall of the cochlear canal. Here it is joined to the latter at the thickest point of a cushion of connective tissue called the ligamentum spirale of Henl^. The division of one scala from the other is now complete, by the formation of this, the membrana basilaris. This membrane does not seem to be very elastic, according to recent observations of Prof. Waldeyer. The upper or vestibular lamella of the lamina spiralis ossea is the thicker of the two. About half way between its origin and the point of the spiral bony lamina, the vestibular lamella is thickest, from which point it seems to taper to the edge of the bony shelf on which it lies. At this thick part there rises a delicate membrane, the mem- brane of Reissner, which springs across the scala vestibuli, and is fastened at a point on the opposite wall of the cochlea about 40° above its starting point. This is a most important mem- brane, since it forms the upper or vestibular boundary of the ductus cochlearis. The membrane of Reissner is said to consist of a thin connec- tive-tissue basement lamella, rich in vessels. On its vestibular surface large-celled, serous epithelium is found, and on its tympanal surface a single layer of regularly arranged, cubic epithelial cells. ■ It will now be seen that the cochlear canal is really subdivided into three canals — the scalse already named and the ductus cochlearis which is formed at the expense of part of the scala Vestibuli. The ductus cochlearis may, therefore, be said to lie upon the membrana basilaris above the grand division line of the scalse, and should indeed be imagined as slipped into a triangular-shaped canal lying between the scalse at their outer edges. The scalse are lined with periosteum covered with large flat epithelium. They are filled with perilymph, and are in 132 INTERNAL EAB. communication with each other only at the helicotrema in the cupola of tlie cochlea. The ductus cochlearis is not in communication with them at any point ; it begins and terminates in so-called blind ends. The scala tympani ends at the membrane of the round window, but the scala vestibuli is in free communication with the vesti- bule. Crista Spiralis. — From the point where the membrane of Reissner is attached to the vestibular lamella of the lamina spiralis ossea, there extends a crest or ridge of connective tissue and developed epithelium called the crista spiralis, the serrated edge of which is called by some anatomists, " aural teeth."' From this free peculiar edge rises the membrana tectoria, which extends as far as the beginning of the organ of Corti. The space between the crista spiralis and the point of junction between the lamina spiralis ossea and the membrana basilaris, is called the sulcus spiralis internus. Corti's organ extends from the junction of the membrana basilaris and lamina spiralis ossea to a middle point on the former membrane. From this point the epithelial lining of the ductus cochlearis pursues a less complicated course outward and upward over the wall of the duct. Just above the attachment of the membrana basilaris to the outer wall, at the spiral ligament, there may be seen a promi- nence known as the accessory spiral ligament, but which really seems to form a passage for a vessel named the vas prominens. Between these two points lies the sulcus spiralis externus. Above the vas prominens, between it and the upper and outer attachment of Reissner's membrane, is found the stria vascularis. Habenula Perforata and the Zones. — The habenula perforata is situate at the extreme thin edge of the osseous spiral lamina, and gives exit to the nerve-branches. The zona denticulata extends from the crista spiralis to the outer end of Corti's organ ; the zona areuata, from the inner to the outer ciliated cells ; and the zona pectinata extends from the outer boundary of the organ of Corti to the spiral ligament of Henl^. These names ' Gehoi'zaline of Huslikc. LABYRINTH AND AUDITORY NERVE. 133 are descriptive of the appearance of the i-egion extending from the crista spiralis to the ligamentum spirale, when viewed from ahovCi According to the investigations of Prof. Waldeyer, three varieties of tissue can be discerned in the first stages of develop- ment of the cochlea. At that time the most external layer is a cartilaginons mass connected with the base of the skull. In this mass is a collection of embryonal mucous tissue, within which is imbedded the epithelial labyrinth vesicle. From the latter, which at last becomes the sacculus, a hollow sprout lined with epithelium grows before the eighth week, and pushing its way into the mucous tissue is forced by the surrounding cartilage to curl itself up into a spiral shape. This is the first trace of the ductus coQhlearis. At one point the cartilaginous capsule is not closed, and here the cochlear branch of the auditory nerve enters. The bony portion of the cochlear capsule, according to Prof. Waldeyer, is divided into a compact inner layer, a tabula vitrea, and the more porous modiolus and lamina spiralis. In the latter is found the canalis ganglionaris, in which lies the spiral ganglion of the auditory nerve. The inner surface of the periosteum of the canal is covered with a layer of simple, large, flat, nucleated cells, similar to those found on the surface of serous membranes. Ductus Cochlearis. — From the foregoing description of the three divisions of the cochlear canal it must have been seen already that the most important of these is the ductus cochlearis. It is indeed from the epithelial lining of this important capsule that the highly organized contents of the cochlea are developed so as to be the recipients of the terminal filaments of the audi- tory nerve, after it passes the habenula perforata and reaches the cavity of the ductus cochlearis. The most important of these structures is the organ of Corti. The Marquis of Corti' was the first to describe this apparatus, and it has from that time justly borne his name. Kolliker and Deiters subsequently enriched the knowledge possessed respect- ing this important apparatus of the internal ear. . The best treatise on the structure of the cochlea and the dis- ' Von SieboUl and Kolliker's Zeitschr. f. Zoologio, 1851. 134 INTERNAL KAR. tribution in it of the auditory nerve has been written by Prof. Waldeyer.^ Dr. Gottstein, his colaborer,.has added the most important facts concerning the ultimate distribution of the auditory nerve to the outer ciliated cells. Organ of CortL — The position on the membrana basilaris occu- pied by the organ of Corti has already been pointed out. (Fig. 32, it-q,) An idea of the general structure and appearance of this wonderful central portion of the ductus cochlearis can be gained by consulting Fig. 33. Fig. 33. Transverse Section of the Organ of Corti. (Magnified 800 diam. : Waldeyer.)— J/, o. Homo- geneous layer of the membrana basilaris. ■«, Vestibular layer of the same, corresponding to the radii of the zona pectinata. p. Tympanal layer with nuclei, gVanular cell protoplasm, and trans- versely cut connective tissue flbriUaj. y; Labium tympanicum of the crista spiralis, w. Continua- tion of the tympanal periosteum of Lamina spiralis ossea. «. Thickened origin of the. membrana basilaris immediately beyond the point of entrance of the auditory nervo 6. t. Vasspirale. u. Bloodvessels, x. Nerve fasciculus, a. Epithelium of the sulcus spiralis internus. d. Inner cili- ated cell. c. Its basilar process. About the latter and above the point of entrance of the nerve are some cells aDd finely granular matter in which the nerve fibrils are distributed (Granular layer). e. Inner part of the capital of the inner pillar and the point where the cilia of the inner ciliated cell are situaJ:o. /. Point of junction of the arches ; the body of the outer pillar is severed in the middle ; behind it appear the body and base of the next pillar at q. t. Base with part of the granular protoplasm of the inner pillar. j7, z, and^'. Three outer ciliated cells, m. Basilar part of two other ciliated cells. I. Heusen's supporting cell. «, k. Lamina reticularis, a, Nerve fibril distributed to the first ciliated cell, fir, and traceable through the arch as far as the point of entrance of the auditory nerve at &. The Pillars and Arches. of CortL — Upon the upper or vestibular surface of the membrana basilaris are two sets of pillars, an Strieker's Manual of Physiology. LABYRINTH AND AUDITORY NERVE. 135 inner and outer row, uniting above and forming a series of arches. The pillars, as the arches, are named after Corti. They are about 3000 in number, according to KoUiker. A head, head-plate, foot, and body are parts into which anatomists have divided the pillars. At the junction of the pillars, the head of the outer is fitted into a depression between the head and head- plate of the inner pillar. (I'ig. 33, /.) The kind of tunnel thus formed by the arches of Corti is triangular in outline, the longest side of which corresponds to the membrana basilaris. This tunnel extends over the entire length of the lamina spiralis almost to the end of the hamulus, as given by Waldeyer. As a rule, the height and width of the arches increase towards the hamulus, as shown by Hensen. Inner Ciliated Cells. — On the inner side of the arched roof thus formed, is found the single row of inner ciliated cells. The latter are lost at their lower end finally, in what is termed the " granu- lar layer." Their upper ciliated ends are received into corre- sponding head-plates of the inner pillars. Their cilia, arranged in dense tufts or plots, are extremely stiff and strong. The Outer Ciliated Cells. — -There are five rows of the outer cili- ated cells. They are arranged in parallel rows beyond the row of the external pillars, and underneath the membrana reticularis. The Membrana Reticularis. — The membrana reticularis, as its name indicates, is a net-like structure. It is one of the most complicated parts of Corti 's organ, extending from the junction of the pillars to the so-called support-cells at the outermost row of the ciliated cells. Into the meshes of this delicate reticulate membrane, fit the tufts of cilia of all the outer ciliated cells. A profile view of this arrangement can be seen in Pig. 33, at i andy. The Surface of the Membrana Reticularis. — Viewed from above the membana reticularis presents not only a very beautiful but an equally complex appearance. It will be seen that the ciliated cells occupy alternate openings in the mesh of the reticulate membrane in both directions, thus giving a checker-board arrangement to the ciliated tufts and the intermediate spaces. To the former, the framework supporting the cilia, the name 136 INTERNAL EAR. ring has been applied by Bottcher, and the finger-shaped inter- spaces have been called the phalanges by Deiters. The latter are filled out by a delicate membrane according to Waldeyer. Over the entire organ of Corti, close to the membrana reticu- laris, is placed the membrana tectoria or Corti's membrane. Membrana Tectoria. — Of this membrane Prof. Waldeyer states that it begins immediately at the point of attachment of Reiss- ner's membi'ane on the crista spiralis in the form of an immea- surably fine layer, covers the crista, while lying close to it, and at the same time increases greatly in thickness. It attains its greatest thickness in the sulcus spiralis internus, and terminates, as shown by lieusen, Gottstein, and Waldeyer, in a free and extremely delicate edge in the neighborhood of the outermost row of ciliated cells. (See Fig. 32, d.) The constituent elements of Corti's organ have now been de- scribed as briefly' and in as condensed a way as possible. Of this wonderful organ, Prof. Waldeyer says, that if there be left out of consideration the peculiarities of the inner ciliated cells, the apparently complicated structure of Corti's organ reveals really a simple plan. Several rows of cylinder-cells (double cells) are arranged in regular order on a broad zone of the spiral shelf. These rows are parallel to each other, and are held firmly in their position between two membranous boundaries, the membrana. reticularis and the membrana basilaris. Two sets of these cylinder-cells, the pillar cells, become developed for the purpose of forming a firm arch of suppport for the whole. Specially worthy of note is the fixation of the outer ciliated cells, which, by means of processes and their head-piece, are immovably held between the membrana reticularis and the basilar membrane. These cells, together with the pillars of Corti, are the exclusive peculiarity of man and other mammals. To this apparatus, i. e., to its peculiar ciliated cells, the terminal filaments of the auditory nerve are directly sent. The Auditory Nerve ; Origin and Distribution. — According to the investigation of Stieda in 1868, with whom Waldeyer agrees, the auditory nerve springs by two roots from the medulla ob- longata. The fibres of one of these are more delicate than those of the other. It originates from a ganglionic nucleus on LABYKINTH AND AUDITOEY NERVE. 137 the floor of the fourth ventricle. The second root, which is said by Stieda to contain larger axis cylinders than any other nerve, springs from a special large-celled ganglionic nucleus in the crus cerebelli. This root acquires, soon after it leaves the medulla, a small ganglion like one of the posterior roots of the spinal cord. Both roots soon unite into a common trunk, but divide again in the porus acustieus internus, into two branches, the vestibular and cochlear branches. Vestibular and Cochlear Branches of the Auditory Nerve. — The first contains a small ganglion, intumescentia ganglioformis ScarpsB, and divides into the ampullar branches and those for the utriculus and the sacculus. The cochlear branch, which is by far the larger of the two, gives off a small fasciculus to the septum membranaeeum between the sacculus and the utriculus, and to the macula cribrosa, and then enters the first turn of the lamina spiralis, from which point it continues its course throughout all the windings of the spiral lamina. Inner and Outer Nerve-ends of the Cochlear Branch. — The ulti- mate fibres of the auditory nerve in the cochlea are named the inner and the outer terminal filaments, in accordance with their distribution to the inner and outer hair cells. According to Waldeyer, both sets of fibres, as they emerge from the openings in the lamina spiralis ossea, pass through the " granular layer" which lies directly over their point of exit. The inner nerve fibres then pass directly to tlie inner hair cells. These fibres are large, and are considered as trae axis cylinders. The outer nerve fibres are distributed, as shown by Gottstein, between the pillars of Corti, at about half the height of the arches, to the inner row of the outer hair cells, and perhaps to the more distant rows. The origin of the auditory nerve, being so near the origin of the pneumogastric nerve, would help to explain the sympathy which seems to exist between an aural disease and the respira- tory and the digestive tracts. There also seems to be a sympathy between the ear and the emotions.' May not cases of apparently hysterical deafness be traced to some such central nervous connection? 138 INTERNAL EAR. Soft Parts of the Vestibule and Semicircular Canals ; the Mem" hranous Labyrinth. — Since, in the consideration of the osseous structure of the internal ear, all of the latter has been comprised under the name of labyrinth, an analogous term might be applied to all of the soft structures of the internal ear considered as a whole. But Prof. Riidinger, who has writteii the best treatise on the subject, limits the term "membranous labyrinth" to the sacculi and the membranous semicircular canals. In this sense, therefore, the term shall be used in the consideration of the soft parts contained in the vestibule and Fig. 34. bony semicircular canals. a I The membranous labyrinth, i. e. the ^^\ sacculi and the semicircular canals, is now I j 1 I considered an important part of the per- ^^^^^K^ ceptive auditory apparatus. Prof Riidin- ^.ff «W I "^ ^®''' ^^® shown that these parts of the V^^p^^ internal ear are in direct contact with the jp '' osseous or cartilaginous structures con- taining them, and that, therefore, they do Membranous Labyrinth n ' ./ or MA!f. (Rudinger.)— a. uot float, as herctofore supposed, entirely Hori.oat,a semicireuUr oa- f^^^ -^^ ^^^ perilymph. nal. r.. Superior semicircu- -t J Jr lar canal. 6. Posterior semi- The perlosteum, lining the bony cavitj circular caual. ft. Caaalia j. • ■ j_i i , • communis, a Ampuuar-iike coutaming thcsc mcmbrauous parts, is a termination of the horizontal modcrately thick layer of connective tissue, semicircular canal, g. Utri- , . „ i j' nt cuius, c. Sacculusrotnndus. With SOmC tlUC elEStlC tlDreS. The Sacculi. — Of the sacculi, the utriculus is more closely con- nected to the inner wall of the vestibule than is the sacculus rotundus. The two sacculi occupy two thirds of the cavity of the vestibule. The utriculus extends further outward towards the tympanum, but neither of them touches the side of the ves- tibule which receives the base of the stapes, i. e, they do not touch the outer wall of the vestibular cavity. The Membranous Semicircular Canals. — These are fastened to the convex side of the bony canals by means of stout connective tissue fibres, which are called by Prof. Riidinger the ligamenta lahyrinthi canaliculorum. These constitute the true support of ' Das liautige Labyrinth. Strieker's Handbueh. Leipzig, 1873. LABYRINTH AND AUDITORY NERVE. 139 the membranous canals. Sometimes there are two or more of these connective tissue stays, so arranged as to simulate under the microscope transverse sections of small canals. But they are to be considered simply as part of the support of the mem- branous semicircular canals. (Fig, 35, e.) Fia;. 35. Transverse Section or the Bony and the Membranous Semicircular Canal of Man. (Eiidinger.) — c*. Bony wall. d. Fasciculi of connective tissue inclosing vessels. 6. Junction of fibres with periosteum, a. Membranous semicircular canal with its three layers, e. Liganienta canaliculorum with their lacunae. /. Junction of the membranous semicircular canal with the periosteum. Another set of connective tissue fibres, passing from the periosteum to the free surface of the labyrinth wall, are for the purpose of supporting the bloodvessels as well as supplying points of fixation for the free wall of the membranous laby- rinth. Dr. Hasse has thought that he could demonstrate the exist- ence of serous membrane in the labyrinth of the frog, but Prof. Riidinger has not been able to satisfy himself on this point. The wall of the membranous semicircular canals has an unequal 140 INTERNAL EAR. thickness, being 0.016 mm. at the point of contact with the perios- teum ; it is thickest [0.060 to 0.080 mm.] at the point of junction with the ligamenta labyrinth i canaliculoruni. The canal wall is composed of four layers in the following order from without, inward, viz. : 1. A layer of connective tissue. 2. Hyaline tunica propria. 3. Papilliform prominences ; and 4. The epithelium. The external layer possesses all the qualities of connective tissue with numerous ceils. When the entire membranous semicircular canals, removed from their connection with the periosteum and ligaments, are subjected to examination, another network is found, closely resembling nerves and ganglia. But it is as yet very uncertain whether these are nerve- elements, since the existence of nerves in the membranous semicircular canals is as yet doubtful. The tunica propria is of unequal thickness in the semicircular canals, but in the utriculus it is of uniform as well as great tenuity. The papilliform prominences, on the inner surface of the- tunica propria, are considered by Prof. Riidinger as normal structures in the adult human being. (Fig. 35, a.) They are so constant in their occurrence that their absence and not their presence is to be considered pathological. They are confined to certain parts of the wall of the canal, are varied in size and shape, and pass imperceptibly into the tunica propria, of which they must be considered a part. They attain their greatest size at the point of insertion of the ligamenta caualiculorum. They are not found on that portion of the tunica propria corre- sponding to the part of the canal in contact with the bony wall, and are but slightly developed on the free side of the membran- ous canal. The papillae are covered with pavement epithelium, which is easily detached ; and hence, perhaps, the assertion on tlie part of some observers, that epithelium does not exist at this point. These bodies are not found in the sacculi, nor at that part of the semicircular canals where the latter pass into the utriculus. Although these bodies may not be found in the new-born child, and are considered pathological by some, Prof. Riidinger says he has never failed to find them in the adult human being. The absence of epithelium, and the reaction between these bodies and iodine, have been urged as proof of their starchy LABYRINTH AND AUDITORY NERVE. 141 nature. But Prof. Eudinger has demonstrated that epithelium can alwa^'s be shown to be present with these bodies by the application of the proper tests ; and as far as iodine is concerned, that gives the peculiar reaction alluded to, in common with the tunica propria and many other tissues, in which the pre- sence of starch has never been proven. In conclusion Prof. Rtidinger says their round form can never be adduced as a proof of their amyloid nature, and if the inner surface of the membranous canals possesses a secerning nature, these bodies will supply a larger surface demanded by such a function. These papilliform bodies are not found in the lower mammals. Sacculi and AmpuUce ; inner Surface. — On the inner surface oi these organs there is found a constant and peculiar yellowish Fi<;. 36. TBAX3VEESE Sectios OP AN AMPULLA OF A FisH : Flook AND WALL. (Hudinger.)— a. Roof of ampulla b. Thin spot on Its wall. c. Thick portiou of wall, d, e, and/. Floor with the nerves, i/. Nerve-epithelium, /i. Acoustic cilia, i. Transition point between floor of ampulla and./ planum semilunare. S. Flat epithelium. 142 INTERNAL EAR. epithelium provided with cilia. There is also found a redupli- cation of the tunica propria extending into the cavity of the ampullae to which the name of crista acustica has heen given by Max Schultze. A similar projection in the sacculi is called by the same authority the macula acustica. Every branch of the acoustic nerve, going to the ampullae, after dividing into two flat fasciculi supplied with ganglion cells, passes through the tunica propria, and is then distributed to the ciliated epithelium of the crista acustica. Planum Semilunare. — At right angles to each end of the crista acustica, extending along the walls of the ampullae, there is an elevation on the epithelial layer, named the planum semilunare.' To this also, some of the terminal filaments of the auditory nerve are conveyed, as shown by Riidinger. The epithelial layer in the sacculi is thinner than that in the ampullse. There areseveral varieties of epithelium in this layer, as shown by Prof. Riidinger. But here too, ciliated cells are found, to which nerve filaments are sent. The Otoliths. — In the endolymph of the sacculi, there are found small crystals of carbonate of lime, called Otoliths. Pig. 37. Otoliths FROM rAEious Akimam. (Eudinger.)— a. Scymnas lichia (Leydig). b. Cyprlnus, carpio or carp. c. Goat. (J. Boach ; flsh, e. Woodgrouse (Leydig). /.Pike. jt. Ptevois voli- tans (Broschet). h. Sea-devil, i. Mackerel, j. Herring. • Steifensand, 1835. LABYRINTU AND AUDITOEY NERVE. 143 Some observers have found otoliths in the endolymph of the semicircular canals and in that of the cochlea, but these are generally considered exceptional occurrences. Henl^, after treating the otoliths with acids, thought he detected a cartilaginous remnant, to which the name of otolith cartilage is given. They are, according to Eiidinger, large and few in reptiles, but small and numerous in man and other mammals. The Topographical Arrangement of the soft Parts of the Internal Ear. — By consulting Fig. 38, the general relations between the soft parts of the internal ear may be learned. It will be seen that the sacculus rotundus pertains more to the ductus coch- Fig. 38. A Scheme of the Membranoijs Labyrinth op Mammals. (Waldeyer.) — U. tTtriculus with the membranous semicircular canals. S. Sacculus. P.. Aqujeductus vestlbuli. G. Canalis reu- niens. C. Ductus cochlearis, with V. Vestibular cul de sac, and K. Cul de sac of the cupola. learis than to the utriculus and the rest of the so-called mem- branous labyrinth. The link between the sacculus and the ductus cochlearis is the canalis reuniens of Hensen. The aquseductus vestibuli is the roundabout way from the utriculus to the sacculus. ' Of this peculiar duct more will be said hereafter. The utriculus, as shown in the diagram, is the cavity with which the membranous semicircular canals and their important ampullae are in close connection. The entire mem- branous labyrinth is filled with endolymph. The JSndolymph. — The general plan upon which the endo- and perilymph of the inner ear are renewed, has been best explained by Dr. Hasse, of Wiirzburg.i jje has shown that all verte- brates possess a duct, which originates in the vestibule ; and in • Anatomische Studien, No. xix, p. 768. 144 INTERNAL EAR. all animals, with the exception of the plagiostomes, in which it passes directly to the surface of the skull, this duct enters the cavity of the cranium, and there terminates either in a closed sac at the confines of an epicerebral lymph-cavity or opens into the same. This is the ductus endolymphatieus or the aqumductus vestibuli, with the saccus endolymphaticus, the former of which arises from the sacculus rotundus in most vertebrates, and con- veys endolymph to the membranous labyrinth. Physiological Functions. — Dr. Hasse has suggested three proba- ble functions of the aquseductus vestibuli, or the endolympha- tic duct. 1. The endolymphatic duct and its sac are the source of the endolymph in embryonal life. In this capacity, the sac plays the part of a kind of gland. 2. In adult life, this duct may act as a conveyer of new material to the endolymph, either by endosraosis from the epi- cerebral cavities in those instances where the saccus endolym- phaticus is closed, or by means of a direct current where the saccus is open, 3. It may be supposed that the sac is useful as a reservoir for the liquor endolymphaticus, when the intra-labyrinthal pressure attains an excessive height. By the reception of the fluid into this sac, the pressure would be reduced in the labyrinth. A very practical deduction is made by Dr. Hasse, respecting the ductus endolymphaticus. Every increased or diminished pressure of the cerebro-spinal fluid in the subarachnoid cavity will make itself felt by continuity through the saccus and the ductus endolymphaticus, in the interior of the auditory appa- ratus, in the endolymphatic cavity, and upon the terminal fila- ments of the auditory nerve. Thus may be explained the im- pairment of hearing for high notes when the pressure in the labyrinth is increased.* Furthermore, pathological processes in the subarachnoid space are conveyed either by continuity or contiguity through the saccus and ductus endolymphaticus, into the interior of the labyrinth, and vice versa, the latter being the rai'er, from the deep-seated position of the inner ear. Thus, every alteration in the chemical constitution of the cerebro-spinal fluid, ' See pp. 98-100. LABYRINTH AND AUDITORY NERVE. 145 necessarily produces a change in the liquor endolymphaticus, which alteration may exercise some influence in the occurrence of subjective acoustic perceptions, but in any event, must change the composition of the endolymphatic fluid. The Perilymph.— The perilymph is poured into the labyrinth from the subarachnoid space through the foramina acustica, and leaves the labyrinth by means of the aquseductus cochleae. The perilymphatic cavity is inserted into the lymphatic tract of all vertebrates,' and being in connection with the subarach- noid space, it is easily seen how changes of any kind in the cerebro-spinal fluid can be communicated to the perilymph and thence to the organ of hearing. Hence, morbid processes in the subarachnoid space may be communicated to the organ of hearing, either by the peri- or endolymphatic tract, or by both ways at the same time. In this manner a not unsound expla- nation may be given of numerous aft'ections of the internal ear. PHYSIOLOGY. Cochlea. — The physiology of the perceptive part of the organ of hearing has been explained most satisfactorily by Helmholtz and Hensen, the latter having made a series of experiments upon the function of hearing in the crab and lobster, since, upon the surface of these animals there are largely developed cilia, endowed with peculiar vibratile functions, and probably connected with the organ of hearing. It is now generally conceded that the cochlea enables- man to perceive musical notes, or notes and sounds with regular periodic vibrations, and that the membranous labyrinth is concerned in the perception of irregular vibrations, which are distinguished as noises. In the labyrinth, the distribution of the acoustic nerve may be traced to particularly firm and elevated spots at five different points, viz., in the two sacculi and three ampuUse. Imbedded in these elevated spots and in connection with the nerve-fibres centring there, are peculiar, stiff, elastic hairs or cilia, which are very brittle and pointed. Of these cilia, Helm- holtz says : " Such delicate, stiff hairs are apparently in a high ' Hasse, op. cit., p. 815. 10 146 INTEENAL EAR. degree susceptible of being moved by the motions of the fluid in which they are, and, in consequence of such movementSj they produce a mechanical irritation of the nerve-fibres lying imbedded in the soft epithelium at their base;"' Furthermore, there are found in close proximity to these acoustic cilia, calca- reotis bodies, the so-called otoliths, which, in the fish, bear an impress on their convex surface of the aforesaid prominence, containing the rich distribution of the acoustic nerve. In man, however, these otoliths only lie close to the wall of the mem- branous labyrinth. These crystalline bodies appear specially adapted to exert a mechanical influence over the nerve-filaments lying near them at each sudden movement of the water of the labyrinth, for, "the delicate and light membrane in which the nervous branches are interwoven, in all probability follows instantly the motion of the labyrinth water, while the heavier crystalline bodies, the otoliths, are set in motion more slowly and are longer in coming to rest. Hence they partly drag and partly press upon the neighboring nerves."^ Thus a powerful and enduring excitation of the vestibular branch of the acoustic nerve is effected by means of the peculiar structure of that part of the membranous labyrinth containing it. "While considering the physiology of the cochlea, the terminal filaments of the cochlear nerve in the ductus cochlearis must be called to mind. It will be remembered that in the nervous fringe lying on the lamina spiralis, there were certain arched supports of the delicate nerve ends on their way to the hair-cells. These, the arches of Corti, were stated to be about 3000 in number. It is supposed by Helmholtz, that each one of these arches is specially tuned so as to perceive a given note in the musical scale, just as in the piano-forte each wire is tuned to a note different from that of its fellows. Although it is generally conceded now among physiologists that the arches of Corti have no sentient properties themselves, but are simply supports for the ciliated cells, which, being connected with the ultimate nerve-fibres, are the true sentient portions of the organ of Corti, nevertheless the arches may be ' Die Lehre Ton den Tonempflndungen, p. 313. 2 Helmholtz, op. cit., p. 314. LABYRINTH AND AUDITORY NERVE. 147 considered as representatives, in a topographical sense, of the terminal nerve-filaments, and Helmholtz's phraseology remains not only intelligible, but his theory extremely plausible. " If," says Helmholtz, " we leave out of consideration two hundred of the arches of Corti, too high to be used in the ordinary musical scale, we still have 2800 for the seven octaves of the ordinary musical instruments, i. e., 400 for each octave and 33|- for each semitone; quite enough to explain the ability of perceiving fractional parts of a semitone, whenever such an ability exists. Skilled musicians, according to E. H. Weber, of Leipsic, can distinguish a difterence between two notes, whose rates of vibrations are in the proportion of 1000 to 1001, equiva- lent to g'^th of a semitone, a quantity too small to correspond with the aforesaid interval between the individual arches of Corti. However, that does not militate against our hypothesis, for if a note is sounded, whose pitch lies between two neigh- boring arches of Corti, it will set both of them in consonant vibration, but that one whose fundamental note agrees most nearly to that of the note sounded will be set most violently in vibration. It will, in fine, depend only on the delicacy in the degree of excitability existing between two such nerve-fibres, and how small a difi'erence in pitch in the interval between fibres we can distinguish. Thus it is we can explain the fact that when a note is continually rising in pitch, our perception of it changes gradually and not with jerking intervals, as it would if only one at a time of the terminal nerve-fibres were set in consonant vibration The simultaneous per- ception of several notes of various pitches is due to the percep- tive power of different nerve-fibres. Hence, the perception of clang-tint or timbre depends upon the fact that any note, besides setting in vibration that particular organ of Corti corresponding to its fundamental note, also excites perception in several different groups of nerve-fibres attuned to its partial tones.'" The theory of audition, as just described, has been further substantiated by the experiments of Hensen,^ upon -the organ of hearino- in crustaceans, in which cilia endowed with acoustic 1 Helmholtz, op. cit., p. 230-231. 2 Physiological Institute of Kiel, Germany. 148 INTERNAL EAR. power are situated on the external surface of the body. This investigator found that after he had desti'oyed the ear, or the saccules corresponding to that organ, in the mysis or opossum shrimp, but retained the external acoustic hairs or cilia on the antennse, the power of hearing was still present in the animals. By conveying musical notes through water in a box in which a mysis was so fastened as to permit of examining the external- acoustic hairs of its tail, Hensen perceived that certain notes of a horn, the instrument used in the experiment, would set certain acoustic hairs strongly in motion, thus demonstrating most forcibly the theory that in the perception of musical notes certain vibratile cilia and nerve-iibres connected with them are intimately concerned. According to Prof. A. M. Mayer,' who has described a similar process in the so-called auditory apparatus of the culex mosquito, the process in both mysis and mosquito is only analogous to the process in the cochlea of vertebrates. In the organ of Corti there is in all probability a means of analyzing sound, whereas in the acoustic cilia of the crustacean and insect already named, there is supplied a means of conveyance of sound rather than an object to which sound is conveyed. Such physical facts were also alluded to by Dr. Christopher Johnson^ in 1855, who believed that whenever auditory organs are developed in insects, their seat is near the antennae. To the question, "Are noises perceived in the cochlea, or is it correct to suppose the existence of another organ by wiiich such sounds are heard?" the following conclusion is offered as an answer by Prof. Sigmund Exner.^ Physiologic acoustic facts force us to the alternative, either that in the ear there is a special organ endowed with the faculty of perceiving noises as such, or that the nerves of the cochlea are endowed with such a peculiarity of function. The latter supposition is deserving of preference, for in obedience to it the nerves of Corti's organ receive an excitation not only when the vibrations of those parts of the membrana basilaris which ' Researches in Acoustics, No. 5, p. 9; American Journ. Sciences and Arts, Tol. viii. 1874. 2 Quarterly Journal of Microscopical See, vol. iii. 3 Zur Lelire von den Gehorsempflndungen. Pflijger's Archiv, xiii. S. 238, and Monatssclirift f. OlirenlieilUunde, No. 9, 187G. labykintb: and auditoky nerve. 149 underlie them have reached a certain length, biit also at such a time as when the motion of the cochlear fibres becomes very rapid even by a slight impulse. The sensation of a musical note occurs if only a few of the cochlear fibres are set in relatively slow consonance, but there occurs the sensation of an objective noise, whenever all the -fibres of the membrana basilaris are hurried out of their position with relatively greater velocity. Function of the Semicircular Canals. — The experiments of Flourens, in 1817, first drew attention to the probability that a lesion of the semicircular canals would produce peculiar dis- turbances in equilibrium of the body. His experiments were performed chiefly upon pigeons and rabbits, and consisted in wounding and irritating the semicircular canals and their con- tents. Subsequently his experiments were repeated by Plarless. Czermak, Brown-S^quard, Vulpian, and G-oltz. Without doubt many of their results, attributed to a lesion in the semicircular canals, were in reality attributable to injuries of the brain and other parts incident to the experimental operations ; a fact which, indeed, Flourens appears to have recognized in his own labors. With the experiments of Boettcher, in 1872-73, there becrins an era of more careful manipulation and protection of the brain and the vessels about the semicircular canals during the investi- gations. This endeavor to exclude results due to lesions of parts other than the semicircular canals has been paramount in the recent labors of Bloch, Cyon, Mach, Berthold, Breuer, Cursch- mann, Lowenberg, and Bornhardt ; and to these men belongs the honor of having conducted the most brilliant physiological experiments of modern times. Flourens noted that wounding the horizontal semicircular canals was followed by to and fro horizontal movements of the head, and that section of the vertical horizontal canals was fol- lowed by a vertical movement of the head upward and down- ward. He was led to conclude that he had found a new pair of nerves in the semicircular canals, " endowed with the singular faculty of influencing the direction of motion" (dou^ de la faculty singuli&re d'agir sur la direction des mouvements).^ He ' Becherches exp&imentales, etc., p. 493, 2cl edition, 1843. 150 INTERNAL EAE. also stated that destruction of the semicircular canals in no way aft'ected the sense of hearing unless it was to render it more sensitive. The experiments of Harless' and Czermak^ were in the main corroborative of those of Flourens; though Harless concluded that he had observed a form of disturbance different from those of Flourens, yet dependent upon a lesion of the semicircular canals. Brown-S^quard^ then endeavored to show that it was a coincident dragging and wounding of the acoustic nerve, in these experiments, which produced the peculiar alter- ations in co-ordination of movements ; but Schifli'* thereupon stated that wounding of the acoustic nerve, so long as the fifth pair was left intact, had no effect upon movements of the body. He also denied the existence of a nerve in the semicircular canals endowed with the peculiar power of co-ordinating muscular movements as was held by Flourens. By wounding the semicircular canals,' Vulpian' obtained results similar to those observed by Flourens ; but he explained them as being due to disordered sensations of sound. This view, however, has not appeared tenable in the light of sub- sequent experiments by others ; it is especially opposed by Boettcher. Goltz,* after a series of experimental sections through the semicircular apparatus of the internal ear in birds and frogs, not only doubted whether the semicircular canals are organs of hearing, but advanced the theory that they constitute an ar- rangement which serves to maintain the equilibrium of the head and mediately of the entire body. In his opinion these canals have more control in regulating the carriage and movements of the head, than the senses of feeling and sight. The investigations of Boettcher' and Bloch* were undertaken with a view of repeating Flourens' experiments ; of discovering upon what the peculiar manifestations he had obtained de- pended ; and of finding out an explanation of them. ' Wagner's Handworterbucb d. Physiologie, vol. iv. 2 Comptes rendus, 1860, and Jenaische Zeitschrift, 1867. ^ Lectures on Nervous System, Philadelphia, 1860, p. 195. •" Lehrbuch d. Physiologie, 1858-59, p. 399. 5 Le(;ons sur la Physiologie, p. 601. , " Pfliiger's Arcbiv f. Physiologie, Bd. iii. pp. 173-193. ' Kritische Bemerkungen, Dorpat, 1873. « Repetitions of Flourens' Experiments, Dorpat, 1873-1873. LABYRINTH AND AUDITORY NERVE. 151 The preliminary labor of Bloch, was followed by a more extended series of experiments by Boettcher. The latter has shown that previous observers have not been fully aware of the injury done to the soft parts, surrounding the semicircular canals, especially to a certain portion first described in this connection by Sehklarewsky, and named by him the cerebellar process. He thought that many of the phenomena obtained by previous observers were really due, not to lesions of the semicircular canals, but to an injury of the above-named portion as he supposed of the cerebellum, extending into the cavitas meso-otica.' Boett- cher claims that this cerebellar process is nothing more nor less than the aqufeductus vestibuli. Boettcher's experiments are further characterized by great care in avoiding injury of all other parts, especially of blood- vessels, and also by a thorough and continued observation of each case operated on, until either recovery or death-ensued. In the latter event the pathological anatomy has been fully studied, and its importance acknowledged. Boettcher divides his experiments into three groups : 1. Those eases in which, partly by accident and partly intentionally, the artificial lesion was considerable ; in these cases the results were similar to those obtained by Goltz. (2) Those cases in which notwithstanding great precaution the operation was incomplete, in so far as that after section of the semicircular apparatus on both sides, very different, but very distinct disturbances in motion occurred and alternated with each other. They were, however, entirely independent of each other. (3) This last group comprises those cases in which, after section of the semi- circular canals on both sides of the head, only very insignificant disturbances in motion occurred, which completely vanished after they had persisted for a short time. The conclusions drawn by Boettcher from his investigations are as follows : — • 1. The twisting of the head to one side and the accompany- ing resting it on the ground, so that the top of the head touches the ground and the beak points more or less backward, can be ' A space described by Sehklarewsky, as peculiar to birds, bounded by the semicircular canals, in direct connection with tlie cranial cavity, and containing an offshoot from the cerebellum. Gottinger Nachrichten, 1873, No. 15. 152 INTERNAL EAR. produced by cutting the canals on one side, if the operation is performed roughly, but if the canals are cut with great care and Avithout simultaneous injury of other parts, the above phe- nomena will not appear. He concludes, therefore, that the twisting of the head is not a symptom of section of the semicircular canals. Since, how- ever, this peculiar rotation of the head does .occur some time after the operation, it must be attributed to secondary changes in the contents of the skull. In such cases he has found either extravasations on the cerebellum or the medulla oblongata, or inflammation of the membranes of the brain. 2. The direction of the rotatory movements and the move- ments of the body backward and forward about the transverse axis was shown to be dependent upon the canal cut, as was first discovered by Flourens ; but they are independent of anatomical changes in the cavity of the skull. I^evertheless, they are not due to section of any two corresponding canals, i. e., not to the destruction of their function. Boettcher does not say, that the cutting of the canals is not the cause of the occurrence of these disturbed movements ; in fact he believes that it is the cause ; but the disturbances which follow, are evidently due not to the injury of the labyrinth purely, but to other changes almost in- separable fi'om it. In proof of this it is stated : {a) that after section of the semicircular canals on both sides the disturbances in motion which have begun may entirely cease, and the animals experimented upon recover. If the vertigo and disturbed move- ments were due to the section of the canals, they should persist. (6) The fact that the disturbances in motion are observed always in the extremities on the side operated on is urged as further proof that not the section of the canal alone is the cause of the altered muscular movements. (c) Again, the motor disturbances are observed in some cases in both walking and flying, in other instances only in walking or in flying. This is urged by Boettcher as a striking proof that vertigo cannot possibly cause the disturbances in motion ; for if it did both acts would be equally interfered with. The lesion, therefore, is supposed by him to be purely a local one, affecting only either the legs or the wings. (d) Finally, it is worthy of note that the character of the dis- turbance in motion is not dependent upon which of the semi- LABYRINTH AND AUDITORY NERVE. 153 circular canals are cut, but upon the point where the section is made. The pendulum movements of the head are only a passing symptom, occurring with greatest intensity immediately after the operation, but gradually diminishing and finally ceasing. These pendulum movements persist in some cases, in which at no time the head of the animal is held in an abnormal position. In some instances, notwithstanding that the canals are cut on both sides, these peculiar movements do not occur. If rotation of the head occur, then the pendulum movements cease. The twisting of the head and the tumbling usually connected with it, occurring after section of the semicircular canals, are attributable either to a cerebral lesion produced at the time of the operation, or to pathological processes developed later in the deeper parts of the central nervous system. The mouvements de manlge, i.e., going round and round in circles, like a horse in the circus-ring, and the tendency to fall forward or backward, are involuntary movements having their foundation in changes produced in the crura of the cerebellum by the section of the semicircular canals, as already pointed out by Flourens. The pendulum movements of the head, to and fro in either a horizontal or vertical plane, are connected with the section of the semicircular canals, but Boettcher is not disposed to admit that their occurrence is dependent on such a lesion. His experi- ments, as he believes, show these last-named movements to be dependent on a sympathetic afiection of the brain. Further- more, the fact that pendulum movements are as a rule followed in a few days by twisting of the head, would seem to indicate that there is a common cause for both. Cyon's' experiments induced him to come to conclusions similar to those of Vulpian, viz. : that the function of the semi- circular canals is to inform the animal, by means of a series of unconscious acoustic perceptions, of the correct position of its head in space, and for this purpose each semicircular canal has an exactly determined relation to a direction in space. He also attributed the disturbances in motion which occur after section of the semicircular canals to direct results of the artificial injury, > Pfliiger's Archiv, Dec. 1873, vol. viii. p. 306. 154 INTERNAL EAR. to involuntary movements resulting from the abnormal acoustic perceptions produced by the same means, and to consecutive manifestations produced by inflammation of the cerebellum, which sets in in a few days after operation. To illustrate the physical phenomena of the semicircular canals, Dr. Breuer' has used a system of three tubular rings filled with fluid, placed at right angles to each other, thus gaining a fair representation of the semicircular apparatus of the labyrinth. If a rotary motion be given to such a system, currents of the contained fluid- will occur in a direction oppo- site to that of the applied motion. Such movements in the lymph of the labyrinth are supposed to occur in every move- ment of the head, the measure of the current in each semi- circular canal depending upon the plane in which the head is turned, aud also upon tlie amount of rotation. A perception of the movements of the fluid of the labyrinth may furnish exact information respecting every turning of the head. The acoustic cilia are brought forward as the possible perceptive apparatus of this movement, for they are situated at a broad, smooth spot in the canal and project at right angles into its calibre. Thus from their position thej'^ would be especially sensitive to the variations of the currents in the endolymph, and it is known that they are connected with nerves, the termi- nations of which they represent. In order to harmonize both of these facts with Goltz's theory, Breuer assumes that every current of the endolymph is perceived by the nerves of the ampullis, that it produces an idea- of the rotation of the head in the plane of the semicircular canal most implicated, in a direction opposite to the current, and that the perceptions of the six ampullae of both labyrinths unite in forming a joint conception. Prof. E. Mach^ has seemed to add corroboration to the theo- ries of Goltz and Breuer by a series of novel experiments upon man, which were published a short time before the results of Breuer's labors. _Mach suspended a chair in which a man could sit with ease, in a framework, so that the chair could be revolved about a ' Wiener Med. Jahvbucher, 1874, Heft I. 2 "Wiener Sitzungsberichte, Nov. 6, 1873. LABYRINTH AND AUDITORY NERVE. 155 horizontal axis and fixed at any inclination. In addition, the entire framework with the chair could be revolved about a vertical axis. In many of the experiments the chair was covered by a paper box, which, following all the motions of the chair, prevented the person sitting in it from observing with his eye the motions of the apparatus in which he was seated. The principal results of the experiments with this apparatus were the following : — A revolution about the peculiar vertical axis of the body is perceived by the person experimented upon only so long as it is accelerated. A continued and constant revolution is not perceived. Retardation of the revolution is perceived as a revolution in the opposite direction. It is apparent that these facts agree with the theories of Breuer. The sensation of revolution in the opposite direction is converted into the sensation of motion in the true direction, in two seconds, by a renewed acceleration of the original motion. This sensation, therefore, must continue a few seconds longer than the cessation of the retardation ; for otherwise, the new acceleration should produce immediately a sensation of revolu- tion in the original direction. If we accept Breuer's hypothesis, we must suppose that by the law of inertia the currents pro- duced in the semicircular canals continue some seconds after the force producing them has ceased. If during the revolution about the vertical axis the head is inclined forward and then suddenly elevated at the moment the revolution ceases, in those cases where the revolution has oc- curred from the left, forward and towards the right, an impres- sion will be gained that a revolution is occurring from the right, upward and towards the left, and the person thus experimented upon will fear that he is about to fall towards the left. This fact is also in harmony with the hypothesis of Breuer, and proves most strikingly that the position of the head is a meas- ure of the sensations of revolution, and that the organ of these sensations must be found in the head. These two fundamental facts have already been observed by Purkinje. Furthermore, Mach has established, by the aid of his apparatus, the fact that we have, either with the body at rest or revolved with a con- stant velocity, a distinct consciousness of the direction of the 156 INTERNAL EAR. resultant accelerating force without the assistance of the eyes. A man sitting in Mach's chair was able to give, by means of an indicator projecting from the case, a tolerably correct statement as to the vertical direction in any of the variously inclined positions of the chair. When the case containing the chair was revolved about a vertical axis situate at some distance from the chair, and when the face of the one experimented with was turned towards this axis, the a^is then given by him as the vertical one was in reality one inclined diagonally downwards from the axis corre- sponding to the resultant of the centrifugal force produced by the revolution with constant velocity, and the weight of the body revolved. Certain facts of a similar nature, perceived prior to this, induced Breuer to add to his hypothesis already described, the supposition that we should consider the macula acustica with the otoliths as possibly an organ for the perception of the posi- tion of the head at rest, in respect to the direction of the resultant accelerating forces and the rectilinear motions. In this portion of the acoustic apparatus he perceives the fulfil- ment of the necessary conditions and assumes that the otoliths are specifically heavier than the endolyniph, and that the}- con- sequently have a tendency to sink in it in the direction of the resultant accelerating force. According to the direction of this force in the head, the otoliths would drag, in vai'ious ways, upon the hairs with which they are connected, and thus produce a varied excitation of the terminal nervous apparatus. In addition to this, the specifically heavier otoliths would have, at the beginning of a rectilinear motion, a tendency to remain behind the endolymph, and at the cessation of the same they would go in advance of it, and therefore they would, bj' mechanical action upon the cilia, produce a perceptive sensation.' BertholdV experiments were performed with great care to avoid any implication of the central organ. He confirmed the above-mentioned statements of Schklarewsky and Boettcher, respecting the danger of wounding the aquseductus vestibuli ; in order to avoid hemorrhage or any undue lesion he used silk ' See abstract by Prof. Fick, Arcliiv f. Ohrenheilkunde, vol. ii. N. F. p. 306. 2 Archiv f. Ohrenheilkunde, Band ix., 1874. LABYRINTH AND AUDITORY NERVE. 157 thread for cutting through the canals. Manage movements, consequent upon section of the semicircular canals, were not observed by Berthold, but vomiting was found to occur in cases where it could not be atti-ibuted to injury of the brain. He also 'observed that injury of the above-named " process of the cerebellum," or aqueeductus vestibuli, alone produced symptoms partly resembling those resulting from injury of the semicircuLir canals. His final conclusions are in favor of regarding the function of the semicircular canals as assisting in the coordina- tion of motion by means of reflex action. They perform their function in company with two other senses, viz., with that of sight and with that of touch. The experiments of Flourens and Goltz, on pigeons, have been repeated by Curschmann,' who has observed three very impor- tant cautions in his investigation, viz.: 1. The least possible destruction of tissue about the semicircular canals ; 2. The avoidance of excessive hemorrhage, especially from the venous sinus near the canals ; and, 3. The infliction of the least possible injury to the bony canals, since, from their intimate relation to the cavity of the cranium, they cannot be destroyed without a previous opening of this cavity, which is followed by an imme- diate or secondary injury of the cerebellum. The conclusions of Ourschmann are that: 1. Injuries of the semicircular canals are positively followed by disturbances in the equilibrium of the body ; 2. The phenomena are propor- tional to the lesions ; 3. The derangements are constantly observed in connection with muscular movements ; 4. The canal operated on, as well as unilateral or ambilateral destruction of the semicircular canals, determines the character of the resultant phenomena; 5. The phenomena are the more intense and defined, the more energetically the animal moves about ; 6. The phe- nomena of dei-anged coordination in muscular movements are expressed in the head, trunk, and limbs of the animal operated on ; 7. The supposition that the derangements of motion of the trunk are due to a defective carriage of the head is not tenable ; 8. After total removal of all three membranous canals on both sides of the head, the pigeons do not appear entirely bereft of the power to direct their movements ; 9. Simple section of a, ' Deutsche Klinik, No 3, 1874, Arcliiv f. Olirenheilkunde, toI. ii. N. F. p. 307, abstract by Prof. Lucee. 158 INTERNAL EAR. single canal, if the structure is not secondarily diseased, is fol- lowed in four or five days by a diminution, if not a total cessa- tion, of the resulting phenomena, even without a restitutio ad integrum on the part of the incised canal ; 10. The almost constant increase of, and frequent changes in, the original symptoms, appearing after extensive injury to the canals, are referable to subsequent disease of the remnants of the injured canals, or to secondary alterations of the canals which were left intact ; 11. The semicircular canals are not to be considered as an organ of the sense of equilibrium ; 12. The phenomena are the result of a cessation of function, not the result of an irritation, certainly not of a specific irritation of the acoustic nerve ; 13. Since the hearing is not materially altered by a removal of the semicircular canals, it cannot be concluded that they are not connected with this sense. Lowenberg's experiments' have led him to the following conclusions: 1. The derangements in motion, which manifest themselves after the semicircular canals are cut through, depend upon such section only, and not upon the accompanying injury to the brain. 2. Vomiting, Avhich was noted by Czermak in his experiments, depends upon the attendant injurj' to the cerebellum. 3. The disturbances in motion are due to irritation of the semicircular canals, not to paralysis of them. 4. The irritation produces, reflectively, spasmodic paralyses, without participation of consciousness ; fresh irritations of the canals are induced only by calling forth voluntary movements. 5. The conveyance of this reflex excitation to the motor nerves occurs in the thalamus. 6. Section of the auditory nerve does not produce these derangements of motion. Bornhardt,^ the latest experimenter upon the semicircular canals, is forced to conclude that the phenomena of deranged movements succeeding section of the canals are due to unavoid- able injuries of other parts. He rejects the theories of Breuer and Mach, and is of the opinion that " the semicircular canals serve, by transmission of the vibrations resulting from muscular contraction^ to intensify the muscular sensation during action of ' Archives of Ophthalmology and Otology, vol. ill. , part 11. pp. 36-44. ' Med. Centralblatt, May, 1875, and Blake's Report on Progress of Otology, American Otological Society, 1875. RELATIONS OF MIDDLE AND INTERNAL EAR. 159 the muscles of the head. The following experiments Bernhardt considers as confirmatory of this conclusion: The horizontal semicircular canal of a rahbit being exposed without injuring its osseous covering, and the back of a knife being rubbed back- ward and forward upon it, by which means it is merely agitated, the same movements of the head and eyes occur, which are characteristic of division of the membranous canal. The direc- tion of the muscles attached to the head is parallel to the direction of the semicircular canals, which fact seems to favor the above conclusion. Movements similar to those resulting from division of the canals have been induced by an experiment which leaves the brain and osseous canals intact. The vertical and hori- zontal canals in pigeons were exposed to a continuous stream of ether by means of an atomizer ; they were also touched by a red-hot needle. In both cases the same symptoms appeared as in division of tiie canals ; the same result was also obtained by touching the canals with a vibrating tuning fork. CHAPTEE II. SCHEME OF RELATIONSHIP BETWEEN THE MIDDLE AND INTERNAL EAR. Schematic Description of the Middle Ear, of the Internal Ear, and of the relation they bear to each other. — In order to understand the general features of the middle ear and of the internal ear and the general relations they sustain to each other, let there be imagined, first, a broad and shallow barrel, closed at each end and divided in the middle by a partition. If this barrel be laid upon its side with one end towards the reader, it will give a fair representation of the middle ear, in the near half, and of the inteimal ear in the far half. The head of the near half of this barrel will represent the membrana tympani or drum-head, while the partition in the centre of the barrel represents the inner bony wall of the tympanic cavity. In this partition let two openings be made, one oval-shaped, situated above and in front of the other which is round. The former represents the foramen ovale or the oval window, and the second, the foramen rotundum or the round window. 160 INTERNAL EAR. i- From the membranous head of the near half of the barrel to the partition in the centre, is sti-etched a bony bridge composed of three pieces. This of course is the chain of ossicles, contain- ing the malleus or mallet, the incus or anvil, and the stapes or stirrup, and stretching from the membraua tympani to the inner wall of the tympanic cavity. The handle of the outermost of the three ossicles, the manu- brium of the mallet, is inserted into the fibrous or middle layer of the drum-head ; the innermost, the stirrup, by means of its foot-plate, fits into the oval window in the inner wall of the tympanic cavity, and the middle bonelet, the anvil, is held in position between the other two. They are furthermore held together and fastened to the roof and wall of the tympanic cavity, by means of ligaments. This bridge of ossicles may be said to have two guys which steady it and give it proper ten- sion, one of which is fastened to the mallet and the other to the stirrup. The former will at once be recognized as the tensor tym- pani and the latter as the stape- dius muscle. In the outer half of the imagi- nary barrel are two bung holes, one in front, the other on the back. The front bung-hole repre- sents the tympanic opening of the Eustachian tube, by means of which the middle ear, or drum, is ventilated, and the atmospheric pressure on each side of the drum- head equalized. The back bung-hole is the communication be- tween the mastoid cells and the cavity of the tympanum. The mastoid portion may be likened to an ivory box filled with sponge, the latter representing the series of bony cells,' which communicate with each other and at last by means of the mas- toid antrum with the cavity of the middle ear. (See p. 115.) Additort Ossicles in connection : VIEWED FROM IN FRONT. They arc sup- posed to te from the right side of a head turned slightly about the vertical axis towards the right. (Magnified 4 diam. : Henl6.)— .7. Malleus. 1c. Incus. I. Stapes, i, Head, h, Neck, g. Long process, /, Manubrium of the malleus, a. Body, 6, Short, c. Long process, e. Processus len- ticularis of the incus. d. Small head of stapes. RELATIONS OF MIDDLE AND INTERNAL EAR. 161 In this simple manner, the middle ear, with its ossicles and more important appendages, may be slcetched. The functions of this cavity are dependent on aerial life, and equal pressure of air on each side of the drum-head. This air-containing cavity is separated from the internal ear, or labyrinth, a water-containing cavity, by means of a bony par- tition, viz., the inner wall of the middle ear already described, in which is the oval window, into which the foot-plate of the stirrup fits. Hence, these two important cavities have one wall in common through which, by means of the foot-plate of the stirrup, the movements of the chain of little bones are com- municated to the fluid of the internal ear and to the thread-like ends of the nerve of hearing suspended in it. In order to understand the general features of the internal ear, let us still retain the simile of the barrel. In this instance the inner half of the barrel must be regarded as made entirely of bone, as filled with water, and communicating at no -point with the atmosphere, but in direct communication with the arachnoid space by means of the aqueducts of the vestibule and cochlea. Since the walls of the internal ear are made of bone, there can be no giving on their part to the pressure of the fluid of the labyrinth produced by the movements of the stapes. In order that these movements may go on, there is found at the extremity of one of the passages of the internal ear, viz., the cochlea, the round window, over which is stretched a membrane which yields slightly to the pressure brought about in the labyrinth by the movements of the stapes. On the front of this inner cavity representing the internal ear, is a spiral tube, with two and a half turns. Being wound around like a snail-shell, it long ago received the name of cochlea. On the back of this inner cavity are found five openings communicating with three semicircular tubes. We would naturally look for six openings into the ends of three semicircu- lar tubes, but only five are found in this instance, as two ends of two of the semicircular tubes, viz., the superior and poste- rior semicircular canals, join together and have a common opening into the internal ear or labyrinth at that part of it called the vestibule. 11 162 _ INTERNAL EAR. On the far-head of this inner barrel-half, we find the nerve of hearing pushing its way into the labyrinth, through a sieve-like spot. After forcing its way into the cavity of the internal 6ar through this sieve-like spot in the inner bony wall of the inter* nal ear, at the fund us of the internal auditory canal, the auditory nerve divides into two main branches, one of which, the cochlear branch, is distributed to the cochlea, and the other, the vesti- bular branch, is given to the sacculi and to the ampullae of the semicircular canals. PAET II, DISEASES AND TREATMENT. SECTION I. EXAMINATION OP PATIENTS. CHAPTER I. INSTRUMENTS AND METHODS OF THEIR EMPLOYMENT. The light employed in examining the ear is usually reflected into the auditoiy canal by means of mirrors, to he described later. But the ear may be examined by direct rays of light in such a way as to give considerable aid in some instances. If daylight is to be reflected into the ear, the light coming from the north will be found to be the most luminous. If, however, examination by direct rays of sunlight is desired, the ear must be so situated that the sun's ra,ys may fall directly upon it. If artificial light is used, that of an Argand gas-burner will be found the brightest. The flame of a petroleimi-burning student- lamp is also very good, but' if neither of these can be com- manded, a candle will render good service, especially at the bed- side, for it is much easier to move the light in examining a patient in bed than it is to adjust the head of the sufl:erer. Examination of the Ear by means of Polarized Light. — This mode of examining the ear has been attempted by Drs. Ilagen and Stimmel,* and they were able thus to efi^ect the entire dis- appearance of the posterior-superior quadrant of the drum-head, and a consequent revelation of the long process of the incus and portions 'of the stirrup. Other portions of the membrana tym- pani appeared much thinner, and it was possible to determine the presence of adhesions and pseudo-ligaments in the tympanic cavity. By using this mode of examination, all opacities of the membrana tympani, such as calcareous spots, ecchymoses, and ■ See Report on Progress of Otology, by C. J. Blake, 1873. 166 EXAMINATION OF PATIENTS Fig. 40. Eak Mi""/>" INSTRTJMENTS AND METHODS OP EMPLOYMENT. 16T the like, appear more distinctly defined, and the bloodvessels of the manubrial plexus were more clearly visible. Transparent spots seemed to disappear entirely. From what has been done already with this mode of illumination of the ear, it would seem that it could he rendered of the greatest aid in diagnosis, if its application be not too complicated. Instruments for Examining the Ear. — The instruments used in examining the ear should be as simple as possible. The first demand is for a concave mirror with a focal distance of from four to six inches, according to the eye of the examiner- That form known as Von Troeltsch's ear mirror is most widely used, and is the best. (Fig. 40.) Otoscopes, or Aural Specula. — The next want will be a nest of specula or ear funnels. There are numerous forms found in the instrument makers' shops, under the names of Kramer, Toynbee "Wilde, Gruber, Politzer, and others. While all are good, pre- Fig. 41. Gruber's AnuAL Specula. ference should be given to Gruher's specula, because a transverse section of their calibre at right angles to the long axis, most closely resembles a similar section of the auditory canal, i. e., it is slightly ovoid in shape. The great object in using a specu- lum or aural funnel, is simply to hold the tragus away from the meatus, and to push away the stiff hairs about the opening of the external auditory canal. In some cases, moderate dilatation of the cartilaginous canal may be effected, hut usually, all 168 EXAMINATION OF PATIENTS. endeavors at dilatation of the external auditory meatus are worse than useless — they are painful and injurious. All forms of specula or ear funnels are made of metal and of hard rubber. Both kinds possess peculiar advantages as well as disadvantages. The first are less brittle than rubber, but they are colder in winter-time, and sometimes are objected to by the patient. On the other hand, the hard rubber ear-funnels, while being more agreeable in feeling to the patient, are extremely brittle. In some instances, ear- funnels have been made of glass. This kind would be as little likely as any to be affected by the various caustics sometimes used in the treatment of aural dis- eases. But when such substances are applied carefully to the ear, no speculum will suffer, for the latter need not be touched by the medicinal substance. In any event, the metallic specula will be more easily attacked by acids, nitrate of silver, and the like, than the hard rubber variety. In no case will it be neces- sary to oil the funnel before it is inserted into the meatus, for if it require greasing to make its way into the canal, then the instrument is either too large for the ear, or the auditory canal is too swollen to permit an examination by means of the ear- funnel. Fig. 43. BOKNAFONT'3 OTOSCOPE. If magnification is desired, it can be . neatly and cheaply obtained by the employment of Bonnafont's otoscope. The specula are adjustable, thus permitting the ready use of various sizes ; these and the case are made of hard rubber. There is a magnifying eye-piece, and a perforated mirror for refiecting light into the auditory canal. Sigle's Pneum,atic Otoscope. — Dr. Siglg of Stuttgart, some time ago, invented a most valuable instrument, which is known in Germany as SigltS's pneumatic ear-funnel. It consists in a hard rubber, round speculum, like Politzer's, to which is attached an air-tight chamber 3 cm. in diameter. The upper, or outer wall of this chamber is glazed, and forms an angle of 40° with INSTRUMENTS AND METHODS OF EMPLOYMENT. 169 Siol£'s Pneumatic Otoscopy-. the plane of the inner wall. On the longer side of the chamber there is an opening with a perforated knob, to which is attached a piece of rubber tubing about a foot in length, ending in a mouth-piece for the surgeon. This chamber is made to screw off and on ear-funnels of different diameters. When all the parts are fully adjusted, the surgeon has an air-tight speculum with a glass end, through which he can examine the movements the drum-head makes during condensation and rarefaction of the air, brought about by his own mouth through the rubber tubing at the side of the instrument. This is really the only means the surgeon has of fully deter- mining the mobility of the drum-head, though both Yalsalva's and Politzer's methods of inflation, if carried out while the surgeon's eye is fixed on the drum-head, will give him some idea of the extent the membrane can Fig. 44. move. But when the Eustachian tube is imper- vious, Sigl^'s instrument is the only means of determining the mobility of parts or of the whole of the membrana tympani. Kramer's Ear-speculum. — There is sold in the shops an instrument under the name of Kramer's ear-speculum. Its inventor. Dr. Kramer of Berlin, designed it for use only in the direct rays of sun- light. This, of course, renders it an instrument of very limited usefulness respecting the ear. As it is a bivalvular instrument, and designed there- fore for dilatation, it will slip from the meatus as soon as the handles of the instrument are brought together, or else great pain will be caused by its use. It is an admirable aid, however, in anterior rhinoscopy. 170 EXAMINATION OF PATIENTS. Blake^s Operating Otoscope. — Dr. Clarence J. Blake's operating otoscope is intended to overcome the disadvantages of the usual monocular examination of the ear. " It consists of a hard rubber speculum (Politzer's) of the largest size, fitted vcith a metallic rim, to which is attached a revolving prism and an arm, bearing at its outer end a lens of about an inch focus; this ai-m is movable, but sufficiently firm to remain fixed at any angle at which it is placed. The prism is just within the focal distance of the lens, and its incident face is armed Avith a small metal shield, having an opening in the centre corresponding in its short diameter to the diameter of the pencil of light falling upon it from the lens. The advantage of the prism over a mirror or other reflecting surface- is, that we have almost total , reflection, and but little of the light concentrated upon the prism by the lens is lost. " In operating, an assistant is required to draw the auricle upward and backAvard, and keep the speculum in position, with the funnel of light upon the opening in the shield of the prism. It is not claimed for the instrument that it at all supersedes the head mirror of Von Troeltsch, but it is certainly of great advan- tage in the more complicated operations, when a steady and uniform illumination is indispensable. The instrument, as a whole, weighs only about one hundred and twenty grains, and can be made much lighter ; so that when once firmly inserted in the meatus, it remains in position, and there is no necessity for holding it nor fear of its slipping out of place during the operation."' Dr. E. De Rossi ,^ Professor in the University of Rome, claims to have invented a binocular otoscope. It is simple and inex- pensive, dift'ering very slightly from the original form of Helm- holtz's ophthalmoscope. It is so arranged on a forehead-band as to allow the use of both hands, but the distance of the eye from the membrana tympani, thirty centimetres, necessary to obtain a binocular view, renders the instrument of no very great practical utility. Voltolini' has devised a pneumatic aural speculum, which is ■ Koosa's Treatise, p. 87, 1873. ' Ein einfaches binaculares Otoscop. Monatsschr. f. Ohrenlieilkvnide, No. 7, 1873. = M. f. O., No. 3, 1873. INSTRUMENTS AND METHODS OF EMPLOYMENT. 171 Fig. 45. a compound of SigU's' pneumatic speculum and Brunton's Speculum. ■ "With this he proposes to investigate more tho- roughly and most boldly the middle ear, after cutting away the posterior segment of the membrana tym'pani and turning it forward over the hammer. He thus obtains a more perfect view of the fenestrse of the labyrinth' and of the stapes. He also proposes to operate with this speculum in situ, by introducing a knife through a slit in the funnel portion of the speculum. He reports one case of tenotomy of the tensor tympani performed successfully by its aid. If tlie instrument is all the inventor claims it to be, it may be considered a valuable addition to the diagnostic as well as surgical means of otology. ; ' The middle-ear mirror of Blake' is the modification of the laryngoscope and rhinoscope, ap- plied to the exploration of the tympanum with reflected light. The mirrors are of three sizes, as represented in the wood-cut, and iare of polished metal. The mir- rors' are niade so as to be flexible at the junction with the shaft, and are thus adjustable at any angle best suited for examining the various walls and the roof of the tympanic cavity. By placing the shaft in a tenotome handle of Weber-Liel, the mirror can be rotated as desired, by moving the thumb-piece on the ivory handle. Under thorough illumination of the auditory canal, these mir- rors can be carried into the tym- panic cavity if the membrana tympani be destroyed, and by careful manipulation the condi- tion of the cavity may be studied. They are specially adapted to the search for, and examination of small polypoid growths on the roof of the cavity. - - : , , ' Blakb's Middle-eab Mibbok. ' Transact. Amer. Otol. Soc, 1873. 172 EXAMINATION OF PATIENTS. Position of Patient's Body and Head. — As by far the most usual way of examining the ear is by reflected light, I shall suppose, in what follows, that reference is made entirely to that mode. The patient should sit with the ear turned from the source of light. He may lean back or sit high and straight in the chair, but the axis of his body should not be inclined either to the right or left. His head should be inclined somewhat towards the shoulder opposite to the ear to be examined. It is important for the comfort of the examiner that the body of the patient should not be inclined away from him, for if it be, then a great strain must come on the back of the surgeon in his endeavor to reach after the ear. Position of Surgeon. — The surgeon standing alongside of the patient, in front of the ear to be looked into, should grasp the auricle at its upper and posterior margin, gently between the index and middle finger of his left hand, and pull the auricle a little upward and backward. This is always to be done by the left hand, no matter which ear is examined. This leaves the right hand free to hold the mirror. The patient should be placed, and the surgeon should stand so that the light may fall on the mirror slightly from the surgeon's right side, or directly from in front — never from the left in the above position of patient and examiner. These rules of position of light, patient, and physician are especially important when artificial light is used. Insertion of Ear-speculum. — With the auricle grasped as directed above, between index and middle finger of the left hand, the speculum or ear-funnel may be gently inserted in a direction slightly downward, inward, and forward, or in general terms towards the patient's nose, by the other hand, and then grasped by the thumb and index of the left hand. Or it may be inserted by the thumb and index of the left hand at the same moment the index and middle fingers grasp the superior posterior margin of the auricle. In the latter instance a very gentle and slight rotation will be all that is suflacient to place the ear-funnel pro- perly. The speculum being now in the meatus, light is to be reflected into it from the mirror. The first point to be decided upon in making an examination of the ear is whether the auditory canal is entirely free from INSTRUMENTS AND METHODS OF EMPLOYMENT. 173 obstruction or not. If it is, then the eye of the observer should, after ascertaining the state of the wall of the canal, seek the mem- brana tympani. The chief obstacle in such a search is usually the misdirection of the axis of the funnel. This, instead of being made to correspond with the axis of the auditory canal, is directed most usually by the unskilled so as to fall on the sides of the canal or only partially on the drum-head. Hence it is not at all uncommon to hear a diagnosis made for the membrana tympani, which is based entirely on a view of the condition of the skin lining the auditory canal. What should be seen at the fundus of the canal is described on p, 47, yet it will be a Jong time befoi^e the eye can accommo- date itself to the conditions of illumination in the external ear, so as to fully interpret what it sees. The experienced eye is able to resolve into depressions, elevations, curves, etc., that which is projected entirely in the same plane by the beginner. RemoDal of Obstacles to a View of the Membrana Tympani. — It requires but a small object, a few stiff hairs, or a flake of cerumen, or of epithelium, to obstruct the view of the drum-head. All such are most easily removed by a few syringefuls of warm Fiar. 46. Delicate Foeceps fok Eehoviuo Fokeign Bodies from the Eak. water ; this, however, will render the drum-head a little mace- rated, and hence deprive it of whatever lustre it may have had. This must be borne in mind in looking at the drum-head after warm water has been syringed upon it. Therefore, when it is especially desirable that the amount of natural lustre in a given 174 EXAMINATION OP PATIENTS. Fig. 47. ,ease should be estimated, an obstructive substance might better be gently and most carefully liftetl or wiped out of the canal. The former is most readily accomplished by the delicate forceps shown in Fig. 46, while the canal is thoroughly illuminated by the forehead mirror. If the obstruction to vision can be wiped or swabbed out, the cotton holder, with its little wad of cotton at the roughened end, will enable one to do this. The Cotton Holder. — This is a most useful instru- ment, both for cleansing the ear and conveying medications to diseased surfaces in the organ. The shaft is made flexible for an inch or two, as indi- cated in the wood-cut, and roughened at the tip. At the latter point, a small tuft of cotton may be coiled, and then used, as already indicated, for cleansing, and for -treating the ear. When the cotton is to be removed, it should be twisted off in a direction opposite to that in which it was wound about the end, and not submitted to a flame, as has been done, greatly to the detriment of the instru- ment. ' . - During all these procedures for removing small obstructions to a good view of the drum-head, the canal is supposed to be most carefully lighted by light reflected from the forehead mirror,- and the operations performed by a skilled hand. If the methods suggested should be inadequate to remove obstacles in the auditory canal, recourse may be had to syringing. The syringe should be carefully chosen; one that holds two fluidounces will be large enough, though both larger and smaller opies may be used. The syringe should work per- fectly, being neither too loose nor too tight in the piston. The model ear-syriuge is one made by Leiter of Vienna, and shown in the wood-cut. (Fig. coTTOK 48 \ j^. holds two fluidounces, is made of fine brass throughout, excepting at its nozzle, where it is of hard rubber. A nozzle of such material is at once less cold to the ear, and less easily corroded by the various fluids syringed into and out of the ear ; its shape, furthermore, renders it less likely INSTRUMENTS AND METHODS OP EMPLOYMENT. 175 to wound the meatus should the instru- I'ig- 48. ment slip or be pressed too firmly against the skin of the canal. To prevent slipping of the instrument, the two rings at the top of the barrel will be found of highest use- fulness. But brass syringes of this kind are expensive in this country, and being rarely called for by physicians, nor ordered for their patients, are rarely found ready made in the shops. There is, however, an excellent syringe for aural purposes always at hand in the hard rubber, male syringe No. 2. This is not only very good, but reasonable in price, so that all patients, even the majority of those seen in the infirmary, can buy it. At this point it may be said unhesitatingly, that all forms of syringes sold in the drug stores and else- where, under the high-sounding name of " ear-syringes," are uniformly dear and as uniformly worthless. There is one specially bad form of syringe sold under the name of ear-syringe. It is made of hard rubber ; the chief, if not the only danger in this instrument, lies in its slender point about a half-inch in length, in which the otherwise harmless conical nozzle is made to terminate. This point, the patient is told by the ignorant vendor, to insert into his auditory canal. This done, the slightest turn, either of the head or of the handle, will drive the point against the sensitive canal and wound it. Such a syringe, with its elongated tip, could, in the shallow meatus of a child, reach, and thus injure the membrana tympani. Basin and Towel. — In syringing the ear a towel should be laid over the shoulder, and brought up as high as, and turned in over, the collar of the patient. The basin or cup for holding the water and catching the return current from the ear may be of various kinds and patterns. An ordinary kind is made of tin, the floor of which is kidney- Ear Syringe and Olive- shaped NOSE-PlECE, fur syriuging narea. 176 EXAMINATION OF PATIENTS. shaped. (Fig. 49.) Such a basin fits very closely under the ear against the neck. But tin soon rusts and becomes useless. If the basin be made of a more durable metal it becomes more costly, but no more easily kept clean. A finger bowl of glass or Fig. 49. Tin Basin used in Syringing the Ear. china is very good, because clean, cheap, and always at hand. A very simple, cheap, durable, and clean bowl may always be had by converting what is known in the china stores as a bird's bath tub, into a cup for holding water during syringing the ear. This little utensil has an oval bottom, the long diameter of which is 12 cm. ; the short diameter 8 cm. The sides are 5 cm. high, and form an angle of about 95° with the base of the bowl. Syrivging the Ear. — In syringing the ear, cold water must never be used. Let the water used for syringing be pleasantly warm ; some patients prefer it much warmer than others. Pro- vided with a syringe as described, as well as with a receptacle for holding and catching the water, let the surgeon grasp the auricle between the thumb and forefinger of the left hand and pull it gently upward and backward. With the auricle thus held let the syringe be emptied slowly but firmly into the audi- tory meatus. Point the syringe downward and forward toward the patient's nose. The current from the syringe should be thrown along the upper wall of the auditory canal, thus per- mitting the return current to take place along the floor of the canal. In some cases considerable force may be used in throwing the INSTRUMENTS AND METHODS OF EMPLOYMENT. 177 current of water into the canal, as, for example, when it is desired to remove a foreign body from the fundus of the canal or when the canal is blocked up with a large and adherent wax- plug. I have found it decidedly advantageous to give to the syringe a gentle spiral motion as the current of water is going into the meatus. This impulse conveyed to the water will thoroughly wash oft' all adherent' matters from the wall of the auditory canal. Examination of the Nares and Fauces, Throat, and Eustachian Tube. — The inspection of the. nares, fauces, and throat, and the examination of the state of the Eustachian tube by means of the Eustachian catheter, form perhaps the most important part of a complete aural examination. This is specially true of the F'g- 50- more chronic forms of ear-dis- ease, for to the parts named the chief treatment must be directed. The inspection of the nares may be made either from behind or in front ; if in the former way, i. e. by poste- rior rhinoscopy, the ordinary laryngeal mirror may be used, and the light either of the brightest day or of a large argand burner may be thrown on the laryngeal mirror by means of reflection from a large forehead mirror. This is at once convenient, inexpensive, and amply suiScient. If a more elaborate mode is desired, recourse may be bad to the very elegant Tobold apparatus. The former method, however, by means of the large forehead mirror and the argand burner, is vastly preferable for the ordi- nary examination of patients. It is the means used in the large clinics of Vienna, and the student, as well as the practitioner, with the forehead mirror once placed upon his head, may pass from one patient to another without the trouble and inconve- nience which would attend transporting a cumbersome appa- 12 Tob-old's Apparatob. 178 EXAMINATION OF PATIENTS. ratus. All that is needed is an argand burner or a bright flame of any kind, unless bright day-light is chosen. I would say, however, that in using the laryngoseopic mirrors, a bright arti- ficial light in a darkened room is by far the best. Bright day- light is too diffuse, illuminating other parts, and not therefore bringing into bold relief the parts specially under examination. Direct sun-rays, on the other hand, are too powerful when col- lected and thrown by the mirror into the ear or throat. It is a very easy matter to burn the parts thus illuminated by concen- trated sun-rays. Pig. R1. Forehead Mirror and small Laryngeal Mirrors. — The forehead mirror which is to be used in the above-named examination is lOJ cm. in diameter, and has a focal dis- tance of about 30 cm. There is a small transparent spot at the centre, the glass being left unsilvered at that point. The metallic back which holds the mirror is bored at the centre so as to correspond with the central bare spot in the mirror. It is entirely unnecessary for purposes of inspection that the glass should be per- forated at this-point. Such a perfoi'ation adds nothing to the optical value of the mirror, but, as it endangers the glass, adds greatly to the cost. All the Vienna re- flectors are now made unperforated, but unsilvered at the centre. The reflector should be provided at a point on the cir- cumference with a small ball which fits into an adjustable socket on the plate of the forehead band. The eye of the examiner may look through the opening in the mirror, in which case it is of course directly in the focal line, or the mirror may be so placed as to permit the surgeon to look either under or to one side of it and yet gain good illumination. The surgeon should provide himself with four sizes of laryn- geal mirrors, two of each size entering into his set. One set should be marked and kept for examining specific or sus- pectedly specific cases, thus removing all danger of contagion from his more fortunate patients. No. 1 should be 1.50 cm. in Forehead Mirb Gi-uber, Lehrbuch d. Ohrenh., p. 397. 2 L'Union M^dicale, 1863. ' Bericlit AUg. Krankenhaus, Vienna, 1863. CIRCaMSCRIBED AND DIFFUSE INFLAMMATION. 259 merge so fast into each other, that the ease gained by the dis- charge of one is hardly enjoyed by the victim until the throb- bing and burning pain of a new one warns him that he must endure the torment of another. The auricle may become sensi- tive to touch and traction, especially if the abscesses are in the cartilaginous part of the canal, and the patient then cannot endure the ordinary pressure of the affected side of the head on the pillow. But such sensitiveness of the ear is not so likely to occur in this form of otitis externa as in the diffuse form. The severest pain and most distressing symptoms are found when the boil is seated in the unpliable parts of the bony portion of the canal ; intense distress, however, may be caused by a boil seated just within the opening of the auditory canal. Usually, the gravity of the pain and febrile symptoms will de- pend upon the depth of the abscess in the tissues of the auditory canal as well as upon its proximity to the drum-head. Small superficial abscesses do occur in the meatus without any pain, a sense of discomfort and dulness of bearing having been the only cause of the patient's seeking surgical relief. More than one such case has been seen where the abscess had run its full course and was on the point of discharging without having caused the patient any pain. But of course such cases are rare exceptions, and are explained by the superficial seat of the in- flammation. Hardness of hearing and deafness are prominent symptoms of furuncles in the auditory canal. In some cases the deafness is almost absolute, and the congestion being so great, and extending consecutively even into the cavity of the tympanum, the deafness is the last symptom to disappear. But the patient can be assured of the ultimate return of the hearing in such cases if there has been no organic lesion o-f the drum- cavity, and as such a lesion is a very unlikely occurrence in this disease, there is every hope of the return of the hearing. Inspection of the auditory canal and membrana tympani is usually very difficult if the disease is advanced and the swelling of the meatus considerable. This difliculty is less likely to occur when the disease is in the cartilaginous part of the ear, for it may be gradually stretched by the speculum. When the disease is in the bony portion of the canal, one can usually obtain a view of the drum-head only in the earlier stages of the disease. In such cases, if the abscess is seated near the drum- 260 EXTERNAL AUDITORY CANAL. head, it will be seen that the latter is more or less congested at that point nearest the abscess, and in many cases where the boil is near the periphery of the membrana tympani in its upper half, considerable swelling will be found in the region of the membrana flaccida or the folds of the drum-head. In such cases, at first sight, one may be inclined to diagnose the disease as myringitis, but the history of the case, and the compara- tively normal condition of the drum-head, excepting at the points of secondary congestion produced by the circumscribed inflammation of the canal, and the greater pain in the latter disease, will make the true diagnosis easy. When the abscess in the bony portion of the canal becomes fully developed, the view of the drum-head will be entirely cut off, and the deafness and tinnitus become great. After the discharge has occurred, the drum-head may be seen as a red, and somewhat sodden membrane, which, however, gradually, in a few days, assumes its normal color and outline, and the hearing will be found to be returning. Inspection of the auditory canal and drum-head by .means of the ear funnel, unless carefully done, becomes very painful to the patient with this disease of the ear ; but it is very important to examine the canal well, in order to determine the seat, the amount, and the stage of the disease, as well as to be assured of the absence or the presence of exostoses, cerumen, or other foreign bodies in the canal, which might interfere with the escape of the products of inflammation and greatly complicate the disease. Having established the presence of either or all of these complications, one must mitigate the efi:ects of the exos- toses, and remove, if possible, any other obstructions, such as cerumen, foreign bodies, etc., by the most gentle and thorough syringing, or by the most careful manipulation. If exostoses are in the auditory canal, care must be taken not to mistake such rounded prominences for the furuncles. This, in some cases, may prove to be no easy task, and, there- fore, as these growths, if congenital, are usually in both canals ; if there be any suspicion that the affected ear contains such bony growths, the well ear should be examined, and if it con- tains them, caution should be observed in ascribing all the swelling in the diseased ear to the furuncles. However, as these prominent growths of bone are not very frequently seen CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 261 in the ear, they will not often be found as complications in circumscribed external otitis, but it is well to bear in mind the possibility of their presence in the affected ear. Miology.—'Perha.T[ia no disease of the ear has so many asserted causes, yet so few well-explained ones, as boils in the external ear. Ifo class nor condition of men appears exempt from it, and in many instances the disease continues to recur for a long time, owing to the fact that the caiise, which must be removed before permanent recovery can take place, has not been found after the most thorough search. According to some authorities, a particular article of rich food has been the cause of the disease, especially in the more wealthy classes, while anaemia and poverty have most usually been considered fruitful causes of furuncles in the external ear. Fatigue and consequent debility from any cause may produce them ; and, it is not uncommon to find furuncles in the auditory canal of young devotees to fashion after a long and gay winter season with its round of parties and fatiguing attendants of late hours, bad air, indigestible food, and loss of sleep. I have never seen this disease in little children. Treatment. — Of course the best treatment for a boil or circum- scribed abscess is a poultice or some form of heat and moisture. But this is not easily applicable to such inflammations in the auditory canal, on account of the narrowness of the passage and the necessary blocking up of the canal which such a treatment might entail. It has, therefore, been deemed best to incise, as deeply as possible, a furuncle in the auditory canal as soon as the circumscribed abscess is detected, without waiting for pus to form in it. With the meatus lighted as well as possible by the aid of the forehead mirror, though in some cases direct light will be suffi- cient if the furuncle is not too far down the auditory canal, and while the head of the patient is allowed to be entirely free, the surgeon may make a thorough and deep cut into the small abscess, taking care that the patient is allowed to jump away from the operator rather than towards him, an end best gained by allowing the patient's head to be entirely unsupported, on the unaffected side, i. e. the side opposite to the operator. The knife is the quickest and surest way of escape from the pain of these furuncles in the auditory canal. It has also seemed 262 EXTERNAL AUDITORY CANAL. that in those cases where the knife has been used promptly on the first boil that makes its appearance, others are less likely to come, or if they come, to be less severe. This may be due to the sudden relief, given to the distended vessels of the skin of the canal by the free cut, at the outset of the inflammation. If the knife cannot be used, other means must be resorted to. Although poultices, in the strict sense of the term, cannot be applied to abscesses in the auditory canal, unless situated very near its mouth, and even then only in a limited way, the con- stant or oft-repeated use of warm water by gentle instillation, the aaral douche, or some of the varied forms of irrigation, will be found very grateful to the patient and favorable to suppura- tion. The simplest and perhaps the best way of applying warm water as a dressing to any acute inflammation in the ear, and especially in the auditory canal, is to fill up the ear with warm water and allow it to remain there as long as possible, while the patient of course lies down with the aff"ected ear uppermost. To the warm water thus used laudanum or morphia, preferably the latter, may be added. Magendie's solution may be repeated often in warm instillations (5-10 drops) to the afl'eeted ear, and will be found very quieting and perfectly safe, even in children. A small dossil of lint or cotton soaked in glycerine or equal parts of glycerine and water, and small conical poultices of flax- seed (Roosa), will be found to act as excellent emollient dressings upon all abscess near the mouth of the auditory canal. The local abstraction of blood with two or three leeches, directly under the ear in the depression behind the lobule, or in front of the tragus, close to the ear, will also give great ease when the congestion and pain are intense. This method has been found very grateful when the abscess is in the bony meatus near the drum-head. The removal of the discharge, which is often very copious, is of great importance. Some form of alkaline wash will be found to act best as a cleanser after the contents of the abscess are being poured into the auditory canal. First of all stands warm water made slightly opalescent with ca&tile soap, which should be applied by means of the syringe twice or thrice daily according to the amount of discharge. In the interval between the sy ringings, or just before them, CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 263 solutions of bicarbonate of soda, x-xx gr. to f.?j,and of biborate of soda, gr. x to fgj, may be instilled into the meatus in quantities of 10-15 drops warmed. These, by remaining in contact with the aftected spot, will soften any hardened crusts of the discharged matters from the abscess and facilitate their removal by the syringe. Usually the wall of the meatus becomes so tumid and macerated that syringing, no matter how thoroughly done, will not give the perfect view one could desire of the diseased spot and the parts adjacent to it. In such a case the meatus should be gently wiped out or swabbed out with a piece of cotton fastened to the cotton-holder. This is not painful if carefully done, and will usually give the best results so far as gaining a view of the abscess and the membrana tympani beyond. By this means, too, the everted edges of the ragged abscess may be pushed down to something like a level with the wall of the auditory canal, and the drum- head may then be seen. It has been said that syringing the ear will usually relieve the deafness caused by a circumscribed external otitis. This will hardly be so if the disease is seated near the dtum-head, i. e. in the bony canal, for in such cases the congestion of the drum- head is too great to permit an immediate return tO' hearing by merely syringing. As has already been said, the occurrence of a small abscess or boil in the auditory canal, denotes that there is a tendency towards the occurrence of another or several in the same spot. Hence, the constitutional, as well as the local treatment becomes of the greatest importance. Perhaps no greater index of constitutional or blood derange- ment can be found in the form of furuncles, than in. the occur- rence of them in the auditory canal. Hence, whatever is em- ployed for their cure, when occurring elsewhere in the body, should most surely be employed when they make their appear- ance in the auditory canal, for they are not only an evidence of the need of an alterative treatment, but they are intensely pain- ful and interfere with hearing. At the head of the list of remedies stand iron and quinine, while in some cases iodide of potassium has been found most efficacious in breaking up a tendency to the formation of boils. But there is no specific in this malady, and if one form of treat- 264 EXTERNAL AUDITOET CANAL. ment does not bring about the desired result, another must be tried, until the trouble disappears. Most frequently, the best results will be gained from those remedies which improve the general condition of the patient. Von Troeltsch strongly recom- mends the internal use of Fowler's soldtion in this disease.^ Local Treatment. — Although local causes have very little to do with this disease of the auditory canal, it will be found ad- vantageous to combine a local treatment with the giving of medicine internally. The use of some soothing or mildly stimu- lating salve, as the case seems to demand, has been found appa- rently to diminish the tendency to recurrence of the abscesses and to favor an early return to healthy action on the part of the various cutaneous structures. As a soothing application, nothing is better than a little cold cream smeared on a camel's-hair pencil and then painted round the walls of the meatus. If a more stimulating ointment is needed, the following will be found to answer very well : — Vf. — Hydrargyri ammoniati, gr. i-ij. Ung. aq. rosse, |j. — M. Ft. ung. 8. apply to the ear -wifli a camel's-liair pencil. A small portion of this ointment may be smeared on and around the affected spot, twice or thrice daily, by means of the hair pencil, for several days, until the skin of the auditory canal appears to be free from the tendency to the formation of these small and painful abscesses. If there is no return of the ab- scesses, the congestion soon goes from the drum-head, and the hearing will be restored. The granulations sometimes left by a furuncle in the ear are best treated by cauterization with solutions of nitrate of silver (gr. 10-100), applied by means of a little cotton on the holder, or by chloro-acetic acid, applied in the same way. As the granulations are distinctly marked centres of disease, touching them is much safer than instillations applied to them. As a rule, one may wait to see what course granulations origi- nating from a furuncle in the ear will take. They may fall off and be washed out, or they may grow and assume a polypoid nature. ■ Diseases of the Ear, 3d Amerioan edition, p. 102. CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 265 If they are found to be increasing in size, they should be touched as indicated above. If they are evidently not growing larger, or are diminishing in size, there had better not be any kind of caustic applied to them. Mild astringents and cleansing with the syringe are then sufficient. A fuller consideration of the best treatlnent for polypoid granulations and polypi follow- ing external otitis will be found further on, where those forms of disease are specially alluded to. DifiTuse Inflammation of the External Auditory Canal. — This disease has been called, preeminently, external otitis, be- cause it invades the entire external ear, not excepting parts of the auricle in some cases. Its only essential difference from the disease treated of in the preceding pages, otitis externa cir- cumscripta, consists in its diffuse distribution to the entire external ear. It is not possible to say with certainty in what anatomical portion of the structure of the auditory canal it has its seat. It has indeed been wisely said that " a simple ery- thema of the cutis in the auditory canal may be considered the lightest form of the disease, and a periostitis of the canal may be called the severest form."* Just as the circumscribed inflammation in the auditory canal shows the peculiar tendency to narrow itself down to a very minute point, the true abscess, the diffuse form of otitis externa shows the peculiarity to spi'ead rapidly to all parts of the exter- nal ear. A pure form of periostitis of the external auditory canal never occurs, for the disease is never confined to the periosteum, but from the outset all the neighboring layers of the wall of the canal are attacked. This is due to the fact that the skin of the canal is more firmly united to the periosteum than the peri- osteum is to the bone. Hence, an inflammation of the cutis readily extends to the periosteum and the bone, this being most probably the usual course of the disease. There is also a con- secutive form of external otitis found in cases of acute otitis media. Symptoms. — The subjective symptoms of diff"use external otitis are more severe in the primary than in the consecutive form. ' Gruber, op. cit., pp. 3-4. 266 EXTEENAL AUDITOEY CANAL. In the former instance pain, tinnitus, and deafness are the prominent and very distressing symptoms. Roosa has found that itching in the meatus is a constant but frequently disre- garded symptom of the approach of this disease. In general the subjective symptoms do not differ greatly from those of the circumscribed external otitis. In the so-called diphtheritic form the pain is said to he intense, continuing vpithout any interruption day and night until the inflammatory product has assumed another character. (Gruber.) The deafness in difl:'use external otitis is perhaps more marked and more obstinate then in the circumscribed otitis, while the tinnitus is very annoying in both. The consecutive variety of diffuse inflammation of the external ear is as a rule less painful than the primary variety. This fea- ture is most marked when the inflammation of the external ear is consecutive to purulent inflammation of the middle ear. The objective symptoms of diffuse external otitis vary with the position, cause, and grade of the inflammation, being more severe in the primary than in the consecutive form. When the inflam- mation is situated in the bony portion of the canal, the disease assumes the nature of a periostitis with intense and continued pain, whereas the symptoms are not so severe when the disease seems to be limited to the outer part of the auditory canal. At the beginning of the disease the skin of the auditory canal is more or less swollen and red, and, in some cases, portions of the cutaneous lining of the auditory canal may be excoriated or even exfoliated at certain points. Usually the redness and swelling are most marked in the bony portion of the canal, with of course great narrowing of the calibre of the canal, so that the latter appears to run to a point, thus assuming a conical shape. The skin of the fundus of the canal becomes puckered by the swelling, and one, perhaps more of the ridges thus formed will shut off the drum-head from view. The congestion and swelling will be greatest in the region of the vessels supplying the hammer and the membrana flaccida, but the entire drum-head soon loses its gray color and its con- tour, so that the walls of the canal and the membrana tympani cannot be distinguished from each other by their appearances, as they are fused into each other. CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 267 AH traces of the normal pyramid of light are lost, and the in- filtration in many cases is so great that the consequent pucker- ing of the drum-head will cause several shining spots to appear on the prominent points thus produced by the swelling of its layers, when light is thrown into the canal from the mirror. The appearance of the disease is somewhat changed when the layers deeper than the skin of the canal are more diseased than the cutis itself. ' In such cases the swelling of the structure beneath the cutis will push it so much out pf place that the two sides of the canal will be made to touch each other, and not even the narrowest speculum can then be pushed between them so as to gain a view of the deeper part of the auditory canal and the drum-head. Very often in such cases, as the superficial layer of the skin of the passage is very little diseased and remains quite dry, it may be somewhat diflicult to say whether the disease is diffuse or circumscribed inflammation of the canal. However, in the former case we shall usually find more or less glandular swell- ing and tenderness about the ear, with pain on moving the jaw. A most important symptom in some cases is the redness and swelling, with some oedema, of the mastoid process. The glandular tenderness under and in front of the auricle is, however, a much more frequent attendant of this disease of the auditory canal, than the mastoid redness and tenderness. The discharge of the products of inflammation in this disease may occur from several points, but usually it comes from one only. In the former instance the disease manifests symptoms similar to those of circumscribed external otitis, whereas, in the latter instance, the symptoms are peculiar to a true diffuse external otitis. In such a case, the discharge is remarkably copious, beginning as a discharge of colorless or bloody serum, and terminating in the course of a few days in a less copious purulent discharge. The amount of odorless bloody serum at the beginning of the discharge is so abundant in some cases, as to require the constant holding of a handkerchief to the ear, in order to protect the bedding or the clothing of the sufierer, and thus several handkerchiefs, in the course of the day, may be soaked with the discharge. The most marked instance of a flow of this kind the author has ever seen, was from the ear of 268 EXTERNAL AUDITORY CANAL. a Japanese naval officer, from whom the discharge was very red as well as very copious, so red, indeed, that the patient con- sidered it blood. It continued three days, and was succeeded by a light-yellowish discharge of purulent matter, exfoliation of epidermis from the fundus of the auditory canal and drum- head, with perforation of the latter in the postero-inferior quad- rant on the eleventh day. The brief mention of this case leads naturally to the statement that many cases of this disease, when situate in the bony portion of the canal, are attended with exfoliation of large pieces of epidermis and perforation of the drum-head from without inward. Perforation of the drum- head does occur frequently as a result of the ordinary course of the disease, but great caution in the use of the syringe should be observed at the stage of exfoliation, for fear of penetrating the drum-head by the force of the stream of water. The swell- ing and exfoliation of the soft parts of the canal may be so great as to increase the pain and distress of the patient by a further distention of the canal, and the renewed irritation of the diseased part may reproduce considerable fever, which, however, subsides as soon as the exfoliated matter and dis- charge are removed. Where it is impossible to gain a view of the drum-head on account of the narrowing of the auditory canal, resort must be had to the catheter, the use of Politzer's bag, or Valsalva's method of inflation, in order to ascertain the condition of the Eustachian tube and middle ear. This is often of the greatest moment, not only in children in whom it is often difficult to make a perfect diagnosis in this disease, but also in adults, in order to determine whether or not the external otitis exists alone or is accompanied by deeper and more serious trouble in the drum-cavity. All the objective symptoms in diffuse in- flammation of the external ear are modified by their causes and the diathesis of the patient. Hence, peculiar symptoms may be expected in that form of the disease produced by the pre- sence of vegetable or animal parasites in the ear, in the diph- theritic form of the disease, and in any form in syphilitic or scrofulous individuals as well as in any traumatic case occur- ring in the more healthy, for in the latter instance the means by which the disease has been produced must be taken into CIRCUMSCRIBED AND DIFFUSE INFLAMMATIOlSr. 269 account, for almost invariably it will complicate and alter the symptoms. The diphtheritic form of diffuse external otitis is not only very rare, being unmentioned by many authorities, and, accord- ing to the best observers, is never a primary aftection, but rather an occurrence in the later stages of the inflammatory process. This form of the disease is usually found in scrofu- lous subjects in whom the original inflammation has been either neglected or improperly treated. In all such cases, after the usual purulent discharge has lasted a longer or shorter time, there is a sudden increase of pain and fever, with the simulta- neous appearance of a white diphtheritic membrane, which adheres most closely to the inflamed structure, and when even lightly touched causes intense pain and some bleeding of the parts beneath, as shown by Gruber. Moos,' and G. A. Callan,^ have each reported a case of idiopathic diphtheria of the ex- ternal auditory canal. In children there ia often found, at the termination of an attack of diphtheria, inflammation in the external ear. This rapidly extends in some cases, directly to the bone of the canal, and backwards to the mastoid process. Pain is not a prominent symptom in these inflammations following diphtheria, and this fact will readily distinguish them from the truly diphtheritic form of external otitis in which the peculiar false membrane is found in the auditory canal. The form of the disease now referred to is one arising from the broken-down condition of the little patient, rather than a form of disease already de- scribed as the diphtheritic. In the former case the pain is not great, the swelling is considerable, and the tendency to attack the bone is marked. Fluctuation is soon felt over the mastoid region, and, after the evacuation of the pus, the bone beneath is felt denuded, and in some cases crumbling. Exu- berant granulations spring up around the opening made by the knife in the soft parts, and the peculiar depressed mouth of a sinus leading to dead bone soon begins to make its appearance. With a probe, a tract of bare bone corresponding to the region around the bony meatus may be detected. For weeks, no por- > Archives of Oph. and Otol., vol. i. No. 2, New York, 1870. 2 New York Med. Record, March 37, 1875. 270 EXTERNAL AUDITORY CANAL. tions of this diseased bone will come away, but at last the nearest edge of the dead tract will appear to rise up, so that a probe may be worked under it, and then gradually, day by day, the dead shell or scale of bone (for it is in many cases the outer wall of the mastoid cells) will be found to be coming out through the sinus. This process is attended with more or less discharge from the ear, but if the sinus behind the ear is kept freely open, the discharge from the auditory canal will be very slight, and hence, granulations are not usually found in such a case, for the drainage is kept up from behind and away from the auditory meatus. During this process the patient has no pain, the discharge is not very copious, but there will be, from time to time, swelling of the glands in front of and under the ear, and down the tract of the sterno-cleido-mastoid muscle. These swellings are not painful nor very hard. They last for a few days and then usually disappear, though they may suppu- rate in the worst cases. Perhaps the form of inflammation over the mastoid, just sketched, may be due to the inflamma- tion of a gland which has become diseased by the diphtheritic poison. In badly fed and delicate children the diphtheritic form of otitis externa may pass into the gangrenous variety. According to Grruber, otitis gangrenosa is much more likely to occur in children than in adults. Although the external otitis occurring in diptheritic children may lead to necrosis in and about the tympanum, with exfoliation of large pieces of the posterior wall of the auditory canal, I have never seen such cases assume a truly gangrenous nature. Causes. — The causes of diffuse otitis may be purely idiopathic or local. The latter variety will be found the most usual, as cold, wounds, injuries of all kinds, furuncles in the auditory canal, and various inflammatory processes both within and out- side of the ear. The latter diseases attack the auditory canal from their nearness to it, as, for example, acute inflammation of the middle ear, some skin diseases, as eczema of the scalp and auricle, the acute exanthemata, and in rare instances pemphigus of the entire surface, may also attack the auditory canal and drum-head, as in a case seen by Von Troeltsch. The improper uses of all kinds of ear-picks, aurilaves, hair- pins, and tooth-picks, for scratching the ear or for the too CIRCUMSCRIBED AND DIFFUSE INFLAMM ATIOIST. 271 zealous removal of cerumen, are constantly found to have been the exciting cause of this very painful disease of the auditory canal. Some of the worst cases I have seen, especially among the patients in the infirmary, have been produced by the rough and persistent use of pins, which appear to have an especially bad influence on the glandular structures of the auditory canal. I have also observed that men verj' often make a very impro- per use of a quill tooth -pick in scratching the meatus with it. This practice I have known to excite a series of obstinate ab- scesses which have at last passed into a chi'onic form of diffuse external otitis. This latter form of the disease is not very painful, but the itching and discharge are very annoying. There are constantly found a few writers disposed to attri- bute some cases of diffuse inflammation of the external ear to syphilitic or gonorrhoeal causes. The disease in the former instance is attributed to papules, the secretion from which is irritating (Grruber) ; and other writers, among whom is Lincke, have endeavored to diagnose some forms of external otitis as syphilitic. The gonorrhceal form appears very doubtful, from the fact that there is no mucous membrane in the external auditory canal. Dr. Ladreit de Lacharriere' has described and defended a form of acute syphilitic otitis which he considers purety a secondary accident, and to which he desires to call especial attention. These cases are said to be not uncommon, but the writer re- ferred to laments that no one but Triquet has devoted much attention to this or any forms of purely syphilitic disease of the ear. The disease described by de Lacharriere as acute syphilitic otitis appears to possess a very distinctive type, so much so " that it may be diagnosed as specific in its nature before the patients confess that they have had any other lesions of this nature." The characteristic signs are said to be the condition of the auditory canals, the nature of the secretion, the rapid onset, and the insignificant pain. The two canals are usually attacked at the same time. Their walls are swollen, but not to the same extent as in the phlegmonous form of otitis. The skin ' Annales des Maladies de I'Oreille et du Larynx, May, 1875. 272 EXTERNAL AUDITORY CANAL. is cracked and red, and the canal is so narrowed that any en- deavor to introduce a speculum will cause the patient suifering. From further description it may be gleaned that the discharge does not differ in quality, amount, nor in any respect from that of ordinary diffuse external otitis, excepting in having a very disagreeable odor. The premonitory symptoms are similar to those of ordinary otitis, for they consist in sensations of fulness in the ear, itching in the auditory canal, and a discharge occurring on tlie same day or a little later. The same writer says respecting the differential diagnosis in this disease that " it should never be taken for a simple otitis, the pain of which is so intense, until the discharge is established ; nor should it be confounded with herpetic otitis, which can always be detected by the presence of the peculiar herpetic vesicles. The affection which most nearly resembles it is eczema, in which, however, scanty secretion which does not run out will keep it from being confounded with the disease described as acute syphilitic otitis. " The disease usually lasts about as long as an ordinary attack of otitis, disappearing without leaving any traces, excepting in some few cases in which the subsequent deafness appears quite persistent either from a thickening of the drum-head or from a catarrhal condition of the tympanic cavity." It would seem, from this deseriptiou, that this disease is a well-marked and independent one. Its symmetrical character, disagreeable odor, copious discharge, and attendant syphilitic history would certainly tend to place it among lesions secondary to the specific inoculation. When the catarrhal tendency in- duced by the specific poison is borne in mind, it would seem that the form of otitis just described might be consecutive to a catar- rhal process in the middle ear. Treatment. — If we are able to begin the treatment of diffuse inflammation of the external auditory canal in the early stages of congestion and pain, the course to pursue will be to apply leeches around the ear, in front of the tragus, close to it, and under the auricle close up behind the lobule. From four to six large European leeches may be applied in this manner, the exact points to which they are to be applied being indicated with ink, for the guidance of the leecher if the surgeon does not wish to, or is unaccustomed to, put them on. Some authorities are also is favor of applying a leech to the wall of CIRCUMSCEIBED AND DIFFUSE INFLAMMATION. 