TINNITUS AURIUM 
OR 
NOISES IN THE EARS. 
SECOND EDITION, WITH CASES. 
BY 
LAURENCE TURNBULL, Ph. G„ M.D., 
PHYSICIAN TO THE DEPARTMENT OF DISEASES OF THE EYE AND EAR OF 
HOWARD HOSPITAL, PHILADELPHIA ; FELLOW OF THE AMERICAN ASSO- 
CIATION FOR THE ADVANCEMENT OF SCIENCE; PERMANENT MEM- 
BER OF THE AMERICAN MEDICAL ASSOCIATION; AUTHOR 
OF ‘‘THE NATURE, CAUSES AND TREATMENT OF NER- 
VOUS DEAFNESS/* *‘A CLINICAL MANUAL OF THE 
DISEASES OF THE EAR,” ETC., ETC. 
(Reprintedfrom the Philadelphia Medical Times, June and October, 1874.) 
PHILADELPHIA: 
J. B. LIPPINCOTT & CO. 
1876. TINNITUS AURIUM 
OR 
NOISES IN THE EARS. 
SECOND EDITION, WITH/CASES. 
BY 
LAURENCE TURNBULL, Ph. G., M.D., 
PHYSICIAN TO THE DEPARTMENT OF DISEASES OF THE EYE AND EAR OF 
HOWARD HOSPITAL, PHILADELPHIA; FELLOW OF THE AMERICAN ASSO- 
CIATION FOR THE ADVANCEMENT OF SCIENCE; PERMANENT MEM- 
BER OF THE AMERICAN MEDICAL ASSOCIATION; AUTHOR 
OF “THE NATURE, CAUSES AND TREATMENT OF NER- 
VOUS DEAFNESS," “A CLINICAL MANUAL OF THE 
DISEASES OF THE EAR,” ETC., ETC. 
(Reprintedfrom the Philadelphia Medical Times, June and October, 1874.) 
PHILADELPHIA: 
J. B. LIPPINCOTT & CO. 
1875. PREFACE. 
The demand for the first edition having been far in 
excess of the supply, and the reception of the brochure 
having been of so flattering a nature both at home and 
abroad, the author has felt impelled by the importance 
of his subject, and a sense of duty to his profession, to 
issue a revised edition of his views in this most distress- 
ing of all maladies. 
LAURENCE TURNBULL. 
i2o8 Spruce Street, Philadelphia, August, 1875. TINNITUS AURIUM. 
r'PHE ringing noises heard in the ears are not only 
a symptom of the diseased condition of the 
organ, but also a very troublesome form of disease 
in itself, for after all apparent disorder has passed, 
the patient is still distressed and disturbed by a 
most persistent form of tinnitus. 
Each individual, although suffering from the 
same symptom, generally describes it according as 
it is suggested by his or her habits or occupation. 
The old lady, fond of her cup of tea, compares the 
noises to the singing of the boiling kettle; while 
the servant in the kitchen has a constant ringing 
of bells in her ears. The engineer will tell you 
that the noise is like a faint locomotive-whistle ; 
the miller compares it to the whirr of the wheel ; 
while the boiler-maker has a succession of knock- 
ings in his ears; the gardener or farmer talks of it 
as a rustling of leaves, or waving of ripe grain ; the 
sailor, or dweller near the sea, identifies it with the 
roar of the ocean. 
Then we have the agreeable forms, as in an old 
deaf lady, who informed the writer that she was 
often serenaded by lovely voices, and would in- 
quire of her children if they did not hear the same 
sweet sounds. Another pleasant form noticed by 
a recent writer* was in the case of a middle-aged 
woman, who spoke of the noise as a low singing of 
birds. 
* Dr. Dalby, of London. 6 
There are some forms which, if neglected, become 
almost a mental malady, especially if the brain is 
diseased, or if there is a hereditary tendency in the 
family, but we have never known of a case of sui- 
cide from this cause, and our opinion is confirmed 
in a letter to the writer from Dr. Kirkbride, who 
for so many years has been the physician-in-chief 
of the Pennsylvania Hospital for the Insane in 
Philadelphia: “I do not now recall a case of insanity 
really owing to aural disease, although I think that 
defective hearing often aggravates some of the de- 
lusions of the insane, and disorder of the hearing- 
apparatus is not infrequent in insanity.” 
Dr. J. H. Worthington, physician-in-chief of the 
Friends’ Asylum for the Insane (Twenty-third Ward, 
Philadelphia), thus writes : “I never knew a case of 
mental disorder which owed its existence to such 
disease (aural), nor any case of suicide in conse- 
quence of tinnitus aurium.” 
A similar opinion is expressed by Dr. John Cur- 
wen, physician-in-chief to the Pennsylvania State 
Lunatic Hospital, Harrisburg, who had also a long 
experience as first assistant-physician of the Penn- 
sylvania Hospital for the Insane, at Philadelphia. 
He writes, “ I do not recollect any cases of insanity 
under my care which were produced by ear-noises; 
all the cases of hallucination of hearing have arisen 
from diseases of the brain, induced in various ways. 
The three most decided cases now in my care are 
caused by intemperance and overwork, both mental 
and bodily, bringing on great cerebral disorder.” 
Von Troltsch,* in his work on the ear, says in 
regard to the tinnitus aurium of the insane, “ It is 
a very important question whether the aural hallu- 
cinations occurring in insane patients do not fre- 
quently depend on peripheric tinnitus, which is 
* Fifth German edition, p. 515. 7 
exaggerated by the patients.” It would be well 
worth the trouble of physicians for the insane to 
examine the ears of such patients. He further 
states, “I am indebted to my esteemed friend Prof. 
L. Meyer, formerly director of the Insane Asylum of 
Hamburg, for the history of a melancholic patient 
who was relieved of a sound in the ear (seeming to 
the patient to be the cry of a child) by the removal 
of a plug of inspissated cerumen, which caused 
deafness of one side. The patient, from that time 
forward, made a rapid and complete recovery.” 
Schwartze, an aural surgeon, and Koppe, a phy- 
sician for the insane, have made this question a 
subject of investigation. 
Schwartze says, “ Subjective aural sensations, 
which are caused by demonstrable affections of the 
ear, may, in predisposed persons, especially when 
there is hereditary tendency to mental disease, 
become the direct cause of aural hallucinations, 
that may accelerate the outbreak of mental disease.” 
He states that he treated such a patient for a long 
time, and she was protected from a threatened 
attack by the local treatment of the aural disease. 
Dr. Koppe, before referred to, assistant-physician 
to the Provincial Insane Asylum at Halle, examined 
this patient with Dr. Schwartze, and was convinced 
that the treatment caused the above-mentioned 
results. In other cases, insane persons who suffer 
from aural disease distinguish its tinnitus from their 
illusions or hallucinations. They hear their 
“sounds” simultaneously, but independently, of 
the tinnitus aurium. 
Dr. Koppe examined thirty-one insane persons 
in whom considerable disease of the auditory appa- 
ratus could be detected. In none of them was 
there tinnitus without at the same time the exist- 
ence of aural illusions and hallucinations. 
Seven insane persons also had chronic hypersemia 8 
of the vessels of the handle of the malleus, and, 
besides the subjective aural sensations, aural illu- 
sions and hallucinations. In two cases of inspis- 
sated cerumen, the tinnitus disappeared after the 
removal of the plugs of wax, but the hallucinations 
remained. In several cases, which are fully detailed, 
both the tinnitus and the hallucinations disappeared 
after local treatment of the ear. Two cases were 
particularly interesting, where only one ear was 
affected, and where the sounds were only heard on 
that side.* 
Troltschf again states, “Perhaps we may desig- 
nate the one variety as nervous tinnitus aurium, the 
other as material or acoustic, and which may exist 
at the same time.” 
