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Cornell university Library 
 OF 126.K89 1863 
 
 The aura. surgao'«^^SIl^ffl 
 
Cornell University 
 Library 
 
 The original of tiiis book is in 
 tine Cornell University Library. 
 
 There are no known copyright restrictions in 
 the United States on the use of the text. 
 
 http://www.archive.org/details/cu31924012166249 
 
THE NEW SYDENHAM 
 
 SOCIETY. 
 
 INSTITUTED MDCCCLVIII. 
 
 VOLUME XVIIT. 
 
THE 
 
 AUEAL SUEGEEY 
 
 OP THE PRESENT DAY. 
 
 BY 
 
 Dr. W. KRAMER, 
 
 WITH TWO TABLES AND NINE WOODCUTS. 
 
 TBAUSLATED BY 
 
 HENRY POWER, Esq., P.R.C.S., M.B. Lond., 
 
 ASSISTANT-SUEGEON AMD LECTDKEa ON PHTSIOLOGT AT THE WESTMINSTEE HOSPITAL, AB 
 ST7EGE0N TO THE ROYAL WESTMINSTEH OPHTHALMIC HOSPITAL. 
 
 WITH COBIfECTIONS AND NUMEKOITS ADDITIONS 
 BY THE ADTHOK. 
 
 THE NEW SYDENHAM SOCIETY, 
 LONDON. 
 
 MDCCCLXIII. 
 
PB.INTED BY 
 
 J. E. ADLARD, BARTHOLOMEW CLOSE. 
 
CONTENTS. 
 
 SECTION I. 
 
 GENEKAL SURGEEY OF THE EAR. 
 
 Comparison between the Eye and Ear — Anatomy — Pathological Anatomy — 
 Physiology — Protection of the Ears — Hardness of Hearing — Deafness 
 — Noise in the Ears — Tabular View of the Diseases of the Ear — 
 Jiltiology of Aural Diseases — Diagnosis — Aural Speculum — Rhino- 
 scopy — Catheterism of the Eustachian Tube — Diagnostic Tube — 
 Catgut and other Bougies — Frequency of Aural Diseases — General 
 Course, Prognosis, and Treatment .... 
 
 SECTION II. 
 
 SPECIAL SUKGEKY OP THE EAR. 
 
 CHAPTER I.— DISEASES OF THE EXTERNAL EAR. 
 
 Diseases or the Cabtilage .... 
 
 Inflammation of the Dermis of the Auricle 
 
 a. Acute Form ..... 
 h. Chronic Form .... 
 
 Inflammation of the Connective Tissue of the Auricle 
 of the Perichondrium 
 
 36 
 ib. 
 ib. 
 
 38 
 
 39 
 40 
 
VI CONTENTS. 
 
 VAGE 
 
 Diseases of the Exteenai Meatus . . . . 41 
 
 Inflammatory Irritation of the Cuticle and of the Ceruminous 
 
 Glands ..... 
 Removal of Poreiga Bodies from the Meatus 
 Inflammation of the Corium of the Meatus 
 
 of the Connective Tissue of the Meatus 
 of the Periosteum of the Meatus . 
 
 Diseases oe the Mbmbbaua Tympani 
 
 Acute Inflammation of the Membrana Tjmpani . 
 
 Chronic Inflammation of the Membrana Tympani 
 
 Perforation of the Membrana Tympani — 
 
 Aural Polypi — Artificial Perforation of Membrana Tympani . 63 
 
 Yearsley's Balls of Cotton Wool 
 
 Toynbee's Artificial Membrana Tympani . 
 
 Haemorrhage from the Meatus 
 
 CHAPTER II.— DISEASES OP THE MIDDLE EAR. 
 
 42 
 46 
 
 47 
 51 
 
 54 
 
 S6 
 
 57 
 61 
 62 
 —70 
 74 
 73 
 79 
 
 86 
 
 90 
 
 97 
 
 105 
 
 Catarrhal Inflammation of the Middle Ear 
 
 With suppressed Exudation .... 
 
 With free Exudation 
 
 With free and interstitial Exudation 
 
 With exclusively interstitial Exudation 
 Noise in the Ears, without Hardness of Hearing . 1 13 
 
 Otalgia . . . . . . .114 
 
 CHAPTER ni.-DISEASES OP THE INTERN A.L EAR. 
 
 Acute Inflammation of the Labyrinth . . . . 115 
 
 Chronic Inflammation of the Labyrinth . . . • 117 
 
 Acute Inflammation of the Pacial Nerve, within the Aqueductus 
 
 Pallopii . . . . . . . 120 
 
 Nervous Hardness of Hearing and Deafness . . .121 
 
CONTENTS. VU 
 
 PAOE 
 
 Deaf-mutism , . . . . . . 129 
 
 Tabular Arrangement of Aural Diseases, briefly showing their Diagnosis, 
 
 Prognosis, and Treatment ..... 138 
 
 APPENDIX. 
 
 Ear Trumpets . . . . . .143 
 
 List of Authors to whom reference has been made in the course of 
 
 the Book . . . . . . . 145 
 
 List of Works by the Author . . . . ib. 
 
LIST OF ILLUSTRATIONS. 
 
 PAGE 
 
 Pig. 
 
 1. Aviral speculum . . . . . .22 
 
 2. Aural catheters . . . . . . 26 
 
 3. Diagnostic tube . . . . . -30 
 
 4. Aural forceps . . . . . . 47 
 
 5. Porte caustique for powders . . -71 
 
 6. Kuife for the removal of polypi . . . • • 77 
 
 7. Scissors for the remoyal of polypi . . . -78 
 
 8. Canula for the application of ligatures to polypi . . 80 
 
 9. Syringe for injecting the tympanic cavity . . .89 
 
THE 
 
 AUEAL SUEaERY 
 
 OF THE PRESENT DAY. 
 
 SECTION I. 
 
 GENEilAL SURGERY OE THE EAR. 
 
 The old dispute for precedency between the eye and the ear 
 admits of an easy solutioUj if we consider these two most important 
 senses in their relation to the several ages of man^ and to his external 
 and internal life. 
 
 Thus the child, duiing the second and third years of life, even 
 when blindness exists, acquires, by the ear alone, easily and playfully 
 as it were, by intercourse with those who speak, the power of speech, 
 the true stamp of man. Those who are deaf born, or who become 
 so before the expiration of the seventh year, either never acquire the 
 power of speech in this natural way, or again forgetting what has 
 been early learnt, remain or become dumb, and thus lose the most 
 important as well as the most natural means for intellectual and 
 spiritual culture. Acute hearing is, therefore, of inestimable value 
 for the period of childhood. 
 
 On the other hand, it is at the entrance into the period of adoles- 
 cence, the possession of voice rendered sure, the elements of intellec- 
 tual and spiritual life alike acquired, that the occurrence of deafness 
 exercises as fatal an influence in checking the healthy development 
 of the mind as the occurrence of blindness, so that at this period of 
 life the importance of both of these organs of sense may be held to 
 be equal. 
 
 1 
 
3 AURAL SURGERY. 
 
 Lastly^ tlie full-grown man passes forth from the quiet circle of 
 his family into public life. He claims independency^ and enters into 
 active relations with the external world. He then needs perfect sight 
 incalculably more than acute hearing. Under these circumstances, 
 it is not surprisingj considering the high importance of this protracted, 
 inteUectualj and peculiarly social period of life, during which the 
 sense of sight is universally acknowledged to be of the utmost value, 
 that to the eye should be given an unqualified, even though a some- 
 what unfair, precedence to the ear. 
 
 Unfortunately, moreover, the latter possesses a rigid form, desti- 
 tute of expression ; its organic changes are difficult to recognise, its 
 functional disturbances are numerous, easily produced, and often seK- 
 deceptive, and there are still additional inconveniences arising from 
 the difficulty of holding personal intercourse with the sufferer ; all 
 circumstances, however, which should only lead to increased atten- 
 tion and care in respect to the diseases of this important organ. 
 
 The anatomy of the ear may, indeed, be considered for the present 
 perfect. It is never requisite, in a practical point of view, to know 
 whether the membrana tympani consists of three or five membranous 
 layers, and whether these are essentially distinct, or only separable 
 from one another by nice dissection : whether upon its inner surface 
 one, or even two " pouches " are discoverable or not, or in what way 
 the auditory nerve appears, under the microscope, to ramiiy and ter- 
 minate, &c. 
 
 Undoubtedly, every reader of surgical works upon the ear (which 
 are, in general, but httle adapted for popular perusal), must set out 
 with an accurate knowledge of the organ of hearing ; and it therefore 
 appears useless to enter — for the description of the diseases of the 
 external, middle, and internal ear, and for the various operations — 
 into any anatomical details of the organs alluded to; for nothing 
 could be introduced but what can easily be acquired by aU readers 
 from the various hand-books of anatomy. 
 
 Scarcely any attempt has yet been made to solve the most difficult 
 problem connected with the pathological anatomy of the ear — the 
 inquiry into the disorganizations of the membranous and bony laby- 
 rinth; nor, though we may indeed regret it, is this a matter of 
 astonishment when we reflect upon the many and great difficulties 
 which oppose themselves to such investigations. 
 
 The following morbid conditions have been found in the tympanic 
 cavity upon dissection : — the membrana tympani in all instances re- 
 
PATHOLOGY. 3 
 
 maining uninjured ; effusion of serum ; the remains of hsemorrhagic 
 effusion; tough, stringy mucus; mucous granules, muco-purulent 
 fluid; inflammatory-exudation-granules; hypersemia of the mucous 
 membrane ; various shades of redness, and various degrees of swel- 
 ling ; spongy hypertrophy, and false membranes, in which the ossi- 
 cula lie more or less imbedded, and are, at the same time, either 
 anchylosed together or to the surrounding parts, this occurring, in 
 particular, between the base of the stapes and the fenestra ovalis ; 
 the membrane of the fenestra rotunda is sometimes thickened, and 
 may even be ossified; the Eustachian tube constricted, in consequence 
 of spongy swelling of its mucous membrane, and stuffed with mucus ; 
 the cells of the mastoid process have, in like manner, been found 
 filled with the same abnormal products that were contained in the 
 tympanic cavity, and with similar alterations of their investing mem- 
 brane. These inflammatory products have, for the most part, been 
 found in the post-mortem examinations of those who have died of 
 severe febrile affections (pneumonia, phthisis, nervous and gastric 
 fevers, and the exanthemata), in whom also similar products of 
 abnormal nutrition were present on the investing membranes of the 
 nasal, pharyngeal, and oral cavities, and on those of the trachea and 
 intestinal canal. It is still doubtful how far these abnormal con- 
 ditions of the tympanic cavity may occur in those who have never 
 suffered from such febrile affections, or who have only experienced 
 a slight attack. Now, it has so happened that only in very few 
 cases where dissections have been made has it been ascertained that 
 any hardness of heariag really existed during life, wliilst the exact 
 degree of that deafness has never been, in any case, determined ; and 
 we are, therefore, by no means in a position to state with certainty 
 that these morbid conditions of the tympanic cavity are the true cause 
 of deafness generally, or of any particular grade of it. 
 
 We cannot but regret the neglect of instrumental investigation 
 during the lifetime of the patients of such ears, as have been subse- 
 quently obtained for dissection, since it is on this account that we 
 are still unable, when the membrana tympani is uninjured, to furnish 
 any sore diagnosis founded on physical signs, of the various diseases 
 of the tympanic cavity. It is important to observe that with these 
 remarkable abnormal conditions of the tympanic cavity the quantity 
 of endo-lymph and peri-lymph contained in the membranous laby- 
 rinth was perfectly natural, furnishing a strong proof of the pro- 
 tection which is afforded to the auditory nerves by their isolation 
 
4 AURAL SURGERY. 
 
 in febrile diseases proceeding to a fatal termination and affecting 
 sympathetically and seriously the surrounding parts. When the 
 patient has suffered from certain chronic affections, deposits of 
 pigment, crystals of chloride of sodium and of carbonate of lime may 
 be discovered in the labyrinth ; or there may be well-marked injection 
 of the blood-vessels ; atrophy of the auditory nerves or of theii- 
 centric extremities, from the pressure of tumours developed in the 
 cranial cavity, or lastly, deficiency in the number of their roots arising 
 from the floor of the fourth ventricle, a cojidition which is especially 
 found in cases of congenital deafness. 
 
 The physiology of the human ear can hardly be expected to make 
 any advance from the study of comparative anatomy and physiology, 
 since it will always remain unknown in what manner and to what 
 degree the power of hearing in man differs from that possessed by the 
 various races of animals, and upon what modifications of structure 
 these differences depend. Moreover, since the human ear has not 
 only to hear inarticulate sounds and noises, but also to comprehend 
 articulate (vocal) sounds as weL, which requires a very high degree 
 of development in this organ, it must be apparent that no com- 
 parison can be made between this faculty as it exists in man and 
 that possessed by animals. 
 
 The only direct attempts to ascertain the acoustic and phy- 
 siological functions of the several parts of the organ of hearing have 
 been made upon the cartilage of the auricle. For this purpose a 
 watch is most conveniently employed, the movements of which can 
 be heard only within a very short distance by the healthy ear (mine, 
 for instance, is only audible within twenty-one inches). The 
 experiment should, of course, always be made when everything is 
 quiet ; and if we are ourselves the subject of it, we should stand 
 before a large mirror. 
 
 If we now cover over the cartilages of both ears with thick flannel 
 dipped in warm water, and stretched on a wire frame made to fit 
 closely the line of attachment of the cartilage, and also covering the 
 floor of the concha, yet so that the entrance of the aperture of 
 the meatus remains free, we shall find that the beat of the watch can 
 only be heard at the distance of fourteen instead of twenty-one 
 inches, a diminution which is to be attributed to the prevention by 
 the flannel cover of that resonance and concentration of sound 
 which is effected by the windings and sinuosities of the surfaces of 
 the auricle. 
 
PHYSIOLOGY OF THE EAR. 5 
 
 When the auricle of one or of both ears is pressed forwards 
 towards the cheeks with the hand, it will be found that both 
 articulate and inarticulate sounds can be heard with increasing 
 clearness the nearer the helix is approximated to the cheek; 
 this can only be ascribed to the greater resonance of the extended 
 auricle. 
 
 If the watch be held opposite the uncovered auricle in such a 
 manner that its face is parallel with the bottom of the coucha, the 
 beat can be heard about three inches further than when its face is 
 placed directly opposite the entrance of the meatus. This singular 
 effect, which is observable also in those who are hard of hearing, and 
 may always be noticed in watches which beat gently, is a strong 
 argument in favour of the power of the concha to concentrate sound, 
 and this conclusion is by no means invalidated by reported observa- 
 tions that after loss of the concha, by a cut or other injury, the power 
 of hearing was not diminished, because it is impossible to prove that 
 no diminution in the power of hearing has been experienced. In 
 these extremely superficial observations the precaution has not even 
 been taken to close the iminjured ear ! No investigations have ever 
 been made as to whether any influence is exercised upon the con- 
 centration of the waves of sound by the tortuous direction and 
 the funnel-shaped expansion of the meatus externus. At all events, 
 slight differences in its diameter do not appear in any way to affect 
 the faculty of hearing, as we may deduce from a comparison of the 
 dehcate and finely organized ear of the female with the more strongly 
 developed organ of the male, in whom the meatus is considerably 
 wider, and yet common experience shows that the faculty of hearing 
 may be equally acute in both. 
 
 The hearing is found to be injuriously affected whenever the 
 meatus is filled up by cerumen or pus, or is closed by the growth of 
 polypi, by foreign bodies, by spongy swelling of the dermis and 
 cellular tissue, or by hypertrophy of the dermis. The extent to 
 which the hearing is affected is in exact proportion to the com- 
 pleteness of the closure and to the nature of the obstruction in 
 regard to its power of conducting sound. 
 
 Daily experience is in opposition to Erhard's statement, that " in- 
 flammatory narrowing of the meatus may exist with undiminished 
 power of hearing/' and it is equally incorrect to say that new-born 
 children hear perfectly with their extremely small meatus. On the 
 contrary, their hearing is very imperfect or even altogether absent^ 
 
b AURAL SURGERY. 
 
 as we may conclude from the extremely sound manner in whicli they 
 sleep during the first months of life. It is only about the middle of 
 the first year that they give unquestionable evidence of hearing by 
 turning the head on the occurrence of a loud noise, music, &c., and 
 it is not until about the second or third year that the acquisition of 
 speech proves their hearing to be perfect. 
 
 The well-marked curvature of the meatus, contracted in its central 
 part, invested in its anterior half with a layer of glutinous cerumen, 
 even though it be uncovered and exposed to the changes of the 
 weather, and scarcely constituting an effective impediment to the 
 entrance of cold air or of cold water (as in submersion), is nevertheless 
 an excellent protection for the tender tympanic membrane and the 
 :'nternal parts of the organ. 
 
 We can only conjecture that the normal strong concavity of the 
 membrana tympaaai is subservient to the concentration of the aerial 
 waves of sound falling upon it, but its smoothness and pohsh and 
 its evident tension are obviously indispensable for normal hearing, for 
 we observe that any crack or fissure (which usually occurs along the 
 handle of the maUeus) very decidedly interferes with the power 
 of hearing, both quantitatively and qualitatively (as, for example, in 
 the right appreciation of musical sounds). This occurs instan- 
 taneously, and therefore before the occurrence of inflammatory con- 
 ditions in the immediate vicinity of the fissure. 
 
 The degree of translucency of this delicate membrane which 
 is present in health is equally important for normal hearing, for 
 every effusion of plastic lymph between its layers, occurring as a 
 consequence of inflammation produced by bathing in cold water or 
 by dropping stimulating fluids into the meatus, deprives the mem- 
 brane of its translucency, and with this there is a very decided dimi- 
 nution in the capacity for hearing, as may easily be shown by taking 
 the trouble to close the unaffected ear and experimenting on the 
 other with the voice and with a watch. 
 
 It is therefore perfectly erroneous to say, with Erhard, that " the 
 most distinctly marked infiammations of the membrana tympani 
 have been observed without any deficiency in the power of hearing." 
 
 That "the concave condition of the membrana tympani is of no 
 importance " will never be proved by the mere assertion that the 
 " concave membrana tympani of man possesses the same power of 
 concentrating the waves of sound as the perfectly flat membrane 
 of the mole or the convex membrane of the bird" (Erhard). 
 
THYSIOLOGY OP THE EAR. ' 
 
 Erhard lias adduced no proofs of tlie " equal '^ capacity for hearing 
 in maUj in the mole^ and in birds, various as the condition of their 
 membranes may be ; but even if we grant his proposition that the 
 membrana tympani is ahke subservient in conducting the waves of 
 sound, whether it be concave, plane or convex, still this proves 
 nothing against the circumstance that special acoustic peculiarities 
 may be connected with special forms of that membrane. 
 
 When we reflect with what force the air is often driven into the 
 tympanic cavity against the membrana tympani in blowing the nose, 
 so that it is even rendered convex on each side of the handle of the 
 malleus, we can easily understand that this delicate httle membrane 
 needs at such times a strong protection lest it should be ruptured. 
 This is afforded to it, in the first place, by its convexity being directed 
 inwards, and in the second place by that convexity being secured 
 by the insertion of the handle of the malleus; and though this 
 an-angement may not afford quite sufficient support to it when it is 
 affected by sounds of great volume and power, yet it is a very rare 
 event for these to produce a rupture. It is very evident also that 
 this support and protection against injury is materially increased by 
 the union of the malleus with the other moveable, resilient and angu- 
 larly placed ossicula. It is in this circumstance that the peculiar 
 value of the chain of small bones seems to consist. It is usual to con- 
 sider them as the means whereby the waves of sound are propagated 
 from the membrana tympani to the labyrinth, but surely it is incumbent 
 upon those who entertain this opinion to explain why this end would 
 not have been better attained by a single bone than by three bones, 
 whose continuity is broken and which are connected together in an 
 angular fashion. 
 
 Miiller's experimental evidence of the conduction of sound through 
 the ossicula proves notliing (see above), and has received no support 
 from any other quarter ; I may therefore immediately adduce the 
 arguments in favour of the conduction of sound taking place through 
 the air contained in the tympanic cavity and through the membrane 
 of the fenestra rotunda to the labyrinth. In support of this view I 
 must rest on evidence derived from pathology alone, for it is impos- 
 sible to adduce direct physiological facts upon such a question. It 
 is clear that we ought to obtain correct ideas in regard to the con- 
 duction of sound through the ossicula before proceeding to consider 
 the recently so much talked of " vibratory power of the ossicula, and 
 the hindrance to this which results from diseased conditions of the 
 
8 AURAL STJUGERT. 
 
 investing membrane of the bones and ligaments." All bodies are 
 certainly vibratory^ and consequently can conduct sound, but only 
 some of these (and then only under certain circumstances) are 
 musical ■when vibrations of sound are excited in them. The con- 
 duction of sound occurs quite independently of the condition of the 
 surface of the bodies in question^ and passes uninfluenced through 
 their substance, except in so far as it is affected by its degree of 
 density. On the other hand, the musical quahty of various bodies 
 is essentially dependent "apon the condition of their surfaces. A 
 tuning-fork, a rod of silver, of steel, or of glass, conducts sound 
 equally well when one end rests upon a watch and the other touches 
 the bones of the head or the teeth, whether these bodies are tightly 
 held in the hand, are covered, or are perfectly free ; but they are 
 only musical when, for example, the struck tuning-fork is so held 
 that it may vibrate with freedom, or when we strike the glass, silver, 
 or steel rod against some hard body whilst it is suspended by a 
 thread. Every kind of cover which is applied to these bodies takes 
 away their musical quality completely and immediately, without at 
 all affecting their power of conducting sound. If we now turn 
 from this to the "vibratory power of the ossicula," no one will 
 attribute to these bones a musical quality, but every one will admit 
 a conducting power, and it must be clear, from what has been said 
 above, that this depends purely on their atomic condition and arrange- 
 ment, and is quite independent of the condition of then* surfaces 
 (the investing membrane or periosteum), which cannot in any way 
 affect it. 
 
 It follows, therefore, that the vibrations of the ossicula, as regards 
 the conduction of sound, will not, as Erhard thinks, be interfered 
 with if their investing membrane be thickened, indurated, swollen, 
 covered with mucus, or in any other way diseased ; this holds also 
 in respect to similar conditions of the ligaments and of the ossicula; 
 for induration and, still more, ossification of the ligaments approximate 
 them in their atomic constitution to the small bones, and must con- 
 sequently facilitate the conduction of sound through this chain, by 
 rendering jit a more homogeneous mass, instead of hindering it, as 
 Erhard imagines. This being premised, we can easily understand 
 the physiological importance of the following facts. There are 
 numerous persons hard of hearing, in whom we can discern neither 
 in the meatus nor in the tympanic membrane any deviation from the 
 healthy condition. But if we introduce the catheter into the 
 
HARDNESS OF HEAUING AS A SYMPTOM. 9 
 
 Eustachian tube, and blow through it so strongly that the air 
 passes into the tympanic cavity, and is propelled against the membrana 
 tympani, we can hear by means of the diagnostic tube, properly 
 applied, a rattling mucous noise in the ear of the patient, who imme- 
 diately after perceives considerable improvement in his hearing, both 
 for articulate and inarticulate sounds, and feels that his ear is freer. If 
 this operation of blowing in air be repeated the next day, the sound 
 of the air passing in becomes clearer and less mucous, and the 
 hearing is correspondingly improved until, after some days or weeks, 
 when the tone of the in-blown air has attained its normal clear, soft 
 character, the hardness of heariag is entirely removed. 
 
 The cure of many uncomplicated cases requires the employment, 
 of no other local means than these, and in such patients the 
 hardness of hearing may literally be said to be blown away. It 
 must, therefore, have had a moveable cause, and whether this has 
 existed in the tympanic cavity, in the Eustachian tube, or in both, 
 is a matter of no moment ; it must, moreover, have been of a humid 
 nature, whether mucous or serous. According to the above re- 
 marks, this exudation cannot have interfered with the conduction 
 of sound by ensheathment of the ossicula, and therefore the cause 
 of the hardness of hearing can only be sought in the fiUing up of 
 the tympanic cavity or in the exudation upon its walls, and especially 
 upon the membrane of the fenestra rotunda and in the consequently 
 diminished power of conduction of sound in these parts. Hence the 
 cure of the hardness of hearing commences as soon as the moist 
 mucus (a bad conductor of sound) is removed by insufflation from 
 the tympanic cavity and from the membrane of the fenestra rotunda, 
 and is replaced by the atmospheric air, which is a good conductor 
 of sound ; the clean surface of the membrane of the fenestra rotunda 
 then once more vibrates normally. 
 
 The same phenomena may be observed in the membrana tympani 
 when this has been either completely or only partially covered, and 
 has again been freed from moist and adherent mucus. 
 
 Now, it is asserted, without the possibility of proof, that accumu- 
 lations of mucus never exist in the tympanum, but only in the 
 Eustachian tube (Erhard). Even granting this hypothesis, nothing ^ 
 i3 gained in proof of the conduction of sound through the ossicula, 
 because we cannot understand how the mucus in the tube should 
 operate in preventing the sounds which impinge upon the healthy 
 membrana tympani from being taken up by the healthy handle of 
 
10 AURAL SURGERY. 
 
 the malleus and conducted by the healthy ossicula to the healthy 
 labyrinth. That all these parts must really be healthy is evident 
 from the return of normal hearing on simply blowing air fre- 
 quently into the tympanic cavity. Lastly, if it be alleged against 
 the conduction of sound taking place through the air of the tympanic 
 cavity, " that the latter is, in the early years of life, constantly more 
 or less filled with a thin, fluid secretion from its mucous membrane, 
 so that no air is contained within it, as the dissection of the ears of 
 children who were possessed of perfect hearing proves, and as is also 
 shown by catheterism during life " (Erhard), we may question, in 
 the first place, whether, if such results are found upon dissection, 
 they are not to be regarded as the products of the disease which has 
 proved fatal, than that they constitute the normal condition of the 
 tympanum of the child. It would, moreover, be very difBcult for 
 Erhard to prove that these children had heard normally up to the 
 moment of death. And again, would the parents of cluldren whose 
 hearing is perfect allow Erhard or any other physician to cathe- 
 terize them during the first years of life — without mentioning the 
 extreme difficulty there would be in accomplishing this operation. 
 At the earliest period I have performed the operation, viz., on 
 children of four years of age who were hard of hearing, the tympanic 
 cavity was indeed filled with mucus, and when this was blown out 
 in the manner above described the hearing was immediately and 
 perfectly restored ; but this only furnishes a satisfactory proof that 
 mucus in the tympanic cavity is not a normal condition in children 
 of four years of age, nor is necessarily associated with perfect hearing. 
 Upon the whole, therefore, there is every probabihty that the con- 
 duction of sound from the membrana tympani to the labyrinth is 
 chiefly effected through the air of the tympanic cavity and the mem- 
 brane of the fenestra rotunda. The latter consequently acquires 
 special significancy, its peculiar concealed position being of little 
 importance when we reflect upon the imperfect information we 
 possess in regard to the resonance and other acoustic properties of 
 irregular-walled cavities like the tympanum. 
 
 Moreover, if " the oval fenestra is the only one constantly present 
 in the lower orders of animals, from which circumstance we may 
 argue for the small importance and dispensability of the round 
 fenestra" (Erhard), such a line of argument is much more in 
 favour of the importance than of the unimportance of any additional 
 part, as may easily be shown by a reference to the addition made in 
 
HARDNESS OF HEARING AS A SYMPTOM. 11 
 
 the development of any other organ, as, for example, the brain 
 amongst the higher orders of animals. 
 
 The bony base of the tympanic cavity (the covering of the laby- 
 rinth) undoubtedly conducts waves of sound from it to the auditory 
 nerve, of which we may assure ourselves by the patient's possessing 
 in many instances a very fair power of hearing though the membrana 
 tympani may be completely broken down, the ossicula destroyed by 
 ulceration, and the round and oval fenestra closed up. In these cases 
 the investing membrane of the tympanum is not spongy and thickened, 
 but smooth and adherent, moderately reddened, with the secretion 
 either diminished or altogether absent, the fenestra ovaKs only repre- 
 sented by a shallow dimple, and very probably closed by bony sub- 
 stance. In these cases the auditory nerve, imbedded in the bony 
 labyrinth, must be considered as the real seat of the special sensibility 
 to sound, since any compression of its centric extremity by tumours 
 developed within the cranium is followed by absolute deafness. 
 No regard need be paid to the argument of Pappenheim against the 
 constant coincidence of these morbid symptoms with deafness, since 
 the woman, on the dissection of whom " a firm tumour of an inch in 
 diameter was found compressing the facial and auditory nerves," had 
 been observed so Httle during life, that, he adds, " she ought not to 
 have been hard of hearing." The physiological importance of the 
 several parts of the membranous labyrinth is veiled in the utmost 
 obscurity. After what has been said above in proof of the great 
 probability that the conduction of sound is chiefly effected by means 
 of the air in the tympanic cavity, we cannot but admit, as being 
 stiU more probable, that the nerve of the cochlea plays a most 
 important part in the perception of the waves of sound. Its remark- 
 able size and wonderfully regular expansion upon the lamina spiralis 
 give to it a clearly superior value to the ramus vestibuli. But if we 
 " perhaps {! !) perceive the loudness of sound by the ramus vestibuli, 
 the ramus cochleae is, perhaps (! !), the means by which we estimate 
 bass and treble notes, their pitch and timbre, and can comprehend 
 speech " (Erhard) . This is merely a vain and foohsh playing with 
 theory, for Erhard has already, in the previous part of his work, 
 " practically reduced the value of the fenestra rotunda, as a membrane 
 conducting sound, to nothing," whilst he elsewhere says " the scala 
 tympani of the cochlea can only be directly affected by those waves 
 of sound which are conducted by means of the foramen rotundum to 
 the fluid of the scala tympani." Such contradictory statementsj 
 
13 AURAL SURGERY. 
 
 resting on the most exact (! !) pathological and physiological observa- 
 tions^ are insufficient to settle " the separate functions of these two 
 branches of the auditory nerve/' and, indeed, give no information 
 whatever upon the function of these parts of the ear. 
 
 The great value of the sense of hearing urgently demands that 
 extreme care should be taken of the organ in which it is lodged, 
 though this is unfortunately only to be expected from those who are 
 or have been deaf. This care consists essentially in the avoidance of 
 exposure to cold and to loud noises, which are the two chief sources 
 of injury to the organ in general, and to the auditory nerve in 
 particular. We shall here, therefore, appropriately give some pre- 
 cautionary advice, the observance of which should be a duty to all 
 who are or have been sufferers from aural disease. 
 
 The ears should not be permitted to become chilly nor to be 
 sensibly penetrated with cold, and, in particular, a cold wind should 
 not be allowed to strike directly upon the membrana tympani. 
 Hence both ears should be stopped in raw, moist, cold, or frosty 
 weather, and especially in stormy, windy weather, with unwashed and 
 well-oiled sheep's wool (never with cotton wool, which diminishes 
 the secretory activity of the ceruminous glands), and this should be 
 done with so much the more care in proportion to the smaUness of 
 the quantity of cerumen. If the cold be very severe, and .the 
 exposure to it prolonged, the ears must be covered with woollen 
 cloths, ear-flaps, &c., with the utmost care, and again, the feet 
 should be kept warm and dry by wearing woollen stockings, overshoes, 
 leathern shoes and boots (especially in the case of ladies), and by 
 giving up hunting in winter, fishing, and similar pastimes. 
 
 If by chance the feet should get wet, the shoes and stockings 
 should be changed as quickly as possible, and the feet immediately 
 put into warm water. The ears should be cleansed with a towel 
 dipped in soft, warm water, and should be immediately dried. The 
 habit of cleaning out the ears of children with wet cloths is much to 
 be censured, and the practice of dipping the head into a large basin 
 filled with cold water, and of thus washing the ears by purposely 
 fiUing them, is very injurious, because the narrowness of the 
 meatus renders it difficult or impossible to dry the deeper-lying 
 parts with the membrana tympani. Then, when they come into the 
 fresh, cool air, evaporation of the moisture in the ears takes place, 
 inevitably producing considerable cold. It is equally injurious to 
 pour water over the ears of little children, or to wash them with 
 
HARDNESS OF HEARING, — NOISE IN THE EARS. 13 
 
 saturated sponges and soap and water. In river or sea bathing, the 
 ears should be stopped with oiled wool, since that alone can prevent 
 the entrance of water. If there be an angry sea and we bathe with 
 the waves running high, we should bind closely over the ears a small 
 linen cloth, in order to prevent the wool from being washed out of 
 the meatus. Bathing-caps do not furnish a sufficient protection. We 
 generally recommended escape from, or, by stopping the ears with 
 fine linen charpie or oiled wool, prevention or moderation of, the 
 injurious action upon the auditory nerves of the noise in mills, 
 factories with clattering machines, blacksmiths' shops, and the work- 
 shops of copper-smiths and boiler-makers, of the noise produced by 
 baU practice of artillery and infantry, by the use of firearms in hunt- 
 ing, by wind instruments, or by violins in a full orchestra, by 
 shrieking parrots, and loud-singing canaries, and by the use of 
 metaUic instruments for hearing, though these latter should never be 
 employed. 
 
 The hardness of hearing so frequently observed in hunters and 
 lovers of sport is not to be so much attributed to the noise of many 
 explosions as to the unavoidable exposure to cold which accompanies 
 such pursuits. 
 
 Amongst the symptoms of diseases of the ear only two are of 
 general importance — hardness of hearing (deafness) and noise in the 
 ears. Diminution in the power of hearing (hardness of hearing), in 
 its infinite modifications up to complete deafness, is never absent in 
 aural diseases with the exception of some isolated and very circum- 
 scribed diseases of the cartilage and of some cases of noise in the 
 ears without deafness (see Tabular view, p. 31, No. 16), as may 
 readily be ascertained if we wiU only take the trouble in each case to 
 experiment carefully on the power of hearing. Many persons first 
 consider themselves to be hard of hearing when they are no longer 
 in a condition to maintain easy personal intercourse in their ordinary 
 avocations or pursuits; this in some measure explains the great 
 variation in the stage of deafness which different patients consider 
 the commencement of their disease, although this may have com- 
 menced at a period long antecedent. It is well known that a certain 
 amount of hardness of hearing — that grade, for instance, which renders 
 it dif&cult to comprehend vocal sounds — can be materially improved 
 by slow speaking, by a sonorous voice in the speaker, by an acquain- 
 tance with the subject under discussion, by attention, mental 
 activity, by quickness of apprehension, and other similar endowments 
 
14 AURAL SURGERY. 
 
 on the part of the deaf person. Hence it is very natural that, in the 
 ordinary intercourse of the world, the same degree of deafness may he 
 very variously estimated in different persons under various circum- 
 stances, both by the speaker and the person addressed. And now, if 
 we admit that no one can possibly maintain his voice constantly at 
 the same strength and pitch, and that, although the comprehension 
 of vocal sounds is the earnest desire of all who are hard of hearing, 
 yet we must also allow that these cannot in any way be employed as a 
 standard or measure of the degree of deafness. It is only in cases 
 of deafness of a doubtful nature (as, for example, in the deaf and dumb 
 and in very young children) that we can have recourse to shouting a 
 few vowels, consonants, sj'llables, or unconnected words, close to the 
 ear of the patient, in order to judge, as accurately as possible, from 
 their being exactly or inexactly imitated, of the degree of deafness 
 actually present. In all other cases only inarticulate sounds which 
 are exactly similar in force and modulation, as the beat of a watch, 
 can serve as a measure of the degree of deafness, though it must at 
 the same time be remembered that acute hearing for inarticulate 
 sounds is not always associated with equally quick appreciation of 
 vocal sounds. In order to remedy this inconvenience as far as 
 possible in the treatment of these cases, we make the patient pay 
 attention, not only to the distance at which he can hear a watch 
 beat with regularity, but also how far he can hear it beat with a full, 
 resonant, metaUic sound. 
 
 It is advisable also, in the examination of the degree of deafness, to 
 move the watch slowly from a distance towards the ear, and to indi- 
 cate as the special hearing distance the point at which the beat of the 
 watch is first perceived to occur regularly and with metaUic reso- 
 nance. Of course any such examination should be undertaken under 
 circumstances in which there are no disturbing noises at hand that 
 might drown the beating of the watch. The loudness of the beat of 
 such a watch is a matter of Kttle importance, if only the patient can 
 hear it with equal distinctness with both ears, and is not of such 
 extreme loudness that it must (in moderate deafness) be held at a 
 very great distance from the affected ear. 
 
 It is therefore useful for these and similar cases to have a watch 
 with feeble beat; on the other hand, another having a loud beat may 
 be employed in cases of extreme deafness. The same watch should 
 always be tried at the same distance from the diseased ear at which it 
 is distinctly heard with the healthy one, a distance which we may 
 
NOISE IN THE EARS AS A SYMPTOM. 15 
 
 indicate by the expression " normal hearing distance." I use three 
 watches in practice, the first of which can be heard by myself 
 and all persons with healthy ears at a distance of two feet, the 
 second at thirty feet, and the third at forty feet, when everything 
 is quiet. The tuning-fork is not well adapted for the examination 
 of the degree of deafness, not only because the souud produced by 
 striking it is of variable strength, but also especially because the 
 successive vibrations become constantly feeble till they die away, and 
 we therefore lose that most important character of a trial note, that 
 it should possess the same force under aU circumstances. 
 
 Hardness of hearing is by no means a disease in itself, but is only 
 a symptom of some organic change in the ear. It is therefore a sign 
 of great ignorance and charlatanism to recommend remedies for deaf- 
 ness and hardness of hearing. These can only be improved in pro- 
 portion to our ability to remove the organic changes to which they 
 owe their origin. 
 
 It is in the knowledge of such structural changes that we possess 
 the most certain means of discovering feigned deafness and hardness 
 of hearing ; the exact recognition of the several structural changes 
 suggests at once the proper means of cure. 
 
 The second symptom of disease of the ear, which is so common, 
 though perhaps not always present, as in cases of circumscribed 
 disease of the auricle, is the perception of noise in the ears (see 
 the Tabular statement). This symptom may be observed to occur 
 without any visible cause, with the utmost variety as to intensity 
 and modulation. It is sometimes continuous, sometimes inter- 
 mittent. It may exist in one or in both ears, and in the head, 
 but rarely in the head alone, and it may last for days, weeks, 
 months, years, or even through the whole of hfe. With few 
 exceptions, it is associated with hardness of hearing; but there 
 is no more certain relation between the two than there is 
 between them and the apparent structural changes of the ear, 
 although we may certainly expect the noise in the ears will cease 
 with the disappearance of the organic changes which called them 
 forth. On the other hand, the noise in the ears not unfrequently 
 ceases or continues whilst the accompanying hardness of hearing 
 continues unchanged, or gradually increases. It is therefore a false 
 prejudice on the part of many patients, that the noise in the ears has 
 kept up, increased, and even produced the deafness. We are equally 
 unable to make the diagnosis of particular forms of disease from the 
 occurrence of certain peculiar sounds in the ear, as, for instance. 
 
16 AURAL SURGERY. 
 
 those of a musical nature, or to attribute such sounds to particular 
 diseases, as, for example, to nervous deafness. The tabular state- 
 ment refates this in the most decisive manner. 
 
 Noise in the ear is such an extraordinarily frequent concomitant 
 of disease in the ear that I have observed it 496 times out of 1000 
 cases (see Table). The sounds of the ear have been referred to very 
 different seats ; the foUowiug observations and researches may throw 
 some hght upon the subject. 
 
 If the tragus of a healthy ear be pressed deeply into the meatus, 
 of course pressure will be made upon the drum of the ear, through 
 the medium of the air contained in the meatus. If we pour water, 
 oil, or quicksilver, upon the drum of the ear (the head being kept in 
 a horizontal position), and, by means of a blunt probe, touch the 
 membrane at the only part which is not painful, above the processus 
 brevis mallei, under which the chorda tympani runs, as I have often 
 done, there occurs a variously modulated noise in the ear so touched, 
 the loudness of which increases with the mechanical pressure exer- 
 cised, and wholly disappears as soon as, but not until, the pressure 
 is removed. The fluid flows out by raising the head, and the probe 
 may now be withdrawn. The same sound is aroused if, when the 
 nose and mouth are closed, we make a strong expiration, and so press 
 the air against the drum of the ear from within. 
 
 When repeated mechanical irritation is made of the easily moveable 
 membrana tympani, the irritation is, without doubt, communicated 
 to the chorda tympani that is so closely connected with it. Sounds 
 in the ear, corresponding in force, and occurring by fits and starts, 
 are thus produced, and this is only expHcable on the supposition that 
 irritation of the chorda tympani awakens, by reflex action, a state of 
 activity in the auditory nerve, a state which is otherwise only pro- 
 duced by the impression of sound. The sensory fibres of the fifth 
 pair distributed to the tympanum can have no share in this, as there 
 is no pain. 
 
 !Prom this point of view we can clearly understand, with the 
 guidance of the subsequent tabular view, how noise in the ears accom- 
 panies a considerable proportion of the diseases of the ear. I found, 
 for instance, in 163 cases of stoppage of the meatus with hardened 
 cerumen, not less than loi who suffered from noise in the ears. 
 These sounds were immediately and completely removed within a 
 quarter of an hour by thoroughly cleansing the ears with an injection of 
 warm water. A little oil was then dropped into the meatus, and, as 
 
TABULAR VI KW OF DISEASES OF THE EAR. 
 
 17 
 
 
 
 Wiih 
 
 
 
 £.^ 
 
 
 a 
 
 
 
 
 
 
 
 Acute. 
 
 &| 
 
 H 
 
 
 
 
 o 
 
 Wittnut 
 
 |1 
 
 ; 
 
 9b 
 
 
 1 
 
 
 
 o 
 
 With 
 
 -■ s 
 
 
 
 
 
 
 o 
 
 Chronic. 
 
 g'Sf; 
 
 lo 
 
 
 
 
 
 
 w 
 
 Withont 
 
 5' 
 
 
 I P § 
 
 
 f 
 
 
 
 o 
 
 With 
 
 Inflammatioa of tlie 
 
 
 
 
 
 ,_, 
 
 Witliout 
 
 tei 
 
 Connective Tissue. 
 
 
 n 
 
 
 
 o 
 
 With 
 
 Inflammation of the 
 
 
 
 
 
 o 
 
 Without. 
 
 
 Perichondrium. 
 
 
 
 
 
 »{ 
 
 3 
 
 ■■ With 
 Without 
 
 
 Inflammation of the 
 Cuticle. 
 
 =, 
 
 g 
 
 ta 
 
 <1 
 
 With 
 
 Inflammation of the 
 
 
 
 gj 
 
 
 en 
 
 Without 
 
 c' 
 
 Dermis. 
 
 
 s. 
 