273 the meatus near its mouth, the meatus being previously well stopped up with cotton beyond the point the leech is to be placed. The only disadvantage of this method lies in the liability of pro- ducing an abscess at the leech-bite. But depletion, thorough and copious, must be brought about in the first stages of this disease, and if leeches will not give the desired relief, thorough and deep scarification, especially by making a deep cut on the superior wall of the meatus, should be promptly carried out. This is very much more painful than leeching, but it depletes the afllected spot at once, and the bleeding may be kept up by syringing the auditory canal with very warm water. If, notwithstanding the leeching and scarification (if the latter is resorted to, as a second choice), the swelling and pain con- tinue, it will be necessary to apply heat and moisture. In this respect the treatment will not differ materially from that of cir- cumscribed inflammation in the auditory canal. Warm water should be constantly and gently applied to the affected auditory canal by irrigation or by instillation. When warm fluid applications are to be retained in the auditory canal, the best way to accomplish this is fqr the patient to lie down with the affected ear uppermost, as already stated when dis- cussing the subject of furuncles in the auditory canal, and the fluids should be kept in the ear as long as they are warm and grateful to the sufferer. To the water thus used may be added various anodynes, pre- ferably, however, laudanum or morphia. Magendie's solution undiluted will be found to be the best anodyne application, be- cause it is the cleanest and most powerful, and, although it should never be resorted to in the undiluted state, unless the pain is very severe, it can be endured in large quantities in the ear, with- out producing any unpleasant narcotism, even in young children. It may be used in instillations of five or ten drops, every half- hour, until relief from pain is obtained, in children as young as three years of age, with the best results. I have frequently used it thus, without observing the least narcotism. The best way to prescribe it is in small quantities, thus: — B. — Morphi-se sulphatis, gr. iv ; AquiB,' flSij.— M. S. Ten drops, waiin, iu the ear, as required. ' For water, cherry-laurel water may be substituled. 18 274 EXTERNAL AUDITOEY CANAL. The only caution to be observed is, that the apothecary, read the quantity of water correctly, for it has happened that the quantity of drachms has been read as ounces, with, of course, no worse result than weakening what would otherwise be a more powerful and more desirable application for the relief of pain. The object of the small prescription is, as will be readily seen, to prevent sixteen grains of morphia from being at the command of patients,- when four grains will do just as well, with proportionately less risk. It is, perhaps, needless to say, that all forms of solid poultices ■of carrots, onions, fat pork, oils, etc., will only tend to aggravate the present sufferings of the patient, and almost inevitably leave behind them portions of the poultice, which, by undergoing decay, or becoming rancid, will lay the foundation of other evils, among which will be found the aspergillus playing a prominent part. The secretion in the diffuse inflammation of the auditory canal may be very copious, and of a sanious nature. This must be carefully removed, and the ear kept as clean as possible by frequent and gentle syringing with pure warm water, to which a little Castile soap or bicarbonate of soda may be added. If the secretion should be tenacious and tend to accumulate in .large quantities, and syringing fail to remove it, it should be carefully and gently wiped out with cotton on the cotton-holder. The cotton-bolder should never be used by the inexperienced or inexpert hand, as in that case it will prove itself as unworthy an instrument as an aurilave, or sponge tied to a stick, which pushes in much more than it brings out and never fails to do harm sooner or later. As the copious serous discharge, often tinged with blood, diminishes, the running from the ear may assume a yellow color and become thick, but much less in amount. This will be apt to assume a chronic tendency, and the deeper parts of the canal may be found red, disposed to bleed, and roughened into little hillocks. The discharge is so much thicker that it is not easily removed, and excites a tendency towards the growth of granu- lations near the membrana tympani. It becomes, therefore, extremely important to cleanse the ear at this stage and keep down the granulations. I have found that the principle of aspiration applied to the CIECUMSCEIBED AND DIFFUSE INFLAMMATION. 275 tumid and sluggish parts will not only cleanse them but stimu- late them into a healthy activity. After cleaning the ear as thoroughly as possible, by syringino- and the cottou-holder, especially in those cases where the der- moid layer of the drum-head has been greatly inflamed, thrown into hillocks, and suppurates freely at several points, I have seen throilgh the Sigl^ pneumatic speculum, as I have sucked upon the India-rubber tube attached to its side, large drops of pus ooze from the openings in the dermoid layer in quantities sufficient to fill up the fundus of the auditory canal. By this means it is possible to cleanse the inflamed deeper parts much better than by any other means. It is surely the most rapid and perhaps the only immediate way of doing it when pus has accumulated under the dermoid layer of the drum-head or in deeper tissues of the skin of the canal, which enter into the structures of an abscess in the wall of this passage. Whether the abscess be of the nature which forms in circumscribed otitis, or the more diffuse and sluggish kind found at the subsidence of the diffuse form of inflammation of the auditory eanal, this method of cleaning out the diseased parts may be used. At the same time that the pus escapes from the sodden parts in such a case as already alluded to, in which aspiration is employed, I have observed that minute drops of blood start out from the excoriated parts everywhere in the canal. This acts as a stimu- lant to these parts, which do not bleed when touched with the cotton-holder; but their bleeding upon gentle suction with the Sigl^ speculum reveals their true sluggish nature and will guide in the treatment. These are the cases which demand the use of strong solutions of nitrate of silver, and we should not hesitate to apply solutions containing 60 to 100 grains of the caustic, every day or two, until the ear becomes more healthy : if neglected, granulations will soon spring up. At home, the patient should keep the ear carefully cleansed and use a solution of zinc, copper, nitrate of lead, and other astringents. But, as a rule, the zinc, in the form of the sulphate or acetate, combined with tincture of opium, in these cases of excoriation of the canal, will be found the best remedy. The following recipe is of value : — 276 EXTERNAL AUDITORY CAjSTAL. R. — Zinci sulphatis, gr. v ; Tinct. opii, n^xx ; Aquse destill. fl|j. — M. S. Ten drops four times daily in the ear. ' It may be well to repeat the direction, that all applications to the ear must be warmed before they are dropped into the ear. When the disease is confined chiefly, if not entirely, to the external ear, as in diffuse inflammation of the external auditory canal, lead is frequently employed by the highest authorities. When granulations spring up in the canal, Politzer, in his clinic, prescribes instillations of lead-water and the application of crystals of sesquichloride of iron. These crystals are applied rapidly, in order to prevent their deliquescing, and after they are placed upon the granulations the canal is packed with cotton, and the whole retained for twenty-four hours, if no discomfort and pain arise from the treatment. By this means, granulations may be made to disappear rapidly, when they are too small and numerous to be pulled out with an instrument. Hinton' recommends the following formula for chronic forms of inflammation in the auditory canal : — IJ. — Liq. plurabi diacetatis, th.x-xxx ; Acid. acet. dil. ttl iij-x ; Liq. opii, n\, xx ; Aq. destill. ad fljj.— M. i He further states : "I have found the same lotion useful, at first, in the excoriated and swollen condition of the meatus that often coexists with afifections of the tympanum in children, especially if neglected." In the treatment of granulations, as well as the roots or bases of polypi, after their complete extraction, nothing is equal to monochloroacetic acid. This is acetic acid in which chlorine replaces one part of oxygen. The preparation I have used for some years is made by Merck, of Darmstadt. By applying a drop of this on the cotton-holder to the granu- lations every other day, or three times a week, they will rapidly disappear. The application of the acid is somewhat painful for an instant, but a syringeful of warm water will ' Questions of Aural Surgery, p. 95, London, 1874. CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 277 relieve it. The advantages of this acid are its promptness, thoroughness, and cleanness. It cannot, however, be applied by any one but the surgeon. It should be applied only to the diseased spot under thorough illumination of the meatus by the forehead-mirror. Some authorities speak in high terms of the eiScacy of brushing granulations in the ear with tincture of opium. If polypi should spi'ing up, with well-defined base or pedicle, they must be extracted by one of the various means described further on, and their attachment to the canal thoroughly touched for several days with monochloroacetic acid. In every case where polypi are pulled out, the patient should be told before the extraction that it will be necessary to touch the base of the growth with the acid or some other caustic. The treatment just described is tliat adapted to the ordinary form of otitis externa diffusa with no worse complication than polypoid granulations or polypi ; there are, however, several other forms of this disease, as already stated, viz., the diphthe- ritic, the gangrenous, the syphilitic, and the parasitic. The treatment will be modified in the first three, by the fact that they are much more painful than the fourth. As the first three indicate a constitutional alteration and poisoning of the blood, their treatment must be largely of a supporting and alterative nature. Their names will indicate the kind of blood- poisoning they are due to, and their general treatment must be conducted on the principles followed in the same diseases when they manifest themselves elsewhere in the body; Otomycosis, — -The growth of either a vegetable or an animal parasite in the external auditory canal, may excite in the latter a form of diffuse inflammation, to which the general term, parasitic otitis may be applied. Judging from the literature of the subject' and my own experience, animal parasites are found in the external auditory canal much less frequently than fungi. E'o special name has been suggested for that form of diffuse external otitis excited by the presence in the auditory canal of animal parasites, but for that kind of aural inflammation excited by the growth of fungi in the auditory canal, the general term otomycosis has been suggested by Virchow. 278 EXTEHNAL AUDITORY CANAL. The subject of animal parasites and insects accidentally lodged in the external ear will be considered under the head of foreign bodies in the ear, but we shall consider at this point that form of diffuse external otitis produced by vegetable parasites. The most common cause of this form of otitis externa diffusa is the growth in the auditory canal of that kind of fungus called Aspergillus. Its two chief varieties are A. nigricans and A. flavescens, the former of which is found in the ear twice as often as the latter. The ascomycete, i. e. the highest form of development of the Aspergillus, is, as we shall see further on, of very rare occurrence in the ear. Other kinds of fungi have been found in the auditory canal of man, viz. : the Graphium peniciUoides, by Hassenstein and Hallier; the Ascophora elegans, by von Troeltsch ; the Tricotheciuvi, by Schwartze and Steu- dener ; and the Mucor mucedo seu fuscus, by Boke. The Aspergillus is so very much more common in its occur- rence in the external ear than . other fungus, that the aural in- flammation it produces is named by Wreden, of St. Petersburg, Myrivgomycosis aspergillina, for he has observed that this vege- table parasite has an especial proclivity to grow upon the mem- brana tympani. Myringomycosis aspergillina has been most thoroughly de- scribed by Wreden,' but before his works were published, Mayer^ and Pacini,' Carl Cramer* and Schwartze, had described the occurrence of this form of parasitic disease in the external ear. Subsequent to the appearance of Wreden's papers, various authors' have given fully detailed accounts of this disease and its successful treatment. In seventy-four cases of the disease observed by "Wreden, only two forms of fung-i have been found, viz., the A. flavescens and the A. ■ nigricans, excepting in one ' Die Myringomycosis aspergillina und ihre Bedeutung ftir das Gehororgan, 1868 ; and Myringomycosis aspergillina, 1869-1873, according to personal and foreign observations, Arcliives of Oph. and Otol., iv. i., 1874. ' Beobachtungen von Cysten, mit Fadenpilzen aus dem ausseren Geliorgange, Miiller's Arcliiv, 1844, p. 401. 3 Supra una muflfa parasitica nel condotto auditiv esterno, Florence, 1851. * Sterigmatocytis autacustica, a variety of Aspergillus, Vierteljalirschrift d. Naturforsch. Gesellschaft zu Zurich, 1859-60. ' Schwartze, Von Troeltsch, Boke, Politzer, Gruber, Weber-Liel, J. Orne Green, C. J. Blake, Roosa, Bezold, Lucse, Nolting, Bezold, et al. CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 279 solitary case, in which there was found a fungus richly supplied with capsular sporangia or asci, and which, on account of its intense purplish-red color, was called by Wreden the Otomyces purpureus. This fungus was examined by Woronin, a distin- Fiff. 64 FOKMS OP AsPERGILLirs PLAVESCENS REMOVED FBOM THE HuMAN EAE. — A. Unique form Of double-headed fruit stalk from tlie ear of a man. B, C, D, B, and P. Various stages of develop- ment observed in a specimen taken from the external ear of a female afTected with a growth of Aspergillus in both auditory canals. guished mycologist of St. Petersburg, who pronounced it to be essentially different from the Ascophora of Hchenk, which belongs to the Mucorini. Upon further investigation, this proved to be the ascomycete or utricular form of the Aspergillus nigricans, the highest form of the " specific aural fungus" of Wreden. Its fertile hyphens were seen to have a double outline under the microscope, and at different places transverse septa, like the fructiferous hyphens in the varieties of Aspergillus which have already been found in the ear. The width of the broadest of them was 0.00572 mm. to 0.00715 mm. in diameter. The double-outlined wall of the fungus is of a bright yellowish- red color, 0.00143 mm. thick. The fruit end of the hyphen is composed of a comparatively very large, red, round, vesicular sporangium, which consists of a thick-walled capsule and a 280 EXTERNAL AUDITORY CANAL. number of round spores, which completely fill its cavity. The diameter of the large sporangia is 0.0572 mm. to 0.06435 ; that of the smaller ones is 0.02145 mm. to 0.0429 mm. The thick- ness of the capsule wall is 0.00143 mm. to 0.00214 mm. Dr. J. Oriie Green^ has lately published an account of finding in the ear a similar fungus, which he calls Aspergillus rubens. Aspergillus is usually found growing at the fundus of the external auditory canal. It seems to seek the most secluded part of the canal, and hence is most likely to grow first upon the membrana tympani, from which it spreads outward over the entire auditory canal, forming a kind of false membrane in the shape of a glove-finger. This false membrane is composed chiefly of mycelial network, with all forms of aerial fructifica- tion of the plant, and some epithelium from the auditory canal. The pseudo-membrane thus formed has been said to have a lardaceous appearance ; it also resembles a piece of wet news- paper lining the auditory canal. The sporangia are usua ly found on the surface of the false membrane turned towards the membrana tympani, and the wall of the auditory canal. Although the most perfect forms of growth of the fungus are usually found near the drum-membrane, I have seen specimens so flourishing at the mouth of the auditory canal, that the latter appeared to be sprinkled with bright-yellow pollen. In such a case, recently observed, the membrana tympani was not seriously implicated. Usually, however, the membrana tym- pani is injured by the aspergillus, but not permanently. An auditory canal which has been the seat of inflammation is most liable to be invaded by the aspergillus. It seems that the remnants of the inflammatory disease, such as pus, dried mucus, epithelial debris or blood, form excellent soil for the growth of the parasite. It has been observed long ago, that an active discharge from the ear is unfavorable to the growth of aspergillus in the ear. Aspergillus cannot be in an auditory canal for any length of time without causing the characteristic symptoms of its presence ; an exceptional case would seem to be one reported by Moos.^ The growth of an aural fungus is usually confined to cutis of the membrana tympani, as shown ' Proceedings of Boston Society of Med. Sciences, 1875. 2 Arcliiv f. Olirenlieilknnde, Bd. II. p. 155. CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 281 by "Wreden, but, in very rare instances, the parasite may invaiie the fibrous layer of the drum-head, and finally take root in the cavity of the tympanum, as has been observed by Politzer' and others. Symptoms. — The symptoms of this disease are a sense of ful- ness, slight pain, burning, itching, tinnitus aurium, and hard- ness of hearing. The vessels of the malleus become congested^ and in a day or two the membrana tympani becomes hidden by a thick, white, false membrane. The slight serous discharge which now sets in, marks the detachment of the false membrane, and the cessation of the pain. In some cases the cutis of the auditory canal becomes deeply inflamed, but not invariably. The pain may become intense if the parasite is not removed. Males are more frequently attacked than females, according to Wreden, who has seen fifty-one of the former, and twenty-three of the latter sex, aftected by fungi in the ear. In ten cases of this disease which have come under my notice in private, only three were females. So far, this disease has never been found in very young children nor in the very aged. The oldest patient I have observed with this disease of the ear was a man 67 years old. The following case, in which a perfect mycelial tube-cast of the auditory canal was removed by the author, will supply all the typical features of an ordinary attack of the disease, and will be seen to agree in the main with the observations of others. The patient was under treatment for so-called chronic catarrh of the middle ears, complicated by ozsena. She stated that for more than a year she had had, from time to time, sudden attacks of pain in the left ear, which lasted for a day or two with more hardness of hearing, and then suddenly ceased, with a slight watery discharge from the afiected ear. The hearing then returned to its relatively normal state. When she told me this she was free from pain, and the drum-head and auditory canal were in the condition usually seen in a case of ordinary progressive hardness of hearing, with intact but opaque drum- head. Within ten days from that time, she came to me, stating that she had had, two days before, an attack of the pain already described, ' Wiener Med. Wochenschrift, 38, 1870. 282 EXTERNAL AUDITORY CANAL. and tliat there was still a little discharge from the ear. I exam- ined the ear and found the inner portion of the osseous auditory meatus and the membrana tympani covered with a false mem- brane looking like wet newspaper. I instantly inferred the presence of a fungus, and removed the false membrane very easily by means of a pair of forceps. The removal of the false membrane caused no pain, nor were the parts beneath it very red and sensitive. There was a slight serous discharge from the ear, a drop of which I examined immediately upon a care- fully cleansed slide nnder the microscope, and found that it contained no pus, but myriads of brownish-yellow spores of the Aspergillus flavescens and vibriones.' The tube-cast into which the mycelial false membrane bad been moulded, was composed chiefly of thalli, and upon its sur- face were free spores and tufts of aerial fructification of the A. flavescens ; throughout the false membrane thus formed were scattered epithelial scales. The hyphens, or fruit-stalks, were not septate, and their large, bulbous ends, from which the spores rise, were a beautiful golden-yellow color, and resembled, in their general shape and appearance, an ordinary onion-top. In reference to the etiology of this case, it may be stated that the patient had lived for some time in a very damp house, the cellar of which was " covered with mould," but before she had come to live in that house she had never suffered from any fungus-disease in the ear, as far as she knew. The chronic disease of the ear may have predisposed the ear to a development of fungi, such a tendency having been found in other cases of chronic aural disease by Wreden and various observers. The hearing was impaired only from the onset of the pain until the false membrane was removed. Had I attempted to remove the false membrane during the pain, I might have found that its removal was difficult for me as well as painful to the patient. In this case, however, the cessation of pain, the easy removal of the false membrane, and the absence of redness ' Pouchet (comptes rendus, 1864, p. 148) has found bacteria and vibriones in a discliarge from the ear, attended vtith itching. Hinton, Questions of Aural Surgery, London, 1874, p. 79. CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 283 of the subjacent parts, seem to indicate that nature had already commenced a process of loosening and removal of the fungus- cast of the parts of the ear attacked by the aspergillus. It has been observed by others that an attempt to remove the false membrane in these cases is usuallj' followed by pain, sometimes bleeding. This must be because the false membrane has been touched in a stage of the disease earlier than the one called the natural process of loosening, in vrhich the tube-cast alluded to was removed. All symptoms of the disease in this case disappeared under treatment which consisted chiefly in the use of instilla,tions of absolute alcohol, several times daily, and persevered in for seve- ral weeks. The hearing, which was not normal before the for- mation of the false membrane, was found to have been unaltered by the disease, although the external auditory canal had passed through the various stages of the light difl:use inflammation incident to an attack of otomycosis. A vegetable parasite, seeking the most secluded spot in the ear for its growth, is most likely to be found on the drum-head, but fungi may grow on the wall of the auditory canal and nowhere else in the external ear, as in a case of ascophora found •by Von Troeltsch in a solitary patch on the wall of the external auditory canal. Aspergillus not only spreads from the drum-head to the wall of the auditory canal and vice versd, but it perforates the drum- head sometimes and finds its way into the drum-cavity, as in the case reported by Politzer.' The following case is one of growth of aspergillus in the tympanic cavity : A young lady, 18 years old, applied in the autumn of 1872, to the author, for relief from a slight but con- stant discharge from the left ear. She stated that the discharge had' never been attended by pain, that it was light colored and almost transparent. I found the external auditory canal free from disease of any kind, but the drum-head was destroyed excepting in the region of the tympanic folds ; the malleus was still present. It was impossible to find out how long the fungus had been growing in the ear, for when it was first detected by the , • TJeber pflanzliclie Parasiten im Olire. Wiener Med. WoclienscUr., 1870, 28. 284 EXTERNAL AUDITORY CANAL. patient's bringing me a flake, dotted with blackish spots, which she had removed from her ear, there were no subjective symp- toms difterent from those which had been connected with the case for years, according to her statements. In order to allay a little itching in the ear, the patient had thrust a hairpin into the tympanic cavity, through the largely perforated membrana tympani, and had pulled out the whitish scale, studded with black spots, alluded to. The auditory canal was, and had been for months previous, free from all traces of anything of this nature or appearance, for she had been under constant treatment for the chronic dis- charge, which had obliged her to syringe the ear several times daily. That this specimen was pulled from the tympanic cavity was fully proven by the patient's using a hairpin again and bringing out in my presence more fungi on similar scales, which were instantly examined under the microscope. By the use of instillations of absolute alcohol thrice daily, and syringing the ear with warm water, all traces of the fungi and the discharge disappeared, and the ear remained free from itching and serous discharge for some weeks. Although the patient was living in afiluence and perfect hygienic surround- ings, the itching and discharge again returned, but all the symp- toms were once more relieved by the use of alcohol-instillations in the ear with careful and thorough syringing. This case I mention as a proof that otomycosis is not neces- sarily a disease of the external auditory canal, although as a rule it is. In the case just narrated, perhaps we have a very rare exception, unless it can be shown that in many cases a thin serous or sero-purulent discharge from the middle ear is kept up by the presence of fungi. Perhaps this case began as one of myringomycosis in which the fungus, after destroying the drum-head, excepting in the region of its folds, penetrated into the drum-cavity and flourished there. Etiology. — Respecting the etiology it may be stated that dampness of the dwelling, previous disease of the ear, and the use of oleaginous remedies for different aural diseases are the most fruitful causes of this disease. Otomycosis is said to be much more frequently met among the poor than in the richer classes of any country. My experience CIRCUMSCRIBED AND DIFFUSE INFLAMMATION. 285 is juBt the reverse. Aa the climate, and consequently the dwell- ings, of northern continental Europe are damper than in this country, we can account for the fact that this disease appears to be more frequent there than here, and therefore attention has been called most thoroughly to this form of aural disease by writers in Germany and Russia. Mr. Hinton, of London, has rarely found aspergillus in the ear; but Dr. Cassells, of Glasgow, has met with it frequently in his experience. Previous diseases of the ear, especially those productive of exfoliation of epidermis, and those which have left behind them collections of dried pus or any of the products of inflammation in the auditory meatus, may induce a growth of vegetable saprophytes. It is now established beyond doubt, especially by the inves- tigations of Bezold,' that the use of oil in the ear for pain is one of the most fruitful causes of the growth of fungi in the auditory canal and on the drum-head. Oils and all forms of grease put into the ear are usually forgotten when the pain is gone for which they were applied. They soon become rancid, and thus favor the growth of vegetable parasites, which finally produce all the well-marked symptoms of otomycosis. The fact furnishes the strongest argument against the com- mon and senseless use of sweet oil for all ear diseases. It is entirely useless as a remedy for pain, and worthless as a solvent for inspissated wax; for a little reflection will at once make it apparent that oil will not dissolve the semi-oleaginous ear wax, but that to soften and detach it we need only a slightly alkaline wash. This is not only more efficient than oil, but cleaner and free from the danger of encouraging the growth of fungi. It would also be well for physicians to see that salves and ointments, which must be prescribed sometimes for aural maladies and applied to the auditory canal, are thoroughly washed out at last, when all further need of their presence in the canal has ceased. In some instances, though a pure form of aspergillus may invade the fundus of the auditory canal, a bastard form of aspergillus and penicillium may spring up nearer the meatus. ' Die Entatehung von Pilzbildung im Ohr. Monatscbr. f. Olirenh., Juli, 1873. 286 EXTERNAL AUDITORY CANAL. This has been observed by Hallier and Blake.* I have fre- quently observed the pure forms of aspergillus, but never any bastard variety of fungus in the ear. TVeaimeni.— Many high authorities in this country regard thorough and frequent syringing the ear with water as sufficient to destroy vegetable parasites. While this is indispensable, it is not entirely sufficient, and must, therefore, be aided by a more powerful parasiticide. One of the best and most soothing parasiticides is hypochlorate of lime (gr. ij-aq. fl,5j), as recom- mended by "Wreden. Next to this, according to the same authority. Fowler's solution, used locally, is the most efficacious. Dr. J. Orne Green found in his own case, that hypochlorate of lime was more soothing than either carbolic acid or solutions of soda. ■ Bichloride of mercury, acetate of lead, solutions of veratria, tincture of iodine, and solutions of tannic acid have been recommended as parasiticides by various authorities. Having' observed that a solution of bichloride of mercury, gr. j to flgj of water, excited nausea, dizziness, and vomiting, I have refrained from ever using this drug, in any way, as a local application in the ear. Of course, a chief element in the treatment of inflammation in the external ear^ caused by the growth of fungi, must be the removal of the: patient from the source of the spores of the fungus. If it should appear that the spores are acquired from ftmgi growing in a damp dwelling, then the patient should be removed from such influences. It would also- be well to see that the particular room or bedding occupied by the patient is not mouldy, and hence the source of the disease in his ear. The masses of fungus which have collected in the ear — and these may be so great as to extend from the fundus of the auditory canal to the meatus externus — should be removed as quickly as possible. The detached masses are easily extracted from the ear; the adherent ones can usually be pulled away by gentle traction, or a safer plan would be to go on, with the use of the parasiticide until the layers of the fungus are spontaneously detached, when they can be syringed out. ' Dr. C. J. Blake ; Parasitic groiyths in the meatus, auditorius extemiis, Transactions American Otological Society, vol. i. p. 170, 1871. FOREIGlir BODIES. 287 Since, in cases of otomycosis, inflammation is usually present, nothing but the most soothing remedies should be employed. Warm water is absolutely an essential means of cure. This should be syringed into the ear, or allowed to flow in from the aural douche. After the ear is thus perfectly cleansed, instilla- tions of alcohol and of hypochlorate of lime should be employed freely in the ear. The former may be used in its absolute state or diluted ; the latter, in the strength of two grains to the ounce of water. It is recommended that the latter be used freshly mixed each time of application to the ear, on account of the chlorine and oxygen set free. So far, I have given the prefer- ence to alcohol, either alone or diluted with water. If the skin in the auditory canal is broken, alcohol may burn at first, but it has never in my experience increased the inflammation, and it always destroys the parasite. CHAPTEE II. FOREIGN BODIES IN THE EXTERNAL EAR. Animate as well as inanimate bodies are frequently found in the external ear, where they become of great surgical importance from the annoyance, inflammation, pain, and deafness which they are very apt to produce, as well as from the fact that they may find their way into the middle ear, Eustachian tube, or even into the internal ear. Their source may be either from within or from without. Under the first class may be placed : abnormal collections of ear- wax from the ceruminous glands ; masses of horny epithelial scales, forming the so-called Keratosis obturans of Wreden ; and collections of stiff hairs from the tragus and auditory 'canal ; also clotted blood, inspissated aural discharges, scales of dead bone, and, in one sense, rn any of the new formations of the external ear. But, of these varieties of foreign bodies, only the first three should be considered here, and the remainder are discussed elsewhere. . Under the second head may be classed all animate or inani- mate things small enough to have gotten into the external ear. 288 EXTERNAL AUDITORY CANAL. The manner in which they smay get into the ear is extremely varied. Foreign bodies of this class are most frequently found in the ears of children, where they are placed usually in play, by the victim or its companions ; or foreign substances may be thrust into the ears of adults and of children, by accidental or intentional violence. Animate bodies fly or crawl into the ear of man. FOEEIftN BODIES OKIGINATING IN THE EAR. Collections of Cerumen in the Ear. — According to P^tre- quin, the cerumen consists mainly of fat and combinations of potash and fatty acids in the following proportions: In 100 parts of cerumen are found : 10 parts of water, 26 of fat, 38 of soapy combination of potash soluble in alcohol, 14 of a similar combination insoluble in alcohol, and 12 of entirely insoluble organic matter, with traces of chalk and soda. The name cerumen is probably a corruption of a word com- pounded of cera and aurium, the wax of the ear. ' The M'ord cerumen, however, does not appear in modern Latin dictionaries. The appearances of an impacted plug of cerumen in the external auditory canal are not very varied. Usually, they are easily recognized, but now and then, especially when the im- pacted mass is due to slow accretion by the daily pushing in and smoothing down of its layers by the towel or fingers of the patient, it will not be easy for the unpractised eye to recog:- nize the mass at once as one of cerumen, for, in some cases, the impaction has so completely adapted itself to the fundus of the meatus and the drum-head, as to resemble a dark and polished membrana tympani. In many cases such a polished mass of cerumen may be regarded as a somewhat abnormally colored drum-head, and treated as such, the deafness dependent upon the impaction of the wax being attributed to other causes, and in some way connected with the " discolored membrana tym- pani." Such failures in diagnosis lead to curious results. It is, indeed, not uncommon to find patients suflfering from impaction of cerumen in the auditory canal, being treated for some other aural affection which they do not possess. Thus, the Eustachian catheter and instillation of nitrate of silver have FOREIGN BODIES. 289 been applied to relieve the deafness which a proper syringing would have speedily cured. The mere fact that the drum-head is hidden from sight should be sufficient proof that an abnormal obstruction has occurred in the auditory canal, and this alone ought to be considered as the probable cause of the unpleasant symptoms for which the patient seeks relief. These unfortunate failures in diagnosis are but the natural result of the unwillingness on the part of most medical men to devote any time to the study of diseases of the ear, but they are mistakes which might be prevented if the general medical eye were at all familiar with even the appear- ances of a normal drum-head and meatus. In fact, many an ear might be saved if the physician first consulted could frankly state to the patient the nature and locality of his aural disease, although he might be unwilling to assume the treatment of it. The rapidity with which masses of cerumen accumulate in the external auditory meatus varies greatly. In some indi- viduals, I have removed second and third obstructive plugs in the course of a few months. In other cases,, judging from statements of the patients, the plug must have been accumu- lating, and giving some annoyance in the way of tinnitus and deafness, for years. As a rule, the deafness caused by a plug of cerumen in the auditory canal is of sudden approach, although the foundation of the offending mass may be much anterior to the hardness of hearing. In most cases the aggravated deafness comes on suddenly after a bath. In such cases, the patient thinks that water has gotten into his ear and is still there, or just after washing out the concha or meatus in the morning, a little more forcibly than usual, the patient finds that he can- not hear so well. In the former ease, the mass which has, up to the time of the bath, permitted the sound waves to pass it, becomes swollen by the water which has gotten into the ear, thus cutting off all approach to the drum-head. In the latter case, not only the water, but the patient's finger, by pushing the plug further in, has contributed to the onset of the hardness of hearing. Etiology of Ra-pid Formation of CerMmen.— There are many opinions respecting the cause of a rapid and abnormal secretion of cerumen, such as is seen in all walks of life. As the ceru- 19 290 EXTERNAL AUDITORY CANAL. minous glands are really perspiratory glands modified, it is reasonable to suppose that a large amount of cerumen is in some way connected with the perspiration. Large amounts of ceru- men are found in the laboring classes, whose perspiratory system is of course very active, and I have observed that in persons leading a life of ease, in whom large and rapid masses of ear- wax are sometimes formed, the perspiratory glands in the axilla are unusually active. But I am not prepared to say that when- ever the axillary glands are unusually active we are sure to find large amounts of ear-wax in such cases. After certain acute processes in the ear, as for example furunculi in the canal, or an otitis media acuta, which has healed rapidly, I have ob- served a tendency to a rapid formation of normal wax in the ear. This is apparently due to the stimulation of the circula- tion of the meatus consequent upon the acute inflammatory aural disease. It is held by some^ that quinine, which affects the nervous structures of the inner ear, may also have great influence over the sound-conducting parts of the ear, i. e. the external and middle ears, and that therefore the secretion of cerumen is stimulated by this drug. The amount of cerumen is sometimes increased, after a tonic course of treatment for the general health, in certain cases of deafness. But the repeated formation of obstructive masses of cerumen in the auditory canal appears to be an idiosyncrasy' in some cases, and is probably unexplained yet. The only apparent connection between it and other glan- dular activity has already been mentioned as possibly occurring in some cases in which active perspiratory glands and abnormal accumulations of wax have seemed to be united. But in such cases great care must be taken to discriminate between impac- tion of cerumen and keratosis obturans, a disease to be described hereafter. When the onset of hardness of hearing in cases of impacted cerumen is rapid, it will usually be found that the mass has formed without the knowledge of the patient, and is in no way due to his endeavors at cleansing the auditory canal. When the deafness due to impacted cerumen has been coming on slowly for months, sometimes for years, it will usually be " Roosa ; Transactions American Otological Society, 1873. FOREIGN BODIES. 291 found that the patient has been in the very bad habit of swab- bing out Ms ears, most commonly with the rolled-up corner of a towel, and sometimes with that most pernicious and repre- hensible implement, a piece of sponge fastened to a stick, and sold by the druggists under the high-sounding name of an " aurilave." In these eases the plug will be found well packed in and moulded to the fundus of the auditory canal and drum- head. Such masses are not very hard to remove, considering the long period of their accumulation ; they are usually found to contain large quantities of short fibres of cotton or linen from the towel used in the eftbrts to cleanse the ear. Impaction of cerumen by attempts at cleansing the meatus not only occurs among adults, but is found among children, whose over-anxious attendants are constantly swabbing out the meatus of their charges, with a corner of a towel, or with other means. ^ Such cases may sometimes result in what may be called a chronic ulcer of the bony portion of the auditory canal, or in the growth of a large polypus from an ulcerated spot on the wall of the bony meatus very near the drum-head. lu these cases of artificially impacted epidermis and cerumen, the foreign mass usually assunies the form of a hollow cast of the auditory canal, or a glove-finger, with a cast of the drum- head on the tip. These cases are usually stubborn, and in some instances threaten the integrity of the bony structure of the auditory canal. In a case which I saw recently, not only a polypus sprang from the ulcer in the auditory canal, but the drum-head was ulcerated through, and water passed into the pharynx when syringed into the external ear. The patient, a boy eight years old, was carefully watched over by his nurse, who used daily the so-called aurilave, upon the little patient's ears. The impacted mass of epidermis and cerumen at last excited pain in the ear, and upon removal of the mass, which came out in the glove-finger shape, the skin of the auditory canal was found to have assumed almost the appear- ' Similar conditions of the ear liave been observed by Mr. Hinton of London. See supplement to Toynbee on the Ear, London, 1868, p. 439. 292 EXTERNAL AUDITORY CANAL. ance of a mucous membrane. The most ulcerated portion was at the anterior wall near the drum-head, and the latter was perforated largely at the postero-inferior quadrant. The dis- charaje was rather thick and dark-colored, not very copious, somewhat offensive, but the hearing was very little altered. Under daily syringing and mild astringents the membrana tympani closed up, and the patient disappeared from my treat- ment for six weeks, at the end of which time, when he was brought again to me, the membrana tympani was found to be still intact, but from the ulcerated spot in the canal near the drum-head, a polypus, the size of a small pea, was detected in the furrow between the drum-bead and the antero-inferior part of the bony canal. The polypus was removed, the discharge ceased directly, and the hearing became normal. Treatment. — The treatment of simple impaction of wax in the ear consists in the use of the syringe, as explained already (p. 175). Cretaceous Bodies in the External Auditory Canal. — According to Rau^ cretaceous masses in the auditory canal are the rarest kind of foreign bodies found in the ear. But accounts of such bodies being scattered throughout the works of other writers, they appear not to have been very uncommon. Du Verney and Leschevin^ appear to have had frequent ex- amples of them in their experience, and in Williams' Treatise on the Ear' (London 1840), the statement is found, on the authority of Auteurieth of Tubingen, that " in the bodies of almost all old people there is found, in the innermost part of the meatus auditorius externus, a firmly attached lump of indurated ear-wax, which, in old age, acquires a disposition to crystallize, partly in an earthy form," and also that " Morgagni has found the cerumen of the hardness of stony matter." But these bodies are not frequently met in the present day. I am ' Ohrenheilkunde, pp. 367-368. The authorities given are, Thom. Bartho- lini, acta medica et philosoph. Hafniensia ann. 1671 et 1672, 4 T. I. p. 82. L. C. F. Germanni, de miraculis mortuorum libri tres. Dresd. et Lips , 1709, 4 Lib. 8. Tit, 8. Sect. 50, p. 1090. Du Verney, p. 156. C. J. Myller, miscall, nat. cur., Dec. 2, Ann. 6, Obs. 262, p. 826. CoUomb, CEuvres M6d. Chirurg., Paris, 1790, p. 304. 2 Lincke's Sammlung, L No. 1, p. 29, 1835. = p. 184. FOREIGN BbDIES. 293 not aware of any record of such a case in modern literature, nor have I ever met such cases in the many hundreds of ears of old people I have examined in various infirmaries. But, since it is a well-known fact that mineral substances, such as potash, chalk, and soda, enter into the composition of the cerumen, it is not improbable that now and then stone-like bodies are found in the auditory canal, which owe their existence to the mineral elements of the cerumen. If they were once more frequently met with than in the present day, and such appears to be the case, it can be accounted for only by the greater prevalence of the custom of syringing and cleansing the ear among the laity at the present time. Treatment. — If such bodies should be found in the ear, the treatment of them may be effected as detailed in the general summary at the end of this chapter. Laminated Epithelial Plug in the External Auditory- Canal. — This obstructive disease of the external ear has recently been described by Wreden^ of St. Petersburg, and named by him keratosis obturans, in contradistinction to ceruminosis obturans, the impacted plug of ear-wax, with which it has often been confounded, though differing from it very widely. The latter disease, as its name implies, consists of a mass of inspis- sated cerumen, but it is easily removed by proper syringing, and the ceruminous nature of the mass removed from the ear is recognized, among other features, by the i-apidity with which it dissolves in water. Keratosis obturans, however, recently described as a separate and special disease of the ear, is a collection of epithelial lami- nse, derived from the cutis of the external auditory canal, of gradual accretion, causing great deafness, and very obstinate in its resistance to removal. Every one who has had any extended experience in removing from the ear impacted endogenous masses, usually of cerumen, must have noticed that now and then a peculiar mass is encountered, requiring a piecemeal re- moval by patient, and careful use of syringe and forceps, and which, after lying a long time in water, will not dissolve as ordiuary ear-wax- does. It is such exceptional masses that ' Archives of Oph. and Otol., 1874. 294 EXTERNAL AUDITORY CANAL. Wreden has investigated, and, finding that their composition is not of cerumen but of the horny elements of the cutis, he has proposed for them the name of keratosis obturans. These obstructive bodies are not confined to any age or sex. Wreden states that his attention was first called to their pecu- liar nature by meeting a very adherent one in the ear of a little girl. In this case he was so fully impressed with the suspicion that he was dealing with a wad of soft white paper, maliciously placed in the ear by the young patient, that he accused her of the deed, and, although she denied it, he was not convinced of the truth of her denial until the microscope revealed the fact that the mass he had with great diflaculty removed was com- posed of epithelial elements arranged in peculiar laminae. Upon inspection of an ear containing such a mass as has been de- scribed, a thin layer of ordinary cerumen may be seen covering the outer surface of the plug, and hence the impression often gained that the case is one of ordinary ceruminous impaction. But continued syringing, by its barren results, soon convinces the operator that he has encountered no ordinary obstruction. The first case of this disease I had the opportunity of ob- serving occurred in July, 1874, since which time I have seen several cases in private as well as in the infirmary. The patient was a banker, sixty years old, suffering from sudden and intense deafness in the occluded ear, with some tinnitus and vertigo. The auditory canal was almost entirely blocked up by the dense, horny mass, with the outer end covered by cerumen. The patient stated that ten years previous he had been liable to attacks of pain in the auricle, especially about the lobe, which were followed by a crop of vesicles and pustules, probably a form of herpes zoster. Since then he has had no pain in or about the ear, but at times he has noticed, without any appa- rent previous cause, a thin and somewhat offensive discharge; At first sight I thought the case one of impacted cerumen, mingled possibly with inspissated mucus and pus, but the utter failure of the attempts with the syringe to move the impacted mass at the first sitting convinced me that the case was one of those described as keratosis obturans. Owing to the fact that the auditory meatus was rendered abnormally tortuous by two large exostoses of the canal, one above, the other beiow, it required patient and careful picking FOREIGN BODIES. 295 and syringing for half an hour for eight days before all of the foreign body was removed, with, at last, a restitution to nor- mal hearing. From statements of the patient it appeared probable that similar though smaller and less annoying plugs had been removed from the same ear before, by himself, but he could not give any idea as to the length of time the present one had been forming, as the onset of deafness, the only symptom first attracting his attention to the ear, had been almost instan- taneous. This patient had a slight return of the disease, one year after the above attack, but it was entirely removed by soak- ing the mass repeatedly for twenty-four hours with a solution of bicarbonate of soda (gr. xx) in glycerine and water, aa f,?ss. Usually in these cases of keratosis in the external ear, no part of the mass comes away as a coherent plug, but the whole must be broken down and removed in small pieces. In the case narrated, however, about half of the mass was removed as a well-defined plug. When the horny and laminated mass was first washed out of the ear, it was perfectly white, and resembled a set of layers of wet tissue-paper slightly separated from each other by the buoyant eflfect of the water. When pressed upon, it had the tough leathery feel of a wad of wet paper, which peculiarity will always distinguish it from the ordinary cerumen-plug of soft and greasy consistence. As insolubility of the removed mass is one of the distinctive features of this peculiar aural disease, a mass may remain as long as five months in glycerine and water without undergoing change. I exhibited such a mass at the Philadelphia Patholo- gical Society, in December, 1874. This specimen, for several months longer, lay in the same preservative fluid, and still there was no dissolution of the mass. Of course, had the mass been formed of ceruminous elements, it would have melted down almost instantly, and distributed itself throughout the fluid. This resistance to solution will readily account for the diffi- culty of its removal from the ear. Etiology. — 'So cause has been suggested for the occurrence of this disease of the external ear, and, although among the lami- nae composing these masses Wreden has sometimes found vege- table spores, he is not inclined to ascribe the origin of the mass to the irritative presence of a fungus in the auditory canal. 296 EXTERNAL AUDITORY CANAL. I have observed that the walls of the auditory canal in these cases is not healthy, but presents a more or less roughened sur- face, with inflamed hillocks, and it may be a chronic inflamma- tion of the skin of the canal, which predisposes it to this peculiar and slow exuviation of its horny elements, which being retained in the canal, at last form into this extremely tough and resisting plug. Treatment. — In cases showing a decided tendency to recurrence or renewal of these growths in the ear, care in preventing an accumulation of the horny laminae, by close watching and speedy removal of the slightest amount of scales, will greatly simplify the disease and the treatment. The solution of soda already mentioned (p. 295) will be the simplest and the best loosener of the plug from the wall of the canal, but sooner or later recourse must be had to forceps and blunt probes, for this disease seems to furnish the exception to the rule never to use anything more forcible than the stream from the syringe for the removal of foreign bodies from the ear. Of course the greatest care must be observed in the use of such instruments, and no one but the most experienced surgeon is justified in attempting to remove such a mass by instrumental means. It is with great caution that I advise their use, and still greater caution that I use them ; but as I have resorted to them, and only by their use succeeded in removing the keratosis, I must, in these cases, give their due to such instruments. With perfect illumination of the meatus, proper instruments and cautious movements, added to a thorough knowledge of the use of the implements and the part to be operated on, success must attend their application. The forceps, represented in the wood-cut, same size as origi- nal, is made to open and close very gently, and, being slender, cannot take a very firm hold upon the impacted mass of kera- tosis, but it is strong enough to pick offhand lift away portions of the obstruction. The loss iu strength caused by the narrow- ness of the branches of the instrument is fully compensated in the greater illumination gained by its slender shape, and it is also a much safer instrument than the stronger, thicker, and stiffer forceps usually made for removing foreign bodies from the ear. For removing objects more delicate than masses of FOREIGN BODIES. 297 keratosis obturans, it is of the greatest value. It is just as necessary to have such a delicate instrument as this to lift things from the ear, as it is to work with delicate and very- pliable forceps in manipulating small objects undergoing pre- paration for microscopic use. In fact most aural instruments are too large. Illumination of the canal has too often been sacri- ficed to the strength of the instrument. Fig. 65. Delicate Forceps fob removal op Foreign Bodies from the Ear. Prof. Gruber^ recommends forceps with branches quite as delicate as these, but much shorter. The longer branches enable the operator to keep his hand much more easily out of his own light. I fully agree with those who earnestly deprecate the use of any other instrument than a syringe for the removal of foreign bodies from the ear, as we shall usually find that where a syringe will not remove the foreign body no other instrument will serve our purpose. But like all other good rules, it has its exception. The forceps of course must never be tried until all other means have proved of no avail, and then only in the hands of the most experienced and under the most perfect ill umination ; for any manipulation of the ear resembling a blind grappling after the foreign body will most surely prove disastrous. Un- " Lehrbuch d. Ohrenheilkunde. 298 EXTERNAL AUDITORY CANAL. fortunately the proper occasion for the use of the forceps is almost invariably in an emergency, and is performed by the most unexperienced hands. An examination into the facts of the case, moreover, where they must be used, will usually reveal that originally they were not needed, and the simplest syring- ing at the outset would have rendered the use of any other instrument unnecessary. The only justifiable use of forceps at the outset may be in a case of keratosis obturans, but even in such cases all instru- ments must be used with the greatest caution in conjunction with repeated and thorough syringing. The accidents happen- ing to the ear, from the ignorant use of instruments for the removal of foreign bodies, are very numerous and are increasing in number all the time. Ingrowing Hairs from the Tragus, resting on the Mem- jbrana Tympani. — Sometimes, though rarely, the growth of hair on the tragus may be so copious as to block up the external meatus or pass into the canal and rest upon the drum-head. Such cases have been* observed and reported by Dr. "Weir,' of Xew York. In some instances the entire auricle, especially at the helix and tragus, may be the seat of excessive and almost ludicrous pubescence. In such cases of excessive amounts of hair near the auditory canal, loose hairs may get into the auditory passage, or masses of them block it up so as to induce hardness of hearing. The symptom of single hairs on the drum-head will be a scraping sound heard only by the patient whenever the jaws are moved. If cerumen aid in the matting of the hair about the external meatus, considerable deafness may be the result. Treatment. — Epilation may be applied to the hairs on the tragus as a preventive means. If the hairs have led to obstruc- tion in the canal, the foreign mass must be removed on general principles. ' Transactions American Otological Society, 1870, p. 30. FOREIGN BODIES. 299 FOREIGN BODIES FROM WITHOUT. Inanimate Objects. — From time immemorial children have pretended to place various kinds of seeds, beads, etc., in one ear and bring them out at the other, for the amusement of them- selves or their younger and more ignorant companions. The latter are often victimized by attempting to imitate the deeds of the elder children, and succeed only as far as inserting the foreign body. Some time ago, I removed a honey-locust bean from the ear of a negro-boy, thirteen years old, where there is every reason to believe the bean had been introduced two years before. The bean was in a perfect state of preservation, and had given no trouble to the boy, who said he had been induced to " put it in his ear, because he had seen the big boys do the samp thing, pretending to remove it again through their noses." He had tried the experiment and failed, but, as the inserted bean never gave him any pain, he had never told any one of, it, "for fear of parental punishment." While examining the ear for purposes of comparison with another, I discovered the bean, whereupon the boy told the above tale. The bean was finally lifted out by forceps with the greatest ease. Children are very fond of stroking their faces and various parts of their body with beads or any similar object with a polished surface. It is while thus amusing themselves, by stroking their ears, that beads, etc., often slip into the audi- tory canal. The variety of such bodies found in the ear is end- less, being wads of paper, all kinds of seeds, and small beans, beads, round tips of pencils and penholders, pieces of slate-pen- cils, and little stones, buttons, etc. Usually the foreign body is placed in the ear by the victim ; sometimes it is pushed in there slily by his playmates. Sometimes during quarrels various long objects, such as straws, pencils, pen-holders, bodkins, etc., are thrust into the ear maliciously, both among children and adults. I remember a case in which a woman, having a grudge against a man, watched her chance to box his ear, during the time he scratched his ear with a pen-holder, siich being his custom. The opportunity offered itself, the man received his box on the ear, and the pen-holder, being pushed suddenly into the canal, penetrated the drum-head. While this could hardly be called a foreign body which 300 EXTERNAL AUDITORY CANAL. remained in the ear any length of time, it serves to show how the ear may he injured by even a short presence of a foreign body in it. Foreign bodies remaining some time in the ear are usually found among little children, as already stated, or if a foreign body is found in an adult, it will often be found upon inquiry to have been put there during childhood. I have in my cabinet a specimen illustrative of such a case. It is a blue bead seven mm. in diameter, four mm. in thickness, and perforated at its centre, removed with a mass of inspissated cerumen from the right meatus auditorius externus of a woman 68 years old. The patient was entirely unaware of its presence in her ear, and, of course, could give no account of its mode of getting there. It was in all probability placed there in her childhood and forgotten, as it produced neither pain nor deafness. Later, however, the accumulation of cerumen became so great as to cause deafness, and the removal of the obstructive mass to relieve the deafness led to the discovery of the blue bead. Upon closer inspection of the bead by the patient, she stated that she could recall having played with just such beads when she was about eight years old, and such being the case, it is fair to presume that the bead had quietly I'csted in her ear for sixty years, one of the longest periods of retention of a foreign body in the ear on record. Dr. Ludwig Mayer,' in an article on foreign bodies in the ear, mentions four cases in which the foreign substances were in for four years, two for twenty years, one for forty-five, and one for over sixty years. The case I have just narrated would of course be a rival of the last one named in Mayer's list. Deleau states that he once removed a small snail-shell from the auditory canal of a woman, who knew nothing of its pre- sence in her ear.^ The same autbor relates having removed from the ear of a boy five years old another shell (pucellage), after it had caused pain and distress by its presence in the ear for a year. MarchaP extracted a coral bead, with a ragged surface, from ' Monatsschr. f. Ohrenheilkunde, Jahr. IV. No. 1. 2 Gazette Medicale de Paris, tome ii. 1834, No. 11, pp. 161-163. ' Revue M6d. Franqaise et Etrangere, Jan. 1844. FOREIGN BODIES. 801 the ear of a military officer fifty years old, in whose ear the head was placed when the patient was fifteen years old. Some time since I removed by a few gentle streams from the syringe a small pearl shirt-button from the ear of a little girl six years old, after I had given her ether. Before she came to me her ear had been very roughly handled by picks and probes, but not once syringed. As she had become very nervous about the painful treatment of the ear, I gave her ether, and the ease with which I syringed out the button only served as another proof of the folly of instrumental picking, probing, pulling, etc., to remove a foreign body from the ear. The ear had commenced to discharge when I first saw her, and the canal was greatly swollen, yet the syringing brought away the oiFending body. Yet we hardly dare call such a body offend- ing ; that term should be applied to the heroic treatment with curettes, etc., to which the unfortunate little victim had been subjected. All kinds of corrosive and scalding fluids, melted metals, etc., are not only exceedingly painful but threaten the life of the suf- erer if poured into the ear. Morrison^ records a case of death following the instillation of nitric acid into the ear. Eau'^ states that melted lead poured into the ear of a drunken man produced deafness with purulent discharge and paralysis of the corre- sponding half of the face, and became so firmly imbedded in the ear that as late as seventeen months after this accident the metal could not be removed. A case similar to that reported by Eau recently occurred in St. Mary's Hospital, Phila., during the service of Dr. Schell. Within a short time I have seen the evil efiects of scalding fluids upon the ear. The case was that of an Irish girl, 20 years old, who had been induced to pour boiling oil into her ear for some slight trouble in it. The agony which ensued was intense, and, although the acute symptoms had ceased entirely when I saw her, the drum-head was white and thick, like a piece of heavy paper, and the hearing was gone. It would seem almost superfluous to mention such folly, but the general ignorance respecting the delicacy of the ear demands such recitals as warnings. ' Wilde, page 378. 2 Ohrenheilkunde, § 319, and Med. Chirurg. Zeitung, 18j3, No. 39. 302 EXTEENAL AUDITOKY CAKAL. While considering fluids which have proved highly injurious to the ear, it may be well to consider briefly some of the odd and, in a measure, irritating fluids placed in the ear for the cure of otorrhcea, deafness, etc. As these fluids have usually done no harm, beyond causing a loss of time and money to the patients, the recital of them may afford another proof of the general ignorance of the nature of ear diseases, and a universal tendency towards doing the improper thing for this delicate organ. Among a large number of patients from the ignorant classes frequenting the dispensaries and infirmaries in our city, I have rarely met one, whose malady was of any duration, who had not tried applications of human urine, woman's and cow's milk, cow-dung, rabbit's fat, neats-foot oil, Harlem oil, the juice of clams and oysters, eagle's gall, etc. Only one man, forty years old, mentioned the imaginary excellence of eagle's gall, but he had spent considerable time and money for more than a year in his endeavors to obtain this coveted cure, and, at last having succeeded in getting it, he had applied it for a long time to his ears. As the man had brought on, by his life of a hunter, an obstinate and progressive form of middle-ear catarrh, it is needless for me to state that his disappointment was great at the want of success on the part of his long-sought remedy for deafness. A curious and self-inflicted irritation from a foreign body in the ear occurred in the case of a young printer, finally applying for relief at the author's clinic in the Philadelphia Dispensary in 1872. The young man stated that two weeks previous to his call at the dispensary, he had placed the core of a roasted onion in his ear, for a slight earache. The pain soon ceased and the onion core was forgotten or " supposed to be absorbed" by the patient, until the secondary irritation, discharge, and hardness of hearing caused by its presence in the auditory canal, drew the patient's attention a second time to his ear. Without any further attempt at self-medication, he applied at the dispen- sary for relief, and, upon examination, I found the auditory canal entirely blocked up by the swollen and rotten remains of the onion core. The walls of the canal were irritated and excoriated, and a horribly stinking discharge poured from the ear, while the mechanical deafness was great. One good syringe- FOREIGN BODIES. 303 ful of warm water removed the offending mass, restored the hearing, and revealed the fact that the drum-head, though deeply macerated, was still intact. With the use of an astrin- gent wash for a few days, this man regained a sound ear. Sometimes the foreign matter is entirely harmless of itself, and might remain in the ear indefinitely, without exerting an injurious effect. The efforts at its removal, made by the igno- rant, are the true cause of injury to the ear. This is illustrated in the following case: — On the 80th of April, 1872, Mr. E. 8., a machinist, 39 years old, consulted me for pain and deafness in the left ear. He stated that three days previous, while crossing a street, a horse had splashed mud in his ear, which at that time was perfectly sound. Upon returning to the shop where he was employed, his ear was examined by some of his comrades, who said they saw " something in the ear," and proceeded to extract the foreign matter with '■'■chips and mechanics' small tools." This of course caused the patient great suffering, for he said " several little white pebbles were taken out" (probably ossicles, as there was no trace of them in the ear when I examined him), and great deafness ensued in the thus roughly handled organ. The pain increased, and a large, red, hard tumefaction appeared under the left auricle and extended to the angle of the inferior maxilla. The patient, naturally a very strong and powerfully built man, was very pale, anxious, and bathed in cold sweat when I made the first examination. There was no discharge from the ear at the time he presented himself to me. My large testing watch, audible at least forty feet, was heard by this man only about two and one-half inches. He heard my voice only when I spoke very close to his ear, and this probably, only by bone conduction. The tuning-fork, vibrating on the vertex, was heard by the patient very distinctly in the affected ear. Upon inspection I found the meatus in this case uninjured. A small piece of black street-mud was adherent to the antero- superior quadrant of the periphery of the membrana tympani. The membrana tympani was found to have been entirely de- stroyed, excepting a very narrow peripheral band, and there was not a trace of an ossicle visible, all of these important structures having, without doubt, been torn out by the ignorant endeavors of the man's friends to remove the mud which had been splashed 304 EXTERNAL AUDITOBT CANAL. into the ear. The inner wall of the tympanic cavity was fully exposed to view, revealing healthy, pale, shining mucous mem- brane, slightly abraded on the promontory. By the Valsalvan method of inflation air passed through the perforation with the characteristic whistle. Twenty days later I saw the patient again at the dispensary. He had been hard at work ever since the injury, not excepting Sundays. He had entirely neglected to follow any of the simple directions I had given him, viz., to apply three large leeches to the swollen glands near the auricle, and to remain quiet. The pain and tumefaction had disappeared, however, and the patient was ruddy and cheerful once more. Wo air passed through the perforated drum-head at this visit, and the hearing distance remained permanently unaltered. Upon inspection I found the edges of the perforated membrane adherent to the promontory and inner wall of the tympanum, the former appearing to pro- ject into the meatus in consequence of the excessive retraction of the small remnant of the membrana tympani around it. It is interesting to notice the sudden and great loss of hearing in this case, as showing the comparatively greater importance of the destroyed ossicles than of the perforation and destruction of the drum-head. A simple accidental perforation of the mem- brana tympani or drum-head, rarely, if ever, causes such a degree of deafness as was found in this case, in which the evulsion of the ossicles must be regarded as the real cause of the great deafness. The impaction and long retention of foreign bodies in the ears of children may lead to deaf-dumbness, which may be cured by removal of the obstructions in the external auditory canals, as was shown in a case observed by Dr. Sara E. Brown' of Boston. In this case, twenty-eight small gravel stones which had lain in the external auditory canals for seven years were re- moved, and recovery of the hearing ensued. This child, a lad of sixteen years, was an inmate of a school for feeble-minded chil- dren, where he had been placed in consequence of his retarded mental development, following his deafness. After the pebbles were removed, the lad became more intelligent in expression, and he regained the use of his speech, which he had begun to lose at the age of nine years, when he placed the gravel stones in his ears. ' Archiyes of Oph. and Otol., vol. iii. pp. 88-90, 1874. FOREIGN BODIES. 805 Animate Objects in the Ear.— Usually, insects which are found in the ear have crawled or flown in during the sleeping hours of the patient. Of course this is most likely to happen to those who sleep upon floors or on the ground. Bakers, who, working at night and becoming very tired, lie down on the floor of the hakerj', always infested with roaches, are very apt to be awakened by the presence of a roach in the ear. The peculiar elongated shape of this insect permits it to wedge itself in the auditory canal, which holds it tightly enough to prevent its escape but not to kill it. It therefore is apt to make most violent endeavors with its front feet to escape, and in so doing it scratches and scrapes upon the deeper parts of the auditory canal and drum-head. Such movements are productive of great annoyance and pain to the patient, and if the animal is not removed, severe inflammation will be set up. Fleas, too, often find their way into the ear, and by their powerful leaps against the drum-head, which produce a noise said by the patients to resemble thunder, cause intense discomfort to the sufferer. Very recently. Dr. Gassner^ found the Dermanyssus avium, or chicken-loiise, in large, numbers, in the ear of a cow, where the parasite had excited a well-marked otitis externa. Von Troeltsch, to whom this specimen was sent, after consulting the literature pertaining to the natural and pathological history of such parasites, makes the following statement : " This animal, the Dermanyssus avium, has never been found in the ear of man ; it would be worth while, however, to look for it in the pus escaping from the ear, as well as the water used for syringing certain diseased ears." Chicken-lice might fall into the external ear of man from chickens flying suddenly and swiftly above his head. I examined, in the early part of the summer of 1875, an intelligent man's ear, and found large cicatrices in the mem- brana tympani, with greatly diminished hearing. The patient stated that in his boyhood, while playing in the fields, the so- called devil's darning needle or dragon-fly had thrust itself, or its long pencil-like body, apparently accidentally, into his ear. Instantly, great inflammation and pain were set up in the organ, ' Von Troeltsch, zur Lehre von den thierisclien Parasiten am Menschen, Archiv f. Ohrenheilk., vol. ix. p. 193. 20 306 EXTERNAL' AUDITORY CANAL. knd the' hearing power was ultimately nearly lost. It seemed probable, from the statement made by the yOung man, that a portion of the insect's body must have broken off and remained in his ear, but it cannot be said positively that such vras the case. M. Gu^rin reported to the Soci^t^ de Chirurgie the case of a soldier, who had returned from Mexico, suffering from facial neuralgia and other affections, which were relieved upon the escape of an Ixodes hominis from the sufferer's ear.' I syringed, not long since, from the ear of a little boy two years old, a dead fly, which was totally enveloped in a kind of epithelial cyst. The mother of the little patient informed me that a year previous, in the summer time, -the child had been attacked suddenly with pain, as she supposed, in the ear, and that his sufferings were so intense as to produce convulsions. The meatus was entirely occluded by the encysted fly ; but upon removal of the foreign mass, the membrana tympani was revealed as perfect, and the hearing became normal. Dead flies are sometimes sj'ringed from the ears of children afflicted with otorrhcea, to which they, are attracted by the odor of the discharge, but in most instances produce no pain or sub- sequent trouble by their presence in the ear. I washed three from the ear of a little girl not very long ago — one the first day I saw her, in very warm weather, and two more on the following day. But there was no subsequent irritation caused by their having flown into the ear and died there. In some instances, however, maggots grow in the ear after it has been invaded by flies. Heine^ and Blake' have published accounts of the gro^Vth' of maggots in the ear, and the latter authority has described minutely the apparatus by which these creatures maintain "a hold in, and wound the canal and drum- head. The former writer describes a case of a little' girl two years old, subject of a chronic otorrhoea, who had gone to sleep in the hot sunlight with the diseased and offensive ear exposed to the incursion of the flies, and in consequence thereof maggots had sprung up in the ear. ' Hinton, op. cit., p. 78. ^ Lincke's Sammlnng, ii. p. 181. ' Living Larvae in the Human Ear. Archives of Oph. and Otol., vol. ii. No. 3. FOREIGJSr BODIES. 307 In the course of a few days, fat, white maggots, with heads spotted black, were seen in the fundus of the auditory canal. Oil was poured into the ear, and as each maggot came to the surface of the oily bath, it was seized with forceps, and thus all trouble was removed from the ear. Heine states that he has never failed to remove maggots and all living creatures from the ear, by means of oil in a very few minutes. But the majority of surgeons have not been so fortunate. One of the earliest if not the first case of transformation of the maggot through various stages to the fly, after its removal from the ear, is recorded liy Dr. Kuntzmann,^ who said, although he had frequently seen and read of maggots in the ear, he was not aware that any surgeon had brought about the perfect trans- formation of such creatures when found in the ear. The case he reports is that of a boy six years old, the son of a poor woman, who was brought to him on 17th July, 1811, for a terrific pain in the ear, which had already lasted fourteen days without any cessation. Bloody pus was found exuding from the auditory canal, which was greatly swollen. Otherwise the boy was healthy. Twenty-four hours after the boy was first seen, quantities of living bodies were detected in the ear, and six large, fully-developed maggots were extracted with the forceps. The pain then ceased, and all symptoms disappeared in a few days with syringing and mild astringents, and the hearing remained perfectly normal. Each maggot was seven lines long and one line thick ; their color was whitish-yellow ; they consisted of several soft rings which fitted one within the other ; on their heads they had two brown, horny hooks, curved downward, between which was the so-called dart (E^aumur), which was not exactly like that of the common house-fly maggot, but curved, yet not so much as the two hooks. This was the only distinctive feature be- tween the two varieties of larvae. Two of these maggots were obtained by the author quoted, and placed in a confectioner's glass jar, in which dry and care- fully sieved earth with a piece of meat was placed to- furnish > Hufeland's Journal der practischen Medicin, August, 1834, S. 108-111. Lincke's Sammlung, ii. p. 178. 308 EXTERNAL AUDITORY CANAL. food for the worms. They did not attack the food, but instantly buried themselves in the earth and on the second day were found to have passed into the chrysalis state. " The chrysalides were brown, cylindrical, tapering each way to a blunt end, immovable, and consisted of several rings, like .all chrysalides of the fly." 'On the fourteenth day after their transformation into the chrysalis, fully developed flies escaped from the shells, which were described as' " very beautiful, gray and black flies, with silver-gray head and beautiful, bright, cinnabar-red eyes; the bright redness of the eye was lost after death, and the color then became dark-brown." These flies were then presented to Count Von Hofmannsegg, who placed them in his cabinet, where they proved to be unique specimens, theretofore undescribed. Prof. Illger pronounced them to be a new species of the class Tachina, and named them Tachina signata. To the Tachina signata found in this case may be added the larvEe of the Muscida sarcophaga (Blake and Gruber) and the Muscida lucilia (Blake). The pain excited by the presence of larvae in the ear is intense, and drives the sufferer to frenzy and even into convulsions. They are usually found in ears previously affected with a more or less offensive otorrhoea, though in the case related by Dr. Kuntzmann the ear attacked by .the larvae was entirely healthy before invaded by the fly which deposited the noxious egg. The pain attending the presence of maggots in the ear is easily explained by the investigations of Kuntzmann and Blake.i The latter authority placed the larvae in a glass vessel con- taining a piece of raw meat soaked in warm water, and then observed the movements and actions of the larvae under the microscope. He found that the apparatus by which the maggot makes and retains his hold is composed of a delicate horny framework, armed with two hooks, of a stout horny nature, articulating with the aforesaid framework. By a repeated ex- tension and retraction of the hooks, the animal pierces and tears the softest and deepest tissues it can lay hold upon. Hence it is ' Archives of Opli. and Otol., ii. No. 3. FOREIGN BODIES. 309 found always in the fundus of the auditory canal and sometimes in the tympanic cavity. Treatment. — From the investigations of Blake and others it appears, that, since maggots retain such firm hold upon the structures of the ear, after they once get in there, syringing and instillations of fluids which would not injure the ear are insuflicient to kill and dislodge such creatures. Blake, Gruber, and others are of the opinion that nothing short of actually seizing the maggots with suitable forceps, and pulling them out, will satisfactorily remove them from the ear. As will be seen from the cases of Heine, Kuntzmann, and others, already recited, worms or maggots may be smothered by oil while in the auditory canal, or they may be syringed out, or they may even crawl out voluntarily, but these are excep- tional cases. Sometimes maggots do not appear willing to seize flesh when placed in their way, but burrow immediately in the earth, as already stated in Kuntzmann's case, and I have observed that a mass of maggots which were just extruded from a fly showed no tendency to seize some meat which was given them, but, on the contrary, burrowed between it and the sides of a glass vessel containing it and them. As maggots are extremely hard to kill by any fluid not in- jurious to the ear, T obtained some for experiment, from a fly, by causing her to extrude her brood of 50 to 60 living creatures about 2 mm. long, '^hese I placed in a glass vessel with the dead fly and nothing more, and after twenty-four hours found them still alive. I then placed a little piece of cold roast-beef, softened in water, into the glass for the maggots to live upon. In twenty-four hours later I found them active and grown to be 5 mm. long, and their alimentary canals stained by the brown juice of the roast meat. In order to try the feflfects of some easily obtained fluids innocuous to the ear, upon the maggots, I placed a maggot, ]S"o. 1, in a few drops of refined kerosene oil. It crawled repeatedly from the oil and continued to live, though constantly thrust back and kept submerged in the oil. This maggot was finally killed in another way. Maggot No. 2 I placed in a saturated solution of salicylic acid (bleached, prepared by Hance Bros. & "White, of Philadel- phia). This one died in a half hour. 310 EXTERNAL AUDITORY CANAL. N'o. 3 I placed in alcohol, and it died in five to ten minutes. No. 4 I placed in ether fortior (Squibh), and killed it by this means in two minutes. 1^0. 5, 6, and 7 I placed in chloroform, and they were instantly killed. Dr. Roosa has found chloroform vapor, as well as Labarraque's solution of chlorinated soda, fatal to the life of these creatures.' An eighth specimen I placed in hydrant water, which seems, as Dr. Roosa has also observed, to make them more lively at first, and they continue to live and work their savage hooks for a long time, even in a glass vessel where they can gain no hold. Water appears not to have the slightest effect in arresting their vrork when they have once gained a hold in the soft, moist tissues of the ear. Even after they have been killed by various applications to the ear, the forceps may be required to detach them, so firm is their hold. Calomel sprinkled over them has been said to kill maggots in the ear ; also solutions of tannin have effected their destruc- tion. Foreign Bodies in the Eustachian Tube and Middle Ear. — In Mayer's article^ on foreign bodies in the organ of hearing, -we learn that three were found in the Eustachian tube. One of these bodies, a barley-corn,^ was found imbedded in the bony portion of the tube, but projected as far as the faucial end. The other two were lying in the wide faucial end of the Eusta- chian tube. The imbedded barley-corn was found at a post mol-tem, the cause of death not given; Bougies not uncommonly break and leave portions behind them in the Eustachian tube. When the bougies are armed with cotton, feathers,^ hairs, etc., this is more likely to occur. In two cases, recited by Mayer, laminaria bougies broke oft", and remnants were left in the Eustachian tube. ' Treatise on Diseases of the Ear, p. 166. 2 Monatsschrift f. Ohrenheilkunde, Jahrg. IV. No. 1. " Prof. Fleisclimanu's Case. Hufeland's and Ossan's Journal, June, 1835, pp. 25-38. ■* Hecksher of Hamburg. Mayer's Article, loc. cit. FOREIGN BODIES. 311 In some instances the foreign feody is rudely pushed at last, by endeavors at its extraction, into the middle ear. One of the most interesting of such cases is given by Deleau,' Jr. It is that of a little boy, who placed a small gravel-stone in his ear, in play with his comrades. The unskilful endeavors with a curette to remove the body, in conjunction with the struggles of the boy, ruptured the drum-head, pushed the gravel- stone into the tympanic cavity, produced hemorrhage and in flammation of the ear, temporary paralysis of the corresponding side of the face, and excessive photophobia in the eye of the paralyzed side. This much happened while the boy* was still in the provincial town where the accident occurred. He was brought to Paris, two weeks later, and Deleau examined the ear carefully, found the pebble seated in the cavity of the tympanum, with its only visible facet in the same plane with the drum-head. By gently touching the body it was found firmly grasped by the swollen mucous membrane of the middle ear, and being so near the chain of bones all traction upon the pebble was deemed highly im- proper. Deleau now wished to use forceps composed of several branches, but tbe patient positively refused to permit any further manipulation of the ear from without, but consented to the introduction of a firmly fitting catheter into the Eusta- chian tube. The third injection of water through this instru- ment threw the offending pebble into the concha. The otitis in this case soon disappeared, but there is no positive statement as to the condition of the hearing. Among the rare instances of this occurrence, is one observed by Moos.^ Before . Prof. Moos saw the case, an unsuccessful endeavor had been made by a physician to remove a coffee bean from the external auditory canal, under chloroform. After unskilful manipulation the bean disappeared from view. Puru- lent inflammation set in, perforation of the drum-head occurred, the incus exfoliated, and numerous polypi were developed. The latter were removed, and, by syringing, together with antiphlo- gistic treatment and the use of astringents in the ear, the bean 1 Lincke's Sammlung, i. pp. 153-157. Gazette M6d. de Paris, 3d Series, tome ii. 1834, No. 11, pp. 161-163. 2 Archives of Oph. and Otol., vol. iii. pp. 103-107, 1873. 312 EXTERNAL AUDITORY CANAL. came into view, though it had passed into the tympanum and could not be seen by Prof. Moos at the first examination, immediately after the removal of the polypoid growths. Upon the authority of Itard and Andry, Rau mentions a case in which an ascaris wandered from the alimentary canal, through the pharynx, into the Eustachian tube. Sudden and powerful coughing in haemoptysis may force blood through the Eustachian tube into the tympanic cavity, where irritation and pain may be set up in consequence of the foreign matter thus brought in contact with the tympanic mucous membrane.' Treatment; Removal of Foreign Bodies from the Ear. — When a foreign body is said to be in the ear, the surgeon should first satisfy himself that such is really the case before he begins any operation for its removal. Grave errors have occurred from the neglect of the surgeon to assure himself on this point. When it is fully decided that the statement of the patient or his friends is really correct, that a foreign substance is really lodged in the ear, if the latter has not become irritated and swollen by the attempts of others at the removal of the foreign substance, usually a gentle syringing, the patient's head being inclined towards the affected side, that gravity may aid our efforts, will bring away the foreign body. In order to carry this out in very young children, already alarmed hj the acci- dental entrance of the foreign body, we may have to resort to etherizing the patient. In any case, when syringing will not remove the foreign substance and th« ear is at all inflamed and swollen, nothing more forcible than syringing should be at- tempted until the local irritation in the ear is allayed. Too often the attempts at removal of a foreign body from the ear are far more injurious than its presence in the ear. After all irritation is allayed, which can often be effected, though the foreign body is still in the ear, syringing may be resorted to, and usually with success, in removing the foreign substance. If this fails, and it appears that other means are demanded for the removal of the impacted foreign body, the greatest care and skill are now needed, in order to avoid • Eindringen von Blut, in die Paukenholile bei Hsemoptoe. Arcliiv f. Ohrenh., Bb. xi. p. 31. Dr. Kiippe. FOREIGN BODIES. 313 injuring the ear. A great many plans for removal of foreign bodies impacted in the ear have been suggested. Voltolini' recommends the use of the galvano-caustic for the removal of foreign bodies which, by unskilful manipulation, have been forced from the meatus into the tympanic cavity and have become imbedded there. By this means, he has cut up and removed piecemeal a bean which had been pushed through the membrana tympani and pressed into the drum-cavit3\ A bean cannot be properly cut up, however, until it has been softened by repeated injections of water. Then momentary glowings of the finest silver wire cautery will char the bean, and the offending body can be gradually removed after several repetitions of the operation, on different days. But no one not extraordinarily familiar with diseases of the ear, as well as with the use of the galvano-cautery, should attempt such an operation. Voltolini has very justly said the most that can be asked of the general practitioner is not that he shall remove, a foreign body such as this from the ear, but that he shall recognize its presence and leave it alone. It cannot be too often brought to mind that it is not the presence of a foreign body that causes ultimate harm to the patient, but the unskil- ful endeavors to get it out. Among the various ways of removing impacted bodies from the external ear should be mentioned the agglutinative method. It has been recently revived by Dr. Lowenberg,^ of Paris. This method was fully described by Riverius^ and Celsus,^ and is also given by Eau.° It consists in smearing with glue or some equally tenacious substance, a piece of linen, cotton cloth, or the like, firmly attached to a handle, which is brought into contact with the foreign body in the ear, and then allowed to remain until perfect adhesion takes place. Then, in most instances, the foreign substance can be Jifted out with the above-named instrument. This method was employed in this country, some years ago, by a layman, Mr. Eli "Whitney Blake,^ ' Ueber fremde Korper in der Paukenliohle und deren Entfernung. M. f. 0., No. 5, 1876. 2 Berliner Klin. Wochenschr., No. 9-10, 1872. 8 Opera Med. Francofurti, M.DC.LXXIV., Cap de Surditate, p. 261. « Strasbourg edition, 1806, p. 342. " Op. cit,, p. 375. ^ C. Hooker, Boston Journal, 1884. 314 EXTERNAL -AUDITORY CANAL. of Conn., for the purpose of removing a foreign body from the ear of a boy employed in his carriage factory. A somewhat similar method is to apply to the foreign body a piece of adhesive plaster fastened to a string, and then warm the minia- ture disk by means of a burning glass. "When adhesion has taken place, traction on the string may remove the foreign body attached to the adhesive plaster. This method is one suggested by Dr. E. H. .Clarke, of Boston. Removal of foreign bodies from the ear by incision through the bony meatus from without and behind the auricle was proposed by Paul of -i^Sgina, but entirely rejected by Fabricius of Aquapen- dente.' Recently, in the case of an impacted bone pencil-head in the tympanic cavity. Dr. IsraeP separated the auricle from its posterior attachment to the mastoid portion of the osseous auditory canal, and, after a crescentic incision had freed the periosteum, the latter with the auricle was drawn forcibly forward, and the foreign body seized and removed through the opening thus formed. Before Dr. Israel saw this case, unskilful manipulation had driven the foreign body from the external auditory canal into the tympanum. The case then began to manifest very curious nervous phenomena. After the more acute inflammatory symptoms consequent upon the introduc- tion of the foreign body and the endeavors at its extraction had subsided, the patient complained of great pain in both arms, the trunk, and the hips, while the head and ear were free from suflfering. Left pupil dilated ; fibrillar twitchings in the orbi- cularis of the left eye and the left levator alse nasi. Excessive hj'peralgesia of the skin in the painful parts of the body caused the patient to scream when touched. On the left side all the symptoms were more pronounced than on the right side. A day later vomiting and irregular pulse ; contraction of the left hand forced the fingers upon the palm; the latter was overcome only by painful and forcible extension. Subcutaneous injections of atropia | mgrm. relieved the eon- traction, the hyperalgesia, pain, and inequality of the pupils. The hyperalgesia returned, however, and toothache set in. After the removal of the foreign body from the tympanum, all nervous phenomena vanished. ' Leschevin ; Lincke's Sammlung, i. No. 1, p. 35. 2 Berlin Klin. Woclienschr. No. 15, 1876 ; also M. f. 0. No. 7, 1876. RESULTS OF INFLAMMATION AND INJURY. 315 CHAPTER III. EESULTS OP INFLAMMATION AND INJURY. Abscesses in the external auditory canal may lead to an eva- cuation of their contents through the duct of Steno,' or through the cleft found in the posterior superior part of cartilage of the auditory canal as descrihed by Poorten, after the occurrence of otitis externa circumscripta.^ Caries of the meatus may follow inflammation of the middle ear f in such a case described by Blake a portion of the mastoid wall of the osseous meatus, one inch long and half an inch wide, came away. Mr. Toynbee met with a case of chronic inflammation of the external auditory canal which extended to the bone and brain, producing death.^ But these are not the commonest results of inflammation in the auditory canal. Those more likely to be met are now about to be described. Chronic Circumscribed Ulceration in the External Auditory Canal. — Chronic difl^use inflammation of the external auditory canal sometimes ends in the formation of distinct and circumscribed ulceration at one spot in the passage. From this diseased point an inflammatory process may be communicated to the tympanic cavity, and hence ulceration in the external auditory canal becomes of importance. Ulceration on the wall of a patulous auditory canal must not be confounded with those cases of secondary inflamrfiation of the skin of the canal, mentioned by Kramer,' " which result from caries of the meatus and of the tympanic cavity, or from destruction of the membrana tympani with disorganization of the investing mem- ' Hribar ; Wiener Med. Presse, No. 161, 1871., 2 Monatsschr. f. Ohrenheilk., June, 1873. 3 0. J. Blake, Trans. Am. Otol. Soc, 1872. * Diseases of the Ear, 1868, p. 73. 5 Diseases of the Bar: Bydenhan Soc, London, 1863. 316 EXTERNAL AUDITORY CANAL. brane of the tympanum. In such instances the meatus tumefies, becomes indurated like cartilage, smooth, and dark red; the opening closes up till it will only admit the head of a pin ; there is a thin acrid discharge, and on introducing a probe, bare, rough, and carious bone may be felt in the deeper part." The ulcers especially alluded to here are found in the unyieldilig skin of the bony portion of the auditory canal, and by their general features of chronicity and sluggishness remind one of the ordi- nary leg ulcer. They throw off a scanty, dark-gray or greenish discharge, somewhat offensive, which shows a tendency to form a dark crust around the mouth of the canal. Sometimes the discharge seems to have ceased, but in a few days it returns again, and, if allowed to run on, the disease will tend to form polypi and to attack the drum-head. The latter becomes congested, all its normal features are lost, and upon syringing the ear, water may pass into the nose and throat. The hearing up to this time may not be much impaired, for the middle ear has remained intact. Upon the occurrence of the perforation, however, the hearing is endangered. In any case, therefore, where there is found a discharge from the ear with an intact membrana tympani, the most careful search should be made for the cause, and, if an ulcer is found in the bony portion of the external auditory canal, to it the treat- ment should be directed. Itard,' when speaking of erysipelatous diseases of the external ear consequent upon erysipelas of the head, alludes to vesicles which form in the auditory canjil, and upon breaking, are con- verted into true ulcers, which suppurate for a long time. Others, including N. E. Smith,^ Williams,^ Wilde,* Rau,' Toynbee,' and E.oosa,' allude with more or less distinctness to an ulceration of the meatus, as a separate and chronic form of aural disease. Etiology. — The causes of this disease are often obscure. But • Maladies de I'Oreille, Paris, 1831, p. 168. 2 Supplement to translation of Saissy on the Ear, Baltimore, 1839, p. 318. « Treatise on the Ear, London, 1840, p. 116. * Aural Surgery, American edition, Phila., 1853, p. 199. 5 Lehrbuch d. Ohrenheilkunde, Berlin, 1856, p. 179. fi Diseases of the Bar, 1868, pp. 79-80. ' Treatise on Diseases of the Ear, 1873, p. 144. EESULTS OP INFLAMMATION AND INJUEY. 817 it will generally be found that a neglected inflammation in the canal has run at last into the chronic disease here described. Treatment. — The treatment should consist in removal of any irritant which keeps up the ulcer, and in stimulation of the inflamed spot. The latter is best accomplished by cauterization by means of strong solutions of nitrate of silver or of chloro- acetic acid, conveyed to the ulcer by means of cotton on the cotton holder. All discharges are to be most carefully cleaned out by syringing, and the general health of the patient examined into and built up if necessary. As scrofulous children are liable to be the subjects of this kind of local trouble in the ear, iron and cod-liver oil will play a most important part in the treat- ment of such ulcerations, when occurring in them. In the interval between the applications of the above local remedies, which of course are to be efl:ected by the surgeon two or three times a week at the outset, the patient's ear should be cleansed at home several times a day, and a mild astringent wash applied by instillation to the auditory canal. The hearing is not usu- ally afl:ected in the early stages, but it will be, unless the disease is arrested. The prognosis is favorable if the ear is attended to in time. Cholesteatomatous Tumors In the Auditory Canal.— Cholesteatomatous or pearly tumors are said, by Lucse and others, to occur frequently in the external ear. They do not appear to be common in this country. Dr. Kipp' has given an account of the occurrence of this disease in both ears of a man 27 years old. These cholesteatomatous masses are usually found in ears which have been the seat of chronic suppuration, but in which the latter process has apparently run its course. In such cases, the mucous membrane of the middle ear, as well as the cutaneous lining of the external auditory canal, seems to retain a tendency to the exfoliation of large masses of epithelial scales, which, accumulating in the ear, undergo a fatty degeneration and give rise to various symptoms, among which the more prominent are pain at times in the ear (but this is not a promi- nent characteristic of these formations), nausea and dizziness, with occasional vomiting. The hearing is of course impaired ' Archives of OpU. and Otol., vol. ir. 318 EXTERNAL AUDITORY CANAL. by the mechanical hindrance offered by these masses, which may be so large as to cause absorption of the bone of the audi- tory canal and a consequent widening of this passage. Even greater irritation than this may ensue as a consequence of the presence of such collections in the ear, and the bone structures on which they press may become carious. The soft tissues thus pressed upon ulcerate and become covered with granulations in some instances, and the membrana tympani and ossicles under- going erosion, the entire tympanic cavity is occupied by the cholesteatomatous layers. The' microscope reveals these forma- tions to be lamellated in structure, the layers of which are composed chiefly of flattened epithelial cells and crystals of cholestearine. In addition to these elements Dr. Kipp has found, in these cholesteatomatous masses, " fatty acids, and minute shining bodies, some round and others irregular."' Treatment — The treatment of such accumulations should con- sist first in the complete removal of the obstructive mass. This may require some patience, for the removal of the more external layers often reveals the presence of deeper and fresher ones, and in some cases new ones seem to form during the treatment. The latter tendency is best combated by an alterative astrin- gent, as solutions of nitrate of silver, sulphate of copper, and zinc. The softening and retaoval of these masses is hastened by the use of solutions of bicarbonate of soda in glycerine and water. Exostoses of the Auditory Canal. — Exostoses, or bony growths of a rounded, hillock-like shape, are frequently found in the external auditory canal. They are covered by the skin of the canal, are entirely painless, and the only annoyance they give is due' to their encroachment upon the calibre of the canal. Their size varies from that of a merely distinguishable elevation on the wall of the canal to that large enough to occlude the canal and produce deafness. The skin covering them is a little paler than that of the canal. Etiology. — These osseous growths may be congenital, or they may be the -result of chronic inflammatory processes in the ' See Dr. Mathewson's Report on the Progress of Otology, Transactions of American Otological Society, 1875. RESULTS OF INFLAMMA'TIOW AKD INJURY. 319 middle and external ear. They are frequently found in those who have been afflicted for a long time with discharges from the ear, though they are also very often found in those whose ears are otherwise normal. According to some authorities, exostoses of the meatus in some instances are plainly of a syphilitic origin. They may develop in the auditory canal at the same time with exostoses on other bones, as shown by Gruber, but he does not consider that all such bony growths in the canal have a specific origin. Contrary to the rule in other parts of the body, they are usu'ally painless in the auditory canal. He has described several cases in which hyperplastic growths of the bone of the meatus were associated with a similar aftection in the bony portion of the Eustachian tube, without, however, possessing any syphilitic origin.' Usually, the causes of exostoses in the auditory canal are obscure, although in many cases Toynbee's theory, that they are due to the rheumatic and gouty diatheses, may be satis- factory. As far as my experience goes, they have been met more frequently in such diatheses than in any others. Dr. C. T. Blake^ has described a peculiarity observed by Prof. Wyman first in the crania of Hawaiian Islanders, and subse- quently in the crania of Peruvians, consisting of exostoses of the external auditory meatus occurring uniformly on the supe- rior and inferior lips of the lamina forming the posterior wall of the passage, the same peculiar growth being described by Welker as occurring in the crania of American Indians. Out of three hundred and thirty-four Peruvian crania examined by Prof. Wyman, these growths were found in six,- and in various degrees, from a small pedunculated growth on the snperior lip of the lamina to double growths on both lips nearly occluding the orifice of the passage. It was "boticeable, moreover, that these growths were nearly uniform in size and shape on both sides. Out of eight Peruvian crania, belonging to the collection of Mr. Blake, in the Warren Museum, but one presented this peculiarity, and then only in the form of an elongated ridge upon the posterior wall of the meatus on one side. The suppo- sition that aquatic habits might have to do with the presence • Lehrbuch der Ohrenheilk., p. 412 and 576. ' Report on Process of Otology, 1874. 320 EXTERNAL AUDITORY CANAL. of these growths, though applicable in the case of the Hawaiian Islanders, would not apply to the Peruvians, living as they did in a tract of country remote from the sea and remarkable for its aridity. That the occurrence of these growths is coincident with the development of the wall of the osseous meatus, as sug- gested by Dr. J. 0. Green, is further supported by the fact that the location 'of the growths was a constant one. The treatment of exostoses in the external auditory canal will be referred to further on. Osseous Closure of the Auditory Canal. — The considera- tion of exostoses in the auditory canal leads naturally to the consideration of osseous closure of the canal and the deafness which ensues. Such a closure of the auditory canal may be congenital or acquired. In a case of the former kind, described by Knapp,' the closure of the auditory canal, on one side only, was associated with rudimentary development of the auricle. The acquired form appears to be the commoner, and this fact should lead to a most careful treatment in those diseases of the ear attended with ulceration and gra,nulations in the external auditory . canal. If such growths are found in the auditory canal, great care on the part of the patient should be observed in not picking at or irritating them in any way. Acquired bony closure of the canal has been observed and described by Bonnafont,^ Dr. L. B.,^ Mathewson,^ and others. In the cases named, operations for relief of the deafness were performed successfully'. The only case of bony occlusion of the auditory canal which has come under my notice presented itself in the right ear of a man 58 years old, and from the history of the case it may bo called one of acquired bony occlusion of the auditory canal. At eight years of age the patient was operated on in the Pennsyl- vania Hospital, for polypus of the left ear. After repeated attempts at extraction of the polypoid growth, which were fol- lowed by severe cauterization with solid sulphate of copper, ■ Transactions American Otological Society, 1870, pp. 86-87. ' L'Union Medicale, May, 1868 ; also Gazette des Udpitaux, No. 64, 1867. s Arcbiv f. Ohrenlieilkunde, Bd. x. p. 110. ■> Report of 1st Congress of International Otological Society, New York, Sept. 1876. RESULTS OF INFLAMMATION AND INJUKT. 321 great pain and total loss of hearing, he was removed by his parents from all further treatment. In 1874, about fifty years after the above-named operations, an examination of the ear revealed a shallow meatus, closed at the bottom by ordinary skin. Nothing resembling a drum-head was visible. The skin at the fundus of the shallow auditory canal moved under the Sigl^ pneumatic speculum. The hearing was reduced to no- thing for external sounds, per aerem. Bone conduction, how- ever, very good on the occluded side. Tuning-fork on the vertex heard best in the occluded ear. Eustachian tube was found to be pervious to air by Politzer's method, and the ordinary cathe- ter. The patient, a man of more than ordinary intelligence, was fully conscious of the entrance of air into his right tympa- num, by artificial inflation, as well as whenever he swallowed. As he was desirous of having an operation on the occluded ear for relief of his deafness, I made an exploratory incision with a paracentesis knife, but found that beneath the skin of the fundus of the canal, there was a bony partition cutting oW the external from the middle ear. Considering the age of the patient and the good condition of his left ear, I was unwilling to perforate the bony septum in the auditory canal ; but it is probable that such an operation might have been carried out with success in this case. The pathology of this case most probably consisted in acute inflammation, followed by suppuration, which was allowed to become chronic. Then there ensued a growth of polypi, for the extraction of which, several rough and painful operations were undertaken. Subsequently, the excessive granulation-tissue be- came organized into a bony septum, covered by a reflection of the normal cutis of the auditory canal. In Dr. A. H. Buck's valuable contribution to the " ultimate forms of granulation-tissue in the ear,"' it is stated that " a mass of granulations may become covered with skin or mucous membrane, and its central portions undergo a change into true osseous tissue." Respecting this form. Dr. Buck says " it would be difficult, particularly in this locality, to determine whether a real transi- tion from granulation-tissue to bone takes place, or whether ' Transactions of American Otological Society, 1874. 21 322 EXTERNAL AUDITORY CANAL. simply the local irritation assumes a new phase, the cellular hyperplasia or formation of granulation-tissue ceasing and bone being formed." I am of the opinion that the closure of the canal I have just narrated was caused by a transformation of a mass of granulations into true bony tissue, at a point about half-way down the auditory canal. Since the subcutaneous and submucous tissues of the ear are, at the same time, periosteal coverings, it is reasonable to suppose that such acquired osseous occlusion as has been described cannot be so very rare, but often escapes recognition. Treatment. — Exostoses in the external auditory canal demand no treatment, unless they occlude the canal and cause deafness by this obstruction. Then they may be bored through or cut away, as has been suggested and performed by several operators. Dr, Mathewson, in the case referrecl to, p. 320, used successfully the dental lathe as the motive power to turn the drill. The skin is to be removed in these cases before the bone is operated on, and to do this, Dr. Mathewson has employed the- instrument known among dentists as the scaler. The bony growth was then perforated at several points near its centre, with the smallest of the drills, about one and a half mm. in diameter. This was easily done, and then larger drills, two and a half to three mm. in diameter, were used to widen the opening thus gained iu the bony diaphragm. The hemorrhage was not excessive, though there was enough to slightly interfere with the operation. But the auditory canal was kept syringed and swabbed out, so that in half an hour a complete canal to the drum-head was made. The granulations which arose subsequently were combated with nitrate of silver, and in the course of a few weeks the drum- head could be seen at the fundus of the canal. The discharge, gradually ceased, and the hearing became normal. As Dr. L. B., of Hamburg, gives an account of an exostosis in his own auditory canal, and the operation on it, by Dr. Knorre, of the same city, the case demands more than a passing notice. The first symptom of deafness occurred in the patient's forty- third year, in 1868, after a bath. On attempting to pick the ear, to free it from water which was supposed to have lodged there, an obstruction was felt by the patient, which he seized and roughly pulled upon. This caused considerable pain and RESULTS OF INFLAMMATION AND INJURY. 323 inflammation, with diminution of hearing. Upon consulting Dr. Knorre, the obstruction was pronounced by him an exostosis near the memhrana tympani. Mild astringent treatment was advised to allay the discharge and inflammation excited hy the patient ; the hearing then gradually grew better, and four years of undisturbed hearing were enjoyed. In 1873, the hearing began to grow worse, apparently without any exciting cause, but the bony tumor was found to be increasing in size ; Dr. Knorre then proceeded to remove the bony obstruction by boring and chiselling. The obstruction was overcome by successively re- moving parts of it with a drill and chisel, touching the bony growth with hydrochloric and sulphuric acid, burning it with a red-hot knitting needle,- and filing down the free surface of it by means of delicate files, smooth on one side, such as are used by jewellers. Most of this treatment was attended with severe pain, so that intervals of rest were rendered necessary on account of the tenderness of the ear. The operations for removal were commenced in June, and by the following January the free surface of the growth had been so much removed as to give a free space between it and the opposite wall of the auditory canal, and the hearing became once more normal. The patient attributed most of the success to the chiselling performed by Dr. Knorre ; ^he other operations were performed by the patient himself. Other forms of acquired obstruction in the external auditory canal may he partial or total, and they may consist of cutaneous bands, diaphragms of skin or bone, and of horny growths. Dr. Engelmann,' of St. Louis, has described a case in which a bridge-like band of skin stretched across the external auditory canal, from one wall to the other. This, he thought, was proba- bly due to a union of two granular surfaces. Dr. A. H. Buck, of New York, has described a similar case.^ Dr. Eoosa^ found, in a case of chronic suppuration of the middle ear, a cartilaginous baud stretched across the outer portion of the canal. Upon division of this band, it was found to contain " scales of bone which seemed to come from the posterior portion of the canah" ' Archiv f. Ohrenli., Yol. ii., N. F. 2 Transactions American Otol. Soc, vol. 1. p. 536. 3 Ibid., 1870, p. 90. 324 EXTERNAL AUDITOEY CANAL. Cutaneous Closure of the Auditory Canal.— Cutaneous closure of the canal at any point appears to be more frequent than bony closure of the same. It may be congenital or acquired. This kind of obstruction in the canal is not alwa^ys recognized at once, especially if the diaphragm of skin is stretched across the canal near the fundus ; in such a position, the obstruction may so closely resemble a thickened drum-head as to lead to some confusion in diagnosis. Dr. Morland' has described a case of congenital imperforation of the auditory canal, caused by a cutaneous diaphragm in the cartilaginous portion of the canal, with hyperostosis of the bony portion. In this and in other cases the imperforation was not discovered until disease and deafness in the other ear drew at- tention to the imperfect hearing in the imperforate ear. In this case, the external ears were well formed. The occlud- ing cutaneous layer in the auditory canal appeared to be a " perfectly natural and smooth extension, or prolongation from the common covering of the auricle. It was not red nor un- even, nor as if thickened by previous or existing disease ; but white and uniform in appearance with the surrounding skin." After the patient was etherized, a crucial incision of the occluding cutaneous diaphragm was made, and the four result- ing flaps were removed with small curved scissors. Ap aperture, " about as large as a crow-quill," was made, through which a probe was cautiously passed, until it impinged against what was probably the drum-head. The lining of the meatus ap- peared normal, but there was considerable hyperostosis in the bony portion of the canal. No view of the inner portion of the meatus could be obtained. A piece of compressed sponge was then inserted, and subsequently sponge-tents were inserted, and the ear cleansed every few days, by the family physician of the patient. By Dr. Morland's advice, a gold tube was also worn in the meatus, and the ear healed in two months, with good hearing. Dr. A. H. Buck^ has recorded the case of a young woman, 26 years old, affected with otorrhcea in the right ear in childhood, in whose right auditory canal he found "a smooth parchment- ■ Transactions American Otol. Soc, 1870, pp. 31-34. '■ Ibid., vol. 1. pp. 586-E87. RESULTS OF INFLAMMATION AND INJURY. 325 like membrane of slight but uniform concavity, outwardly." It had a translucent appearance, with no evidence of being pro- vided with vascular supply, and it was tough and decidedly thicker than the membrana tympani. When this was pressed upon by a probe it yielded with a crackling sound, audible even to the by-standers. This horny diaphragm was continuous with the skin of the meatus at all points. A free crucial incision was made through this membrane, and it was found to lie about a line on the outer side of the normal plane of the membrana tympani. Through the incision thus made by Dr. Buck, the red and succulent mucous membrane of the promontory was all that could be seen at first beyond the diaphragm. As an evidence of the vitality of the false membrane, it is stated that " at the end of the examination a glistening border of bloody serum was noticed along the cut edges of the triangu- lar flaps. At a subsequent visit it was ascertained that the malleus was still present, its tip being adherent to and covered by the tissues of the promontory. The short process of this ossicle could be distinctly recognized at the inner edge of the base of the false membrane, which had now become " a simple constriction with sharply cut edges." Dr. Buck states that subsequent to his publication of this case, he learned from Dr. Simrock, of isew York, that the latter had seen three cases of false membrane, resembling the one just quoted, in one of which the membrane lay much nearer the external orifice of the auditory canal. In some cases polypoid growths, invading the same transverse plane of the auditory canal, may grow together, and skin forming over them, a diaphragm is formed, which stubbornly occludes the canal at that point. Beyond the diaphragm the passage may be normal. In some cases an orifice is found in the centre of this dia- phragm, and by dilatation of this the diaphragm may be reduced to a constriction simply, and then the latter carefully widened.^ In such a case the constriction may be overcome by an appli- cation of nitric acid, made only once, as in the case of Dr. Buck referred to. ' See case by Dr. Buck, Transactions American Otolog. Soc, vol. i. p. 538. 326 EXTERNAL AUDITORY CANAL. Dr. 0. J. Blake^ has met tumors of a horny nature in the audi- tory canal. These growths closely resemble the cornua humana'. (See p. 231.) Epileptiform Symptoms from Irritation in the Auditory Canal. — It is well known that irritation set up in the auditory canal by the presence of a foreign body will produce epileptiform and even paralytic symptoms. This is amply confirmed by the experience of Fabriciua Hildanus, Toynbee, Von Troeltsch, Wilde, Handfield Jones, Hillairet, Moos, and others. It therefore becomes of the highest importance to examine the ear among other organs in a case of epileptiform disease of doubtful origin. The possibility that the ear or a foreign body in it may have something to do with the case in question should lead every physician to examine this organ or have it examined. It would be but safe to examine the ear as often as the pupil of the eye. Ear-cough. — Ear-cough, a name recently applied by Dr. Fox, of Scarborough, England, to a peculiar reflex cough, excited by irritation of the external auditory canal, was known to medical men a long time ago. In the celebrated case, given by Fabricius Hildanus (1596), among the various reflex neuroses mentioned as the result of irritation of the external auditory canal by the presence of a glass bead, was a peculiar dry cough. Tissot^ wrote of this peculiar cough as generally known in his time, and narrates an instance of it in " a French gentleman who consulted him for total deafness, but whose external audi- tory canal he could not touch, without occasioning a violent cough (toux tr^s forte), which was absolutely uncontrollable." He also states that EtmliUer (Francofurti, 1696-97) had ob- served, that, by touching the external auditory canal with a probe, one could produce a dry cough, which the latter attrib- uted to the " sympathy between the nerves of the ear and those of the trachea." Pechlin^ regarded the peculiar cough (ear-cough) arising from ' Trans. Amer. Otolog. Soc, vol. i. p. 538. ' Trait6 des Neifs et de lenrs Maladies. Paris et Londres, 1780, pp. 54-56. ' Observationum Pliysicomedicanim Ties libri, lo. Nicol. Pechlini, Ham- bnrgi, auno M.DC.XOI., Lib. 3, obs. 45 — quoted by Tissot, op. cit., p. 55. RESULTS OP INFLAMMATION, AND INJURY. 327 irritation of the external auditory canal as a common occurrence, but mentions as a rarity a peculiar reflex sympathy (" consensus") existing between the ear and the stomach (I'ouie et I'estomac), a striking example of which he observed in a military officer, who vomited considerably whenever his extremely sensitive external auditory canal received the slightest touch even of the finger. "With the object of ascertaining the percentage of those subject to this sympathetic peculiarity. Dr. Fox carefully examined one hundred and eight persons; males, thirty-seven; females, forty- five ; sex not noted, twenty-six. His conclusions are as follows : — "1. From amongst the unknown group of idiopathic coughs, may happily be rescued from obscurity a cough which is excited by an irritation of the meatus auditorius externus in certain individuals. " 2. The persons referred to are those who possess a hyper- sesthetic condition of the nerve supplying that canal, and in whom any slight titillation of this nerve induces a feeling of tickling in the throat. " 3. This hypersesthetic state generally exists in both ears, sometimes, however, only in one, and occurs in about twenty per cent, of those examined. " 4. Its existence can usually be traced to childhood, and i? probably a congenital peculiarity. " 5. The nerve of the ear concerned in the production of ear- cough, is not a branch of the "^agus, as Romberg and Toynbee have affirmed, but is a branch of the auriculo-temporal branch of the fifth cranial nerve. " 6. This sympathy between the ear and the larynx is an example of a reflected sensation, in which the connection be- tween the nerves involved takes place in the floor of the fourth ventricle. " 7. Vomiting is occasionally, but rarely, the result of the application of an irritant to the nerve distributed to the audi- tory canal." Sometimes otitis externa difl^usa will also produce the most obstinate ear-cough. The attacks may not be frequent, but they are severe and distressing, not uncommonly ending in vomiting. 328 EXTERJTAL AUDITOEY CANAL. Bleeding from the Meatus. — Hemorrhage from the ear occnrs not uncommonly from traumatic causes which apparently produce no further lesion. A physician informed me recently that, slipping suddenly, he struck his mastoid process violently on a projection of some kind in his office. The blow was fol- lowed by hemorrhage from the meatus, but by no further trouble. Hemorrhage from the meatus, connected with injuries to deeper parts of the ear, will be considered further on, when alluding to injuries of the internal ear. Bleeding from the ear has been observed in some instances of suppressed menstruation. It may be preceded by pain and a sense of fulness in the ear, to which it will give relief.* Treatment. — If the bleeding is due to an injury limited to the skin of the external canal, a mild styptic may be required. In any event the blood must not be allowed to form permanent clots or crusts in the meatus. ' Hinton ; Questions of Aural Surgery, p. 97. SECTION IV. MEMBRANA TYMPANI. CHAP TEE I. ACUTE AND CHRONIC INFLAMMATION, INJURIES, AND MORBID GROWTHS. Acute Myringitis, — la many eases it may be of great clini- cal convenience to speak of an inflammation of the drum-head ; but, anatomically, it is not easy to describe such a disease of the ear. By many it is regarded as one of the rarest of aural maladies, and some authors deny its existence. Being so intimate in structural relation with the external auditory canal on one side, and with the tympanum on the other, it is to be supposed that disease in either of these parts may very easily extend to the drum-head ; but as the middle or fibrous layer is the only layer peculiar to the drum-head, and as it has no nervous and vascular supply of its own, it may indeed be said in safety that a true myringitis rarely if ever occurs, ilifevertheless, it is often observed that an inflammation of the external auditory canal may localize itself in the outer layer of this important partition between the outer and middle ear. Perhaps, too, an inflammation of the mucous membrane of the middle ear may localize itself on the inner surface of the drum-head. Hence, clinically, many of the best observers pre- fer to tabulate myringitis among the diseases of the ear, for the fact is that an inflammation of the skin of the external canal or of the mucous membrane on the inner surface of the' membrana tympani, having culminated in the drum-head, will produce such modifications in that membrane as to demand attention somewhat different from that obtained if the inflammation occurring in these constituent structures had localized itself elsewhere. 330 MEMBRANA TYMPANI. Hence it is found that Dr. Blake and Prof. Gruber' have drawn especial attention to this disease, as far as it can be termed an independent one, in their clinical teachings. The latter repeats what he has stated in his treatise on the ear, that as an idiopathic disease myringitis is of rare occurrence ; as a secondary event very frequent. Symptoms. — A typical ease of so-called myringitis is character- ized by pain and tinnitus, but not intense hardness of hearing. Upon inspection it will be seen that the membrana tympani is congested, usually very greatly if the disease has advanced, but that its position is not abnormal, and that the adjacent wall of the auditory canal is little or not at all congested. At the same time the Eustachian canal may be found entirely free, and, if the membrana tympani be cut through, it will he found that there is no secretion in the tympanum. Hence, then, there may be an inflammation localized in the membrana tympani, the external auditory canal and the middle ear being free from inflammation. It would seem but fair_ to give the name of myringitis to such a disease, and mark out for it a special treat- ment. By further watching such a case, it will be found that the membrana tympani becomes gradually thicker from infiltration, and at last pus will be found on the outer surface, without the existence of a spontaneous opening in the membrane. By wiping away this product of inflammation, the outer surface of the membrane will be found very red, in some cases almost raw, and it will bleed if touched roughly. This condition of breaking down may go on to a. perforation by erosion, apparently from without inward, and an ulcerated spot may at last form on the outer surface of the drum-head. The hearing in the mean time, however, does not suffer as it does when the tympanic cavity is affected by disease. As I have assured myself, by means of the catheter and by incisions through the drum-head, that the tympanum is free from disease in all such cases as could be termed myringitis, which T have seen, I am disposed to consider so-called myringitis an inflammation usually, if not always, of the dermoid layer of the drum-head. I have seen so many of these cases, arising from external cold, ' Monatsschr. fiir Ohrenlieilkuncle, Nos. 9, 11, and 13, 1875. INFLAMMATION, INJURIES, MORBID GROWTHS. 