William Harvey, F.R.C.S.,| mentions hysterical, 
hypochondriacal, and nervous patients, as suffering 
from every possible form of tinnitus. Wilde§ says, 
“ In some forms of hysteria, and in cases of mental 
aberration and lunacy, as those familiar with such 
know full well, the patients often complain of all 
manner of noises, whisperings, and unnatural sounds, 
but these are, I believe, generally the result of a 
disordered imagination, like the ocular spectra 
which afflict certain individuals.” 
Saissy,|| in treating of symptomatic tinnitus, says 
it depends on “ nervous diseases, such as hysteria, 
hypochondriasis, convulsions, and mental aliena- 
tions.” 
Dr. O. D. Pomeroy,of New York, made an 
examination of sixty lunatics at the Blackwell’s 
* Berliner Klinische Wochenschrift, 1866, Nos. 12, 13,—“ Gehorstorun- 
gen und Psychosen.” Allgem. Zeitschr. fur Psychiatrie, 1867, Bd. xxiv. 
Auszugsweise im Archiv fiir Ohrenheilkunde, B. iii. S. 332. 
+ Allg. Zeitschr. f. Psych., iii. 332. 
t The Ear in Health and Disease, London, 1865, p. 25. 
| Diseases of the Ear, Philadelphia, 1853, p 361. 
|| An Essay on the Diseases of the Internal Ear. J. A. Saissy, Balti- 
more, 1829, p. 132. 
V Transactions Am. Otol. Society, Boston, 1871, p. 44 9 
Island Lunatic Asylum, New York, thirty of whom 
had hallucinations of hearing, and thirty had none, 
with the view of determining whether diseases of 
the ear had any agency in the production of the 
symptoms, and his conclusions were as follows: 
“ The result of the examination is a little in favor of 
the hallucination cases being oftener associated with 
ear-disease. The proportion is not, however, any- 
thing like that previously quoted from Von Troltsch 
and others.” “Neither was it possible to observe 
any connection between the tinnitus aurium and the 
hallucinations.” Certainly, the aural disease did 
not, in a single instance, develop or excite the in- 
sanity, as has been quoted. This confirms our own 
examinations and correspondence, and gives a more 
hopeful and proper view of even the worst form of 
this affection. Our rule should be that if there is 
any hereditary tendency to mental disease, and there 
are persistent hallucinations resembling any of the 
forms we have given as examples, care should be 
taken that the ears be examined, and, if it be possi- 
ble, this symptom removed. We cannot pass from 
this part of our subject without a short reference to 
the observations made by Nussbaumer, in which he 
attacks the physiological axiom that each organ of 
sense is capable of peculiar perceptions, which can 
be excited by no one of the other organs of sense. 
“The author himself, and his older brother, both 
have this peculiarity, that every perception of sound, 
either musical or otherwise, excites also a percep- 
tion of light. His ear is so delicate that with the 
deep notes of a piano he is able to hear eleven 
over-tones, and with each one of these has a dis- 
tinct perception of light. As children, he and his 
brother were in the habit of designating frequently 
the tones of different objects when struck, not by 
the sound, but by the color produced. 
“To learn whether the perceptions of the two 10 
brothers were always the same, a long series of 
questions, to be answered by each, was written, 
from which it seemed that, although each had a 
perception of light with each sound tried, the color 
of the light varied : being, for instance, for the 
note A, in one, dark Prussian blue, and in the other, 
dark yellow. 
“ The color was never seen externally, but, as he 
expressed it, his brain suffered from the action of 
a sound-wave in the meatus, not only the normal, 
but also such a change as produced in his conscious- 
ness an impression of color. When in concentrated 
thought, however, the perception of color might 
escape notice.” 
“ In the discussion which followed, Prof. Benedict 
considered that the phenomena were not physiolog- 
ical, but pathological. Optical perceptions, as the 
direct result of acoustical perceptions, could only 
be pathological. Similar obscure diseases of the 
mind and brain were frequently observed in hyster- 
ical, hypochondriacal, and melancholy persons, but 
were not understood, as most physicians were un- 
skilled in psychology. He predicted that similar 
observations to those of Nussbaumer would soon be 
reported, now that attention had been called to 
them. Finally, Prof. Benedict warned the patient 
against further observations on himself, lest the 
phenomena would overpower him, especially as it 
was evident that there was a hereditary tendency; 
possibly, heterotopia was the cause of the phenom- 
enon.”* 
THE DIAGNOSIS AND CAUSES OF TINNITUS AURIUM. 
The first and most frequent cause we shall notice 
is the pressing of a portion of altered cerumen 
* Report on Otology, by J. O. Greene, M.D., from Nussbaumer. Re- 
printed from the Boston Med. and Surg. Journal, October, 1873, p. 9. Ueber 
subjective Farbenempfindungen die durch objective Gehorempfindungen 
erzeugt werden. Wiener Med. Wochenschrift, Nos. 1, 2, 3, 1873. upon the membrana tympani. This usually arises 
from cold, heat, or moisture, or the three combined, 
detaching it from the side of the auditory canal and 
causing it to press on the membrane. The second 
cause is an elongation of the hairs in the external 
orifice of the auditory canal, passing across and 
interlacing with cerumen or epithelium scales, and 
when in the air producing a sound like an Hiolian 
harp. In another form, the point of a single hair 
was found to rest upon the surface of the membrana 
tympani. A particle of dried pus on the same 
membrane gave not only a sound, but a disagreeable 
one, until removed. 
A third cause is a small quantity of adhesive 
mucus on the inner surface of the membrana tym- 
pani, or middle ear, pharyngeal orifice of the Eus- 
tachian tube, or on the mucous membrane near 
the tube. These conditions are almost always an 
attendant in acute, subacute, or chronic catarrh. 
A fourth cause is a foreign body in the Eus- 
tachian tube, as, for instance, a beard of barley,* 
or a bullet.f In the first case, the beard caused otitis 
media purulenta, with most distressing noises, and 
was ultimately discharged through a perforation of 
the membrana tympani without the loss of the hear- 
ing, and with entire relief to the tinnitus. The 
bullet could not be removed. In a case related by 
Fleischmann, the result was not so satisfactory. 
A man complained for years of a continuous 
sound in his ears and of a very peculiar sensation 
in his pharynx. He subsequently died, and on a 
post-mortem section a beard of barley was found 
projecting from the pharyngeal orifice of the tube, 
and reaching up into its osseous portion.| 
A fifth cause of tinnitus occurs synchronously 
* Turnbull on Diseases of the Ear, p. 78. 
f Ibid., p. 94. 
X Ibid., p. 79. 12 
with the action of the heart, and may be caused by 
ancemia or a diseased condition of the blood, or 
enlargement or narrowing of some of the numerous 
arteries or their branches in the vicinity of the ear. 
This narrowing occurs generally in a branch of the 
temporal, posterior auricular, or carotid arteries, and 
we can determine by pressure whether it depends 
upon them, after finding no physical cause in the 
ear itself. 
A sixth class comprises a large number of doubt- 
ful cases, under the head of nervous tinnitus, in 
which it is conjectured that there is inflammation, 
irritation, extravasation, or disturbed circulation of 
blood in the labyrinth, cochlea, semicircular canals, 
auditory nerve, or reflected lesions of the brain. 
The diagnosis in this class of cases is made by 
excluding all causes which would be at all possible 
to produce the sound in the external or middle ear. 