 A 
 
 
 M C 
 
 -J 
 
 With 
 
 K 
 
 Infljimmation of the 
 
 
 i 
 
 
 -Q 
 
 
 "I 
 
 M 
 
 Without 
 
 P 
 
 Connective Tissue. 
 
 
 1 
 
 1 
 
 ( 
 
 O 
 
 With 
 
 Inflammation of the 
 
 
 
 
 
 n 
 
 w 
 
 Without 
 
 
 Periosteum. 
 
 
 
 3 
 
 >• 
 P 
 
 ^ j^ 
 
 s 
 
 With - 
 
 
 
 
 
 
 
 
 M . 
 
 to 
 
 Without 
 
 
 Acute Inflammation. 
 
 «o 
 
 1 
 
 r 
 
 f 
 
 CO 
 
 With 
 
 ^ 
 
 
 
 
 
 if? j 
 
 
 
 '^ 
 
 Simple. 
 
 Q 
 
 
 
 
 (%i 
 
 
 to 
 
 
 s 
 
 Without 
 
 f 
 
 
 ^ 
 
 
 11 
 
 g CO 
 
 
 /• 
 
 ^ 
 
 With 
 
 
 
 \,v^ 
 
 "> 
 
 iiS ■ 
 
 ^ 
 
 Without 
 
 "With perforation. 
 
 M 
 
 l-J 
 
 o 
 
 
 f 
 
 
 With 
 
 
 
 1^ 
 
 
 JS ] 
 
 
 
 ^ 
 
 With Polypi. 
 
 1 
 ST. 
 
 s 
 
 
 B 
 
 
 1 
 
 3' ^ 
 
 
 I 
 
 •f- 
 
 AVithout 
 
 
 
 
 i" 
 
 
 "1 
 
 o 
 
 With 
 
 With both. 
 
 CB O 
 
 
 ^ I 
 
 CO 
 
 Witliout 
 
 
 
 
 
 
 
 ' 
 
 VI 
 
 With 
 
 
 Without Exsu- 
 
 
 ^ 
 
 
 
 
 
 
 -f- 
 
 Witliout 
 
 
 datlon. 
 
 p 
 
 ■" 
 
 
 .., f 
 
 o 
 
 -«ith 
 
 With free Exsu- 
 
 _, 
 
 
 --.- 
 
 
 " I 
 
 10 
 
 CI 
 
 Without 
 
 
 dation. 
 
 E 
 
 to 
 
 M 
 
 
 
 
 i{ 
 
 fe 
 
 With 
 
 With both free 
 inferslitial 
 
 
 O 
 
 
 tr< 
 
 g 
 
 Without 
 
 5- 
 
 and Exsudation. 
 
 S- 
 
 
 g 
 
 13 
 U 
 
 
 f°' 
 
 .( 
 
 g 
 
 With 
 
 With interstitial 
 
 
 
 
 
 n 
 
 o* 
 
 Without 
 
 P 
 
 Exsudation. 
 
 
 s 
 
 r 
 
 o 
 
 With 
 
 
 
 
 
 
 •" i 
 
 
 
 
 Otalgia. 
 
 l-l 
 
 
 
 CT 
 
 
 I 
 
 M 
 
 Without 
 
 
 
 
 , ( 
 
 I-" 
 
 With 
 
 Noise in the Ear, with- 
 
 
 ^3 
 
 
 I I 
 
 o 
 
 Without 
 
 
 out Deafness. 
 
 a> 
 
 
 t c 
 
 
 With 
 
 
 
 
 
 
 
 4 
 
 C5 
 
 Without 
 
 g 
 
 Acute Inflammation. 
 
 "<» 
 
 &! 
 
 c 
 
 
 With 
 
 
 
 
 
 ° \ 
 
 
 
 K 
 
 Clu'onic Inflammation. 
 
 w 
 
 !5 
 
 
 
 l 
 
 o 
 
 Without 
 
 
 
 
 M 
 
 c 
 
 
 With 
 
 
 
 
 ■^ ^ 
 
 
 
 Nen-ous Deafness. 
 
 
 
 I 
 
 e 
 
 Without 
 
 tel 
 
 
 
 h 
 
 ( 
 
 ^1= 
 
 Acquired. 
 
 
 
 
 '" i 
 
 a 
 
 
 
 Deaf and Dumb. 
 
 s 
 
 
 
 i i 
 
 g.<i 
 
 Congenita] 
 
 
 
 
 
18 AURAL SURGERY. 
 
 in the above-mentioned experiments^ they remained free from the 
 noise as long as the membrana tympani was covered with oil^ a proof 
 that the collections of cerumen produced the noise only by contact 
 with, and mechanical irritation of, the membrana, and especially of 
 the chorda tympani. In the remaining 6a cases of this affection, 
 without noise in the ears, we may venture to say that the collection 
 of cerumen had not been in actual contact with the membrana tym- 
 pani. In the same way mechanical irritation of the chorda tympani, 
 by the direct contact of mucus collected in the tympanic cavity, ex- 
 plains the presence of noise in the ears in nine out of 48 cases of 
 free and of free and interstitial exudation in the middle ear (see Nos. 
 13 and 13 in the Table), the removal of which by insufflation, in 
 some instances improved, in others cured the deafness, but in all 
 cases completely removed the noise in the ears. The more or less 
 fluid nature of the collection of mucus in the tympanic cavity ex- 
 plains, not only the frequent spontaneous disappearance and return 
 of the noise in the ears, but also the entire absence of this symptom 
 of disease in circumstances which have frequently been noticed (in 
 25 out of 60 cases of this form of disease). Noise in the ears pro- 
 duced by inflammatory irritation of the chorda tympani is, as regards 
 its pathogeny, included in the same category with the direct or in- 
 direct mechanical irritation of that nerve, as we have already described. 
 This is in accordance with the very general occurrence of noise in 
 the ears in inflammation of the membrana tympani and immediately 
 adjacent parts. Thus, it occurred in acute inflammation of the mem- 
 brana tympani twenty-six times in ^^ cases (= 3 : i) ; in simple 
 chronic inflammation only thirteen times in 64 cases (=1:4); in 
 perforation of the chronically inflamed membrane = 1:3; in polypi 
 springing from it = i : 5 j and in perforated, chronically inflamed 
 membrana tympani, with polypi = 0:3. Very acute inflammation 
 of the connective tissue of the meatus — which, however, does not by 
 any means constantly imphcate the membrana tympani — is more fre- 
 quently accompanied by noise in the ears (vide the Table, 7:11 = 
 I : i^) ; but in the more chronic inflammation of the corium of this 
 part of the ear (7 : 15 = i : a). When the exudation in the middle 
 ear is exclusively interstitial, noise in the ears occurs in the great 
 majority of cases (344 : 163 = i^ : i), and is here recorded as the 
 result of a catarrhal irritation of the chorda tympani and of the 
 membrane of the tympanic cavity investing it, because in all these 
 cases of disease the noise in the ears, even when not previously 
 
NOISE IN THE EARS AS A SYMPTOM. 19 
 
 present, is always produced when strong and repeated blasts of air 
 are blown into the tympanic cavity against the chorda tympani. 
 
 On the other hand, in about thirty cases of complete destruction of 
 the membrane and of the chorda tympani, I have never observed 
 noise m the ears to be an accompanying symptom. Lastly, noise in 
 the ears is one of the most constant symptoms of complete deafness and 
 is often present to a very intense degree (especially in those cases 
 where the deafness is not the result of partial destruction of the tym- 
 panic membrane accompanied by disorganization of the structures in 
 the tympanic cavity. 
 
 Noise in the ears, when it is at all severe, is always very depressing 
 to the patient, often even more so than the accompanying deafness, 
 and, no doubt, because it is more marked in the hours of rest and 
 solitude. I have known an instance of a man, once strong and 
 healthy, who voluntarily committed suicide to escape from a persis- 
 tent and loud noise in the ears, which had lasted for many years. 
 
 From what has now been said it may easily be understood that 
 noise in the ears is no disease having an independent existence, nor 
 does it admit of any specific mode of treatment being applied to it, 
 as is the case with other affections ; and only the most careful inquiry 
 into the local conditions of disease in the external or middle ear can 
 furnish the proper indications for its treatment. No doubt an ana- 
 logous beating in the head and in the temples is experienced where 
 there is great congestion of the head, and in violent fevers, but there is 
 no real noise in the ears. No doubt this symptom, if already present, 
 will be increased by all means which excite the circulation, as by 
 stooping, by continuous elevation of the arms, and by strong intel- 
 lectual exertion : whilst, on the removal of these causes, it usually 
 returns to its accustomed grade. Still all this by no means proves 
 that noise in the ears owes its origin to plethora or to great nervous 
 excitabihty, or to any preceding constitutional affection. It is 
 rather to be regarded as a completely local affection of the ear, wliich 
 may be produced, and is always proportionably increased, by sym- 
 pathy with general derangement of the system. 
 
 liereditary tendency must certainly be struck out of the cate- 
 gory of the causes of aural disease. For it has lately been clearly 
 ascertained, upon statistical data, that it is a circumstance of very 
 rare occurrence for those who are born deaf and dumb, or who have 
 become so during the first years of life, to transmit this peculiarity 
 to their children (see section on Deaf-Mutism). 
 
 3 
 
20 AURAL SURGERY. 
 
 It cannot be denied, however, that we have sufficient grounds for 
 admitting a certain predisposition to disease, especially in the external 
 and middle ear, during the period of childhood and in those of a 
 scrofulous constitution ; but it cannot be maintained that the rheu- 
 matic, gouty, herpetic, syphilitic, or scabious dyscrasise or cachejdse 
 have any tendency to produce aural diseases, nor even that the scro- 
 fulous diathesis itseK impresses any speciiic character upon any of 
 the forms of disease of this organ. We have no objective proofs of 
 the existence of any of these specific inflammations of the membrana 
 tympani, as, for example, of that form which Bonnafont calls 
 "syphilitic myringitis." He only adduces three cases of this 
 disease, and of these only one suffered from inflammation and per- 
 foration of the membrana tympani, with discharge from the ears, and 
 there were no distinguishing peculiarities, whilst the two others pre- 
 sented an obscurely white membrana tympani, from which no sup- 
 puration took place. 
 
 The throat of these patients was of a violet-red colour, without any 
 ulceration. One of them had had a superficial ulcer on the glans 
 penis eight or nine years previously, which had healed after being twice 
 touched with caustic ; the second had only a discharge for a few days 
 from the urethra ; and the third had had the last chancre six years 
 before, without suffering in the intervening period from secondary 
 or tertiary symptoms, so that in none of them was any actual causa- 
 tive relation made out between the syphilitic infection, which was 
 of very various grades of intensity, and the disease of the ear. 
 Bonnafont assures us that he cured the deafness of these three 
 patients with corrosive sublimate and iodide of potassium, but the 
 second and third cases were certainly not instances of inflammation 
 of the membrana tympani, and therefore, even if they were so cured, 
 it furnishes no proof that they were of a syphilitic nature. In truth, 
 we can only recognise and describe inflammations of the membrana 
 tympani and other diseases in the external and middle ear as occurring 
 in scrofulous, rachitic, or gouty subjects, or in those who have 
 some other dyscrasia ; we caimot, with propriety, speak of scrofulous, 
 gouty, or rachitic disease of the ears. The most frequent causes of 
 disease of the ear are undoubtedly exposure to a cold draught of air, 
 sudden changes from a warmer to a colder atmosphere, the 
 admission of cold water into the ear, catarrhal affections, the 
 exanthemata, scarlet fever, measles, fee, and other fevers, especially 
 typhus. 
 
CAUSES AND PHYSICAL DIAGNOSIS OF AURAL DISEASES. 21 
 
 The general custom in England amongst all the better classes of 
 society of washing the head and ears every morning with cold water^ 
 of using the shower bath, &c., together with the habit of keeping, 
 even in very cold weather, a window and door wide open, with a 
 large fire in every parlour — these customs, I say, explain the constant 
 occurrence of deafness, with suppressed secretion in the external and 
 middle ear, amongst the English. Several months' practice as an aural 
 surgeon in London has sufliciently convinced me of the truth of 
 this statement. The majority of patients who suffer from disease 
 of the ears are unable even to make a conjecture respecting their 
 origin, and have- paid so little attention to the matter that even the 
 time of commencement is wholly unknown. Many date this from 
 the period at which a discharge occurred, when noise in the ears was 
 heard, or some other striking symptom made its appearance ; or when, 
 after they have endured protracted suffering with one ear, the other 
 becomes affected, and the hardness of hearing which has long been pre- 
 sent in the one ear now attains such a height as to render ordinary 
 intercourse with the world more or less difficult. Various affections 
 of the system generally, such as disturbances of the functions of the 
 abdominal viscera or of the female organs of generation, &c., 
 are often associated in a genetical relation with the aural disease, 
 but this merely depends on the circumstance that these chronic 
 morbid conditions are coincidently produced during particular periods 
 of development. 
 
 The diagnosis of diseases of the ear, that is to say, of those 
 structural changes which produce distinct groups of symptoms, and 
 occur in consequence of some lesion or derangement of the external, 
 middle, or internal ear, rests but very shghtly upon the sensations of 
 the patient. Pain, pressure, fulness, noise in the ears, hardness of 
 hearing and the like, are subjective symptoms, upon which but very 
 little rehance can be placed, and the diagnosis must reaUy rest upon 
 those objective and more trustworthy symptoms of which we our- 
 selves can form a judgment in consequence of the easy accessibility 
 of the middle ear. Now, amongst these objective or physical signs we 
 may include those which can be recognised by the eye, ear, and touchy 
 supposing the membrana tympani to be uninjured. By these means 
 we can obtain an accurate diagnosis of the diseases of the external 
 and middle ear, but no objective symptoms are at present known 
 which enable us to distinguish any of the diseases of the internal ear, 
 if we except only carious destruction of the labyrinth. 
 
ii 
 
 AtJBAL SORGERV^. 
 
 The objective (or physical) examiBation of the diseased ear 
 proceeds naturally from without inwards. It commences with the 
 cartilage of the ear, which does not here require particular directions 
 
 for its investigationj nor spe- 
 c's- !• cial measures. It is different 
 with the diseases of the meatus 
 and ofthemembranatympanij 
 neither of these, on account 
 of the winding course of the 
 former, can be examined with- 
 out special manoeuvres. It is 
 necessary to employ an instru- 
 ment which will extend the 
 anterior sharp curve of the 
 meatus, and widen its external 
 cartilaginous part, in order to 
 permit the free entrance of 
 light to its deeper portion and 
 to the membrana tympani, 
 and to allow free examination 
 of these parts by the surgeon. 
 The instrument best adapted 
 for this purpose is my aural 
 speculum (see Fig. i), which 
 I have tried and approved 
 during the last thirty years 
 upon many thousand cases 
 of disease. Any defects it may 
 appear to possess when in use 
 result simply from a want of 
 dexterity on the part of the 
 operator, who iatroduces or 
 opens it with too heavy a hand. 
 Its length is about sis inches, 
 and it consists of a funnel 
 split longitudinally into equal 
 parts, and of two handles, like 
 a pair of pincers, which are 
 connected at right angles, with 
 them . By lightly pressing on 
 
THE EAR SPECULUM. 23 
 
 the latter tlie funnel readily opens. The speculum is one inch and 
 two thirds in length ; five sixths of an inch wide at the broadest, and 
 one sixth of an inch at the narrowest part ; its narrow and quite 
 cylindrical extremity is three fourths of an iuch long ; and its inner 
 surface is made slightly dull, in order that the reflection of light may 
 not interfere with the examination. 
 
 Others have supplied the place of this so-called " awkward" 
 instrument, which cannot easily be put into the waistcoat-pocket, 
 with small, undivided, highly polished specula of different sizes, but 
 by those instruments the absolutely indispensable expansion of the 
 outer part of the meatus cannot be accomplished, and there is con- 
 sequently no possibility of examining at one glance the whole 
 surface of the membrana tympani. The chief advantage which is 
 said to belong to these small specula is that, when they have once been 
 introduced into the meatus, they remain there, and do not require 
 the hand of the operator, so that he has both his hands at liberty to 
 perform any operation on the ear. Now, this is completely illusory, 
 for there are no operations which require the use of the speculum and 
 of both hands at the same time. Those polypi only which project from 
 the orifice of the meatus, so as to become visible and easily accessi- 
 ble, are fit to be removed by the knife, scissors, or ligature ; small, 
 flat polypi which are only perceptible by means of the speculum, can 
 be destroyed by caustics, and these can be applied with perfect 
 facility with the right hand alone. "We place the patient with the 
 affected ear turned towards the light, which may either be that entering 
 through a large window or may be derived from some artificial source. 
 The upper part of the ear is now firmly grasped with the finger and 
 thumb of the left hand and the cartilage pulled upwards and back- 
 wards with some force; the closed speculum is now cautiously intro- 
 duced into the meatus, as deeply as its width will permit without pain 
 to the patient ; the handle of the instrument is now lightly pressed 
 so as to open the speculum as far as can be painlessly accomphshed. 
 When the external ear of adults is healthy, the daylight penetrates 
 easily to every part, so that we can readily recognise the shining 
 membrana tympani, and roughly determine the presence or absence 
 of any organic disease ; but if we wish to ascertain some particular 
 point, to discern some peculiar diseased condition in or on these parts, 
 the direct admission of sunlight into the ear is indispensable. Yon 
 Troeltsch is completely in error when he says that " sunlight-" is too 
 brilliant. No alterations of colour, no structural changes in the 
 
24 ATJRAL SURGERY. 
 
 inner part of the meatus and niembrana tympani, can recognised 
 without the light of the sun, nor can any important therapeutical 
 measures be determined on, nor any operation performed with cer- 
 tainty unless the rays of .the sun brilliantly illuminate the bottom of 
 the meatus. Por this reason the residence of an aural surgeon should 
 be in such a situation that it may receive the direct light of the sun 
 for some hours, at least, of the day, and that he may consequently 
 make use of it for the investigation and treatment of aural disease. In 
 case of necessity we shall often find sunlighted windows in the 
 houses of patients. But unfortunately there are many days^ es- 
 pecially in winter, during which the sun never shines, so that we are 
 either compelled to give up the investigation and treatment of the inner 
 part of the meatus and membrana tympani or to examine these parts by 
 means of artificial illumination. WaxKghts and the flames of 
 Argand, photogen, or gas lamps, are much less serviceable, even 
 when increased by concave mirrors and doubly convex lenses (as in 
 Bonnafont's oloscope), than the direct light of an unclouded sky; 
 so also the perforated concave mirror, reflecting the light " of a white 
 cloud or of a white wall," recommended by V. Troeltsch, furnishes, 
 indeed, a white, yet only a very dull, light, by no means sufficient for 
 the certain recognition of deeply seated disease of the membrana 
 tympani or meatus. Moreover, white clouds only occur when there 
 is sunshine, and therefore, in obtaining the latter, all difficulty is 
 removed ; besides, in bad winter days there are no " white clouds," 
 so that in this protracted and gloomy period of the year, when we are 
 referred by V. Troeltsch to the reflection of light from white walls, we 
 should probably find them admirably adapted for the magic lantern, 
 but of no service in revealing the conditions of the diseased membrana 
 tympani. 
 
 The photogen lamp of Mitscherhch, recommended by Voltohni, 
 through the flame of which a stream of oxygen is conducted, is, how- 
 ever, well worthy of notice ; the light produced in this way is very 
 white and clear, yet is not equal to that of the sun, nor does it 
 enable us to ascertain with certainty the nature of the more delicate 
 structural changes occurring in the deeper parts of the meatus or in 
 the membrana tympani, as I have satisfactorily conviaced myself, by 
 using the flame of a large apparatus, in the laboratory of Mitscherlich. 
 We can endure its brilliancy without shading our eyes, but who can 
 with impunity, look at the sun ? It must be remembered also that 
 the combustion of oxygen in the photogen flame is not quite free from 
 
EHiNOscopr. 25 
 
 the danger of an explosion. Only the light of the oxyhydrogen appa- 
 ratus and the electrical light can supply the place of the sun, but these 
 have not been adapted for practice, nor have any sufficiently cheap 
 forms of apparatus been constructed to bring them into general use. 
 
 We consequently maintain that the direct light of the sun, with the 
 use of the speculum, is indispensable for the diagnosis and treatment 
 of the diseases of the external ear, especially of those of the tympanum. 
 
 The examination of the soft palate and of the pharynx, as of the 
 parts in the immediate vicinity of the guttural opening of the Eusta- 
 chian tube, can be effected by the patient making a deep inspiration 
 ■ndth his mouth wide open, and then holding his breath, by which 
 means the root of the tongue is drawn downwards and backwards, 
 and the soft palate, on the contrary, upwards, so that we are only 
 occasionally obliged to hold the tongue down with the handle of a 
 spoon or other flat object. 
 
 Yoltolini shows how to bring into view the (esophageal opening of 
 the Eustachian tube in the following way (rhinoscopy).* "Whilst the 
 velum is raised by a deep insphation, it is to be pressed upwards as 
 far as possible by means of a wire loop ; then the pharyngoscope is to 
 be passed quickly into the throat, and the light of his photogen 
 lamp (with a cylindrical wick of iJ-" in diameter) directed upon the 
 pharynx, in order to illuminate the oesophageal opening of the 
 Eustachian tube. Yoltolini may, indeed, have demonstrated the prac- 
 ticability of this complicated procedure to his colleagues of Breslau, 
 but very few patients possess the strength of wiU and the insensi- 
 bility of the velum palati which are indispensable in order to allow 
 such a method of research to be carried out. Eortunately, tiie oeso- 
 phageal opening of the Eustachian tube is seldom or never the seat 
 of diseased conditions which are not equally weU marked in the 
 mucous membrane of the oesophagus. To this optical means of 
 diagnosis the tube, in its whole extent, and the tympanic cavity 
 when the membrana tympani is entire, is, of course, wholly inac- 
 cessible. Acoustic means must here be employed. These consist of 
 blowing air with the mouth through aural catheters of various calibre 
 into the Eustachian tube with the use of the diagnostic tube ; this is 
 again to be followed by the introduction of catgut, bougies through 
 the Eustachian tube, in order to complete the acoustic diagnosis of 
 the diseased conditions by symptoms derived from the sense of touch. 
 
 * Eor details on this subject, the reader may consult Czermak's ' Monograph,' 
 p. 25, New Sydenham Society's Translation, — Tbans. 
 
26 
 
 AURAL SURGERY. 
 
 No. I. 
 
 No. 
 
 Fig. 2. 
 No. 3. No. 4. No. 5. 
 
EUSTACHIAN CATHBTERS. 27 
 
 For the catheterism of the Eustachian tube my cylindrical and 
 inflexible silver catheters are best adapted (see Kg. 2). They are 
 six and a half inches in lengthy with a beak bent laterally for three 
 quarters of an inch at an angle of 144°, to suit the position of the 
 oesophageal openmg of the Eustachian tube. The proximal extremity 
 of the catheter expands into a funnel-shaped dilation of three quarters 
 of an inch, in lengthy to which is attached an oval ring, on the same 
 side as that to which the beak is bent ; by the position of this we 
 are enabled to judge of the position of the beak when it has been 
 introduced through the nasal meatns. 
 
 Catheters made of gutta percha (Eau) should never be employed, 
 because they cannot be kept so thoroughly clean, nor be manufac- 
 tured of such uniform and, at the same time, various sizes as those 
 made of silver. 
 
 Eor the thorough acoustic investigation of the middle ear, we 
 make use of four catheters, gradually increasing in size, on blowing 
 through which we are able to obtain a succession of streams of air, 
 which whilst they gradually increase in force, can at the same time be 
 constantly maintained of equable strength (see Eig. 2 ; the numbers 
 I — 4 indicate the sections). 
 
 No. I catheter corresponds to the diameter of No. i of Charriere's 
 draw-plate (filiere), well-known to all instrument makers; it will 
 scarcely admit the entrance of a common pin. No. 2 catheter cor- 
 responds to No. 3 of the draw-plate, and is quite equal to the diameter 
 of the healthy Eustachian tube at its narrowest part, which is at the 
 point of union between the osseous and cartilaginous portions. 
 Catheter No. 3 has the width of No. 6. No. 4 catheter has the 
 width of No. 7 of the above-mentioned draw-plate. No. 5 catheter 
 has the same curvature at its beak, but is about 5'" longer, and 
 serves for the catheterism of the Eustachian tube through the nasal 
 meatus of the opposite side, when circumstances prevent the passage 
 of a catheter on the same side of the nose. It is useless to divide 
 the catheter into inches and lines, and we have long considered 
 Bard's proposal unpractical, which consisted in endeavouring to 
 ascertain, before using the catheter, the distance of the oesophageal 
 opening of the tube from the entrance of the nasal meatus, by measur- 
 ing the distance of the base of the uvula from the upper incisors. 
 
 As a rule, the catheterism of the Eustachian tube should be 
 accomplished with one of the catheters i — 4, introduced through the 
 corresponding nasal meatus of the ear that is to be examined. For 
 this purpose the patient, if an adult, is to be placed upon a chair with 
 
38 AURAL SURGERY. 
 
 a common back^ or with one somewhat higher than usnal^ in order 
 that the head may be supported. Children between the ages of eight 
 and fourteen should be placed with their back against a grown-up 
 person, who may support them, or, if rehance can be placed on their 
 steadiness, against a waU, a table, &c. Younger children should be 
 taken on the lap of an intelligent person, against whose breast they 
 can lean their heads. This person should keep the legs of the child 
 between his thighs and hold his hands, whilst the head of the child 
 is fixed by the left hand of the surgeon. These measures are very 
 necessary, as children are often restless and unruly. 
 
 After the patient has blown his nose (partly for the purpose of 
 clearing away a too abundant secretion, partly, in case the nose is too 
 dry, to moisten it, and thus enable the instrument to slide along it 
 with greater facility), we dip the catheter into pure oKve oil, and blow 
 through it, to assure ourselves of its permeabUity ; the head of the 
 patient is then fixed with the left hand ; the catheter is held with the 
 thumb and finger of the right hand close to the funnel-shaped extre- 
 mity, in such a manner that the ring attached is turned downward ; 
 the beak is placed in the nasal meatus, resting upon its floor, close to 
 the septum, with the convexity upwards. From this point it is 
 pushed backwards with a very light hand, sweeping as much as pos- 
 sible along the floor of the nostril, with continual elevation of the 
 handle, tiH the instrument becomes horizontal and its extremity rests 
 against the posterior wall of the pharynx ; the thicker the catheter, 
 the more easily are these movements executed, on which account I 
 am accustomed to use the No. 3 catheter for the flrst operation, 
 even in young children. 
 
 Sneezing is rarely induced, if we do not keep the beak of the 
 instrument too long in contact with the external entrance of the 
 nasal meatus. 
 
 Irregularities in the form of the inferior turbinate bone and strong 
 lateral displacement of the septum may render the first introduction 
 of the catheter very difficult, and test severely the delicacy of the 
 sense of touch in the hand of the operator. As the point of the 
 beak arrives at the posterior wall of the pharynx, the funnel-shaped 
 end of the catheter is to be raised a little above the horizontal line, 
 and at the same time to be hghtly withdrawn ; the beak then sinks 
 and rests upon the posterior wall of the soft palate, which at that 
 instant contracts, performs a swallowing movement, raises itself, and, 
 when assisted by a quarter turn upon its axis from within outwards, 
 lifts the beak of the instrument into the tube. 
 
INTRODUCTION OF THE EUSTACHIAN CATHETER. 39 
 
 If this rapid movement is not successful in the hands of an inex- 
 perienced person, the beak of the catheter must be conducted back 
 to the upper part of the pharynx, in order that it may be slowly 
 drawn forwards and turned at the same time laterally a quarter-turn 
 upon its axis towards the outside, by which means the ring upon the 
 fannel-shaped end is directed horizontally. It now slides over and 
 into the swelling of the tube itself, where the beak of the catheter is 
 directed, with its concavity against the anterior swelling of the tube, 
 and here it hooks into it, and can be clearly felt to be grasped by it 
 upon quickly withdrawing it. The catheter lies here quite conve- 
 niently, being in no way a source of annoyance to the patient, even in 
 speaking, in swallowing, or in any of the movements of the head. 
 Por the sake of security, we now slightly elevate the beak of the 
 catheter above the horizontal line, directing it upward and outward, 
 the position of the beak being determined and rendered evident 
 by the direction of the ring upon the funnel-shaped end. 
 
 If, in consequence of impassability of the corresponding meatus, 
 we are compelled to introduce the catheter into the Eustachian tube 
 from the other side of the nose, we pass No. 5. catheter, which is 
 about equal in diameter to No. 3, in accordance with the above 
 directions, quite to the posterior wall of the pharynx ; gently turning 
 it inwards, we withdraw it to such a distance that it touches the 
 velum palati ; and then, during the strong elevation of tliis which 
 immediately follows the lateral quarter turn of the catheter upon its 
 own axis towards the affected ear of the opposite side must be accom- 
 phshed with a sure and steady hand, because there is barely room 
 for its prolonged beak. Hence this manoeuvre cannot, in general, be 
 performed without some degree of discomfort to the patient. If, 
 however, it be effected, the beak is firmly grasped, sometimes so 
 firmly that some difficulty is experienced in withdrawing the catheter. 
 As a rule, the removal of both the ordinary and of the elongated 
 catheters is best accomplished by performing the same movements as 
 those which effected their introduction, only in an inverted sequence. 
 The catheter being in position, we now place in the meatus of the 
 patient's affected ear one end of a tube, made of vulcanized India 
 rubber, a quarter of an inch in diameter, and about two feet in 
 length, which is provided with a funnel-shaped extremity. The 
 opposite end, which is also conical, is firmly fixed in the meatus of 
 our own ear. This tube can be kept in the ear of the patient, either 
 by himself or by some bystander. This done (and it may be accom- 
 plished before the introduction of the catheter, if preferred), we blow 
 
30 
 
 AURAL SURGERY. 
 
 Kg. 3- 
 
 Fig. 3.— n, Tlie patient, i. The surgeon, c, d. The Indk-mbber diagncslic tube, 
 e. The Eustachian catheter. 
 
 through the catheter, which is kept steadily fixed in the Eustachian 
 tube with the right hand, cautiously increasing the pressure of the 
 air (not using any caoutchouc bag, bellows, or air-press^ either large 
 or small) (see Eig. 3). 
 
 If the passage of the middle ear be completely free, the air appears 
 to pass through it, and to penetrate into the diagnostic tube fixed 
 in our own ear, which we may briefly indicate by the expression the 
 a ir passes freely. 
 
 This important acoustic symptom presents different characters 
 according as there is diminished permeability of the Eustachian tube, 
 diminution of the cavity -of the tympanum, increase or diminution in 
 the amount of secretion from both these parts of the organ, and. 
 
EUSTACHIAN BOUGIKS. 31 
 
 finally, after the protracted employment of catheters^ the size of 
 which has been gradually increased in diameter, as from i to 4. It 
 thus leads to an objective knowledge of the various organic changes 
 of the normal structure and secretion of the tube and tympanic 
 cavity, as will be further shown in the description of the diseases of 
 the middle ear. The physical characters of these acoustic symptoms 
 are far more clear and distinct than those which present themselves 
 when the stethoscope is used for the diagnosis of the diseases of the 
 respiratory organs. Here, in order to obtain certain acoustic signs, 
 the respiratory activity of the patient is indispensable, whilst this 
 mode of examining the middle ear enables us to accomplish every- 
 thing without any co-operation on the part of the patient. If we 
 find, on blowing into the Eustachian tube, any obstacle to the trans- 
 mission of air into the tympanic cavity, we may conclude there are 
 contractions in the former, the position, extent, and tightness, of 
 which may best be ascertained by the introduction of a catgut or 
 elastic bougie. Tor this purpose the finest harp or lute string about 
 one sixth millimetre in diameter should be employed. This should be 
 pushed into catheter No. a till it just appears at the end, and a mark 
 made upon the catgut, indicating the length of the catheter ; then ad- 
 ditional marks should be made with ink at distances of one inch, half 
 an inch, and again another half inch, from the first. These indicate 
 respectively the distance of the point of union of the cartilaginous 
 and osseous portions of the tube, the opening of the tube into the 
 tympanic cavity, and, lastly, the transverse diameter of the tympanic 
 cavity, measured from the oesophageal opening of the tube. Pro- 
 vided with this catgut. No. % catheter is passed into the Eustachian 
 tube, and the end of the catgut, about half a millimetre in diameter, 
 being slightly bitten, so as to soften it, is to be slowly passed along 
 the catheter, which may be fixed by the right or left hand. Catheter 
 No. % has so small a calibre that, though it easily permits the pas- 
 sage of the catgut, yet this retains, on emerging, the curve of the 
 beak, and it has never occurred to me to sHp the catgut down into 
 the throat, but it has always entered the tube with certainty. 
 
 The patients frequently complain, when the catgut is pushed on- 
 ward, of more or less acute stabbing pain in the neck, in the region 
 of the ear, which must not mislead us if we are only certain of the 
 right position of the catheter in the tube. 
 
 If there be a contraction in the Eustachian tube, to which the cat- 
 gut reaches, but will not pass, we should then wait a few minutes, 
 and upon renewing the pressure we may, perhaps, succeed in passing 
 
32 AURAL SURGERY. 
 
 througli itj tlie patient experienoing at the same time more or less 
 acute pain ; the catgut then passes on readily, unless there should be 
 another constriction at a greater or less distance from the first. The 
 marks on the catgut enable us easUy to determine the distance of 
 the contraction from the oesophageal opening, of what extent it is, how- 
 light, and other points of importance. My elastic bougies commence 
 with a diameter of a quarter of a millimetre and increase very gradually 
 in size, the difference never being more than one-twentieth of a milli- 
 metre. These must be introduced through catheter No. 3 ; the mark- 
 ings of the above-mentioned distances upon the bougies can be made 
 with white oil colour. Bonnafont has strongly recommended for this 
 purpose filiform bougies of caoutchouc, half, one, and one and a half 
 millimetres in diameter, which are to be forcibly pushed through the 
 constriction; this, according to his own statement, produces much 
 pain, but is followed by very good results. But if we reflect that there 
 is often considerable dif&culty in passing a constriction with a catgut 
 bougie of one sixth of a millimetre in diameter, we can hardly com- 
 prehend how bougies from three to nine times thicker (half to one 
 and a half millimetres), can be made to force a passage. Caoutchouc 
 bougies possess this great disadvantage — that they cannot be made 
 so soft at their points as a weU-chewed piece of catgut, so that they 
 often inflict an amount of injury upon the diseased and always very 
 irritable mucous membrane of the tube, which may be followed by 
 serious consequences. 
 
 In opposition to this acoustic, tactile, and decidedly objective 
 method of examining the middle ear, now for the first time published, 
 stands the so-caUed Yalsalva's experiment. This consists in a strong- 
 expiration being made by the patient whilst the oral and nasal 
 orifices are closed. Its success depends as essentially upon the intel- 
 ligence of the patient as upon the skill and judgment of the surgeon, 
 and it therefore possesses a completely subjective and consequently 
 very uncertain character. Now, I say, that in this experiment the 
 patient only perceives in one or both ears a slight feeHng of pressure, 
 with an equally weak, crackling sound, which may also be heard by 
 the surgeon if he place his ear against that of the patient or uses 
 the diagnostic tube. Wilde describes this faint noise as " a sort of 
 thug," which he considers, with Toynbee, Erhard, and others to be 
 a satisfactory proof of the complete absence of any obstruction iu the 
 middle ear, but in which, as a means of diagnosis, it requires a very 
 lively imagination to discover any value. 
 
 The diseases of the internal ear are unfortunately completely inac- 
 
FREQDENCY OF AURAL DISEASES. 33 
 
 cessible to our physical method of examination^ and we must there- 
 fore endeavour to remedy this deficiency partly by negativCj and 
 partly by fmictional symptoms. Hitherto all such attempts have 
 been fruitless^ but at a future page we shall have the opportunity 
 of entering more fully upon these important circumstances when 
 treating of the diseases of the middle ear. The majority of the 
 diseases of the external and middle ear are essentially infl.ammatory, 
 and the inflammation has a great tendency to become chronic. To 
 what extent this is truCj in regard to the parts constituting the 
 internal ear, has not yet been satisfactorily determined by dissection, 
 and much less, therefore, during the life of the patient. At all events, 
 there are neither pathological nor anatomical data from which we 
 can at present positively assert the existence of the "frequent 
 dangerous and even fearful rheumatic inflammation of the labyrinth, 
 and of the auditory nerve in particular " of Erhard. 
 
 Diseases of the ear are exceedingly common, probably even more 
 frequent than diseases of the eye, as may be calculated from the 
 great number of the deaf and dumb. In 1856 there were in Prussia 
 13,297 deaf mutes, and 10,206 blind, which numbers are in the 
 proportion to the whole population of 1 deaf mute in 1109, and i 
 blind in 1738. The opposite opinion is the more natural one, 
 because the affections of the eye, and their consequences, are in every 
 way more obvious than those of the ear, whose troublesome accom- 
 paniment, deafness, is infinitely less apparent. 
 
 The numerical proportion between the diseases of the ear in 
 males and females is in favour of the latter, and is naturally to be 
 attributed to their being much less liable to injurious influences, 
 from the quiet nature of their ordinary avocations. 
 
 It is worthy of remark that the greater number of affections 
 belong to the middle ear (560 in 1000), whilst the apparently much 
 more exposed external ear, including the dehcate membrana tympani, 
 is much less frequently affected (437 in 1000). The number of 
 cases of undoubted disease of the internal ear is extraordinarily 
 small [l'^, the great majority of which consist of nervous hardness 
 of hearing and deafness. (See the above Table, p. 17.) 
 
 Some few diseases of the ear commence with an acute stage, but 
 even these have a strong tendency to become chronic, and thus assume 
 the general character of all aural affections. Pain, and especially fever, 
 are symptoms of rare occurrence, and must be rather attributed to the 
 fault of the patient himself, since they are induced essentially by neglect. 
 
34 ADRAL SURGERT. 
 
 Diseases of the ear are seldom dangerous to life^ and then only 
 indirectly, by the extension of inflammation from the internal or 
 middle ear to the dura mater, brain, or cerebellum. 
 
 The prognosis of diseases of the ear is generally very unfavorable, 
 partly on account of their gradual and imperceptible approach, com- 
 mencing first in one ear only, partly on account of the concealed 
 position of the affected parts, which are accessible only to the edu- 
 cated hand. The numerous exceptions which fortunately occur to 
 this general rule shall be duly noticed in the subsequent sections of 
 this work. As regards treatment, it is of little importance to deter- 
 mine the nature of the primary cause, nor does the investigation 
 into the constitutional affections which accompany the aural disease 
 (as plethora, anasmia, amenorrhoea, abdominal disease of any kind, 
 nervous debility, &c.) prove of much service in enabling us to arrive 
 at an early and accurate diagnosis ; if we therefore make the treat- 
 ment and cure depend upon the discovery of such constitutional 
 symptoms, much valuable time will be lost that might have been 
 more advantageously employed ; and hence, though it may be very 
 important to combat the general symptoms with the most active 
 means at our disposal, we must not expect to make much impression 
 on the aural disease, and should not hesitate for a moment to adopt 
 local remedies in addition to the general or constitutional treatment. 
 The immediate causes of aural disease do not present anything defi- 
 nite for consideration in a therapeutic point of view ; their operation, 
 even in recent cases, as when they have been produced by exposure 
 to cold, has long ceased before surgical interference is demanded, 
 whilst ia the majority of chronic cases all knowledge of their real 
 cause is completely lost. 
 
 In each form of disease that which it is of primary importance to 
 ascertain, in order that appropriate treatment may be adopted, is a 
 knowledge of the material changes which the sohd parts of the ex- 
 ternal, middle, and internal (?) ear have undergone. In a word, the 
 treatment of aural affections, whether the general health of the 
 patient be affected or not, is essentially local. Whence it follows 
 that we are never, in any case, to regard what are really only symp- 
 toms of disease, as hardness of hearing, noise or pain in the ear, or 
 discharge or dryness of the meatus, &c., as independent diseases, nor 
 as the objects of treatment by the so-called specifics, glycerine, 
 Pinter's ear pUls, ear oil, blisters, the application of the constant or 
 induced electric current, &c. 
 
SECTION II. 
 
 SPECIAL SURGERY OE THE EAR. 
 
 The division of tte diseases of the ear in accordance with ana- 
 tomy^ into those of the outer, middle, and internal ear, is thoroughly 
 consonant with experience, especially if, with such a division, we 
 enter upon a consideration of their different elementary parts ; for 
 the various forms of disease which present themselves not only differ 
 from one another by characteristic groups of symptoms, but exhibit 
 also a great tendency to independent progress and a corresponding 
 indisposition to extend themselves to the adjoining structures or to 
 complications of any kind. The latter are most frequently the con- 
 sequences of destructive processes which have taken place in the 
 delicate membrana tympani, whereby the more deeply seated and 
 important parts are deprived of their natural protection, and become 
 liable to injury, which is, in truth, a far more frequent cause of their 
 disease than the extension of chronic inflammation from the per- 
 forated membrana tympani. 
 
 CHAPTEE I.— DISEASES OF THE EXTEENAL EAE. 
 
 According to the above Table, p. 17, these are next in frequency 
 to the diseases of the middle ear. They would probably exceed 
 them in number if the diseases of the cartilage generally, instead of 
 only exceptionally, fell under the care of the aural surgeon, for the 
 cartilages are, as is well known, often implicated in the exanthemata 
 and other febrile affections and in chronic skin diseases, and the 
 hearing is not unfrequently also affected. 
 
 The nature of the diseases of the external ear can, in general, be 
 readily investigated by the eye of the surgeon, whilst it requires but 
 little manipulative skUl to apply an appropriate local and effective 
 
 i 
 
36 AURAL SURGERY. 
 
 treatment. A favorable prognosis may therefore, in general, be given, 
 especially since the symptoms of the various forms of disease, as 
 swelling and discharge, are singularly patent, whilst the pain and the 
 weU-marked functional disturbance which accompany their sudden 
 onset call the attention of the patient to their presence at a very 
 early period. 
 
 DISEASES OP THE CAETILAGE OP THE EAR. 
 
 These diseases, as long as they are limited to the cartilage, and do 
 not affect the meatus, are of little importance to the ear as an organ 
 of sense, especially if one side only be affected. Since the part 
 which the auricle normally plays in the concentration of sound, is 
 not materially affected by such affections, though the patient may 
 find them sufficiently troublesome and annoying in his ordinary 
 pursuits, in the following descriptions I have distinguished between 
 inflammations of the dermis, connective tissue, and perichondrium, 
 but I have omitted simple erythema, because, in the first place, it is 
 in itself exceedingly unimportant, and secondly, because it is alto- 
 gether lost in the far more serious character of the exanthematous 
 affection with which it is associated. 
 