331 that I am inclined to the above view of their nature. If the mucous surface only of the membrana tympani is inflamed, it is not easy to make such a delicate diagnosis, and, furthermore, there is no proof that inflammation would remain localized on the inner as it does on the outer surface of the membrana tympani. Doubtless, localized inflammation does occur on the inner surface of the drum-head, but the symptoms it produces are not as distinctive as those produced by inflammation of the dermoid layer. The symptoms of acute myringitis may be learned from the following case, which will also show the clinical significance of the disease : — A gunsmith, a large, healthy man, 40 years old, complained of some earache, considerable deafness, and marked tinnitus in his left ear, all of which he attributed to exposure to cold air on that side of the head for several hours, while at work. On inspection, the membrana tympani was found reddened, dr}'', scaJy, and somewhat thickened, i. e. it looked more like a piece of thick sheepskin than the delicate normal drum-head. The hearing was found to be g"^ in. for small watch. Tuning-fork, on vertex, heard best on affected side. The position of the membrane did not seem altered, but, as the latter looked thick, and as I suspected there might be retained secretion in the tympanum, the membrane was incised: nothing but air came whistling through the cut when Valsalva's inflation was per- formed. The hearing improved slightly. The perforation healed in a few hours, and the next day the hearing was reduced again to /g for the watch. The pain, though slight, continued; the membrane looked more swollen; the tinnitus was still annoying. In the course of two or three days, the man presenting himself at the infirmary, the membrana tympani was found to be covered with a film of pus, beneath which the membrane was quite red. The pain had now become less. Under instillations of zinc and opium, the secretion ceased, the drum-head healed, and the hearing returned, without there having been any symptom of disease, excepting in the dermoid layer of the membrana tympani. Differential Diagnosis between Acute Myringitis and Acute Otitis Media. — The disease most likely to be confounded with acute myringitis is acute inflammation of the middle ear, but it will 332 MEMBEANA TYMPANI. be found that there are some very characteristic features by which the one may be distinguished from the other. In acute otitis media there is found, early in the disease, an indrawing of the membrana tympani, without thickening, and the redness is limited to the manubrial plexus and the upper periphery. In acute myringitis, however, the membrane becomes first rough and evenly red all over, then thick and infiltrated, but not indrawn ; rather fiattened than otherwise, or its position remains very nearly normal. The pain in otitis media is intense, while in acute myringitis it is not so terrific. In the former disease, the secretion forms within the tympanum, and there is consequently a marked tendency to perforation of the membrana tympani from within outward. In acute myringitis there is no special tendency to perforation, though there may be such an occurrence in the membrane, by erosion from without inward. Then, further, the secretion in otitis media is copious, and it may be either of a mucous or purulent nature. In acute myringitis, however, it is scanty and purulent. In the former, the febrile and' constitutional symptoms are severe and often grave, while in acute myringitis, such severe symptoms are wanting. These facts, added to others previously mentioned,' would seem to warrant a conclusion that there may be, at least clinically, an independent disease, which may be termed acute myringitis. Etiology. — The most usual cause of myringitis is sudden ex- posure of the drum-head to cold. This may occur either from blasts of cold air on the drum-head or from exposure of it to sudden cold in plunging or bathing in cold water. The latter exposure is most commonly incurred at the seaside bath. The disease may also be caused by instillations of irritating fluids into the auditory canal or by violence from any source. Treatment. — The treatment indicated in the acute stage is depletion of the congested membrane. Leeching near the ear will give relief, but a quicker way is scarification of the membrana tympani, as suggested by Dr. Blake. From two to four cuts may be made in each case, the points selected for incision being those of greatest prominence or congestion. Care must be taken not to cut through into the tympanic cavity. Belief is obtained, as a rule, by one scarification. I have INFLAMMATION, INJURIES, MORBID GROWTHS. 333 practised this form of treatment, with success, in acute cases. In those which are more chronic, the disease must be treated chiefly by cleansing with warm water and weak solutions of zinc and opium. An ordinary wash of zinc, gr. j-ij to fjj, will in most cases be sufficient. If the disease tends to become chronic, it will be necessary to touch the surface of the diseased membrane with nitrate of silver, in order to prevent the dermoid layer from becoming ulcerated. If granulations form they may be touched either by strong solutions of silver or by the saturated solution of chloroacetic acid. CHRONIC INFLAMMATION. Ulcers in the Dermoid Layer. — As a consequence of acute external otitis or of acute myringitis, ulcers may form on the membrana tympani. As has been intimated when alluding to acute myringitis, erosion of the dermoid layer of the drum-head may occur in that disease. The first stage of such erosion would implicate the outer layer, while subsequent advances of the disease would involve the deeper layers. Hence, an ulcer on the drum-head may assume a terraced shape, the upper stratum being the dermoid, the middle, the fibrous, and the inner, the mucous layer of the membrana tympani. Most usually, however, the ulcerative process on the drum- head does not pass beyond the two outer layers. That true ulcerative processes do occur here, has been fully shown by J, Orne Green.' Symptoms. — The symptoms of such a process on the drum- head may be attended with no very great loss of hearing, but there is usually some tinnitus aurium, but pain is entirely absent. The attention of the patient is called to the ear by more or less .hardness of hearing and the subjective noise, but chiefly by the scanty and slow discharge. The latter features of the discharge lead to a hardening of it about the meatus, and the ear, feeling dry and stift", the patient is inclined to pick at it. By such manipulation, dry scales of dark matter are pulled ' Ulceration of dermoid layer of membrana tympani. Trans. Amer. Ctol. Soc, vol. i. p. 431, 1873. 334 MEMBEANA TYMPANI. from the meatus, and are usually another incentive to the patient to seek medical aid. Causes. — This ulceration of the dermoid and other layers of the membrana tympani, I have uniformly found in the poorly nourished classes of the Infirmary. A process in the external ear, especially on the outer surface of the membrana tympani, which otherwise would run an acute course and then disappear, tends to become chronic in the poor and the unclean. In addi- tion to poverty and uncleanliness, there must be added ignorant neglect or improper domestic treatment, the latter consisting chiefly of instilling oils which clog the ear and become rancid, or by the direct instillation of irritants of various kinds. It can be seen how readily all these circumstances tend to provoke, in the cachectic especiallj',' a chronic ulceration in the external ear. For it is a skin disease, a cutaneous ulcer, that is to be contended with in such cases. Prognosis and Treatment. — The prognosis is favorable if the proper treatment is carried out, but, like every other aural dis- ease, this tends to chronicity in the most favorable circumstances if not properly managed. Should the condition of the patient demand constitutional remedies (and it always will, accoi'ding to my observation), some form of iron will be found of great benefit. The syrup of the iodide of iron, or some one of the numerous preparations of iron and cod-liver oil, will render good service in these cases. The local treatment is of the greatest importance in ulcera- tion of the membrana tympani. The auditory canal must be carefully cleansed by syringing with warm water often enough to prevent accumulation of matter. But the secretion in these cases is not usually copious. It is, however, tenacious, and the patient does not seem able to remove it thoroughly by syringing. It is, therefore, of prime importance that the surgeon should wipe oif the drum-head and inner end of the canal, by means of the cotton holder. This should be done very carefully and thoroughly, under good illumination of the canal, by means of the forehead mirror. To attempt to cleanse an ear by swabbing it out, without such illumination, is worse than useless; it is always painful, and most usually dangerous. The perfunctory custom of turning the sufferer's ear towards a window, and blindly forcing into it a probe, armed or un- INFLAMMATION, INJURIES, MORBID GROWTHS. 335 armed with a tuft of cotton, or a brush, is almost culpable. The canal varies enough in every patient to warrant special illumination, by means of ear-funnel and forehead mirror. By this means the curves in the canal are not struck and M-ounded, as they are when the canal is manipulated in a less desirable way. After the canal is properly lighted and the membrana tympani perfectly visible, let the latter be wiped off by means of a tuft of cotton on the flexible cotton-holder. When the ulcerated membrane is thus cleansed, the local remedies may be applied. These may consist of applications of nitrate of silver or of sulphate of copper. Dr. J. 0. Green has found the latter very beneficial in ulceration of the dermoid layer of the drum- head. Nitrate of silver is best employed in solution ; it may be either instilled into the ear and allowed to find its way to the fundus of the canal and the drum-head, or it may be applied 'by means of cotton on the holder, directly to the diseased spot. Solutions of sulphate of copper may be applied by means of the cotton-holder, or the solid crystal may be used. Dr. Green prefers the latter to the nitrate of silver in any form, in these cases. InsuflSations of powdered crude alum, equal parts of magnesia and salicylic acid, and equal parts of alum and iodoform may be of great advantage if the disease should appear to be spread- ing to the adjacent walls of the canal with increased amount of secretion. But cleanliness is the chief consideration; then stimulation of the sluggish ulcerated parts, and, if they appear to be disposed to pursue a less sluggish course, simple astrin- gents may be employed. The latter should be the sulphate of zinc in weak solutions (gr. j-ij to f|j) with a little wine of opium or laudanum. The prescription I am most likely to use in these cases, if only a weak astringent instillation is needed, is : — 5. — Zinci aulphatis, gr. j-ij ; Tinct. opii, fSj ; Aquse, fjj.— M. Of this mixture 10-12 drops may be instilled warm into the ear twice or thrice daily after syringing. For the zinc, a grain of sulphate of copper may be substituted. But no specific treat- ment can be laid down ; each case must be studied and guided back to health. 336 MEMBRANA TYMPANI. Perforation of the Membrana Flaccida. — Perforation of Shrapnell's membrane, or the membrana flaccida, appears to be an uncommon occurrence. It is usually found to be the result of chronic disease, and is invariably attended with great hard- ness of hearing. Most probably the ulcerative process attack- ing this part of the membrana tympani also greatly implicates the joints of the ossicles. Dr. Blake has recorded two cases' of perforation of the membrane of Shrapnell (membrana flaccida), one of which was the only perforation in the membrana tym- paili, and the other, a very small one, was associated with a larger perforation in the inferior segment of the membrane. Through both of these perforations a discharge existed. In the first case, small polypoid growths surrounded the neck of the malleus, in the other the fundus of the canal was filled up by a soft polypus, the removal of which revealed the presence of the two perforations. So far as I know. Dr. Blake's case of double perforation of the membrana tympani, one of the open- ings being in Shrapnell's membrane, is unique. I have seen five cases of perforation of the membrana flaccida, all of them large, but unassociated with perforations elsewhere in the membrana tympani. As accounts of cases of this nature are not common, it will not be amiss to give in detail those observed by the au- thor. Case I. Chronic Discharge from the Tympanum, with Perfora- tion of the Membrana Flaccida posteriorly. — John M., 17 years old, came under my care in the Presbyterian Hospital of Phila- delphia, in July, 1872. He states that his first ear-trouble occurred when he was four years old. He is a pale, intelligent lad, a hard student in a classical school. His father died insane, and he has a brother who is hopelessly insane. When the patient was twelve years old he began to have " gatherings in his ear" about twice each winter. A year before he became my patient, a constant and most copious discharge, preceded by pain, became established in the right ear. "When I made my first examination of his ear, in July, 1872, the membrana tympani was found saturated with a yellowish-green pus. The only perforation in the membrana tympani was in the membrana flaccida, above and behind the short process of the malleus, but ' Dr. C. J. Blake, Perforation of Membrane of Shrapnell in Otitis Media Purulenta ; vol. i. Trans. Amer. Otol. Soc.,p. 546, 1875. INFLAMMATION", INJURIES, MORBID GROWTHS. 337 at no time was there a perforation-whistle obtained by any mode of inflation of the tympanic cavity. The hearing was reduced to ^. foJ" the watch, and for the voice, nil. I passed a probe a short distance into the perforation. The cavity was sensitive, and there was no denuded bone. The treatment consisted of instillations of a solution of nitrate of silver (80 gr. to fgj) once a week, at the hospital, and the patient was ordered to syringe his ear three times daily at home, and to instil a solution of zinc (gr. X to fgj). For the latter solution were sometimes substituted solutions of alum, and later a solution of nitrate of lead. In four months the discharge ceased, the nitrate of lead apparently having had the best effect on the aural disease in this case. In IvTovember, five months from the beginning of treatment, the membrana tympani had assumed an almost normal appear- ance, except the cicatrix in the membrana flaccida. At no time were there any granulations, and the discharge remained, uniformly, of a light color, and of the consistence of cream. The hearing improved to ^'-^ for the watch, and the voice could be heard close to the affected ear. The Eustachian tube was pervious. On the first of January, 1873, the patient was found com- plaining of pain and soreness in the mastoid process of the affected ear, but he had no symptoms of fever. Perfect physical rest, with attention to general health, was ordered, and by the 10th of the month all mastoid symptoms had vanished. There was no return of the discharge as the pain subsided, but, as the patient was studying too much at his school, his health began to fail, and he was therefore ordered to quit school and take as much exercise in the open air as possible. By the 1st of December, 1873, the discharge returned, with pain in the ear and soreness when the auricle was pulled gently. The discharge continued for three months and a half, with per- sistence of the old perforation in the membrana flaccida. I could readily see the discharge oozing slowly from the perfora- tion, after drying the orifice with the cotton-holder. At this second attack of discharge from the ear, the strength of the solution of nitrate of silver was increased to 480 gr. to fjj. This caused intense pain for a few minutes; then the pain ceased entirely. In conjunction with applications of the strong 22 838 MEMBEAJSTA TYMPANI. solution of silver, the patient used a strong solution of the sul- phate of zinc (30 gr. to fSj) at home, which seemed to exert a good effect in the course of one month. The most careful syringing became necessary while using this strong solution of sulphate of zinc, in order to remove the coagula produced by it. A few painful furunculi followed the cessation of the discharge. On the 22d March, 1874, the voice and the watch were heard five paces. There was a depressed cicatrix in the membrana flaccida, above and behind the short process. The membrana tympani, below the folds, was almost normal in color. Dr. J. Orne Green^ has called attention to this varietj'^ of puru- lent inflammation of the tympanum, in a paper read before the Boston Society for Medical Improvement, Dec. 22, 1873. He says, " While in the common purulent inflammation of the tympanum, the pus secreted by the mucous membrane which lines that cavity finds an exit by rupturing the drum-membrane, either in the anterior or posterior segment, somewhere about its centres, I have seen a few cases where the rupture has occurred in the extreme upper portion of the membrane, the membrana flaccida, and these have been so obstinate under treatment, and so serious, that I desire to direct special attention to them." Dr. Green then alludes to five eases occurring in his practice, two of which he describes minutely. There are many points of resemblance between Dr. Green's cases and the case just given, viz., " the intensity of inflammation confined to the upper por- tion of the tympanic cavity ; that is, the lower portion of the tympanum was never filled with pus, nor was any congestion seen, except in the neighborhood of the perforation ;" it was also a noticeable fact that no perforation- whistle followed the perfect inflation of the tympanum in these cases, The following features, however, seem to characterize my case, but do not appear to have been prominent in Dr. Green's cases. This case came on with attacks of great pain, while the patient was a child ; there was no denuded bone ; the perforation in tlie membrane was just large enough to admit the small round head of a silver probe, and there were from time to time attacks of pain and throbbing in the affected ear, and finally the discharge ceased under the use of astringents, in stronger solutions after ' Boston Medical and Surgical Journal, March 26, 1874. INFLAMMATION, INJURIES, MORBID GROWTHS. 339 the relapse, than at first: there was marked hardness of hearing, but no tinnitus at any time. It is of interest to note that the first cure was effected in the autumn of 1872, with no relapse until the winter of 1878-74. In the winter of 1872-73, there were simply ten days of mastoid soreness and pain, with no discharge. The patient has resumed his studies at school, and has gained in stature, strength, and hearing. Throughout the previous history of this case there is a ten- dency to recur; but during the two years he has been my patient, he has had only eight months of aural discharge, viz., the first four months, which were fallowed by one year of freedom from aural discharge, and then a recurrence of otorrhoea for three and a half months, which brings the history to March, 1874, since which date the patient went to reside in another city. The patient remained away, and did not give any report of himself until K^ovember 26th, 1876, when it was found that the discharge had returned, and that a small polypus was protruding from the perforation in the membrana flaccida. The polypus was easily removed, but its precise point of attachment could not be determined. A small piece of cotton on the holder was moistened with chloroacetic acid and passed through the per- foration, and thus near to the attachment of the polypus. The patient has passed from observation on account of his residence in a distant city, though from his accounts it may be inferred that the ear is doing well. Case II. Perforation of the Membrana Flaccida. — A second case of perforation of the membrana flaccida (Shrapnell's membrane) was observed in a man 22 years old. He stated that the first symptom in the affected ear, the left, was an attack of pain which had occurred seven months previous ; this was followed by a dis- charge, which had gradually become less. Becoming anxious to have it entirely checked, he had applied for treatment. The perforation was large, embracing most of the flaccid mem- brane, and exposing the neck of the hammer. The discharge was very slight. Unfortunately for the further history of this case, like many others seen in public practice, it passed from notice after the second visit. The hearing in this case was greatly impaired. 340 MEMBEANA TYMPANI. There was no perforation-whistle produced in this ease at any time by any mode of tympanic inflation. Case III. Perforation of the Membrana Flaccida ; Polypus pro- truding through the Opening thus made. — A third case presents more clinical interest^ as it has been long watched (Sept. 7, 1875), and is still under observation. The patient, a German woman, 35 years old, stated that two years previously her left ear had troubled her for the first time. There was then some pain followed by an offensive discharge ; the latter had con- tinued, greatly to her annoyance. The hearing was reduced to ^^ for the loudly-ticking watch ; for the voice, similarly. The meatus was found smeared with a slight but offensive discharge which came from a large perforation in the flaccid part of the membrana tympani. The membrane was not perforated else- where, but it appeared abnormally thickened, as it always does, so far as my experience goes, when a perforation exists in the membrane of Shrapnell. A polypus as large as a small pea pro- truded through the perforation. The attachment of the polypus was inside the tympanum, posteriorly ; when it had been re- moved, which was easily done with a hook, it was found that the polypus attached posteriorly had grown forward between the membrana tympani, i. e. the region of the perforation, and the contents of the upper part of the tympanic cavity. Its inner surface was flattened ; its outer surface, being free to grow out through the perforatiouj had assumed a convex shape, and this it was that was seen protruding through the opening in the membrane. There was no perforation-whistle at any time. The ear was kept carefully cleansed, and chloroacetic acid was applied by means of the cotton-holder to the perforation and the tympanic cavity adjacent to it. The patient syringed the ear well two or three times daily at home, and instilled a weak solution of zinc. The discharge diminished greatly, lost its fetor, and at, last ceased entirely. The hearing has not materially improved, as indeed might be expected, when it is remembered how near the articulations of the ossicles the brunt of the disease must have fallen. Indeed, I have yet to see a perforation of the membrana flaccida unattended with great deafness. The latter and the loss of substance in the drum-head appear to be due to the same cause. INFLAMMATION, INJURIES, MORBID GROWTHS. 341 Case IV. Perforation of the Membrana Flaecida, probably from External Causes ; Foreign body in the Canal} — This case, besides presenting the comparatively rare occurrence, perforation of the membrana flaecida, also furnishes an example of the still rarer feature of being probably caused by external erosion. The patient, a Scotchman, 35 years old, complained of an in- tense pounding noise in the right ear, which caused him much annoyance, and brought on frequent attacks of headache and dizziness. In the diseased ear the watch was heard only in contact with the auricle. His aural discomfort, which had become especially annoying to him within several years, had led him to pick at his right ear, from which he had now and then brought " small pieces of something which had an offensive odor." He was entirely unsuspicious of the presence of a foreign body in the ear. The examination of the ear revealed an apparently free audi- tory canal, but a very much thickened and irritated yet imper- forate membrana tympani. From the line of the folds of the latter and the short process, over the region of the membrana flaecida and the inner portion of the upper wall of the auditory canal, there seemed to be dark adherent wax. Upon laying hold of this obstruction, it was easily removed, and proved to be a grain of corn imbedded in cerumen. The place occupied by this mass was very much altered in appearance. From the line of the folds of the membrane to the segment of Rivinus, i. e. the region of the membrana flaecida, appeared much more ex- tensive and sunken than usual ; from the segment of Rivinus outward along the upper wall for one-eighth of an inch, the bony roof of the auditory canal seemed greatly hollowed out, into a dome-like space, and here the major portion of the grain of corn was lodged. The membrana flaecida appeared to be gone ; at the place usually occupied by it there was a whitish, roughened, cica- trized depression, bounded below by the distinct upper edge of the membrana tympani proper. Upon inflation the membrana tympani below the folds bulged, but no air escaped from the region of the flaccid portion. The membrana flaecida had been eroded apparently by external pressure in this case. ' See also Proceedings of Pathological Society of Philadelphia, 1876. 342 MEMBKANA TYMPANI. The foreign body had been in this man's ear probably twenty- five years, as gleaned from the apparently trustworthy history of his life. The membrana tympani below the folds may be perforated from external pressure and consequent irritation, and it would seem fair to conclude that the same process may go on in the membrana flaccida. The latter, however, being pi'otected by its high position from pressure from a foreign body in the canal, is not as likely to be perforated from such external causes as is the membrana tympani below the folds. Upon the removal of the foreign substance from the ear in this case, the subjective noise and the disagreeable head symptoms ceased, but the hearing was not improved, which would seem to show that the impair- ment of this function was due to a process of disease in the tympanum, probably in its upper part, in the region of the membrana flaccida, and not dependent upon the presence of the foreign substance. Case V. Ulceration of the Membrana Flaccida^ from External Irritation. — This case, without presenting a membrana flaccida entirely perforated, was unmistakably one of ulceration of this part of the membrana tympani, due to pressure of a plug of hardened cerumen. The patient, a man 40 years old, com- plained of dull aching in the ear of several days' duration ; the hearing was only slightly diminished. Upon inspection the canal was found to be filled with cerumen, and the membrane consequently hidden from view. After removal of the obstruc- tive mass, the only change observed in the drum-head was an ulcerated spot in the membrana flaccida, immediately above the short process of the malleus. This ulcer was about 1.50 mm. in diameter, and bled slightly on being touched ; it was tender on gentle pressure. The ear was let entirely alone for a week, at the end of which time the ulcer had healed, and the ear had resumed .its entirely normal function. This case furnishes an example of the fact that the membrane of Shrapnell may be ulcerated from without. TRAUMATIC INJURIES OF THE MEMBRANA TTMPANI. The membrana tympani is liable to a number of injuries from without. These, while not directly interfering greatly with INFLAMMATION, INJURIES, MORBID GROWTHS. 343 the function of hearing, usually expose the mucous lining of the tympanic cavity to the direct irritation of the external air, and thus lead secondarily to inflammation and loss of hearing. Prominent among the causes which lead to traumatic rupture of the drum-head may be cited, boxing the ears, and receiving the force of a wave on the ear while bathing in the sea. The healthy membrane will usually resist these forces, but of course one which is in any way diseased by fatty degeneration, atrophy, and by calcareous deposits, or one prevented from assuming proper equilibrium by a closure of the Eustachian tube, is ex- tremely liable to yield to external violence above named. The drum-head may receive very injurious concussion from diving into the water, from the discharge of musketry or of a cannon, from falls, from a gunshot wound near the ear, — for example, in the upper maxilla and the horizontal plate of the ethmoid ;^ also from the kick of an animal on the mastoid process, and from the sudden introduction of long and slender instruments or implements into the auditory canal. In the case of a young man, 21 years old, killed by a fall from his horse, upon a pavement, the left membrana tympani was found to have been fissured in the posterior half. The length of the fissure was 2| mm.^ In some cases of traumatic rupture of the drum-head, the primary wound is followed by symptoms of aural vertigo, as has also been noted by others.^ The following case shows that there may be such a liability : — John M., Englishman, married, 30 years old ; the patient looked thin and somewhat anxious when he presented himself for treatment. The history given was, that the evening before, while sitting quietly reading, a companion playfully boxed him on the ear. Instantly he felt a roaring in the ear, but fortu- nately did nothing in the way of pouring in fluids with the ' Casuistische Beitrage zu den traumatischen Verletzungen des Trommel- fells. Dr. E. Zaufal. Archiv f. Ohrenheilkunde, B. i., N. F. pp. 18S, 280, and B. ii. p. 31. 2 Trommelfellbefund nacli Sturz mitdem Pferde. Dr. Trautmann. A. f. 0., B. ii., N. F,, p. 101. ' Fall von traumatischer Ruptur des Trommelfells mit Symptomen von Labyrinthreizung. Dr. Parreidt. A. f. O., Band ix. p. 179. Dr. Holmes; Trans. American International Otological Congress, 1876. 344 MEMBEANA TYMPANI. view of relieving the noise and hardness of hearing. The fol- lowing morning it was found, on inspecting the memhrana tympani, that it was ruptured in the posterior and lower part ; that the diameter of the perforation was about 2 mm., and that there was little or no congestion in the drum-head. The patient had suflPered greatly from heat of the previous night (it was July), and had been exhausted by nursing a sick infant. Upon his rising suddenly in my office, he grew very pale, said he was dizzy, and fainted. It was a long time, an hour or more, before he could go home, and then only in charge of an attendant. He remained very dizzy all day, but, the perforation healing in the course of a few days, the hearing became good, but not entirely normal, and the symptoms of dizziness disappeared. Had the perforation by taking away some of the power the drum-head has of resisting the traction of the tensor tympani, allowed the latter to draw the chain of ossicles inward, produc- ing temporary pressure in the labyrinth, with consequent dizzi- ness? The memhrana tympani has been found ruptured in those who have been executed by hanging. Dr. Ogston^ has described such a case in which the fissure of the drum-head was ragged, and running from the tip of the manubrium downward to- wards the periphery of the membrane. The edges were everted, but there was neither blood nor any other fluid in the cavity of the drum. From the eversion of the edges in such a case, it might be supposed that the force which breaks the membrane acts from within the tympanic cavity outward. The rupture of the membrane in such cases may be explained by supposing that the air in the tympanum, at the moment of the fall, is thrown into violent concussion, and, not being able to escape by the Eustachian tube, owing to the constriction of that canal by the rope, it is forced violently outward, producing the fissure of the memhrana tympani. The memhrana tympani may be rup- tured by an increase in the atmospheric pressure, if the latter is very extraordinary, and if the Eustachian tube is more or less impervious.^ ' Archiv f. Ohrenheilkunde, Band vi. 2 Dr. John Green, " Condensed Air, 60 lbs. to square inch ; its Effects on the Eustachian Tube." Tr. Amer. Otol. Snc, vol. i. p. 139, 1870. INFLAMMATION, INJURIES, MOEBID GROWTHS. 345 The membrana tympani is probably able to endure sudden pressure from without, as in discharges of artillery, musketry, etc., whether expected or not, only through the loose valve-like nature of the Eustachian tube. This seems fully shown by the observations and experiments of Rudinger, Brunner, Lucse, and the observations of John Green, referred to. Fracture of the Handle of the Malleus.— There are a few cases of fracture of the handle of the malleus on record. This rare accident has been described by M^ni^re,' von Troeltsch,^ and R. F. Weir :^ the first observed it in the ear of a gardener, who had received a thrust from a twig, while working ; and the second saw a fracture of this part of the malleus, resulting from the accidental thrusting of a penholder into the auditory canal. In both cases the manubrium appeared to have united. Dr. Weir's case presents the additional rarity of an ununited fracture of the manubrium. It occurred in an Irish laborer, in consequence of a fall from a height of fifteen feet, four months before Dr. Weir saw the case. The lower portion of the manubrium was seen to be distinctly movable upon the upper part, whenever the tympanum was infiated. The fracture occurred just below the short process ; inflation restored the parts to their normal position, but displacement occurred again in about fifteen minutes. Atrophy of the drum-head may occur in consequence of pressure, long kept up, by a mass of hardened cerumen. This process is favored if the Eustachian tube is at the same time closed.* It is not uncommon to find, in those suff'ering with chronic aural catarrh and deafness, hardened pieces of ear-wax in contact with the drum-head. Though such an obstruction may add nothing to the existing deafness, it may and often does produce sensations of fulness in the head and, at times, vertigo. Such cases are apt to escape detection, simply because the patients have given up all treatment, considering their cases hopeless, and are no longer under examination. Although the ' Gazette Med. de Paris, p. 50, 1856. ' Treatise on tlae Ear, p. 151. ' Ununited Fracture of Manubrium of Malleus, Tr. Amer. Otol. Soc., vol. i. p. 121, 1870. 4 S Moos, Archives of Oph. and Otol., vol. i. pp. 331, 334, 1869. 346 MBMBRANA TYMPANI. deafness may remain unchanged after the removal of such masses of cerumen, the cerebral symptoms are greatly relieved. Beproduction of the Membrana Tympani. — The popular impression, that the membrana tympani once perforated can never be healed, is a wrong one. The drum^head, on the contrary, has great power of healing and restoration, as shown by Dr. H. IS". Spencer.^ A simple slit in it will heal in a few hours if there is no inflammation in the drum-cavity. Larger, and even gaping, perforations, caused by disease, tend to heal, unless the disease in the tympanum keeps up and by its chro- nicity leads to a cicatrization of the edges of the opening in the membrana tympani. The tympanic disease behind the perfo- rated drum-head should receive more attention than the simple perforation, which is but the vent for the hypersecretion result- ing from the disease in the middle ear. It is, therefore, not only unwise, but harmful, to attempt to close, by stimulation of its edges, a hole in the membrana tympani. If one should succeed in doing it, so long as the mucous membrane behind it is diseased, the closing of the perforation would deprive the drum-cavity of a direct way of treatment of its diseased lining, and sooner or later the drum-head would give way again. It is not easy, however, to cause a perforation in the head of the drum to heal while disease exists behind or about it. In endeavoring to do this, by stimulation of its edges, the hole is most usually made larger. In the Philadelphia Medical Times for May 10, 1873, 'Eo. 80, vol. iii., I reported a rare case of restitution of the membrana tympani after fifteen years of disease. The chief features of the case were as follows : On the last day of July, 1872, Chris- tian L., a German, 15 years old, consulted me respecting a chronic discharge from his right ear. The disease dated from infancy, without any history of a discharge from the left ear. All the statements of the boy were corroborated by his father, who ac- companied him. Examination revealed the presence of a copi- ous, light-green discharge in the meatus. Upon removal of the obstruction in the canal, a large perforation was discovered in ' Case of Reproduction of the Membrana Tympani, Transactions American Otol. Soc, vol. i. p. 179, 1871. INFLAMMATION, INJURIES, MORBIU GROWTHS. 347 the upper posterior quadrant of the memhrana tympani. Hear- ing distance for watch one-fourth of normal amount. Eusta- chian tubes pervious to inflation by Politzer's method. After cleansing the auditory canal and middle ear as thoroughly as possible, I instilled ten drops of a strong solution of nitrate of silver (3j-f3j) into the ear. This was syringed out in a few moments, and the lad ordered to syringe his ear at home thrice daily, with warm water, and after each syringing to drop into the ear ten drops of a two-grain solution of sulphate of zinc warmed, and to allow the latter to remain in the ear five minutes. One week later I saw the boy; his ear was much better, and he was ordered to continue the treatment. By the middle of August, two weeks after he was first prescribed for, the discharge from the ear had ceased, and the hearing for the watch had increased to one-half the normal distance. A few days later, the perforation in the membrana tympani had closed, and the membrane, which at the time of the first examination was swollen and discolored, had assumed the normal lustre. The hearing had now become normal, and the drum-head was exquisitely restored. Medico-legal Significance of Traumatic Injuries to the Drum-head. — After a blow has been received on the ear, either during a quarrel or in play, an action for supposed injury to the drum may be instituted to recover damages. The surgeon will be called on, in such cases, to decide, first, whether there has been an injury done the drum-liead, and if so, how far it will impair the hearing. In the first consideration he must bear in mind that the drum-head may have been perforated before the blow was received, though the patient or complainant may or may not know it. The chronic perforation can be readily distin- guished from, the acute. If it should be determined, however, that ,a previously normal drum-head has been ruptured by a blow on or a thrust in the ear, it then remains for the surgeon to determine whether the hearing has been or will be impaired by the injury. The mere fissuring of a normal membrana tym- pani in the above way may not necessarily injure the hearing nor oblige the patient to give np his daily work. If, however, there has been a severe blow on the ear, the hearing may be impaired from concussion of the nerve in the labyrinth, which, though asso- 348 MEMBRANA TTMPANI. ciated with rupture of the drum-head, is not necessarily caused by it. If there has been no concussion of the inner ear and no inflammation set up in the drum-cavity, the ruptured drum- head will heal quickly if let alone, i. e. if nothing is dropped or poured into the ear. Ignorance on the latter score has led very often to the use of drops the moment a fissure in the drum has been noticed. The matters thus poured into the canal, having entered the drum-cavity through the perforation, have set up inflammation in the delicate raucous membrane of the middle ear, and disease has been established where otherwise, by letting the ear intelligently alone, the perforation would have healed in a day or two. Thus it might appear that the blow had caused disease in reality produced by improper treatment of the ear. If, in a case of asserted traumatic violence to the drum-head, deafness should be immediately discovered by the surgeon, it must be determined whether it has been produced by the same blow which has ruptured the drum, or whether it existed before. A temporary diminution of hearing is very likely to occur after a blow on the ear, hard enough to rupture the membrana tympani, but if great and sudden deafness comes on after a blow on a previously healthy ear, and if it remains for several days without signs of improvement, it must then be adjudged per- manent, and the claim for damages must be in accordance with the facts. Even if it should be decided that the injured ear was not in a state of health before the blow, it would seem that all the greater claim could be made by the sufferer. In such a case, however, it must ever be borne in mind that it is not the fissure in the drum-head that has done the damage, but the con- cxission to deeper and more delicate nervous parts of the organ of hearing. MORBID GROWTHS. Wart-like Bodies on the Drum-head. — Wart-like excres- cences on the membrana tympani, first described by Dr. Urbant- schitsch,' I have observed in but one case. There were in this case, that of a man 24 years old, two pale yellow warts about ' Ueber eine eigenthumliche Form von Epithelialauflagerung am Trommel- fell, nnd im ausseren Geliorgang. A. f. 0., B. x. p. 7. INFLAMMATION, INJURIES, MORBID GROWTHS. 349 a millimetre in diameter, on the upper and posterior quadrant of the memhrana tympani. There seemed to be no explanation for their occurrence, unless it could be found in the instilling of various fluids, which the patient had practised on his own re- sponsibility, for some time for the cure of deafness resulting from chronic catarrh of the middle ear. The constant irritation thus applied to the delicate dermoid layer of the drum-head may have provoked the growth of some of its papillse into the above- named wart-like bodies. Endothelial Cholesteatoma of the Membrana Tympani. — As an antithesis of desquamative inflammation of the middle ear. Dr. "Wendf has described a new growth, which he calls genuine or endothelial cholesteatoma. The nature of this new growth is better understood when Dr. Wendt's investigations respecting the membrana propria of the drum-head are known. According to him this membrane consists of coarse and fine fasciculi ; both are inclosed in hyaline tunics, which are very resistent and contain cells of various forms (endothelia). Some- times the nuclei are unaccompanied by protoplasm, but usually the latter, of round, oval, and stellate form, is present. These forms are subject to change according to the position of the cells. Lymphatics are found in the interstices. Endothelial cholesteatoma was found by Dr. Wendt in the right middle ear of a man who had died of typhus fever. The macroscopic exa- mination revealed the following conditions. " In the anterior inferior part of the inner surface of the membrana tympani, there was found a slightly rough hemispherical mass IJ mm. in diameter ; the transparent golden lustre was characteristic. The lower part of the tumor passed into the membrana tympani, the upper part projected, hemispherical in shape, into the tympanic cavity, and was united to the membrana tympani by a fold of mucous membrane. The growth, after displacing the rete Mal- pighii, extended outwardly at some points as far as the surface of the external auditory canal ; at others it pressed upon the corium of the dermoid layer. "The mucous membrane of the tympanum was swollen and ' Archlv f. Heilkunde, 1873, pp. 551-563 ; also abstract by Dr. Trautmann, Archiv f. Ohrenh., B. ix. p. 381. 350 MEMBRANA TYMPANI. hypercemic. The malleus at its anterior surface was detached from the membrana tympani, but still united to it posteriorly. The membrana tympani was flattened and somewhat thickened, it contained several small, round perforations, its layer of epi- dermis was discolored and broken down, and its mucous layer was swollen and intensely injected." The microscopic examination of this growth revealed the following : " The tumor is enveloped in a capsule of connective tissue ; the latter is loose at some points, stretched at others, runs parallel to the surface of the tumor, contains hsematoidine, and is covered with cubical epithelium. The capsule covers the outer part of the tumor and that part of it which projects into the tynipanum ; the lower part passes over into the pathologi- cally altered substantia propria. The capsule is to be regarded as emanating from the mucous layer of the membrana tympani."' In the membrana propria numerous cavities filled with parallel and concentrically arranged, nucleated pellicles were found. The trabeculae were separated by these accumulations. These cavities became larger in the neighborhood of the tumor, in which the trabeculse ran parallel to the surface of the membrana tympani ; they also ran in curves and at various angles. They consisted of extensive fibrils of connective tissiie, arranged in fasciculi and inclosed in opaque, cylindrical, nucleated sheaths. These trabeculse wei'e further united into coarser fasciculi. In the interstices the same pellicles were found as in the membrana propria. In the upper and older portion of the tumor, numerous crys- tals of cholestearine and drops of oil lay upon the pellicles, in- dicating retrograde metamorphosis. The pellicles were found to surround concentrically the coarser trabeculse ; some of the cells of the former were transparent, rhomboid or crenated in form, and contained an oval nucleus. The above described changes in the membrana tympani are adduced by Dr. "Wendt as proof of the endothelial origin of this new growth. Cholesteatoma of the Drum-head. — Among recent ob- servers Dr. Kupper,^ of Elberfeld, G-ermany, has described a ' Review by Dr. Trautmann, loc. cit. ' Cholesteatom des Trommelfelles. A. f. O., B. xi. p. 18. INFLAMMATION, INJURIES, MOEBID GROWTHS. 351 small tumor found on the membrana tympani of a man 30 years old, who had died of consumption. This small growth, 1^ mm. in diameter, was situated below the umbo of the membrana tympani, and was easily removed by simply touching it with a needle. The little tumor was pearl-gray in color, and composed of several layers arranged like those of an onion. The micro- scopic examination showed that these were composed of layers of epithelium with here and there some crystals of cholestearine. Dr. Kiipper thinks that ultimately this new growth might have penetrated the membrana tympani, and invaded deeper parts. He is not disposed, however, to thus explain the origin of every pearly tumor of the tympanum, for it is well known, as he says, that such tumors may grow in the tympanic cavity, the drum- head remaining entirely intact, as shown by Lucae. SECTION V. MIDDLE BAR. CHAPTER I. ACUTE CATARRHAL INFLAMMATION. Acute catarrhal inflammation of the middle ear is a process characterized by an increased formation of mucus, but which stops shoi't of the production of pus. This increased amount of mucus in the middle e^r usually escapes through the Eustachian tube, or by absorption ; it rarely causes a rupture of the mem- brana tympaui, for the tendency of acute catarrh is rather towards a swelling and a thickening than to a breaking down of tissue. An acute catarrh of the middle ear, which advances to a per- foration of the membrana tympani, will most commonly be found to have led to purulent products, for pure mucus alone is rarely found escaping through a rupture in the drum-mem- brane. If, then, an acute catarrhal inflammation of the middle ear advances to the formation of pus, a more destructive form of inflammation, a purulent variety may be said to be present. While the latter condition must always be preceded in the middle ear by the former, catarrhal inflammation may have a distinct existence without the presence of pus. For the sake of clinical convenience, the endeavor is made to describe two forms of acute inflammation of the middle ear, but the fact must not be lost sight of that very often these so- called forms are but stages of the same disease, and that, there- fore, up to the point of succession, i, e. where the mucous symp- toms are succeeded by the purulent^ the symptoms and treatment are the same for both forms. In fact all treatment in a case of acute catarrhal inflammation ACUTE CATARRHAL INFLAMMATION. 353 of the middle ear is based an the hope of preventing the forma- tion of pus, which is known to be only too likely to follow the catarrhal or mucous stage. Syra-ptoms and Course.— The lightest form of acute catarrh of the middle ear comes on during an ordinary cold in the head, or from any other cause which produces only a slight swelling and closure of the Eustachian tube. In this light form it is little more than a congestion and slight swelling of the mucous lining of the Eustachian tube, and per- haps of that of the tympanum, accompanied by an unusual amount of mucus. It may thus affect one or both ears. It causes no pain, in this mild character, and but little hardness of hearing ; it brings about rather a stuffed feeling in the ears, with a slightly altered timbre of objective sounds. There is usually some tinnitus, though a slight chronic tinnitus may cease upon the occurrence of a mild tubal catarrh. The patient's voice may be subjectively altered ; though this is rare in light cases of catarrh of the ear. The membrana tympani may not even lose its lustre, though its vessels may appear slightly con- gested, and it may assume, if it is ordinarily transparent, a pinkish hue from the shining through of the congested tympanic vessels. This form of catarrhal congestion of the middle ear rarely troubles the patient, and therefore receives very little attention. It may disappear as rapidly as it came, in the course of a day, without any treatment. That form, however, characterized chiefly by pain, hardness of hearing, and subjective noises in the ear, is not only more annoying to the patient, but demands prompt treatment. It comes on usually after exposure to cold ; but it may be caused by various diseases involving the mucous membrane of the nose, mouth, throat, and naso-pharynx, as syphilis, various continued fevers, and the exanthemata. Acute catarrh is more likely to affect one ear than both, and is apt to come on in an ear already affected by chronic catarrhal disease. Pain. — The pain is not as severe as that of purulent inflam- mation of the middle ear, and this is perhaps the chief early diagnostic point between the two diseases. The pain, usually darting only from throat to ear, may become sharp and boring 23 354 MIDDLE EAR. and not limited to the ear. It is then very apt to follow the course of the fifth and seventh cranial nerves, and in this phase is not unfrequently mistaken for neuralgia both by patient and physician. It intermits during the day, growing worse at night, but never becomes as intense and unendurable as the pain of acute purulent otitis. It is often more a sensation of great fulness than true pain. Fever is rarely present, and the cerebral symp- toms are by no means grave ; unless of course the aural disease accompanies or is caused by a febrile disease. The pain is caused primarily by the inflammation of the mucous membrane, but it is aggravated and kept up by the results of the inflammation, i. e. by the swelling of the mucous membrane and by the increased amount of secretion. The first acts by diminishing the size of the cavity of the middle ear and closing the Eustachian tube, by which means the air is excluded from the tympanic cavity, and the products of inflammation cause pain by directly pressing on the inflamed mucous lining of the tympanum and upon the membrana tym- pani. Vacuum formed in the Tympanum. — If the faucial mouth of the Eustachian tube becomes swollen and blocked up with mucus, the tympanic cavity is deprived of its proper ventilation, the air which was in the cavity at the beginning of the tubal catarrh becomes absorbed, and, since no fresh supply of air can get through the swollen tube, a vacuum is formed in the cavity of the drum. This condition tends to produce pain ; in children, it is often the only cause of pain in acute catarrh of the tube and tympanum, for, the external atmospheric pressure remaining constant, the membrana tympani is forced inward, carrying with it the chain of ossicles. A continuance of the vacuum may lead not only to a great extravasation from the tympanic vessels, but even to their rupture. Hence, it is not uncommon to find true ecchymosis on the membrana tympani, after the Eustachian tube has been closed for some hours, in a case of acute aural catarrh. In some such way we may account for the rare cases of so-called otitis media hemorrhagica, to be referred to here- after. Pain- increased by talking, coughing, sneezing, and eructation. — This is a prominent feature of acute aural catarrh, in which the ACUTE CATARRHAL INFLAMMATION. 355 faucial raouth of the Eustachian tube is always affected. It is due, partly, to the muscular movements beneath the inflamed mucous membrane, and also to the direct effects of the forcibly expired air upon the inflamed lining of the tube and tympanum, before secretion has taken place. According to investigations of Lucse,^ it seems highly probable that, at each expiration, the air in the naso-pharyngeal space is condensed, and hence pushed into the more or less normally patulous Eustachian tube. No one symptom in acute aural catarrh is so universally spoken of by patients as the painful effect of eructation. It is very common, indeed, for this to be complained of as the only symptom in cases of congestion in either a previously perfectly healthy tube, or during an intercurrent acute congestion in a chronic aural catarrh. Patients under treatment for the latter will, upon changes in the weather, complain of the above symptoms. As those affected with chronic aural catarrh are also very apt to have a slight paresis of the velum, which prevents its being able to perfectly close the upper from the lower pharynx, it would seem that sudden eructations or any forcible expiration may be all the more likely to strike against the pharyngeal mouth of the Eustachian tube, and, in some cases, even pene- trate into the tympanic cavity. Both Senac and Tissot^' observed difficulty in swallowing in cases of ear-ache which the former attributed to sympathy (con- sensus) between the pharynx and the ear, but which the latter observes " is connected with a slight inflammation of certain of the muscles of deglutition." I have observed in my own case that when the faucial mouth of the Eustachian tube is slightly swollen, i.' e. when, with a slight cold in the head, the tube does not become readily patulous on swallow- ing, a slight touch of the finger in the external auditory canal produces an intense tickling in the fauces high up behind the velum, and I am forced to cough. This peculiar sensibility does not exist in my ear when the Eustachian tube is unaffected, but probably every observer knows, as the author does, of many ' Virchow's Archiv, Band Ixiv., Zur Function der Tuba Eustachii und des Gaumensegels. « Traite des Nerfs et de leurs Maladies, Paris et Londres, 1780, p. 54. 356 MIDDLE EAE. persons in whom the gentlest touch of the finger upon the mouth of the auditory canal will almost always bring about this peculiar dry cough, called ear-cough. (See p. 326.) I have observed that children whose ears are perfectly healthy, as well as those whose ears are more or less diseased, are especially susceptible to this reflex cough. I have seen infants exhibit marked ear-cough upon their mothers' most gently touching the concha or brushing some small object from the vicinity of the mouth of the external auditory canal. But even those of any age in whom this reflex cough is found, are not always equally sensitive, for it is more easily produced at one time that at an- other. It is, on the whole, most likely to attend some morbid condition of the ear, and I have seen it often in cases of acute catarrh of all grades. Hardness of Hearing. — The hardness of hearing is caused chiefly by the swelling of the mucous membrane and the col- lection of mucus and extra vasated serum in the tympanic cavity. These alterations in the tympanum interfere with the vibratory motions of the auditory ossicles, the former by a direct stiffen- ing of all their joints, and the second by loading not only the ossicles but the fenestra. Hence, hardness of hearing is most marked after secretion has taken place. At the onset of the inflammation the hearing may be morbidly acute. A secondary implication of the labyrinth by an extension of inflammation or congestion from the tympanum very probably often occurs, and tends to further impair the hearing. Throughout this dis- ease the resonance of the patient's voice is liable to annoying subjective alterations, most probably due to the altered condi- tion of the Eustachian tube. Tinnitus Aurium. — This is one of the chief symptoms of acute aural catarrh. It is caused principally by the altered circulation in the tympanum, and seems to become more aggravated as the inflammation advances. It resembles, very often, painfully' high musical notes, and is one of the most distressing symptoms, being complained of almost as much as the pain. I have ob- served that the tinnitus is of the constant variety, i. e., unaffected by the pulsation, in simple catarrh with an increased amount of mucus ; when the inflammation becomes more severe, and puru- lent symptoms supervene, then, in some cases, the tinnitus be- comes interrupted by the pulsations, and each heart-beat is felt ACUTE CATARRHAL INFLAMMATION. 357 in the ear most painfully. The tinnitus of acute catarrh is referred rather to the ear than the entire head ; the latter variety seems to indicate severer inflammation. The more musical variety of tinnitus aurium is probably due to a secon- dary implication of the cochlea in the congestion. The sub- jective noises may be entirely unmusical in their sound, resem- bling merely a crackling of mucus or the bursting of bubbles of a tenacious substance. This latter kind of noise il^ the ear would seem to be not very difficult of explanation, and should be referred to the movements in the mucus in the middle ear. It is, of course, characteristic of a late stage. It may, therefore, be concluded, until a better explanation can be given, that tinnitus aurium, and in fact all forms of sub- jective noises in the ears, are due to what are best termed, in' short, morbid vibrations originating in the various parts of the organ of hearing, i. e., they have truly an objective existence in the subject. That a morbid circulation of the blood, let us say a too rapid flow of it, through the temporal artery may cause tinnitus aurium, I know by personal experience, and I also am fully aware that such a form of tinnitus may be hushed by pressure over that artery just in front of the tragus. A distinguished professor of the University of Pennsylvania has told me that while he was a resident physician in the Penn- sylvania Hospital, he was greatly annoyed by tinnitus in both ears, which he could always relieve by gentle pressure over the carotids. Such facts would tend to show that the blood may throw the vessels of the ear into such morbid vibrations that the latter are interpreted by the ear as sounds. If sound is motion, what can be more reasonable than such an explanation? Tinnitus aurium, in general, may be explained by the " vas- cular theory" of Theobald.' At the outset in this theory a subjective sensation is to be regarded as having no imaginary but a real existence, and therefore tinnitus aurium has a real existence, being due to morbid vibrations produced in the vessels of the internal ear and then communicated to the nerve. Two modes whereby vibrations of the vessels of the labyrinth may be ' Tinnitus Aurium, a consideration of the causes upon which it depends and an attempt to explain its production in accordance with physical principles, Samuel Theobald, M.D., Baltimore, 1875. 358 MIDDLE EAR. enabled to produce a sensible impression upon the auditory nerve, are suggested by Dr. Theobald, viz. : 1. The amplitude of the vibrations may be increased; 2. The vibrations remaining un- altered, their effect upon the nerve may be magnified, either by reflection and concentration or by resonance. The first condition may be said to exist vphenever an undue amount of friction attends the movements of the blood. " This will happen when the normal relationship between the intra- vascular and the intra-labyrinthine pressure is disturbed, or when, in any other way, the natural and easy fiow of the blood is perturbed, as, for instance, in hyperaeraia or ansemia of the labyrinth vessels, increased or diminished intra-labyrinthine tension, partial compression or obstruction of the trunks of the vessels by inflammatory or other causes, and finally, when the constitution of the blood itself is altered, as in spantemia or chlorosis. The tinnitus which is known to occur in increased labyrinthine pressure is attributed " to the accompanying vas- cular disturbance, rather than regarded as the expression of an irritation of the nerve, the immediate result of compression." Tinnitus aurium occurring in diseases of the middle and external ear, unaccompanied by pressure in the labyrinth, may be referred to the defect in the sound-conducting apparatus, as suggested by Theobald. Whenever waves of sound cannot obtain normal admission from without, to the percipient parts of the ear, tinnitus aurium may also be referred to the same kind of obstruction, " for those conditions of the sound-con- ducting apparatus which prohibit the entrance of sounds from without will also prevent their escape from within, and this, as we well know, will magnify their efiect upon the nerve, or, as we would say, increases their loudness." The well-known fact that tinnitus aurium is not often complained of when a perfora- tion in the membrana tympani exists, is explained by Theobald as due to the ready escape thus offered to the vibrations occur- ring in the ear. The probability of the origin of tinnitus in this way is in- creased by the fact that just the notes of high pitch which these delicate vascular vibrations would make, would correspond to the generally high quality of subjective noises in the ear. Dr. Blake' has shown that notes of tuning-forks which give ■ Transactions American Otological Society, vol. i. p. 438. ACUTE CATARRHAL INFLAMMATION. 859 an extremely high number of vibrations per second are heard much more easily when the membrana tympani is perforated, that is, they gain access to the auditory nerve more readily. This being undoubtedly the case, as shown by Blake's experi- ments. Dr. Theobald is apparently fully justified in his theory as to the ready escape of high tones originating in the vascular movements of the labyrinth, which might be interiireted by the ear as tinnitus, did they not readily escape through the perfora- tion in the membrana tympani. Why the ordinary normal vascular movements in the laby- rinth are not productive of tinnitus aurium is not yet explained, excepting on the supposition that a normal ear permits of the escape of all vibrations produced by ordinary vascular move- ments in the ear, without perceiving them as sound. The optic nerve, less the retina, is entirely insensible to light, and it is highly probable that the auditory nerve, less its terminal filaments in the labyrinth, is equally insensible to sound ; there- fore Dr. Theobald raises the very significant question, "Since these two nerves are respectively incapable of responding to the stimulus of light itself or sound itself, is it at all likely that such sensations could be excited in them by an other mode of stimulation ?" He therefore asserts his conviction that tinnitus is invariably due to an excitation of the percipient elements of the auditory nerve, and he disbelieves that it can exist as the result of direct irritation of the nerve-trunk, and also questions the existence of what may be termed cerebral tinnitus, i. e. tinnitus originating in the brain independently of the auditory nerve. But he admits that aural hallucinations may and do originate in this manner as the result of certain cerebral disorders ; but these are different in character from true tinnitus, and should not be con- founded with it. That motions sufficient to produce sound are constantly going on in the ear, which, however, the latter fails to hear, in the normal correlation of forces obtaining in the healthy organ, is proven by gently stopping a well ear, whereupon tinnitus of varied pitch may be perceived. This, as has already been said, is due to the altered resonance and reflection brought about in the ear by the stoppage of the meatus witii the finger ; for that which prevents sounds, i. e. 360 MIDDLE EAR. vibrations, from entering the ear will also prevent the escape of those originating in the ear, and thus the ear hears the so- called subjective sounds. Double Searing or Subjective Echo-like Sensation ; Paracusis Duplicata ; Subjective Alteration in Pitch. — Double hearing, or a subjective echo-like perception of tones or words, has been noted by several authors as connected with acute catarrh of the middle ear. Generally the latter part of the word is thus perceived ; it seems to be higher in pitch, as I can testify by observation of this phenomenon in my right ear. During a slight catarrhal closure of the Eustachian tube without pain, I heard a disagree- able echo of the last syllables of words in my right ear. The tones of the syllables thus perceived were certainly higher in pitch thii,n the' word as spoken to me. How great this sharping was, I cannot state. The notes of the piano did not seem to me to be thus sharped, nor were tliey subjectively echoed in their true pitch. In some cases both words and musical notes are perceived in this peculiar echo-like way, without alteration in pitch ; this is more likely to be the case with words than with musical tones. The latter are usually sharped a half tone or more. Some of the earliest accounts of this phenomenon are those of Sauvages, Itard, and Von Gumpert ;' the same symptom has been noted by Von Troeltsch and Politzer. The cases of Sauvages and Itard were observed in patients suffering with catarrh of the middle ear. Von Gumpert observed the pheno- menon on himself. The subjective difference in the note varied between the third, the fourtli, and the octave. He also per- ceived the echo-like ending of words. The peculiarity lasted for a week. Von Wittich,^ too, observed most critically a similar alteration in his own hearing, four weeks after an inflammation in his ear. " The notes of a tuning-fork appeared exactly a half-tone higher in the diseased ear than in the well one. The same was perceived respecting notes of the middle scale, either when whistled or ' Quoted by Bressler : Die Krankheiten des Kopfes und der Sinnesorgane, Berlin, 1840, Bd. ii. p. 375. See Moos and Gniber. * Kouigsberg Med. Jalirbiicher, Bd. iii., 1861. ACUTE CATARRHAL INFLAMMATION. 361 struck on the piano. They were beard double^ the difference be- tween the two sides ,being a half tone." " This phenomenon remained unaltered, both when the ex- ternal auditory canal on the affected side was filled with water or cotton-wool, and when by inflation the membrana tympani was made to change its tension. Apparently, a somewhat different phenomenon presented itself when a vibrating tuning-fork was placed on the teeth, for the natural tone was heard gradually to die away into the next halftone higher." In the latter instance there was apparently a double hearing, or an after-hearing of the true note sharped, in the diseased ear. When the fork was placed on the vertex, the tone appeared higher the nearer it was to the affected ear. Two forks, one of which was half a tone higher than the other, were heard as the same note, when the higher was held before the well ear and the lower before the diseased ear. Sir Everard Home' has related the case of an eminent music teacher, who, after catching cold, perceived, in addition to con- fusion of sounds in his ears, that the pitch of one ear was half a note lower than that of the other ; and also that the percep- tion of a simple sound did not reach both ears at the same time, but seemed as two distinct sounds following each other in quick succession, the latter being the lower and weaker. This phenomenon was considered by Home to be due to defective action in the muscular structures governing the ten- sion of the membrana tympani, although it is evident he was entirely unacquainted with these structures, since he de- scribed as he thought a radiate muscle lying in the drum-head, whereas no such structure exists as part of the layers of this membrane. But that he has accurately described a case of double hearing and subjective alterations in pitch, is beyond doubt. Prof. Moos^ places this peculiarity among the longest known afi"ections of Corti's organ. He relates two cases : one, that of a tenor singer who, for four- teen days after a severe coryza, heard simultaneously the treble of all the notes he sang. This was found to be due to catarrh of the middle ear and some hardness of hearing on both sides. ' Philosophical Transactions, Royal Society of London, Part I. 1800. 2 Klinik d. Ohrenheilkunde, pp. 319-320, 1866. 362 MIDDLE EAR. Catbeterization and injections of sal ammoniac (gr. x to f|j) entirely relieved the patient. The same author gives an account of double hearing in a case of chronic catarrh of the middle ear. In this instance the phe- nomenon of double hearing came on after the patient used chlo- roform for relief from an attack of asthma. Immediately after the narcosis the hearing was worse, subjective noises of various descriptions were perceived, and the patient noticed that .all notes from a' up were heard double in both ears. Later the notes thus doubled were e" and all notes from that point up the scale. Could not these subjective phenomena of hearing be ascribed to the exacerbation of catarrh produced by the breathing of the chloroform, and secondarily to the congestion and altered tension in Corti's organ ? Prof. Gruber' has noted the plienomenon in two cases: in one case, that of a musician, a musical tone was heard a third higher. In some instances the after sound may be of the same pitch as the original note. Among later accounts of this peculiar phenomenon, one given by Dr. H. Knapp^ is of interest, and may be regarded as rare. The double hearing in this instance was observed in the case of a young man suffering from acute otitis media on the left side. The hearing for the watch was very much reduced ; musical sounds were heard nearly normally, but the note of a tuning-fork placed on the glabella was heard about two notes higher in the afi'ected ear than in the well ear. Wittich and Knapp do not seem to use the word double as it is used by others ; most writers seem to mean that a note is heard double when it is perceived as it were twice by the same ear — first in its true pitch, then, in an echo-like way, sharped. But, judging simply from the context in the cases just named, it would appear that the note was heard by the diseased ear only sharped, while the true pitch was perceived by the well ear. In this sense the original note was heard double. Terhaps this phenomenon, double hearing, would be noted more frequently if the patients were generally educated in ' Op. cit., p. fi26. 2 Trausactious American Otological Society, 1869, p. 21. ACUTE CATARRHAL INFLAMMATION. 363 music, for it is worthy of note that in the cases recorded the sufferers were musical. Case I. The first instance of double hearing, or, as I prefer to call it, subjective alteration of pitch, which I observed was in a young Austrian oflBcer of good musical education, an amateur performer on the violin. During an acute otitis media on the left side, he noticed that in tuning his violin the note appeared a third higher in the affected than in the normal ear. This condition lasted for several days, but disappeared with the acute disease of the ear. In this case the hearing could be called double in the sense that the normal ear heard the true note and the diseased ear another, viz., one apparently higher than the original note, producing subjective confusion. Case II. In this case the subjective alteration in pitch oc- curred in both ears. During a successful treatment for chronic purulent disease of both ears, the patient, a young woman of 23, music teacher, suffered from a slight intercurrent acute otitis media on both sides. All sounds became disagreeable, and she especially noted and' complained of a sharping of all musical tones of the voice of others in singing and of the notes on the piano. This, however, disappeared in a week, and the purulent disease was finally cured. The hearing in this case became almost normal after the disappearance of the suppurative disease of the middle ears. In this second case it could hardly be said the patient suffered from double hearing, for she heard a similar subjective sharping of piano-notes in both ears. This she knew to be the case, not by discord but by her knowledge of music, for she knew, when she struck a given note on the piano, that the note her ears perceived in their diseased state was sharper than the note she heard when the same key was struck by her in health. Intra- Ti/mpanic Pressure during Phonation. — Under normal conditions, phonation produces variations in pressure both in the mouth and naso- pharyngeal space. Experiments of Dr. C. J. Blake' show that this pressure is sufficient to be communicated to the tympanic cavity through the Eustachian tube. Tliis pres- I Intra-tympauic Pressure during Phonation, Trans. Amer. Otol. Soc, vol. ii. p. 75, 1875. 364 MIDDLE EAR. sure may become painful in some cases of disease of the middle ear. In such instances the patient may voluntarily avoid pro- nouncing the nasal consonant sounds m, n, and ng, since the pressure in the tympanum, brought about by their phouation, is painful. The sensations produced by their pronunciation has been de- scribed as a disagreeable cracking and bursting sound, least so with m ; most so with ng. In a case of this kind observed by Dr. Blake, a cicatrix in the membratia tympani was seen to make vibrations with each of the above consonant sounds ; least with m, a larger one with n, and " with ng a double excursion was observed, the membrane only partially resuming its original position between the two movements." All of these unpleasant symptoms were relieved by excision of a portion of the flaccid cicatrix. A round opening was thus made, the symptoms above named disappeared, and the patient articulated normally. Dr. Blake also found that a manometric column of water (diam. 1 mm.) connected with the meatus, when m. was pronounced, rose and fell J mm. ; with n, nearly 1 mm. ; and with ng, a double rise and fall of nearly the same degree was observed. Recurrence, every year for fourteen years, of a Peculiar Subjective Noise and Altered Resonance of Voice, in the Left Ear ; Tempo- rarily relieved by Pressure on the Auricle aiid Meatus. — Septem- ber 9, 1873, Mrs. C, 35 years old, living in affluence, states that for fourteen years she has experienced an altered resonance of her voice and some buzzing noise in the left ear, which come on together in June, with the warm weather, and last until Sep- tember. She also makes the strange statement that these sub- jective alterations become appparent to her toward midday and last until about bedtime. She can always gain relief for a few moments by pi'essing and pushing the auricle and meatus on the affected side, but as soon thereafter as she swallows, the altered resonance returns. The hearing remains unaltered and certainly appears perfect on testing. The voices of others are never changed in quality as her own is. She says she has iu winter, catarrh of the throat, at which time there is more or less soreness confined to the Eustachian region on the side where these peculiar alterations occur in the summer season. In winter, however, these subjective alterations have never ACUTE CATAREHAL INFLAMMATION. 365 occurred. Examination revealed a somewhat granular throat, without hypersecretion. The membrana tympani was normal in every respect, unless an exception be found in its being a little more indrawn than its fellow. The tuning-fork placed on the top of the head was heard equally well in both ears. The Eustachian tubes were readily pervious to air from Politzer's bag. If the statements concern- ing these peculiar subjective symptoms in the left ear are to be credited (the woman was thoroughly intelligent and truthful), there are several points of great interest which earnestly de- mand some explanation. 1. The occurrence of these peculiar symptoms in summer time only. 2. Their coming on towards midday and passing off towards bedtime, i. e. about 9-10 P. M. 3. The temporary relief gained by pressing on the auricle and in the meatus; and 4. Their instantaneous return on swallowing. Naturally the mind connects their causation with summer and its heat, which idea is only strengthened by the statement that they grew worse as the day grew warmer, and disappeared as the sun went down and the temperature fell. The chief cause of this subjective alteration in the ear must be sought in the condition of the Eustachian tube. It is not uncommon to find the nasal mucous membrane subject to an irritability from the heat of summer ; it, therefore, seems fair to presume that the same irritability — a kind of erectility — may exist around the faucial end of the Eustachian tube. Let us suppose then that the heat of summer caused in this case a swelling in the tube in a manner suggested above ; at the same time, it expanded the air locked up in the tympanum by the closure at the mouth of the Eustachian tube. The expansion of the air contained in the tympanum forced the membrana tympani outward, and unlocked the malleo- incudal joint. This disturbed the equilibrium of these parts and brought about very much such an altered resonance as any one experiences after blowing the nose during an ordinary nasal and faucial catarrh. This pushing outward of the membrana tympani was sus- tained by the expanded air of the tympanum until the patient pushed the auricle and pressed the finger-end into the meatus. Then the column of air in the external auditory canal, being condensed by the pressure from the finger-tip, forced the mem- 366 MIDDLE EAR. brana tympani inward. The latter, in turn, pushed some of the expanded air of the drum-cavity out through the slightly swollen Eustachian tube, and resumed, with the ossicula, a posi- tion of equilibrium, and then vibrated normally until an act of swallowing occurred. Then the altered resonance returned. The return of the peculiar subjective resonance after the act of swallowing can be explained thus: The first effect of swal- lowing is to open the Eustachian tube and to force air in the drum-cavity, but in the normal, loosely closing, or closed tube (Lucbb), more than the requisite amount of air recoils, and the equilibrium is maintained in the tympanum. In this case the tube was enough swollen to interfere with the recoil of a surplus of air which it was obliged to permit to enter the drum-cavity at the relatively powerful act of swallowing. According to Lucse, so powerful is this act, and so great is the amount of air forced into the tympanum by it, that the first effect in the latter cavity is one of condensation. In this case the tube was not so much swollen as not to permit the usual large amount of air to enter the tympanum at swallowing, but it was enough irritated and narrowed by the effects of heat to interfere with the ready recoil of the surplus of air forced into the drum-cavity by swallowing; hence too much air remained in the tympanum, the equilibrium remained disturbed, and the peculiar resonance became once more apparent, until the finger forced the mera- brana tympani back to a normal position. Acute Aural Catarrh in Infants and Young Children. — Since this disease constitutes the so-called ear-ache in little children, it will be well to bestow more than ordinary comment on its occurrence in infants and very young children. Unfortunately it is a disease too commonly overlooked in them, partly on account of their inability to locate their pain and communicate tlieir feelings to others, and also on account of the difficulty of examining young and suffering infants. Hence the disease may escape proper treatment and lead finally to permanent injury of hearing, and even to results fatal to life if allowed to pass into the purulent form of tympanic inflammation. This disease of the ear is apt to come on with catarrh of the air-passages, teeth- ing, whooping-cough, and the exanthemata. Its most common occurrence is during a cold. If in an infant, the little victim will suddenly cry out most piteously, at first only with every ACUTE CATAREHAL INFLAMMATION. 367 severer twinge of the increasing pain, but at last it will utter a quick succession of piteous and peculiar shrieks. This cry has been said to resemble that occurring in acute bowei-disease, and has often been mistaken for that in infants. But the continu- ance of the pain, despite the treatment directed to the bowels, will soon show the careful observer that the disease is not in the intestines. The infant will refuse all nourishment, the breast or the bottle is pushed away, and if the nurse now en- deavors to dandle the little sufferer, each movement Avill cause it to shriek more loudly, and convulsions may supervene. The cries may be so dreadful that isolation of tlie patient in a re- mote part of the house becomes necessary in order not to alarm his relatives and neighbors. Such severe forms usually termi- nate in suppuration. Very frequently, attacks of ear-ache from acute aural catarrh come on only at night, for several nights in succession, but in the intervening daytime the little patient plays about as usual. If the ear is examined in such cases, the membrana tympani will be found greatly drawn in and lustreless, looking like ground glass, or a polished steel surface just breathed upon. The manubrium of the malleus in such cases is so much retracted and foreshortened, that it will appear far up and behind in the posterior superior quadraiit of the drum-head. These cases are primarily and emphatically tubal catarrh, with more or less hypercemic swelling of the lining mucous mem- brane of the tympanic cavity. The pain is aggravated at night, especially by the recumbent position, which, of course, increases the congestion and swelling, both in the tube and tympanum. Thus, the vacuum already alluded to is made greater, and the external air presses with greater force on the outer surface of the membrana tympani, forcing the latter inward, and with it the chain of ossicles. The freedom from pain in the daytime is due to a partial subsi- dence of swelling in the tube and tympanum, and consequently to less of a forcing inward of the membrana tympani and the ossicles. A want of air in the tympanic cavity is, therefore, one of the chief causes of pain in these cases of acute catarrh of the ear ; and hence, sneezing, blowing the nose, or an artificial infla- tion of the tympanum will usually cause a cessation of the pain, by overcoming the vacuum in the tympanic cavity and relieving the undue tension of the drum-membrane. 368 MIDDLE EAR, In very young children, a high degree of deafness may he present from merely a persistent simple catarrhal process in the Eustachian tube. If the latter is opened, usually by one good inflation with Politzer's air-bag, the hearing is instantly greatly improved, and a few repetitions, every other day, of this manipu- lation will eft'ect an entire cure of the case.' But such cases, I believe, are rarely recognized soon enough for beneficial treat- ment. Yet, I have seen enough of them to lead me to conclude that many cases of chronic deafness, in those just arriving at the age of puberty, are attributable Solely to neglect of simple catarrh of the tube four or five years previously. In such cases the closure of the Eustachian tube, especially if it be on only one side, is either not noticed by the patient or his friends, or, if noticed, is neglected, in the hope that the child will outgrow the trouble : and it appears that it sometimes does. Usually, however, the tube being closed for a long time and the tympa- num deprived of air, the latter loses, often irretrievably, its function, just as an air-sac in the lung would, beyond a stopped- up bronchial tubule. Acute aural catarrh in larger children is usually the result of undue exposure to dampness and cold while at play in winter sports. I have seen this intense suffering come on after the child's companions had "washed" its ears with snow. Although these attacks of acute catarrhal inflammation of the middle ear, from imprudent exposure to cold, are both common and painful, they are not usually so likely to become chronic, and thus permanently injure the hearing, as those forms of aural inflammation brought on by the exanthemata. The latter usually lead to purulent inflammation and spontaneous rupture of the membrana tympani, but acute catarrh may run a painful course, without producing spontaneous rupture of the drum-membrane. In fact, this tendency to produce a sponta- neous rupture of the drum-head, or not, is one of the distin- guishing marks between acute purulent and acute catarrhal inflammation of the middle ear. The large majority of all cases of chronic purulent inflamma- tion of the middle ear, are unhesitatingly attributed by the ' Seltener Fall einesi einfachen chronischen Mittelohrkatarrha. Dr. E. Polil- zer, of Pesth, Arcliiv f. Ohrenheilkimde N. F., Band i. p. 48. ACUTE CATARRHAL INFLAMMATION. 369 patients to the exanthemata or to some of the continued fevers. If the purulent discharge is said to be the result of earache from cold, it is usually found to date back to earliest infancy. An- other equally striking fact is that chronic aural catarrh — i. e. oft-returning and slowly increasing hardness of hearing, the so- called progressive hardness of hearing -(Weber-Liel), or prolife- rous inflammation (Roosa) — is almost invariably attributed to, or at least said to be aggravated by, cold in the head. It may be that inflammation of the middle ear, caused by cold in the head or acute inflammation of the air-passages, is of a sthenic type, while that produced by blood-poisoning of any kind, exanthemata, continued fevers, syphilis, etc., is of a decidedly asthenic type, tending to destruction of tissue. Objective Symptoms in Acute Catarrh of the Middle Ear. — If the membrana tympani can be examined in the first stages of this disease, there will be noted, first, a slight congestion about the periphery of the membrane, with a somewhat greater amount in the membrana flaccida and in the vessels lying over the handle of the malleus. The color of the membrana tympani, in general, will not be much altered at first, but its lustre may be slightly dimmed, and the pyramid of light will become faint or fade entirely. In many cases, even in those with considerable accumulation of mucus in the tympanum, the membrana tym- pani will not lose its contour, as it does in the purulent form of otitis media. A marked objective symptom, however, is the retraction of the membrana tympani. Retraction of Membrana Ti/mpani. — The retraction of the mem- brana tympani may be so great in these cases, on account of exhaustion of the air from the tympanic cavity, that mucus in quite large quantities may be present without causing any bulging of the drum-head. In such cases, however, unless the drum-head is very thick, the mucus can be seen through the delicate membrane; the color of the latter will then be in- fluenced by that of the mucus in the tympanic cavity, and the surface of the membrana tympani may flnally be made to bulge, either in spots, by lumps of mucus, or regularly at some one segment, mostly the hinder, by a more homogeneous kind of mucus. Spontaneous Rupture of the Membrana 2]/mpan2.— Spontaneous rupture of the membrana tympani is rare in simple acute 24 370 MIDDLE EAR. catarrhal inflammation of the middle ear. I consider this the chief diagnostic point between this disease and acute purulent inflammation of the middle ear, to which, I grant, the acute catarrh is only too likely to lead. But since, as a matter of fact, we rarely find purely mucous products breaking down the membrana tympani and discharging themselves through the opening thus made, while we constantly find pus escaping in this manner, I am forced to conclude that acute catarrhal inflammation leads rather to a thickening of tissue than to the more destructive disease — acute purulent inflammation of the mucous lining of the middle ear. In the latter instance we invariably find purulent discharge escaping from one or more spontaneous ruptures in the membrana tympani. The same view was entertained by Eau,' who states that the results of inflammation, comprehended " under perforation of the mem- brana tympani, destruction of the ossicles of hearing, caries of the mastoid," etc., do not follow acute catarrhal inflammation of the ear, but are results of the acute purulent form of aural disease. I observed, not long since, in a medical man, 60 years old, just recovering from pneumonia, an apparent exception to what seems the rule, that pure mucus is never found escaping through a spontaneous opening in the membrana tympani. A little pain, with considerable dulness of hearing, were the first symptoms. These were noted by the patient some days before the membrana tympani was examined. I found the membrana tympani uni- formly pinkish and thick in appearance, lustreless and bulging in its entire posterior half; the position of the malleus plainly visible. Paracentesis of the drum-membrane was proposed by me, but not performed, at request of patient; and that night and the next morning jelly-like, transparent mucus, resembling thick white of egg, came from the tympanum through a sponta- neous opening in the drum-membrane. This perforation healed in a day. Although this case was complicated by a deep-seated abscess of the cellular tissue over the mastoid portion, the hearing was fully restored. The membrana tympani now shows a small, grayish spot in the posterior segment where the open- ing occurred. ' Ohrenheilkunde, sec. 195. ACUTE CATAEEHAL INFLAMMATION, 371 In addition to the chief symptoms, fulness and pain in the ear, with hardness of hearing and tinnitus aurium, we shall find, usually, in acute catarrh of the ear, general catarrhal symptoms of sore throat, cold in the head, cough and hoarse- ness, and some headache ; but vertigo and fever are not common attendants of this disease. The latter symptoms are usually proportioned to the severity of the pain. As a rule, all the symptoms of acute aural catarrh will be found abating with the cessation of the general catarrhal symptoms, excepting, perhaps, the deafness, which may increase with the general increase of local secretion from the various parts of the mucous tract implicated in the general catarrh. The cause of this increase in the deafness is, of course, due to the mechanical obstruction in the Eustachian tube and tympanic cavity, brought about by the large amount of thick mucus retained in the middle ear, by the swelling of its mucous lining. The latter may be kept up by additional attacks of slight catarrhal swell- ing- Course. — This affection may lead rapidly to purulent inflam- mation of the middle ear. It is not, however, the more violent , form, either in children or adults, which leads to permanent deafness. The oft-recurring, slight attacks of fulness in the ears, with every cold in the head, are most likely to lead to a chronic catarrhal swelling and deafness. Such cases finally cause an accumulation of inspissated mucus in the tympanic cavity, according to some observers (Hinton). My experience would lead me to believe that such accumulations are not as common in this country, with its drier climate, as they are in England, where, as is well known, the atmosphere is more moist. Be this as it may, respecting the accumulations of mucus, it is very sure that the oft-recurring stuffed feeling in the ears, with every cold in the head, usually leads to permanent changes in the hearing unless relieved by proper treatment. Etiology. — Acute catarrh of the middle ear is most apt to occur in the spring and autumn, or in changeable weather in mid-winter, and is usually found whenever catarrh of the air- passages is prevalent. It is also caused by teething, whooping- cough, continued fevers, the exanthemata, and syphilis. In summer-time there are two great causes for its occurrence, viz., 372 MIDDLE EAR. cold bathing and diving, and sitting in a draught of air to cool the heated body. In the first instance, the exposure of the ear to breakers or to the cold water in diving is the cause of the in- flammation. This is easily understood when one reflects that the membrana tympani is so thin that its mucous surface is practically brought into direct contact with the cold water whenever the latter enters the external auditory canal, as in diving, or by any other incautious means. It would seem that in such cases the inflammation of the tympanic cavity is secondary to a myringitis produced by the cold water. In the second instance, when inflammation of the middle ear comes on after cooling oflf in a draught of air, it seems to be the result of a general constitutional disturbance due to the exposure of the heated cutaneous surface to cold air, and the result is similar to a chilling of the surface of the body in winter, when, as is well known, the aural disease is often joined to sore throat and coryza, all of which are due to the same atmospheric or telluric cause. Many cases of catarrhal inflammation of the tympanic cavity may be said to be to a great extent mechanical in their origin. The catarrh of the Eustachian tube closes up that important communication between the tympanum and the fauces, causing a vacuum and a retention of mucus in the drum-cavity. Conse- quently an irritation is set up there, both by the want of air in the drum and a slow decomposition of the retained tympanic excretions. Hence many an acute catarrhal process in the tym- panic cavity, accompanied even by pain, may be cut short by one or two good inflations by means of Politzer's air-bag. A great many cases of acute catarrh of the middle ear are produced by sudden exposure to the air after all forms of vapor baths. The heroic Turkish and Russian baths, so largely advertised, are constantly producing acute catarrh of the ear. The same evil result is often due to " cold packing" in water-cure establish- ments. Acute catarrh of the middle ear is most frequently caused by cold bathing. In Jiine, 1875, a gentleman 40 years old came to me complaining of pain and tinnitus in his right ear follow- ing a long swim of one hour and a half in the surf at Cape May. In swimming he had always presented his right shoulder, and consequently his right ear, to the brunt of the waves. This ACUTE CATAERHAL INFLAMMATION. 373 occasioned no pain at the time, but shortly after leaving the water the above-named unpleasant symptoitns set in, and con- tinued with rather lessening severity for four days, after which I. examined the ear. The membrane was shining and unaltered, excepting by a little congestion and the pinkish hue it obtained from the hypersemic condition of the mucous membrane of the tympanic cavity. In this case it is seen that the mucous lining of the tympanum was chiefly aftected by the effects of the cold water transmitted through the drum-head, which had escaped injury. As the man was in perfect health, and the weather mild, the congestion disappeared in a few days by resolution, and the organ of hearing remained unaffected. But such con- ditions of the ear, brought on by cold bathing, usually termi- nate less favorably. In September of 1875, 1 had the opportunity of observing a case of acute inflammation of the membrana tympani and tym- panum, occurring in a waiter, a mulatto 22 years old, after repeated baths in the surf at Long Branch. The patient was phthisical, and had suffered from chronic purulent discharge from one ear for years ; he had also persevered in his bath for days after the acute symptoms had set in in the previously well ear. The heretofore uninflamed membrana tympani was greatly congested, but intact when I first examined it, ten days after the cold bath. There were pain, loud tinnitus, and slight deafness in the ear. A little bulging or irterlamellar swelling had occurred in the middle of the posterior segment of the membrana tympani, which I incised, and a small amount of opaque serum came out. On the following day a small granu- lation appeared at the incised point, the only granulation I ever saw as the result of a paracentesis of the drum-head. There was no otorrhcea before nor after this. The patient, being very much debilitated after a summer's hard work, was ordered to take iron thrice daily, and to protect the meatus with cotton- wool, as the weather was growing cooler. The pain ceased, but the tinnitus continued, being always worse at night. The hearing began to improve, but the membrana tympani still remained congested, there being a delicate vascular tracery over its entire surface. I stopped all local treatment, gave con- tinued doses of iron ; the granulation at the point of incision flattened, and at last shrivelled and disappeared ; then the mem- 374 MIDDLE EAR. brana tympani grew paler, and the ear recovered its function entirely in about six weeks from the onset of the inflammation. Another case of ear-disease from sea-bathing with rather mys- tifying symptoms came under my observation on August 31, 1875. A merchant, 35 years old, after prolonged bathing and diving through the breakers at Cape May, experienced increas- ing pain with annoying tinnitus in the right ear. This he endured for three weeks, putting in hot oil now and then, ac- cording to the vague advice of a local physician. At the end of that time and at the expiration of his visit at the sea-side, the patient presented the following symptoms : Great pain and tenderness on pressure deep in the mastoid portion, with con- stant buzzing in the ear; the pain radiated forward toward the temple and backward to the occiput ; all of which symptoms grew worse at evening, reaching their intensity at midnight, but growing a little more endurable towards daylight. The hearing was g"^ in. for the watch. The examination of the membrana tympani showed it to be somewhat puffy, as though distended by an interlamellar or interstitial exudation ; but the congestion was not marked. The former swollen condition would attract the eye of the observer much sooner than the redness. Paracentesis caused a drop or two of opaque serum to exude, apparently from the substance of the swollen membrana tympani ; but inflation of the middle ear by the method of Valsalva forced no fluid from the cavity of the tympanum. The air whistled through the perforated drum-bead most freely, thus excluding any stoppage in the Eustachian tube. The operation of paracentesis and inflation gave no relief to the pain, tinnitus, and hardness of hearing. I learned the next day that the patient had passed another dreadful night. The membrana tympani was found to have healed, and the symptoms of congestion in it remained about as before the para- centesis. The mastoid symptoms, pain, and tenderness increased, the patient's pulse was 100, and he had fever and loss of appetite, with general malaise and muscular weakness ; but his intellect remained perfectly clear, though the signs of mastoid disease appeared to be grave. The bowels were freely opened by a ACUTE CATARRHAL INFLAMMATION. 375 saline purgative, and the mastoid portion and ear freely leeched, two leeches being placed in front of the ear and two behind it. This giving only slight temporary relief, I advised an incision (Wilde's) down to the bone of the mastoid portion, but this was rejected by the patient at the urgent request of his family. The case then passed from my notice, through some misunder- standing of messages ; but in a few days, as I learned months after my last visit to the patient, all pain ceased, and the hear- ing gradually returned with the return of general strength to the suflerer, in the course of a month. The hearing, as far as I can learn, has never been as good, however, as it was before the attack. The only possible explanation of the favorable issue of this severe and at one time apparently life-threatening attack, must be sought in a resolution of an intense hypersemia of the perios- teum of the mastoid region, consequent upon imprudent sea- bathing, the latter having also produced an inflammation of the membrana tympani, as seen by the discharge from the incision made in the membrane at the first visit. Earache from Teething. — Earache occurs very often in teeth- ing ; so frequently is it an attendant of this period of childhood that I have known mothers to prophesy with accuracy the com- ing through of a new tooth, on account of the sudden attack of earache. The vast majority of these cases never pass beyond the simple catarrhal form. This peculiar connection between teething and earache was also noted by Rau.' In some instances we may find that the catarrhal inflamma- tion has passed into the acute purulent form of tympanic inflam- mation, attended by perforation of the membrana tympani and discharge of puriform matter. Earache in Whooping-Gough. — Whooping-cough is not an un- common cause of acute catarrh of the middle ear ; the perforation of the membrana tympani occurring in these cases is due to the mechanical force of the cough, not to merely spontaneous results from the catarrhal disease. Without doubt the inflammation in the tympanum weakens the lining of the cavity and favors its easy rupture by the force of the coughing. ' OhrenUoilkunde, sec. 168. 376 MIDDLE EAR. Diagnosis. — The diagnosis of acute catarrh of the middle ear will be aided, chiefly, by the comparatively slight pain, the marked hardness of hearing, and the annoying hissing tinnitus, and, in a minor degree, by the presence of other catarrhal symptoms, such as sore throat, cough, etc., with little or no fever, nor any marked constitutional disturbance. It will also be noted that the pain is more easily overcome than the hard- ness of hearing, and that there is no tendency to a spontaneous rupture of the membrana tympani. When the patient inflates his ear, or when it is inflated artificially by the surgeon, loud mucous rSles will be heard in it. These are audible in a marked degree to the patient, and easily heard by the surgeon's ear, when assisted by the ausculting tube. Objectively, the diagnosis will be aided by careful inspection of the membrana tympani. The latter will be found to present the varying appearances already described, according to the stage of the disease. At times it may be noted with surprise, that the membrana tympani has not undergone great objective changes, notwithstanding the marked subjective symptoms in acute catarrh. If the secretion of mucus has been large and consequently the deafness of a high degree, usually it will be seen that the membrana tympani is forced to bulge before the pressure of the retained tympanic mucus. Another important aid in diagnosis is the freedom of the auricle and auditory canal from inflam- mation. These may be handled without pain to the patient in acute aural catarrh, but if there is inflammation of any part of the external ear, ordinary examination with the speculum, which necessitates some traction on the auricle and meatus, will cause pain. This is often a means of finding out, in a case of asserted pain in the ear, where the seat of the disease is, or at least what division of the ear is probably most aflfected. Prognosis. — The prognosis of acute catarrh of the middle ear is, on the whole, favorable. By careful observanee of all the symptoms and prompt application of the treatment about to be detailed, usually the disease will terminate favorably. It should never be neglected, even in its mildest forms, since repeated slight attacks are very likely to lead at last to severe and perhaps permanent hardness of hearing. ACUTE CATARRHAL INFLAMMATION. 377 Treatment. — The milder forms of congestion are to be treated by relieving the general catarrhal symptoms, and a thorough inflation of the tympanum. The first object is to be gained by opening the bowels, if necessary, and restoring the function of the skin, which is usually more or less disturbed. A mild diet must be observed, and spirituous drinks, smoking, chewing, and snuffing tobacco are to be sedulously avoided. The second object, inflating the tympanic cavity, is to be gained by using Politzer's air-bag, the Eustachian catheter, or Valsalva's method of inflation. By thus inflating the tympanum, the formation of a vacuum is prevented and the secretions are forced away from the ossicles and allowed to escape through the artificially opened Eustachian tube. This is purely a rational treatment, and no novel one ; in little children we may employ, as suggested by Mr. Hinton, of London, a piece of India-rubber tubing, through one end of which the surgeon may blow, while the other end is inserted into a nostril of the child. Air thus blown into the nostrils of children, will force open the Eustachian tube without any cooperation on the part of the patients; in fact, crying on their part will only lift up the palate, shut off the lower from the upper pharynx, and facilitate the passage of air into the tympanum. If the child is tractable, prolonged phonation of the vowel a, or of the words hick, hack, hock, etc., according to the sug- gestions of Lucse' and G-ruber,^ will aid in lifting the soft palate and in closing the naso-pharynx from the cavity of the mouth and throat. At the moment of, or during, this prolonged phonation, air may be forced into the tympana by Politzer's bag ; if only one tympanum needs inflation, the one opposite to it may be firmly stopped with the finger during the operation of infla- tion, and thus, in some cases, it seems that more air is forced into the ear to be ventilated, because of the greater resistance offered by the voluntarily stopped ear to the column of air pressed into the naso-pharynx. The treatment need not be actively antiphlogistic unless the pain and fever become severe. Should the pain grow intense, leeches must be applied in front of the tragus, as near as possible ' Virchow's Archiv, vol. xliv. "- Moualsschr. f. 0., Nos. 10 and 11, 1875. 378 MIDDLE EAR. to the ear, and directly under the auricle. This is demanded in order to prevent suppuration. Before leeches are applied, the mouth of the auditory canal should be stopped with cotton to prevent their crawling into the meatus. Such a mishap would cause the patient not only intense pain hut most prohably a severe external otitis. Hence, the advice sometimes given to deliberately apply the leech to the meatus is to be rejected. Even in the most favorable spot a leech-bite not unfrequently produces a circumscribed abscess. Anodynes. — Anodynes should be given in doses sufficient to allay pain and produce sleep at night. A hop pillow will often prove ver}' grateful in this malady. In addition to the above means, warm and soothing gargles, and warm applications with the syringe or nasal douche, to the nose and naso-pharynx, together with rest in bed or in the room, will be found to hasten restoration to health and hearing. Irrigation of the Naso-pharynx. — In most cases of acute aural catarrh, especially those in which the fauces, naso-pharynx, and Eustachian tube are inflamed, irrigation of these parts by. warm fluids will be found grateful to the patient and very useful in the treatment of the disease. "Warm water, slightly impregnated with salt (tablespoonful to the pint) is most usually employed, and in acute cases is the best. Warm water containing chlorate of potash (3-5 gr. to f3j) will also prove useful in some cases. Fig. G6. AtTEAL Douche op Clarke. The most convenient form of application of warm irrigation to the naso-pharynx is by means of Weber's (also called Thudi- cum's) nasal douche. Clarke's aural douche, and the ordinary syphon arrangement with a bowl of water and a piece of rubber tubing, will also well convey warm water applications to the naso-pharynx. ACUTE CATARRHAL INFLAMMATION. 379 Fig. 67. Irrigation of the nares and naso-pharynx may be accom- plished by the syringe. But as the force with which the warm water is carried into these cavities by a syringe cannot always be regulated, great care must be exercised, to apply the fluids slowly and gently when obliged to use this means. It should be regarded as the last resort. "Whatever has been urged against the nasal douche can most surely be urged against syringing the nares or the Eustachian tube. Yet I have been surprised to hear the former condemned by those who are willing t6 force a stream of fluid by means of a syringe directly through the Eustachian catheter into the Eustachian tube. The use of nasal irrigation will be further considered when the treatment of chronic aural catarrh is reached. It can but be repeated here that all forms of oils and fats are to be kept most carefully out of the ear, in this as in all other acute aural diseases. Sweet oil and other fats not only clog the ear and mask the disease, but they load the drum-mem- brane, increase the pain, and, as they are usually forgotten and left in the ear after the pain ceases, they become rancid and favor the growth of fungi. These in turn produce a painful and troublesome acute disease of the external, and even of the middle ear. It would be well if it were remembered that most of the so-called remedies for earache would make a well ear painful if they were put into it. Paracentesis of the Membrana Tympani. — If the collection of mucus in the tympa- num becomes great, it will generally be best to incise the membrana tympani. This should be done by means of the specially devised knife, at the posterior inferior quadrant, unless some other point protrudes very greatly. Some authorities advise waiting to incise the membrana tympani until spontaneous rupture is im- Paracentesis Knife. 380 MIDDLE EAE. minent. Then, in order to have an opening in the most depen- dent portion of the drum-membrane, it is advisable to perforate it. Absorption of the effusion may be brought about by a thorough ventilation of the tympanum, by means of Politzer's air-bag and the Eustachian catheter. Therefore, it may not be imperative to incise the membrana tympani in acute catarrh of the middle ear, unless the collection of mucus is great, the Eustachian tube stopped up, the pain severe, or spontaneous rupture is imminent. However, to insure an entire removal of all products of in- flammation in acute catarrh of the ear, especially if the disease occurs in a tympanum already aftected and thickened by pre- vious inflammatory processes, it will be found advantageous to perforate the membrana tympani. Cases recover without this operation ; but the incision of the membrane is so safe and simple that it is preferable to thus as- sure one's self that no mucus is left to harden in the tympanum and lay the foundation of future deafness. CHAPTER II. CHRONIC CATARRHAL INFLAMMATION. The onset of this disease is usually insidious. It may be preceded by numerous painful attacks of acute aural catarrh, but more frequently there is no history of precedent acute catarrh of the ear. Chronic catarrh of the middle ear is seen under two chief forms : (a) the secretory or moist, and. (6) the asecretory or dry form. To these aspects of the chronic disease different names, and in some cases vastly different natures, have been assigned. But in both these chief forms it is usually found, on close examination, that a markedly catarrhal condi- tion of adjacent and related mucous tissues either has preceded or attends the chronic aural disease. Even in those cases of chronic aural disease in which the nervous features are promi- nent, the latter usually are seen to be due to nutrient dis- turbances in the nerves of the middle ear, and possibly of the internal ear, induced by the antecedent aural catarrh. Indeed, CHRONIC CATARRHAL INFLAMMATION. 381 it seems that many cases of aural vertigo, under its numerous names, might be traced* back to a chronic catarrhal disease of the middle ear. Chronic aural catarrh, therefore, with its multitude of symp- toms, has given rise to many different opinions as to its real nature and also to a very diverse nomenclature. This is due to the fact that the observation of the disease has usually begun at a more or less advanced stage of the affection, and but rarely continued until terminated by a careful study of the diseased tissues after death. Hence the number of names applied to this malady, as, " nervous deafness," " hypertrophic" and " pro- liferous inflammation," " sclerosis," and " chronic thickening of the mucous membrane of the tympanum," " anchylosis of the stapes," and " progressive hardness of hearing." They all pos- sess the merit of designating at least marked characteristics of the malady to which they are applied. To the inquiring and observant student of aural disease, each of these terms will offer itself in many cases as the best descriptive name of the tedious complaint he finds before him. But no single one of them admits of universal application. " Chronic catarrh" seems to me to be indeed the only universally applicable name. It is comprehensive, and surely serves to denominate the essential nature of the disease. SUBJECTIVE SYMPTOMS. The earliest subjective symptoms of this disease are tinnitus aurium and a gradual diminution of the hearing. These symp- toms appear usually only in one ear at a time, most commonly the left, and a varying period may elapse before the other ear is attacked. The onset of the subjective noise in the ear may be quite sudden; the time of its first occurrence can usually be stated accurately by the patient. This subjective buzzing, chirping, or hissing may appear on rising in the morning, during or after a severe cold in the head or after a depressing illness. The noise is not intense at first, but gradually becomes louder and more annoying, the hearing usually diminishing at the same pace. The statements of patients as to the quality and character of the subjective aural noise are extremely varying. The ob- jective sounds to which they are likened are commonly taken 382 MIDDLE- EAR from the sounds to which the patient is most exposed ; the mechanic seems to hear noises of machinery, the student the hissing or buzzing of a lamp, while the simmering of the tea- kettle is a universal similitude used to explain the quality of tinnitus aurium. In many cases a hypersesthesia to objective sound seems to come on with the annoying subjective noises. I have known patients suffering with distressing subjective hissing in the ear and greatly reduced hearing, to complain bitterly of the intensely disagreeable effect on the diseased ear of the noises of the street, and of the blowing of the wind across the auricle while walking. This sensitiveness may per- sist for months. Sometimes patients seem to get used to the noise in the ear. When their attention is specially drawn to it they will state that they are aware of a singing in the ear but it is of no great moment to them. The singing in the ears is not very severe, nor does it grow louder in these cases. All subjective noises of the ear in this disease may be increased by fatigue, drinking spirits, smoking, and prolonged conversation. In some cases, after each meal the noise seems much louder. Some authorities' state that abnormal conditions of the genito- urinary apparatus tend to aggravate the tinnitus of chronic aural catarrh. But in some cases, tinnitus aurium either never appears in the disease or only at a later stage, loiig after the hearing is much reduced. These cases, being deprived of the warning as to the threatened failure of the function of the ear found in tinnitus aurium, are rarely made aware of the loss in hearing until it becomes very great. This is especially the case when one ear remains perfect. A failure of hearing in it, temporary or otherwise, is often the iirst occasion for noticing the defect in the other ear. Or, a patient will come with the statement that while lying on the good ear in bed, accidentally it was discovered that some ordinary sound, such as the voice of a friend, the crying of a child, or the bell on the street-car, was not perceived by the free ear. This has lead to domestic testing with a watch or a clock, ' Weber-Liel, Progressive Schwerliorigkeit, p. 19. CHRONIC CATARRHAL INFLAMMATION. 383 and these are not perceived, or but imperfectly, in the ear which now for the first time is discovered to be faulty. The coming on of this kind of deafness is so insidious that, in many cases, even among the most intelligent, there is no reliable history of the origin of the disease. I have known children of physicians to be thus affected, but their fathers were not able to state when and how the disease probably began. These cases, with no definite account of the beginning of deafness, seem in my experience to belong to a class with hered- itary tendencies to chronic catarrh of the ear. In the case of a physician's child, I found the father affected in one ear ; in a young lawyer's, the father and uncles were similarly troubled. A young gentleman, growing markedly deaf in both ears, lately aggravated as he thought by shooting, stated that his family in some branches grew deaf, but he could not tell when the disease began to appear in him ; he thought perhaps after undue exposure in the army ten years before. And such cases might be cited by scores. Darts of pain are felt in some cases, every day or two ; but this is not a very frequent symptom. If it occur it is only in the earlier stages. Most patients complain of a sense of fulness and discomfort in the ear, as the disease advances. If the secre- tion of mucus is considerable, more or less cracking is heard in the ear by the patient. After the ear cracks, it seems open for a little while, and the patient may hear better. But in a short time the sense of stoppage in the ear returns, and the hardness of hearing is again present. Both pain and the sense of fulness are increased by changes in the weather during the winter season. In summer all such symptoms are very much less prominent. A great sensitiveness of the ear may coexist with great deaf- ness. Sounds which cannot be fully understood, i. e. words which are perceived only as sound, uttered very near an ear rendered entirely deaf by catarrh, will often produce pain in the ear. With the tinnitus aurium, loss of hearing, and darting pain in some cases, disagreeable sensations are felt in the fauces, throat, and larynx. The character of these subjective conditions is variously described by the sufferers. 384 MIDDLE EAE. Most of them complain, however, of constriction, tickling, sense of fulness, and burning in the throat. All of these are aggravated by cold, any depressed state of health, or often by stimulating food. In some instances after an ordinary hearty meal, the throat will feel more or less burning, which is aggra- vated if the patient is obliged to talk in any prolonged way. Very often the disagreeable feeling in the throat is described as that of a hair or foreign substance lying in the fauces, but which still clings there notwithstanding all eftbrts at swallow- ing. • According to "Weber-Liel,' this symptom is specially apt to be complained of by females. In a state of health all acts of swallowing can be felt, or heard, in the Eustachian tube and middle ear. But in these cases of chronic aural disease attended with pharyngeal symptoms, swallowing cannot be perceived in the affected ear by the patient ; not even when the attention is drawn to the normal process by the physician. Very few persons are aware that at each act of swallowing, they can perceive, if the Eustachian tube is in a normal state, a sensation of opening and crackling in the ear. This peculiar thud felt in the ears, at swallowing, is but the normal process of ventilation of the tympanic cavity. When the attention of one possessing good ears is drawn to this fact, it is then recog- nized, usually for the first time, so accustomed do all become to normal physiological processes. Consequently any symptomatic change in this respect must be inquired for by the physician ; for the patients never volun- teer any information on this point, being, as already stated, ignorant of what a normal ear might perceive in swallowing. Vertigo is sometimes felt in the later stages of this disease, but it cannot be considered a very common symptom according to my experience. "When it is present as a symptom of chronic aural catarrh, it is paroxysmal in character. This character- istic alone would help to diagnose it from vertigo caused by cerebral disease. In the latter instance, the vertigo, if it occurs, is either constant or invariably produced by some particular act, like walking, and there is more or less permanent alteration in the gait. Vertigo caused by chronic aural disease is usually ' Op. cit., p. 23. CHRONIC CATARRHAL INFLAMMATION. 385 connected with an increase in the subjective noises and an aggravation of the deafness. In such cases, any force which increases the pressure in the tympanic cavity is apt to bring on an attack of giddiness, as for example sudden swallowing, pro- longed acts of deglutition, and powerful inflations of the tym- panic cavity, whether by natural or artificial means. Changes in the weather, and consequent increases in the catarrhal symp- toms, will often lend their aid in producing a greater tendency to aural vertigo. In most cases, by abatement of the catarrhal congestion, the vertigo will be lessened. In all such cases the Eustachian tube will be found to be at least temporarily narrowed , and the tympanum consequently imperfectly ventilated. The vertigo produced by inflation of a middle ear already diseased by chronic catarrh, and in which the membrana tympani is in- drawn and more or less unyielding to forces intended to push it outward, is due to pressure on the foot-plate of the stirrup bone and upon the membrane of the round window. The latter membrane is highly susceptible to changes of atmospheric pres- sure in the tympanum, as recently shown by Weber-Liel.' Since, in the almost sclerosed ear, the drum-head is both stiffened and held inward by the retraction of the tensor tym- pani muscle, air forced into the drum-cavity, instead of equal- izing the pressure by carrying ahead of it the membrana tympani, which forms so large a part of the outer wall of the drum-cavity, is suddenly spent upon the more delicate coverings of the fenestrse in the inner wall of the tympanum. Pressure thus exerted on the labyrinth-fluid must produce not only a morbid oscillation and compression of the terminal filaments of the nerve of hearing, but also an alteration in the pressure of the cerebro-spinal fluid, for the labyrinthine fluid has been shown^ to be in direct communication with the cerebro-spinal water. It can be seen easily, therefore, how undue pressure in the labyrinth could be conveyed to the brain, and it seems also most rational to thus account for many cerebro-aural symptoms, rather than to seek for their elucidation in obscure affections of ' Centralblatt fiir die Med. Wissenschaften, No. 2, 1876. 2 Weber-Liel, Monatsschr. f. Ohrenh., Berlin, August, 1870^ and Prof. Hasse, Anat. Studien, No. xix. p. 768. 