The seventh cause is immoderate contraction 
of the tensor tympani muscle, which contraction 
not only moves the malleus and with it the mem- 
brana tympani, but also, if the contraction is excess- 
ive, draws the whole chain of ossicles inwards, and, 
as a consequence, the plate of the stirrup is pressed 
deeply into the oval window (fenestra ovalis), caus- 
ing violent subjective noises from the intra-laby- 
rinthal pressure. “ Dr. Gruber* observes that the 
tensor tympani muscle arises from the cartilaginous 
portion of the Eustachian tube, but is connected 
with the tensor veli palati muscle by a tendinous 
prolongation in such a way that the intimate con- 
nection between the two is completed; and L. 
Meyer even asserts that he considers the two mus- 
cles as a single digastric muscle. It is well known 
how often this muscle suffers in the frequent diseases 
of the naso-pharyngeal structures. If notice 
* Tenotomy of the Tensor Tympani, by Prof. Joseph Gruber, M.D. 
Translated by Charles S. Turnbull, M.D., Phila., 1873, p. 23. the soft palate and usually hypertrophied tonsils 
into which this muscle enters, we will see how the 
same is displaced and drawn out of its position, 
and it will be clear that this muscle in such cases is 
unable to properly perform its function—viz., the 
opening of the Eustachian tube; and this abnor- 
mity, sooner or later, will be sure to affect its com- 
panion muscle—the tensor tympani—and so cause 
the spasmodic contraction of the latter, which will 
exert a further influence upon the labyrinth.” 
Now the question arises, Are there any positive 
symptoms by which we can with certainty diagnos- 
ticate in the living such a retraction of the tensor 
tympani muscle ? We must answer most decidedly 
in the affirmative. 
I will not speak of the anamnesia, and of the 
subjective symptoms, which certainly deserve some 
consideration, but pass at once to those positive 
signs especially apparent in such cases. In conse- 
quence of the peculiar connection between the 
malleus and the membrana tympani, that is, the 
lower end of the malleus with the adjacent portion 
of the membrana, it is directed inwards, while at 
the upper end the short process pushes it outwards ; 
and there originate two folds, the posterior of 
which is much more distinct, running backward, 
while the anterior fold runs forward, and in the 
comparison of this bulging with the sunken condi- 
tion of the membrane we have an important indi- 
cation, which Dr. Gruber was the first to describe 
and employ in diagnosis. 
When the membrana tympani is drawn forcibly 
inwards, the lower end of the malleus is drawn with 
it, while the upper end remains nearer its normal 
position, so causing the posterior fold of the mem- 
brana tympani to become more prominent, and we 
have at once an abnormal inward bulging of the 
membrana tympani. Of course, such a condition 14 
of the membrana tympani can be produced by 
causes other than a contraction of the tensor tym- 
pani, but we possess very positive means of investi- 
gation for distinguishing other abnormities which 
show the same pathognomonic appearances on the 
part of the membrana, and by exclusion we can 
make our diagnosis sure. 
Since I have here considered the greater prom- 
inence of the folds of the membrane as a diagnostic 
symptom of the sunken condition, and as a phe- 
nomenon related to shortening of the tendon of the 
tensor tympani, I might also describe many others 
which are all caused by shortening of the tendon. 
We know how to recognize and appreciate them, 
and, by a minute examination and some diagnostic 
acuteness, should seldom remain in doubt. 
In this connection, I might mention a few of 
the symptoms which are here of great diagnostic 
value, but which, as it seems to me, have not been 
sufficiently appreciated by my colleagues. 
These appearances are as follows: The handle 
of the malleus appears broader, the membrana tym- 
pani is twisted (torquirt sein), the axis-band of the 
malleus becomes more conspicuous, and the mem- 
brana tympani returns more or less rapidly, by re- 
traction, into its former abnormal position, after 
the application of the air-douche had caused it to 
bulge outward. 
The eighth cause is “Aspergillus in the auditory 
canal or on the membrana tympani;” this is a 
mould or fungus lining the auditory canal and mem- 
brana tympani. It causes inflammation and pain 
with a discharge as in otorrhoea, and, after syringing, 
of a whitish-yellow membrane which is frequently a 
complete cast of the external auditory meatus and 
membrana tympani. In every obstinate case of 
inflammation of the auditory canal, we should care- 
fully examine the discharged material under the microscope to be certain of the diagnosis. The 
symptoms are fulness of the ear, constant tinnitus 
aurium, and pain of a dull heavy character.* 
PATHOLOGY. 
We have noticed, under various causes, that “tin- 
nitus aurium” results from affections of the external 
ear, both the anterior and posterior surface of the 
membrana tympani, cavity of the tympanum (mid- 
dle ear), and Eustachian tubes, when closed by ad- 
hesive secretion or thickening of the mucous mem- 
brane, or from the opposite condition of being too 
open. The noises in the internal ear have also been 
confounded with an affection of the brain itself or 
its coverings. It is possible to have ringing noises 
in the ear even when there are, so far as our exami- 
nations can penetrate, no organic changes in any 
portion of the ear. 
In the post-mortem examination of persons who 
have suffered from “tinnitus” for a long period 
without any disease of the middle ear, the appear- 
ances found on dissection of the petrous bone by 
Meniere,f Schwartze,§ and Hinton,|| are 
disease of the semicircular canals, ecchymoses in 
the vestibule, hypersemia of the cochlea, general 
enlargement and fulness of the vessels of the laby- 
rinth. 
We must therefore for the present come to the 
conclusion that the semicircular canals and vesti- 
bule are also the seat of the diseased conditions above 
described, with now and then apoplexy or endo- 
labyrinthic fulness of the labyrinth, showing more 
or less pressure within its walls or irritation of the 
auditory nerve. 
* See paper by the writer on “Aspergillus,” in Transactions Med. Soc. 
of the State of Pennsylvania, 1873. Diseases of the Ear, pp. 104-7. 
(• Gazette Med. de Paris, 1861, p. 29. 
Archiv des Ohrenheilkunde, vol. ii. p. 88. 
Ibid., Bd. i. p. 206. 
ij Diseases and Injuries of the Ear, by Dalby, p. 182. 16 
TREATMENT. 
In the first class of cases to which we referred— 
namely, pressure from cerumen upon the tnembrana 
tympani—the treatment in the great majority of 
cases is simply to remove the offending cause by 
means of the injection of tepid water or weak solu- 
tion of soda. Numerous cases of this class are 
relieved by this simple procedure; many of which 
are of a most distressing character. 
The second variety is caused by excessive growth 
of stiff hairs in the meatus. The treatment con- 
sists in carefully cutting the hairs close up to their 
point of exit by means of curved scissors, and re- 
moving each one when cut. The objection to 
plucking them out is that it will frequently cause 
an abscess at the termination of the hair-follicle. 
Another form of this same variety is when a hair 
becomes detached and falls upon the membrana 
tympani, from which it must be removed by means 
of acamel’s-hair pencil slightly moistened in glycerin. 
The patient referred to in whom pus from an ab- 
scess was washed'" to the surface of the membrana 
tympani was a distinguished hospital surgeon, who 
caused it by attempting to wash out his own ear. 
When the syringe was properly employed in the 
hands of another, the pus was removed, and the 
tinnitus ceased. 