 Inflammation of the Dermis of the Auricle. 
 
 (a) Acute form. — Acute inflammation of the dermis commences 
 with more or less fever, pain in the head, coated tongue, loss of appe- 
 tite, and a general feeling of illness ; sometimes there is a sensation 
 of heat, extending to the neighbouring cheek, with itching, redness of 
 a livid colour, tension, and swelling, which causes the elevations and 
 hollows of the auricle to disappear, and the meatus to become, more or 
 less, occluded. Sometimes even the membrana tympani is inflamed, 
 and the inflammation spreads from thence over the dermis of the 
 auricle. These last cases are always accompanied by hardness of 
 hearing, and sometimes by noises in the ears. The swollen, dark-red 
 auricle is often covered, on the first or second day, with vesicles con- 
 taining yellowish serum, or with larger bladders, which, after a few 
 days, burst, and dry up into thin, blackish-gray crusts. Abenit this 
 time, or, at latest, on the fifth day, the inflammatory appearances just 
 described gradually decrease in the auricle, whilst they slowly extend 
 over the cheek, nose, forehead, and the skin of the head, even as far 
 as the other ear ; here, finally, in the same maimer as in the ear first 
 
DISEASES OF THE CARTILAGE. 87 
 
 affected, the symptoms disappear, with marked remission of the 
 general febrile disturbance, about the ninth day of the attack. If the 
 meatus and membrana tympani be implicated a thin discharge takes 
 place from the former as soon as the inflammation commences in it, 
 the cure of which presents no peculiar difRculty as soon as the in- 
 flammatory swelling of the auricle and that of the meatns are 
 subdued. 
 
 Cold, the stings of insects, exposure to the sud, gastric irritation, 
 mental excitement, &c., are the most frequent causes of this form of 
 disease, which in itself is by no means dangerous, unless, from great 
 neglect, it should extend to the membranes of the brain. It is only 
 in very cachectic subjects that the inflammation attacks the peri- 
 chondrium, with a tendency to destructive and fcetid suppuration of 
 the auricle. 
 
 With the exception of the last two cases, which are very rare, 
 inflammation of the dermis of the auricle, as a rule, runs a favorable 
 course, and its short duration, with the absence of important distur- 
 bances in the function of the ear, constitute the chief reasons why 
 these acute inflammations so seldom come under the care of the 
 aural surgeon. 
 
 The prognosis, if ordinary care be taken by the patient, is very 
 favorable. The inflammation runs its course completely in nine days, 
 the auricle desquamates, and returns to its original form, the meatus 
 again opens, and the inflammation of the membrana tympani soon 
 yields to mild antiphlogistic treatment. 
 
 The life of the patient is only in danger Avhen the inflammation 
 extends to the membranes of the brain. The treatment consists, in 
 the first place, of the negative duty of avoiding exposure to cold, 
 moist air, and secondly, in attention to the accompanying febrile 
 condition. The patient should remain in bed, or in a warm room, 
 take slops, or mild warm drinks which favour perspiration, mth cool- 
 ing aperients ; after which, perhaps, an emetic may be requisite. 
 
 Inflammation of the dura mater, with foetid suppuration and de- 
 struction of the auricle, must be treated in accordance with the 
 general principles of surgery, and need not here be discussed. 
 
 If, after the inflammation of the dermis has run its course, any 
 inflammation of the dermis remaui, with muco-purulent discharge, it 
 may very soon be removed by the daily injection of warm water into 
 the ear, and the subsequent dropping in of a few drops of warm olive 
 oil, or of a warm solution of sulphate of zinc (gr. i— iij in Aq.gj.) 
 
38 AURAL SURGERY. 
 
 (b) Chronic form. — Eedness and swelling occur without any febrile 
 symptoms or constitutional disturbance, but with some burning and 
 itching in one or both ears, occasionally extending to the meatus or 
 to the adjoining part of the cheek, which is soon covered with little 
 vesicles, whose serous or purulent contents dry up into crusts and 
 scales of various extent, thickness, and colour. In old cases, and in 
 very unhealthy constitutions, very painful burning cracks form in 
 the tense, dark-red, shining skin of the auricle, the secretion from 
 which sometimes becomes very offensive and irritating. Where the 
 necessary cleansing of the parts has been neglected, where the diet 
 has been bad, or where some form of cachexia is present, the inflam- 
 matory process insidiously extends to the connective tissue and peri- 
 chondrium, producing knobby thickening, cancroid degeneration, 
 foetid suppuration, and partial destruction of the auricle (cancer of 
 the ear, elephantiasis, lepra), on the occurrence of which, fever of a 
 typhous character may supervene and lead to a fatal issue. I re- 
 member a case in which the remarkably thickened and discoloured 
 cartilage of the left ear was converted into an extensive ulcerated 
 surface, without any trace of its original structure. It was covered 
 with foetid pus, and surrounding it was a groove nearly an inch in 
 breadth and of equal depth, with hard hvid edges, fiUed with similar 
 dark stinking pus. In this case, in spite of the violent burning 
 pain and the insufferable odour which the irritating purulent secre- 
 tion spread around the patient, he had endeavoured for two years to 
 cure himself with ordinary domestic remedies. 
 
 If the inflammation of the dermis extend itself to the correspond- 
 ing membranous layer of the meatus, with more or less occlusion of 
 the passage, hardness of hearing, and noise in the ears accompany 
 it as soon as the membrana tympani becomes affected. 
 
 "WJien the inflammation subsides in cases that are not very serious, 
 the violent itching in the skin diminishes, the formation of fresh 
 vesicles on the surface ceases, cracks and clefts dry up, scabs separate 
 and fall off, leaving behind them a very sensitive, thin, shining, red 
 cuticle, which, after the lapse of some weeks, assumes the natural 
 hardness and colour ; the meatus again becomes pervious, and the 
 normal power of hearing is then restored. Cancerous and nodulated, 
 passing into ulcerative degeneration of the auricle, does not admit of 
 a return to a healthy state. The course of this inflammation is extra- 
 ordinarily protracted, lasting for months, for years, or even through 
 the whole hfe of the patient ; and it may almost always be considered 
 
DISEASES OP THE CARTILAGE. 39 
 
 as connected with a more or less strongly -marked scrofulous diathesis, 
 which, when combined with bad food, want of cleanliness, unhealthy 
 locality, improper local treatment with strong irritants, &c., causes 
 the disease to assume an exuberant, ill-conditioned, and destructive 
 character. 
 
 The prognosis is by no means unfavorable if the chronic inflam- 
 mation have not yet produced any remarkable degeneration, exuberant 
 growths, suppurative destruction, &c., and the constitutional disorder 
 be capable of improvement. The treatment must be essentially con- 
 stitutional, and directed to the general condition of the patient. Fat, 
 acids, farinaceous food, and, in general, all food difficult of digestion, 
 should be excluded from the diet of these cachectic patients. They 
 require strong, nourishing aliment, both fluid and solid. 
 
 It is indispensable that the bowels should be kept freely open, but 
 in cachectic individuals this should not be allowed to pass into 
 diarrhoea. Either artificially made baths, or those especially of 
 Kreuznach, Nauheim, and similar places, should be taken, and, at 
 the same time, the use of the Adelaide and Eliza springs, of whey, of 
 iodide of potassium, &c., are especially to be recommended. If these 
 means should fail, we may employ, if the patient's strength will per- 
 mit. Fowler's solution of arsenic, in doses of from two to four drops, 
 two or three times a day, a quarter of an hour after meals. The 
 local treatment consists in carefully removing and drying up the 
 diseased secretion by means of a soft sponge dipped in warm water, 
 and subsequently powdering the surface with the semen lycopodii. 
 If the itching and burning be very severe, soft lint dipped in a warm 
 solution of sulphate of zinc (gr. ii — iv ad 5j), should be placed upon 
 the ear. Thick, hard, purulent scabs are softened with great relief 
 to the patient, by the appUcation of warm bread or linseed meal 
 poultices. Ointments and oily applications are in general of little 
 or no service. When the chronic inflammation of the dermis has 
 proceeded to the formation of nodulated, cancerous degeneration, or 
 purulent ulceration, its treatment comes under the care of the surgeon, 
 who may restore the patient to a tolerably satisfactory condition by 
 the removal of the indui'ated auricle. 
 
 Inflammation of the Connective Tissue of the Auricle, 
 
 commences with more or less acute tensive pain, which is accompanied 
 by the formation of an apparently well-defined, pale-red swelling of 
 small size, upon the external surface of the auricle. With suitable treat - 
 
40 ArRAL SURGERY. 
 
 ment relief is soon obtained^ the little abscess bursts^ and discharges 
 laudable pus streaked with blood. In a few days it heals up, and 
 leaves no mark. As a rule, only one ear is attacked, and neither 
 hardness of hearing nor any constitutional disturbance accompanies 
 this trifling aUtnent. 
 
 We are unable to assign the causes which give rise to this inflam- 
 mation of the connective tissue, which is, upon the whole, a somewhat 
 rare disease. 
 
 The treatment requires only the application of very warm emollient 
 poultices of linseed meal, renewed every half-hour until fluctuation 
 is perceptible. After bursting, a free discharge takes place, and there 
 is no subsequent induration, the small purulent cavity closes up in a 
 few days, without further assistance, and so terminates this light but 
 still characteristic ailment. 
 
 Inflammation of the PericJiondrmm. 
 
 This presents essentially different characters, according to the 
 general state of the patient's health. In strong constitutions a 
 bright-red swelling arises upon the external surface of the auricle, 
 with acute, tensive pain. It increases till it attains the size of half 
 a hen's egg, and fluctuation can be perceived in it at an early period. 
 Some febrile symptoms are present, but they never become very 
 acute. If the tumour, which is slow in bursting of itself, be opened 
 with a lancet, we find effused between the perichondrium and the 
 cartilage a dark-coloured bloody fluid, which soon collects again, 
 making it necessary to repeat the incision, until at last suppuration 
 takes place in the cavity. After the lapse of some weeks this closes 
 up, without leaving any deformity of the auricle. 
 
 In debilitated individuals, on the other hand, especially in the im- 
 becile and melancholic tenants of madhouses, a tumour usually develops 
 upon the anterior surface, and most frequently upon the upper half 
 of the auricle of the left ear. It attains the size of half a hen's egg, 
 or more, so that it even occludes the meatus. It is bluish-red, 
 convex, slightly undulating on the surface, tense, painful on pressure, 
 and even from the commencement, though only obscurely, fluctuating. 
 "When laid open, thin venous blood, which has been effused between 
 the perichondrium and the cartilage, is discharged. 
 
 If it be only of small size, all tension wiU disappear spontaneously 
 in a few days, the tumour becoming soft, pale, and continually diminish- 
 
DISEASES OF THE EXTERNAL MEATUS. 41 
 
 ing, even if it be unopened, in consequence of absorption of the 
 effused blood. If it have attained a remarkable size, fresh cartila- 
 ginous tissue is deposited in the form of larger or smaller islets upon 
 the inner surface of the perichondrium, where it has been separated 
 from the cartilage, the union of which with the original cartilage of 
 the auricle, and with the thickened and relaxed integuments, pro- 
 duces a strange kind of deformity. 
 
 Three or four weeks are required for its cure ; sometimes the whole 
 process is repeated in the other ear, sometimes both ears are attacked 
 in the same manner at the same time, though this has only rarely 
 been observed. In some few instances, after complete recovery from 
 one attack, the disease has recurred in the same ear. 
 
 The causes of these bloody tumours on the cartUage of the ear 
 are unknown, though we must admit that they are especially likely 
 to be produced by violence (blows on the ear), which perhaps ex- 
 plains their more frequent occurrence on the left ear. 
 
 If the inflammation of the perichondrium have developed itself in 
 a strong constitution, with synocha, we must recommend rest to the 
 patient, with cooling diet, mild aperients, and locally cooling and 
 dispersive applications of lead lotion. The necessity of surgical 
 interference with the tnmour must be determined by its size, and the 
 presence or absence of fluctuation. Some very plethoric persons may 
 require to be bled. 
 
 In cachectic and debilitated subjects the tumour should be laid 
 open at an early period, even though the sense of fluctuation be 
 obscure, the effused blood thoroughly pressed out, and the tumour 
 covered with stimulating applications of warm aromatic tinctures. 
 The use of these should be continued till the cure is effected. Good 
 nourishment, easily digestible food, good port wine, invigorating and 
 tonic medicines and baths, residence in pure warm air, and moderate 
 exercise, essentially further the process of heaHng, and prevent 
 relapses. 
 
 The personal attendants of the insane should carefully watch them^ 
 in order to prevent them from injuring themselves. 
 
 DISEASES OE THE MEATUS. 
 
 These may be divided very characteristically into inflammatory 
 irritation of the cuticle, inflammation of the dermis and connective 
 tissue, and of the periosteum of the meatus. Bonnafont is quite in 
 
42 
 
 AURAL SURGERY. 
 
 error, as may easily be deduced from our description of these forms 
 of disease, in declaring that it is impossible to distinguish between 
 inflammation of the dermis and of the connective tissue. In accounts 
 of the diseases of the meatus we frequently meet with the striking 
 error that this passage possesses no mucous membrane, and is only 
 protected by a cuticle, and that in healthy conditions no kind of 
 secretion is observed in the meatus except cerumen. 
 
 The inflammatory diseases of the various layers of the integument 
 of the meatus have, even when strongly marked, when of long con- 
 tinuance, and when much neglected, little, if any, tendency to run 
 into one another. The only exception to this rule is periostitis, 
 whose consequence — caries of the osseous meatus — generally induces 
 inflammation of the dermis. 
 
 Injlammatory irritation of the Cuticle and Ceniminous Glands. 
 
 This affection often commences with a somewhat severe dragging 
 or tearing sensation in one or both ears, with pain in the head, neck, 
 and jaws, or it may be associated with very severe catarrhal symptoms ; 
 generally, however, there is such slight inconvenience that it is soon 
 forgotten by the patient. It either very quickly attains a high 
 degree of intensity, or else, gradually increasing in severity in the 
 course of a week or two, fulness, dulness, and, in many instances, 
 difiiculty of hearing and noise in the ears are developed. Whether 
 these last are continuous or intermittent symptoms, whether they are 
 relieved by yawning, lateral movements of the jaw, or strong pulling 
 of the auricles ; whether the immediate vicinity of the ear be insen- 
 sible, as is often the case, or not, is a circumstance to which no atten- 
 tion need be paid, for the diagnosis is determined by other and more 
 certain means. There is no constitutional disturbance, and any 
 present or previous disorder which the patients may state they are 
 or have been suffering from, in their enumeration of commemorative 
 symptoms, will be found, on close inquiry, to be whoUy independent 
 of the aural disease. If we examine the affected ear with bright 
 sunshine and the speculum (with both of which we may often dis- 
 pense in the case of adults), we discover, sometimes only in the 
 deeper parts, sometimes nearer the entrance, filling up the meatus, 
 dark-brown or even black, hard or soft, shiny masses of cerumen 
 clinging together. Subjacent to these the integument of the meatus 
 is often reddened, or even excoriated, and very tender. The mem- 
 
DISEASES OF THE EXTERNAL MEATUS. 43 
 
 brana tympanic after the removal of the ceraminous masses^ always 
 appears dullj but little translucent^ and here and there strongly 
 injected, especially along the line of attachment of the handle of the 
 malleus. Out of about 800 cases, some of which have been of long 
 standing, I have never observed any disorganization of the membrana 
 tympani, or of the meatus (perforation, caries, &c.), and it must, 
 therefore, be admitted that these degenerations have only been 
 ascribed to mechanical pressure and inflammation, produced by col- 
 lections of acrid and depraved cerumen, because the diagnosis of these 
 masses from dry pus scabs was not known ; the latter being often 
 found in the deeper part of the meatus, in cases of neglected caries, 
 and chronic inflammation of the perforated membrana tympani. The 
 greenish colour, and foetid odour of these pus scabs when dissolved in 
 warm water, very easily distinguish them from old and hardened masses 
 of cerumen. It is only in very rare cases that we find the meatus 
 apparently completely filled up vrith soft cerumen, and yet no dimi- 
 nution in the power of hearing, either for vocal sounds or for the 
 movements of a watch ; in such cases we can only conclude that the 
 cerumen does not whoUy occlude the passage, so as completely to 
 prevent the entrance of the waves of sound, for it is observable that 
 in those cases of greater hardness of hearing which are usually asso- 
 ciated with such collections of wax, the patient can be immediately 
 relieved by passing a blunt silver probe through the mass until it is 
 close to the tympanum, so that after its withdrawal a passage, if 
 only a smaU. one, is left to conduct the vibrations of sound, without 
 let or hindrance, to the membrana tympani. 
 
 On the other hand, though only occasionally, we do find col- 
 lections of cerumen as complications of deep-seated diseases of the 
 tympanic cavity, the existence of which is proved by the very shght 
 alleviation of the hardness of hearing which takes place after the 
 complete removal of the cerumen. 
 
 In the great majority of cases, both the hardness of hearing and 
 noise in the ears disappear immediately and entirely with the removal 
 of the cerumen, so that we have no room for doubting that these 
 collections exert both an obstructing and an irritating influence upon 
 the membrana tympani. (See above, p. 16). 
 
 Immediately after the clearing out of the ears, the patients are 
 somewhat stunned from the violent contrast which they experience 
 in the loudness of sounds. This, however, scarcely lasts an hour, 
 and is not even remotely to be compared with the extreme sen- 
 
44 AURAL SURGERY. 
 
 sibility of tlie retina after the operation for cataractj which requires 
 to be very cautiously and gradually accustomed to light. 
 
 The hardness of hearing by which collections of cerumen are ac- 
 companiedj is usually very well marked ; so that for instance, a watch, 
 the normal hearing distance of which is thirty inches, can only be 
 heard at the distance of a few inches ; and we may doubt whether 
 the conduction of sound takes place through the ceruminous masses 
 or the bones of the head. That a more abundant secretion of ceru- 
 men may take place, as a result of exposure to severe cold, dis- 
 covering itself by hardness of hearing and noise in. the ears, is per- 
 fectly certain, and by no means unfrequent. The increase of the 
 secretion is the consequence of a suddenly increased activity of the 
 ceruminous glands, which again, in its turn, is followed by an erythe- 
 matous inflammation of the cuticle of the meatus which may be 
 recognised in such, if we may so call them, acute cases, by clefts in 
 the ear, and excoriations of the cuticle. 
 
 By far the greatest number of cases of ceruminous collection in 
 my practice have occurred amongst those who pay considerable, 
 though not, perhaps, the most anxious attention to the thorough clean- 
 liness of the ear. I am unable, therefore, to derive it from neglect 
 of cleanliness, and stiU less from too strong a growth of hair at the 
 entrance of the meatus, since this is rare, and only occurs at an 
 advanced period of life ; whilst these collections are more frequently 
 met with in middle age and youth. If we reflect, moreover, that in 
 consequence of the extreme sensibility of the inner two thirds of 
 the meatus, in which part the ceruminous glands are always dis- 
 tributed, it is impossible to remove anything which has thus col- 
 lected by means of an ear-pick or other instrument ; we can easily 
 imagine that these collections of wax would be far more frequent, 
 especially amongst the lower classes, than is actually the case if they 
 depended merely upon neglected cleansing of the ears. 
 
 The most frequent cause of this disease is the entrance of water 
 into the ears, during river or sea bathing, in our daily washings, 
 cold shower-baths, douches, and the like, for it is impossible to 
 dry the meatus, especially in its inner two thirds : so that the 
 moisture still remaining evaporates, and thus cools the surface. 
 In favorable circumstances this only stimulates the cuticle and the 
 glands lying immediately beneath it, but in unfavorable conditions 
 the deep layer of the skin, the membrana tympani, and even the more 
 deeply seated membrane of the tympanic cavity, are excited to in- 
 
DISEASES OF THE EXTERNAL MEATUS. 45 
 
 flammation. The operation of bitterly cold and damp air upon the 
 surface of the meatus is exactly similar. Inflammation of the cuticle 
 of the meatus with diseased secretion of cerumen is very frequent ; 
 for example, in looo cases of aural disease, it occurred 163 times 
 ( = 16: 100=-^). The cure of this trifling, yet troublesome disease, 
 which may be accomplished so easily and by so many different 
 methods, is a circumstance favorable indeed for the patient, but 
 very unfavorable for the development and improvement of the art of 
 aural ■ surgery. The cure may be effected by many means applied 
 almost at random, and purely empirical in their nature, as by oils of 
 aU kinds, drops, injections, fomentations, vapour baths, sea water 
 and other baths, in which the water easily penetrates into the ear, 
 gradually softens the wax, and imperceptibly but thoroughly cleanses 
 the meatus. These means, whether employed by educated physicians 
 or by charlatans, effect a great number of brilliant cures, which 
 make an impression on the pubhc, and even on many professional 
 men, in exact proportion as the functional disturbances of these 
 superflcial affections of the meatus simulate those which accompany 
 other much graver and more incurable diseases of the ear. We 
 can in this way only too readily explain how the above-men- 
 tioned remedies, acting simply and gradually by the removal of the 
 ceruminous masses, have obtained the unmerited name of specifics. 
 The prognosis of this disease is extremely favorable. It is always 
 easy to remove the abnormal ceruminoas secretion, and thus to ensure, 
 in by far the majority of cases, the immediate and complete removal 
 of the accompanying hardness of hearing and noise in the ears — or 
 at least to effect material improvement in these symptoms. 
 
 The treatment of inflammation of the cuticle of the meatus is com- 
 pleted on removal of the ceruminous secretion. In the greater 
 number of cases, no preparatory treatment is necessary ; occasionally, 
 however, it may be requisite to soften very hard collections of ceru- 
 men (which cannot be perforated by an ear-pick), with the instil- 
 lation of a little warm olive oil. When this has been done, the best 
 injection is that of pure lukewarm water, by means of a caoutchouc 
 syringe, the size of the fist. The stream of water should be directed 
 against the plug of cerumen by pulling the auricle upwards and 
 backwards ; usually it becomes loose after the syringe has been dis- 
 charged a few times, and in a few minutes is completely removed. 
 We must convince ourselves, in each case, that this has really taken 
 place, by careful examination with the speculum. Immediately after 
 
46 AUEAL SURGERY. 
 
 its removal the noise in the ears always vanishes completely^ the ac- 
 companying deafness being in great measure relieved^ if it be due to 
 the ceruminous masses ; if, on the other hand, it results from disease 
 of the tympanic cavity, it is only improved ; and this in proportion 
 to the share which the ceruminous collection may have had in its 
 production. After the ears have been injected, they should be fiUed 
 with warm olive oil, and plugged for a few hours with soft charpie ; 
 as a rule, we then find that all redness of the membrana tympani, 
 and of the integuments of the meatus, have passed off. The former 
 is again brilliant and transparent, or becomes so at latest on the 
 following day, and the treatment may then be considered to be 
 completed. 
 
 Bemoval of Foreign Bodies from the Meatxis. 
 
 The removal of all foreign bodies (a term which has often and 
 justly been applied to ceruminous collections) is to be effected 
 by the same means. Foreign bodies may be of very various nature ; 
 they include glass and other kinds of beads, beans, peas, bulbous 
 roots, needles, cut stones, &c. ; these are commonly found more or 
 less tightly wedged into the meatus, close to the membrana tympani, 
 and always so placed that every time it is touched it presses in an 
 extremely painful manner either upon it or upon the integuments 
 of the meatus, so that neither the voluntary control of the patient 
 himself, nor the application of external force, is sufficient to prevent 
 violent movements of the head from being made ; and it is, there- 
 fore, almost impossible to employ instruments for the removal of 
 foreign bodies ; every attempt to do so in children being fruitless, 
 even when chloroform is administered. Laceration of the membrana 
 tympani, serious injury to the periosteum of the tympanic cavity, 
 with consecutive and fatal inflammation of the dura mater, are con- 
 sequences which, even in the hands of eminent surgeons, I have 
 seen result from attempts to remove foreign bodies from the meatus. 
 It would, therefore, be quite useless to enumerate the various in- 
 struments which have, even up to a very recent period, been sug- 
 gested for this purpose. It is only in cases where the foreign body 
 lies in the outer part of the meatus, and does not quite fill it, or 
 where it is of a fibrous nature, that we can advantageously emplov 
 without any risk, a pair of closely approximating angular forceps, 
 with broad ends, which should have little teeth upon their inner 
 surface (see fig. 4). In all other cases, we need only employ in- 
 
REMOVAL OF FOREIGN BODIES FROM THE MEATUS. 47 
 
 Im. 
 
 Ff 4 
 
 
 mi 
 
 jections of lukewarm water, by means of a vul- 
 canized India-rubber syringe, the size of the closed 
 hand, with which we are enabled to direct the 
 stream of water upon, the foreign body, if the 
 auricle be strongly pulled upwards and backwards. 
 By this means, the water penetrates behind it with 
 the continuance of the injection, raises it, and even 
 where most firmly impacted, in a perfectly gentle 
 and quiet manner washes it unfailingly out of the 
 ear. Where the meatus is inflamed and swollen in 
 front of the foreign body, so that there is no space 
 for it to escape, which indeed only results from 
 violent instrumental interference, we must allay the 
 inflammation by leeching and the instillation of oil, 
 and we may then have recourse to injections with 
 every prospect of success. But since it has actually 
 happened that persons have believed that they have 
 had a foreign body in the ear when none was pre- 
 sent ; we ought always to convince ourselves of the 
 fact by making a careful examination with the 
 speculiun and direct sunhght. Living insects and 
 worms should be kiUed by pouring in warm oil 
 before using the injection. If, from the improper 
 use of instruments, the meatus or the membrana 
 tympani, or as sometimes happens the parts even 
 within the tympanic cavity, be injured and ia- 
 flamed, antiphlogistic treatment should be adopted 
 as soon as the foreign body has been removed, with 
 the apphcation of leeches and the instillation of oil, 
 or a weak solution of acetate of lead, &c. 
 
 Inflammation of the Corium of the Meatus. 
 
 In - one, or more rarely in both ears, there appears a pale-red, 
 granular, vesicular, uneven or smooth swelling, which spreads itself 
 over the whole meatus, and greatly contracts its diameter. This 
 is accompanied with considerable itching, burning, and dragging 
 pain, that gradually becomes very severe, especially towards night. 
 The secretion of cerumen rapidly diminishes, and is replaced by 
 a serous or sero-mucous secretion, that at a later period becomes 
 soft, caseous, purulent, foul, or even foetid and corrosive, causing 
 
48 AURAL SURGERY. 
 
 ulceration of the auricle, and the neighbouring pai-t of the cheek. 
 When this occurs, these parts present numerous pustules, bleeding 
 cracks and fissures, with great heat and redness. If the ear be 
 cleansed by injection and the meatus be not too much narrowed, the 
 membrana tympani may be seen dull, opaque, white like paper, or 
 more or less reddened. In rare cases a croupous and apparently firm, 
 dark-colottred membranous exudation forms, with sUght swelling 
 of the dermis, which completely closes up the meatus, and is very 
 firmly attached, so that its removal produces acute pain. After 
 being detached, it frequently reappears quickly, and this will occur 
 several times consecutively. In other rare cases flat or pedunculated 
 fleshy tumours spring from the inflamed dermis of the iuner third 
 of the meatus. Constitutional febrile disturbance is seldom present, 
 and generally soon passes off ; but there is always well-jnarked diffi- 
 culty of hearing, the grade of which is in exact proportion to the 
 narrowing and obstruction of the meatus from the sweUing of the 
 dermis, and from the abnormal secretion. ]?foise in the ears is only 
 experienced when the membrana tympani is inflamed. To these 
 tolerably numerous cases of primary inflammation of the dermis must 
 be added, the far less frequent instances of secondary inflammation 
 of the integumentary layer, which result from caries of the meatus 
 and of the tympanic cavity, or from destruction of the membrana 
 tympani with disorganization of the investing membrane of the tym- 
 panum. 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. 
 
 If the carious bone be thrown off, as it usually is, by imperceptible 
 exfoliation, the inflamed surfaces of the dermis readily coalesce, and 
 the meatus is permanently occluded. This secondary inflammation 
 of the dermis affects usually the inner third only of the meatus. It 
 very rarely attacks, in addition, the dermis of the auricle, producing 
 the already described chronic form of inflammation (p. 37) with the 
 formation of obstinate scabs (milk scabs, cancer, elephantiasis, 
 lepra, &c.). 
 
 The course of both of these forms of inflammation of the dermis 
 is chronic, and they are not accompanied by febrile symptoms, unless 
 at a later period hectic fever is established, and then it does not 
 proceed from the am'al disease alone. 
 
DISEASES OF THE EXTERNAL MEATUS. 49 
 
 The primary dermal inflammation never attacks the deeper layers 
 of the skin, and even the consecutive inflammation of the membrana 
 tympani takes on no destructive character. The primary dermal 
 inflammation generally proceeds from catarrh, but occasionally from 
 some chemical or mechanical irritation, as from essential oils, 
 tinctures, eau de Cologne, or brandy and salt being dropped into the 
 ear, or from rough attempts to remove foreign bodies from the ear 
 by means of surgical instruments ; an unhealthy constitution has a 
 marked tendency to produce a chronic form of the affection, or to 
 develope secondary inflammation of the membrana tympani. 
 
 The prognosis varies considerably, according to the nature of the 
 causes producing the disease. The catarrhal subacute form is in 
 general readily curable in persons of sound constitution, as is also 
 that form of inflammation which is occasioned by the application 
 of local, chemical, and mechanical irritants. When the scrofulous 
 diathesis is unmistakeably present, the cure of the aural disease is 
 wholly dependent upon the removal or essential improvement of that 
 constitutional disorder. We may readily conceive that incurable 
 cases are sometimes met with, as in those in whom the dermal 
 inflammation results from caries of the meatus and tympanic 
 cavity, with coalescence of meatus, that is of the surfaces of the 
 dermis of the meatus. 
 
 The treatment of subacute inflammation of the dermis when the 
 weather is cold and damp, consists in rest at home, simple unstimu- 
 lating food, and regular daily evacuations. The ear should be 
 injected with warm water once or twice a day, with the caoutchouc 
 syringe, after which a few drops of a weak solution of sulphate of 
 zinc (gr. i — v ad §j aquae) should be dropped into it, allowed to 
 remain for ten minutes, then removed, and the meatus stopped with 
 fine charpie. Under this treatment the discharge becomes less acrid, 
 the clefts and cracks of the skin in the immediate vicinity heal up, the 
 itching and burning of the ear cease, the hypertrophy of the dermis 
 gradually diminishes, and becoming dry entirely disappears. The 
 meatus reassumes its natural colour and size. The membrana 
 tympani becomes white, and by degrees transparent and sliining, 
 and the power of hearing is regained. Lastly, the suppressed 
 secretion of cerumen returns. Counter-irritation by blisters, &c., 
 behind the ears is perfectly useless, and does not in any way pro- 
 mote the cure. 
 
 When chemical and mechanical irritants have acted on the meatus, 
 
50 AURAL SURGERY. 
 
 daily repeated injections must be used for their removal from tlie 
 suppurating ear, with subsequent instillation of lukewarm oil, in 
 order to check the rapid course of the inflammation. 
 
 Croupous exudation must be softened by the application of warm 
 poultices of bread or linseed meal; the accompanying pain may 
 then be moderated, and the softened plug removed by strong injec- 
 tions of lukewarm water. 
 
 The shining, red, but slightly swollen, yet very sensitive dermis, 
 must be painted every second or third day with equal parts of 
 tincture of iodine and tincture of laudanum, throughout the whole 
 length of the meatus. Acute pain is experienced, but the reproduc- 
 tion of the croupous exudation is prevented, and the inflammation of 
 the dermis completely subdued. 
 
 If the secretion from the meatus be very corrosive and the itching 
 very violent, so as even to prevent sleep, very great advantage is 
 derived from daily injecting the ears with lukewarm water and 
 then dropping in a solution of corrosive sublimate (gr. ss — ^j in aquse 
 §j) once or twice a day. If any constitutional affection, such as 
 scrofula, be present, and especially in protracted cases, full meat diet 
 should be ordered, with the well-known anti-strumous remedies, espe- 
 cially the Kreuznach, Eliza, Adelaide, and other baths. In suitable 
 constitutions, Fowler's arsenical solution should be prescribed. 
 
 Where the dermal inflammation is secondary, and is the result of 
 some deep-seated disease of the bones, the cure of this must first be 
 accomplished by injecting the meatus thoroughly every day, in order 
 to remove and prevent any accumulation and decomposition of the 
 abnormal secretion. All attempts to widen the contracted condition 
 of the meatus which accompanies this disease, by means of catgut, 
 sponge-tents, metallic tubes, nitrate of silver, or any other caustic, 
 are perfectly useless, and these means are equally unsuccessful if 
 employed to maintain the meatus pervious after the swelling of the 
 dermis has been incised with a bistoury or penetrated with a trocar. 
 
 Sometimes polypi form upon the inflamed dermis, and these may 
 be either flat or pedunculated ; the flat ones should be destroyed by 
 sprinkling them with powdered sulphate of zinc or nitrate of silver; 
 but the pedunculated variety may either be snipped off or ligatured, 
 and the root destroyed by the means just mentioned. The instru- 
 ments to be employed will be described hereafter, in discussing the 
 treatment of the far more frequent polypi of the inflamed mem- 
 brana tympani, and drawings of them will also be given. 
 
DISEASES OP THE EXTERNAL MEATUS. 51 
 
 Infiammation of the Connective Tissue of the Meatus. 
 
 Near the entrance of the meatus, seldom more deeply seated, and 
 never beyond the outer half, there appear one or more round tumours, 
 ahout the size of a pea, which are painful on pressure, but present 
 Kttle or no redness. These are always developed with symptoms 
 that are somewhat similar, though often still more violent than those 
 which accompany the last-described affection. There are lancinating, 
 tearing, or boring pains in one or both ears, which destroy sleep, and 
 extending to the vertex, occiput, and cheeks, into the throat, and 
 even into the upper arm, make the opening and shutting of the mouth 
 difB.cult, or even impossible. The meatus closes up to an almost 
 imperceptible sUt, from which on the second or third day, or even 
 later, there proceeds a very sparing, thin, and colourless secretion. 
 The tumour itself is quite dry, elastic, and smooth, and upon intro- 
 ducing a blunt probe we can perceive that the meatus behind the 
 swelhng is wide, and free from tumefaction. With the occurrence of 
 these symptoms the secretion of cerumen immediately and com- 
 pletely ceases, and does not reappear till the inflammation has sub- 
 sided.' When the pain is very great, and the patient irritable, a 
 febrUe condition is often established, which, however, is often absent, 
 though aU patients suffer from debility, loss of appetite, &c. 
 
 •It is impossible to ascertain whether the membrana tympani be 
 implicated or not, except by observing after the cure of the obstruct- 
 ing tumefaction has been effected, whether it is opaque, white, or 
 red in colour, and forms a secreting surface. In a few instances the 
 cellular inflammation extends from the meatus to the connective 
 tissue of the temporal muscle and of the processus mastoideus, with 
 severe pain, great tension, and dark, livid, redness of these parts. 
 
 Inflammation of the connective tissue is constantly associated with 
 very great difficulty of hearing, and the deafness is in proportion to 
 the closure of the meatus. Noise iu the ears is more rarely observed, 
 and only in those cases in which it can subsequently be shown that 
 the membrana tympani was inflamed. 
 
 When the disease is neglected, it drags on slowly for weeks, the 
 pain continuing with unbroken violence, whilst under proper treat- 
 ment, and frequently even in a few days, the tumour can be so far 
 matured as to form pus ; fluctuation may be perceived, and it opens 
 spontaneously ; on its opening, and with the evacuation of its con* 
 tents, which always consist of a mixture of blood and pus, the patient 
 
53 
 
 AURAL SURGEP.T. 
 
 feels immediate and complete relief from all pain ; if^ however, there 
 be several abscesses in the meatus, of which only the most external 
 one. has burst, the reUef wiH of course only be partial. In order to 
 complete the cure, it then only remains to secure the maturation, 
 and the evacuation of the contents of the others ia succession. At 
 the summit of the small tumours a scarcely perceptible opening may 
 often be seen, from which the last remains of pus may be squeezed 
 out by pressure. It is far more diflicult to produce softening, or 
 even obscure fluctuation in the inflammatory swelling upon the 
 mastoid process and temporal muscle, and we may wait in vain for 
 its spontaneous opening. 
 
 "When these small abscesses have discharged, their cavities quickly 
 heal up, and require no further attention ; whilst the cure of the affec- 
 tion above and behind the ear demands but little interference on the 
 part of the surgeon. The inflammation of the cellular tissue over the 
 temporal muscle and mastoid process only extends to the periosteum 
 in cachectic and very debilitated persons. It produces widely spread, 
 but seldom deeply penetrating caries ; and this terminates either in 
 imperceptible exfoliation, or in the separation of larger fragments 
 of bone. 
 
 The dermis of the meatus is never implicated in inflammation of 
 the connective tissue ; in fact, the inflammatory process in the latter 
 is so distinct in its course and characters, that we can scarcely com- 
 prehend how Bonnafont can make the assertion that it is impossible 
 to distinguish one from the other. 
 
 Inflammation of the connective tissue occurs most frequently in the 
 middle period of hfe, and in those who have previously enjoyed good 
 health. I have never observed it below the age of twelve or above that 
 of sixty. The most frequent cause of the disease appears to be expo- 
 sure to cold, as may be proved, or presumed, for so many other affec- 
 tions, though this does not in any way aid us either in their prevention 
 or cure. The prognosis is very favorable. Even in unhealthy consti- 
 tutions, the inflammation is limited to the connective tissue; suppu- 
 ration soon occurs, and the little abscess bursts quickly and without 
 danger. Under very unfavorable circumstances, slight purulent 
 infiltration does certainly take place, followed by inflammation of the 
 periosteum and caries of the bone. 
 
 As regards the treatment, in spite of the sharp local inflammatory 
 symptoms, we have only seldom to deal with general febrile con- 
 ditions, or to apply the usual well-known measures for their relief. 
 
DISEASES OF THE EXTERNAL MEATUS. 53 
 
 In by far the greater number of cases it is sufficient to leave the 
 patient to bis own natural aversion to foodj to keep Mm in the 
 house, and to carry out fully the local treatment. The affected 
 ear, as well as the inflammatory swelling, above or behind the auricle, 
 must be covered with thick hot poultices of bread or linseed meal, 
 inclosed in soft linen, and renewed every half hour through the 
 day and night. The poultice should be so moist as to thoroughly 
 wet the bnen, without dropping from it. It should never feel cold 
 to the ear ; on the contrary, the hotter it is applied and kept without 
 burning the skin, by so much the more rapid is the progress of the 
 disease, and by so much the greater is the relief from pain. If the 
 fatigue and weariness be extreme at night, the poultice may be 
 removed, and its place supplied by a small quantity of charpie dipped 
 in warm olive oil, which can be retained in the ear by a bandage 
 round the head. As soon as the patient awakes, the use of the poul- 
 tice should be recommenced, and continued until the pain in the ear 
 (usually suddenly) completely disappears, which indicates that the 
 abscess has burst, and its contents have been discharged. If the 
 pain still continues, we may feel assured that there are several 
 abscesses, one only of which has burst, and we must endeavour, and 
 shall certainly succeed in procuring the discharge of the others by 
 the continuous application of poultices. 
 
 Whether there will be one or more abscesses cannot* be deter- 
 mined, even after eight days have elapsed, siace the number is entirely 
 dependent upon the constitutional peculiarities of the patient upon 
 the duration of the disease, and his previous care or neglect of it. 
 
 Suppuration in the connective tissue of the meatus never requires 
 opening by the surgeon. The pus is always evacuated spontaneously 
 into the meatus, and so advantageously that no further after treat- 
 ment is requisite, since the feeling of pain in mastication, in 
 yawning, and on firm pressure made before and behind the ear, soon 
 cease. The meatus quickly returns to its natural dimensions, and 
 the normal power of hearing, which existed previously to the attack 
 of inflammation, is again restored. Wlien this occurs, the meatus 
 should in all cases be thoroughly injected with warm water, in order 
 to clear out the purulent secretion, which has by this time usually 
 become only sparing in quantity. 
 
 When the inflammation of the connective tissue has extended itself 
 over the temporal muscle and the mastoid process, the continuous 
 application of emollient bread poultices is all that is necessary to lead 
 
54 
 
 AURAL SURGERY. 
 
 to fluctuation in the frequently very tense swelling. Immediately 
 upon the occurrence of this, the abscess should be opened with 
 a lancet. The treatment here also occupies but little time if the 
 patient be otherwise healthy and strong. The cavity of the abscess 
 closes up with sm-piising rapidity, even when it is of considerable 
 size, and has contained much pus. If, however, the patient be very 
 much debilitated, or suffer from some unhealthiness of constitution, 
 or be an aged and cachectic person, he requires not only an improve- 
 ment in the social conditions under which he is living (moist, cold 
 habitations, bad and insufficient food), but the bread poultices must 
 be min gled with aromatics (chamomile flowers), grated onions, and 
 soft soap, in order to awaken sufficient activity in the inflammatory 
 swelling for the formation of pus. The abscess must then be opened 
 as quickly as possible by a free incision. By these means infiltration 
 of pus and caries wiU probably be avoided, but if not, the subsequent 
 treatment must be conducted according to the ordinary rules of 
 surgery. 
 
 Inflammation of the Periosteum of the Meatus. 
 
 The process of development of this form of disease is generally 
 almost completely withdrawn from medical observation, partly on 
 account of the very small amount of pain, or complete absence 
 of pain, which accompanies it, partly on account of its being 
 frequently associated witli other far more violent and fatal dis- 
 eases — as smallpox, scarlatina, measles, and typhus — and partly, 
 also, on account of the usually very tender age of the patients. 
 It is in general discovered by pure accident. A discharge of pus 
 takes place from one ear, and, on examination, a narrow fistulous 
 opening is perceived deeply situated in the meatus, and close to the 
 tympanum. Upon introducing a blunt probe it strikes against a 
 surface of exposed bone, contact with which produces only occasion- 
 ally a little pain. At other times, we find fistulous openings on the 
 mastoid process which communicate with the meatus, and the probe, 
 when introduced, leads to carious portions of the bone forming the 
 meatus, and caries of the mastoid process. In these cases of simple 
 caries of the meatus the membrana tympani still remains entire, and 
 only appears white and thickened ; but very frequently, and especially 
 in complicated cases, it is perforated, and, in many cases, wholly de- 
 stroyed, the exposed mucous membrane of the tympanic cavity being 
 dark-red, swollen, and sometimes very sensitive; in which cases, 
 periostitis and caries are also usually present. 
 