25 \ 386 . MIDDLE EAR. limited spots in the labyrinth, as for instance in the semicircular canals. Even could a specific lesion of these canals be more frequently demonstrated than it is, it is highly probable that all the sj'mptoms of chronic aural catarrh can be found to have long preceded the symptoms of so-called M^ni^re's disease. As the distinctly catarrhal precede the vaguer labyrinthine symp- toms in point of time, I believe they are more frequently causa- tive than is generally supposed. Hearing Better in a Noise. — Hearing better in a noise is very often a marked symptom of the later stages of chronic aural catarrh, when the condition of the tympanum has become dry and sclerotic, or when the thickening of the mucous membrane has become great in the moist form. This condition of the hear- ing, once supposed to be a mere fancy on the part of the patients, or at least due to the general elevation of the voice all are obliged to assume in a noise, has been shown to be real. Those pre- senting this symptom, Paracusis Willisiana, are found upon examination to hear the ticking of a watch somewhat better in a noise, for instance in a mill or a railway train, than in a quieter place. ISTo entirely satisfactory explanation has ever yet been given for this. Dr. A. H. Buck mentions,' but does not claim as an original idea, the following explanati6n for this peculiarity in hearing. " The pathological condition in the cases here under considera- tion is assumed to be one of rigidity, either of the annular membrane or ligament which holds the foot-plate of the stirrup in the fenestra ovalis, or of the secondary tympanic membrane covering the fenestra rotunda. Ordinary waves of sound, such, for instance, as are produced in ordinary conversation, are not of sufficient strength to overcome the rigidity of the annular ligament or of the secondary tympanic membrane ; consequently the patient fails to hear the conversation. In the midst of loud noise, however, waves of sound are produced of sufficient strength to set the stirrup in motion in spite of the existing pjathological obstacles. Once in vibration, this little ossicle, which might very properly be called the key to the auditory chamber, can perform with a certain degree of freedom the sub- ordinate vibrations called into existence by the conversation ' Report on the Progress of Otology, N. Y. Med. Record, June 5, 1875. CHRONIC CATARRHAL INFLAMMATION-. 387 which is being carried on near by, vibrations which are neces- sary to the act of hearing it. The louder tones open the door for the entrance of the feebler ones." This can be most safely considered a sign of great rigidity in the sound-conducting parts of the tympanic cavity, and also one of unfavorable omen. Hereditary Tendency. — The tendency to this disease is markedly hereditary. Within a year I have been consulted by a woman and her seven children for chronic aural catarrh. The woman was about 40 years old ; the oldest child was about 18 years old. The disease manifested itself early in life in the children, the worst of whom was a boy about 11 years old. The family were in the hard-working class, and but moderately nourished. The boy, the worst case, was at school. Odor. — A symptom of this disease is a peculiar odor which I have noted, pervading the vast majority of those in the mature stages of chronic aural catarrh. It is not at all like the odor of ozqena; it is more like that of saliva. By simply passing one's tongue over one's finger, and allowing the saliva to slowly evapo- rate, this odor may be simulated. It cannot be called offensive, and it is not perceived at any distance from the patient. It seems to emanate through the nose, and is more noticeable in females than in males, because in the latter it is usually dis- guised by tobacco. This odor, I think, is due to a disordered condition of the follicles of tlie mucous membrane of the fauces, mouth, naso-pharynx, and nose. OBJECTIVE SYMPTOMS. Appearances in the External Auditory Canal. — It may be said that in chronic aural catarrh characteristic changes occur in the external auditory canal. Chief among these is the diminished or suspended secretion of cerumen. The ear-wax not only becomes smaller in amount, but often assumes a brittle quality ; later it often ceases to be formed at all. This points to a great altera- tion in the nutrition of the organ of hearing, and also seems to indicate a considerable degree of intimate structural relation between the vessels of the canal and those of the middle ear. This important excretion's ceasing to be poured into the auditory canal is succeeded by a dryness and scaly condition of the skin of the meatus. This latter state favors the growth of asper- 388 MIDDLE EAR. gillus most surely; but, although I have met this parasitic fungus in individuals affected with chronic aural catarrh, I am not prepared to name its occurrence as a characteristic symptom of this disease. Weber-Liel considers its appearance in such cases as not at all uncommon.^ Membrana Tyywpani ; Changes in Color. — The membrana tym- pani usually loses its lustre and transparency in chronic aural catarrh. But as these changes are not always indicative of such a disease in the tympanum, they must never be regarded as of positive value. In some cases of chronic catarrh of the middle ear, the membrana tympani may be thinner than usual, and cases are met with in which the lustre remains unchanged. In the latter instance, the chronic alterations in the mucous mem- brane of the middle ear have most probably occurred elsewhere than on the inner surface of the drum-head. Another important fact to bear in mind respecting color- changes in the drum-head is, that, even in those with normal hearing, especially in children, the membrana tympani is not unfrequently rather dull in appearance for longer or shorter periods. The lustre of the membrane is most easily lost ; alte- rations in tenuity are more indicative of a deeper change in structure. Calcareous Deposits. — Chalky spots may be found in the drum- head of an ear affected by chronic catarrh ; but they cannot be considered characteristic of the disease. They are usually trace- able to a previous purulent disease in the ear, all other traces of which have gone, for it is not uncommon to find these deposits entirely unaccompanied by hardness of hearing, as has also been noted by Prof. Roosa.^ Reverting to European authority, we find, however, that cal- careous spots may arise in the course of a chronic aural catarrh, as observed by Moos in a woman more than seventy years old.' But this must be regarded as an exceptional case. After an experience of seven years, in the daily examination of the drum-head, both in Europe and America, I am struck by the general rarity of chalky spots in the membrana tympani of those born in the latter country. It seems that these deposits are much more frequent in those born and reared in Northerly ' Op. cit., p. S9. 2 Op. cit., p. 273. » Roosa, loe. cit. CHRONIC CATARRHAL INFLAMMATION. Europe. Perhaps the milder climate of the latitude of this city may account for their rarity in the drum-heads of those born here. Changes in Position of the Membrana Tympani. — A much surer objective symptom of chronic aural catarrh, especially when joined to opacity and loss of lustre, is a retraction of the mem- brana tympani. The drum-head then appears drawn in, and the manubrium of the malleus foreshortened, the short process of the latter projects more sharply than usual, and the folds of the membrana tympani (see p. 52) are very prominent. The manu- brium is not only indrawn, but is pulled backwards and upwards, and the entire concavity and curves of the drum-head being thus altered, the pyramid of light, normally found in the antero- inferior quadrant, is very much shifted in position, or it may disappear altogether (see p. 53). As the latter reflection depends on the lustre as well as the curve and position of the drum-head, and as more or less opacity is found in chronic aural catarrh, the normal pyramid of light is usually one of the first appear- ances to vanish from the diseased membrane. The manubrium not only appears indrawn, but rotated about its long vertical axis so as to pull the posterior half of the drum-head into greater prominence, and to drag the anterior half into a greater depression. The causes of this retraction' of the membrana tympani and malleus have been variously assigned by several distinguished observers. Politzer is of the opinion that the swollen and chronically diseased condition of the Eustachian tube interferes so much with the normal ventilation of the tympanic cavity as to cause a constant want of air, if not an entire vacuum, in it. This want causes a disturbance in equi- librium in the atmospheric pressure on each side of the drum- head, and the preponderance of the external air forces the drum- head in and relaxes the tendon of the tensor tympani muscle. This in turn may, by fatty degeneration or adhesion, or both, or by contraction from want of use, fix the drum-head in its indrawn position. In such a condition, the want of air in the tympanic cavity is the prime factor in the retraction of the drum-head. "Weber-Liel ascribes the drawing in of the membrana tympani chiefly to the retraction of the tensor tympani muscle. This muscle is described by him as a part of the palatal and tubal 390 MIDDLE EAR. muscles (see p. 109). The latter, becoming diseased and under- going fatty degeneration, are no longer able to preserve their proper amount of tension, and hence occur disturbances in the equilibrium of the muscular structures of the middle ear. " In this process (defective motility of the faucio-tubal muscle), the paralysis of the tensor veli sive dilator tubse plays very probably the chief part, not only because of the resultant persistent and ever-increasing hindrance to the ventilation of the tympanic cavity, but also because this muscle (which, according to my investigations, stands in the relation of antagonist to the tensor tympani), when paralyzed, is 'the chief causative power of the antagonistic contraction of the tensor tympani."' Implication of the Sympathetic and other Nerves ; Flushing of the Cutaneous Surface adjacent to the Ear. — Among the objective symptoms of chronic aural catarrh may be mentioned implica- tions, more or less frequent, of the sympathetic nerve. It is not uncommon to find " complex disturbances in the correlated tracts of the vagus, glosso-pharyngeus, facial, auricularis mag- nus, and the accessorius nerves, standing in close connection with aural maladies of this nature. It is also not at all uncom- mon to find in deaf females, suffering from spinal irritation, muscular weakness, and rheumatic pains in the muscles of the throat and neck, sensitive spots along the side of the neck, behind the sterno-cleido-mastoid muscle, where the auricularis magnus and accessorius arise. Pressure on these spots causes not only pain running down to the shoulder, but also occasions, in the ear on the corresponding side, a feeling of fulness and more or less tinnitus aurium."^ In some cases of chronic aural catarrh, especially in the dry form, called by some writers progressive hardness of hearing, a flushing of the skin near the ear is observed. I have seen but three cases in which distinct, deep-tinted, and circumscribed flushing of the surface of the skin near the ear, was connected with tinnitus aurium and progressive hardness of hearing.' The history in these cases was such as to lead to the conclusion that this peculiar vascular congestion in the skin may be, in ' Weber-Liel, op. cit., p. 14. ^ ■y^eber-Liel, op. cit., p. 3. ' Three cases of tinnitus aurium and deafness, accompanied by very distinct flushing of the cutaneous surface adjacent to the ear, by the author, in Archives of Oph. and Otol., vol. iv. CHRONIC CATARRHAL INFLAMMATION. 391 some instances, a symptom of aural disease. "Weber-LieP has described a case which presented, in one ear, symptoms resem- bling those observed by Bernard, after section of the cervical sympathetic. In some cases it must be admitted that the distinctly catarrhal symptoms are much less prominent than the nervous features of the disease, and such cases have given rise to the theory of nervous deafness. But my conviction is that upon ordinary search all such cases, no matter how prominent the nervous symptoms may be, when the case presents itself for treatment, can be traced back to a causative catarrhal trouble in the fauces, Eustachian tube, and middle ear. But it must be admitted that there are many good reasons for assigning to some cases a nervous nature, as may be seen by the following cases : — Case. I. I was asked by Dr. T. Hollingsworth Andrews, in May, 1874, to see with him a young lady, 26 years old, of large and handsome figure, unmarried, a resident of the western part of Pennsylvania. Six years previous to the time I saw her, she had sufiered from an attack of probably rheumatic facial paraly- sis on the right side. Within two or three years she had noticed a diminution in hearing, accompanied by an uninterrupted and distressing singing in her ears. The hearing on the right side was reduced to g'^ ; on the left, to s% for the watch. The tuning- fork, placed on the vertex, was heard better in the better ear. The membrana tympani on the right side was more retracted than on the left. The lustre of both was good. The Eustachian tubes were pervious. There was, in this case, a constant quivering of the buccal and labial muscles, which dated back for a year or more. There was also a distinct purplish-red flush over the cheeks and neck as far as the clavicle, with an increase in the tinnitus lohenever the patient was even ordinarily excited or fatigued. The application of the constant electric current from a Brenner apparatus, at the time of the examination, did not afibrd even temporary relief to the tin- nitus. I saw the case but once. Case II. Mrs. Van C, 56 years old, patient in the Presbyte- rian Hospital in Philadelphia ; a farmer's wife, small and thin. ' Op. cit., p. 3. 392 MIDDLE EAR. She states that at the menopausis she experienced a sudden and excessive tinnitus aurium, which, however, has diminished in severity since then, but, though it has become quite endurable, it has never entirely ceased even temporarily. The hearing does not appear to be affected in this case. There is, however, a peculiar vascular congestion or flushing, looking like a car- mine stain, which comes on with any considerable fatigue or excitement, and is attended with an increase in the tinnitus aurium. This flush extends from both ears, where it seems to start, over each sterno-cleido-mastoid muscle, forward towards the thyroid gland, where the blushes of each side coalesce and extend over the chest and mammse. At the same time, a similarly tinted blush extends over the nucha and upper part of the back and shoulders, so that the woman appears covered by a carmine- colored cape with the limits already designated. The rest of the skin-surface is sallow. There are at this time some linear blushes running from the ears forwards over the temples, uniting across the forehead. This was truly objective flushing, and altogether ' different from the subjective flushes, so often felt by women at the menopausis. Case III. Mrs. McA., of Delaware, a very large, strong woman, aged 45 years,- living in a malarial district, and now in her eleventh pregnancy. The patient states that she has had an increasing hardness of hearing, with tinnitus on both sides, for some years. The drum-heads are opaque. In her case there is a peculiar flush on the left cheek, corresponding to the worse ear, which becomes apparent on exertion or exposure to heat or cold, and is coincident with an increase of tinnitus aurium. This case grew much better while taking ^'g gr. of strychnia thrice daily and using the constant electric current. The history of these cases adds something to the knowledge of a form of aural disease in which the nervous symptoms pre- dominate. Since similar flushing has occurred from well-known direct lesion of the sympathetic, it is fair to assume that the flushing in the cases I have just narrated must also have been due to an irritation of the sympathetic. In two of the cases, as there were other symptoms of chronic alterations in the organ of hearing, it would seem probable that in them at least, the flushings were CHRONIC CATARRHAL INFLAMMATION. 393 directly traceable to the aural malady. In the second case it may have been but the precursor of deafness. Circumscribed flushing of the cutaneous surface in any part of the body, whether from external violence or internal causes, is rare and in many respects unsolved. In a case' of direct mechanical violence to the sympathetic nerve, the only known case at that time on record, " the face presented, after walking in the heat, a distinct flush on the right side, and was pale on the left. The right half of the face was very red. The flush extended to the middle line, but was less definite as to its limit on the chin and lips than above these points." Dr. "Wm. Ogle^ has reported a case of probable destruction of the right cervical sympathetic by abscesses. In this case " the eyeball was retracted, the palpebral fissure narrowed, the pupil contracted, the right side of the face redder and hotter than the left during repose, but after violent exercise or fever, colder. The left side of the face alone sweated, and the right side of the mouth and tongue was complained of as being dry." In a case' under the care of M. Tr^lat, at the St. Louis, in Paris, in which the sympathetic nerve had been destroyed by an operation for removal of a deep-seated tumor of the neck, " on the day following the operation, the face was deeply congested, especially on the right side, which displayed well-defined patches of violet and red color." These cases are cited because they present instances of flushing of the face and parts of the head from known and direct lesions of the sympathetic nerve. In the three cases I have related above, there was well-defined flushing without history of ex- ternal violence to the sympathetic nerve, nevertheless it seems fair to conclude that the nerve was aifected from within, and to it treatment would be well directed. The Condition of the Pharynx and Throat. — On examination, the pharynx, tonsils, and velum will be found to present varying appearances according to the form of the disease. In the moist form the secretion of mucus will be markedly ' " Gunshot and other Injuries of the Nerves." Mitchell, Morehouse & Keen, 1874. Philadelphia. « Medico-Chirurgical Transactions, vol. lii. p. 154. 3 See Abstract in Med. Press and Circular, p, 78, Jan. 1869. 3^)4 MIDDLE EAR. increased, and the glandular structures of the mucous lining of the fauces will appear enlarged and inflamed, their function being of course stimulated by the disease. The tonsils are usually very much enlarged in this form of the disease, and the velum appears swollen. But this is only an accompaniment of the general catarrh, not the cause of it in the ear nor of the hardness of hearing. It will very often be found that the most swollen tonsil is on the side of the better ear. The secretion of the nose is also very apt to be abnormally great. This form of the disease really deserves the name of catarrh in its strict meaning of " flowing" or " running." But many cases of chronic aural catarrh do not continue to show this abnormal amount of secretion in the pharynx. In these cases the mucous membrane has either rapidly ceased to throw off large amounts of mucus, or it has slipped at once into an atonic and dry state. In such cases the mucous membrane of the entire pharynx, especially on the posterior wall, is pale and, at spots, apparently cicatrized. It may even somewhat resemble granular pharyngitis without marked secretion. The velum appears rather thinner than natural, as though its muscular structures were atrophied, as indeed they are ; and the raphe is no longer directly in the median line, nor are the halves symmetrical in shape and position. A paresis has appa- rently affected one-half more than the other, and the uvula and the weaker half will be drawn towards the stronger side, which will usually be found to agree with the better ear. All of these changes in the action of the muscles of the fauces must be attributed to the effects of the catarrh. Loss of Function in the Velum. — The loss of normal mobility in the velum is further seen when the patient is told to phonate the vowel a broad. Then, the velum and uvula, instead of rising quickly to shut off the lower from the upper pharynx, will fail to fulfil this function. The uvula either hangs loose and downward, quite relaxed, or it clings to one or the other side, on the edge of the velum. As the patient phonates, the uvula may slip from this position on the velum and hang loosely downward, or it may curve forward. In such conditions, sud- den eructation, coughing, or sneezing may at times produce pain in the ear. It is also very noticeable that the act of swal- lowing cannot be performed rapidly by persons thus affected in the faucial muscles. CHRONIC CATARRHAL INFLAMMATION, 395 Changes in the Voice. — "With these alterations in the ear and throat, the vocal functions usually become weaker. The timbre of the voice is altered, and, if the patient has been a singer, the voice is found to be rapidly losing musical power. A kind of hoarseness sets in, when singing or prolonged conversation is attempted. The voice "breaks" or "cracks," and a general sense of fatigue in the throat becomes a prominent and distress- ing symptom. My observation leads me to conclude that all of these alterations in the throat usually begin to appear before the early morbid changes in the ear. The latter seems to become affected by a passing upward of the throat-disease, through the tube into the tympanic cavity. When once there, a long series of nutrient changes begin, which, with varying symptoms, usually terminate in total deafness ; though in some cases, chronic aural catarrh seems to stand still after having diminished, but not destroyed, the function of the ear. A marked peculiarity of chronic aural catarrh is not only to advance slowly and surely in one ear, but to pass to the other, sooner or later. The changing of the voice, i. e. the gradual assumption by the patient of a high and peculiar pitch in the voice in talking, will often aid in diagnosing a chronic catarrhal affection of the middle ear, even when the patient is sure that the aural malady is of sudden advent. " An explanation of the numerous symptoms of affections of the vocal organs, so often associated with aural disease, may be sought in the direct connection between the acoustic nucleus (by means of the acoustic trunk) and the probable centre of speech in the cortex of the island of Riel. On the other hand, it is important to bear in mind the anastomosis between the vagus and the petrosal ganglion of the glosso-pharyngeal nerve (tympanic plexus, tubal nerves) and the auricular branch of the pneumogastric nerve, which, in this instance, plays the part of a communicating link. During the insertion of a probe into the Eustachian tube of one possessed of good ears, pain is felt in the larynx when the probe reaches the isthmus. This is felt before the person operated on is aware of the presence of the probe in the ear. In perichondritis crico-arytenoidea there is always pain in the ear."' 1 Weber-Liel, op. cit., p. 35. 396 MIDDLE EAR. Saissy relates that in the records of the Parisian Academy of Sciences for the year 1705, a singular case is accredited: "A young man, 20 years old, lost both hearing and speech after his larynx had been squeezed by a strong man, in a fight. All means tried for the restoration of hearing failed in this case."' Objective Changes in the Eustachian Tube. — As may be inferred, from what has been already said in the preceding pages, the Eustachian tube, being lined with mucous membrane continuous with that of the fauces and of the tympanic cavity, and forming such an important part of the middle ear, undergoes serious and most important changes in chronic aural catarrh. These changes are due primarily to thickening of the lining of the tube, or to obstruction of its calibre by mucus. Hence arise very striking objective symptoms, which become apparent to the surgeon upon using the Valsalvan method, Eustachian catheter, Politzer's inflation-bag, or bougies for dilation of the tube. To all of the processes of inflating the drum, and to the probe, the tube will oflfer more or less resistance ; in some rare instances the inflam- matory process may have been so great as to cause an entire closure of the tube at the isthmus. Upon auscultation of a catarrhal ear, into which some air enters from the catheter, the sound perceived by the auscultator will reveal the presence of mucus in the Eustachian tube, or a narrowing of the same with perhaps a diminution of secretion. The first condition is found in the moist form ; the latter sound, that of air rushing through a narrow and dry tube, is of course found in those cases in which the secretion is not in large amount, and in which the catarrh has led to a hypertrophic process throughout the mucous and submucous tract of the tube. These symptoms of obstruction, usually ascribed to the changes just named, are accounted for somewhat difl:erently by one high authority, Weber-Liel. This observer states that in many cases of asecretory catarrh of the middle ear, or, as he calls it, progressive hardness of hearing, the Eustachian tube is easily permeable to a bougie, but not to air by any means of ordinary inflation. The cause assigned for this obstruction to the entrance of air, is the relaxed condition of the muscular walls of the tube. So great is this relaxation, that the flaccid walls cannot ' Quoted by "Weber-Liel, loc. cit. CHRONIC CATARRHAL INFLAMMATION. 397 be forced apart by any of the ordinary means of inflation. Be this as it may, the cause of this muscular weakness, atrophy, or paresis, is, in my opinion, to be considered secondary to the catarrhal inflammation. This is analogous to processes in other muscular structures underlying mucous membrane, elsewhere in the body. Thus in the alimentary tract, muscular derangements are constantly found following close upon catarrhal disease of its mucous lining ; the same may be said of the bladder and of the lung. In all of these, a prominent symptomatic change, following close upon inflammation of their mucous layer, is the want of proper contractility in the subjacent muscular structure. It would, therefore, seem much simpler to account for the symp- toms of muscular derangement in the middle ear, affected by chronic catarrh, in the same way as muscular alterations occur- ring in a chronically inflamed bronchus are explained. The mucous membrane of the nose, pharynx, and Eustachian tube may be not only greatly congested and swollen, but ex- tremely irritable, assuming almost an erectile nature. In such eases, merely smelling an irritating substance has been known to produce an instantaneous closure of the Eustachian tube, altered pressure in the tympanic cavity, deafness, and sudden unconsciousness. Erhard' mentions the case of a boy, whose nasal and Eusta- chian mucous membrane possessed such peculiar irritability that upon applying his nose for an instant to a bottle containing sulphuric ether, all of the above symptoms ensued, not only once, but repeatedly for many days in succession, whenever Erhard desired to demonstrate the case to his pupils. Upon inflating the tympana in this case, consciousness instantly re- turned. This case points unmistakably to a sudden closing of the tubes, a disturbed equilibrium in the membrana tympani, forcing inward of the chain of ossicles, pressure by this means on the labyrinth-water, and thence to the cerebro-spinal fluid. Adenoid Growths and Granulations in the Naso-Pharynx.—hi a number of cases of chronic aural catarrh, there are found adenoid growths and granulations in the naso-pharyngeal space. Their nature and the symptoms they produce have been very ' Outlines of Physical Otiatrics. Translation in Phila. Med. Times, Jan. 4, 1873. 398 MIDDLE EAR. carefully studied and described by Czermak, Turck, Semeleder, Voltolini, Lowenberg, and W. Meyer.' These growths are described as benignant in nature, and more or less leaf-like or conical in their shape. They are usually situate quite high in the naso-pharynx, are extremely delicate, and hence bleed on being touched. Their height or length rarely exceeds three cm., and their breadth or thickness varies from a few lines in the smallest to one or two centimetres in the largest. As might be supposed, such growths interfere not only with respiration and enunciation, but also with the normal ventilation of the Eustachian tubes and the tympana. The symptoms are a tendency to bleed whether touched or not, alteration in the pronunciation of certain vocal sounds, as m, n, and ng, and a great change in the facial expression, from the falling in of the alse of the nose, and the respiration through the mouth, necessitated by the obstruction in the posterior part of the nares. The hearing, too, will in time become greatly lessened from the chronic stoppage in the Eustachian tubes, and the interference to the normal ventilation of the middle ears. The proportion of aural disease in persons thus affected in the naso-pharynx has been placed by Meyer at 130 in 175. Although not uncommonly I find this condition of the naso- pharynx, the proportion is by no means similar to the above, a fact to be accounted for, very probably, by the milder climate of Philadelphia, Dr. Meyer having made his observations in the high latitude of Copenhagen. A naso-pharynx thus affected is apt to secrete large amounts of tough greenish mucus, the velum may be swollen, and the lower pharynx chronically inflamed. On the other hand, these growths may be present in the naso- pharynx without any marked accompanying changes in the pharynx and velum. Is^ot uncommonly, the altered enunciation, respiration, and facial expression arouse a suspicion of their presence, which is subsequently confirmed by rhinoscopic exami- nation, and manipulation with a probe, the latter causing the growths to bleed. Symptoms in the Eustachian Tube and Tympanum revealed by Inflation and Auscultation. — Unless there is total occlusion of the Eustachian tube, some air can be forced through it into the tympanic cavity in every case of chronic aural catarrh. To ' Archiv fur Obrenh., Bd. ii. N. F. pp. 129 and 341. CHRONIC CATARRHAL INFLAMMATION. 399 accomplish this, the methods employed may be those known as Valsalva's and Politzer's, or that more direct one, with the catheter and hand-balloon. The sounds produced by forcing air into the drum-cavity are easily heard by means of the auscul- tation-tube. These sounds, however, are greatly modified by the means used to inflate the drum and by the condition of the Eustachian tube, and, very probably, of the tympanic cavity. In using the catheter it will be found that its calibre and the column of air forced through it, influence the pitch and quality of the sound heard on auscultation. For, the air passed through the catheter, like every column of air passing rapidly through a pipe, will produce in the latter its fundamental tone, dependent upon the length and diameter of the pipe. Hence, in a wide catheter, a fuller and deeper sound is heard ; in a narrower one, a whistling noise. Unless this is borne in mind, the quality of the sound thus produced might be referred to the condition of the Eustachian tube. Having, therefore, found out, before the catheter is inserted, the general quaility and pitch of the sound produced by forcing air through it from the hand-balloon, the surgeon can, with advantage, study the sounds resulting from inflation of the tube and tympanic cavity by the catheter. These sounds will be found to be very different from those obtained even in the same ear by Valsalva's or Politzer's inflation. In the former, there is no instrument employed which, of course, excludes any sounds from such a source ; in the latter, the instrument being so re- mote from the fauces, no sound produced in the hand-bag is conveyed into the middle ear and thence to the ear of the aus- cultator. In both of these latter methods of inflation, only the movements of the natural parts concerned and the thud of the entering air are perceived. In that respect they ai-e certainly superior to the Eustachian catheter, since, by their use^ the con- dition of the tube can often be determined without confusing sounds originating in the instrument. The catheter, however, is of the greatest aid and usefulness, if it be but remembered that the quality of the sound made by the air forced into the tube, is influenced by the calibre of the instrument. Air forced into the normal Eustachian tube and middle ear by artificial means, couA'eys to the auscultator the impression of air passing with freedom through an unimpeded tube. When 400 MIDDLE EAR, the methods of Valsalva or Politzer are used, the air enters with a thud, the ear seems to have been filled by the air sent in, and the impulse thus conveyed upon the membrana tympani reveals itself most distinctly to the ear of the auscultator joined to the ear of the one operated on by means of a rubber tube. Auscultation by the same means, applied to an ear the Eusta- chian tube of which is narrowed or clogged by the products of chronic inflammation, reveals a different physical condition of the ventilating apparatus of the tympanic cavity. If mucus is present, bubbling sounds will be heard ; if the tube is dry, then of course a dry sound. At the same time the tube seems nar- rowed, for the quality of the sound made by the air inflated is that of air passing through a narrow tube. Air inflated through a normal Eustachian tube enters inde- pendently of the act of swallowing ; in the tube narrowed or altered by chronic catarrhal inflammation, this act on the patient's part aids greatly in the artificial ventilation of the drum-cavity. So resisting is the diseased Eustachian tube to ventilation, that in some cases air can be forced through only during swallowing. This latter condition is highly character- istic of alteration in the tube. The Objective Effects of Inflation upon the Membrana Tympani. — The effects of inflation upon the membrana tympani are among the most important objective symptoms. In some re- spects they have been duly considered, hut there are some signs which are deserving of special notice. One reason why the action of the membrana tympani during inflation has not been as highly rated as it should be, is due to the fact that there is only one method which can be ernployed, Valsalva's,' during which the surgeon can inspect the drum-head and the effects produced on it by the motions of the contents of the tympanic cavity. More or less bulging of the drum-head will be caused by inflation. If the handle of the malleus is held retracted, by alteration in the mobility of the tendon of the tensor tympani, this bulging of the membrane will occur behind and before the manubrium ; but if the manubrium is not held in as above sug- gested, then it and the membrane will be moved more or less as a whole. At the same time, if there is movable fluid in the ' This mode of inflation consists in the patient's holding his nose and forcing air, by powerful expiration, into the tympana while the mouth is closed. CHROXIC CATARRHAL INFLAMMATION. 401 cavity of the drum, it will be forced against the membrana tyrnpani and modify the picture presented to the observer. Bubbles may be seen then distinctly through the membrane, or inspissated secretion may be found to change position in the drum. A most interesting and instructive change, produced by infla- tion, in the ajipearance of the drum-head, is the forcing outward of depressed spots or cicatrices. Unless this symptom is sought for, and promptly noted after the air is forced into the tympa- num, it may escape notice. Very often depressed cicatrices are considered retractions adherent to the inner tympanic wall, but on inflation these depressions may not only return to the plane of the rest of the drum-head, but not uncommonly they project beyond it, into the auditory canal, forming thus bladder- or blister-like spots. In some cases these are filled only with air ; in other cases, in fact often, they are filled with brownish fluid, which will give them an amber tint. Not only will these appearances come out on the drum-head by inflation, but they can be produced very easily under suction by Sigld's speculum. This latter method of examination of the drum-head is of the greatest value, for, when the tube is stopped up and absolutely impervious to air, Sigle's pneumatic speculum or its equivalent becomes the only means of producing movements in the drum- head, and secondarily of the contents of the drum-cavity. ifTot uncommonly inflation of the tympanic cavity, especially by Valsalva's or Politzer's method, produces objective sounds, readily audible without the aid of the auscultation-tube. Especially is this observable when the entire drum-head is flaccid and easily moved to and fro, or when, in a comparatively normally tense membrane, flaccid scars are found. The sound produced in either instance is that of a loose crack- ling and flapping of the flaccid tissue. In a case recently ob- served, so loud was this flapping-sound that it was heard across a large room, not only during Valsalva's method of inflation, but also during rapid breathing through the congested nares, the mouth being kept closed. Causes of Chronic Catarrh of the Middle Ear. — Very few patients can give a satisfactory cause for their disease. In fact, 26 402 MIDDLE EAR. it is not an easy task for the physician to assign the positive cause for chronic aural catarrh in the majority of cases. It does seem that very often chronic catarrh of the middle ear is caused by cold. It would be safer, in most cases, to say that chronic aural catarrh is found associated with, rather than produced by, certain diseases ; though the latter may have much to do in its aggravation and chronicity. Thus, chronic catarrh of the ear is frequently observed joined with chronic catarrhal disease of the mucous membrane elsewhere ; phthisis ; grief and weeping ; nursing the sick, especially by night, with loss of sleep ; progressive locomotor ataxia ; sciatica ; general neuralgia, but especially neuralgia of the fifth nerve ; insanity ; intemperance and debauchery. It may also be found following close upon pregnancy, the menopause, uterine diseases, continued fevers, any of the eruptive fevers, mumps, great shock after frac- ture of limbs, sedentary life, rheumatism, gout, and, perhaps, secondary syphilis. In this country, within the last few j'ears, I have observed a number of cases of chronic aural catarrh trace- able to exposure, by sleeping on the ground, while in the field as soldiers during the recent war. Anglo-Saxons born in tropical countries, as well as those whose parents are, one an Anglo-Saxon, the other a native of a tropical region, seem specially liable to chronic aural catarrh. This has been remarked by Hinton, of London, who has had large opportunity of seeing such cases among the English with connections in India. In our country I have observed such a tendency in children born of Anglo-Saxons in Mexico and South America. In these cases Hinton has observed a thinning of the membrana tympani in its posterior segment. In the few cases I have seen, a similar condition of the drum-head was noted. I have ob- served a number of cases of chronic catarrhal deafness in young women from eighteen to thirty years of age, associated with, and apparently caused by, ozaena and menstrual irregularities ; according to my experience, ozsena is more frequent in the female than in the male. Hunting, which often brings with it a wetting, and especi- ally duck-shooting, seems to be a cause of chronic aural catarrh in men. Also, diving and ducking the head in cold water most surely produce a thickening of the drum-head and lead to CHRONIC CATARRHAL INFLAMMATION. 403 a chronic catarrhal state of the tympanic cavity. Mill-hands of both sexes are specially liable to chronic catarrh of the middle ear; as also are carpenters, boiler-makers, and female domestics. In the first class, the noise, the confinement of the work, and the dust certainly tend to produce catarrh of the air- passages, genei'al debility, and aural disease. ' Carpenters are constantly exposed to the varying temperatures around a new building ; the latter cause, added to their liability to perspire and the fact that they are generally insufficiently clad, makes them very often the victims of aural disease. Boiler-makers' and telegraph operators' deafness may be due as much to nervous exhaustion from continuous shock, as from catarrhal disease ; but the latter is generally found to have a part in the train of symptoms. Female domestics, and females forced to do their own house- work, are constantly exposed to great changes in temperature, because their labor takes them one moment to the hot kitchen and the next moment to the cold court or " flat" to hang up wet clothes, or from cooking in the house to scrubbing in the open air. To these facts may be added that such women are usually found in damp skirts, and when they rest for a moment it is usually without any covering for the head, at the front door or at a window, in a draught. These are some of the more manifest causes; there are other causes assigned by patients, but these are chiefly fanciful. Since, however, some of these causes have been given by really intelli- gent people, it may be well to cite a few : thus, a lady informed me that her deafness, markedly catarrhal, was ushered in by a hasty journey to Europe and back again to America. Two persons of intelligence have assured me that they became deaf in Switzerland, as they thought, from the chilly air and damp rooms of hotels. Others attribute their hardness of hearing to blows on or about the ear, excessive night study, editorial work, and sudden noises near the ear, as of firing guns, etc. The latter cause very frequently produces an injury of the labyrinth, but it, like many of the causes given by patients, has only served to call attention to the ear already diseased by chronic catarrh. In some cases no reason is given ; it seems that the patients in such cases have been growing deaf so long that they have become used to it. This is specially noticeable in children 404 MIDDLE EAR. who have become deaf, or in adults who became chronically deaf while children. One might suppose that deafness for which no cause is as- signed, would be found in neglected children of the poor. But I have been surprised to find that children of the rich and educated — children well cared for — are frequently placed under treatment for hardness of hearing for which no reason is given by the parents, nor can the latter be assisted by the surgeon in recalling any probable cause. These cases are almost invariably found in families having, apparently, an hereditary tendency to deafness. The treatment of chronic aural catarrh is to be con- sidered in the following chapter. CHAPTER III. TREATMENT OF CHRONIC CATARRHAL INFLAMMATION. In treating chronic catarrh of the middle ear, the particular form presenting itself, either the moist or the dry, must be kept sharply in mind. It is very evident that grave mistakes have been made in applying empirically one form of treatment, steam for example, to every case of hardness of hearing which could be attributed in any way to chronic catarrh. A moment's re- flection would surely show the folly of using such a remedy in a case of moist catarrh. On the other hand, some such relaxing or softening means may be of value in the dry and sclerotic forms of catarrhal deafness. The treatment of any case of chronic catarrh of the ear re- solves itself very quickly into the question, what will restore the middle ear to its normal condition of containing air and conducting sound? The answer to this will depend upon the power to decide, whether the interference to hearing is due to an excess of secretion in any part of the mucous lining of the middle ear, or to an absence of such a secretion combined with the thickening, stiffening, or drying of any or all the parts concerned in conducting sound. With this divergence in form, or in these different stages if yqu will, comes a vast diver- TREATMENT OF CHRONIC CATARRH. 405 gence in treatment. And, at the outset, it must be confessed that treatment applied to the moist, secretory forms is far more satisfactory to patient and physician than that applied to the so-called dry, asecretory, " proliferous," " chronically thickened," or " anchylosed" forms. Doubtless, many cases have been placed in the latter category, that of the dry form, which really should have been placed in the former class. Among recent authors, Mr. James Hinton of London has brought out this fact most brilliantly before the minds of those specially interested in the treatment of aural diseases. That distinguished writer has shown, that a large number of cases formerly diagnosed as purely dry chronic catarrh of the middle ear, are really cases of inspissated accumulations in the tympanic cavity, and by their removal hearing is restored. Of course, those cases in which masses of fluid behind the drum-head cause the latter to bulge, have long been recognized by aurists, but Hinton, Schwartze, and Weber-Liel have gone really a step in advance by proving that many cases of what was once called hopeless thickening and hardening of the drum and its contents, are really very remediable examples of simply hardened old secretions in the drum. Without doubt such is the case, but the great obstacle in the way of their successful treatment is the impossibility of always diagnosing them. The more fluid these old accumula- tions are, the more readily are they recognized ; the older and harder they are, the more diflicult they are of recognition through the drum-head. But it seems, to fair judges, that a more hopeful era has begun in the treatment of many cases of chronic catarrh, by the mere knowledge that such cases may depend on the presence in the tympanum of hardened mucus, the remnant of successive acute and subacute catarrhs, and not on an organic change in the tympanic tissues. Constitutional Remedies and Hygiene. — Constitutional remedies are of the greatest value in the treatment of chronic aural catarrh. They are most efllcient when chosen from the list of so-called alterative medicines or alterative tonics. The pre- ferable drugs are, perhaps, iodide of iron, iodide of potassium, and bichloride of mercury. These are especiiilly adapted to the cases presenting strumous features, glandular enlargements, and the more secretory characteristics. In the dry form, I have 406 MIDDLE EAR. obtained the best effects by using iron and strychnia, and the combination found most desirable is wine of iron with strychnia (gr. ss-j to fSiv). The dose of such a mixture should be a tea- spoonful thrice daily. For some time past, internal remedies have fallen into disuse in the treatment of aural diseases, but lately, it has seemed best to return to them, fully aware that they are not to be relied on for all the aid needed, but as admirable adjuvants to the local treatment. Mr. Hinton has advised' the giving of perchloride of mercury ; this he has given in doses of j'g or ^'g gr. two or three times a day, with the perchloride of iron, and he believes this combination is often useful in the dry or proliferous form. Applications to the Nares, Naso-pharynz, and Throat. — Medi- cated applications to the nares, naso-pharynx, and fauces are of important aid in the treatment of chronic aural catarrh. From what has been said elsewhere, it will be seen that from the nature of the origin of this disease in many instances, treat- ment of the parts just named would be indicated. In by far the vast majority of cases of chronic catarrh, more benefit is derived from the proper treatment of the nares and pharynx than from direct medication of the tympanum. The latter is probably not as often reached by injections aimed at it as is supposed, and, if reached by such substances, is probably more frequently injured than not. In every case of chronic aural catarrh, the lesion in the tympanum either has been, or still is due to want of air in the cavity. This, of course, has been due chiefly to the occlusion, either temporary or permanent, of the Eustachian tube. Such being the case, the treatment must aim either at the removal of this obstruction to ventilation of the tymjianum, or to its effects. The latter may have obtained so long as to be irremediable, but the first aim in the treatment should be to restore the tube to its physical function as conveyer of air to the tympanum. There are, however, some cases of chronic catarrh of the middle ear, in which the Eustachian tube is found to be per- vious, both to natural and artificial inflation, and yet the hear- ing is much impaired. In these cases it will be found that the lining membrane of the tympanum has undergone a change, ' Op. cit., p. 243. TREATMENT OF CHRONIC CATARRH. 407 mostly a thickening, or that the tympanic cavity is filled with inspissated mucus, the result of passed subacute catarrhs. Although the tube is found pervious in these cases when examined by the surgeon for the first time, there must have been a period in their history when the tube was stopped up and aided in bringing about the condition of the drum-cavity just mentioned. It may be said, therefore, that these two chief forms, viz., {a) a closed tube with an empty tympanum, and (6) the pervious tube with a full tympanum, are classes into which' chronic aural catarrh may be placed. A third class (c) may also be found composed of a union of the two forms in the same ear. If fluids ever can be or should be thrown into the tj'mpanic cavity, the class c would aflbrd the proper opportunity. Irrigation of the Naso-pharynx by means of the Nasal Douche. — Any form of irrigation applied to the naso-pharynx may be called a nasal douche. But this name is specially applied to an instrument devised by E. H. Weber, during his physiological studies on the velum and pharynx. It consists of a bottle to the lower part of the side of which a hose is attached. The latter has a nose-piece, best made of glass, olive-shaped, which fits snugly into one nostril. In this country and in England, such an instrument is usually called Thudicura's nasal douche, after him who introduced it to the notice of the profession in the latter country. It is, without doubt, the best means surgery possesses of irrigating the nares and naso-pharynx. Accidents to the ear have happened by improper use of the nasal douche. When it is carefully and correctly applied, however, I do not know that water has ever been forced by it into the middle ear. The following rules will be found to give the greatest assur- ance of safety. And, so far as I have observed, no accident has ever happened where they have been fully observed : — 1. The vessel containing the fiuid to be injected must not be higher than the forehead of the patient. 2. The forehead must not be inclined forward too greatly, for if it be, the fluid enters the frontal sinuses. 3. The fluid used in each case must be tepid, and in bad weather the patient should not leave the room for a quarter of an hour after the use of the douche. 408 MIDDLE EAR. These are substantially the rules given by Dr. Seyfert,' of Oderau, as in foi'ce in the celebrated clinic of Prof. Wendt, of Leipzic. The discovery of the nasal douche is attributed to E. H. Weber, while be was making his experiments on the organs of smell. According to Dr. Seyfert {loe. eit), Theodore Weber, of Halle, was the first to utilize the fact that a stream of water passed through one nostril will escape through the other, after passing through the naso-pharyngeal space. This is due to the well-known reflex action of the velum palati, which causes it to retract and shut oif the naso-pharynx from the pharynx. Where the above general rules have been followed, Dr. Seyfert states that he has never known a case of secondary inflammation to occur. A universal mistake of physicians and patients is to place the vessel holding the fluid at a very great height above the head. The surface of the fluid in the douche-bottle must have only that elevation above the nose sufficient to carry the irrigation into the naso-pharynx. If the vessel is held or placed higher than this, it is plain that the fluid used may be forced too high, even into the frontal sinuses and tympana. Before the nasal douche is used by the patient, the surgeon should satisfy himself that there are no obstructions to the passage of the water through either nostril. An obstacle to the return current of the irrigating stream would be just as danger- ous as too high a position of the source. For by such hindrance, the water entering the naso-pharynx might easily be forced into the middle ear. The patient's head must be held erect. If it is bowed forward the water is very likely to enter the frontal sinus and the tympana, since these parts are thus more likely to be brought below the hydrostatic source. After using the douche the patient should not go immediately into the open air. It will be safest to apply the douche in a pleasantly warm room, and to remain there at least a quarter of an hour after the irrigation is ended. These precautions are absolutely imperative in winter time. ' Ueber die vielfache Anwendung des Irrigationsapparats, Wiener Med. Presse, Nos. 33, 34, 36, 1872. TREATMENT OP CHROXIC CATARRH. 4C9 In summer, if the douche is used, the temperature of the room will not demand so much attention. But going into a cooler place, or sitting in a draft of air, must be avoided even in summer time, after using the nasal douche, just as carefully as after a warm bath. Patients often ask how much fluid they are to use in the douche, and how long the curi'ent should be allowed to flow through the nares without being interrupted? To the first question, it may be said that half a pint is enough to begin the use of the douche with ; the amount can be increased gradually as the patient becomes better practised in the use of the instru- ment. The second question is more important, and to it the reply may be given that at first the current, must run but a short time through the nares without interruption, say during the short holding of the breatb. Gradually the patient learns to breathe comfortably through the mouth, while the current of water runs thi'ough the nai'cs. When proficiency in this respect has been attained, perhaps an entire pint or even more may be run through the nostrils and naso-pharynx without interruption. But at the outset of the employment of this apparatus, the patient must be told of the importance to him of not gasping or gulping during the operation. It has seemed to me that the latter danger is most easily avoided by allowing the current of fluid to run through the nares only as long as the patient can quite comfortably hold his breath. In the warm water used in the douche, all that will be most usually necessary at first will be common table salt, in the pro- portion of one-half tablespoonful to the pint of fluid. In many instances I have found it very beneficial to use a preparation of salt known as " sea-salt." This is said to be the result of evapo- ration of sea-water; it surely is stronger to the taste than common table-salt, and doubtless contains'more haloid elements than it. It is quite agreeable to patients, but, being stronger than common salt, must be used in the proportion of a large , teaspoonful, finely crushed, to a pint of water. In ozsena, in addition to the common salt, a few drops of a strong solution of permanganate of potash may be thrown into the water, until the latter becomes thoroughly impregnated with it. As a rule, a saturated solution of this drug may be written 410 MIDDLE EAR, for, and the patient instructed to use about 10-20 drops to the pint of water. Gruber's method of injecting fluids into the nares and the naso-pharyngeal space consists in throwing, by means of a syringe, fluid into one nostril, the 'other being stopped by the' finger of the surgeon. The fluid, upon reaching the naso-pha- rynx,. causes the velum palati to rise up and shut off the upper from the lower pharynx, just as it does in the case of the nasal douche. As the fluid, however, is deprived of its only way of escape outward by the stopping up of the nostril as stated above, it must seek the Eustachian tubes. " According to the force with which the syringe is emptied, according to more or less firm closure of the outer opening of the nostril and the superior pharyngeal space underneath, further, according to the degree of perviousness of the Eustachian tubes, by this method the fluid can, with greater or less force, be thrown into the middle ear, while the rest of the fluid flows out through the re-opened nose, and in many instances a small portion escapes through the mouth."! This is a method which should be employed only by the sur- geon ; it is not advisable to give it into the hands of the patient. If it is brought into requisition, the surgeon has a ready means of controlling the force with which the injected stream enters the naso-pharynx. According to the direction of the proposer'' of the procedure, only two fluid ounces are to be injected at once; he usually employs a weak solution of borax (one drachm to the pound of water), recommending that the drum-head be inspected immediately thereafter, and that the air-douche in some form be used to modify by displacement the effects of any fluid which shall have entered the tympanum, if such modifica- tion be demanded. Applications to the Eustachian Tube. — In most cases of swelling and narrowing of the Eustachian tube, the use of inflation simply will be quite suflicient to overcome the obstacle. If, however, after the catheter is known to be properly placed in the mouth of the tube, no air is forced into the tympanum, the tube may be considered occluded, and resort may be had to the ' Gruber, Ohrenheilkunde, p. 264, Vienna, 1870. ' Gruber, Monatsschr. f. Ohrenh., Jalirg. vi. No. 8. TREATMENT OF CHRONIC CATARRH. 411 careful use of a probe of catgut, lami- naria, or whalebone. Perhaps the most desirable form of bougie for this purpose is the small catheter-bougie of Weber- Liel; it is best employed with a gradu- ated catheter devised to go with it. All bougies or probes, for use in the Eusta- chian catheter and tube, should first be fitted into the catheter, and marked at two points, on that end nearest the sur- geon. The first point should correspond to tlie exact length of the catheter used, which will indicate when the distal end of the probe is about to leave the beak of the catheter and enter the tube; the second point should be as distant from the first as the length of the amount of probe it is desired to push into the tube. This may vary from one to one and a half inches. Inflation should be done as thoroughly as possible before the probe is inserted, never afterwards, for fear of emphysema. Even the most gentle ma- nipulation may abrade a diseased mucous membrane, and then an inflation might produce the above-named undesired com- plication. Various applications have been ad- vised and made to the mucous lining of the Eustachian tube, in order to allay chronic inflammation. In most cases they do more harm than good; beyond weak solutions of bicarbonate of soda (gr. v-f3j), and sulphate of zitic (gr. j.- f|j), all injections into the Eustachian tube are of risk. Steam is not to be considered anything more than useless; it is not harmful, unless carelessly ap- plied, when the patient may be scalded. In all cases, the. fluid injected either into the mouth, or further into the calibre of the tube, should be warmed. Great Fig. 68. B. Weber-Liel's graduated metallic Eustachian catheter A., for passage of the small hougie- cathoter of gummed silli B. 412 MIDDLE EAR. benefit may result from making various applications to the mouth of the tube, but no further inward, in chronic catarrh of the middle ear. In this way, applications to the nares and naso- pharynx act in this disease. Much good may be thus done by touching the faucial region of the tube with nitrate of silver in solution. In order to accomplish this, an aluminium cotton- bolder, such as is found in all surgical instrument-makers' shops, may be made to carry up behind the velum the fluid to be applied. The point of the probe may be directed towards cither tube, or, if both tubal mouths are to be touched, the probe may be held in the median line, behind the velum. Then the natural reflex action of the pharyngeal and palatal muscles will tend to bring the mouths of the tubes towards each other and the probe lying in the median line. Such a mode of application is especially necessary when granulations or ulcers exist in the naso-pharyngeal space. Such a condition may exist without any marked disease in the pharynx below the velum. Some- times the first real indication of its existence is obtained by the blood found on the cotton-tuft at the end of the probe when it is withdrawn from the naso-pharynx. The treatment of adenoid and polypoid growths should con- sist in their evulsion or cauterization, and in subsequent appli- cations of astringents to the naso-pharyngeal space. The mechanical destruction of these formations, however, is painful and inconvenient, while their cautei'ization is simple, and in most eases all that is needed. It has been proposed by Dr. Meyer,' to crush and tear these adenoid bodies by means of an instrument, somewhat like a lithotrite, to be introduced through the nares. An index-finger of the surgeon is to be inserted at the same time through the mouth and behind the velum, so as to direct these growths between the prongs of the crushing implement. But in many cases it will be necessary only to wound these growths with the finger, or a probe armed with a large tuft of cotton, and then apply a solution of nitrate of silver to the naso-pharynx, by means of the last-named instrument. After the application of silver, which may be in strength varying from 10-20-30 gr. to faj of water, astringent solutions may be employed by means of the ' Archiv f. Ohrenh., Bd. ix. TREATMENT OF CHRONIC CATARRH. 413 nasal douche. Salt and water, in the proportion of a tablespoon- ful of the former to a pint of the latter, will usually be all that is required, but if a stronger fluid appears to be demanded, sul- phate of zinc, in the strength of gr. i-ij to fjj of water, may be used, and, if there is an oifensive odor to the discharges from the nares, solutions of permanganate of potash may be em- ployed. Politzer' finds that in cases of adenoid growths in the naso- pharynx, which bring about swelling and closure of the mouth of the Eustachian tube and hardness of hearing, touching the affected parts with nitrate of silver is more effectual than cutting or dragging away the new growths. Excision of the Tonsils. — This operation I consider rarely, if ever, necessary for the relief of hardness of hearing or deaf- ness, simply because the altered function of hearing is in no way dependent on the tonsillar enlargement. The larger tonsil is often on the side of the better ear ; some- times on the side of a perfectly normal ear, and not uncommonly enlai'ged tonsils are found in those with perfect hearing. When enlargement of the tonsils is associated with deafness, they are to be regarded simply as symptoms of a catarrhal con- dition which has also brought about alteration in the glandular structures of the naso-pharyux, Eustachian tube, and in the middle ear. Their violent excision (and excision is always vio- lent) is worse than useless — it is positively harmful and always alarming. If the tonsils are enlarged and interfere with respira- tion and enunciation, they interfere at the same time with the proper ventilation of the Eustachian tube and tympanic cavity. They may therefore be diminished in size by the application to them of London paste. A small tuft of cotton on the end of a cotton-holder may be smeared with this and then forced into the clefts or gaping follicular openings in the tonsil. This is never alarming to the patient, nor painful, or at most only pro- ductive of slight aching for a short time, and has the effect of causing a shrinkage rather than a destruction of the gland. I am all the more convinced of the futility of excision of the tonsils for hardness of hearing, because the largest tonsils I have ' Zuv Therapie der mit adenoidett Vegetationen im Raohenraum complicirten Erkraiikungen des Mittelohrs. Arcliiv f, 0., Band x. p. 55, 414 MIDDLE EAR. seen were the successors of excised ones. They might almost be regarded as recidives of a morbid growth, like those succeed- ing fibrous tumors of the lobule. Clipping the Uvula. — In some instances an elongated uvula keeps up a constant irritation of the fauces and posterior wall of the pharynx, thus contributing to an aggravation of an aural catarrh. All that is required in such cases is to clip oiF the redundant mucous membrane, carefully avoiding an ablation of the muscular part of this important appendage to the velum. A removal of such a fold of mucous membrane is generally stimulation sufficient to excite the rest of the uvula to contrac- tion. The entire removal of the uvula is as reprehensible as it is common. Applications to the Cavity of the Drum. — That which was said against applications to the cavity of the Eustachian tube may be repeated here. Few applications which are aimed at the tym- panic cavity ever reach it. If they did they would probably do more harm than good. To render the Eustachian tube pervious to air, and hence to ventilate the drum-cavity, is more important than to inject fluids into it, unless, the membrana tympani being perforated by disease, a means of escape of medicated fluids is aff'orded. Vapors of iodine, ether, or chloroform may be of assistance in stimulating a delicate but diseased mucous lining, but it would be just as wise to fill, with a fluid, an air vesicle in the lung by the way of a bronchial tube, as to fill up the tympanum, if one could, by injecting fluids through the Eustachian tube, in chronic aural catarrh, unless there is evidence of inspissation of mucus in the drum-cavity. In such cases, weak and warm solutions of bicarbonate of soda (3-5 gr. to fsj) are of service. But even with these, great caution must be observed. In all cases in which injections thus directed have apparently produced good results, I have felt inclined to ascribe the benefit to the gentle stimulation and ventilation of the Eustachian tube, rather than to the direct contact of the injected fluid with the cavity of the drum. The latter is an air cavity, and resents the pre- sence of fluid. Operations with the Knife on the Drum-Head. — When it has been found impossible to send into the tympanum as much air as seemed demanded, resort has been had to the knife. And the TREATMEN-T OF CHRONIC CATARRH. 415 mere incision, with the subsequent admission of air to the drum, has had much more to do with the good result than the choice of the particular spot of the operation. This is proven by the well-known fact, that, no matter where the perforation is made, the hearing, which at first has been increased, Kas diminished as soon as the opening in the drum healed. And this, as every surgeon knows, occurs sometimes even in a few hours. Space forbids my entering upon the history of cutting ope- rations on and through the drum-head. This subject, further- more, has been most ably and exhaustively treated by Profs. Schwartze, of Halle,* and Roosa, of ISTew York,^ to both of whom I am largely indebted for the few historical facts that I shall give here. To those interested in going further into the sub- ject, these two works will prove of the greatest aid. The proposal of the operation of cutting through the mem- brana tympani is supposed to have originated with Johannes Eiolanus, of Paris, in 1650; Sir Astley Cooper, one hundred and fifty years later, performed the operation in several cases, with apparent success, but subsequently abandoned it on account of his want of encouragement. About seventy-five years before Sir Astley Cooper's operations on the drum-head of man, Chesel- den perforated the drum-heads of dogs, and believed that the latter were not only not made deaf by it, but that they became more sensitive to some sounds. In the latter part of the eigh- teenth century, the operation appears to have fallen into the hands of quacks, and to have been disregarded by the regular practitioners: a reaction too often found when the latter, in their enthusiasm, make use of an operation in a multitude of cases, whether suitable or not. The indications for the operation had been very vaguely given up to 1800, when Himly in Germany, and Sir Astley Cooper in England, proposed to make use of the operation of perforation of the drum-head in closui'e of the Eustachian tube. Cooper operated in a number of cases, with a variable success ; but as he operated rather empirically, simply for deafness arising from closure of the Eustachian tube, a. condition he does not seem to have been fully able to diagnose, he soon ceased to obtain ' Archiv f. Ohrenh., Bd. ii. pp. 24, 239, 245. 2 Treatise on the Ear, pp. 319-344. 416 MIDDLE EAR.. results as good as those he first appeared to have obtained, and he then abandoned the operation entirely. Again, the unfortu- nate reaction in the minds of the regular profession, and natu- rally enough, again the operation is found almost entirely in the hands of quacks, with not only no good results, but appa- rently most disastrous ones. liimly now threw a ray of light into this surgical night, by pointing out the truth, that the operation, when it had proven of benefit, was in exceptional cases of deafness due to hermetical closure of the Eustachian tube. But the operation ceased to be regarded with favor, because it had been widely and ignorantly applied ; and Wilde is found obliged to speak in defence of the operation, since some had condemned it as dangerous to life — which, however, they could not prove. As Dr. Eoosa has said: "From this chaos of ill-defined indications and imitative experiment, there came out one fact in proper form. That one fact was this : That it was preemi- nently proper to perforate the membrana tympani in order to remove mucus, blood, or pus which could not find an exit through the Eustachian tube." This has been shown by the operations of Cooper, Itard, Saunders, and Schwartze. But, as a great demand has ever been, and still is, made on the aurist for relief from chronic, neglected catarrh of the middle ear, without fluid accumulations in the latter, but with every symptom of sclerosis and retraction of the membrana tympani and even of deeper parts of the sound-conducting appa- ratus, assistance has been sought in various forms of incision and excision of the membrana tympani ; in the maintenance of permanent perforations in it ; and in tenotomy of the tensor tympani muscle. Various forms of incision and excision of the membrana tympani for the relief of hardness of hearing not dependent on accumulations of fluid in the tympanum^ but upon chronic thicken- ing, hardening, stifi"ening and retraction of the membrana tym- pani and other parts of the sound-conducting apparatus of the middle ear, have beep proposed by several authorities. The operations about to be named have been undertaken with no empirical intent, but with a knowledge of a cleai'ly diagnosed condition of the auditory apparatus. This must be said of them as preeminently distinguishing these from previous operations TREATMENT OF CHRONIC CATARRH. 417 on the drum-head; though the best results of paracentesis membranse tympani are obtained when fluid has collected in the drum-cavity. When the membrana tympani is indrawn, Lucae and Politzer have proposed to incise the folds of the mem- brane. Gruber has advocated repeated prickings or incisions, and even excision of parts of the drum-head (myringectomy) ; while Wreden has proposed, but probably abandoned, a heroic treatment consisting in excision of the handle of the malleus, the chief object in this procedure being to retain a permanent opening in the membrana tympani. It is hai'dly necessary to say that such an operation, even of so distinguished a man, must be deprecated. Repeated incisions through cicatrices, or an incision through the posterior fold of the membrana tympani, most surely lead to good results in many cases of progressive hardness of hearing. In the former instance the benefit is due to the tightening of the previously flaccid part of the drum-head, which ensues with the healing of the cuts ; in the second instance the drum-head, already too tightly stretched, is freed, and very often it and the chain of ossicles will swing more freely in consequence of this simple opei'ation. With the head of the patient gently supported, and the canal properly illuminated, by light reflected from the forehead mirror, the incisions may be made best with a spear- headed knife, the shaft of which should be six cm. long, and curved at an angle of 45° from the hard rubber handle.^ Similar procedures are recommended by Prof. Gruber^ for the correction of anomalies in tension of the membrana tympani. The same authority has also suggested to excise a piece of the drum-head by means of an instrument arranged especially for the operation. The great aim of otologists, from the time of Paroisse to the present moment, has been, and still is, to make and retain a perforation in the membrana tympani, in a manner at once simple and free from danger. If such a perforation could be obtained, it has been supposed, and now quite amjply substan- tiated, that the hearing, in many cases of chronic aural catarrh, would be improved. To attain this end', numerous suggestions ' Prof. Politzer, "Wiener Med. Woclaenscli., 1871, Nos. 1 and 3. « LehrbucU, pp. 581-582. 27 418 MIDDLE EAR. have been made : as, to keep the perforation open by means of a triangular-shaped sound (Paroisse) ; to insert into it a bougie (Saissy), or, small solid or hollow bodies (Philippeaux and Frank) ; but as they have proven of no value, it will be better to confine the attention to the few exceptional forms which have seemed to ofter reasonable aid. The simplest, safest, and most efficient means of retaining the artificial perforation in the drum-head, is by means of a small, hard rubber eyelet, as suggested by Politzer.' The eyelet, with a furrow on its outer surface — its general shape being that of a miniature barrel — is fastened to a piece of fine silk or cotton thread, and then inserted into a small cut in the membrane, at „ , ^ ^ „ anv chosen point. Prof. Po- Politzer'3 Eyelet and Eyelet Forceps. " ^^ litzer has devised, for the inser- tion of the eyelet, a special kind of forceps. These forceps are curved and so arranged, that when at rest the points of the branches are in contact. At the distance of 1| cm. from the point there is fastened to one of the branches a short round pin, just long enough to touch the opposite branch. When the branches are made to approximate each other at the angle where they are curved, the aforesaid pin near their points forces the latter apart. The instrument is small, being not quite 11 cm. long, and made to work smoothly but firmly, so that if an eyelet be placed between the points, it is held there firmly until it can be carried to the perforation in the membrana tympani. A gentle pressure at the angle on the handle, now frees the eye- let, the latter is left in the artificial opening in the drum-head, and the forceps are withdrawn. The thi-ead attached to the eyelet provides a means of pulling it from the ear, when such a procedure becomes necessary. If the eyelet becomes clogged with dried mucus. Prof. Politzer has found that a drop of gly- cerine, placed in it by means of a Pravaz syringe, will soften such an obstacle and permit of its being removed by means of a stiflF bristle. ' Wiener Med. Wochensclirift, 1868 and 1869. TREATMENT OF CHRONIC CATARRH. 419 Prof. Politzer has found that in many cases the eyelet is borne without any inflammatory reaction in the drum-head or tympanic cavity ; yet, in some instances, the good result of the operation has been nullified by the irritation in the ear, conse- quent upon the introduction of the eyelet. Since, in several cases in which the eyelet set up inflammation, sharp projections were found on it. Prof. Politzer urges the ne- cessity of making the eyelet perfectly smooth before it is put into use. Another method of retaining a permanent opening in the membrana tynipani has been suggested by Voltolini,' of Breslau. It consists in making a long incision both in front of and behind the manubrium, and then encircling the latter with a tubular ring of fine gold. The latter is about 2J mm. in diameter, and is so constructed that when its two free ends are brought tosrether on the inner side of the drum-head behind the malleus, they do not fit closely together but permit of a passage of air into the tympanum, which is further insured by an opening in the canule on the outer side. The latter opening marks the hinge-like division in the canule, and is opposite the point of junction of the free ends. Into the caliltre of each half of the tube at this hinge- or joint-like point, Voltolini passes the delicate and flar- ing pointed ends of specially devised forceps, by which the canule is pressed into its circular shape after its free ends are brought behind the manubrium. But necrosis of the manu- brium having resulted from this manipulation, it would seem that this procedure could not be of universal application when a permanent opening in the drum-head is to be obtained, though the conception of the plan must be considered brilliant. Aluminium being of specific gravity, lighter than that of gold, has been substituted by Voltolini in the manufacture of the tubular ring.^ It has been proposed, by Weber-Liel,' to make a cicatrix in the membrana tympani, at its inferior posterior quadrant, by means of the galvano-cautery, and in the spot tlms deprived of its regenerative power, to make an opening, with the hope ' Monatsschrift f. Olirenh., No. 3, 1874. 2 See Weber-Lie), M. f. 0. No. 4, 1875. 3 Eine persistente.CEft'nung im Troinmelfelle. Dr. Weber-Liel, M. f. O. No. 3, 1871, and No. 4, 1875. Also "Progressive Soliwerhorigkeit," p. 185, 1873. 420 MIDDLE EAR. that such a perforation would persist. By this method, a per- foration has been maintained for 3J years, with the greatest improvement in the hearing. In a number of cases of chronic otitis catarrhalis, with little or no opacity of the membrana tympani and with a pervious Eustachian tube, Simrock has resorted to puncturing the drum-head by the application of sulphuric acid, usually to a spot on the posterior half of the membrane. The method is said, by its proposer, to be not at all hazardous, as a very little acid will produce all the desired effect, and be entirely under control. The acid is applied to the desired spot by means of a tuft of cotton on the end of a probe, and an opening is effected almost instantly by gentle pressure of the probe point, or by smearing the acid carefully over 'the membrane at a circum- scribed point ; the tissue is rapidly destroyed, and the hole is cleared by lifting away the dead substance. The asserted ad- vantages of this method are the rapidity and permanence of its effects. Of 17 orifices thus made, three remained open for four months. In three cases slight inflammation of the middle and external ear occurred, but without serious complications. Hear- ing for conversation improved markedly in six ; less so in four; no improvement for hearing in seven. Of seventeen cases the tinnitus disappeared in five; in nine it was much diminished; in three unimproved. " After the perforation has thus been made, the ear should not be syringed even if slight discharge occur."' I have never emjDloyed either of these two last-named methods, nor, in fact, any method to retain a perm.anent opening in the membrana tympani. The latter structure is emphatically a protection to the mucous lining of the drum-cavity, and rather than incur the probability of a suppuration in the middle ear by exposure, I have refrained from that which would be un- likely to prove of great help to the hearing, but which might be very apt to excite inflammation in the drum-cavity. Tenotomy of the Tensor Tympani.— In 1868, Dr. Weber-Liel,' of Berlin, acting upon a suggestion of Hyrtl, invented the ope- ' New York Med. Record, March 27, 1875. 2 Monatsschrift f. Olirenh. No. 4, 1868 ; No. 12, 1868 ; No. 10, 1870 ; No. 11, 1871 ; No. 12, 1871 ; No. 1, 1872 ; No. 3, 1872. Vortrag : Berliner Medi- cin. Gesellschaft, 8 Juli, 1874. See Virchow's Archiv, Bd. 63. TREATMENT OF CHRONIC CATARRH. 421 ration of tenotomy of the tensor tympani, for which he devised a special instrument, his so-called " hook-knife."' At various times since then Dr. Weher-Liel has published articles on this subject, setting forth the indications for, and the manner of this operation, together with the results of it, which he claims are in the main advantageous. His views have met with warm support by some, but with entire opposition by others, on the other side of the Atlantic. In America the operation has been regarded with caution ; a few have performed it and published their results ; but on the whole, the operation has not afforded here the aid, in treatment of progressive hardness of hearing, which it appears to have done in the land of its origin. I have had the great pleasure, as well as the privilege, of seeing Dr. Weber-Liel perform this operation, and although its performance, with the inventor's instrument, seems to have been difficult for most of those who have attempted it, Dr. Weber-Liel certainly performs the operation with ease. The indications for the operation are permanent retraction of the tensor tympani muscle, indrawing of the membrana tym- pani and the chain of ossicles, with a consequent increased intra-labyrinthine pressure. The latter may produce, besides tinnitus and dizziness, gradual atrophic alterations in the ter- minal filaments of the auditory nerve. After all known methods of treatment of these symptoms had failed. Dr. Weber-Liel has had recourse to tenotomy of the tensor tympani. The instruments requisite for the performance of this opera- tion are : 1. The peculiar tenotome devised by Weber-Liel ; 2. A short speculum ; and 3. A fixation-apparatus for the head. The operation consists in four acts : — L The introduction of the tenotome into the external auditory canal, and an incision, by means of the upper cutting edge of the hooked blade, through the membrana tympani, about one to one and a half mm. long, a little below and in front of the short process of the malleus. 2. Insertion of the hook-knife into the tympanum : " by a movement of the handle of the instrument downward and forward, the hook-blade, if introduced with the most accurate ' Hakenmesserchen. 422 MIDDLE EAE. Fig. 70. knowledge of the anatomical relation of the parts, glides over the tendon of the tensor, which is thus seized from in front." JSTow, the greatest care must be ex- ercised not to wound the chorda tympani, nor yet to come too close to the inner wall of the tympanum, for fear of wounding the stapes. 3. When the hook-blade is firmly engaged over the tendon, a gentle dragging force, accompanied by a movement of the handle of the te- notome forward towards the face )4 of the patient, and a pressure down- lip ward of the slide in the handle, will cause the blade to make a quarter of a revolution about the tendon, which is thus severed. At the moment of the latter occurrence a distinct snap is heard. 4. The operator must make evei'y eft'ort to keep the instrument in the front part of the drum-cavity, in order to avoid the delicate parts at the back part, and then to restore the blade to the position it occupied before pressed over the tendon, that it may be removed the more readily through the opening in the drum-head. Anaes- thesia during the operation, has not been deemed necessary by Weber-Liel, as the procedure is not painful. Dr. Carl Frank' was one of the first to put into practice the operation of Weber-Liel, substituting, however, a simpler knife, in which the blade, -with its edge downward, was attached at an angle of 60° to the shaft. It is to be employed in those cases presenting a very limited view of the anterior half of the drum- head, on account of the excessive curvature backward of the anterior wall of the auditory canal. With this modification, however, he has found reason to rely on the operation of tenotomy of the tensor tympani, as proposed by Weber-Liel. Weheh-Liel's Tenotome. ' M. f. 0., Noa. 7 and 9, 1873. TREATMENT OF CHRONIC CATARRH. 423 Dr. E,. M. Bertolet, of Philadelphia, performed the operation in sixteen cases, and published an account of the results.' He used the tenotome as proposed by C. Frank, making the incision in front of the short process, and obtained good results respecting the quelling of the tinnitus aurium in eight cases. It must be borne in mind, that, up to this point in the history of tenotomy of the tensor tympani, only the worst and most hopeless cases, occurring chiefly in infirmaries, had been operated on, and, therefore. Dr. Bertolet is justified in his views that the opera- tion is an addition to operative otology and demands further development, a view which he holds in common with Grruber. Prof. Gruber" has written respecting the choice of the initial incision, through the drum-head, in the operation of tenotomy of the tensor tympani. He alludes to the great services of F. E. Weber-liiel, connected with the introduction of this opera- tion into otological surgery, and, while agreeing with him that usually the incision in the membrana tympani may be made in front of the short process of the malleus, says that this is not an invariable rule. His reasons for these views are as follows : The rostrum of the semicanalis musculi tensoris tympani varies in its position in the tympanum, being sometimes over the anterior seg- ment of the upper arch of the oval window (or it may be over the window), and in some cases it may be over the posterior segment of the oval window. The direction of the tendon, as it passes from the rostrum cochleare to the handle of the hammer, must vary greatly according to the position of the former bony process, and accordingly the handle of the hammer, in cases of retraction, will have a variable appearance. If the rostrum cochleare is placed far backward, the hammer will appear drawn more backward and inward than if the rostrum is situate further forward, when the handle of the hammer will appear to be drawn directly inward. In the latter case the anterior segment of the membrana tympani will not appear to be as large as it does in the former case, where the handle is apparently drawn far backward and upward. Hence, Grruber concludes that no positive rule can be established respecting the choice of a point ' Transactions American Otol. Society, 1873. 2 TJebei- die Walil der Binstichsstelle am Trommelfelle bei Durclisclineidimg der Sehne des Trommelfellspanner. Prof. J. Gruber, M. f. 0., No. 4, 1873. 424 MIDDLE EAR. Fig. 71. for incision, most likely to reach the tendon of the tensor tympani muscle ; but the variable relations in the membrana tympani, and especially the position of the manubrium of the malleus, must aid in deciding where the incision should be made. Various Tenotomes. — Prof. Gruber has devised a simple and efficient instrument for performing tenotomy of the tensor tympani. It consists of a simple blade about 1 cm. long, slightly curved at the end ; by being used in a handle in which it is adjustable, it may be employed for either ear. I have had the pleasure of seeing ^rof. G-ruber operate with this instrument, upon a young peasant woman. The well-known click as the tendon is severed, was heard ; the membrana tympani at once assumed a less retracted appear- ance ; the tinnitus aurium was relieved, but the hai'dness of hearing was apparently not altered. The latter could not be accurately tested by speech, as no one present could speak the peculiar Bohemian dialect, the mother tongue of the patient. There was no subsequent inflam- matory reaction. In 1873, Voltolini* proposed to perform tenotomy of the tensor tympani through the posterior segment of the drum- head; and in the same year, J. Orue Green^ published an ac- count of his investigations into the choice of a similar point for the initial incision. The latter authority rejects Weber-Liel's 3. Gruber's Tenotome and adjustable handle. 2. Gnibers Tenotome. S. .1. o. Green's Tenotome. 4, o. Two views of Hartmann's Tenotome. ' M. f. O., No. 5, 1873. 2 Trans. Aiiier. Otol. Soc, vol. i. p. 401, 1873. TREATMENT OF CHRONIC CATARRH. 42J operation entirely, and, not being entirely satisfied with Gruber's operation through the anterior segment of the drum-head, has resorted to section through the posterior segment, between the manubrium and the long process of the incus. This is done by reversing Gruber's knife, turning the curve forwards, when the tendon can be easily and surely reached ; but as this knife ife sharp-pointed, Dr. Green used a knife of his own invention, rounded at the end and with curved edges (Fig. 71, 3). With this. Dr. Green has been enabled, in every case, to divide the muscle a short distance from its exit from the osseous canal, and in no case were the ossicula even touched. The danger of wounding the carotid artery in those exceptional eases where its osseous canal is very thin or entirely wanting is, in Dr. Green's opinion, obvi§,ted in great measure by having the end of the knife round instead of pointed. Dr. 0. D. Pomeroy,' of !N'ew York, has corroborated, in the main, the views of Gruber and Green respecting this operation as performed by the posterior method. He prefers, however, to enter the tympanum near the end of the manubrium, and then, cutting upward until the tendon is reached, to divide the latter by an up-and-down movement. While tiimitus has been re- lieved greatly in some cases, the hearing has not been much improved. As recently as 20th September, 1875,^ Weber-Liel, in speaking of the practical results of this operation, stated that he had per- formed it in more than 300 cases. He insists on the necessity of the greatest previous practice on the cadaver, before the ope- ration is attempted on the living subject. He rejects the as- sertions that the operation is in any way dangerous to life or detrimental to the amount of hearing still existing anterior to the operation. The best result of the operation, he thinks, has been the quelling of the tinnitus aurium ; greater benefit to hearing would accrue if the tendon were cut at a much earlier stage than heretofore deemed necessary. Some of the most brilliant results have been nullified at last by a want of care of the ear, on the part of the patients, subsequent to the tenotomy. In the discussion which ensued, Dr. Kessel drew attention to ' Transactions American Otol. Soc. 1874. 2 48 Versamralung Deutscher Naturforscher und Aertze in Gratz. 426 MIDDLE EAR. the important fact that an attempt should always be made, before the operation was performed, to find out the condition of Corti's organ, especially whether speech (C^-C of the musical scale) were perceived. If this were not heard, then in his opinion the operation should not be attempted ; a view apparently not to be received in its entirety, if the operation is specially able to relieve tinnitus aurium, an ill more complained of sometimes than deafness. Prof. G-ruber took the ground that the one great indication for the operation was shortening of the tendon and a consequent indrawing of the membrana tympani, of the chain of ossicles, and the increase of the intra-labj'rinthine pressure, and that it is not necessary to wait until all further indications are known and explained. In the same discussion Magnus stated that to him the indications so far given by Weber-Liel were not suffi- ciently clear, as synechial adhesions, synostosis of the stapes in the oval window, thickening of the membrane of the round window and changes in the tympanum, other than shortening of the tensor tympani, might account for retraction of the drum- head. Prof. Schwartze' has performed the operation of tenotomy of the tensor tympani by means of a simple and efficient tenotome not unlike that of G-ruber and Green in its principle. He has not found fixation of the head nor anaesthetics neces- sary ; the point of initial incision, made by means of a paracen- tesis needle, has been behind the upper end of the manubrium and the short process ; the cutting of the tendon has been accomplished by sawing movements and not by a solitary act of cutting. Immediately after the severance of the tendon, if the membrana tympani is not too thick, an effusion of blood can be seen in the tympanum. Among all the cases operated on by Schwartze, there has not been one permanently benefited ; but none have been harmed. While indisposed to accord a future to the operation of teno- tomy of the tensor tympani, so far as total severance is con- cerned, Schwartze agrees with Von Troeltsch, who has suggested a partial loosening of the tendon from its insertion on the malleus, that the latter modification may have a beneficial effect. ' Zur Tenolomie des Tensor Tympaui. A. f. 0., B. xi. p. 124, 1876. TREATMENT OF CHRONIC CATARRH. 427 Such a partial looseniug, as it corresponds to the alteration of insertion, as in Von Graefe's operation for squint, should be at- tempted by operating from below upward, in which instance the introduction of the tenotome from in front of the malleus would be preferable. Dr. Arthur Hartmann,' of Berlin, who has worked in company with Prof. Politzer, of Vienna, has found it advantageous to use a tenotome with two curves (Fig. 71, 4 and 5), one upward on its cutting edge, the other forward, on its flat surface. This gives a sabre-like form to the instrument, by which means it appears that the stapes and the chorda tympani are fully insured against injury. While apparently successful in making the severance of the tendon, Dr. Hartmann concludes that the result of tenotomy of the tensor tympani can never be fully established, until all other elements entering into the operation can be ex- eluded from participation in any apparent good which may accrue. Thus, in one instance, before the tendon was severed, the posterior fold of the membrane was cut, and the tinnitus aurium was greatly relieved ; but the subsequent tenotomy pro- duced no further relief. I feel great reserve in giving an opinion derived from per- sonal experience respecting the operation of tenotomy of the tensor tympani, as I have performed it but once on the living. The result, so far as 1 could discern, appeared to be null ; per- haps I failed to sever the tendon. It has appeared to me, there- fore, that whatever I should record here respecting this opera- tion should be gleaned from those who have performed it frequently. Another reason why these authors should have almost a detailed notice is because they are in the minority. I also have borne in mind, as all must, that theoiy usually comes after practice, in the introduction of all. new procedures in sur- gery. It is right that a new invention should gain admission to the list of acknowledged operations, only after a struggle and a thorough test of its merits. 'No fair-minded man dai'e reject this operation in a summary manner ; neither dare he accept, apply, and vaunt it unless his knowledge of the anatomy of the middle ear be accurate, his preparative operations on the cadaver I Ueber die Operations MetUoden der Tenotomie des Tensor Tympani. A. f. 0., B, xi. p. 137, 1876. 428 MIDDLE EAR. thorough and numerous, and' his experience in results on the living, rich and beyond cavil. Removal of Fluid and Inspissated Matter from the Cavity of the Drurn and Eustachian Tube. — Before inflation of the tympanum provided the surgeon with an efficient and harmless method of clearing the Eustachian tube, it was customary to inject bland fluids into the tube. The stream thus forced into the middle ear was found to be most efiicient when it could escape by the external auditor^' canal.' Mr. James Hinton, of London, believed that mucus often became hardened in the tympanic cavity, behind an intact drum-head, and, giving to the latter a white, opaque appear- ance, led to a diagnosis of thickening of the membrana tympani. To obviate the deafness in such cases, he made an incision 2-3 lines long in the drum-head, behind the malleus, and then forcibly injected, from the external auditory canal, a warm solu- tion of bicarbonate of soda. He laid great stress on the herme- tical fitting of the nozzle of the syringe into the meatus. I have never found this procedure necessary in this country, where I believe inspissatioii of mucus is less likely to occur than in more humid and colder climates. It is not uncommon in syringing an ear affected with chronic discharge, to find that the water passes into the nares. This is no disadvantage if it is produced by gentle syringing, but forcible syringing in any case in which there is an opening in the membrana tympani, must be regarded with caution, since a force thus applied with a view of carrying matter through the Eustachian tube into the pharynx might force some of the injected fluid into the mastoid cavities and set up irritation there. Accumulation of fluid in the tympanic cavity and the best means for its removal are illustrated in the following cases: — Case I. Brownish Transparent Fluid in the Tympanic Cavity, visible only through a thin depressed Cicatrix ; Incision and total Belief. — Dee. 1, 1875, Dr. A;, 80 years old, a hale, hearty man, single. Has an extraordinarily well-preserved constitution. Patient states that for a month, since a cold in his head, he has noted a failure of hearing in the right ear. He is liable to accu- mulations of ear-wax, according to his statement, and has had ' Ran, op. cit.. Bection 310. TREATMENT OF CHRONIC CATARRH. 429 his ear syringed, on the supposition that the deafness was due to inspissated cerumen. Eut no relief was thus obtained. On examination of the ear, the raembrana tympani appeared rather opaque, excepting at the upper and hinder quadrant, where it was thin and depressed, and through which the incudo-stapedial joint was plainly visible. This thin, depressed quadrant was markedly of a dark .brownish-yellow color ; the rest of the membrane was opaque and gray. Under Sigl^'s pneumatic spe- culum, it swelled out into a bladder-like protuberance, and seemed to be filled from behind with a dark yellowish-brown fluid, as the air was exhausted by the speculum from the auditory canal. The hearing was about a foot for voice and g'j for watch. The tympanum could not be inflated by any method, as the Eu- stachian tube was markedly occluded by the remnants of the catarrh. The patient also stated that the Eustachian tubes wei-e never easily inflated by Valsalva's method; in fact, he doubted whether they were of the average width. ITo form of inflation caused any alteration in the appearance of the depressed spot, which moved so easily under the Sigle speculum. Incision of this spot gave instant escape to some brownish transparent serum or mucus, and suction with the Sigl^ speculum brought out a good deal more, in all about twenty to thirty drops. The hearing immediately arose to about the normal grade. Voice and watch were heard easily 30 feet. In the course of a week, as was to be expected from the swollen state of the Eustachian tube, the tympanic cavity filled again. Paracentesis of the same thin spot gave vent to about the same quantity of fluid, and the hearing again went up. In the course of another week, a slight return of " mufiled feeling" in the ear, which was relieved by incision and escape of a small amount of fluid. At this visit the Politzer bag forced the Eustachian tube open, and there was no further return of deafness. On March 30, following, I examined the membrana tympani, and found that the thicker part was more shining, and the thin spot, though depressed, was not discolored by any brownish fluid in the drum-cavity. Hearing normal. Case II. Re-accumulation of Mucus in the Tympanum. — July 1, 1874, Jacob Y., aged 55 years, single, American, furnace-maker, a healthy, spare man. JSTot very strong. Seems to be a man of more than ordinary intelligence for one in his position. He 430 MIDDLE EAR. states that for a year or more past, he has noted a gradual dimi- nution of hearing on the left side. The right meatus auditorius is occluded as described on page 320, on which side the tuning- fork, when vibrating on his vertex, is best perceived. The case has been treated by several physicians as one of ordinary chronic catarrh of the middle ear. The drum-head has been said to be thickened, the catheter has been used to inflate the tympanic cavity and to convey various fluids into the Eustachian tube. This treatment, he says, always produced a temporary improve- ment in the hearing. When I examined the ear, the membrana tympani appeared thickened, and resembled in general the opaque lustreless drum- head of chronic catarrh. The hearing for the watch was about ^-^. I also inflated the middle ear by means of the catheter, oO in. '^ ' several times a week for a month. Each inflation improved the hearing a little, but in a few hours it sank back again to its low point. The inflations were repeated from time to time for a few weeks longer, with always some improvement in hearing. On the 12th of September, the patient came with the state- ment that the benefit of the catheter, though marked, was only temporary; that he constantly felt something like a drop of fluid moving in his ear whenever his head was moved, and that whenever he lay down he heard better. He had told me this before, but I paid no heed to it. But it was now discovered that when he reclined, the hearing really became better, as was shown by testing with a watch. This seemed to point to mov- able fluid in the drum-cavity, and consequently it was proposed to the patient that the drum-head should be incised. This being acceded to by the patient, a puncture was made in the posterior inferior quadrant of the membrana tympani, and there instantly escaped, on inflating by Valsalva's method, about twenty drops of a brownish, transparent, serous fluid, with some streaks of opaque mucus. But its presence had been in no way, as far as I could discover, indicated by any appearance of the membrana tympani. The hearing arose from one inch to five feet for a watch. The membrana tympani became more concave, and of a bluer hue ; before the incision it was flat and steel-gray. The hearing, thus regained, remained unimpaired until March, 1875, when, after catching a cold, the symptoms returned in the ear. In this instance there was rather a sense of fulness than of TREATMENT OF CHRONIC CATARRH. 431 movable fluid. A paracentesis in the same spot restored the hearing, by giving vent again to a similar thinnish fluid, nearly transparent, and tinged with brown. By the 23d of same month the ear filled up again. The mem- brane was again perforated, as it resembled the membrana tym- pani in the previous conditions ; though I do not pretend to say that a dark-grayish color of the drum-head indicates mucus or serum in the tympanic cavity. The perforation gave vent to the same kind of brownish fluid, strongly suggestive of extra- vasated serum from the capillaries of the tympanum. The hearing instantly arose to its relatively normal point. By the 15th of April following, the same symptoms of muf- fled hearing returned, and the membrana tympani seemed flat- tened somewhat, but not enough to attract the attention of one entirely unacquainted with the case, and not on the lookout for changes in the membrane. The color of the drum-head might be said to be dark gray. After the incision it always assumed a light bluish-gi'ay color. Again the paracentesis of the drum- head was resorted to, and after the usual brownish-red fluid escaped, the hearing returned. Again, on May 8, the same note is made, and again on June 8. Then perfect immunity from aural trouble until Sept. 8, when the symptoms returned, but relief was obtained as above. Ao-ain, on October 26 and ISTovember 24, the membrana tym- pani was punctured, which completed the history for 1875. On January 3, 1876, the hearing had become again dulled, the condition being soon recognized by the patient, who came to have his ear operated on again. The incision was made with just the same results as above, and then again on Feb. 19, and on March 28. Only once, February 19, were bubbles in the tympanum, be- hind the membrane, visible through the latter. On Valsalva's inflation they moved very markedly. The amount discharged in this instance was less than on previous occasions. In evei-y other instance there was nothing to call special attention to the presence of fluid in the drum ; and this circumstance leads one to believe that many such cases are treated as chronic catarrh, and regarded as gradual sclerosis of the tympanum, because there is no special change on the drum-head indicative of fluid in the tympanic cavity. As the fluid gradually gets 432 MIDDLE EAR. harder, the case is abandoned as hopeless. This would seem to be avoidable in some cases, judging from this and others, by incising the membrane, at least as a last resort, even when the case resembles those of so-called dry catarrh, with thickening of the tissues of the tympanum. The operation never caused the slightest pain, the perforation always healed within twenty-four hours, and the relief gained by the evacuation of the fluid contents of the tympanum lasted, in each instance, for a month at least and sometimes longer. In only one instance could bubbles be seen in the tympanum before the raembrana tympani was incised, viz. : on the 19th Feb. 1876. ' The case never presented, on any other occasion, the ordinary signs of mucus in the tympanum. In fact, the paracentesis in the fii'st instance was performed solel}' on the strength of the subjective feelings of moving fluid in the drum-cavity. The point the case just narrated illustrates is, the great pro- bability that many a case of chronic deafness is only due to retained mucus in the cavity of the drum, the symptoms of which have not been, and cannot always be, clearly defined, for they may not be at all sharply expressed on the drum-head. Where this fluid came from, and what caused its constant recurrence, are not easily answered. The Eustachian tube was always pervious to Valsalvan inflation, and to the air of the catheter, Politzer's bag, etc. There was no faucial or nasal catarrh, nor any intercurrent nor chronic disease. The patient enjoyed, throughout the ob- servance of the case, good health, and a life of comparative ease, for he did not work constantly at his trade, being supported otherwise. The difficulty of diagnosing the presence of fluid or even in- spissated mucus in the tympanum, in these cases of chronic catarrh, depends on several causes. The chief obstacle is of course the more or less altered condition of the membrana tym- pani. This may be so uniformly thick as to preveut seeing the delicate outlines of bits of mucus or bubbles lying against its inner surface. If it is cicatrized at any point, the retained fluid will cause a bulging at the cicatrix almost invariably, but, if the membrane is uniformly thick, the mucus cannot make it bulge at any one point. TREATMENT OF CHRONIC CATARRH. 433 Fluids in the tympanic cavity will also discolor a thin cicatrix, but they do not alter the color of a thick membrana tympani enough to acquaint the observer with the state of the tympanic cavity. And just here the diagnosis has usually stopped. It has been correct in determining a thick state of the drum-head from chronic catarrh; but just this state of the membrane has pre- vented a further judgment as to the tympanic condition and contents. This same thickening and consequent rigidity has prevented anything in the way of marked protuberance or bulging of the membrane. Its position is not i-n such cases altered enough to aid in diagnosing any obstructive mass behind it. The only aid in such a case is to observe the other mem- brana tympani and compare the two. If one ear is worse than the other, and the worse ear presents a membrana tympani flatter, I. e. less concave inwardly and on the whole more protuberant, than the better ear, a conclusion might then be drawn in favor of the view that retained mucus is behind the drum-head, which thus projects relatively. Mr. Hinton states that in some instances of retained and in- spissated mucus in the tympanum, the membrana tympani may be abnormally retracted. This of course is due to the partial vacuum in the drum-cavity. ELECTRICITY IN AURAL DISEASES. In 1868, Dr. Rudolph Brenner, of St. Petersburg, published his renowned work on Electro-otiatrics. His book consisted of a series of investigations and observations respecting the ope- ration of electric currents upon the organ of hearing, both in health and in disease. It was avowedly an endeavor to found a rational electro-otology. For seventy years previous to this time, i. e. from the time of Yolta, and his zealous pupil Hitter, numerous experiments had been made to find out whether and how the auditory nerve reacted under electric stimulation; but, as Brenner says, this period closed without any definite knowledge on this point. In the historical sketch, which precedes the account of Brenner's labors, the reader is informed that the first experiments were performed in 1800-1802 by Volta and Eitter; afterwards by Grapengiesser, who apparently was the first to produce sensation 28 434 MIDDLE EAE. of sound by means of a simple current. From this time the entire subject remained untouched until Erman, in 1812, revived it. A long pause in this kind of work then ensued, until once more the subject was resumed by R. Wagner in 1843, who stated that it was extremely difficult to produce sound- sensations in the ear b}' means of galvanism. Then followed the testimonies of E. H. Weber, 1846, E. Harless, 1853, and Longet, 1850, that sound-sensations could b6 produced in the ear by means of the electric current. Schiff, 185'8, Ludwig, 1858, and Fick, 1860, appear to be in doubt whether the nerve is really electrically excited in these cases in which sound-sensation appears to be produced ; they in- cline to the view that it is due to purely mechanical excitation of the sound-conducting parts, as did E. H. Weber. Dr. Brenner has usually employed in his experiments a zinc- copper battery, but he has also used zinc-carbon batteries. The first, especially the Siemen's modification of Daniel's batter^', is preferable on account of its more constant stream and slow exhaustion. Twenty of the above-named cells will be sufficient for all purposes connected with the application of electricity to the ear. Mode of Application of Electricity to the Organ of Hearing ; Instruments employed. — The electrodes are connected to the ear by means of wires inclosed in rubber tubing. They should be from six to ten feet long, in order to allow of perfect freedom in movement, change of position, and varying distances between battery and patient. The electrodes may vary in pattern : small ball-shaped ones, covered with thick muslin, which can be wet with salt and water, are preferable when the electrode is to be simply placed in the meatus, unfilled with water. The form of electrode for the ear, used chiefly by Brenner, consists of an ordinary hard rubber ear-furtnel, to which is fastened copper wire extending down the long axis of the funnel. This form is to be used in the auditory canal filled with tepid water. The number of elements to be inserted into the current is decided by means of what is called a polarity chooser (Strom- wahler), the current is turned by a polarity changer (Strom- wender), and its rapidity, i. e. intensity, is lessened by a rheostat or resieter. Inserted into the current may be a magnetic needle, which will always give information to the surgeon, respecting TREATMENT OP CHRONIC CATARRH. 435 the activity of the current. After ten years of most careful observation, Dr. Brenner has become convinced that the audi- tory nerve can be excited by the electric fluid, and he has announced the following formula for describing the phenomena which occur during such galvanic excitation. Brenner's Normal Formula of the Reaction of the Auditory Nerve. — The signs used in this formula are : G (Gerausch, noise), to designate the acoustic sensation excited by the galvanic current ; the degrees of intensity, by G' and g ; closing the current by S (Schliessung) ; duration of the current, D (Dauer) ; and the opening of the same by (Oefl'nung). The direction is indicated by the name of the electrode in the ear at each moment of sepa- rate excitation, i. e. the kathode by Ka, and anode by A. Then the phenomena occurring by galvanic excitation of the auditory nerve may be expressed thus : — Ka S G' : means that a marked sensation of sound occurs at each closure of the current, while the organ of hearing is under the influence of the kathode and the anode is placed upon a spot of the body at a distance from the ear. Ka D G > : means that a sound is heard, which rapidly diminishes and finally ceases, while the current runs in the same direction. Ka — : When the current is opened no sound sensation is perceived. A S — : If, now, the current be turned, so that the organ of hearing come under the influence of the anode, there occurs no sensation of sound by closing the current. A D — : E^or does such occur during the continuance of the current. A G : But by opening the current, sound sensation occurs, which corresponds qualitatively with that which was perceived when the current was closed while running in the opposite direction. But this sensation is much slighter and only of momentary duration.' There may be several deviations from this normal formula in certain pathological conditions of the auditory nerve. Dr. Brenner gives the following : — 1. Simple hypersesthesia : An auditory nerve thus aftected, ' Brenner ; Electro-Otiatrik, p. 91. .436 MIDDLE EAR. reacts under electric currents very much weaker than those required to produce a corresponding excitation in the normal auditory nerve. Thus the duration (D) of the reaction during the moments Ka D and A is much longer, and during a moderate current the Ka D-sensation does not terminate before the opening of the current.' 2. Hypersesthesia with qualitative alteration of the formula : In this state the reaction of the auditory nerve under the electric excitation manifests not only an easy excitability, but also a change in its mode of occurrence. Thus, with Ka S, Ka D, and A there is a subjective ringing, and with A S, A D, and Ka there is hissing.^ 3. Inversion of the formula for simple hypersesthesia : In some cases the disappearance of the normal formula in presence of the pathological, can be very striking. The former may be characterized by the lower notes of the scale, and distinguished from the pathological reactions by shortness of duration. With weak currents this condition does not manifest itself. 4. Hypersesthesia of the auditory nerve with the paradoxical formula in the unarmed ear. This form of hypersesthesia is very curious and very frequent, and has been observed by Brenner only in old and deep disease of the ear. This form is characterized by the circumstance that during the application of electricity to one ear, not only the auditory nerve of that side but also that of the other ear responds, but in an inverted manner, so that in the ear not under treatment the perceptions of sound occur at those moments of excitation, dur- ing which the nerve of the ear immediately under treatment is silent ; the ear not treated reacts exactly as if it were under the influence of the other electrode.^ The observations and formula of Brenner have been fully verified by Erb,* Moos,* and Hagen,^ in Germany, and by Blake and others in this country. ' Op. cit, p. ISa. 2 Op. cit., p. 195. 3 Bveuner, op. cit, p. 201. I W. Erb, Die galvanische Reaction des nervosen Gehorapparates, etc. Arcliiv f. Aug. und Ohrenheilk., Band i. p. 156, and Band ii. pp. 1-51. 5 Klinilc der Ohrenltranklieiten, 1866, p. 333, and elsewhere. 5 Electro-otiatrische Studien. Wiener Med. Wochenschrift, 1866. TREATMENT OF CHRONIC CATARRH. 437 Scliwartze,' Shulz,^ and Benedikt,^ have been the principal opponents of the views of Brenner. The present status of the question may be said to be as follows : Brenner and his co-la- borers believe that they have demonstrated that the subjective sound-sensations occurring during a galvanic examination of the ear, are produced by direct stimulation of the auditory nerve. The opponents above named, strong men in science, believe that these sensations depend upon reflex irritation of the trigeminus and the sympathetic nerve. It appears, however, that the bur- den of proof still lies with the latter party. A somewhat new field of therapeutic application of the con- stant electric current has been opened by Dr. Weber-Liel, of Ber- lin. This observer introduces the current through the Eusta- chian tube by means of a silver wire conveyed through a catheter.' By this method he claims to bring the muscular structures of the tube and perhaps those of the middle ear (ten- sor tympani and stapedius) under the direct influence of the galvanic current. It will be seen that in such an application of electricity, the direct irritation of the auditory nerve is left out of consideration. The treatment is really applied to the middle eaf-, and probably marks a new era in the use of electricity in some forms of aural disease, as for example, in cases of atrophy, flaccidity, or degeneration of the muscles. In such cases per- haps the muscular structures of the middle ear derive a benefit from the gymnastic, as well as from the dynamic effect of the electric current. It is claimed by Weber-Liel that this kind of intra-tubal electrization will relieve the symptoms of paralysis in the tubal muscles, cause the subjective noises to cease, and bring the hear- ing almost to the normal standard, if the treatment is begun before secondary changes have occurred in the tympanum, and if no other complication exists. He also states that after the tubal muscles have been thus galvanized, the air from the cathe- ter can be forced into the tympanum more readily, without the aid of swallowing, the latter is more easily performed and in- ' Archiv f. Olu-enh., Band 1. 2 Sitzung der k. k. Qesellacliaft d. Aertze, 3 July, 1865, also Wiener Med. Zeitung, 1865, No. 23. 3 Wiener Med. Presse, 1870, Nos. 37, 39, 43, 43, 47, 48, 50, 51, and 52. * Progressive Scliwerlioiigkeit, p. 36. 438 MIDDLE EAR. flation by Valsalva's method succeeds where before it failed, all of which he adduces as proof that the paralysis of the muscles' concerned in these acts has disappeardd, and that the disappear- ance is due to the use of electricity.^ But the latter part of the proposition cannot be so easily admitted, since exactly the same improvement in these parts does occur after a careful Catheterization, and the use of a bougie passed up into and even past the isthmus tubfe. Not only in recent but in chronic cases of catarrhal disease, and closure of the tube, in w'hich neither by the catheter, Val- salva's method, nor by the act of swallowing, the tube could be opened, a bougie passed into the tube on two or three successive days, has appeared to stimulate the tubal muscles to proper action, without the aid of electricity. To illustrate this let me bring forward the following case : Mr. T., 40 years old, of Maine, consulted me with his physician, for deafness in the right ear, following a copious and chronic naso-pharyngeal catarrh. The active catarrhal symptoms had been checked, and the mucous membrane of the nares and pharynx was abnormally dry. The right membrane was thin ; promontory and incudo-stapedial joint visible through the mem- brane ; lustre good. Great tinnitus, hearing for watch ^% in. At the first visit, air could not be forced into the tympanum by the catheter nor by the Politzer bag. A silver catheter was then introduced, and through it one of Weber-Liel's admirable tym- panic catheters (delicate flexible bougie-catheters of gummed silk) was pushed through the silver instrument and into the tympanum. This produced an immediate though slight im- provement in hearing ; but the operation was repeated on three consecutive days, and by the fifth day after the first operation the patient volunteered the statement that "his ear opened whenever he swallowed, a sensation he had not noticed for nearly a year." Air could now be forced into the tympanum both by the catheter and Politzer's method. The hearing arose to g5^ for the watch, but the tinnitus was not materially al- tered. The patient, being obliged to leave the city, passed from under my treatment. The case is quoted chiefly to prove that the signs of muscular ' Op. cit., p. 165. UNUSUAL DISEASES OF THE MIDDLE EAR. 439 paralysis may be made to disappear, without the aid of elec- tricity. Since in this case, and in many similar ones, the physical manipulation of the diseased parts is almost identical with that adopted by Weber-Liel in his intra-tubal electrization, excepting that the latter factor, the passage of the electric current, is left out, and since the result is about the same in both instances, it would really seem that the benefit in such cases depends upon a thorough opening of an occluded Eustachian tube, and the con- sequent restoration of the tympanum to a proper degree of ven- tilation, and not upon electricity. Dr. Hitzig^ prefers the so-called external application of electricity for therapeutical purposes. But he thinks that the electrization of the muscles in the tympanum, by means of the electrode (wire) introduced into the Eustachian tube, may in the future be shown to be of value, but for the direct excitation of the acoustic nerve this method has but a limited supplemental worth. CHAPTER IV. UNUSUAL DISEASES OF THE MIDDLE EAR. It is proposed to devote this chapter to the consideration of several rare and interesting pathological processes, in the middle ear. Some of these about to be described have been observed in close connection with catarrhal processes in the tympanum, and some of them may have had their origin in such a process in the tympanic cavity. They are certainly full of interest to the aurist, and not without interest to the general practitioner. As these diseases are rare, and some of them malignant, it must be accepted beforehand that the treatment is an open question in some, and unsatisfactory in others. One of the rarest and most interesting is that first described. • Bemeikungen fiber die Aufgaben der " Electro-Otiatrik" und den Weg zu deren Losung. E. Hitzig. A. f. 0., N. F. B. 3, p. 70. 440 MIDDLE EAR. Objective Snapping Noises in the Ear.— Sometimes there occurs a snapping or craclcing noise in the ear, which is audible not only to the sufferer bat to his attendants and friends. This noise has been likened to the snapping of the finger-nails, or to the sudden drawing apart of the finger-ends when slightly moistened with saliva or a tenacious fluid. The first simile is the more strikijig. Some persons possess the power of volun- tarily producing such a sound in the ear. It is known that Fabricius ab Aquapendente and Johannes Muller,* were able to produce such a sound ; the former only on both sides at the same time, but the latter in either ear according to his desire. It was ascribed by him to a voluntary contraction of the tensor tym- pani muscle. Muller'' was disposed to regard this voluntary power as not uncommon, and mentions the fact that Meyer had known a gentleman who possessed it. Lucse^ has observed this power to voluijtarily produce a snap- ping noise in the ear, or to contract the tensor tympani, as he believes, in three friends, all of them scientific men. Politzer* observed both the voluntary and involuntary production of this snapping noise, in the ear of a young physician, and Schwartze" alludes to the voluntary ability to make this peculiar noise, as do Scbrapinger' and Delstanche, fils.'' . I have observed on several occasions this power in certain individuals, all of them affected with an aural disease. Two of them were physicians, and with the noise, which was rather a creaking or a whizzing than a snapping, visible motion occurred in the membrana tym- pani. In one it was heard on both sides, and cicatrices in the membranes were seen to move most distinctly, and also seemed to contribute to the noise by a kind of crackljng sound. In the second case the noise was not very loud, but the membrana tym- pani moved visibly. The third instance was. in a patient, a young man twenty-three years old. The hearing was normal in the ear in which the noise was made. Instances of the in- ' Manual of Physiology, London, 1888-1843. Translated by Wm. Baly, M.D., p. 1263, vol. ii. 2 Loo. cit. 3 Archiv f. Olirenhellk., Bd. iii. p. 301, 1867. « Ibid., Bd. iv. pp. 19-29, 1868. » Ibid., Bd. vi. p. 338, 1870. ^ Transactions of tbe Auslrian Acad, of Sciences, vol. 62, sec. 2, 1870. ' Etude sur le Bourdonuement de I'Oreille ; Paris et Bruxelles, 1872, p. 47. UNUSUAL DISEASES OP THE MIDDLE EAR. 441 voluntary occurrence of a snapping sound in and from the ear have been observed by Schwartze,' Boeck," Politzer,' Leudet,* KUpper,= and myself. Dr. R. M. Bertolet, of Philadelphia, has informed me that he has observed a case of this character, but as he saw the man but once, he was unable to make as full an examination as he desired, and therefoi'e he has never pub- lished an account of the case. An objective whizzing sound may come from the ear during mastication, as observed by Moos, but this is not to be classed with the distinct involuntary spasmodic snapping sounds in the ear, which may be heard objectively in some rare instances. There are, however, several cases on record in which such a peculiar objective noise in the ear has occurred without any act of volition on the part of the patients. The noise is often very frequent, loud, and distressing in its occurrence, which presents interesting and varied features enough to warrant it a separate mention here. Since the time of Miiller's observations on himself, this peculiar snapping noise in the ear has been variously ascribed to either voluntary or involuntary contraction of the tensor tympani, to clonic spasm in the stapedius muscle, in a single case, by Wreden, or to spasm in the palatal muscles whereby the anterior wall of the mouth of the Eustachian tube is suddenly drawn away from the posterior wall and the noise is thus produced. The latter view is that of Politzer and Lushka and is now received as sufficiently explanatory of the majority of the cases which have been observed. According to this theory the noise is really produced in the naso-pharnyx, but is conveyed to the ear of the subject through the Eustachian tube. The ear of an observer also perceives the noise as coming from the ear of the person in whom the peculiar sound originates. The noise is also heard equally well at the nostril of the patient in many cases. > Archiv f. Olirenheilkunde, Bd. ii. p. 5, 1867 ; also Ibid., Bd. vi. p. 328, 1870. 