The third variety of causes is when adhesive mucus 
is on the posterior surface of the membrana tympani, 
in the middle ear, or in the mastoid cells. This is 
removed by the catheter or a few blasts from Polit- 
zer’s air-bag or douche; if these means are not 
effectual, paracentesis of the membrana tympani 
and washing out the middle ear with a weak solu- 
tion of biborate or sulphocarbolate of soda in warm 
water. At the same time attention must be given to 
the naso-pharyngeal region, with the use of the 
nasal douche, sprays, and gargles. In the fourth variety, or foreign bodies in the 
Eustachian tube, the treatment will be to reverse 
the action of the air-bag and withdrawing 
the air, or by means of an elastic catheter 
in the pharyngeal orifice of the tube, at 
the same time compressing the nostrils, or 
by means of a valved bag attached to a 
curved glass tube introduced through the 
mouth as near as possible 
to the orifice of the tube, 
and rarefying the air. If 
there be much swelling, 
thickening of the Eusta- 
chian tubes, etc., I have 
found the Eustachian for- 
ceps one of the most 
valuable instruments in 
making applications of 
stimulating agents, such 
as nitrate of silver, sul- 
phate of copper, iodine, 
and carbolic acid, directly 
to the parts. 
The annexed figures 
will illustrate the author’s 
Eustachian forceps (Fig. 
i), also the improved rhe- 
ophore (Fig. 2) ; the first 
to make applications by 
means of a fine piece of sponge charged 
with the fluid, either by the nose or under 
the soft palate to the Eustachian tubes. 
The second apparatus is placed in the 
auditory canal, which being previously 
half filled with warm salt-and-water, the 
metallic wire which projects is insulated by the vul- 
canite envelope. By means of the metallic screw 
a connection is made with the conductor of a gal- 
Fig. i. 
Fig. 2. 18 
vanic or inductive apparatus, and the circuit is 
closed by placing upon the mastoid process the 
other moist sponge, which communicates with the 
second conductor, and the galvanic current im- 
presses not only the muscles but the portio dura 
nerve by means of a few fascicules of fibres, which 
constitute what Wrisberg called the “portio inter- 
media,” forming a connecting link between the 
auditory and the facial nerve. 
Should the foreign body produce inflammation, 
with effusion, bulging of the membrane, etc., its escape 
should be facilitated by perforation of the membrane 
by an aspirator-needle or Prof. Gruber’s syringe. 
In the fifth form, or pulsating tinnitus, the result of 
some alteration in the blood-vessels, anaemia, or ex- 
cessive action of the heart, we must try compression 
of the temporal or carotid, diminishing the fre- 
quency of the heart’s action by aconite or digitalis; 
or, if the patient is anaemic, administer the salts of 
manganese, or the lactate or citrate of iron, with 
good nourishing diet and out-door exercise, avoid- 
ing all forms of excitement, as dancing, violent 
exercise, or mental effort. 
In the sixth class we must make a careful diag- 
nosis by exclusion to discover whether we have 
excitement of the brain causing subjective noises, 
or on the other hand exhaustion of the brain from 
over-effort or some drain upon the nervous system. 
For in the first instance we resort to large doses of 
bromide of potassium, or, if there is any suspicion 
of syphilitic complication, add the iodide of potas- 
sium until we produce bromidism on the one hand or 
iodidism on the other, with its characteristic eruption. 
If it is the second, from exhaustion, we resort to 
a solution of phosphoric acid employed in the form 
of a lemonade, or to the phosphites or hypo-phos- 
phites, in conjunction with strychnia or its salts, 
with the use of the galvanic current to assist in 
completing the cure. 19 
In the seventh class of cases the operation of 
tenotomy of the tensor tympani is to be recom- 
mended, and the mode of operation is that of Dr. 
Fr. E. Weber-Liel,* of Berlin, which we have here 
employed in a number of cases with more or less 
success, depending upon the cause. 
In the eighth class of cases, which are generally 
the result of a patulous condition of the orifice of 
the Eustachian tube, the remedy should be the 
application of a powerful solution of nitrate of sil- 
ver or sulphate of copper or carbolic acid to the 
mouth of the tube by means of the Eustachian for- 
ceps, and washing it by the use of the double 
Eustachian catheter, with the internal use of strych- 
nia, to stimulate the muscle to contract and close 
the orifice. 
The ninth class, or “Aspergillus;” the vegetable 
parasite or fungus is to be removed by the injection 
of spirits of wine or a warm saturated solution of 
sulphite of soda, and the discharge of mucus or 
serous fluid is to be checked by the use of an injec- 
tion of a strong solution of sulphocarbolate of zinc. 
A number of these cases of a mild character we have 
treated after the summer season in patients who have 
allowed the sea-water to pass into the ears and 
dampen the hair. In these cases a mild solution of 
an astringent, acetate of lead or sulphate of zinc, 
will remove all the symptoms of itching, deafness, 
and distressing tinnitus, in a very short time. 
Case I.—Tinnitus. The sounds resembling the 
action of a pump and the hissing of a snake, the result 
of impacted cerumen and the excessive use of tobacco. 
Henry L., aged 30, residence Philadelphia, occu- 
pation painter, complained of deafness, with sounds 
* Tenotomy of the Tensor Tympani, by Fr. E. Weber-Liel, Lecturer 
on Otology, University of Berlin. Translated by Laurence Turnbull, 
M.D. Pamphlet, pp. 14. J. Moore, Phila., 1873. 20 
like the hissing of a snake and the action of a pump. 
The patient uses tobacco to excess, both smoking 
and chewing. He is so deaf in the right ear that a 
loud-ticking watch is only heard in close contact. 
Left ear almost normal in hearing. On examination 
of right ear the meatus is found covered with patches 
of altered cerumen, while the membrana tympani is 
entirely covered with a concave mass, as if melted 
by heat. There is not much doubt that by its press- 
ure it first displaced and caused absorption of the 
air in the middle ear, driving the malleus inwards 
and pressing the stapes into the fenestra ovalis. 
Directed a warm solution of biborate of soda, in 
equal parts of glycerin and water, to be dropped 
into the meatus warm for three nights, and on the 
morning of the fourth day the parts were washed 
out by means of the syringe. This procedure did 
not give entire relief until fresh warm air was blown 
in by Politzer’s apparatus, when the concave mem- 
brane assumed its normal character, and the deaf- 
ness and sound disappeared. 
Case II.—Fluttering tinnitus with deafness of one 
side since June, 1873/ the result of bathing. Treat- 
ment for two weeks with altnost entire relief. 
Oliver W. L., aged 14, student, Berks county, 
Pa., sent by Dr. E. B. Shapleigh, of Philadelphia. 
General health good, pulse rapid, no valvular mur- 
mur, no enlargement of heart; has constant flutter- 
ing noise in left ear; never free, night or day. 
Mother deaf in both ears, from cold; no other 
member of the family deaf. Deafness and noises 
commenced in June, 1873; no discharge, no pain. 
Left ear—hearing-distance, right, *-§•. No dis- 
ease of auditory canal or membrana tympani. Right 
Eustachian tube open and free ; left contained inspis- 
sated mucus. The naso-pharyngeal mucous membrane 21 
swollen, and considerable discharge from it. Treat- 
ment prior to coming under the writer’s care, wash- 
ing out ear, applying counter-irritation, oils, etc., 
but with no benefit. Treatment first two days, 
inflated the middle ear; slight relief. Finding the 
mucus tough and somewhat dry, resorted to Lucae’s 
plan of injecting a few drops of a solution of chloral 
hydrate (io to 30 grains) to f3j of tepid water into 
the middle ear by means of the Eustachian catheter. 
This was disagreeable, but not painful; after ten 
applications, as the results did not afford permanent 
relief, omitted it, and employed the nasal douche 
with warm solution of common salt, alternated with 
solution of zinci sulphas in water, to wash out any 
accumulation in the naso-pharyngeal space. This 
relieved him, but only temporarily, and was con- 
tinued for four days, followed by the use of the 
galvano-magnetic current, applied by the author’s 
modification of the rheophore of Duchenne. The 
insulated conductor was passed near to the mem- 
brana tympani through a warm solution of chloride 
of sodium. This gave him considerable pain, but 
entire relief from the noises, with improved hearing 
in the left ear, so that he was able to resume his 
studies. 