DISEASES OF THE EXTERNAL MEATUS, 55 
 
 If the caries of the meatus be only of moderate extent^ the inflam- 
 mation extends to the dermis in the immediate neighbourhood of the 
 membrana tympani, which reddens^ swells up^ and narrows the meatus 
 in its inner third to the size of a pint's head j from this the commonly 
 tliin dark- coloured secretion of the diseased periosteum oozes. 
 
 Hardness of hearing is present in all these cases, and often amounts 
 to almost complete deafness. If the periostitis of the meatus extends 
 to the mastoid process, there appears a gradually increasing, deep- 
 seated, and obscurely fluctuating tumour, accompanied by a dull, 
 heavy pain, and great tension, of the parts. Upon the spontaneous 
 bursting of this tumour, or after it has been opened, the probe either 
 strikes against an extensive surface of carious bone, or else penetrates 
 deeply into the substance of the mastoid process, and may be passed 
 from it mto the external meatus. Injections thrown into either 
 passage return by the other one, indicating that they communicate 
 in the substance of the bone. The discharge, especially in thesQ 
 complicated cases, is dark coloured, irritating, foetid, sharp, excori- 
 ating, containing black particles of bone, or even considerable pieces 
 of the bony meatus and of the mastoid process, after the exfoliation 
 of which the healing of the iistula occurs, a deep scar indicating its 
 former position. Complete deafness is a constant result of this 
 disease. When portions of necrosed bone are discharged after long 
 suppuration, the chronically inflamed dermis usually hypertrophies 
 and occludes the meatus. 
 
 Periostitis of the meatus is apparently a rare disease; at least I 
 draw this conclusion from the cases which have come under my 
 observation. It either results from a well-marked dyscrasia or 
 unhealthy constitution, or from the operation of injurious influences, 
 which, as in the virus of scarlet fever, smallpox, or measles, are in 
 certain epidemics especially liable to affect dangerously the organ of 
 hearing. It is almost always met with in cliildhood, and probably 
 because at that time both the constitutional disorder and the ten- 
 dency to the local disease, are more rife than at any other period of life. 
 
 The prognosis is very unfavorable, because the disease in question 
 is not usually recognised until it has attained its full development, 
 and also because the tedious constitutional affection requires to be 
 combated by abundant nourishment continued for a long period; 
 and even if our skill enable us to overcome the caiious disease, still 
 the functions of the ear remain irreparably damaged. The treatment 
 must be chiefly directed to the improvement of the general health by 
 
56 AXJBAL SURGERY. 
 
 residence in warm, pure air, cleanliness, simple but good food, specific 
 alterative medicines, as natural and artificial baths, and the use of 
 Molten, Kreuznach, Eliza, Adelaide, and other similar springs. 
 Locally, it is indispensable to maintaiu perfect cleanliness by the 
 daily injection of warm water, that the accumulation of foetid pus in 
 the fistulous canals may be avoided. 
 
 If we are so fortunate as to recognise the periostitis at an early 
 period, as it is extendiug over the mastoid process, we should endea- 
 vour to check its progress by leeches and by rubbing in blue oint- 
 ment, and if obscure fluctuation be perceived, early suppuration 
 should be promoted by the apphcation of emoUient poultices of bread, 
 in order that we may then evacuate the contents as soon as possible, 
 and thus prevent further destruction of the bones. When loose 
 pieces of bone can be felt in the fistulous canals, we must endeavour 
 to remove them by widening the fistulse, the cure of which wiU thus 
 be materially hastened. 
 
 If the meatus closes up, we are unable either to open it, or, if that 
 be accomphshed, to maintaiu it pervious, and are, therefore, incapable 
 of improving the deafness by these means. This condition is simply 
 incurable. 
 
 DISEASES OE THE MEMBEANA TYMPANI. 
 
 Notwithstanding the position of the membrana tympani, protected 
 ahke by the small diameter and the windings of the meatus, notwith- 
 standing its comparative dryness and its inability to perform any act 
 of secretion, it is yet so frequently affected that in almost every fifth 
 case of aural disease it becomes more or less imphcated ( Fide Table, 
 p. 17. 218: 1000 =-5-). It is even still more frequently affected 
 when it is iucluded among the general integuments of the meatus 
 (a 1 8 : 206). 
 
 The diseases of the membrana tympani always originate in an inflam- 
 matoty process, which, in the majority of instances, is primarily de- 
 veloped in the membrane itself, and does not affect the neighbouriug 
 structures, especially if its continuity be preserved and no perforation 
 have taken place. Inflammation of the membrana tympani is always 
 followed by a kind of disorganization, producing thickening and per- 
 foration of this originally very delicate structure. These changes 
 immediately destroy its vibratory power, and necessarily, therefore, 
 seriously impair the faculty of hearing. Jn fact, diificulty of hearing, 
 
ACUTE INFLAMMATION OF THE MEMBRANA TYMPANI. 57 
 
 though of course varying much in degree, never fails to be present 
 in disease of the membrana tympani, and it is much to be regretted 
 that our information on this subject is often restricted to the vague 
 and loose statements of the patient. 
 
 The prognosis of the diseases of the membrana tympani is very 
 unfavorable, so far as regards the recovery of its normal state, because, 
 on the one hand, there is a great deficiency of vessels of any kind, and 
 especially of the absorbents ; and on the other, because of the rapid 
 and very remarkable disorganization to which it is liable. The 
 injurious effect ■which these circumstances have upon the recovery of 
 the hearing, especially in those cases where the disease has escaped 
 notice, is often very strikingly exhibited. 
 
 The treatment, considered from a general point of view, consists 
 chiefly in the application of local means, though doubtless there are 
 various cases in which constitutional remedies should be by no means 
 entirely neglected. Every disease of the membrana tympani, in order 
 that it may be rightly understood and rightly treated, requires the 
 most careful examination by means of my split speculum, with good 
 sunlight illumination, the place of which can neither be supplied by 
 reflected light from "'white clouds or walls" (v. Troeltsch), nor by 
 the light of oil, gas, or photogen lamps, even when increased by a 
 stream of oxygen (Yoltohni), nor by biconvex lenses and reflectors. 
 This must always be borne in mind, wherever in the following treat- 
 ment of diseases of the membrana tympani, I speak of the symp- 
 toms, for I have always made my examinations by this objective 
 mode of inquiry ; and further, I will here remark, once for all, that 
 for the purpose of injection I only employ, as above mentioned, a 
 caoutchouc syringe the size of the closed fist. 
 
 Acute Inflammation of the Membrana Tympani. 
 
 This affection usually commences without any premonitory 
 symptoms j but deep-seated, stabbing, and tearing pains suddenly set 
 in, especially at night, in one or the other ear, very often extending 
 to the vertex, to the throat, jaw, and neck, on the same side. It is 
 rare for both ears to be attacked at the same time, or for one to be 
 seized after the other. The pain, often within a few hours, becomes 
 extraordinarily acute, completely preventing sleep, and making the 
 patient very agitated and restless. Noise in the ears is generally 
 present (in twenty-six cases out of thirty-five), hardness of hearing 
 
58 
 
 AURAL SURGERY. 
 
 always, and at an early period, though it can often only be ascer- 
 tained by tightly closing the sound ear. Febrile symptoms are not 
 often present, and then only iu a mild form. We must, however, 
 make an exception to this statement in those cases of acute inflam- 
 mation which, though often unnoticed, so frequently occur in the 
 course of violent exanthematous and typhus fevers. The pain almost 
 always remits towards morning, with the discharge of a colourless 
 serous fluid, and again returns in the evening with increased severity. 
 How often these alternate remissions and exacerbations will take 
 place before permanent improvement occurs, depends upon the 
 nature of the case, the constitution of the patient, and the treatment 
 that may have been adopted. The change of the serous iato a 
 mucous creamy discharge, containing shiaing white epithehal scalesj 
 is usually accompanied by complete remission or very material rehef 
 of the pain. 
 
 If we inject the affected ear with warm water, and then examine 
 the meatus, it will be found healthy, with only a deficiency of 
 cerumen. At the bottom the membrana tympani appears duE, 
 opaque, partially or generally reddened, and of all shades of colour, 
 from pale rose to purplej it is flattened, its natural concavity being lost, 
 and it may even be convex forward, in either case from the effusion of 
 plastic lymph between its layers. Its surface may be either smooth, 
 or uneven and granular, like a strawberry, the manubrium and 
 processus brevis of the malleus being no longer ^dsible. We may 
 often discern during the first few days a perforation in the larger 
 posterior part of the membrane, where it forms a depression, in which 
 a drop of fluid rests. This may be seen to pulsate isochronously 
 with a beating felt by the patient m the ear, which often becomes 
 very annoying; the membrana tympani is extraordinarily sensitive, 
 the slightest touch, even the gentlest stream of water, or the softest 
 paint-brush, producing stabbing pain, so that when we inject the 
 ear we are compelled, in consequence of the absence of cerumen, to 
 direct the stream, not against the membrane itself, but against the 
 posterior wall of the meatus ; the water then flows gradually back 
 and sufBciently cleanses it. Inflammation of the membrana tympani 
 is sometimes a consequence of a severe catarrh of the tympanic cavity. 
 In such cases we find the membrane within the first forty-eight 
 hours reddened, as above mentioned, dry, shining, and concave. The 
 secretion of cerumen in this case is unaffected, until the inflam- 
 mation extends to the external layer, and thus induces the usual 
 
ACUTE INFLAMMATION OF THE MEMBRANA TYMPANI. 59 
 
 group of symptoms that indicate inflammation of the membrana 
 tympani. 
 
 In these rare cases the patients observe the first lancinating pains 
 in the ear on strongly blowing the nose when the mouth is closed, by 
 which means considerable pressure is exerted by the air upon the 
 inner side of the membrana tympani. When left to itself, the 
 discharge from the membrane, which was at first colourless, changes 
 into a thick, clotted, greenish-yellow, puriform substance, in which 
 the white shining epithelial scales are no longer to be discerned. 
 With this alteration in the character of the discharge, the pain ceases, 
 and the acute passes gradually into the chronic form, of the disease. 
 Amongst 7000 cases of diseases of the ear that have fallen under 
 my observation, acute inflammation of the membrana tympani has 
 occurred 177 times ; 164 times in one ear and 13 times in both ears. 
 These have been accompanied 151 times with violent, and 16 times 
 with only slight and transient pain. In 38 cases febrile symptoms 
 were present, in 139 cases there were none. Noise in the ears was 
 complained of in 133 cases, but was absent in 53. Perforation of 
 the membrana tympani occurred in 137 cases, whilst in 40 it was 
 entire. 
 
 Hardness of hearing is iu all cases distinctly marked, and some- 
 times amounts to almost complete deafness. Acute inflammation of 
 the membrana tympani occurs generally in young and healthy persons. 
 In unhealthy constitutions it passes quickly into the chronic stage. 
 Its most frequent causes are keen, chilly draughts of air, the entrance 
 of cold water into the ears in washing or in the shower bath, or 
 whilst bathing in the sea or river, the dropping in of sharp spirituous 
 fluids (to remove toothache !), injury to the membrane from surgical 
 instruments in the attempt to remove a foreign body, blows on the 
 ear, and violent shocks produced by salvoes of artillery. 
 
 Whether in the exanthemata it is produced by the extension of 
 the exanthematous inflammation or of the inflammation of the throat 
 to the membrana tympani, has not yet been precisely ascertained ; 
 and its mode of origin in typhus fever is equally uncertain. The 
 prognosis is in general very favorable if the disease run its course 
 without any complication. It is completely curable with all its 
 accompaniments of perforation, noise in the ears, hardness of hearing, 
 thickening, and the hke, providing the treatment is commenced early, 
 and is appropriate, and that we are able to subdue the febrile con- 
 dition which is associated with it. The impossibility of fulfilling this 
 
60 
 
 AURAL SURGERY. 
 
 last condition in the exanthemata^ in typhus and in phthisical feveVj 
 is the true reason why, iu these affections, acute inflammation of 
 the membrana tympani takes on so dangerous and destructive a 
 character. 
 
 The treatment consists in paying the closest attention to the 
 general febrile symptoms, the exposition of which does not belong to 
 this work ; locally, it must be at once sustentative and antiphlogistic. 
 In unfavorable weather, the patient should not leave the room, nor 
 even the bed, he .should take nothing heating, and daily free evacua- 
 tion, of the bowels should not be neglected. Leeches should be 
 ■applied around the ear, iu number proportioned to the violence of 
 the pain, and the subsequent bleeding encouraged until the pain has 
 entirely ceased. A warm bath in recent cases, and especially amongst 
 children, operates very favorably in aUeviating the pain. Counter- 
 irritation of the skin, blisters &c., especially when applied at a dis- 
 tance from the ear upon the nape of the neck, or lower down still, 
 and not larger than a dollar, remaining open perhaps one day are 
 perfectly valueless. 
 
 The meatus of the affected ear must be daily, or according to the 
 quantity of the secretion two or three times a day, injected very gently 
 with lukewarm water, in order that the cerumen may not accumulate. 
 The head should then be inclined to one side, and the ear thoroughly 
 dried with soft liuen. Warm olive oil must now be poured in, and 
 the meatus stopped with soft charpie, in order to keep the membrana 
 tympani in a warm oil bath. As long as the pain continues, the 
 application of this warm oil should be repeated three times a day ; 
 and its effect will be promoted, should the pain be very violent, by 
 using warm bread or linseed meal poultices, mixed with hyoscyamus 
 or the water hemlock. 
 
 Under this treatment the pain, as a rule, vanishes in a few days, 
 and the discharge of pus from the membrane gradually ceases as the 
 inflammatory symptoms disappear. The membrana tympani becomes 
 again concave, transparent, and even the perforation itself leaves 
 scarcely any trace behind ; noise in the ears and dulness of hearing 
 pass away by degrees, and at length the returning secretion of 
 cerumen indicates the termination of the whole inflammatory 
 process. 
 
 If, contrary to expectation, after the removal of all the acute 
 symptoms, considerable discharge of pus and reddening of the 
 membrana tympani contkue, we have then to deal with the chronic 
 
CHRONIC INFLAMMATION OF THE MKJIBRANA TYMPANI. 61 
 
 stage of the maladyj the treatment of which will be fully detailed in 
 the following pages. 
 
 If we are so fortunate as to recognise, amongst the other serious 
 symptoms, the commencement of acute inflammation- of the membrana 
 tympani in the progress of exanthematous and typhus fevers, we must 
 reconunend, in addition to the above-described local means, especial 
 circumspection in the avoidance of cold poultices and applications. 
 
 "When acute inflammation of the tympanum accompanies pneumonic 
 or laryngeal disease, we must look for the means of cure, not, indeed 
 in local remedies, which will prove of no avail, but in a removal of the 
 patient to some warm climate, as to Egypt. 
 
 Chronic Inflammation of the Membrana Tijmpani. 
 
 This disease commences with slight pain in one, or more frequently 
 in both ears ; but which, on account of its slight character, often 
 remains almost unheeded, or is soon altogether forgotten. 
 
 Presently, a greyish, yellowish, greenish, or dark-brown secretion, 
 sometimes streaked with blood, begins to flow in greater or less abun- 
 dance j it is irritative, sharp, corrosive, foetid, sometimes thin, some- 
 times tenacious or clotted ; it soon dries up in the meatus and on the 
 membrana tympani, with dark-brown strongly adherent crusts. These 
 are so well characterised by their foetid odour, by their green colour, 
 by the pus which adheres to their inner surface, and when dissolved 
 in warm water by the greenish tint which they give to it, that they can 
 scarcely be mistaken for hardened concretions of cerumen. When 
 the abnormal secretion has been removed by the injection of warm 
 water into the ear, we find (with the exception of certain cases where 
 the secretion has been very acrid, and where, consequently, the dermis 
 is inflamed and swollen), the meatus healthy and natural in colour, 
 but in its deeper part there is sometimes visible a dirty-white, 
 speckled, or dark-red, smooth or uneven, lustreless, opaque surface, 
 which from its position {\\ inches from the tragus, capable of being 
 reached with the probe in adults, and firm, hard, and painless on 
 being touched), we must consider to be the degenerated membrana 
 tympani, although it is only rarely that we can recognise in shadowy 
 outline, the manubrium and processus brevis of the malleus. This 
 simple form of chronic inflammation of the membrana tympani 
 (No. lo, a, in the Table), which I have observed 64 times in 183 
 cases of chronic inflammation, and in 1000 cases of aural disease, has 
 been associated 13 times with noise in the ears, whilst in ^51 cases • 
 
63 AURAL SURGERY. 
 
 this symptom was not present j the proportion between the two 
 being therefore as i : 4, a proportion which is directly reversed in 
 acute inflammation of the membrana tympani, involving the chorda 
 tympani, when noise in the ears existed in the ratio of a6 : 9 = i : 4. 
 Perforations of the chronically iailamed membrana tympani, with 
 thickening and induration from interstitial deposit^ are more fre- 
 quently met with (87 times in 183 casesj Table No. lo^ h). They 
 occur most frequently in the posterior and larger half of the mem- 
 branCj and are occasionally^ though very rarely, met with in the 
 form of ulcers above the processus brevis mallei. The perforations 
 vary in size from that of a piu's head to the complete destruction of 
 the membrane, in the latter case the three ossicula are inevitably 
 lost, unless perchance, owing to the swelling of the investing mem- 
 brane of the tympanum, the stapes is retained. I have only once 
 seen (where the membrana tympani was wholly destroyed), the chain 
 of bones still fixed m natural position in the exposed cavity of the 
 tympanum. When the loss of substance extends to that portion of 
 the membrane which covers the malleus all that part of the latter 
 which is thus exposed is destroyed, and comes away by ulceration. 
 
 Sometimes the membrana tympani is reduced to a narrow, circular, 
 or semilunar strip, and we then generally find the neck of the mal- 
 leus in the form of a short, pointed process, directed upwards and 
 forwards, and extremely sensitive to the touch. Perforations of the 
 membrana tympani are usually very regularly circular, and we never 
 see several present together in the same membrane. In rare 
 instances the membrana tympani is of a grey colour, and but httle 
 thickened, and then the edges of the perforation are weU and sharply 
 defined; but in the majority of cases the opposite holds good. 
 
 The perforations of course expose a similarly-sized portion of the 
 cavity of the tympanum, which enables us to see its mucous mem- 
 brane, which appears very red, moist, and swollen, sometimes indeed 
 to such an extent, that it presses against the membrana tympani, 
 and fiUs up the perforation. In these cases, it is by the sharp border 
 of the membrane alone that the surgeon is enabled to distinguish 
 between the remaining portion of it, and the swollen and closely 
 approximated mucous membrane of the exposed tympanic cavity. A- 
 pale, or dark -red, moist, spongy, or fibro-cartilaginous outgrowth, 
 which is sometimes flat, sometimes pedunculated, the projecting 
 portion protruding from the meatus, is sometimes developed from 
 the altered and now secreting surface of the chronically inflamed 
 
CHRONIC INFLAMMATION OF THE MEMBRANA TYMPANI. 63 
 
 membrana tympani, which may be either perforate or entire. Some 
 of these bleed easily (mucous polypi), while others pour forth an 
 abundant purulent secretion. This occurs according to the Table 39 
 and 3 times amongst 183 of these cases (see Tabular statement, 
 No. 10, c and d). Tt is extremely rare to find the root of the 
 polypus implanted on the mucous membrane of the exposed tym- 
 panic cavity ; when this does occur, it is indicated by the exquisite 
 sensibility it displays on being touched, and especially on any sur- 
 gical interference. The contradiction which many writers give to 
 the statement that these polypi spring from the membrana tympani, 
 may be best shown to be erroneous by treating their roots with 
 nitrate of silver, which always indicates that they end at, or spring 
 from the membrane. Polypous growths from the membrana tympani 
 are still less frequently accompanied by noise in the ears than per- 
 forations (5 : 34 = I : 5 = o : 3 ), in which last, however, it must 
 be stated that noise in the ears is always absent providing the mem- 
 brana tympani be wholly destroyed, and with it the chord tympani, 
 the presumed seat of the noise. 
 
 In all these various forms of chronic inflammation of the mem- 
 brana tympani, one thing is never wanting — diminution in the power 
 of hearing, which may be either mere dulness or hardness of hearing, 
 or may amount to complete deafness. The higher grades of deafness 
 are generally met with in association with the thickened and imper- 
 forate, and in the completely destroyed, or indurated membrana 
 tympani ; in these latter cases remarkable instances of very complete 
 deafness occur. In aural polypi, deafness is always well marked, 
 whether they are pedunculated or sessile ; but it is generally greater 
 in degree, in proportion to the more or less complete occlusion of 
 the meatus, and the more or less complete disorganization of the 
 tissues of the chronically inflamed membrane. 
 
 Occasionally the inflammation of the imperforate membrana tym- 
 pani extends to the connective tissue or periosteum of the mastoid 
 process, with more or less violent, tearing pain, tension, swelling, 
 and livid redness of the iateguments, and marked tendency to the 
 formation of pus. Very rarely, and it is fortunate indeed that it is 
 so rare, the inflammation extends from the perforated membrana 
 tympani to the periosteum of the tympanic cavity, the dura mater, 
 and to the substance of the cerebrum, and especially to that of the 
 cerebellum. This sometimes comes on slowly, sometimes rapidly, 
 but is always very dangerous; it is indicated by deep-seated,. 
 
64 AURAL STJRGERT. 
 
 either persistent or intermittent pain, reaching to the vertex or to 
 the occiput, which is especially excited by contact with the polypi, 
 when present, or by touching the exposed tympanic cavity. It is 
 indicated also by sensations of pressure, weight, and numbness in the 
 head, and by incapability of maintaining the head erect, as well as by 
 great sensitiveness to shocks, as in walking on stone pavement, 
 striking the head with the knuckles, and the like ; by typical or 
 atypical rigors repeated several times a day, with or without subse- 
 quent hot fits, by paralysis of the facial muscles, and even of the arm 
 on the same side, and especially by abundant irritative foetid dis- 
 charge from the ear which has already long been perfectly deaf. 
 Death generally ensues accompanied by deceptive symptoms of 
 typhus fever, with cerebral complication. Thus the chronological 
 succession of the entire series of symptoms indicates that the primary 
 cause of the caries of the temporal bone, of the discoloration, detach- 
 ment and suppuration of the dura mater attached to it, of the sinuses, 
 and of the cerebrum or cerebellum, as shown by dissection, lies in 
 inflammation and perforation of the membrana tympani. There has 
 never yet been even a single accurate observation made which could 
 furnish any grounds for admitting " otorrhoea cerebrahs primaria," 
 and we must therefore regard such an affection as purely theoretical, 
 and wholly unsupported by experience. 
 
 When the membrana tympani is perforated, water, which has been 
 injected by the ears, will flow out by the nose and mouth, either drop 
 by drop, or in a full stream, the latter occurring if the stream of the 
 injection exactly hits the opening, and there happens to be neither 
 swelling of the mucous membrane of the tympanic cavity, nor of the 
 Eustachian tube, which may form obstacles to the flow of the water. 
 When such swelling, however, does exist, it will be found to be impos- 
 sible either to press or blow air (tobacco smoke) with an audible noise 
 through the perforation, although it may be perfectly visible to the eye. 
 
 In making an examination of the middle ear of those who are 
 sufl'ering from chronic inflammation of the membrani tympani, we 
 find that the air wilL only pass by driving a strong blast of air through 
 catheter No. 3 (see below). Moreover, interstitial exudation is con- 
 stantly present, and is but rarely accompanied by free exudation on 
 the surface of the membrane. The expulsion of the latter by cathe- 
 terism rarely proves of much service to the patient in the recovery of 
 his hearing ; in fact, as a rule, the hearing is more or less impaired 
 by the operation, though only transiently. 
 
CHRONIC INFLAMMATION OF THK MEMBRANA TYMPANI. 65 
 
 Chronic inflammation of the membrana tympani is so frequent 
 that it occurs in the proportion of almost one in five of all aural 
 diseases (183 : 1000). 
 
 Supposing now that we include also the above-mentioned thirty- 
 five cases of acute inflammation of the membrane, the proportion of 
 cases in which there is an abnormal muco-purulent secretion will be 
 218 in 1000, whilst, on the other hand, this symptom is observed 
 only in twenty-two cases of inflammation of the dermis, and in three 
 cases of periostitis of the meatus (see Table, Nos. 6 and 8). "We thus 
 obtain the knowledge of an important fact in the treatment of aural 
 diseases; that in cases where there is an abnormal muco-purulent 
 discharge from the ear, we may predict, without making any special 
 examination, that not less than nine cases in ten (318 + 25 = 2(43) 
 are sure to be inflammation of the membrana tympani, and only one 
 inflammation of the dermis of the meatus. 
 
 Children, and those of an unhealthy constitution, have the strongest 
 predisposition to chronic inflammation of the membrana tympani, 
 and in them it is occasioned by exposure to cold, and especially by 
 the exanthemata, scarlet fever, measles, and smallpox. We find in 
 reference to these causes that various authors describe scarlatinous, 
 morbillous, variolous, catarrhal, rheumatic, arthritic, and even syphi- 
 litic inflammation of the membrana tympani, but the proofs of the 
 specific and characteristic symptoms of each of these have not yet 
 been given, so that there is little or no practical value in such minute 
 distinctions. The prognosis of chronic inflammation of the mem- 
 brana tympani is upon the whole very unfavorable, and by so much 
 the more the greater the structural alterations which this part has 
 suffered, either by thickening and induration, or by actual loss of 
 substance (perforation). It is only in a few cases that a return to 
 a normal condition (translucency, concavity, and repair of the loss 
 of substance of the membrana tympani) is possible, and it is only 
 ■ivith this return that recovery of the hearing can take place. 
 
 The prognosis of the simple form of chronic inflammation of the 
 membrana tympani is least unfavorable when the disease is not of 
 very ancient date, when the patient is still young (the interstitial 
 changes yet active), and otherwise healthy, and the membrana tym- 
 pani does not give the sensation of much hardness to the blunt probe. 
 Under these circumstances we may hope for complete absorption of 
 the interstitial exudation. Under opposite conditions we must be con- 
 tent with partial absorption, or with the removal of the chronic inflam- 
 
66 AURAL STJRGERY. 
 
 mation and suppuration. The membrana tympani then becomes grey, 
 dry, flat, insensible, indurated; cerumen is again secreted, and the 
 hardness of hearing is improved to an extent that cannot be pre- 
 dicted with any degree of exactness. They are in the worst pre- 
 dicament in whom the deafness increases when the affected ear is 
 cleansed by an injection, however gently performed : and when the 
 loss of. substance is associated with thickening produced by inter- 
 stitial deposit, the prognosis is still more unfavorable. 
 
 Reparation of substance is accomplished with dif&culty propor- 
 tionate to the thickening of the membrane, and here (in opposition 
 to what occurs in cases of perforation of the acutely inflamed mem- 
 brane), there is always a visible cicatrix, which is depressed below 
 the level of the membrane. Such a cicatrix always appears as a 
 sinning, whitish, translucent membrane, surrounded by the old 
 membrana tympani, which is now white and dry, and seldom again 
 resumes its normal appearance. Perforations, the edges of which are 
 pressed against by the swollen mucous membrane of the tympanic 
 cavity, and ulcers situated above the neck of the maUeus, heal with 
 extraordinary difficulty, and, indeed, in some instances they never heal 
 at aU. The prognosis is most unfavorable when the perforation of the 
 membrane is accompanied by the abeady described extension of the 
 inflammation, not only to the mucous membrane but also to the 
 periosteum of the tympanic cavity, the dura mater, and even to the 
 brain itself, in which case a fatal result is extremely likely to occur. 
 When the tumefaction of the mucous membrane of the tympanic 
 cavity is considerable, great difficulty is experienced in effecting a 
 cure ; whilst periostitis in this part must be recognised and subdued 
 at once, if it is not to prove fatal to the patient by the uncontrollable 
 rapidity of its extension to that lining the cavity of the sktiU. 
 
 Polypi of the membrana tympani must always be removed, care 
 being taken so to destroy their roots that they cannot grow again. 
 Those remedies must then be employed which have already been 
 described as applicable to simple chronic inflammation and perfora- 
 tion of the membrana tympani (the basis of the polypi). The pro- 
 gnosis which may be derived from those polypi that grow so exuber- 
 antly from the mucous membrane of the exposed tympanic cavity, 
 and are so exquisitely painful, is sufficiently worthy of notice, since 
 they constantly indicate caries of the temporal bone, with all its 
 dangerous consequences. Amongst the symptoms of cerebral mis- 
 chief which belong to this disease, periodic or non-periodic rigors. 
 
CHRONIC INFLAMMATION OE MEMBRANA TYMPANI. 67 
 
 indicating suppuration in the cranial cavity, are the most remarkable, 
 since they show that immediate danger to life, which cannot be 
 averted, is to be apprehended. Still, cases sometimes, though very 
 rarely, occur, in which paralysis of the coiTesponding side of the 
 face (from periostitis of the temporal bone, extending into the Fallo- 
 pian canal !), can be completely removed, and the life of the patient 
 preserved. Caries of the temporal bone always produces complete 
 deafness, whether the portions of dead bone be thrown off at once in 
 the form of large sequestra, of which some remarkable instances are 
 on record, or by imperceptible exfoliation. 
 
 As regards the treatment of chronic inflammation of the tympanic 
 membrane, it is necessary, in the first place, to pay close and con- 
 tinuous attention to the local treatment, as this, in healthy constitu- 
 tions, includes almost everything that art can accomplish for the 
 relief or cure of the disease. At the same time, where there is any 
 constitutional affection the treatment of this must not be neglected. 
 The unjustifiable admission by some authors of a constitutional 
 dyscrasia (scrofulous), which they consider accompanies all chronic 
 discharges from the ear, especially in the young, leads to great harm 
 by inducing neglect of the local treatment in order that the "discharge 
 may not be suppressed," and to a bhnd reliance upon the good effects 
 of alterative antiscrofulous remedies, which are certainly unable to 
 check the disorganization, much less to effect the repair of the 
 chronically inflamed membrana tympani. On the other hand it is 
 unquestionably right to place those patients who present well-marked 
 signs of a scrofulous, herpetic, or any similar dyscrasia, under appro- 
 priate and special treatment, both dietetic and therapeutic. Local re- 
 medial means must at the same time be most carefully applied, for, as 
 M'e have already shown, they are amply sufficient in otherwise healthy 
 persons to lead to the cure of the chronic inflammation. Scabs and 
 crusts should first be softened with warm water and then gently re- 
 moved, after which one or both ears, as the case may be, must be 
 thoroughly cleansed by warm water, once or twice a day, according 
 to the quantity of the purulent secretion. A vulcanized india-rubber 
 syringe, equal in size to the fist, is to be used for injecting, and the 
 stream should be thrown directly upon the inflamed membrane. The 
 point of the syringe must, consequently be introduced to at least 
 the depth of half an inch into the meatus, so as to pass the anterior 
 curve and occupy the middle of the meatus, when the stream wiU 
 strike full upon the membrane, and completely remove all secretion. 
 
 6 
 
68 Aural surgery. 
 
 If tlie relatives of tlie patient are very timid they are not fit to per- 
 form this operation ; intelligent people, on the other hand, wiLL accom- 
 plish it very satisfactorily, even in young patients, for they can 
 conveniently hold the syringe, filled with water, in the left hand for 
 the left, and in the right hand for the right ear, and with hght 
 pressure propel the fluid into the meatus. After the injection, the 
 head being inchned to one side, the ears should be thoroughly dried 
 with soft old linen, and then plugged with soft linen charpie. Some- 
 times after the injection, pain, hardness, and swelling (iuflammation 
 of the connective tissue?) occur in the tragus and orifice of the 
 meatus, necessitating the employment of a soft and thick camel hair 
 brush for the purpose of cleaning out the latter. These symptoms 
 are generally soon removed by the application of warm bread or lin- 
 seed-meal poultices, and, in trifling cases, by stopping the ear with 
 a plug of fresh fat pork. The patient must abstain from all stimu- 
 lants and fatiguing corporeal exertion. He must avoid cold baths 
 in summer, and must sleep warmly covered in winter. If we have 
 only to deal with simple chronic inflammation of the tympanic mem- 
 brane, we shall find the quantity and fetid odour of the abnormal 
 secretion from the ears materially diminished by the daily injection 
 of warm water, or by the use of the brush, which must be employed 
 regularly for from eight to fourteen days. If the improvement ceases, 
 the ear should be filled, after each injection, with a lukewarm solution 
 of sulphate of zinc (gr. j — x, ad Aq. gj), gradually increasing the 
 strength; or, as is frequently advantageous, we may alternate this with 
 a solution of acetate of lead (gr. j in Aq. jj ; a larger quantity of the 
 acetate of lead does not dissolve, and therefore does not act properly 
 on being applied to the inflamed membrana tympani) ; these solutions 
 should be allowed to remain in the ear for about five or ten minutes. 
 After they have flowed out, the ears are again to be thoroughly dried 
 with soft linen and plugged with soft linen charpie. As a general 
 rule, after this treatment has been persevered in for some weeks or 
 months, the redness of the membrana tympani disappears, the abnor- 
 mal secretion vanishes, the long suppressed ceruminous secretion 
 returns, and the hardness of hearing diminishes proportionately to 
 the absorption of the interstitial exudation in the membrana tym- 
 pani, and in proportion, also, to the return of its natural concavity, 
 transparency, and normal biilliancy. But if the progress of re- 
 covery be again checked, it wfll be wise to omit for a few weeks 
 the dropping in of these solutions, and to rest satisfied with the daily 
 
CHRONIC INFLAMMATION OF MEMBRANA TIMPANI, 69 
 
 thorough cleansing of tlie ear with water, rather than to apply any 
 solutions of alum, nitrate of silver, corrosive sublimate, sulphate 
 of copper, or the like. It is at this time that we may make use 
 of counter-irritant plaisters (Empl. Lithargyri comp. 5ij, Potassio- 
 tartrate of Antimony, 5j, 01. crotonis gtt. vj), cut to the size of a doUar, 
 and applied about two fingers' breadth below the affected ear tiU sup- 
 puration takes place. BKsters of cantharides are of little service in 
 inflammation of the membrana tympani. They are a valueless remedy 
 bequeathed to us from the time when the nature of aural diseases 
 was wholly unknown. If exacerbations occur in the course of chronic 
 inflammation of the membrana tympani, in consequence of exposure 
 to cold, or other injurious influences, accompanied by more or less 
 severe pain, and diminution or entire stoppage of the purulent 
 discharge, we should intermit the injections or the brushing out 
 of the ears, and, as in the treatment of acute inflammation (see 
 above, p. 60), the ears should be filled several times a day with warm 
 olive oil, and a sufficient number of leeches should be apphed in front 
 of or below them, and sustentative treatment and rest be prescribed, 
 until the pains entirely disappear, the abnormal secretion returns with 
 its former character, and the uicreased redness and sensibihty of the 
 membrana tympani again pass away. It is then time enough to 
 return once more to the above-described treatment for the complete 
 cure of the chronic inflammation. When, although considerable 
 improvement has taken place, the membrana tympani remains white, 
 opaque, and thickened, and the accompanying hardness of hearing 
 still considerable, it is unfortunately seldom possible to effect the 
 absorption of the interstitial exudation in the layers of the mem- 
 brana tympani by the employment of either local or general means. 
 The activity of the interstitial changes which take place in youth 
 alone permits us to hope for improvement in these symptoms in the 
 course of a few months, after the cure of the chronic inflammation 
 has been accomplished; if this fail, or be retarded beyond the 
 expectations or the exigencies of the patient, perforation of the 
 thickened membrana tympani has sometimes been performed, in 
 order to permit the waves of sound to gain entrance to the tympanic 
 cavity, and to the labyrinth. Deleau assures us indeed, that, by 
 means of his punch-like instrument, which is provided with a sharp- 
 edged disk, he has bored through even an ossified membrana tympani 
 and removed a round portion from it. Bonnafont lays claim to the 
 the same operation, which he performs with his similarly constructed 
 
70 ATJRAL SURGERY. 
 
 instrument ("il suffit pourperforer une membrane si dure qu'elle soit"); 
 but if we are unable to bore through the indurated and thickened 
 membrana tympani by means of a -well-tempered cataract needle, we 
 may consider these assertions as but little worthy of credit, and that 
 the perforation of the membrane, when thus degenerated, is im- 
 practicable. If we reflect also upon Bonnafont's statement, that 
 artificial perforations of the tympanum, in spite of being from 
 3 — 4 mm. in diameter, had without exception, closed up under his 
 eyes ("?ouverture du tympan se fermait toujours"), although he 
 declares he has performed this operation upon several hundred 
 patients, we lose, and we think justifiably, all confidence in the 
 results of this much vaunted operation ; and lastly, if we take into 
 account the circumstance that in chronic inflammation of the mem- 
 brana tympani, interstitial exudation (very rarely free) has, without 
 exception, been proved to be present in the middle ear, by means of 
 catheterism of the Eustachian tube, and recollect the important share, 
 not to be removed by perforation, which the indurated and thickened 
 membrana tympani has in producing deafness amongst such 
 patients, we shall, especially after what we have already said of our 
 mistrust in the results of this operation, consider it in these cases at 
 least, perfectly impracticable. Perforation here, therefore, appears to 
 be, not only almost incapable of being accomplished, but even, if 
 accomplished, perfectly useless. 
 
 If we have convinced ourselves by means of catheterism of the 
 Eustachian tube, of the presence of free exudation, which however is 
 very unfrequent, or of free and interstitial exudation in the middle 
 ear, in cases of chronic inflammation of the membrana tympani (see 
 below), the time has arrived, the cure of the latter having been 
 accomplished, to consider what means can be employed for the 
 removal of such exudation, and thus to effect an improvement in the 
 hearing. These means we shaE. presently describe. We shall also 
 take the opportunity of treating of the palliative effects of "pads or 
 balls of cotton " when the perforations of the cluronically inflamed 
 membrana tympani are under discussion. 
 
 When the chronic inflammation of the membrana tympani has 
 been treated, in the manner just described, by perforation, we must 
 pay particular attention, in the requisite daily cleansing of the 
 affected ear, to the prevention of the entrance of the injection into 
 the nose and mouth. This is extremely unpleasant to the patient, 
 and sometimes produces fainting. We should take care therefore. 
 
CHRONIC INPIiAMMATlON OF MEMBRANA TYMPANI. 
 
 71 
 
 Pig, 
 
 that the stream of water is directedj not against the uiembrana 
 
 tympani itself, but against the wall of the meatus, near the mem- 
 
 branCj and always with great gentleness. In this way, whilst the 
 
 ear is effectually cleansed, the entrance of the water 
 
 into the nose and mouth, and the vertigo are 
 
 avoided. If, however, it should still continue, we 
 
 supply the place of the injecting syringe, by brush- 
 ing the meatus out with a fine camel-hair pencil ; 
 
 this can be readily and conveniently introduced even 
 
 in young patients, as far as the membrana tym- 
 pani, and they can easily learn to clean out the 
 
 meatus with it for themselves. When, by one 
 
 means or the other, we are certain of the thorough 
 
 cleansing of the affected ear, we must pour into it 
 
 once, twice, or three times a day, a lukewarm 
 
 solution of sulphate of zinc, containing from i — 4 
 
 grains in 3J of water, perhaps alternating it with 
 
 a similar solution of acetate of lead (gr. i — 3 in 
 
 aquae 3J). These should be retained in the ear from 
 ten to fifteen minutes. If the solution flows out 
 through the mouth and nose, which indeed but 
 seldom occurs, the diseased membrana tympani 
 should merely be touched with a soft camel-hair 
 brush dipped in the solution. This treatment 
 will lead to the cure of the inflammation, and, in 
 some very rare cases, to repair of the loss of sub- 
 stance at the point of perforation, but it must be 
 patiently and persistently continued for months or 
 even for years. Suppuration at length ceases, the 
 membrana tympani becomes white, and exhibits 
 at its deepest point, which is shining and white, the 
 cicatrix of the original perforation. The recovery 
 of the hearing, which accompanies this process of 
 repair varies very much in degree, and cannot be 
 predicted. If the cure of the perforation cannot 
 be effected by these means, its edges, if it do not 
 exceed the size of a pea, should be touched 
 with very fine powder of sulphate of zinc (either 
 pure, producing a subsequent feeling of pain, or 
 mixed in various proportions with sugar) by means 
 
72 AURAL SURGEE.T. 
 
 of my "porte caustique" for powders (Eg. 5), whose platinum 
 pointj when moistenedj_ will take up any desired quantity of zinc 
 powder^ and when introduced through the aural speculum can be 
 applied with precision to the seat of disease. If a fine camel hair 
 brush be applied to the point of the instrument, it serves excellently 
 for the application of the powder to the edges of the perforation, 
 which then gradually approximate ; in favorable cases the opening 
 ultimately closes, by the formation of a concave, greyish-white, and 
 smooth cicatrix. Neither nitrate of silver, applied in the solid form, 
 in powder, nor in solution, nor laudanum (Sydenham) nor any 
 other means promote this process of heahng so well as the method 
 just described. We may await it in vain, in all cases of perforation, 
 when there is much sweEing of the mucous membrane of the tympanic 
 cavity, and in ulceration above the collum mallei. If after the 
 inflammatory process in the perforated membrana tympani has been 
 wholly subdued, the membrane itself remains white and dry, the 
 heahng up of even the smallest perforations is never observed to 
 take place. With the exception of these cases, Bonnafont errs 
 in denying the perfect cure of those perforations which are pro- 
 duced by inflammatory processes; for in acute inflammation of 
 the membrana tympani this is the rule, and it is by no means a 
 very rare event, even in chronic cases. Swelling of the mucous 
 membrane of the exposed tympanic cavity, ought not to be treated 
 with caustics, nor even -nith powdered zinc, and certainly not 
 with nitrate of silver, in substance at least, if we are desirous of 
 avoiding violent pain, and very considerable inflammation of the 
 subjacent periosteum. In these, as in cases of extensive loss of 
 substance, sometimes amounting even to complete destruction of the 
 membrana tympani, which are unfortunately only too numerous, 
 we must generally give up all expectation of perfect recovery. 
 We can then only thorouglily cleanse the affected ear, seek to 
 dimiuish the purulent secretion by the use of mild solutions of zinc, 
 and by a judicious regimen endeavour to remove every source of 
 congestion or irritation from the ears. These considerations must 
 engage th? attention of the patient often for many years, or even 
 throughout life, if he is desirous of staving off the development of 
 acute inflammation in the ears and neighbouring parts, which, once 
 hghted up, may possibly even prove dangerous to life itself. Should 
 tliis serious condition however, be established, as indicated, by the 
 above described symjitoms of periostitis, of inflammation of the dura 
 
CHRONIC INFLAMMATION OF MEMBRANA TYMPANI. 73 
 
 mater and of the brain^ it becomes absolutely necessary to adopt a 
 most active and energetic local antiphlogistic treatmentj in order to 
 prevent the formation of pus in the cranial cavity^ and its almost 
 certain fatal issue. 
 