2 Ibid., Bd. ii. p. 203, 1867. 3 Ibid., Bd. ir. pp. 19-29, 1868 ; also Wiener Med. Presse, 1871. ' Gazette Medicale de Paris, Nos. 32, 35, 1869 ; Comptes rendus de I'Aca- demie de Science de Paris, May 10, 1869. 6 Archiv fvir Olirenheilkunde, Bd. i. N. F. 1873, p. 296. 6 Philadelphia Medical Times, Nos. 172 and 181, 1875. 442 MIDDLE EAR. The case of spasm of the stapedius muscle described by Wreden is, so far as I know, unique, unless a very low and gentle tap- ping sound which I once heard in the ear of a patient, by plac- ing my ear close to his, was to be explained by an involuntary twitching of the stapedius. There was nothing but its faintness that led me to this conclusion. There was no dizziness nor deafness. The cases of Leudet and Delstanche are considered by them as examples of an objective snapping noise in the ear, due to spasm of the tensor tympani muscle. That of the former was involuntary, while that of the latter was voluntary.. But the account of Leudet is evidently one of this peculiar noise pro- duced by the spasmodic opening of the mouth of the Eustachian tube ; as indeed was that of Delstanche, for in both there is his- tory of simultaneous movement in the palate. Simultaneous Spasm in the Soft Palate. — In the vast majority of all the cases on record, this noise, whether voluntary or not, has been accompanied by a spasmodic elevation and retraction of the soft palate, and sometimes of other muscles of deglutition. In the case observed by Kiipper, there was, in addition to the movements in the velum, a simultaneous elevation of the larynx, the floor of the mouth, and the root of the tongue. Simultaneous movements, i. e., retractions of the membrana tympani, have been observed less frequently than the above- named motions in the velum. The indrawing of the membrane, when observed, has not always been at the same spot. It has varied from being at the point of the manubrium, to being at various other portions of the membrane. This would seem to militate against the theory that the noise, and consequently the retraction of the drum-head, is due to spasm of the tensor tym- pani muscle. For were it due to the latter, the indrawing of the membrane would be likely to occur in a line with the handle of the malleus, and not in one of the quadrants of the membrane, at some distance from the malleus, as it did in the case I have observed. Simultaneous Twitchings Elsewhere. — In some instances the involuntary objective noise in the ear has been accompanied by simultaneous twitchings of the muscles of the brow, nose, and face, as in Kupper's case, which was ambilateral, or with simul- taneous spasms of the mylohyoid muscle, of the anterior belly UNUSUAL DISEASES OF THE MIDDLE EAR. 443 of the digastric, and in the brow on the- same side, as was noted by Leudet. In the latter case there was neuralgia in the brow and amyosthenia of the fingers, on the side corresponding with the ear in which the noise was heard. The age of those thus affected varies from five to fifty years, as shown in the cases reported by Schwartze. Of all those in whom such an objective aural noise, either voluntary or involun- tary, has been observed, only three were females ; two of whom were adults, the cases of Moos and Leudet ; while a third was a little girl five years old, one of the cases observed by Schwartze. Involuntary objective noises in the ear, and the attendant symptoms already described, rarely occur on more than one side at a time ; in three instances, however, they were observed to be in both ears, twice by Schwartze and once by Kiipper. The mode of the occurrence of the involuntary snappings in the ear varies greatly. It may be too rapid to be counted (Schwartze), or isochronous with the pulse, and so loud as to -waken the patient at night (Boeck), or it may resemble the ticking of a watch, with pauses (Schwartze). In the case ob- served by Leudet, the noises occurred in pairs, the one being a " kind of echo" of the other, and in the case cited by Kiipper, they occurred irregularly, and as often as 140 times in a minute. The state of the hearing in an ear thus aff"ected varies with the cases, being in some, normal ; in others, noises occur in an ear already somewhat hard of hearing, while in some the hear- ing is momentarily aft'ected, apparently by the altered tension which ensues in the tympanum, with each spasmodic occurrence of the noise. The following is a short account of the above-named curious afltection, occurring in a Japanese lad eighteen years old, sent to me by Dr. R. M. G-irvin, of "West Philadelphia. The patient came under my care for treatment of a chronic suppurative inflamma- tion of the left middle ear, with perforation of the membrana tympani, the result of acute inflammation incurred in July, 1874, by diving in cold salt water. The patient complained only of the left ear. He did not draw my attention to the right ear, affected by the spasm about to be described, but while inspect- ing the right ear for purposes of comparison, I heard distinctly a noise resembling the snapping of the finger-nails, emanating from it. The snapping was most audible when the ear of the 444 MIDDLE EAR. listener was placed close to the right ear of the patient, but it could be distinctly heard ten feet from the ear from which it came. It was also heard very distinctly when the ear was placed near the right nostril of the patient. It was not, how- ever, audible in the left ear of the patient, neither by placing my ear on his ear, nor by the use of the auscultation-tube. In- spection revealed a thickened and reddened condition of the right membrana tympani ; and the patient stated that he had had, some years previous, discharges from the right ear, and it was found that the hearing was defective in it. The snapping sounds began in it in the previous summer, one week after the acute inflammation in the left ear. At the first ex- amination, by simple inspection, no motion was detected in the membrana tympani at each snapping, but in the course of a month, the thickening of the drum-head becoming less, a very slight retraction of the drum-head at its antero-superior quadrant was seen. Before any motion in the drum-head was observed by simple inspection to occur with each of these peculiar objective noises, I placed a small glass manometer devised by Politzer, with its capillary calibre, one milli- _u_ metre in diameter, filled with colored water, into the meatus of the right ear, also filled with water, the two columns of water being hermetically joined by an India-rubber stopper on the mano- meter. The column of water thus brought into contact with the mem- poLiTZER's manomeT^ braua tympani, showed a negative fluc- tuation of one-half millimetre at each snapping sound, thus demonstrating a retraction of the mem- brana tympani too small to be seen at that time by inspection, but later, apparent upon close and attentive inspection. The drum-head moved readily under the Sigld pneumatic speculum. The examination of the fauces revealed an elevation and retraction of the velum palati, chiefly on the right side, with each snapping sound in the ear and each manometric depression. The negative fluctuation — i. e. depression in the manometric column — amounting to one-half millimetre, occurring at each objective sound in the ear, was entirely distinct from a very UNUSUAL DISEASES OP THE MIDDLE EAR. 445 slight positive oscillation in the same column at each cardiac impulse. The latter could not always he discerned. Deglutition, respiration, and speech exercised a marked in- fluence over the spasmodic condition already described. The patient stated that deglutition and rapid respiration increased the frequency of the snapping noise in the ear, but that when he held his breath, the spasms in the velum palati and the snapping noise in the ear, ceased entirely, to begin again with renewed respiratory acts. I found, indeed, that so long as the patient held his breath neither he nor I could hear any snapping, nor could I detect any spasmodic movement of the velum ; but they all recurred as soon as the patient resumed his breathing. During ordinary respiration I counted twenty spasms in a minute, which appeared to be the average number ; but with a voluntarily increased number of respirations, the number of snappings and spasms of the velum rose to thirty in a minute. During continued speech no snappings occurred. These peculiar snappings were not in regular succession, nor synchronous with the respirations. Tavo or three snappings usually occurred in quick succession, were followed by a pause, then there were several more, thus completing twenty in a minute. These noises interfered so much with the hearing in the ear in which they occurred, that the patient, when specially desirous to increase his hearing, held his breath, which, as already stated, would control the spasms. It was found by testing with a watch, audible normally sixty inches, that the liearing was indeed influenced by the spasms and their tempo- rary cessation, as the' patient had stated ; for the watch, audible to him only on contact during the spasms, was heard two inches when the noises were arrested by holding his breath. Tuning-forks held before the ear, appeared to the patient to rise in pitch at each spasm. The rise in the note was well imitated by the patient. This altered pitch was to be expected , because at each spasm the drum-head was retracted, and ren- dered, by this increased tension, more sensitive to high than to low notes, and hence the ear perceived the higher, to the ex- clusion of the lower partial tones of the tuning-forks. The snapping sounds, but not the spasmodic elevations in the velum, could be arrested in two other ways. By throwing the patient's head back as far as he could get it, although the 446 MIDDLE EAR spasms in the velum palati went on with the usual intervals, the objective noises in the ea,r were arrested. r could also stop the noise by pressing my finger firmly against the velum, and pushing it upward towards the pharyn- geal opening of the right Eustachian tube. Although a power- ful twitching, with the usual intervals of repose of the muscular structures thus pressed upon, could be felt, all snapping noises ceased. Pressure upon the left half of the velum palati and mediately upon the pharyngeal opening of the left Eustachian tube re- vealed no twitching in that region, nor did it influence in any way the spasms and noises on the opposite side of the pharynx and in the right ear. As the patient expressed no desire for relief from this objec- tive noise in the ear, seventy-two days went by, with a number of opportunities of observing all the phenomena just detailed. On the seventy-second day after I had first heard the snappings from the ear, the patient informed me that within a few days, a perforation had occurred in the drum-head of the ear from which the noises emanated, and that the latter had greatly de- creased in loudness and frequency. Inspection then revealed, indeed, a perfectly Avell-defined dry perforation in the antero- superior quadrant of the membrana tympani, where previously the slight but spasmodic indrawing of the membrane had been observed ; but there was no explanation of the perforation so far as could then be discerned, nor could the patient give any solution of its occurrence. In a few days, the snappings, which had become very infrequent and nearly inaudible, ceased entirely. Although a little mucous discharge ensued in about a week after the perforation, probably from exposure of the mucous lining of the tympanic cavity to the winter atmosphere, it was easily checked, and the membrana tympani closed. Since then there has been no return of the snapping noises, nor any spasmodic motion in the velum palati, Eustachian tube, middle ear, nor membrana tympani. The young gentleman has remained under observa- tion until his, return to Japan in the autumn of 1876. Causes. — The causes of the occurrence of involuntary objec- tive noises in the ear, have been sought for in several ways, as in neuralgia of the superior maxillary branch of the fifth pair, with tic of the seventh, and. of the branch which the inferior UNUSUAL DISEASES OF THE MIDDLE EAR. 447 maxillary sends to the tensor tympani by means of the otic ganglion (Lendet), or in a reflex spasm, conveyed from the sensory nerves of the diseased mucous membrane to the cor- responding motor nerves, in cases connected with catarrh of the pharynx (Kiipper). It is a notable fact that many of these occurrences are in con- nection with catarrh of the pharynx, but that is not considered sufficient by Kiipper to account for the spasms. They may be explained by a predisposition to spasmodic affections in the individual. As an analogue to this peculiar affection of the ear, Dr. Kiipper cites spasms of the orbicularis palpebrarum in con- nection with diseases of the conjunctiva. They might also be explained as already suggested. Doubtless the retraction of the membrana tympani in some instances of objective noise in the ear, may have been due to a contraction of the tensor tympani muscle, but in the single case which I have observed, I believe the retraction of the drum-head was due to the formation of a vacuum in the tympanum, produced by the sudden drawing apart of the walls of the faucial mouth of the Eustachian tube. This I consider all the more probable since the retraction ceased, as did the spasm of the velum and the noise, as soon as the membrana tympani ruptured. Treatment. — The whole number of these cases is so small, and the individual experience in regard to them is so limited, that our knowledge respecting the therapeutics of this variety of aural disease is of course very meagre. So far as we can glean an opinion from what has been written concerning the treat- ment of these cases of clonic spasms, the induced current has effected the only apparent relief and cure (Schwartze, Politzer, and Boeck). This was tried without any good effect in the case narrated as occurring in my own experience. Since spontaneous perforation of the membrana tympani was soon followed by entire cessation of the clonic spasm in the velum, and elsewhere in the ear, and of the peculiar noises in the ear, I would recom- mend artificial perforation in any similar case, if relief from the symptoms should be urgently required. Extravasation of Blood into the tympanum in Bright' s Disease of the Kidneys.~An extravasation of blood into the 448 MIDDLE EAR. tympanum in Bright's disease has been observed by Schwartze,* Buck, and others.' It has likewise been observed^ that deafness is a symptom of Bright's disease not directly traceable to uraemia, and that pain and suppuration may occur in the later stages of this malady.' In the latter instance Dr. E,oosa has thought, that there was every probability that the tympanic disease had originated in an extravasation of blood into the drum-cavity. It is not difficult to comprehend how, in the atheromatous and weakened condition of the vascular system in this form of renal disease, an extravasation may occur in the ear as it does in the eye and elsewhere. Hence such an occurrence in the ear might be an aid in diagnosing the existence of the above-named affection of the kidneys. Otitis Media Hemorrhagica. — Under this name Dr. Roosa* has reported two cases of " acute aural catarrh which had an unusual course and termination," inasmuch as the disease ran a rapid course terminating in perforation of the membrana tympani without suppuration, but with hemorrhage through the ruptured membrane. This afi'ection, according to Dr. Roosa, is to be considered entirely different from the process occurring in the atheromatous vessels of the tympanum in some cases of renal disease : on the contrary, it is to be considered an acute inflammation of the lining membrane of the middle ear, termi- nating in rupture of the vessels, hemorrhage into the tympanum, and rupture of the membrana tympani without suppuration. This disease has been also observed by Dr. Mathewson, of Brooklyn, and Dr. Hackley, of ISTew York. Tubercular Disease of the Ear, — Dr. Schiitz' has made a study of tuberculosis of the inner and middle ear with special reference to the etiology of this process and the manner of its further dissemination throughout the body. His investiga- ' Archiv f. Olirenlieilkunde, Bd. iv. p. 13. 2 G. M. Smith, Transact. N. Y. Academy of Medicine, vol. iii. ^ Roosa, op. cit., p. 357. < Treatise, p. 354. 5 Die Tuberculose des inneren und raittleren Olirs beim Schweine nebst, etc. Vircliow's Arcliiv, Ixvi. p. 93. See review by Steudener, A. f. O., pp. 130-133, vol. ix-. UNUSUAL DISEASES OP THE MIDDLE EAR. 449 tions show that the disease is usually ushered in by a catarrh of the pharynx, accompanied by a pulpy swelling and subsequent cheesy degeneration of the neighboring lymphatic glands (lym- phatic catarrh), and finally passes into the tympanic cavity through the Eustachian tube. The disease then attacks the bony tissue of the pars tympanica, which soon passes into a state of proliferation, and in the inflamed and swollen tissue the first small gray tuberculous nodules make their appearance (tubercu- lous osteomyelitis of the pars tympanica). At the same time small miliary nodules arise in the inflamed mucous lining of the cavum tympani. The tuberculous new formations finally fill completely the drum-cavity, dislocating the auditory ossicles which become necrosed. The entire pars tympanica is changed into new growth, and the disease advances in a peculiar manner along the tracts of the nerves which touch the tympanic cavity. At an early period the tuberculous growth penetrates into the Fallopian canal and attacks the facial nerve, which by this deposit of tuberculous nodules in its interstitial connective tis- sue, is entirely separated into its individual fasciculi. Finally the internal ear is attacked, the semicircular canals and the cochlea are filled with an exuberant tuberculous mass, which by the way of the aquseductus vestibuli et cochlese passes into the cranial cavity. In the same manner the process advances in the connective tissue of the acoustic nerve and into the internal auditory canal, from which at last a tumor as large as a walnut may extend into the cavity of the cranium. It is worthy of re- mark that the dura mater is never invaded by the new growth ; it is only pushed ahead of it towards the brain. From the tympanic cavity the new growth, after it has embraced the membrana tympani, passes into the external audi- tory canal and extends as a nodulated polypoid excrescence over the sulcus tympanicus and outwa-rd beyond it. At a later period, caseous as well as fibrous and calcareous transformation, takes place in the morbid growth. Secondarily, tuberculous eruptions may occur in any other of the organs of the, body. Desquamative Inflammation of the Middle Ear ; Cho- lesteatoma of the Petrous Bone.— Dr. Wendt has given a new explanation of the greatly discussed question concerning 29 . 450 MIDDLE EAR. the true nature of the so-called cholesteatoma of the petrous bone. He believes that in these cases there is present a special kind of inflammation which he terms desquamative. This dis- ease is regarded as a collection of epithelium which is thrown off by the mucous membrane of the middle ear, in altered form and increased quantity, and which, finding no way of escape, is accumulated in the cavities of the middle ear, until it gradually fills them. Eleven cases of this disease were observed in the living, one of which was examined post mortem. In every case the collec- tions were composed of cells resembling scales of epidermis. The cells were arranged in lamellae, through which were various, but never large quantities of oil and cholestearin. In six instances the point of origin of these masses was undoubtedly the tympanum. In the other cases, simply their presence but not their origin in the tympanum could be shown. Dr. Wendt has based upon his clinical and anatomical studies the following conclusions : — " 1. In some cases collections of a peculiar matter resembling greatly the cerumen, are found in the external auditory canal, and in the osseous middle ear. " 2. These masses originate in a desquamative inflammation, characterized by a prolific growth and exfoliation of epidermis- scales entirely like the cells of the mucous membrane of the osseous middle ear, the epithelial lining of which, during or after a chronic inflammatory process, may, by exposure to ex- ternal irritation, through the perforated membrana tympani, assume a cutaneous nature with the formation of a rete Malpighii, and external layers, which on account of the clogging up of the ear and the consequent shutting off of the air, may undergo par- tial fatty degeneration. " 3. They produce hardness .of hearing of a moderate degree when they are dry and loosely placed, and when no greater changes in the sound-conducting apparatus are present. "When the opposite conditions prevail, the deafness is of a high degree, and pain will be produced if these masses swell, either under the influence of spontaneous suppuration in the middle ear, or of moisture from without. " 4. They can produce important changes in the ear, the petrous bone, and even in the contents of the cranium, by means of the UNUSUAL DISEASAS OF THE MIDDLE EAR. 451 pressure they exert in their vicinity when they soften and swell, and also by their growth ; perhaps too their size may increase by absorption of the broken-down fluid elements of themselves or of neighboring pathological formations. " 5. Their removal, though usually attended with pain and tediousness, is absolutely imperative. " 6. It is not improbable that similar masses originating in a chronic inflammation of the walls of the external auditory canal, may pass into the tympanic cavity through perforation* in the membrana tympani and produce there the same symp- toms. " 7. The collections of epidermis-cells, described in the litera- ture as cholesteatoma of the petrous bone, are likewise to be regarded as products of a desquamative process in the middle ear, until it shall be proven by a comprehensive study of the masses, that they originate in some other way." Prof. Von Troeltsch is of the opinion that cholesteatoma and the above described process in the petrous bone, are distinct and separate diseases.* New-formed Membranes and Bands in the Middle Ear. — Morbid membranes and bands occur very often in this cavity, and are very delicate in consistence and of a whitish or gray tint. In the membranes there are deficiencies which can be detected macroscopically ; in the synechial bands these defi- ciencies are seen only under the microscope. All of the above- named new formations (membranes, bands, and cords) may be found in the same ear. Their situation is very varied, they may connect the various walls of the tympanum with each other and with the ossicula, they may be found in the mastoid cells, in connection with the membrana tympani, spread over the round window and the niche of the oval window, the rami of the incus, the stapes, and over the tympanic mouth of the Eustachian tube, and the tendon of the tensor tympani. Calcareous and osseous deposits may occur in these growths; the functional derangements depend upon the consistence and situation of the latter. The diagnosis of these structures is ' See fifth edition of his Treatise, pp. 433-437 ; and the review of Wendt's papers, Archiv f. Ohrenh., B. ix. p. 134. 452 MIDDLE EAR. possible during life if the membrane is thin enough, and Sigli^'s pneumatic speculum is used to aid in the examination. Re- specting the treatment, Prof. Wendt lays greatest stress on pre- vention ; the perfectly visible ones may, in some instances, be relieved by operations, which must consist in excision of a part, and not simply incision.' Treatment— r^eapectmg the treatment, Dr. Trautmann very justly says : "After the pathological process has set in, constant use of the catheter, by stretching and positive atmospheric pres- sure, will do more in producing atrophy and complete destruc- tion, perhaps entire cure, than an operation in which a piece of the morbid deposit must be cut out in order to prevent fresh ad- hesion. Such an excision becomes very unsatisfactory, since the remote point of attachment of the morbid ligament cannot be seen." The Corpuscles of Politzer and Kessel ; Prof. Wendt's Examination. — Prof. Wendt has subjected these structures to a careful examination, and concludes that too much importance has been attached to them by their discoverers. He has found these thickenings on the cords and bands in the tympanum and mastoid cells in thirty-three per cent, of all cases examined, both in the healthy and in the diseased ear. The form of these bodies is very varied, and hy no means as typical as held by Politzer and Kessel. Both Wendt and Trautmann believe that the majority of these bodies are foetal remnants, though a few of them may be of recent date and of pathological origin. Dr. Trautmann considers them entirely insignificant, unless, on ac- count of their situation and rigidity, they should become me- chanical hindrances to the function of the middle ear.^ Embolism in the Mucous Membrane of the Tympanic Cavity. — In some instances of general embolism and pysemia, it has been supposed that embolism may occur in the mucous lining of the tympanum.* In such a case observed by Wendt " Prof. "Wendt, Arclaiv f. Heilkunde, 1874, pp. 97-100 ; also review by Dr. Trautmann, in Archiv f. Ohrenli., B. ix. 279-281. 2 See review of Wendt's paper by Dr. Trautmann, Archiv f. O., B. ix. p. 281. 3 Wendt ; A. f. 0., Bd. ix. p. 121. Abstract by Von Troeltscb. UNUSUAL DISEASES OF THE MIDDLE EAR. 453 there were found, besides naso-pharyngeal catarrh, great altera- tions in the drum-cavity. The latter consisted in excessive swelling, maceration and friability of the mucous membrane, which appeared to be stained with the coloring matter of the blood, and filled in its interstices with blood-corpuscles. The stapedes were buried in the swollen membrane, which fact pro- bably helps to explain the great and sudden deafness which preceded death. The changes in this case were referred by Dr. Wendt to embolism of the tympanic artery, but the embo- lism could not be found. Primary Cancer of the Middle Ear. — Cancerous disease often passes from neighboring tissues to the middle ear, as, for example, in cancer of the auricle,' cancer at the base of the skull,^ malignant disease of the parotid gland,' and of the antrum of Highmore,^ but cases in which it can be shown that the primary seat of the cancer has been in the middle ear are extremely rare. • Instances of primary cancer of the middle ear have been recorded by Toynbee,* Billroth,^ Wilde,' Travers,^ Wishart,' Boke,'" Robertson," and Schwartze,''' as referred to hj the latter. History, Course, and Symptoms. — In most cases there is a his- tory of previous chronic purulent discharge, from the ear which finally becomes the seat of the primary cancerous disease. The purulent affection may continue for a long time before the symptoms of the malignant disease appear. These are usually more or less sudden hemorrhages, with a more acrid and fetid discharge from the ear, and at the same time the ear becomes the seat of constant and increasing pain. The parts about the • Gruber ; Lehrbuch, p. 596. 2 Turck ; Zeitschr. der K. K. Gesellschaft der Aerzte zu Wien, 1855. 3 Schwartze ; Archiv f. Ohrenh., Bd. ix. p. 315. * Schwartze ; Ibid. ^ Diseases of tlie Ear, chap. xvii. 6 Archiv f. Klin. Chirurgie, x. 67. ' Quoted by Schwartze, loc. cit. Osteo-Sarcoma. 8 Froriep's Notizen, Bd. 25, No. 33, p. 353. " Edinburgh Med. and Surg. Journal, xviii. p. 393. "> "Wiener Med Halle, 1863, Nos. 45 and 46. " Transact. American Otol. Soc, 1870. '2 Archiv fiir Ohrenh., Bd. ix. p. 308, 1875. 454 • MIDDLE EAE. ear may become swollen and infiltrated, at last breaking down into ulceration. An abscess not uncommonly forms over the mastoid portion, and in a short time sequestra may escape from the sinus left by the circumscribed inflammation. The hemorrhages may now become less frequent, but a discharge more or less copious and of a sanious nature still continues from the ear. The hearing is of course greatly impaired ; if the tuning-fork is not heard on the vertex, the disease may have invaded the labyrinth. Facial paralysis may ensue, and the glands near the ear usually become infiltrated and ' may suppurate. As the tissues about the ear break down, forming ulcers with eroded edges, the hemorrhages from the ear increase in amount and frequency, the pain is terrific, and the fetor intolerable. In the case re- ported by Schwartze, the palate became paralyzed on the aft'ected side. Finally the patient dies from exhaustion. Etiology. — Toynbee thought that, so far as his experience and observation had gone, malignant disease of the ear most usually arose in the mucous lining of the tympanum.' Schwartze^ believes with Roosa^ that malignant disease in an ear, previously affected with chronic and neglected otorrhcea, may have its origin in the latter process. Both of these authors are of the opinion that some of the cases of death supposed to be due to the removal of aural polypi, should have been referred to an extension of a malignant disease, rather than to the excision of a tumor. Gruber states that malignant growths in the middle ear are usually the result of extension thither from neighboring parts, as, epithelial cancer from the external ear, and fibrous and medullary carcinoma from the pharynx or from the dura mater.^ ^ Treatment. — It has generally been supposed that treatment is futile in these cases, but Schwartze claims to have obtained beneficial results from perforation of the mastoid process, when the disease has seemed to be extending inward, or to be pent up in the tympanum and mastoid cavity. 1 Op. cit., p 386. 2 Op. cit., p. 218. 3 Treatise, p. 394. < Lehrbuch, p. 59G. UNUSUAL DISEASES OF THE MIDDLE EAR. 455 Cancer of the Mastoid Process. — The mastoid process may become the seat of cancer, as shown by Eondot.^ Its history and symptoms are similar to those given as characteristic of primary cancer of the middle ear, inasmuch as it seems to be a consequence of neglected chronic otorrhoea. The earliest symptoms, besides the chronic aural discharge, are hemorrhages from the ear, soon followed by intense pain and swelling of the mastoid and the parts about the seat of the disease, great deafness, and tinnitus aurium. As the disease advances, facial paralysis may ensue, the mastoid portion be- comes more swollen and painful, the extreme point of the process may be most tender, giddiness and vomiting are apt to be joined to the other symptoms, and the entire mastoid region is covered with suppurating and fungoid nodules. Emphysematous Tumor over the Mastoid Portion. — ITatural dehiscences in the mastoid portion of the temporal bone sometimes persist, and favor the escape of air from the middle ear and mastoid cavity to the skin lying over the latter, as has been observed in a case reported by Prof. Wernher,^ of Giessen. This curious affection may show itself suddenly after an ordinary act of sneezing, in the form of a tumor, the size of a pigeon's egg, over the mastoid. There is no pain attending its formation, and the patient may be entirely unconscious of its occurrence. So perfect may the connection be between the mastoid cavity and the emphysematous tumor, that gentle pres- sure will force the air from the latter into the middle ear and fauces ; but renewed expiratory efforts will reproduce the tumor. Gradually such a formation over the mastoid may extend, until the entire corresponding half of the scalp is involved, and the latter is lifted at some points IJ to 2" above the skull, as was observed in the case referred to. The middle ear and membrana tympani may be normal, but a large dehiscence, the remnant of the natural openings in the infantile bone, may be found running across the entire mastoid ' Annales des Maladies de I'Oreille, p. 237, 1875. 2 Deutsche Zeitschrift fur Cliirurgie, Band iii. ; also Arcliiv fiir Ohrenli., Band ix. 456 MIDDLE EAE. portion, as in the case reported by Wernher. Compression long kept up, having failed in the case reported, to produce a cure, a successful endeavor was made to set up adhesive inflammation between the edges of the dehiscence and the superjacent soft tissues. This was accomplished by means of subcutaneous injections of tincture of iodine at various points in the tumor. Hairs in the Mastoid Cells. — Another curious condition of the mastoid cavity is the following, related by the late Mr. Toynbee. He showed' a specimen of hairs in the mastoid cells, and said that according to his experience the case was unique. The hairs were firmly imbedded in the mastoid cells, and surrounded by masses of epidermis. Dr. Tilbury Fox, who examined them, agreed that the hairs could not have been introduced from without, but were nourished in the cells. CHAPTER V. ACUTE PURULENT INFLAMMATION. The disease previously treated of, catarrhal inflammation of the middle ear, is characterized by its tendency to harden and stiffen the original tissues of the ear, and in some cases to develop hypertrophy of the same. But purulent inflammation of the middle ear, which it is now proposed to consider, is char- acterized, both in its acute and chronic form, by its tendency to break down and to desti'oy the tissues of the ear invaded. These two distinctions cannot be too constantly kept in mind, when endeavoring to study diseases of the middle ear, for it will be found upon careful examination that every inflamma- tion invading the mucous membrane of the middle ear, in the vast majority of instances, must be placed in one of these two general divisions. Already it has been shown that catarrhal inflammation of the middle ear is conservative of tissue, and limits itself strictly to the ear. But there is another large ' From the report of the Pathological Society of London, in the Medical Times and Gazette, March 3, 1866, p. 238. ACUTE PURULENT INFLAMMATION. 457 number of cases of inflammation of the mucous lining of the middle ear, which tend at the outset to the formation of pus. This form of inflammation of the middle ear, not only breaks down and destroys the tissues of the ear, but it is characterized by its tendency to invade other parts of the head, especially the cranial cavity. In this virulent form it not unfrequently pro- duces pyemia, cerebral abscess, and death. SUBJECTIVE SYMPTOMS. The subjective symptoms of acute purulent inflammation of the middle ear are usually very rapid and violent in their suc- cession. They are chiefly itching and tickling, referred to the Eustachian region and the ear; a sense of fulness and pain deep in the ear, which is greatly increased by coughing, sneezing, talking, or eating ; tenderness of the adjacent maxillary articula- tion (though the latter symptom is not as marked in this disease as it is in inflammation of the external auditory canal); vertigo; tinnitus aurium ; and hardness of hearing. To these distressing symptoms in the ear, is added pain in the side of the head corresponding with the affected ear, running forward to the eye, temple, and frontal sinus, and backward to the occiput. The condition of the suiferer becomes at last most pitiable ; every movement of the head and body causes intense agony, the eyes roll about in a frenzy of pain, no comfortable position can be obtained either in sitting or in lying down, and even the strongest man may be forced to shriek, so dreadful is the sufl'ering from acute purulent otitis media. If the victim is an infant or young child, all these symptoms may be mistaken for another disease, very often for incipient brain-disease, and this erroneous opinion is all the more confirmed by the not uncommon convul- sion, into which the child may be thrown by its frightful suffer- ings. Usually these symptoms are relieved by a spontaneous rupture of the drum-head and escape of purulent matter. But this result will be more fully discussed under the consideration of the objective symptoms of the disease. It becomes indeed one of the prime duties of a physician to be on the lookout for the acute occurrence of this disease in chil- dren, for upon its timely recognition may depend the life of the 458 MIDDLE EAR. little patient. Certainly much suffering would be avoided, perhaps many lives saved, if the ear were even once thought of as the possible cause of an apparently obscure disease, in those too young to tell where the seat of their pain is. Not only in children, but in adults, this disease is one of the most important the physician meets. The importance of treating it properly in its acute stage can- not be too fully appreciated. Yet it is lamentable to state that it is usually entirely disregarded. Itching in Throat and Ear. — ^The itching and tickling of this disease are felt running from the throat, along the Eustachian tube, and to the depths of the ear, or vice versa. "Whether this is due to a direct passage of the inflammation from the throat to the ear, or whether it is purely reflex, like ear-cough, is not yet shown. Very often this sense of itching is the first symptom which . calls the attention of the patient to his ear. It may, however, be entirely overlooked, and the ear is disregarded, until sharp pain in it arrests the attention of the sufferer. Pain. — In the pain of acute purulent inflammation of the ear, we have perhaps the earliest diagnostic symptom of this disease. It will be found that, as a rule, the severity and continuance of pain is much more marked than in the catarrhal form of in- flammation of the middle ear. As has been stated, the pain in that disease is never so in- tense as in acute purulent inflammation of the ear, and it very often remits during the daytime ; but the pain in the acute purulent disease often leaps at once to an unendurable severity, and, if left to itself, is eased only by the escape of puriform matter from the tympanic cavity. While the pain of the former is often not severe enough to keep the patient from his daily avocation, the pain of the disease under consideration is usually so intense as to excite secondary symptoms of fever, and in some cases delirium. Alteration in Hearing. — At the beginning of this disease the hearing may become abnormally sensitive, and ordinary sounds will cause increase of pain in the ear. The patient's own voice may also occasion him pain. As the inflammation advances and its results are more fully established, the hearing will grow ACUTE PURULENT INFLAMMATION. 459 dull, and by the time secretion is fully established, the deafness may be great. The subjective noises are usually very annoying, and in many cases very distressing. Concerning tinnitus aurium and all kinds of so-called subjective aural sounds, the reader is referred to page 356. Vertigo, Fever, and Delirium. — Vertigo may be a symptom in this as in many other aural diseases. It seems most marked after secretion is established, and before the membrana tympani is ruptured. It is, therefore, apparently due to pressure com- municated to the labyrinth. Fever and delirium, excited by the intense acutu inflamma- tion, must be treated on general principles, with this exception, that cold applications to the head, near the affected ear, should be avoided. "While cold may allay inflammation elsewhei-e, no good results can come from its application to an acutely in- flamed middle ear. This is due to the specially bad effects of cold in any form, upon the ear. OBJECTIVE SYMPTOMS. Membrana Tympani. — If the drum-head is examined in the early stages of this disease, it will be found congested at its periphery, and markedly about the membrana flaccida and the malleus. Gradually this congestion spreads inward from the periphery and outward, i. e. backward and forward from the manubrium of the malleus, until the entire drum-head is de- cidedly pinkish, with especially deep shades in its upper half. When so much congestion has occurred, the usual contour of the membrane will be less marked, the handle of the hammer will be less distinct, and the lustre of the dermoid layer and the pyramid of light will disappear. Vesicles may form on the membrana tympani at this point of the disease, but they are not common. The normal features of the drum-head are thus made to vanish, but in the lighter cases they may not become more distorted than above described, while in the severer cases the congestion and swelling of the membrane become so great that, at the fundus of the canal, there is only an undefined and sodden red diaphragm in the place of the normal drum-head. 460 MIDDLE EAR. Spontaneous Rupture of the Membrana Tympani. — This event is to be regarded as a chief symptom of purulent inflammation of the middle ear. Whatever may have been the nature of the inflammatory action in the tympanum at the outset, it will be found that when the disease has advanced so far as to pro- duce spontaneous rupture of the membrana tympani, the matter discharged through such a ruptured spot will be of a purulent nature. This is in keeping with the tendency of the disease to break down tissue. Mucus in large amount may accumulate behind the membrana tympani, and, after clogging the tym- panum for a time, be absorbed. I do not know, however, that if pus forms in the tympanum it is ever absoi'bed, or, if let alone, escapes in &xij other way than by spontaneously rupturing the membrana tympani. Nor does nature long delay the rupturing of the membrana tympani after pus has formed in the tympanic cavity. But mucus may lie in the tympanum long after all acute symptoms have subsided, and is usually the cause of the continued deafness after a comparatively slight attack of ca- tarrhal congestion and inflammation. In acute purulent inflammation of the tympanum, the mem- brana tympani will be found to be bulging very soon after the onset of the acute symptoms. It is usually confined to the pos- terior half of the membrana tympani, because all the efforts of blowing the nose, sneezing, and the like, force the products of inflammation backward toward the hinder part of the tympanic cavity. I have noted that the presence of pus in the tympanum in- variably causes bulging of the membrana tympani, while an equal amount of mucus usually does not produce a similar alte- ration in the membrane. So often has this been the case, that a marked bulging of the membrana tympani at its posterior segment might be regarded as diagnostic of the presence of pus in the tympanum. This has seemed to me to be due to the fact that catarrhal collections of mucus occur, if not in an ear the membrana tympani of which is already somewhat thickened by previous catarrhs, certainly in tympana thickened by the con- servative nature of the catarrhal disease. On the other hand, purulent inflammation of the middle ear is much more likely to be found in a previously healthy ear, and in one apparently ACUTE PURULENT INFLAMMATION. 461 not provided with any power to resist the destructive tenden- cies of the latter variety of inflammation. Whether some diatheses have an inherent tendency to mucous results rather than purulent ones, after inflammatory processes in the mucous tract, and why this is, as it really sometimes ap- pears to he, remains yet to he shown. COURSE. The course of acute purulent inflammation may, therefore, be said to he tending to a greater or less destructive process in the mucous lining of the cavity of the tympanum, and to rupture of the memhrana tympani. The latter event is usually the first destructive result of the disease, and is very likely to give relief to pain. In some of the more violent cases, pain may not only continue, but increase after the rupture of the membrane. In such cases, a well-grounded suspicion may be aroused that the disease has invaded parts deeper than the mucous lining of the drum-cavity, and then it is likely that eitlier the mastoid cells, or the cranial cavity, or both, may have become affected. Authentic accounts of death resulting directly from acute purulent inflammation of the ear are rare — though doubtless death has occurred from this disease in its early stages, but has been set down to other causes. Death from the chronic form is a common occurrence. Possible Fatality of the Acute Form of Purulent Inflammation of the Middle Ear. — It is a great misfortune, but one to be attri- buted to the hitherto imperfect means of examining the ear, and the consequent ignorance concerning the processes which go on there, that so few positive and accurate facts can be found as to the number of deaths occurring from acute purulent inflam- mation in a previously healthy ear. Most writers mention its occurrence, but few give details of cases. Toynbee' found that the dura mater partook in the tympanic inflammation of typhus fever, which fact would seem to indicate that the tympanic disease shared largely in the fatal result. Itard, quoted by Toynbee, gives an authentic account of death ■ Op. cit . p. 32\ 462 MIDDLE EAK. in a short time after the onset of acute tympanic disease, the latter being undoubtedly the cause of death. Wilde^ says death occurs frequently from acute inflammation of the ear, among the lower classes in Ireland ; but he gives no account of these cases, probably because he considered them so well known as to need no illustration. Dr. Edward H. Clarke,^ of Boston, has narrated a case occur- ring in his practice, of a boy, in whom the acute inflammation of the middle ear proved fatal in fourteen weeks after its onset? by producing an abscess in the brain. In this case the inflam- mation of the middle ear passed through the tegmen tympani and thence to the brain. " The moisture and redness of the petrous bone at that point served to mark the track of the disease." This case was of three weeks' standing when Prof. Clarke first had the opportunity of treating it, and he very justly observes: " If it had been possible to arrest the disease when it first attacked the ear, and before the bone, or rather the periosteum, was invaded, the life of the patient would probably have been saved."' I saw, not long since, in the Philadelphia Infirmary for Diseases of the Ear, a case of acute inflammation of the tym- panic cavity, in a woman thirty years old, Avhich proved fatal in less than a month, by an extension to the mastoid cells and brain. The patient rejected the treatment proposed to her, viz., trephin- ing the outer wall of the mastoid portion, and did not return to the Infirmary ; but I learned from her friends that she at last succumbed, with every symptom of most violent inflammation of the brain. Though these two cases show the course acute inflammation of the drum-cavity may take, it much more usually pursues a more favorable course. But they show the importance of early and intelligent treatment. Darolles* has given an account of acute otitis media purulenta of the right side, followed by facial paralysis on the same side on ' Op. cit., p. 241. ' ArcWves of Scientific and Practical Medicine, Jan. 1873, No. 1. » Loc. cit., p. 47. * Bulletin de la SocietfiAnatomique de Paris, 1 fasc. 1875. See review by Kuhn, Archiv f. Ohrenheilk , Band x. p. 253. ACUTE PURULENT INFLAMMATION. 463 the tenth day ; acute meningitis was caused in this case by irrup- tion of the pus into the aqueduct of Fallopius. On the sixteenth day profuse sweating, involuntary discharges of urine and feces, paralysis of the left arm, dilated pupils, reacting sluggishly, thready pulse, temperature 40.6° C. are noted. Death occurred the same evening. The post-mortem examination revealed : Veins of the pia and dura mater greatly congested ; copious purulent infiltration into the subarachnoid cellular tissue, confined chiefly to the base, and the convexity of the right hemisphere ; on the left side only those portions of the brain overlying the sphenoid bone were affected. Small insulated purulent foci were found along the bloodvessels of the convexity of the brain. The pia mater adhered at several points to the gray substance. The outer surface of the petrous bone presented no abnormal feature, but the tympanic cavity was filled with pus, in which the ossicles fioated about free. A small perforation the size of a pin-head was found in the upper segment of the drum-head ; the mastoid cells were also filled with pus. The facial nerve was exposed as far as its second turn, at the Fallopian hiatus, and was covered throughout its course with thick pus. The other walls of the tympanum were normal. Dr. Gahde' has related a case of death resulting from an acute purulent inflammation of the middle ear. The patient was a young private soldier, under Dr. Gahde's observation in Mag- deburg, German3^ The acute symptoms occurred on the 27th August, but appeared to subside after a slight discharge had occurred from the affected ear, the right. By the 12th Septem- ber, however, the discharge from the ear and the pain having in the mean time ceased, the patient complained once more of pain in the ear, and his mastoid portion was found to be very sensitive to pressure. Ifotwithstanding rest in bed and free leeching behind the affected ear, cerebral symptoms set in, and on the second day after the appearance of the symptoms, the man died. The post-mortem examination revealed that the pus had ac- cumulated in the tympanic cavity in large amount, but instead of bursting through the membrana tympani a second time and thus saving the life of the patient, it had forced its way into I Archiv f. Ohrenlieilk. N. F., vol. ii. p. 98. 464 MIDDLE EAR. the mastoid cavity, and through a defective spot in its posterior wall until the products of inflammation were brought in con- tact with the dura mater. This of course set up an irritation in the covering of the brain, and fatal meningitis soon followed. Might not a free opening in the membrana tympani have saved this man's life ? Surely, had a free exit for the pus been provided by art, since it was not by nature, the results of the tympanic inflammation would not have found their way so readily to the mastoid cells and from that point, through a defect in the bone, to the meninges. I have observed, not infrequently, that a perforation in the membrana tympani will heal up after giving vent to some of the products of inflammation in the tympanum, but before the cavity is entirely drained. If the case is watched now for several days, it will be found that there is a return of pain, and the drum-head will be seen to be bulging again. Disease may have already thickened it so much that it will not give way as quickly as it did before, and therefore it becomes imperative to open it artificially, and allow whatever may have accumulated behind it, to escape. It may be said that sometimes the membrana tympani heals up too soon. In some cases before the acute process had entirely disappeared, I have found it necessary to puncture the mem- brana tympani several times. By this means the drum-cavity has been kept thoroughly drained, and, as the mucous membrane lining it returned to its normal state, no excess of secretion has remained either to irri- tate the lining of the tympanum or to become the nucleus of an inspissated mass. The avoidance of the latter is of great im- portance. For, inspissated matter may cause not only deafness, but a form of deafness often ascribed to other causes. Without doubt many cases of so-called chronic thickening of the drum- head are in reality chronic accumulations of inspissated mucus, the remnant of half-cured, because improperly treated, catai-rh of the middle ear. ETIOLOGY. The most usual causes of acute purulent inflammation of the middle ear are the exanthemata, local cold in various forms, and ACUTE PURULENT INFLAMMATIOX. 465 direct violence to the ear. The first two are well known as the most fruitful sources of "this severe malady. Whooping-cough also very often produces acute purulent disease of the tympanum. When acute purulent inflammation arises in these diseases it is always a serious complication, chiefly because it is either un- recognized or neglected for the supposed sake of more attention to the general disease. The latter, however, can receive every possible attention, while the ear disease gets its share too. Even if the attention is not drawn to the ear by symptoms of aural disease, the knowledge that the latter is likely to occur in the already named maladies, should prompt an early and careful examination of the ears in every case of exanthematous disease. If the treatment of the ear were made an important part of the general treatment, the latter would certainly be more eifectual in the exanthemata, for not only would the general disease run a more favorable course in its acute stages, because relieved of a most painful complication, but there would be less chronic puru- lent disease of the ear with its dreadful results followinsr in the track of the above-named affections. Mr. Hinton,' of London, was of the opinion that the mortality from scarlatina might be diminished by bestowing care upon the ears when affected by that disease. Gold Bathing ; its Effect on the Middle Ear. — The effect of cold bathing on the ear has received of late a good amount of the attention due it. The exposure of the ear to cold water, in div- ing, sea-bathing, and the like seems to be a very common cause of acute inflammation in the middle ear. While it cannot be denied that seaybathing may be very beneficial to certain forms of ear-disease, the contact of cold water with the membrana tym- pani is always fraught with danger to the ear. Therefore all forms of cold water bathing must be so con- ducted as to preclude this dangerous contact of cold water with the drum-membrane. This can be done only by keeping the head above water, or by stopping up the external ears, if the head is to go under the surface of the water. This may seem' an extreme view, and it may be said that thousands bathe with- out incurring acute inflammation in the ear. Such may be the case, but while acute processes may be avoided^ it is equally ' Questions of Aural Surgery, p. 133. 30 .466 MIDDLE EAR. certain that the frequent contact of cold water with the mem- brana tyrapani, lays the foundation of chronic deafness of a catarrhal variety. In the latter case the conservative force of nature thickens the drum-membrane in order to resist the fre- quent assaults of the cold water, which is allowed to enter the external auditory canal. It is noteworthy that no mammal but man goes voluntarily under water, without being provided with a means of prevent- ing the water from running into the ears. I am informed by a phj'sician of the south, and it is a fact well -known to others, that hunting dogs taught to dive, become deaf. Acute Inflammation of the Tympanic Cavity produced by Concus- sion. — Now and then an acute inflammation in the drum-cavity is set up by a fall, a blow upon the auricle, or an explosion near the ear. In such a case the traumatic force seems to be the powerful compression of the air in the tympanic cavity and external auditory canal, brought about by the sudden concussion. These cases are entirely distinct from cases of deafness result- ing from concussion of the nervous apparatus of the ear. In the latter we find deafness, unattended by any signs of acute inflammation of the middle ear, the only symptom. When an acute inflammation in the middle ear is caused by a fall, an explanation may be sought for in the peculiar way in which the force of the fall is spent upon the air of the tympanic cavity. The concussion of the air in this cavity may be so jiowerful as to really wound the mucous membrane. As no direct violence is oflered to the middle ear in these cases, the inflammation must be due to the effect of the violent oscillation of the air in the tympanic cavity. I have seen but one case of acute inflammation of the middle ear resulting from a fall, and that was in Prof. Politzer's clinic, in Vienna, in 1872. Prof. Politzer stated at that time, that " he had seen a few cases of what he termed traumatic catarrh' of the middle ear, a disease entirely distinct from those forms of disease resulting from concussion of the cochlea." Acute Purulent Inflammation of the Tympanic Cavity, from a Mow on the Auricle. — The only case I have observed of acute in- ■ Siiissy alludes to a similar form of disease, Eng. Trans, by N. R. Smith, Baltimore, 1829, p. 109. ACUTE PUEULENT INPXAM MATION. 467 flammation in the tympanic cavity, following a blow on the auricle, happened iu a boy thirteen years old, who was struck on the ear by a ball. There was in this case, very little external otitis, the auditory canal remained unswoUen, though rather more tender than usual, there was pain deep in the ear, with tinnitus and deaf- ness, great redness and swelling of the membrana tympani, per- foration of the same, and a discharge of blood, mucus and pus from the tympanum. Mastication was painful to the affected ear, and the boy lost appetite and strength. Inflation of the tympanum was easily done by the method of Valsalva and by that of Politzer, showing no obstruction in the Eustachian tube. The ear was syringed regularly each day with warm water, and mild astringents were instilled into it, tonics were given, and in six weeks the boy began to recover his health and hearing, both of which were finally restored. Concussion plainly caused this case of tympanal inflammation. "Was it done by a sudden compression of the column of air in the auditory canal, as the ball struck the auricle, and by a consequent forcing inward of the membrana tympani, and a compression or shaking of the delicate structures in the middle ear ? Of course, every surgeon knows that a direct wound of the drum-head and mediately of the tympanic mucous membrane and contents, may produce an acute inflammation of the middle ear, but that which is specially referred to here is a form of acute inflammation of the tympanum, brought about by con- cussion. The powerful compression of the column of air in the auditory canal and tympanic cavity, produced by the concussion, is the only means by which the membrana tympani and drum- cavity may be said to be struck, and it is this force which probably causes the inflammation. Yery interesting cases of this kind of acute inflammation of the middle ear produced by concussion, are four reported by Dr. J. Orne Green.^ Two of these cases of acute tympanal dis- ease were caused by an explosion^ of a bag of gas, one by a blow on the ear from a policeman's club, and a fourth by a fall thirty • Trans. Amer. Otol. Soc, 1873. 2 One of the two cases caused by explosion was under the care of Dr. Shaw, to whom Dr. Green acknowledges himself indebted for the notes of the case (loc. cit.). 468 MIDDLE EAR. feet, upon the head. In all of these cases the drum-membrane was ruptured by the traumatic force, and iu the first three, purulent, and in the last-named, simple catarrhal inflammation ensued. These cases, as Dr. Green observes in his paper, are examples of accidental injury to the sound-conducting appa- ratus of the ear, and should be carefully diagnosed from cases of partial or total loss of hearing, from accidental injury to the brain or nervous structures of the ear. Such cases become of the greatest importance in legal medicine on account of the accuracy of diagnosis demanded by their occurrence. ISTot long since, an intelligent man presented himself for treat- ment of deafness and tinnitus resulting, as he said, from a blow on the ear, fi-om a policeman's club, a few days before. He stoutly asserted the integrity of his ear hefore the blow, but after removal of dry blood from the auditory canal I found an unmistakably chronically diseased drum-head, and, on examin- ing the fauces, a markedly granular pharynx. On the next day, after the drum-head had become dry from the water syringed into the ear, it was found to be lustreless and retracted, the handle of the malleus prominent and twisted on its long verti- cal diameter, and the lower segment of the drum-head contained calcareous spots. The Eustachian tube was pervious to the air of the catheter. With all these features of chronically diseased throat and a more or less atrophied drum-head, an opinion as to the cause of deafness should be given guardedly. It is well known that a progressive hardness of hearing may advance very far, before the attention of the patient is drawn to it. In the case just mentioned, it appears probable, to one familiar with aural dis- ease, that the blow from the policeman's club was not the sole cause of the deafness, yet, at the first recital of such a case, one naturally thinks immediately of an acute injury to the nervous structures of the ear. DIAGNOSIS. In the diagnosis of this disease there are several prominent subjective and objective symptoms for guidance. In the first instance the severity of the pain will be so much greater and persistent than that of acute catarrh, that it alone will aid in ACUTE PURULENT INFLAMMATION. 469 forming a true diagnosis, and the general systemic disturbance which also accompanies it, will be an additional evidence as to the real nature of this disease. With all this intense pain in the ear, we may be surprised to find the auricle and meatus not sensitive to gentle traction. This latter feature of the disease should at once free our minds from the idea that the pain is caused by any form of external otitis. In either the circumscribed or diffuse variety of external otitis, the slightest manipulation of the auricle and auditory canal is usually attended with pain. The objective symptoms too, in external otitis, enable us to form a diagnosis between it and acute inflammation in the middle ear. The differential diagnosis becomes more difiicult when there is a diffuse exter- nal otitis consecutive to the tympanic inflammation, especially if the former should close the auditory canal. This mishap, however, is not so likely to occur in the consecutive as in the idiopathic form of external otitis. Another aid in diagnosis is the fact that diffuse external otitis, consecutive to an acute inflammation of the middle ear, is comparatively rare, and not very rapid in its onset. Before it appears, an opportunity is generally afforded to examine the membrana tympaui and estab- lish a diagnosis of the original tympanic disease. If doubt is still present, as to the condition of the drum-cavity, its state must be further determined by the use of the Eustachian catheter, inspection of the fauces and nares, and a careful noting of all the general symptoms. Earache from Decayed Teeth. — The pain of acute inflammation of the tympanic cavity may be confounded with that caused by decayed teeth. Von Troeltsch has already noticed that it is often diflicult to distinguish pain in the molar teeth from pain in the middle ear. Many cases of earache occur, not only in those with neglected carious teeth, but in the more foi-tunate whose teeth are filled with gold. In the latter, otalgia is often produced by inflammation and caries beneath the filling. I see constantly many eases in the former class, in the infirmarj', and now and then cases of the latter variety present themselves in private. Although, in such cases, the objective aural symptoms would remove all doubt from the mind of one familiar with the appearances of a normal ear, still, the possible cause of pain in the ear, arising from diseased teeth, should be borne in mind 470' MIDDLE EAR. until the diagnosis of a different cause is fully established. "Whenever we find earache without sufiicient objective symp- toms of its cause, it is never amiss to inquire after the teeth. Rau^ says that, in young children, dentition is always attended with irritation in, and sometimes discharge from, the skin lining the external auditory canal. The fact that an unchanging pain is usually the only symptom present in otalgia from carious teeth, will aid the diagnosis. Appearances of the Membrana Ti/mpani. — As is the pain, so is the general alteration of the membrana tympani more intense in acute purulent otitis media. The membrane will be found passing from a stage of congestion around its periphery and malleus, to successive ones of greater intensity, until all its contours are lost, and either a bulging or misshapen diaphragm is seen at the fundus of the auditory canal. But we cannot point out any specific symptom in the membrana tympani as peculiar to this disease ; it is rather the general and severe implication of the whole membrane that would seem to distinc- tively mark its condition in this disease. Whenever any matter collects behind the membrana tympani, in quantities large enough to force the latter to bulge, such protrusion is almost invariably in the posterior half of the membrane. Whenever the membrane appears to be in hillocks, or puck- ered, there is most probably exceptional implication of its dermoid layer, in all likelihood due to a consecutive diffuse external otitis. The latter may not advance further outward than the immediate region of the membrana tympani ; or it may, unfortunately, invade the entire external ear. PROGNOSIS AND TREATMENT. The prognosis in properly treated acute purulent inflammation of the middle ear, though usually favorable, must always be modified by the cause of the disease and the general condition and age of the patient. The cases arising in acute exanthemata are the least favorable, because usually neglected. Those occur- ring in an ear previously diseased, or in one occluded to an ' Ohrenheilkunde, p. 158, Berlin, 1856. ACUTE PURULENT INFLAMMATIOK. 471 extent likely to prevent the escape of the products of inflam- mation, must be considered as gravely complicated, not only as to the hearing, but as to the life of the sufferer. An ordinary uncomplicated case of acute inflammation of the middle ear, arising from cold or exposure to traumatic violence, is rarely fatal to life. This disease usually causes some permanent alteration in the hearing, though the amount is small in the best cases. The treatment of acute tympanic inflammation must be em- phatically antiphlogistic. The first endeavor must be to reduce the congestion and pain and to prevent suppuration. This is best accomplished by leeching, the depletory effects of which are most successfully gained by placing the leeches close to the ear. The points to which they should be made to attach themselves, are close in front of the tragus and along the limits of the auricle where it fades into the cheek. If the pain and tenderness are marked in the region of the mastoid portion of the temporal bone, some of the leeches should be placed in the hollow close under the auricle, and over the mastoid. The so-called European or Swedish leeches will be found the best, because the largest and strongest. From three to six of such leeches will usually relieve the pain and check the advance of inflammation, if they are put on in time. From three to six ounces of blood should be drawn in the earliest stages of the disease. If any of the products of inflammation have appeared, deple- tion by this means is most positively contraindicated : if blood is to be drawn it must be done at the outset of the inflammation. Of course, this is a mode of treatment more easily carried out in a city and upon adults ; but even children will submit rather than suflfer, and where leeches cannot be gotten, Hourteloup's artificial leech may do us a good service. Unfortunately, however, the parts about the ear, being bony and uneven, are not well adapted to the firm suction this instrument requires. Blood should be drawn as soon as possible, and if not in any of the ways mentioned, I should rather resort to venesection than to run the chance of severe inflammation in the middle ear, with all its possible train of evils. I have never resorted to the latter means of depletion for an inflammation in the ear, but, although it is not a local bleeding. 472 MIDDLE EAE. such as is demanded in these cases, it is not to be despised as a last resort where blood should emphatically be drawn bj'- some means. Eeraember, we are endeavoring to check the advance of an acute inflammation. Jifext to leeching, local and constitutional anodynes in doses to give ease and sleep, will do the most good. The local use of Magendie's solution of morphia (16 gr. to fSj) will be found the most eff'ectual. This may be used even in children, as an instil- lation into the ear, in quantities of five to ten drops at a time, well warmed. The bowels should be opened as soon as possible by a saline purgative, and a mild sudorific should be given to place the skin in free action. It is of importance that the latter should be kept in brisk action during the acute stage of the catarrh. If in spite of all depletory efforts, the inflammation is surely and plainly advancing, the ear should then be subjected to warm irrigation. This will most certainly give great comfort to the patient and hasten the formation of pus, if it must come ; but in some instances I have thought the warm water-douche seemed to bring about a resolution of the inflammation, and thus spare the ear the ravages of a purulent process. Irrigation may be. accomplished by the nasal douche, the fountain syringe, a siphon made of a bowl of warm water and a piece of rubber tubing or by means of Clarke's aural douche. Paracentesis of the Drum-head. — The drum-head should be fre- quently and carefully examined, and if the slightest bulging appears in it, or if the products of inflammation become visible through it, and it appears likely to be ruptured, it will be better for the surgeon to choose the place of opening than to leave it to nature. The best point for -paracentesis of the drum-head has been found to be the postero-inferior quadrant, for from that point the tympanic cavity is most easily drained. Nature may rupture the drum-head at any point, but since perforations in the posterior parts of the membrana tympani heal more rapidly than those elsewhere in the membrane, and as perfect drainage of the drum-cavity is very important and most easily accom- plished from below, it is best to select the point named, for in- cising the membrana tympani. Some authorities advise waiting until the membrana bulges before incising it. Then in order to relieve tension and to choose CHRONIC PURULENT INFLAMMATION. 473 the best place for the opening, paracentesis at the postero-inferior quadrant is advised. Incision of the membrana tympani is so easily carried out, and in no event injurious, that it is not necessary to wait for protrusion of the membrana tympani, before incising it. Even in the earliest stage of tympanic inflammation, before secretion has appeared, paracentesis of the drum-membrane is often of great benefit. It relieves congestion and tension and reveals the condition of the tympanic cavity. All forms of continued poulticing should be most carefully and especially avoided in acute inflammation of the drum-cavity. In the first place they cannot be brought into very close proximity with the diseased spot, and secondly, in any event, they favor too great a maceration, and consequent formation of granulations in the ear. They are therefore especially evil in aural diseases, for the formation of granulations, brought about by a poultice to the ear, may leave the organ chronically diseased, or destroy its functions altogether. This is the experience of every aurist, and is amply testified to in every modern work on Otology. A kind of compromise may be made with the old prejudice in favor of poultices over the ear, by allowing the patient to wear a fold of cotton-wadding over the auricle and side of head, or to hold a warm hop-pillow to the painful ear. But simplicity of treatment added to a careful and thorough diagnosis, are the best means with which to combat acute disease in the ear, as well as elsewhere. CHAPTER VI. CHRONIC PURULENT INFLAMMATION. When alluding to acute inflammation of the middle ear, the greatest stress was laid on preventing suppuration. If in spite of all efforts, suppuration does occur, or if before the patient con- sults any one concerning his aural disease, suppuration shall have become established in the ear, then every endeavor must be made to check the discharge. There should be no feat to do this as promptly as possible, for so long as a chronic purulent 474 MIDDLE EAR. discharge comes from an ear, the patient is in da;nger. There need be no anxiety therefore about " drying up" the running from the ear ; " of driving it in on the brain," etc. Unhesi- tatingly it can be said that unless the otorrhoea is cured, the disease will surely extend to the brain. If it does not reach the brain, it will be because the patient will die of pysemiaand meta- static abscesses, before the central, organ in the skull is reached. Look at it then as one may, chronic discharge from the ear demands earnest consideration, careful and prompt treatment, and thorough cure, if it can be attained. So grave in fact is this disease that some insurance companies in Grreat Britain are advised by their medical examiners to refuse to take a risk on the life of one thus diseased.' The hearing is generally gone, beyond hope of recovery, before any treatment is sought for or given to the purulent disease in the ear. At last the oflfensiveness of the running usually leads the patient to seek medical aid. The surgeon too often, after finding the hearing gone, ftdvises the patient to let the dis- charge alone, " that it will dry up," etc. This is a mistake as fatal as it is common. Just because the hearing is destroyed, and the disease will advance from the middle ear to the internal ear, the mastoid cells, and the brain, the patient should be made aware of his condition and urged to undergo prompt treatment. His doctor should teach him that a disease which has destroyed the hearing can destroy the life ; that cerebral abscess is but the logical sequence of such a corroding disease in the tympanum. Treatment therefore should be instituted, not with a view of regaining the hearing, though some may be regained, but with the hope of freeing the patient from an ofl'ensive, annoying, and dangerous disease. ETIOLOGY. Respecting the causes of chronic purulent otitis media it is almost enough to say that they are the same as those productive of acute otitis media, and that the latter is the forerunner of the chronic form. Briefly, they are exposure to cold, traumatic influ- ences, diphtheria, and the exanthemata. The latter, especially measles and scarlatina, are notoriously assigned as causes of a ' Dalby ; Diseases and Injuries of the Bar, p. 176. CHRONIC PURULENT INFLAMMATION. 475 large number of the cases of chronic purulent discharge from the ear, which the surgeon is called upon to treat. Most common of all assigned causes, is scarlet fever. The question naturally arises, is this necessarily the case ; is there something in the scarlati- nous poison which tends to eliminate itself through the mucous membrane of the middle ears ? Can it for a moment be sup- posed that, just as the kidney is likely to become congested and inflamed in scarlet fever, so is the mucous lining of the ear? Since the throat and naso-pharynx are very apt to be diseased in scarlatina, and since an aural disease is prompt to follow close upon a throat-disease, the acute process in the middle ears, in scarlet fever, may be accounted for. But is there a specific tendency in the aural disease of scarlet fever, to become chro- nic? CTpon close examination of these cases, it will be found that, though the sufferer has passed through a disease which has made him weak and liable to affections of the mucous tract, neglect of the acute inflammation in the ear has done the real mischief. Were this not true, then prompt attention to the in- flamed ear in scarlatina would not be fraught with the good result it always is. Diphtheria as a Cause. — Diphtheria is very often followed by a virulent form of chronic purulent inflammation of the ear, in children. There seems to be a tendency in this disease for the purulent otitis to fall at once into a chronic form. Pain is not always present and the acute stage is not well marked, but granulations spring up in a few days, the bone becomes necro- tic, and sequestra are thrown, off from various parts of the tem- poral bone. In a child sixteen months old, without any pre- vious symptoms of pain or acute inflammation in the ear, a large cold abscess formed behind the auricle, pus ran from the meatus, the abscess was opened by the family's medical adviser, and denuded bone was found extending along the posterior wall of the external auditory canal and over the outer wall of the mas- toid portion. In another instance, a little girl four years old was attacked with diphtheria ; without any severe symptoms of acute otitis media, the child complained of discomfort in her right ear ; then suddenly facial paralysis set in and continued for many days. This disappeared after a copious and fetid dis- charge from the meatus of the affected ear. Rapidly, without pain, an abscess formed over the mastoid and was opened, dead 476 MIDDLK EAR. bone was found in the auditory canal and over the mastoid ; the ear was blocked with large granulations, and the major portion of the mastoid was thrown oft" as a sequestrum, from the opening behind the auricle. The rapidity with which the chronic form of purulent otitis is established in these cases, is worthy of note. It is, therefore, advisable in order to prevent destruction of the ear, to examine the organ in every case of diphtheria, espe- cially if the patient's attention is called to the ear by the least discomfort, and, if necessaiy, to make a free vent in the mem- brana tympani. This would permit the escape of matter from the drum, and prevent a buiTOwing to deeper parts. Such a procedure forms at least the best and perhaps the only means of preventing the rapid, almost gangrenous destruction of the ear, so likely to follow diphtheria in children. But ignorance of this fact, or unwillingness and inability to carry out the necessary manipulation in the examination and operation on the mem- brana tympani, have led the majority of physicians to under- estimate the importance of doing that which is necessary to save the hearing and prevent necrosis of the temporal bone. Consequently the patient is said to have recovered from the diptheritic disease, in cases in which he survives, but his hear- ing is lost, and he is spared only to undergo a tedious and exhausting suppuration iu his ear, and finally to die from an extension of the aural inflammation to the brain, or to other organs of the body, or from general pyaemia. In order to convince one's self of the fearful ravages of chronic purulent inflammation of the middle ear, it is only requisite to take a casual glance at the literature pertaining to otology in Europe and America. But, though many cases of these evil consequences are recorded, every one whose attention is spe- cially drawn to the point, will state that numerous cases of death, from aural disease, are put down to other causes. Age and sex have nothing to do with the causation of chronic purulent disease of the middle ear in children. The desire on the part of parents to have their girls free from the necessarily disgusting feature of an offensive aural discharge, leads them to bring their daughters sooner perhaps than their sons, for treat- ment. Grirls are more closely observed than boys, which also accounts for the fact that among young patients the girls are in the majority. Boys, with a chronic aural discharge, are more CHRONIC PURULENT INFLAMMATION. 477 likely to escape notice from the simple fact that they are absent from home more than the girls are. When, however, the boys begin to lag in their school tasks, on account of hardness of hearing, the aurist is consulted. Such circumstances may have more or less influence in causing an apparent preponderance in the number of young female patients, over that of the young males, but one sex is just as liable as another to chronic purulent inflammation of the middle ear, in childhood. Of adult patients afflicted with chronic purulent otitis media, the men seem to be in the majority. This is accounted for in part by the above- mentioned want of care bestowed on them in boyhood, and subsequently by their more exposed life. Among the patients met with in infirmary practice, females, whose lives are exposed, as servant girls, are just as liable as men to contract chronic purulent disease of the middle ear. SYMPTOMS. The chief symptoms of chronic uncomplicated purulent otitis media, are hardness of hearing, deafness, and an oftensive puru- lent discharge from the ear. The defect in hearing may vary from but slight hardness of hearing to absolute deafness. The vibrating tuning-fork on the vertex may be heard quite well in the aflected ear if the labyrinth has not been invaded by the inflammation. If the latter has advanced inward towards the labyrinth, then the auditory nerve will have been more or less affected, and the failure to hear the tuning-fork, by bone-conduction, can be easily accounted for, and must, therefore, as a rule, be regarded as an unfavorable symptom respecting the extent of the disease, and also regarding the prognosis. But it should spur on the physician to renewed efi'orts to quell an inflammation which has reached already so far, before it go further. While the deafness may be thus demonstrated to be absolute and irremedi- able, this fact is not sufficient to induce the physician to dis- suade his patient from treatment, but rather to encourage him to go on, that matters get no worse. The Discharge. — The discharge is usually much mOre copious in children than in adults. In the latter, the discharge is more likely to be copious the less chronic the disease, a feature, due 478 MIDDLE EAR. in all probability, to the more active condition of the inflapied mucous membrane. As the disease advances, the mucous mem- brane is either destroyed, or so greatly altered in structure as to cease to throw oft' much secretion, and the discharge in such cases becomes thinner, more oti'ensive, irritating, and suggestive of necrosed bone. In children the discharge is copious because of the activity of the mucous membrane of the naso-pharynx. Eustachian tube, and middle ear. Hence, in these young pa- tients the purulent discharge is mixed with ropes of mucus, quite transparent, from the Eustachian tube and the tympanum. The color of the discharge varies from a light-yellow to a dark- yellow or green, but there is no rule aboiit this. I have observed that the more copious discharges of children are lighter in color than the scanty, which are usually darker. The slighter dis- charges of adults, afflicted with chronic purulent disease of the middle ear, are dark and more likely to form crusts or scabs in the meatus. In some rare instances the color of an otorrhoea may be bluish, as mentioned by Dr. Zaufal.' Such a discharge was found to contain the bacterium termo ; and the blue color- ing matter gave a reaction characteristic of litmus. In most cases there seems to be something almost specific in the odor of chronic suppuration from the ear. While this is hardly to be considered as necessarily so, it is so, mainly on account of the want of cleanliness. There will be very little odor in an ear thus aflected if it is kept clean and there is no necrosed bone retained. But if the latter provisions are not met, then of course all the peculiarly disagreeable and butyric odors of putrid pus and decaying bone will be emitted. Appearances of the External Auditory Canal. — Inspection of the ear by means of the ear-mirror and the funnel will reveal maceration of the skin of the auditory canal, more or less destruction of the drum-head, and inflammation of the mucous membrane of the tympanic cavity. This is the view in an ordinary uncomplicated ease ; if there are complications arising from the purulent disease or from any other source, in the ex- ternal or middle ear, they will now become apparent. But all such features of chronic purulent inflammation of the ear, will be considered under the consequences of the unchecked > Archiv f. Ohrenh., Bd. vi. p. 206. CHEONIC PURULENT INFLAMMATION. 479 disease. In order to obtain a good view of the external and middle ear, the auditoiy canal must be syringed out, and usually it will be found necessary to wipe off the drum-head with a little tuft of cotton-wool on the cotton-holder. This is de- manded if the pus is tenacious or hardened on the membrane. Syringing without the latter manipulation has often led to error, since the red and inflamed pai'ts beneath the film of tena- cious muco-pus have not been seen. Inspection of the external auditory canal in the simplest form of chronic purulent inflammation of the middle ear, reveals maceration of the cutaneous lining of the passage, and some- times one or more exostoses. The latter are the more likely to be found the more chronic the case. They rarely exceed two in number. If the chronic discharge is not copious, the macera- tion of the skin in the canal is not great, and instead of that, there are found scales and crusts of hardened pus, mucus, and epidermis in the inner part of the auditory canal and on the outer surface of the upper part of the drum-head. In cases of copious discharge, the delicate lining skin of the inner part of the bony auditory canal, becomes more like- mucous membrane than skin. This has led to the erroneous idea that the inner part of the auditory canal is normally lined with mucous mem- brane. It never is, but only assumes somewhat the appearance and nature of diseased mucous membrane, when subjected to constant irritation. This condition of the lining of the external auditory canal, is apt to be most marked in those individuals who have resorted to the injurious sponge-swab instead of the bland syringe, for cleansing their ears. Appearances of the Drum-head and the Tympanic Cavity.— Chro- me, purulent discharge from the tympanum presupposes a perfo- ration in the membrana tympani. Such a perforation may be at any point in the membrane, least frequently, however, in the flaccid part or the membrane of Shrapnell. A perforation in the membrana tympani may vary from the size of a pin's point to that which embraces the entire drum-head. Usually, even in the worst cases, a rim about the annulus is left, from which, if the purulent process is stayed, a new membrane may grow to a greater or less extent. Multiple perforations are rare, sometimes two may be found close together in the under part of the membrane, separated by 480 MIDDLE EAR. a thin band, and, in very rare instances, three perforations may be found in the same membrana tympani. The handle of the hammer may remain intact, notwithstanding large destruction in the drum-head. In other instances, the manubrium may be more or less eroded as the perforation extends. If the mem- brane is destroyed, or if the perforation in it is in the upper and hinder part, the lower portion of the long process of the incus, the incudo-stapedial joint, and the rami of the stapes, as well as the niche of the round window, may come into sight after the ear has been well cleansed of pus and then dried out with cotton on the holder. Nevertheless, a large perforation may exist in the upper and hinder part of the membrana tympani, and the afoi-esaid ossicles may be intact, yet invisible, for they are apparently a little higher in the tympanum in some individuals than in others. The mere fact that they cannot be detected in cases generally favorable to their exposure, does not prove that they are de- stroyed. In some cases, the mucous membrane around about them is too swollen to permit of their ready recognition. When a large perforation is about on the same plane with them, their lower ends may become visible by inclining the patient's head as far as possible towards the opposite shoulder, and look- ing up and behind the curtain-like rim of the membrana tym- pani, between them and the observer. In order to obtain a good view of the relations of these bones to each other, and of the separate rami of the stapes when they are to be seen, the patient's head will always have to be moved about gently from one position to another, till the desired view is obtained. The eye of the observer must always be directed towards the roof of the tympanum rather than towards the plane of the membrana tympani or inner wall of the tympanic cavity. The appearance of the membrana tympani or its remnant, will vary from one of great opacity and grayness, with red and cica- trized edges of the perforation, to that of uniform redness and thickness. The manubrium of the malleus may be buried in the thick and swollen membrane, or, if the latter is gray and thickened, the position of the manubrium is marked often by only a tracery of congested vessels. In other cases, the handle of the hammer is seen as a ridge in the membrane of the same color, be that either red or gray ; or, the handle of the malleus CHRONIC PURULENT INFLAMMATION. 481 may project alone in the plane of the former membrana tym- pani. In such cases, the so-called folds of the membrane may still remain, extending from the short process of the malleus, one backward, the other forward towards the periphery. It is usually the posterior one which interferes with a good view of the deeper-lying ossicles. TREATMENT. Two fundamental rules of treatment must be observed in every form of chronic purulent inflammation in the middle ear, cleanli- ness and perseverance. In some cases it seems highly probable that careful and thorough syringing of the running ear, several times a day, persevered in, would have cured the disease without the aid of astringents. It would certainly be far better to rely on the use of tepid water and the syringe, with a good hope of success, than to do absolutely nothing for the inflamed and offensive ear, since, in the latter course, the condition of the ear and of the patient will almost surely go from bad to worse. Especially at the beginning of the treatment should the ear be made clean, in order that its real condition should be seen, and then it should be kept clean iji order that the remedies applied to the mucous membrane may have an effect. So important is this cleansing that it would be well to leave it to the surgeon were it practicable, but it is not. The surgeon, however, should cleanse the ear at least several times a week, at the outset of the treatment ; in the mean time the patient or some member of his family should be instructed how the ear should and can be syringed. When this part of the treatment is learned by the patient or his friends, it can be left to them for the most part ; however, the surgeon must frequently assure himself that the ear is properly syringed at home, for on that depends success. I have never found it necessary or desirable to employ any of the heroic methods of forcing water either through the meatus, the middle ear, and Eustachian tube, or vice versa. Saissy, Millingen, and Hinton have advocated this procedure for clean- ing the middle ear of inspissated contents arising in chronic purulent inflammation. If, in syringing the ear, some water escapes into the Eustachian tube and throat, it is of no moment. It may, indeed, be a sign of more thorough cleansing of the 31 482 MIDDLE EAR. middle ear ; but it is not desirable to force water to take this course, for, at the same time, some of it might be injected into the mastoid cells and there set up acute inflammation. In any event, forcible syringing of the ear is very liable to make the patient dizzy. Moderate syringing will not thus affect the patient : it is usually borne perfectly : only in one case of chro- nic purulent otitis media which came under my notice, no form or manner of syringing nor the aural douche could be tolerated, on account of vertigo, which was easily brought on. Cleansing the ear, in this instance, was effected by using a camel's hair pencil, moistened with warm water and a solution of perman- ganate of potassa. The patient was an intelligent adult, and could thus cleanse her ear moderately well. But, as a rule, such manipulation for cleansing purposes is to be forbidden, and total reliance on the syringe to be enforced. Sometimes, however, the most complete syringing will not remove all that should be washed out from the ear, especially the more tenacious variety of muco-purulent matter which collects like a film over the membrana tympani and the mucous membrane of the middle ear. In such cases, Castile soap may be added to the water, in sufficient amount to make the latter a little opalescent ; or, before each regular syringing, a solution of bicarbonate of soda (10-20 gr. to fij) may be instilled into the ear and allowed to soak there three to five minutes. Then, the matter thus softened may be more easily washed out. Still, in these cases, the surgeon must use his judgment as to whether the inspissated matter is to be removed or not. If the discharge is still active, then such masses should be removed, but if the running shows signs of stopping, it has seemed better in some eases not to wash these adherent films or crusts away. They do not invariably form ; most discharges tending not to harden, but to come away if the ear is properly cleansed. [N'ot uncommonly, however, • perforations in the drum-head close, first, by the formation of a kind of scab over the opening, then by true cicatricial tissue. The former finally falls oft", leaving the latter as a permanent closure. But what I specially wish to call attention to is, first, the importance of favoring the formation of this scab-like closure in the perforated membrane of an ear affected with a chronic discharge from the tympanic cavity, and, secondly, the importance of letting such formations CHRONIC PURULENT INFLAMMATION. 483 alone when they have once closed the perforation in the mem- brana tympani. Such formations must he regarded as an eifort of Nature to protect the lining mucous membrane of the tym- panum. The normal drum-head must be regarded, to a very great extent, as a barrier between a mucous surface and the direct eftects of cold air. I have often observed that as a discharge from the tympanum ceases, the matter now being poured out in small quantities from the hole in the membrana tympani begins to stick to the edges of the vent ITature provided it, until, at last, a small scab or plug fills the perforation and the discharge has stopped. The application of remedies, now, must be timed so as not to prevent this forming of a natural plug for the hole in the drum-head. When a discharge begins to diminish, it is decidedly better to taper off the amount of remedial applications to the ear ; for they will not only prevent the healing or scabbing over of the perforation, but they will enter the tympanum, where they have ceased to be needed, and act as irritants. Doubtless, many discharges are kept up by continuing to syringe the ear and to put in drops. But no positive law on this point can be laid down. Each case must be studied pretty much for itself. It will, however, never be amiss to pause in the instillations in order to find out whether there is really any further need for them, and to discover that which is still more important, viz., whether they are so far irritants as to keep up the slight discharge which still lingers. Cessation of treatment is not unfrequently followed by the formation of the above-named covering over the perforation, and the healing of the ear. That this covering of yellow in- spissated muco-purulent matter over the hole in the drum-head is of greatest value, is seen in those cases in which it has been unfortunately removed. In several instances where such a covering had formed, before the cases came under my notice, and before I was aware of the real meaning and value of this natural patch to the wounded drum-head, in my zeal to remove what in one sense was a for- eio-n body, from the membrana tympani, I softened the scab and removed it. In two instances a clean-cut perforation be- came visible, and through it the healthy mucous lining of the tympanic cavity could be seen. But in a few days the mucous 484: MIDDLE EAK. lining of the drum became congested, because the air had too free access to it, and an otorrhoea, which had subsided, returned. ISTot only do I now leave such formations alone when found on the otherwise normal drum-head, but I have also learned that where the membrana tympani is largely destroyed, and the remnants of it and the visible parts of the cavity of the drum are smeared with a dense creamy matter, which cannot be called fluid, and therefore creates no discharge from the meatus, it is wise to leave such natural coverings alone, for beneath them are mucous tissues in the process of healing, and it is meddlesome to disturb them. After a longer or shorter period these purulent coverings will dry, as the parts beneath heal and can dispense with them, and then they will peel off and escape as tough or hard shells. But unless there is an active discharge, running down the canal and out of the meatus, it is necessarj' to use great caution in re- moving what may be called aids to the natural repair going on in the tympanum and membrana tympani. Too much can never be done to check a running from the ear ; what has been said above is only intended to call atten- tion to the importance of aiding nature in her process of repair, after an active discharge from the ear has ceased. After careful observation of a number of cases of disease of the ear, it will not be difficult to discriminate between that which should be removed and that which should be let alone. The Chief Remedies to Check the Chronic Discharge. — Cleanli- ness and perseverance have already been named as necessary rules in the general treatment of a case of chronic purulent otitis media. To these might be added three names to guide in forming a pharmacopoeia, viz. : zinc, silver, and alum. Very few — perhaps none — of the numerous and ordinary un- complicated cases of otorrhoea will defy the proper use of the syringe and the drugs named. The latter should be employed in the order in which they are mentioned, the first two in solu- tion with water for instillation ; the last in powder for insuffla- tion. Doubtless many other drugs are useful as local applications to the chronically diseased ear, but they are emphatically in the secondary list. Solutions of zinc, preferably of the sulphate, though the acetate is also very good, should be used in the strength of CHRONIC PURULENT INFLAMMATION. 485 from one to five grains to the fluidounce of water. Only in the rarest instances will any advantage he derived from increas- ing their strength beyond this point. If they are thus concen- trated the discharges are curdled, the ear is blocked up and the fresh secretion retained. Solutions of nitrate of silver are useless in checking a chronic discharge from the ear, unless used in considerable strength. The most efiicient are those ranging from 30 to 100 grains to the fluidounce ; and not uncommonly saturated solutions (480 gr. to f3j) are instilled not only without injury, but with posi- tive good, as shown by Dr. Pomeroy.' The solid stick should never be used. Prof. Schwartze^ was the first to draw the attention of the profession to the use of strong solutions of nitrate of silver ; he considered those of 15 grains the weakest, and of 40 grains the strongest ; latterly he has used much stronger solutions. It is not necessary to wash out the ear with salt and water after the application of the solution of silver. I think that caution demands careful consideration before very strong solutions of silver are instilled into the middle ear in chronic purulent otitis media, simply for fear of implicating the facial nerve. Though I have never met with such an accident, nor do I know of a reliable account of facial paralysis produced by the instillation of nitrate of silver into the tympanum, caution would forbid its use if there is any reason to suspect disease of the bone, for, if the latter exist, the Fallopian canal might be so far deficient as to permit some of the caustic to penetrate to the nerve. So long as there is reason to believe the chronic purulent inflamma- tion has not advanced beyond the mucous tissues, there can be no harm in using solutions of nitrate of silver in the middle ear. Prof. Schwartze's advice is adverse to instillations of nitrate of silver in solution unless there is positive evidence of the absence of granulations on the exposed mucous membrane or upon the remnants of the membrana tympani, and unless there is entire absence of disease of the bone. Prof. Roosa,^ however, believes that nitrate of silver in strong solutions may be used I N. Y. Med. Journal, Dec. 1872. ^ Aichiv f. Ohrenb., Bd. iv. p. 1. 8 Op. cit., p. 376. 486 MIDDLE EAR, with safety and profit even where there are granulations and polypi. It has seemed to me that Dr. Pardee's' advice is timely, to regulate the choice of an astringent by the character of the secretion. Hence, if the discharge is predominantly of a mucous character, he advises nitrate of silver ; if chiefly purulent, weak solutions of zinc, acetate of lead, and alum are to be used. Grossman,^ as quoted by Schwartze,' advises the use of sulphate of zinc with catarrhal secretions, acetate of lead if the discharge is blennorrhceic and the perforation of the membrana tympani small, and crude alum in powder if the discharge is both blen- norrhceic and copious and the perforations in the drum-head very large. Mode of Instilling Solutions of Nitrate of Silver. — The solution need not be warmed, as shown by Politzer, though Schwartze pursues an opposite plan. After the ear has been cleansed and dried, let an ordinary medicine-dropper be filled with the solu- tion of silver, and then, with the head of the patient slightly inclined forward and toward the opposite shoulder, drop the caustic fluid into the meatus. If the Eustachian tube is per- vious, Valsalva's or Politzer's inflation may be performed while the solution is in the meatus. Bubbles of air will rise through the fluid in the ear, and, upon ceasing the inflation, the solution will find its way still more readily into the tympanum and Eustachian tube. Such a distribution of the fluid is desirable, since an application is thus made to the Eustachian tube and naso-pharynx, both of which are more than likely to be as much diseased as the tympanum in chronic purulent otitis media. Prof. Schwartze has known an instillation of nitrate of silver to pass from the middle ear to the Eustachian tube and from the latter across the naso-pharynx to the tube of the opposite ear, causing acute inflammation of the latter ;* an accident which he further warns against lately,' since he believes it very likely to occur if the head is laid in a horizontal position during the instillation. Although he has assured himself of this possi- bility by experiments on the cadaver, his experience, so far as I am aware, is solitary. ' Trans. Amer. Otol. Soc, 1871. 2 Ungar. Med. Presse, 1870. ' Archiv f. Olirenh., Bd. vi. p. 83, 1873. * Archiv f. Ohrenh., Bd. iv. p. 288. = Archiv f. Ohrenh., Bd. xi. p. 123. CHRONIC PURULENT INFLAMMATION. 487 The application of solutions of nitrate of silver, should never be entrusted to the patient or his attendants, for, if it be, there is every likelihood of staining his ear and cheek, and ruining his clothing. To properly apply a solution of nitrate of silver is somevrhat laborious, and hence not likely to be carried out in the vast majority of cases, unless by a skilful hand. From motives of cleanliness it is well to put salt into the water with which the ear is washed after solutions of silver are used, since they are thus neutralized, and little or no staining of the ear occurs. Beyond this object it is not necessary to- neutralize the silver. But it is very obvious, that in a treatment which is more than likely to be tedious, every effort should be made to free the patient from the additional annoyance of black stains on his ear and his cheek, besides ruining his clothes and towel- ing. I have known patients to be justly indignant at having been advised to use an expensive solution, the entire nature of which they were unacquainted with until they discovered that, besides disfiguring their faces, they had ruined costly garments. Mothers who thus have been allowed to spoil their children's dresses, are not likely to be enthusiastic for a continuation of the use of silver, even when properly applied. Yet tucking a towel around the patient's neck and ear, be it child or adult, careful instillation of the silver solution, its momentary repose in the ear and its washing out with salt arid water, will prevent any annoyance. In the ear, as in every other part of the body, it is usually more important how a drug is used than what it is. The diseased mucous membrane of the middle ear is not very sensitive, so that the patient can be assured the drops of nitrate of silver will not pain him. This assurance will be not only comforting but frequently demanded. The association of the names nitrate of silver and caustic will then cease to be as alarming as it often is, until the patient is reas- sured respecting his comfort. It must be stated, however, that if the skin of the external auditory is abraded in any way, nitrate of silver dropped into the ear will be for a moment acutely painful. But in such cases, the healing of these abraded cutaneous parts is brought about by the use of the silver, and there is no further pain. In the latter way, may be explained the assertion on the part of some observers that nitrate of silver dropped into the middle ear causes pain, when in reality the 488 MIDDLE EAR. pain is due to cauterization of an abraded spot in the delicate and highly sensitive skin in the inner part of the auditory canal. I have yet to see pain caused by contact of a solution of silver with the mucous membrane of a middle ear in a state of chronic purulent inflammation. Ahim may be used in solution or in powder; although some have regarded a solution of alum as most potent to check chronic otorrhcea, the powder is now almost universally employed for this purpose. After the ear is cleansed and dried, the powdered alum maj' be blown in by means of a simple instrument. I have used for this purpose a home-made instrument, consisting of a small glass mouth-piece — a piece of glass tube or a small olive- shaped nose-piece from the nasal douche will answer — and a flexible rubber tube 35 cm. long and 8-9 mm. in diameter, into one end of which a piece of quill 3 cm. long may be inserted. The latter at its free end can be cut diagonally to its long axis, thus making a scoop for the powder. With the canal and middle ear, or as much of it as is exposed to view, well lighted by means of the forehead-mirror, powdered alum may be blown into the ear with the above-described tube. The utility of the latter is greatly increased by the greatest amount of flexibility of the rubber tubing employed. In many cases it will be best to allow the alum to remain several days at a time in the ear, as recommended by Politzer. If the discharge is still copious, it will run out, though the pow- dered alum is left in the ear ; but if the discharge is slight, it will not accumulate fast enough to prevent the alum from remain- ing some time in the ear, and thus acting for a continued period on the diseased tissues. An ear undergoing this form of alum- powdering should be examined frequently by the surgeon, and if there appears to be a ball of alum and muco-purulent matter forming, it should be washed out. Usually, however, the best eftects of alum are obtained by allowing it to remain indefinitely in contact with the diseased mucous membrane of the middle ear. Solutions of alum are apparently not as potent as the powder ; and it is held by Von Troeltsch, and corroborated by others, that they cause furuncles in the cartilaginous part of the external auditory canal. Other Powdered Svhstances for Insufflation into the Ear. — Dr. Hinton has found powdered talc of great use in drying up a CHRONIC PURULENT INf LAMM ATIOX. 489 slight but persistent discharge; Dr. Chisholm' recommends a powder of two parts of magnesia and one of salicylic acid in chronic purulent otitis media. This is certainly a most impal- pable and beautiful form of applying salicylic acid. Dr. F. H. Eankin,^ of New York City, has recently recommended the use of powdered iodoform in chronic purulent discharges from the ear. After the ear is cleansed and dried, the iodoform is to be blown into the ear. I have used this, as well as equal parts of it and crude alum, in a number of cases, and I have thought I observed benefit from the application. The eases in which it has seemed of most value have been so-called scrofulous children. The peculiar odor, affecting some individuals really painfully, renders it objectionable as a means of treatment in pi'ivate prac- tice. It has never, so far as my experience goes, proven in the least degree irritating. Schwartze' recommends, as powders useful in checking slight chronic discharges from the ear, calomel (Rust), tannin, nitrate of bismuth, and magnesia usta (Hinton). In the use of all kinds of powders, for insufflation the greatest watchfulness must be observed, in order to prevent concretions of the matters thus blown in. Other Astringents used in Chronic Purulent Otitis Media.— ^vl- phate of copper, acetate of lead, aluminate of copper, nitrate of lead (Von Troeltsch), and tannin are among the astringents which may prove of great benefit in some forms of chronic puru- lent inflammation of the middle ear. It will be observed in the vast majority of cases, the mineral are preferred to the vegetable astringents in the treatment of diseases of the ear. Tannin is rarely used, as it is regarded almost inert in checking a chronic purulent discharge from the ear. Sulphate of copper is especially beneficial when the bone is diseased. It should be used in weak solutions (1-3 grs. to f ,?j), as it is much more powerful than sulphate of zinc — i. e., it will cause burning in the ear much more readily than the latter, if it is used in solutions of greater strength than just named. It was first recommended in aural diseases by Rau, and since, ' Philadelphia Medical and Surgical Reporter, vol. 33, p. 103. 2 New York Medical .Journal, May, 1875. ' Archiv f. Ohrenheilkunde, Bd. xi. p. 123. 490 MIDDLE EAR. greatly lauded both by Lucse and Schwartze. I have never found that the slight staining of the ear, which it sometimes produces, has materially interfered with the proper examination of the diseased parts. It is a valuable astringent, but irritating unless used in weak solutions. Preparations of lead, though admirable astringents, are open to the same objections in treating diseases of the middle ear, as in diseases of the eye. The insoluble precipitates with albumen which they form have caused their almost total banishment from the treatment of chronic purulent otitis media. Lead- water has been used by Wilde, Schwartze, and Politzer, with asserted success, in checking suppuration from the ear.* But they are very cautious in its use, for fear of the aforesaid tendency of it to form, like other preparations of lead, insoluble precipitates. Nitrate of lead has been recommended by Von Troeltsch^ as of some value in chronic purulent discharges from the middle ear, after other mild astringents have seemed to fail. I have used this preparation of lead in solutions of ten grains to f3j, without perceiving any of the injurious effects of lead, and in some cases it has seemed of value as an astringent. Other astringents, as aluminated copper (lapis divinus), sesqui- chloride of iron, chloride of zinc, sulphate of cadmium, and acetate of copper have been used to check chronic discharges from the ear. The greatest caution should be observed in the employment of solutions of iron in the ear. They are likely to mechanically obstruct the ear by rusty deposits, and are inclined to irritate and inflame the organ. The course and consequences of unchecked chronic purulent otitis media are so common and so dreadful that it is proposed to devote the next chapter to their consideration. ' See paper by Schwartze, Archiv fiir Ohrenh., N. F. , Bd. 1, p. 34. * Treatise, Roosa's translation, 1869, p. 461. CHRONIC PURULENT INFLAMMATION. 491 CHAPTER VII. COURSE AND CONSEQUENCES OF CHBONIC PURULENT INFLAMMATION OF THE MIDDLE EAR. "Without doubt, many of the bad results of chronic purulent otitis media are entirely due to bad treatment or neglect. The fatal issue so often seen is not a necessary one, if the case had received even a fair amount of rational and intelligent treatment. This is amply attested by the statements of every one who has paid a little more than ordinary attention to the subject of aural disease. Doubtless, many more of the evil con- sequences of neglected otorrhoea would be recorded if they were even recognized as such. But, as every aurist knows, menin- gitis from an extension of an aural inflammation to the brain is by no means rare ; yet the records are strikingly meagre, a fact only to be accounted for, either by ignorance on the part of the would-be diagnostician, or his unwillingness to acknowl- edge the cause and njiture of the disease which has proven fatal while under his care. However, long before chronic purulent otitis media has reached its later and alarming stage, although some of its annoying consequences may have shown themselves, it is still curable if it is recognized and properly treated. Now, in addition to the efforts to cure the original disease of the mucous membrane in the middle ear, other endeavors must be made to remove the evil consequences of this chronic inflam- mation which may have arisen. Chronic purulent inflammation of the middle ear tends to the production of: 1. Permanent hardness of hearing and deafness. 2. Epileptiform and other nervous manifestations. 3. Granula- tions and polypi in the ear. 4. Ulceration of the mucous membrane of the tympanic cavity ; periostitis ; ostitis ; caries and necrosis of any or all of the parts of the temporal bone and portions of the adjacent bones; inflammation of the meninges and sinuses of the brain ; embolism ; cerebral abscess ; pyaemia ; and death. 492 MIDDLE EAR. 1. Hardness of Hearing and Deafness, — Among the earliest consequences of chronic purulent otitis media, is destruc- tion of the sound-conducting parts in the middle ear. This produces hardness of hearing and deafness, both of which are more or less permanent ; though in some cases a surprising amount of hearing is regained under proper treatment. Usually, the perforation in the drum-head will close if the mucous lining of the tympanum is restored to health ; but if the latter is not gained, or if the perforation of the drum-head be extensive and the ossicles have become carious, necrosed, and destroyed, a per- manent diminution in hearing must be expected. The diminu- tion of hearing and the extent of the loss in the membrana tympani and the ossicles do not seem to be in any fixed propor- tion. Sometimes it is found that a long-continued suppuration in the middle ear is accompanied by a small perforation in the . membrana tympani, but that the deafness is great. Again, the perforation may be large and some of the ossicles deeply impli- cated, yet the hearing is by no means gone. In cases resem- bling the former it is often found that bleeding and other evi- dences of granulations in the tympanum exist. In the latter instances, though the sound-conducting parts are for the most part deeply diseased, the stapes and the mucous membrane round about its foot-plate and the oval window may be in a comparatively normal condition, which allows a free motion of this small ossicle in and out of the fenestra ovalis. At the same time it will be found that the membrane of the round window is intact, and that the delicate parts of the in- ternal ear are quite well protected. "With the two fenestrse thus in nearly a normal state, sound- waves are conducted by the stapes to the labyrinth. Should one or both of these fenestrse become diseased, or should the stirrup become impacted by swollen mucous tissue, in the oval window, then the hearing will be found greatly impaired. In some instances the stapes has been supposed to be relaxed and thus to fail to convey the undulations of sound to the laby- rinth. To support this bone seems to be the endeavor of most surgeons, in applying an artificial drum-head, as is held by Hinton.^ ' Op. cit., p. 189. CHRONIC PURULENT INFLAMMATION. 493 Most cases of chronic suppuration in the middle ear have already undergone great loss of substance in the sound-conduct- ing parts, long before a rational treatment has been instituted. Although, now, by use of means already mentioned when con- sidering the treatment of an uncomplicated case of chronic puru- lent otitis media, the discharge may be checked and the pro- gress of the disease in the tympanum arrested, the hearing will usually be found greatly impaired, in consequence of a loss of substance in the sound-conducting parts and their failure in function. If the sound-perceiving parts, the labyrinth and its contents, are in a normal condition, an endeavor may in some cases be demanded and made to substitute the loss in the sound- conducting parts, or to help those. portions which still remain, to convey sound-waves to the nerve of. hearing in the labyrinth. This is best accomplished by some form of that which is known as an artificial membrana tympani. Artificial Membrana Tympani. — Contrivances to protect the middle ear in cases of perforation of the membrana tympani, were considered necessary and employed by Marcus Banzer, 1640, Leschevin, 1763, Autenreith, 1815, and Lincke, 1840. In one important sense, these devices were artificial drum-heads, because they were intended to supj)ly the protective function of the natural membrane. They consisted mainly in short and delicate tubes, over one end of which a thin membrane was stretched and varnished, and then the instrument was worn in the auditory canal. But there is no good account of either an attempt to improve the hearing by their use, or that they even suggested the artificial mem- branes. In fact they were considered as an impediment to hear- ing.i As is well known, the first account of an artificial drum-head worn for the purpose of improving the hearing, is that of an American, who, of his own accord and device, thus used a spill of paper. He communicated his invention, and the good hearing he was able to gain for himself b^ its application, to Dr. Years- ley, of London, in 1841.^ The hint thus gained by Dr. Yearsley led him to try pellets of ' Lincke's Sammlung, p. 183, 1. 2 See " Deafness Practically illustrated," London, 1863, p. 221. 494 MIDDLE EAR". cotton instead of twisted paper, since a trial of the latter in other patients invariably failed. His success with cotton-pellets, however, is universally known, and his method used with great advantage at present, in a large number of cases, but with neces- sary modifications. Itard, Deleau, and Tod, are quoted by Toynbee, as having observed deafness relieved by the introduction of cotton or lint into the external auditory canal, and its contact with the par- tially destroyed membrana tyrapani.* Mr. Wilde^ states that a lady informed him as early as 1845, that she had discovered that she could improve her defective hearing by inserting, down to the drum, a moist pellet of cotton. Mr. Toynbee, in 1853, suggested the use of a disk of India rubber, to the centre of which was fastened a silver wire by which the artificial membrana tympani could be inserted and adjusted.^ Fig. 73. ToYNBEK's Artificial Membrana Tympani.- Politzer* subsequently modified this instrument by fastening a wire to one end of a simple strip of thin India rubber, and he has found that it answers nearly if not quite as well as the disk. In 1867, Dr. Lochner' published his improvement in the mode of fastening the wire to the rubber disk of Toynbee's artificial membrana tympani. Instead of holding the disk to the wire by soldering it between two very small metallic plates, the wire was twisted into a double spiral at one end, thus forming two small rings, between which the rubber disk was wedged and firmly held. The inner end of the wire, which would naturally project and irritate the ear, was bent about and pushed into the rubber. Dr. Lochner further suggested the substitution of vul- canized rubber instead of the more pliable rubber sheeting 1 Op. cit., p. 160-161. » Op. cit., p. 395. Amer. edit., 1853. 8 Op. cit., pp. 161-175. * Wiener Med. Halle, 1864. ^ Arcliiv fiir Ohrenli., Bd. ii. p. 147. CHRONIC PURULENT INFLAMMATION. 495 employed in the original instrunaent, and also the use of thin gold-plated silver wire for the thicker silver wire. Prof. Gruber's* modification consists in attaching a silk thread to a circular disk of thin rubber sheeting. This instrument is to be considered as having less tendency to irritate the ear, and as being more sightly than one in which the wire projects from the meatus. The inventor thinks that the silk thread is less likely than the wire to tear from the rubber membrane. Dr. A. Hartman,^ of Berlin, has successfully used a new form of artificial drum-head devised by him. It consists in a very thin piece of whalebone 6-7 cm. long and 1-2 mm. wide, scraped very smooth and specially thin at the central part. When thus prepared, yet still retaining a good amount of elasticity, the whalebone strip is wound round with cotton-wool, and then, after its two ends are brought together, it is so fastened as to form a loop. This simple and apparently satisfactory instru- ment is inserted either by the surgeon or the patient into the meatus, and adjusted to the proper place on the remnant of the sound-conducting apparatus. If the loop is made narrower and wound round more thickly with cotton-wool, its action is similar to Yearsley's cotton pellet, but if the loop is broader and not so thickly wound with cotton, it will exercise more pressure on the sound-conducting parts, as suggested by Dr. Hartmann. Mode of Application of the Artifieial Membrana Tymfani. — l^othing seems more simple than the direction to pass a small pellet of moistened cotton down the external auditory canal to the membrana tympani; yet to do this, so that the hearing is improved, is by no means easy. Tlie universal statement of those who have used this simple means with success, is that the pre- cise spot, which being touched and rested upon by the cotton, the hearing is improved, must be gently and often persistently sought for. This is best done by the surgeon at first ; after- wards, intelligent adult patients learn to apply and remove the artificial drum-head whenever it is needed. Children are in no case to wear one, and, perhaps, the artificial membrane should never be worn in one ear if the function of the other ear is good. ' Wiener Med. Presse, 1874, No. 40. 2 Archiv f. Olirenh., Bd. xi. p. 167, 1876. 496 MIDDLE EAR. The cases of perforation of the drum, with little or no dis- charge, a,re the best suited for a trial of the artificial membrana tympani. If, however, there is any hypersecretion from the drum or external auditory canal, it should be removed before the artificial drum-head is applied. Then, when the auditory canal, membrana tympani, and the exposed tympanic cavity are illumi- nated as thoroughly as possible, by means of light reflected from the forehead mirror, the insertion of some form of artificial membrane may be made. Preferably, the earlj" trial should be made with cotton-pellets. One of these may be made, varying in diameter from two mm. to seven or eight mm., and moistened with a little glycerine and water, to which is added by some a little sulphate of zinc. This pellet should then be grasped by the most delicate and slender forceps (see p. 297) and, under good illumination, brought down to the opening in the drum- head. If the stapes is exposed it will be best to place the pellet of cotton at once on it. If the ossicles, or parts of them, are still present and in connection with the stapes, the artificial membrane must be shifted until the proper point of support is reached. But in some, perhaps in many, cases of large perfora- tion of the membrana tympani, no improvement in hearing can be gained after many patient endeavors at placing the artificial membrane. If Toynbee's rubber-disk-membrane, or its modifications, are to be used, the ear must be illuminated in the same way as just indi- cated, but these instruments are inserted by means of the silver wire to which they are attached. The same general rules respect- ing preparatory and continued cleanliness, adaptation of size, and careful manipulatioii for the right spot must be observed here, and in the use of all other forms of artificial membrane. But it is no easy matter to convey by writing the varied, per- haps endless, ins and outs of the manipulation which is required in the successful employment of an artificial drum-head. Each case must be studied, to a great extent, by itself, only intelligent adults must be chosen for a trial, cleanliness must always be observed, and the effects of the wearing of the membrane most carefully watched, for, in many cases, even in the most propi- tious, the artificial membrane, of whatever form, may prove to be an irritant. The latter feature is their worst. IsTo one should push cotton down the auditory canal unless conscious CHRONIC PURULEN-T INFLAMMATION. 