Case III.—Tinnitus the result of chronic catarrh, 
with depressed membrana tympani {deafness). 
H. G. H., aged 40, native of Pennsylvania; mer- 
chant, doing business in Philadelphia; has suffered 
from constant noises in the left ear, with deafness 
to low sounds, for years. General health impaired, 
loss of appetite, and much depression. Applied to 
the writer December 25, 1873, being recommended 
by Dr. Levis of this city. 
History: frequent attacks of cold in the head ; 
employed tobacco, and had all the symptoms of 22 
follicular pharyngitis, with nasal catarrh, using a 
number of handkerchiefs each day, and expecto- 
rating disgusting masses of altered mucus, which was 
hardened, and in some instances tinged with blood. 
The left Eustachian tube was narrowed and dimin- 
ished in its power of opening during deglutition, 
and the hearing in the left ear to ; in the right 
the hearing was and the tube more free. In the 
right membrana tympani there was sub-acute inflam- 
mation, and handle of malleus injected, with short 
process very prominent and membrane sunken. 
Left, no symptoms of inflammation, but deeply- 
sunken membrane. 
Prior to his coming under the writer’s care, this 
gentleman had been under the treatment of almost 
every quack in this city, and had spent a large sum 
of money without benefit. He had also been 
treated by a number of able medical gentlemen, 
regular members of the profession. 
The treatment of the throat, pharynx, etc., was 
continued until the patient ceased to have the con- 
stant discharge. The sunken membrana tympani 
was elevated by means of Siegle’s aural speculum, 
and the middle ear was medicated with various solu- 
tions, restoring it to a more healthy condition. It 
was still found that the sounds were moderated, but 
no definite change in the “tinnitus.” 
May 8, 1874, performed tenotomy of the tensor 
tympani after Weber’s method, and placed the 
patient on the use of a mixture of spiritus terebin- 
thinse ; this was followed by no great change in the 
sounds. On the 12th, injected through the open- 
ing, which had not closed, a warm solution of sul- 
phate of zinc, gr. iij to of water. This was done 
by fitting the nozzle of the syringe to the meatus by 
means of an extra india-rubber packing. The 
syringe was very carefully and gradually employed, 
until the fluid passed by the nostril. This was 23 
followed by a dull, heavy pain, and the patient felt 
faint; relieved by the application of the air-douche, 
one-fourth grain of morphia by the mouth, and the 
inhalation of chloroform. He complained also of 
a crackling like the breaking of bubbles of air; still 
no permanent relief of the noises, which he likened 
to those of a boiling tea-kettle. 
Faradization was then tried ; for several weeks he 
had the fly-like noise in the ear, but when the appli- 
cation was withdrawn he was no better. 
Having tried all the ordinary means of relief, and 
the throat being improved, middle ear free, mem- 
brana tympani raised, I placed the patient upon a 
supporting and stimulating treatment for his brain, 
by the use of diluted phosphoric acid, with iron, 
with decided benefit, while I simply kept the orifice 
of the Eustachian tube free from mucus by the pos- 
terior nasal syringe and solution of common salt. 
To correct the fulness of his head and constipation, 
I directed Oak Orchard Salts, a mild saline aperient. 
This latter treatment he has been under, and he 
feels freer from the noises, is in better spirits, and 
is now able to say that he feels better than he has 
felt for years. 
During my absence in the summer, 1874, he visited 
my friend Dr. Cohen by my request, who tried the 
constant current with much the same results as those 
obtained by faradization, so that he fell back upon 
the same treatment under which I had placed him. 
Case IV.—Tinnitus the result of collapse of the 
Eustachian tube, without deafness. 
B. N. B., M.D., aged 34 years, residence Phila- 
delphia, applied April 7, 1874, to the writer, suffer- 
ing with a buzzing noise in the right ear. This 
was of four months’ duration, and the blowing 
sound increasing as if into a bottle. It disturbed 24 
his sleep, and he was unable to perform his duties 
with comfort or satisfaction. He had consulted 
four physicians, and, having some sore throat, all 
the remedies were applied to it. 
On examination, found the hearing of both sides 
normal, membrana tyrnpani of the right slightly 
drawn inwards, but no prominence of the handle 
of the malleus, with no opacity of the membrana 
tyrnpani. The left Eustachian tube was free, 
and air passed into the middle ear without any 
difficulty. The right was found obstructed in the 
pharyngeal orifice, which the writer endeavored to 
overcome by the use of the air-douche and Eusta- 
chian catheter, which were followed by slight im- 
provement. A few days after, a Eustachian bougie 
was introduced by the aid of the rhinoscopic mirror, 
and an application made to the orifice of the tube, 
of equal parts of diluted carbolic acid and tincture 
of iodine. This treatment was continued, and re- 
moved every trace of the noises. The bougie was 
a metallic one, acutely curved, introduced by the 
mouth, and its use was to stimulate the mucous 
membrane lining the tube, and thus remove the 
collapse and swelling. This bougie was introduced 
only into the wide portion of the tube. These 
bougies are employed from No. 2 to No. 5 of the 
French scale, and it is well to remember that the 
distance from the widest portion to the mouth of 
the isthmus, or narrowest part of the tube, is seventy- 
four millimetres, and the distance from the point to 
the tympanic cavity eleven millimetres, and the 
width of the cavity thirteen millimetres. 
Another case of much the same character came 
under the writer’s notice, but the results were not so 
satisfactory, owing to the length of time which 
elapsed before the patient applied for relief. It was 
as follows: 
Case V.—Isabella V., aged 25, resident of Phila- delphia, a lady of education, and very intelligent, 
applied May, 1874, stating that she was suffering 
with a constant buzzing sound without deafness; 
thought it was due to the result of a very severe 
cold ; no pain. On examination of the offending 
ear, which was the right, found her hearing was 
it left, right showing an amount of deafness by 
the watch which was not noticed in hearing the 
human voice. In the right meatus there was an 
excess of cerumen, the removal of which improved 
that ear to §f. The right membrana tympani was 
found normal. Left membrana tympani sunken, 
and Eustachian tube of left side closed by a dark 
mass when it was examined by the rhinoscopic 
mirror. This was removed by the nasal douche, 
and the iodine and carbolic acid applied to the 
ulcer which was found under it. A strong solution 
of common salt alternating with a solution of sulphate 
of zinc was then directed to be employed at home. 
May 22.—Returned, and expressed her thanks for 
the relief afforded ; she was so much improved as to 
be able to sleep, and was almost free from the tin- 
nitus unless much excited. She has been under the 
care of an aural surgeon of this city for three months, 
who had employed a large Politzer’s air-douche at 
each visit, and the application of the constant cur- 
rent to the ears, which, she stated, instead of im- 
proving her had only increased her distress. 
We have now and then very favorable results 
from the galvanic excitement in isolated cases, as 
may be noticed by a reference to the author’s 
statement of cases of nervous deafness treated by 
Brenner’s formula;* yet Brenner states that he had 
failed in seventeen cases of tinnitus. In a carefully 
prepared paper by H. Schwartze,f of Halle, he ob- 
serves, “I am far from denying favorable effects of 
25 
* Turnbull, Clinical Manual of the Diseases of the Eax, p. 389. 
f Archiv fur Ohrenheilltunde, March, 18,74. 26 
the galvanic excitement in isolated cases, but I have 
not been able to convince myself at any time of any 
real and permanent results from galvanization. . . . 