 To further this end, the patient should be kept in bed, with the 
 head raised on horsehair pillows, (which give a sensation of agree- 
 able coolness,) and inchned to the affected side, so that the dis- 
 charge of matter may be facilitated. The room should be kept at a 
 moderate temperature, the diet should be low, and no stimulants 
 should be given. The bowels should be kept very freely open by 
 salines with jalap and calomel. The affected ear should be thoroughly 
 cleansed by the injection of lukewarm water, and if the discharge of 
 pus be much diminished or suppressed, filled with warm oil, or even 
 covered with a warm bread or linseed-meal poultice, until the dis- 
 charge reappears, and the pain in the ear ceases. Prom four to eight 
 leeches should be applied around the ear, and repeated, if requisite, 
 each time permitting a more abundant flow of blood ; at the same 
 time ice should be applied to the vertex, or still better to the occiput, 
 until the pains in the ear and in the head have wholly ceased, and the 
 paralysis of the muscles of the face and arm has entirely disappeared. 
 When this is effected, we may employ a strong counter-irritant plaister, 
 composed of Ant. Pot. Tart. 5j, Empl. Litharg. co. ^ij, 01. Crotonis 
 gtt. X, of about two inches square, which should be applied below the 
 ear, or upon the neck, until numerous pustules have formed. The 
 suppuration should be kept up for a considerable period. I have 
 obtained exceedingly good results by these means, in cases where the 
 cerebral symptoms have been very serious, and have also seen great 
 benefit derived from the simultaneous application of emollient bread 
 poultices upon the ear, and ice to the occiput, continued through the 
 day and night. When the patient can endure the vibrations and 
 shocks of the head produced by riding, walking, striking it with the 
 knuckles, &c., we must discontinue the use of these powerful re- 
 medies, and return to the treatment which I have already detailed 
 for chronic inflammation of the perforated membrana tympani. 
 
 The occurrence of daily, or of still more frequently repeated rigors 
 (pyaemia), typhus fever, vomiting, and similar symptoms, in associa- 
 tion with paralysis of the facial muscles, mth violent pain in the ear, 
 and especially in the head, indicate that the disease is perfectly 
 hopeless. We can only look forward to the death of the patient 
 as certain, life usually passing away with the supervention of con- 
 
74 AURAL SITRGEllY. 
 
 pulsions or deep coma. Fortunately, however^ this disease has but 
 rarely any tendency to a fatal issue. 
 
 If we now turn to the very numerous cases in which, on account 
 of extensive loss of substance, or remarkable degeneration of the 
 stiU remaining membrana tympani, or on account of considerable 
 swelling of the exposed membrane of the tympanic cavity, with 
 chronic inflammation of these parts, there exists a well-marked 
 degree of deafness which cannot be removed, we may well imagine 
 the frequent and earnest wish, the longing for the improvement 
 of the hearing that these unfortunate patients feel; and when 
 we further reflect that in a considerable proportion of cases, when 
 the difficulty of hearing has been very great, sudden and repeated 
 improvement has occurred after a variable period, from some un- 
 known and inexplicable cause, we are clearly not in a position to 
 deny the possibility of a radical cure, nor to advise the patient to 
 resign himself calmly to the sad condition of complete deafness. It 
 is in these cases, therefore, that the contrivances of moistened pieces 
 of cotton wool (Tearsley), and the artificial membrana tympani 
 (Toynbee), have been hailed with enthusiasm. To follow out the 
 former plan, a httle piece of wadding, after having been dipped into 
 warm water and lightly squeezed, is rolled between the fingers into 
 a ball of the size of a pea. With the aid of a rounded pair of 
 forceps, this is introduced as far as the chronically inflamed (entire 
 or) perforated membrana tympani in such a manner that it does not 
 completely occlude the opening in the membrana tympani. " The 
 little ball is now introduced through the speculum, and adjusted 
 superiorly, inferiorly, anteriorly, or posteriorly, according to the 
 situation of the perforation; immediately after it has been placed 
 in position, a very marked improvement of the deafness will be 
 produced.'" We have now accomplished the application of these 
 "ear spectacles" (Erhard), and though it cannot be denied that 
 the little piece of cotton-wool effects an improvement in numerous 
 cases of chronic inflammation of the membrana tympani, yet it 
 must also be acknowledged that in very many cases of this dis- 
 ease it wholly fails. In many cases also it wiU be found impos- 
 sible to adjust the ball of cotton to the perforation, except after 
 numerous futile attempts, whether the forceps are introduced by the 
 surgeon in attendance, or, as is most frequently the case, by the 
 patient himself. Moreover, supposing the ball of cotton to have been 
 placed in the right position with more or less trouble, a new difficulty 
 
CHRONIC INPLAMMATION OF MEMBRANA TYMPANI. 75 
 
 arises; for it only maintains its position so long as it remains 
 moist, a difficulty whicli is not trifling when the vertical position 
 of the smooth membrana tympani is considered. Hence it often 
 happens that in such movements as those of speaking, mastica- 
 tion, yawning, dancing, or jumping, the little ball suddenly be- 
 comes detached, and there is a consequent immediate return of 
 the deafness. This effect is also produced as soon as the ball 
 becomes dry ; it then becomes necessary to remove and moisten 
 it, and, with a repetition of the same troublesome mancEuvrea, to 
 attach it to the same spot. The difficulties which stand in the way 
 of applying this remedy, and want of patience on the part of the 
 patient, render it almost impossible to give relief by these means, and 
 the mechanical ii-ritation produced by the ball upon the inflamed 
 membrana tympani, and still more upon the exposed and inflamed 
 membrane of the tympanic cavity, is a very serious additional incon- 
 venience — an inconvenience which may perhaps be somewhat alle- 
 viated, but certainly cannot be wholly removed by soaking the ball 
 in a solution of acetate of lead. I have seen very considerable 
 increase of the inflammation, enlargement of the perforation, and 
 increase of the deafness result from its use, so that, upon the whole, 
 I consider the moistened ball of cotton- wool, so far as regards that 
 form of deafness which accompanies chronic inflammation and per- 
 foration of the membrana tympani, a very uncertain palhative, applied 
 with difficulty, and easily producing injurious effects. 
 
 I have observed the injurious effects of the ball of cotton-wool not 
 only in those cases when the membrana tympani was entire, but 
 when it was wholly destroyed, with the loss of the three ossicula, and 
 also in those instances where only partial destruction had taken place. 
 The same remarks may be applied to the operation of the " artfficial 
 membrana tympani," which Toynbee recommends to be used in 
 cases where the membrane is perforated. This is a round, very deh- 
 cate plate of vulcanised India rubber, about three quarters of an inch 
 in diameter, which, supported by a thin silver wire attached to its 
 centre, is to be introduced in a moistened state into the ear, and 
 apphed in such a manner to the perforated membrana tympani, that 
 it shall close the orifice " air-tight, the patient being in the mean- 
 while in no way incommoded, and the mucous membrane of the 
 cavity of the tympanum nowhere touched. The hearing will be 
 immediately found to be greatly improved.'"'' That an "air-tight 
 closure " for an opening in the membrana tympani can be effected by 
 
76 AXJRAL SURGEKY. 
 
 the application of a soft caoutchouc membrane, every unprejudiced 
 person will admit to be an impossibility ; moreover, the exact spot of 
 the membrana tympani, on touching which the hearing is remarkably 
 improved, can only be discovered by some mancEuvriag of the artificial 
 membrane. It is as difficult to maintain in its position as the ball of 
 the cotton-wool. Both shp with equal ease, and then the improve- 
 ment of the hearing as completely disappears as when they become 
 dry. But, lastly, the mechanical, injurious irritation, which the arti- 
 ficial membrana tympani exercises upon the inflamed membrana 
 tympani, to which it is applied, is yet greater than that of the ball of 
 cotton wool, so that, in my opinion, of the two palliatives, the cotton- 
 wool is preferable to the artificial membrana tympani. Both, how- 
 ever, require to be applied with caution, and careful observation 
 should always be directed to the premonitory symptoms of increased 
 inflammation of the membrana tympani and of the membrane of the 
 tympanic cavity. 
 
 The attempts hitherto made to explain the action of the moistened 
 ball of cotton-wool, and of the artiflcial membrana tympani in im- 
 proving the hearing, completely fail, since on the one hand the organic 
 conditions which enable them to operate are very imperfectly known, 
 and on the other hand our information respecting the acoustics of the 
 ear is extremely imperfect. 
 
 The chronically inflamed membrana tympani, whether it be per- 
 forated or entire, may be covered either partially or entirely with a 
 flat, soft, elastic, and easily bleeding tumour, of a bright-red colour, 
 presenting a smooth or granular surface, and usually painless. The 
 treatment to be adopted is to touch it every day or less frequently, 
 hghtly or freely, according to the sensitiveness of the tumour and of 
 the patient, with pure sulphate of zinc in powder, or with a little 
 admixture of sugar, or more rarely with nitrate (A silver in powder. 
 These may be applied by taking a httle up on the moistened point 
 of my "porte caustique for powders" (see Pig. 5, p. 71), until the 
 tumour disappears. When the deep red and apparently prominent 
 surface of the membrane feels hard upon touching it with the blunt 
 probe, whether it be painful or painless, the appKcation of every kind 
 of caustic is contraindicated, as they would only act injuriously upon 
 the ossified or cartilaginous membrana tympani. "We must consider 
 this condition of disease as wholly incurable. 
 
 If the outgrowths of the cluonically inflamed membrana project 
 as pedunculate or capitate polypi, it will depend partly upon their pro^ 
 
CHRONIC INFLAMMATION OF MEMBRANA TYMPANI. 77 
 
 minence and partly upon the manual dexterity of the surgeon^ 
 whether they should be removed in the way above described, by 
 means of caustics, or whether the knife, scissors, or ligature should 
 be employed. 
 
 Tery nervous patients who dread the knife, readily decide in 
 favour of the ligature, which indeed is to be preferred to cutting 
 instruments for fibro-cartilaginous polypi. In either case, how- 
 ever we should always first pass a blunt silver probe completely 
 round the tumour, in order to convince ourselves that it has not 
 coalesced with any part of the meatus, and that its root does not 
 originate from this instead of from the membrana tympani. When 
 this has been ascertained, the head of the polypus should be seized 
 as low down as possible, with a sharp pair of forceps, pulled strongly 
 outwards, and the curved (on the flat surface) double-edged, round- 
 pointed knife (see Kg. 6) introduced along its -p g 
 side deeply into the meatus j the stalk of the ^ ^ 
 tumour can then be cut through by one or two I \ 
 sawing movements of the knife. If its texture is 
 fibro-cartilaginous, on the other hand, it will be cut 
 through much more easily with the scissors than 
 with the knife ; these instruments (Kg. 7) should 
 also be curved and blunt, and introduced as deep 
 as possible, towards the root of the polypus, then 
 opened, the stalk included between the blades, and 
 with one or more strokes severed, The separated 
 portion may be removed by means of a hook. When the after bleeding, 
 which may be pretty free, has been stopped, the affected ear should 
 be injected and we should ascertain the size and position of the root 
 of the polypus, in order that, according to the particular circum- 
 stances of the case, the application of sulphate of zinc or of nitrate 
 of silver may be made either day by day, or less frequently, until the 
 last visible remnants of the polypus are destroyed. 
 
 The thin end in which my porte caustique or caustic powder 
 carrier terminates, allows of the application of caustics to a limited 
 spot, with great precision and with complete safety to the adjoining 
 parts. 
 
 When we are desirous of employing the ligature for the removal 
 of a polypus, we use a diminutive "Leveret's ligature canula" 
 (see Kg. 8, natural size) with a fine silver wire attached, having 
 a sufficiently large loop, to allow of its introduction over the forceps 
 
78 
 
 AURAL SURGERY. 
 
 ¥iG. 7. 
 
 and the head of the polypus. This should be passed deeply into the 
 meatus towards the root of the outgrowth^ and having encircled it, 
 the loop should be drawn tightj the two ends of the silver wire being 
 
 fastened to the small lateral rings. The 
 whole instrument should now be 
 twsted a few times upon itself, until 
 we feel a sHght resistance. The stalk 
 of the polypus is then girt with suffi- 
 cient tightness. As this instrument 
 is very small and lights it hangs from 
 the meatus without producing any in- 
 convenience to the patient. After a 
 few days the polypus becomes brown 
 or blackish, the discharge very fetid, 
 and the pedicle nearly severed, so that 
 it only requires a shght pull to divide 
 it entirely from its root. When it is 
 not so, the ligature should be tightened 
 by twisting the canula a few more 
 times upon itself, when the polypus 
 wiU certainly fall off in. a day or two at 
 farthest. We have now once more only 
 to take care that the root of the poly- 
 pus is completely destroyed by the 
 application of the caustic powder. 
 
 It is perhaps hardly necessary to 
 state here expressly that the appHca- 
 tion of causticj especially to the flat 
 polypi, to the short-stalked tumours, 
 and to the roots of the long-stalked 
 tumours springing from the membrana 
 tympani and meatus, should only be 
 made with good sunlight illumination 
 and the use of my aural speculum. 
 
 When we have removed the last 
 traces of the aural polypi by these 
 means, we have only to deal with their 
 original cause — the chronic inflamma- 
 tion of the entire or perforated mem- 
 brana tympani. This demands exactly 
 
CHRONIC INFLAMMATION OF MEMBRANA TYMPANI. 79 
 
 the same treatment M'hich. has been above given for the well- 
 marked forms of this inflammation. When the polypi are of a 
 rounded form and project from the meatus, we may seize and 
 drag them out at once with forceps. This is, indeed, a somewhat 
 rough procedure, but not to be despised in robust individuals, 
 and is to be followed by the already frequently described appli- 
 cation of caustic to the remains of the root. We have already 
 referred to certain capitate polypi, which are extraordinarily sensitive 
 to the slightest touch, root themselves in the tympanic cavity — exposed 
 in consequence of perforation of the membrana tympani — and are con- 
 stantly accompanied by caries of the temporal bone, which has either 
 already affected the dura mater, or threatens to implicate it. Aural 
 polypi of this kind are completely inaccessible ; and it is useless to at- 
 tempt to remove them by knives, scissors, ligature, forceps, or caustics, 
 if we are not desirous of greatly increasing the deep-seated inflamma- 
 tion so dangerous to life. They appear and disappear with the perios- 
 titis in the tympanic cavity, and the resulting caries of the temporal 
 bone, for which the treatment above given must be adopted (p. 73). 
 
 To the foregoing description of the diseases of the membrana 
 tympani, I may be permitted to add a few words upon the ap- 
 pearances which not unfrequently present themselves in the ear, 
 and subsequently in the membrana tympani, after exposure to near 
 and violent explosions of artillery, after a fall upon the head, or 
 after severe blows upon one ear or upon one side of the head. In 
 such cases a continued discharge from one or both ears may be 
 observed for days or even for weeks, consisting in the first instance 
 of blood, then of a sero-sanguinolent, and finally of an apparently 
 pure serous fluid. When the patient escapes with life, the discharge 
 gradually and spontaneously diminishes ; but if with the discharge 
 there is complete deafness, we believe it must be regarded as 
 an unfavorable sign, indicating fracture of the temporal bone, and 
 in particular of its petrous portion. However, as the mem- 
 brana tympani has never been thoroughly examined during life in 
 any of these cases, we can only doubtfully consider that the dis- 
 charge proceeds from the torn blood-vessels of the membrana. When 
 the discharge is abundant, it probably proceeds from the cranial 
 cavity, and especially from the arachnoid, since in one case of this 
 krud the fracture was found to pass through the membrana tympani 
 and the petrous portion of the temporal bone. 
 
 The treatment of these cases is limited to keeping the head in- 
 
80 AURAL SURGERY. 
 
 clined, so as to facilitate as much as possible the discharge of the 
 fluid. Whatever further measures are requisite must be suggested 
 partly by a careful examination of the membrana tympani, and 
 partly by the presence or absence of symptoms indicating cerebral 
 disturbance. 
 
 Im. 8. 
 
 CHAPTER II.— DISEASES OE THE MIDDLE EAR. 
 
 The middle ear includes the Eustachian tube, tympanic cavity, and 
 mastoid-cells ; but we shall here only take into consideration the 
 diseases of these parts as they occur with an imperforated membrana 
 tympani. Those forms of disease which present themselves with 
 perforation of the chronically inflamed membrane have already been 
 fuHy discussed in the previous chapter. 
 
 At the outset, then, we may observe that the diseases of the 
 middle ear are completely inaccessible to ocular inspection, which 
 is so important in enabling us to form a correct diagnosis; 
 for the normal transparency of the membrana tympani wiU not 
 permit us to penetrate further, at least with any precision, than 
 the handle of the malleus. This is the more to be regretted as 
 the diseases of the external ear are rather less numerous than those of 
 the middle ear (427 : 560, see table), and the diagnosis of the latter 
 is of great importance ; in order that we may avoid rashly assuming 
 the existence of " nervous deafness." The symptoms which we 
 can observe by the senses of hearing and touch are of the greatest 
 value in the investigation of the various morbid conditions of the 
 middle ear ; but these can only so far furnish a scientific character to 
 the diagnosis as they are observed by the surgeon, and not by the 
 patient, or in other words, as they possess an objective value. In this 
 respect, Valsalva's experiment, which consists in making the patient 
 propel air into his ears, by a forcible expiration, while the mouth 
 
DISEASES OF THE MIDDIiE EAR. 81 
 
 and nose are closed, utterly fails. The success of tliis experiment 
 depends upon the address of the patient, and his knowledge of 
 what he is expected to do ; and even in favorable cases only a M'eak 
 sound (" thug ") is produced, which is of very short duration, and 
 only proves that there is a passage through the Eustachian tube, 
 that it is not altogether closed up. But this is almost equivalent 
 to proving nothing at all, since the tube never closes up entirely, 
 or so rarely that it can scarcely be numbered in the category of aural 
 diseases. Amongst 500 individuals suffering from diseases of the 
 middle and inner ear, and whom I have repeatedly catheterised, I 
 have never once observed it, though I certainly suppress two such 
 cases which occurred to me thirty years ago, at the period when I 
 first devoted myself to the study of aural surgery. 
 
 The ear catheter constitutes an essential improvement in the mode 
 of investigation, but if we blow air through it into the ear, or 
 conduct compressed air into it, and then rest satisfied with asking 
 the patient what he feels or bears, so that our decision upon the 
 results of the experiment is subjected to the judgment of the 
 patient, the value of the symptom as a means of diagnosis is im- 
 mediately lost. But if we put our ear to the ear of the patient, 
 during the passage of the compressed air j or if we connect, at the 
 time of the passage of the air through the catheter, the ear of 
 the patient with our own by means of an elastic tube, this method 
 of inquiry entirely loses its subjective and uncertain character 
 and never presents any variation ia the objective and acoustic 
 phenomena. 
 
 Those physical signs which characterise the various diseases of 
 the tube and of the tympanic cavity, may best be perceived by 
 employing catheters of gradually increasing calibre, as from i — ^4 (see 
 Kg. a, p. 26, sections i^ — 4), by which a corresponding increase of 
 strength in the stream of air blown into the Eustachian tube is ob- 
 tained. By the use of the elastic tube (Fig. 3, p. 30) the surgeon is 
 enabled himself to form accurate conceptions of the objective symp- 
 toms. The operation of blowing air through the Eustachian catheter 
 should therefore always be accompanied by the use of this tube. 
 The air should always be blown in by the mouth of the surgeon and 
 not driven in by either large or small compression machines, for it is 
 then of an agreeable temperature, and the insufflation can be con- 
 veniently prolonged or repeated, whilst it is easy to hold the catheter 
 fiimly and steadily in position. It is very rare for obstacles of a 
 
83 AUEAL SURGEKY. 
 
 mechanical nature to present themselves in the middle ear which 
 cannot be overcome by a person blowing against them, providing he 
 has sound lungs, which are indispensable to an aural surgeon. 
 
 The mode of introduction of the catheter into the tube has been 
 already (see p. 38) carefully detailed, and it will therefore only here 
 be briefly referred to. The blowing in of air is best accomplished by 
 slowly increasing the pressure, so as to prolong the period of ob- 
 servation, and enables us to ascertain accurately the strength of the 
 obstructions which have to be overcome in the middle ear. 
 
 If we blow into the Eustachian tube of a healthy person, through 
 the smallest catheter (No. i), we hear, not in the ear of the patient, 
 but as though in our own ear, a full, clear, soft, and somewhat moist 
 rushing sound, which lasts as long as we continue to blow into the 
 catheter, and which increases or diminishes with the changes in the 
 strength of the blast. 
 
 The air blown into the tube appears to be driven into our own 
 ear, through the diagnostic tube, so that we can indicate, for 
 the sake of brevity, this acoustic evidence of the free permeability of 
 the middle ear, by the expression " the air passes.'" Every departure 
 from this normal state, either in the size of the catheter required, in 
 the full and unbroken character of the stream, or in the sound of the 
 air blown in, depends upon, and indicates changes in the size, and in 
 the activity of secretion in the middle ear. If, for example, the air 
 only penetrates through catheter No. i by fits and starts, but easily 
 through No. 2, or only through Nos. 3 and 4, or lastly not eveu 
 through these, we possess in this progressive increase of difficulty in 
 surmounting the obstruction, an objective symptom of a determinate 
 nature, furnishing information of the relative decrease in the cahbre 
 of the tube resulting from interstitial exudation. If no air can be 
 driven through the catheter into the tympanic cavity, but the instru- 
 ment remains iu position in tlie Eustachian tube, we hear through 
 the diagnostic tube, distantly as it were, in the ear of the patient, a 
 more or less dull, but always dry, rushing sound, which enables 
 us in some measure to recognise the position of the constriction as 
 nearer or further from the tympanic cavity. The subsequent intro- 
 duction of the catgut or bougie, wiU then supply us M'ith more 
 exact information. 
 
 On the blast of air gaining admission into the cavity of the 
 tympanum, that is to say, when it passes apparently through the 
 diagnostic tube into the ear of the observer, we hear, when every- 
 
DISEASES OP THE MIDDLE EAR. 83 
 
 tiling is in a healthy condition, a clear, soft, full sound ; in abnormal 
 conditions this sometimes becomes hard, sharp, and dry, sometimes 
 moist, loose, rattling, and mucous, sometimes dull, without resonance, 
 and more or less attenuated — ^variations which indicate with great 
 exactness corresponding changes in the secretion, in the secreting 
 surface, and in the capacity of the tympanic cavity. When we intro- 
 duce into the healthy Eustachian tube of an adult a catgut or 
 caoutchouc bougie (about one millimetre in diameter, on which the 
 length of the catheter is marked, with another mark at the distance 
 of one inch and a half showing the length of the Eustachian tube) 
 we find that it glides easily along without any pain, let, or 
 hindrance for one inch and a half till it reaches the entrance into 
 the tympanic cavity. On pushing it still further— but varying in 
 different people from half a millimetre to four mm. from its entrance 
 into the tympanic cavity — pain of such an extremely acute character 
 is produced that we are obhged to withdraw the catgut or bougie 
 immediately. Usually, withdrawal to the extent of half a millimetre 
 is sufficient to produce entire cessation of the pain. Whether this 
 is produced by contact of the catgut with the membrana tympani (to 
 which it is conducted) or with the malleus or stapes it is impossible 
 to determine, nor is it practically of any importance, since it is per- 
 fectly useless to push the catgut or bougie into the tympanic cavity 
 beyond the entrance of the Eustachian tube. The pain just de- 
 scribed is infinitely more acute than that which is experienced when 
 the catgut or bougie is forced through a stricture of the tube. 
 
 When an obstruction is presented to the further introduction of 
 the bougie it indicates the point of constriction, a point the distance 
 of which from the guttural and tympanic openings of the tube 
 can be most accurately ascertained by the marks on the catgut or 
 bougie. Not unfrequently, upon overcoming one obstruction, we 
 find a second beyond it. We are able to ascertain when these 
 constrictions are circular and narrow by the slipping tlirough of the 
 catgut, which is somewhat compressed as it passes through them, 
 whilst a broad constriction, or a general swelling of the mucous 
 membrane of the tube throughout its whole length, gives quite 
 a different kind of sensation to the fingers, at least when these are 
 endowed with high tactile sensibility. Bonnafont assures us that 
 he has passed elastic bougies up to one and a half milhmetres in 
 diameter for the dilatation of the constricted portions of the tube, but 
 
 7 
 
84 AIDRAL SURGERY. 
 
 this is hardly credible, as he in another part of his work states "j'y 
 introduis chaque jour des bougies dont le diametre ne peut jamais 
 depasser i millimetre/'' 
 
 If Erhard admits the value of these tactile symptoms as evidences 
 of stricture of the Eustachian tube, we may well ask why he 
 should describe the sounding of the tube by the catheter as 
 "a. useless and troublesome proceeding/'' but he confesses that it 
 has never been in his power " to introduce the sound deeper than 
 two or three lines beyond the end of the catheter in a healthy 
 Eustachian tube.'''' Now, he may certainly attribute this either to 
 his own want of manipulative dexterity or to the bad construction 
 of his instruments, and should not judge of others by himself. I 
 at least scarcely know of a single case, during an experience of more 
 than twenty-five years, in which I have been unable to introduce 
 catgut or other bougies of sufficient fineness until a painful impres- 
 sion was produced by their contact with the membrana tympani. 
 
 By these means of research, derived from the senses of hearing and 
 touch, we are able to recognise objectively, not only the normal 
 conditions of the middle ear, but also its abnormal states, in refer- 
 ence to the structure and secretory activity of its walls, under the 
 forms of — 
 
 (a) Suppressed, 
 
 lb) Eree, 
 
 (c) Eree and interstitial, 
 
 {d) Exclusively interstitial exudation. 
 
 These are well-marked forms of catarrhal inflammation of the 
 investing membrane of the tympanic cavity and Eustachian tube 
 either closely resembling or identical with those which may be 
 observed in the mucous membrane of the respiratory tract, so that 
 we can very well dispense with the proofs of their existence 
 derived from actual dissection, which, indeed, have never yet been 
 obtained. 
 
 " Membranous bands, anchylosis of the ossicula between them- 
 selves or by means of ligamentous bands with the promontory, 
 anchylosis of the stapes into the fenestra ovalis, thickening of the 
 periosteum of the tympanic cavity and of the membrane of the 
 fenestra rotunda in particular," and other similar diseased conditions 
 of the tympanic cavity observed upon dissection, cannot certainly 
 yet be diagnosed by my acoustic and tactile method ; but as all these 
 results of post-mortem examination have been found only in the 
 
DISEASES 0]? THE MIDDLE EAE. 85 
 
 bodies of those who have died from severe exanthematouSj typhus^ 
 and gastric fevers, in dropsy, jaundice, and other similar diseases, 
 which effect important alterations in the nutrition of mucous mem- 
 branes in general, it becomes a question whether they are not 
 entirely the products of these diseases when they have proved fatal ; 
 and still more questionable whether they are to be assumed to be 
 present in the very numerous cases of hardness of hearing in which 
 these severe constitutional affections have not attacked the patient. 
 This doubt is greatly strengthened by the circumstance that such 
 pathological conditions have never been objectively diagnosed during 
 Kfe, nor have they and the deafness ever been shown to stand in the 
 relation of cause and effect. On this account it appears to be some- 
 what precipitate to enumerate these results of dissection amongst 
 the diseases of the middle ear, and we are still less justified in in- 
 cluding, with Erhard, " induration and hypertrophy of the ossicula," 
 for the evidence of which he appeals to Toynbee's 'Eeports of 
 Dissections.' But Toynbee never mentions any such morbid con- 
 ditions. He found the membrane lining the tympanic cavity " thick, 
 red, soft, vascular, swollen, and pulpy,'' but never "indurated." 
 Erhard thus fails as prominently in establishing a physical diagnosis 
 for his " induration and hypertrophy of the ossicula " as he does in 
 his other hypothetical diseases of the middle ear, a deficiency which he 
 seeks to supply by proposing a functional diagnosis, or, in other words, 
 a diagnosis derived from or depending upon the functions of the ear, 
 which he forthwith declares to be " apodictically certain," that is, 
 absolutely certain, though he again modifies this statement by saying 
 " that the functional diagnosis can almost (!) be called purely 
 objective." If we examine more closely this very dubious explana- 
 tion of the " functional diagnosis," we find that he lays down as 
 its fundamental proposition " the absolute fact, the pathognomonic 
 symptom," that " those who are deaf on both sides, with perfectly 
 occluded meatus, hear the sound of a watch clearly and distinctly 
 when it is pressed against the head," a proposition the incorrectness 
 of which could easily be shown experimentally if Erhard had not 
 himself already made so many important exceptions and limitations 
 to it, that aU "absolute certainty" has entirely disappeared. 
 
 Erhard, for example, excludes from these "persons deaf on both 
 sides," aU those who — 
 
 (i) Are of great age, in whom the power of conduction in the 
 bones of the head is diminished. 
 
86 AURAL SURGERY. 
 
 (2) In those above forty, and those who are no longer young (!) and 
 are hard of hearing. 
 
 (3) Those who have a strong diploe and thick integuments. 
 
 (4) Those also who are nervously deaf, or 
 
 (5) Those who are apparently nervous, and who suffer from reflex 
 deafness. 
 
 (6) Those who are deaf on one side only, amongst whom some may 
 be able to hear a watch through the cranial bones of the affected side, 
 the ear being, nevertheless, nervously deaf, with no morbid condi- 
 tions in the middle ear, and therefore, not acoustically deaf. 
 
 When we reflect on the great number of these exceptions, it appears 
 ridiculous to apply the term " apodictic " to a functional diagnosis 
 resting upon no better foundation than the ability or inability of the 
 patient, under certain circumstances, to hear the sounds of a par- 
 ticular watch. 
 
 CatarrJial inflammation of the Middle Ear. 
 
 This disease attacks the investing (serous) membrane of the cavity 
 of the tympanum and (mucous) of the Eustachian tube, and is 
 recognised by various changes which are produced in the processes 
 of nutrition and secretion. The chief forms which present them- 
 selves, and which but seldom run into one another, are — • 
 
 {a) Cases of suppressed exudation. 
 
 [b) Cases of free exudation. 
 
 (c) Cases of free and interstitial exudation. 
 {d) Cases of interstitial exudation. 
 
 The general symptoms of these difi'erent forms of disease are, that 
 their course is tedious, being often protracted for months or years ; 
 the local inconvenience is exceedingly shght, rarely amounting to 
 pain, and by no means persistent ; occasionally, however, some pain is 
 experienced. There is usually a gradual and progressive tendency to 
 become worse, and the patient very seldom improves spontaneously, 
 especially if there be a general febrile condition of the system. 
 Nature does little towards the cure. There is no danger to hfe, nor is 
 the ear organically affected, although its function is so seriously 
 impaired. The deafness which constantly accompanies these affec- 
 tions is only to be explained on the theory already (p. 7 etseq.) given, 
 that the conduction of sound takes place through the air of the 
 tympanic cavity and the membrane of the fenestra rotunda. Free 
 exudation in the tympanic cavity compresses the air normally con- 
 
CATARRHAL INFLAMMATION OF THE MIDDLE EAR. 87 
 
 tallied within it, and renders tlie transmission of the vibration of 
 sound difficult in proportion to the inferior conducting power of the 
 free exudation (mucus) as compared with air. If the surface of the 
 membrane of the fenestra rotunda be covered with mucus, its power 
 of vibrating will be lost, in exactly the same manner as when this 
 Kttle membrane participates in interstitial exudation affecting the 
 lining membrane of the tympanic cavity. Interstitial exudation in 
 the mucous membrane of the Eustachian tube produces constrictions 
 of the tube of various degree and length ; these interfere with the 
 requisite renewal of the air contained in the tympanic cavity, which 
 probably becomes rarefied, and therefore less adapted for the con- 
 duction of sound from the membrana tympani. The various grades 
 of hardness of hearing owe their origin in many cases to these 
 organic changes. 
 
 Notwithstanding the anatomical differences between the lining 
 membranes of the tympanic cavity and of the Eustachian tube, it is 
 impossible to separate these diseases in practice by any points of 
 physical diagnosis, and it is therefore useless to attempt to define 
 their differences on purely theoretical grounds. 
 
 The most important cause of the catarrhal inflammation of the 
 middle ear is cold, though the time and manner of its operation 
 cannot always be exactly determined. Sometimes the exposure to 
 cold has been general, sometimes, and more frequently, local. Amongst 
 the more common modes in which cold acts are cold draughts of air ; 
 the entrance of cold water iuto the ears in washing and bathing, 
 and in showier and douche baths, &c. ; cold and wet feet. Weak 
 and unhealthy constitutions, such as the scrofulous, are especially 
 susceptible to these inducing causes ; but injurious influences, operat- 
 ing powerfully, or less energetically and more frequently, often 
 produce severe attacks of catarrhal inflammation of the middle ear, 
 even in persons who have been previously in excellent health. 
 
 The diagnosis of these affections is determined, in the first jDlace, 
 by convincing ourselves by ocular inspection, of the healthy con- 
 dition of the external ear ; and, secondly, by the physical examination 
 of the middle ear, by means of the insufflation of air throi:gh a series 
 of regularly graduated catheters and the use of the diagnostic tube. 
 In certain cases it is further requisite to introduce bougies througli 
 the catheters. 
 
 The prognosis and treatment vary so much wdth the form that the 
 disease assumes, that w'e can only state generally that constitutional 
 
88 AUEAL SURGERY. 
 
 remedies are but rarely of service^ and then only to a limited 
 extentj whilst local measures applied directly to the Eustachian tube 
 and the tympanic cavity are very effective in expediting the cure. 
 
 Catarrhal inflammation of tlie Middle Uar with suppressed 
 exudation. 
 
 This disease usually commences during or immediately after a 
 violent cold in the head. It sets in with a sensation of great fulness, 
 hardness of hearing, and loud noise in one or, more frequently, in 
 both ears. These symptoms continue without any cessation for 
 several weeks or months, and are generally associated with various 
 abnormal sensations, as loud rushing noise or deceptive musical 
 sounds, which may be either limited to one or two notes or range 
 over a scale of greater or less extent. 
 
 In these cases we find the meatus and membrana tympani healthy ; 
 the throat vascular, somewhat swollen, but devoid of mucus. The 
 chief general symptoms of which the patient complaias are the cough 
 and catarrh. 
 
 When, under these circumstances, air is blown into the Eustachian 
 tube through No. i catheter, we hear it passing through the 
 diagnostic tube, as it were, with a dry, sharp sound, into our own 
 ear. The operation of insufflation not only effects no improvement 
 in the symptoms, but actually produces an immediate and very 
 decided iacrease in the hardness of hearing, noise, and sense of 
 fuhiess in the ears; this generally passes off after the lapse of 
 some hours, the patient then returning to his previous condition. 
 The more force is employed in performing the operation, and the 
 more frequently it is repeated, the longer and the more serious is the 
 increase in the severity of the symptoms, a proof that they proceed 
 from mechanical irritation of the inflamed membrane of the tympanic 
 cavity, such inflammation being the organic cause of this disease. 
 
 Diagnosis. — A fuU stream of air passing quite easily and freely, 
 even through a No^ i catheter, proves the completely normal size 
 and space of the whole middle ear, that is to say, the absence of the 
 smallest interstitial exudation in it, whilst the sharp, dry tone pro- 
 duced by the air in its passage clearly proves the absence of free 
 exudation, and that even the normal sparing secretion which at other 
 times makes the sound of air passing into the tympanic cavity appear 
 soft has altogether disappeared. This cessation of secretory activity 
 must obviously affect the whole of the membrane lining the tympanic 
 
CATARRHAL INFLAMMATION OF THE MIDDLE BAR. 
 
 89 
 
 cavity, including, therefore, of course, the merabrana tympani and 
 the membrane of the fenestra rotunda ; the capacity to respond to 
 the vibrations of sound is therefore diminished in both, and a cor- 
 responding hardness of hearing is produced. As soon as the serous 
 secretion in the middle ear is again restored, this symptom of 
 disease completely disappears, together with the noise in the ears 
 which so frequently accompanies catarrhal inflammation of the 
 lining membrane of the tympanum, when the chorda tympani is 
 implicated. 
 
 The prognosis is generally favorable, if the patient be not too far 
 advanced in age. 
 
 In the treatment of recent cases attention must be -p,^^ 
 paid to the accompanying general febrile condition of 
 the patient, for which the usual well-known remedies 
 should be employed ; amongst these a few warm baths 
 deserve special notice. When the mucous membrane 
 of the pharynx is observed to be reddened and in- 
 flamed, whilst little or no secretion is present, mild 
 emollient gargles of decoction of barley, &c., should 
 be ordered, with the internal use of sal ammoniac 
 in solution and mild mucilaginous drinks, until the 
 suppressed secretion in the pharynx and on the gums 
 returns. When the weather is cold and damp, the 
 patient should stay at home, and the ears should be 
 stopped with wool. These measures only operate 
 indirectly upon the middle ear, by preventing inju- 
 rious influences acting upon it from without, and espe- 
 cially inflammation extending to it from the throat. 
 
 Local treatment applied to the cavity of the tym- 
 panum itself is always indispensable, and is easily 
 accomplished, since we have so ready a means of 
 access to it through the Eustachian tube. The most 
 appropriate remedy is a very diluted solution of liquor 
 potassse, containing about six drops to one ounce of 
 water, of which about three or four drops should be 
 warmed and thrown into the tympanic cavity. By 
 means of a fine, long-tubed, injecting syringe (Kg. 9), 
 we take up a little of this lotion, and allow a few ' 
 drops to enter catheter No. i -(whose funnel has 
 previously been stopped by a cork), by the capil- 
 
90 AURAL SURGERY. 
 
 lary-like termination of which they are retained, so that they do not 
 flow out when the catheter is introduced into the Eustacliian tube 
 through the nostril. When this has been accomphshed with a steady 
 hand, we remove the cork and blow quickly into the catheter, by 
 which the fluid contained within it will be propelled tlirough 
 the Eustachian tube into the tympanic cavity, as is clearly shown by 
 the air apparently passing through the diagnostic tube. As a general 
 rule, the propulsion of the solution into the tympanic cavity at first 
 increases the sensation of fulness in the ear (very seldom diminishing 
 it) . After some minutes or hours it returns again to its original 
 condition. It is, therefore, necessary to be particular in not blowing 
 in more than a very few drops at a time. In favorable cases the 
 sense of fulness and heaviness in the ear are alleviated in the course 
 of the same or of the next day, with simultaneous and corresponding 
 improvement in the deafness. The solution is again to be blown in 
 if either the improvement which was at first perceptible make no 
 further progress or if scarcely any alleviation of the symptoms be 
 experienced. The solution should never be reapplied until any 
 increase in the fulness of the ear it may have caused has passed off, 
 or, in other words, until the patient has again returned to his 
 usual state. By careful attention to these precautionary measures 
 I have seen in all the cases that have hitherto come under my care, 
 though the application of the remedies has been extended over a very 
 variable period of time, the fulness and noise in the ears, the hardness 
 of hearing, over-acute hearing, or other disturbance of the faculty as 
 regards the perception of musical sounds, more or less completely 
 disappear : at the same time the sound of the current of air blown 
 through No. i catheter, and passing through the Eustachian tube, 
 gradually lost its abnormal dryness and resonant hardness, and 
 became soft, which indicated that the healthy secretion in the tym- 
 panic cavity had returned. The cure was then considered to be 
 completed. Throughout the whole course of the treatment we must 
 take care not to blow with too much force through catheter 3 or 4, 
 lest the powerful stream of air should increase the inflammation of 
 the lining membrane of the tympanic cavity, and with it the weight 
 and fulness in the ear. 
 
 Catarrhal inflammation of the Middle Ear, with free exudation. 
 
 This affection generally commences with sudden and well-marked 
 hardness of hearing, occasionally accompanied with transient but 
 
CATARRHAL INFLAMMATION 01? THE MIDDLE EAR. 91 
 
 violent tearing pain. These symptoms may be limited to one 
 ear, or, as is more frequently the case, occur in both, either coin- 
 cidently or in quick succession. Noise in the ears, varying in cha- 
 racter and duration, is very often present, as may be seen by a refer- 
 ence to the table at p. 17. More or less considerable improvement 
 is often experienced by the patient, even when the disease is wholly 
 neglected, in dry, warm weather, or after violent physical exertion, 
 producing profuse perspiration ; after spontaneous or artificially 
 excited vomiting ; after violently blowing the nose whilst the mouth 
 is closed, or any other similar cause ; but such improvement is seldom 
 of long duration, and is, perhaps, never more than partial. 
 
 The general health of the patient, with the exception of some 
 catarrhal disorder, is usually good. Upon making an examination 
 of the mucous membrane of the velum palati and throat, it often, 
 though by no means constantly, appears red, swollen, and covered 
 with mucus ; the amygdalae are tumid, and we not unfrequently 
 observe a well-marked catarrhal inflammatory condition of all these 
 parts, which may remain for weeks or months without any hardness 
 of hearing. We cannot admit that there is any exact genetical 
 connection between these diseases of the throat and the affection of 
 the ear, though we may, perhaps, concede that the catarrhal affection 
 of the throat may protract that of the middle ear, and increase tlie 
 difficulty of cure. The meatus contains, with few exceptions, a 
 proper quantity of cerumen, of a healthy soft consistence, and 
 natural colour. In adults the membrana tympani is generally 
 shining and translucent ; in children it is, as it ought to be, semi- 
 opaque, less shining, with the handle of the malleus showing through 
 it, and quite free from any. interstitial exudation. 
 
 In catheterizing the tube, air can generally only be blown in 
 through catheters No. 3 and 4, and some force is requisite. It then 
 passes with a moist, rattling sound, and the patient immediately 
 experiences very remarkable improvement in his hearing, both for 
 vocal and other sounds. The noise ia the ears, also, which was pre- 
 viously present, often disappears entirely in the course of an hour, 
 and is far less distressing if it recurs. The entrance of a strong 
 stream of air into the cavity of the tympanum generally produces, 
 especially in young and excitable persons, a strong rigor, and the 
 patient moves the hand to the head involuntarily, without experi- 
 encing any pain or being able to assign any reason for it. If the 
 catheter No. i or 2 be used, the thin and weak stream of air which 
 
92 AURAL SURGERY. 
 
 passes through it may not be able to press its way into the cavity 
 of the tympanum ; we can then only hear the air, which neither 
 passes through the Eustachian tube nor reaches the membrana 
 tympani, rusliing at a distance, and we accordingly find there is no 
 improvement in the deafness. 
 