497 that he is doing it with every guard for success. The want of an intelligent adaptation of means and ends has led to barren results and to a general disuse of that which might prove of much greater benefit than generally supposed, if it were but pro- perly used. Action of the Artificial Membmna Tym-pani. — That the artificial menibrana ty.mpani greatly improves the hearing in many cases is amply shown by the experience of all aurists. Plow it acts in restoring the hearing has been variously explained. It may be by support, or support and pressure combined, as shown by Yearsley. The latter action would be required .in cases in which there is no visible perforation, for Yearsley believed that the arti- ficial membrana tympani was worn with improvement to the hearing in some cases of imperforate membrana tympani, as did Erhard, of Berlin. Von Troeltsch relates such a case too, of a judge whose hearing was improved by pressure on the imper- forate membrane, but this action of the artificial membrane is considered doubtful by most authorities of the present day. If the hearing is ever improved by wearing any form of artificial membrana tympani against or pressed upon the imper- forate natural membrane, it can only be explained as was done by Yearsley and Erhard, that, by an inflammation in the tym- panum, the incus had become detached from the stapes, and the continuity of the chain of sound-conducting ossicles destroyed, without any accompanying perforation of the membrana tympani. Pressure now exerted upon the natural membrane, and mediately on the ossicles, might bring together the disunited incudo-stape- dial joint, and sound-waves be again transmitted to the brain. The artificial membrane probably does not act by merely stopping the perforation in the membrana tympani, tlius con- fining the vibrations of sound to the tympanic cavity and concentrating them upon the labyrinth, as held by Toynbee.' Moos,^ Politzer,^ and Lucte* believe it to be shown that the benefits arising from the application of the artificial drum- membrane are due to intra-aural, i. e. labyrinthine, pressure. Helmholtz, as quoted by Moos, supposes that, in cases in which the stapes is isolated from the rest of the chain, the artificial ' Op. cU., p. 161, London, 186S. ^ Archivf. Ohrenh., Bd. i. p. 119, 1804. 3 Wiener Med., Halle, 1864. » Virchow's Arcliiv, Bd. 29. 32 498 MIDDLE EAR. membrane takes the place of the natural one ; or, as Politzer has expressed it, the artificial membrane, by virtue of its large surface, is able to convey to one of the ossicles a quantity of vibrations, which otherwise might be lost in their passage towards the labyrinth. Mr. Hinton' believed that "the question whether the artificial membrane operates by closing the orifice in the membrana tympani, or supporting the oasicula, and espe- cially the stapes, is now decided in favor of the latter view," and, accordingly, he made the endeavor to place the artificial drum-head in contact with the head of that bone. Pressure may indeed be necessary in some instances to restore the hearing, especially if the stapes alone of all the ossicula is left and exposed by the great destruction of the membrana tym- pani. But there are cases in which all the ossicula are present and vibratile, the stapes neither isolated from its fellows nor visible through the perforation in the membrana tympani, and the latter largely perforated and greatly retracted. Yet in these cases the proper application of an artificial membrane, especially of a cotton pellet, will improve the hearing. In such cases it is very plain that direct pressure on the already retracted drum-head and chain of ossicles w^ould but increase the hardness of hearing, since the latter disturbance is doubtless due to too much laby- rinthine pressure by the indrawing of the foot-plate of the stapes. The object of an artificial drum-head should be to overcome this undue retraction of the sound-conducting parts and take off the pressure from the contents of the labyrinth. An important function of the normal membrana tympani is to act as a partial antagonist to the tensor tympani. If this function is diminished, as it most undoubtedly is, if a portion of the membrane is lost and its tension overcome, the tensor acts with undue power, the ossicles are drawn inward, their proper swinging interfered with, and the labyrinth-fluid unduly compressed. The cause of deaf- ness is now very plain, and its remedy indicated in overcoming this retraction of the conducting chain. If a pellet of cotton be so adjusted that its upper surface or periphery is gently tucked under the region of the tip of the manubrium, it will be found that the retraction is overcome, the chain of ossicles liberated, and the hearing improves. ' Op. cit., pp. 189-190. CHEONIC PUKULENT INFLAMMATION". 499 By bearing in mind that the ossicles of hearing are but a set of jointed bones, and that consequently their function depends upon neither disjunction nor ankylosis, an explanation is the more readily found for the failure in many cases of pressure only, in the application of the artificial drum-membrane. The Protective Function of the Artificial Membrana Tympani. — In addition to other good results, Yearsley' claimed that a pellet of moistened cotton-wool used as an artificial drum-head, would cure an aural discharge. This function of the artificial membrana tympani is one that has been somewhat overlooked of late. Many an otorrhoea is kept up by the exposure of the tympanic mucous membrane beneath the drum-head, especially in those cases in which the inflammation has commenced in the latter structure. In such cases, by protecting the drum-cavity with a pellet of cotton laid over the perforation in the membrana tympani, a slight discharge which may not have shown any tendency to be checked will cease as soon as the drum-cavity is thus protected. If the perforation be not too chronic, such artificial protection will stimulate the edges of the perforation and favor a rapid closure. This is especially well shown by the use of small paper disks, of sized paper, as first recommended by Dr. C. J. Blake, of Boston. Eespecting the application and results of these paper disks. Dr. Blake writes^ me as follows : — " It consists in treating perforations of long standing, where the vibratory power of the membrana tympani and ossicula is not wholly impaired, by covering the opening with a piece or pieces of sized paper wet with water ; the sizing gives sufficient adhesion. The applications generally improve the hearing immediately, and the paper stimulates new growth from the edges of the perforation, and protects it until repair is effected. The new growth, being protected by the paper, is firm and tense, and serves to assist in the vibration of the membrana tympani as a whole, as a lax cicatrix would not do. The paper is then removed by a natural process of repair and growth of the dermoid coat, which I am now making the subject of fur- ther experiment, showing a provision, as yet, so far as I am ' Op. cit., p. 263. '^ Boston, April 38, 1876. 500 MIDDLE EAR. aware, undescribed, for the protection of the membrana tym- pani." I have tried the use of such disks as Dr. Blake has recom- mended, and have found them of great service. 2. Epileptiform Manifestations and other Nervous Phe- nomena in consequence of Chronic Purulent Inflamma- tion in the Middle Ear. — Chronic suppuration in the middle ear often gives rise to epileptiform manifestations and other nervous phenomena, as irritation of the chorda tympani with permanent facial paralysis, anomalies of taste, and disordered secretion of saliva, alterations in sense and sensibility of the tongue, temporary facial paralysis, alterations in gait, like those in M^ni^re's disease, softening of the ganglion of Gasser, with altered nutrition in the eye, and perhaps, hemiplegia ; but, gravest of all, reflex psychoses may be thus brought on. The epileptiform manifestations occurring as a consequence of chronic suppuration of the middle ear, are to be regarded as reflex phenomena, due to pathological irritation of the sensory nerves of the ear. This is manifest from the record of cases made by Schwartze and Kdppe,' Hughlings Jackson,^ Moos,^ and others. The subjects of these attacks are usually young persons from 15 to 21 years of age, and so far as recorded, are observed to be of the male sex. The chronic suppuration had, in most cases, con- tinued for a long period, was accompanied by repeated attacks of earache, the growth of granulations in the ear, large perfo- rations in the membrana tympani, and foul discharges from the ear. In most of the cases, attacks of intense earache preceded the epileptiform seizure, and in one case, that given by Schwartze, there was precordial discomfort and a well-marked aura in the ear several hours before the fit. In this case, too, the headache was intense, but gradually located itself in the mastoid region, the gaze then became fixed, and twitchings in the region in front of the ear supplied by the facial nerve, would usher in uncon- sciousness. The predisposition to these attacks may last for ' ArcWv f. Ohrenli., vol. v. p. 383, 1870-72. 2 British Medical Journal, June 36, 1869. ' Arcliives of Oph. and Otol., vol. v., 1876. CHRONIC PURULENT INFLAMMATION. 501 several years and then disappear if the disease in the ear is lessened or removed. They occur in conjunction with chronic suppuration in one or in both ears. These seizures have been observed to occur first at night (Koppe and Hughlings Jackson), then in daytime ; they come on at irregular intervals usually, though they may appear as often as two or three times daily, as observed by Kdppe in an idiot boy in whom for ten years both ears had been seriously diseased after scarlatina. In the case of a boy 12 years old, observed by Hughlings Jackson, a chronic discharge set in after scarlatina ; nine months later facial palsy was noted, but this disappeared, and three months later, one year from the beginning of the aural disease, the first epileptoid seizures occurred at night. "It wakes him up, he feels giddy, he loses his sight, and does not know what he is doing. He then goes into the fit, struggles, and foams at the mouth; he does not bite his tongue ; next day he is seemingly well." Causes. — These epileptoid seizures may be due to minute changes in tracts in the brain which give rise to occasional discharges of nerve force, as held by Hughlings Jackson. Although it is not known what cerebral region is affected, it may be found that these seizures are due to instability of those regions of the brain in which disease of the ear sometimes leads to abscess, a view also advanced by the same observer. One thing is very certain, that peripheral irritation in the ear is known to be the cause of a number of previously unrecognized reflex nervous phenomena. In some instances the cause of the epileptoid symptoms has been supposed to be due to irritation of the tympanic plexus from inflammation in the tympanum, as shown by Moos. " This condition of irritation communi- cated itself to the brain and produced there the described attacks, which were favored by an hereditary tendency." In some instances, epileptoid symptoms, or at least conditions of more or less sudden unconsciousness, occur in those aftected with great naso-pharyngeal catarrh and catarrh of the Eusta- chian tube, unattended with chronic purulent discharge from the tympanum. In such cases there are always evidences of increased swelling of the mucous membrane of the mouth of the tube, closure of the latter, and indrawing of the membrana tympani and the chain of ossicles. This, by carrying the foot- plate of the stapes further inward, causes increase of intra-laby- 502 MIDDLE EAR. rinthine and cerebro-spinal pressure, and the unconsciousness. If vomiting occurs, as in the case described by Moos, or if infla- tion of the tympana be eflected, as in a case recorded by Erhard, the attack is ended, for the closure of the tube is overcome in the first instance by relaxation of the mucous tissues, and in the second, by the mechanical effect of inflation, which draws the foot-plate of the stapes from the deep position in the oval "window. Treatment. — It is almost needless to say that the treatment should consist in the endeavor to remove the cause of irritation, especially if these seizures are to be regarded as reflex in origin. Hence, in Schwartze's case, recovery ensued upon trephining the mastoid ; in Kdppe's case by both constitutional and local means. Belladonna and a seton are classed by him under the first head, and under the second he places the treatment of the diseased mucous membrane in the ear. By this means the " vulner- ability and refiex excitability" of the brain and the peripheral irritation are combated. In Moos's case the epileptiform symp- toms were allayed by appropriate treatment of the mucous surfaces in the ear. Even reflex mental diseases may be cured by proper treatment of the middle ear and naso-pharynx, and, in one instance, symptoms of intense headache, sensitiveness of the scalp, and the most melancholic psychical disturbances, were entirely and almost immediately relieved by removing hardened blood-clots from each external auditory canal, where they had remained for years after a fall, in which hemorrhage into, if not from, the ear had occurred. Various Nervous Phenomena produced by Chronic Purulent Otitis Media. — Prof. Moos^ observed a ease of chronic purulent dis- ease of the midddle ears, in which alterations of sense and sensibility in the tongue were produced by the application of an artificial membrana tympani to each perforated drum-head. Since these phenomena were due to pressui-e on the diseased membrana tympani, and mediately on the chorda tympani, an important deduction to be drawn from this case, as Moos states, is that the chorda tympani contains and transmits not only fibres of taste, but also those of common sensibility. Dr. CarP ' Archiyes of Oph. and Otol., vol. i. pp. 140-148, 1869. 2 Archiv f. Ohrenheilk., Band x. p. 153. CHRONIC PURULENT INFLAMMATION. 503 has described phenomena of altered sense of taste, occurring in himself, in consequence of chronic purulent otitis media, which were probably due to destruction of the chorda tympani. The coincidence of hemiplegia with chronic and neglected suppuration of the middle ear has been pointed out in two cases by Roosa,^ and their possible causal relation suggested. The one case was that of a boy, ten years old ; the other, a farmer, sixtj'-two years of age ; though inclined to regard the former case as one of coincidence, Dr. Roosa regards it as probable " that a blood-clot might readily form between the dura mater and the bone, from rupture of the middle meningeal, in the existence of caries of the temporal bone, and hemiplegia be induced by pressure communicated to the motor tract, or, as Mr. Hutchinson says, as quoted by Hughlings Jackson,^ by squeezing the blood from the corpus striatum or thalamus opticus." Paralysis of the Facial Nerve. — Paralysis of the facial nerve is not a common occurrence in chronic suppuration of the middle ear, but if it occurs with necrosis of the temporal bone it is very apt to be permanent. During chronic suppuration of the ear, however, temporary paralysis of the facial nerve may appear. Such attacks of palsy may be referred to temporary congestion and an acute inflammatory process in the middle ear, in addition to the already existing chronic disease. Temporary palsies of the parts supplied by the facial nerve occur in perfectly healthy ears which have become the seat of acute inflammation, and are probably due to congestion, especially in children, and to pres- sure of accumulated secretion, as shown by Gruber.' That such palsies may occur, and probably by an acute process, in a chro- nically suppurating ear, is shown in the following case: — The patient, a lad of fourteen years, stated that he had had a neglected aural disease ever since childhood. Some weeks previous to the time I first saw him, August, 1874, he had been attacked by severe pain in the left ear, after bathing in the sea, at Cape May, where he was employed. He then came to Phila- delphia to obtain relief from the terrific pain in the ear, and ' Transact. Amer, Otol. Soc, vol. i. p. 118, 1870. 2 Reynold's System of Medicine, vol. ii. p. 505. » M. f. 0., No. 10, 1873. 504 MIDDLE EAR. applied to Dr. A. D. Hall, who made a' deep incision over the mastoid process, giving vent to a large amount of exceedingly offensive pus, and relieving greatly the suffering of the patient. The next day Dr. Hall sent the boy to me. I found the lad very weak, with a pulse over 100, forehead bathed with clammy perspiration, anorexia, less pain since the mastoid incision, with considerable vertigo, and an offensive purulent discharge from the ear and the incision over the mastoid process. I found that a probe entered over the mastoid process point-blank, three-fourths of an inch, coming in contact with dead bone. There was also a sinus running from the external auditory meatus, upward and backward, to dead bone in the mastoid cavity. The patient stated that about a year previous to this time a piece of dead bone had worked its way from the auditory meatus, after an attack of pain in the ear. A probe, passed through the sinus in the auditory canal, and another passed through the sinus behind the auricle, could be made to touch each other in the mastoid cavity, and dead bone was felt everywhere in their path. The silver probe passing into the sinus running from the auditory meatus became instantly blackened, and from this sinus crumbs of black and offensive bone were constantly discharged, for several days. At the point in the auditory meatus where the probe entered, there was a large bunch of granulations, which was finally removed by a wire-snare. I could not detect any sequestrum at that time. I placed the boy in the Presbyterian Hospital, and gave him milk-punch and tincture of chloride of iron thrice daily for several weeks, during which period the pain became very much less in the ear ; that which he still experienced was above, and running forward from the auricle. The vertigo disappeared, and the patient was able to take muscular exercise ; the ear became less tender, and permitted all necessary manipulation, but the patient could not lie on the ear in bed. Under this treatment the discharge grew less, and on the 24th of September I extracted, through the opening in the mastoid process, a spongy sequestrum one-half inch square, and then, placing the broad, blunt nozzle of a syringe in the opening, I gently injected a stream of warm water, which washed out a copious amount of large cheesy-looking masses through the external auditory meatus, and some portions of the mass, passing through the Eustachian tube, escaped by the CHEONIC PDKULENT INFLAMMATION. 505 mouth. The masses were composed of large acicular crystals of cholesterlne and fatty epithelial debris, and strongly reminded one of the matter found in cholesteatoma of the ear, as described by Lucse.i The removal of the sequestrum and the subsequent syringing, with its fruitful results, gave still further relief to the patient ; all pain disappeared, and he could now lie on the ear in bed. The sinus behind the auricle closed in four days after the removal of the sequestrum, and in a week from that time the discharge from the ear had almost ceased, and the odor of diseased bone, which had pervaded the patient, had disappeared ; but I could still feel loose crumbs of dead bone lying in the sinus leading from the auditory meatus to the mastoid cells. There- fore, 1 widened the sinus with my knife, cutting from the meatus towards the mastoid process, and inserted a tent in the widened sinus. The tent was reinserted ; for five days crum- bling bone came away, the odor and discharge lessened, and the sinus in the meatus closed October 17, under instillations of a solution of sulphate of copper (3 gr. to fjj). The patient had become by this time quite strong under the constant use of tincture of chloride of iron, and, occasionally, alcoholic stimu- lants. During the night of the 19th of October, four weeks after the removal of the mastoid sequestrum, the patient experienced some pain in the ear, but not enough to keep him awake. On the morning of the 20th, he found that " he could not whistle," and that the tears ran over his left cheek constantly. Facial paralysis became fully established on the left side by the 21st ; so much so that food lodged between the cheek and teeth on the affected side. There was no continuance of pain, and the patient expressed himself as feeling very well. He took, with- out my consent, a situation offered to him, and went to work at- this time, the paralysis disappearing in two weeks, as I learned subsequently, for I did not hear from him until nine months later, when he visited me, and I found him entirely free from paralysis and all aural discharge. He had continued, on his own responsibility, to take the tincture of the chloride of iron until the paralysis had disappeared. ' Arcbiv fur Ohrenlieilk. , Bd. i. No. 1. 506 MIDDLE EAR. Facial paralysis is not of frequent occurrence in necrosis of tbe mastoid process, but if it occurs it is likely to be permanent. Its permanence is due to the erosion of the Fallopian canal, and an oi;ganic lesion of the facial nerve. Its occurrence and sub- sequent disappearance in this case is of interest, and worthy of consideration. It can be explained, I think, as follows : — 1. It is well known that the facial nerve will resist the chronic inflammation attacking the petrous bone, long after the Fallopian canal is destroyed. Gruber has reported a case, with an en- graving, in which the facial nerve was exposed for two-thirds of its length in the tympanum, by necrosis of the Fallopian canal, and yet no paralysis ever occurred {Lehrbuch, p. 541). 2. It is, therefore, probable that, the facial nerve becoming unduly exposed, in the case I have described, by caries of the Fallopian canal, a slight acute inflammation in the middle ear furnished pressure sufficient to produce the functional paralysis. The disappearance of the paralysis was of course due to the absorption of the products of the acute inflammation, from which it may be learned that, alarming as paralysis of the facial nerve is in necrosis of the mastoid cells, it is not necessary when it occurs, to give an unfavorable prognosis, for it may be, as in this case, simply a temporary paralysis, due to pressure from an effusion of fluids, which can soon become absorbed and permit the nerve to res-ume its function. Alterations in Gait. — In connection with chronic suppuration of the middle ear and caries of the petrous bone. Dr. Tedonat' observed peculiar alterations in gait, by which the patient was made to pursue a curved line in walking, and, at the same time, was inclined to turn about his vertical axis from the affected towards the well side. There was at the same time facial paralysis, softening of the ganglion of Gasser, and altered nutri- tion in the eye. Post-mortem examination revealed destruction of the semicircular canals in this case. Irritation of the Chorda Tympani. — Dr. H. D. Noyes^ has given an account of irritation of the chorda tympani produced very probably by disease in the tympanum. The patient, a physician ' Lyon Medical, No. ?6, 1874; also abstract by Schwartze, A, f. O., Bd. x. p. 356. 2 Transactions American Otol. Boc, vol. i. p. 556, 1875, CHRONIC PURULENT INFLAMMATION. 507 33 years old, stated that at the early age of one year and six months, he had an abscess in hie ear, but exactly in what part of the organ he conld not tell. A discharge was thereby estab- lished in his ear, attended with perforation of the membrana tympani, impaired hearing, and constant tinnitus aurium. This condition prevailed until the patient's twenty-third year, when the discharge became somewhat altered in its appearance, and subject to variations in amount. About this time the per- foration in the membrana tympani is supposed by the patient to have closed. About the same time a feeling of " weight, pres- sure, of obstruction, and of distension affected the entire left side of the head." Not long after this the patient states that the chorda tympani nerve began to manifest symptoms of irri- tation. . Morbid sensations of taste were easily excited by pinching the pinna, or by stroking the left side of the face with the tip of the finger. This phenomenon, at first paroxysmal, at last became permanent without any external exciting cause. The flow of saliva has been proportional to the amount of irri- tation. Large portions of it have come from Wharton's duct, but the left parotid gland also secretes more abundantly than the right. Latterly, that is about ten years after the supposed closure of the membrana tympani, facial paralysis was suddenly developed, and has remained constant. When Dr. ISToyes inspected this case he found complete paraly- sis of the left side of the face, including the forehead and orbicularis oculi ; the mouth was drawn to the opposite side ; the tongue was protruded straight, and its mobility was perfect. The external auditory canal was large and straight, and the membrana tympani was nearly flat, tense, white, and thick, not vascular. Seated upon its upper and middle portion was a polypoid growth as large as a pea, firm to the touch, red but not disposed to bleed. " The slightest touch of it, though not pain- ful, excited sensations in the tongue." The auditory canal contained a moderate amount of pus, the Eustachian tube was pervious, and the tympanum easily inflatable ; hearing reduced to contact. The polypus was removed ; the membrana tympani assumed an appearance which did not seem to indicate the presence of granu- lation-tissue in the drum-cavity, and there was no perforation. The discharge ceased, the hearing improved, and the disagree- able head-sensations disappeared. Dr. Noyes states that the 508 MIDDLE EAR, polypus sprang from the handle of the malleus, and his expla- nation of the peculiar symptoms of irritation, is that " this bone had been the seat of chronic inflammation, involving its sub- stance and periosteum, and which had caused the irritation of the chorda tympani." That the cause of the irritation in this case was in the middle ear, as well as in the membrana tympani (malleus), is fully shown by the facial paralysis. It must be borne in mind that the chorda tympani has no part in the nervous function of the tympanum ; it is only on its way in the tympanum from the facial nerve to the tongue (see p. 89). This branch of the facial is, of course, liable to be injured by morbid processes in the tympanum, but it is in no physiological way connected with the functions of that cavity any more than the facial nerve is, as it passes through the Fallopian canal in the posterior part of the same cavity. In many respects the name chorda tympani is unfortunate, as it would naturally sug- gest a nerve of more than ordinary importance to the drum- cavity. Anomalies of Taste and Salivary Secretion in Chronic Purulent Disease of the Tympanum. — The sense of taste, as well as the secretion of saliva may be altered, either diminished or increased, by the presence of chronic purulent disease in the cavity of the drum. Dr. Urbantschitsch' found, in an examination of fifty individuals affected with chronic purulent disease of the tym- panum, that the sense of taste is most highly developed in the region of the posterior wall of the pharynx, the uvula, the arcus palato-glossus, the base of the tongue, and on the mucous membrane of the cheek. In forty-six individuals, anomalies of taste were discovered : only in four cases, of purulent disease on one side, was the sense of taste undisturbed, remaining equal on both sides. In thirty-eight cases the taste was diminished, three times abnormally increased ; in five cases it was in some respects increased and in others diminished ; thus in a case of chronic purulent disease in the right ear the sense of taste for salt and bitter substances was impaired, while it was augmented for sweets and acids. Besides these disturbances of taste, there ' Ueber Anomalien der Geshmaksempfindungen der Speichel Secretion in Folge eitriger Erlirankung der Paiikeuholile, Gesellschaft d. Aerzte in Wien., 31 April, 1876. Wiener Med. Presse, No. 33, 1876. M. f. 0., No. 10, 1876. CHEONIO PURULENT INFLAMMATION. 509 was in twentj^-four cases a blunted sense of touch ; in six cases, though the sense of taste was lost on the affected side, the sense of touch was normal. The causative effect of the purulent disease in the ear is con- firmed by the fact that in many cases the anomalies of taste and touch vanished with the healing of the ear. The chorda tympani and the plexus tympanicns are to be looked to for the explanation of these changes. In addition to the above changes, anomalies in the secretion of saliva have also been noted by Dr. Urbantschitsch ; in one instance where a polypus was situ- ate near the upper part of the tympanum, and in other cases, after yarious powders had been blown into the ear, and the tympanum had been touched by nitrate of silver. In the first instance the stimulation is supposed to have been brought about through irritation of the chorda tympani, and in the other cases by excitation of the lesser superior petrosal nerve, the influence of, which over the parotid was distinctly and directly observed on a patient. These clinical observations of Dr. Urbantschitsch appear to be in harmony with the experiments of 01. Bernard, Schift", Ludwig, and others. Vertigo in Chronic Purulent Disease of the Middle Ear. — It sometimes happens that well-marked symptoms of aural vertigo occur in chronic purulent disease of the middle ear. But I have not found this to be common. The following case will illustrate, however, its occurrence. A. B., age 18 years, student in classics, has had purulent disease of both ears from scarlatina in infancy. On the right side, the membrana tympani is destroyed and the hearing gone. The discharge has become very slight. On the right side, the membrane is perforated. The mucous mem- brane of the tympanum is thickened over the promontory. Hear- ing for moderate speech 4 paces. The discharge is slight on this side. Jan. 1877, the patient states that a day or two ago, while in the lecture-room, he was suddenly seized as never before, with a roaring in the left ear, which was followed by nausea, dimness of vision, giddiness, and faintness, but he was able to leave the room unaided, and went home. While riding home the symp- toms all vanished, and within fifteen minutes he felt quite well. In this case the lesion must have been in the middle ear, but the dizziness, etc., were probably due to an irritation extended 510 MIDDLE EAR. to the Tabyrinth, from pressure by an over-accumulation of secretion in the tympanum. Reflex Psychoses from Chronic Purulent Inflammation of the Middle. Ear. — Quite recently, Koppe' published an account of two cases of reflex psychoses, in one of which the mental dis- order was in all probability excited and kept up by chronic purulent otitis media. In the other case hardened blood-clots in each external auditory canal were very plainly the exciting cause of the insanity. In both of these men, though possessed of an hereditary tendency to insanity, and having been exposed to violence on the head, by falls and blows, the mental disorders, melancholia with tendency to murder and suicide, were entirely relieved by treatment applied to the ears and the chronically inflamed nares and naso-pharynx. 3. Granulations and Polypi. — Purulent inflammation of the middle ear may lead rapidly to the formation of granulations and polypi. These results are, however, the more likely to be found as a consequence of neglected and chronic suppuration of the tympanum. According to my observation, granulations are less common than distinct and solitary polypi. The former may appear quite soon after a purulent process has been estab- lished in the middle ear, and may be attached either to the mucous membrane of the tympanum, the membrana tympani, or to the walls of the auditory canal. Upon inspection of an ear in which granulations have sprung up, the view obtained will depend upon the size and quantity of these growths. When growing on the mucous membrane of the tympanic cavity, they will give to it a roughened and granular appearance, very readily seen if the perforation in the membrana tympani is large, and unobstructed by granulations. The latter may grow on the edges of, or near the perforation, on the mucous side of the drum-head. If granulations have also sprung up in the auditory canal, these may obstruct all further view of the membrana tympani and tympanic cavity. AH granulations should be considered as incipient polypi. Polypoid Hypertrophy of the Mucous Membrane of ilie Middle Ear. — Wendt'' has described under this terra, elevations of the ' Archir f. Ohrenheilk., vol. ix. p. 326, 1875. 2 See reTiew by Von Troeltsch, Arcliiy f. 0., Band ix. p. 119. CHRONIC PITRULENT INFLAMMATIOK. 511 muco-periosteal lining of the middle ear, which occur very frequently in exudative inflammations, and are characterized as exceedingly small polypi in their structure. In rare instances these prominences may assume a fold-like elevation, but more commonly these bodies possess a thread-like, or villous form, as well as a finger-shape. They may also be spherical or ovoid in shape, and are attached either by a long pedicle or by a broad strip to the mucous membrane. Sometimes they constitute ex- tensive lobulated masses. The size of these prominences and villi is very varied, reaching in the larger ones a size of 1 mm. According to their composition, these prominences are shown to be proliferations of the subepithelial layer of mucous membrane. A direct participation in them of the periosteal layer could not be found, nor could a corresponding elevation in it be detected. In the spaces between the network of connective tissue, nume- rous cells resembling lymph-corpuscles were found. The epithe- lium was sometimes cubical, and, in some instances, cylindrical, both kinds often being found in the same microscopic section. The same kind of miniature polypi were found on the inner surface of the membrana tympani by Wendt. The mucous membrane of the tympanic cavity is in any case predisposed to hyperplastic processes, and to the formation of rugous elevations and firm projections. By continued growth and constant enlargement these formations may entirely fill up the tympanum, and, after perforation of the membrana tympani, fill the entire auditory canal. They may also cause flat, bridge- li ke adhesions to form between the membrana tympani, auditory ossicles, and the walls of the tympanic cavity. Cystic cavities may be formed by the union of several elevations with each other. T3y degeneration and exfoliation these polypoid growths may disappear. Spontaneous degeneration is brought about in these oases by deposition of fat, or by hemorrhages ; the vascu- larity of these growth greatly predisposes to the latter mode. The pathological alterations in the veins and lymphatics of the mucous membrane of the tympanum, in cases of chronic purulent discharge with perforation of the membrana tympani, have been described by Prof. Politzer." These changes chiefly ' Studien fiber Gefassveranderung in der erkr^ikteu Mittelohrauskleidung, A. f. O., N. F., Baud i. p. 11, 512 MIDDLE EAR. consist in dilatation. In some instances the veins, especially on the inner surface of the mucous membrane, covering the promon- tory, are greatly widened, very tortuous, with here and there large dilatations. Prof. Politzer concludes that in chronic inflammation of the lining of the drum-cavity, large numbers of new vessels are formed. The walls of the bloodvessels are often opaque and thickened, being infiltrated with a granular exudation, and pig- mented ; or, in other cases, the vessels may be filled with blood- globules, while the walls are thinned at some points, and conse- quently dilated here and there. The changes in the lymphatics of the mucous membrane of the tympanum are much less common than the alterations in the bloodvessels. The altered lymphatics have been found by Prof. Politzer in new connective-tissue growths in the cavity of the drum, when aflected by chronic purulent inflammation. Treatment of Granulations. — Since granulations are very often the result of poulticing in the acute stage of an inflammation in the ear, it should be said again that all such treatment as contains any of the elements of heated moisture, must be avoided in the endeavors to cure granulations in any part of the ear. The ear should be kept scrupulously clean by syringing, to be repeated as often as is necessary to gain this object. Then some form of astringent or caustic should be applied. An en- deavor may also be made to remove, by evulsion, the large granulations, if they can be gotten hold of with convenience to the surgeon and without pain to the patient. But it is not absolutely necessary to thus remove granulations from the ear. They may be pencilled with solutions of nitrate of silver (60-100 gr. to fjj) or with chloro-acetic acid, and with chromic acid in concentrated solutions. These applications are best made by means of a small tuft of cotton on the cotton-holder; great care should be taken to have not too much of these fluids on the cotton, but just enough to paint the growths without caus- ing any surplus of fluid to be squeezed out and run upon other parts of .the ear, as soon as the cotton-tuft is brought into con- tact with the granulations. Prof Politzer has caused granula- tions in the ear to disappear by bringing in contact with them crystals of sesquichloride of iron. The ear is then gently packed with cotton and allowed to remain so twenty-four CHRONIC PURULENT INFLAMMATION. 513 hours. While I have seen granulations thus treated, rapidly disappear, I have also produced some inflammation and con- siderable pain in the ear. Aural Polypi. — The term polypus is a relic of the older no- menclature, which classed nev? growths according to their form or general appearance, rather than their structure. The term must have been suggested simply by the ragged, many footed or many rooted appearance of the surface of a new growth, when torn oiF by a ruder surgical procedure than that in vogue at present. The term " many-footed" of the days of Celsus and others, was analogous, perhaps, to the term " roots" of the pre- sent day, both terms being suggested simply by a physical appearance of that part of the growth once attached to the body. The name polypus \yas originally applied to all tumors which, originating by means of a distinct pedicle from the inner surface of any cavity of the body, projected at last as an inde- pendent growth into the same. Aural polypi presuppose the existence of a purulent process in the ear, attended with the formation of granulation-tissue, the latter being the essential structural nature, in most cases, if 'not in all, of these growths, as shown by Billroth,^ Roosa,^ and others. By a subsequent development of this granulation-mate- rial, aural polypi become independent but benignant tumors. Classification. — Aui-al polypi may be classified into four varie- ties, viz : 1. Mucous polypi ; 2. Fibromata ; 3. Myxoma ; and 4. Angioma. The first three are the classification of Steudener;' the fourth variety has been described by A. H. Buck.* The latter two varieties have been observed only once ; myxoma by Steudener, and angioma by Buck. Mucous polypi are by far the most common in their occur- rence, of all aural polypi. The fibromata stand next in the order of frequency. Mr. T. Whipham found, in an aural poly- pus removed by Mr. Dalby, elements resembling those of round- celled sarcoma.* ' 1855, seeRoosa, op. cit., p. 389. 2 Op. cit., p. 329, and American Medical Times, August 6, 1864. 3 Archiv f. Ohrenh., Bd, iv. pp. 199-312. ^ Transactions Amer. Otol. Soc, 1870. 5 See " Diseases and Injuries of the Ear," Phila., p. 156. 33 514 MIDDLE EAR. Aural polypi vary greatly in their size, shape, color, and consistence. Their average size is that of a small bean ; Steu- dener has recorded one, the length of which was 3 cm., and the greatest width of which was IJ cm. They not uncommonly exceed an inch in length. Their usual shape is more or less club- or pear-shaped, though they may assume a spiral, sigmoid form corresponding in general to that of the external auditory canal. The bony canal is rarely altered in shape by them, but they not uncommonly cause a widening of the cartilaginous part of the meatus. The surface of the long, club-shaped polypi is usually pale and smooth. In some instances, polypi have a red and lobulated appearance, like a raspberry. Their consistence varies from the dense hardness of the fibroid, to the softness of the gelatinous myxoma, the former being the commoner. The surface of the polypus projecting from the meatus may become ulcerated from the action of the secretion, the atmosphere, and the picking of the patient. Epithelium is found on all aural polypi ; ciliated cylinder- epithelium on their inner end surfaces, pavement epithelium on their outer surfaces. It is the latter which finally may resemble epidermis. Aural polypi are almost invariably attached to the mucous membrane of the tympanum, it being a rarity to find them attached to the auditory canal with an imperforate drum; I have seen but two cases in which the latter feature characterized the growth. Polypi may be situated in the mastoid antrum and cells, as has been shown by Eysell,' in the case of a male child four years old, who had died of pharyngeal diphtheria. Dr. Borberg^ found the malleus entirely imbedded in a large polyp removed from the ear. "Whether the polyp grew from the malleus, was not determined. A polypus with a cartilagi- nous base, apparently attached to a bony diaphragm in the external auditory canal, is reported by Dr. 0. D. Pomeroy.' Histology. — Mucous polypi, according* to the investigation of Steudener, consist of a stroma of fibrillated connective tissue of varied arrangement, containing mucin. Lying in this stroma are a few spindle-shaped and stellate connective-tissue cells, with a distinct nucleus. In addition to these are numerous round, ' Archiv f. Ohrenh., Bd. vii. p. 311, 1873. = Ibid., p. 55, 1873. 3 Trans. Amer. Otol. Soc, p. 541, 1874. CHRONIC PURULENT INFLAMMATION. 615 granulated cells with a round nucleus. These cells are either separate or in clusters. The cellular element of polypi is richest in the deeper parts of the growth ; the fibrillated structure com- poses the superficial portions in which the spindle and stellate cells are in excess of the round cells. The surface of a mucous polypus is not entirely smooth, since, in the smoothest, a few papillae will be found projecting far enough into the outer epithelial layers to give this surface a slight roughness. The papillae are usually richest at the inner end of the polypus. In some instances, however, the red, papil- lary structure extends throughout the growth and gives it a characteristic raspberry-like appearance. The quantity of bloodvessels varies in these growths : some- times the vascular supply is very great. The outer portions of the growth may be very sparsely supplied with vessels, while the deeper parts may contain a generous vascular distribution. As a rule, the large vessels run down the centre and send off branches toward the surface. The investigations of Steudener have shown that mucous polypi are covered with cylinder- epithelium on the inner portions, and with tesselated epithe- lium on the more exposed, outer surfaces. Also, that in the central portions of these growths there are glandular structures and cyst-like spaces. The latter were first described by Meiss- ner,' as quoted by Steudener. Fibromata. — These growths are characterized by their tough- ness and their general freedom from a papillary surface. They are covered with several layers of pavement-epithelium. Histo- logically, they, may be said to be formed chiefly of a dense con- nective-tissue stroma, containing numerous spindle-cells and stellate connective-tissue corpuscles, which form an anasto- mosing network. The intercellular substance varies even in the same polyp, as shown by Steudener ; it may be either entirely homogeneous or coarsely fibrillated. The bloodvessels are always much less numerous than in the previously described variety of aural polyp. Hence, their pale color. . They contain no glands nor cystic cavities. They are said by Steudener to be free from mucin, nor has he discovered in them calcareous deposits, as were described by Klotz. ' Zeitschr. f. Rationelle Med., p. 350, 1853. 516 MIDDLE EAR. Myxomata. — In only one instance has a myxomatous anral polyp been described, and that was by Steudener. It was found in the ear of a young man seventeen years old. It was very gelatinous in appearance and consistence. Its surface was covered with pavement-epithelium. The stroma consisted of an entirely homogeneous, gelatinous mass traversed by a delicate network of anastomosing spindle and stellate cells. The gelati- nous mass was composed of mucin, in which were a few lymph- cells. • Angioma. — "Angioma is a circumscribed tumor, made up chiefly of newly-formed vessels, or vessels in whose walls are newly-formed elements." Its occurrence throughout the body is not uncommon, but an aural polypus of this nature has been described only by A. H. Buck. It grew in the ear of a lad, 19 years old, who had suffered for twelve years with chronic puru- lent discharges from both ears. He had also noticed a humming, pulsating noise in his left ear, from which there finally occurred a hemorrhage during the night. The pillow upon which his head had rested, was covered with blood. There was no pain, but oozing of blood continued all day from the ear. The new growth looked dark, and was found to be attached by a long pedicle to the manubrium of the malleus. The pedicle was snipped by Dr. Weir, and the growth examined by Dr. Buck. "The entire mass consisted of bloodvessels, .radiating from an irregularly-shaped central cavity, and separated by a network of fibrous connective tissue holding blood corpuscles in its meshes." Six weeks later a second growth occurred, which is considered by Dr. Buck a proof that an angioma is an independent new growth of vessels, as held by Virchow. Perhaps under this head should come a so-called "venous blood-sac" (venoser Blutsack), observed by Dr. A. Magnus" on the inner tympanic wall, in about the position once occupied by the malleus, in an adult male, who had suffered with otorrhoea since childhood. The new growth was the size of a pea, bluish, opaque, quite smooth, and reflected the light like a glass ball ; when touched by the probe, it felt like a sac filled with fluid. Incision caused the escape of some dark venous blood, and in a few days the sac shrivelled and disappeared. Two rare forms, epithelioma and a clot of blood in process of ' Arohiv f. Ohrenh., Bd. ii. p. 42. CHRONIC PURULENT INFLAMMATION. 517 organization, have been described by Kessel.' The former was seated in the external auditory canal ; the second grew from the tympanic cavity. An Organized Vesicular Polypus, containing the Necrosed Long Process of the Incus. — After the removal of a mucous polypus as large as a pea, from the left ear of a boy seven years old, an inmate of the surgical ward of the Presbyterian Hospital in Philadelphia, I discovered a bright red body, which, at first sight, I supposed was a clot of blood. I gentlj' pulled it out, when I discovered it was an organized vesicular body, contain- ing apparently fluid blood, and a small hard substance imbedded in it. This proved to be a portion of one of the auditory ossi- cles, and upon its being subjected to examination by Prof. H. Allen, of the University of Pennsylvania, it was pronounced by him to be the long process of the incus. The vesicle-like polypus, when placed in a mixture of equal parts of water and glycerine, gave up its blood, but retained a membranous, sac-like appear- ance, though pale and flaccid. Symptoms. — It cannot be said that there is any special train of symptoms which betray the presence of an aural polypus. "Wherever a chronic purulent discharge from the ear has existed a long time, the presence of a polypus may be suspected, but the usual sj'mptoms are only those of chronic otorrhoea. In rare instances, aural polypi may be productive of hemiplegia, as shown by Schwartze.^ In such instances it is supposed that retention of pus, inducing a severer inflammation in the tym- panum, causes a hypersemia of the meninges of the brain. In the case given by Schwartze, there was incomplete hemiplegia on the corresponding side, together with anaesthesia and ptosis, without facial paralysis. Removal of the polypi caused the above symptoms to vanish. Ilemicrania, sensations of fulness, vertigo, retention of pus, nausea, and vomiting have been observed as results of the pres- ence of a large, obstructive polypus in the auditory canal ; but they are not tO be regarded as characteristic of the presence of polypi generally. The vast majority of aural polypi are dis- covered by the surgeon when the patient applies for relief from an aural discharge, the latter being the only symptom. ' Arcliiv f. Ohrenh., Bd. iv. p. 185. 2 Ibid., Bd. i. p. 147. 518 MIDDLE EAR. Spontaneous Detachment of Polypi. — Polypi sometimes become detached without any greater application of force than syring- ing. In some instances they undergo what is termed spontaneous detachment. Schwartze* observed two such cases; one, the detachment of a mucous polypus; another, that of a sarcomatous growth. He also quotes Saissy, Toynbee, and Kramer as having observed similar occurrences. In two instances I have observed' the detachment of small polypi by syringing: one, from the wall of the meatus; another, from a small opening in the posterior-superior quadrant of the drum-head. In the former case, a discharge had lasted for a long time, much to the annoyance of the patient, a lady twenty years old. The discharge ceased, and the perforation closed as soon as the polypus was washed out. In the second case there was no perforation of the drum-head. The small polypus, I am dis- posed to regard as the result of a furuncle in the canal. Treatment of Aural Polypus. — The treatment of an aural polyp begins with its removal. The after treatment of the ear, and especially of the point to which the growth was attached, is as important as removing the polypus. The patient should be told this and enjoined to persevere, after the evulsion of the growth, with the subsequent local treatment of the ear. Unless this is properly and thoroughly done, it is almost useless to remove the polypus, for the patient will at least have undergone some annoyance and pain by the extraction of the growth, and, after a short freedom from it, a new one will spring up. Many patients are deterred from undergoing the removal of an aural polyp because of their fear of a renewal of the growth. This will, indeed, happen if, after the polypus is removed, the point of attachment is not treated, but if the after-treatment is pro- perly gone through with, no fresh polypus will grow from the point of previous attachment, and, furthermore, the tendency to their formation anywhere in the ear, will be removed. The best instrument for the removal of an aural polyp is Wilde's^ snare, or Blake's' modification of it. Wilde's instru- ment consists of a fine steel stem five inches long, and bent in the middle. It is provided with a movable bar which slides on the square portion of the shaft near the handle, which latter ' Archiv f. Ohrenli., Bd. ii. p. 9, 1867. 2 Diseases of the Ear, Phila., 1853, p. 397. 3 Arch, of Oph. and Otol., vol. i. p. 435, 1870. CHRONIC PURULENT INFLAMMATION, 519 part fits over the thumb. At the distal end there is a button- like projection perforated by holes running parallel to the stem, one on each side of it. There are also two small rings at the angle. Through these a fine wire of silver, platinum, or iron, or a strand of Jack-line or fishing-gimp (Hinton) may be drawn to form a small loop or noose at the point, while the ends of the wire, or whatever is used to form the snare, are coiled about the crossbar at the handle. Fig. 74. ^.,«#«^^ Wilde's Snarb. When the instrument is in order, the crossbar may be at any point on its part of the shaft, most convenient to the surgeon. I prefer to have it rather nearer the angle than the handle. By traction on the crossbar, the loop at the end is narrowed and the polypus or its pedicle constricted. Blake's modification of the valuable instrument of Wilde consists chiefly in causing the wire, left bare between the point and the angle in the shaft, to run in a miniature barrel slightly widened at the end and perforated by two holes through whi<;h a wire passes to form the loop. Instead of fastening the free ends of the wire to a crossbar, they are wound in opposite Blake's Wilde's Snaee, with adjustable Paracentesis Needle. directions around a button on top of a short square canule 1 cm. long, which is made to slide smoothly on. the square portion of the shaft. To the under surface of the canule there is attached a ring in the plane of the long axis of the instru- 520 MIDDLE EAR. Fig. 76. Fig. 77. ment, by which traction is made and the loop narrowed. The handle or thumb-piece of the instrument is formed of a ring placed at an angle of 45°, transversely to the shaft. The aforesaid barrel is made to fit into a socket at the angle of the instrument and held in place by a set-screw. Dr. Blake has also planned a paracentesis- needle to go with this instrument, and which is made to fit into the socket at the angle where it is held in place by means of the set- screw. The whole affords an admirable improvement on the original Wilde's snare. Before the snare or any other means is employed for the removal of a polypus, the latter should be carefully examined by a curved probe, in order to determine if possible the point of attachment of the base or pedicle of the growth, I have gained great aid in this search by means of a very simple instrument, consisting of a platinum wire ring 4 mm. in di- ameter, soldered very neatly to a cotton-holder. This is as large a ring as will prove useful ; smaller ones may be used with advantage. By passing this instrument down the well-lighted meatus, the polyp may be very much more easily and thoroughly moved about on its attachment by means of this ring-end than if the growth were touched by a smooth and blunt t i Silver Pkohe for manipitla- nos OF Poiipi. Permanent Pla* TiNUM Wire Loop ON FLEXIBLE SHAFT. probe. By observing on which side the ring glides most easily, or where it meets with a resistance, a' fair, if not a positive idea of the point of attachment of the polypus may be obtained. This instrument is also an excellent means of scraping ofl:' the slough from a cauterized pedicle. CHRONIC PURULENT INFLAMMATION, 521 The Use of the Snare. — With the canal well lighted by means of the forehead-mirror, let the snare be passed over the polyp and brought as near the point of attachment as possible. There is no sensibility in the growth, but the walls of the canal which must be touched in this manipulation are extremely sensitive, and unless great skill be used, the patient will suffer pain. As a rule, the snare should be used without an ear-funnel or specu- lum in the external meatus. "When the snare has disappeared over the polyp, let gentle constriction and traction be made, and then, if the instrument has been well adjusted, the growth, or the major portion of it, will be removed. Some hemorrhage will usually ensue, and all further operative endeavor should be postponed until a clear view of the external canal and the fundus can be obtained. Itard' observed a rapid hemorrhage of four ounces of blood after the removal of a polyp from each ear, and Moos^ records an " alarming hemorrhage from the ear after the extraction of a small polypus from the short process of the malleus, necessitating a tampon." But these are rare occurrences, and are not to be cited to deter from the removal of an aural polyp as soon as it is discovered. Polypus Scissors. — When the aural polyp is very large and tough, and projects from the mouth of the canal, I have found that, even after the wire of the snare is well adjusted, it breaks before it will cut through. In such cases I have seized the Fig. 78. Polypus Scissors. polyp with a pair of curved dressing forceps and, drawing it as far out as possible, have cut off as much as I was able by means of slender, strong, slightly curved, blunt-pointed scissors. The rem- nant may be removed by means of caustics and the wire-snare. ' Maladies de I'Oreille, tome ii. p. 124, 1831. 2 Arch, of Opli. and Otol., vol. iii. p. 107, 1873. 522 MIDDLE EAR. Polypus Hook. — When polypi are quite Bmall, not more than half the diameter of the auditory canal, I have found it very convenient to use a small steel hook, which I have caused to be Fig. 79. Polypus Hook, CHRONIC PUKULENT INFLAMMATION. 523 fitted to a tenotome holder (Gruber's or J. 0. Green's). By this means, which is quite simple and attended with less darkening of the canal than the use of the more cumbrous wire-snare, a small polypus can be lifted from its stem without touching the wall of the canal, and, consequently, without any pain to the patient. The Lever-ring Forceps of Toynbee. — Wilde's snare cannot always be easily adjusted about the polyp if the latter is small ; and, in that case, either the hook just described, or Mr. Toynbee's Fig. 80. Toynbee's " Lever-binq" Fobceps. lever-ring forceps may be used. But this instrument has the great disadvantage of being complicated, expensive, and easily broken or put out of order. In addition to these objections, it is straight, and in its employment the hand of the operator interferes with his vision. But, if a small, slightly attached polypus be caught by the rings of the instrument, the growth may be very easily removed by it. If a polypus extends to the meatus externus and can be easily reached, it may be seized Fig. 81. Forceps for removal of a Polypfs or a Foreign Body situate near the Mouth of the External Auditory Canal. with a small but strong instrument, shown in Fig. 81. But this instrument should never be used in a narrow meatus, nor should an attempt be made to seize with it a polypus situate far down the external auditory canal. 524 MIDDLE EAR. Dr. Jacoby,' of Breslau, has applied the galvano-caustic method to the removal and treatment of granulations and polypi in the ear, with asserted success. But it is a means no surer nor more rapid than the more usual and less complicated methods just detailed, and certainly no less, but perhaps more, painful. Mr. Toynbee proposed to destroy polypi by applying to them potassa cum calce, an unmanageable, slow, and dangerous pro- cedure, and one not at all in practice now-a-days. In the latter part of his career, Mr. Toynbee succeeded in destroying polypi by gentle and continued pressure by means of small pieces of sponge or wool.^ Dr. Edward H. Clarke' has succeeded in causing aural polypi to disappear by injecting into their structure, by means of a hypodermic syringe, a few drops of the solution of perchloride of iron, or of persulphate of iron. Treatment after removal of the Aural Polyp. — A number of suggestions have been made respecting the applications to be made to the diseased ear after the polyp is removed by evulsion. Both the matter and the mode of its application are deserving of the greatest consideration. The best applications are, nitrate of silver, monochloro-acetic acid, and chromic acid, all of which are to be used in concentrated solution. Nitrate of silver in the solid state may be applied by means of a porte-caustique, as recommended by Wilde. But he enjoined the greatest care in getting to the seat of the polypus, and only there, lest the auditory canal be cauterized and inflamed. But at best the "solid stick" is a dangerous application about the ear, and should, therefore, be kept out. A saturated, aqueous solution of nitrate of silver (480 gr. to fSj) may be advanta- geously applied to the seat of the polypus and any surrounding granular surface, by means of a tuft of cotton on the cotton- holder. This will cause no pain so long as it is not brought in contact with the skin of the auditory canal. The remnant of the polyp and the more or less granular mucous tissues in the drum-cavity are not sensitive to it. But even the saturated ' Archiv f. Ohrenh., Bd. v. p. 1, and Bd. vi. p. 235. 2 See "Diseases of the Ear ;" supplement by Mr. Hinton, p. 433. ' Obseryations on the Nature and Treatment of Polypus of the Ear, Boston, 1867, p. 71. CHRONIC PURULENT INFLAMMATION. 525 solution of nitrate of silver may act too slowly, on account of the superficial slough which it forms. Ckloro-aeetic acid,^ as suggested hy Mr. Dalby/ is much stronger, and therefore better. Its application should be made like that of nitrate of silver in solution, viz., by means of a tuft of cotton on the cotton-holder ; or it may be applied, as sug- gested by Mr. Dalby, by means of a camel's hair brush. It should never he instilled into the meatus. Its application at best will cause some burning, which is, however, invariably quelled by a syringing with warm water. In order not to get too much into the ear, it has been my plan to wrap the point of the cotton- holder with a small, firm tuft of cotton, which projects about two mm. beyond the point of the holder and is about two mm. thick. This free end of the tuft is soaked with the acid and then applied to the diseased spot — nowhere else — under the best illumination. This should be applied every day or two until all signs of the root of the polyp have disappeared. I^J'o positive length of time can be assigned over which such treatment may extend, but it must be kept up until every vestige of the growth is removed, or the pain and annoyance of the patient will have been endured for nothing. The caustic may be alternated with strong solutions of sulphate'of zinc (5, 10, or 20 gr. to fgj water), or with the undiluted liquor plumbi, as suggested by Hinton and others. Chromic acid, an escharotic still more powerful than either of the two preceding ones, may be used with great and rapid aid in removing granulations, or the remnants of a polypus, as has been shown by Dr. W. W". Seely,' of Cincinnati. 1 have em- ployed this for the destruction of the broad attachment of the large mucous, and fibroid polypi, but not very often for the destruction of smaller polypoid growths or their attachments. Its application may cause pain, which comes on an hour or more after the root of the polypus is touched, and continues as a dull aching for some time. This gradually wears ofil', if the acid has not been applied too freely, and every possible precaution must be observed to avoid this, and when the patient is next seen it ' I have always ased that made by Merck, of Darmstadt. 2 Diseases and Injuries of the Ear, p. 160, Philadelpliia, 1873. 3 Tr. Amer. Otol. Soc, vol. i. p. 166, 1871. 526 MIDDLE EAE. will be found that a large eschar has formed at the points touched by the acid. Under no other application does the remnant of the pedicle of a polypus disappear so surely and so rapidly. It should be applied in the same manner as the solu- tion of silver or the chloro-acetic acid. A few crystals should be crushed and slightly moistened with water, and, into this concentrated mixture, the tuft prepared as described above, when alluding to chloro-acetic acid, should be dipped and then conveyed to the diseased spot. The latter may be gently brushed or pressed upon by the tuft of cotton thus prepared. The cotton tuft must not contain much acid, nor should that which it carries be too fluid — it should be pasty — for otherwise when the cotton is pressed on the granulation, or the cut surface of a pedicle, an excess of acid woul j^g- cm. for the watch. Respecting convulsions, Itard states that this caiase of deafness^ is very rare in the adult, but very frequent in infancy. When the hearing is lost in the first three or four years of life, it is generally in consequence of convulsions. A number of infants,, who had become deaf at the period of dentition, had, for the most part, ceased to hear immediately after a light convulsion. I have seen a number of mute children who were supposed to- ' Archiv f. Ohrenh., Bd. Yi. p. 33. 564 DISEASES OF THE INTERNAL EAR. have become deaf in consequence of convulsions. Upon closer investigation there was no history of cerebro-spinal meningitis, and T am inclined to believe that the cause assigned by the parents, "fits," was the true explanation of the destruction of hearing. Most writers are in accord that the following diseases produce secondary results in the labyrinth : cerebro-spinal menin- gitis, mumps, and syphilis ; typhoid, intermittent, and other continued fevers ; the exanthemata, and some skin diseases about the head, as erysipelas ; the puerperal state, and its diseases. Hardness of Hearing, and Total Deafness after Cerebro- spinal Meningitis. — Hardness of hearing and total deafness frequently occur as sequelae of cerebro-spinal meningitis, a fact noted by all writers on the nature and course of this fever. Tn a recent epidemic in the Philadelphia Hospital,' occurring in 1866-67, deafness existed to a greater or less extent in sixteen cases. In twenty -four cases observed by Fassett, referred to by Stille, one-half recovered ; but three of them with entire loss of hearing, and one with partial deafness as well as strabismus. Dr. Knapp^ had an opportunity of seeing seventy-one cases of deafness, and fourteen of blindness, mostly in children under ten years of ag^, the result of epidemic cerebro- spinal menin- gitis in New York, in 1872-1873. He states that " the deafness or blindness was, in most cases, first noticed during the first or second week of the fever; in rare cases the deafness set in during the mostly protracted period of convalescence, and, ex- ceptionally, even so late as six months after the beginning of the cerebro-spinal inflammation. In these latter cases, however, some hardness of hearing was observed when the patients had so far recovered that their hearing could be tested. The hard- ness of hearing then increased slowly, and terminated in complete deafness within some weeks or months." In the majority of cases the patients are found to be entirely deaf when they recover their consciousness. During the febrile stage, or during convalescence, it appears, from the observations of Dr. Knapp, that the pharynx and middle ear may be con- 1 See "Epidemic Meningitis, or Cerebro-Spinal Meningitis," by Prof. Alfred Stille, Phila. 1867, p. 71. 2 Deafness from Epidemic Cerebro-spinal Meningitis. Trans. Amer. Otol. Soc, vol. i. p. 448, 1873. PRIMARY AND SECONDARY INFLAMMATION. 565 gested or inflamed. These symptoms may subside, but the hearing once lost is never recovered. This observer also notes that when at the first examination the hearing was found im- paired in consequence of the meningitis, it went on diminishing to total deafness. Dr. Levi' has noticed that the membrana tympani of those becoming deaf in consequence of cerebro-spinal meningitis, may assume a chocolate hue. But I am not aware that this has been noted by any other observer. This peculiar color was seen by Dr. Levi only in the lower segment of the membrana tympani. A symptom noted by all is the deafness of both ears. Accord- ing to Prof. Roosa, both meningitis, and cerebro-spinal menin- gitis may lead to disease of the labyrinth by direct transmission of the inflammatory action. Disease of the middle ear also results from those aflrections, and in many cases these two parts of the ear may be simultaneously affected.' But according to the observations of all, the labyrinth is the part most usually attacked by meningitis. The nature of the lesion is supposed by some to be suppuration of the labyrinth (Lucse, Haller, Knapp), but by others is not thus explained, as there are not enough post-mortem proofs of such a lesion. According to Prof. Roosa, it seems probable, that the seat of the lesion is to be found in the labyrinth proper, and not in the auditory nerve-trunk, for the facial nerve is seldom affected. Von Troeltsch is disposed to. place the lesion in the fourth ventricle of the brain, from which the auditory nerve springs. (Work on the Ear, American edition, 1869, p. 511.) We learn from the work of Prof. Stilld, already referred to, that "the ventricles are the seat of effusion in many cases ;" the nature of this may be serous (Stuart), aqueous (Jackson), purulent (Ames), a limpid fluid (Craig), and sero-purulent (Armstrong and Clarke), while Klebs has found the fourth ventricles and the aqueduct of Sylvius fully distended by thick yellow pus.' According to the investigations of Weber-Liel and Hasse (see p. 143) it is fully established that the sub-arachnoid cavity and the labyrinth are in direct communication, the endo- and peri-lymph of the latter being really part of the arachnoid ' Maladies del'Oreille. Paris, 1873, Plate iii. Nos. 29 and 30. 2 Roosa, op. cit., p. 500. ' Stills, op. cit., p. 81. 566 DISEASES OF THE INTERNAL EAR. fluid. By this means, as Dr. Hasse justly observes, morbid pro- cesses may be communicated from the brain to the ear, or vice versd. 'Now, it is one of the marked anatomical features of this disease that the arachnoid tunic is constantly found altered by the morbid process. Lymph and pus may be found, between it and the brain, as has been fully demonstrated by many post- mortem examinations. It would seem highly probable, there- fore, that in this disease the morbid process is conveyed from the brain to the ear by continuity. In a case observed by Moos, the hearing failed on the third day ; the other symptoms ceased on the ninth day, and four days later the hearing began to improve. It is stated by Moos,* that, in the cases terminating favorably, reported by Ziemmsen and Hess,^ the hardness of hearing began mostly on the third day. After a careful dissection and microscopical examination of the internal ears in a case of cerebro-spinal meningitis, which proved fatal thirty-six hours from its inception, Prof. Lucse^ found the hemispheres, base of the brain, pons, and medulla affected by a purulent inflammation of the pia mater. The microscopic examination traced the purulent inflammation along the auditory nerve to the cochleae. Purulent inflammation of the sacculi, ampullse, and canals of the membranous labyrinth was also found ; along their vessels were masses of pus-cells and free blood-corpuscles ; the vessels were intensely congested and much thickened ; the semicircular canals also showed occasional ecchymoses. The tympanic cavities, except a slight injection, were normal. The fibres of the facial nerve were subjected to microscopical examination, but were found to be normal. In the ampullsS and sacculi were here and there deposits of fat and chalk. Prof. Lucae concluded that it was probable the disease began first in the brain and then passed to the ear. In the same article it is stated that Heller* found, in a case presenting similar disorganization in the labyrinth, purulent inflammation of the middle ears. ' Archives of Opli. and Otol., vol. i. ' Deutsches Archiv fur Klin. Med., 1865. ' Archiv f. Olirenheilk., vol. v. * Archiv f. Klin. Med., Bd. iii. s. 482. PRIMARY AND SECONDARY INFLAMMATION. 567 In some cases there appear to be gaps in the power of hearing ■} thus, speech is heard very imperfectly, while the patient's own step and loud noises in the street are heard comparatively well. The low notes on the piano are not heard in some of these cases. This seems to indicate that parts of the terminal nerve-filaments have been impaired, while others have escaped. When some hearing still remains, hope of further recovery may be enter- tained if the treatment be applied promptly. This has seemed most efficacious, according to some observers, when consisting in the application of the constant electric cui'rent, after Bren- ner's method. The tone lacunae, or gaps in the hearing, were very marked in a young man seventeen years old, whom I examined several years after his recovery from an attack of epidemic cerebro-spinal meningitis. He could not hear the voice of others, but he heard his own. He could easily perceive some sounds, as the cracking of a whip (he was a storekeeper in a rural district), the rolling of heavy carts past his door, etc. His voice was peculiar, and wanting in timbre, like that of the deaf mute. The intellect was good, and his capacity for business well known. Elec- tricity, applied in Brenner's way, made no improvement ; very probably, because applied too late. The staggering gait is usually noted only, at first, in those who have been made deaf by cerebro-spinal meningitis. This sequel was marked in a little boy six years old, whom I saw six weeks after convalescence. The deafness was absolute. In walking, his gait was sailor-like, and he assumed the peculiar attitude, of those on shipboard, in order to steady himself. The staggering gait does not remain, however, as the deafness does. Prognosis and Treatment. — The prognosis is always highly unfavorable. The treatment, certainly in the early stages of the deafness, would naturally be the treatment carried out for the cure of the primary disease. After convalescence from the meningitis, electricity in the form of the constant current, and the administration of strychnia, either internally or hypoder- mically, have been thought to be of value, if there is any • S. MooB, Peculiar Disturbances of Hearing after cerebro-spinal meningitis ; considerable Improvement by the Galvanic Current. Archives of Oph. and Otol , vol. i. pp. 332-340, 1869. 568 DISEASES OF THE INTERNAL EAR. remnant of hearing. But they are not usually attended with satisfactory results, and if the hearing be entirely gone, they are powerless to restore it. Disease of the Internal Ear from Syphilis.— Although the majority of writers upon syphilis, agree that the ear is often afiected in the constitutional form of that disease, aurists have not felt warranted in making such assertions. Prof Schwartze,' who has written the best paper on this sub- ject, states very justly that "the question to be decided is whether the aural diseases which occur in the course of constitutional syphilis, possess distinctly characteristic and ever-recurring ana- tomical and clinical peculiarities. Only by proving that such is the case can it be positively shown that a given ear-disease is of a specific nature." Se further regards the recovery of an aural affection, in consequence of an anti-syphilitic treatment, as inadequate proof of the origin of the ear-disease. After con- sidering syphilitic affections of the external and middle ear, he alludes to sj'philitic diseases of the nervous apparatus of the ear. Six cases are given, four of which were affections of one side only. The characters of these were, intra-cranial paralysis of the acoustic nerve, anaesthesia of the left acoustic nerve, in consequence of otitis interna syphilitica, and paralysis of both acustici, from double otitis interna syphilitica. Some of these cases were benefited in their hearing, by anti- syphilitic treatment, which is considered by Prof. Roosa, in cases observed by him, as establishing the syphilitic nature of the disease of the internal ear. The possible occurrence of syphilitic disease of the internal ear has also been shown by J. Hutchinson, Lucse, Hinton, Politzer, and Knapp. My own experience leads me to consider the invasion of the internal ear by syphilis, as extremely rare. Symptoms, Prognosis, and Treatment. — The chief symptoms are sudden deafness, accompanied sometimes by paralysis of other parts of the body, and by vertigo, nausea, and unsteadiness of gait. Tinnitus aurium is more or less constant, and may, with sensations of fulness and beating in the ear, precede the deafness. ' Arcbiv f. Ohrenli., vol. iv. p. 253. PRIMARY AND SECONDARY INFLAMMATION. 569 Headache is generallj' complained of, the scalp being very often, in such cases, the seat of a cutaneous eruption of a more or less markedly specific nature. The prognosis is not fayorable ; if the syphilitic nature of the disease can be established, the treat- ment, of course, should be an anti-syphilitic one. Disease of the Internal Ear from Typhoid Fever.— In some instances it would seem that the internal ear had been afli'ected by typhoid fever. But the vast majority of cases thus diagnosed appear, on closer investigation, to be diseases of the tympanum. A labyrinth-affection must be considered, so far as it follows typhoid fever, as at most secondary to a tympanic disorder. As I have observed a number of neglected cases of tympanic inflammation following typhoid fever, I am led to conclude that it is in the middle ear, rather than in the laby- rinth, that an aural disease after typhoid begins. A chronic aural catarrh having such an origin is as likely to be incorrectly diagnosed as nervous or labyrinthine, as it is when arising from other causes. By neglect of the tympanic disease, a labyrinthine disorder may be established. Hence, the erroneous impression that the labyrinth has been the seat of the primary affection. Aural Vertigo from Chronic Catarrh of the Middle Ear. — In considering the symptoms of acute catarrh of the middle ear, vertigo occurring in it has been already alluded to, and a pos- sible explanation of it given. It cannot, however, be said that in such cases the vertigo could ever be confounded with the more typical variety found in the so-called Mdni^re's disease. Under the term aural vertigo from chronic catarrh of the middle ear may be included those eases which might be called light forms of M^ni^re's disease. The irritation is doubtless in the middle ear; a reflex action is communicated apparently to the internal ear. But as yet no serious lesion has occurred there. A high degree of deafness is wanting in these cases, and their onset is slow. Since they lack the suddenness of all the symp- toms of aural vertigo, caused by a more direct lesion in the internal ear, they are not very difficult of recognition. Thus, a car-conductor, 28 years old, comes with the statement 570 DISEASES OF THE INTERNAL EAR. that he has noted for a year or more, whenever he is exposed more than usual, and catches cold, he has great roaring in one ear, then dizziness, nausea, fainting, and vomiting — with relief. This occurs in a short space of time, perhaps while at the depot, and he is able to run his car at the appointed time. The drum- head is somewhat opaque, the hearing is impaired, but by no means destroyed. The throat and fauces are catarrhal. Treat- ment of the fauces and Eustachian tubes diminishes the tendency to vertigo. Another case is that of a gentleman, 55 years old. He states that he has been deaf in the left ear twenty years, but became much worse after a severe cold about eight years ago. It was during the latter attack of ear-disease that he noticed the spells of vertigo and nausea, which usually occurred at the table. This probably indicates a high degree of irritability of the pneu- mogastric. As spring came on, and the catarrhal deafness diminished, the vertigo became less frequent, and less intense ; but ever since the attack of increased deafness, each winter finds him suffering with throat and ear disease, and frequent attacks of vertigo with noise in the ear, on the left side chiefly. Both ears are diseased, the membrana tympani being perforated on the right side, but now cicatrized; on the left side, the mem- brane is intact, but opaque and retracted. To this side he refers the cause of the vertigo. The tuning-fork not heard in either ear, through the bones. The hearing for the watch was — 4 cm. right ; 20 cm. left. • 60 ft. The treatment was begun Dec. 4, 1873, and kept up for a month. It consisted in applying nitrate of silver in solution to the mouth of the left Eustachian tube, and in inflations of the tympana by Politzer's method, together with catheterization of the left Eustachian tube. The latter seemed to give most relief, as that tube was decidedly narrowed. There was no attack of vertigo during the treatment, and throughout the winter the patient was free from it. This would seem to show that here the vertigo was caused by catarrhal disease of the middle ear. The hearing was not improved to any great extent. But there are on record a few cases, though doubtless many others have occurred, which have been recognized, but not re- corded in literature, in which all the above-named symptoms of PRIMARY AND SECONDARY INFLAMMATION. 671 labyrinthine disease have existed, excepting the high degree and permanence of the deafness. Mr. Hinton records such cases,* with the statement that the recovery of hearing was perfect. He, therefore, raises the question, " Were they not caused by muscular spasm?" Aural Vertigo with Variable Hearing. — Especially noteworthy is that form of acute aural vertigo in which the hearing diminishes during the paroxysm, improves during the intervals, and finally is recovered, when the paroxj'sms of tinnitus, vertigo, etc. cease to recur. In such cases it is manifest that the direct lesion cannot be in the labyrinth, and the question may be asked, Are not such cases due to a spasmodic affection of the muscular structures of the middle ear? Future investigations may show that such cases are produced by undue inward pressure of the foot-plate of the stirrup, brought about either by a tonic con- traction of the tensor tympani, so powerful as to overcome the equilibrium normally existing between the latter and the stape- dius muscle, or, perhaps, by a relaxation of the latter, thus permitting the normal tensor tympani to act without the antago- nistic counterbalance of the stapedius muscle. As tending to answer in the afiirmative the question thus proposed, I would cite the following case : — Mr. X., 41 years old, single, a stock-broker, was brought to my door in a carriage, on May 8, 1875, apparently in collapse. Upon approaching him, however, he was found to be perfectly conscious, but very pale and weak, and his surface cold and clammy. I was asked to accompany him immediately to his home, and, while doing so, learned from him that he had been suddenly attacked about an hour previous, while attending the meeting of the board of brokers, with sudden and intense tinnitus aurium arui vertigo, with entire inability to stand, and that he had at last vomited; but during all of this most dis- agreeable attack, his mind had been perfectly clear. I may state that the patient's moral character is above the slightest suspicion. I found his pulse about 75, but weak, and he stated that there was still some vertigo, but that the buzzing in the ear had given place to a " stunned feeling" in the head, attended with a boring sensation, which seemed to start behind the auricle, and to ex- tend inward to the centre of the head — a symptom often ■ Questions of Aural Surgery, pp. 361-26S. 572 DISEASES OF THE INTERNAL EAR. mentioned by patients presenting the general train of so-called Meni&re-naanifestations. There was no complaint of altered hearing at this time, but I found that the watch was heard only /iy in. by the affected ear. The patient was put to bed, a little warm brandy and water was given him, as his surface was very cold, and warmth was applied to his feet. In about an hour the vertigo became very much less, the head was more comfortable, and the face lost its intense pallor. Pulse 80. The patient then stated that, four or five weeks previous, he had noticed occasional attacks of slight tinnitus in the left ear. This was increased somewhat by cold air blowing on the ear. Tn a week or two later he observed some dizziness with the tinnitus, and also some con- fusion in hearing, especially during the playing of the organ and the singing in church. The patient had a good musical ear, and he heard all notes sharpened, i. e. heightened in pitch, in the left ear, which, of course, produced subjective discord with what he heard in the good ear. This was also true for the tuning-fork (small a) with which I tested him ; it seemed higher in pitch in the left, the affected, ear. As the tinnitus passed off, however, notes appeared once more to have their true pitch in the affected ear. With the cessation of the tinnitus, and with the return of the power, in the affected ear, to hear notes in their true pitch, the hearing also improved for the watch, rising from ^% in. during the attacks to f^ in. as the paroxysms ceased. This occurred not only once, but repeatedly, and it was also observed that a mantel clock, easily heard by the patient across the room in the affected ear, when unattacked by the above paroxysms, was not heard during the latter. The left membrana tympani was more retracted than the right. The Eustachian tubes were pervious; the fauces, normal. The patient remained in bed four days. On the first day it was observed that rest in a reclining posture relieved the tinnitus and vertigo; on the second day, however, a severe attack came on in bed, and lasted several hours; on the third day an attempt to rise brought back all the symptoms, finally relieved by vomit- ing ; on the fourth day, another severe and long attack occurred ; on the fifth day, the patient observed the " stunned" feeling in the side of the head as alternating with the tinnitus. The PRIMARY AND SECONDARY INFLAMMATION. 573 latter invariably precedes the attacks of vertigo, beginning aa a low and distant singing or ringing, and increasing to a loud roaring, which culminates in the vertigo and nausea. On the sixth day there was no attack ; on the seventh, he felt very much better till 11 A.M., when another severe paroxysm occurred. As a rule, the attacks occurred always in the after- noon or evening ; on the eighth day, there was no attack, but on the ninth there was a not very severe one. Again on the tenth day there was no attack, but at midnight of the eleventh day there was a very severe attack of vertigo, which woke him up. Closing his eyes had always aggravated the vertigo, and now he found that the darkness of his room greatly increased his dizziness, and being entirely unable to help himself he was obliged to call for a light in order to gain some relief from the terrible discomfort brought about by the vertigo. He felt that his whole body was being borne through space. Usually the apparent motion of surrounding objects during the attacks, was around the patient from right, over his head, to left, under him, and up again to the right. The severe attack of vertigo of the eleventh day extended into the twelfth, but the patient did not vomit. On the thirteenth day he had two attacks, but they were short and not severe ; there was no vomiting. On the fourteenth day there were again two attacks, but they Avei-e light, and there was no vomiting. On the fifteenth day there was no attack, but on the sixteenth there was one very light and short paroxysm of tinnitus and vertigo. On the seventeenth day there was none, but on the eighteenth there was a very slight one, which was the last the patient had. The hearing now became normal. The patient had been under intense mental excitement (and his general health had failed) from the time of the financial panic of 1873 to the date of his attack of vertigo. He had also been, in his weakened, nervous condition, obliged by his business to endure the intense and peculiar noise of the brokers' board, and also to strain his ears to catch, and his vocal organs to perform his share of, the bidding which goes on in such places. The treatment consisted in general support with good food, and some alcohol, together with large doses of bromide of potas- sium during the prevalence of the paroxysms. As the latter 674 DISEASES OF THE INTERNAL EAR. diminished in severity and frequency, iron and quinine were given. On the sixth day of the disease, when its spasmodic features were fully shown, twenty grains of bromide of potas- sium were given every hour, which was continued until the tenth day, when but ten grains were given every hour or two. On the sixteenth day the bromide was taken every three hours, and kept up in this way until the paroxysms ceased to occur. The patient then went to Europe, made a short tour, and returned to business in the autumn, about six months after his first attack of vertigo. There has been no severe return of these attacks ; in the spring of 1876, however, when he was under considerable mental ex- citement once more, he had a slight return of the tinnitus, and a tendency to vertigo, but no sickness of the stomach. These symptoms came on just exactly one year after the former severe ones. A few days of rest, and from six to eight grains of qui- nine daily, dissipated all these unpleasant warnings, and the patient was soon able to resume his work. This case of aural vertigo is especially interesting on account of the variable hearing which was so prominent among the symptoms during the disease, and also on account of the recovery of hearing, which ensued as soon as the paroxysms of tinnitus, vertigo, nausea, etc. ceased to recur. These features of the dis- ease would tend to place it either in the list of those of unfrequent occurrence, or else among those the true nature of which is not recognized, and hence undescribed. The case of Mr. X. presented all the prominent symptoms usually found in labyrinthine vertigo, excepting the sudden, total, and permanent deafness. But the want of this latter, symptom would exclude it entirely from aural vertigo due to labyrinthine disease. It was certainly not caused by any irrita- tion in the external auditory canal, and it is entirely out of the question that it could have had its origin in cerebral tumor, because such a supposition is unwarranted by the symptoms, and the finally good result obtained in the case. May it not be, however, classified as aural vertigo of a tympanic variety, in which the immary lesion lay most probably in the muscular structures of the tympanum? As tending to cause such a dis- turbance may be mentioned the intense strain on the vocal organs, as well as on the muscular accommodation of the tym- PEIMARY AND SECONDARY INFLAMMATION. 575 panum, which necessarily occurs among those frequenting the brokers' board meeting, where bidding aloud and listening to bids go on. From the observations of James Hinton,' respecting " laby- rinthine vertigo, sometimes called Meniere's disease," it is also made evident that a perturbed perception of musical notes is a marked symptom of this aftection, g of the third octave being heard twelve notes lower, or as c of the octave below. The note most distinctly heard in this case was g". The following conclusions may also be drawn from the cases observed by Mr. Hinton : — 1. It appears that in some instances the hearing power is "worse at the time of the paroxysms of giddiness and vomiting. In others, the hearing power is at once impaired, and remains so, or is observed gradually to improve. 2. All the marked and serious symptoms may be present, and yet recovery finally occur. 3. Tinnitus in these cases may be due to muscular spasm, either in the tensor tympani, or in the stapedius muscle. Aural Vertigo resulting from Secondary Inflammation of the Labyrinth, — The symptoms generally known as those of Mdni^re's disease, or labyrinthine vertigo, which very pro- bably occur sometimes in consequence of a primary lesion in the labyrinth, most certainly are observed in connection with secondary processes in the internal ear. They are more usually the result of the latter than of the former disease, as can be shown by reference to cases which are recorded in the literature of the subject of aural vertigo, and by observation of those occurring constantly in the experience of every physician. Per- haps most of the cases recorded as M^ni&re's disease come under this head. The diseases to which labyrinthine vertigo is most likely to be a secondary result, are those of the tympanic cavity, as acute or chronic catarrh, or chronic purulent inflammation. Such cases might well be considered, as suggested by Brunner,^ transition-forms of M^ni&re's disease, in which the chronic aural catarrh obviously existed as the primary affection. ' Gny's Hospital Reports, vol. xviii., 1872. ^ Archives of Oph. and Otol., vol. ii. pp. 293-343. 576 DISEASES OF THE INTERNAL EAR. Even the most marked symptoms of so-called M^ni^re's dis- ease may be traced to disease of the tympanum, as is shown in the following case,' which occurred in the practice of Dr. Wm. Pepper, Clinical Professor of Medicine in the University of Pennsylvania, to whose courtesy I am indebted for the oppor- tunity of examining the anral features of the case. Dr. Pepper's notes in the case are as follows : — "JSTov. 11, 1873, John French, aged fifty; a large, heavy, strong man; works in a rolling-mill at Trenton, 1;T. J.; of temperate habits, and without suspicion of venereal taint. En- joyed good health until the spring of 1871. Once he observed that, on walking home in the evening, his gait became irregular, and he pitched awkwardly. In June, 1871, he was suddenly seized in the mill, while sitting down, with a sense as though ' the whole mill was coming down,' and then he immediately pitched forward on the groiand, hurting himself on the flag pave- ment. He thinks he did not lose consciousness. It was five minutes before he could get up, and he was unable to vrork for six months. He noticed immediately, ringing in the left ear, like the roaring of a sea-shell, or sometimes like a little bell. For some months he vomited occasionally, usually immediately before being seized with a dizzy fit. He vomited severely with the first attack. Since that time he has had very numerous similar spells, all occurring suddenly without warning ; he is then seized with sudden, extreme vertigo, seeing all surround- ing objects whirling around and also rising up into the air ; at the same time he feels something moving or running through his head ; the ringing in the left ear increases, and seems to extend upward to the left temple, and, on reaching there, he instantly falls to the ground violently and without any power of controlling the direction of his fall, so that he has frequently hurt himself severely. Still, there is never the least loss of consciousness. He knows he is falling, sees the ground and surrounding objects, and when he reaches the ground usually cries out to any one near at hand that he is not hurt and will get up in a few minutes if let alone. He feels intensely giddy while on the ground, for from two to five minutes; is then able to get up, and, after sitting for ten or fifteen minutes, I Reported by the author to the American Otological Society, 1874. PRIMARY AND SECONDARY INFLAMMATION. 577 feels as usual again, or merely a little weak and shaky. These attacks occur very irregularly as to frequency, severity, hour of day or night, season, etc. Occasionally he passes two weeks without a spell : at other times he has them very frequently. His eyesight is good ; appetite good and regular, with fair digestion. ITeeds a laxative pill occasionally. Sleep is irregular when he does not work. Has been in the habit of being freely cupped (by order of other physicians who treated the case as epilepsy) behind ears and at back of head, having from six to eight fluidounces of blood drawn every month or three weeks ; also dry cups on temples. At first, this relieved the sense of fulness and giddiness, but lately it has not afforded much relief. Patient is not troubled with palpitation of the heart." The treatment consisted in small doses of iodide of potassium, to which were added small doses of digitalis. After being on this treatment for about two months, Dr. Pepper ordered nitrate of silver, in doses of J gr. thi'ice in twenty-four hours. This was taken for two months, and produced apparently the greatest freedom from the attacks of vertigo. But, as the man began to show signs of growing worse, he was ordered to take iodide of potassium (4 gr.) and bichloride of mercury (^Jg gr.), with com- pound syrup of sarsaparilla, upon which mixture he remained for several months. This was succeeded by nitrate of silver, J gr. in pill ; but again he was placed on iodide of potassium, which he continued to take until his recovery seemed assured. On the 11th of November, 1872, 1 examined the ears of this man, and made the following notes, to which others of a later date have been added. The drum-heads presented unmistakable evidences of chronic catarrh of the middle ear. Their lustre had disappeared, and they were thickened. On the left side there was absolute deaf- ness for external sounds, with constant tinnitus, " like the roar- ing of a sea-shell." On the right side, the hearing for the watch gS ft. ; for voice, five paces, confirming the supposition of previous aural disease, based on appearances of the drum-heads. Tuning-fork vibrating on the vertex, heard only on the right, i. e. the better side. Eustachian tube, with difficulty pervious to inflation by the catheter, on the left side. Before the first attack of vertigo and falling, the patient weighed two hundred 37 578 DISEASES OF THE INTERNAL EAE. and forty pounds, but now his weight is one hundred and eighty- five pounds. Formerly, the ringing or " roaring of a sea-shell" moved slowly upward toward the vertex on the left side just before an attack of vertigo ;. but subsequently this was not so marked, and he no longer had this warning of an attack. The next time I saw the patient was 18th February, 1873, three months after the first notes of his case. He looked much better, but felt weak ; still had attacks of vertigo, which were not more severe, however. The tinnitus continued without change, and at this visit I applied the constant electric current of Brenner : 12-16 el. (S. and H.), 2100 R., positive pole, ball-electrode in the meatus of affected ear. This increased the tinnitus. The nega- tive pole was then applied to the aftected ear, the number of elements increased to twenty, and the tinnitus was diminished greatly. , The patient stated that the ringing apparently left the interior of the head, moved to the meatus, and then to the auricle. He subsequently stated that he felt this relief for several hours after the visit. Apparent Motion during the Vertigo. — During the vertigo objects appear to revolve in an antero-posterior direction, in a vertical plane. There is a total loss of equilibrium, but consciousness is perfect. The attacks come and go suddenly, and are followed by a cold sweat. Since the apparent motion of surrounding ■objects seemed to cause considerable distress to the patient, the suggestion was made to him to close his eyes at the next attack, which he did ; but he stated that he felt the motion in the ;alreadj described meridian, just the same. During these attacks, when he feels that he, with all sur- irouuding objects, is revolving from before, backward in a ■vertical plane, he says that he does not seem to revolve any further than a point at which he appears to have been placed on his back, i. e., if he is in a vertical position when attacked, he seems to move backward or to be dragged backward 45°, while objects about him seem to rise from the fioor or ground and revolve in a circle about him. The attacks of vertigo increased in frequency about May 1, after which he had one spell characterized by a,pparent motion in a horizontal plane from left to right, at which time, instead of falling backward, he fell toward the right, with the apparent motion. The first thing which attracts .the attention, in this case, is PRIMARY AND SECONDARY INFLAMMATION. 579 the probability that a so-called chronic aural catarrh existed on the left side before the attack of labyrinthine vertigo. Chronic aural catarrh most surely exists now on the right side, and as the membranse are similar in appearance, each presenting un- mistakable evidences of the aforesaid disease, I believe the left side bad been att'ected by chronic catarrh some time before, which in all probability induced the vertiginous attacks by an extension of disease to the labyrinth, and perhaps to the semi- circular canals. It is also very interesting to note the various planes of the apparent motion experienced by the patient during the attacks of vertigo, and the length and character of the arcs of the ap- parent meridians described, both by the patient's body and surrounding objects. Most of the attacks of vertigo, always accompanied by perfect consciousness, were characterized by an apparent motion in a vertical plane from in front backward, i. e., in the plane of the superior semicircular canal. Once the apparent motion was in the plane of the horizontal or inferior semicircular canaL The apparent motion was always felt, even when the patient closed his eyes, a clinical fact, entirely in hai'- mony with the experimental observations of Mach.' At the time of the attacks of vertigo, the apparent or subjective motion of the patient's body, ceased when he reached the ground, and lay upon his back, although the apparent motion of surrounding objects continued. The paroxysmal nature of the vertigo, with temporary increase of the tinnitus, in an already diseased ear, would seem to indi- cate that whatever the cause of the irritation is, it is not con- stant nor totally destructive of the part chiefly attacked. This case presents a collection of clinical phenomena, partly of a subjective nature, most strikingly in accord with the recent investigations^ of Mach, Breuer, Cyon, and Curschraan, all of which have added facts tending toward the conclusion that, although the semicircular canals may not be devoid of acoustic functions, they seem to possess well-marked functions of presid- ing over the pose of the head, and mediately over that of the entire body. The man who suffered as described above, finally recovered ' Page 154. « Pages 153-156. 580 DISEASES OF THE INTEENAL EAK. from the liability to be attacked by vertigo, but he remains totally deaf in the left ear. Vertigo from Cerebral Tumors. — I have seen lately two cases of tumor in the brain, one proven post-mortem, the other diagnosed as such, but still living, in which the new growth produced symptoms very like those of labyrinthine vertigo. Still, there were points of diflerential diagnosis in these cases, inasmuch as the first, a woman, sufi:ered for many years with most of the distressing symptoms of labyrinth-disease, with the exception that she became sloioly entirely deaf, whereas, as has been said, the deafness of true labyrinthine disease is sudden, intense, and permanent. Farther account of this case will be given when considering sarcoma of the auditory nerve. In the other case, that of a man, the presence of a tumor of the brain has been diagnosed- The patient has some of the symptoms of aural vertigo, but there is permanent alteration of the gait, which is not characteristic of Meniere's disease, nor of any form of aural vertigo originating in the tympanum or ex- ternal ear. Furthermore, he is not very hard of hearing, and though he has constant tinnitus in both ears, and frequent attacks of giddiness, the latter are always relieved by sitting down. Although these cases might be classed under aural vertigo, they are manifestly not cases of labyrinthine vertigo, known as Mdni^re's disease. In fact, they present a train of symptoms sufiiciently distinctive of a morbid growth in or pressing upon the auditory nerve and cerebellum. CHAPTEE II. MORBID GROWTHS OF THE AUDITORY NERVE. The auditory nerve is more frequently the seat of morbid growths than any other cerebral nerve, as shown by Yirchow. Such formations are usually of a fibrous or sarcomatous nature; the nerve may also undergo amyloid degeneration. MORBID GROWTHS OF THE AUDITORY NERVE. 581 Fibrous Tumors. — Fibrous tumors of the auditory nerve may be idiopathic in origin, but more usually they are found in connection with caries of the temporal bone (Gruber). Such growths have also been described by Landiforth and L^vSque- Lasouree, as stated by Moos.' Boyer^ describes a case of what was termed by him "cancer of the occipital fossa." In this instance, the morbid growth invaded and destroyed the auditory nerve, as it did most of the nerves distributed to the right side of the head. The subject was a man, 33 years old. Carr^' observed a case of what he termed cancer of the annular protuberance (pons Varolii) in a man 29 years old ; the hearing was diminished ; at the post-mortem examination, the auditory nerve was found pressed upon, but not destroyed. Sarcoma, — Cases of sarcoma of the auditory nerve have been observed by Voltolini and Fdrster.* In the case given by the former, a sarcoma filled the entire left internal auditory canal, and the auditory nerve was destroyed. In the case observed by Fdrster, a sarcoma as large as a goose's egg had sent oft' a peg-like process into the left internal auditory canal, which was enlarged. Other cases presenting more or less striking symptoms of sar- comatous growths in the auditory nerve, have been recorded by Cruveilhier,° Moos,^ and Boettcher.' The latter denominated the growth observed by him, fibro-sarcoma. Symptoms. — It would appear from the published accounts of the occurrence of this form of cerebral tumor that it is found most frequently in females. The ages of those aftected vary from seventeen to forty-nine years. The duration of the dis- ease, counting from the earliest symptoms, may extend over seven or eight years ; though it may run its full course in a ' Archives of Opli. and Otol., vol. iv. 1874. ' Bulletins de la Society Anatoraique, 9 series, 1834, p. 273. » Ibid., p. 115. ' Wiirzbnrger Med. Zeitschr., 1863 ; see Moos, Archives of Oph. and Otol., p. 484, vol. iv. 5 Anatomic Path., livraison 26; see Kramer " Die Erkenntniss, etc. der Ohrenh.," 1849, p. 858. " Loc. cit. ^ Archives of Oph. and Otol , vol. iii. pp. 134, 171, 1873. 582 DISEASES OF THE INTERNAL EAE. year, as shown in a case recorded by Moos. The cause of this disease of the auditory nerve has been supposed to be due, in some cases, to exposure to cold ; but the most frequent causes, as stated by Virchow, are mechanical injuries to the head and syphilis. The earliest and most striking symptoms are tinnitus aurium and failure in hearing, with more or less dizziness ; these are followed by greater deafness, increased noise and distress in the head, and dizziness on motion, with consequent uncertainty of gait. Then there may come a period of relief and apparent recovery from most of these symptoms, excepting the hardness of hearing. But, sooner or later all the above symptoms return and become aggravated ; the power of controlling the limbs, both upper and lower, fails ; pain in the head is intense and lasting ; the dizziness grows worse ; the patient walks with legs apart, inclining to one side in walking ; and nausea and vomiting may occur. In some cases, facial paralysis occurs quite early in the disease, and there may be anaesthesia of the mucous mem- brane of the nose, as noted by Moos. Wot uncommonly there are sj^mptoms of chronic aural catarrh in the ear corresponding to the side on which the auditory nerve is invaded ; and this has often misled in making a diagnosis. Finally, the general nutrition of the patient begins to fail ; the strength goes ; diar- rhcEa may supervene ; or the patient may sink into coma, and die with or without convulsions. Through the kindness of Dr. Morris Longstreth, Pathologist to the Pennsylvania Hospital, I have had the opportunity of consulting the ante-mortem notes, and of aiding in the post- mortem examination, of the following case of tumor of each audi- tory nerve : — Catherine C, admitted to the medical wards of the Pennsyl- vania Hospital on October 12, 1874. Is an American by birth, but of Irish parentage; is forty-two years old; single, and a seamstress. Has always been well until within a year of her admision to the hospital, when she took a severe cold in the head. She also began to have at this time pain in her forehead and vertex. In the previous June her hearing began to fail rapidly, until she became very deaf. Then there supervened tinnitus aurium, unsteadiness in gait, pain in her limbs, impairment of sensation in the legs, vertigo, and occasional nausea. There MOKBID GROWTHS OF THE AUDITORY NERVE. 583 had never been any loss of power in the limbs, nor muscular trembling. On Nov. Ist, when Dr. James H. Hutchinson* took charge of the ward, it was noted by him that there was a tendency on the part of the patient, when walking, to fall forward and to the right, and that on some occasions she had fallen. Attacks of vertigo could be induced, in the erect position, by closing her eyes ; but she was free from them when lying in bed. There was great pain in the head, generally referred to the vertex and to the forehead over her eyes. The tinnitus aurium continued very intense and annoying ; it was, however, paroxysmal, being worse in the morning. There was nausea, but no vomiting. There was no loss of power in the limbs, nor paralysis of any of the cranial nerves, and no disturbance of sensibility at that time, as noted by Dr. Hutchinson. She was deaf, but not absolutely so. There was no history nor suspicion of syphilitic taint. The physical condition of the Eustachian tubes and tym- pana was found, by Dr. R. M. Bertolet, to be normal. The ophthalmoscope revealed, in the right eye, " indistinct outline of disk; left eye, changes more marked, viz., outline of disk obliterated, veins much enlarged and curved at margin of disk, which is redder than normal, vessels not usually seen being distinctly visible towards its outer side." The subsequent history of this woman shows that she was deafer at some times than at others : the right ear was better than the left (post-mortem examination revealed on the left auditory nerve the larger tumor) ; there was headache, falling, with inability to rise, loss of power to assist herself, and, finally, confinement to bed. There then ensued loss of power over legs, failure of intellect, and diflBculty in swallowing. Muscles of eyeball prolapsed ; pulse and respiration increase in frequency ; cyanosis of face ; involuntary evacuation of urine. Disks of both eyes become indistinct in outline ; there is impaired sensa- tion of extremities ; unconsciousness and death supervene. Temperature, a few hours before death, 106° F. Two hours after death an examination was made by Dr. Morris Longstreth, to whom I am indebted for the following notes : — ' See Phila. Med. Times, May 8, 1875. 584 DISEASES OF THE INTERNAL EAR. The thoracic and abdominal viscera were normal, in general ; the only point to be noted was marked congestion of lung, with a small area of pneumonia in left lower lobe. Only one kidney was found, the right one, weighing nine and a half ounces. The cranium was normal, except the conditions noted below in relation to the internal auditory meatus and jugular foramina. Dura mater was normal, excepting two small spieulse of bone in the neighborhood of the falx cerebri. Arachnoid membrane normal. Pia congested. Cerebral convolutions were flattened, especially at convexity. At the base, the floor of the third ventricle was bulging downward and fluctuating. On the left side, behind the petrous bone, below the tentorium was a large tumor, pressing on the left hemisphere of cerebellum, left half of pons, and left crus cerebri. The nerves springing from the left side of the medulla oblongata, passed on the under surface of this tumor, were flattened by it and somewhat adhe- rent to it. The left eighth pair (auditory and facial) winds inward, forward, and then downward around the tumor, to which it is tightly adherent, and by which it is flattened into a ribbon- like band, appearing transparent. The two divisions of this nerve could not be separated without destroying them, as their consistence is so much reduced. This tumor measured two inches transversely ; one and three- quarter inches antero-posteriorly. It was lobulated, and made up of cysts with solid intervening structure-like partition. Some portions were reddish or pinkish (cystic) ; other parts white, fii-m, and opaque. This tumor extended along with the eighth nerve into the left internal auditory meatus, which was considerably widened. The nerve ran along the forward and inner part of the canal, whilst the projection from the tumor-mass was on the outer and back part of this tube. In the removal of the brain the left nerve with the tumor was cut through at the surface of the petrous bone, thus separating part of the tumor and leaving it within the internal auditory canal. After removal of the brain, there was quite unexpectedly found a second tumor, resting on and adherent to the posterior, surface of the right petrous bone. It was oval in shape ; five-eighths of an inch long, extending along the bone; seven-sixteenths of an inch in its vertical MORBID GROWTHS OP THE AUDITORY NERVE. 585 diameter, and of doughy consistence. It was attached by a sort of pedicle, which was found to extend into the right internal auditory canal. Its consistence was considerbly greater than the larger tumor, on the left side, and the eighth nerve was more intimately united to it. As its presence was not known until after the removal of the brain and the division of the nerves was made, it is not known positively what relation it sustained to the eighth nerve ; but, apparently, the nerve-trunk ran under it to reach the internal auditory meatus. The tumor had, as on the other side, considerably enlarged the porus acus- ticus internus. The bone was not uncovered, the dura mater being still adherent but thinned. The right eighth nerve, from its origin, seemed of normal size and consistence. Tiie cochleae were carefully dissected from the petrous bone by myself, and were prepared for microscopic examination by Dr. Longstreth. When the latter had made the sections, we examined the microscopic conditions most carefully, and the results of that investigation are here given. Microscopical Examination of Left Cochlea. — The tumor on the left petrous bone, as already described in the post-mortem record, had pressed flat the nerves entering the porus acusticus on this side. The new growth had, by pressure, enlarged the opening and bulged into it for some distance, making the internal audi- tory canal funnel-shaped. There was no evidence that the growth extended in the nerve-trunk itself, or that it had reached the fundus of the canal. The canal was occupied by an increase of connective tissue substance toward the base of the cochlea. The walls of the internal auditory canal were covered by a thin periosteum ; the bone was everywhere covered, and presented no erosion or roughness. The shape of the modiolus was normal. The spaces in its substance, which normally are occupied by divisions of the cochlear nerves, show no trace of nerve-fibrillse or ganglia. At one point is seen some exceedingly delicate fibrous tissue ar- ranged in a regular, wavy manner. Many of the spaces con- tain granular and fatty detritus, showing in its midst a few fine fibres, by which the material is held in place in connection with the walls of the spaces ; these fibres take somewhat the form of a network. Others of the spaces are nearly free of 586 DISEASES OF THE INTERNAL EAR. contents, showing sometimes a scant fibrous network ; some- times the space is crossed by a delicate bony trabecula. A number of vascular lumina are here visible, often to be recog- nized by their corpuscular contents ; their size is small and their number not great. The lamina spiralis ossea is normal in shape ; the space between the lamellae of bone contains no trace of nervous tissue, but is occupied by a very fine fibrous material, containing in it much less granular matter than similar tissue in the spaces of the modiolus with which it is continuous. The membrana basilaris is not sufiiciently well-preserved in any of the sections to admit of a particular description. The pieces of it that were examined, however, showed no marked changes. Nothing was seen of Corti's organ. The ligamentum spirale externum of Henle was normal in appearance. The lining cubical epithelium of both scalse was very distinct, and presented a smooth, even surface. The bone at all parts presents, microscopically, perfectly normal conditions. Microscopic Examination of Right Cochlea. — The tumor has grown deeply into the internal auditory meatus, which is dilated from atrophy of its wall by pressure. This atrophy extended markedly towards the base of the cochlea, reaching close up to or into the modiolus, where parts of the tumor in mass may be seen. In consequence, the bony parts between the scalse and the fundus of the internal auditory canal are rendered thin. The modiolus does not 'present the characteristic form, and differs in shape also from that shown in similar sections taken from the opposite cochlea. The alteration is more noticeable in parts nearer the summit, and is partly due to new material extending within the scalse, and partly to a change within the bone itself; whether this is from an extension of the tumor, or from other changes in the bone, was not determined. The bloodvessels were not a conspicuous feature in the modi- olus ; they certainly were not increased in number, nor were their lumina exaggerated. A number of them contained corpus- cular elements. The bone-tissue at this portion was normal in appearance. The ganglionic spaces in the modiolus presented a markedly different picture from those on the opposite side ; they contained a granular, amorphous material or cell-structure. MORBID GEOWTHS OF THE AUDITORY NERVE. 587 No appearance of new fibres, nor indeed of fibrous material, was made out. Near the junction of the lamina spiralis ossea with the modiolus these spaces became larger, and the cellular nature of their contents was more distinctly to be seen. In some sec- tions this cellular material seemed directly continuous with the material deposited within the scalse. The lamina spiralis ossea presented about the same appearance in all the sections, and was unchanged in form. The space between the bony lamellse of the lamina spiralis showed no nervous structure, but contained granular material pretty dense in character. The demarcation between the osseous laniellse and the space itself was very distinct ; the lamellae themselves, except in their rigidity, gave no characteristic bony appearance. They took the staining of chromic acid quite deeply, whilst the granular material between was nearly cleared of color by wash- ing and soaking in oil of cloves. In one or two places only, in all of the sections, was seen, between the lamellae, a trace of fibrous tissue. At the habenula perforata there are no nerve-fibres to be recognized. The membrana basilaris, in sections equally delicate with those taken from the opposite side, is much better preserved in the right cochlea than in the left. It shows sometimes in cross section, sometimes in mass, giving a profile view of some extent of its surface; sometimes it is in connection with the ligamentum spirale, sometimes it is torn loose from this con- nection, and is lying free in the scala ; again, it is crumpled up by the separation of the ligamentum spirale from the outer bony wall. In none of the sections does it appear to have any of Corti's organ in relation with it. In some of the specimens there seemed to be a thickening or a growth developed upon this membrane, as will be spoken of below. Corti's organ, ex- cept in one doubtful instance, is not to be seen, even in a frag- mentary condition, in the preparations. I do not mean to imply that Corti's organ was destroyed or wasted, but simply state the fact that, in carefully treated specimens, no certain trace of it was discovered. The membrane of Eeissner was, of course, not preserved ; only its ends of attachment at the outer wall and at the lamina ossea were represented by a trace of tissue. The membrana tectoria was seen in a more or less fragmentary 588 DISEASES OP THE INTEBNAL EAR. condition in all the specimens, attached to the extremity of the labium vestibulare, while the other end of it was not in connec- tion with any tissue, but floated freely in the ductus cochlearis. In the sulcus spiralis was seen in some specimens a small collec- tion of material, mostly of a granular nature, although sometimes it presented distinct cell-elements, not unlike in appearance those seen at other parts, whose origin from the new growth was un- doubted. Concerning the scalse, it was noted that, when the cochlea was first laid open, a material was seen by the naked eye within them, placed at the junction of the lamina spiralis ossea with the modiolus, and both above and below the lamina, {. e., in both the scala vestibuli and the scala tympani. "With the microscope, this material is very conspicuous in all of the sections examined, and it is more abundant in the scala tympani. In places, there is seen a connection or continuity between the new growth within the spaces of the modiolus and that of the scalae. This material shows an extension of itself along the fibrous covering of the lamina spiralis ossea. In no instance does it extend, how- ever, to the membrana basilar is, although in some specimens there can be seen an uneveness of the epithelial lining of the scalse. At the outer wall of the cochlea, especially at the ligamentura spirale and its stria vascularis, there was more material of nearly the same appearance ; it was never seen in masses, projecting into the cleared spaces, but showed as a roughness and irregu- larity of the lining membrane. This change was chiefly in the ductus cochlearis on its outer wall. The change was not limited merely to the surface, but showed itself in the deeper parts, and the condition was more apparent in instances where the liga- mentum spirale had been dragged and separated from the outer bony wall. The efiect of this new material was to give an appearance of greater thickness to the ligamentum spirale, espe- cially near its union with the membrana basilaris. In some specimens it appeared as though this material extended along the membrana basilaris ; in no instance was it seen in continuity with similar changes on the lamina spiralis ossea, but was co- existent with such a condition. As far as the membrana basi- laris itself was concerned, the change appeared limited to the upper (ductus cochlearis) surface ; although the limitation of the MORBID GROWTHS OF THE AUDITORY NERVE. 589 material to this surface could not be affirmed positively in cross sections, other specimens seen in profile from below showed no material to be present on the under (scala tympani) surface. Ifo good or distinct profile view of the floor of the ductus cochlearis was obtained. No examination with gold solution was made for the presence of nerve-fibres, as this test, as is universally conceded, is value- less, except when carried out in perfectly fresh tissues. In- numerable pigment-masses were seen at the periphery of the sections, and in the modiolus, such as have been seen on other occasions in bone treated with chromic solution and acid for the purpose of decalcification. May not this be the origin of the " bi'ownish pigment, mostly deposited in multipolar cells," de- scribed by Boettcher as occurring in a similar position ? This case, as well as the one about to be given, will furnish many points of guidance in establishing a differential diagnosis between M^ni^re's disease, or labyrinthine vertigo, and the vertigo associated with permanent alteration in the gait, very often observed in cases of cerebral tumor. Feb. 1, 1876. James L., aged 35, laborer. Irishman, was admitted to the wards of Prof. J. M. Da Costa, in the Pennsyl- vania Hospital. The patient admits having had a chancroid ten years previous, but denies all secondary symptoms, and none can be found. Six years previous to admission to the wards he had suffered from malarial fever, for which he had taken large doses of quinia without poisonous eflects, but he had been sali- vated. His health had been good up to seven weeks before entering the hospital, but he took cold at that time from expo- sure, had a severe coryza, and in less than a week he had noticed buzzing in his ears, vertigo, staggering in his gait, but no altera- tion in hearing. When he would sit or lie down, his vertiginous symptoms would vanish. Headache was complained of, and nausea and vomiting had occurred at times. On admission to the hospital, it was found that there was a depression in the skull a,t junction of sagittal and coronal sutures, but no other evidence of violence to the head; he could give no account of the origin of the depression in the skull. Pupils were normal; tongue extended straight; voice high pitched,; patient cheerful; the hearing was found to be for the 590 DISEASES OF THE INTERNAL EAE. watch, on the right side ^ ; on the left side j-°;. There was decided loss of sensation and power on the left side, in arm and leg. Electro-muscular contractility was not impaired; slight loss of co-ordination; he could walk with eyes shut as well as open; stands poorly on one leg, but picks np small objects well. He walks with his legs far apart, tending to the left side, towards which side he easil}' falls. Stands with legs widely separated, for when erect he soon leans towards the left ; the least push would then throw him toward the left side, whereas he was quite firm when pushed in any other direction. Dimness of vision had been noted by patient ; the ophthalmic examina- tion made by Dr. W. F. N'orris showed slight haziness, and striation of the retina in each eye. The urine was high colored, and slightly turbid ; sp. gr. 1021 ; acid ; no albumen ; no sugar ; there were traces of urates. Occa- sionally severe pain in back of head, relieved by bromide of potassium ; vertigo felt only in the upright posture ; feels a subjective, not an objective, uncertainty in walking. No murmur in temporal or mastoid region. Such were the general notes on the ward-book. Aural Notes. — Both drum-membranes were normal in lustre, color, and tenuity; not the slightest congestion in them any- where. Inclination of membranes nearly normal ; left (deafer side) a little more retracted than right. The former, therefore, shows less of a pyramid of light than the latter. Under the pneumatic speculum the left moves more readily than the right membrane. Hearing for watch L.