Moreover, we must remember that a series of (more 
recent) ear-troubles, also of such whose causes must 
be sought for in the cranial cavity, are capable of 
a spontaneous cure. Whoever has not frequently 
convinced himself of this fact is apt to over-esti- 
mate his therapeutics. The physician who is in the 
habit of treating all diseases by the preference of 
one remedy, as, for example, electro-therapeutics, 
of necessity over-estimates the results of his favorite 
remedy.” See two cases of tinnitus aurium re- 
ported as treated with success by Dr. Thos. F. 
Rumbold, by the galvanic current, with zinc and 
carbon battery of eighteen, ten, seven, and four 
cups, after local medication by solution of muriate 
of ammonia, and also by a solution of carbolic acid 
and ext. pinus Canadensis into the pharyngo-nasal 
cavity by spray-producer, with inflation continued 
for two and a half months. The doctor avoided the 
opening reaction of the anode. His conclusions are 
as follows: “In nearly one-fourth of my cases 
electricity has been either a valuable adjuvant or a 
specific.”—Arch. Electricity and Neurology, vol. i., 
May, 1874, p. 54. 
Dr. Seely, of Cincinnati, in an article on the 
use of galvanism in ophthalmic and aural affections, 
states his opinion in reference to the latter: “My 
attempts thus far have been rewarded by more hopes 
than practical results.”—Arch. Electricity and Neu- 
rology, vol. i., Nov. 1874, p. 221. 
In the same journal, vol. ii., May, 1875, Prof- 
Benedict is reported to have stated in reference to 
tinnitus aurium: “This disorder is best cured by 
the galvanization of the great sympathetic in the 
neck and the so-called external application of the 
galvanic current,—i.e., one electrode applied to the ear, and the other, as a wet compress, placed around 
the forehead of the corresponding side. Frequent 
inversions of the direction of the current are useful.” 
One successful case is reported. 
George P. Field, M.R. C.S., Aural Surgeon to 
St. Mary’s Hospital, and Lecturer on Aural Surgery 
in the Medical School, London, has published a 
paper on “Tinnitus Aurium” (8vo, cloth), read 
before the Harveian Society of London. We have 
not seen the paper, but take the following abstract 
of a notice of it from the Medical Press and Cir- 
cular, July, 1875 : 
“The remedies used in times past are touched 
upon, and finally the treatment which he suggests— 
namely, faradization of the membrana tympani and 
of the intrinsic muscles of the ear—is illustrated 
by recording some fifteen cases under treatment, 
together with the results obtained. 
“ He uses Dr. Stohrer’s double-celled induction 
apparatus, and passes the current directly on to the 
membrana tympani by means of a vulcanite specu- 
lum with a piece of platinum wire passed through 
it and attached to one of the wires of the battery. 
As the speculum is not actually in contact with the 
membrana tympani, a silver probe is made to touch 
the platinum and at the same time the membrana 
tympani. A very weak current is applied at first, 
and gradually strengthened. If the current is too 
strong, hemorrhage or acute pain may be the result. 
“ The fifteen cases reported are from among cases 
treated by Mr. Field at the hospital, and have 
therefore been shown to and explained to the pupils 
of the medical school. 
“Without going into a description of the cases, 
it may be sufficient to say that in all various noises 
and singing in the ears gradually disappeared under 
the repeated application of the current, and that in 
all the deafness decreased, as shown by the distance 
at which the watch could be heard.” 
27 28 
Case VI.—Extreme deafness, with noises, from 
sun-stroke. 
Henry C. K., aged 44, has suffered from complete 
deafness of eight years’ duration ; supposed cause, 
sun-stroke. He had applied cold water to his head 
after exposure to the intense heat of the sun ; no 
pain ; says he has ordinary noises in the ear. His 
deafness commenced in California. Has also granu- 
lar pharyngitis, extending into Eustachian tubes, 
with ulceration of the mucous membrane lining the 
vomer. Left Eustachian tube closed. The right 
Eustachian tube is pervious, but much narrowed. 
Cicatrix on left membrana tympani. Right mem- 
brana tympani more normal in appearance. Watch 
not heard on either side. Tuning-fork heard only 
on temporal bones. The patient having tried all 
manner of treatment without success, the writer 
perforated the membrana tympani, and, with 
Weber’s improved tenotome, divided the tendon 
of the tensor tympani, with the assistance of the 
resident physician of Howard Hospital, Dr. Parish. 
The operation was followed by pain and a few drops 
of blood. 
Directed oil of turpentine, ten drops every three 
hours, in mucilage of gum arabic, until all the acute 
symptoms had disappeared; electricity was then 
applied by Dr. Warrington, who has furnished the 
following notes of the case : 
July 21.—First application of electricity. Stoh- 
rer’s battery, six cells. Cathode in ear; anode in 
right hand. No impression. 
July 22.—Eight cells. Slight sensation of sound. 
August 1.—Eight cells. Continued to apply elec- 
tricity six times a week, about the same force and 
the same effect; hearing constantly improving. 
The throat treated by scarification and application 
of tincture of iodine and glycerin, equal parts. Im- 29 
provement. Internal treatment, iodide of potas- 
sium from four to eight grains three times a day, 
combined with tincture of columbo or ginger. 
Also chlorate of potash, 5iji tincture of chloride 
of iron, f3ij", syrup, f§j; glycerin, f^j; water, 
fgiij.—M. Tablespoonful doses three times a day. 
The patient felt so much better that he desired the 
operation of tenotomy of tensor tympani of the 
other ear. 
September 20.—On performing the operation, he 
was immediately deprived of the power to hear 
words in that ear. Inflammation and suppuration 
followed. Eustachian tube became very patulous. 
On speaking into the ear, words were seldom dis- 
tinguished, but the sound was intense and distress- 
ing. Throat more inflamed. Injected the ear with 
sulphate of zinc, gr. iii; sulphate of morphia, gr. 
i; water, Symptoms of improvement, and 
some return of hearing. In three weeks applied 
electricity, eight cells, slight effect. 
October 10.—Throat improved; hearing in right 
ear good, also in left ear. 
December 11.—Hearing for sounds better than 
at any time since the operation. Throat well; able 
to hear words in conversation better than ever 
before. 
Case VII.—Concussion, with extravasation of 
blood into labyrinth, terminating in an acute attack 
with deposit in the mastoid cells, with deafness and 
severe tinnitus of left ear. 
Edward McH., native of Wales, aged 45. He 
stated that, when passing up the Mississippi River 
during the war, on the flag-ship “ Hartford,” under 
Commodore Farragut, a cannon was fired immedi- 
ately over his head, the left ear being towards the 
gun. So close was he that his hair was burned. He 
immediately became insensible, and, on arousing in about an hour, found himself very giddy, and with 
pain in his head, but not in the ears. Nausea and 
vomiting were present, and occasionally occurred 
during the following two or three days. Prior to 
this accident he could always hear well, and never 
had any trouble with either ear. Since the acci- 
dent, the left ear has been almost completely deaf, 
but at no time has he had tinnitus in the left ear. 
At the same time, hearing diminished in the right 
ear, but was not abolished. 
About September 15, 1873, right ear lost almost 
entire appreciation of sound, when tinnitus and 
buzzing supervened. 
About October 1 a purulent discharge appeared 
in right ear. 
October 27.—At present both membranes per- 
forated ; left apparently drawn in; purulent dis- 
charge from right meatus. Had both washed out, 
and applied argenti nitras in solution. 
October 30, 1873.—Hearing improved in right 
ear; left ear still very deaf; perforation of right 
apparently healing; that of left still very large. 
Solution of argenti nitras passed into left ear; it is 
felt in the pharynx, and is tasted by the patient. 