 Occasionally, quite recent cases excepted, the improvement which 
 occurs after the insuiflation of air proves to be only temporary, but 
 it may again be effected by repeating the operation, and always with 
 gradually diminishing difficulty in blowing in air in greater quantity 
 and for a longer time, until at last, in the course of some weeks (rarely 
 months), the sound of the air blown in loses its moist mucous 
 character, and becomes clear and soft, whilst the passage to the tym- 
 panic cavity itself becomes free, even for the thin stream of air blown 
 in through catheters No. i and a, so that we can hear it, continuous, 
 full, and clear, passing through the diagnostic tube into our own ear. 
 At the same time hardness of hearing and noise ia the ears are com- 
 pletely removed, and the patient again feels himself perfectly well. 
 
 Sometimes this regular course of events is interrupted by some 
 disturbing conditions, which may very easily embarrass the unprac- 
 tised observer. Thus, sometimes, in particular, the already com- 
 menced improvement suddenly ceases, without any obvious cause, or 
 even a retrocession may occur almost to the original condition of 
 deafness, whilst upon strongly blowing in air it is directly perceptible 
 that the sound of the stream is sharp, clear, and dry. The con- 
 dition of suppressed exudation has now supervened, a condition of 
 disease already described, and the treatment of which will be con- 
 sidered hereafter. 
 
 Diagnosis. — The impossibility of driving air into the tympanic 
 cavity through catheters No. i and a proves the presence of a mecha- 
 nical obstruction in the middle ear. On the other hand, our ability 
 to overcome this obstacle by blowing through catheters No. 3 and 4, 
 and the moist mucous sound that is then produced, indicate the pre- 
 sence of a more or less abundant sero-mucous or purely mucous and 
 tenacious secretion, in the cavity of the tympanum (free exudation), 
 and also shows us that this obstacle is capable of easy removal; 
 and, further, the greater or less difficulty felt in propelling the blast 
 of air enables us to judge with great accuracy of the nature and con- 
 sistence of the exudation. If, now, after repeatedly and strongly 
 blowing in air at one and the same sitting, the sound, which was at 
 first moist and mucous, becomes at last clear, it follows that the 
 
CATARRHAL INFLAMMATION OF THE MIDDLE EAR. 93 
 
 current of air^ upon again streaming out, must have carried with it 
 the free exudation contained in the middle ear ; and the improve- 
 ment of the deafness which immediately follows the passage of the 
 air, and, finally, the removal of the moist mucous sound of the 
 current, prove that the free exudation has been the cause of the 
 deafness and of the noise in the ears, by interrupting the waves of 
 sound passing from the membrana tympani through the air of the 
 tympanic cavity to the membrane of the fenestra rotunda (p. 7 
 et sec[.). But when the tone of the in-blown air is dull, and 
 the current does not pass through the tube nor arrive at the mem- 
 brana tympani, there is never any improvement of the hearing, and 
 a proof is obtained that the free exudation only occasions deafness by 
 its accumulation in the tympanic cavity, and very probably is wholly 
 absent, or exists in but very small quantity, in the Eustachian tube. 
 
 If, after repeated insufflation at one or several sittings, the stream 
 of air driven through No. i catheter arrives at the tympanic cavity, 
 it proves that besides the free exudation, no interstitial exudation, is 
 present. 
 
 There is a strong predisposition to the formation of free exudation 
 in the middle ear amongst stout, scrofulous people. At the same 
 time it is by no means uncommon in strong and healthy adults. 
 Amongst the latter, however, cold must act more intensely, in order 
 that the same number of cases may occur as in strongly predisposed 
 individuals. The course of this disease is extremely tedious, and 
 there is little prospect of spontaneous cure. The partial improve- 
 ment which sometimes occurs independently of treatment probably 
 depends on the flowing out of the free exudation contained in the 
 tympanic cavity from the above-mentioned favorable circumstances. 
 
 In the majority of cases no spontaneous improvement of the 
 deafness occurs ; but after the earlier stages of the disease have 
 lasted for a variable period, this symptom stiU remains well marked 
 after many years, and even to extreme old age. In these cases the 
 deafness is usually very complete. The free exudation undergoes 
 no essential change, even when it is long retained in the middle ear ; 
 it is, at all events, a grave error to attribute to it an operation as of 
 a mechanical body pressing upon the membrana tympani, and pro- 
 ducing absorption or inflammation, or, stiU less, perforation. The 
 advocates of this view (Toynbee, Erhard, &c.), in consequence of 
 their predilection for Valsalva's experiment, have scarcely ever really 
 ascertained the presence of free exudation in the tympanic cavity 
 
94 AURAL SURGERY. 
 
 antecedently to such perforations, whilst I have diagnosed many 
 hundreds of such cases, ia which the free exudation was subsequently 
 removed by treatment, and had been of long standing, but in which 
 there was no concomitant affection of the membrana tympani. Rau 
 is the only surgeon who has made any exact observations on in- 
 flammatory perforation of the membrana tympani taking place from 
 the tympanic cavity, that is, from within outwards, without having 
 ascribed the inflammation to pressure of the free exudation ac- 
 cumulated in the tympanic cavity. Erhard's assertion that free 
 exudation does not occur in that cavity, but only in the Eustachian 
 tube, and that it is constantly accompanied by the dropping out of 
 tough mucus on the wall of the pharynx, is sufiiciently disproved, 
 not only by the great rarity of this last phenomenon, but especially 
 by the exact physical diagnosis already detailed, by which it is shown 
 that the tubes in all probability contain httle or none of this 
 exudation. 
 
 The prognosis, on the whole, is very favorable, for free exudation 
 can always be removed with certainty, and in recent cases and in 
 strong constitutions the catarrhal inflammation of the middle ear 
 either terminates in free exudation, and is therefore easily curable, or, 
 where this does not occur, the disease can still be permanently and 
 completely cured by perseverance in the use of appropriate local and 
 general remedies. Eecovery wiU be essentially aided by mild, warm, 
 and dry weather, and by residence in an agreeable climate ; when the 
 opposite atmospheric conditions prevail, the cure will be rendered 
 proportionately more difficult. Special regard must be paid in the 
 treatment to the condition of the mucous membranes in general, and 
 to the activity of the digestive organs. If the patient have a tendency 
 to abundant secretion of mucus, digests his food imperfectly, and has 
 inactive bowels, we must exclude fat, starch, milk, and similar food, 
 from his diet. Daily free evacuations must be obtained, and where 
 there is an abundant secretion of mucus covering the throat and 
 mucous membrane of the stomach, as occurs in some rare cases, 
 we may prescribe a strong emetic at the commencement, and follow 
 it up with astringent gargles, alum and sulphate of zinc. We 
 should recommend the patient to wash the upper part of the body 
 with fresh cold water and rub himself dry with coarse towels, but he 
 should not take much physical exertion in dry, even if it be cold, 
 air, and any scrofulous predisposition is to be combated by the usual 
 weU-kno^m specific remedies. 
 
CATARRHAL INFLAMMATION Ol' THE MIDDLE EAR. 95 
 
 These general remedial means are^ however, very gradual in tlieir 
 effects, and in great measure insufficient for the cure of the disease ; 
 at aU events, they should not be allowed to interfere even for a 
 single day with the local treatment, which gives the mogt encourag- 
 ing results, and, when the patient is otherwise healthy, wiU alone be 
 sufficient to lead to perfect recovery. In order to remove the free 
 exudation, air should be blown through catheter No. 3 or 4 with 
 sufficient force, the pressure being gradually increased, to drive it 
 through the Eustachian tube into the tympanic cavity, so that it 
 may appear to pass through into our own ear. When this occurs, 
 immediate and great improvement is experienced in the various local 
 symptoms. Upon repeating it, the mucous character of the sound 
 becomes gradually less distinct, and at length entirely disappears, and 
 we have thus a limit fixed, beyond which it will not be advisable to 
 go at any one time, lest by too frequently or too strongly blowing 
 into the tympanic cavity we may excite mechanical irritation of its 
 membrane, which is now freed from exudation, or may increase the 
 catarrhal condition, which is abeady present. It is important, there- 
 fore, to remember, in the treatment of these diseases, that the force 
 and size of the blast of air (dependent upon the diameter of the 
 catheter) should merely be sufficient to allow the air to pass into the 
 tympanic cavity. A large size of both is required at the commence- 
 ment of the treatment and in cases when the mucus is particularly 
 tenacious, bu.t with the progress of cure and with the easier passage 
 of the current we may diminish, not only the pressure, but also the 
 volume of air, by using a smaller catheter, so that we must often 
 commence with a No. 4 catheter, but must always conclude the 
 treatment with a No. i. 
 
 If the strength of our lungs be not sufficient to bear the fatigue 
 of repeated acts of insuffiation without injury to ourselves, the strong 
 compression machine will prove of service which I have described in 
 my ' Diseases of the Ear,' 1849, '^^- ^^> ^^E- ^> P- A95> and will not 
 here repeat, because it is'only required for these exceptional cases. 
 
 If we now return from this digression to the termination of the 
 first sitting, and to the resulting improvement of the hearing, 
 freedom from noise in the ears, &c., it now becomes necessary to 
 ascertain the distance from each ear at which a test watch can be 
 regularly and distinctly heard. The period when the operation of 
 insufflation should be repeated depends upon the duration of the 
 improvement. If, after a few days, no further improvement occur, we 
 
96 AURAL SURGERY. 
 
 delay the next operation for two or three days, being persuaded that 
 the excessive secretory activity of the inflamed membrane of the 
 tympanic cavity will be best restored to its healthy condition by the 
 exercise of* moderation in repeating the operation. But if the 
 improvement have partially or completely passed off within the first 
 twenty-four hom's after the operation, it should be immediately 
 repeated, ia order to remove the large quantity of free exudation 
 which has reaccumulated, and to exercise a stronger mechanical 
 irritation upon the membrane lining the tympanic cavity. If, after 
 daily repetitions of the op'eration, the improvement become weU- 
 marked and more permanent, it should be repeated only after the inter- 
 mission of one or two days, in order to avoid too great irritation of 
 the tympanic membrane. By these simple proceedings, perfect re- 
 covery may in many instances be effected. If, on the other hand, 
 continual relapses take place, and the increase obtained in the volume 
 of the air entering at each operation be not sufficient, whilst the 
 mucous character of the sound still remains very distinctly perceptible, 
 we must assume that the free exudation is very tenacious. In such 
 cases we take up a few drops of a warm solution of gum arabic in 
 the beak of a No. i catheter, the funnel of which is stopped by a 
 cork (as has just been described in the treatment of suppressed 
 exudation), introduce the catheter into thetube^ remove the cork, and 
 quickly blow the drops into the tympanic cavity. The propulsion of 
 the current of air is much less troublesome through catheters No. 3 
 and 4, and an excellent and permanent improvement generally 
 follows their employment. The operation must then be repeated 
 daily tiU the patient is well. 
 
 The same procedure is advisable if the improvement which may 
 have already commenced be checked, or if the patient be actually 
 thrown back by the supervention of nasal or bronchial catarrh. 
 Lastly, if the mucous sound be completely removed, with great 
 improvement in the hearing, but the moist tone of the entering 
 current be replaced by a hard, dry tone, gradually producing great 
 increase of the deafness, whilst the general health of the patient 
 continues good, we may consider that we have to deal with over- 
 excitement of the inflamed membrane of the tympanic cavity and 
 suppressed exudation. That this is the result of too strongly and too 
 frequently blowing in air is shown by its general occurrence after 
 forcing in cold air by the compression machine. The treatment 
 already described (p. 89) is then indicated, until the free exuda- 
 
CATARRHAL INFLAMMATION OF THE MIDDLE EAR. 97 
 
 tion is again poured forth, always taking special care not to 
 repeat the operation too frequently. By thus modifying our 
 treatment according to the nature of the case, the free exudation 
 usually, after a few repetitions of the operation," disappears, at 
 least in recent cases and in strong individuals ; but under un- 
 favorable circumstances three or fonr weeks may be required, and 
 sometimes as much as several months, before the air blown in 
 tlirough catheters No. i and a reaches the tympanic cavity easily 
 and in full stream, and with the production of a clear, soft tone. The 
 hardness of hearing is then permanently removed, whilst the noise 
 in the ears has usually already vanished at an early period of the treat- 
 ment. When we observe in bloated, unhealthy patients, or even in 
 those who are otherwise healthy, abundant free exudation in the 
 middle ear, which is constantly recurring, the membrane of the 
 tympanic cavity requires the application of certain remedies in order 
 to relieve this chronic catarrhal and inflammatory state. To effect 
 this, air should be driven in daily through a No. 3 catheter, to clear 
 out the free exudation ; a few drops of a weak and slightly warmed 
 solution of sulphate of zinc (gr. j ad iv, ad gj aq.) should be blown 
 into the tympanic cavity through No. 7 catheter, untO. the secretion 
 returns to a healthy state, when there will be an immediate and 
 permanent improvement in the hearing. In all these cases there is 
 a strong tendency to relapse, and it is therefore advisable, even when 
 the patient appears to be weU, and especially in those cases where the 
 excessive secretion has only just been subdued, to keep such 
 convalescents under our eye for some time — where possible, for some 
 months — so that if any shght recurrence of the deafness should occur, 
 indicating fresh accumulations of free exudation, we may immediately 
 remove it by blowing in a strong stream of air through a No. 3 
 catheter. In very obstinate cases we must once more employ the 
 sulphate of zinc injection. 
 
 Catarrhal inflammation, of the Middle Ear, with free and interstitial 
 
 This form of disease commences with hardness of hearing, which 
 vefy gradually increases, until the patient ultimately becomes almost 
 completely deaf. There is no local pain ; both ears are usually at- 
 tacked simultaneously, and the" disease proceeds to the same extent 
 in each. Noise in the ear is sometimes present, sometimes absent. 
 The patients often complain of great fulness in the head and in the 
 
98 AURAL SURGERY. 
 
 eai", both when they are quite healthy, as is often the case, or are 
 afflicted with other local or general disorders. 
 
 Ocular inspection of the external ear offers nothing characteristic. 
 The ceruminous secretion is sometimes perfectly normal, sometunes 
 deficient both in quantity and quality, friable, dry, or entirely absent. 
 The membrana tympani is sometimes transparent and shining, but 
 more frequently dull, white, and opaque. The manubrium of the 
 malleus is scarcely or not at all cognizable. The examination of the 
 middle ear yields much more satisfactory results. If we blow through 
 No. I or a catheter into the Eustachian tube we can only hear a 
 distant, duU sound in the ear of the patient, and even when the ah 
 is blown through No. 3 or 4 it generally passes with difficulty, and, 
 perhaps, only by making the patient swallow at the same moment. 
 It may be then heard to enter the tympanic cavity (and apparently 
 also the ear of the observer), sometimes with full, sometimes with a 
 thin and prolonged, stream, and moderately moist sound. The patient 
 immediately experiences a very marked improvement in the power 
 of hearing vocal sounds, though the hearing is not always con-e- 
 spondingly increased for inarticulate sounds, like the ticking of a 
 watch. The duration of this improvement varies very considerably, 
 but can always be renewed by repeating the operation of insufflation. 
 The more moist the sound has been at the commencement of insuf- 
 flation, and the more freely the air has entered the tympanic cavity 
 at first, the more complete is the subsequent improvement, though, 
 perhaps, the perfectly healthy condition is never regained. 
 
 In the majority of cases the difficulty which was first experienced 
 in blowing the air through the Eustachian tube rapidly diminishes 
 up to a certain point, and up to that point also the patients 
 acknowledge that they experience a considerable improvement in the 
 power of hearing. They are usually very well satisfied with this 
 amount of relief, and declare that they are perfectly well. Noise in 
 the ears, when present, is usually even still more completely reUeved 
 than the deafness. 
 
 If we inquire into the real cause of the difficulty in blowing air 
 through the tube, we perceive immediately that it arises from a con- 
 striction in the tube (produced by interstitial deposit). On the 
 introduction of catgut or elastic bougies not exceeding -J- mm. 
 in diameter into the Eustachian tube, we strike either in the first 
 half, or certainly at the end of the cartilaginous portion, against an 
 obstruction, which can only be surmounted by gentle pressure. This 
 
CATARRHAL INFLAMMATION OF THE MIDDLE EAR. 99 
 
 occasions more or less acute stabbing pairi to the patient^ but upon 
 passing it the bougie can be pressed onward without hindrance into 
 the tympanic cavitjj unless, indeed, it be stopped by another con- 
 striction. These obstructions are either broad and fiat or circu- 
 lar and narrow, the latter being usually -very tight, as we may 
 assure ourselves by the effort required to push the bougie through 
 them. 
 
 The velum palati and walls of the pharynx are usually dark red 
 and swollen, with little or no mucus upon them. The amygdalae 
 are occasionally much enlarged, but never at any time form an 
 obstacle to the entrance of the catheter into the tube. 
 
 Biagnosis. — The difficulty of propelling air into the cavity of the 
 tympanum, even through catheters No. 3 or 4, indicates at once that 
 there is some mechanical obstacle in the tube, which, from the difficulty 
 (never, however, amounting to impossibility,) experienced in intro- 
 ducing sufficiently firm and very fine catguts or bougies, can readily 
 be recognised as an organic constriction ; that is to say, a constriction 
 formed by interstitial exudation in the tube. We may judge with 
 sufficient exactness of its position, that is to say of its distance from 
 the guttural and tympanic terminations of the tube by marking on 
 the catgut or bougie the length of the catheter, and then from this 
 point marking off towards the handle, one whole and two half inches. 
 In adults the junction of the cartilaginous and osseous portions of 
 the tube is about one inch from the pharyngeal opening ; about half 
 an inch further, the osseous portion opens into the tympanic cavity, 
 and if the bougie be pushed onward another half inch, it will tra- 
 verse the diameter of the tympanic cavity ; unless on its entrance 
 into this, its immediate withdrawal be not rendered necessary, (even 
 when its diameter is only half a line) from the intolerable pain pro- 
 duced by touching the membrana tympani, or the still more distant 
 malleus and incus. 
 
 It is by this interstitial exudation in the tube that the form of 
 disease we are now considering is mainly distinguished from catarrhal 
 inflammation of the middle ear accompanied by free exudation alone, 
 of which we have already treated. The immediate improvement which 
 takes place in the hearing, noise in the ears, &c., as soon as a current 
 of air is driven through catheters No. 3 or 4, distinguishes this 
 form of disease from the succeeding one, namely, catarrhal inflam- 
 mation of the middle ear with interstitial exudation alone ; whilst 
 this and the first-mentioned point of diagnosis render it impossible 
 
100 AURAL SURGERY. 
 
 to confound it with catarrhal inflammation accompanied jby suppressed 
 exudation. It is very difiicult to determine the precise share which 
 the free and interstitial exudation individually take in the production 
 of the deafness. The more moist the sound of the air passing through 
 the tube is, by so much the more important becomes the free exuda- 
 tioUj and by so much the greater will be the improvement of hearing 
 which follows its removal by insufflation ; whilst in many cases and 
 especially in young people, a perfectly normal sound of the current 
 of air becomes perceptible, which is followed by extraordinary im- 
 provement in the hearing, but which after four-and-twenty hours, 
 or even sooner, prematurely passes off. It is difficult to explain this 
 circumstance otherwise than by supposing that the chief cause of 
 the deafness is extensive interstitial exudation, interrupting the 
 communication between the external air and that contained within 
 the cavity of the tympanum, and that this is transitorily re- 
 established by the operation of blowing in air. Perhaps the same 
 explanation wiU apply to those cases where the patient is able to 
 recover his hearing for a short period by driving air into the cavity 
 of the tympanum with a forcible expiration whilst his mouth and 
 nose are kept closed. It has been customary to attribute this 
 transient improvement to increased tension of the membrana tympani, 
 (which was supposed to be relaxed,) occasioned by the pressure of 
 the air entering the cavity. 
 
 The chief cause of the disease is doubtless exposure to cold, though 
 from the dilatory manner in which the disease progresses, it can seldom 
 be accurately determined. Many patients are very healthy and strong, 
 and it generally affects the male sex ; occurring at all periods of hfe 
 even up to sixty or seventy years. This form of disease constitutes 
 lo per cent, of all aural affections (io8 : looo. See Table, p. 17). 
 
 The progress of the case is always tedious, with a gradual but 
 certain tendency to become worse, which is especially favoured by 
 general catarrhal indisposition, and by typhous and gastric fevers. 
 We can never calculate upon spontaneous recovery, and it is easy to 
 err in this respect, for there are many patients in whom both ears are 
 apparently equally deaf, though in point of fact the hearing of one 
 only is deteriorated, and we might thus be easily led to consider that 
 the ear which has really remained unaffected has unproved. 
 
 The prognosis is very favorable as far as relates to the free 
 exudation and the loss of the power of hearing which is either wholly 
 or partially dependent upon it, but very doubtful as regards the 
 
CATAEEHAL INFLAMMATION OF THE MIDDLE EAE. 101 
 
 removal of the interstitial exudation, even if, as in the most favorable 
 cases, it is limited to the Eustachian tube, and either does not affect 
 at all, or but very slightly, the cavity of the tympanum. In pro- 
 portion to the difficulty and pain experienced in introducing evMi the 
 finest bougies through the tube ; in proportion also to the duration of 
 the complaint, and to the age and general health of the patient, will 
 be the difficulty of procuring absorption of the interstitial exudation, 
 and of restoring the canal to its normal dimensions. Portunately, 
 however, the patients feel in general such marked relief in regard to 
 their hearing, the noise in the ears, and duhiess and weight in the 
 head, from the removal of the free exudation, that they willingly 
 submit to further treatment for the interstitial exudation. 
 
 Care should always be taken to ascertain whether any constitutional 
 affection is present, and, if so, the ordinary general treatment should 
 be applied, though it must not be expected, even when the most 
 favorable results are obtained, that any weU-marked improve- 
 ment will be observed in the free, and still less in the interstitial 
 exudation in the middle ear. The most perfect cures of consti- 
 tutional affections accomplished by the Carlsbad, Toplitz, Kreuz- 
 nach, and other similar baths, effect as little improvement in the local 
 disease, that is to say, in the aural affection, as Zittmann^'s decoction, 
 or the use of iodine or mercury, pushed to its fullest extent. In 
 all such cases local treatment applied to the middle ear is still ab- 
 solutely required, and the only advantage we obtain is that our local 
 remedies are no longer injuriously influenced by the presence of a 
 constitutional disorder. When the patient however is healthy, and 
 altogether free both from imaginary and real constitutional disease, 
 we should not waste time, but proceed at once to the local treatment 
 of the aural affection. If, however, the patient should be attacked 
 by a violent catarrh, all treatment must be immediately discontinued, 
 and it can only be advantageously resumed when the catarrhal 
 symptoms have been subdued.' The directions respecting the diet 
 of the patient— as that it should be free from fat, and of a strongly 
 nourishing character — having been abeady fully detailed in reference 
 to the previous form of disease, and being equally applicable here, 
 I need not repeat them. 
 
 In weU-marked chronic catarrh of the mucous membrane of the 
 gums and of the throat, the most serviceable remedies are astringent 
 gargles, and the painting of these parts with solutions of nitrate 
 of silver, alum, sulphate of zinc, and tincture of iodine. When 
 
103 AURAL SURGERY. 
 
 tlie disease is very obstinate^ these means should on no account be 
 neglected, and we must then endeavour to accomplish the removal 
 of the free exudation. Air must be driven with gradually in- 
 creasing pressure, with catheters No. 3 or 4, tlii-ough the tube 
 into the tympanic cavity, the patient swallowing at the moment, if any 
 difficulty is experienced, for upon the passage of the air depends 
 the removal of the free exudation and all subsequent improvement 
 of the functional disorders of the ear. If the air can be made to 
 pass by these means in the first instance, we must rest content, 
 and not attempt by a too frequent repetition of the operation to 
 excite the diseased and irritable membrana tympani. If, however, this 
 has occurred, it is recognised by sensations of weight and fulness 
 in the ears, and also by the circumstance that the improvement 
 of the hearing, which was at first perceptible, does not continue to 
 progress. But if by cautious treatment no such irritation has been 
 produced, whilst the improvement of the hearing and the diminu- 
 tion in the noise of the ears are persistent, we may venture on the 
 operation every day, stiU taking every precaution both as regards 
 the increase in the size of the catheter, and the force of the blast, 
 so that we may exercise no unnecessarily strong mechanical irri- 
 tation upon the membrane lining the tympanic cavity. We may 
 venture to hope that we have obtained a complete mastery over the 
 free exudation, when no further improvement takes place in the 
 hardness of hearing, and noise in the ears, whilst at the same time 
 the moist sound of the inblown air is entirely lost, especially when 
 No. 3 catheter is used. It is then time to commence the treat- 
 ment of the interstitial exudation in the tube, in other words to 
 efi^ect its absorption ; when this is accomplished, even the thin and 
 weak stream of air blown in through catheter No. i, will enter 
 the tympanic cavity with ease and freedom. 
 
 We can only expect to effect the absorption of the interstitial 
 exudation by the local appHcation of gently stimulating remedies, 
 and then only in young persons who are in full health, and whose 
 nutritive and interstitial changes are rapid and vigorous. In such 
 cases we blow into the Eustachian tube from three to five drops of a 
 weak solution of nitrate of silver (gr. i — iij, ad 3J) through No. x 
 catheter, whose beak, as well as the small tubular mouth-piece of 
 the syringe, are constructed of platinum. The solution should 
 penetrate as far as the stricture. The patients must not make 
 any movement of swallowing, lest some of the fluid should be im- 
 
CATARRHAL INFLAMMATION OF TIIK MIDDLE EAR. 103 
 
 pelled through the stricture into the cavity of the tympanum, which 
 might produce a disagreeable sense of pressure and fulness. 
 In general this proceeding can only be repeated every third day. 
 
 Thus in the course of some weeks or months we may be able gra- 
 dually, without resorting to other means, to restore the permeabiHty 
 of the tabe for a weak and thin stream of air. Should these means, 
 however, prove inefficient, or should the duration of the disease, 
 the age, and the constitution of the patient present no prospect 
 of success from their employment, we must then endeavour, by 
 means of properly applied pressure, to effect the absorption of the 
 exudation. Tor this purpose, catgut and elastic conical (not Bon- 
 nafont's cylindrical) bougies are best adapted. Catgut is particu- 
 larly convenient in those cases where the stricture will not permit 
 the finest bougies {-^ mm. in diameter) to pass, for the finest lute- 
 strings have a diameter of only three twentieths of a millimetre, and 
 others can be obtained of gradually increasing diameter If, how- 
 ever, bougies can be passed through the stricture, they should cer- 
 tainly be preferred, on account of their conical form, and because 
 also they can be repeatedly employed without being spoilt, whilst 
 the catgut becomes so soft in the Eustachian tube, that they must 
 be thoroughly dried before they can again be used. Moreover, the 
 conically-shaped bougies exert greater and more even pressure upon 
 the surface of the stricture than the catgut, although this also 
 swells at the same time that it softens. Before introducing catgut 
 into the tube, it should be lightly chewed for about -l mm. in ex- 
 tent — a proceeding which is unnecessary in the case of the bougie, 
 on account of its uniform softness. On both instruments, the 
 exact length of the catheter must be indicated (on the bougies with 
 white oil-colour) . Another mark should be made one inch from 
 this point, and again two others at successive distances of half 
 an inch, so that we may be able to determine the distance l:o 
 which the instrument has penetrated into the Eustachian tube. 
 It is not sufficient to have only Bonnafont's bougies of i, i, aad 
 li mm. in diameter, for use. I employ those of -^\, -jL, -"j-, J-^, 
 (4- mm.) -if, -i-i, l-g-, = I mm. and li mm. in diameter, so that 
 in very tight strictures the size of the instrument may be \'ery 
 gradually increased, without occasioning pain to the patient. As 
 a general rule, it is advisable only to employ the means of dilatation 
 of such magnitude that they require a moderate amount of pressure 
 and produce but slight pain to pass through the stricture, and the 
 
104 
 
 AURAL SURGERY. 
 
 size of the instrument should only be increasedj when the smaller 
 one previously used passes with facility. 
 
 Bonnafont proposes to force a passage tlirough strictures which 
 have their seat immediately in front of the osseous portion of the 
 Eustachian tube, with strong elastic bougieSj which might tear up 
 the mucous membrane. From a theoretical point of view, this 
 may, perhaps, be readily accomplished, but it will be found prac- 
 tically, that even with every care it is impossible to succeed in its 
 execution. Bonnafont not only extols this operation highly, but 
 also the application of caustic, as of nitrate of silver in powder to 
 the stricture, which he applies by means of a small hoUow, silver, 
 " Porte caustique," 3 mm. iu length, and about i mm. in diameter, 
 attached to the end of an elastic bougie introduced through a 
 catheter j but such an operation, on account of the great tenderness 
 and narrowness of the part, must demand great care and skill. 
 
 Let us return from this digression to the treatment of inter- 
 stitial exudation in the tube. In the first place, an endeavour 
 should be made to ascertain what sized catgut or bougie can be 
 pushed along the tube (as far as the entrance into the tympanic 
 cavity) by moderate pressure, and without giving very severe pain 
 to the patient. It should remain in this position for about a 
 quarter of an hour, to which end the catheter can be fixed by my 
 forehead band. This consists of a metallic plate, about the size of 
 a dollar (easily capable of being moulded to the form of the forehead) 
 which can be attached by two lateral straps buckling at the back 
 of the head. On the middle of the plate is a ball and socket-joint, 
 in which a little circular pair of forceps moves. These can be 
 fixed by a side screw, when the arms of the forceps have embraced 
 the catheter, and this again is retained in a convenient position in 
 the nostril, by means of a small screw passing through one or both 
 arms of the forceps. The patient is thus enabled to make any 
 movement of the head, to speak, to swallow, and the like, without 
 in the least altering the position of the instrument. In order to 
 spare the patient pain, the catgut or bougie should only be passed 
 as far as the entrance into the cavity of the tympanum, con- 
 tact with the membrana tympani or ossicula being avoided, and 
 this can only be done when the distances are marked upon the 
 instrument in the manner we have described. When the catgut 
 or bougie has remained long enough in the Eustachian tube, it 
 should either be replaced with one of larger diameter or simply 
 
CATARRHAL INFLAMMATION OF THE MIDDLE EAR. 105 
 
 withdrawn, and the operation be completed. The instrument 
 should then be carefuUy dried with soft, clean, linen rag, and a few 
 drops of the above-mentioned solution of nitrate of silver blown 
 into the tube against the stricture, through a No. i catheter, which 
 may be done twice a week with advantage, whilst on the other 
 hand, the catgut or bougie may, in the majority of cases, be cau- 
 tiously introduced every day. Months may elapse, even in 
 favorable cases, before absorption of the interstitial exudation can be 
 effected to such an extent that a bougie of i mm. in diameter can 
 be readily introduced without producing severe pain, as far as the 
 cavity of the tympanum, and before a current of air will pass with 
 facility into the cavity through a No. i catheter. 
 
 But unfortunately we are not able in many cases to accomplish 
 this, partly on account of the firm organization of the interstitial exu- 
 dation, and partly from the want of time and patience on the part of 
 the patient. In such cases, in which the improvement in the hearing 
 and of the noise in the ears resulting from a strong blast of air blown 
 through the tube into the tympanic cavity, endures only a few days 
 or weeks, nothing remains to be done but perforation of the mem- 
 brana tympani, which restores the communication of the air with the 
 tympanic cavity, hitherto interrupted by the interstitial exudation of 
 the tube. The membrana tympani is not thickened in all these cases, 
 though it usually is so when chronic inflammation has been removed, 
 and some deafness remains. It is, therefore, in general readily per- 
 forated, but unfortunately this easily accomplished, and frequently 
 practised operation invariably fails, because we are unable to keep open 
 the hole in the membrane, so that we must protest, even in these cases, 
 against what would otherwise be a perfectly justifiable operation. 
 
 Catarrhal Inflammation of the Middle Ear, with exclusively/ Inter- 
 stitial Exudation. 
 
 The commencement of this disease is usually first observed on some 
 occasion when the hearing is put to some particularly severe test. It 
 is then apparent, both to the patient himself and to his friends, that 
 there is a marked defect in the power of hearing in one or both ears. 
 Usually, httle or no disquietude is felt on the discovery of this circum- 
 stance, either because one ear only is affected, or because the power of 
 hearing with the two ears is still sufficiently serviceable for ordinary 
 intercourse. The patient continues to endure, with infinite patience, 
 many inconveniences as the deafness increases, in the vain hope that. 
 
106 AURAL SURGERY. 
 
 his healtli being in other respects good, so insignificant an affection 
 will soon disappear. As years roll on, however, and the deafness still 
 increases, he is unable any longer to conceal the fact of its existence. 
 He feels, also, that noises in the ears are becoming troublesome, and 
 in many instances he observes, after some febrile ailment (catarrhal, 
 gastric, intermittent, typhus fever), that the deafness has rapidly 
 increased in severity. The occurrence of this may often be considered 
 rather fortunate than otherwise, since it leads him to subject himself 
 to appropriate treatment. On the other hand, it often happens that 
 the patients, whilst travelling over paved streets, or on the railway, 
 or during a temporary stay in mills, factories, or in the immediate 
 vicinity of a large orchestra, experience so great an improvement in 
 their hearing for vocal sounds, that they are much inclined to 
 consider their aural disease as not demanding assistance, and care- 
 lessly to allow it to acquire its fullest development, when it becomes 
 perfectly incurable. 
 
 In this way numerous cases of hardness of hearing, approximating 
 to complete deafness, occur, without the patients experiencing any 
 mental disquietude in respect to the grave nature and incurability of 
 their disease. 
 
 The secretion of cerumen remarkably diminishes, the meatus be- 
 comes dry, there is great and very troublesome itching, small, dry, 
 and dark-brown scales form, or bran-like, or even fish-scale-like 
 desquamation occurs, the scales being white and shining. In like 
 manner very often the secretion of the pituitary mucous membrane 
 diminishes, so that the patient seldom has occasion to use his hand- 
 kerchief. The appearance of the membrana tympani is generally, 
 though not indeed always, dull, opaque, white, like paper, with 
 the manubrium of the malleus showing less distinctly in proportion 
 as the concavity of the membrane is diminished by increased inter- 
 stitial exudation. 
 
 The velum palati, uvula, and walls of the pharynx are usually 
 abnormally red, and the amygdalae are occasionally considerably 
 swollen, though their surface is never covered with mucus. If we 
 direct the patient to make the experiment of Valsalva, whilst we listen 
 either with the otoscope, or with our own ear applied to that of the 
 patient, we hear, or may think we hear, a crackling sound in his ear. 
 If, not content with this, we blow air into the Eustachian tube, either 
 by means of a machine, or through a catheter of medium size, and 
 feel or hear the air press through into the tympanic cavity, we may 
 
CATARRHAL INFLAMMATION OF THE MIDDLE EAR. 107 
 
 in all these cases, no doubt, make tlie diagnosis of free passage of the 
 current, and may suppose that there is no organic disease in the 
 middle ear, or, in other words, we may diagnose the presence of 
 nervous hardness of hearing and deafness. 
 
 But if my variously sized catheters be employed for the operation 
 we obtain quite different results. The air never reaches the tympanic 
 cavity through No. i and 3 catheters, but only through No. 3, or in 
 well-marked cases through No. 4, and not even then unless the 
 patient at the same time makes a movement of swallowing. The 
 stream passes generally only by iits and starts, but even if it be 
 continuous though fine, the sound produced is dull, non-resonant, and 
 dry, and there is not only no improvement in the hearing, but if the 
 operation be performed too frequently, or the pressure employed be 
 too great, there is an actual increase in the deafness, whilst 
 noises in the ear, which may not have hitherto been perceived, are 
 induced. 
 
 Upon the introduction of catgut and other bougies, even of the 
 smallest diameter (-^ mm.) into the Eustachian tube, they are in- 
 variably found to strike against one or several consecutive con- 
 strictions, which may vary considerably in extent. These can only 
 be overcome by exerting more or less pressure, so as to force the in- 
 strument through into the tympanic cavity, a proceeding which is 
 always accompanied with most acute, stabbing pain, continuing till 
 it reaches the middle of the cavity. It follows from this, that in these 
 cases the tube is by no means free, but, on the contrary, is consider- 
 ably narrowed by interstitial exudation. In like manner the cavity 
 of the tympanum is greatly diminished in capacity, from the same 
 cause, and is not only wholly destitute of all free exudation, but is 
 not even covered by its normal sparing exudation ; as is indicated 
 by the dull, dry, non-resonant tone, produced by the current 
 of air. 
 
 Interstitial exudation of the tympanic cavity affects apparently the 
 (opaque, white, but slightly concave or even plain) membrana 
 tympani, and also in all probability the membrane of the fenestra 
 rotunda. These changes furnish a sufficient explanation of the hard- 
 ness of hearing, though the interstitial exudation in the Eustachian 
 tube appears to be an important element in its production, by inter- 
 rupting the communication between the tympanic cavity and the 
 external air. 
 
 The difficidty with which the air penetrates the tympanic cavity 
 
108 AURAL SURGERY. 
 
 when blown tlirongh a No. 3 catheter, enables us to diagnose this 
 affection very easily from catarrhal inflammation of the middle ear 
 with suppressed exudation, whilst cases of free exudation are sharply 
 defined by the moist tone of the stream of air blown in, and by the 
 immediate and remarkable improvement which then takes place in 
 the hearing and noise in the ears. 
 
 Catarrhal inflammation of the middle ear with interstitial exudation 
 of the Eustachian tube, and of the cavity of the tympanum, is the 
 most common of any of the diseases of the ear, occurring in the pro- 
 portion of 407 : 1000, and constituting, therefore, more than 40 per 
 cent. In disproof of this statement, the rarity with which it has 
 been observed on dissection by Toynbee has been adduced by Erhard, 
 but on insufficient grounds, since it appears that Toynbee chiefly 
 dissected ears that had been cut out of the dead subject, and had 
 been sent to him without the tube, so that he himself says that, 
 "judging from practical experience, there can be little doubt that 
 this appendage of the hearing apparatus is more often affected than 
 the morbid conditions, detailed in this volume, would seem to indi- 
 cate." {Fide 'Descriptive Catalogue,' p. 8.) 
 
 This explanation, however, would scarcely lead us to expect so 
 great a proportion of these cases of disease as that above mentioned, 
 especially since we are only able to recognise them during life, with 
 any degree of certainty, by physical investigation of the middle ear, 
 with the catheter and catgut bougies. We are unable to determine 
 what specially occasions or predisposes to this exclusively interstitial 
 exudation of the middle ear, which is so common, unless we are 
 contented to acknowledge the usual causes of disease in general, 
 cold, scrofula, &c. It is certain that this disease occurs at every 
 period of life, and with nearly the same frequency, and with equal 
 obstinacy both in the healthy and the unhealthy. 
 
 During a residence of several months in London, in 1861, I ob- 
 served this form of disease very frequently ; indeed, out of about aoo 
 cases occurring in the middle and higher classes of society, there were 
 about 7 a per cent, of this disease, whilst of free and interstitial exu- 
 dation there were only 9 per cent., and of free exudation alone only 
 5 per cent. The causes of the frequency of this unfavorable form 
 of disease of the middle ear in England, I attribute to the common 
 custom of washing the head and ears every morning with cold 
 water ; to the general employment of sea bathing without stopping the 
 ears with sheep's wool, to the practice of keeping open one window at 
 
CATARRHAL INFLAMMATION OF THE MIDDLE EAR. 109 
 
 least in the sitting and bed-rooms, in the latter even at night, whilst 
 a constant draught of air is kept up by the open chimney and fire- 
 place, which is greatly increased by the doors being left open, and 
 lastly to the injurious effects of the strong meat diet of the English, 
 which causes a deficient secretion of mucus {i. e. free exudation) 
 from all mucous membranes. 
 
 The progress of this affection is extremely slow. It is often pro- 
 tracted through many years, or even through hfe, the symptoms con- 
 tinually increasing in severity. There is httle tendency to improve- 
 ment, and spontaneous recovery perhaps never takes place ; but on 
 the other hand, in various constitutional afiections, especially of a 
 febrile character, sudden increase in the hardness of hearing and 
 noise in the ears occur either as accompaniments or as consequences ; 
 the latter not unfrequently gradually disappearing as recovery takes 
 place, whilst the former remains, and increases in severity. The 
 prognosis is exceedingly unfavorable, and the more so in proportion 
 to the small size of the catgut bougie required to penetrate the con- 
 striction in the Eustachian tube, and in proportion also to the acute- 
 ness of the pain experienced in passing it, to the annular form and 
 tightness of the stricture, to the dulness and want of resonance in the 
 sound of the entering stream of air, and to the deterioration in the 
 hearing, and increase of noise in the ears, consequent upon the opera- 
 tion. The concomitance of the scrofulous diathesis, with advanced 
 age and long duration of the disease, is of bad augury for the resorp- 
 tion of the interstitial exudation, especially of that thrown out in the 
 tympanic cavity. On the contrary, the occurrence of the affection in 
 the course of severe catarrhal, gastric, typhus, and other fevers, with 
 deafness either then first produced, or greatly increased if previously 
 of long standing, permits us to entertain good hope of spontaneous 
 recovery ; providing great attention be paid to the ear during con- 
 valescence from the primary disease ; after this period has passed, 
 however, we cannot expect much assistance from nature. 
 
 In the treatment, attention should be paid in the first instance 
 to any constitutional affection that may be present, whether in the 
 blood, in the nervous system, or in the functions of the abdominal 
 viscera, even if we are unable to show any genetic relations, between 
 them and the aural disease. By attention to these, we may at least 
 reasonably expect to produce considerable improvement if we do not 
 effect a perfect cure. At any rate we shaU then feel that we have 
 neutralized as far as possible the injurious effects of such general 
 
110 
 
 AURAL SURGEKY. 
 
 conditions of disease upon the organ of hearing. Perfect restoration 
 to health, the chief problem with -which we have to deal, now depends 
 upon local remedial means ; the application of which, in otherwise 
 healthy people, should now be immediately commenced. It is seldom 
 necessary in these cases to give any specific directions in regard to 
 diet. The slight catarrhal affection of the pharynx and velum palati 
 usually present, only demands the patient and persevering application 
 of astringent gargles, or lotions of zinc and nitrate of silver. 
 