= g'g; K.. = ^. Speech is heard relatively much better than the watch. This would seem to indicate integrity of the cochlea. Patient said he heard a vibrating tuning-fork placed on his vertex in both ears. Eustachian tubes .perfectly pervious, as shown by Eustachian catheter. Hearing was. not altered by inflation of tympanum. Unusually severe sneezing was caused by the introduction of catheter ; he thought his ears buzzed a little more after examination. Vertigo and gait were in no way changed by manipulation and examination. He says he is dizzy whenever, and. only whenever he attempts to walk, and relief is always obtained by sitting down. MORBID GROWTHS OP THE AUDITORY NERVE. 591 There was considerable naso-pharyiigeal catarrh, hut the Eustachian tubes were pervious, as stated. There was no evi- dence of accumulation of mucus in the tympanum, and the external auditory canal was entirely normal. J!^othing, there- fore, was found in either of these parts of the ear to account for the peculiar symptoms in this case. If the man's statement be true, that his hardness of hearing, peculiar vertigo, and altered gait came on at the same time, it would look like a case of so- called aural vertigo, but every well-marked case of vertigo from aural irritation is ^aroarysma^ as to the onset of dizziness, reeling, falling, etc. Some tinnitus, and usually considerable alteration in hearing remain, but the gait is never permanently changed. Pathological Changes. — In a case recorded by Moos,^ the post-mortem examination revealed a tumor of the left auditory nerve, which had caused compression of the pons cerebelli, and of the left oculo-motor, the fifth, and the facial nerves; there was also gray degeneration of the spinal cord. The condition of the organ of Corti was one of fatty change, and partial destruction. In the case of Cruveilhier referred to, there was found under the tentorium cerebelli on the left side, a hard nodulated tumor, which pressed upon the left half of the pons, the medulla, the peduncles of the cerebellum, and upon the cerebellum itself. The tumor hung by a stout pedicle over the posterior surface of the petrous bone. The seventh pair of nerves were destroyed at the porus acusticus. Fibro-Sarcoma. — Dr. Boettcher,^ of Dorpat, writes oi fibro- sarcoma of the auditory nerve as of no uncommon occurrence. But he believes, that the microscopic changes in the labyrinth in such cases have usually escaped attention. Fortunately for otology, the article on the case referred to is offered by its dis- tinguished writer as the beginning of a pathological histology of the cochlea. In the case of a young woman, 21 years old, who died in consequence of the cerebral tumor, the morbid growth was found connected with the common trunk of the facial and the auditory ' Archives of Oph. and Otol., vol. iv. p. 484. ' On Changes in the Retina and Labyrinth in a case of Fibro-sarcoma of the Auditory Nerve. Archives of Oph. and Otol., vol. iii. pp. 134-171, 1873. 592 DISEASES OF THE INTERNAL EAR. nerves. The latter appeared like a white cord, 2 cm. long, and 1 mm. thick, showing under the microscope, medullary nerve fibres in all its fasciculi, but the medullary sheath was nowhere complete. The great denudation of entire fasciculi of axis-cylindersj noted in this case, was considered very extraordinary. All the fibres were colored by chloride of gold, intensely violet. Fatty degeneration was not discoverable in the specimen mounted in alcohol. Part of the tumor extended into the porus acusticus internus. This canal was found dilated in all directions by the morbid growth. This was deemed simply the result of atrophy from pressure. At the bottom of the internal auditory canal, where the tumor was found in contact with the base of the cochlea, the growth bulged toward the modiolus. Ifot a trace of nervous elements remained in the modiolus. An absence of the nerve fibres was also demonstrable in the spiral canal of the modiolus. The lacunoe once occupied by the spiral ganglion were empty. Changes in the Vestibule and Semicircular Canals. — " Here the epithelium, and connective tissue-envelope of the sacculi, and membranous canals were well preserved; large and numerous vessels were observed in the envelope. The macula and the cristas acusticse were unaltered in form, but no nervous fibres were seen to enter these structures." The facial nerve was present from the angle of, and filled the bony canal. The ganglion geniculi was found to be atrophied. There was facial paralysis on the corresponding side. The tumor was classed by Dr. Boettcher among the fibro-sareomata. Glioma. — Briickner^ has described a cerebral tumor, which occurred in his wife, in whom the suspected cause was a fall on the back of her head on the ice, in her thirteenth year. "The first symptoms of the disease were noted about three years later, in the form of uncertainty in the use of her upper and lower limbs. Four years before her death, which occurred when she was twenty-eight years old, a diminution of hearing upon the left side was accidentally noticed, with giddiness and catarrh ' Berliner Klin. Wochenschr., No. 39, 1867. MORBID GROWTHS OF THE AUDITORY NERVE. 593 of the middle ear ; and, finally, complete deafness."' A singu- lar phenomenon in this case was that, three or four months before death, a whirring, like the placental murmur, could be heard by applying the ear directly to the patient's left temple ; once, very feebly on the right temple; the sound ceased to be heard by herself or others after she had taken large doses of iodide of potassium. The left auditory nerve was found to be entirely obliterated, and in its place there was a large glioma. The Labyrinth in Ileo-Typhus. — By post-mortem exami- nation, Prof. Moos^ found in the labyrinth of a soldier who had died of ileo-typhus or typhoid fever, a large quantity of lym- phoid corpuscles on the lamina spiralis membranacea, on the sacculi and the ampullae. Some of these had undergone fatty degeneration. They were most numerous in the region of the point of entrance of the cochlear branch of the auditor^'- nerve, into the labyrinth. Fatty metamorphosis of the organ of Corti, closely resembling that found in sarcoma of the auditory nerve, may also be the result of hemorrhages into the cochlea, as shown by Moos.^ Amyloid degeneration of the auditory nerve has been fully described by Forster* and Voltolini,' and its occurrence corrobo- rated by Lucse and Politzer. It appears to be of common occur- rence, as stated by G-ruber. Corpora Amylacea. — Certain bodies found in the semicir- cular canals of man, are considered by Lucse" to be of a patho- logical nature and aa peculiar to the adult. It is claimed that they are never found in the new-born child, but that they are produced by local disturbances or by general systemic diseases in advanced life. These products, or amylaceous structures, are found in cases ' Moos, Archives of Oph. and Otol., vol. iv. 2 tJeber die Anatomischen Veranderungen des Hautigen Olirlabyrinths bei Ileo-Typhus. Verhandl. d. Naturwiss. Med. Vereins zu Heidelberg, v. 169 ; also M. f. O., No. 2, 1873. 3 Archives of Oph. and Otol., vol. iv. pp. 497-503, 1875. •• Atlas of Pathological Anatomy, p. 86, 1854. 6 Virchow's Archiv, vol. 33, p. 114, 1861. s Virchovr's Archiv, Band 54, Heft 1. 38 594 DISEASES OF THE INTEHNAL EAR. of gray degeneration of the spinal cord, typhus, tumor of the brain, tuberculosis, Bright's disease of the kidneys, peritonitis, chronic ulcer of the stomach, and in those in whom an aural disease has been present up to the time of death. It is further- more asserted that these bodies are never found in the lower mammals, birds, fishes, or amphibia, which is considered by Prof. Lucse as additional proof of their pathological nature. So far as the occurrence of these bodies in the diseases men- tioned above is concerned, it may be said, as Riidinger has already suggested, that it is rather x>ost hoc than propter hoc; for it is just such diseases which supply material to the anatomist for his investigations; and hence, if they are normally present, these subjects in common with all others should present ex- amples of the so-called corpora amylacea. Hallucinations of Hearing in the Insane. — Hallucinations of hearing are common in the insane. They are very often not dependent upon any aural disease ; though in many instances they seem to have been induced by a disease in the ear. In some instances, after the removal of a plug of cerumen or other morbid cause of the hallucinations, the latter have been dimin- ished, but not entirely removed. They have been noted in women afl&icted with nymphomania. In such, the hallucination has been the supposed hearing of a man's voice, which, as Dr. 0. D. Pomeroy' has observed, indicates rather a disease of the nervous system than of the ear. Still, whenever insane patients complain of subjective hearing, their ears should be examined, for a removal of the aural irritation, if one should exist, may relieve, if it does not entirely banish the hallucinations. Prof. Moos'" found an enlargement of the bulb of the jugular vein in the right petrous bone of an insane man, who had suf- fered with the most intense and distressing noises in the ear, and to escape which he finally committed suicide. Prof. Moos thinks that when blood passed from the lateral sinus into the enlarged bulb of the jugular vein, vortices must have been formed in the current, and in consequence thereof a ' Hallucinations of Hearing in the Insane, Trans. Amer. Otol. Soc, vol. i. p. 184, 1871. 2 Archives of Oph. and Otol., vol. iv. pp. 479-482, 1875. MORBID GROWTHS OF THE AUDITORY NERVE. 595 blood murmur must have been produced, which on account of its nearness to the labyrinth must have been heard as a loud subjective noise. In this account, allusion is made to the theories of Oppolzer, Friedreich, and Boudet. They explain the tinaitus of chlorotic patients as a subjective perception of the bruit de diable, because it disappears usually on compression of the carotid. Prof. Friedreich has not found this rule invariable. I have known an insane woman to be distressed and made worse by the imagined hearing of an infant's cry. As she could not stop the imagined cry of pain, that of her own child, whose death had caused the insanity, the brain symptoms became markedly worse. The ear was not examined in this case. An insane man, with normal ears, once or twice presented himself for treatment to gain relief from sounds of a peculiar kind, " spirit voices," which he seemed to hear in the air above his head. These sounds were not always disagreeable to him, but were annoying by their long continuance, and by their preventing sleep. The ears were carefully examined in this case, but nothing whatever abnormal was found in them. Nervous Deafness. — Strictly nervous deafness must be re- garded as among the greatest rarities. Among the peculiar nervous symptoms which sometimes attend acute articular rheu- matism, may be found a form of acute deafness, which might be called nervous. At the same time hysterical symptoms may manifest themselves. Dr. S. Weir Mitchell has called my attention to what he terms hysterical deafness. In the case of a young woman he observed a deafness, which would apparently come and go during conversation. At other times, the patient would fail to hear under circumstances in which she had but a short time before appeared to hear well. I have never observed such a case, but I doubt not that such should be classed under hysterical phe- nomena. Moos' observed a case of intra-cranial disease after acute rheumatism, with peculiar nervous phenomena, combined with complete deafness for noises, musical tones, and speech. The ' Archives of Opli. and Otol., vol. i. p. 464. 596 DISEASES OF THE INTERNAL EAR. patient was communicated with hj writing, for several weeks. Under the use of the constant electrical current, the patient entirely recovered. When it is remembered that there is a close connection between acute articular rheumatism, chorea,' and meningitis, it can be understood how the hearing might be either temporarily or permanently affected by the rheumatic poison. Total deafness may be the result of a fall brought on by dizziness from causes other than aural. This fact must be care- fully borne in mind in estimating the part the ear may have had in the production of the primary disease, as is shown in a case given by Moos,^ as follows : A soldier suddenly fainted and fell, without any previous warning. Upon the return of conscious- ness, he was found to be entirely deaf to all sounds. Subjective noises were noticed at first, but they gradually ceased. Dr. Moos was led to believe that, in consequence of the fall, an extravasation of blood took place at the origin of both auditory nerves ; in no other way can the total and sudden deafness be accounted for. Fracture of the bone would in all probability have produced death. The precise seat of the extravasation was supposed to have been in the medulla oblongata, at the point of origin of the deep root of the auditory nerve. Respecting diagnosis and prognosis in this and similar cases. Prof. Moos says: "In cases of considerable impairment of hear- ing, or total deafness, no prognostic value can be attached to auditory sensations occasioned by the application of the constant current. If, however, a repeatedly applied galvanic current of such intensity as will cause twitching of the muscles of the face and the extremities, fail to produce sensations of hearing, we may infer the existence of complete paralysis of the auditory nerve, and form an unfavorable prognosis." The Eflfects of Quinine upon the Ear.~The question is often asked, Does quinine cause ear-disease — Does it make one permanently deaf? And the answer, so far as I am able to give it, is always in the negative. I say this with all reserve, and ' Germain See ; De la Choree, Paris, 1850. 2 Archives of Opli. and Otol., vol. ii. pp. 199-203, 1871. MORBID GROWTHS OF THE AUDITORY NERVE. 597 with the full knowledge that many high authorities' have taken an opposite view, and have, as they believe, adduced proof of its correctness. Wherever quinine has been supposed to be a cause of deafness, usually it can be shown that the disease for which the drug has been given is the underlying cause of the failure in hearing. It is most positively known that malarial diseases — chills and fever — for which large doses of quinine are usually given, are frequently followed by hardness of hearing and deaf- ness, whether quitiine be given or not. But yet malarial disease often runs its most virulent course, and quinine is also given in large doses, without the production of deafness. In the case of a young physician, cited by Dr. Roosa as one of aural disease probably caused by quinine, there was not only history of throat- and naso-pharyngeal disease, but also of mala- rial taint. There were also intense neuralgia and general de- bility, just such symptoms and diseases as would be treated by quinine. The supposed causative connection between the giving of quinine and paroxysms of pain in the ear must, I think, be regarded as occurring after, but not in consequence of, the administration of one of the most valuable drugs the physician can resort to. A great many patients think they are deaf in consequence of taking quinine ; but in all such cases which I have observed, there was most evident cause for the deafness, in catarrhal disease of the naso-pharynx and throat, which antedated the administration of quinine. In many cases, the diseases for which the quinine had been given, as puerperal diseases, con- tinued fevers, chest-diseases, etc., were much better known to be causes of deafness than the taking of the drug in question. It is admitted that quinine will cause ringing in the head and ears as well as temporary hardness of hearing. It is sup- posed to be due to congestion of the nerve. But were quinine injurious to the ear, its ill effects could be plainly seen when given to those affected with aural disease. On the contrary, a partially .deaf person may be made temporarily deafer, but when the quinine is no longer taken, the hearing returns to its ' Dr. Roosa, Trans. Amer. Otol. Soc, vol. i. p. 276; also vol. ii. p. 93 ; also M. M§lier, M^moires de I'Acadeinle Eoyale de M^decine, p. 722, quoted by Drs. Roosa and Hammond. 598 DISEASES OF THE INTERNAL EAR. relatively normal point. Furthermore, some kinds of tinnitus aurium, viz., from anaemia and debility, are stopped by taking quinine. Of course, poisonous doses of quinine, like any other morbific element introduced into the blood, might have a bad effect on the nerve of hearing and perhaps on the sound-conduct- ing parts too. But, so far as my experience goes, all necessary doses of this useful drug can be given in any case with impunity whether the ears are aftected or not. And I base my belief on the observation of about 1600 cases of ear-disease in Philadel- phia, besides upon the large numbers I have seen in the clinics of Europe. In the later paper by Dr. Roosa,^ upon his investigations into the effects of quinine upon the ear, made upon and in conjunc- tion with Dr. Hammond, it would appear that sometimes con- gestion of the external ear occurs as the result of the administra- tion of this drug. Dr. Eoosa believes " that tinnitus aurium and impairment of hearing following the use of quinine, depend upon congestion of the ultimate fibres of the auditory nerve in the cochlea, and that the redness of the drum-heads is merely an index of the former condition." But it does not yet appear to be established that the adminis- tration of quinine does produce disease of the sound-conducting parts, i. e., of the external ear or drum-cavity. ' Transactions American Otolog. Soc, vol. ii. p. 93. SECTION VII. DEAF MUTES AND PARTIALLY DEAF CHILDREN. CHAPTER I. METHODS OF RELIEF AND EDUCATION. DEAB-dumbness may be either congenital or acquired. In some instances the two forms may be united, as shown by Moos.' Recent investigations by Luys^ into the structure of the central nervous system, have led him to locate the sense of hearing in the posterior lobes of the cerebrum, in which theory he believes himself further strengthened by the condition of the brain in two deaf mutes. In one, an intelligent man 72 years old, who had died of pneumonia, some of the inner convolutions of the posterior lobes of the cerebrum were atrophied, yellowish, and at points cede- matous; on the right side these changes were more marked than on the left side. The white fibres of the brain, which connected these parts with the optic thalami, the point deemed by Luys the centralizing area of all outward nervous impres- sions, were traversed by growths of connective tissue, and had undergone amyloid degeneration. At the optic thalami only, the posterior nuclei were infiltrated by serum, soft, and amyloid. The gray substance about the aquseduct of Sylvius presented a similar condition. The remainder of the brain was normal, but the acoustic nerve was atrophied at spots. ' Archives of Oph. and Otol., vol. ii. p. 138, 1871. 2 Contributions & I'^tude de li5sions intrac^rfibrales de la sui-di-mutitd, Ann. des malad. de I'oreille, 1875, pp. 313-333. See A. f. 0., B. xi. p. 179 ; abstract by Kuhn. 600 DEAF MUTES AND PARTIALLY DEAF CHILDEEN. In another mute, 14 years old, a similar condition was found. Dr. Kuhn states that Hunter^ has also described quite extensive changes in the optic thalami in a case of absolute deafness. The congenital form of deaf-dumbness has generally been considered as the commoner occurrence. In comparatively few instances its existence has been proven by post-mortem exami- nation to have been due to malformation of the internal ear or of parts of the brain. Knowledge as to its true nature and cause would be greatly enhanced by more thorough records, in deaf and dumb institutions, of the condition of the ear during life and a complete description of its state, as revealed by post- mortem investigation. Beard and Eoosa^ have placed the average of congenital deaf- muteness at about sixty-one per cent, of all cases of mutes ; Wilde placed it at fifty per cent. By a reference to the reports of the last three years, of the Pennsylvania Institution for the Deaf and Dumb, Philadelphia, it will be found that one hundred and thirty-seven children were admitted within that time, who lost their hearing from fever and other causes, and had in consequence become dumb. They constituted two-thirds of the entire number of admissions, thus showing that, in this institution at least, congenital deaf- muteness is considerably less frequent than the acquired form. It is held by Von Troeltsch that an hereditary tendency to deaf-dumbness exists in some families. Within a very short time I have seen a family in which four children were deaf mutes. But it appears from the investigations of modern times that the acquired form of deaf-muteness is by far more gommon than was once supposed. In many instances the history of a case points to a destruc- tive disease of the sound-conducting parts in the tympanum and also in the labyrinth, at a very early period of extra-uterine life. But even in these lamentable cases, to state that the sufferer came into the world endowed with the power to hear, is often a grain of comfort to parents who cannot bear to regard a child as congenitally defective. Every physician may be called upon to decide whether a child is deaf and dumb, and if it be, to suggest, if not a cure for the ' Transactions of Medico- ohirurg. Soc, London, 1825. 2 Op. cit., p. 515. METHODS OF RELIEF AND EDUCATION. 601 deafness, at least a plan for the proper education of the little patient. In very young children it cannot be readily decided whether total deafness exists or not. But whether a child is totally deaf or not, it may be too deaf to learn to talk by hearing others speak. It is not unusual to find pupils in deaf and dumb insti- tutions, who can hear loud sounds, and even the human voice when shouted into their ears. Without deciding, therefore, that the child is entirely devoid of hearing, a physician may find, on examination, that it is too deaf to learn to talk in the ordinary way, in which case he should advise its parents to arrange for its proper education in another manner. Advice is rarely sought respecting the aural condition of a child until, having come to an age when most children begin to use words intelligently, it arouses suspicion as to its peculiar defect, by showing no evidence of learning to talk. It may be stated by the parents that they believe the child was, at one time, able to talk, because it has spoken such words as " mama or papa ;" but the mere utterance of these elemen- tary sounds of speech, which may occur entirely involuntarily in extremely young infants, is no evidence that the child hears. If there is reason to believe that the fears of the parents respect- ing the deficiency in the child are well grounded, a thorough examination of the ear should be made. If nothing abnormal can be discovered in the external or middle ear by inspection, or by inflation, and if the child has reached an age when it ought to talk, it may be concluded that it is too deaf to learn to talk by hearing others, and that, in all probability, its deaf- ness cannot be relieved. If, however, on inspection an obstruc- tion or deficiency in the sound-conducting parts is found, or if a suppuration exists in the ear, all such interferences to hearing should be combated in the ways already named in a previous part of this work. Without doubt some cases of deaf-muteness might be prevented by an early treatment of the local symptoms. There is every reason to believe that very young children may be the subjects of chronic aural catarrh, which comes on insidiously, producing in them progressive hardness of hearing. While the same grade of hardness of hearing which has resulted in them, would not seriously impede an adult who had already 602 DEAF MUTES AND PARTIALLY DEAF CHILDEBHr. learned to talk, a child thus affected is too deaf to learn to talk by hearing others speak. I have found that mute children, in whom the membrana tympani showed signs of chronic aural catarrh, at the age of four and a half years, could hear the voice probably well enough to be taught to speak, when addressed by means of an ear-trumpet, if it were possible for any one in their family to undertake so laborious a method of instructing them. Beyond combating a disease already firmly seated in the sound-conducting parts of the ear of a deaf mute, the surgeon can do nothing. If the changes in these parts have not been of a deeply organic nature, the hearing may be benefited, and a portion of it re- tained. But if these changes have been of a structural nature, or have extended to the internal ear, little, if any, benefit to hearing can be hoped for. The only plea for treating a suppu- rative disease, which is not uncommon in deaf mutes, would be to prevent the fatal results of neglected otorrhoea. While it is by no means the province of this book to describe or advocate any particular method of instructing deaf mutes, a word may be said respecting the methods which are usually employed. In all civilized communities there are provisions for the proper corporeal, moral, and intellectual training of the deaf and dumb. Deaf mutes naturally communicate with each other by means of a sign-language which, in most respects, is common to all nations. This method, scientifically elaborated, is termed dactylology or finger-talking. Until within a few years it has been the usual mode of instructing deaf mutes in England and the United States. The G-erman system of educating mutes by teaching them to understand and use language, by observing and imitating the articulate speech of others, in which method the pupils are most positively forbidden to use the sign-language, has been employed for a long time in most of the countries of Continental Europe. An accurate and succinct account of this so-called German method may be found in a most interesting brochure on the subject, by Mr. W. B. Dalby.' • ■. ' " Education of the Deaf and Dumb by means of Lip-reading and Articu- lation." By W. B. Dalby, F.R.O.S., M.D. (Cantab.), London, 1872. METHODS OF EELIEF AND EDUCATION. 603 Instances of mutes learning to understand what was said to them, by watching the lips of the speaker, are on record from the beginning of the eighth century, when John De Beverley, Archbishop of York, thus instructed an adult mute in the Christian religion, to the middle of the seventeenth century, when the book of John Bulwer induced John Wallis, of the University of Oxford, and William Holder, Canon of Ely and St. Paul's, to devote themselves to the education of the deaf and dumb by means of lip-reading. It has also been practised in Spain and Italy between these two periods above alluded to, England, however, appearing to have been the pioneer in this mode of instruction, though among the last to give it an extended trial. Heiniche, of Germany, in the middle of the eighteenth cen- tury, seems to have been the next notable advocate of instructing deaf mutes by lip-reading and articulation. It is now univer- sally employed in that country. In order to accomplish education by this moans, the child must possess ordinary intelligence, normal vocal organs, and it must begin its studies in this direction at not later than seven years of age. The average length of time which must be given this course of education before the pupil can understand and communicate with any one he may meet, is about eight years. But great attainments are thus made. It is a well-known fact that English mutes thus instructed have learned to talk not only their own language, but the French and German, and have become brilliant ornaments to society. In Vienna, I have frequently conversed with deaf mutes in theip own language, who attained such accuracy of observation of the lips of the speaker that they immediately perceived my foreign accent. Bell's System of Visible Speech. — There is another means of teaching deaf mutes articulation, and that is the system of visible speech, or phonetic writing, of A. Melville Bell. It is based on the physiological action and position of the vocal organs during speech, and is practically an alphabet of sounds, in which the symbols inform the child how to place its lips, tongue, and palate, and thus produce a 'vocal sound. It was successfully employed in England in 1869, since which time it has been introduced in several institutions in this country. 604 DEAF MUTES AND PARTIALLY DEAF CHILDREN. Lip-reading and visible speech may become of great value in the education of children who have become deaf after having learned to talk in the first four or five years of their life. Chil- dren of this age, who become entirely deaf in consequence of scarlatina, cerebro-spinal meningitis, or of any disease, will often voluntarily cease to talk, and thus, forgetting how to use speech, become mutes. I recall the case of an intelligent boy, six years old, who, becoming entirely deaf after cerebro-spinal meningitis, showed the greatest reluctance to talk, and relapsed at once into making signs, with the result of becoming mute, l^o matter how deaf a child may have become after it has learned to talk, it should be coerced to continue the use of speech, and discouraged in the use of signs. His conception of what speech is and his ability to use it are invaluable aids in his further education by means of lip-reading and articulation, or by visible speech. Partially Deaf Children. — There is a large class of children, who are by no means deaf mutes, yet who hear so badly as to be under constant disadvantages at ordinary schools. Such children, on account of their poor henring, are often imposed upon, both by their companions and their instructors ; the former deceiving them, tlie latter misunderstanding them, and conse- quently losing patience with them. Do as they may, such pupils must fall behind. It is not desirable for many reasons that children who have learned to talk, but who have become quite dull of hearing, should be isolated into separate classes ; it is much better they should continue their studies M'ith those among whom their lives are to be spent. But allowance should be made for their defective hearing. This can only be accomplished by first ascertaining it. Many a child is hard of hearing without knowing its defect ; it is, therefore, the place of its elders to find out and determine the amount of its deficient hearing. That some special provision must be made for such children is fully justified by the statistics compiled by Dr. C. J. Blake, who has shown that out of 8715 cases of ear-disease, accom- panied by impairment of hearing, 2175, or 25 per cent., were children under fourteen years of age, all of them pupils in the public schools. In order that proper allowance be made for their defective METHODS OF RELIEF AND EDUCATION. 605 hearing;, he has suggested that a careful examination " should be made in each case, to determine the degree of deafness as tested by the distance at which the voice of the teacher can be heard in ordinary conversation tone, and again by the pronun- ciation of consonant tones." These tests could be made by the teacher, and the following directions for making them are given: The teacher should always occupy, in testing the different cases, the same position, preferably the rostrum or seat usually occupied by him in school hours. He should speak in the same tone of voice used in the school-room exercises. The child to be tested should be placed in front of the teacher, and at the extreme limit of the farthest line of seats, and gradually ad- vanced toward the teacher at certain intervals, the tests being repeated until a point is reached at which the child can hear distinctly. This point should determine the place the child should occupy in the school-room. The ears should be tested separately, the ear to be tested being turned toward the teacher, while the other is artificially closed. The child should be required to repeat distinctly the words as he hears them. The use of the voice in making tests of this kind was preferable to the use of watch, musical instruments, and the like, as being more applicable to the child's needs. The tests should be re- peated when the child passes from one room to another, as the degree of deafness often varies at different ages. The examina- tion of pupils by a medical expert was recommended as preferable, since an opinion of the nature of the aural disease and the mode of treatment could thereby be afforded the pupil. Dr. Blake strongly recommended the establishment of a medical supervisor of schools ; the post to be occupied by a competent physician, who had made the matter of school hygiene a study, and his whole time to be devoted to the duties of his position. Such a careful and scientific examination would reveal that some of the children were suffering from a disease of the ear, entirely amenable to treatment if taken at that time. They would, by thus being taken care of, not only regain hearing, and make more rapid advances in their studies, but tViey would often be enabled to get rid of a disease which would otherwise gradu- ally grow worse, because unrecognized, and finally, becoming irremediable, render them permanently deaf. There is no greater fallacy in hygiene than that a child " will outgrow deafness." 606 DEAF MUTES AND PARTIALLY DEAF CHILDREST. Ear-Trumpets. — It has been proposed that the hopelessly hard of hearing use ear-trumpets. Such instruments are of most service when the defective hearing is due to a chronic catarrhal process in the middle ear, in which the ossicles and the mem- hrana tympani are present. J3y a concentration of sound upon the conducting parts, the latter are in many instances made to perform their function better. If, however, the nerve is dis- eased, the concentration of sound by means of ear-trumpets will not be of much aid. It has also been observed that, in cases of chronic suppuration with perforation and destruction of the drum-head, the use of the ear-trumpet is more apt to produce confusion and dizziness, than better hearing. ITo one form of ear-trumpet can be con- sidered the best ; each patient must be tried by a series of instruments, until one is found which proves of service to him. It may be said most positively that all small, and so-called " invisible" ear-trumpets, or instruments to assist the. hearing, no matter under what name they are vended, are useless, be- cause they neither concentrate more sound upon the drum-head, nor increase the resonance of the external ear. In every instance all such instruments, which lie in the auditory canal, interfere with what little hearing may still exist. There is one excep- tion, viz., in cases of hardness of hearingdue to a collapse of the cartilaginous auditory canal, if such cases exist. Here, relief may be gained by holding the walls of the meatus apart by means of a small tube of some kind. Although I have never seen such a case, I am able to conceive that some instances of impaired hearing in old people may be due to such causes, after the loss of teeth, and the consequent alteration in the position of the under jaw, and the encroachment of its condyle upon the tissues of the external meatus of the ear. I have heard of a case of hardness of hearing in an old woman, as relieved by the wearing of a complete set of artificial teeth, which, of course, would render the position of the under jaw normal, and thus relieve what probably has beeq, called collapse of the auditory canal. Since in this case, the introduction of any instrument to hold the walls of the canal apart would have relieved the obstruction to hearing, it is possible to explain the vaunted triumphs of some small and expensive instruments, which at various times have been largely advertised. INDEX, ACID, chloroacetic, 525 chromic, 525 Acoumeter, 206 Adenoid growths in naso-pharynx, 397 Air-bag or hand-ballooD, 183 Alum, use of in otorrhoea, 488 Ampullae of semicircular canals, 129 Annulus tendinosus, of membrana t;m- pani, 58 tympanicua, development of, 42 Anomalies of taste and salivary secretion, 508 Antihelix, 19 AntitragicHS, 21 Antitragus, 19 Anvil. See Incus. Applications to the Eustachian tube, 410 Aquseductus ooohlese, 40, 145 vestibuli. See Vestibule. Arachnoid sac and the lymph of the laby- rinth, 99 Arteria stapedia of Zuokerkandl, 92 Artificial ear of Dionysius of Syracuse, 29 Artificial membrana tympani, 493 action of, 497 paper disks as, 499 protective function of, 499 Aspergillus, 278 in the ear, symptoms of, 281 Attollens aurem, 20 Attrahens aurem, 20 Audition, 146, 147 Auditory canal, 38 anatomy, 43 animate objects in, 805 bleeding from, 328 chicken louse in, 305 cholesteatomatous tumors, 317 chronic circumscribed ulceration, 815 circumscribed inSammation, 258 collections of cerumen in, 288 cretaceous bodies in, 292 cutaneous closure of, 824 dead files in, 806 development of, 42 diffuse inflammation, 265 diphtheritic, 269 Auditory canal, diffuse inflammation- gangrenous, 270 gonorrhoeal form, 271 diseases of, 258 ear-cough, 826 epileptiform symptoms from irrita- tion in, 826 exostoses, 318 foreign bodies, 299 functions of, 4b inanimate objects in, 299 ingrowing hairs from tragus 298 Ixodes hominis in, 806 keratosis obturans, 293 laminated epithelial plug in, 293 maggots in, 306 osseous closure, 820 removal of living objects from, 309 results of inflammation and injury of, 315 temperature of, 37 vessels and nerves of, 45 Auditory nerve, 136 cochlear branch, 137 hypersesthesia of, 435 morbid growths, 580 vestibular and cochlear branches, 187 Auditory ossicles, 68 articulations of, 77 ligamentous support of, 78 Aural specula, 167 Aural vertigo, apparent motion during, 578 from chronic catarrh, 569 secondary to inflammation of the labyrinth, 575 secondary to tympanic disease, 577 Auricle, 19 anatomy, 19 angioma, 238 of the lobule only, 239 bloodvessels, 22 cancer of, 245 chimney sweep's cancer, 246 chronic inflammation of cellular tis- sue, 246 608 INDEX. Auricle — comparative functions, 28 congenital fistula near, 225 Copies auricles, 24 cornu cutaneum, 231 cutaneous diseases, 223 cysts in, 238 diseases of, 220 eczema, 227 epithelial cancer, 245 erysipelas, 224 erythema, 223 fibrous tumors of the lobule, 240 frost-bite, 225 gangrene, 226 glandular hypertrophy of lobule, 242 herpes zoster,- idiopathic. 234 of the tragus, 237 injuries, 255 integument, 22 intertrigo, 224 in architecture of skull, 25 in aquatic mammals, 29 in cranium progenicum, 25 in Egyptians, 24 in Giotto's drawing of Envy, 24 in lower animals, 31 in women and children, 25 ligaments, 22 lymphatics, 22 malformations, 221 mobility, 23 morbid growth and injuries, 238 muscles, 20 nerves, 22 organic defects, 220 othaamatoma, 247 pi'mphigus gangrenosis, 226 phlegmon, 230 plurality and abnormal position, 220 pointed, 25, 26 resonant functions of the human, 30 sarcoma of the lobule, 241 secondary syphilitic eruptions, 232 subterranean ear, 29 sudoriferous glands, 23 tophi in, 226 traumatic cleft of lobule, 256 tubercular syphiloderm, 282 vascular nsevus maternus, 239 Auscultation tube, 182 interference otoscope of Lucse, 204 three limbed, 204 Axial ligament. See Tympanum. BASIN and towel, for cleaning ear, 176 Better hearing in a noise, 386 Bibliography : Caries of mastoid and other parts of the temporal bone, 545 naembrana tympani and ossicles, 103 operations on mastoid, 545 retsults of otorrhoea, 645 Blake's Wilde's snare, 519 Bone conduction, tuning-fork in, 203 Bougie-catheter, 411 CANAL, external auditory, 38 Canals about the tympanic cavity, 88 Canalis chordae, 88 musculo-tubarius, 80 Cancer, chimney sweep's, 246 epithelial, of auricle, 245 of mastoid process, 455 primary, in middle ear, 453 Cartilaginous groove about malleus, 59 in membrana tympani. 59 Catarrhal inflammation of middle ear, acute, 352 course, 371 diagnosis, 376 double bearing, 360 etiology, 371 hardness of hearing, 356 in infants and young children, 366 nasal douche, 378 paracentesis of membrane, 379 paracusis duplicata, 360 prognosis, 377 subjective alteration in pitch, 360 subjective echo-like sensation, 300 symptoms and course, 359 tinnitus aurium, 356 treatment, 377 Catarrhal inflammation of middle ear, chronic, 473 applications to the cavity of drum, 414 aural vertigo from, 509 calcareous deposits in membrana tympani, 388 causes of, 401 changes in position of membrana tympani, 389 changes in the voice, 394 clipping the uvula, 414 condition of pharynx and throat, 393 Eustachian tube and tympanum, 399 excision of tonsils, 413 external auditorj' canal, appearances of in, 387 hereditary tendency, 387 loss of function in velum, 394 objective symptoms, 387 odor, 387 operations with the knife, on drum- head, 414 sympathetic nerve, implication of, 390 symptoms, 381 treatment, 404 Catheterization of Eustachian tube, 184 Cauda helicis, 21 Cerebellar process of Schklarewsky, note, 151 INDEX. 609 Cerebro-Bpinal meningitis, deafness from, 504 Cerumen, collections of, 288 Ceruminous glands, 45 Chimney sweep's cancer, 246 Chloro-acetio acid, 525 Cholesteatoma of the petrous bone, 449 of the middle ear, 449 Chondritis from piercing lobule, 22 Chorda tympani, 88 course and function of, 89 fold in mucous membrane for, 63 in tympanum, 80 irritation of, 506 Chromic acid, 525 Cochlea, 126 aquseductus, 145 "aural teeth" of, 132 canal, 126 canalis reuniens of Henseu, 148 crista spiralis, 132 ductus cochlearis, 181, 183 exfoliation of, 528 habenula perforata, 132 lamellae of lamina spiralis ossea, 131 lamina spiralis ossea, soft parts of, 131 ligamentum spirale of Henle, 131 membrana basilaris, 131 membrane of Reissner, 131 modiolus, 127 organ of Corti, 182 physiology of, 145 scalse, 128 lining, 131 soft parts, 129 stria vascularis, 182 vas prominens, 132 Comparative distribution of bloodvessels in membrana tympani, 64-67 functions of auricle, 28 Concavo-convexity of drum-head, 60 Concha, 19 function of, 35 Concussion, deafness from, 562 Consonants, acoustic character of, 211 Convexity of membrana tympani, 51 Corpora amylacea, 698 Corpuscles of the membrana tympani, 62 Cotton-holder, 174 Cranium progenicum, position of auricle in, 25 Crista acustica. See Semicircular canals. vestibuli. See Vestibule. DEAF-DDMBNESS, 599 Deaf mutes, education of, 602 and partially deaf children, 599 Deafness, boiler-makers', etc., 403 from cerebro-spinal meningitis, 564 from concussion, 562. hysterical, 595 39 Deafness — nervou<, 595 test for one-sided form, 216 "Deaf points" of ear, 194 Dentiform structure of membrana tym- pani, 61 Dermoid layer of membrana tympani, 47 in children, 60 Descending fibres of membrana tympani, 61 Dilatator tubse, 108 (foot note) Diphtheritic external otitis, 269 Double hearing, 360 Drum. See Tympanum. Drum-head. See Membrana tympani. Ductus endolymphaticus, 100 EAR, external. See Auricle, External Auditory Canal, and Membrana Tympani. Ear, internal. See Labyrinth and Audi- tory Nerve. Ear, middle. See Tympanum, Eustachian Tube, and Mastoid Portion. Earache from bad teeth, 90 from teething, 375 from whooping-cough, 375 Ear-cough, 326, 355 Ear-instruments, 167 Ear-mirror, 166 Ear, perception of musical tones, 209 Ear- syringe, 175 Ear-trumpets, 606 entotic application of as test, 218 Electricity in aural diseases, 433 Embolism in mucous membrane of tym- panum, 452 Eminentia stapedii, 84 Emphysema of the mastoid portion, 465 Endolymph, 143 Endo- and perilymph, 100, 148, 145 Epileptiform phenomena from aural irri- tation, 500 symptoms from irritation in external ; ear, 826 ■ Epithelioma (polypus),, 516 Erysipelas of the auricle, 224 Erythema, simple,, of the auricle, 223 Eustachian tube and mastoid portion, 104 Eustachian tube, 109 attachment of cartilage of, to base of skull, 106-107 attachment of muscles, 107 bloodvessels and nerves, 112 cartilaginous portion, 105 catheters, 180 catheterization, 107, 185 connection of inner pterygoid mus- cle, 109 differences in the mouth, 111 dimensions, 105 emphysema, 188 610 INDEX. Eustachian tube — examiDation, 177 foreign bodies in, 310 glands, 110-111 inflation of, by Politzer's method, 190 inner dilator of, salpingo-pharyn- geus, 107 inner pterygoid muscle, 109 in pronunciation of vowels, 117 isthmus, 105 ligamenta salpingo-pharyngea of, 110 membranous part, 106 mucous membrane of, 110 muscular or membranous part of, 100 nomenclature, 107 origin of name, 104 osseous portion of, 105 petro-staphylinus muscle, 107 physiology of, 116-123 relation of levator palati (petro- staphylinus) to, 107 relations of, to the tympanum, 104 rhinoscopic examination of, 179 safety tube and accessory cleft in, 106 sphenoid bone in formation of, 105 tensor palati or dilatator tubse, 108- 109 tensor tympani and tensor veli, 109 Examination of ear by polarized light, 165 of patients, 165 Excision of tonsils, 413 Exfoliation of cochlea, 528 of cochlea, vestibule, and semicircu- lar canals, 529 External auditory canal. See Auditory canal. Extravasation of blood into tympanum, 447 Extrinsic muscles of the auricle, 20 Eyelet in membrana tympani, 418 1 RACIAL angle, and the position of au- ' ricle, 25 Facial canal, lymphatic cavity in, 89 Facial nerve, course of, in the tympanum, 87 paralysis of, 503 Fauces, examination of, 177 Faun's ear, 25 Fenestra ovalis, 83 rotunda, 83 Fibro-sarcoma of auditory nerve, 591 Fistula of the ear, congenital, 223 Fixator baseos stapedis, 84 Floor of tympanum, 80 Fluid in the tympanum, removal of, 428 Flushing of cutaneous surface, 390 Folds of the membrana tympani, 52 Folius, process of, 09 Fonimen Rivini, 53 Foreign bodies in external ear, 287 in Eustachian tube, 310 in middle ear, 810 treatment, 312 Fossa helicis, 19 navioularis of the auricle, 19 of Rosenmiiller, 107 triangularis of the auricle, 19 Fracture of the skull, ear in, 558 of base of skull, 560 Fungi, aural, 278 GAIT, alterations in, in chronic puru- lent otitis, 506 Geometric divisions of the membrana tympani, 57 Glands, ceruminous, 45 Glaserian fissure, 42, 68 Glioma of auditory nerve, 692 Gold-stained nerves and vessels of mem- brana tympani, 65 Granulations and polypi, 510 treatment of, 512 HEARING, 192 better in a noise, 386 hallucinations of, 594 high notes, 212 limits of,' 209 low tones better than high ones, 215 normal, 197 record of, 198 tests of, 196 variable, 215 Helicotrema of cochlea, 128 Helicis major, 21 Helicis minor, 21 Helix, 19 "High and low hearing," 103 Human auricle, resonant functions of, 30 Hysterical deafness, 595 TNCISION of folds of membrana tym- 1 pani, 417 Incus or anvil, 73 articulating surfaces of, 74 dimensions of, 74 incudo-tympanic joint, 80 portion of, in polypus, 517 Inferior maxilla, connection between auri- cle and, 25 Injuries of the auricle, 255 Inner wall of tympanum, 83 Integument of the auricle, 22 Internal ear, 124-162 ancemia and hypersemia, 551 anatomy, 124 anomalies of formation, 550 diseases of, 550 INDEX. 611 laternal ear — scheme of relationship between mid- dle ear and, 159-1B2 traumatic injuries, 558 Intertrigo of the auricle, 224 Intra-tympanio pressure during phona- tion, 363 Intrinsic muscles of the auricle, 20 [ACOBSON'S nerve, 91 LABYRINTH and auditory nerve, 124 See Vestibule, Cochlea, and Semi- circular canals, aural vertigo from inflammation of, 575 endolymphatic duct, 144 endo- and perilymph, 143-145 functions of endo- and perilymph, 144-145 in ileo-typhus, 593 membranous labyrinth, 138 nerve-filaments, 142 perilymph, 145 pressure, artificial means of produc- ing, 98 effects of, on movements of ossi- cles, 99 serous membrane, 139 Lamina spiralis ossea, 128 granular layer, 137 Laxator tympani, 72 Legal significance of injuries of the membraua tympani, 347 value of shape of the auricle, 28 Levator palati, attachment of, 107 (foot- note) Lever-ring forceps of Toynbee, 523 Ligamenta salpingo pharyngea, 110 Ligamentous support of ossicles of hear- ing, 73 Ligaments of the auricle, 21 Lissajou's method, 96 Lobule, 19 Lymphatics of the auricle, 22 MACULA acustica. See Vestibule. Maculae cribrosae, 126 Malformations of auricle, 221 ■ of ear in arrested development of first visceral cleft, 24 Malleo-incudal joint, 74 Malleo-incudal and incudo-stapedial joints, 77 Malleus, 68 articulating surface, 70 axial ligament, 72 cartilaginous groove about handle, 59 dimensions, 71 divisions, 69, 71 Malleus — fixation of, by ligaments, 71 head, neck, and handle, 70 hook-shaped end of handle, 71 ligaments, 71, 72 manubrium, 50 processes, 68, 69 prominences on handle, 71 shape, 70 short process, 51, 59 surfaces, 70 Manometer, Politzer's, 444 Manubrium of malleus, from without, 50 Mastoid portion of temporal bone, 112 antrum, 87, 115 cancer of, 455 cells, 113 development, 113 emphysema of, 455 ethnological features of, 115 foramina, 113 hairs in, 456 inflammation, symptoms, etc., 532 modes of trephining, 543 perforation of, 541 process, 115 surfaces, 113 treatment of mastoid disease, 540 Meatus auditorius exteruus. See Exter- nal auditory canal. Mechanism of the ear, bibliography of, 103, 104 .Membrana flacoida, 47 inflammation, acute, 82 Membrana tympani, 47 acute inflammation, 329 anatomy, 47-67 annulus tendinosus, 58 appearances of malleus in, 51 artificial, 493 calcareous spots, 388 cartilaginous structure, 59 changes of position, 389 chronic catarrh, 389 chronic inflammation, 333 color of, 48 comparative distribution of blood- vessels, 64-67 concavo-convexity, 60 convexity, 51 corpuscles of, 62 dentiform structure, 61 dermis of, in children, 50 dermoid layer, 47 descending fibres, 61 diameters, 48 diseases, 329-351 epithelium, 49 flaccid portion, 47 fold of mucous membrane for chorda tympani, 63 foramen Rivini,-53 geometric divisions, 57 612 INDEX. Membrana tympani — in lower animals, 64 incision of the folds, 417 inclinations, 50 layers, 47 membrana propria, 60 membrana flaccida, acute inflamma- tion of, 82 mucous layer, 61 outer surface, 47 perforation in, effect on hearing, 211, 216 perforation of the membrana flaccida, 336 _ - permanent opening, 417 pockets or pouches, 63 pyramid of light, 53 quadrants, 48 removal of obstacles from, 173 retraction of, in acute catarrh, 369 shape, 48 Shrapnell's membrane, 52 spontaneous rupture, 369 ulceration in the dermoid layer, 333 umbo, 51 ■vascular loops in, 64 vessels and nerves, 65 villi on inner surface, 63 yellow spot at end of manubrium, 52 Membrana tympani secundaria, 85 Membranous labyrinth, 138 disposition of, in perilymph, 138 layers of wall, 139, 140 membranous semicircular canals, supports of, 139 otoliths, 142 papilliform prominences, 140 sacculi and ampuUse, inner surface, 141 topography, 143 Middle ear. See Tympanic cavity. Eus- tachian tube, and Mastoid portion. acute catarrhal inflammation. See Catarrhal inflammation. acute purulent inflammation. See Purulent inflammation. chronic cartarrhal inflammation. See Catarrhal inflammation. chronic purulent inflammation. See Purulent inflammation. desquamative inflammation, 449 embolism of mucous membrane, 452 foreign bodies in, 310 membranes and bands, 451 objective noises in the ear, 440 polypoid hypertrophy of mucous membrane, 510 primary cancer, 453 tuberculosis, 448 unusual diseases, 439-456 Middle ear mirror of Blake, 171 Mirror, forehead, and laryngeal, 178 Modified sudoriferous glands of meatus, 23 Modiolus and lamina spiralis ossea, 127 Morbid growths of auditory nerve, 580 Movements of the ossicles of hearing, 100 Musculus incisurse Santorini, 21 Musical notation by letters, 193 Musical tones, perception of, 209 Myringitis, acute, 329 Myringomyoosis aspergillina, 278 NARES, examination of, 177 Nasal douche, 407 Nerves of the auditory canal, 45 of the auricle, 22 Nervous deafness, 595 phenomena from chronic otorrhoea, 500 Nitrate of silver, 524 instillation of, 486 OBLIQCUS auriculse, 21 Organ of Corti. See Cochlea, ciliated cells, 135 Corti's membrane, 136 membrana reticularis, 135 tectoria, 136 Os orbiculare or os Sylvii, 68 Ossicles of hearing, 68 dimensions, 78 Othsematoma, 247 in the sane, traumatic, 254 Otic ganglion, 90 Otitis externa, gangrenous, 270 gonorrhoeal, 271 parasitic, 277 labyrinthica, 555 media hemorrhagica, 448 Otoliths, 142 / Otomycosis, 277 Otorrhoea. See Purulent inflammation of middle ear. Otoscopes, 167 Blake's operating, 170 Bonnafont's, 168 De Rossi's binocular, 170 Gruber's, 167 Sigl^'s pneumatic, 168 Voltolini's pneumatic, 170 Oval window, 83 Overtones. See Sound. PAPER disk as artificial membrana tympani, Blake's, 499 Papilliform prominences in semicircular canals, 140 Paracusis duplicata, 360 Willisiana, 386 Paralysis of facial nerve, 503 Partially deaf children, 604 Partial tones. See Sound. Patients, position of body and head, 172 Perception of high musical tones, 209 INDEX. 613 Permanent opening in membrana tym- pani, 417 platinum-wire loop, 520 . Petrostnphylinus of HenM, 107 Petrotympanic or Glaserian fissure, 42 Petrous bone, anatomy, 88 cholesteatoma, 449 Pharyngeal tonsil. 111 Piercing lobule, chondritis from, 22 Pillars and arches of Corti, 134 Pinna, 19 Pitch. See Sonnd. Planum semilunare. See Semicircular canals. Pockets or pouches of membrana tym- pnni, 63 Pointed auricle, 25 Polarized light, examination of ear by, 165 Politzer's method of inflation of tympana, 190 Polypus, aural, 513 after-treatment of, 524 angioma, 516 classification of, 513 fibromata, 516 forceps, 523 histology, 514 hook, 522 scissors, 521 symptoms, 517 treatment, 51ti Position and shape of auricle in nations, 24 of auricle and the facial angle, 25 of auricle in the architecture of the skull, 25 Pouches of membrana tympani, 63, 81 Process of Bau or Folius, 69 Processes of malleus, 68-69 Processus coohleariformis, 85 lenticularis of the incus, 73 longus, 69 spinosus, 69 Prominences on malleus, 71 Proper muscles of the auricle, 20 Psychoses in chronic purulent otitis, 510 Purulent inflammation of middle ear, acute, 456 course, 461 diagnosis, 468 etiology, 464 prognosis and treatment, 470 symptoms, objective, 459 subjective, 457 Purulent inflammation of middle ear, chronic, 473 alterations in gait, 506 anomalies of taste and salivary secretion, 508 course, 526 epileptiform phenomena, 500 etiology, 474 exfoliation of cochlea, vestibule, semicircular canals, etc., 529 Purulent inflammation of middle ear, chronic — granulations and polypi, 510 irritation of chorda tympani, 506 nervous phenomena, 500 paralysis of facial nerve, 503 reflex psychoses, 510 results of, 491 symptoms, 477 treatment, 481 vertigo, 509 Pyramid of light on membrana tympani, 53 causes, 54-57 Pyramis vestibuli. See Vestibule. QUADRANTS of membrana tympani, 48 Quinine, effects of, on ear, 596 RECES30S cochlearis. See Vestibule. Becessus ellipticus. See Vestibule. Recessus sphsericus. See Vestibule. Relation between middle and internal ear, 159-162 Resonator for high tones, the auricle, 32 Retrahens aurem, 20 Rhinosoopic examination, 179 Rivinus, foramen of, 53 segment of, 43 Rosenmiiller's fossa, 107 Round window, 83 functions of membrane of, 95 length of vibrations of mem- brane, 101 SACCULl and ampuUse, inner surface, 141 Sarcoma of auditory nerve, 581 of each auditory nerve, 582 microscopic examination, 585 of the lobule, 241 Scalse of the cochlea, 128 Scapha of the auricle, 19 Segment of Rivinus, 43 Semicircular canals, 128 ampullar mouths, 125 corpora amylacea, 593 crista acustica of Max Schultze, 142 dimensions, 129 enlargement at ampullae, 129 experiments on, 149 functions, 149-159 papillse, 140 planes, 129 planum semilunare, 142 terminal filaments of nerve, 142 Septum tubse, 85 Serous membrane in labyrinth, 139 Shape of membrana tympani, 48 614 INDEX. Short process of malleus, 51, 59 Shrapnell's membrane, 52 Significance of shape and size of auricle, 24 Sinus sulciformis, 125 Sound, aerial and bone conduction of, 196 clang tint or quality, 193 definition, 192 overtones, 193 partial tones, 193 pitch, 193 sound and color, 196 Speech as a test, 208 system of visible, 603 Spheno salpingo-staphylinus, 108 (foot- note) Sphenoid bone in formation of Eustachian tube, 105 (foot-note) Spina tympanioa antica, 42 postica, 42 Stapedius muscle, function of, 84 Stapes or stirrup, 75 dimensions of, 76 divisions of, 75 joint between base of, and the oval window, 77 obturator ligament of, 76 Stop-Vfatch as a test, 199 Sudoriferous glands of auricle, 23 Sulcus malleolaris, 42 Surgeon, position of, in examining ear, 172 Syphilis, diseases of internal ear from, 568 Syringing the ear, 175 TEGMEN tympani, 79 Temperature of auditory canal, 37 Temporal bone, anatomy uf, 38, 41 development of, 38 Tenotomes, 424 Tenotomy of tensor tympani, 420 Tensor palati, origin and attachment of, 108, 109 Tensor palati and tensor tympani, con- nection between, 109 Tensor tympani, functions of, 92 innervation of, 92, 93 origin of, 85 transverse section of, 80 Tensor tympani and stapedius, action of, 103 Tensor tympani and tensor palati, 109 Tensor veli, 108 (foot-note) Tests of hearing, 196 acoumeter, 201 by means of voice, 216-218 entotio, by means of ear-trumpet, 218 of one-sided deafness, 216 tuning-forks, 200 watch, 197 whispering, 214 Third pouch of membrann tympani, 81, 82 Throat, examination of, 177 Tinnitus aurium) 356 Tones, whispering and loud, 214 Tonsilla pharyngea of Luschka, 111 Tonsils, excision of, 413 Tragus, 19 Transversus auriculae, 21 Tubal catarrh, 367 Tubercular disease of ear, 448 Tuning-forks, 200 applied to vertex, 202 bone-conduction, 203 vibrating on parietal protuberance, 206 Tympanic plexus, 91 Tympanum, or tympanic cavity, 79 anatomy, 68-92 anterior and posterior walls, 87 articulations of ossicula auditus, 77 axial ligament of malleus, 72 bands, physiological nature of, 94 bloodvessels of, 91 canalis musculo-tubarius, 80, 85 chorda tympani in the, 88, 89 development of canals about, 88 dimensions of, 79 experiments on the ossicula auditus, 97-103 extravasation of blood into, 447 fixation of base of stapes, 77 floor of, 80 function of muscles in the, 103 incudo-tympanio joint, 80 inner wall of, 83 Jacobson's nerve, 91 lymphatic cavity in facial canp,l, 89 raalleo-incudal joint, 74 from above, 79 mastoid antrum, 87 mechanism of the middle ear, 104 muscular accommodation, 103 nerves of mucous membrane of, 90 ossicula auditus, 78 osteophytes in, 96 outer wall of, 81 planes of the fenestrse, 85 processus cochleariformis, 85 removal of fluid, 428 roof or tegmen of, 79 round window and its functions, 95 round window, membrane of, 101 septum tubse, 85 stapedius muscle, 84 stapes, 75 tensor tympani, 85 tympanic bands, 94 vacuum in, 354 weight of the ossicula auditus, 78 Typhoid fever, disease of ear from, 569 labyrinth in, 593 INDEX. 615 u MBO of membrana tympani, 61, 70 VACUUM in tympanum, 354 Valsalva's inflation of the middle ear, 400 Variable hearing, 215 Vascular loops in membrana tympani, 64 Vertigo. See Aural vertigo. from cerebral tumors, 580 in chronic purulent otitis media, 509 Vestibule, 124 oquEeduotus vestibuli, 143 crista vestibuli, 125 macula acustica of Max Sohultze, 142 maculae oribrosEe, 126 otoliths, 143 pyrarais vestibuli, 125 reoessus coohlearis, 125 recessus ellipticus, 125 recessus sphtericus, 125 soft parts, 138 Vestigia, in auricle, 20 Villi or papilla) on inner surface of mem- brana tympani, 63 Visceral cleft, arrest of development caus- ing defect in ear, 24 Visible speech, 603 Vowels, acoustic character of, 211 WATCH as test of hearing, 197 Weight of the ossicles of hearing, Blake on the, 78 Whispering as a test, Dennert's observa- tions, 215 Wilde's snare, 519 Blake's modification, 519 Women, shape and position of auricle in, 25 VE ELLOW spot at end of manubrium, 52 ZINC, use of in otorrhcea, 484 Zonse of membrana basilaris, 132 HEII^RY C- LEA.'S (late lea i: BLANCHABD's) OF MEDICAL AND SUEGIOAL PUBLICATIONS. In asking the attention of the profession to the works advertised in the following pages, the publisher would state that no pains are spared to secure a continuance of the confidence earned for the publications of the house by their careful selection and accuracy and finish of execution. The printed prices are those at which books can generally be supplied by booksellers throughout the United States, who can readily procure for their customers any works not kept in stock. Where access to bookstores is not convenient, books will be sent by mail post-paid on receipt of the price, but no risks are assumed either on the money or the books, and no publications but my own are supplied. Gentlemen will therefore in most cases find it more convenient to deal with the nearest bookseller. An Illustrated Catalogue, of 64 octavo pages, handsomely printed, will be for- warded by mail, post-paid, on receipt of ten cents. HBNEY C. LEA. Nos. 706 and 708 Sansom St., Philadelphia, October, 1877. ADDIIIONAL INDUCEMENT FOR SUBSCRIBERS TO THE ilERICAN JOURNAL OF THE MEDICAL SCIENCES. THEEE MEDICAL JOUEIfALS, oontaining over 2000 LARGE PAGES, Tree of Postage, for SIX DOLLARS Per Annum. TEBMS FOE 1877: Thr American Journal of the Medical Sciences, and l Five Dollars per annum The Medical News AND Library, both free of postage, J in advance. OK The American Journal op the Medical Sciences, published quar- ] y. terly (ll.nO pages per annum), with ' | °'^ Dollars The Medical News and Library, monthly (384 pp. per annum), and J- per annum The Monthly Abstract of Medical Science {.592 pao^es per annum), j i° advance. %* Advance-paying subscribers can obtain at the close of the year cloth covers for each volume of the Journal (two annually), and of the Abstract (one- annually) free by mail, on receipt often cents for each cover. SEPABATE SUJiSCBIfTIOlfS TO The American Journal of the Medical Soibnce.s, when not paid for in advance Five Dollars. ' The Medical News and Library, free of postage, in advance. One Dollar The Monthly Abstract of Medical Science, free of postage, in advance Two Dollars and a Half. ' It is manifest that only a very wide circulation can enable so vast an amount of valuable practical matter to be supplied at a price so unprecedentedly low. The pub- lisher, therefore, has much gratification in stating that the very great favor with which these periodicals are regarded by the profession promises to render the enterprise a permanent one, and it is with especial pleasure that he acknowledges the valuable assistance spontaneously rendered by so many of the old subscribers to the '• Jour nal," who have kindly made known among their friends the advantages thus offered' and have induced them to subscribe. Relying upon a continuance of these frienrllv exertions, he hopes to be able to maintain the unexampled rates at which these work's (For "The Obbtbtrical Journal," see p. 2.3.) 2 Henry C. Lea's Publications — {Am. Jqurn. Med. Sciences). are now offered, and to succeed in his endeavor to place upon the table of every reading practitioner in the United States the equivalent of three large octavo volumes, at the comparatively trifling cost of Six Dollars per annum. These periodicals are universally known for their high professional standing in their several spheres. I. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, Edited by ISAAC HAYS, M.D., is published Quarterly, on the first of January, April, July, and October. Each num- ber contains nearly three hundred large octavo pages,- appropriately illustrated wher- ever necessary. It has now been issued regularly for over fifty years, during nearly the whole of which time it has been under the control of the present editor. Through- out this long period, it has maintained its position in the highest rank of medical periodicals both at home and abroad, and has received the cordial support of the en- tire profession in this country. Among its Collaborators will be found a large number of the most distinguished names of the profession in every section of the United States, rendering the department devoted to ORIGINAL COMMUNICATIONS full of varied and important matter, of great interest to all practitioners. Thus, during lb77, articles have appeared in its pages from over one hundred gentlemen of the highest standing in the profession throughout the United States.'* Following this is the "Ebview Department," containing extended and impartial reviews of all important new works, together with numerous elaborate " Analytical AND Bibliographical Notices" of nearly all the medical publications of the day. This is followed by the "Quarterly Summary of Improvements and Discoveries IN THE Medical Sciences'," classified and arranged under different heads, presenting a very complete digest of all that is new and interesting to the physician, abroad as well as at home. Thus, during the year 1877, the "Journal" furnished to its subscribers 89 Orig- inal Communications, 99 Reviews and Bibliographical Notices, and 241 articles in the Quarterly Summaries, making a total of over Four Hundred and Twenty-Five articles emanating from the best professional minds in America and Europe. That the efforts thus made to maintain the high reputation of the " Journal" are successful, is shown by the position accorded to it in both America and Europe as a national exponent of medical progress: — America coatlnues to take a great place in this cJasB of journale (quarterlieB), at the h4ad of which the great work of JJr. Hays, the American Journal of tlit Medical Sciences, still holds its ground, as our quotations have often proved. — Dublin Med, Press and Circular, Jan. 31, 1872. Of English periodicals the Lancet, and of American the AtH. Journal of the Medical Sciences, are to be regarded as necessities to the readingpractitioner. — A'' r. Medical Qazttte, Jan. 7, 1671. The American Journal of the Medical Sciences yields to none in the amount of original and bor- rowed matter it contains, and has established for itself a reputation in every country where medicine is cultivated as a science. — Brit, and For. Med. -Chi- rurg. Rmiew, April, 1871. This, if not the best, is one of the best-condncted medical quarterlies in the English language, and the present number is not by any means inferior to its predecessors. — London Lancet, Aug 23, 1873. Almost the only one that circulates everywhere, all over the Union and in Europe. — London Medical Times, Sept. 5, 1!)68. And that it was specifically included in the award of a medal of merit to the Pub- lisher in the Vienna Exhibition in 1873. The subscription price of the "American Journal op the Medical Sciences" has never been raised during its long career. It is still Five Dollars per annum ; and when paid for in advance, the subscriber receives in addition the "Medical News and Library," making in all about 1500 large octavo pages per annum, free of postage. II. THE MEDICAL NEWS AND LIBRARY is a monthly periodica! of Thirty-two large octavo pages, making 384 pages per annum. Its "News Department" presents the current information of the day, with Clinical Lectures and Hospital Cleanings; while the "Library Department" is de- voted to publishing standard works on the various branches of medical science, paged * Commanicatious are invited from gentlemen in all parte of the country. Elaborate articles inserted by the Editor are paid for by the Publisher. Henry C. Lea's Publications — (Am. Journ. Mid. Sciences). 3 separately, so that they can be removed and bound on completion. In this manner subscribers have received, without expense, such works as " Watson's Practice," " Todd and Bowman's Phtsiolooy," " West on Children," " Malgaignb's Soe- ORRY," "Stokes's Lectures on Fever," &c. &c. With July, 1876, wag commenced the publication of Gossemn's " Clinical Lectures on Surgery," translated from the French by Lewis A. Stimson, M.D., Surgeon to the Presbyterian Hospital, New York (see p 28). Gentlemen commencing their subscriptions with 1877, can obtain the portion of " Gosselin" issued in 1876 for Fifty cents, if remitted promptly. As stated above, the subscription price of the " Medical News and Libbart" is One Dollar per annum in advance; and it is furnished without charge to all advance paying subscribers to the "American Journal of the Medical Sciences." III. THE MONTHLY ABSTRACT OF MEDICAL SCIENCE. The "Monthly Abstract" is issued on the first of every month, each number con- taining forty-eight large octavo pages, thus furnishing in the course of the year about six hundred pages. The aim of the Abstract will be to present a careful condensa- tion of all that is new and important in the medical journalism of the world, and all the prominent professional periodicals of both hemispheres will be at the disposal of the Editors. To show the manner in which this plan has been carried out it ia sufficient to state that during the first nine months of the year 1877 it contained — as Articles on Anatomy and Fliysiology. 4:'^ " *' Materia Medica and Therapeutics, a.5« " " Mi-dicine. 110 " " Surgery. 69 " " Midtvifery and Gyncecology, 5 " " JHedical tTtiri^pncdence and Toxicology — or at the rate of Five Hundred and Fifteen articles in a single year. The subscription to the " Monthly Abstract," free of postage, is Two Dollars and a Half a year, in advance. As stated above, however, it will be supplied in conjunction with the " A.-iierican Journal of the Medical Sciences" and the "Medical News and Library," makin" in all about Twenty-one Hundred pages per annum, the whole /ree of postage, for Six Dollars a year, in advance. Those who desire to have complete sets, can still procure Vol. I. July to Decem- ber, 1874, 1 vol. 8vo., cloth, of about 300 pages, for $1 50, and Vol. II. and III. for 1876 and 1876, 1 vol. 8vo , of about 600 pages cloth, for $3 00 each. In this efi'ort to bring so large an amount of practical information within the reach of every member of the profession, the publisher confidently anticipates the friendly aid of all who are interested in the dissemination of sound medical literature. He trusts, especially, that the subscribers to the "American Medical Journal" will call the attention of their acquaintances to the advantages thus offered, and that he will be sustained in the endeavor to permanently establish medical periodical literature on a footing of cheapness never heretofore attempted. PREMIUM rOE OBTAINIITG NEW SUBSOEIBEES TO THE "JOUENAL." Any gentleman who will remit the amount for two subscriptions for 1877, one of which must be for a new subscriber, will receive as a premium, free by mail, a copy of "Flint's Essays on Conservative Medicine" (for advertisement of which see p. 1.5), or of "Sturqes's Clinical Medicine" (see p. 14), or of the new edition of "Swaynb's Obstetric' Aphorisms" (see p. 24), or of "Tanner's Clinical Manual" (see p. ,5), or of "Chambers's Kestorative Medicine" (see p. 18), or of "West on Nervous Disorders of Children" (see page 21). %* Gentlemen desiring to avail themselves of the advantages thus offered will do well to forward their subscriptions at an early day, in order to insure the receipt of complete sets for the year 1877, as the constant increase in the subscription list almost always exhausts the quantity printed shortly after publication. 1^ The safest mode of remittance is by bank check or postal money order, drawn to the order of the undersigned. Where these are not accessible, remittances for the "Journal" may be made at the risk of the publisher, by forwarding in registered letters. Address, HENRY 0. LEA, Nos. 706 and 708 Sansom St., Philadelphia, Pa. Henry C. Lea's Publications — {Dictionaries). jyUNQLISON (ROBLEY), M.D., Late Professor of Inatitviea of Medicine in Jefferson Medical College, Philadelphia. MEDICAL LEXICON; A Dictionary of Medical Science: Con- taining a concise explanation of the various Subject? and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters; Formulae for Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology of the Terms, and the French and other Synonymes; so as to constitute a French as veil as English Medical Lexicon. A New Edition. Thoroughly Revised, and very greatly Mod- ified and Augmented. By Richard J. Dunglison, M.D. In one very large and hand- some royaloctavo volume of over 1100 pages. Cloth, $6 60; leather, raised bands, $7 50. {^Just Issued.) The object of the author from the outset has not been to make the work a mere lexicon or dictionary of terms, but to afford, under each, a condensed view of its various medical relations, and thus to render the work an epitome of the existing condition of medical science. Starting with this view, the immense demand which has existed for the work has enabled him, in repeated revisions, to augment its completeness and usefulness, until at length it has attained the position ■of a recognized and standard authority wherever the language is spoken. Special pains have been taken in the preparation of the present edition to maintain this en- viable reputation. During the tfn years which have elapsed since the last revision, the additiors to the nomenolatureof the medical sciences have beengreater than perhaps in any similar period of the past, and up to the time of his death the author labored assiduously to incorporate every- thing requiring the attention of the student or practitioner. Since then, the editor has been equally industrious, so that the additions to the vocabulary are more numerous than in any pre- vious revision. Especial attention has been bestowed on the accentuation, which will be found marked on every word. The typographical arrangement has been much improved, rendering reference much more easy, and every care has been taken with the mechanical execution. The work has been printed on new type, small but exceedingly clear, with an enlarged page, so that the additions have been incorporated with an increase of but little over a hundred pages, and the volume now contains the matter of at least four ordinary octavos. A book well known to our readerp, and of which every American ought to be proud. Whtn the learned author of the work passed away, probably all of us feared lest the book should net maintain its place ID the advancing Rcience whope terms it defines. For- tunately, Dr. Richard J. Dunglison, having apsisted his father in the revision of several editions of the work, and having been, therefore, trained in the methods and imbued with the spirit of the book, has been able to edit it, not in the patchwork manner so dear to the beart of book editors, fo repulsive to the taste of intel- ligent book readers, but to edit it as a work of the kind siouldbe edited — to carry it on ateadil>, without jar or interruption, along the grooves of thought it lias travelled during its lifetime. To show the magnitude cff the task which Dr. Dunglison has assumed and car- ried through, it is only necessary to stale that more than six thousand new subjects have been added in the present edition. Without occupying more space with the theme, we congratulate the editor on the successful completion of bis labors, and hope he may reap the well- earned reward of profit and honor.— -P/nto. Med. Times, Jan. 3, 1874. About the first book j^urchased by the medical stu- dent is the Medical Dictionary. The lexicon explana- tory of technical terms is simply a sine qua non. In a science so extensive, and with such collaterals as medi- cine, it is as much a necessity also to the practising physician. To meet the wants of students and most physicians, the dictionary must be condensed while comprehensive, and practical while perspicacious. It was because Dunglison's met these indications that it became at once the dictionary of general use wherever medicine was studied in the English language. In no former revision have the alterations and additions been 60 great. More than sis thousand new subjects and terms have been added. The chiefterms have been set in black letter, while the derivatives follow in small caps; an arrangement which greatly facilitates reference. We may safely confirm the hope ventured by the editor " that the work, which possesses for him a filial as well as an individual interest, will be found worthy a con- tinuance of the position so long accorded to it as a standard authority." — Cindnnatx Clinic, Jan. 10, 1874. We are glad to nee a new edition of this invaluable work, and to find that it has been so thoroughly revised, and so greatly improved. The dictionary, in its pre- Hent form, is a mfdical library in itself, and one of which every physician should be possessed. — iV. Y. Med. Journal, Feb. 1874. With a history of forty years of unexampled success and universal indorsement by the medical profession of the western continent, it would be presumption in any living medical American to essay its review. No re- viewer, however able, can add to its fame ; no captious critic, however caustic, can remove a single stone from its firm and enduring foundation. It is destined, as a colossal monument, to perpetuate the solid and richly deserved fame of Kobley Dunglison to coming genera- tions. The large additions made to the vocabulary, we think, will be welcomed by the profession as supplying the want of a lexicon fully up with the march ol sci- ence, which has been increasingly felt for some years past. The accentuation of terms is very complete, and, as far as we have been able to examine it, very excel- lent. We hope it may be the means of securing greater uniformity of pronunciation among medical men. — At- lanta Med. and Surg. Journ., Feb. 1874. It would be mere waste of words in us to express our admiration of a work which is so universally and deservedly appreciated. The most admirable work of its kind in the English language. — 9lasgov> Medical Journal, January, 1866. A work to which there is no equal in the English Language. — Edinburgh Medical Journal. Few works of the class exhibit a grander monument of patient research and of scientific lore. The extent of the sale of this lexicon is sufQcient to testify to its laefalness, and to the great service conferred by Dr. Robley Dunglison on the profession, and indeed on »thers, by its issue. — London Lancet, May 13, 1866. It has the rare merit that it certainly has no rival in the English language for accnracy and extent of references. — London Medical Gazette. TJOBLYN (RICHARD D.), M.D. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. Revised, with nnmerons additione, by Isaac Hats, M.D., Editor of the "American Journal of the Medical Sciences." In one large royal 12mo. volume of over 500 double-columned pages ; cloth, $1 50 ; leather, $2 00. It Is the best book of deflnltions we have, and ought always to be aponthe itudent'e table,— fiovM'rn Mid. and SuTg. Journal. Henry C. Lea's Pijbltoations — (Manuals), A CENTURY OF AMERICAN MEDICINE. 1776-1876. By Doctors E. H. -*^ Clarke, H. J. Bigelow, S. D. Grosa, T. G. Thomas, and J. S. Billings. In one very hand- some 12aio. volume of about 350 pages : cloth, $2 25. {Just Ready.) This work has appeared in the pages of the American Journal of Medical Sciences during the year 1876. As a detailed account of the development of medical science in America, by gentle- men of the highest authority in their respective departments, the profession will no doubt wel- come it in a form adapted for preservation and reference. One of the most charmiog Mowoenira of the year, just pasBed, is the volnrae before us. Allhough in- tended us an especial offeriog to eQ. '76.. R N' OD WELL {G. F.], F.R.A.S.. Sfc. A DICTIONARY OF SCIENCE: Comprising Astronomy, Chem- istry, Dynamics, Electricity, Heat, Hydrodynamics, Hydrostatics, Light, Magnetism, Mechanics, Meteorology, Pneumatics, Sound, and Statics. Preceded by an Essay on the History of the Physical Sciences. In one handsome octavo volume of 694 pages, and many illustrations : cloth, $5. EILL {JOHN), M.D., and "^MITH {FRANCIS O.), M.D., Prof, of the TnstUuteaof Medicineinthe Univ. of Penna. AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE ; for the Use and Examination of Students. A new edition, revised and improved. In one very large and handsomely printed royal 12m(i . volume, of about one thousand pages, with 374 wood outs, cloth, $4; strongly bound in leather, with raised bands, $4 75. TJARTSHOBNE {HENRT), M. D., Professor of Hygiene in the University of Pennsylvania. A CONSPECTUS OF THE MEDICAL SCIENCES; containing Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, Surgery, and Obstetrics. Second Edition, thoroughly revised and improved. In one large royal 12mo. volume of mora th^an 1000 closely printed pages, with 477 illustrations on {^Lately Issued.) their raemories with the smallest possible expendi- ture of time.— JV, Y. Med. Journal, Sept. 1874. The student will find this the most convenient and useful boot of the kind on which he can lay his band. — Pacific Med. and Surg. Journ., Aug. 1874. This is the best hook of its kind that we have ever examined. It is an honest, accurate, and concibe compend of medical sciences, as fairly as possible representing their present condition, The changes and the additions have been so judicious and thorough as to render it, so far as it goes, entirely trustworthy. If students must have a conspectus, they will be wise to procure that of Dr. Hartshorue.— 2)e«roif Rev. of Med and Pliarm., Aug 1874. Cloth, $4 25 i leather, $5 00. royal wood The work before us has already successfully assert- ed its claim to the confidence and favor of the profes- sion • it but remains for us to say that in the present edition the whole work has been fully overhauled and brought up to the present status of the science.- Atlanta Med. and Surg. Journal, Sept. 1874. The work is intended as an aid to the medical stu- dent and as such appears to admirably fulfil its ob- lect by its excellent arrangement, the full compilation of facts the perspicuity and terseness of language, and the clear and instructive illustrations in some parts of the work.— American Journ. of Pharmacy, Philadelphia, July, 1874. The volume will be found useful, not only to stu- dents, bnt to many others who may desire to refresh f VDL.0 W {J. L.), M. D. A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised and greatly extended and enlarged. With 370 illustrations. In one handsome royal 12mo. volume of 816 large pages, cloth, $3 25 ; leather, $3 75. The arrangement of this volume in the form of question and answer renders it especially suit- )le for the office examination of students, and for those preparing for graduation. mANNER {THOMAS HAWKES), M.D.,^c. ^ A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- NOSiS. Third American from the Second London Edition. Revised and Enlarged by TiLBUKT Fox, M. D., Physician to the Skin Department in University College Hospital, &0. In one neat volume small I2mo.,ofabout 375 pages, oloth, $150. #41.* On page fill, it will be seen that this work is offered as apremium for procuring new sub- scribers to the "Ambbioan Jodrhal of thb Mbdioai Scibnobs." Henry C. Lea's Publications — (Anatomy). QBAY (HENRY), F.B.S., Lecturer on Anatomy at Si. Qeorffe's SoapUalj London. ANATOMY, DESCRIPTIYE Al^D SURGICAL. The Drawings by H. V. Cartbr, M. D., late Demonstrator on Anatomy at St. George's Hospital ; the Dissec- tions jointly by the Author and Dr. Carter. A new American, from the fifth enlarged and improved London edition. In one magnificent imperial octavo volume, of nearly 900 pages, with 466 large and elaborate engravings on wood. Price in cloth, $6 00 ; lea- ther, raised bands, $7 00. {Lately Publisked.) The author has endeavored in this work to cover a more extended range of subjects than Is ons- tomary in the ordinary text-books, by giving not only the details necessary for the student, but also the application of those details in the practice of medicine and surgery, thus rendering it both a guide for the learner, and an admirable work of reference for the active practitioner. The en- gravings form a special feature in the work, many of them being the size of nature, nearly all original, and having the names of the various parts printed on the body of the out, in place of figures of reference, with descriptions at the foot. They thus form a complete and splendid series, which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to refresh the memory of those who may find in the exigencies of practice the necessity of recalling the details of the dissecting room ; while combining, as it does, a complete Atlas of Anatomy, with a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of essential use to all physicians who receive students in their offices, relieving both preceptor and pupil of much labor in laying the groundwork of a thorough medical education. Notwithstanding the enlargement of this edition, it has been kept at its former very moderate price, rendering it one of the cheapest works now before the profession. The illuHtrationB are beautifully execnted, and ren der this work an indispensable adj anot to the library of the surgeon. This remark applies with great force to those surgeons practising at a distance from our large cities, as the opportunity of refreshing their memory by actual dissection is not always attain- able.— Canatia Med. Journal, Aug, 1870. The work Is too well known and appreciated by the profession to need any comment. No medical man can afford to be without it, if its only merit were to serve as a reminder of that which so soon becomes forgotten, when not called into frequent use, viz., the relations and names of the complex organism of the human body. The present edltionis much improved. '-California Med. Gazette, July, 1870. Gray's Anatomy has been so long the standard of perfection with every student of anatomy, that we need do no more than call attention to the improve- ment in the present edition. — Detroit Review of Med. and Pharm., Aug. 1870. 'From time to time, as snccesslve editions have ap- peared, we have had much pleasure in expressing the general judgment of the wonderfnl excellence of Gray's Anatomy. — Cincinnati Lancet, July, 1870. Altogether, it is unquestionably the most complete and serviceable text-book in anatomy that has ever been presented to the student, and forms a striking contrast to the dry and perplexing volumes on the same subject through which their predecessors strug- gled in days gone by. — K. T. Med. Record, June 15, 1870. To commend Gray's Anatomy to the medical pro- fession is almost as much a work of supererogation as it would be to give a favorable notice of the Bible in the religious press. To say that it is the most complete and conveniently arranged text-book of its kind, is to repeat what each generation of stndenta has learned as a tradition of the elders, and verified by personal experience. — If T. Med. Ga%ette, Dec. 17,1870. gmiTH {HENRY B.), M.D., and TJORNEB ( WILLIAM E.), M.D„ '^Prof. of Surgery in the Univ. of Penna., Ac. Late Prof, of Anatomy in the Univ. ofPenna., Ar. AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, cloth, with about six hundred and fifty beautiful figures. $4 60. The plan of this Atlas, which renders it so peon- 1 the kind that has yet appeared ; and we must add liarly convenient for the student, and its superb ar- 1 the very beautiful manner in which it Is "«ot up ' tistical execution, have been already pointed out. We j is so creditable to the country as to be flattering to must congratulate the student upon the completion of this Atlas, as it Is the most convenient work of i our national pride. — American Medical Journal. OCHAFER [EDWARD ALBERT), M.D., fJ Assistant Profetsor of PhyHology in University Oollege, London A COURSE OF PRACTICAL HISTOLOGY: Bei'n^ an Introduction to the Use of the Microscope. In one handsome royal 12mo. Tolume of 304 pases, with numerous illustrations: cloth, $2 00. (Just Ready.) We are very much pleased with the book, which teaches the student simply how to use his instruments and conduct his studies without going further into the microscopic anatomy of the tissues and organs than is absolutely necessary. What we particularly praise in it is the way in which it takes the student by the hand, as it were, showing him what to do, and explaining simply, hut thoroughly, how to do \t,—Bosu. n Med. and Surg. Jou/rn„ April, 1877. It is devoted wholly to the use of the microscope in the study of histology. It is a very thorough and prac- tical httle handbook of the best methods of making his- tological preparations and examining them under the microscope— ^m Joum. of Microscopy, May, 1877. From first to last the hook shows that it has been made by one who is accustomed to teaching the subject about which he writes, and has practical knowledge of the obstacles and difficulties to be met with. We heartily recommend the volume to those who wish a concise and reliable handbook.— iVeMi Bemedies, May 15, 1677. HORNER'SSPECIAL ANATOMY AND HISTOLOGY. Eighth edition, extensively revised and modified In 2 vols. 8vo., of over 1000 pages, with more than 300 wood-ciitB : cloth. IB6 00 HODGES' PRACTICAL DISSECTIONS. Second Edition, thoronghly revised. In one neat royal 12mo. volume, half hoand, $2 00. SHARPEY AND QUAIN'S HUMAN ANATOMY. Re- vised, with Noles and Additions, by Joseph Leidt M.D., Professor of Anatomy in the University of Pennsylvania Complete in two large octavo vol- umes. of about 1300 pages, with 511 illustrations • cloth $6 00. '^ILSON (ERASMUS), F.B.S. A SYSTEM OF HUMAN ANATOMY, General and Special. Edited by W.H. GoBRBCHT, M.D., Professor of General and Surgical Anatomy in the Medical Col- lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In one large and handsome octavo volume, of over 600 large pages; cloth, $4 00; leather, She publisher trusts that the well-earned reputation of this long-established favorite will be more than maintained by the present edition. Besides a very thorough revision by the author it has been most oarefuUy examined by the editor, and the efforts of both have been directed to in- troducing everything which increased experience in its use has suggested as desirable to render it a complete text-book for those seeking to obtain or to renew an acquaintance with Human Ana- tomy. fJEATH (CHRISTOPHER), F. R. 0. S., ■*-*■ Teacher of Operative Surgery in Ohiveratty Golleffe, London. PKACTICAL ANATOMY: A Manual of Dissections. From the Second revised and improved London edition. Edited, with additions, by W W Kbem M. D., Lecturer on Pathological Anatomy in the Jefferson Medical College Philadelohia' In one handsome royal 12mo. volume of 678 pages, with 247 illustrations. ' Cloth $3 50 • taining Its hold upon the slippery slopes of anatomy —At. iouts Med. and Surg. Journal, Mar. 10, 1871. ' It appears to ns oertaio that, as a guide in'disseo- tlon, and ae a work containing facts of anatomy in brief and easily understood form, this manual is complete. This work contains, also, very perfect Illustrations of parts which can thus be more easily understood and studied ; in this respect it compares favorably -rlth works of much greater pretension Buch manuals of anatomy are always favorite wovke with medical students. We would earnestly recom- mend this one to their attention; it has excellences which make it valuable as a guide in dissecting ar well as in studying anatomv.— Bw^-aJo Mediealand Surgical Journal, Jan. WJl. leather, $4 00. Dr. Keen, the American editor of this work, In his preface, says: "In p:fe8enting this American edition of ' Heath's Practical Anatomy,' I feel that I have been instrumental in supplying a want long felt for a real dissector's manual," and this assertion of its editor we deem is fully justified, after an examina- tion of its contents, for it is really an excellent work. Indeed, we do not hesitate to say, the best of'its class with which we are acquainted ; resembling Wilson In terse and clear description, excelling most of the so-called practical anatomical dissectors in the scope of the subject and practical selected matter. . . . In reading this work, one is forcibly impressed with the great pains the author takes to impress the sub- ject upon the mind of the student. He is full of rare and pleasing little devices to aid memory in main- B ELLAMY(E.),F.R.C.S. THE STUDENT'S GUIDE TO SURGICAL ANATOMY: A Text- Book for Students preparing for their Pass Examination. With engravings on wood -In one handsome royal 12mo. volume. Cloth, $2 25. (Lately Published.) We welcome Mr. Bellamy's work, as a contribu- tion to the study of regional anatomy, of equal value to the student and the surgeon. It is written in a clear and concise style, and its practical suggestions add largely to the interest attaching to its technical details — Chicago Med. Examiner, March 1, 1874. We cordially congratulate Mr. Bellamy upon hav- ing produced it — Med. Times and Qaz. We cannot too highly recommend ii.—StuienVs Journal. Mr. Bellamy has spared no pains to produce a re- ally reliable student's guide to surgical anatomy- one which all candidates for surgical degrees may consult with advanrage, and which possesses much original mutter.— Med. Press and Circular pLELAND (JOHN), M.D., ^ Professor of Anatomy and Physiology in Queen'' s College, Oalway. A DIRECTORY FOR THE DISSECTION OP THE HUMAN BODY In one small volume, royal 12mo. of 182 pages: cloth, $1 25. (Now Ready.) This work makes no pretensions to be a manual of descriptive anatomy, the aim of the author being to furnish such instruction as will enable the student to make the most of his opportuni ties in a practical course of dissections. It in nowise supersedes the ordinary text-books of anatomy, but in conjunction with them, will afford, in a clear and compendious form the infer mution required as a guide in the dissecting-room. The author is well known us one of the most experienced practical anatomists in Great Britain, and has here recorded the results of many years' assiduous labor in guiding beginners through this arduous part of their training. The distinguished Professor of Anatomy in Galway fm.:~<-- _.,.. .... has done good work by the publication of this small volume. Every student of anatomy workingin the dis- secting room must often have felt the want of a short, concise, and handy guide to his work. This he will find in the "Directory." The directions are short, not overloaded with facts, and caneftsilyberead over before beginning a part, so that in a short time a working plan of the proposed method of procedure is brought clearly before the student's mind. We cor- dially recommend every dissector to provide himself at once with this shortbut invaluable "Directory." —Edin. Med. Journ., Feb. 1877. This Is a plain, convenient, dissecting guide to bo used oyer the subject. As such, it will commend it- self to the student by the lucid composition and di>. tinct directions of the author.— Jfeci and Reporter, Feb. 1877. Surg. This volume does not interfere with the text-books in comm.jn use, but tnerely supplements them and piepai-esthe dissector for many practical difficulties that are apt to perplex the inexperienced It is of a. convenientsizeforcarryingin the pocket, and should .T 'S 'Jsi""^"'^''"" °f *™''y "'nieat of medicine - N. ¥. Med. Journ., March, 1877. H ARTSHORNE (HENRY). M.D., Professor of Hygiene, etc , in the Univ. ofPenna. HANDBOOK OF ANATOMY AND PHYSIOLOGY. Second Edj. tion, revised. In one royaU2mo. volume, with 220 woodcuts; cloth, $1 76. {Just Issued ) Henry C. Lea's Publications — (Physiology). flARPENTER (WILLIAM B.), M.D., F.B.S.„F.G.S., F.L.S., ^ Regi/ttrar to University of London, etc. PRINCIPLES OF HUMAN PHYSIOLOGY; Edited by Henry Power, M.B. Lond., F.R.C.S., Examiner in T^atural Sciences, University of Oxford. Anew American from the Eighth Revised and Enlarged English Edition, with Notes and Addi- tions, by Francis Q. Smith, M. D., Professor ofthelnstitntes of Medicine in the Univer- sity of Pennsylvania, etc. In one very large and handsome octavo volume, of 1083 pages, with tv. opiates and 373 engravings on wood; cloth, $5 50; leather, $6 60. {Notv Ready.) The great work, the crowning labor of the distinguished author, and through which so many generations of students have acquired their knowledge of Physiology, has been almost metamor- phosed in the effort to adopt it thoroughly to the requirements of modern science. Since the appearance of the last American edition, it has had several revisions at the experienced hand of Mr. Power, who has modified and enlarged it so as to introduce all that is important in the investigations and discoveries of England, France, and Germany, resulting in an enlargement of about one-fourth in the text. The series of illustrations has undergone a like revision, a large proportion of the former ones having been rejected, and the total number increased to nearly four hundred The thorough revision which the work has so recently received in England, has rendered unnecessary any elaborate additions in this country, but the American Editor, Pro- fessor Smith, has introduced such matters as his long experience has shown him to be requisite for the student. Every care has been taken with the typographical execution, and the work ig presented, with its thousand closely, but clearly printed pages, as emphatically the text-book for the studentandpractitioner of medicine — the one in which, as heretofore, especial care is directed to show the applications of physiology in the various practical branches of medical science. Notwithstanding its very great enlargement, the price has not been increased, rendering this one of the cheapest works now before the profession. What an enormous labor the editor has had to perform, incorporating into the text the isolated discoyeries, and observations of various authors in the different depart- ments of physiology, may be partly gathered from his preface. Such editing is, indeed, a most arduous task, and one to which but few "would aspire, for the reputa- tion gained is by no means proportionate to the labor expended. In this case the work has been well and faithfully done, and no mean skill has been exbibited in iniroducing so much that is new, and leaving the work BO thoroughly " Carpenter's Physiology" after all. — Ohio Med. ajid Surg. Journ.f Feb. 1877. "Good wine needs no bush" says the proverb, and an old and faithful servant like the " big" Carpenter, as carefully brought down as this edition has been by Mr. Henry Power, needs little or no commendation by us. Such enormous advances have recently been made in our physiological knowledge, that what was perfectly new a year or two ago, looks now as if it had been a received and established fact for years. In this encyclopffidic way it is unrivalled. Here, as it seems to ua, is the great value of the book; one is safe in sending astudent to it for information on almost any given subject, per- fectly certain of the fulness of information it will con- vey, and well satrsfied of the accuracy with which it will there be found stated. — London Med. Times and Gazette. Feb. 17,1876. Thusf ully are treated the structure and functions of all the important organs of the body, while there are chap- ters on sleep and somnambulism; cbapterson ethnology; a full section on generation, and abundant references to the curiosities of physiology, as the evolution of light, heat, electricity, etc. In short, this new edition of Car- penter is, as we have said at the start, a very encyclo- pedia of modern physiology. — The. Clinic, Feb. 24, 1877. The merits of " Carpenter's Physiology are so widely known and appreciated that we need only allude briefly to the fact that in the latest edition will be found a com- prehensive embodiment of the results of recent phywio- logical investigation. Care ha.s been taken to preserve the practical character of the original work. In fact the entire work has been brought up to date, and bears evidence of the amount of labor that has been bestowed upon it by its distinguished editor, Mr Henry Power. The American editor has made the latest additioris, in order fully to cover the time that has elapsed since the last English edition. — N. T. Med. Journal, Jan. 1877. A more thorough work on physiology could not be found. In this all the facts discovered by the late re- searches are noticed, and neither student nor practi- tioner should be without this exhaustive treatise on an important elementary branch of medicioe. — Atlanta Med. and Surg. Journal, Dec. 1876. We regard it, as a textrbook, aa near perfect as could be, and a book of reference ofihe greatest value to the practitioner, the student, and the lecturer.— iVas/iuii/e Joum. of Medicine and Surgery, Dec. 1876. ^IRKES (WILLIAM SEJSfHOUSE), M.D. A MANUAL OF PHYSIOLOGT, Edited by W, Morrant Baker, M.D., F.R.C.S. A new American from the eighth and improved London edition. With about two hundred and fifty illustrations. In one large and handsome royal 12mo. vol- ume. Cloth, $3 25; leather, $3 75. {Lately Issued.) Kirkes' Physiology has long been known as a concise and exceedingly convenient text-book, presenting within a narrow compass all that is important for the student. The rapidity with which successive editions have followed each other in England has enabled the editor to keep it thoroughly on a level with the changes and new discoveries made in the science, and the eighth edition, of which the present is a reprint, has appeared so recently that it may be regarded ae the latest accessible exposition of the subject. On the whole, there is very little in the book which either the student or practitioner will not find of practical value and consistent "with our present knowledge of this rapidly changing science ; and we have no hesitation in expressing our opinion that this eighth edition is one of the best handbooks on physiology which we have in our language. — N. T. Med. Record, April 16, 1873. This volume might well be used to replace many of the physiological text-books in use in this coun- try. It represents more accurately than the works of Dalton or Flint, the preeent state of onr knowl- edge of most physiological qdestions, while it is much less bulky aod far more readable than the lar- ger text-books of Carpenter or Marshall. The book is admirably adapted to be placed In the hands of atndentB.—Boston Med. and Surg. Joum., April 10, 1873. In its enlarged form it is, in onr opinion, still the best book on physiology, most useful to the student. —Phifa.'Med. Times, Aug. 30, 1873. This is undoubtedly the best work for students of physiologyextant.— Cinei7inafiJf«d. iVewff, Sept. '73. It more nearly represents the present condition of physiology than any other text-book on the subject.— Detroit Rev. of Med. Pharm., Nov. 1873. Henry C. Lba'b Publications — (Physiology). f)ALTON {J. p.), M. D., "'-' Professor of Physiology in the College of Physieia/ns and Surgeons, New York, &c. A TREATISE ON HUMAiN^ PHYSIOLOGY. Designed for the use of students and Practitioners of Medicine. Sixth edition, thoroughly revised and enlarged, with three hundred and sixteen illustrations on wood. In one very beautiful octavo vol- ume, of over 800 pages. Cloth, $5 50 ; leather, $6 50. {^Just Issited.) From the Preface to the Sixth Edition . In the present edition of this book, while every part has received a careful revision, the ori- ginal plan of arrangement has been changed only so far as was necessary for the Introduction of new material. The additions and alterations in the text, requisite to preselit conci3ely the growth of positive physiological knowledge, have resulted, in spite of the author's earnest efforts at condensation, in an increase of fully fifty per cent, in the matter of the work. A change, however, in the ty- pographical arrangement has accommodated these additions without undue enlargement in the bulk of the volume. The new chemical notation and nomenclature are introduced into the present edition, ns hav ing now so generally taken the place of the old, that no confusion need result from the change. The centigrade system of measurements for length, volume, and weight, is also adopted, these measurements being at present almost universally employed in original physiological investiga- tions and their published accounts. Temperatures are given in degrees of the centigrade scale, usually accompanied by the corresponding degrees of Fahrenheit's scale, inclosed in brackets. ^Ew York, September, 1875. During thii past few years several new works on phy- siology, and new editions of old works, have appeared, competing for the favor of the medical student, but none will rival this new edition of Dalton. As now enlarged, it will be found also to be. in general, a satisfantory work of reference for the practitioner. — Chicago Med. Joum. and Examiner, Jan. 1876. Prof Dalton has discussed conflicting theories and conclusions regarding physiological questions with a fairness, a fulness, and a conciseness which lend fresfa. ness and vigor to the entire book. But his discussions have been so guarded by a refusal of admission to those speculative and theoretical explanations, which at beat exist in the minds of observers themselves as only pro- babilities, that none of his readers need be led into grave errors while making them a study. — The Medical Record, Feb. 19, 1876. The revision of this great work has brought it forward with the physiological advances of the day, and renders it, as it has ever been, the finest work for students ex- tant. — Nashvills Joum. of Med. and Surg., Jan. 1876. For clearness and perspicuity, Dalton's Physiology ■sommended itself to the student years ago, and was a pleasant relief from the verbose productions which it supplanted. Phyaiolngy has, however, made many ad- vances since then— and while the style has been pre- served intact, the work in the present edition has been brought up fully abreast of the times. The new chemical notation and nomenclature have also been introduced into tlie present edition. Notwithsianding the multi- plicity of text-books on phyBiology, this will lose none of its old time popularity. The mechanical execution of the work is all that could be desired. — Peninsular Journal of Medline, Dec. 1875. This popular texi-book on physiology comes to us in its, sixth edition with the addition of about fifty percent, of new matter, chiefly in the departments of patho- logioal chemistry and the nervous system, where the principal advances have been realized. With so tho- rough revision and additions, that keep the work well up to the times, its continued popularity may be confi- dently predicted, notwithstanding the competition it may encounter. The publisher's work is admirably done. — St. Louis Med. and Surg. Journ , Dec. 1875. We heartily welcome this, the sixth edition of this admirable text book, than which there are none of equal brevity more valuable. It is cordially recommended by the Professor of Physiology in the University of Louisi- ana, as by all competent teachers in the United States and wherever the English language is read, this book has been appreciated. The present edition, with its 316 admirably executed illustrations, has been carefully revised and very much enlarged, although its bulk does not seem perceptibly increased. — New Orleans Medical and Surgical JournaXf March, 1876. The present edition is very much superior to every other, not only in that it brings the subject up to the times, but that it doss so more fully and satisfactorily than any previous edition. Take it altogether, it re- mains, in our humble opinion, the best text bock on physiology in any land or language.— T^ Clinic, Nov. 6. 1875. 7) UNOLISON (ROBLEY), M. i>., -^-^ Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and extensiTely modified and enlarged, with five hundred and thirty-two illastrations. In two large and handsomely printed octavo volumes of about 1600 pages, cloth, $7 00. ■^ PHYSIOLOGICAL CHEMISTRY. Translated from the second edi- tion by aBOESE B. DAT, M. D., F. R. S., ic, edited by R. B. Robers, M. D., Professor of Chemistry in the Medical Department of the University of Pennsylvania, with illustrations selected from Fnnke's Atlas of Physiological Chemistry, and an Appendix of plates. Com- plete in two large and handsome octavo volumes, containing 1200 pages, with nearly two hundred illustrations, cloth, $6 00. •DT THE BAME AUTEOR. ^ MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German, with Notes and Additions, by J Chbston Mohris, M. D., with an Introductory Essay on Vital Force, by Professor Samubi, Jackson, M. D., of the University of Pennsyl- vania. With illustrations on wood. In one very handsome octavo volume of 336 paeos oloth, $2 2S. MARSHALVS OUTLINTS OF PHYSIOLOGY, HU- MAN AND 00MP4KATIVB. With AdditionB by Fkaxcis GcEifEy Smith, M.D. With aumeroas II- lustratiotis. la one larjje and bandaome octavo volume, of 1028 pages ; cloth, $6 SO ; leather raised baadf, $7 50. 10 Hbnbt C. Lba's Publications — (Chemistry). ATTFIELD [JOHN), Ph.D., Professor of Practical Ghemiatry to the PharmaceiUical Society of Oreat Britain, &c. CHEMISTRY, GENERAL, MEDICAL, AND PHARMACEUTICAL ; including the Chemistry of the TJ. S. Pharmacopoeia. A Manual of the General Principles of the Science, and their Application to Medicine and Pharmacy, Seventh American edi- tion, revised from the Sixth English edition by the author. In one handsome royal 12mo. volume of 668 pages, with 87 illustrations : cloth, $2 75 ; leather, $3 25 (Just Issued. ) This work has received a very careful revision atthe hands ofthe author, resuUingin aconslde- rable increase in size, together with the addition of a handsome series of illustrations. Notwith- standing these improvements, the price has been maintained at the former very moderate rate. A book which has passed through six editions in nine years needs from joumaliats only such announcements as are necessary to keep the profession aware of the continued interest of the author in hia progeny ; we, therefore, are content with the commendation that the book before us is broufthfe abreast of the times. — Phila. Med. Times, Oct. 28, 1876. After having used it as a text-book in the laboratory of the PhiladelpbiaCoUege of Pharmacy during the la^ five years, we can speak from our own experience, and testify to its intrinsic value in the instruction of the student. The mor^ we have used it, the more we were pleased with it, and on the appearance of a new, revised, and enlarged edition, we take occasion to again cordi- ally recommend it, helieTing that for the practical in- struction of pharmaceutical students in chemistry it has no superior in the English language.— .4m. Joum. of Pharm., Nov. 1876. The book, by a well arranged system, introduces the student into the Science of Chemistry, giTing him at each step suflBcient information to enable him to per- form experiments with his own hands; the experiments are partly of synthetical and partly of analytical inte- rest; in this way the editor succeeds admirably in avoiding a dry monotonous enumeration of facts. The variety which he gives is certainly well calculated to prevent the reader from getting tired. This variety. however, is not such as to bewilder the mind, nor are the experiments described calculated only to serve a^ a pleasant pastime. The student who reads the book and executes the experimentfl mentioned, cannot help but fee] deeply interested in the subject, and indeed, will, going through the practical work, find it a very agree- able recreation. — Cincinnati Clinic^ Oct. 28, 1876. It brings up our knowledge of the subject to the pre- sent date, and has been enriched with numerous wood engravingsillustrative of apparatus and modes of work. The arrangement of the work is admirable, and to each element its more important compounds used in medi- cineor pharmaey are given, togetherwith both syntheti- cal and analytical reactions. The systematic analysis of compounds, substances or fluids is also treated of, and copious tables are ^ven showing the modes of sys- tematically separating thR different elements from one another. — Canada Med. and Surg. Journ., Nov. 1876. As a compact manual ofthe general principles of the science and their applications in medicine and phar- macy, it has no rival, and the frequent and thnrouizh revision it receives keeps it in all respects up with the times. The American edition, which covers the United States Pharmacopoeia, is prepared under the author's supervision — Boston .Toumal of Chemisiry, Nov 1^76. Admirably adapted to the use of medical students.— Atlanta Med. Journ.jOct. 1876. F' OWNES [GEORGE), Ph.D. A MANUAL OP ELEMENTARY CHEMISTRY; Theoretical and Practical. With one hundred and ninety-seven illustrations. A new American, from the tenth and revised London edition. Edited hy Robert Bridges, M. D. In one large royal 12mo. volume, of about 860 pp., cloth, $2 75 ; leather, $3 25. This work is so well known that it seems almost puperfluons for us to, speak about it. It has been a fivorite text-book with medical students for years, and its popularity has in no respect diminished. "Whenever we have been consulted by medical stu- dents as has frequently occurred, what treatise on chemistry they should procure, we have always re- commended Pownes', for we regarded it as the best. There is no work that combines so many excellep- cas. It is of convenient size, not prolix, of plain perspicQouB diction, contains all the most recent iiecoveries, and Is of moderate price. — Cincinnati Med. Repertory, Aug. 1869. Here is a new edition which has been long watched for by eager teachers of chemistry. In its new garb and under the editorship of Mr. Watts, it has resumed its old place as the most successful of text-books.— Indian Medical Qazette, Jan. 1, 1869 ■ Large additions have been made, especially in the department of organic chemistry, and we know of no other work that has greater claims on the physician, pharmaceutist, or student, than this. We cheerfully recommend it as the best text-book on elementary chemistry, and bespeak for it the careful attention of students of pharmacy. — Chicago Pharmacist, Aug. 1869. It will continue, as heretofore tohold the first rank as a text-book for students of medicine. — Ohicai;o Med. Examiner, Aug. 1869. Fownes's Chemistry has for many years maintained a foremost rank as an authority, and now it comes ta us in its tenth edition, thor ugbly rejuvenated and fully up to the present demand of the student and practitioner. Any one who studies the work carefully will be surprised at the perfect ness of its method, the conciseness of its langnaa;e, and the lucidity "f the ideas advanced, This latter is saying a great deal for those parts of the science generally considered the most abstruse.— iV. 7. Med. Record, Sept. 1, 18()9. T>OWMAN (JOHN E.),M. D, PRACTICAL HANDBOOK OF MEDICAL CHEMISTKY. Edited by C. L. BiiOXAM, Professor of Praotioal Chemistry in King's College, London. Sixth American, from the fourth and revised English Edition. In one neat volume, royal 12mo. , pp. 351, with numerous illustrations, cloth, $2 25. nr THE SAME AUTHOR. [Lately Issued.) INTRODUCTION TO PRACTICAL CHEMISTRY, INCLTTDINO ANALYSIS. Sixth American, from the sixth and revised London edition. With numer ouB illustrations. In one neat toI., royal 12mo., cloth, $2 25. KNiPP'S TECHNOLOGT ; or Chemistry Applied tc the Arts, and to Mannfactures. With American additions by Prof. Walter K. Johnson. In two very handsome octavo volumes, with 500 wood engravings, cloth, $6 00, Hknry C. Lka's Publications — (Chemistry). 11 J>LOXAM CO. L.), ■^^ Professor of Ohemistry in Single College, London. CHEMISTRY, INORGANIC AND ORGANIC. From the Second Lon- don Edition. In one very handsome octavo volume, of 700 pages, with about 300 illustra- tions. Cloth, $4 00; leather, $5 00. It has been the author's endeavor to produce a Treatise on Chemistry sufficiently comprehen- sive for those studying the science as a branch of general education, and one which a student may use with advantage in pursuing hischemlcal studies at one of the colleges or medical schools. The special attention devoted to Metallurgy and some other branches of Applied Chemistry renders the work especially useful to those who are being educated for employment in manufacture. titioners who wish to review their chemistry, or have We have in this work a complete and most excel- lent text-book for the use of echools, and can heart- ily recommend U as such. — Boston Med. and Surg. Journ., May 28, 1874. The aboveis the title of a work which we can most conacientiouBly recommend to students of chemistry. It is aa easy as a work on chemiHtry could be made, at the same time that it presents a full account of that science as it now stands, We have spoken of the work as admirably ad apted to the wants of students ; It is quite as well suited to the requirements of prac- occaiilon to refresh their memories on any point re- lating to it. In a word, it is a book to he read by all who wish to know what is the chemistry of the pre- sent A&y.— American Practitioner j Nov. 1873. Prof. Bloxampossessespre-eminently the inestima- ble gift of perspicuity. It is a pleasure to read his books, for he is capable of making very plain wbat other authors frequently have left very obscure. — Va. Clinical Record, Nov. 1873. fJLO WES (FRANK), D.Sc, London. ^ Senior Science- Master atthe SighSchool, Newcastle-uvder Lyme, etc. AN ELEMENTARY TREATISE ON PRACTICAL CHEMISTRY AND QUALITATIVE INORaANIC ANALYSIS. Specially ndapted for Use in the Laboratories of Schools and Colleges and by Beginners. From the Second and Revised English Edition, with about fifty illustrations on wood. In one very handsome royal 12mo. volume of 372 pages : cloth. $2 50. {Jicst Ready.) *' It h.as been my aim throughout to give all necessary directions so fully and simply as to reduce to a minimum the amount of assistance required from a teacher. The language employed has been rendered simple and intelligible by avoiding the unnecessary use of scientific terms and by explaining or paraphrasing in ordinary words any such terms when introduced for the first time. The directions how to work and the description of the preparation and use of appa- ratus have been given more fully than is usual. . . . The introduction as appendices into this edition of the reactions and methods of detection of the rarer elements and of the use of the spectroscope with a spectrum chart, will, it is believed, render th.6 book more useful to advanced students. ' ' — Preface. ance of the professor. The aim of the author has been to make it as simple as possible, and for tbis purpose he has abandoned many technical phrases and substituted therefor simple paraphrased terms. — Nashville Med. and Sun ■ Journ., July, 1877. From J. S. Schawck, M.D., LL.D., Prof, of Chemistry in College of New Jersey, Princeton. "It seems to me that it deserves to rank high among the considerable number of small works upon analytical chemistry of late issued from the press. It is clear and concise, and yet full enough to be read where hut little aid can be had from a teacher." From F. A. Genth, Ph.D., Prof, of Chemistry, Univ. of Penna. ** Clowes' work is admirably adapted to the wants of beginners in analytical chemistry. A distinguish- ing feature of it is the minute description given for the execuHon of each experiment. Attention is con- tlnnally called to the characteristic reactions of the members of the various groups ; something which should always he done, but which is generally dis- regarded in similar publications.'* With this manual before him, the advanced stu- dent can undertalie experiments without the assist- pEMSBN {IRA), M.D., Ph.D., -*'«^ Professor of Ofiemistry in the Johns ffopkins University Baltimore. PRINCIPLES OP THEORETICAL CHKMISTRY, with special reference to the Constitution of Chemical Compounds. In one handsome royal 12ino. vOl. of over 232 pages: oloth, $1 50. (iVbw Ready.) have led to many important discoveries, — Am.. Journ. "f Pharm., June, 1877. It is an admirable presentation of the leading doc- trinPB of modern chemistry. If some subjects seem briefly treated, it in simply because so little is really known about them, and the author has had the rare This volume is devottd to the principles upon which the theoretical structure of modern chemi'^try is based, and as such it is a very valuable addition to ' our litera- ture, insomuch as it discusses, in a clear and compre- hensive manner, the various laws governing chemical combination and decomposition, and the various theo- ries which have been advanced for explaining an- nounced facts. In our opinion, the work will prove to be a valuable aid to the chemical student who would familiarize himself with the theories of the science that good sense not to lumber his pages with unprotitahle ppeoulationa and mere " guesses at the truth " — Boston Journ. of Chem., May, 1877. TUOHLER AND FITTIG. ^' OUTLINES OF ORGANIC CHEMISTRY. Translated with Ad- ditions from the Eighth German Edition. By Ika Remsen, M.D., Ph.D., Professor of Chemistry and Physics in Williams College, Mass. In one handsome volume, royal 12mo of 550 pp., cloth, $3. As the numerous editions of the original attest, this work is the leading text-book and stjindard authority throughout Germany on its important and intricate subject — a position won for it by the clearness artd conciseness which are its distinguishing characteristics. The translation has been executed with the approbation of Profs. Wijhler and Fittig, and numerous additions and alterations have been introduced, so as to render it in every respect on a level with the most advanced condition of the science. 12 Henry C. Lea's Publications — (Mat. Med. and Therapeutics). pARRJSH (ED WARD), Late Professor of Maierta Medica in the Philadelphia GoUeffe of Pharmacy. A TREATISE ON PHARMACY. Designed as a Test-Book for tie Student, and as a Quide for the Physician aad Pharmaceutist. With many Formiilse ana Prescriptions. Fourth Edition, thoroughly revised, by Thomas S. Wib&and. In one handsome octavo volume of 977 pages, with 280 illustrations ; cloth, $b 50 j leather, $6 50, (Lately Issued.) The delay in the appearance of the new U. S. Pharmacopoeia, and the sudden death of the au- thor, have postponed the preparation of this new edition beyond the period expected. The notes and memoranda left by Mr. Parrish have been placed in the hands of the editor, Mr. Wjegand, who has labored assiduously to embody in the work all the improvements of pharmaceutici|} sci- ence which have been introduced during Ghe last ten years. It is therefore hoped that the new edition will fully maintain the reputation wbitfh the volume has heretofore enjoyed as a standard text-book and work of reference for all engaged in the preparation and dispensing of medicines. an honored place on our own bookabelves. — I>uMin Of T^r. Parrisli's great work on pharmacy it only remains to be said that the editor hab accomplished his work so well as to maintain, in this fourth edi- tion, the high standard of excellence which it bad attained in previous editions, under the editorship^of its accomplished auchor. This has not been accom- plished without much labor, and many additions and Improvements, involvingchangesiD the arrangement of the several parts of the work, and the addition of much new matter. With the modifications thus ef- fected it constitutes, as DOW presented, a compendium of tlie science and art indiapensable to the pharma- cist, and of the utmost' value to every practitioner of medicine desirous of familiarizing himself with the pharmaceutical preparation of the articles which he prescribes for his patients. — Chicago Med. Journ.f July, 1874. The work is eminently practical, and has the rare merit of being readable and interesting, while it pre- serves a strictly scientific character. The whole work reflects the greatest credit on author, editor, and pub- lisher Itwill conveysomeidea of theliberality which has beeuhestowed upon its production when we men- tion that there are no less than 280 carefully executed illustrations. In concluj-ion, we heartily recommend the work, not only to pharmacists, but also to the multitude of piedical practitioners who are obliged to compound their own medicines. It will ever hold Med. Press and Qircular, Aug. 12, 1874. We expressed our opinion of a former editioa ia terms of unqualified praise, aad we are in bo mooS to detract from that opinion in reference to the pre- sent edition, the preparation of which has fallen into competent hands. Itisabook with which no pharma- cist can dispense, and from which no physi^an can fail to derive much information of value to himia practice. — Pacific Med. andSurg.Journ., June, '74. With these few remarks we heartily commend the work, and have no doubt that it will maintain its old reputation as a text-book for the stndent, and a work of reference for the more experienced physi- cian and pharmacist . — Chicago Med. Examiner, June 16, 1874. Perhaps one, if not the most important boob upoa pharmacy which has appeared in the English lan- guage has emanated from the traoaatlantic pre^s. "Parrish's Pharmacy" is a well-known work on this side of the water, and the fact shows us that a really useful work never becomes merely local in its fame. Thanks to the jndjcioos editing of Mr. Wiegand, the posthumous edition of "Parrish" has been saved to the public with all the mature experience of its au- thor, and perhaps none the worse for a dash of new blood.— iond. Pharm. Joumaly Oct. 17, 1874. CfTILLE {ALFRED), M.D., ^ Professor of Theory and Practice of Medicinein the XTniversity of Penna. THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and Histor j . Fourth edition, revised and enlarged. In two large and handsome Svo . vols, of about 200« pages. Cloth, $10; leather, $12. {Lately Issued.) The care bestowed by the author on the revision of this edition has kept the work out of the market for nearly two years, and has increased its size about two hundred and fifty pages. Not- withstanding this enlargement, the price has been kept at the former very moderate rate. It is unnecessary to do much more than to an- nounce the appearance of the fourth edition of this well known and excellent work. — Brii. and For. Med.