November 2, 1873.—Hearing much improved in 
right ear, but severe pain in it and mastoid cells 
and over right side of head, with swelling. I 
punctured the swelling down to the bone with a 
bistoury, giving severe pain at the time, and causing 
the man to become quite pale and faint. 
November 6.—Returns entirely free from pain. 
Hearing much improved, and tinnitus entirely gone. 
Patient much pleased with result. 
Case VIII.—Concussion, with symptoms of extra- 
vasation of blood into labyrinth or semicircular canals. 
During the summer of 1864 Dr. Parish saw a sol- 
dier in apparent general good health, very deaf, 31 
and with constant and great tremulousness of head 
and upper extremities chiefly, but also to some ex- 
tent of lower extremities ; very giddy on attempting 
to walk, and gait very unsteady. He stated that a 
few days previously, while lying in front of the 
breast-works, a heavy cannon was fired in close 
proximity to him, and that the ball passed but a few 
feet from his head. He was instantly rendered un- 
conscious, and continued so for a few hours. On 
returning to consciousness, found himself in condi- 
tion as above. He was on his way home on fur- 
lough when Dr. Parish saw him, and he was not 
again heard from. 
Case IX.—Congestive tinnitus, the result of work- 
ing at a heated furnace with head bent to one side ; 
all the ordinary re?nedies employed, with tenotomy of 
the tensor tympani; no improvement. 
Margaret A., aged 36, an intelligent woman, liv- 
ing as a domestic, applied at Howard Hospital with 
intense tinnitus. She has had charge of a large 
furnace; while looking into and raking it when in 
full blast she was suddenly seized with headache, 
giddiness, and noises on the side nearest the heated 
part, in the winter of 1871. She consulted Dr. H., 
a young and intelligent physician, a resident of one 
of our large hospitals, who syringed her ear, giving 
her quinia, etc., but with no relief. She then visited 
the Philadelphia Eye and Ear Infirmary, and was 
under the judicious care of the aural surgeon of that 
institution for some time, but his treatment was of 
no benefit to her. Came to Howard Hospital in 
January, 1873. A careful examination was made, 
and the Eustachian tubes were found open in both 
ears. Right ear, the one in which the noises dis- 
turbed her, the membrana tympani was retracted, 
with axillary rotation of the handle of malleus; no 32 
catarrhal trouble in pharynx. After employing all 
the local remedies, as the air-douche, injection by 
the double catheter, and washing out Eustachian 
tubes, also injecting into the middle ear solution of 
potash and hydrate of chloral, with no benefit, she 
was advised to have perforation of the posterior fold. 
She willingly consented, and returned on April io. 
The writer then perforated the posterior fold of the 
membrana tympani, in the presence of Dr. Mathews, 
resident physician in Howard Hospital (1871), and 
passed a warm solution of bicarbonate of soda, by 
a closely-fitting air-tight syringe; this gave her 
considerable pain, and she was ordered a solu- 
tion of zinci sulphas, gr. iii to the ounce of warm 
water, to be applied at night, also a quarter of a 
grain of morphia if in pain, with extract of hyos- 
cyamus applied around the ear. The perforation 
kept open for one month, but with no relief to the 
noises. 
On May 5, 1873, I performed tenotomy of the 
tensor tympani, and applied electricity to the 
pharyngeal orifice of the Eustachian tube. The 
patient did not complain of much pain. I directed 
a mixture of spiritus terebinthinse, etc., as advised 
by Weber-Liel. 
On the 12th of May I injected the middle ear 
with solution of zinci sulphas, gr. vi to 5j aquse, 
which gave her pain ; directed hydrate of chloral 
to relieve her. 
She returned to the hospital on the 15th, 18th, 
21st, and 29th,—no improvement. On the 29th 
she desired to have the operation repeated, in hopes 
of some benefit; this was again done. She suffered 
but little during the last operation ; no bleeding as 
at the first operation. She could pass air by the 
perforation, but there was no improvement in the 
noises. 
Called at the hospital, by request, in six months. December, 1873, still troubled with the noises; no 
impairment of hearing since the operation. No 
pain. Membrana tympani shows two spots of 
opacity. Able to attend to her duties; is as well 
as before the operation. 
Case X.—Complete deafness, with no tinnitus ; 
not any loud sounds heard, and no articulate sounds 
recognized even by the use of the most powerful ear- 
trumpet. 
A. H., aged 55, a lawyer by profession, and a 
gentleman of fine literary taste and philosophic 
knowledge, applied to the writer during the winter 
of 1873. The history of his case was as follows: 
He gradually lost his health, and with it his hear- 
ing, about one year before he applied; he still 
heard sounds when he placed himself under the 
care of a physician of this city, who, he stated, 
first introduced steam into his middle ear, and then 
blew cold air, which was followed by total deafness 
(doubtful). When he came to the writer he was 
under Prof. Agnew’s care for his general health, 
and the writer made but a casual examination, and 
advised him to continue, and ,found both Eustachian 
tubes open,—one more than the other,—with dense 
opacity of both membrana tympani, without tin- 
nitus, showing complete paralysis of the auditory 
nerve. In partial paralysis we have subjective or 
pseudo-subjective sensations. This patient again 
presented himself in the fall of 1874, and was very 
desirous of having something done for his hearing. 
His health was improved, but with the improve- 
ment no sounds were heard. We had therefore to 
inform him that no means that we knew of would 
be of any benefit to his hearing. His only brain- 
symptom was vertigo. 
33 34 
Case XI —Deafness, but hearing by the use of the 
ear-trumpet; tinnitus with distressing vertigo ; patient 
relieved by the operation of tenotomy of the tensor 
tympani. 
The following are the notes of this case: George 
B., aged 45, Princeton, Indiana, applied May 16, 
1874. Has been a merchant in the neighborhood 
of Pike’s Peak; was a soldier for one year, but was 
discharged on account of his deafness and his lia- 
bility to fall from dizziness. History: has had no 
children’s diseases, but had intermittent fever for 
ten years, with enlargement of the spleen. Has 
never had any pain in his ears, but on one occasion 
accidentally struck his left ear with much force, and 
had a discharge of yellowish pus for one week. In 
the year 1859 heard as well as anyone; became in- 
terested in a mill, when, owing to exposure, his 
hearing began to leave him. He became a soldier, 
but he could not hear the fife or drum; and yet he 
could distinguish some of the low notes of the piano 
but none of the upper notes ; could hear the human 
voice in his own ear-trumpet, made by himself, of 
thin platinum in the form of an auricle, which was 
so light in weight that he balanced it in one ear. 
The treatment he had been under consisted in 
syringing the ear, and soon after it was followed by 
a pulsating noise in the left ear, which was at first 
intermittent, but after a time became constant. He 
had in his right ear sounds like a letting-off of 
steam. He had been under physicians at his home 
and in New York City. Examination: external 
meatus normal; chronic inflammation of membrana 
tympani of left ear, with injections along the handle 
of the malleus, with deposit of lymph and adhesions. 
This was evidently the effect of the blow. Right 
membrana tympani injected, with depression, with 
deposit of lymph on the vessels along the handle of 35 
the malleus. Rhinoscopic examination of the ori- 
fices of the Eustachian tubes: left, open and patu- 
lous, with enlarged glands; right not so much open. 
Tuning-fork heard best in the right ear; left not so 
perfect, showing conduction of the bones of the 
head, and not entire paralysis of the auditory nerve, 
as in the other case. Examination by exhausting 
the air by Siegle’s pneumatic apparatus repeatedly 
applied, afforded no relief to the pulsating noises. 