 In the treatment of diseases affecting the middle ear, we should 
 take care not to blow too frequently or too strongly into the cavity 
 of the tympanum, lest we produce sensations of pressure and fulness, 
 with increased deafness and noise in the ear. We can easily 
 ascertain whether any changes are taking place in the interstitial 
 exudation by introducing bougies or catgut, or by blowing in air 
 through No. i or 3 catheter. The next difficulty to be overcome 
 is the re-establishment of the passage through the tube by the 
 absorption of the interstitial exudation. A few drops of a solution of 
 nitrate of silver (gr. iii, ad jj) may be employed for this purpose in 
 young subjects, or in cases where the disease has been of short 
 duration. It should be applied in the manner I have so frequently 
 described, when speaking of other diseases of the middle ear, by 
 means of catheter No. i, whose beak is constructed of platinum, 
 and the funnel-shaped end closed with a cork. The application of 
 the solution should be repeated every third day. The immediate 
 effect of this operation is generally so irritating that there is an in- 
 crease in the spongy swelling of the mucous membrane, and a tem- 
 porary increase in the difficulty of blowing air into the tympanic 
 cavity. After a few days have elapsed, however, this diminishes, 
 and after the application of the solution has been properly repeated, 
 slowly progressing absorption of the interstitial exudation takes 
 place, so that after some months of persevering attention, air can be 
 blown with facility into the tympanic cavity through catheters No. 
 I or 3. I have never found stronger solutions of nitrate of silver to 
 act beneficially. In many cases the excitability of the mucous mem- 
 brane of the tube is so great, that I am accustomed to diminish the 
 dose of nitrate of silver to gr. j, ad 5j aq., or to exchange it for a 
 solution of sulphate of zinc (gr. v, ad 3J aq) . In the propulsion of 
 these fluid remedies, the patient should be directed not to make the 
 movement of swallowing, lest the drops should, if the stricture be 
 only moderately tight, be driven into the tympanic cavity, producing 
 
CATARRHAL INFLAMMATION OF THE MIDDLE EAR. Ill 
 
 pressure^ fulnesSj and dulness of liearing. If we cannot restore the 
 passage of the Eustachian tube by these means, we must have re- 
 course to catgut and conical bougies, especially in very old and well- 
 marked cases, with firmly organized interstitial exudation ; more par- 
 ticularly in old people. In such cases, these instruments must be 
 employed from the commencement. 
 
 It may be stated as a fact of general application and of considerable 
 importance, that no violent stimulation applied to the strictures, 
 either by nitrate of silver or by mechanical pressure, will produce 
 re-absorption of the interstitial exudation, but will, on the contrary, 
 rather tend to increase it ; and this in proportion to the pain produced, 
 and to the pressure exerted by the catgut or boagie. Such an instru- 
 ment should therefore be employed, as requires the application of but a 
 moderate degree of force to pass it through the stricture, and does not 
 give much pain to the patient. It is often necessary to begin with 
 an instrument of ^ mm. in diameter. This size can only be ob- 
 tained in catgut ; elastic bougies never being made so small, because 
 even when only -^ mm. in diameter, they are far too pliable to 
 permit sufficient force to be used to force them through close 
 strictures. In these cases, therefore, the treatment must in general 
 be commenced with catgut, and the bougies may be employed at a 
 subsequent period. Bonnafont recommends bougies of at least 
 i mm. (44) in diameter, which he forces through with considerable 
 pressure, and disregards the "dechirure du retrecissement" thus 
 produced. He smears the bougie with a caustic salve, and even arms 
 its apex, as we have abeady mentioned, with a " porte caustique," 
 of nitrate of silver. These measures, however, have not in my hands 
 been productive of any good results. Bonnafont's " filiform bougies" 
 are moreover cylindrical, and are therefore not so well adapted as my 
 conical ones for the forcible dilatation of the strictures. Yet I have 
 never found much benefit result from using great force ; whilst the 
 application of irritating salves of red precipitate, and of iodine, or of 
 solutions of nitrate of silver, iodine, &c., even when very weak, have 
 always proved positively injurious, though I have frequently employed 
 them with the aid of catgut and elastic bougies. Bonnafont assures 
 us that by means of his " bougies filiformes'' he is able " de triompher 
 de tous les obstacles qu'on pent rencontrer dans le Trompe," a 
 statement we would willingly admit if it were not in such direct 
 antagonism to the results of our experience. It is impossible to 
 regard strictures of the Eustachian tube in the same light, as regards 
 
113 AURAL SURGERY. 
 
 treatment, with strictures of the urethra, for the latter is everywhere 
 surrounded by soft parts ; whilst the former in its narrowest part 
 consists of an iaelastic bony canal, whose point of union ■ndth the 
 cartilaginous portion is usually the chief seat of the interstitial 
 exudation. 
 
 The dUating instrument therefore will press the thickened mucous 
 membrane of the Eustachian tube against the unyielding bony walls 
 at this point, producing a greater or less amount of irritation, 
 increased interstitial exudation, and very decided increase in the 
 diiRculty of passing any instrument. We here, therefore, see the 
 great advantage of using instruments which gradually increase in 
 size, and the necessity of patience in their employment; and we 
 must learn, from their effects in each individual case, whether they 
 should be introduced daily or more rarely, and whether they shordd 
 be allowed to remain a few minutes only, or an hour. As a matter 
 of convenience, I am accustomed to apply my frontal band (see above, 
 p. 104) round the head, and after the introduction of No. 3 catheter 
 (or on using bougies of i mm., in diameter, 'No. 4 catheter) into 
 the tube to fix it firmly between the arms of the frontal band in the 
 nasal cavity. The bougie, its point lubricated with a little oil, may 
 then be introduced as far as the entrance into the tympanic cavity, 
 but not beyond that point, lest the membrana tympani may be un- 
 necessarily irritated. We may thus spare the patient from suffering 
 acute pain, and the operation is easily accomplished, because the 
 length of the catheter and of the Eustachian tube are indicated upon 
 the catgut or bougie, and it is only necessary to adapt with care the 
 size of the bougie to that of the constriction which it has to pass. 
 After a short time, the bougie must first be withdrawn, and 
 then the catheter ; unless we are disposed to apply to the constriction 
 a few drops of a weak solution of nitrate of sUver or sulphate of 
 zinc, or of hydrochlorate of ammonia, through ISTo. i catheter. If 
 by the employment of these troublesome remedial means we are suc- 
 cessful after the expiration of some months in re-estabhshing the 
 normal diameter of the tube, the insufflation of a few drops of one 
 of the above-mentioned very dilute solutions into the tympanic 
 cavity, constitutes the best means for the removal of the still 
 remaining interstitial exudation ; coincidently with the gradual 
 absorption of this, the hearing improves, the noise in the ears 
 diminishes, and in favorable cases may even altogether disappear, 
 and the patient may be dismissed, cured. 
 
NOISE IN THE EARS. 113 
 
 Noise in the Ears without Hardness of Hearing. 
 
 This disease almost always affects both ears equally^ and either 
 suddenly or gradually rises to a great degree of intensity. It may 
 last for months, or even for life. It rarely affects one ear only. 
 The sounds vary much in character. The faculty of hearing 
 for either articulate or inarticulate sounds, does not seem to be 
 impaired. The meatus and membrana tympani are normal. The 
 Eustachian tube and tympanic cavity are pervious to the weak 
 stream of air which can be blown in through a No. i catheter, 
 which produces a clear, soft tone. If the air be driven in with great 
 force through a No. 3 catheter (producing direct irritation of the 
 chorda tympani), an increase in the noise is an immediate result. 
 The seat of the noises perceived can only be in the chorda tympani, 
 since the healthy condition of the. external and middle ear can 
 readily be shown by a physical examination, whilst the perfect 
 power of hearing possessed by the patient indicates clearly enough 
 the absence of any disease of the auditory nerve. Strong insufflation 
 against the membrana tympani and the chorda causes an increase of 
 the noise, and this can only be explained as a consequence of 
 their abnormal irritability, though we may perhaps suspect that it has 
 its origin in some organic change. 
 
 The diagnosis of this disease depends upon the results obtained 
 by instrumental investigation in respect to the state of the external 
 and middle ear, and upon the existence of a healthy faculty of 
 hearing in the affected ear or ears. It is a rare affection, occurring 
 only after violent cold applied to the head, or to the ear itself, such 
 as cold winds, water, &c. 
 
 The prognosis is not unfavorable, since the passage to the tym- 
 panic cavity and to the chorda tympani is quite free. Local treat- 
 ment will alone effect a cure, and a few drops of a solution of 
 nitrate of strychnia (gr. i, in 5] of water) will be found of great 
 value, when injected iuto the cavity of the tympanum through a No. 1 
 catheter. This may either be repeated daily, or once or twice a 
 week, according to the activity of absorption possessed by the 
 membrane of the tympanic cavity. 
 
 Constitutional remedies, and counter-irritants, whether applied 
 in the immediate vicinity of the ear, or elsewhere, are perfectly 
 valueless. 
 
114 
 
 AURAL SUllGERY. 
 
 Nervous Pain in the Ear [Otalgia). 
 
 Coincidently with acute pain in a molar tooth of either the upper 
 or lower jaw, there occurs very violent and indeed almost intolerable 
 pain in the ear of that side. The pain is deep seated and extends 
 to the vertex, throat, neck, and even to the upper arm. It is 
 generally continuous, but sometimes presents an intermittent cha- 
 racter, unaccompanied by fever, and without serious disturbance of 
 the general health beyond what is produced by the sleep being 
 much broken. I have never observed noise in the ears or hardness 
 of hearing to accompany it, but have always found the meatus, 
 membrana tympani, and the middle ear, upon careful instrumental 
 investigation, perfectly sound, and entirely free from aU inflammatory 
 symptoms. 
 
 In some bad cases the pain continues for weeks and months, long 
 after the original pain in the tooth has been forgotten. In such 
 instances little effect seems to' be produced on its character and 
 progress, when the patient is attacked by other febrile affections, as 
 pneumonia, gastric fever, &c. The whole succession of the symp- 
 toms, together with the dentalgia from carious teeth on that side, 
 and the absence of aU inflammatory appearances in the affected ear, 
 show clearly enough the secondarily nervous character of this pain 
 in the ear. Its seat is doubtless in the ramifications of the fifth 
 pair of nerves in the tympanic cavity, which painfully sympathises 
 with the irritation of a few fibres of the alveolar branches of the same 
 nerve distributed to a carious molar. 
 
 The curative treatment of this oftentimes intolerably painful 
 affection depends entirely upon the removal, at as early a period as 
 possible, of the originally aching or still painful molar tooth : im- 
 mediately after the operation the pain in the ear vanishes completely 
 and for ever. 
 
 The description which we have now given of the diseases of the 
 middle ear does not, indeed, include those of the cells of the 
 mastoid process, but these are never affected independently, nor 
 are they recognisable or accessible to treatment, except when co- 
 incident with chronic inflammation of the perforated membrana tym- 
 pani, or of the membrane or periosteum of the tympanic cavity. In 
 the sections devoted to these affections we have already discussed the 
 complications of the mastoid cells, and to these, therefore, it will be 
 quite sufficient to refer. 
 
ACUTE INELAMMATION OF THE LABYRINTH. 115 
 
 CHAPTEE III.— DISEASES OF THE INTERNAL EAR. 
 
 Stkictly speaking, the consideration of the diseases of the internal 
 eaa- should be limited to those of the osseous and membranous laby- 
 rinth ; but these parts are in such close anatomical and physiological 
 relation with the central extremities of the auditory nerves, that we 
 may fairly include under this heading the various diseased conditions 
 of those nerves ; and we shall also here describe acute inflammation 
 of the facial nerve, so far as it is contained within the petrous 
 portion of the temporal bone, and affects sympathetically the auditory 
 nerve; deaf-mutism, which must generally though by no means 
 exclusively be attributed either to congenital or acquired disease of 
 the internal ear, may also properly be considered in this chapter. 
 
 The deeply seated and concealed position of the internal ear, 
 whilst constituting an effectual protection against external injury 
 of aU kinds, adds materially to the difficulty, and in fact renders it 
 perfectly impossible to form a diagnosis of its diseases, from 
 symptoms which are perceptible to the eye or the touch of the 
 surgeon. The only exception that can be made is in the case of 
 destructive inflammatory disease, such as caries of the temporal 
 bone, resulting from chronic inflammation with perforation of the 
 membrana tympani. 
 
 "With the difficulty which is experienced in making an accurate 
 diagnosis in these forms of diseases, there is, of course, a concurrent 
 difiiculty in determining the nature of the remedies which shall be 
 employed. "We can say, therefore, but little upon the treatment of 
 cases, the exact nature of which is not always ascertained even on 
 dissection : for treatment should always rest upon positive and not 
 upon hypothetical curative indications. 
 
 Acute Inflammation of the Labyrinth. 
 
 This disease sometimes commences with extremely violent and 
 deeply seated pain in the ear, acute febrile symptoms, loss of con- 
 sciousness and convulsions J but sometimes with only moderate 
 pain, extending from the ear over the squamous portion of the tem- 
 poral bone and the corresponding half of the head, slight fever, 
 
 9 
 
116 AURAL SURGERY. 
 
 inability to hold the head up, coma, vomiting, and other serious 
 symptoms. "Withia twenty-four hours after the commencement of the 
 attack a sero-purulent discharge, which it is impossible to relieve 
 or check, begins to take place from the affected, but previously 
 perfectly healthy ear ; and in the course of a few days in the acute 
 form of the disease, or in the course of a few weeks in the more 
 chronic form, death terminates the sufferings of the patient with the 
 well-known symptoms of general inflammation of the brain. 
 
 In both forms of the disease, dissection discovers serious lesions, 
 such as destruction of the membrana tympani, of the ossicula, and of 
 the osseous labyrinth, sero-purulent effusion in the middle and 
 internal ear and into the cranial cavity, induration of the cortical 
 substance of both the brain and cerebellum on the affected side, &c. — 
 lesions which place the acutely inflammatory nature of the disease 
 beyond a doubt. 
 
 The same series of symptoms constantly arises when the membrana 
 tympani and labyrinth have been injured by sharp-pointed instru- . 
 ments, as, for example, by the incautious introduction of a kitting- 
 needle, with which some persons clean out the ear, or by violent 
 and awkward attempts to remove foreign bodies froni the ear in 
 spite of the struggles of the,patient, by means of hooks, forceps, levers, 
 and other similar instruments. 
 
 An accurate diagnosis can always be made in such cases by ascer- 
 taining what has occasioned the pain, and by examiijing the meatus by 
 the direct light of the sun, when the destruction of the membrana 
 tympani, and the effusion either of blood or of a sero-sanguinolent 
 fluid into the cavity of the tympanum is rendered very apparent. 
 
 The prognosis is in the highest degree unfavorable when the 
 cerebral symptoms are very severe and there is deep coma ; and even 
 with less violent inflammatory symptoms the danger to life is very 
 great. 
 
 In all cases the treatment must be energetically antiphlogistic. 
 The head must be kept cool and elevated, and the patient as quiet 
 as possible ; coohng drinks may be given with antiphlogistic purga- 
 tives ; free local and frequently repeated bleedings must be adopted 
 from the ear and nape of the neck ; ice must be applied to the occiput, 
 luke-warm oil repeatedly poured into the ear, and when the pain is 
 very obstinate the ear must, in addition, be covered day and night 
 with warm poultices of hnseed-meal. By these means, we may 
 perhaps subdue the inflammation in the ear and in the dura mater 
 
CHKONIC INFLAMMATION OF THE LABYRINTH. 117 
 
 and the violence of the pain ; and the ' life of the patient will be pre- 
 served, but the hearing of the affected ear is always irrecoverably- 
 lost. 
 
 Chronic Inflaimn,ation of the Labyrinlh. 
 
 In this affection, after an apparently harmless discharge, varying 
 in quantity and quahty, has existed for some years from one or both 
 ears, accompanied by more or less intense pain, the patient suddenly 
 complains of dull pain in one ear, wliich spreads with greater or less 
 rapidity to the temple and vertex, or to the occiput and neck. 
 The discharge sometimes remains unchanged and is sometimes 
 diminished. Occasionally, though more rarely, the pain in the ear 
 is lancinating and extraordinarily severe, radiating as it were into 
 the back, into the tongue, and into the soft parts of the neck and 
 upper arm, which has very naturally led some to confound it with 
 " Tic douloureux." In these cases the meatus contains, either in 
 its deeper portion or more externally, an extremely sensitive ileshy 
 outgrowth, which renders any examination with the aural speculum 
 and blunt probe very difficult, or may altogether preclude their 
 employment. In all cases the pain becomes perfectly insufferable 
 on walking or driving on paved roads, on succussion of the head 
 with the hand, or any other movement which produces vibration. 
 The aspect of the patient becomes dull and apathetic, and he is 
 greatly depressed. Wakefulness or comatose symptoms supervene, 
 with inability to keep the head erect. Paralysis of the muscles of 
 the face, and indeed of those of the upper arm of the affected side 
 may occur, and sooner or later iU-defined febrile symptoms set in, 
 the patient experiences rigors either of a typical or non-typical cha- 
 racter, recurring several times a day, to which hot and sweating 
 fits sometimes succeed. This condition may pass into typhus fever, 
 accompanied by coma, delirium, fainting, and vomiting, leading to a 
 fatal issue, when the sick man finds a happy release from his 
 suffering. Por some time before death the discharge acquires irri- 
 tating properties, and becomes very fetid; and when this occurs, 
 the patient who was previously only hard of hearing now becomes 
 perfectly deaf. 
 
 If an ocular examination can be made by the direct light of the 
 sun, we can sometimes discern the above-mentioned fleshy outgrowth 
 in the meatus ; or far more frequently, the membrana tympani appears 
 either in great part or wholly destroyed : none of the ossicula can be 
 
118 
 
 AURAL SURGERY. 
 
 perceived, the tympanic cavity is fiUed witli dirty pus ; its liiiing 
 membrane is dark-red, swollen or partially ulcerated, and the 
 rough surface of the carious bone is easily recognised on intro- 
 ducing a bluat silver probe. After death, besides the caries of the 
 labyrinth just described, we iind that the PaUopian tube is often 
 also carious, the dura mater attached to the temporal bone dis- 
 coloured, detached, thickened and covered with pus ; and the brain 
 or cerebellum, especially the latter, affected in the most various 
 ways by the inflammatory process, indurated or hyperaemic, sof- 
 tened or perforated by abscesses, which may communicate by means 
 of carious openings in the temporal bone, with the labyrinth and 
 the exposed tympanic cavity. 
 
 These disorganizations are so remarkable, and the original pain in 
 the ears proceeding from chronic inflammation of the membrana 
 tympani, is, on account of its long duration and the neglect with 
 which it has been treated, so completely thrown into the shade, that 
 various authors (Abercrombie, Itard, 'Otorrhcea Cerebralis Pri- 
 maria'), founding their opinion upon the results of dissection, have 
 sought to attribute to this dangerous and thoroughly secondary 
 disease a primary character. 
 
 In some very rare cases the inflammation of the periosteum of 
 the temporal bone does not spread to the dura mater and brain, but 
 terminates in the exfohation of portions of the carious bone. A 
 most remarkable case of this kind came under my care in a 
 boy seven years old, from whose left ear, which had been for 
 several years discharging pus, I removed a piece of carious bone 
 i" long and -i-'' thick. This piece contained the meatus audi- 
 torius internus to the extent of -f-'", a portion of the diploe of 
 the temporal bone, and both fenestrse. A second smaller piece was 
 subsequently removed ; and in the course of a month the ulcer in 
 the external meatus had healed up, and the boy was allowed to 
 leave the hospital without any other circumstance occurring worthy 
 of note, except, indeed, that he was perfectly deaf on that side, 
 and had paralysis of that half of the face. 
 
 The diagnosis of the chronic from the acute form of inflammation 
 of the labyrinth depends chiefly upon the slow and gradual develop- 
 ment of the former from an inflammatory condition -nhich has long 
 been present in the perforated membrana tympani and in the 
 periosteum of the tympanic cavity. We can but seldom trace the 
 causes (as exposure to cold) which have led to the extension of the 
 
CHRONIC INFLAMMATION OF THE LABYRINTH. 119 
 
 previously chronic inflammation of the membrana tympani to the 
 periosteum of the tympjinic cavity and to the labyrinth. We cannot^ 
 at all events, consider the diminution of the discharge from the ear 
 as the cause of this extension, for it has only been occasionally 
 observed ; it is rather the result, as are also the dangerous head 
 symptoms, of the sudden and violent inflammation of the lining 
 membrane of the tympanic cavity. 
 
 The prognosis is very unfavorable, especially in those cases where 
 polypi and extremely sensitive outgrowths are developed either from 
 the meatus or from the surface of the tympanic membrane ; and 
 still more unfavorable where frequently recurring rigors occur, 
 whether of the typical or non-typical character, for these may, with 
 great certainty, be considered to indicate the occurrence of fatal 
 suppuration in the cavity of the cranium. 
 
 That form of caries which is perceptible to the touch and is 
 apparently merely superficial in the tympanic cavity is by no means 
 so likely to terminate fatally, and the paralysis of the facial muscles 
 on the same side is sometimes curable. But though in some cases 
 we may, by good fortune, save the life of our patient, the faculty of 
 hearing is, in all instances, irrevocably lost in the affected ear. 
 
 As regards the treatment, it should be commenced at as early 
 a period as possible, and should consist in active local antiphlogistic 
 means. The head should be elevated upon cushions stuffed with 
 horsehair, and the patient should be kept in a cool room ; his bowels 
 should be thoroughly opened by calomel and other purgatives, and 
 as many leeches should be applied around the ear and on the occiput 
 as his strength will permit. Ice should be applied to the back of 
 the head, and lukewarm oil poured into the ear, especially if there 
 be a cessation of the usual purulent discharge ; lastly, some power- 
 fully counter-irritant ointment should be rubbed into the nape of 
 the neck, till an abundant crop of pustules is produced. Circum- 
 stances must guide the practitioner as to the length of time the 
 suppuration should be maintained. The existence of painful out- 
 growths seated in the meatus or in the periosteum of the tympanic 
 cavity renders the application of every kind of caustic, of Ugatures, 
 cutting instruments, or even of weak solutions of zinc or lead, per- 
 fectly inadmissible, since all these produce more or less violent irrita- 
 tion of the tumour, and infallibly cause its increase or return. In all 
 such cases I have seen death occur without a hope for the recovery 
 of the patient. 
 
130 AURAL SURGERY. 
 
 Acute Inflammation of the Facial Nerve within the Fallopian Canal. 
 
 At the commencement of this disease a sudden, violent, and drag- 
 ging pain is experienced in the cheek and ear of one side, which is 
 greatly increased on making pressure over the point of issue of the 
 nerve at the stylo-mastoid foramen. The pain is accompanied by 
 paralysis of the facial muscles of the same side. Subacute febrile 
 symptoms are present even on the first day ; hardness of heariag 
 and noise in the ears are subsequently perceived. If the affection 
 be not subdued, pain ia the head supervenes, followed by dehrium 
 or coma, by rigors, alternating with hot fits, and lastly by stupor, 
 terminating in death. In favorable cases an abscess forms below 
 the mastoid process, the opening of which reacts favorably 
 on the progress of the disease, and materially aids in removing the 
 pain in the ears and cheek, the paralysis, the febrile symptoms, and 
 the hardness of hearing and noise in the ears, and renders the 
 recovery of the patient certain. When death occurs, the facial nerve 
 is found on dissection, in its whole course from the stylo-mastoid 
 foramen forwards, soft, swollen, and spongy, and the auditory nerve 
 so soft as to be almost fluid. Pus is also found in the labyrinth and 
 on the trunk of the seventh pair of nerves ; a large quantity of serum 
 between the membranes of the brain, and softening of the cerebral 
 substance. The membrana tympani and the meatus, on the other 
 hand, are perfectly healthy. This last point furnishes a well-defined 
 diagnostic mark between the disease we are now considering and 
 the acute and chronic forms of inflammation of the labyrinth, both 
 of which are frequently accompanied by paralysis of the facial 
 muscles of one side. In like manner the paralysis of the muscles 
 of the face enables us to distinguish between inflammation of the 
 facial nerve and nervous deafness — otalgia nervosa (see next section). 
 
 " Exaltation of the faculty of hearing " has been described as 
 a highly characteristic symptom of inflammation of the facial nerve, 
 and it has been suggested that such "exaltation-" results from 
 paralysis of the tensor tympani muscle (Landouzy, Longet). But 
 if we reflect that in those cases of disease which have been adduced 
 in proof of this statement the inflammation had only been of short 
 duration, and had never been very severe, whilst the subsequent 
 paralysis of the facial nerve was of long continuance ; if we reflect, 
 moreover, that the " exaltation of hearing " was not always present. 
 
NERVOUS HARDNESS OP HEARING AND DEAFNESS. 131 
 
 and when present was only of short duration ; and lastly, when we 
 consider that this exaltation of hearing is observed in very various 
 diseases of the ear, unaccompanied by paralysis of the facial nerve, 
 we cannot but arrive at the conclusion that the above-mentioned 
 theory is entirely Unsupported by facts. 
 
 Acute inflammation of the facial nerve is a very rare lesion, and 
 is only occasioned by exposure to severe cold, as, for example, wash- 
 ing the face with cold water whilst covered with perspiration, cold 
 draughts of air against the side of the head when heated, and the like. 
 
 The prognosis must be given with some degree of caution ; for if 
 the disease be neglected, either by the patient himself or by the 
 surgeon, it may very easily prove fatal, by extension of the inflam- 
 mation to the brain and its membranes. 
 
 In the treatment, active antiphlogistic means must be employed. 
 The necessity for venesection must be determined by a review of the 
 general symptoms, and especially of the state of the brain. If this 
 be not implicated, a considerable number of leeches should be 
 applied over the stylo-mastoid foramen, and these may be repeated, 
 if required, whilst mercurial ointment should be rubbed into the 
 adjoining parts. If painful swelling occur behind the angle of the 
 lower jaw, hot linseed-meal poultices should be applied, and all 
 abscesses should be opened as soon as their presence is recognised, 
 even though fluctuation may only be obscurely perceptible. When 
 the inflammation extends to the brain and its membranes, the 
 appHcation of leeches and ice-cold applications to the head, and the 
 administration of active purgatives, are indispensably requisite, to 
 prevent, if possible, exudation into the cranial cavity. If we 
 succeed in subduing the inflammation whilst paralysis of the facial 
 muscles stiU remains, we must rub in iodine or tartar emetic oint' 
 ment over the stylo-mastoid foramen, which are very serviceable in 
 promoting absorption of the exudation in the EaUopian canal and 
 effecting a cure of the paralysis. 
 
 NervQus Hardness qf Hearing and -De^nesS. 
 
 The expressions "nervous hardness of hearing'-" and " nervous deaf- 
 ness," used as names for diseases, when regarded from a scientitic point 
 of view, immediately produce mistrust. They do not, as in the case of 
 the names of the previously considered affections of the ear, furnish any 
 indication of the nature or seat of the disease, but merely describe a 
 
122 AURAL SURGERY. 
 
 symptom, and a symptom, too, which possesses no diagnostic value, 
 siace it is common to all diseases of the ear excepting those which 
 are limited to the auricle. 
 
 The term " nervous" is an expression utterly devoid of meaning ; 
 it merely indicates the presumptive cause of the functional disorder 
 to be some lesion of the auditory nerve, but does not even hint at 
 the nature of the lesion. This is strikingly apparent when we 
 examine accounts of dissection of the auditory nerves, and of the 
 organic changes in their immediate vicinity in cases of this disease. 
 Thus it is stated " that the labyrinth is filled up with otoconia ; that 
 there are accumulations of pigment and dark spots, as of extravasated 
 blood ; congestion of the vestibule, yellow discoloration of the osseous 
 substance, slight redness of the periosteum, unusual secretion of the 
 perilymph, unusual deposition of crystals, and sometimes the 
 appearance of a chalky fluid. As regards the auditory nerves, 
 they may be inflamed, softened, iadurated, atrophied, or hyper- 
 trophied; or they may be compressed by the growth of tumours 
 near their central extremities ; crystals of carbonate of lime may be 
 found in the perilymph, and peculiar talc-like particles in the am- 
 pullae ; and lastly, there may be a great deficiency in the number of 
 the fibres of origin of the auditory nerve from the fourth ventricle.^' 
 Toynbee, whose authority in these matters is prized so higlily by 
 Erhard, found in the dissection of fifty-four ears (Nos. 74 — 793; of 
 which Nos. 74 — 73a, and 755 — 770 must be excluded, because they 
 do not refer to the inner ear, but to the tympanic cavity and the 
 membrane of the fenestra rotunda), atrophy of the auditory nerves 
 (thirteen times, but only in persons who were from sixty to ninety 
 years of age), im.perfect structure, and various diseases of both the 
 osseous and membranous semicircular canals, black pigment de- 
 posited in the cochlea, constriction of the scala vestibuli of the cochlea, 
 and abnormal quantity of otoconia ; in one instance there was blood 
 in the vestibule, and in another blood in the cochlea; whilst in 
 a third there were dark flecks on the lamina spiralis in both ears of 
 the same individual, who had fallen on his head some years pre- 
 viously, and had subsequently suffered from deafness. 
 
 Now, although it may be very difficult and perhaps even impossible 
 to demonstrate exactly in what manner many of these post-mortem 
 appearances have led to the production of the hardness of hearing 
 and deafness, we must admit, as a general principle, that the heahhy 
 performance of its function by the auditory nerve must always be 
 
NERVOUS HARDNESS OF HEARING AND DEAFNESS. 123 
 
 connected with, and dependent upon its healthy structure. Unfor- 
 tanately, however, the practitioner gains but little by this ; because 
 no one has ever yet made an attempt to diagnose any of the various 
 organic changes in the labyrinth just enumerated, or to bring them 
 into genetical relation with the functional disturbances. We may 
 remark, in addition, that oftentimes no information can be obtained 
 even from a post-mortem examination in regard to the deafness which 
 has been present during life ; so that in fact the nature and extent 
 of the organic lesions, as they cannot be determined, so they may 
 be wholly disregarded in the treatment. "When, therefore, it is 
 considered how few and meagre are the results of dissection, we 
 cannot but think it in the highest degree rash and presumptuous to 
 unite in one category a large number of diseased conditions which 
 have been found iu the labyrinth as causes " of nervous hardness of 
 hearing and deafness ;" and as in the case of " chronic inflammation 
 of the tunica nervosa," not only to describe the affection as " very 
 frequent" but actually to subdivide it, as Erhard has done, into " a 
 subacute form (hyperismia rheumatica and catarrhalis) and a chronic 
 form," and this, without any other means for its diagnosis than 
 " the characteristic and persistent rushing sound, unaccompanied by 
 pain," and the "pathognomonic symptoms that the secretion of 
 cerumen is never normal, and that there is diminution of the power 
 of conduction of sound through the bones of the head" (respecting 
 which we shall speak more in detail hereafter). If we add to these 
 the so-called " reflex deafness, hysterical, plethoric, and anaemic deaf- 
 ness, and lastly, the " peculiar paralysis of the auditory nerve," or 
 " dynamic deafness," it will readily be understood how urgently more 
 exact means of diagnosis are required for these imaginary diseases. 
 
 It is, moreover, self-evident that we can never correctly apply to 
 any case the term " nervous hardness of hearing and deafness," 
 uidess there is a complete absence of all disease of the external and 
 middle ear ; because we have seen that the various organic changes 
 which take place in these parts, are themselves constantly associated 
 with deafness, which is often very complete. But the science of 
 acoustics furnishes us with no means of determining whether the func- 
 tional disturbance is altogether, or only partially due to such morbid 
 condition. Lastly, the objective mode of investigation, by sight, 
 touch, and hearing on the part of the surgeon, cannot be applied 
 to the diseases of the labyrinth, however practicable it may be 
 for the affections of the middle and external ear; yet the importance 
 
124 AURAL SURGERY. 
 
 of sucll a mode of inquiry for the diagnosis of " nervous hardness of 
 hearing and deafness" is generally admitted, though very imperfectly 
 carried out. If we are desirous of forming a diagnosis of some 
 disease of the external ear, it is only requisite to examine it ynth. a 
 speculum and the direct rays of the sun. Por the examination of 
 the middle ear, on the other hand, many aurists, with Toynbee and 
 Erhard, still believe that the experiment of Valsalva is sufficient, 
 although the success of the experiment is actually dependent upon 
 the patient himself; and in the most favorable cases, whilst the 
 duration of the effect is extremely brief, the only information ob- 
 tained is that the tube is not altogether occluded ; no knowledge 
 whatever being gained upon the important circumstance of the 
 presence or absence of free or interstitial exudation ia the middle 
 ear. AH deductions, therefore, respecting the nature of the diseases 
 of the middle ear, restuig on the " experiment of Valsalva," which is 
 supposed to furnish negative evidence for the diagnosis of " nervous 
 hardness of hearing," rest on very uncertain and, in fact, erroneous 
 data. Those who have participated with me in these views, have en- 
 deavoured to obtain exact information of the conditions of the middle 
 ear by catheterism and the pressure of air ; but hitherto comparatively 
 little success has attended their efforts, because they have only em- 
 ployed a catheter of medium size (about that of No. 3 ; see above, 
 p. a6), from which positive information could only be obtained in 
 respect to free, and the more severe grades of interstitial exudation. 
 Thus it happened that the middle ear, examined by this imperfect 
 means of observation, was supposed to be very frequently wholly 
 free from organic disease ; and in such instances, comprehending 
 nearly 50 per cent, of all aural diseases, the deduction was conse- 
 quently drawn that the real disease which was present was nervous 
 hardness of hearing and deafness. The error of tliis deduction 
 could only be recognised, and an accurate knowledge of the 
 more delicate alterations in nutrition and secretion, vrith the con- 
 secutive changes in the size of the middle ear, could only be ob- 
 tained, by the employment of catheters varying in cahbre (p. 2,6) 
 of the diagnostic tube, and of catgut bougies (p. 3a). By this 
 physical method of diagnosis we have ascertained that the number 
 of those deaf persons whose external and middle ear are free from 
 organic changes, and whom, on this account, we are justified ia 
 considering the subjects of disease of the internal ear, is reduced to 
 a muimum (4 in 1000, see tabular view, p. 17). But whether this 
 
NERVOUS HARDNESS OF HEARING AND DEAFNESS. 135 
 
 disease affects the centric or peripheric extremity of the auditory 
 nerve can only be ascertained by a careful inquiry into the presence 
 or absence of cerebral symptoms^ of which we shall speak hereafter. 
 To this objective, and therefore certain mode of diagnosis (even 
 if it be also negative) of "Nervous hardness of hearing and 
 deafness," Erhard and Bonnafont have preferred a subjective, func- 
 tional, very uncertain, and still only negative diagnosis. According 
 to Erhard, " the most general physiological and pathological symp- 
 tom of all (?) nervous deafness is diminished conduction of sound 
 through the bones of the head so that an ordinary watch cannot 
 be heard at all, and a timepiece only seldom, and then very 
 inperfectly." Here, then, the determination of the presence of very 
 serious disease of the ear is made to rest altogether upon the ob- 
 servation of the patient himself, delusive as this frequently is, and 
 upon his power of hearing certain movements of a watch ? The 
 unlikelihood of having a clock at hand in many cases, and the 
 uncertainty in others as to whether it is really only " very im- 
 perfectly heard," is stiU further increased by the statement that 
 "the conducting power of bones of the head for sound is di- 
 minished by age, and also to a remarkable extent by great thickness 
 of the diploe and of the integuments of the head," and " that only 
 those are nervously deaf in whom this conducting power of the 
 cranial bones fails, and who do not exceed forty years of age ;" and 
 lastly, "that those only amongst younger persons can be con- 
 sidered nervously deaf who are unable to hear a watch through the 
 bones of the head." "What age then must those " younger persons" 
 be when the fortieth year has been declared the limit of the 
 occurrence of nervous deafness ? and how shaU the nature of the 
 hardness of hearing be determined in persons over forty years of 
 age ? How are we to ascertain that the diploe and the investing soft 
 parts are too thick, or that in such cases the inability to hear " a 
 watch or a clock through the bones of the head" is indeed no proof 
 of nervous hardness of hearing. What conclusion can we draw 
 in respect to this " functional diagnosis" if " patients who present 
 well-marked (?) symptoms of nervous deafness can also be at the 
 same time acoustically deaf." These questions Erhard wiU find it 
 difficult to answer satisfactorily ; but in the mean time they furnish 
 a proof, that we must be very much prejudiced, if, in opposition to 
 the comments now made, and to the limitations in their value which 
 even Erhard himself acknowledges to exist, we still consider that 
 
1.26 
 
 AURAL SURGKKY. 
 
 the diminished conduction through the bones of the head is " the 
 most general physiological and pathological symptom of all nervous 
 deafness." Bonnafont makes it a very easy matter ; for he asserts 
 with much satisfaction that he has made a new and important 
 diagnostic discovery, " that the sensibility of the auditory nerves 
 must be quite normal" — " si la montre est entendue sur toutes les 
 parties du crane." If the watch be heard only when placed upon 
 the mastoid and zygomatic processes, the hardness of hearing may 
 still be curable. If the watch is inaudible when resting upon any 
 of the cranial bones, whilst a tuning-fork (vibrating '' ut " of the third 
 octave) can still be heard at five centimetres distance from the 
 ear, or at least by being applied to any part of the cranial bones, 
 the curability of the deafness is at best but doubtful, whilst, lastly, 
 if the tuning-fork can only be heard at a very short distance, or 
 when directly apphed to the cranial vault, the incurability of the 
 disease is indubitable. But here, again, the difficulty occurs, that it 
 rests with the patient to determine whether he does, or does not hear 
 " the watch or the tuning-fork" when in contact with any particular 
 point of the cranial bones— a matter of fact which cannot be stated 
 with certainty by the uneducated, or the disconcerted, by the very 
 young or old, or by the very nervous patient. It is, indeed, by no 
 means an easy task for a deaf person to decide whether he can really 
 hear the vibrations of the tuning-fork or only feel them through the 
 cranial bones. Lastly, in consequence of the very various strength 
 in the beats of watches, their audibility on being applied to the 
 cranial bones of those who are hard of hearing varies considerably ; 
 so that, according to Bonnafont's principle, we can quite at pleasure 
 make cases of nervous deafness either very frequent or very 
 rare, according as we apply to the cranial bones, watches the move- 
 ments of which are very strong or very weak ; for instance, thousands 
 of my patients affected by the most various kinds of deafness, have 
 not been able to hear my feeblest ticking watch, which is normally 
 audible at twenty-one inches, even when it has been actually applied 
 to the cranial bones; all these, therefore, according to Bonnafont, 
 ought to have been considered cases of nervous deafness, but, on the 
 other hand, they could distinctly hear my strongest-beating watch, 
 which is normally audible at forty feet, when applied to any part 
 of the sknU ; and should, therefore, not be described, according 
 to Bonnafont, as cases of nervous deafness. It will, therefore, we 
 think, be admitted that — i. The organic changes observed upon 
 
NERVOUS HARDNESS OE HEARING AND DEAFNESS. 127 
 
 dissection of the auditory nerves and the surrounding solid and 
 fluid parts, are still utterly unknown so far as regards their 
 power of causing the destruction of the function of the audi- 
 tory nerves and of producing nervous hardness of hearing, 
 a. That we have no certain means of diagnosing during life 
 any one of the known organic changes of the auditory nerves, 
 or of the fluid and solid parts ia their vicinity (in those cases 
 at least in which the temporal bone is not carious), whilst we must 
 also acknowledge that the objective investigation of the external 
 and middle ear can alone determine the presence or absence of 
 organic changes in these several parts, and can thus only render 
 possible {i. e., in the cases of absence of organic change) the 
 recognition of a nervous hardness of hearing and deafness. 3. That 
 it is quite impossible, where there are organic changes present 
 in the external and middle ear, to diagnose with any approxi- 
 mation even to correctness the diseased condition which may exist 
 in the internal ear. 4. And that it is only in complete deafness 
 that we can, without investigation of the diseased ear, assure 
 ourselves of its being purely nervous, because there is no kind of 
 abnormal change in the organization or of the atomic constitution of 
 the parts in the ear which can take away from them the power 
 of conducting sound to the auditory nerve. 
 
 But when complete loss of hearing is present, the auditory nerve 
 must have lost its sensibiKty for sound, let the organic condition of 
 the ear be what it may ; and notwithstanding the innumerable grades 
 of diminished functional activity of the auditory nerve (nervous hard- 
 ness of hearing) which may be present, still they do not exist, so far 
 as the diagnosis is concerned, which only recognises one single form 
 of disease of the internal ear, namely, nervous deafness, or in other 
 words, annihilation of the functions of the auditory nerve, without 
 regard to the anatomical and pathological conditions that may have 
 produced it. Moreover, if we are not desirous of losing ourselves in 
 unsupported hypotheses, we cannot at present touch upon the origin, 
 symptoms, progress, prognosis, and treatment of nervous hardness of 
 hearing, since the mode of transition to that form of deafness is 
 entirely unknown, and perfectly inaccessible to any of our means of 
 diagnosis. 
 
 Nervous deafness occasionally, though rarely, originates in a 
 gradually increasing hardness of hearing, but far more frequently 
 it comes on quite suddenly, after some violent shock to the whole 
 
128 AURAL SURGERY. 
 
 body, or the head alone; such, as a fall from a considerable 
 height on the feet, buttocks, back, chin, or upon the head ; from 
 blows on the head or ears, from violent explosions of artillery in the 
 immediate neighbourhood ; from apoplexies; or it may supervene in the 
 course of severe and dangerous febrile diseases ; or lastly, after ex- 
 posure to long-continued and very cold draughts of air applied directly 
 to the ears. "Whether it be possible for one ear alone to be completely 
 destitute of hearing, that is, nervously deaf, or not, without carious 
 destruction of the petrous portion of the temporal bone, must 
 remain undecided, because loud sounds, used as tests, afford no means 
 of positively determining the healthy from the unhealthy ear, whilst 
 weak sounds also give no satisfactory means of formiog a decisive judg- 
 ment as to whether one or both ears have lost the faculty of hearing. 
 
 The symptomatology of nervous deafness is not so simple- The 
 patient is indeed incapable of heariug anything ; but he can readily feel 
 strong vibrations in the air and on the ground upon which he stands, 
 walks, lies, or sits. Nearly all suffer from persistent, variously modu- 
 lated noises in their ears, and therefore furnish a striking proof that 
 this symptom does not proceed from any morbid condition of the 
 auditory nerve, the functions of which are in these cases so completely 
 abohshed. 
 
 Nervous deafness, commencing at the periphery, is quite free from 
 cerebral symptoms (with the exception of frequent fainting fits), but 
 these on the other hand are very characteristic of gradually increasing 
 deafness, commencmg at the nervous centres, and produced by various 
 kinds of pressure or irritation on the auditory nerves in their course 
 through the cranial cavity. Amongst such cerebral symptoms may be 
 enumerated, continuous fixed pain in the head, loss of memory, paraly- 
 ■ sis of the optic nerves, or of the motor nerves of the eye, or of the 
 same side of the face, and lastly, fainting. 
 
 The prognosis for both forms of nervous hardness of hearing is in 
 the last degree unfavorable, providing we do not confound great 
 hardness of hearing irith absolute deafness, a mistake that is by no 
 means uncommon. I have at least never met with a case which has 
 been cured, or even materially improved by treatment. Centric 
 deafness, occasioned by blood or serum being poured out at the base 
 of the brain, might, if it were recognised, afford some prospect of 
 relief, or cure, since the absorption of these fluids is not absolutely 
 impossible. 
 