-Ohir. Review, Oct. 1675. For all who desire a complete work on therapeutics and materia medicafor reference, in cases involving medico-legal questions, as well as for information concerning remedial agents, Dr. Still^'s is "par ex- cellence'^ the work. The work being out of print, by the exhaustion of former editions, the author has laid the profession under renewed obligations, by the careful revision, important additions, and timely re- issuing a work not exactly supplemented by any other in the English language, if in any language. The mechauical execution handsomely sustains the well-known skill and good taste of the publisher, — 8t. Louis Med. and Surg. Journal^ Dec. 1874. The prominent feature of Dr. Still6 s great work is sound good senne. It is learned, but itR leaining is of inferior value compared with the discriminating judgment which is shown by its author in the dis- cussion of his subjects, and which renders it a trust- worthy guide in the sick-room. — Am. Practitioner, Jan. 1875. From the publication of the first edition *' Still^'s Therapeutics" has been one of the classics; its ab- sence from our libraries would create a vacuum which could be filled by no other work in the lan- guage, and its presence supplies, in the two volumes of the present edition, a whole cyelopiedia of thera- peutics.— Cfticapo Medical J'our»ai, Feb. 1875. The magnificent work of Professor Stille is known wherever the English language is read, and the art of medicine cultivated ; known so well that no enco- mium of ours could brighten its fame, and oo unfa- vorable criticism could tarnish itsreputaLion.— PAi7- adelphia Med. Times, Dec. 12, 1874. The rapid exhaustion of three editions and the uni- versal favor with which the work has been received by the medical profession, are sufficient proof of its excellence as a repertory of practical and useful in- formation for the physician. The edition before ns fully bustains this verdict, as the work has been care- fully revised and in some portions rewritten, bring- ing it up to the present time by the admission of chloral and croton-chloral, nitrite of amyl, bichlo- ride of methylene, methylic ether, lithium com- pounds, gelseminnm, and other remedies.— j4m. Journ. of Pharmacy, Feb. 1875. We can hardly admit that it has a rival in the muUitflde of its citations and the fulness of Us re- search into clinical histories, and we must assign it a place in the physician's library; not, indeed, as fully representing the present state of knowledge in pharmacodyna.mics, but as by far the most complete treatise upon the clinical and practical side of the question.— Boatom Mtd. and. Surg. Journal, Kov 3 1S74. Henry C. Lea's Publications — ( Jfa«. Med. and Therapeutics). 13 SITILLE [ALFRED), U.D, LL.D., and l/fA *-' Prof of Tlisory and Practice of OHntaal -'-'-'- Med. in Unvo. of Pa. fAJSCH {JOHN M.). PKD.. Vri.f. of Mat. Med. and But in Phila. dnl'l. Phnrmacy, Sney to the American Pharmaceutical Asaneiation. THE NATIONAL DISPENSATORY: Embracing: the Chemistry, Botany, Materia Medica, Pharmacy, Pharmacodynamics, and Therapeutics of the Pharmaco- pceias of the United States and Great Britain. .For the Use of Physicians and Pharma- ceutists. In one handsome octavo volume, with numerous illustrations. The want has long been felt and expressed of a work which, within a moderate compass, should give to the physician and pharmaceutist an authoritative esposi+ion of the Pharmaco- poeias from the existing standpoint of medical and pharm iceubioal science, For several years the authors have been earnestly engaged in the preparation of the present volume, with the hope of satisfying this want, and their labors are now sufficiently advanced to enable the pub- lisher to promise its appearance during the coming season. Their distinguished reputation in their respective departments is a guarantee that the work will fulfil all reasonable expectation as a guide in the selection, compounding, dispensing, and medicinal. uses of drugs, complete in all respects, while convenient in size, and carefully divested of all unnecessary and obsolete matter. PARQUHAESON [ROBERT], M.D., -^ Lecturer on Materia Medica at St. Mary's Hospital Medical School. A GUIDE TO THERAPEUTICS. Edited, with Additions, embracing the TT. S. Pharmacopoeia. By Frank Woodbcbv, M.D. In one neat volume, rojal 12mo. (Nearly Ready.) The object of the author has been to presf^nt in a compact and compendious form the the- rapeutics of the Materia Medica, unincumbered by botanical and pharm>ieeutical details. The volume is thus emphatically a work for the medical student, to aid in his acquiring a clear and connected view of the subject in its most modern aspects; and for the busy practitioner who may wish to refresh his memory. Under each article, In parallel columns, are given its phy- siological and therapeutical action, thus enabling the rear^erto take in at a glance the essential facts with respect to each remedy, and numerous formulae are given as examples of their prac-, tical use. Considerable additions have been introduced by Dr. Woodbury, who has made numerous changes to adapt the work, to the wants of the American student. QEIFFITH [ROBERT E.), M.D, A UNIVERSAL FORMULARY, Containing the Methods of Prepar- ing and Administering Officinal and other Medicines. The wholeadapted to Physiciars and Pharmaceutists. Third edition,thoroughly revised, with numerous additions, by John M. Maisch, Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large and handsome octavovolume of aboutSOO pages, cloth, $4 50; leather, $5 50. (Lately Issued. ) As a comparative view of the United States, the British, the German, and the French Pharmacopoeias, together with an immense amount of unofficinal formulas, it affords to the prac- titioner and pharmaceutist an aid in their.daily avocations not to be found elsewhere, while three indexes, one of "Diseases and their Remedies," one of Pharmaceutical Names, and a Weneral Index, afford an easy key to the alphabetical arrangement adopted in the text. to say that the third editioa is mach improved, and The young practitioner will find the work invalu- able in suggesting eligible modes of administering many remedies. — Am. Journ. of Pharm., Feb. 1874. To the druggist a good formulary is simply indis- pensable, and perhaps no formulary haH been more extensively used than the well-knowo work bofore as. Many physicians have to officiate, also, as drug- gists. This is true especially of' the country physi- cian, and a work which shall teach him the means by which to administer or combine hia remedies in the most efflcaciouB and pleasant manner, will al- ways hold its place upon his shelf. A formulary of this kind is of beueflt also to the city physician in largest practice.— CiTipinuaii llinic, Feb. 21, 1874. The Formulary has already proved itself accepta- ble to the medical profession, and we do not hesitate of greater practicii,! value, in consequence of the care- ful revision of Prof M&i&Gh. —Gfticago Med. Bscam^ iner, March 15, 1874. A more complete formulary than it is in its pres- ent form the pharmacist or physician could hardly •desire. To the first some such work is indispeUfia- ble, and It is hardly less easeotial to the practitioner who compounds his o wa medicines. Much of what is contained in the introduction ought to be com- mitted to memory by every student of medleiae. As a help to physicians it will be found invaluable, and doubtless will make its way into libraries not already supplied with a staudard work of the kind, — The American Practitioner, Louisville, July, '74. K LLIS {BENJAMIN), M.D. THE MEDICAL FORMULARY: being a Collection of Prescriptions derived from the writings and practice of mnny of the moat eminent physicians of America and Europe. Together with the usual Bietetic Preparations and Antidotes for Poisons. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Twelfth edl tion, carefully revised andmuch improved by Albert H. Smith, M.D. In one volume 8vc». of 376 pages, cloth, $3 00. W HATTO OBSERVE AT THE BEDSIDE AND ASTEE Death iw Medical Oases. Published under the authority of the London Society for Medical Obeei' vation. From the second London edition. 1 vol. royaliamo. cloth. *1 00. OH ilSTISON'S DISPENSATORY. With copious ad- ditions, and 313 large wood-engravings. By E. EoiiESPBLD Geifpith, M. D. One vol. 8vo., pp. 1000 ; clolh. WOO. CARPENTER'S PRIZE ESSAY ON THE USE OF Alcoholic Liquors in Health and Disease. New edition, with a Preface by D. F Oondte, M.D., and explftnationsofacientidc words. In one neat 12mo. volume, pp. 178, cloth. 60 cents. 14 Henry C. Lea's Publications — {Pathology, die). 'PENWICK (SAMUEL), M.D., •^ Assistant Physician to the London Eosptta Z. THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. From the Third Revised and Enlarged English Edition, With eighty-four illustrations on wood. In one very handsome volume, royal 12mo., cloth, $2 25. {Just Issued.) cise, practical manner, well calcalated to asBlst the Of t-Le m»ny guide-bouks on medical dlaguoKis, cli'imed to be wi-itten for the special instTueiion of Btadents, thip Is the best. Theauthor ia evidently a well-read and accompliHbed physician, and he knows bow to *eacb practical medicine. The charm of sim- plicity is not the least Int^reetiogfeature in the caan- uer in which Dr. Penwick conveys instruction. There are few books of tbiu bize on practical medicine that contain so much and convey it so wellab the volume before us It Is a book we can sincerely recommend to the student f<)r direct instruction, and to the prac- titioner as a ready and useful aid to his memory. — Am. Journ. of Syphilography, Jan. 1874. It covers the ground of medical diagnosis in a con- student in forming a correct, thorough, and system- atic method of examination and diagnosis of disease. The illuatrationa are numerous, and finely executed. Those illustrative of the microscopic appearance of morbid tissue, &c., are especially clear and distinct. — Chicago Med. Examiner, Nov. Ig73. So far superior to any offered to students that the colleges of this country should recommend it to their respective classes. — iV. 0. Med. and Surg. Journ., March, 1874. This little book ought to be in the possession of every medical student. — Boston Medical and Surg. Journ., Jan. 15, 1874. QREEN { T. HENR Y) , M.D., ^-*^ Lecturer on Pathology and Morbid Anatomy at Qharing-Oroas Hospital Medical School PATHO LOGY AND MORBID ANATOMY. Second American, from the Xhird and Enlarged English Edition. With numerousillustrationa on Wood. In one very handsome octavo volume of over 300 pages, cloth, $2 75 {Just Issued.) This useful and convenient manual has already reached a third edition, and we are glad to find that, aUhough it has grown somewhat larger, it still remains a little hook, and we are inclined to forgive the increase in size on account of the valuahle additions which the author has made hoth to the printed matter and to .the illustrations. The new illustrations, drawn by Mr. Col- lings from preparations by Dr. Green himself, are very good, and the care and trouble expended by the author in the preparation of this edition will no dobt increased the popularity of his book, great though it already is. — Thu London Practitioner, Feb. 1876. We observe that the whole has been carefully revised, that a considerable addition has been made to the illus- trations, and that much new matter has been added. We have not space for noting each of the additions that have been made, and it is quite unnecessary to attempt this, for a work which has already gained a deservedly solid reputation. It is enough to say that it has been brought thoroughly up to the knowledge of the present day, and that the student can have no better or safer guide to pathology and morbid anatom^ than Dr. Green's book.— iorad. Times and Gaz., Sept 1876. The author of this ralnable little work is to be congratulated on the demand for it that has already called for a third edition. Itaffords gratifying tes- timony to its value and popularity as a text-book It possesses further all those qualities which render such a work popular among studentfe. ■ It is written in clear and concise language, it is confined almost entirely to statements of facts, theoretical views hav- ing for the most part been kept out of sight, and il is above all fully and exceedingly well illustrated — London Lancet, Aug. 2, 187o. aLUGE'S ATLAS OF PATHOLOGICAL HISTOLOGY. Translated, with Notes and Additions, by Joseph Lbidt, M. D. In one volume, very large imperial quarto, with 320 copper-plate figures, plain and colored, oloth. $4 00. LA KOCHE ON YELLOW FEVER, considered in it! Historical, Pathological, Etiological, and Therapeu- tical Relations. In twolarge and handsome octavo volumes ofnearly 1500 pages, cloth. Jl7 00. HOLLAND'S MEDICAL NOTES AND EEFLEC- TI0M8. 1 vol. 8vo., pp. 500, cloth. $3 60. BARLOW'S MANUAL OF THE PRACTICE OF MEDICINE. With Additions by D. F. CoHDIB, M D. 1 vol. 8to., pp. 600, cloth. M 50. TODD'S CLINICAL LECTUEES ON CERTAIN ACUTB DisEASBS. In one neat octavo volume, of 320 pasea. oloth. «2 60. > r e . S^TURGES (OCTAVIUS), M.D. Cantab., *^ Fellow of the Royal College of Physicians, &o. &e, AN INTRODUCTION TO THE STUDY OP CLINICAL MED- ICINE. Being a Guide to the Investigation of Disease, for the Use of Students In nn« handsome 12mo. volume, oloth, $1 25. {Lately Issued.) D AVIS {NATHAN S.), Prof. 0/ PHnciples and Prantici^ of Medicine, etc., in Chicago Med College CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES • ''.^"'.S^ °°""'>''" °f '5^*^"?,''"'' ^'^"'■"■•es delivered in the Medical Wards of Mercv Hos' p.tal, Chicago. Edited by Frank H. Davis, M.D. Second edition, enlarged In one handsome royall2mo. volume. Cloth, $1 75. (Lately Issued ) ' ""'^'^Soa- m one fyTOE:ES [WILLIAM), M.D., D.G.L., F.R.S., *-^ Regius Professor of Physic in the Univ. of Dublin, *o. LECTURES ON FEYER, delivered in the Theatre of the Meath Hos- pital and County of Dubim Infirmary. Edited by John William Moore MD Assistant Physician to the Cork Street Fever Hospital. In one neat octavo volume Cloth $20(1 (Just Issued.) ' ' • Henry 0. Lea's Publications — {Practice of Medicine). 15 F^ 'LINT (AUSTIN), M. D., Professor of the Principles and Practice of Medicine in Bellevue Med. Gollege, N. T. A TREATISE ON THE PRINCIPLES AND PRACTICE OF MBpICINB ; designed for tlie use of Students and Practitioners of Medicine. Fourth edition, revised and enlarged. In one large and closely printed octavo volume of about 1100 pagea ; oloth, $6 00 ; or strongly bound in leather, with raised bands, $7 00. (Just Issued.) By common consent of the English and American medical press, this work has been assigned to the highest position as a complete and compendious text-book on the most advanced condition of medical science. At the very moderate price at which It is offered it will be found one of the ctheapest volumes now before the profession. This *'XO'iUent treatise on medicine has acquired for ithelf in the TTnited States a reputation eimilarto thateaioyed in England by the admiralile lectures of Sir Thomas Watson. It may not poRsesR the same charm of style, but it has like solidity, the fruit of loDg and putieut observation, and presents kindred moderation and eclecticism. We have referred to many of the most important chapters, and find the re- vision apolcen of in the preface is a geouine one, and that the author has very fairly brought up his matter to the level of the knowledge of tbe present day. The work has this great recommendatioa, that it is iuoue volume, and therefore will not be so terrifying to the student as the bulky volumes which several of our Eus^lish texi-books of medicine have developed into, —British aid Foreign Med.-Chir. Rev., Jan. 1876. It is of course uunecesRary tointroduce or eulogize this now stindard treatise. All the colleges recom- mend it as a text-book, and there are few libraries in which one of its editions is not to be found. The present edition has been enlarged and revised to bring it up to tie author's present level of experience and reading. His own clinical studies and the latest con- tributioii* to medical literature both in this country and in Europe, have received careful attention, so that some portions have been entirely rewritten, and about seventy pages of new matter have been added. — C/iicago Med Journ., June, 1873. Has ne'^er been surpassed aa a text-hook for stu- dents and a book of ready reference for practitioners. The force of its logic, its simple and practical teach- ings, have left it without a rival in the field — N. T. Med Record, Sept. 16, 1874. Flint'sPracticeof Medicine hasbecomeso fixed in its position as an American text book that little need be said beyond the announcement of a new edition. It may, however, be proper to say that the author has imp'roved the occasion to introduce the latest contributions of medical literature together with the results of his own continued clinical observatiouM. Not so extended as many of the standard works on practice, it still is sufilciently complete for all ordi- nary reference, and we do not know of a more con- venient work for the buRy peneral practitioner.— Gineinnati Lancet and Observer, June, 1873. Prof. Flint, in the fourth edition of his great work, has performed a labor rellecting much credit upon himself, and conferring a lasting benefit upofi the pro-' fession. The whole work shows evidence of thorough, revision, so that it appears like a new book written expressly for the times. For the general practitioner and student of medicine, we cannot recommend the book in too strong terms. — N. T. Med. Jour., Sept. '73, It is given to very few men to tread in the steps of Austin Flint, whose single volume on medicine, though here and there defective, is a masterpiece of lucid condensation and of general grasp of an enor- mously wide subject. — Lond. Practitioner, Dec. '73. T>Y THE SAME AUTHOR. ESSAYS ON CONSERYATIYE MEDICINE AND KINDRED TOPICS. In one very handsome royal 12mo. volume. Cloth, $1 38. (Just Issued.} Thw lit.Iework comprisesanumber of essays written at various times for medical journalsand societie.i. Ttis unnerepPLry to say aughtin regard to the style in which they are written, for Dr. Flint is familiar as a house- hold word to the profession. His name is a guarantee that the subjects are treated in a masterly manner. The fo!iowint.sutyects are discussed : Conservative medicine, as applifd to therapeutics and hygiene, medicine in the past, tlifl present, and the future, alimentation in dis- ease, tolerance of disease, on the agency of the mind in etiology, prophylaxis, and thprapeutics, and divine de- sign, as exemplified io the natural history of diseases. A more suggestive collection of topics it would be difl&- cult to conceive. The essays on conservative medicine are peculiarly valuable. The author in these takes a very common-sense view of the treatment of disease, and shows the nece.«sity of " conserving" to the fullest extent the strength ofihe system in order to devise the bRBt results from thevis medicatrixncUurcE. — Peninsular Med. Journ , Oct. 1874. TUATSON {THOMAS), M. D., Sfc, LECTURES ON THE PRINCIPLES AND PRACTICE OP PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- vised and enlarged English edition. Bdited, with additions, and several hundred illustra- fltions, by Henry Hahtshornb, M.D., Professor of Hygiene in the University of Pennsylv- nia. In two large and handsome 8vo. vols. Cloth, $9 00; leather, $11 00. (Lately PublisJted.) It i» a subject for congratulation and for thankful- ness faat Sir Thomas Watson, during a period of com- parative leisure, after a long, laborious, and most honorable professional career, while retaining full possession of bis high mental faculties, should have employed the opportunity to submit his Lectures to a more thorough revision, than was possible during the earlier and busier period of his life. Carefully passing in review some of the most intricate and im- portant pathological and practical questions, there- suits of hiscloar insight and his calm judgment are now recorded for the benefit of mankind, in langoape which, for precision, vigor, and classical elegance, has rarely been equalled, and never surpassed The re- vision has evidently been most carefully done, and the results appear in almost every page. — Brit, Med. Jnurn., Oct. 14, 1871. The lectures are so well known and so justly appreciated, that it is scarcely necessary to do more than call attention to the special advantages of the last over previous editions. The author's rare combination of great scientific attainments com- bined with wonderful forensic eloquence has exerted extraordinary influence over the last two generations of physicians. His clinical descriptions of most dis- eases have nev.er been equalled; and on this score at least his work will live long in the future. The work will be sought by all who appreciate a great book. — Amer. Journ. of Syphilography , July, 1873. Maturity of years, extensive observaiion, profound research, and yet continuous enthusiasm, have com- bined to give us in this latest edition a model of pro- fessional excellence in teaching with rare beauty in the mode of communication. But this classic needs no eulogium of ours. — Okioago Med. Journ., July, 1872 D UNOLISON, FORBES, TWEEDIE, AND CONOLLT. THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medioa and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &e. &c. In four large super-royal octavo volumes, of 3254 double-columned pages, strongly and handsomely bound in leather, $15; oloth, $11. 16 Henry C. Lea's Publications — (Practice of Medicine). DRISTO WE [JOHN SYER), M.D., F.R.C.P., -L^ Physician and Joint Lecturer on Medicine, St. Thomas's Hospital. A MANUAL ON THE PRACTICE OF MEDICINE. Edited, with Additions, by Jambs H. Hutchinson, M.D., Physician to the Penna. Hospital. In one handsome octavo volume of ver llOOpages : cloth, $5 50; leather, $6 50. {Now Ready.) In the effort of the author to render this volume a complete and trustworthy guide for the student and practitioner he has covered a wider field than is customary in text-books on the Practice of Medicine, and has sedulously endeavored to present each subject in the light of the most modern developments of observation and treatment. So much has been done of late years to enlarge our knowledge of disease by improved methods of dingnosis, .and so many new agen- cies have been called into service in treatment, that a condensed and compendious work, tho- roughly on a level with the advance of medical science, can hardly fail to prove of value to the profession. In the present volume this has been so completely accomplished that the Editor has found it necessary only to make such additions as seemed requisite to present in more detail matters in which the'practice of this country differs from that of Europe. The bu8y practitioner will be able by its perusal to keep abreast with the great progress which bcieu- tiflc medicine has made within the past few year -i, and for which he has neither the time, nor frequently the opportunity to consult larger treatipes, mono- graphs and jonrnals. While all of it is deserving of high praise, we must particularly commend thepor- tiou devoted to nervous diseases, which is very com- plete, and well represents the present state of our knowledge on thits important subject. The style of the work is plain and lucid ; though coudenaed, it is never bald. Controversy is avoided, and illustra- tive cases are omitted in order to give roopn to prac- tical teaching. As an accurate and praiseworthy guide it is of the highest order of merit, and thongh it will not probably supersede in this country Dr. Flint's admirable treatise, it has the advantage of embodying the discoveries and improvements which have been made since the last issue of that work. — Boston Med. and Surg. Journ., Dec, 7, 1876. The style is clear, the matter and method good. Whoever buys this book gets as complete a repre- sentation of modern medicine as has been, and probably can be, put inside of one thou'taad pages of similar size and type. — The Medical Times, Philadelphia, Dec. 9, 1876. Upon reading it our first emotion was thai of sur- prise — surprise mingled with pleasure, to perceive that, notwi.hstanding thepame work bad been done by so many, it yet could be done «o much better. In 1056 pages the author has compressed the most complete treatise upon the theory and practice of medicine we have ever seen. Almost every disease known to the profession, including many not found ia similar works, is treated of As a hand-book for students, therefore, we do not think It has an equal in the English language while older members of the profession may ^:onsall it with equal pleasure and profit. The style is remarkably clear, plain and familiar, and is perfectly comprehensible to the least cultivated, while the most highly cultured can hardly fail to be pleased at the purity of its English. —Physfcian and Surgeon, Baltimore, Nov, 1876. It is impossible to look over its pages without being impressed with the amount of information which they have been made to contain, with no appearance of conciseness at the expense of completeness. A fiuperficial survey even shows that, as atext-boob, it is far in advance of those publithed ^nly a few years ago; and a more careful examination of Pome of its sections — such, for example, as the one devoted to diseases of the nervous system, demonstrates that in provinces which have accomplished the greate*.t advances of late years, the author has kept his work quite abreast with the labors of the m6st reliable clinical observers. Features qnitennusu^lin a pure- ly medical treatise are included in the sliape of ex- cellent chapters on diseases of the skin, thealfections of the genito-urlnary organs in femal6s,;which can but resultin lessening the tendency on the part of the geDer3,l practitioner to neglect thelnportaiit classes of complaints with the Reeling that, llkejderange- ments of the chief organs of the special setises, they can better he managed by specialists. — iffeti) Reme- dies, Not. 1876. ! We recommend highly this book, and feel justi- fied in doing so by the thought that, of its fclans it is the best we have yet seen. The judicious remarks of the American editor add very much to he value of the work ; his jealous guard over American medi- cine is most praiseworthy ; in fact, our oLly com- plaint is that so little of his own well-known style appears —Ohstet. Journ. of Great JBHtainund Ire- land, American SupplcTnent, Nov. 1876 i It may, therefore, be assumed with .^somd show of probability, that the author has kept in mini the spe- cihI needs of medical studuots. Nor is the e^jpeciatioa disappointed when we open the book. But it pust not be assumed that this volume is for students opiy, who are reading for examinations. It well deserves a place in the library ofevery physician, and of everj practi- tioner of the medical art. The work is one which will greatly enhance the author's reputation. We pVophesy that it will be the favorite for the Loudon ana other universities, and the College of Physicians, whilst many who never pass these examinations, but content them- selves with ball and college, will be glad to purnhase a book which, once acquired, they will not wish :o part with, but will carry with them to their resideneeSn the country, or to the distant colony, on board 8hi|3, and even in the knapsack on the march with troops.— Xood. Med. Recm-d, Dec. 15, 187 6. fJARTSHORNE {HENRY), M.D., •M.-L Professor of Hygiene in the University of Pennsylvania. ESSENTIALS OP THE PRINCIPLES AND PRACTICE OF MEDI- CINE. A handy-book for Students and Practitioners. Fourth edition, revised and im- proved. With about one hundred illustrations. In one handsome royal ]2mo volume, of about 650 pages, cloth, $2 63 ; half bound, $2 88. (Jtat Issued.) The thorough manner in which the author has labored to fully represent in this favorite hand- book the most advanced condition of practical medicine is shown by the fact that the present edition contains more than 260 additions, representing the investigations of 172 authors not re- ferred to in previous editions. Notwithstanding an enlargement of the page, the size has been increased by sixty pages. A number of illustrntions have been introduced which it is hoped will facilitate the comprehension of details by the reader, and no effort has been spared to make the volume worthy a continuance of the very great favor with which it has hitherto been received. As a handbook, which clearly setB forth the essen- tials of the principles and practice of medicine, we do not know of \ta equal.— Va. Med. Monthly. As a hrief, condensed, but comprehensive hand- book, it cannot be improved upon. — Chicago Mkd Examiner, Nov. 15, 187-t The work is brought fully up with all the lecent advances in medicine, is admirably condensed, and yet sufficiently explicit for all the purposes! ntended, thus maklDftitby far the best worli of its character ever piiblii.hed.— OmcinnnH Olivie, Oct. 24, 1874. Without doubt the best book of theliind published in the En(!li»h language.— Si. l^ouie Med. andSuro. Journ , Kuv. 1874. Henry C. Lea's Pubhoations — {Practice of Medicine). 17 'POTHERGILL (J. MILNER), M.D. Edin., M.R.O.P. Land., •^ Asst, Fhya. to the West Lnnd Hosp. : Asst. Phyg. to the City of Lond, Hoep., etc. THE PRACTITIONER'S HANDBOOK OF TREATMENT; Or, the Principles of Therapeutics. In one very neat octavo volume of about 550 pages : cloth, $4 00. (Now Ready.) It may be said thiit the scope of this work is not dissimilar to thnt of th,e well known *' Principles of Medicine," by Dr J. C. B. Williams, now long out of print, which in its day met with such unusual acceptance. More practical in its eharaoter, however, it seeks to bring to the aid and elucidation of positive therapeutics, the vast accumulation of scientific facts and theories made by the presentgeneration, pointing out the measures to be adopted nt the bedside and establishing them on firm rational grounds. Such a work, by a first-iate man, and fully up to the advanced oondition of science, cannot fail to prove of the utmost service to both student and practitioner. Our frieuUs will find tbia a very readable book ; and that it pheds ilghiupon every theme it touches, causing the practitioi.er to feel more certain of bis diagnosis in difficult cases", We confidently commend the work to our readers as one worthy of careful perusal. It lighm the way over obscure aud difficult passes in merlical practice. The chapter on the circulation of the blood is the most exhaustive and instructive to be found. It is a book every practitioner needs, and would have, if he knew bow suegestive and helpful it would be to him.— ^i. Louis Med. and Surg. Journ., April, 1877. The object is one of the meet important which a med- ical writer can propose to himself, for therapeutics is the goal of medicine, and the plan is an excellent one. In justice to Dr. Fotherpill we ought to eay that he has ad- hered to his plan throughout the work with fidelity, and has accomplished his object with a rare degree of snccess. We heartily commend his book to the medical student as an honest and intelligent guide through the mazes of therapeutic^, and assure the practitioner who has grown gray in the harness that he will derive pleasure and in- struction from its perusal The imperfections and errors which we have noticed are few and unimportant. Onthe other hand, the excellences are many and patent. Valuable suggestions and material for thought abound throughout. The chapters on body heat and fever, in- flammation, action and inaction, and the urinary sys- tem are particularly good. The descriptions of patho- lexical conditions, and the character of the therapeutic measures advised give evidence of sound clinical obser- valion.- Boston Med. and Surg. Journcd, Mar 8, 1877. The strong good sense, the racy style, the practical " haracter of his instruction, are qualitiep in ihe author wliich commend bim to American physicians. In the volume before us Dr. Fotbergill appears in his best mood. Our readers, especially the younger members of the profession, will find this a most suggestive and use- ful book. There are few old practitioners who will not be benefited by its perusal. We commend it to all classes of readers, with the expression of belief that those who buy it will be hardly content to cIosh it until the last leaf is turnedover. — Cincinnati Clinic^ Mar. '6, 1877. It is our honest conviction, after a careful perusal of this goodly octavo, that it represents a great amount of earnest thought and painstaking work, and is therefore one of those books which both deserve and are likely to survive. This book, although written ostensibly for the young and inexperienced, may be very profitably studied by those who have been practiping their profession more or less empirically for thirty or forty years. We particularly recommend ihe chapters on Public and Private Hygiene, Food in Health and Ill-Health, and the Conclusion — the Medical Man at the Bedside. The last is high-toned, and indicates much shrewdness of ob- servation. Our space will not admit of further quotation. We content ourselves with again recommending the book very cordially. — JEdin. Med. Journ., Jan. 1877. ' It is of great advantage to the practitioner to have gen- eral principles to guide him, and that he should not, when confronted with an assemblage of pathological symptoms, he at the liiercy of an unreasoned experience of^ a similar case, or be obliged to swear in verba magiurt. He will find reasons in this work for not looking upon drugs as grouped in fixed and unalterable categories, but learn when and why he may give opium to cause purgation, and castor oil to check it. We strongly re- commend it to oar readers. — The London Fractttioner , Jan. 1877. TNCOLN (D. F.).M.D., ' PhyHcian to the Department of Nervous Disea-tes, Boston Dispensary. ELECTRO-THERAPEUTICS; A Concise Manual of Medical Electri- city. Inone very neatroyall2mo. volume, cloth, withillustrations, $1 50. {Just Issued.) This little book is, considering i ts size, one of the very best treatises in the language on the subj act that has oome to our notice, pos^ebsing, among others, the rare merit of dealing avowedly and actually with principles, mainly, rather than with practical details, thereby supplying a real want, instead of helping merely to flood the literary market. Dr. Lincoln s style is usually remarkably clear, and the whole book is readable and interesting. — Boston Med. and Surg. Journ., July 23, 1874. A /ROBERTS ( WILLIAM), M. D., Lecturer on Medicine in the Manchester School of Medicine, Ac. PRACTICAL TREATISE ON URINARY AND RENAL DIS- BASES, including Urinary Deposite. Illustrated hy numerous cases and engravings. Sec- ond American, from the Second Revised and Enlarged London Edition. In one large and handsome octavo volume of 616 pages, with a oolored plate ; cloth, $4 50. {Lately Published.) The most complete and practical treakieenpon renal diseases vre have examined. It is peculiarly adapted to the wants of the majority of American practition- ers from its clearness and simple announcement of the facts in relation to diagnosis and treatment of urinary diKorders, and contains in condensed form the inveeti' gations of Bence Jones, Bird, Beale, Hassall, Prout. and a host of other well-known writers upon this sub- ject. The characters of urine, physiological and pa- thological, as indicated to the naked eye as well as hy microscopical and chemical investigations, are con- cisely represented both hy description and by well executed engravings. — Cincinnati Journ. of Med. By A. I Meatb LECTURES ON THE STUDY OF FEVER. HDD80N, M.D., M.R.LA., Physician to th< Hospital, In one vol. 8vo., cloth, $2 50. A TREATISE ON FEVER. By Robbbt D, Lyons, K C C. In one octavo volume of 382 pages, cloth, fj(2 2.0, CLINICAL OBSERVATIONS ON FUNCTIONAL NERVOUS DISORDERS BvO. Handfteld Jones, M.D., Physician to St. Mary's HospiPal, &c. Sec- ond American Edition. In one handsome octavo volume of 348 pages, cloth, $3 25 BASHAM ON RENAL DISEASES: a Clinical Guide to their Diagnosis and Treatment. With Illustra- tions. In one 12mo. vol. of 30-1 pages, cloth, >fc2 00. 18 Henry C. Lea's Ptjblioations — (Diseases of the Chest, ScA. JPLINT [AUSTIN], M.D., -*• Professor of the Principles and Practice of Medicine in Sellevue Hospital Med. College, N. T. PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY, SYMPTOM- ATIC EVENTS AND COMPLICATIONS. FATALITY AND PROGNOSIS, TREAT- MENT, AND PHYSICAL DIAGNOSIS; in a series of Clinical Studies. By Austin Flint, M.D., Prof, of the Principles and Practice of Medicine in Bellevue Hospital Med. College, New York. In one handsome octavo volume : $3 60. (Just Issued.) This volume, containing the results of the author's extended observation and experience on a subject of prime importance, cannot but have a claim upon the attention of every practitioner. This book contains an analysis, in the author's lucid titioner. While the author takes issue with many of the style, of the notes which he has made in several hun- dred cases in hospital and private practice. We com- mend the hook to the perusal of all intttrested in the study of this disease. — Boston Med. and Surg. Journal, Feb. 10, 1876. The name of the author is a sufficient guarantee that this book is of practical value to both student and prac- leading mindsof theday on important questions arising in the study of phthisis, the strong testimony of expe- rience and authority will have great weigiht with the seeker after truth. As the result of clinical study, the work is unequalled. — St. Louis Med. and Surg Journal, March, 1876. ^T TME SAME AUTHOR. (Now Rearfy.) A MAISrUAL OF PERCUSSION AND AUSCULTATION; of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. In one handsome royal 12mo. volume : cloth, $1 75. In this little work the object of the author has been to present in a clear and compact form the existing condition of physical exploration, showing the manner of conducting it and the diagnostic value of the several signs thereby elicited. This manual, from so experienced a pen as that I dent or practitioner who ie somewhat ruaty on tbe of its author, conld not be otherwise thau coucise, "physical signs" it will prove ju&t the book he clear, and practical. It is all these, and to the stu- j wants. — Med. and Surg, Reporter. Aug. 19, 1876. JDY THE SAME AUTHOR. A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE HEART, Second revised and enlarged edition. In one octavo volume of 550 pages, with a plate, cloth, $4. Dr. Flint chose a difficult subject for bis researches, and has shown remarkable powers of observation. and reflection, as well as great industry, in his treat meut of it. His book must be considered the fullest and clearest practical treatise on those subjects, and should be in the hands of all practitioners and stu-- ients. It is a credit to American medical literature. —Amer. Journ. of the Med. Sciences, July, 1660. T>T THE SAME AUTHOR. A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume of 595 pages, cloth, $4 50. Dr. Flint's treatise ie one of the most trustworthy] mcy to over-reflnement and unnecessary minuteness guides which we can consult. The style is clear and vhich characterizes many works on the same sub- distinct, andis also concise, helngfree from that tend- iject. — Dublin Medical Press, Feb. 6, 1867. lY^LLIAMS (C. J. B.); M.D., Senior Consulting Physician to the Hospital for Consumption, Brompton. PULMONARY CGNSTJMPTIOlSr; Its Nature, Varieties, and Treat- ment. With an Analysis of One Thousand Cases to exemplify its duration. In one neat octavo volume of about 350 pages, cloth, $2 50. (^Lately Published.) pHAMBERS (T. K.), M.D., ^ Consulting Physinian to St. Mary^s Hospital, London, &c. A MANUAL OF DIET AND REGIMEN IN HEALTH AND SICK- NESS. In one handsome octavo volume. Cloth, $2 75. (Just Issued.) DIPHTHERIA; its Nature and Treat iieiit, with an account of the History of its Prevalence in vari- ous Coantries. By D. D. Si.ADR, M.D. Second and revised edition. In one neat royal 12nio. volume, cloth, $1 29. WALSHB ON THE DISEASES OF THE HEAKT ANT GREAT VESSELS. Third American edition. In 1 vol. 8vo.. 420 UT>., cloth. «3 0" FULLER ON DISEASES OF THE LUNGS AND AIR- PASSAGES. Their Pathology, Physical Diagnosis, Symptoms, and Treatment. From the second and revised Eaglish edition. In one handsome octavo volume of about .oOO pages : cloth, $3 50. LA KOCHE ON PNEUMONIA. 1 voL 8vo., cloth, of 500 pages Price *3 00. SMITH ON CONSUMPTION ; ITS EAELT AND RE- MEDIABLE STAGES. 1 vol. Svo., pp. 264. «2 26 LECTURES ON THE DISEASES OP THE STOMACH. With an Introduction on its A natomy and Physio- loiry. By \frii,u*M Brinton, M D., F.R.S From the second and enlarged Londonedition. With il- lustrations on wood. In one handsome octavo volume of about 300 page-'*: cloth, $3 26. CHAMBERS'S RESTORATIVE MEDIOINB. An Har veian Annual Oration. With Two Sequels. In one very handsome vol. small 12mo , cloth, !|il 00. PAVY'S TREATISE ON THE FUNCTION OF DI- GESTION; its Disorders and their Treatment. From the second London edition. Tn one band, some volume, small octavo, cloth, $2 00. PAVY'S TRF,ATISE ON FOOD AND DIETETICS. Physiologically and Therapeutically Considerp/l In one handsome octavo volume of nearly tilO pages, cloth, $4 73. Henry C. Lea's Publications — ( Venereal Diseases, Sc). 19 T>UMSTEAD (FREEMAN J.), M.D., •*-' Professor of Venereal Diseases at the Gol. of Phys. and Surg. , New Tork, ic. THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- EASES. Including the results of recent investigations upon the subject. Third edition, revised and enlarged, with illustrations. In one large and handsome octavo volume of over 700 pages, oloth, $5 00 ; leather, $6 00. In preparing this standard work again for the press, the author has subjected it to a very thorough revision. Many portions have been rewritten, and much new matter added, in order to bring it completely on a level with the most advanced condition of syphilography, but by careful^ compression of the text of previous editions, the work has been increased by only sixty-four pages. The labor thus bestowed upon it, it is hoped, will insure for it a continuance of its position as a complete and trustworthy guide for the practitioner. It is the most completebook with which we are ac' qnainted in the language. The latest views of the beBt authoritiea are put forward, and the information is well arranged — a great point for the student, and still more for the practitioner. The anbjects of vis- ceral syphilis, syphilitic affections of the eyes, and thetreatmentof syphilis by repeated Inoculations, ar? .very fully discussed. — London Lancet,-3&TX. 7, 1871. Dr. Burastead's work is already so universally Known as the best treatise in the English language on venereal diseases, that it may seem almost superflu- ous to say more of it than that a new edition has been Issued. But the author's indastry has rendered this new edition virtually a new work, and so merits as (lULLERIER (A.), and ^ Surgeon to the Hdpital du Midi. much special commendation as if its predecessors had not been published. As a thoroughly practical book on a class of diseases which form a large share of nearly every physician's practice, the volume before us is bv far the best of which we have knowledge.— N. T. Medical Gazette, Jan. 28, 1871. It is rare in the history of medicine to find any one book which contains all that a practitioner needs to know; while the possessor of "Bumstead on Vene- real" has no occasion to look outside of its covers for anything practical connected with the diagnosis, his- tory, or treatment of these affections. — N. T. Medical Journal, March, 1871. nUMSTEAD {FREEMAN J.), •*-^ Professor of Venereal Diseases in the College of Physicians and Surgeons, N. Y. AN ATLAS OF VENEREAL DISEASES. Translated and Edited by Freeman J. Bomstbad. In one large imperial 4to. volume of 328 pages, double-columns, with 26 plates, containing about 160 figures, beautifully colored, many of them the size of life; strongly bound in cloth, $17 00 ; also, in five parts, stout wrappers, at $3 per part. Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- lars a Part, thus placing it within the reachof all who are interested in this department of prac- tice. Gentlemen desiring early impressions of the plates would do well to order it without delay. A specimen of the plates and text sent free by mail, un receipt of 25 cents. We wish for once that our province was not restrict- ed to methods of treatment, that we might say some- thing of the exquisite colored plates in this volume. ^London Practitioner, May, 1869. As a whole, it teaches all that can be taught by means of plates and print. — London Lancet, March 13, 1869. Superior to anything of the kind ever before issued on this continent. — Canada Med. Journal, March, '69. The practitioner who desires to understand this branch of medicine thoroughly should obtaio this, the most complete and best work ever published. — Dominion Med. Journal. M&y, 1869. This is a work of master hands on both sides. M. Cullerier is scarcely second to, we think we may truly ■ay is a peer of the illnstrlons aud venerable Ricord, while in this country we do not hesitate to say that Dr. Bumstead, as an authority, ia without a rival Assuring our readers that these illuEtratiouH tell the whole history of venereal disease, from its inception o its end, we do not know a single medical work, which for its kind is more nece**ary for them to have. —California Med. Gazette, March, 1869. The most splendidly illustrated work in the lan- guage, and in our opinion far more useful than the French original.— J.m. Journ. Med. Sciences, Jan. '69 The fifth and concluding number of this magnificent work has reached us, and we have no hesitation in saying that its illustrations surpass those of previous numbers.— 5o*t jWifd. ond Swrfir. J"?., Jan. 14 1869. Other writers besides M. Cullerier have given us a good account of the diseases of which he treats, but no one has_ furnished us with such a complete series of illustrations of the venereal diseases. There is, however, an additional interest and value possessed by the volume before us ; for it is an American reprint and translation of M.. Cullerier's work, with inci- dental remarks by one of the most eminent American syphilographers, Mr. Bumstead. — Brit, and For. Mediao-Ohir. Review, July, 1869. T.EE [HENRY], Prof, of Surgery at the Royal College of Surgeons of England, etc. LECTURES ON SYPHILIS AND ON SOME FORMS OF LOCAL DISEASE AFFECTING PRINCIPALLY THE ORGANS OF GENERATION. In one handsome octavo volume: cloth; $2 25. {Lately Published.) modificaMons of these procefses in prtieuts previously syphilitic; primary and secondary syphilitic diseases of the mucous membranes and their liability to commu- nicate constitutional syphilis, etc. The book is full of clinical material illustratinjc these topics, original or quoi^di,— Archives nf Dermatology, April, 1876. The work is valuable, as it treats quite fully of sub- jects which are not dwelt upon in the systematic works of other Enfrlish authors of the present day, as the inoc- ulability of syphilitic blood ; the conditions under which the secretions of primary and secondary syphilitic man- ifestation^l maybe inoculated naturally or artificially; the morbid processes produced by such inoculation ; the IF LL (BERKELEY), Surgeon to the Lock Hospital, London. ON SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. In one handsome octavo volume ; cloth, $3 25. ISSL (H.), M.D. COMPLETE TREATISE ON VENEREAL DISEASES. Trans- lated from the Second Enlarged Germnn Edition, by Frbsbbic R. STirReis, M.D. In one octavo volume, with illustrations. (Freparing .) 20 Henry C. Lea's Publications — (Diseases of the Skin). F^ ^OX [TILBURY), M.J).,F.R.C.P., and T. C. POX, B.A., M.R.C.S., Physician to the Department for Skin Diseases-, University College Hospital. EPITOME OP SKIN DISEASES. WITH F0RMULiE3. For Stu- In one handsome 12mo. volume, of 120 pages: cloth, $1. DENTS AND PRACTITIONMRS (Now Ready.) A Tery clear and concise description is given of the elementary lesions and ihe author's remarks on the gen'Tai character, complications, and modifications of erupt Jonfj. toffPtber with their practical hints on theex- ■aoiination of skin diseases, will be of great assistance to the novice in this department of medicine. We know of no other which, in so little space, contains so much reliable information.— iV. T. Med. Journ., Dec. 1S76. It has no especial features other than it is concise and quite practical. The early chapters, treating of ele- mentary matters, in the study of skin diseases, are very good, and the list of formulae is excellent.— .^rcAiweso/ Clinical Surgojy, Dec. 1876. If doctors neglect the study of diseases of the skin, it will not beforlackof opportunities of instruction. This little handbook contains wonderfully condensed know- ledge that cannot but be most useful to every one who will read it.— American Practitioner^ Jan. 1877. This little work cannot fail to acquire a large circle of readers. In a very small compass all the essential points of the classification, diagnosis, symptoms, and treatment of skin diseases are accurately and completely stated without being cramped. The book is so well ar- ranged that the reader will have no difficulty in fiinding at once exactly the information he may require. A carefully compiled formulary of remedies for skin afTec- tions and some notes on diet in skin diseases, considera- bly enhance the value of the epitome. — London Lancet, Nov. 4, 1876. It must be admitted that even those well prepared for general practice find diseases of the ski a difficult of clas- sification, and as diflicult of diagnosis, and that nothing is more desirable than some work which, not elaborate in nature, shall be a useful ordinary guide, and issued by some one of recognized authority, it is believed that this manual of Tilbury Fox and T. C. Fox exactly meets the wants indicated. It epitomizes, in a very short com- pass, the clinical features in the treatment of diseafes' of the akin. The volume i.-; so small that it can be car- ried in the pocket, while the text furnishes briefly, but clearly, the information desired by tlie general practi- tioner. It meets fullv au almost universal want.— ^m. Si- WeeJdij, Jan. 6, 1877. J^ILSON- [ERASMUS), F.E.S. ON DISEASES OF THE SKIN. With Illustrations on wood. Sev- enth American, from the sixth and enlarged English edition. In one large octavo volume of over 800 pages, $5. A SERIES OF PLATES ILLUSTKATING "WILSON ON DIS- EASES OP THE SKIN ; " consisting of twenty beautifully executed plates, of which thir- .teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and embracing accurate representations of about one hundred varieties of disease, most of them the size of nature. Price, in extra cloth, $5 50. Also, the Text and Plates, bound in one handsome volume. Cloth, $10. _gr THE SAMS AUTHOR. THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- eases of the skin. In one very handsome royall2mo. volume. $3 50. ^ELIGAN (J. MOORE), M.D., M.R.I.A. ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, with exquisitely colored plates, Ac, presenting about one hundred varieties of disease. Cloth, $5 50. The diagnosis of eruptive disease, however, under «1 circumstances, la very difficult. Nevertheless, Dr. Neligan has certainly, "as far as posaible," given a faithful and accurate representation of this class of diseases, and there can be no doubt that these plates will be of great use to the student and practitioner in drawing a diagnosis as to the class, order, and species to which the particular case may belong. While looking over the "Atlas" we have been induced to ixamine also the "Practical Treatise." and we are inclined to consider It a very superior worK, com- bining accurate verbal description with sound viewa of the pathology and treatment of eruptive diseases, — Glasgow Med. Journal. £JILL1ER [THOMAS), M.D., Phyincian to the Skin Department of ITniversity College EoapUal, *e HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. Second Am. Ed. In one royal 12mo. vol. of 358 pp. With Illustrations Cloth, $2 25. It Is a Guucise, plain, practical treatise on the vari- ous diseases of the skin ; just such a work, indeed, as was much needed, both by medical stndenta and practitioners. —CMoafFO Medical Examiner, Mar, We can conscientiously recommend it to the stu- dent; the style is clear and pleasant to read, the matter le good, and the descriptions of disease, with »lie modes of treatment recommended, are frequently rinstrated with well-recorded cases.— ioudon MeA Timen and Gazette. April 1, 1 86i5. ^MITH [E USTA CE), M. d"., ~ PhysiHan to the Northwest London Free Dispensary for Sioh Children \^t^OYi%t'^omSiS>'^f ^A ^^^^ WASTING DISEASES OF F^„lf»h J-r ^II-DHOOD. Second American, from the second revised and enlarited English edition, f^ jnehandsome octavo volume, cloth, $2 50. {LatelVhmed) This 18 in every way an admirable book. The modest title which the author has chosen for 1 1 scarce- ly conveys ap adequate idea of the manysobjects .upon which it treats. Wasting is so constant an at- tendant upon the maladies of childhood, that a trea- tise upon the wasting diseases of children must neces larily embrace the consideration of many affections of which itisasymplom ; and fhisis excellently well done by Dr. Smith. The book might fairly be de- scribed as a practical handbook of the common die- eases of children, so numerous are the affections con- sidered either collaterally or directly Wo ar« acqaalnted with no safer guide to the- treatment of children's diseases, and few works eive the in«i»i,. lrL'}Lfr'f°^ltf r' o'"" Pecul7ari i'e' orXu ipril 8, U?;; " """^ ^"^'-BrU. JUed. ^^ournl, Henry C. Lea's Publioations — (Diseases of Children). 21 fJMITH {J. LE WIS), M. D., *^ Professor of Morbid Anatomy in the Belleiyue Bospltal Med. College, N. T. A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Third Bdition, revised and enlarged. In one handsome octavo volume of 726 pages. Cloth, $5; leather, $6. {Just Issued.) The eminent success which this work has achieved has en^iouraged the author, in preparing this third edition, to render it even more worthy thim heretofore of the favor of the profession. It has been thoroughly revised, and very considerable additions have been made throughout. To accommodate these the volume has been printed in a smaller type, so as to prevent any notable increase in its size, and it is presented in the hope that it may attain the position of the American textbook on this important department of medical science. This work took a stand as an authority from its first appearance, and every one interested in studying the diseases of which it treats is desirous of knowing what improvements are apparent in the successive editions. The principal additions to which we refer, and which will be the distinguishing features of th6 third edition, are chapters on diphtheria, cerebro-spinal meningitis, and rbtheln. The former disease is considered much more in detail than formerly, and a great amount of very practical information is added, and altogether it is one of the most comprehensive and one of the best writ- ten chapters of the subject we Iiave thus far read. His description of ce re bro- spinal meningitis, founded also for the most part on personal experience, is admirably clear and exhaustive — The Med. Record, Feb. 19, 1876. In presenting this deservedly popular treatise for the third time to the profession. Dr. Smith ha? given it a careful preparation, which will make it of decided su- periority to either of the former editions. The position of the author, as physician and consultant to several large children's hospitals in New York city, has fur- ni.-hed him with constant o'ccasions to put his treatment to the test, and his work has at once that practical and thoughtful tone which is a marked characteristic of the best productions of the American medical press. — Med. and Surg. Eeporter^ Feb. 1876. The former editions of this book have given it the highest rank among works of its class, and the present edition will confirm and add to its reputation. Having been brought up to the present mark in the rapid ad- vance of medical science, it is the best work in our language, on itp ranfie of topics, for the American prac- titioner.— Pac/^c Med. and Surg. Journ., Feb. 1876. Dr. Smith's Diseases of Children is certainly the most valuable work on the subjects treated that the practi- tioner can provide himself with. It is fully abreast with every advance: it should be in the hands of prac- titioners generally, while, because of the conciseness and clearness of style of the writing of the author, every professor of diseases of children, if he has not already done flo, should adopt this as his text-book. — Va. Medical Monthly, Feb. 1876. The third edition of this renUy valuable work is now before us, with a hundred pages of additional matter, an altered size of page, new illustrations, and new type. Of the diseases treated of for the first time, we notice rdtheln and cerebro-spinal fever, which lately prevailed in epidemic form in some parts of the country. The article upon diphtheria, containing the latest develop- ments in the pathology and treatment of that dread dis- ease, which so lately ravaged our country, is peculiarly interesting to every practitioner. We gladly welcome this standard work, and cheerfully recommend it to our readers as the best on this subject in the English Ian f»uage. — Nashville Journal of Med. and Surgery ^ March, 1876. (JONDIE (7). FRANCIS), M.D. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely- printed pages, cloth, $5 25 ; leather, $6 25. The present edition, which is the sixth, is fully up teachers. Ab a whole, however, the work is the best to the times in the discussion of all those points Id the American one that we have, and in its special adapta- pathology and treatment of infantile diseases which tion to American practitioners it certainly has no have heenhroughtforwardhytheGermau and French equal. — New York Med. Seoord, March 2, 1868. VU'EST ( CHARLES). M. D., ' ' Physician to the Hospital for Sick Children, &c. LECTURES ON THE DISEASES OF INEANCY AND CHILD- HOOD. Fifth American from the sixth revised and enlarged English edition. In one large and handsome octavo volume of 678 pages. Cloth, $4 50 ; leather, $5 60. (.Jiist Issued.) The continued demand for this work on both sides of the Atlantic, and its translation Into Ger- man, French, Italian, Danish, Dutch, and Russian, show that it fills satisfactorily a want exten- sively felt by the profession. There is probably no man living who can speak with the authority derived from a more extended experience than Dr. West, and his work now presents the results of nearly 2000 recorded oases, and 600 post-mortem examinations selected from among nearly 40,000 cases which have passed under his care. In the preparation of the present edition he has omitted much that appeared of minor importance, in order to find room for the Introduction of additional matter, and the volume, while thoroughly revised, is therefore not increased materially in size. Of all the English writers on the diseases of chil- I living authorities in the difficult department of medl- dren, there is no one so entirely satisfactory to us as | oal science in which he is most widely known.— ^r. West. For years we have held hie opinion as I Boston Med. and Surg. Journal. J adicial, and have regarded him as one of the highest | JiY THE SAME AUTHOR. [Lately lamed.) ON SOME DISORDERS OP THE NERYOFS SYSTEM IN CHILD- HOOD; being the Lumleian Leolures delivered at the Royal College of Physicians of Lon- don, in March, 1871. In one volume, small 12mo., cloth, $1 00. WEES ON THE PHYSICAL ANT) WEDIOAL TEEATMBNT OF CHILDEEN. 1 vol. 8vo. of 048 pages. Cloth, $2 80. Eileveuth edition. 22 Hknet C. Lea's Publications — (Diseases of Women). rPROMAS {T.GAILLARD),M.D., Professor of Obstetrics, Ac, in the College of Physicians and Surgeons, y. 7., Ac, A PRACTICAL TREATISE ON THE DISEASES OP WOMEN. Fourth edition, enlarged and thoroughly revised. In one large and handsome ootaYO volume of 800 pages, with 191 illustrationa. Cloth, $5 00; leather, $6 00. {Just Issued.) The author has taken advantage of the opportunity afforded by the call for another edition of this work to render it worthy a continuance of the very remarkable favor with which it has been received. Every portion has been subjected to a conscientious revision, and no labor has been spared to make it a complete treatise on the most advanced condition of its important subject. A work which has reached a fourth edition, and that, too, in the short space of five years, has achieved a reputation which places it almost beyond the reach of criticism, and the favorable opinions which we have already expressed of the former editions seem to re- quire that we should do little more than announce this new issue. We cannot refrain from saying that, as a practical work, this is second to none in the Eng- liifh, or, indeed, in any other language. The arrange- ment of the contents, the admirably clear manner in which the subject of the differential diagnosis of several of the diseases is handled, leave nothing to be ^ desired by the practitioner who wants a thoroughly clinical work, one to which he can refer in difl&cult cases of doubtful diagnosis with the certainty of gain- ing light and instruction. Dr. Thomas is a man with a very clear head and decided views, and there seems to be uothiag which he so much dislikes as hazy notions of diagnosis and blind routine and unreasonable thera- peutics. The student who will thoroughly study this book and test its principles by clinical observation, will certainly not be guilty of these faults. — London Lancet^ Feb. 13, 1875. Tlie latest edition of this well-known text-book retains the essential characters which rendered the earliest so deservedly popular. It is still pre-emi- nently a practical nianaal, intended to convey to students in a clear and forcible manner a sufficiently complete outline of gyncecology. In a word, we should say that any one who intended to make a special study of gynecology could hardly do better thau to begin with a minute perusal of this book, and that any one who Intended to keep gynecology sub- ordioate to geaeral practice, should hardly fail to have it on hand for future reference. — N. 7. Med. Journ., Jan. 1875. Reluctantly we are obliged to close this unsatis- factory notice of so excellent a work, and in conclu- sion would remark that, as a teacher of gynfficology, both didactic and clinical, Prof. Thomas Ijas certainly taken the lead far ahead of his confrhrest and as an author he certainly has met with nnuBual and mer- ited success. — Am. Journ. of Obstetrics, Nov. 1874. This volume of Prof. Thomas in its revised form is cla8sical;without being pedantic, full in the details of anatomy and pathology, without ponderous translation of pages of German literature, describes distinctly the details and difflcnlties of each opera- tion, without wearying and aseless minutise, and is in ail respects a work worthy of confidence, justify- ing the high regard in which its distingniahed au- thor is held by the profession, — Am. Supplement, Obstet. Journ. Oct. 1874. Professor Thomas fairly took the Profession of the United States by storm when his hook first made its appearance early in IS6S. Its reception was simply enthusiastic, notwithstanding a few adverse criti- cisms from our transatlantic brethren, the first large edition was rapidly exhausted, and in six months a second one was issued, and in two years a third one was aDnouneed and published, and we are now pro- mised the fourth. The popularity of this work was not ephemeral, and its success was unprecedented in the annals of Americao medical literature. Six years is a long period in medical scientific research, but Thomas's work on " Diseases of Women" is still the leading native production of the United States. The order, the matter, the absence of theoretical disputa- tiveness, the fairness of statement, and the elegance of diction, preserved throughout the entire range of the book, indicate that Professor Thomas did not overestimate his powers when he conceived the idea and executed the work of producing a new treatise upon diseases of women. — Pkof. Pallen, in Louis- ville Med, Journal^ Sept. 1874. TDARNES [ROBERT), M.I)., F.R.G.P., ^-* Otatetric Phyncian to St. Thomas's Hospital, *c. A CLINICAL EXPOSITION OP THE MEDICAL AND SURGI- CAL- DISEASES OF WOMEN. In one handsome octavo volume of about 800 pagea, with 169 illustrationa. Cloth, $5 00; leather. $6 00. (Just Issued.) Dr. Barnes is not only a practitioner of exception- sion with which his name has so long been honorably ally large opportunities, which he has used well, bat he has kept himself informed of what'has been said and done by others ; and he has in the present vol- ume judiciously used this knowledge. We can strongly recommend Dr. Barnes's work to the gynae- cological student and practitioner. — N. ¥. Med. Bee- ord, Jane 15, 1874. We can only repeat that, as a thoroughly sound, practical, clinical treatise, we know of no EngliMh work which can compare to this of Dr. Barnes. -To the so-calted specialist, as well as to the general prac- titiouer, it will prove a most useful guide. — London Lancet, Jan. 10, 1874. In conclusion, we must express our conviction that, io view of the wide range of subjects comprestsed into a single volume, this book is admirable for the conciseness and clearness with which practical points are treated, and evidently from a large expe- rience. For students, and, indeed, for a good many of thdse who for want of time cannot, or for want of inclination will not, be students, it is a safe and sat- isfactory guide, and no one who iittempts to treat the diseases peculiar to women can afford to be without it. The volume is profusely illustrated; many of the cuts ure new togyaaecological literature, and most of them are essenti-il adjuncts to the text.— Boston Med. and Surg. Journ., April 17, 1874. Dr. Barnes's present work is a raaguiflcent contri- bution to the literature of that branch of the profes- connected. To attempt, however, an exhaustive an- alysis of so voluminous a treatise woald carry us far beyond all reasonable bounds. — Glasgow Med. Journ. f July, 1874. Embodying the long experience and personal obser- vation of one of the greatest of living teachers in dis- eases of women, it seems pervaded by the presence of the author, who speaks directly to the reader, and speaks, too, as one having authority And yet, not' withstanding this distinct personality, there is noth- ing narrow as to time, place, or individuals, in the views presented, and in the instructions given; Dr. Barnes has been an attentive student, not only of Eu- ropean, but also of American literature, pertaining to diseases of females, and enriched his own experience by treasures thence gathered; he seems as familiar, for example, with the writings of Sims, Emmet, Tho- mas, and Peaslee. as if these eminent men were his countrymen and colleagues, and gives them a credit which must be gratifying to every American physi- cian.— ^m. Journ. Med. Soi., April, 1874. Throughout the whole book it is impossible not to feel that the author has spontaneously, conscientious- ly, and fearlessly performed his task. He goes direct to the point, and doeR not loiter on the way to gossip or quarrel with other authors. Dr. Barnes's book will be eagerly read all over the world, and will everywhere be admired for its comprehensivenesH, honesty of purpose, and ability —The Obstet. Journ of Great Britain and Ireland, March, 1874. Henry C. Lea's Publioationb — (Diseases of Women). 23 fJODGE {HUGH L.), M.D., ■*-* Emeritus Professor of Obatetrica, Ac, in the University of Pennsylvania. ON DISEASES PECULIAR TO WOMEN; including Displacements of the Uterus. With original illustrations. Second edition, revised and enlarged. In one heautifuUy printed octavo volume of 531 pages, cloth, $4 50. From Prof. W. H. Btfoed, o/ the Rttsh Medical College, Chicago, The book bears theimpreBB of a master band, and mnst, as its predeceaeor, prove acceptable to the pro- fession. In diseases of women Dr. Hodge has entab- llshed a school of treatment that has become world- vide in fame. Professor Hodge's work la truly an original one .'rom beginning to end, consequently no one can pe- ense Ub pages without learning something new. Asa contribution to the study of women's diseases, it is of great value, and is abundantly able to stand on its own merits.— .y. T. Medical Record, Sept. 15, 1868. IJ/'EST {CHARLES), M.D. LECTmES ON THE DISEASES OF WOMEN. Third American, from the Third London edition. In one neat octavo volume of ahout 550 pages, cloth, $3 75 ; leather, $4 75. As a writer, Dr. West atanda, in our opinion, se- seeking truth, and one that will convince the student eond only to Watson, the *'Macaulay of Medicine;' he possesses that happy faculty of clothing instruc- tion in easy garments ; combining pleasure with profit, he leads his pupils, in spite of the ancient pro- verb, along a royal road to learning. His work is one which will not satisfy the extreme on either side, but it is one that will please the great majority who are that he has committed himself to a candid, safe, and valuable guide.— .W. A. Med.-Chirurg Review. We have to say of it, briefly and decidedly, that It Is the best work on the subject in any language, and that it stamps Dr. West as the facile prineeps of British obstetric authors. — Edinburgh Med. Journal. D3WBES'R TREATISE ON THE DISEASES OF FE- MALES. With illustrations. Eleventh Edition with the Author's last improvements and correc tlons. In one octavo volume of 636 pages, wltb ulates. cloth. $3 00. CHURCHILL ON THE PUERPERAL FEVER AND OTHER DISEASES PECULIAR TO WOMEN 1 vol. 8vo., pp. 450, cloth. $2 50. ASHWELL'S PRACTICAL TREATISE ON THE DIS- EASES PECULIAR TO WOMEN. Third American, from the Third and revised London edition. 1 vol . 8vo., pp. 628, cloth. S3 50. MEIGS ON THE NATURE, SIGNS, AND TREAT- MENT OF CHILDBED FEVER. 1 vol. 8vo. pp. S65, cloth. $2 00. mANNER (THOMAS H), M.D. ON THE SIGNS AND DISEASES OF PREGNANCY. First American from the Second and Enlarged English Edition. With four colored plates andillustrationB on wood. In one handsome octavo volume of about 500 pages, cloth, $4 25. With the Immense variety of subjects treated of and the ground which they are madeto cover, the im- possibility of giving an extended review of thip truly remarkable work must be apparent. We have not a single fault to find with it, and most heartily com- mend it to the careful study of every physician who would not only always be sure of his diagnosis of We recommend obstetrical students, young and old, to have this volume in their collections. It con- tains not oqIj- a fair statement of the si^ns, symptoiuo, and disease* of pregnancy, but comprises in addition much interesting relative matter that is not to be found in any other work that we can name. — Edin- burgh Med. Journal, Jan, 1868. /THE OBSTETRICAL JOURNAL, [Free of postage for 1877.) THE OBSTETRICAL JOURNAL of Great Britain and Ireland; Including Midwifery, and the Diseases of Women and Infants. With an American Supplement, edited by J. V. Ingham, M.D. A monthly of about 80 octavo pages, very handsomely printed. Subscription, Five Dollars per annum. Single Numbers, 50 cents each. Commencing with April, 1873, the Obstetrical Journal oonaista of Original Papers by Brit' ish and Foreign Contributors ; Trnnsactions of the Obstetrical Societies in England and abroad Reports of Hospital Practice; Reviews and Bibliographical Notices; Articles and Notes, Edito rial. Historical, Forensic, and Miscellaneous; Selections from Journals; Correspondence, &c Collecting together the vast amount of material daily accumulating in this important and ra pidly improving department of medical science, the value of the information which it pre sents to the subscriber may be estimated from the character of the gentlemen who have alrendy promised their support, including such names as those of Dra. Atthill, Robert Barnes, Henry Bennet, Thomas Chambers, Fleetwood Churchill, Matthews Duncan, Graily Hewitt, Braxton Hicks, Alfred Meadows, W. Leishman, Alex. Simpson, Tyler Smith, Edward J. Tilt, Spencer Wells, &o. &e. ; in short, the representative men of British Obstetrics and Gynss- eology. In order, to render the Obstetrical Joitrnal fully adequate to the wants of the American profession, each number contains a Supplement devoted to the advances made in Obstetrics and Gynsecology on this side. of the Atlantic. This portion of the Journal is under tbe editorial charge of Dr. J. V. Ingham, to whom editorial communications, exchanges, books for re- view, Ac, may be addressed, to the care of the publisher. *^* Complete sets from the beginning can no longer be furnished, but subscriptions can com- mence with Vol. v., April, 1877. 24 Hbnet C. Lea's Publications — {Midwifery). >LATFAIR ( W. S.), M.D., F.R.G.P., Professor of Obstetria Medicine in King's College, etc. etc. A TREATISE ON THE SCIENCE AND PRACTICE OP MIDWIFERY. In one handsome octavo volume of 576 pages, with 166 illustrations : cloth, $4 00 ; lea- ther, $5 00. {Jtist Issued ) The student and also the busy practitioner will find here a rich mine from which he may obiain valuable information to aid him in his attendance on the puc.r- pe-al female- The whole chapter upon the management of a natural labor is by itself worth the price of the book. Indeed, authors generally seem to regard this matter as of trivial importance, as though it were a thing too well known to need elucidation, while they dwell at great and tiresome length upon malprepenta- tions, malformations, etc., matters which so rarely are encountered by the general practitioner. But we might continue at still greater length, so fascinating have we found this book of Dr. Playfair's. We would earnestly recommend it to all our readers as a book which should occupy a prominent position on their shelves, and one, too. which they should constantly and carefully study^,. — J/ed. and Swrg. Reporter^ Sept. 30, 1876- ' The author's reputation was sufficient to warrant great expectations, when his forthcoming work was an- nounced, and its appearance has caused no disappoint- ment It deals in a m,asterly way with many disputed points, and gives conclusions which it would be difficult to gainsay. The work is the most valuable acquisition to the subject on which it treats which has been given the profession in a long time, and in saying this we do not forget the many admirable treatises which have re- cently appeared, • No practitinnej can afford to be with- out it — Peninsular Journ. nf Me,d., Sept. 1875. The high reputation already won by Dr. Playfair in this special department of medicine is a sufficient guar- antee for the meritorious character of this work. Every page is replete with interesting and instructive matter, containing the very latest information regarding the subject of obstetrics, full of hints of the greatest prac- tical value. This work will find, we predict, a large and ready sale The book is profusely illustrated with valu- able wood-cuts, and is printed in beautiful type.— CTti- cinnati Lancet and Observer, Nov. 1876. This is pre-eminently a work adapted to the wants of students, and will do moretowa'd accomplishing the profession at lar^e in that particular branch of medicine than any other work in the field of obstetric literature. In praise of this work too much cannot be said — in ad- verse criticism very little. We advise every student and every graduate to obtain it, and hope, ere long, to see it adopted as the principal text booK of obstetric medicine in every college in the United States. — Nash- ville Med. and Surg. Journ., Oct. 1876. ffODOE {HUGH L.), M.D., •*■-*■ Emeritus Professor of Midwifery, Ac. in the University of Pennsylvania, &c . THE PRINCIPLES AND PRACTICE OP OBSTETRICS. Illus- trated with large lithographio plates containing one hundred and fifty-nine figures from original photographs, and with numerous wood-cuts. In one large and beautifully printed quarto volume of 550 double -colui^ned pages, strongly bound in cloth, $14. The work of Dr. Hodge is something more than a ■Imple presentation of his particular views in the de- partment of Obstetrics ; it is something more than an ordinary treatise on midwifery ; it is, in fact, a cyclo- pasdia of midwifery. He has aimed to embody in a single volume the whole science and art of ObBtotrics. An elaborate text is combined with accurate and va- ried pictorial illustrations, so that no fact or principle Is left unstated or unexplained. — Am. Med. Times^ Sept. .3. 1864. It IS very large, profusely and elegantly illnstrated* and is fitted to take its place near the works of great obstetricians. Of the American works on the subject it is decidedly the beat. — Edinb. Med. Jour., Dec. '64. We have read Dr. Hodge's book with great plen- Bure, and have much satisfaction in expressing oni commendation of it as a whole. It is certainly highly instructive, and in the main, we believe, correct. The great attention which the author has devoted to the mechanism of parturition, taken along with the con- clusions at which he has arrived, point, we think, conclusively to the fact that, in Britain at least, th« doctrines of Naegele have been too blindly received. — Glasgow Med. Journal, Oct. 1864. *** Specimens of the plates and letter-press will be forwarded to any address, free by mail, on receipt of six cents in postage stamps. j^AMSBOTHAM (FRANCIS H), M.D. THE PRINCIPLES AND PRACTICE OP OBSTETRIC MEDI- CINE AND SUEGEEY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the author. With additions by W. V. Kbatins, M. D., Professor of Obstetrics, Ac, in the Jefferson Medical College, Philadelphia. In one large and handsome imperial octavo volume of 660 pages, strongly bound in leather, with raised bands ; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in all nearly 200 large and beautiful figures. $7 00. QHURCHILL (FLEETWOOD), M.D., M.R.I. A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American from the fourth revised and enlarged London edition. With notes and additions by D. Feakcis Condie, M. D., author of a "Practical Treatise on the Diseases of Chil- dren,' ' 4c. With one hundred and ninety-four illustrations. In one very handsome octavo volume of nearly 700 large pages. Cloth, $4 00 j leather, $5 00. MOJfTGOMEST'S EXPOSITION OP THE SIGNS iND SYMPTOMS OP PREGNANCY. With two exquisite colored plates, and numerous wood-cats. In 1 vol. 8vo., of nearly 600 pp., cloth. $3 75. BIOBT'S SYSTEM OP MIDWIPEKY. With Notes and Additional Illustrations. Second American ^dition. One volume octavo, cloth, 422 pages. Henry 0. Lea's Publications— (M Feb. 1876. Perhaps the most useful one the student can procure. Some important additions have been made by the editor, in order to adapt the work to the profession in this coun- try, and some new illustrations have been introduced, to represent the obstetrical instruments generally em- ployed in American practice. In its present form, it is an exceedingly valuable book for both the student and practitioner. — New York Med. Jov/rnal, Jan, 1876. In about two years after the issue of this excellent treatise a second edition has been called for. We regard the treatise as thoroughly sound and practical, and one which may with confidence be consulted in any emer- gency. — The London Lancet, Dec. 11, 1876. The appearance of a second edition of this System is the fulfilment of the prophecy which we made in a former review, that the book was destined to •' become a favorite." The additions by Dr. Parry are usually not abundant, but certain places which are pointed out as the weak part of Dr. Leishman's handicraft have been greatly strengthened by abundant and very judicious addenda.— i'Ai/oci. Med. Times, Dec. 25, 1875. SIWAYNE [JOSEPH GRIFFITHS), M.D., *^ Physician-Accoucheur to the British General Hospital, Ssc. OBSTETRIC APHORISMS FOR THE USE OP STUDENTS COM- MENCING MIDWIFEKY PRACTICE. Second American, from the Fifth and Eevised London Edition, with Additions by E. K. Hutohihs, M. D. With Illustrations. In one neat 12mo. volume. Cloth, $1 25. {Lately Issued.) *#* See p. 611 of this Catalogue for the terms on which this work is offered as a premium to Bubscribers to the " Amzbican Jouknal of the Medical Sciences." T^INCKEL (P.). ' ' Professor and Director of the QyncBcologieal Clinic in the Unitsersify of Eostoch. A COMPLETE TREATISE ON THE PATHOLOGY AND TREAT- MENT OF CHILDBED, for Students and Practitioners. Translated, with the consent of the author, from the Second German Edition, by Jambs Read Chadwick, M.D. In one ootavo volume. Cloth, $4 00. (Just Issued.) We feel quite sure that the profession of this country will give this interesting and learned work a cordial welcome — Cincinnati Mai. News, June, 1876. In Germany this treatise is regarded as a standard authority in this branch of medicine, and as -it con- tains the re«ent advances in the pathology and treat- ment of diseases that pertain to the puerperal condition, will be gladly received by a large portion of the profes- sion in this country. — Cincinnati Lancet and Observer, June, 1876. This work was written, as the author tells ub in his preface, to supply a want arising from the very brief consideration given to puerperal diseases by wrirers on Obstetrics, in which respect it seems the profession in his country is not different from ours, and to fill a blank left between the treatises upon tbe subject already in the field, and the present standpoint of science. The work has reached a second edition, and bears evidence throughout of careful study and practical experience. As its title implies, it is a manual rather than a treatise. — American Journal of Med. Sciences. April, lb71. JpARRY [JOHN S.), M.D., Ohfttetrician to the Philadelphia Hospital, Viee-Prest. of the Obstet. S'^ctety of Philadelphia. EXTRA-UTERINE PREGNANCY: ITS CLINICAL HISTORY, DIAGNOSIS, PROGNOSIS, AND TREATMENT. In one handsome oetaTo volume. Cloth, $i 50. {Lately Issued.) It is with genuioe satisfaction, therefore, that weread the work before us, which is far in advance of any mo- nograph upon the subject in the English language, and exceeding very much, in the number of cases upon which it is based, we believe, any work of the kind ever published. The author has given great care and study to the work, and has handled his 'statistics with judg- ment ; so that, whatever was to he gained from them, h"e has gained and added to our knowledge on the sub- ject. We owe the author much for giving us a clear, readahle book upon this topic. He has, so far a<; it is at present possible, removed the obscurity attending certain points of the subject. He has brought order out of something very like ch&os.— Philadelphia Mf.d. Times, Feh. 19, 1876. In this work Dr. Parry has added a most valuable contribution to obstetric literature, and one which meets a want long felt by those of the profession who have ever been called upon to deal with this class of cases. — Boston Med. and Surg. Journ., March 9, 1876. This work, being as near as possible a collection of the experiences of many persons, will afford a most useful guide, both in diagnosis and treatment, for this most interesting and fatal malady. We think it should be in the hands of all physicians practising midwifery. — Cin- cinnati Clinic, Feb. 5, 1876. 26 Henry C. Lea's Publications — (Surgery). f^ROSS {SAMUEL D.), M.D., ^-^ Professor of Surgery in the Jeferson Medical Oollege of Philadelphia, A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fifth edition^ carefully revised, and improved. In two large and beautifully printed imperial octavo vol- umes of about 2300 pages, strongly bound in leather, with raised bands, $15. (Just Issued.) The continued favor, shown by the exhaustion of successive large editions of this great work, proves that it has successfully supplied a want felt by American practitioners and students. In the present revision no pains have been spared by the author to bring it in every respect fully up to the day. To effect this a large part of the work has been rewritten, and the whole enlarged by nearly one-fourth, notwithstanding which the price has been kept at its former very moderate rate. By the use of a close, though very legible type, an unusually large amount of matter is condensed in its pages, the two volumes containing as much as four or five ordinary octavos. This, combined with the most careful mechanical execution, and its very durable binding, renders it one of the cheapest works accessible to the profession. Every subject properly belonging to the domain of surgery is treated in detail, so that the student who possesses this work may be s^aid to have in it a surgical library. We have now brought our task to a conclusion, and have seldom read a work with the practical Talue of which we have been moreimpressed. Every chapter i» so concisely put together, that the busy practitioner, when in difficulty, can at once find the information he requires. His work, on the contrary, is cosmopolitan, the surgery of the world being fully represented in it. The work, in fact, is so historically unprejudiced, and so euiinently practical, that it is almont a false compliment to say that we believe it to be deptined to occupy afore- most place as a work ofreference,whilea8ystfim of sur- gery like the presentsystem of surgery is the practice of surgeons. The printing and binding of the work is un- exceptionable; indeed, it contrasts, in the latter re- spect, remarkably -with English medical *nd surgical cloth-bound publications,wbich are generally so wretch- edly stitched as to require re-binding before they are any time in use. — Dub. Journ. of Med. ScL^ March, 1874. Dr. Gross's Surgery, a great work, has become ptill greater, both in size and merit, in its most recent form. T he difference in actual number of pagef is no t more than 130, but. the size of the page having been increased to what we believeia technically termed ■■elephant." there has been room for considerable additions, which, toge- ther with the alterations, are improvements. — Land. Lancet, Nov. 16, 1872. It combines, as perfectly tie possible, the qualities of a text-book and work of reference. We think this last edition of Gros>'s " Surgery," will confirm his title of " Primus inter Pares" It is learned, scholar-like, me- thodical, precise, and exhaustive. We scarcely think any living man could write so complete and faultless a treatise, or comprehend more solid, instructive matter, in the given number of pages. The labor must have been immense, and the work gives evidence of great powers of mind, and the highest order of intellectual discipline and methodical disposition, and arrangement of acquired knowledge and personal experience. — N. Y. Med Journ., Feb. 1873 As a whole, we regard the work as the representative "System of Surgery" in the English language. — St. Louis Medical and Surg. Journ., Oct. 1872. The two magnificent volumes before us afford a very complete view of the surgical knowledge of the day. Some years ago we had the pleasure of presenting the first edition of Gross's Surgery to the profession as a work of unrivalled excellence; and now we have the result of years of experience, labor, and study, all c6n- deosed upon the great work before us. And to students or practitioners desirous of enriching their library with a treasure of reference, we can simply commend the purchase of these two volumes of immense research. — Cincinnati Lancet and Observer, Sept. 1872. A complete system of surgery — not a mere text-book of operations, but a scientific account of surgical theory and practice in all its departments. — Brit, and For. Med.- Chir. Rev., Jan. 1873. D Y THE SAME A UTEOE. A PRACTICAL TREATISE ON THE DISEASES, INJURIES, and Malformations of the Urinary Bladder, the Prostate Gland, and the Urethra. Third Edition, thoroughly Revised and Condensed, by Samuel W. Gross, M.D. , Surgeon to the Philadelphia Hospital. In one handsome octavo volume of 574 pages, with 170 illus- trations: oloth, $4 50. {Now Ready.) The editor has availed himself of the opportunity afforded by the call for a new edition of this work to thoroughly revise and render it in every respect worthy of its position as a standard iiu- thority. Being in great part rewritten, the opportunity has been taken to condense it as much as possible, so that it will be found reduced in size, while yet containing the latest views on the subjects discussed. This work is a very valuable addition to surgical lite- rature, and will be found useful to all who may refer to it. — Journal of Nervous nnd Mental Disease, Oct. 1876. The book is fully up to the times, and we know of no monograph on the subject of urinary diseaees that is fuller and more complete than the one under notice. — Cincin. Lancet and Observer, Dee. 1876, It is a valuable and exhaustive treatise on the surgery of the urinary organs, brought fully up to the exi.«tiug state of our knowledge. A perusal of its 674 pages will amply repay the investigator.— Pac(^c Med. and Surg. Journ, Nov. 1876. Nothing need be said to commend this standard work to the profession. It has long been considered one of the most valuable from the pen of the distinguished author. The editor has done his work ably and faith- fully, and several of the chapters, by no means the least useful ones, are from his pen ; as a monograph repre- senting all the surgery of the parts of which it treats, it has nosuperiorin our tongue. — Med. and Surg. He- pnrter, Oct. 21, 1876. J^Y TBE SAME AUTHOR. ' ' A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PASSAQBS. In 1 vol. 8vo., withl!lHgtrationfl= t^t 468 "lotih- *? *fi For reference and general information, the physician or surgeon can find no work that meets their necessities more thoroughly than this, a revised edition of an ex- cellent treatise, and no medical library should be with- out it. Eeplete with handsome illustrati(.nfi and good ideas, it has the unusual advantage of being easily comprehended, by the reasonable and practical manner in which the various subjects are sytitematized and arranged We heartily recommend it to the profession as a valuable addition to the important literature of dis- eases of the urinary ot^i^ub.— Atlanta Med. Journ., Oct. 1876. It is with pleasure we now again tnke up this old work in a decidedly new dress. Indeed, it must be regarded as a new book in very many of its parts. The chapters on "Diseases of the Kladder," "Prostate Body," and 'Lithotomy," are splendid specimens of descriptive writing; while the chapter on "Stricture" is one of the most concise and clear that we have ever Tn&d—Aew York Med. Journ., Nov. 1876. Henry C. Lsa's Publications — (Surgery). 27 ASHHURST (JOHN, Jr.), M.D., ■^^ Prof, of Clinical Surgery, Univ. of Pa., Surgeon to the Episcopal Hospital, Philadelphia. THE PRINCIPLES AND PRACTICE OF SURGERY. In one very large and handsome octavo volume of about 1000 pages, with nearly 550 illustrations, cloth, $6 50; leather, raised bands, $7 50. opinions of others. He is conservative, bat not hide- bound by authority. His style is clear, elegant, and scholarly. The wirk is an admirable text-hook, and a useful book of reference. It is a credit to American profeauional literature, and one of the first ripe frnits of the soil fertilized by the blood of our late unhappy w&T.—N. Y. Med. Record, Feb. 1, 1872. Its author has evidently tested the writings and experiences of the past and present in the crucible of a careful, analytic, and honorable mind, and faith- fully endeavored to bring his work up to the level of the highest standard of practical surgery. He is frank and definite, and gives us opinions, and gene- rally sound ones, instead of a mere resume of the TIOLMES [TIMOTHY), M.D., Surgeon to St. George's Hospital, London. SURGERY, ITS PRINCIPLES AND PRACTICE. In one hand- some octavo volume of nearly 1000 pages, with 411 illustrations. Cloth, $6; leather, $7. {Just Issued.) We believe it to be by far the beet surgical text-book that we have, insoranch as it is the completest, and the one most thoroughly broughtnp to the knowledge of the present day. All who will give this book the careful perusal that it deserves and requires, -whe- ther student or practitioner, will agree with us, that, from the happy way in which justice is done, both to the principles and practice of surgery, from the care with which its pages are brought up to modern date, from the respect which is paid all along tn the opin- ions of others, it deserves to take the first place among the text-books on surgery. — BHWsA Med. Journ., Dec. 25, 1375. This is a work which has been looked for on both sides of the Atlantic with much interest. Mr. Holmes is a surgeon of large and varied experience, and one of the best known, and perhaps the most brilliant writer upon surgical subjects in England. V, is a book for students — and an admirable one — and for the busy general practitioner. It will give a student all the knowledge needed to pass a rigid examina- tion. The book fairly justifies the high expectations that were formed of it. Its style is clear and forcible, even brilliant at times, and the conciseness needed to bring it within its proper limits has not impaired its force and distinctness. — N. T. Med. Record, April 14, 1876. It will be found a most excellent epitome of pur- gery by the general practitioner who has not the time to give attention to more minute and extended works, and to the medical student. In fact, we know of no one we can more cordially recominend. The author has succeeded well in giving a plain and practical ai'count of each surgical iojury and disease, and of the treatment which is most commonly advisable. It will no doubt become a popular work in the pro- fession, and especially as a text-book. — Cincinnati Med. News, April, 1806. In point of literary structure we have no words but those of praise to write of Dr. Holmes's book. His diction is always graceful and clear, and he usually works with great conscientiousness. There is much independence of thought and a healthy disposition to resist the tendency to walk in old tracks simply be- cause they are old. On the whole, he has done his work in a manner for which it wonld be ungenerous not to give him very high credit indeed. — Dublin Journ. rf Med., Oct. 1876. THE PRINCIPLES AND PRACTICE OF SURGERY. By William Pfrrir.F.R S E., Professor of Surgery Id the University of Aberdeen. Edited by John Neill, M.D., Professor of Surgery in the Penna Medical College, Surgeon to the Pennsylvania Hos- pital, &c. In one very handsome octavo volume of 780 pages, with 316 illuatrations, cloth, $3 75. B IGELO W [HENRY J.), M. D., Professor of Surgery in the Massachusetts Med. College. ON THE MECHANISM OF DISLOCATION AND FRACTURE OF THE HIP. With the Reduction of the Dislocation by the Flexion Method. With numerous original illustrations. In one very handsome octavo volume. Cloth, $2 50. TJAMILTON [FRANK H.), M.D., Professor of Fractures and IHalocaUons, Ac, tn SeUevae Soap. Med. College, New Yorli. A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- TIONS. Fifth edition, revised and improved. In one large and handsome ootavovolume of nearly 800 pages, with 34-t illustrations. Cloth, $5 75 ; leather, $6 75. (Now Ready.) This work is well known, abroad as well as at home, as the highest authority on its important subject — an authority recognized in the courts as well as in the schools and in practice — and again manifested, not only by the demand for a fifth edition, but by arrangements now in pro- gress for the speedy appearance of a translation in Q-ermany. The repeated revisions which the author has thus had the oppartunity of making have enabled him to give the most careful consid- eration to every portion of the volume, and he has sedulously endeavored in the present issue, to perfect the work by the aid of his own enlarged experience and to incorporate in it whatever of value has been added in this department since the issue of the fourth edition. It will there- fore be found considerably improved in matter, while the most careful attention has been paid to the typographical execution, and the volume is presented to the profession in the confident hope that it will more than maintain its very distinguished reputation. of its teachings, but also by reason of the medico legal bearings of the cases of which it treats, and which have recently been the subject of useful papers by Dr. Hamil- ton and others, is sufBciently obvious to every one The present volume seems to amply All all the requisites. We can safely recommend it as the best of its kind in the Mngliah lanfiuage, and not excelled in any other. — Journ. of Nervous and Mental Disease, Jan 1876. There is no better work on the subject in existence than that of Pr. Hamilton. It should be in the posses- sion of every general practitioner and surgeon. — The Am. Journ. of Obstetrics, Feb, 1876. The value of a work like this to the practical physi- cian and surgeon can hardly be over-estimated, and the necei^sity of having such a book revised to the latest dates, not merely on account of the practical importance 28 Henry C. Lea's Publications — {Surgery, Jurisprudence, &c.). PJRICHSEN {JOHN E.), ■^ Professor of Surgtry in University College, London, etc. THE SCIENCE AND ART OF SURGERY; being-a Treatise on Sur- gical Injuries, Diseases, and Operations. Kevised by the author from the Sixth and enlarged English Edition. Illustrated by over seven hundred engravings on wood. In two large and beautiful octavo volumes of over 1700 pages, cloth, $9 00 j leather, $11 00. {Lately Issued.) These are only a few of the points in which the states In his preface, they are not confined toany one present edition of Mr. Erichsen's work surpasses its portion, hut are distribnted generally through the predecessors. Thronghout there is evidence of a subjects of wbich the work treats. Certainly one of laborious care and solicitude in seizing the passing J the most valuable sections of the book seems to us to knowledge of the day, which reflects the greatest! be that which treats of the diseases of the arteries credit on the author, and much enhances the value andtheoperativeproceedings which they necessitate of his work. We can only admire the industry which has enabled Mr. Ericbsen thus to succeed, amid the distractions of active practice, in producing emphatic- ally the book of reference and study for British prac- titioners of surgery. — London Lancet, Oct, 26, 1872. Considerable cbanges have been made in this edi- tion, and nearly a hundred new illustrations have been added. It is difficult in a small compass to point oat the alterations and additions ; for, as the author In few text-books is so much carefully arranged in- formation collected. — London Med. Times and Gaz-, Oct. 26, 1872. The entire work, complete, as the great English treatise on Surgery of our own time, is, we can assure our readers, equally well adapted for themost junior student, and, as a book of reference, for the advanced . practitioner — Dublin Quarterly Journal. SKET'S OPERATIVE SURGERY. In 1 vol. 8vo. cl., of 6fl0 pages ; with about 100 wood-cats. $3 25. COOPER'S LECTURES ON THE PRINCIPLES AND Practice OF SuBOERT. Inl vol. 8vo.cloth,750p. $2. GIBSON'S INSTITUTES AND PRACTICE OP SUR- GERY. Eighth edition, improved and altered, With thirty-four plates. .In two handsome -octavo vol- umes, aboutlOOOpp., leather, raised bandF. $6 F>(^. MILLER'S PRINCIPLES OF SURGERY. Fourth Ame- rican, from the Third Edinburgh Edition. In one large Svo. vol. of 700 pages, with 340 illustrations : cloth, $3 75. MILLER'S PRACTICE OF SURGERY. Fourth Ame- rican, from the last Edinburgh Edition. Revised by the American editor. In onelargeSvo. vol. of nearly TOO pages, with 364 illustrations: cloth, $3 75. D RUITT (ROBERT), M.R. G.S., ^c. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new and revised American, from the eighth enlarged and improved London edition. Illus- trated with four hundred and thirty-two wood engravings. In one very handsome oota^p volume, of nearly 700 large and closely printed pages, cloth, $4 00 ; leather, $5 00. practice of surgery are treated, and so clearly and perspicuously, as to elucidate every important topic We bave examined the book most thoroughly, and can say that this success is well merited. His book, moreover, possesses the inestimable advantages of having the sabjects perfectly well arranged and clas- sified, and of being written in a style at once clear ind succinct. — Am. Journal of Med. Science's. All that the surgical student or practitioner could dftsire. — Dublin Quarterly Journal. It is a most admirable book. We do not know when we have examined one with more pleasure. — Boston Med. and Surg. Journal. In Mr. Druitt's book, though containing only some •even hundred pages, both the principles and the QOSSELIN [L.), Professor of Surgery in the Faculty of Medicine^ Paris, etc. CLINICAL LECTURES ON SURGERY. Delivered at the Hospital of La Charitc. Translated from the French by Lewis A. Stimson, M.D., Surgeon to the Presbyterian nospital, New York. With illustrations. {Publishing in the Medical Neuis and Library, coTrvmencing with the July No. 1876.) Pakt I. ScKsiOAL Diseases op Youth— 8 Lectures. I Paet IT. TB40.uatic Fetee. Septicemia, Ac— 4 Lect. II. Fractures of the Limes— 18 Lecture.!. V. Diseases of the Articulations- 7 Lectures. ni. Traumatic Osteitis AMD Necrosis— 2 Lectures | VI. Phlfgmo,'). Abscess, Fistula-S Lectures. Itwillbeseenfromthisbrief abstract of the contents that these Lectures treat of subjects which are of daily interest to the practitioner, while some of them hardly receive-in the text-books the attention which their impbrtanoe deserves. The very distinguished reputation of the author and the practical manner in which he has handled the topics before him are sufficient assurance that this work will be in every way satisfactory to the subscribers of the " Medical News and Li- and that it will in no sense detract from the character of the very valuable series of books I Library Department of the "News" during the last thirty-three years. ORYANT (THOMAS), F.R.G.S., ■*-' Surgeon to Guy^s Hospital. THE PRACTICE OP SURGERY. With over Five Hundred En- gravings on Wood. In one large and very handsome ootavo volume of nearly 1000 pages, cloth, $6 25 I leather, raised bands, $7 25. (Lately Published.^ Again, the author gives us his own practice, his own beliefs, and illustrates by his own capes, or tho&e treated in Guy*s Hospital. This feature adds joint BRARY which have occupied the emphasis, and a solidity to his statements that inspire confidence. One feels himself almost by the side of the surgeon, seeing his work and hearing his living words. The views, etc., of other surgeons are con- sidered calmly and fairly, but Mr. Bryant's are adopted. Thus the work is not a compilation of other writings; it is not an encyclopaedia, but the plain statements, on practical points, of a man who has lived and breathed and had his being in the richest surgical experience. — Detroit Remew of Mtid. and Pharmacy, August, 1873. ASHTON 02^ THE DISEASES, INJURIES. ANDMAT>- | FORMATIONS OF THE RECTUM AND ANUS : with remarks on Habitual Conftlpatiun, Second Ameri- ] can, from the fourth and enlarged London EditioTi- i With illustrations. In one 8vo vol. of 287 pag cloth, $3 25. SARGENT ON BANDAGING AND OTHER OPERA- TIONS OF MINOR SURGERY. New edition, with sn additional chapter on Military Surgery One l2mo. vol. of 3S,S naaes. with 18t wood-cuts. Cloth. Henry C. Lea's Publications — (Psychological Medicine, <6f 29 B ROWNE {EDGAR A.), Suronon to the Liverpool Eye anfi v.nr InfivTriary, and tn the Dispensary for Skin Diseases. HOW TO USB THE OPHTHALMOSCOPE. Being Elementary In- struotiona in Ophthalmoscopy, arranged for the Use of Students. With thirty-five illustra- tions. In one small volume royal 12mo. of 320 pages: cloth, $1. {Now Ready.) very homely way, which cannot be misunderstood, and if the student follows the arguments in the first part of the book, and supplements the descriptions by perr^onal and dii'ect obeeryationa. he will possess a knowledge of the ophthalmoscope that will be amply suflicicnt for ail ordinary purposes. — London Practitioner, March, 1877. Especial care is taken to make the student familiar with the changes in surface level, as in the varieties of cupping, and the elevation from intracranial disease or neuntip. This portion of the book will be found upcful to a larger audience than that Mr. Browne professedly addresses — Med.-Ghir QuurWrly Rev. We congratulate the author on so successfully accom- plishing his object, and recommend the book to all stu- dents interested in this particular line of study. — Mtd. and Surg. Eeporter, June 2, 1877. The information is given in a very concise, but we may also add, in a very clear and forcible manner Many of the diagrams that illustrate the text arc original and iojieniouB in their construction, and very instructive.— Miin. Med. Jaurn. It is by no means an easy task to write a good ele- mentary work on a diflicult subject. The author must not only possess a comprehensive and accurate know- ledge of it, but must be able to express himself in sim- ple and easily intelligible terms. He requires to have the power of seizing the epsential facts and placing them in a striking light before the reader. He must noi weary him with long discussions, nor confuse him by the mul- tifilicity of details: he must be short, but clear. The little book before us fulfils these requirements in a very satisfactory manner. The explanations are given in a Edit- In one {Jusi pARTER [R. BRUDENELL), F.R.C.S., ^ Ophthalmic Surgeon to St. George s Hospital, ftc. A PRACTICAL TREATISE ON DISEASES OP THE EYE. ed, with test-types and Additions, by John Green, M.B. (of St. Louis, Mo.). handsome octavo volume of about 500 pages, and. 124 illustrations. Cloth, $3 75. Ready. ) Dr. Green, whose reputation and experience in this department are well known, has given this work a very careful revision, and has introduced much matter which will be found of importance to the practitioner. Aa his system of test-types is the one recommended by the author, they have been inserted in the volume in a shape which will admit of their being detached and mounted for convenient office use. These test-types, on a sheet for mounting, can be had separate, price 25 cents. It would be diflicult for Mr. Carier to write an unin- . in view, and presents the subject in a clear and concise etructive book, and impossible for him to write an un- interesting one. Even on subjects with which he is not bound to be familiar, he can discourse with a rare degree ot clearness and effect. Our readers will therefore not be surprised to learn that a work by him on the Diseases of the ISye makes a very valuable addition to ophthal- mic literature. . . . The book will remain one useful alike to the general and the special practitioner. Not the least valuable result which we expectfrom it is that it will to some considerable extent despecialize this bril- liant department of medicine. — London Lancet, Oct. SO, 1875. It is with great pleasure thatwe can endorse the work as a most valuable contribution to practical ophthal- mology. Mr. Carter never deviates from the end he has manner, easy of comprehension, and hence the more valuable. We would especially commend, however, as worthy of high praise, the manner in which the thera- peutics of disease of the eye is elaborated, for here the author is particularly clear and practical, where other writers are unfortunately too often deficient. The final chapter is devoted to a discussion of the uses and selec- tion of spectacles, and is admirably compact, plain, and useful, especially the paragraphs on the treatment of presbyopia and myopia. In conclusion, our thanks are due the author for many useful hints in the great sub- ject of ophthalmic surgery and therapeutics, a field where of late years we glean but a few grains of sound wheat from a mass of chuff — New York Medical Record, Oct. 23, 1875. T/f^ELLS {J. SOELBERO), ' ' Professor of Ophthalmology in King's College Hospital, &c. A TREATISE ON DISEASES OF THE EYE. Second Americai., from the Third and Revised London Edition, with additions j illustrated with numerous engravings on wood, and six colored plates. Together with selections from the Test-types of Jaeger and Snellen. In one large and very handsome octavo volume of nearly 800 pages; cloth, $5 00; leather, $6 00. {Lately Published.) • On examluing it carefnily, one is not at all sur- prised that it should meet with_ universal favor. It is, in fact, a comprehentiive aad'thoroughly practical treatise on dit^eases of (he eye, setting forth the prac- tice of the leadiog oculists of Europe and America, and' giviijg the author's own opinionii and preferences, which are quite decided and worthy of high consid- eration. The third English edition, from which this is takeo, having been revised by the author, com- prises a notice of all the more recent advances made in ophthalmic science. The style of the writer is jucid and flowing, thereiu differing materially from some of the translationsof Continental writers on this subjects thai are tn the market. Special pains are taken to esplaih,at length, those subjects which are particularly difficult of comprehension to the begin- uer, as the use of the ophthalmoscope, the interpi-e- tation of its images, etc. The book is profusely and ab y illustrated, and at the end are to be found 16 excellent colored ophthalmoscopic figures, which are ~ copies of some of the plates of Liebreich's admirable atlas. — Kansas City Med. Journ., June, 1874. f A VRENOE {JOHN Z.), F. R. G. S., Editor of the Ophthalmic Review, Ac. A HANDY-BOOK OF OPHTHALMIC SURGERY, for the use of Practitioners. Second Kdition, revised and enlarged. With numerous illustrations. In one very handsome octavo volume, cloth, $2 75. r.A WSON {GEORGE), F. R. C. S., Engl., -* Assistant Surgeon to the Royal London Ophthalmic Hospital, Moorjtelds, Ac. INJURIES OF THE EYE, ORBIT, AND EYELIDS : their Imme- diate and Remote Effects. With- about one hundred illustrations. In one very hand- some octavo volume, cloth, $3 50. 30 Henry 0. Lea's Publications— (Swrgrcry). THE EAR, ITS ANATOMY, PHYSIOLOGY, AND DISEASES. A Practical Treatise for the Use of Medical Students and Practitioners In one hand. some octavo volume of 620 pages, with eighty-seven illustrations : cloth, $4 50 , leatner, $5 50. (Just Ready.) Recent progress in the investigation of the structures of the ear, and advances ma^e in the modes of treating its diseases, would seem to render desirable a new work '"^l';.«5 ""*>'« 'f" sources of the most advanced science should he placed at the disposal »f t^\P'»«*'*'°°^';„„y," it has been the aim of Dr. Burnett to accomplish, and the advantages which he has enjoyed in IhespecM study of the subject are a guarantee thnt the result of his labors will proveofserv.ee to the profession at large, as well as to the specialist in this department. rpsOMPSON (SIR HENRY), ^ „, ■* Surgeon and Professor of Olinleal Surgery to TTniversity College Hospital . LBCTTJRES ON DISEASES OP THE URINARY ORGANS. With illustrations on wood. Second American from the Third English Edition. In one neat octavo volume. Cloth, $2 25. (Just Issued.) Mv aim has been to produce in the smallesll possible compass an epitome of practical knowl- edee concerning the nature and treatment of the diseases which form the subject of the work ; and I venture to believe that my intention has been more fully realized in this volume than m either of its predecessors— .duiAor's Preface. ^ f}T THE SAUB AUTHOR. ON THE Pathology and treatment of stricture op THE URBTHBA AND UKINARY FISTUL.*:. With plates and wood-cuts. From the third and revised English edition. In one very handsome octavo volume, cloth, $3 50. (Lately Published.) ■DY THE SAME AUTHOR. (Juat Issued.) THE DISEASES OF THE PROSTATE, THEIR PATHOLOGY AND TREATMENT. Fourth Edition, Revised. In one very handsome octavo volume of 356 pages, with thirteen plates, plain and colored, and illustrations on wood. Cloth, $3 75. rpAYLOR [ALFRED S.), M.D., ■ ^ Lecturer on Med. Jurisp. and Chemistry in Quy^e Hoapital. MEDICAL JURISPRUDENCE. Seventh American Edition. Edited by John J. Reese, M.D., Prof, of Med. Jurisp. in the Univ. of Penn. In one large octavo volume of nearly 900 pages. Cloth, $5 00 j leather, $6 00. {Lately Issued.) To the members of the legal and medical profession, in behalf of a work on medical jurisprudence by an __ — !_..__ . . - tjtinjp w\i,o is almost univevMally esteemed to be the best authority on this specialty in our language. On this point, however, we will oay.tliat we coBsider Dr. Taylor to be the safeat medico-legal authority to fol- low, in general, with which we are acqnaintedin any language.— Ka. Olin. Record, Nov. 1S73. Thislaateditionofthe Manual is probably the best of all, as it contains more material and is worked up to the latest views of the author as expressed in the last edition of the Principles. Dr. Reese, the editor of the Manual, has done everything to make his work acceptable to his medical countrymen.— .ff. Y. Mad. Record, Jau. 15, 187^. it is unnecessary to say anything commendatory of Taylor's Medical Jurisprudence. We might as well undertake to speak of the merit of Chitty's Plead- ings.— d^capo Legal News, Oct. 16, 1873. Little can be added to what has already been said of this standard work of Dr. Taylor's. As a manual it is doubtless the most comprehensive extant, meet- ing fully the demands of the dtudeut of medicine and l^vr , — Western Lancet, Nov. 1873. It is beyond question the most attractive as well as most reliable manual of medical jurisprudence published in the English language. — Am, Journal of Syphilography, Oct. 1873. It is altogether superfluous for us to offer anything jyT THE SAME AUTHOR, THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- DBNGE. Second Edition, Revised, with numerous Illustrations. In two large octavo volumes, cloth, $10 00; leather, $12 00 This great work is now recognized in England as the fullest and most authoritative treatise on every department of its important subject. In laying it, in its improved form, before the Ameri- can profession, the publisher trusts that it wiU assume the same position in this country. J^¥ THE SAME AUTHOR. {New EdiHon—Just Issued.) POISONS IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE, Third American, from the Third and Revised English Edition. In one large octavo volume of 850 pages ; cloth, $5 60 ; leather, $6 50. To tbc members of the legal and meilical profer^sion it is unnecea'iary to say anythiug commendatory of Taylor's Medical Jurisprudence. We might as well un- dertake to speak of the merit of Chitty's Pleadings.— Chicago Legal News, Oct. 16, 1873. This last edition of the Manual is probably the best of all, as it contains more material and Ik worked up to the latest views of the author as expretistid in the last edition of the Principles. Dr. Reepe, the editor of the Manual, has done everything to make his work accept- able to his medical countrymen. — New York Medical Record, Jan. 15, 1874, It is beyond question the most attractive afl well ad most reliableman'ual of medicaljurisprudence published in the English language. — American Journal of Syphilo- Henry C. Lea's Publications — (Ophthalmology). 31 rpOKE (DANIEL HACK), M.D., -*■ Joint author of "The ifanual of Psychological Medicine,^* &e. ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON THE BODY IN HKALTH AND DISEASE. Designed to illustrate the Action of the Imagination. In one handsome octavo volume of 416 pages, clotlj, $3 25. (Just Issued.) The object of the author in this work has been to show not only the efltect of the mind in caus- ing and intensifying disease, but also its curative influence, and the use which may be made of the imagination and the emotions as therapeutic agents. Scattered facts bearing upon this sub- ject have long been familiar to the profession, but no attempt has hitherto,, been made to collect and systematize them so as to render them available to the practitioner, by establishing the seve- ral phenomena upon a scientific basis. In the endeavor thus to convert to the use of legitimate medicine the means which have been employed so successfully in many systems of quackeryj the author has produced a work of the highest freshness and Interest as well as of permanent value. f>LANDFORD {G. FIELDING), M. D., F. R, C P., -*-' Lecturer on Psychological Medicine at the School of St. George's Hospital, &c. INSANITY AND ITS TREATMENT: Lectures on the Treatment, Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the United States on the Confinement of the Insane. By Isaac Rat, M. B. In one very handsome octavo volume of 471 pages; cloth, $3 25. This volume is presented to meet the want, so frequently expressed, of a comprehensive trea- tise, in moderate compass, on the pathology, diagnosis, and treatment of insanity. To render it of more value to the practitioner in this country, Dr. Ray has added an appendix which affords in- formation, not elsewhere to be found in so accessible a form, to physicians who may at any moment be called upon to take action in relation to patients. It aatiafies a want which mast have beeu sorely felt by the busy general practitioners of this country. It takea the form of a manual of clinical description of the various forms of insanity, with a description of the mode of examining persona suspected of in- eanity. We call particular attention to this feature of the book, as giving it a unique value to the gene- ral practitioner. If we pass from theoretical conside- rations to descriptions of the varieties of insanity as actually seen in practice and the appropriate treat- ment for them, we find in Br. Blandfurd's work a considerable advance over previous writings on the subject. Hie pictures of the various forms of mental dihease are so clear and good*that uo reader can fail to be slruck with their superiority to those given in ordinary manuals in the English language or (so far as our own reading extends; in any other. — London Practitioner, Feb. 1871. W: INSLOW (FORBES), M..D., D.C.L., ^c, ON OBSCURE DISEASES OF THE BEAIN AND DISORDERS OF THE MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Pro- phylaxis. Second American, from the third and revised English edition. In one handsome octavo volume of nearly 600 pages, cloth, $4 25. EA (HENRY a). SUPERSTITION AND FORCE: ESSAYS ON THE WAGER OF LAW, THE WAGER OF BATTLE, THE ORDEAL, AND TORTURE. Second Edition, Enlarged. In one handsome volume royal 12mo. of nearly 500 pages; cloth, $2 75. {Lately Published.) interesting phases of human society and progress. . The fulness and breadth, with which he has carried out his comparative survey of this repulsive field o* history [Torture], are such as to preclude our doing We know of no single work which contains, in so ■mall a compass, so much illustrative of the strangest operations of the human mind. Foot-notes give the authority for each statement, showing vast research and wonderful industry. We advise our confreres to read this book and ponder its teachings. — Chicago Med. Journal, Aug. 1870. As a work of curious inquiry on certain outlying points of obsolete law, " Superstition and Force" is one of the most remarkable books we have met with. -^■London AthencBum, Nov. 3, 1866. He has thrown a great deal of light upon what must be regarded as one of the most instructive as well as justice to the work within our present limits. But here, as throughout the volume, there will be found a wealth of illustration and a critical grasp of the philosophical import of facts which will render Mr. Lea's labors of sterling value to the historical &tii- deat— London Saturday Review, Oct. 8, 1870. As a book of ready reference on the subject, it is of the highest -vaXusi.— Westminster Review, Oct. 1867. B r THE SAME AUTHOR. {Late^^y Published.) STUDIES IN CHURCH HISTORY— THE RISE OF THE TEM- PORAL POWER— BENEFIT OF CLERGY— EXCOMMUNICATION. In one large royal I2mo. volume of 616 pp. cloth, $2 75. The Btory was never told more calmly or with greater learning or wiser thought. We doubt, indeed, if any other study of this field can be compared with this for clearness, accuracy, and power. — Chicago Examiner, Dec. 1870. Mr. Lea's latest work, * * Studies in Church History, " fully sustains the promise of the first. It deals with three subjects— the Temporal Power, Benefit of Clergy, and Excommunication, the record of which has a peculiar importance for the English student, and U a chapter on Ancient Law likely to be regarded as final. We can hardly pass from our mention of such works as these— with which that on "Sacerdotal Celibacy*' should be included— without noting the literary phenomenon that the head of one of the first American houses is also the writer of some of its most original books. — London AthencBum, Jan. 7, 1871. Mr. Lea has done great honor to himself and this country by the admirable works he has written on ecclesiologicaland cognate subjects. We have already had occasion to commend his "Superstition aud Force" and his "History of Sacerdotal Celibacy." The present volume is fully as admirable in its me- thod of dealing with topicci and in the thoroughness — aqualitysofrequentlylackingin American authors— with which they are investigated. — A". T. Journal f/ Psychol Medicine, July, 1870. 32 Henry C. Lea's Publications. INDEX TO CATALOGUE. American Journal of the Medical Sciences Abstract, Half-Yearly, of the Med. Sciences Anatomical Atlas, by Smith and Horner Atihton on the Rectnm and Anns . Attfield's Chemistry .... Ashwell on Diseases of Females . Ashhurst" s Surgery Browoe on Ophthalmoscope BametE on the Ear . Barnes on Diseases of Women Bellamy's Surgical Anatomy Bi-yanl's Practical Surgery Bloxam's Chemistry blandford on Insanity . BdrSham on Kenal Di-seases . Brinton on the Stomach Bigelow on the Hip Barlow's Practice of Medicine Bowman's (John E.) Practical Chemistry Bowman's (John E.) Medical Chemistry Bristowe's Practice Bumetead on Venereal .... B umstead and CuUerier's Atlae of Venereal Carpenter's Human Physiology . Carpenter on the Use and Abuse of Alcohol Carter on the Eye .... Cleland's Dissector .... Clowes' Chemistry .... * Century of American Medicine Chambers on Diet and Begimen . Chambers's Restorative Medicine Christison and Griffiths Dispensatory Churchill's System of Midwifery . Churchill on Puerperal Fever Condie on Diseases of Children . Cooper's (B. B.) Lectures on Surgery . CuUerier's Atlas of Venereal Diseases Cyclopedia of Practical Medicine . Dalton's Human Physiology Davis' Clinical Lectures Dewees on Diseases ofFemales Dewees on Diseases of Children . D mitt's Modern Surgery Dunglisoa's Medical Dictionary . Dunglison's Human Physiology . Etlis'B Medical Formulary, by Smith . Erichseu's System of Surgery Farquharson's Therapeutics Fenwick's Diagnosis .... Flint on Respiratory Organs . Flint on tlie Heart Flint's Practice of Medicine . Flint's Essays Flint on Phthisis Fliut on Percussion .... Fothergill's Handbook of Treatment . Pownes's Elementary Chemistry . Fox on Diseases of the Skin Fuller ou the Lnngs. &c. Green's Pathology and Morbid Anatomy Gibson's Surgery Gluge's Pathological Histology, by Leidy Galloway's Qualitative Analysis , Gray's Anatomy Grifflth's (R. E.) Universal Formulary Gross on Urinary Organs ... Gross on Foreign Bodies in Air-Passages Qross's Principles and Practice of Surgery Gosselin's Clinical Lectures on Surgery Hamilton on Dislocations and Fracturee Bartshorne's Essentials of Medicine . Hartshorne's Conspectus of the Medical Scienc Hartshorne's Anatomy and Physiology Heath.'8 Practical Anatomy . Holtilyn's Medical Dictionary Hodge on Women Hodge's Obstetrics Hodges' Practical Dissections Holland's Medical Notes and Reflections Holmes's Surgery ... Horner's Anatomy and Histology PAGE 1 Hudson on Fever .... am on Venereal Diseases timer's Handbook of Skin Diseases Jones (C. Handfield) on Nervous Disorders Kirkes' Physiology Knapp's Chemical Technology Lea's Superstition and force Lea's Studiesin Church History Lee OB Syphilis Lincoln on Electro-Tlierapeutics . Leishman's Midwifery . La Roche on Yellow Fever . La Roche on Pneumonia, &c. Laurence and Moon's Ophthalmic Surgery Lawson on the Eye .... Lehmann's Physiological Chemii^try, 2 vole Lehmann's Chemical Physiology . Ludlow's Manual of Examinations Lyons on Fever .... Marshall's Physiology . Medical News and Library ^ Meigs on Puerperal Fever Miller's Practice of Surgery . Miller's Principles of Surgery Montgomery on Pregnancy , Neill and Smith's Compendium of Med. Science Neligan's Atlas of Diseases of the Skin Obstetrical Journal Parry on Extra-Uterine Prt^gnancy Pavy on Digestion Pavy on Food ; Parrish.'s Practical Pharmacy Pirrie's System of Surgery . Playfair's Midwifery .... Quain and Sharpey's Anatomy, by Leidy Roberts on Urinary Diseases . Ramsbotham on Parturition . Remsen's Principles of Chemistry Rigby's Midwifery Rodwell's Dictionary of Science . tiwayne's Obstetric Aphorisms Sargent's Minor Surgery Sharpey and Quain's Anatomy, by Leidy Skey's Operative Surgery Slade on Diphtheria .... Schafer's Histology .... Smith (J, L.) on Children Smith (H. H.) and Horner's Anatomical Atlas Smith (Edward) on Con.sumption . Smith on Wasting Diseases in Children Stmt's Therapeutics .... Stillfe & Maisch's Dispensatory Sturges on Clinical Medicine Stokes on Fever Tanner's Manual of Clinical Medicine . Tanner on Pregnancy .... Taylor's Medical Jurisprudence Taylor's Principles and Practice of Med Jurisp. Taylor on Poisons . Tuke on the Influence of the Mind Thomas on Diseases of Females Thompson on Urinary Organs Thompson on Stricture . Thompson on the Proi*tate Todd on Acute Diseases . Walshe on the Heart Watson's Practice of Physic . Wells on the Eye . West on Diseases of Females West on Diseases of Children West on Nervous Disorders of Children What to Observe in Medical Cases Williams on Consumption . Wilson's Human Anatomy . Wilson on Diseases of the Skin . Wilson's Plates on Diseases of the Skin Wilson's Handbook of Cutaneous Medicine' Winslow on Brain and Mind WOhler's Organic Chemistry Wlnckel on Childbed . Zeissl on Venereal , PAGE . 17 . 19 . 20 . 17 . 8 , 10 . 31 . 31 . 19 . 17 . 25 . U . IS . 29 . 29 . 9 9 . 17 For "The Obstetrical Jourxal," Five Dollars a year, see p. 23.