Pressure by shutting the nose modified them some- 
what. Faradization with the sponge on wire insu- 
lated produced a sound like that of a fly on a 
window-pane; on increasing the power the pain 
became much more intense under the ear and in his 
teeth, but no relief to the tinnitus. By the use of 
the author’s double otoscope, heard the sound of 
the air in the right Eustachian tube loudest. 
May 26, decided to operate by tenotomy of the 
tensor tympani, and to break up the adhesions as 
the only chance for relief. This was performed at 
Howard Hospital, assisted by the resident physi- 
cian, Dr. J. Barr (1874), and in the presence of two 
medical students. On perforating the drum, there 
was some difficulty in dividing the tendon of the 
muscle, which was unusually thick and resistant, 
and the patient experienced considerable pain, 
owing to the adhesions which had to be broken 
up by passing the knife under them. To prevent 
inflammation, the ear was carefully covered up, and 
a mixture of terebinthinae spiritus and ammonii 
chloridi given three times a day. 
Reported same day : parts looking very well and 
open; all pain ceased by 7 p.m. the evening of the 
operation. Feels relieved of a certain disagreeable 
sensation in his head (vertigo),—feeling of falling. 
May 30.—Still continues well; injected a solu- 
tion of one grain of sulphate of zinc through the 
opening; not much pain ; this was repeated twice. 36 
The patient left for his home in a few days after 
the operation, and when he arrived the writer re- 
ceived the following letter from him, in which he 
states, “I arrived at home all right; no trouble 
with ear. The left Eustachian tube is now more 
open than it ever was; hearing about the same in 
both ears; had no trouble with my head since the 
operation.” 
I gave him certain instructions to be carried out, 
also advised a more extended trial of the faradic 
current, as Brenner’s formula had been obtained 
by its use in our first experiment with his deaf ear. 
This, it is true, is rather like a confirmation of 
Schwartze’s second conclusion, “that Brenner’s 
normal formula is obtained in absolute deafness;” 
but there must be no tinnitus, for we have no such 
result in cases where there is absolute paralysis of 
the auditory nerve (see Case X. before referred to). 
The following are the conclusions of the eleven 
cases reported: four were cured, two much im- 
proved, two improved, one not improved, and two 
not treated. One of those not improved is a form 
of deafness accompanied with distressing noises, 
where the patient apparently was in sound health a 
few hours before; this is followed by apoplectic 
symptoms, with giddiness, and is due to hemorrhage 
into the labyrinth, and is known as Meniere’s dis- 
ease. The same results shown in another from injury 
may occur from fracture through the bony labyrinth 
by contre-coup. In one we had absolute paralysis 
of the acoustic nerve, with little or no tinnitus. 
“ Nolet,* of Leyden, has made experiments con- 
cerning the origin of pulsating tubular noises which 
have been so much discussed, the main results of 
which are here given, because they are important. 
Vascular or pulsating noises are produced in tubes 
* Troltsch, Ohrenheilkunde, Fifth (German) Edition, p. 507. Nolet of 
Leyden (see Archiv fur Heilkunde, 1871, xii.). 37 
of equal calibre, if the velocity of the current be 
great; and this velocity must be the greater the 
smaller the diameter of the tubes and the smoother 
their walls. The rougher their walls are, the sooner 
will noises be produced. If there be a strictured 
place in the tube, a noise becomes perceptible 
already at a rate of velocity when there would be no 
noise perceptible if the narrowing were not present. 
When the velocity of the current was considerable, 
a quivering was to be felt before and behind the 
strictured place, which was more readily produced 
in tubes with thin walls than in such as had thick 
walls. When the tubes were partially widened, 
noises were produced in them by a greater velocity 
of the current (? translator). The noises are pro- 
duced by the viscidness (vertices of the fluid), and 
not by vibrations of the walls of the tubes nor by 
rhythmical friction (?) of the out-flowing jet.” 
The treatment of such pulsating noises is of two 
kinds: first, constitutional treatment if the disease 
depends upon thinness of the blood or a want of 
certain elements; these must be supplied,—if from 
want of iron, by chalybeates, if from want of fibrin, 
by wheat, etc. ; if the other important elements are 
wanting, blood in some form itself, as the expressed 
juice of beef, like Valentine’s, or by lamb’s blood 
taken warm. If the blood is too thick or viscid, 
it must be reduced by salines. If the noises are 
very distressing, resort may be had to nervines and 
agents that will control the violent action of the 
heart, as aconite, digitalis, with chloral hydrate or 
fluid extract of valerian, Prunus virginiana, or water 
of the bitter almond or orange-flower. Mechanical 
means are also to be tried, by compressing the jugu- 
lar vein over the highest point of the hyoid bone. 
The observations of Benedict, Tiirck, and Politzer 
confirm us in the opinion that pressure over the 
mastoid apophyses would, in some instances, modify 38 
these subjective noises. By removal of the narrowed 
condition of the meatus auditorius, as performed by 
Larrey and Cloquet, or by some mechanical and 
surgical means as related in the author’s work, p. 
xvi. In a certain class of cases of chronic catarrh 
of the middle ear, Politzer has recommended the 
closing of the external meatus by wax or cotton 
charged with wax. Schwartze employed for the 
same purpose a ball of gutta-percha oiled, softened 
by means of warm water, or, as the writer prefers, 
gas-heat and olive oil. Lucae has employed and 
recommended the rarefaction of the air by fitting 
the external meatus with an instrument like Siegle’s 
pneumatic apparatus, especially in catarrh of the 
cavity of the tympanum. The condensation of the 
air in the auditory canal by the same instrument 
gives, sometimes, good results in cases of pressure 
of the stapes, or stirrup, over the fenestra ovalis, or 
oval window. 
Then follows puncturing of the membrana tym- 
pani, recommended as early as 1722, and first 
received into favor as a legitimate operation in sur- 
gery about the year 1800, for deafness and sounds 
in the ear. We have repeatedly performed this 
operation, and in certain cases with success; again, 
we have operated with no relief to the noises. 
Schwartze, who has performed this operation over 
one hundred times, has established it in cases where 
there has been an accumulation of mucus, blood, or 
pus. He prefers a transverse incision in the poste- 
rior and inferior part of the membrana tympani. 
Dr. Lucae* has also resorted to this operation in the 
treatment of deafness and noises, by a division of 
the posterior fold or pocket for the purpose of re- 
ducing the tension of the membrane of the drum. 
Where he has had the peculiar rattling sound de- 
* Dublin Journ. Med. Sci., Oct. 1871, p. 322. noting a collection of secretion, which is also to be 
perceived by a sufficient transparency of the mem- 
brane, after cutting the posterior fold, he extends 
the cut to about the middle of the membrane, in 
order to facilitate the escape of the not unfrequently 
very viscid and tenacious secretion. He has per- 
formed this operation (division of the posterior 
fold) up to 1870 forty-eight times in forty-five cases, 
as follows: First, in cases without demonstrable 
adhesions, fourteen operations: greatly improved, 
seven; a little improved, seven; not at all im- 
proved, none. Second, in expressed otitis media 
adhesive, twenty-seven operations: greatly im- 
proved, five; a slight improvement, eleven; not at 
all improved, eleven. Third, in genuine catarrh of 
the cavity of the drum, at the same time letting 
out the secretion, seven operations: of these, six 
were greatly improved, one a slight improvement. 
Politzer performs the same operation by incision of 
the posterior fold (not pocket) of the membrana 
tympani. His incision is a longitudinal one, at right 
angles to the long axis of the fold between the short 
process of the malleus and the peripheric end of the 
fold.* Of the operation of tenotomy we have already 
given our experience in the cases above reported. 
39 
* Monatsschrift fur Ohrenheilkunde, Jahrgang ii. p. 51. The Medical Times 
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