 The treatment of nervous deafness, however hopeless, can 
 
DEAF-MUTISM. 129 
 
 only be based^ in the absence of any special indications, on general 
 principles. Where the deafness results from the above-men- 
 tioned violent mechanical causes, serious febrile conditions, &c., 
 we presume that there is local congestion or some other organic 
 change, either in the auditory nerves themselves or in their immediate 
 vicinity ; so that we are quite justified in using those general and local 
 derivative means which are calculated to promote absorption. . Upon 
 the details of these I need not here dilate, as I have already stated, 
 that not one single case has occurred in my practice in which any 
 benefit has been experienced from the use of these remedies. The 
 prospect of success, therefore, being so slight, it is surely judicious 
 to avoid tormenting the patient by the application of painful or 
 debilitating counter-irritants, such as setons, moxas, large issues, 
 violent purgatives, &c. 
 
 On the other hand, it is quite unjustifiable to attribute nervous 
 deafness to nervous debility, and, proceeding on this supposition, to 
 employ the so-called excitants, amongst which electricity in its 
 various forms, applied as a constant or induced current, plays the 
 most important part ; for this method of treatment, like the former, is 
 unable to adduce a single well-established cure; it only offers a 
 wide and profitable field for greed and charlatanry. 
 
 Deaf-mutism. 
 
 Deaf-mutism depends upon congenital or acquired extreme hard- 
 ness of hearing, or complete deafness. The deafness, however, must 
 have been present before the first six or eight years of hfe, 
 that is to say before the acquisition of written language, and 
 before vocal sounds have been learnt by intercourse with others. 
 When the deafness has been complete at birth, articulate sounds are 
 never learnt, but when the deafness is acquired at an early period, 
 they may indeed be learnt, but are soon again forgotten. In the former 
 case the little patients remain, in the latter they become dumb. 
 Congenital deaf^mutism is probably far more frequent than acquired ; 
 certainly more frequent than appears from the statistics hitherto 
 given, since the parents of deaf-mutes, readily delude themselves as 
 to the power of their children to hear during the first and second 
 years of life. 
 
 The deafness of the deaf and dumb is not always complete. In 
 45 cases of deaf-mutism there were found 37 cases of congenital deaf- 
 mutism, and 1 8 cases of acquned deaf-mutism* 
 
130 
 
 AUUAL SURGEUr. 
 
 Congenital. Acquired. Total. 
 
 With complete deafiiess lo 13 23 
 
 With some perception of soand .... 5 3 8 
 With uncertain perception of vocal sounds . . 7 1 8 
 With distinct perception of vocal sounds . . 2 o 2 
 With hearing for all words of which they had ac- 
 quired a knowledge by education ... 2 i 3 
 With hearing for all words, whether they had 
 
 heen taught them or not ..... i o i 
 
 27 18 45 
 
 In the last two cases the words, which were always unconnected, 
 were spoken to the deaf-mutes with the mouth so close to their ears, 
 that it was impossible they could see the movements of the lips. 
 The deaf-mutes belonging to the last two or three categories are called 
 partial deaf-mutes, though their social position in no respect differs 
 from their unfortunate companions. The slight power which they 
 possess of hearing, no doubt, facilitates their acquirement of speech, 
 and makes the tones of their voice less rough ; but they are never in 
 a position to attend schools with other children who are in the full 
 possession of their senses with advantage, to learn articulate sounds 
 like them, or, like them, to choose and follow any of the ordinary 
 avocations of life. This must be borne in mind, in order that we 
 may determine whether any of the pretended cures of these unfortu- 
 nate children, have really attained their object, for it is not enough 
 that they should be able to perceive and repeat a few letters, syllables, 
 words, or short sentences, to permit us to acknowledge that a cure 
 has been effected; for -even when they have accomphshed this, they 
 are still unable to be separated from the ranks of the deaf-mutes, and 
 no real cure has been wrought. 
 
 At the commencement of the second year of life, or occasionally a 
 year or two later, children in the full possession of their senses begin 
 to acquire articulate sounds, from their intercourse with those who 
 speak ; if, therefore, at this period, there be a total absence of the 
 usual early attempts to speak, the suspicion of present deafness 
 arises, which acquires strength with the lapse of each month, untH 
 at the close of the second or third year of hfe, without the ac- 
 quisition of any articulate sounds, no further delusion can exist 
 upon the subject, however the relatives of the patient may adduce 
 imaginary proofs of the child's capacity to hear. 
 
 As regards the seat of the deafness in deaf-mutism, after the full 
 
DEAE-MUTISM. 131 
 
 explanations into which we entered when describing nervous hardness 
 of hearing and deafness, we must attribute it to lesion of the peripheric 
 or of the centric^ or even of both extremities of the auditory nerves. 
 It is obvious that in all cases there must be complete inability to 
 conduct sound in both nerves. In congenital deaf mutes, the fol- 
 lowing morbid conditions have been particularly remarked on dissec- 
 tion : — Defective development of the semicircular canals and of the 
 cochlea, atrophy of the auditory nerves, and deficiency of the striae 
 auditorise on the floor of the fourth ventricle : but in many, perhaps , 
 even in the majority of cases, no structural changes are discoverable 
 either in the labyrinth or in the centric extremity of the auditory nerve. 
 
 In acquired deaf-mutism, similar organic lesions have been found 
 to those which are present in nervous deafness — lesions, whicli are 
 as completely hidden from physical inquiry and diagnosis during life 
 as are those which accompany congenital deaf-mutism. I have 
 myself examined a considerable number of deaf mutes with the 
 aural speculum, aural catheter, diagnostic tube, and catgut bougies, 
 but, with the exception of the above-mentioned inflammation and 
 perforation of the membrana tympani, ulcerated ossicula, and inflam- 
 mation of the membrane liningthe tympanum, &c., I have alwaysfound 
 the external and middle ear quite normal, and apparently not in any 
 way instrumental in causing the deafness. At all events, I am con- 
 vinced that collections of cerumen in the meatus, or of free exudation 
 in the middle ear, are insufficient to produce complete deafness or 
 even such a degree of hardness of hearing as must necessarily be 
 present in any case of deaf-mutism, either congenital or acquu-ed. 
 
 Deaf-mutism, that is to say, deafness producing dumbness, is not 
 an hereditary disease. Amongst the parents of forty-five deaf-mutes 
 above-mentioned, only three suffered from hardness of hearing ; the 
 remainder were in full possession of their hearing. In the year 
 1855 I found in Berlin, amongst 198 deaf mutes, eighteen men, six 
 of whom had married women who were deaf mutes, and twelve, 
 women who heard perfectly. Of the six former couples five 
 had families, and of the twelve latter, eleven had children, all of 
 whom could both hear and speak well. In the Hertford Asylum 
 for the deaf and dumb at Boston, in North America, there were 
 in 1 851, aoo deaf mutes, of whom 103 were married. Tliirty- 
 one of these couples were childless, the remaining seventy-two had 
 102 children, of whom ninety-eight were in full possession of voice 
 and hearing, whilst the remaining four were deaf mutes. One 
 
 10 
 
133 
 
 AURAL SUEGERT. 
 
 of them was the child of parents who were both congenital deaf 
 mutes ; the others were the offspring of a mother who was a con- 
 genital deaf mute, and of a father who acquired his deaf -mutism in 
 his second year. In 1851 there were in Ireland 437 deaf mutes in 
 339 families; amongst these the father had been a deaf mute only 
 twice ; the mother four times, the grandfather five times, and the 
 grandmother three times. But it is a noteworthy circumstance that 
 the deaf and dumb children in 317 famihes had, more or less, 
 numerous deaf mutes amongst their male or female cousins. 
 
 Consequently, nothing can be urged against the marriage of deaf- 
 mutes with healthy people in the fuU possession of speech and hear- 
 ing, on the ground of the defect being likely to be propagated to 
 their issue. Acquired deaf-mutism occurs most frequently within 
 the first six or eight years of life after severe fevers, whether cerebral 
 excitement, convulsions, and loss of consciousness have been present 
 or not ; after convulsions with loss of consciousness, but without 
 fever ; after scarlet fever, measles, smallpox, severe chiUs, violent 
 concussion of the head from faUs, blows, &c. It often appears quite 
 suddenly, but the deafness is always fully established in a few Weeks. 
 It then continues quite unchanged, even if the patient, whose con- 
 stitution has been severely shaken by the original and often very 
 dangerous febrile disease, be completely restored to health. Children, 
 in particular, who have been thus affected, are often left in so debili- 
 tated a state that months often elapse before they are again able to 
 stand and walk. 
 
 Of the eighteen cases above adduced of acquired deaf-mutism, 
 seven resulted from severe nervous fevers, four from convulsions with 
 loss of consciousness, three from scarlet fever, three from inflamma- 
 tion of the brain, and one from exposure to severe cold. Only in 
 one of these cases did the power of hearing return during convales- 
 cence to a sufficient extent to enable the child to understand vocal 
 sounds and words, of which he had already acquired a knowledge by 
 education, when the mouth of the speaker was placed close to his 
 ear. Amongst congenital deaf mutes three out of twenty-seven 
 possessed this degree of the faculty of hearing. 
 
 Simulated deaf mutes betray themselves usually by shaking the 
 head and pointing the finger to the tongue and ears, whilst real 
 deaf mutes are not aware that the ears are subservient to hearing 
 or the tongue to speech. If these deceivers appeal to the fact of 
 their having received a pretended methodical education, we must 
 
DEAF-MUTISM. 133 
 
 have recourse to the advice of a deaf-mute teacher in order to unmask 
 them J butj should even tliis faUj we must admit them into the hos- 
 pital and administer chloroform^ under the influence of which the 
 tongue of the most crafty dissembler becomes loosened. 
 
 The prognosis of deaf- mutism is very unfavorablcj and I have no 
 hesitation in calling it aii incurable disease ; because^ on the one hand, 
 the morbid conditions of the auditory nerve producing the deafness are 
 as completely unknown as are the curative means that might prove 
 serviceable, and, on the other hand, a great variety of remedies have 
 been employed, but hitherto without any good results. This state- 
 ment requires that the indications for the treatment of this disease 
 should be considered somewhat in detail. As we have akeady said, deaf- 
 mutism results from the circumstance that, owing either to acquired 
 or congenital deafness, the power of speech is either never acquired 
 or is lost at an early period ; the cure of the deafness, therefore, must 
 reproduce this process of development, i. e., a case of cured deaf- 
 mutism ought to learn, in the course of a couple of years, a period 
 sufficient for the youngest child, without any methodical education, 
 but merely from intercourse with those who speak, the tones of the 
 voice, as they are wont to be learnt and spoken by children of 
 three years of age in full possession of their senses. Deaf mutes, 
 therefore, who have been reaUy cured ought to be iu the same 
 position as children who are perfectly organized, even amongst the 
 poorer classes of society ; ought to be able to converse orally upon 
 the occurrences of everyday life, not only with their teachers, but 
 with every person they may meet, and ought, therefore, to be able 
 to attend, with advantage to themselves, an ordinary day-school for 
 healthy children, and, like them, to be able to select some occu- 
 pation by which they may gaia their livelihood. 
 
 "When this, however, does not come to pass in cases where it is 
 pretended that the deaf-mutism has been cured, no real cure of the 
 deafness, nor even any noteworthy improvement of it, has been 
 effected, since mutism is only produced by complete, and never by 
 partial deafness, unless indeed it be of the very highest grade. 
 Measured by this — the only valid means for forming an estimate, 
 deaf-mutism has never yet been cured. No deaf-mute has ever yet 
 acquired the power of speech by simple intercourse with those who 
 speak, nor attended with advantage a school for children who had 
 the perfect use of their ears and tongue, nor could select and fulfil 
 the duties of a calling in life, unless he have had the advantage of 
 
134 AURAL SURGERY. 
 
 a properly directed and methodical education. If this cannot he 
 denied or contested^ the so-called cures of deaf mutes should no longer 
 he pubhshedj since they only indicate charlatanism or an unpar- 
 donable ignorance of the essential conditions of deaf-mutism. Tlie 
 most recent statements of this kind have proceeded from MM. 
 Bamberger, Duchenne, and Blanchet. Bamberger has electrified his 
 patients for months at a time for two years consecutively. Duchenne 
 has " Paradized " a deaf-mute boy months together for three years. 
 Blanchet treated several classes of deaf mutes for years with " vocal 
 and auditory gymnastics/' and with private instruction, and yet the 
 children improved no further than that they were able to say after 
 him, "letters, syllables, and a few words or short sentences, such as 
 'bon-jour. Monsieur Duchenne,'" &c. — an improvement in the 
 comprehension of the speaker which we are by no means certain did 
 not result rather from the eye than the ear. But even granting the 
 latter, the feat is only what many deaf and dumb children can 
 accomplish (as I have elsewhere stated), without their ceasing to be 
 considered deaf mutes, and to require a proper methodical education, 
 through the sense of sight, &c. After such performances in hearing 
 and speaking, Bamberger, Duchenne, and Blanchet consider their 
 pupils cured, and as requiring only careful and continued instruc- 
 tion, conveyed through the hearing, to enable them to acquire 
 speech ; without regard to the circumstance that they would have 
 done better to have attended to this — " acquisition of speech" before 
 publishing the cases as cures of deaf-mutism. This, however, could 
 never have been accomplished, since these very cases have never yet 
 learnt to speak, and they err greatly in thinking that the teachers 
 were ever able to convey information to the patients by shouting 
 loudly into their ears. Moreover, those who are hard of hearing 
 cannot endure the effort of listening required to comprehend the 
 loud shouting of another person into their ears, independently of the 
 fact that deaf mutes whose deafness has been cured ought to acquire 
 the power of speech with the same facility, by simple intercourse 
 with those who speak, as is ■ the case with young children who are 
 in the full possession of their senses. 
 
 The treatment, therefore, has nothing to do with " conversational 
 exercises " on the part of the patients, but consists simply in the 
 removal of the causes of their deafness. It is highly unphilosophical 
 to think, as Erhard does, that " every case of deaf -mutism is acquired, 
 and is caused by some centric lesion," and that " numerous observa- 
 
DEAF-MUTISM. 135 
 
 tions show that only some centric nervous process is at the bottom 
 of acquired deaf-mutism;" for these "observations" can only con- 
 sist in accounts of dissection in cases of deaf-mutism ; and it would 
 have been well had he thought fit to pubhsh them, since such 
 examinations have only been made in very small numbers in other 
 quarters. As long as Erhard does not do this, we may look upon 
 his "numerous observations" as only another instance of the rash 
 and unfounded statements of this author, and altogether discard 
 them. We might, perhaps, feel tempted, as an experiment, to try 
 his proposed means "of causing the absorption of the peccant 
 material from the fourth ventricle by the application of a cold-water 
 douche of the size of the thumb upon the back of the head, whilst 
 the patient is in a warm bath," if this had hitherto furnished any 
 other than " apparent success." 
 
 Toynbee requires in the treatment of deaf-mutes, but only 
 ia cases of acquired deaf-mutism, a certain degree of the faculty of 
 hearing. " The nervous system of the ears must then be excited 
 to natural action by the perservering use of the long elastic 
 tube, and where either the membrana tympani or the mucous 
 membrane lining the tympanum has been thickened, counter- 
 irritation over the mastoid process will aid the use of trum- 
 pets." Toynbee only adduces three cases where, by the use of these 
 remedies, he was convinced that the hearing was decidedly improved. 
 In the first case counter-irritation and the use of the long elastic 
 tube were recommended, but he does not state whether both were 
 applied. The improvement experienced in the hearing was of no 
 account. In the second case the same treatment was applied for 
 four months. After that time Toynbee received a letter from the 
 patient's sister — not having examined her himself — saying that "they 
 do think she is improving," a statement which, in a matter of such 
 extreme scientific interest, is perfectly valueless as to the beneficial 
 effects of a particular line of treatment. In the third case Toynbee 
 determined to try a plan of treatment having for its object the ex- 
 citement of the nervous apparatus of the ear ; but here also he leaves 
 us in doubt as to whether it was applied, and had produced the 
 supposed " improvement " of the hearing, or not. "We shall not, 
 therefore, be much in error if we attribute but little scientific value 
 to either the indications for treatment, remedial measures, or success 
 in the treatment of this particular disease by this author. 
 
 In those cases of deaf-mutism which have occurred after violent 
 
136 AURAL SBRGERY. 
 
 concussion of the head, or after convulsions, febrile attacks, or 
 inflammation of the brain, or, lastly, after the exanthemata, with 
 destruction of the membrana tympani, and swelling and suppuration in 
 the tympanic cavity, strong counter-irritants (setons, counter-irritation 
 to the shorn scalp, behind the ears, or on the neck, issues in the arm) 
 have been continuously and energetically applied, and the body has been 
 lowered by spare diet and active purges, for the purpose of removing 
 imaginary discharges of serous or bloody fluid in the neighbourhood 
 of the auditory nerve; and all without arriving at any other result 
 than an extraordinary diminution in the general strength of the 
 patient. Passing to another extreme, electricity has been employed, 
 in order to remove the supposed, and certainly very obvious inac- 
 tivity, of the auditory nerve, but without the smallest success either 
 with the induced or continuous current. 
 
 Since nothing positive can be predicted in regard to the cause of deaf- 
 mutism, the deafness can only be referred to some one of the already de- 
 scribed aural diseases ; and any measures undertaken for the treatment 
 of deaf-mutism must be founded on careful physical examination of the 
 external and middle ear, the internal ear, which is here so important, 
 being unfortunately inaccessible. Should anymorbid conditions of the 
 external and middle ear be present, these of course must be treated and 
 removed, according to the ruleswhichwe have laid down in the sections 
 appropriated to their consideration. But in the mean time, we may 
 perhaps perceive that the extraordinary difficulties which beset the 
 treatment of deaf-mutism are partly causedbythe frequent concurrence 
 of chronic inflammation of the perforated membrana tympani, and of 
 the exposed, much swollen, and spongy membrane of the tympanic 
 cavity. How far, and in what manner, this chronic inflammation 
 affects the internal ear, and produces changes in its organization, has 
 unfortunately not yet been shown by dissection. 
 
 Amongst the diseases of the middle ear, when the membrana 
 tympani has been whole, I have found " exclusively interstitial 
 exudation " a frequent concomitant, the removal of which, in a com- 
 pletely (acquired) deaf mute produced such recovery of the hearing 
 power in the right ear, that the little patient heard and repeated all 
 letters, syllables, words, and short sentences which were spoken with 
 the mouth closely applied to his ear ; but he was not on that account 
 fltted to receive education with children in th^ perfect possession of 
 their senses^ nor to be removed from the category of deaf mutes. 
 
 When no apparent morbid changes are present in the external or 
 
DEAP-MPTISM, 137 
 
 middle ear, we must suppose that the seat of the deafness is either in 
 the peripheric or centric, or even in both extremities of the auditory- 
 nerve ; but as the nature of the affection (whether it be due to non- 
 development, or some disease subsequent to birth), is wholly unknown, 
 no diagnosis can be made, and it would be very foolish to under- 
 take the treatment; we must therefore consider such deaf mates 
 incurable, and it only remains for us to see that they are subjected 
 to a well-directed, methodical education, founded upon the sense 
 of sight. 
 
138 
 
 AUliAL SURGERY. 
 
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TABULAK STATEMENT OF AURAL DISEASES. 
 
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 AURAL SXJRGElir. 
 
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TABULAR STATKMENT OF AURAL DISEASES. 
 
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142 
 
 AURAL SURGERY. 
 
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APPENDIX. 
 
 ON MECHANICAL APPAHATUS FOR THE IMPROVEMENT 
 OP HEARING. 
 
 As soon as the power of hearing in both ears is so much impaired 
 as to render ordinary colloquial intercourse difficult or altogether 
 impossible — a condition which may terminate in the members of the 
 patients' own family finding it difficult to communicate with him^ 
 even when in close proximity — and when no relief can be obtained 
 from the resources of medicine^ acoustic apparatus must be em- 
 ployed. These vary as much in shape as in the material of which 
 they are constructedj and are yet of but little service to the patient^ 
 which need not surprise us, when we reflect upon the extremely 
 imperfect knowledge we possess of the laws of acoustics and of the 
 physiological importance of the several parts of the organ of hearing. 
 
 Por those who are hard of hearing, the simplest mode of relief is 
 to direct the auricle forwards, either with the whole hand, which 
 increases the surface for the reflection of sound, or with the finger 
 only. The more the auricle is directed forwards and stretched, the 
 sharper will be the resonance, and the more distinct the reverberation 
 of sound, as may be clearly perceived with the healthy ear. Thus 
 by placing the hand behind the ear, we have a readily applied and 
 efficient means of rehef for hardness of hearing. 
 
 The ordinary apparatus for the improvement of the hearing pre- 
 sents two principal forms ; the first only collects and concentrates the 
 passing waves of sound, without in any way affecting their character, 
 except by sharpening them, and remarkably increasing the resonance ; 
 the second affords the means of maintaining conversation with a single 
 individual, or in general society. A point of primary importance in 
 the construction of these instruments is the material' of which they 
 
■144 AURAL SURGERY. 
 
 are made^ as funnels and tubes of caoutchouc and the elastic tube 
 constructed by Dunker ; or, on the other hand, funnels and trumpets 
 of metal, gold, silver, copper, brass, and iron. And another important 
 point is their form, whether they are merely elastic tubes or are 
 fashioned as sound-collectors of various size and whether made of 
 caoutchouc or metal. Usually both points are attended to. 
 
 Those who are hard of hearing can generally understand best 
 when they are addressed slowly and with distract articulation, and 
 with a strong, but not elevated clear voice ; sharp screaming voices, 
 on the contrary, do not make themselves readily intelligible to the 
 deaf. "We might therefore almost anticipate that metallic ear-trum- 
 pets, which render sound more acute without making it clearer, 
 afford as a rule little or no reUef, but, by over-excitiag the auditory 
 nerve, actually rather deteriorate the power of hearing, exactly in the 
 same manner as too bright a light injuriously excites the optic nerve. 
 
 K the patient desire to hold intercourse with persons whose organ 
 of voice is extremely weak, he should employ Bunker's tube, or 
 one composed of vulcanized India rubber, with a short wooden 
 funnel at one extremity, to which the speaker must apply his 
 mouth, and with a thin leathern or India-rubber prolongation at 
 the other end, which can be inserted into the ear of the patient. 
 Such tubes may be of any length ; they do not ia any way alter 
 the sound of the voice, and are most efficient when spoken iato 
 with the usual tone of the voice. When this kind of tube ceases 
 to be of service to the patient, a larger funnel of vulcanized India- 
 rubber may be employed, or the same instrument may be stiffened 
 and varnished. Gutta-percha ear trumpets are still more ef&cient, 
 but they give a remarkable degree of sharpness to the sounds trans- 
 mitted through them, which is often injurious. The most common 
 form is a flattened trumpet of sufficient size to cover the ear. Usually 
 two of these trumpets are united by a steel spring passing over the 
 head and conveniently retaining the innner extremities in the ears. 
 "With the increase of the size of these variously formed ear-trumpets 
 and especially of the sound-collecting extremity, the strength of the 
 sound transmitted increases, but it must be remembered that their 
 stimulant effect upon the auditory nerves is correspondingly injurious, 
 and therefore they should only be used as seldom, and for as short 
 a time as possible, if we wish to avoid the rapid increase of the 
 hardness of hearing. 
 
APPENDIX. 145 
 
 Authors to whom reference has been made in the preceding 
 
 pages. 
 
 'Compendium of Auxal Surgery/ by Dr. W. Eau, 1856. 
 'Treatise on the Diseases of the Ear/ by D. E. H. Triquet, 1857. 
 Dr. W. Kramer ia 'Deutsche Klinik/ 13th June, 6th Dec., 1856; 
 15th Oct. 1857; 29th May, 5th June, 30th Oct., 9th Nov., :25th 
 Dec, 1858; 9th Jan., 38th May, 1859. 'Diseases of the Ear, 
 illustrated by Clinical Observations,^ by J. Nottingham, 1857. 'A 
 Catalogue description of Preparations illustrative of the Diseases of 
 the Ear," 1857, by J. Toynbee. The 'Diseases of the Ear/ by 
 J. Toynbee, i860. 'Eationelle Otiatrik,' by Dr. Erhard, 1859. 
 'Deafness and Diseases of the Ear,' by W. "Wright, i860. 
 ' Theoretical and Practical Treatise on the Maladies of the Ear, and 
 of the Auditory Organ,' by Bonnafont, i860. Hyrtl, ' Handbook 
 of Topographical Anatomy/ 4th edit., i860 ; Hinton, in 'Medico- 
 Chirurgical Transactions,' vol. xxxix, 1856, p. loi ; VoltoHni in 
 Virchow's ' Archiv/ 1859, July, p. 193; i860, I, p. 43, 558; 
 'Deutsche Klinik,' 1858, p. 339; Y. Troeltsch in Yirchow's 
 ' Archiv/ 1859, July, p. i. 
 
 Works by the same Author. 
 
 ' Practical Hints upon the Eecognition and Cure of Protracted 
 Hardness of Hearing,' 1833. 
 
 ' The Precognition and Cure of Aural Diseases' 1836; translated 
 into English 1837; into Erench, 1840-48; Swedish 1843; Danish 
 1843.' 
 
 'The Curability of Deafaess', 1843. 
 
 'Contributions to Aural Surgery', 1845. 
 
 'The Eecognition and Cure of Aural Diseases,' 3nd edition, 1849. 
 .'Aural Surgery/ in the years 1849, 1850, 1851. 
 
 ' Aural Surgery,' in the years 1851, 1855-56. 
 
 ' Aural Surgery,' of the present day. 
 
INDEX. 
 
 42j 
 
 Abscess below mastoid process . . . .120 
 
 in external meatus 
 
 treatment of 
 on auricle . 
 
 on the cartilage of the ear 
 over mastoid process . 
 Accumulations of cerumen 
 
 Acute inflammation of the facial nerve, within the Eallopiaa canal 
 Apparatus, mechanical, for the improvement of the hearing 
 Auditory nerve, pathological changes in . 
 Aural diseases, aetiology of . 
 diagnosis of . 
 division of . 
 complications of, usually the result of injury to the mem- 
 
 brana tympani 
 general considerations respecting treatment of 
 hereditary tendency not a cause of : 
 predisposition to, iu childhood 
 from gout 
 from rheumatism . 
 from scrofula 
 from syphilis 
 prognosis of . 
 seldom dangerous to life . 
 tabular view of 
 tabular arrangement of , 
 usually chronic 
 Aural catheters 
 Aural forceps 
 Aural speculum 
 Aural syringe, employment of 
 Auricle, diseases of . 
 
 do not affect the hearing 
 inflammation of the dermis of . 
 
 11 
 
 47. 49) 53. 56. 57. 58. <io. ('I, 
 
 51 
 53 
 39 
 40 
 
 54 
 44> 45 
 120 
 
 143 
 
 122 
 
 20 
 
 21 
 
 35 
 
 35 
 34 
 
 19 
 20 
 20 
 20 
 20 
 20 
 34 
 34 
 17 
 138 
 
 33 
 
 26 
 
 47 
 22 
 68,71 
 
 36 
 36 
 36 
 
148 
 
 INDEX. 
 
 Auricle, inflammation of the dermis of, causes of . . -37 
 
 chronic form of . -38 
 
 symptoms of . -38 
 
 complications of . -37 
 
 pathological appearance of . 38 
 
 prognosis of . . 37, 39 
 
 symptoms of acute form of . 36 
 
 treatment of . 37, 39 
 
 perichondrium of . . .40 
 
 the connectire tissue of . . -39 
 
 of the ear, uses of . , . . -5 
 
 Baths of Kreuznach, Nauheim, &c. . . . 39, 56, 101 
 
 Bleeding from the ears . . . . -79 
 
 Bougies, mode of introduction . . .32, 103, 107 
 
 Cannla for removal of polypi . . . . .80 
 
 Caries of eiternal meatus . . . . 67,118 
 
 Cartilage, auricular diseases of . . . • 3^ 
 
 of the ear, uses of . . . . -5 
 
 Catarrhal inflammation of the middle ear . . .86 
 
 with suppressed exudation 
 
 with free exudation 
 
 with free and interstitial exuda 
 tion 
 
 with exclusively interstitial ex- 
 udation 
 
 90 
 97 
 
 Catgut bougies, mode of introduction . . .32, gg, 107 
 Catheters, employment of . . 28, 81, 83, 88, 92, 102, no 
 
 Eustachian, mode of introduction . , .28 
 
 in children . .28 
 
 Cerebral symptoms in aural disease . . . 116,117,128 
 
 Cerumen, collections of . . . .42, 44, 4f; 
 
 deficiency of . . . . .106 
 
 Ceruminous glands, inflammation of . . . .42 
 
 Chorda tympani, irritation of, a cause of noise in the ears . 16, 113 
 
 Cicatrices of membrana tympani after perforation . . .66 
 
 Collections of cerumen . . . . 5, 42, 44 
 
 Coma, a symptom of aural disease . . . 116,117 
 
 Comparison between the eye and ear . . . ,1 
 
 Conducting power of different parts of the ear for sound . . 7 
 
 Connective tissue of auricle, inflammation of . . '39 
 
 of external meatus, inflammation of ■ '51 
 
 Convulsions, a symptom of acute inflammation of labyrinth , -115 
 
 Corium of the meatus, inflammation of , . . -47 
 
 Cuticle of meatus, inflammation of . • . .42 
 
INDEX. 
 
 149 
 
 Deaf mutism • . . . 
 
 Dermis of auricle, inflammation of, acute form 
 
 chronic form 
 meatus, inflammation of 
 Diagnosis, physical, more trustworthy than subjective 
 Diagnostic tube, employment of 
 
 Discharge from the ears . , .54, 64, 
 
 Diseases of external ear . 
 
 frequency of . . 
 
 are readily recognisable 
 their prognosis generally favorable 
 the auricular cartilage 
 external meatus 
 internal ear . 
 middle ear . 
 Division of the diseases of the ear 
 Draughts of air, exposure to, a cause of aural disease 
 
 Ear and eye, comparison between 
 Ears, necessity of protecting them 
 Elastic bougies 
 Eustachian catheters 
 
 mode of employment of 
 tube, injection of , 
 
 syringe for 
 Exposure to cold, injurious effects of 
 External meatus, examination of healthy . 
 
 injection into 
 
 removal of foreign bodies from 
 
 Facial nerve, acute inflammation of 
 
 prognosis of 
 treatment of 
 Faculty of hearing imperfect in very young children 
 becomes evident about first year 
 Fenestra ovalis, importance of . 
 rotunda, importance of 
 Forceps, aural 
 
 Foreign bodies in external meatus, removal of 
 Frequency, comparative, of diseases of the eye and ear 
 
 of aural diseases in males and females 
 of diseases of the middle ear relatively great 
 internal ear relatively small 
 Fulness, sensation of, a symptom of aural disease . 
 
 Ccout, a predisposing cause to aural disease 
 
 Habits, peculiar, of the English, a cause of aural disease 
 Haemorrhage from the ears . i . 
 
 68, 79, II 
 
 129 
 
 36 
 
 38 
 
 47 
 21 
 
 30 
 6, 117 
 
 3S 
 35 
 35 
 36 
 36 
 41 
 
 115 
 
 80 
 
 35 
 20 
 
 I 
 12 
 
 32 
 26 
 27 
 
 89, g6, 102, no 
 89 
 13 
 23 
 43 
 46 
 
 120 
 121 
 121 
 
 5 
 
 6 
 
 10 
 
 10,86 
 
 47 
 46 
 
 33 
 33 
 33 
 33 
 
 20 
 
 21 
 
 19 
 
150 
 
 INDEX. 
 
 Hardness of hearing and deafness as symptoms of various aural diseases 
 
 13. 15. SI. 53> 59. 63, 86, 88, 90, 117 
 a general symptom of aural diseases 
 a symptom of inflammation of the cuticle of the 
 
 external meatus 
 of the corium of the 
 
 meatus . 
 of the connective tis- 
 sue of the meatus . 
 of the periosteum of 
 
 the meatus 
 ofmembranatympani 59,63 
 of diseases of the middle ear 
 
 86, 88, 90, 93, 105 
 
 121 
 13 
 
 44 
 
 51 
 
 55 
 
 of the internal ear 
 determination of amount of, in deaf and dumb 
 means of overcoming 
 not an independent disease 
 not caused by noise in the ears 
 produced by cerumen 
 
 by foreign bodies 
 
 by polypi . 
 
 by pus 
 
 by swelling of conucotive tissue 
 
 by sweUing of the dermis 
 slow discovery of . 
 Herpes a predisposing cause to aural disease 
 
 Inflammation, extension of, to dura mater and brain . 37, 64, 79, 116, i 
 of membrana tympani 
 
 acute form 
 chronic form 
 frequency of 
 Inflammation of membrana tympani, prognosis of 
 
 treatment of 
 connective tissue of the meatus 
 corium of the meatus 
 
 prognosis of . 
 treatment of . 
 the cuticle of external meatus 
 periosteum of the meatus 
 Injections, employment of . 47, 49i 53> 55. 57. 58. 60, 67, 68, 
 
 Injuries to the membrana tympani 
 
 Knife for removal of polypi 
 
 Labyrinth, acute inflammation of 
 chronic inflammation of 
 
 117 
 
 14 
 
 13 
 
 15 
 
 15 
 
 5.43 
 
 5 
 
 5 
 
 5 
 
 5 
 
 5 
 
 13 
 
 20 
 
 8, 120 
 
 • 57 
 
 • 57 
 . 61 
 . 6s 
 
 59. 66 
 
 60, 67 
 
 • 51 
 
 • 47 
 
 • 49 
 
 ■ 49 
 . 42 
 
 . 54 
 71,89 
 . 116 
 
 • 77 
 
 ■ IIS 
 , 117 
 
INDEX. 151 
 
 Labyrintli, pathological cbanges in 
 Lamp, photogen, of Mitscherlich 
 Leveret's ligature canula 
 
 54 
 6 
 
 48, SS 
 47 
 
 47 
 
 23 
 
 41 
 
 61 
 
 60,68 
 
 6 
 
 6 
 
 7 
 6 
 
 143 
 
 23 
 
 3<5= 57 
 
 62, 66, 116, 117 
 
 69, 70 
 
 . 116 
 
 II 
 
 24 
 
 80 
 
 Mastoid process, abscess on 
 Meatus a protection to the membrana tympani 
 caries of . 
 
 cerium of, inflammation of 
 dermis of, inflammation of 
 examination of healthy . . 
 
 external, diseases of . 
 
 inflammation of connective tissue of 
 injection of ... 
 
 memblrana tympani, uses of 
 
 effects of effusion in 
 importance of the convexity of 
 injury of 
 Mechanical apparatus for the improvement of the hearing 
 Membrana tympani, healthy, examination of 
 inflammation of 
 perforations of 
 
 artificial 
 symptoms of injury of 
 Membranous labyrinth, uses of, unascertained 
 Middle ear, catarrhal inflammation of, with suppressed exudation . 86 
 
 causes of . • §7 
 
 diagnosis of . .88 
 
 prognosis . . 89 
 
 treatment . . 89 
 
 with free exudation . • 91 
 
 diagnosis . .92 
 
 prognosis . . 94 
 
 treatment . . 94 
 
 with free and interstitial exudati'^n 97 
 
 diagnosis . . 99 
 
 causes of . . 100 
 
 prognosis . 100 
 
 treatment . . loi 
 
 with exclusively interstitial exudation 105 
 
 symptoms . . 106 
 
 frequency . . 108 
 
 prognosis . .109 
 
 treatment . . 109 
 
 Middle ear, diseases of . . . . .80 
 
 Morbid appearances in ear . • . . . .2 
 
 Mucus, accumulations of, in tympanum, seriously affect the hearing . 9 
 
 Necrosis of external meatus . . , . -55 
 
152 
 
 INDEX. 
 
 Nervous hardness of hearing, and deafness 
 
 PAGE 
 121 
 
 causes of 
 
 • 127 
 
 diagnosis of 
 
 . 124 
 
 treatment of 
 
 128 
 
 pain in the ear 
 
 It4 
 
 Noise in the ear, frequency of . 
 
 16 
 
 a local affection 
 
 • 19 
 
 causes of . 
 
 . 16 
 
 increased by vascular excitement' . 
 
 19 
 
 not an independent disease 
 
 19 
 
 proceeds from mechanical irritation of chorda tympani 
 
 i8 
 
 produced by cerumen . 
 
 18 
 
 produced by collection of mucus . . ^ 
 
 l8 
 
 suicide from .... 
 
 19 
 
 very depressing 
 
 19 
 
 with interstitial exudation 
 
 18 
 
 with chronic inflammation of the raembrana tympani 
 
 . 18 
 
 with complete deafness 
 
 19 
 
 ears a symptom of aural diseases . ig, 21, 48, 31, 88, 5 
 
 I, 128 
 
 without hardness of hearing 
 
 • 113 
 
 diagnosis of 
 
 "3 
 
 prognosis of 
 
 "3 
 
 Noises, injurious effects of 
 
 
 13 
 
 Oiled wool, employment of, in bathing 
 
 
 13 
 
 Ossicula, are conductors of sound 
 
 
 8 
 
 conduction of sound through 
 
 
 7 
 
 do not convey musical sounds . 
 
 
 8 
 
 importance of 
 
 
 7 
 
 Miiller's experiments upon 
 
 
 7 
 
 Otalgia ..... 
 
 
 114 
 
 treatment of . 
 
 
 114 
 
 Pain a symptom of aural disease 
 
 
 21, 37. 38, 39. 40, 42; 47. SI. 5S. S7. 59. 63, 91. " 
 
 5. "7 
 
 Pathological changes in ear . 
 
 2 
 
 of the labyrinth 
 
 
 122 
 
 Perforations of membrana tympani 
 
 
 62 
 
 Perichondrium of auricle, inflammation of 
 
 
 40 
 
 Periosteum of external meatus, inflammation of 
 
 
 54 
 
 Periostitb of external meatus . 
 
 
 • 54 
 
 prognosis of 
 
 
 • 55 
 
 treatment of 
 
 
 • 55 
 
 Physiology of the ear 
 
 
 4 
 
 Polypi in external meatus 
 
 50,(3 
 
 2, 117 
 
 treatment of 
 
 50, 66, 71, 
 
 77.78 
 
 Porte caustique 
 
 
 71,76 
 
 Predisposing causes of aural diseases 
 
 
 . • 20 
 
INDEX. 153 
 
 Prognosis of aural diseases generally . . . -34 
 
 of inflammation of the dermis of the auricle . . 37 
 
 of acute inflammation of membrana tympani . . 59 
 
 of the labyrinth . . .116 
 
 of catarrhal' inflammation of middle ear with suppressed exu- 
 dation . . . . . .89 
 
 of catarrhal inflammation of middle ear with free exudation . 94 
 of catarrhal inflammation of middle ear with free and interstitial 
 exudation . . . . , 100 
 
 of catarrhal inflammation of middle ear, with exclusive inter- 
 stitial exudation ..... 109 
 
 of chronic inflammation of membrana tympani . . 67 
 
 of the labyrinth . . .119 
 
 of deaf mutism . . . . -133 
 
 of diseases of the membrana tympani . . • 57 
 
 of hsemorrhage from the ears . . . • 19 
 
 of inflammation of facial nerve . . . .121 
 
 of noise in the ears without hardness of hearing . . 113 
 
 of otalgia. . . , . .114 
 
 of perforation of membrana tympani . . 66,71 
 
 of periostitis of the meatus . . ■ -55 
 
 of the chronic form of auricle . . . -39 
 
 of the corinm of the external meatus . . - 49 
 
 of the perichondrium of the auricle . . -41 
 
 Prophylactic treatment of aural diseases . . .12 
 
 Protecting the ears, necessity for . . . .12 
 
 Rachitis, a predisposing cause to aural disease . . .20 
 
 Rheumatism, a predisposing cause to aural disease . . .20 
 
 Rhinoscopy as practised by Voltolini . , . ■ ^5 
 
 Rigors a symptom of grave import . . . 64, 73, 91, 119 
 
 Scissors for removal of polypi . : . . -78 
 
 Scrofula, a predisposing cause to aural disease . . .20 
 
 Sound, conduction of, through different parts of the ear . .7 
 
 Speaking-trumpets ...... 143 
 
 Special surgery of the ear . . . . • 53 
 
 Speculum, aural . , . . . .22 
 
 Stricture of Eustachian tube, treatment of . . 32, 83 
 
 Sudden atmospheric changes a predisposing cause to aural disease . 20 
 
 Sunlight, importance of, for the examination of the ear . . 23 
 
 Suppuration in meatus . ■ . . -53 
 
 Syphilis, a predisposing cause to aural disease . . .20 
 
 Syringe, aural, employment of . . . .45, 47, 68, 89 
 
 Toynbee. Artificial membrana tympani . . . '73 
 
 Treatment, general, of aural diseases . . . -34 
 
154 
 
 INDEX. 
 
 suppressed 
 
 free exu- 
 
 exclusively 
 
 Treatment of inflammation of dermis of auricle 
 
 of connective tissue of auricle 
 of perichondrium 
 of abscess in external meatus . 
 of acute inflammation of the labyrinth 
 
 of membrana tympani 
 of catarrhal inflammation of middle ear, with 
 
 exudation 
 of catarrhal inflammation of middle ear, with 
 
 dation .... 
 of catarrhal inflammation of middle ear, with free and in 
 
 terstitial exudation 
 of catarrhal inflammation of middle ear, with 
 
 interstitial exudation 
 of chronic inflammation of the labyrinth . 
 
 of membrana tympani 
 of collection of cerumen in the meatus 
 of deaf mutism 
 
 of diseases of membrana tympani 
 of inflammation of connective tissue of meatus 
 of facial nerve 
 of the cuticle of meatus . 
 of the dermis of the meatus 
 of insects, &o., in external meatus 
 of noise in the ears, without hardness of hearing 
 of otalgia 
 
 of periostitis of external meatus 
 of polypi in external meatus . 
 Tube, diagnostic, employment of 
 Tumours, bloody, on auricle 
 Tympani cavity, injection of 
 
 Voltolini's rhinoscopy 
 
 Watches, several, requisite for experiments on the deaf 
 superior to tuning-fork for experiment 
 
 Yearsley's balls of cotton wool . 
 
 50, 66, 71, 
 
 37 
 40 
 
 41 
 
 53 
 
 116 
 
 66 
 
 9-1 
 
 loi 
 
 109 
 
 119 
 
 67 
 
 45 
 
 134 
 
 57 
 
 S3 
 
 121 
 
 45 
 
 49 
 
 47 
 
 "3 
 
 114 
 
 56 
 
 77,78 
 30 
 41 
 89 
 
 25 
 
 15 
 
 74 
 
 PJIISTED BY J. li. ADLAKD, BABTHOI.OJIEW CI-OSK. 
 
'k^ tt S » • 
 
 
 
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